Abstract
Those who work in the area of vocabularies, like all researchers, bring some assumptions to that work. Such assumptions include both cultural notions and beliefs specific to particular social worlds within the broader society. In this article, assumptions and beliefs expressed by participants during the conference on “Implementation of Nursing Vocabularies in Computer-based Systems” are summarized. Questions are raised concerning the relationship between cultural notions and beliefs and nursing vocabularies.
Like much research in medical and nursing informatics, work on vocabularies raises epistemological issues. Those who work in the area of vocabularies, like all researchers, bring some assumptions to that work. Some of these are explicit, while others remain tacit. Anthropologic fieldworkers listen for assumptions in ongoing discourse; that is, what people seem to be taking for granted about the world they discuss. Such assumptions include both cultural notions (i.e., beliefs about the way the world functions and the way people do and should operate within it) and beliefs specific to particular social worlds within the broader society (e.g., academic disciplines and sub-disciplines). It is useful to be aware of such assumptions because they help shape the work of particular disciplines in ways that actors may not be aware of. Scientists and health care professionals may be especially vulnerable in this regard because they typically believe their work to be value-neutral.
During the conference on “Implementation of Nursing Vocabularies in Computer-based Systems,” I heard a number of assumptions expressed during presentations and discussion. Some of these were explicit; others remained tacit but were noticeable to me in part because they differed from things that anthropologists tend to assume. Some of these assumptions seem characteristic of American medicine or medical informatics in general; others may belong to American nursing, to nursing informatics as a field, or to particular approaches within the world of nursing informatics. My goal in this article is to name what I heard (or thought I heard), and then in some cases comment on it or raise questions about it.
These are assumptions I heard or inferred:
The task of representing nursing knowledge and practice is about developing and standardizing vocabulary. In other words, knowledge and meaning are solely a matter of words and the relationship between those words; language is a matter of logic.
Epistemology, interpretation, culture, and meaning are issues of vocabulary.
It makes sense to represent concepts separately from attempting to represent the cultural and practice contexts in which these concepts have meaning.
It is possible to have a vocabulary effort that is not “culturally bound” and could be used in any culture.
Getting down to the atomic level (identifying the correct “atoms”) will deal with the problem of meaning. In other words, there is a “truly granular level” at which a non-redundant simple vocabulary can be found or created.
It should be possible to translate freely between different vocabulary schemes in different languages in use by patients and caregivers.
Every nursing vocabulary is inherently cultural, just as languages in general are cultural. An American may perceive the cultural nature of European vocabulary systems but fail to see the same quality in American vocabularies because the American assumptions are so familiar as to be invisible. As we heard from an audience member at the conference, however, the cultural nature of American vocabularies is quite apparent to non-Americans. Issues of epistemology, interpretation, and meaning are not solely matters of vocabulary. They also have to do with other things, including cultural context. For example, the conference was attended by a nurse from another English-speaking society. She commented that “grief” is treated somewhat differently in American nursing and in her home society. In an American vocabulary, “grief” was tagged as “coping mechanism, deficit” whereas she and her nursing colleagues at home saw grief as a normal process. As a native English speaker, she understands the word “grief” as readily as any American. But what “grief” means to her, and what she as a nurse sees as appropriate to do in relation to a grieving individual, is clearly not the same as the understanding that might be assumed by an American nurse.
It is difficult to make “universal” assumptions because there is no universal society; there are only specific ones, and they all differ to some extent in how they arrange things. American nurses appear not to see the American (cultural) nature of their own nursing vocabularies. However, these vocabularies appear to incorporate a great many assumptions and meanings that are specific to our society and its approach to health care. For example, our current vocabularies grow out of what one speaker described as a sickness-oriented health care system; is this reflected in the vocabularies themselves? What about the incorporation in vocabularies of American institutions (e.g., the American Cancer Society), of American ways of dividing up health care between home, hospital, nursing home, maternity setting, and such; of American categories for health care workers; of the U.S. style of health care education (e.g., medical school after university), and so on? Such cultural and social assumptions are bound to permeate any classification system, wherever it is developed. How much similarity is there cross-culturally in the meaning of “nurse” and “nursing”? How much variation is there within the United States?
It seems to me that standardizing names is only one piece of conceptual standardization. There is also the issue of the underlying categories named by those synonyms. Part of cultural and subcultural difference is a propensity to divide up the world somewhat differently. That is, the underlying categories for which synonyms are sought may not be the same. Thus, even if a local synonym can be found or made to fit, this does not seem to address the question of the boundaries between categories or the meaning of those categories to different speakers.
Understanding terminology is not a black-or-white issue. In addition to the question of whether people understand a particular term, there is the issue of variability of understanding. That is, several people may all understand a term but may each do so somewhat differently. Within the same cultural tradition and local group, people routinely bring somewhat different meanings to terms and categories that they all understand; in real life, shared understanding does not mean identical interpretation.
“Universalizers” in the vocabulary world hold that it is rational to try to develop standardized national and international vocabularies. From this perspective, it is irrational or perhaps selfish to resist the generalizing tendency. But are there other reasons why people and institutions might prefer to retain a local or specialized vocabulary? For example, is there an identity component to retaining local usage? In other contexts, local and regional languages often carry a great deal of meaning in terms of creating and maintaining identity. How should we evaluate the possible claims for local meaning in such cases compared with the utility for other people of standardizing word usage?
The same question could be asked about professions. Why have even one specialized nursing vocabulary, as opposed to a standardized health care vocabulary that incorporates nursing and other practice? Does the notion of one or more nursing vocabularies carry identity meaning for nurses? How should we evaluate the possible claims of benefit to nursing identity of such a vocabulary compared with the utility for others of standardizing word usage?
Judy Warren opened with a quote from Norma M. Lang: “If you cannot name it, you cannot teach it, research it, practice it, or put it into public policy.” I agree that the effort to name things is often very valuable. However, the quotation seems to ignore the issue of culture as well as the human ability to act in accordance with patterns of which we are not (or are not fully) aware. By putting into practice patterns that we may not recognize in ourselves, we also help teach them to others. We take for granted much that we do not or cannot name. Names are part of meaning and worldview, but they are by no means all of it.
The observations and commentary in this paper were taken from a larger report prepared by Dr. Forsythe for the invitational conference of the AMIA Nursing Working Group entitled “Implementation of Nursing Vocabularies in Computer-based Systems,” which was held on May 28, 1997, in conjunction with the AMIA Spring Congress. The words are Dr. Forsythe's. The sections of that report appearing here were selected by Suzanne Bakken Henry following Dr. Forsythe's death.