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What is ‘normal’? Rethinking constructions of normalcy to enact patient-centred care

Why standards may hinder nurses’ ability to deliver individualized care

Nov 29, 2021, By: Michelle Danda
“We rely on patients telling us their experiences of realities that we are not able to access, with their own understanding of what they conceive as normal,” Michelle Danda says. “Over the course of my nursing career, I have come to understand that my assumptions and limited understanding of the patient’s experience and life context require me to let go of ‘normal."

The term “normal” is something that I often think about with respect to my clinical practice area, mental health and addiction. Living through the COVID-19 pandemic has challenged the global understanding of “normal,” a term frequently used in psychiatric and psychological assessments. Sometimes the term “baseline” is used as a synonym for normal, as a measure of what we assume is the day-to-day behaviour of patients when they are not in need of acute mental health interventions, when they are taking their medications as prescribed, when they are in recovery, and when they are not using non-prescription substances. But, as nurses, we must ask who decides the standards of normal. Moreover, is this standard useful in terms of delivering person-centred, individualized care?

Standards of normal

Standards of normal are set by studying the normal patient, and we must consider the population that comprises the normal patient to inform nurses’ judgments of the standard comparison. The problematic realities constructed by such standards have been magnified in the last year in response to large-scale social justice movements raising awareness of social inequity and systemic racism, highlighting how “normal” is often constructed using the standards of whiteness and the middle class. Many nursing theories — for example, Rizzo Parse’s Human Becoming Theory, Peplau’s Interpersonal Relations Theory and Watson’s Caring Theory — are based on conceptualization of the subjective experience of patients describing their concerns; that is, what they consider “abnormal,” which led to their interaction with the health-care system. Their subjective experience is met with diagnostic tools to help the clinician formulate the diagnosis.

From a medical model perspective, identification of problems and symptoms is key in determining a diagnosis and guiding the course of treatment. In contrast, a recovery-oriented approach focuses on adapting to the illness and optimizing quality of life, as determined by the patient’s needs and perspective. The concept of normal is instrumental in decision-making around pathologies; however, it is heavily dependent on each individual’s concept of normal. In the field of mental health, normal shifts in relation to what is socially acceptable and scientifically understood.

The standard of abnormal in mental health in Canada is largely determined using the Diagnostic and Statistical Manual of Mental Disorders and sometimes the International Classification of Diseases. These diagnostic tools are re-evaluated and changed based on research and the opinions of people working in the mental health field. Disorders of the past century may not be considered disorders of the current day because of new research and collection of scientific evidence and because of shifting social norms about behaviour. Within a nursing paradigm, the conception of normal and diagnostic criteria may guide clinical decision-making, but have limited value in guiding nurses’ actions because they are problem-based tools that may perpetuate stigma and otherness rather than accommodate variation. Problem-based paradigms are neither recovery oriented nor person centred.

The standards and norms set by health-care professionals are influential in determining what is normal, but, curiously, sometimes they result in distress. The longer I worked in mental health services, the more I began to question whether the classification of normal results in more harm than good. Is there an inherent normal that we must strive for? I began to question the value of health care as a normalizing process. For example, if someone is identified as living with schizophrenia, what is considered normal? Is the ultimate goal to take psychotropic medication to alleviate psychotic symptoms, mimicking the life of the person not living with schizophrenia? Or is there a different type of normal? The complexity of my questioning only increased when I thought about addictions and substance use because I saw the standard of normal based on ideals of substance-free lifestyles and other moral arguments.

Nurses must take a step back and question how notions of substance use have been constructed and normalized.

Throughout my career, I have observed that substance use has become pathologized; it is considered a problem depending on the amount, frequency of use, and particular substance. Understanding substance use addiction from a health-care perspective — rather than construing it as a moral failing — is helpful in developing, funding and implementing health interventions to help people with substance use issues. I began to question whether substance use has become a disease process. Nurses must take a step back and question how notions of substance use have been constructed and normalized. They should consider how this construction and normalization affect treatment options for those who experience substance use issues. Different standards of normal are contingent on legal substance use versus illegal substance use. For example, alcohol use (and now cannabis use) can be viewed on a spectrum of normal use to abnormal use; however, crack cocaine or crystal methamphetamine use tends to be viewed as abnormal regardless of the amount of substance used.

Changing conceptualization of normal

The term “normal” seems to have fallen out of favour in recent years. The term “appropriate” has been adopted as a means of distinguishing between normal and pathological, to embrace both the physical and the behavioural, and as a means of describing the behaviours of patients and their family members. However, it is questionable whether it is a more objective term or a relabelling of “normal.” The adoption of the term “appropriate” allowed for communication of information but acts as a process of passing moral judgment about normal and pathological, positioning the clinician as the one holding the power to determine whether someone was acting appropriately. The word “appropriate” is frequently used in mental health in the discussions that clinicians have about patients and in clinical documentation. For me, the words “appropriate” and “normal” indicate moral judgment about whether we think the patient has conformed to a subjective standard, without consideration as to what the standard is or how it was set. I have made a conscious effort to stop using both words because they are context specific and their meaning lies in the assumption that there is a common and accepted understanding of what they are, which shifts based on situation, context and often social norms.

Implications for nursing practice

Throughout my career, I have constantly struggled with my perception and understanding of mental health and addictions because there seems to be an increasing pathologization of behaviour that does not fit into classifications of “normal.” The dichotomy of pathological as the opposite of healthy is problematic in the sense that healthy also exists subjectively, where it can be defined in many different ways based on shifts in both research findings but also shifts in response to social norms. Healthy is conceptualized as tolerance to several different norms and is perhaps more akin to resiliency. Thus, healthy is less about adhering to specific rules and standards and, instead, more about being in a relationship with different norms, shifting in response to social norms and being able to recover.

Our world is seen through the constraint of the language that we use to describe it. When I think about applications to mental health, I wonder about the limitations of language to describe the patient’s experience of something such as psychosis. We rely on patients telling us their experiences of realities that we are not able to access, with their own understanding of what they conceive as normal. Over the course of my nursing career, I have come to understand that my assumptions and limited understanding of the patient’s experience and life context require me to let go of “normal.”

Moving forward, nurses must question the ways that ideals of normal are enacted in health-care processes, such as standardized care plans, data-driven decision-making based on generalized data, and programs and services designed for the most visible or dominant group. These notions of normal ignore and silence individualized care, hinder relational practices such as knowing patients within the unique context of their lives, and fail to see those on the margins who may not be regularly accessing care.

Michelle Danda, RN, MN, MPN, CPMHN(C), graduated from the Bachelor of Nursing Accelerated Track program at the University of Calgary in 2008. She currently lives in New Westminster, B.C. She is an informatics nurse in Vancouver, B.C., and practises mental health nursing at Lion’s Gate Hospital in North Vancouver, B.C. She has four beautiful children with her partner, who is also an informatics and mental health nurse. She is also a full-time doctoral student in the PhD Nursing program at the University of Alberta studying the history of psychiatric nurse education in B.C.