19 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 Agata Križan University of Maribor, Slovenia Barbara Majcenovič Kline University of Maribor, Slovenia NURSE-PATIENT INTERACTION IN VIEW OF APPRAISAL LANGUAGE: EXPLORING ESP FOR TRAINEE NURSES Abstract Since the quality of communication between nurses and patients has a significant impact on their relationship and ultimately on patients’ well-being, the nurses’ use of language is undoubtedly critical. Due to increased mobility and migration in today’s globalised world, there is a growing need for trainee nurses to learn English and, particularly, for nurses to use English effectively in their communication with both native and non-native English-speaking patients. The paper explores the occurrence of ap- praisal, which is the language of evaluation, in nurses’ propositions in sample nurse-patient interac- tions in English by applying the appraisal model (Martin & White, 2005) with the aim of establishing if and how nurses’ propositions employ appraisals that help build a good rapport with patients, and thus effective interaction. Our data show that nurses’ propositions in these interactions with patients frequently employ language that explicitly and implicitly evaluates nurses’ behaviour and approaches towards their patients positively, which is significant due to the educational purposes of these sample interactions. It is hoped that the findings here will help improve trainee nurses’ communication with patients, as well as increase their awareness of appraisal as a potential linguistic means of a good rapport building. Keywords: ESP, nurse-patient communication, trainee nurses, appraisal, rapport 20 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 1 Introduction In today’s globalised world, English has become the dominant language, particularly in the fields of science, technology, economics, and culture, not only because the majority of (med- ical) academic and scientific research, and conferences for healthcare professionals take place in English, but also due to increased workforce mobility, migration, and the relentless development of information technology. According to Keating (2020), “English is still the most spoken language in the EU by far, with German now spoken by 36% of citizens and French spoken by 29% of the EU’s new smaller population of 446 million people” (para. 5); therefore, knowledge of English remains important for healthcare professionals, including nurses, for interaction among themselves and with patients from different linguistic, ethnic, and cultural backgrounds. Moreover, “[f]indings from the literature review and qualitative research indi- cate strongly that English will continue to be the dominant language in Europe and remain the preferred second language for most Europeans in 2025.” (The future demand for English in Europe: 2025 and beyond, 2018, p.13, n. a.) Additionally, many non-English speaking Europe- an countries currently offer courses and even entire nursing degree programmes in English (Pitkäjärvi, 2012). English is also the most spoken language in the world, not just in the EU, with 379 million native speakers and 753 million non-native speakers (Berlitz, 2021), which in- creases the possibility that patients of other countries speak, or at least understand, English. Nurses both occupy a vital position in the healthcare environment and constitute an exten- sive body of healthcare workers. In hospital settings especially, they are usually the personnel with whom patients first come into contact and are engaged in interactions with patients over longer periods of time. It is therefore paramount that nurses establish a rapport with patients for effective communication. Defined as “foundational to building relationships with others”, rapport encompasses three core facets – trust, empathy, and mutual respect – with slight vari- ations among them (Hoessler & West, 2017, pp. 21-24). According to Stričević and Ivanc (2006), lack of trust seems to substantially jeopardize relationships in healthcare services. As in most communication, the relationship between the health professional and the patient also encompasses the attitudes, behaviours and expectations that participants have and ex- press through their interaction (Feldman-Stewart et al., 2005; Carlsson et al., 2005). For Ule (2003)1, communication in healthcare is not only an ‘ointment’ that is used to carry out effi- cient and smooth medical procedures, as well as achieve medical goals but also a meeting of two people in a joint event. It means that both participants bring their feelings, expectations, values, views, knowledge, skills, memories, and limitations into the relationship. Similarly, Stričević (2011) describes the relationship between nurse and patient as professional yet hu- man, in which the nurse’s and patient’s feelings, experience, characteristics, expectations and fears intertwine. Pajnkihar and Lahe (2006) state the relationship between nurse and patient depends on their cooperation and is affected by the characteristics of both participants. Sim- ilarly, Riley (2008, p. 20) states that in a “nurse-patient interaction, both nurses and patients bring their individual respective knowledge, attitudes, feelings, experiences, and patterns of behaviours to the relationship.”  It is thus through communication that nurses support patients in expressing their feelings towards their illness and encourage and help satisfy the patients’ needs through communication (Črnčec & Lahe, 2001). 1 All translations are by the authors of the paper. 21 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 Since there is a direct link between communication and good nursing practice (Gunther & Alligood, 2002), communication training in nursing education for registered nurses is crit- ical, “yet [it is] not systematically developed nor regulated” (Bullington et al., 2019, p. 141). Quinn (as cited in McCabe, 2004, p. 47) emphasises the need for critical reflection in nursing education on how trainee nurses communicate with patients (e.g., role play). Wilkstrom and Sviden’s study (2011) of the curriculum in undergraduate nurse education in Sweden, for example, shows that while the curriculum does have a communication skills programme for nurses in the first three years of education, it lacks adequate guidelines for teachers and students. At an undergraduate and postgraduate level, education relating to patient-centred communication should focus on illustrating that this type of communication does not require a great deal of time. The review of literature on developing interpersonal communication and rapport building through encounters with ‘real patients’ by Ross (2013) shows that training in- volving ‘real patients’ is beneficial for both students and practising health care professionals. As a mode of communication, “language is integral to professional accountability for nurses” (Allen et al., 2007, p. 49), and “cannot be underestimated as it is through communication (and hence meaning and understanding) that care services are delivered to the general popula- tion” (ibid., p. 50). In a nutshell, appropriate use of language is vital for nurses to communi- cate effectively, including the use of evaluative language, which, among others, “construct[s] and maintain[s] relations between the speaker or writer and hearer or reader” (Hunston & Thompson, 1999). To bridge the gap between the necessity for building a good rapport (as part of a successful communication) by nurses and appraisal as an interpersonal feature, the paper aims to ex- plore the occurrence of appraisals, which are concerned with evaluative language, and their role in a rapport building in nurses’ propositions in sample nurse-patient interactions in Eng- lish through the prism of appraisal theory (Martin & White, 2005). 2 Nurse-patient communication There is an extensive body of literature that accentuates the importance of effective nurse-pa- tient communication (e.g., Park et al., 2018; Sibiya, 2018; Vera, 2020; Arnold & Boggs, 2020). Vuković et al. (2010, p. 82) find that “[...] the quality of nurse/patient communication is one unique factor that incorporates strongly correlated verbal and non-verbal communication as unity, even in relation to the communication objective itself.” The study conducted by Jangland (2011) shows that negative interactions with health professionals, which patients defined as lacking in empathy, respect, and emotional support, resulted in long-term insecu- rity, worry and suffering on the patients’ part. On the other hand, empathy is recognized as a pivotal element in patient-centred communication (McCabe, 2004). Macdonald’s (2016) linguistic analysis of small talk in nurse-patient conversation reveals that small talk effectively contributes to a therapeutic outcome. Other features of effective com- munication such as humour, relational practice, strategic use of multifunctional questions, and commentary are also identified by Macdonald (2003). In their study of nurses’ chatting in a neonatal nursery, Fenwick et al. (2001) show that small talk triggers effective interaction with mothers. The study of nurse-patient interaction by Major and Holmes (2008), carried out 22 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 while preparing patients for procedures, shows that nurses also attempted to establish a good rapport with patients when describing these procedures to them by frequently assuring them of a positive outcome and reassuring them about any further interventions. They also used other signals of empathetic exchange such as minimal feedback, hedges while discuss- ing procedures, interactive particles, softening devices, paraphrasing, and repetition. In their pilot study, Holmes and Major (2002) establish that nurses used several linguistic strategies to soften their directives, such as conditionals, pronoun choice (we), tag questions, mod- al adverbs (probably, perhaps, maybe, possibly, just), discourse particles (yeah, well, anyway), proper nouns (person’s first name), colloquial language (a bit, pop out), discoursal position (explanation or justification for a directive), and humour, which points to greater patient-cen- teredness. Alsufyani (2018) explores the use of language and comfort talk by nurses in two graduate nurse-patient interactions during practical training in a hospital from the systemic functional perspective, identifying several interpersonal and pragmatic features, such as mo- dality, direct address pronouns, and types of clauses and questions. As mentioned above, the awareness of the need for communication skills in English in nursing has been growing. The study by Badrov and Jurković (2017) shows that nursing students at a technical college in Bjelovar in Croatia generally consider communication skills in English, pri- marily spoken communication, as well as the implementation of English into their study pro- grammes, as significant. In Slovenia, for example, English is taught as a compulsory subject to students of the first Bologna cycle in their first year in all nursing care study programmes of state health science faculties. Some of the course contents for the study year 2020-2021 include the development of professional vocabulary in crucial areas of nursing (collocations, word formation, phraseology), and improving general English language proficiency, including techniques for effective reading and writing (Fakulteta za zdravstvene vede, 2021). The necessity for healthcare professionals to learn English is also emphasised via various on- line courses available for healthcare professionals, including nurses, whose native language is not English, with one of the purposes listed as [b]y studying and practising medical English, you will be able to make your patients feel more comfortable and have a better understanding of their needs. You will also learn how to talk to their loved ones and communicate with other medical staff who speak English (English Club, 2021). 3 Appraisal Located within systemic functional linguistics (SFL), an appraisal is [...] a collection of semantic resources for negotiating emotions, judgments and val- uations. These include gradable resources for evaluating people, places and things in our experience (ATTITUDE), for adjusting our commitment to what we evaluate (ENGAGEMENT) and for turning up or down the volume of these (GRADUATION) ( Macken-Horarik, 2003, p. 296). Evolving from SFL, appraisal is placed within discourse semantics (Martin & White, 2005). Ac- cording to Halliday and Mathiessen, 23 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 [t]he basic unit of semantics is the text – language functioning in context, an in- stance of the semantic system. A text is organized internally as patterns of logical, experiential, interpersonal and textual meaning. At the same time, it is organized ex- ternally as a unit operating in context: the structure of the context of situation that a text operates in is, as it were, projected onto the text (2014, p. 43, original emphasis). Concerned with the evaluative feature of language use, an appraisal is closely related to the interpersonal component of meaning, i.e., appraisal construes the interpersonal metafunction of a text (Martin & White, 2005). Language, specifically, is also2 used to “interact with other peo- ple, to establish and maintain relations with them, to influence their behaviour, to express our own viewpoint on things in the world, and to elicit or change theirs” (Thompson, 2004, p. 30), thus “[…] enabl[ing] us to participate in communicative acts with other people, to take roles and to express and understand feelings, attitude and judgments” (Bloor & Bloor, 2004, p. 11). As a system, an appraisal is categorised as attitude, graduation, and engagement. Attitude is subcategorised as affect (language expressing feelings, e.g., excited), judgement (language evaluating human character and personality, e.g., evil) and appreciation (language assessing the value of things, e.g., simple). It can be expressed as an inscription, explicitly (e.g., She is ignorant), or as a token, implicitly (e.g., She spoke loudly in the library = she is evaluated neg- atively as e.g., ignorant/rude/selfish), and can be of positive or negative value. Attitudinal inscriptions encode attitudes in attitudinal lexis, whereas attitudinal tokens are evoked via ideational meaning and/or co(n)text (Martin & White, 2005). Graduation is an amplification of attitudinal force (e.g., very excited) or sharpening /softening of attitudinal focus (e.g., a true friend). Engagement, as a resource for “placing a speaker’s voice in relation to alternative voices” (Hood & Martin, 2007, p. 742), is subcategorised as disclaim (rejection of contrary positions, e.g., They did not make this), proclaim (suppression of alternative positions, e.g., Of course, they made this), entertain (acknowledgement of alternative positions via authorial sub- jective position, e.g., They might have made this), and attribution (acknowledgment of external subjective position, e.g., She said that they had made that) (Martin & White, 2005). 4 Methodology Drawing upon the established theoretical foundations and the objective of the paper, the following question is addressed: Do nurses’ propositions in sample nurse-patient interactions that are designed primarily for educational purposes also employ appraisals that help build a good rapport with patients, thus contributing to effective communication? The corpus for the analysis of appraisal in nurse-patient interaction consisted of 80 oral and written nurse-patient dialogues in English, selected from the Internet, YouTube and text- books on English for nurses, comprising a word total of 23,000. Since most of the selected nurse-patient interactions are designed for educational purposes, they were considered a val- uable resource in exploring whether nurses’ propositions employ appraisals that contribute to the building of a good rapport, hence contributing to successful communication. As most 2 Two other metafunctions of language are ideational (language construing human experience) and textual (language constructing a text) (Halliday & Mathiessen, 2014). 24 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 of these interactions have an educational purpose, it is implied that they are adjusted, hence non-authentic. This may have affected the results in the sense that nurses’ behaviour and approaches towards patients in these non-authentic interactions are frequently presented in a positive light, which may not always be the case in authentic interactions. First, the oral dialogues were transcribed. The analysis was conducted by using the appraisal framework by Martin and White (2005) as an analytical tool, adopting both quantitative and qualitative research methods. In nurse-patient dialogues, appraisals were tagged as attitude, graduation and engagement. As regards attitude, instances were also tagged as positive or negative, and as inscriptions or tokens. As regards graduation, instances were also tagged as force or focus3, and as regards engagement, instances were also tagged as disclaim, pro- claim, entertain or attribution. Additionally, for each appraisal instance, the source of utter- ance was identified (nurse or patient). The UAM analytical and statistical corpus tool was used (O’Donnell, 2008). Whereas inscribed attitudes are mostly expressed via individual instances, tokens primarily depend on the co(n)text and ideational meanings, hence tagged as longer chunks of language. This paper presents the statistical data in tables, followed by data inter- pretation and discussion, illustrated with examples from the sample nurse-patient dialogues. Since the identification of appraisals is often co(n)text dependent, the analysis took the ‘Rus- sian doll syndrome” into consideration, i.e., an inscribed attitude may not only trigger an additional attitude differently but may also be of a different category from the inscribed one due to the context (Thompson, 2014). For example, in the nurse’s proposition It is hard to go through all this, appreciation is inscribed lexically in hard, evaluating negatively the patient’s situation and his/her struggle to cope with it; however, the co-text (language in the vicinity) and the situational context (medical environment) signal the nurse’s sympathy for the patient by acknowledging their feelings and situation, which implicitly evaluates the nurse’s sympa- thetic and understanding behaviour and response as positive judgement. Based on Hood’s graduation categories (2004), specificity, one of the focus subcategories, was relevant for this study. Thus, instances (lexical and grammatical) conveying what is spe- cific, what has a special application or is of a particular kind (e.g., names for medical equip- ment, type of medication) were identified as specificity because of their potential to evoke attitudes, in particular, judgement (more on this in 5.2). Furthermore, the structure I + will, which indicated the nurse’s inclination, i.e., tendency and readiness to help patients, was coded as inscribed judgement targeting nurses (see Martin & White, 2005). However, since this modulated inclination is still presented as one of the possi- ble positions, hence subjectively, this structure was also coded as engagement. 5 Results This chapter presents and interprets the results of the appraisal analysis in sample nurse-pa- tient interactions, with an exclusive focus on nurses’ propositions. The reasons for focusing solely on nurses’ propositions are, firstly, the relevance of the language in nurses’ proposi- tions for trainee nurses in developing their English language skills; secondly, the dependence 3 For the identification of graders, the extended version of graduation by Hood (2004) was also taken into account, in particular, the grading of non-attitudinal meanings. 25 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 of effective communication with patients on nurses’ communication skills, and lastly, the space limitations of this paper. 5.1 The occurrence of appraisals in nurses’ and patients’ propositions Table 1 shows the frequency of occurrence of attitude, graduation and engagement in nurs- es’ and patients’ propositions. Table 1 Distribution of appraisals in nurses’ and patients’ propositions N Percent N Percent N Percent ATTITUDE N= 2398 GRADUATION N = 3218 ENGAGEMENT N = 1620 nurse 1469 61.39% 2231 69.33% 1054 65.06% patient 924 38.61% 987 30.67% 566 34.94% As shown in Table 1, the main appraisals in nurses’ propositions significantly outnumber the main appraisals in patients’ propositions. Regarding attitude, 61.39% of attitudes are encoded in the language used by nurses, whereas 38.61% of attitudes are expressed in the language used by patients. Nurses are more frequently engaged in dialogues (65.06%) than patients (34.94%). In nurses’ propositions, graduation (69.33%) and engagement (65.06%) outnum- ber attitude (61.39%). The prevalence of appraisals in nurses’ propositions results primarily from nurses leading the conversations with patients by eliciting and gathering information, explaining medical procedures, and establishing a rapport with them. 5.2 Attitude Table 2 shows how attitudinal subcategories, their status and manifestation are distributed in nurses’ propositions. Table 2 Distribution of attitudinal subcategories in nurses’ propositions nurse N Percent ATTITUDE N = 1469 affect 120 8.17% judgement 778 52.96% appreciation 571 38.87% positive 120 82.30% negative 260 17.70% inscription 687 46.77% token 782 53.23% 26 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 As seen in Table 2, which indicates how attitudinal subcategories are distributed in the nurses’ propositions, positive attitudes (82.3%) and attitudinal tokens4 (53.23%) prevail in nurses’ propositions, with judgement as the main attitude (52.96%), followed by appreci- ation (38.87%). The least frequently occurring attitude is affect (8.17%). The predominant attitudinal value is positive (82.3%) and the predominant attitudinal expression is the token (53.23%), but with a minor difference (6.46%) in the occurrence between the tokens and inscriptions. Table 3 shows how the status and manifestation are distributed within each attitudinal sub- category in nurses’ propositions. Table 3 Distribution of attitudinal inscriptions and tokens, as well as attitudinal positive and negative value in nurses’ propositions nurse N percent AFFECT N = 120 positive 63 52.50% negative 57 47.50% inscription 108 90.00% token 12 10.00% JUDGEMENT N =778 positive 757 97.30% negative 21 2.70% inscription 159 20.44% token 619 79.56% APPRECIATION N = 571 positive 389 68.13% negative 182 31.87% inscription 420 73.56% token 151 26.44% Table 3, which illustrates the frequency of occurrence of attitudinal inscriptions and tokens, and attitudinal positive and negative value in the nurses’ propositions, displays a considera- ble difference in the occurrence of affect, with inscriptions (90%) largely dominating tokens (10%). Although affect is primarily expressed as positive, the difference between negative (47.5%) and positive affect (52.5%) is minor. Judgement occurs mainly as a positive value (97.3%) and a token (79.56%), whereas judgement with a negative value (2.7%) and with an in- scribed expression (20.44%) is the least frequent of the attitudes. Appreciation occurs mainly as a positive value (68.13%) and as an inscription (73.56%), whereas negative appreciation accounts for 31.87% and appreciation token accounts for 26.44%. 4 Attitudes that are expressed implicitly/evoked. 27 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 Based on the analysis, the following sections exemplify5 appraisal language in nurses’ prop- ositions that positively evaluates nurses’ behaviour and approaches towards patients, and thus contributes significantly to the building of a rapport with patients, hence effective communication. 5.2.1 Affect Affect is mainly inscribed in lexis conveying: • patients’ health and health-related problems, symptoms, and accompanying unpleasant feelings (1a-b), which despite its negative status, shows nurses’ interest in patients’ cur- rent well-being and comfort, hence with a soothing effect. The same effect is observed with positive affect in reference to the patients’ future well-being and to other patients’ unpleasant feelings as well as positive feelings as a common occurrence (1c-h). 1) a) You feel a bit warm. b) You’ve had a bit of a shock. c) Anything else you were concerned about? d) Nothing to worry about. e) You’ll feel calm and relaxed soon. f) A lot of people worry/complain about… g) It is not unusual for patients to suffer. h) People always feel better… • the nurses’ assurances and sympathy for the patients’ emotional discomfort and situation (2a-b), as well as happiness related to the patients’ progress and cooperation (2c). 2) a) I’m sure we’ll be able to… b) I’m so sorry to hear that. c) I’m really pleased that you… • the fulfilment of healthcare procedure needs, and the nurse’s desires and intentions dur- ing the healthcare procedure, which help alleviate the patients’ anxiety and distress (3a-b). 3) a) I got the blood that I needed. b) I want to ask a few more questions. Affect as a token occurs rarely and appears mainly in nurses’ responses to positive or nega- tive information volunteered by the patients, signifying the nurses’ attention (wow, ohh). 5 All examples are taken from the sources listed at the end of the paper. Examples that require (more) co- text are listed separately from the main text, whereas simple examples are provided in the main text. 28 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 5.2.2 Judgement Inscribed judgement is frequently encoded grammatically in the modal verb will, paired with the personal pronoun I, conveying the nurses’ willingness and inclination to help patients feel better and more comfortable (4a-b), and understand their instructions and explanations (4c- e). Additionally, by familiarising patients with what to expect during a physical examination, trust is built, and the patient’s sense of safety bolstered (4f-g). 4) a) I’ll just close the curtain. b) I’ll get you extra blanket. c) I’ll show you how. d) I’ll go through all steps with you. e) I’ll just repeat the important information. f) I’ll leave you here for a minute. g) I’ll put the thermometer under your tongue. Tokens of positive judgement targeting nurses’ helpful behaviour and approaches occur via (closed-ended) questions (5a-d), the phrase let’s see if (5e), politer commands (5f), and the en- gagement elements that present compliance with the request as obvious (e.g., sure/certainly; of course, I can do this), occasionally intensified with the expression here you go and express advice/a solution to the problem (5g-i). Additionally, the graders just and right are used to sig- nal the simplicity of requesting assistance from the nurses, and the immediacy of the nurses’ response, as well as their readiness to help (5j-k). 5) a) Is there anything I can do for you? b) Feeling all right? c) Have you settled in yet? d) Are you comfortable? e) Let’s see if we can make you feel a little better. f) Let me know if you need any help. g) You can also use heat pads. h) Perhaps your wife might…? i) Can I suggest… j) Just ring when you want me to collect… k) I’ll be right back with… Tokens of positive judgement targeting nurses’ polite behaviour and approaches are ob- served in the nurses’ choice of polite requests over a more authoritative command via the modulated command (6a-b) and interjection (6c) to examine and make demands of patients, as well as of polite questions to address patients as participants and decision-makers to avoid any confrontation (6d). 29 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 6) a) I’d just like you to… b) You can step down now. c) Please, hold your arm. d) Would you be willing to try the medication for a day and see if it helps …? Furthermore, a respectful approach which aims at trust-building is further demonstrated with expressions of gratitude for the patients’ visit and their cooperation (7a), names and roles that nurses use to introduce themselves to patients (7b), language conveying atten- tive listening by the nurses (e.g., wow, ohh), with occasional descriptions of behaviours in parenthesis (e.g. [leans towards the patient and nods]), questions (often elliptical, e.g. OK?) checking patients’ feelings and well-being during diagnostic testing, physical examinations and health care assessment, questions such as asking patients for permission to perform or continue with a physical examination and testing (7c-f), and language conveying discretion on the part of the nurses (7g). 7) a) Thank you for coming in today. b) I’m Shona and I’ll be admitting you to the ward. c) Would you mind if…? d) If that’s all right with you? e) If you’re ready? f) Can I have a look? g) Your relatives are here, I am going to leave you with them for now. Tokens of positive judgement also occur significantly as nurses’ empathetic and sympathetic responses to show understanding and acknowledgment of patients’ (unpleasant) feelings (8a-c), as reassurance (8d-g), as confirmation of patients’ understanding and interpretation of nurses’ explanation of instructions, procedures and treatment (8h-i), as a cautious and caring approach to patients in (regular) monitoring of their state of health and well-being (8j-m), as questions for the purpose of verifying patients’ comprehension of crucial information (8n-o), and as clarification of questions for the sake of avoiding any confusion or embarrassment on the part of patients (8p). 8) a) I know how you feel. b) It is hard to go through all this. c) It must be very difficult for you. d) It’s normal to… e) You’re in good hands here. f) You’ll feel better soon. g) It will only feel like a little pinprick. 30 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 h) That’s right/correct/OK. i) You did well to remember. j) We have to check… k) I will check on you later. l) Is this better? m) How are you doing? n) Right, the first step is? o) Do you see what I mean? p) Can/could you tell me your family history? Is there anyone with high blood pressure? Additionally, the use of medical terminology and clarification of it (9a), explanations and de- scriptions of symptoms and illnesses (9b-c), the reasons for their occurrence, and the conse- quences of (non)treatment display nurses’ professional knowledge, hence building trust (9d). 9) a) It’s called... b) That means… c) Erythema – that’s the redness... d) If your kidneys… then… Moreover, to help alleviate patients’ anxiety, nurses employ a number of strategies to inform patients of what to expect: explanations of procedures (10a), steps during the physical exam- ination, kinds and purposes of medical instruments that are/will be used (10b-c), test results (10d), as well as information about the duration of the physical examination and its beginning and ending, its straightforwardness and completion of steps as they are performed (10e-g). 10) a) We are going to use… b) I am going to do… c) We’ll have a chat about your breathing now, and then I’ll have a talk to you about... d) The pulse is… e) That was it. f) It’s finished. g) It only takes 2 minutes. 5.2.3 Appreciation Inscribed appreciation is frequently encoded in lexis which conveys what is essential for pa- tients (e.g., It’s important to treat/to remember/to use), assessment of the results of medical ex- aminations/tests (e.g., normal), illnesses and symptoms (e.g., severe, dangerous), medication (e.g., strong, suitable), activities (e.g., beneficial, important), additional information (e.g., leaflet to help), organs and bodily substances (e.g., harmful type of cholesterol), caution (e.g., careful), 31 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 validity of information (e.g., correct), medical tools and equipment (e.g. convenient, protective), instructions (e.g., simple), food and diet (e.g., fresh); advice (e.g., best to), and healing (e.g., nasty complications, good sign). With the previously mentioned language, which inscribes both positive and negative appreciation, nurses signal concern for the patient’s well-being, health, and safety. Appreciation is also inscribed in nurses’ positive responses and reactions to patients’ infor- mation about their attempts to improve their health and well-being (11a-b). Some of the nurs- es’ reactions (also formed as tag questions) acknowledge patients’ anxious feelings, hence showing empathy (11c-d), which additionally evokes positive judgement targeting nurses, as discussed in 5.2.2. 11) a) That’s nice to hear. b) That’s great/right/lovely. c) It’s frightening when it happens, isn’t it? d) That would be frustrating. 5.3 Graduation Table 4 shows distribution of graduation subcategories in nurses’ propositions. Table 4 Distribution of graduation subcategories in nurses’ propositions Nurse N Percent GRADUATION N= 2231 Force 1687 75.62% Focus 544 24.38% According to Table 4, which displays the frequency of occurrence of grading of the attitudinal force and focus in the nurses’ propositions, grading of the attitudinal force (75.62%) features far more frequently than attitudinal grading of the focus (24.38%). Regarding grading of the force, nurses occasionally grade their responses to patients’ coop- eration and emphasise patients’ shared feelings and attitudes via isolated (12a) and infused intensification to show understanding and interest in patients (12b-d). 12) a) You have a really caring family. b) That’s great. c) It’s frightening, isn’t it when it happens? d) Hilarious. 32 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 Additionally, acquainting patients with symptoms, injuries, troublesome body parts, causes of health problems, important nutrients (13a-d), and with the details of procedures via next steps and instructions (13 e-f) by listing them (intensification: repetition), may result in pa- tients feeling more comfortable and trustful, although some of these intensify a problem. 13) a) red and swollen b) head and face c) change of diet, lack of sleep and some types of medication d) high in fibre, potassium, and fat e) clean and put on the dressing f) put on the mask and tighten the elastic straps Nurses also use quantification as grading of the attitudinal force to inform the patient about test results (14a), consequences of medication and treatment (14b-c), safety measures (14d), sequences in procedures and treatments (e.g., first…then), duration of treatment, healing, medication, immediacy of procedures and treatments (14e-g), and to encourage patients by enabling them to identify with those who have similar problems, i.e., helping patients realise that the problem is common to minimise their anxiety (14h-j). 14) a) Oxygen sat’s ninety-six per cent on three litres of oxygen. b) …lower the amount of cholesterol. c) You may also feel lethargic. d) …give you antibiotics as well. e) …until healed. f) You should take them five times per week. g) …as soon as possible. h) People always feel better. i) …common problem for busy people. j) A lot of people suffer from… Grading of the attitudinal focus is often used in nurses’ questions specifying a desired an- swer, hence guiding patients to necessary information to avoid embarrassment (15a-c). 15) a) What about food allergies? b) Tell me more about…, c) Anything else - what about lactose intolerance? Additionally, nurses specify a source of information (e.g., patient leaflet), medical/technical terminology (e.g., tourniquet), location of problems, symptoms and targets of treatment (e.g., in your urinary tract), treatment/medication (e.g., anticoagulant medication), solution 33 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 (e.g., Why don’t you…?), target patients (e.g., people with end stage renal failure), as well as medical staff and employees (e.g., the wound management clinical specialist nurse), indicate the kind and purpose of medical tests (e.g., check oxygen saturation), and the purpose of use of medical equipment and instruments (e.g., measure your pulse rate). By being specific, nurses display their professional knowledge and concern for patients, which fosters and increases feelings of safety. 5.4 Engagement Table 5 shows distribution of engagement subcategories in nurses’ propositions. Table 5 Distribution of engagement subcategories in nurses’ propositions Nurse N Percent ENGAGEMENT N = 1055 Disclaim 208 19.72% Proclaim 254 24.08% Entertain 568 53.84% Attribution 25 2.37% According to Table 5, which presents how engagement subcategories are distributed in nurs- es’ propositions, nurses are most frequently engaged in dialogues via the resources of enter- tain (53.84%), followed by the resources of proclaim (24.08%) and disclaim (19.72%). The least used engagement category is attribution (2.37%). Nurses typically entertain their propositions via modality to signal their readiness to be at the patients’ disposal (16a-b), ask patients for permission to be examined (16e-f), elicit answers from patients as a part of an examination (16d), ask patients for cooperation during the examination (16g), show familiarity with patients’ knowledge (16h), and give a nonintrusive advice (16i-k), which may be a sign of respect. 16) a) I can help you with that. b) May I help you? c) Can I take your temperature? d) Can/could you tell me…? e) Would you mind if I check out some…? f) Can I keep going? g) Can you put your finger…? h) You probably know that… 34 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 i) Could your sister perhaps...? j) You might like to speak to your doctor? k) Can I suggest you…? Modal verbs are also used to minimise patients’ anxiety by acquainting them with the possi- bility/probability of the occurrence of health problems/symptoms and their causes (17a-c), complications (17d), and treatments (17e). A similar effect is achieved with the modal expres- sions of usuality, which are mostly found in presenting patients’ feelings and symptoms as anticipated (17f-h). 17) a) It could signal an infection. b) That’s probably the reason. c) It sounds like indigestion. d) Might lose some feeling in your toe. e) …will probably start you on some antibiotics. f) Nausea is sometimes a reaction to post-operative. g) This is common with glandular fever. h) It isn’t unusual for patients to… Moreover, the necessity of nurses’ actions is shown primarily via the modal verbs need to and have to, which may be less threatening than must (18a-b). Similarly, less threatening modulat- ed formulations expressing obligation and necessity on the part of patients are used to con- trol patients’ behaviour (18c). However, strong obligation related to medication is expressed with the modal verbs must and should to signal nurses’ maximum engagement in making patients take their instructions with the utmost seriousness (18 d-f). 18) a) We’ll also need to make sure that… b) I have to put this tourniquet on your finger. c) You need to follow some instructions. d) You should also make sure to… e) Statins which you must take every day. f) You should always take the tablets with food. By proclaiming, nurses show that they listen attentively and understand their patients’ feel- ings (19a-b). Similarly, nurses use of course and sure to exclude all other possibilities but willingness to help when asked for help. Additionally, nurses’ clarifications for the sake of the patients’ comprehension of important information and instructions, medical explanations of causes of health problems/symptoms, and reasons and purposes for using medication, as well as treatment and procedures (19c-h), not only increase the credibility of these proposi- tions but also point to the nurses’ knowledge and patient-centred approach. 35 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 19) a) It certainly is painful. b) I know what you mean. c) This means… d) That’s why/because/the reason…, e) … caused by…, f) …so/that… g) It’s to minimise infection h) …is a result of… Regarding disclaiming, denials (often in commands) are used to alleviate patients’ doubts and worries (20a-d), show empathy (20d-e), and act carefully and professionally by rejecting the possibility of changing the protocol of using medication (20f), the disclosure of certain information (20h), and the necessity for certain medication (20j), by clarifying (20g), prohibit- ing certain food (20k), and giving instructions for use (20l). Some of the counter-expectancy elements used by nurses function as reassurance of the patients, which may have a soothing effect (21a-b). 20) a) Nothing to worry about. b) No, your temperature is normal. c) Don’t worry. d) Don’t be embarrassed/cry. e) It’s not easy for you. f) It is not possible to start with… g) I am not saying that. h) I cannot give you any more information. i) Don’t take more than… j) You don’t need any antibiotics. k) Don’t eat a lot of snacks. l) Don’t touch the inside. 21) a) It’s only a short-term treatment/a gentle suction. b) They are still not medications. Attribution, although rarely used, may also help trigger positive judgement targeting nurses based on their professional knowledge (22a). 22) a) They are called statins. 36 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 6 Discussion Effective communication between nurses and patients is of enormous importance (Gunther & Alligood, 2002), with language being a means of communication. Due to the globalised nature of today’s world, in which English has become the world’s dominant language, nurses may deal with a diversity of patients. It is thus vital for trainee nurses to learn and use English appropriately as it is not only “integral to professional accountability for nurses” (Allen et al., 2007, p. 49) but also a tool for building rapport with patients via empathy, trust and respect (San Miguel et al., 2006). The present study set out to explore the occurrence of appraisals, hence the language of evaluation, in nurses’ propositions in sample nurse-patient interactions, which are designed primarily for educational purposes, by applying the appraisal model (Martin & White, 2005). In this way, we set out to establish whether these also employ appraisals that help build a good rapport with patients, thus contributing to effective communication. As anticipated, due to the educational nature of these interactions, which was also expected to emphasise the role of rapport in effective communication, the findings have confirmed this. This also shows that the application of the appraisal model by Martin and White (2005) proved to be useful in exploring the establishment of rapport via language. The findings show that all three main appraisals – attitude, graduation and engagement – are used in nurses’ propositions, and that most of these participate in the building of a rapport with patients. Judgement is the most commonly used attitude, more specifically, as a positive attitude and as a token. The reason for the prevalence of the judgement may be attributed to the frequent use of language that nurses use to build a rapport with patients, i.e., language that indirectly conveys, for example, empathy, respect, politeness, support, interest in the patients’ well-being, support, readiness to help, immediacy of help, reassurance, and trust, which implic- itly evaluates nurses’ behaviour as positive judgement, particularly in terms of social sanction (propriety). Kindness, helpfulness, respect and sensitivity are listed as some of the characteris- tics of a caring relationship in healthcare (Croona & Gustafsson as cited in Jangland, 2011, p.19). Based on the high frequency of occurrence of judgement, together with the occurrence of other appraisal, in sample nurse-patient interactions, as the results of the analysis reveal, obviously points to the significance of a rapport building, especially since these interac- tions are mainly designed for educational purposes. Our findings thus support not only the claim that the establishment of patient rapport is of utmost importance (Leach, 2005) but also the claim that that a nurse-patient relationship is not only of a professional nature but also encompasses human components (e.g. Ule, 2003; Riley, 2008; Stričević, 2011), i.e. “seeing the patient as an individual” (Croona & Gustafsson as cited in Jangland, 2011, p.19). Further, our findings show that affect is rarely used. The rare occurrence of emotions in nurses’ propositions may not be surprising since health problems should be approached with utmost care and seriousness, whereby (too many) emotions from nurses could be per- ceived as unprofessional and too personal, hence frivolous. Appreciation occurs mainly as language that implicitly conveys nurses’ empathy, as well as concern for the patient’s well-be- ing, health, and safety. Perhaps surprisingly, graduation and engagement occur more frequently than attitude. How- ever, our findings reveal that both play a significant role in the expressions of implicit positive 37 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 judgement targeting nurses’ respectful, trustful, polite and knowledgeable behaviour as a part of a strategy for building a rapport with patients. Our findings are in agreement with the Major and Holmes (2002, 2008) findings which showed that certain language that is identified in our study as an explicit or implicit positive evalua- tion of nurses’ behaviour and approaches is claimed to be one means of achieving a positive nurse-patient relationship. The findings of the current study seem to provide good cues for material developers and teachers of ESP in nursing to incorporate language that evaluates nurses’ behaviour and ap- proaches positively. In this way, trainee nurses not only become aware of lexico-grammatical features that express attitudes explicitly and implicitly, helping build a rapport with patients, but also the potential of graduation and engagement in the expression of attitudes. The present study is useful for pedagogical purposes as it gives practical examples of apprais- als as a rapport building linguistic tool. This language is relatively straightforward and thus easy for trainee nurses to learn. Trainee nurses become aware of lexico-grammatical sources of appraisals such as, for example, evaluative lexis, questions, certain set phrases, denials, coun- ter-expectancy elements, modal verbs and adjuncts, intensifiers, logico-semantic elements, repetition as listing, quantifiers, and modulated commands, which are identified in our study as direct and indirect realisations of positive judgement. Since tokens of attitudes, which slight- ly prevail over inscriptions (with some disparity among individual attitudinal subcategories re- garding the frequency of occurrence), play a significant role in a rapport building, it is even more important for trainee nurses to become familiar with the language that realises them. Teachers can compile consciousness-raising tasks to be carried out to equip nursing train- ees with these linguistic resources. For example, student nurses search for language that expresses nurses’ professional knowledge as a trust building element, or language that con- veys nurses’ empathy. Additionally, evaluative language that boosts effective communication based on nurses’ positive behaviour and approaches can be focused on aural and written nurse-patient interactions that are already used in ESP classes for nurses. Further, the fo- cus can also be widened from appraisals in nurses’ propositions to appraisals in patients’ propositions to prepare student nurses for appropriate reactions and responses. Equipping nursing students with the above listed lexico-grammatical evaluative sources can help boost their linguistic and communicative competences. It is necessary to add that our findings are not only applicable for (trainee) nurses as non-native speakers, thus in a non-English cultur- al setting, but also for (trainee) nurses who are native speakers of English to increase their awareness of evaluative language (appraisals) in building a rapport with patients. 7 Conclusion The importance of language in good communication and the quality of nursing care has been widely acknowledged. With increased workforce mobility, student exchanges, and the dom- inance of the English language also comes the need for nurses to learn English and devel- op communication skills. To communicate effectively with patients from different linguistic, ethnic and cultural backgrounds, nurses’ choices in language and language use per se are certainly vital elements. 38 Križan, Majcenovič Kline / Scripta Manent XVI/1 (2021), 19–41 The paper aimed to examine the occurrence of appraisal in nurses’ propositions in sample nurse-patient interactions in English as an effective interactive linguistic means for building a rapport with patients. The findings show that nurses’ propositions frequently display language that not only inscribes attitudes but also implicitly conveys empathy, understanding, willing- ness to help, respect, politeness, interest in patients, support, reassurance, and trust-build- ing, hence evaluating nurses’ behaviour as positive judgement. 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