By Katherine Evans (@kabrahamevans)
The language we use in our daily interactions has clear implications for how clinicians’ roles are seen and defined.1 It is more important than ever to understand how language choices have the potential to impact bias, create oppression, promote ineffectual hierarchies, and is detrimental to social justice movements, thereby thwarting inter-professional collaboration.
Over the past two decades we have seen an increasing focus on the roles of interprofessional teams and creation of more functional roles. There is clear evidence and importance of highly effective interprofessional teams in all areas of healthcare. Even amongst those who value the collaborative models as well as all members practicing “to the top of their education and licensure,” we continue to utilize ineffectual language to describe team members.
An example of a term commonly used in the United States to describe nurse practitioners and physician assistants is “midlevel” or “extender.” Many individuals find these words demeaning for a variety of reasons. Let’s consider the use of this word and the impact, on those it describes, in the Interprofessional Collaborative Practice Competencies (IPEC) framework.
Values/Ethics for Interprofessional Practice
Shared values and mutual respect are crucial to a high functioning team. When two professions are lumped together in a single term it diminishes the value for those team members as well as others. Using proper descriptors shows respect for the unique culture of each profession while elevating the team through a supportive environment.2
While professional respect is inherent in high functioning interprofessional teams, these team members bring an expertise that exists inside and outside of the team. Interprofessional teams should not be required for any professional to gain respect for their contributions.3 By not defining the team members in the most appropriate terms we create an environment lacking trust and collaboration.
Role ambiguity puts nurses at much higher risk of burnout versus their physician colleagues.4 In order to preserve our workforce, we must provide clear roles and allow professionals to address the needs of the patient and population through the lens of each specific role.5 Each role brings unique abilities to optimize team care and should be adequately addressed with appropriate language. While all roles have limitations, they also provide unique value. Using the word “midlevel” combines two unique professions without regard to the differentiations of education, training and models of care. While many of our functions overlap, nurse practitioners, like other health professions, bring their own philosophy rooted in the nursing profession.
How can we create more clear roles and eliminate this confusion?
This begins with a solid foundation in interprofessional education. When team members learn together, they have early clarity of team roles and responsibilities. Each profession begins with an understanding of where individual roles create value. However, we cannot simply expect education to solve this issue. While new teaching models can create change, those currently practicing must also adapt to accurate descriptors and engagement in new models.3
Fostering an environment of strong, effective communication, rooted in respect and an open dialogue, is core to team success. Labeling team members “midlevels” or “extenders” implies a hierarchical structure where information flows from top to bottom. This creates an inherent structural bias leading to ineffective communication. The word “midlevel” is a demarcation strategy to demonstrate the boundaries of one profession over another. While this may not be deliberate, it leaves one professional in a subordinate position.1
How do we remove this structural bias and create effective teams?
Using effective language can eliminate a perceived power imbalance and provides teams with a more harmonious backdrop. Clear and accurate nomenclature is recommended by the American Academy of Nurse Practitioners, the Institute of Medicine and other nursing organizations who endorse the term nurse practitioner as the appropriate role descriptor.6 By eliminating the hierarchical structure, communication can flow more freely and team members are assured of the value of their contribution. This also creates clarity for the patients served by the team. Unclear terminology creates confusion for consumers of the healthcare system who become unsure of the team members background and role.7
Teams and Teamwork
For many, I do not believe using the word “midlevel” is intentional to diminish one person over another, but words do matter. This word creates a boundary that forces the clinician to feel the need to defend the uniqueness of their profession on the team.3 It is a simplification, meaning it is easier to say “midlevel” than nurse practitioner and physician assistant, or many of the newly coined terms such as “advanced practice clinician or advanced practice professional.”
By saying the nurse practitioner is a mid-level, we are not only creating a hierarchy within care providers, but we are implying a group is both higher and lower than the “mid”. If we use this framework, one can only assume that registered nurses and other members of the care team are low level within the hierarchy and physicians occupy the top of the hierarchy. It also begs the question of “where do patients fit in this hierarchy?”
The goal is to create a culture where all members of the care team, including the patient, are included in a team where their expertise, knowledge and input is considered equal and of equal value when developing a plan of care. Language that perpetuates this segregation by power gradients does not cultivate a culture of teamwork.
As we consider the crosswalk of Interprofessional Education (IPE) and Interprofessional Collaborative Practice (IPCP) accurate and inclusive language is critical to success in both arenas. By coming together through IPE and engraining the use of effective language in teams early, we create an environment where IPCP has the greatest potential for success. As professionals, we must always recognize the power of our words and how simple changes can have important impacts on outcomes.
- Cahn, Seven Dirty Words: Hot-Button Language That Undermines Interprofessional Education and Practice, Academic Medicine, vol. 928, pp. 1086-1090, 2017.
- E. W. C. Paradise, Louder Than Words: Power and Conflict in Interprofessional Education Articles, Medical Education, vol. 49, pp. 399-407, 2015.
- L. E.-L. E. M. M. R. S. Baker, Relationships of Power: Implications for Interprofessional Education, Journal of Interprofessional Care, vol. 25, pp. 98-104, 2011.
- T. K. R. Tunc, Role conflict, role ambiguity, and burnout in nurses and physicians at a university hospital in Turkey., Nurs Health Sci, vol. 11, no. 4, pp. 410-416, 2011.
- T. N. J. Shanafelt, Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout, Mayo Clinic Pro., vol. 92, no. 1, pp. 129-146, 2017.
- A. A. o. N. Practitioners, Use of Terms Such as Mid-level Provider and Physician Extender, 2015. [Online]. Available: https://www.aanp.org/advocacy/advocacy-resource/position-statements/use-of-terms-such-as-mid-level-provider-and-physician-extender.
- S. &. P. J. Hoyt, Why the Terms “Mid-Level Provider” and “Physician Extender” Are Inappropriate, Advanced Emergency Nursing Journal, vol. 34, no. 2, pp. 93-94, 2012
About the Author: Katherine Evans DNP, FNP-C, GNP-BC, ACHPN, FAANP, is a nurse practitioner board certified in geriatrics and hospice and palliative care. She received her master of science in nursing from Emory University and her doctor of nursing practice from Vanderbilt University. Dr. Evans is a past national president of the Gerontological Advanced Practice Nurses Association (GAPNA) and is Chief Nursing Officer for UnitedHealthcare Retiree Solutions. Prior to her role at UnitedHealthcare she was Director of the Doctor of Nursing Practice program at Georgia State University. She also serves on the board of directors for the Georgia POLST Collaborative and is a Fellow of the American Association of Nurse Practitioners.
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