Nursing and healthcare

Do nurses change the way they speak in different situations? What strategies do they use when talking to patients? To doctors? To other nurses?

From 2000 to 2002 the Language in the Workplace team investigated nurse/patient interactions at a New Zealand hospital. The primary objective was to pilot a methodology suitable for collecting data on spoken interactions between a nurse and their interlocutors during different shifts in a given week. Another objective was to investigate the suitability of the methodology as one that could be used in a wide range of professional contexts (for example private homes and medical centres).

Two contrasting features of interaction feature here as foci for analysis, directives, and humour.


Softening a directive: linguistic strategies

Nurses are in constant demand in the ward. They need to keep their patients happy, even when coaxing them through painful procedures, in the middle of a busy and stressful workplace. Nurses' talk is characterised by a lot of directives, or ways of giving instructions to patients. We found that nurses make their directives seem less bossy by adding softeners such as "if" or "just" to them, e.g. "so if you take those I'll be back in a minute", and tag questions e.g. "just hold on to those for a moment OK?".

Nurses used a wide range of different kinds of linguistic strategies to soften their directives, including grammatical devices and lexical items. In the examples below, the softening devices are in italics. The unsoftened version of the directive is provided in brackets for comparison.

(i)"if " clauses
"If" clauses are traditionally considered to be conditional clauses "if X then Y".
In the hospital data if often functioned as a softener like now or just rather than as a conditional conjunction.
(1) so if you take those I'll be back in a minute (vs take those)

(ii) Pronoun choice
The pronoun usually associated with directives is you, as illustrated in (1). Another device used to soften a directive was to use a different pronoun such as we or us or their. The effect is to soften the directive.
(2) we'll need to get you up to get to the loo soon (vs you need to get up…)
there's nothing to eat or drink after midnight (vs you mustn't eat or drink..)

Most nurses will be unaware of their linguistic choices, yet the effect they have is very significant in terms of making patients feel comfortable and cared for. The very wide range of softening devices used in our small sample of interaction indicates considerable linguistic sophistication, as well as the nurses' sensitivity to the contextual factors relevant in their exchanges with patients.


The second area we have selected in order to illustrate the sociolinguistic skills developed by nurses is the way they use humour in their interactions. Humour serves many functions. It is yet another strategy which can be used to soften a directive, but humour also maintains and develops good relationships between people and enables them to express feelings or views they might not get away with otherwise. Friendly humour: to help patients feel more relaxed.

One important function of humour in the interactions between nurses and patients was to reduce the stress of a potentially uncomfortable situation, and to help their patients to feel more relaxed. There are many examples of this in our data; here we discuss just one.

In excerpt 1 Sophie, a patient, expresses some anxiety about the anticipated removal of a cannula (a small device giving access to a vein). Earlier in the day, Tara, the nurse, had removed a large drain from a wound which had been a painful and distressing experience for Sophie.

Excerpt 1

Context: The nurse comes into the patient's room to take out a cannula

Tara: and I'll take out your cannula + sorry
Sophie: this is just a little thing eh not like the other

Tara responds to Sophie's worry by reassuring her and then introduces the topic of Sophie's leaving hospital soon. Sophie tells Tara that she will stay with her parents initially, since her flat is being decorated. Excerpt 2 illustrates the way in which Tara skilfully distracts Sophie from the unpleasant medical procedure she is undergoing.

Excerpt 2

Context: The nurse is in the patient's room taking out a cannula. [The words between slashes/\ indicate overlapping talk].

Sophie: so I’m staying with mum and dad
Tara: wicked yeah
Sophie: yeah
Tara: a few home comforts don’t /hu- don’t hurt\
Sophie: /oh mum would\ insist on it even if I don’t want to /she’d insist yeah [laughs]\
Tara: /yeah [laughs]\ mothers have that right /don’t they\
Sophie: /they do\
Tara: yeah /okay\
Sophie: /well I don’t mind\ cos I get treated like a queen /so [laughs]\
Tara: /exactly \ lap it up

During all this talk, Tara is taking out the cannula. Her colloquial friendly chat, full of humour, helps distract Sophie from the discomfort involved. The overlapping talk indicates the informality and good rapport between the two young women. The talk focusses on Sophie, and on the comfort and care she can look forward to from her mother when she leaves the hospital. The two women establish a collusive bond, expressing a shared wry, yet appreciative, attitude to the way mothers fuss over their daughters. Establishing friendly rapport like this obviously helps the patient feel more relaxed in this clinical setting, and this clearly assists the nurse achieve her goals as well.

Subversive humour: to soften a criticism

Humour is often used to soften negative messages (Holmes 1999). In many workplaces where we have observed, humour was used to soften criticism, for instance. It is particularly useful when an individual wants to express a critical comment to someone whom they don't wish to offend, such as a close colleague or someone in a position of power, for instance. We found a number of examples of humour used this way by the nurses in our sample.

One example occurred in a context where two staff nurses had been waiting for some time for the doctor to arrive. They were getting very irritated by the fact that he was so late coming up to the ward, as excerpt 3 illustrates.

Excerpt 3

Context: Two staff nurses, Tracey and Rebecca, are talking in the nurses' station while they wait for the doctor to arrive.

Rebecca: I wonder where André is
Tracey: well he said an hour and I think he's been longer than an /hour so I'm I'm not\ happy with that
Rebecca: /no I know\ I know
Tracey: gonna have to have a word with him about that…
not good time management
Rebecca: not good /time management\  that's right
Rebecca then pages the André and he returns her call
Telephone rings.  Rebecca answers
Rebecca: hello ward fourteen staff nurse speaking
André are you coming up to war-  [pause]
thank you very much /thank you bye bye\
Tracey: how long will he be
Rebecca: five minutes
Tracey: oh
Rebecca: [laughs] I know it's getting a bit desperate isn't it

Clearly both nurses are getting frustrated waiting for André to turn up. However, when he does arrive rather than "having a word with him" about his time management, as they threatened, they in fact turn their irritation into teasing André, as illustrated in excerpt 4.

Subversive humour provides a "socially acceptable cover" for criticisms of individuals, as well as for challenges of other sorts. Humour here allows the nurses to criticise the doctor in a non-threatening and acceptable way, which in turn relieves the tension which has been building up because of his lateness.

Nurses use humour regularly and constructively in their work. There are many examples in the data, with humour serving many different functions. In this section we have briefly illustrated just two contrasting functions: firstly the use of humour to relax a patient and assist the nurse in achieving her work objectives more efficiently; secondly the use of humour to relieve tension and thus maintain good workplace relationships between colleagues.

EAL education

Nurses are required to interact with a wide range of people in a variety of roles, so the job demands a remarkable flexibility in communicative skills. This is particularly challenging for nurses for whom English is an additional language (EAL). To address this issue, members of the LWP team asked nurses to record all their interactions in the course of a typical day and used the data to develop practical resources to enhance EAL nurses' social skills in a New Zealand nursing setting.

Since the data showed that 60% of the nurses' talk constituted friendly, social talk about non-medical issues, the materials developed for the EAL nursing programme encouraged students to identify the form and function of nurse-patient social interactions. The talk of New Zealand nurses is characterised by small talk, humour, and personal anecdotes, and in discussing the material the EAL students expressed shock at the personalisation of the nurses' responses to their patients.

e.g. Tara the nurse talking about her up-coming trip overseas with her patient Mia

Tara: okay just relax your arm um yeah, its people keep saying oh it's expensive and you know it's grim but at the moment I don't know anywhere else so
Mia: no
Tara: okay just a wee jab

The exposure to genuine interactions helped prepare the EAL students for employment in New Zealand hospitals, and showed the importance of developing rapport rather than maintaining formal relationships. It is expected that the findings of this study will be relevant to many other English language-teaching contexts where effective communication is a crucial part of work performance.


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