Sticks and Stones & Stigmatizing Language

by Rose L. Horton, MSM, RNC-OB, NEA-BC, FAAN

Originally published by Synova Associates

Remember the adage “sticks and stones may break my bones, but words will never hurt me?” I was in tears when a teacher shared those words with me. As an immigrant girl, newly learning the English language, I tried my best to wrap my head around these words. My teacher looked at me with eyes full of compassion and I remember thinking, if she believes this to be true, it must be the case. I don’t remember the words that reduced me to tears so many years ago, but I do remember the pain. What we know to be true is that words are incredibly harmful and traumatic.

Language is commonly defined as the principal method of human communication made up of words and conveyed by writing, speech or nonverbal expression. In the context of clinical care, language has power and meaning and reflects priorities, beliefs, values and culture. Stigmatizing language is defined as language that communicates unintended meanings that can perpetuate socially constructed power dynamics and results in bias. Stigmatizing language may also be intentional and represent reflexive use of the normative language. It is important to note that when bias is present, the number and quality of clinician interactions may decrease. (Barcelona, 2023)

Some examples of stigmatizing language in healthcare are geriatric pregnancy, incompetent cervix, non-compliant, drug seeking, addict, and FLK or funny looking kid, and failure speak; failure to progress, failure to descend, failed induction, failed VBAC to name a few. These are words and phrases that are commonplace and often used in speaking with patients.

Microaggression is defined as “brief commonplace daily verbal, behavioral, or environmental indignities whether intentional or unintentional, that communicate hostile, derogatory, or negative…slights and insults.” (Torino, 2017) Some examples of microaggressions are ‘what do your people think’, ‘where are you from, no, where are you really from’, ‘you’re pretty for a fat girl’, ‘you speak English very well’, ‘you’re so articulate’, ‘I don’t see color.’ Discrimination contributes to poor health directly and indirectly. The presence of high levels of stress hormones in the bloodstream for long periods of time can lead to wear and tear on the body.  Not only does microaggression harm mental and physical health, they can also undermine trust in the providers and clinicians and serve as a barrier to care.

Marginalized people are at the highest risk of experiencing stigmatizing language and microaggression. The wheel below is a visual representation of the people referred to as marginalized. These are the people we must be intentional in protecting, and not at the exclusion others.

Make it stand out

Fig. 1. Power wheel from the Canadian Council for Refugees, depicting power, privilege, and marginalized identities of birthing people who experience stigmatizing language documented by clinicians. Modified from Canadian Council for Refugees. Accessed September 4, 2023. https://ccrweb.ca/en/anti-oppression. Used with permission. Barcelona. Power of Language in Hospital Care. 2023

In her pivotal work, Giving Voice to Mothers, Dr. Vedam states “global health experts agree that how people are treated during childbirth can affect the health and wellbeing of the mother, child, and family…” The study revealed that 1 in 6 reported mistreatments. Among all participants, being shouted at or scolded by a healthcare provider was the most commonly reported type of mistreatment (8.5%), followed by “healthcare providers ignoring women, refusing their request for help, or failing to respond to requests for help in a reasonable amount of time” (7.8%).

How do we change the narrative around stigmatizing language and mistreatment in the healthcare system and as it relates to the care of the birthing community? Here are 5 commitments the clinical team can adopt: also known as the 5 tenets of #notonmywatch:

1. Treat Everyone with Dignity and Respect. The American Nurses Association Code of Ethics clearly: “the nurse practices with compassion and respect for the inherent dignity, worth and unique attributes of every person.” Clinicians may start by asking each birthing person their preferred name and pronouns, eliciting and listening to their fears, and respecting inherent autonomy and expertise that people have over their own bodies.

2. Listen to and Believe Women. As nurses, providers and clinicians, we may think since we have cared for hundreds of people, we can attribute our experiences across all cases and make correct assumptions about people. When a woman says to us, with panic in her voice, ‘the baby is coming!’ Our one job is to believe her, not to disqualify her concerns by saying something like: ‘I just checked your cervix’ or ‘this is your first baby’. When a parent in the NICU says, ‘something is wrong with my baby’. Our job is not to counter with ‘I just assessed your baby’ or ‘your baby is fine’. We must listen to and believe our patients and families.

3. Evidence Based Care. As nurses we are scientists, researchers, experts who lean into and learn from data and research. We standardize our care, based on reliable and valid data, because we know that variation in care leads to errors. We know that standardizing care decreases the likelihood of allowing bias to interfere with how care is rendered; thereby leading to equitable outcomes for all women and neonates.

4. Shared Decision Making. This tenet speaks to our commitment to honor the birthing person’s autonomy by centering their voice and choice. We understand that our role is to inform and educate our patients and then encourage them to make a decision. Once our patient makes a choice, our job is to support them and their choice. Because we are centering the patient and what’s important to them, the likelihood of us using coercion to get a desired outcome is minimized. The choice is not ours to make. Our role is to support.

5. Advocacy. This is us showing up for the patient and amplifying their voice and choice to the healthcare team, as needed. This is us respectfully speaking up for the patient if in a huddle or during a procedure, we forget that we are privileged to care for a birthing person, an infant, at term or born prematurely. The opportunity exists, especially in emergent situations that we forget about the patient, and this cannot be the case.

It is within our locus of control as nurses to take the lead in mitigating stigmatizing language. We spend the most time with patients in the hospital and for over 21 years we have been voted as the most trusted profession. The words we use create our reality. What reality are you willing to create on behalf of the women, birthing people and infant?

References

Vedam, S., Stoll, K., Taiwo, T. K., Rubashkin, N., Cheyney, M., Strauss, N., . . . & the GVtM-US Steering Council. (2019). “The Giving Voice to Mothers study: Inequity and mistreatment during pregnancy and childbirth in the United States”. Reproductive Health, June 11, 1-18. DOI: 10.1186/s12978-019-0729-2

Barcelona, Veronica PhD, RN; Horton, Rose L. MSM, RN; Rivlin, Katherine MD, MSc; Harkins, Sarah BSN, RN; Green, Coretta MSN, APRN; Robinson, Kenya MSN, RN; Aubey, Janice J. MD, MPH; Holman, Anita MD; Goffman, Dena MD; Haley, Shaconna MA, CHD; Topaz, Maxim PhD, RN. The Power of Language in Hospital Care for Pregnant and Birthing People: A Vision for Change. Obstetrics & Gynecology 142(4):p 795-803, October 2023. | DOI: 10.1097/AOG.0000000000005333