Another BMJ Blogpost on Mid-Level Language

Just had this posted on the BMJ blog. 

I hope you share it.  Here it is:

Suzanne Gordon: What we call healthcare professionals matters

The other day I attended a patient safety workshop at a major US hospital. The physicians and nurses, IT, and other quality and safety staff in the room were deeply concerned about the latest report in The BMJ documenting that 250,000 patients a year die from preventable errors, making this the third leading cause of death in the US. Almost all the attendees agreed that learning concrete teamwork skills and flattening hierarchies is critical to patient safety as well as job satisfaction, employee engagement, and staff retention. And yet, as the attendees shared their concerns and experiences, almost all of them used terms that are inherently anti-team and reinforce the steepest healthcare hierarchies.

When, for example, the physician participants talked about nurse practitioners (NPs), physician assistants (Pas), and certified registered nurse anesthetists (CRNAs) as a group, they referred to them as “mid-level providers” or “mid-levels.” When talking about this group of clinicians as well as pharmacists, social workers, or physical therapists (PTs), the conglomerate became “allied health professionals” or “allied health.” When some doctors talked about nurses, or “mid-levels,” the latter were also described as “physician-extenders, “ or sometimes “the doctors’ eyes and ears.”

This was hardly an isolated example. This language is rife in North American health care. Nurses, who hate these terms in private, use them in public and academic discourse and cheerfully deploy their own status reinforcing terminology. Nurses who have a masters (or now sometimes doctorate) degree and who are licensed as nurse practitioners or CRNAs who do what physicians have traditionally done—are referred to and licensed as “advanced practice” nurses (APRNs). Nurses and other “allieds,” PTs for example, also use the term “extender” (nurse-extender, PT extender) to describe those who work with them to care for patients.

Why are these terms problematic? Because they don’t tell us who people are as professionals or what they do, they tell us where people are located on the healthcare ladder, what their status is in regard to someone on a higher rung and how much better they are than someone lower down in the pecking order.

Consider the term “advanced practice nurse.” To use the term “advanced practice” to define a group of nurses who have learned and are—now licensed—to perform activities over which physicians have held a traditional monopoly, i.e. diagnose, treat, and prescribe, suggests advancement lies in mastering medical rather than nursing activities. Additionally this term implies that registered nurses who do not have an APRN but who may have worked for decades do not—and cannot—have an advanced practice but are instead, as the antonym of advanced makes clear—behind, or backward (and thus inferior) in their practice.

Or what about the term mid-level? Again, the term does nothing to describe what an NP, PA, or CRNA does. This term is a powerful message to the bedside nurse. If an advanced practice nurse is not really at an advanced—but actually at a mid-level then the registered nurse is a “low-level” professional. (As for the nursing assistant, or licensed practical or vocational nurse—she, or he, isn’t even on the ladder at all.)

Not only does this language send a message to those who work in healthcare, it also sends a message to patients. As a patient, your health, even your life, may well depend on the knowledge and skill of a nurse, nursing assistant, or NP, PA or CRNA (as well as many others who work in healthcare.) Yet, we, as patients, are constantly being told that these professionals are either mid to low—inferior to the physician. But not to worry, all of these healthcare workers are “allied to medicine” and some are even the “doctor’s eyes and ears”—attached not to their own, but to the physician’s brain (or if they are extenders, to the RNs, PTs.) How very reassuring!

This language has an impact on patient care and safety in another important way. Patient safety depends on an environment in which all staff feel psychologically safe to speak up, raise an issue, prevent a mistake, share an insight or idea, and, most importantly, challenge a superior, without fear of being humiliated, dismissed, or reprimanded. As Jones and Kelly’s 2014 article on Deafening Silence so eloquently argued—people do not speak up when organizational “leaders” do not listen to and heed their concerns, and when those they work with do not support them when they express concerns. In an environment in which people are viewed as highs, mids, and lows, will the lows or mids feel safe to speak up to the highs? Will the highs listen to, much less invite, input from the mids and lows? Will the mids support the lows, and the lows support each other? I doubt it.

These Adams rib definitions of different healthcare professionals or healthcare workers persists no matter how staunchly and vociferously academics, administrators, and clinical staff profess their committment to interprofessional education and practice, as well as to patient safety and teamwork. If the latter are to become a reality rather than an aspiration, we will need to invent or utilize new terms to replace the old. If you want to talk about non-physician professionals, how about referring to NPs, PAs, and CRNAs? If you want to talk about a nurse or a nursing assistant don’t attach the term extender to the higher ranking professional. (And please, ditch the eyes and ears, since they are pretty useless without a brain). As for advanced practice nurses, I’ve thought long and hard about a replacement term and have failed to come up with one. Somebody should sponsor a contest.

Suzanne Gordon is a healthcare journalist and co-editor of The Culture and Politics of Healthcare Work Series at Cornell University Press. Her latest book is Collaborative Caring: Stories and Reflections on Teamwork in Healthcare, which she co-edited and she is co-author of Beyond the Checklist: What Else Healthcare Can Learn from Aviation Teamwork and Safety. Most importantly she is a patient.