Words matter: Labelling, bias and stigma in nursing

I began learning ‘labels’ and stigmatizing phrases about patients when I was in nursing school. The first labels I learned were ‘drug seeker’ and ‘non-compliant’. These terms were introduced when discussing pharmacology in my first year of nursing school. The nurse educators who introduced the labels and biases thought that they were teaching accurate and essential information. They learned their language from someone, just as I did, and spoke from their own experience and positionalities. After graduation, I moved into emergency nursing, and by the time I had 3 years of experience, I had learned many labels and stigmatizing phrases. I took them as fact and embedded them into my practice. These labels, stigmatizing language and biased communication are not only seen in emergency nursing. Scientific racism, ableism and gender essentialism are prevalent in healthcare. It took me many years to understand that the labels used to describe patients, families and community members by healthcare professionals were harmful. Over time and with the aid of diverse colleagues and accountability partners, I learned that labels lead to stereotypes and biased care, which results in harm and can result in adverse health outcomes. Nurses' messages about patients frame their care; therefore, nurses must be intentional and mindful with their communication to ensure that they are not biasing other care team members. The Joint Commission (2016) published a safety and quality advisory discussing the impact of cognitive biases in healthcare. There are numerous forms of cognitive bias that can impact patient care. Anchoring bias and confirmation bias are the two forms of bias that are common in nursing. Anchoring bias occurs when initial information or communication shapes the treatment of patients regardless of conflicting information. In this type of bias, the healthcare professional is anchored to the initial information (often from patient handoff), and delays in care or misdiagnosis can occur from not adjusting to new information (The Joint Commission, 2016). Confirmation bias occurs when people selectively seek or accept information that confirms their opinion despite information available to the contrary. Stereotypes and discriminatory beliefs about people based on their age, racialized identity, ethnicity, disability, gender, sexuality and socioeconomic status can play a role in confirmation bias. Understanding these biases is very important while thinking about how labelling patients can result in adverse outcomes. When I think about anchoring and confirmation bias, an example that comes to mind involves a young Latine trauma patient. I started my shift in the ED and was assigned to the trauma rooms. The off-going nurse was busy, and I had not received a handoff report yet, so I started my trauma assessment. On my initial assessment, I determined that the patient had significant pelvic pain and tachycardia. When I checked the patient's chart, I found no diagnostic studies had been completed except for a pending urine and drug screen. I approached the physician and shared my concerns about the patient's assessment findings. I suggested that they order additional diagnostic studies. The off-going nurse and physician responded that the patient was fine and could go home after collecting a urine specimen. According to the staff, during patient handoff the paramedics reported that the patient was ambulatory on scene and was faking because they were a ‘drug addict’. After some discussion, the physician agreed to do a computerized tomography scan, and the results showed that the patient had a severe pelvic fracture and was haemorrhaging. Both the nurse and the physician experienced anchoring and confirmation bias. Labelling this patient at the onset of care influenced future care decisions and could have resulted in their death. Unconscious or implicit bias is described by Marcelin et al. (2019) as ‘associations or attitudes that unknowingly alter one's perceptions’ and affect their behaviours and decision-making (p. 563). Implicit bias is often unrecognized, whereas explicit bias comes from personal beliefs and prejudiced or discriminatory attitudes. Implicit bias is often seen as less dangerous and more morally acceptable because it is unintentional, but both types of bias are harmful and have no place in healthcare. The use of stigmatizing language and labelling of patients perpetuates harmful stereotypes and bias. For example, Goddu et al. (2018) conducted a randomized vignette study using two chart notes for a 28-year-old patient admitted with sickle cell disease. One chart included stigmatizing language, whereas the other included neutral language. Medical students and residents (n = 413) were randomized to read one of the charts and then complete a survey assessing their attitudes about the patient and treatment decisions (residents only). This study indicated that all participants who read the chart with the stigmatizing language had more negative attitudes about the patient. In addition, residents who read the stigmatizing language were less aggressive with pain management (Marcelin et al., 2019). Over the past 30 years, I have seen and heard a significant amount of dangerous communication about patients and their families. I am embarrassed to say that, at times, I used stigmatizing and harmful language. For example, early in my career, I used labels like ‘addict’, ‘frequent flyer’, ‘drug seeker’, ‘homeless’, ‘clean or dirty’ and ‘non-compliant’. At the time, I did not understand how this language resulted in biased care and harmed my patients. Unfortunately, using this language is so common in healthcare that it seemed usual and customary. I now realize that the language I used perpetuated stereotypes, influenced care decisions and probably prevented people from seeking care (Raney et al., 2021). Using these questions can help nurses shift from biased to neutral language and ultimately lead to a more welcoming healthcare system that delivers equitable, compassionate and unbiased care. Table 1 includes some examples of biased and neutral language. The list of examples and potential harm is not comprehensive and serves only as a brief example. Misdiagnosis, delays in care, missed opportunities to provide treatment for substance use disorder (if diagnosed) and hesitancy to seek care. Objective and individual descriptions of the patient's concerns. Use the patient's subjective reports of pain. Objective assessments of pain by healthcare professionals are frequently inaccurate. Use neutral description that describes the patient's history, present concerns and assessment findings. Note: Examine if anchoring or confirmation bias may be a factor in the patients unresolved healthcare needs. Describe the cause of the failed treatment plan. Examine how social determinants of health, patient education and communication with the care team may have influenced patient decisions. Use person-centred care to develop a plan of care with the patient that accounts for access, resources and is culturally informed. Misdiagnosis, delays in care, missed opportunities to provide treatment for SUD (if diagnosed) and hesitancy to seek care and failed opportunities for harm reduction. Patient reports using XYZ or being in sustained recovery for XYZ length of time. Implies that the patient cannot participate in their own care. Does not communicate any relevant diagnosis or findings to guide treatment. Inequitable care, delays in care, failure to engage the patient in healthcare decisions. Ask the person their gender and pronouns. Document what you are told and use the person's pronouns, name and gender in communication. Include sex assigned at birth only if it is relevant to care. Shames and blames the patient. Can result in delays in care, inadequate assessment and adverse outcomes. Does not address the factors that cause people to be unhoused or the health outcomes associated with being in an unhoused state. The newly released Future of Nursing report discusses nurses' critical role in charting a path toward health equity (National Academies of Science, Engineering, and Medicine, 2021). Reckoning with implicit and explicit biases in nursing and healthcare is a crucial step towards achieving health equity and eliminating racism, ableism, transmisia and other forms of discrimination and oppression in healthcare. Nurses can begin this process by understanding that the words they use matter and then committing to using neutral, non-stigmatizing, respectful and compassionate language. Thank you to colleagues and accountability partners from Nursing Mutual Aid, Dr. Justin Fontenot, and Patrick McMurray for reviewing and offering feedback on this editorial. I am grateful for your shared wisdom and expert guidance. I do not have any conflicts of interest to report.