Communication in the hospital setting: A survey of medical and everyday language use amongst patients, nurses and doctors

Sm. Ser. Med. Vol. 28, No. 4, pp. 339-346, 1989 0277-9536189 $3.00 + 0.00 Printed in Great Britain. All rights reserved Copyright c 1989 Per@non Press plc

COMMUNICATION IN THE HOSPITAL SETTING: A

SURVEY OF MEDICAL AND EVERYDAY LANGUAGE USE AMONGST PATIENTS, NURSES AND DOCTORS

RICHARD Y. BOURHIS, SHARON ROTH and GLENDA MACQUEEN

Department of Psychology, McMaster University, Hamilton. Ontario L8S 4KI. Canada

Abstract-Forty physicians, 40 student nurses, and 40 hospital patients were surveyed regarding their usage and evaluations of medical and everyday language use in the hospital setting. Medical language (ML) and everyday language (EL) were operationalized as distinct speech registers that doctors. nurses and patients can use in their encounters with each other. A complex interaction of speaker characteristics (bilingualism in ML and EL) motivational factors (accommodation theory). situational language norms in favor of communicative effectiveness, as well as status and power differentials that exist between health professionals and patients were hypothesized to influence language switching strategies in the health setting. While doctors reported using mostly ML with health professionals, they did report converging to the EL of their patients. However, patients and student nurses did not perceive doctors converging to the EL of their patient. Student nurses reported using an equal mixture of ML/EL with each other, while converging to the ML of the doctor and converging to the EL of their patients. The ‘communication broker’ role of the nurse was corroborated by perceptions of nurses’ language use from all groups. Patients reported using mostly EL with each other while attempting to converge to the ML of the health professional. Nurses perceived these attempts to converge by the patients, but doctors did not report a change in the patients’ register as a function of conversants. Regarding the evaluation of language use strategies, all groups felt that it was more appropriate for health professionals to converge to the EL of patients than to maintain ML. In conversations with health professionals, patient use of EL was seen as more appropriate than ML. Use of ML by health professionals was felt to be a source of problems for patients. while EL was seen to promote better understanding for patients. The results are discussed with regard to the interplay of factors influencing language choice strategies in complex organizational structures such as hospitals.

Key bvords-medical language. everyday language. convergence, maintenance

INTRODUCTION

A substantial body of research describing communications between doctors and patients in the consultation office has accumulated in the last decade [ 1,2]. This literature suggests that communication breakdowns between doctors and their patients seem more the rule than the exception. Despite detailed docu- mentation of communication breakdowns between doctors and patients, reasons for the breakdowns have not been integrated within a coherent concep- tual framework. Much of the work has lacked a theoretical focus and has failed to look at the consultation as a social interaction process. For instance, much research has focused on doctor-patient communication with little regard for other role partners, such as nurses, who are integrally involved in medical settings such as hospitals. Pendleton [I] as well as Jaspars. King and Pendleton [3] have called for a broader formulation of the consultation process within a psychological model of communicative be- havior [l, p. 46: 31.

A useful approach to this problem is to adopt a

An abridged version of this paper was presented at the Third Inrern>tional Confew& on Social-Psychology and Lan- mme. Julv 1987, University of Bristol. England. This ia& was also presented it the Chedoke-McMaster Hospital Educorion Round, April 1987. Hamilton, On- tario, Canada.

communication broker, accommodation theory.

social psychological analysis of the communication patterns that emerge between health professionals and their patients. One aspect of the communication process that is worth examining from this perspective is the use of different registers adopted by health professionals and patients in the hospital setting. Doctors are functionally bilingual; they speak at least their native everyday language (EL), and they also are fluent in a highly specialized register, namely, medical language (ML). Nurses are also bilingual since they are fluent in both the ML register and in everyday language. Patients, on the other hand. are unilingual in EL as they are typically unfamiliar with much of the specialized ML terminology.

A number of studies have established that there arc real differences in the speech registers used by doctors compared to that of patients [4, 51. Samora et ~11. [5] have shown that even words familiar to both parties, such as ‘stomach’, can have different meanings for doctors employing a strict medical definition of the term while patients employ the term in its everyday meaning. Scott and Weiner [4] proposed the com- pilation of a ‘patientspeak’ dictionary to be used by doctors to alleviate some of the disparity in vocabulary and meaning that exists between physicians and their patients. Swenson (61 coined the term ‘surgeonspeak’ as she described her struggle as a nurse in the operating theater to translate surgeons’ requests into terms comprehensible to attending

339

340 RICHARD Y. BOURHlS et al.

nurses. In Canada, the Patients’ Rights Association of Ontario has sought to address the problem of medical jargon by publishing a glossary of medical definitions [7] designed to clarify some of the medical terms patients are frequently confronted with in encounters with health professionals in the hospital setting. It has been established, then, that there are differences in the register used by doctors, nurses and patients in the medical setting.

ingratiation with powerful. high status health professionals whose medical expertise is needed for the well being of the patient.

The use of contrasting languages and registers during interpersonal and cross-cultural encounters has been investigated internationally in both the sociolinguistic [8] and social psychological literature [9, IO]. Using a social psychological approach, Giles, Bourhis and Taylor [1 l] proposed a framework known as interpersonal speech accommodation to account for the motivational bases of speakers’ use of similar or different linguistic codes during interpersonal encounters. In its basic form, accommodation theory describes the motivational processes at work when speakers fluent in different codes communicate with each other [l2]. According to accommodation theory, people have three options when communicating with someone fluent in a speech code different from their own: convergence, maintenance or divergence.

Convergence occurs when one or both participants attempt to adopt the speech pattern of the other. Utilization of this strategy is reflected by changes in speech rate. vocal intensity, language switches and accent switches [9]. Speech convergence can promote mutual intelligibility between speakers and reduce the uncertainty that often characterizes first encounters between strangers [13]. Speech convergence has also been shown to promote interpersonal liking while also reflecting speakers’ conscious or unconscious need for social integration with their interlocutor [ 121. Thus speech convergence is a strategy that promotes both interpersonal and ethnic harmony where speech differences between interlocutors could otherwise be serious stumbling blocks to communicative effectiveness and intercultural communication [lo].

Communicative norms within the hospital setting should favor strategies that maximize communicative effectiveness both amongst health professionals themselves and between health professionals and their patients. To the degree that doctors are expected to communicate as effectively as possible with patients concerning medical issues. convergence from ML to EL by doctors with their patients should be expected. Convergence to EL can maximize communicative effectiveness with patients and may promote patient compliance to health professional guidelines and directives. Convergence to EL may have the added advantage of making patients feel more at ease in their interactions with doctors. Indeed, as regards other communicative norms such as those that prevail in a client/clerk encounter. Genesee and Bourhis [17] found that customers were expected to feel more relaxed, comfortable and confident when sales- persons conformed to the communicative norms by converging to the language of their customer than when they did not. Beyond making the patient more comfortable, the Ontario Patients’ Rights Associ- ation handbook states that “most complaints against health care providers involve a misunderstanding or lack of communication” [7, p. 151. Furthermore. there is evidence to suggest that patients who are not satisfied with the interactions they have had with their doctors will exhibit less compliance and the outcome of their consultations will be less fruitful [I. p. 441.

Speech maintenance occurs when speakers fail or decide nor to adapt their speech patterns to that of their interlocutor [IO, 141. Speech divergence results when one or both speakers accentuate the differences in speech patterns that exist between them as contrasting social groups (e.g. ethnic. class, occupational groups, etc.) [IS]. Both maintenance and divergence can be interpreted as expressions of speakers’ dislike of their interlocutor as an individual or as an outgroup member. These two dissociative strategies may also be employed when speakers wish to assert the status and power differentials that exist between themselves and outgroup interlocutors. Such dissociative strategies have been shown to bolster the social identity of group members in both field and laboratory settings [IO, 11, 161.

From an interpersonal accommodation perspective [I 1, 121, one could expect that doctors who make the effort of converging to everyday language should be perceived more favorably by patients than doctors who do not converge from ML to EL with their patients. Conversely, consultations in which doctors maintain or accentuate their use of ML (divergence) with patients may foster tense, unfriendly consultations and may result in communication breakdown between the patient and doctor [IQ Doctors who maintain ML with their patient may do so because they wish to maintain or assert their status and power as medical authorities vis-a-vis their patients [16. 18, 191. Alternatively, doctors may maintain ML because after many years of medical practice they are no longer aware or sensitive to the fact that ML is a specialized register unfamiliar to patients [20].

Doctors and nurses are fluent in both ML and EL and can adopt either of the three strategies described above when interacting with patients. Patients are functionally unilingual in EL, and may be limited to language maintenance in EL. However, patients might be expected to have some rudimentary knowledge of ML which they may attempt to use for the sake of communicative effectiveness and possible

Norms in favor of communicating as effectively as possible with patients suggest that nurses should also converge to the EL of their patient. Indeed, the ability of nurses to understand and meet patients’ communicative needs may be hindered if convergence to EL is not adopted as the communication strategy. Nurses are an integral part of the hospital setting and their importance to patient-health professional interactions has not received adequate attention in pre- vious work. Furthermore, nurses are in an interesting position relative to doctors and patients. They typically have less power, and correspondingly less status than physicians, yet within the hospital they have more expert power than the patient. Nurses are communicatively bilingual, and thus competent in both EL and ML. In addition to other duties, nurses

Communication in the hospital setting 341

appear to play a mediating role between doctors and patients on several dimensions, and this might be reflected in their choice of communicative strategies. Nurses are capable of converging to the ML of doctors and to the EL of their patients. Thus in the hospital setting nurses may act as ‘communication brokers’, a role which, among many other functions, could involve translating into EL the ML spoken by doctors to their patients.

As for doctors, nurses’ efforts to converge to the everyday language of the patients may be much appreciated by patients. However, given their inter- mediary status within the hospital setting [16, 191, nurses may choose to maintain or accentuate their use of ML with patients as a way of asserting their status and expert power vis-a-vis patients. Such a maintenance strategy may also be used as a way of seeking status equivalence with doctors, at least as regards knowledge of medical jargon.

Four classes of factors affecting the use of medical and everyday language in the hospital setting have been identified. These factors are: (I) the linguistic background of patients and health professionals in EL and ML; (2) motivational factors related to speakers’ choice of convergence or maintenance strategies with their interlocutors; (3) communicative norms in the hospital setting; and (4) status and power differentials which characterize patient, nurse, doctor relations in the hospital setting.

The aim of this study was to examine the interplay of these factors through the use of a survey questionnaire designed to monitor the use of medical and everyday language by patients, nurses and doctors in the hospital setting. How health professionals and patients use medical and everyday language in their encounters may not only uncover the communicative strategies that prevail in the hospital environment, but may also reflect the motivational, normative and power relations that exist between role partners such as doctors, nurses and patients in the health setting.

METHOD

Respondents

Three groups of respondents participated in this study: 40 physicians, 40 student nurses, and 40 patients. All doctors, student nurses and patients reported English as their mother tongue. The three groups of respondents had the following characteristics:

The physician group. The physicians included in the study were from the Hamilton-Wentworth area of southern Ontario, Canada. The sample included 29 males and I1 females; their average age was 42 years. Twenty-seven respondents were general practitioners while 13 respondents were specialists. The average length of hospital experience the 40 physicians had was 17 years. Doctors were recruited on voluntary basis either during their office hours in private practice (22 doctors) or while attending a continuing education program offered in Hamilton (18 doctors). The study was presented to the physicians as a survey on doctor/patient/nurse communication in the hospital setting.

The student nurse group. The student nurses were enrolled in the third or fourth year of the Bachelor of Science in Nursing program at Chedoke- McMaster University hospital in the Hamilton- Wentworth region. Thirty-nine females and one male participated; their mean age was 22. The average length of hospital experience for the student nurses was 500 hr of work on the wards. Student nurses were chosen because they were more accessible than employed nurses, and had recent experience in different hospital wards of the region. It was also thought that student nurses might be more aware of the differential use of medical and everyday language in the hospital setting since they were still in the process of consolidating their own use of the medical register as an occupational tool. Student nurses were recruited on a voluntary basis following visits to nursing classes announcing the study as a survey of nurse/patient/doctor communication in the hospital setting.

The patient group. Patients were recruited for the study only if they had been hospitalized for a period of at least 2 days within the past 2 years. Their average duration of hospitalization was 9 days. All but two subjects had been hospitalized in the Hamilton-Wentworth region; one had been in a small town hospital, the other in a number of hospitals in southern Ontario. The sample consisted of 26 females and 14 males with a mean age of 30 years. Patients were recruited on a voluntary basis in doctors’ waiting rooms and in a hospital cafeteria. The study was presented to them as a survey on patient/doctor/nurse communication in the hospital setting.-

Procedure

All respondents were asked to volunteer in the research project by completing a written survey questionnaire. Printed instructions on the first page of the questionnaire included the following definitions of ML and EL:

Medical hmguuge (ML). The technical language used by medically trained people such as doctors and nurses. Medical language includes technical terms used in diagnosis, terms used to describe or explain surgical and other medical acts, as well as terms used to describe normal bodily functions.

Everyday language (EL). What must be said in the hospital setting using ordinary language that people with no medical training can readily understand.

The questionnaire consisted of four sections. The first section dealt with self reports of the percentage of ML/EL the respondent employed with patients, nurses and doctors in the hospital setting. In the second section, respondents estimated, in percentage terms, the amount of ML and EL employed by other members of their own group and outgroup members when communicating with patients, nurses and doctors. The third section sought evaluative ratings (on a seven-point scale) of the appropriateness of ML/EL use amongst patients, nurses and doctors in the hospital setting. The final section dealt with background information on respondents and their atti- tudes concerning different communication issues in the hospital setting.

342 RICHARD .Y. BOURHIS er al

RESULTS

Respondent ,f/uencJ, in ML /EL

One way analyses of variance were performed between groups for the ML fluency and ML comprehension self ratings. The difference between groups was significant for fluency (one was ANOVA: F[Z. I 171 = 93.60, P < 0.001) and for comprehension (one way ANOVA: F[2.117] = 103.04, P < 0.001). There were significant differences in the degree of ML spoken and comprehended by health professionals and patients, with medical professionals feeling equally at home with EL and ML and patients reporting less fluency and comprehension with ML than with EL. The three groups of respondents reported an equivalent high level of comprehension (M = 6.9) and fluency (M = 6.8) with everyday En- glish (seven-point scale: I = not at all fluent; 7 = very fluent). Doctors reported the same level of fluency and comprehension for ML as for EL (ML fluency: M = 6.7; ML comprehension: M = 6.9). Likewise, student nurses reported a statistically equivalent level of fluency and comprehension for ML as for EL (ML fluency: M = 5.3: ML comprehension: M = 5.8. As expected, patients reported fluency in ML (M = 3.0) and comprehension in ML (M = 3.9) to be lower than proficiency in EL.

Self‘ reports of ML/EL usage

Health professionals and patients did differ sub- stantially in their self reports of ML and EL language use in the hospital setting. Analyses of variance were performed on the self reports of ML and EL usage amongst the three groups of respondents. There was an overall significant difference in amount of ML spoken by health professionals and patients (3 x 2 ANOVA: F[2, I 181 = 20.30. P < 0.001). Newman Keuls tests were significant at P < 0.01 with health professionals (M = 51.8%) using more ML than patients (M = 22.3%) at all times. The amount of ML employed varied within each group depending on the person addressed by that group member; speakers from the three groups reported using more ML when speaking with health professionals (M = 52.8%) than with patients (M = 21.3%: Newman-Keuls tests significant at P = 0.01). Correspondingly, patients spoke more EL than health professionals and were spoken to in EL more often than were health professionals.

As expected, patients reported using EL much more than ML in the hospital setting. As can be seen in Fig. I, patients reported using EL most of the time (89%) when speaking to other patients, though some use of ML (I I %) was reported in conversations between patients. However, when speaking to nurses. patients reported using ML 2 I % of the time while self reports of ML usage rose to 35% in conversations with doctors.

Figure 2 indicates that nurses reported speaking EL (47%) as much as ML (53%) when speaking to other nurses in the hospital setting. When speaking to patients, nurses reported using mostly EL (70%) while ML was used only 30% of the time. Conversely, nurses reported using ML most of the time (67%) when speaking with doctors. Thus. nurses reported

Fig. 1. Patients’ self reported use of ML EL

converging to both the EL used by patients and to the ML used by doctors.

Amongst each other in the hospital setting. doctors reported using mostly ML (73%) and only a little EL (27%). As can be seen in Fig. 3. doctors also used mostly ML (65%) when speaking with nurses. How- ever, when speaking with the patients, doctors reported they used mostly EL (77%) and only some ML (23%). Thus, relative to their conversations amongst each other, doctors reported converging to the EL of their patients in the hospital setting.

Perceived use of ML/EL in the hospital setting

As Table 1 indicates, patients. nurses and doctors reported their perceptions of the amount of ML/EL used by doctors, nurses and patients in the hospital setting. Patients and nurses were in strong agreement when assessing patients’ use of ML with other patients (10% and 13% reported by each group respectively). Patients and nurses were also in agreement about the amount of ML patients used with nurses (15% and 16% respectively) and doctors (19% and 23% respectively). However, doctors’ perceptions of the amount of ML employed by patients differed from patient and nurse perceptions since doctors perceived patients to use ML only 5% of the time with other patients. 6% of the time with nurses, and 7% of the time with doctors. Analyses of variance showed that indeed doctors consistently underestimated patients use of ML relative to perceptions by nurses and patients (3 x 2 ANOVA: F[2.106] = 7.46; P < 0.001). Thus, whereas patient and nurse perceptions tended to corroborate patients’

.-_

G: so

oil 80

Fig. 2. Student nurses’ self reported use of ML/EL.


d go-

-8 60- 77%

i 70- 8 i-

60-

! 50-

WITH WrrH NURSES DOCTCIRS

L Fig. 3. Doctors’ self reported use of ML/EL

self reports of ML/EL usage (cf. Fig. l), the patients’ self reports were not corroborated by doctors’ perceptions of ML/EL use.

As can be seen in Table 1, nurses perceived that other nurses used 43% ML with other nurses, while patients perceived nurses to use 58% ML when conversing with each other. Doctors perceived nurses to use 52% ML when speaking with each other. As regards their communication with patients, the three groups of respondents perceived that nurses converged a great deal by using more EL than ML with their patients. Indeed, nurses’ convergence to EL with patients was perceived to be 73% by patients, 69% by nurses and 75% by doctors.

Conversely, nurses’ self reported convergence to ML with doctors (67%, see Fig. 2) was perceived to be 66% by doctors, 58% by nurses and 72% by patients. Thus, nurses were perceived to converge linguistically to both patients (in EL) and doctors (in ML). Analyses of variance showed that these perceptions of the nurses’ language strategies were shared by the three groups of respondents since no differences emerged between the three groups in the perceptions of nurses’ ML/EL language use (one way ANOVA: F[297] = 1.88; P = 0.157).

As can be seen in Table 1, the three groups of respondents agreed that doctors used mostly ML when speaking to other doctors and to nurses. As regards perceptions of doctor-patient communications, however, doctors’ observations were at odds with those of patients and nurses. In line with doctors’ own ratings of extensive EL usage with patients (77%, see Fig. 3), doctors did perceive other doctors as mostly converging to the EL of their patients (72% EL, Table 1). In contrast, both patients and nurses reported that doctors used much ML when speaking to patients (49% and 59%, respectively).

Analyses of variance showed significant differences between estimations of ML provided by nurses, patients and doctors when the estimations were of doctors’ ML/EL usage (3 x 2 ANOVA: F[2,101] = 7.68. P = 0.001). A significant interaction (3 x 2 ANOVA: F[4,202]= 13.69, P < 0.001) reflected the difference in each groups’ perceptions of doctors’ ML/EL usage with patients. Doctors consistently underestimated patients’ use of ML relative to perceptions by nurses and patients. More im- portantly, neither nurses nor patients perceived doctors as converging to EL with patients as much as doctors asserted they did. Instead, patients and nurses perceived doctors to use much ML when conversing with patients (see Table 1).

Finally, the three groups of respondents recognized that doctors, nurses and patients conversed in EL significantly more often when speaking to patients than to health professionals. Conversely, both doctors and nurses were seen to speak more ML to health professionals than to patients (one way ANOVA for doctors: F[2,200] = 36.06, P < 0.001; one way ANOVA for nurses: F[2,194] = 145.00, P < 0.001). Patients were also seen to speak significantly more ML to health professionals than to other patients (one way ANOVA: F[2,212] = 18.39, P < 0.001).

Communication issues in the hospital

Opinions regarding the optimum language strategies for communications between patients, nurses and doctors in the hospital setting were also assessed in this survey. Respondents evaluated the desirability of communicating by using ML only, EL only, or by using a SO/SO mixture of ML/EL. Evaluations were made on a seven-point scale ranging from 1 = ‘strongly disagree’ to 7 = ‘strongly agree’.

Though patients and student nurses agreed that patients were entitled to use EL when speaking to both nurses (M = 4.4) and doctors (M = 4.3); it was doctors who felt most strongly in favor of patients using EL alone with nurses (M = 5.4) and doctors (M = 5.2). Interestingly enough, the three groups of respondents concurred in their feelings that a SO/SO mixture of ML and EL could be acceptable for patients to use with nurses (M = 4.0) and doctors (M = 4.2). However, the three groups disagreed with the notion of patients using only ML when speaking to either nurses (M = 2.2) or doctors (M = 2.1).

In cases of doctors speaking to patients, a SO/SO mixture was viewed as more appropriate by patients (M = 5.5) and nurses (4.5) than the use of EL alone (M = 3.7; M = 2.5, respectively). Doctors evaluated both a mixture of EL/ML (M = 3.9) and EL alone (M = 4.4) as being appropriate codes in which to

Table I. Perceived use (in %) of medical (ML) and everyday lanauane (EL) in the hosoital setting

As reported bv

Patients speaking to Nurses speaking to Doctors speaking to

Patients NUWS Doctors Patients NUBCS Doctors Patients Nurses Doctors ML EL ML EL ML EL ML EL ML EL ML EL ML EL ML EL ML EL

Patients IO 90 15 85 19 81 27 73 58 42 72 28 49 51 75 25 82 18 (n=40) Nurses 13 87 16 84 23 77 31 69 43 57 58 42 59 41 62 38 69 31 (n =40) Doctors 5 95 6 94 7 93 25 75 52 48 66 34 28 72 63 37 75 25 (n = 40)

344 RICHARD Y. BOLRHIS er ul

speak to patients. It is noteworthy that relative to patients (M = 1.8) and student nurses (M = 2.1) it is doctors (M = 1.1) who most strongly disagreed with the notion that doctors use ML only when addressing their patients. Virtually identical patterns of results emerged when the three groups of respondents rated the suitability of different registers in nurses’ communications with their patients.

There was general agreement that EL alone was nor the best register for doctors and nurses to use when communicating with each other (nurses speaking to doctors, M = 2.2; doctors speaking to nurses, M = 2.5). Instead. both ML alone and a 50’50 mixture were viewed as the more appropiate registers for doctor and nurses to use with each other (nurses speaking to doctors: ML: M = 4.1; ML:EL: M = 4.6; doctors speaking to nurses: ML: M = 4.2: ML,EL: M = 4.6). The above patterns were confirmed in the analysis of variance results which showed significant interaction effects for strategy rated most effective dependent upon both the group that made the rating (3 x 3 ANOVA: F[2.1 171 = 5.91. P = 0.004) and the group member to whom the register was to be spoken (3 x 3 ANOVA: F[2,234] = 54.40. P < 0.001).

As regards other communication issues in the hospital setting, patients, student nurses and doctors concurred in their views that the use of ML by doctors (M = 5.3) and nurses (M = 5.0) often leads to communication problems for patients. In contrast, the three groups of respondents felt that the use of EL by doctors (M = 2.6) and nurses (M = 2.6) only rarely fostered communication problems for patients in the hospital setting.

Opinions regarding the value of providing courses in health communication techniques to patients. nurses and doctors were also assessed in the survey. Both patients and doctors rated communication courses to student nurses. medical students. and doctors as very valuable (M = 6.7). Doctors and patients rated the provision of such courses to patients to be of moderate value (M = 4.6). Student nurses reported that the current communication courses in which they were involved were of significant value for improving nurse-patient interactions (M = 6.1), but of moderate value (M = 4.9) for nursedoctor interactions. The three groups thus agreed that communication courses for health professionals were quite valuable. while courses for patients might be somewhat valuable.

DlSXSSlOlri

The general hypothesis that doctors and nurses would converge to the everyday language of their patient in the hospital setting received some support. However, doctors’ self reports concerning their efforts to converge to the EL of their patients was corroborated by other doctors’ perceptions but nof by patients’ and nurses’ perceptions of doctors’ ML/EL usage with patients.

Furthermore, the expectation that patients maintain EL in the hospital setting was only partially supported since patients reported making some effort to speak ML with health professionals. An important finding in this survey supported the notion of the nurse as a ‘communication broker’ who converged

linguistically to both the EL of the patient and the ML of the doctor. Both the nurses’ self reports and perceptions respondents had of the nurses’ ML ‘EL use reflected the nurses’ role as a ‘communication broker‘ between doctors and patients in the hospital setting.

Regarding the evaluation of the use of medical and everyday language. it is noteworthy that the three groups. mcluding doctors. agreed that everyday language rather than medical language was more appropriate for communications with patients. Further- more, an equal mixture of EL and ML was viewed by the three groups of respondents as an acceptable compromise for optimal communication with patients. In line with these findings. the three groups of respondents felt that the use of ML had frequently led to communication difficulties between health professional and patients while the use of EL only rarely led to such problems.

Compared with their self-rated skill in EL, patients reported only some familiarity with ML. However. patients reported using their limited ML vocabulary in an attempt to converge to nurses and doctors in the hospital setting. This convergence by the patient may represent an attempt to maximize communicative effectiveness with health professionals. Through convergence to the high status ML register, patients may also have been attempting to minimize the status and power differentials separating them from health professionals [ 191. From an accommodation perspective [1 I. 121. patients may feel that convergence to ML may promote more liking on the part of health professionals and perhaps lead to better patient care.

As with patients and student nurses, doctors did not encourage the use of ML by patients when queried about the optimal communicative strategy for a patient to use. In fact, doctors expressed the strongest desire of all groups that the patient employ only EL. It may be that doctors are not confident that pattents are proficient enough with ML to use it accurately. and fear that inaccurate use of ML by patients might impede diagnosis. Furthermore, while nurses did perceive patient convergence to ML as reported by patients themselves (cf. Fig. I and Table I). doctors did not perceive patients as making an effort to use ML with health professionals. Con- versely. even though doctors asserted they converged to the EL of their patients, they were not seen to be doing so to a great extent by either the nurses or the pattents. Taken together, the above results suggest that doctors may use communicative strategies as a way of maintaining the status and power differentials that exist between them and their patient in the medical setting [I I].

Scott and Weiner [4, p. 8901 pointed out that medical students work hard to acquire a specialized vocabulary, and having mastered this vocabulary are eager to use it. Use of ML established physicians as hona.fide members of the medical community, with the status and power granted to this group within society. Use of ML may symbolize for doctors the distinctiveness and status of belonging to the medical profession as a group [5, 161. From an accommodation perspective [I I, 121, strong motivation thus exists for doctors to maintain and even accentuate their use of ML as a way of asserting their superior


status position vis-a-vis patients. Conversely. to the degree that ML does serve as a badge of the physician’s expert status, doctors may feel that patient use of the distinctive ML register could erode the status differentials long enjoyed by medical professionals relative to their patients.

It must be kept in mind that nurses also work hard to master medical language and that they too could need to use ML as a way of asserting their status position within the medical establishment. Unlike doctors, however, nurses reported and were seen to converge to the EL of their patients. These patterns of results suggest that nurses are less concerned with asserting their status differentials in the hospital setting than doctors [cf. 211. However, it is important to note that these respondents were student nurses with less experience than nurses who have spent many years working on the wards. Compared to more senior nurses, the respondents in our study may not have had time to fully internalize their status position within the hospital setting and were perhaps less concerned with asserting their status differentials than other health professionals [l6].

Though both interpersonal accommodation and status maintenance factors seem quite relevant in accounting for the above results, other factors may play a complementary role in accounting for doctors’ communicative strategies.

To the degree that medical language symbolized the doctors’ superior ‘expert power’ as a healer of medical ailments, then doctors’ use of ML may serve the function of reminding patients that they have good reasons for maintaining their ‘act of faith’ in the physicians’ capacity to solve health problems. Though some could use this rationale as a way of legitimizing doctors’ use of ML with patients, it remains that results from the present survey showed that patients as well as nurses and doctors felt that EL was more acceptable than ML for communications between health professionals and their patients.

Doctors reported that they did converge to EL with patients though neither nurses nor patients perceived doctors as converging very much to EL with patients. Research by Broadbent, FitzGerald and Broadbent [20] has shown that when a skill becomes highly practised, it becomes difficult to monitor application of the skill, and the knowledge surrounding it becomes implicit or automatic. Im- plicit knowledge appears to be a factor in expert systems where highly skilled people are unable to monitor or articulate their use of a specific skill. This may partly account for the discrepancy in reports of doctors’ language usage. Because doctors use ML everyday, it may become in some way an everyday language. After years of medical practice, it may be difficult for doctors to clearly differentiate between medical and everyday language when discussing medical issues with their patients. Terms commonly used within medical language may be. perceived by doctors as everyday language. Words and expressions classified as belonging to the ML corpus may only be those used least frequently by doctors themselves. In contrast, to the degree that student nurse respondents in this survey were still consolidating their use of ML, it may be the case that student nurses were not yet

using ML as an implicit nonanalytic skill. Con- sequently, both patients and student nurses were perhaps more sensitive to ML use than the seasoned physicians who participated in our survey. One way of further testing the validity of the ‘implicit knowledge’ explanation would be to conduct the survey with medical students who were still consolidating their knowledge of medical language. Evidence for the implicit knowledge hypothesis would be obtained if it were found that medical students responded to our hospital communication survey as did the student nurses in the present study.

It was clear to the three groups of respondents that nurses converged to both the EL of patients and to the ML of doctors. Nurses emerged as ‘communication brokers’ capable of mediating between doctors and patients. That it is important for nurses to have good communication skills has been established in the literature [22-241. While lipservice has been paid to this skill, Engstrom [24, p. 2431 has outlined the difficulties involved in attempting to enhance the communicative role of the nurse. This may be due in part to a lack of clarity about why both nurses and doctors need good communicative skills in the hospital setting. Eastwood [22, p. 2491 noted that nursing students and instructors agreed good communication skills were important, but it was not clear to either group what the student nurses should be taught, and in what way communicative skills would make better nurses. Good communication skills were sometimes reported to make: “The patient relationship a real person experience.” Our study has pointed to a more concrete role for the communicative skills of nurses- as mediators of complex doctor-patient interactions. Given their perceived status position in the medical encounter, patients may often feel embarrassed to ask their doctor all the questions they have in mind or to request explanations. As middle status role partners with doctors, nurses are in an excellent position to mediate in favor of patients’ communication needs in the hospital setting. As regards the specific communicative needs addressed in this study, nurses can act as translators for patients attempting to understand the ML employed by doctors.

The above considerations suggest that both doctors and nurses could benefit from aids similar to the ‘patientspeak’ dictionaries of Scott and Weiner [4] designed to facilitate appropriate use of ML and EL in the hospital setting. Doctors can use these devices to determine words with which patients are likely to have difficulty. Patients may also use these devices to interpret the physicians’ message should it contain too much ML.

Problems in doctor-patient communication have been attributed to differences in education, status, culture and other features which distinguish health professionals from patients [I]. Communication problems between health professionals and experts from other fields have also been documented in the literature. For instance, Stein [25] listed communication problems between doctors and educators of sick children, while Sheppard [26] found inadequate and inaccurate communication between doctors and social service workers [21]. Barcia [27] noted that communication difficulties also arise when specialists and general practitioners interact. For instance, Bar-

346 RICHARD Y. E~OURHIS el al

cia [27] noted that general practitioners are often unfamiliar with the terms used by their specialist colleagues. Communication difficulties thus arise between highly skilled professionals when the specialized register of one professional group is unfamiliar to the other. Failure to converge to the other’s specialized register may reflect attempts by health professional role partners to retain their respective distinctiveness and the corresponding status and power differentials that exist between them in the hospital setting. With even less professional jargon to share in common, it is not surprising to find that patients often experience communicative difficulties with doctors’ use of medical language.

Health communication courses for doctors, nurses and patients should emphasize the need to be sensitive to the diversity of speech registers being employed in the medical setting. The results of the above survey suggest that seasoned doctors and nurses. as well as students, could benefit from courses designed to enhance their ability to communicate more effectively with patients. As well, increased understanding of the motivational factors behind choices of specific registers may ultimately be the best way of avoiding communication breakdowns between health professionals and their patients.

Acknowledgemenrs-We wish to thank the doctors, student nurses and patients who took part in this survey and without whom this research would not have been possible. We also wish to thank John Premi, Heather Craig, Cecilia Conover, Janice Johnson and Ellen Ryan for their valuable comments on earlier versions of this paper.

REFERENCES

Pendleton D. Doctor-patient communicatton: a review. In Doctor-Patient Communicarion (Edited by Pendleton D. and Hasler J.). pp. 5--57. Academic Press. London. 1983. Richards J. and McDonald P. Doctor-patient communication in surgery. J. R. Ser. Med. 78, 922. 1985. Jaspars J., King J. and Pendleton D. The consultation: a social psychological analysis. In Doctor-Parienr Com- munication (Edited by Pendleton D. and Hasler J.), pp. 139-l 57. Academic Press. London. 1983. Scott N. and Weiner M. F. “Patientspeak”: an exercise in communication. J. med. Educ. 59, 89&893. 1984. Samora J., Saunders L. and Larson R. F. Medical vocabulary knowledge among hospital patients. J. Hlth Human Behac. 2, 83-92. 1961. Swenson P. Communicating with surgeons is possible when you learn the language. AORN J. 40, 784, 1984. Handbook of Patients’ Rights. Patients’ Rights Associ- ation of Ontario, Ontario. 1984. Hudson R. A. SociohnguDfics. Cambridge Umversity Press, 1980.

9

10

II

I2

I3

14

IS

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

Giles H. and Powesland P. F. Speech and Social Era/u- ation. Academic Press. London. 1975. Bourhis R. Y. Language in ethnic mteraction: a social psychological approach. In Language and Ethnic Re- larions (Edited by Giles H. and St Jacques B.). Per- gamon Press. Oxford. 1979. Giles H.. Bourhis R. Y. and Taylor D. Towards a theory of language in ethnic group relations. In Lun- page Ethnici!!, and lnrerpersonal Relarions (Edited by Giles H.). Academic Press. London. 1977. Giles H.. Mulac A., Bradac J. and Johnson P. Speech accommodation theory: the first decade and beyond. In Communication Yearbook (Edited by McLaughlin M. L.), Vol. 10. Sage, Beverly Hills, Calif.. 1986. Berger C. R. and Calabrese R. J. Some explorations m initial interactions and beyond: toward a developmental theory of interpersonal communication. Hum. Commun. Res. 1, 999112, 1975. Bourhis R. Y. Cross cultural communication in Mon- treal: two field studies since Bill 101. Inr. J. Sot. Lang. 46, 3347. 1984. Bourhis R. Y.. Giles H., Leyens J. P. and Tajfel H. Psycholinguistic distinctiveness: language divergence m Belgium. In Language and Social Psycholog! (Edited by Giles H. and St Clair R.). Vol. 3. Blackwell. London. 1979. Sachdev I. and Bourhis R. Y. Status differentials and intergroup behaviour. Eur. J. Sot. Psych. 17, 277-293. 1987. Genesee F. and Bourhis R. Y. The soctal psychological significance of code switching in cross-cultural communication. J. Lung. Sot. Psych. I, l-27. 1982. Treichler R. A. Problems and problems: power re- lationships in a medical encounter. In Language and Powser (Edited by Kramarae C. e( al.). Sage. Beverly Hills. Calif., 1985. Berger C. Social power and interpersonal communication. In Handbook of Interpersonal Commumcatwn (Edited by Knapp M. L. and Miller G R.). Sage, Beverly Hills, Calif.. 1985. Broadbent D. E. FitzGerald P. and Broadbent M. Implicit and explicit knowledge in the control of complex systems.. Br. J. Psych. 77, 33-50, 1986. York G. The Hiah Price of Healrh. Lorimer. Toronto,

.I

1987. Eastwood C. M. Role of communication in nursing. J. Adv. Nurs. 10, 245-250, 1985. Eastwood C. M. Nurse-patient communication skills in Northern Ireland. Inf. J. Nurs. Smd. 22. 99- 104. 1985. Engstrom B. A study of changes in the information routines in a neurological ward. In(. J. Nurs. Sfud. 23, 79-85. 1986. Stein R. E. Promoting communication by health care providers and educators of chronically ill children. Top. Early Childhood Sp. Educ. 5, 70, 1986. Sheppard M. Communications between general practitioners and a social services dept. Br. J. Sot. work 15, 25. 1985. Barcia D. Communication between psvchiatrists and general practitioners. Actas Luso-Eip;nolas Neural. Psiquiar. Cienc. Afines 13. 259, 1985. Huddleston J. The language of doctor--patient communication. A study of commands and requests. Ausr. Fam. Phvs. 13, 543-544, 1984.

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Communication in the hospital setting: A survey of medical and everyday language use amongst patients, nurses and doctors