Misconceptions and the misappropriation of nursing: an ironic response

The NURSE mnemonic ( Back et al., 2009) was developed by doctors to guide doctors’ communication when dealing with patients and/or families struggling with severe or life-limiting illnesses. NURSE represents:

N – Name it:

    … it sounds like you’ve been worried about what’s going on … 

U – Understand the core message:

    … if I understand you correctly, you are worried about what to say to your family and how they will react … 

R – Respect /Reassurance at the right time:

    … I’m really impressed that you’ve continued to be independent … 

S – Support:

    … would you like me to talk to your family about this … 

E – Explore:

    … I notice that you’re upset, can you tell me what you’re thinking?

At first glance, this appears to be a useful tool as it provides students and novice clinicians, unsure of how to assist patients to cope with the psychological and emotional impacts of life-threatening illness, with some guidance. Why then, does this mnemonic elicit the sense that the nursing profession is being expropriated in such a facile way, to remind doctors how to express normal human emotion?

In part, this is because the very idea of using NURSE as a mnemonic is a continuation of the inter-professional challenges nursing has encountered for centuries. Many nurses continue to struggle with the challenges of working in a female-dominated profession, which historically has been and continues to be, seen as subservient to medicine and medical (and male) dominance. Nursing also continues to struggle with the notion that cure is the doctor’s work, and care is the nurse’s work. Rather than being abstract ideas, the power imbalance is a persistent and significant problem that leads to nurses being overworked, undervalued, and underpaid in comparison with their medical colleagues who enjoy superior social and economic status. Gender and power issues in nursing are inexorable and inescapable as evidenced by some professional societies continuing to ascribe nurses a lower membership status and denying them voting rights (Haematology Society of Australia and New Zealand HSANZ, 2022).

What makes all of this so unbearable is the knowledge that this type of discourse perpetuates the misrepresentative trope that nurses are doctor’s handmaidens. Contemporary nurses are highly skilled and educated healthcare professionals, working in autonomous, time-critical life-saving roles (National Nurses United, 2015). Nurses are educators, advocates, technicians, navigators of complex healthcare systems, policy-makers, and leaders. Nurses do not simply act as an intermediary between doctors and patients. Nurses apply scientific principles, advance healthcare knowledge through leading research, manage complex healthcare institutions, engage in public and professional discourse, and mobilise healthcare teams, administration, government, and the public when needed, to improve the health and well-being of individuals and the community. Nurses achieve healthcare outcomes equivalent to those of their medical colleagues, with some studies suggesting nurses are better at managing patient’s symptoms, physical function and satisfaction with care, in ways that are more efficient and cost-effective than their medical counterparts (Htay & Whitehead, 2021). Nurses communicate with patients and their families with authentic compassion and empathy, despite often struggling to find the time to do so, without having to rote learn a mnemonic for guidance.

So while the NURSE mnemonic appears innocent, well-meaning and common place in medical vernacular (FAST HUGS BIDS (Nair et al., 2017), the Alphabet (A-I) (Zanker & Ng, 2017), DiapHRaGM (Tulaimat & Trick, 2017), Some Lovers Try Positions That They Can’t Handle (Mnemonic Devices Memory Tools, 2018)), using NURSE to assist doctors be empathic diminishes nursing and proffers a reductionist paternalistic view of the nursing profession. A mnemonic like NURSE may assist doctors, but it does nothing to recognise or advance nursing, encourage interdisciplinary work, or garner professional respect. While some may claim ‘it’s only words’ to explain away unintentional hurt, words carry meaning, and the words people use say something about the things they value and the things they attach status or importance to. Words are also not a-historical or a-cultural but arise at a particular time, in a particular context, for a particular reason. Language, therefore, frames what people think about others and about themselves. It is the means through which social stereotypes are created, shared and maintained (Beukeboom & Burgers, 2019). This means that the words people use must always be open to critique and that we should be ready to recognise that words may (both intentionally and unintentionally) create advantage or disadvantage, empower or disempower, or confer status or stigma. Consequently, we need to also accept that words used in one time or place may need to be changed as social views and norms change, and scholarship improves our understanding of concepts being described (Broyles et al., 2014).

So how does one remedy this trivialisation of an entire profession? A recent study titled ‘Care for Joy: Evaluation of a humour intervention and its effects on stress flow experience, work enjoyment, and meaningfulness of work’ (Bartzik et al., 2021) explored ways in which humour may be used to address the ‘care crisis’ and reduce the alarming number of nurses walking away from the profession due to the enormous physical and psychological impacts of their work (particularly in the aftermath of the pandemic). Intriguingly, although consistent with the literature on ‘black humour’, a humour intervention was found to increase nurse work enjoyment, flow and meaning.

Inspired by this study, I offer you my satirist ‘humour intervention’ in the form of an ironic counter-mnemonic to NURSE. The DOCTOR, while hopefully more humorous than the NURSE mnemonic, provides a point of reflection when dealing with inter-professional interactions in the workplace for nurses and inexperienced colleagues.

DOCTOR:

D: Direct.

   Simple, is always right.

O: Obnoxious.

   Remember, no-one else’s opinions matter. Speak more and speak loudly.

C: Confident.

   Never ever display weakness of any sort. Vulnerability is for the vulnerable. Be strong. People will love you for it.

T: Teamwork.

   Avoid this at all costs. This is a liberal, lefty mechanism for sharing power and should never be taken seriously. There is only one boss and that is you.

O: Over-bearing.

   This is simply not true. If other health professionals even imply this, ignore them.

R: Run.

   Don’t create space for discourse or even for other opinions. The more you stick around the more likely it is that people may try to disagree with you. Just say your piece, set things right, and leave. Someone else will clean up the mess.

Acknowledgement

Thank you to Prof. Ian Kerridge, Professor of Bioethics and Medicine (USYD) and Haematologist and Stem Cell Transplant Physician (RNSH), who helped craft the DOCTOR mnemonic.