Careful language is good policy

We have looked at language and its importance before, but what about policy implications? Is it possible to mandate the way we speak to each other? Recognizing the power of language, Centers for Medicare & Medicaid Services (CMS) in F-tag 241 483.15(a) Dignity, does specifically mention certain aspects of language and their impact. It reminds us that how we show respect, or a lack thereof, through the way we address residents is important enough to be formally guided by regulation. CMS’ intentions are good; the F-tag description is “the facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.” Few would disagree that being treated with dignity is important in giving good care. And how we speak to those we care for is firmly tied to conveying respect and preserving elders’ dignity.

In the interpretive guidelines, CMS specifically states “respecting resident’s social status, speaking respectfully, listening carefully, treating residents with respect (e.g., addressing the resident with a name of the resident’s choice, not excluding residents from conversations or discussing residents in community setting); and focusing on residents as individuals when they talk to them and addressing residents as individuals when providing care and services.”

As CMS recognizes with these guidelines, one of the major issues that may come into conflict is which social protocols to follow (such as status in terms of address, the subject to be spoken about or who may initiate a conversation). Do your residents prefer to be called by traditional “respectful” titles such as Mr. and Mrs.? Or are they accustomed to a more casual and familiar culture in which first names are OK?

In some areas, a geographically cultural norm may dictate forms such as Miss Anne. And preferences may vary from person to person. Miss Anne may be fine for one resident and another will prefer Mrs. Smith. The best practice is to ask each person, and make sure to use an open-ended question such as, “How would you like to be addressed?” rather than one that backs the respondent into a corner such as, “It’s okay if I call you Anne, right?” This form sets the person up to be contrary if he or she is not comfortable with what you have suggested, or to acquiesce to be congenial, and possibly agree to a form of address that would otherwise not be selected.

The guideline about not discussing residents when others are around is also an important consideration. So much of our work takes place in a community setting; it can be difficult to remember this. And a major channel of communication is actually not the words used but things such as intonation, gesture and body language (eye contact, posture, positioning of each speaker in space). Sometimes when we need to get things done, we may inadvertently convey disrespect by towering over a seated elder in conversation, or talking while walking briskly by, or standing too far away when speaking to a resident. These unconscious and unintentional slights do convey negative messages about status and respect, and are avoidable by being aware of body language and positioning.

Language is important not solely because it is a means of communication, but because of what it communicates. It conveys the important things about how we, and the many others in our environment (seen and unseen), expect us to go about our lives, and how we think about others in how we speak to them. Consider these few examples of how language works:

• It can inform in a desired way, by what it says and doesn’t say.

• It can exert power over or control someone else’s actions and emotions.

• It can create distance, opposition or isolation.

• It can confirm a person’s identity and sense of self and bring them comfort.

• It can shatter a person’s self-esteem and bring them pain.

It can do all these things and more when we intend to or when, at times, performed outside of our conscious awareness and contrary to our conscious intent. We can talk to, at, through, with, about, around and despite other people and events. And if that wasn’t difficult enough, those who populate our world have the same effect on us. It can get very complex and confusing at times. It is no wonder that slips of the tongue are so critical, and that once said, something can’t be unsaid.

How elders are spoken to and how employees are addressed tells them how they are viewed and how dedicated the organizational culture is to satisfying their needs. Is the culture of long-term care organized so it fulfills or frustrates the universal human needs of those who are in it? Does the language facilitate or constrain the range of human needs it promises to fulfill? How does it signal this intention by the range of expression in words and types of relationships it defines as acceptable?

One indicator of this aspect of the cultures’ values is whether conversations that occur use terms of address that support self-esteem by honoring each person. Throughout life, each person is motivated to satisfy a universal set of human needs to pursue the highest possible quality of life that each environment they are in will satisfy or frustrate to some degree. Does language in the LTC setting honor those needs, or denigrate them? Consider the following actual examples:

Elder: Nurse, I don’t like this food. Can I have something else?

Nurse: Honey, that’s what we have. Your doctor said you have to eat this and, anyway, the kitchen is closed.

Elder: I have to go to the bathroom.

Aide: I just took you. Just wet the bed and I’ll clean it up later.

(Aside to another employee: Remind me to clean up Room 320 later.)

Scenario: It is time for the mid-day meal at a well-respected nursing home and the elders are arranged around tables for four. At one table, three elders are in a semi-reclined position, each being fed by a staff member. The residents are all facing up at a bright, translucent skylight, while the employees talk only to each other and spoon mouthful after mouthful of soft food into the elders’ mouths.

The preceding examples illustrate how the dignity of the elders was dishonored in multiple ways. Language is uniquely able to honor or destroy the dignity of the listener merely by how he or she is addressed by the speaker. Terms of address for elders should recognize their longevity and accomplishments, that they have lived long and productive lives even though they are not presently “productive” in the traditional work-oriented sense. Their dignity and value as human beings are not situational or relative.

For employees, the terms of address used must honor their status as human beings who occupy important roles at work, in their homes and communities, and must communicate their needs regardless of where they are on the organizational chart. Language is the key channel through which the culture says what it thinks of whose needs are valid, when they may be pursued, and whether a person has the authority to pursue quality of life goals as he or she desires. CMS agrees: Respectful language is a good policy.

Judah L. Ronch, PhD, is the Dean of and a professor at the Erickson School, University of Maryland Baltimore County, which offers undergraduate and Master’s degrees in Management of Aging Services as well as online and live Executive Education programs and customized industry training. He can be reached at

JudahRonch@UMBC.edu. Long-Term Living 2011 September;60(9):18-20