How nurses accommodate language in professional discussion: a case of multilingual Malaysia

Author: Iloka Benneth Chiemelie

Published: 04/12/2013

CHAPTER 1

INTRODUCTION

1.1 Introduction

The forms of address used in the openings and closings of a conversation are an important part of language studies for a number of reasons. Research on these forms of addresses may lead to explanation about how individuals in various communities address their conversation partners. Such conversations could be between any addressors and addressees such as family members, teachers and students, members of the royal family or employers and employees.  Slobin, Miller & Porter (1968) revealed the communication patterns between employees and their superiors. The variables observed by him were the address forms the employees used with their superior, fellow workers and subordinates. He found out that first names were used between equals and subordinates while title and last name were used with superiors; also, the different forms of address used were important to establish relationships between strata within organizations.

The present study analyses communication between nurses and patients to add to the contributions made by previous research. Such a study is especially useful in multiethnic societies like Malaysia. A study on forms of addresses in openings and closings of conversation between nurses and patients in multicultural, multiethnic Malaysia may provide information on the sensitivity to language related issues in such societies. The forms of address used by nurses with patients depend on a number of factors including the language used by the interlocutors. In addition language choice or preference of an interlocutor influences the term of address used. This issue was discussed in a study entitled “The study of address terms and their translation from Persian to English” by Keshavarz (1988). She found that when translating from Persian to English, selecting appropriate and equivalents forms of address is one of the problematic areas. Keshavarz clarified the complexity of the terms of address used in Persian and English and used the translation strategies proposed by Newmark (1981) for translating cultural words. It should be noted that culture is one of the most important factors involved in the use of address terms and the choice of appropriate and equivalent terms must be done carefully when translating from one language to another.

This study is based on the importance of effective communication between nurses and patients. Nurses are individuals who communicate with patients more frequently compared to other hospital staff. It is vital for the patients to receive correct information in an appropriate manner from the nurses. It is the duty of a nurse to know how to speak and converse effectively. The forms of address used by nurses in the openings and closings of a conversation play a major role in producing effective rapport and hopefully will result in effective communication. Dellasega (2009) has stated that nurses tend to have intimidating and disruptive communication behavior. Thus, a study on forms of address used in the nurse-patient communication could fill the current gap which exists in the research about communication between nurses and patients.

The studies on the quality and service of Malaysian nurses provided in the literature show that the Malaysian nurses are skilled, trained well and capable of multitasking and handling emergency situations. Despite that, it was found that most nurses lack communication skills. Very little research has been conducted on forms of address used in openings and closings in nurse-patient communication. It is hoped that this study focusing on address forms used by nurses will help to fill the gap which exists and lead to suggestions that can contribute to effective nurse-patient communication.

The aim of this paper is divided into two. The first aim of this study was to determine the forms of address used in nurse-patient communication, specifically in the openings and closings, in a multilingual setting. The second aim of the research is to study the relationships between the forms of addresses used and language choice in nurse-patient communication.

CHAPTER 2

LITERATURE REVIEW

2.1 Introduction

In this chapter, the researcher will explore the literature related to verbal nurse-patient communication and will analyze studies on why communication between nurses and patients is important for successful nursing care, before describing various studies which focus on the use of appropriate forms of addressing patients.

According to Macleod-Clarke (1984), communication is a fundamental foundation of all nursing care and yet it is often been taken for granted or underestimated in the nursing area. Research conducted on communication in health professions provides a negative rather than positive point of view of such communication. It is challenging to conduct studies on communication in health profession as communication is difficult to measure or quantify, and despite its importance it is clearly not the only factor contributing to positive health outcomes. Most of the research on communication in nursing and related professions mentions the source of failures and possible solutions (Simpson, et al., 1991; Dickson, 1995; Heaven & McGuire, 1996; Alexander, 2001).

This study examines the appropriate forms used in addressing others, especially patients. Such appreciative enquiry aims to identify and build on positive aspects of what is being studied which, in this case, is effective communication using proper forms of address.

2.2 Communication in workplace

The use of language is important in a workplace and effective communication is crucial in professional relationships such as nurse-patient, nurse-doctor and more (Tullin, 1997).There have not been many studies on the role of language resulting in effective communication and the important ways in starting or closing a conversation in the nursing field. Effective communication between nurses and patients is vital as it enables the nurse to understand how a patient feels. Effective conversation using appropriate address forms is important as what is considered lacking in effective language might negatively impact on the welfare of patients.

2.3 The importance of communication in nursing

Producing effective communication especially in the nursing field is important not only because it can help provide accurate diagnosis and treatment, but also because communication is a significant factor in patient satisfaction surveys. For patients, it is important to feel respected and valued and this, or indeed the opposite feelings of being disrespected and undervalued can be determined by the way a nurse starts a conversation with them, and how the nurse closes the conversation.

It is not only about talking, but talking to give and take important medical information. In a selective review of the literature on the nurse’s role in nurse-patient communication, Jarrett and Payne (1995) identify several factors which are important in communication. They are:

·         Having good interviewing skills to understand and identify the problem

·         Attending to the patient as an individual rather than a collection

·         Sharing information between nurses and patients reduces stress

According to Jarrett and Payne (1995) patient satisfaction surveys show that poor communication and lack of information are significant areas of complaint. Kasch, 1986; Gunther & Alligood, (2002) explain that high quality nursing care (reflected in positive clinical outcomes) is characterized by effective communication. Communication in itself actually constitutes the care or nursing action in some instances (Mishler, 1984; Kasch, 1986; Parker & Gardner, 1991; Candlin, 2000; Fenwick, Barclay & Schmied, 2001).

2.3.1 Complaints and Patient satisfaction

According to the complaints received by health professionals from patients, lack of effective communication is the most common cause of complaints (Fosbinder 1994; Jarrett & Payne, 1995; Macleod-Clarke, 1984; Simpson et al., 1991). The complaints were not always about insufficient information but also sometimes too much, rather than too little, information was provided. At times the style and method of communication was inappropriate. Most nurses prefer using phone calls rather than providing information face-to-face. When the patients were asked about their perceptions of nursing care, “patients almost exclusively described the nurses’ as interactive style but don’t know what task she was doing” (Fosbinder, 1994, p.1087). A similar comment was made in relation to doctor-patient interactions, “Most complaints by the public about physicians deal not with clinical competency problems, but with communication problems” (Simpson et al., 1991, p.1385). Even today, in the health profession, communication problems seem to feature in the complaints received from the patients.

 In some professions, communication may not be considered as an essential tool in building a friendly working environment. But in the health profession, communication is fundamental and is the only way a patient can inform a nurse or a doctor on their health issues.

2.3.2 Beneficial effects of giving information

There is a strong trend towards sharing information between health professionals and patients’ even though there is the danger of too much rather than too little information occurring. Hinckley, Craig and Anderson (1990) state, “advocates for patient consumerism have encouraged more active participation by patients and activities focused on encouraging question-asking have developed” (p.524). In meeting the demands and needs of a patient, the medical profession is making much effort, but some physicians still underestimate the patients’ decision making capabilities and their desire for more information on the medical processes they are to undergo. This finding is reinforced by Simpson et al. (1991), who found that “Patient anxiety and dissatisfaction is related to uncertainty and lack of information, explanation, and feedback from the doctor” (p.1385). This shows that even when nurses respond to patients’ desire to be involved in the decision making process, they still do not provide sufficient information for the patients to make their own choices on treatment. In many circumstances, giving information is not only beneficial but also essential. Discussing options for medical treatment in such a way that the patient is fully informed but not unduly alarmed or burdened is a skill in itself and the only way to properly inform a patient about their health is through this high-quality, effective communication.

2.3.3 Interviewing skills to identify patient concerns

When using appropriate address forms, it is likely to become easier to communicate with the patient. As mentioned above, diagnosis and treatment can be most efficiently done with effective communication and there are various techniques of communication. The most common style, the question-answer method, can be used to get the immediate facts needed. For this method, closed questions are often considered effective. For example, asking a patient “Are you experiencing pain in this area” will require the patient to answer yes or no. Thus by using this method of questioning, the nurse will immediately get the answer she needs. But in the health profession, a more exploratory and less direct approach is often much more useful.

According to Mishler (1984), nurses are supposed to listen carefully to the stories related to their patient’s life. This can be useful in understanding their previous experiences and apprehensions. The nurses are then better able to contribute to diagnosis and treatment for the patients based on the stories told. This was agreed by Simpson et al., (1991), who said nurses should encourage and provoke patients to talk out what is captured in their inner selves to smooth the consultation process. 

A conversational style of interview is also advocated for nurses by Brown (1995), who explains the potential for such an approach to produce an accurate and good understanding of the client’s health. An advantage of this approach, she explains, is a more client-focused and less controlling environment than the traditional question-answer format of many medical interviews. In many cases in the health profession, patients feel that nurses dominate the entire conversation and do not give them space to voice their concerns. Patients are the most important entity in the health profession and the nurses should let them speak since this is likely to influence and ease the entire treatment process.

Appropriate and suitable forms of address are essential in starting a conversation as it forms the foundation of the talk. Using proper forms of address will make a patient feel more comfortable and may also encourage them to “come out” and express their hidden feelings, hopes and fears. Addressing patients with full respect, mentioning their titles properly when opening conversations and thanking them sincerely in closing conversations will lead to a better relationship and consequently more effective communication. This seemingly small step will likely in turn produce a potentially large positive impact on the health services being provided and result in considerable benefit for patients, health professional’s clinics and hospitals alike. According to Macleod-Clark (1984), patients with unrecognized psychosocial needs will take longer to recover. Because psychosocial needs should be identified and attended to largely through conversation, nurse-patient communication therefore becomes an essential part of these needs being identified and met.

2.3.4 Collaboration in the nurse-patient relationship

A nurse-patient relationship is the fundamental aspect in developing quality nursing care (Christensen, 1990; Johnson, 1993; Fenwick, Barclay & Schmied, 2001; Gunther & Alligood, 2002). Such a relationship can only be built on effective communication which basically starts from a suitable and appropriate opening. In a study conducted by Kasch (1986), quality nursing care is created through the role of communication and helps to maintain a positive relationship with a patient. He mentioned that “talk can be a great starting point to establish, maintain repair and even to terminate relationships”. Both the nurses and patients have professed that the quality of care increases when the nurse informs the patient the details of the treatment. Related to the activity of collaboration but not explored in depth is the notion of co-constructed meaning.  Coupland (2000) explains, through talk there is a co-construction of meaning, a concordance or therapeutic alliance so that both parties (nurse and patient) can work together for an optimal outcome.

2.3.5 Communication in itself can be remedial

There are number of researchers who have agreed that communication is not only beneficial to the perception of care, but also the verbal interaction can contribute to nursing care in some cases. According to Mishler (1984), communication is not only considered as mere talk, but an essential and critical component in clinical practice. Kasch (1986), too stated that nurse-patient interaction is important and runs parallel with nursing objectives.

Based on research done by Parker and Gardner (1992), nurses talk in their everyday work whilst performing ongoing supportive, maintenance and restorative activities such as delivering both technical and comforting care. Mishler (1984) was of the view that “talk is work” for the nursing profession and Parker and Gardner (1991) echo that with the sentiment that “work is talk”. Eventually both hold the same meaning that talking is important and very meaningful in the nursing profession. To facilitate such opportunities for “therapeutic talk” however, it is important to use appropriate address forms in the opening of the conversation.

2.4 Nurse-patient relationship and communication

                                                   

According to Aguilera (1967), the nurse-patient relationship is arbitrated by verbal and nonverbal communication. Despite the use of somewhat exclusive professional terminologies, relationships and communication do not differ much in any profession and so it is in nursing. According to Anderson (1979), just like communications, relationships are unique situations and are mutually constructed within a responsive and inter-subjective nurse-patient relationship. This was agreed by Aranda and Street (1999) in their studies on nurse-patient relationship. Relationships or communications can be said to place human beings in strategic situations aimed at overcoming their inner obstacles or problems. For example, in this study the only way for a patient to seek treatment is through communication and conversation regarding their health condition. For a nurse, only through effective communication is she able to gather information which is essential to the diagnostic process and treatment for her patients.

A nursing career and nursing care can be portrayed as two different entities. A career can be a fully professional pursuit, a striving for the highest standards of academic knowledge whilst good nursing care, despite a dependency on up-to-date knowledge, can be categorized as more humanitarian and directly interactive. Thus interpersonal relationship can differentiate nursing and caring (Tuckett, 2005). In the nurse-patient relationship, benefit is gained by both the parties. Thus patients gain more benefits, in the sense that they will get proper treatment for their illnesses and as previously stated, those benefits can only be obtained with a proper communication and sharing of information. The only way of sharing or gaining accurate and adequate information is through good communication based on a strong relationship between nurses and patients. Aspects like empathy, intimacy and esthetical distance, are important concepts within communication and interaction and can occur in the discourse of nurse-patient relationships. This was based on Larsson and Starrin (1990) research. Most of the studies conducted on nurse-patient communication and relationship are intertwined and strong concepts can be derived from the research. The most common empirical findings based on these studies were “being authentic” and “being a chameleon”.

According to Aranda and Street (1999), these two concepts were important in the nurse-patient relationship which carries the necessity of two different behavioural styles of interaction. Nurses, who adopt the career model mentioned above which may involve a more formal and less patient-focussed approach, need to be authentic and adaptive to the patient and the situation as well.

Understanding type of patients will enable nurses to deal with proper communication and use appropriate forms of address. For example, if a nurse does not build good relationship with her patients and addresses the patient incorrectly, misunderstandings and a less than ideal relationship may result. For this reason, as previously stated the opening to a conversation carries considerable importance and needs to be thoroughly understood by nurses and other health professionals. This is defined in the study done by Breeze and Repper (1998) who indicates that the professional relationship is an important aspect of nursing profession and medical interventions. How this is done may lead to positive or negative effects on the experience of patients related to nurses and this can in turn have an effect on a nurse’s working career. Bearing that in mind, this researcher is enthusiastic about studying the basic principles in a relationship between nurses and patients and the effect that forms of address have on subsequent developments within those relationships.

Anderson (1979), in his research, states that the nurse-patient relationship has the power to create major impacts on those who come in seeking care and treatment. In this case, the patients are the second entity in the relationship and guiding them properly can only be done through effective communication. When patients are treated well and respectfully by medical staff, they often cherish and value the relationship that results.  On the other hand, if a patient feels he or she has been treated disrespectfully the opposite can occur. The therapeutic relationship is constructed based on cultural values that often reflect the majority culture such as rugged individualism, autonomy, competition, progress and future orientation and rigid timetables. Among the principal factors in the development of any relationship but especially in the nurse-patient relationship are the different perceptions of the parties to that relationship. A nurse who uses names such as “kakak” for Malay females, “Achiee” for Indian old ladies or “po-po” for old Chinese ladies may well mean no harm and have entirely positive intentions however patients may see this form of address as disrespectful. These differences in perception can therefore result in serious problem within the development of an effective therapeutic relationship which could possibly be avoided in the first place by the simple mechanism of using proper address forms such as “Sir” or “Madam” or those preferred by the patients themselves, illustrating that major constraints or problems occurring in the developing nurse-patient relationship are sometimes avoidable with courtesy. Nurses mostly are not aware of the effect of using appropriate addressing terms to patients, in directly it also affects the relationship which at the end can be a downfall for the health profession.

In a nurse-patient relationship, the very first step upon which the entire relationship may be based is the initial communication which should be positive and respectful. Considering this from the psychological standpoint, it can be expected that a patient, who experiences this positive and respectful communication from a nurse and comes to consider the nurse as a professional and well-intentioned helper is probably more able to communicate his or her inner feelings without any constraints. This would seem to be a prerequisite for a good therapeutic relationship. According to Spiers (2002), irrespective of the specialist field of nursing, it becomes more important for nurses to have the necessary skills in developing effective relationships in order to cope effectively with ever increasing number of patients.

2.5 Theoretical Framework for data analysis

According to Paltridge (2000), discourse analysis is a process that can assist the understanding of what was said, what was meant and what was understood, especially in a particular context. Discourse analysis has been used in this study as a useful means for data analysis in chapter four. Many approaches can be used to analyze a discourse but there are two basic categories of discourse analysis, namely written and spoken, which are used in varies studies in the literature including those related to nursing communication

In analyzing the forms of address used in nurse-patient communication spoken discourse analysis was chosen as the medium in which the data was collected through naturalistic observation and noting down the nurse-patient communication. Spoken discourse analysis has been implemented in various qualitative studies. According to Brown and Yule (1983), spoken discourse analysis can be interpreted as a process in construing the collected text as records instead of raw data. In this case study, the spoken discourse analysis was considered appropriate as the researcher can immediately observe and understand the different forms of address used in the openings and closings of nurse-patient conversations.

According to Halliday (1989), a number of characteristics can be generated and assumed in the spoken discourse analysis, for example spoken analysis should generally be captured fast and the sound variable also has to be considered.

The researcher intended to apply spoken discourse analysis in her study as it permits more gestures and “non-verbal communication” to be taken into account in the process of data collection. Factors such as intonation, rhythm, pause duration and phrasing also can be observed and recorded, thereby contributing in no small way to the analysis of the data. For example, referring to patient with improper forms of address like “hey” can create different facial impressions in the addressee, directly indicating a patient’s level of discomfort with the form of address. For this reason and because the entire thrust of this study is communication and conversation, the spoken discourse analysis appears to offer the best options for data analysis.

Variations of approach as a conversation is terminated also impact the outcome of an interview or nurse-patient interaction.  This study will assess this aspect of communication and its impact on the patient relationship. As an example, if a patient is dismissed with the convenient but possibly disrespectful term “Aunty”, the entire “flavour” of the interview or communication may be considered by the patient as negative, however well the actual discussion may have been conducted. This is what will be analyzed in this study.

Spoken discourse analysis (SDA) takes the transcribed conversations and analyzes those texts to understand particular language choices made in each interaction. Discourse analysis assists the researcher to explain the relationship between what is said and what is meant in naturally occurring conversations between nurses and patients. One of the ways of approaching discourse analysis is to examine the “text flows” from one speaker to another speaker and from one topic to another. Factors like ethnic issues, politeness, being respectful and the need for the usage of forms of address with significant impact on the patients were analyzed. The content of the text and the way the relationship between nurses and patients was expressed in the text were studied and analyzed. The three features mentioned above textual, ideational and interpersonal are used by Mishler (1984). His research was conducted in a study of discourse used in nurse-patient interactions and has influenced the writer to utilise these features in her own study. An analysis of the data based on this framework will be presented in chapter four.

2.6 Forms of Address

In a conversation, it is very important to take note of the form used when addressing the other party. According to Baron (2007), addressing people with proper names or starting a conversation may well vary according to the age of the participants. The young may prefer to be called by their first names, whereas older people might not prefer to be called by their first name. Use of appropriate or suitable address forms helps in establishing and maintaining good relationships. Use of appropriate address forms is important both when starting and closing a conversation.

The use of appropriate address forms also varies according to cultures. For example in Malaysia, one may, in some circumstances, address a person as “sister” or “brother”, but it is not common in European countries. According to Gaudart (2008) problems therefore occur between Malaysian English speakers and native English speakers from other parts of the world. She suggests that Americans, British and Australians sometimes felt uncomfortable when addressed as ‘Uncle’ or ‘Aunty’. They preferred to be addressed by their first name, for instance, Carlos instead of Carlos Paul. Gaudart (2008) also explained that there are some consistencies of words like Mr, Mrs, Miss and Ms, in the form of address used in the English-speaking world. She found that Americans wished to be identified by their given name rather than using, for example, the more formal “Miss…” with their subordinates. However, Malaysians prefer the use of titles.

Young people and children are trained to address elders as ‘Uncle’ and ‘Aunty’ at an early age despite the fact that they may not be related to the person. This, in Malaysia, is considered a form of respectful address to be used when conversing with people older than the speaker.

In addition, problems often occur between Malaysians and non-Malaysians with Chinese names. For instance, “Thong Kok Loon” may be addressed as “Mr. Loon” instead of “Mr. Thong” or “Mr. Kok Loon”. Gaudart explained that Malaysians address people by using the honorific followed by the first name. For example, Lisa Lindly would be addressed as Miss Lisa.

The function of the address form is to maintain the distance, closeness and intimacy between the speakers. A word used with the intention of expressing respect or esteem towards a person is defined as honorific. Sometimes, the term of address being used does not exactly refer to the honorary title of the speaker because the use may depend on the social status and age of the speaker. For example, Miss, Mr, and Mrs are honorifics mainly used in the second and third persons.

The politeness theory initiated by Brown and Levinson (1978) is related to the address forms which function to sustain rapport between speakers. Forms of address are essential aspects of polite conversation. Wood and Kroger (1991) stated that “the way in which one person addresses another and in turn is addressed constitutes a pattern of great regularity” (p. 37). Hence, effective communication and the relationships which result which occur in institutional interactions may depend heavily on the use of correct forms of address and the maintenance of these patterns. Classification of forms of address varies according to countries. In India address terms were classified into nine categories, whereby in Columbia there are deemed to be five categories (Wood and Kroger, 1991). Listed below are types of forms of address and the way these have been customized in Malaysian usage.

2.6.1 Honorific or Terms of Formality

For most languages, the use of the honorific becomes a common feature. It is employed when the speaker wants to show respect to the addressees. In Bahasa Malaysia, like other oriental languages such as Tamil, Austronesia or Hindi, there are a number of ways to express feelings, which inclusive of honouring or used in order to dignify the addressed person. Honorific terms may include religious, cultural, occupational, and ideological meanings and even pet name (Aliakbari and Toni, 2008). Such terms as described above can also be used in number of ways; before, after or even with or without the name of the addressee. In making the speech appear more formal, Malaysian speakers often use terms of address such as sir, madam, gentleman, lady etc. Although the honorifics can be used as a term of address by themselves, they may also be used in conjunction with other forms of address such as “Dato Seri Najib” in which the honorific and family name are used. As in the previous example the honorific in language can even be used as evidence of socio-political status or function or the loss thereof.  For example, in post-revolutionary Iran, certain types of honorific terms have fallen into disuse. Terms relating to former royal families like prince or princess, his majesty, her majesty and your majesty are very rarely used in Iran today. (Aliakbari and Toni, 2008).

2.6.2 Kinship or Family/Relative Terms

A good number of Malaysian address terms indicate strong bonds in a family relationship among individuals (Afful, 2006) and the list of terms can be extensive in multi-lingual Malaysia. People of Indian, Chinese, Malay and other backgrounds use different terms of address with family members or other addressees. An interesting characteristic of some Malaysian speakers is the use “reverse addressing” in which a speaker uses his own title when addressing another.  An example of this might be a man calling to his son, “daddy, open the door”. In this example, the dad is using his own title in addressing his son and asking him to open the door. Another interesting and special addressing strategy is the use of family or relative terms for non relative addressees, as if they are calling a family member or a relative (Aliakbari and Toni, 2008). For example, terms of address may include appa/(father), enmagan/(my son), pakcik/(uncle), makcik/(aunt, however, among these “uncle” and “aunty”are common terms used by speakers addressing older people, irrespective of any actual familial relationship (Gaudart, 2008).

2.6.3 Title terms

In order to indicate social rank or gender in different situations, titles, represented by initials are used by most individuals (Brown, Roger and Gilman, (1960)). Some examples of gender-specific titles which Malaysian male and female speakers may use in their conversation are as follow.

Male addressees may be referred to by:

-          General Title (GT), such as Mr.boy,

-          GT plus first names like Mr. Ahmad,

-          GT plus last names like Mr Zain

-          Or a combination of all of these, e.g Mr Ahmad Zain.

Malaysian females are addressed in a similar way, using different title terms, general titles, being Mrs or Miss, Miss girl. So, for an example, a combination of general title and first names could be expressed as “Mrs Maryam” or a general title and last name becomes “Mrs Ahmad” with combined general title, first name and last names becoming “Mrs Maryam Ahmad”. But in Indian culture, husband names will be introduced into females’ names after marriage (Brown, Roger and Ford, 1964). As seen from these examples, although Malaysian people from different cultural backgrounds may use various combinations of title, first and family names, different terms and practices, based on cultural factors, may still be apparent in communication.

2.6.4 Personal Names

In Malaysia, addressing an individual by personal name may also occur in some situations with the possibilities such as:

1.      By first name, for example “Ahmad”

2.      By last name, for example “Zain”

3.      By full formal name, including both first and last name, “Ahmad Zain”

Malaysian names may vary according to the cultural or ethnic background. For example, Chinese and Malays mostly have middle names whilst this is not generally a part of the tradition for Indians. Furthermore, after marriage, many Indian females prefer to use the husband’s family name rather than their own family name. In Western culture, it is often appropriate and normal to be called by one’s family name rather than a given name, although this is also highly contextual and not always appropriate, depending on rank and social position.

It is common place for younger people to address each other by their given names and so this practice is not generally considered disrespectful. Thus, inserting honorific terms when addressing others may vary considerably according to a number of variables such as culture, ethnicity, age and more and it becomes necessary in most situations, including professional nursing interactions to be aware of these factors to avoid damaging a newly formed relationship upon which a good clinical outcome may depend.

2.6.5 In Openings

A nurse-patient interaction is constructed of three stages, the opening, the conversation and closing. The opening generally consists of greetings or “polite enquiries”. Greetings like “Good day to you Sir”, “Lovely morning Madam” and so on can be considered as a good opening strategy because they are positive and respectful. According to Parker& Gardner (1991), an opening of a conversation is generally briefer compared to the usual closings used in a conversation. According to Schegloff (1986) there are several elements in openings which are “summons/answer; identification/recognition; greeting tokens; and initial inquiries (“how are you”) and answers (Hopper et al. 1991: 370)”.

When discussing interpersonal relationships, a speaker can choose to make use of all the conversation strategies known at the beginning of a conversation as explained by Gumperz, (1982) and Schegloff (1986). Schegloff (1986) explains that the summons-answer opening sequence is used in telephone conversations and also in face to face interactions. The summon-answer telephone opening is used during conversations when the phone rings and hello is uttered by the party who answers the phone. The identification-recognition sequence explains the response of the second speaker and enables the parties to identify each other. When the identification/recognition sequence is being used, the speakers are able to identify and recognise an interlocutor. For instance, speaker A: Michael? : speaker B : yes! is mainly used in telephone conversations.

The third sequence which is the exchange of greeting tokens explains that a greeting is given and is responded to by the listener. This sequence is also used in daily conversations as it is connected to adjacency pairs and the turn taking process. For example, speaker A greets: Hello, speaker B replies: Hi. Finally the initial inquiries (how are you sequence) is where the first speaker asks or inquires about the second speaker. For example, how are you / I’m okay. How are you? The reply shows the action of a turn-taking process for an adjacency pair. This is used in daily conversations where changes to another topic occur soon after the greetings and signals the end of an opening. Soon after the actual conversation ends, the closing commonly occurs and this process represents the normal sequence in most conversations.

2.6.6 In Closings

Closings are important in a conversation. Simply saying “Good bye” is not the only way, or even the best way, to end a conversation. Labov and Fanshel (1977) said that closing a conversation is harder compared to starting a conversation. Schegloff and Sacks (1973) added that a particular conversation does not simply end but is brought to a close. Levinson (1983) states that it is technically and socially delicate to close a conversation whilst Button (1987) and Schegloff and Sacks (1973) have shown that effective closings have principles. Levinson (1983) supported the theory and formulae introduced by Laver (1981) and Coulmas (1981) so that whatever the nature of the conversation, the convention does not force one party to just leave while they still have something to say. Strenstorm (1994) said that speakers tend to initiate closings when they feel like ending the conversation. This implies that the initiation of a closing can start at anytime during a conversation, even, for example, before the intended conversation has taken place. For that reason, a mechanism is needed to identify the closings.

Giving a “closing signal” to the other party is one of the strategies used in closing a conversation. Goffman (1976) said that it is very important for a speaker to know and recognise the signal which is sent by the addressee using this strategy to close the conversation. Without this awareness and recognition of signals, the conversation may falter with negative consequences for the therapeutic relationship as one party attempts to continue whilst the other is desirous of an ending.

It becomes easier and more socially acceptable when both parties agree to end the conversation at the same time. To close the conversation, a topic closing is needed, followed by a pre-closing and then a closing so that a respectful termination of conversation can occur. A finishing and finalizing is defined as “topic closing” by Levinson (1983) whereas Strenstrom (1994) explained that topic closing is “the closure of any topic or closing of the whole conversation”.

The pre-closing is defined as a willingness to close the conversation which is done by putting some effort to bring it to an end as explained by Schegloff and Sacks (1973). Strenstrom (1994) explains that closings happen after pre-closing and take place when the party says goodbye. He added that ‘it functions as a post message talk ending the conversation’. Termination marks the end of a conversation and is the point at which words are no longer required.

Schegloff and Sacks (1979) explain that pre-closings are considered as identifying markers in American English and are signs that one party is prepared to terminate the talk but is offering the opponent an opportunity to start another topic of conversation. They explained that certain words such as “okay then” and “well…” should be taken into account to indicate that a topic or conversation is coming to an end. Schegloff and Sacks (1979) introduced several types of closings. Besides pre-closings, they identified the introduction of new topic which indicates the possibility of opening of a new topic as a means by which the current topic could be terminated. They also postulated the concept of a ‘summarising theory’ which is a brief summary of the subject or issue being discussed and arrangements that are made as a pre-closing strategy.

Finally they hypothesised the ‘final-closing, the actual ending of a conversation which takes place according to the context of the conversation. For example, good bye or thank you in formal context and see you later in the informal context. Closing strategies can be related to ‘politeness strategies’ because, in order to end a conversation successfully, it is important pay due respect to the other party. Brown and Levinson (1978) “we assume that being regarded as polite is achieved in part by maintaining, and, in case of threat, saving desired or conventionally valued aspects of others’ face” (p.1). This theory relates to avoiding offending the other party by simply leaving the conversation without proper, respectful closure.

Since these strategies and conventions obviously apply to everyday conversations, it becomes highly likely that in, nurse-patient interactions, they would be even more important in developing the professional relationships upon which the accurate information necessary to successful treatment is provided by both parties.

Brown and Levinson (1978) also explained that politeness strategies encompass both the “positive face” and “negative face”. They defined negative face as ‘the basic claim to territories, personal preserves, rights to non-distraction’ and positive face as‘the positive consistent self-image or ‘personality’ claimed during interaction’. They explained that positive politeness basically maintains a speaker’s self-image whereas negative politeness respects another speaker’s speaking rights and freedom to finish their conversation. Weinreich (1986) mentioned that “verbal interaction which comprises of openings and closings is easy to be accepted as being important for an interpersonal relationship, as it evolves, develops, and provides the face work”, supporting the contention that it is important to use correct and appropriate linguistic forms (openings or closings) during an interaction. Cameron (2001) explains that a speaker should take note of endings which involve inherent face threats.

Conversation strategies are created to save a speaker’s “face”. Ending a conversation without a proper closing can damage the possibility of a positive relationship, (critical in a healthcare environment), but can also reflect negatively on the reputation and professionalism of the person involved. Goffman (1967) explained that it is important to give the freedom to a specific speaker to end a particular conversation or continue speaking on the subject being discussed and interrupting a conversation avoids the ‘negative politeness’.

Coppock (2005) discusses several kinds of strategies in closings. The first one is ‘the positive comment’ which can be described as the most common closing strategy. It is a direct indication to indicate that the other interlocutor is not annoying or boring. For example, “I had a great time with you.”

Another is the ‘excuse strategy’ which explains “where the conversation gets to the root of the face-threatening chain of implications” (p.3-4). For example, “I’d better continue my work.” It takes away the insinuation that one desires to end the conversation by giving an alternative motivation, an alternative explanation for one’s potentially face-threatening behaviour.

Lastly is the ‘imperative to end strategy’ where it shows that a conversation must come to an end. Therefore, the interlocutors may use phrases such as ‘It’s time to leave’ or ‘It looks like times up!’

Pomerantz (1984) explained that dispreference markers are usually combined with many politeness strategies particularly “non-preferred responses”, for example, the opposing of or disagreement with statements in a peaceful discussion. For example, the use of words like “well…” or “so…”, followed by silence. Schegloff and Sacks (1973) disagree with Pomerantz suggesting that words such as ‘well’ may function like “pass” in the ending of turn-taking conversations. They further added that “its use as a marker as to that which is not preferable also contributes to its function in conversation endings”. Though Schegloff and Sacks (1973) disagree with Pomerantz, word like ‘well’ functions in the same way as the excuse and imperative to end strategies in the strategies of closing a conversation.

The combination of positive and negative strategy is one important strategy to be examined. On the other hand the blame which is a form of excuse explains that the need to leave by blaming and attributing the need to the other party (Schegloff and Sacks, 1973). For example, a statement such as “I think you’re not free now, I’ll get back to you” makes a speaker appear polite by saving their own ‘positive’ face.

When a conversation is coming to an end, it suggests that the goal of the conversation has been reached and that it need not be continued. Schegloff and Sacks (1973) explained that when a conversation need not be continued, ‘this construes ending as desirable outcome for the other, and is therefore a negative politeness strategy’. Next, may appear the summary which prepares for the up-coming end of the conversation. The summary indicates that the conversation took place, that it ended successfully and that the other party is now free to leave if he or she wishes to.   As a sign that the conversation is about to end, clearly this strategy also offers, for example, an opportunity for a patient to contribute further information to a nurse if necessary, which again may prove crucial in diagnosis and treatment.

In addition, Schegloff and Sacks (1973) introduced the topic-bounding which proposes up-coming pre-closings such as “well”. This explains that a topic may possibly close when a speaker proposes to one party and the latter concurs, allowing the topic to be brought to a close. This is a form of negative politeness which gives the interlocutors their freedom from the norms of usual conversation.

Another closing strategy in conversation is the “solidarity closing” (Schegloff and Sacks, 1973). Solidarity closing strategy is used to maintain the relationship between both speakers. Therefore, norms of politeness reflect the solidarity between the speakers. Schegloff and Sacks (1973) explained that when making arrangements to meet: for instance, ‘see you on Saturday’, ‘talk to you in a short while’ indicates that a speaker has made an arrangement for further discussion. This will maintain the solidarity between the speakers. Button (1991), cited in Coppock (2005), indicated that the general wish is aimed at fixing the solidarity threat posed by ending a conversation.  Expressing their good and positive wishes, like ‘have a fruitful day’ or ‘have fun!’ displays solidarity between the speakers. Brown and Levinson’s (1978) explanation on the second definition of positive face is related to Button’s (1991) ‘general wish’ theory which explains that solidarity is shown when one shows good wishes towards the other interlocutor.

2.7 Language in multi cultural society

Communication worldwide is a common effective way of sharing information and knowledge (Smith, 2011). Every religion in the world encourages their devotees to promote values of harmony, duty, respect, honor and allegiance to family through conversation or any other practices. Within societies of various ethnic and cultural backgrounds, one of the issues that often arise in a country such as Malaysia where over a hundred languages and dialects are spoken daily by the people is the choice of language (David, 2006).

When having conversation with someone, it is appropriate to know their cultural background, how to respect them, using polite terms and most important addressing people with forms, first names or last names. A good communication practice is responsive and sensitive to the addressee and this needs timely action or proper follow up after an intervention. Such manners show consideration of the individual’s wishes and preferences and family or care bond. Good communication respects the customs, beliefs, emotions and values of an individual. The following criteria highlights good communication practices in caring patients in a hospital setting according to Multicultural Communities Cultural, (2005).

·         Learn and use key words in the person’s own language to improve communication during routine care and doing some other medical practices.

·         Use proper gestures and physical prompts

·         Use proper language during assessment or consultation and seek the assistance of language interpreters when necessary. The person chosen for this task needs to understand the specific health situation of the patient,(for example whether the person is critically or dangerously ill),  and understand the general wellbeing of the patient.

·         If all information in delivering the service care can be implemented in the patient’s own language and the need to use respectful sentences is understood the communication is likely to be of a much higher quality.

As a way to achieve cultural competence, health care providers should have a sense of compassion and respect for patients with different backgrounds and cultures. When a nurse has an inherent caring, respect and appreciation for a patient, that patient may display warmth, empathy and openness in return, thereby improving the therapeutic relationship. According to Asmah (1982) “the social environment in Malaysia is a situation where various languages are used in daily communication”. This means that in a multicultural country different languages are used in daily conversations and it is therefore highly desirable for successful nurse-patient relationships for nurses to have at least some proficiency in the basics of major languages and cultural customs.

Using polite language is one of the ways of showing respect towards addressee. For example, the speaker may have high respect for the addressee, but if they use language that may not seem polite, it will affect the whole communication process. A common feature among Malaysians from the same linguistic background is to have their conversation with much linguistic interference as well as code-switching. Communication among Malaysians, where inter and intra group encounters are common, is seldom a straightforward use of one language, be it Malay, Chinese, Tamil or any of the vernacular languages (Jariah Mohd. Jan, 2003).

According to Baskaran (2005), the Malaysian array of English, which is widely used in informal settings in the country today, has endured massive “nativization”. In a study of a car assembly plant in Malaysia, Morais (1998) found that Bazaar Malay is generally used by members of all ethnic groups to varying degrees in day to day informal communication. The Bazaar Malay frequently used by older members of the Chinese and Indian communities differs in terms of pronunciation and intonation due to L1 interference. Morais furthermore pointed that the manifestation of occasional code-mixed varieties where lexical items of the minority languages and even English are inserted in the dominant Malay.

2.8 Accommodation in Communication

The linguistic form to build rapport and create effective communication will be discussed in this section. This includes the CAT theory otherwise known as Communication Accommodation Theory which was developed by Howard Giles, psychologist and linguist. The theory was the result of his studies in 1973, in which he sought to explain the process of creating communication bonds between speakers. Giles also suggested that the CAT encompasses the changes in communication style, vocal patterns, speech and gestures that occur to influence listeners. According to CAT theory, speakers in a communication carry their experience and backgrounds into the conversation, suggesting that speech and behavioural resemblance occur in all communication processes (Giles, 1979). Similarly, the theory suggests that accommodation is influenced by the way that people differentiate and gauge what takes place throughout a conversation, how people interpret and judge the messages. Furthermore, in the communication accommodation method there is a “tuning” of the speaker’s style of presentation to that of the listener in order to improve the listener’s comprehension and adoption of the message being conveyed, a clearly vital objective in any medical therapeutic interaction but especially so in the case of the “front-line” interactions of nurse and patient. Accommodation Theory involves understanding the patient’s ethnic, cultural and language style, enabling nurses to tune their own communication method and adjust the way they talk to maximise the effectiveness the gathering and imparting of information critical to the diagnosis and treatment of the patient.

According to Street (1991), accommodation is a combination of strategy and theory of communication which is also known as ‘Communication Accommodation Theory’ created by Giles. The theory of accommodation suggests that when people wish to establish rapport, win approval, associate, identify socially or communicate effectively, they become willing to adjust their conversation or, in other words, to use strategy to achieve their aims. According to Bourhis, Roth and MacQueen (1989), convergent accommodation is reflected in many ways such as changes in speech velocity, vocal strength, language changes and pronunciation switches. According to Street (1991), complementarity occurs when speakers mutually attempt to maintain their social differences communicatively. Accommodation divergence occurs when a speaker intentionally does not change the communicative style based on the person they are talking to. So, when an effective nurse communicator speaks to an Indian patient, the addressing style will be different to that used in the case of a Malay patient. In another example, if the nurse herself is Malay, then it would be appropriate for her to greet the Malay patient with a religious greeting whilst this may not be appropriate for other ethnic backgrounds. Accommodation is noted in the data of this study and will be referred to in the analysis in the Chapter 4.

2.9 Summary and conclusion

Address form is an important aspect in almost all communication as it is a major influence in the creation of a good relationship, rapport and the demonstration of respect. This applies in all careers and in almost all social settings, including the nursing field however address forms alone are not sufficient as they should be supplemented by ‘effective communication’. Starting a conversation with a proper opening and closing appropriately will enhance the entire communication process. In the health profession, nurse-patient communication is important as it is one of the most important ways vital information is exchanged and the patient’s comfort enhanced. As stated by Gaudart (2008) (See 2.6), young Malaysians are trained from their early years to use the term ‘Uncle’ and ‘Aunty’ to respectfully address older people however nurses, in order to be considered effective and professional, should be encouraged to broaden their communication to enhance the nurse-patient relationship with patients from other ethnic, cultural and language backgrounds. Accommodation theory can be considered an important and effective educational tool for this process.

 CHAPTER 3

METHODOLOGY

3.0 Introduction

In this chapter the methodological framework used to collect the data and the way the data is analyzed is discussed.

3.1 Selection of Method      

A mixed method was used to conduct this study. The data from this study has been obtained from observations and questionnaires. Williams (1993) has mentioned that “qualitative observations are believed to generate more valid information because it allows researcher to empathize with his or her respondents and view their situations from their own points of view”.

The sampling method chosen in this study was purposive sampling which is mostly adopted in qualitative research. Honigmann (1987) mentioned that “this method is logical as long as the field worker expects mainly to use his data not to answer questions like “how much” or “how often” but to solve qualitative problems, such as discovering what occurs, the implications of what occurs, and the relationships linking occurrences” (p.84).

 For the quantitative phase of the study, a set of questionnaires was given to participants. Participants were chosen based on a flexible set of criteria.  Participants who could deliver valuable data to answer research objectives of this study were selected. Selected participants were then asked to name another possible participant (Merriam, 1998).

            The data was collected by observing the conversations which took place between the nurse and the patient. Only the utterances related to the objectives of this study were recorded. This observation was considered to be ‘naturalistic observation’ under the unstructured observation. An observation carried out in a real-world setting is considered as naturalistic observation. ‘It is an attempt to observe things 'as they are', without any intervention or manipulation of the situation itself by the researcher. This has been described as a 'pure' or 'direct' observation’ (Punch, 2009, p.154). After observing the conversation, the researcher took a few minutes to complete the notes, which had been written by adding the necessary actions observed. After completing the conversation, the researcher confirmed any doubts with the other party to get more clarification. This procedure was conducted in accordance with Mack (2011) stating that “in community settings, researchers usually make careful, objective notes about what they see, recording all accounts and observations as field notes in a field notebook” (p.13).

            Connelly and Clandinin (1990) state that in all cases, qualitative observational research involves preparing a caring, kind and well-understood relationship and rapport between the researcher and participants. In order to understand more about the address forms used in openings and closings, observation was found to be an appropriate methodology. Observation plays a very important role in understanding the physical, social, cultural, economics which studies a participant’s life, the relationships among and between people, ideas, norms, characteristics, behaviors and activities. For instance, what are the activities which are being done, how frequently or often is it being done etc.

Besides using the non-participant observation method in the qualitative research, the quantitative research was also used in this study. Quantitative research statistically determines the research participant’s behavior, performance and attitudes and will normally give in data that develops to a bigger population using a sequence of tests and techniques. Quantitative research can efficiently decode and interpret data into easy quantifiable charts and graphs because it totally originates in numbers and statistics. A questionnaire was used to conduct the quantitative phase of the study. The questionnaires were then analyzed according to the frequency counts on the use of a particular address form used.

3.2 Instruments

The non-participant observation was used in the qualitative phase of the research whereas questionnaires were used to conduct the quantitative phase of the research. All conversations, which were observed, were written down unobtrusively and questionnaires related to the objective of this study were given to nurses to be answered. This questionnaire contains two parts. Nurses are supposed to answer all the questions in this questionnaire.

3.3 Setting

This research was done in University Malaya Medical Center (UMMC). The observations took place at 7U, the surgical ward. This research was conducted for 3 days at various times of the day.  In the ward, there were 3 other patients who were admitted. The conversations of these four patients with the four nurses in charge in this ward were also noted. On the other hand, the questionnaires were also given out to nurses in University Malaya Medical Center (UMMC). All the nurses who participated in this questionnaire were from various wards in University Malaya Medical Center (UMMC).

3.4 Participants

To conduct the qualitative phase of this research the non-participant observation method was used. Eight conversations were observed involving four female nurses, (three Malays and one Indian) one male Chinese patient, an Indian male and two female Malay patients. In contrast, the quantitative research using questionnaires involves only 30 nurses. As this is just a small study, 30 nurses were considered sufficient to conduct this quantitative research.

Each participant was observed on different times of the day, when the nurses on duty came to check the patient’s pressure, temperature and drip.  Each conversation was short as the nurses had to move on to the next patient so that they could complete their duty before the doctors came to examine the patients.

3.5 Pilot study

            Before the actual study was conducted, the researcher did some pilot testing by collecting data from few sample nurses and interviewing them. This was to ensure that the interview questions chosen and the survey questions would be understandable. See Table 1 and 2 below for the characteristics of the involved nurses and patients in the pilot study.

Table 1: Characteristics of patients involved in the participant observation

Patient Id	Gender	Race	Age (years)
Patient A Patient B Patient C Patient D	Male Male Female Female	Indian Chinese Malay Malay	55-59 35-39 50-55 45-49

Table 2: Characteristics of nurses involved in the participant observation

Nurses Id	Gender	Race	Age (years)
Nurse A Nurse B Nurse C Nurse D	Female Female Female Female	Indian Malay Malay Malay	25-30 25-30 25-30 30-35

           

Each patient was observed and checked by different nurses at various time of the day.  There were total of eight conversations which were observed. These are shown in Table 3.

Table 3: Conversations and patients involved at various dates

Conversation	Date	Patient involved	Nurse Involved
1	23rd November 2011	A	A
2	23rd November 2011	B	C
3	24th November 2011	A	D
4	24th  November 2011	C	B
5	25th  November 2011	A	C
6	25th  November 2011	A	A
7	26th  November 2011	D	D
8	26th November 2011	A	A

           

The questionnaires were distributed to 30 nurses for the pilot study. There were 19 Malay nurses, 7 Indian nurses and 4 Chinese nurses involved in this questionnaire (See Table 4).

Table 4: Characteristics of nurses involved in the questionnaire

Age group (years)	Race			Gender
	Malay	Chinese	Indian	Male	Female
20 – 25	2
26 – 30	5		2
31 – 35	2	1	1	1
36 – 40	3	1	2	1
41 -45	4	1
46– 50	2	1	1
51- 55	1
None			1

The table above shows the age groups, race, and gender of the nurses who were involved in the quantitative phase of the research. The table above shows that there were 30 nurses involved. One participant did not specify age. This, therefore; was categorized under the age group of ‘none’.

Although all the tables (Table 1-4) above illustrate the differences in age groups, race and gender, as mentioned earlier in limitations (See 1.5), this study focuses only on the objectives of this study regardless of the mentioned variables. The characteristics shown in the tables above (Table 1-4) are only to give an idea about the participants who are involved in this study.

3.6 Data collection

            Many factors needed to be considered in the qualitative phase of the study. One of these important factors was to obtain genuine data and naturally occurring conversations during observation. The researcher’s role here was to neutrally and objectively record the interactions using the qualitative investigation tools. All the observations were noted. The conversations were not recorded. This is not a disadvantage because this research mainly focused on the address forms used in the openings and closings of conversations. Saville-Troike (1982) mentioned that if the observer is absent, the observer would not be able to observe [hear] what would have been taking place (p.113). The writing of notes was conducted unobtrusively during the routine check up between nurse and patients, which took place more than three times a day. Throughout the interview process, the researcher wrote down the statements made by the interviewees.

             Delamont (2002) in Fieldwork in Educational Setting explains that recording what was said throughout the observation should be done as discreetly as possible, if possible not word for word but some key words or phrases would be helpful to jog the memory later.

In conducting the quantitative research, many important elements and aspects were considered. A questionnaire (See Appendix) is merely a ‘tool’ to bring together and accumulate information about a specific aspect of interest. It contains a list of questions. This composed questionnaire contains two parts, Part 1 has four questions regarding general personal particulars whereas Part 2 is divided into 2 sections, Section A and Section B. There are three questions which require short answers in Section A. Section B contains 4 parts. Part a discusses address forms in the openings and closings, Part b asks about the languages used to communicate with patients, Part c is about the openings and Part d is about the closings. All the questions in Part B are answered using likert scale (5-always/ 4-often/ 3- sometimes/ 2-seldom/ 1-never). Three statements in Part a require explanation whereas three statements in Part b are multiple choice questions.  The nurses were supposed to answer all the questions.

A questionnaire needs to have clear and understandable instructions, therefore; the instructions for this questionnaire were written clearly in order for better understanding of the participants. Questionnaires must always have an exact reason which is related to the objectives of the research. Thus, the objectives of this study were written on the front page and the title of Section A and Section B explained what were the objectives of the questions and

A pilot study was first conducted to check people’s understanding and ability to answer the questions, highlight areas of confusion and look for any routing errors, as well as providing an estimate of the average time each questionnaire will take to complete. Therefore, the first pilot study using this questionnaire showed that the instructions were not precise and clear. The participants did not know how to answer the questions as there were many redundant questions. This was then amended to remove the redundancy and repeated questions in different forms. After amending it, a second pilot study was done. This showed improvement as there were no questions asked which caused any doubts.  The second pilot study was considered to be successful. The participants involved were then given the final erosion of the questionnaire. They were informed about the aim of the questionnaire in order to understand the questions.

It is important to analyze and interpret the collected data carefully. The collected data were interpreted objectively. The forms of address used in the openings and closings, and languages used in the openings and closings in nurse-patient communication will be analyzed in the following Chapter. All the collected data will be analyzed and interpreted focusing on the aim of this research.

CHAPTER 4

DATA ANALYSIS

4.1 Introduction

In this chapter, findings obtained through observations and questionnaires will be discussed. The quantitative analysis of the data is done using the survey results from 30 nurses working in various wards of East Tower (Menara Timur) of University Malaya Medical Centre (UMMC). After highlighting the relativity of the survey questions and expected research findings together with the research objectives and research questions (See 1.4 and 1.5), the findings of the survey were tabulated in tables and graphs to represent the findings. The findings of the survey then were discussed based on the research questions (See 1.5) and answer them based on Paltridge (2000) discourse analysis frame work. The overall research findings and data analysis were summarized at the end of this chapter.

4.2 Analysis of the Results based on Research Objectives

The main objective of this research was to determine the forms of address used in openings and closings of conversations between nurses and patients. The gaps that exist along the way of the nurses’ communication can be recognized by identifying the forms of addresses used by them when communicating with the patients. The other objective of this research was to study the relationship between the forms of address used and the language choice in the communication between nurses and patients. In identifying this element, the relationship between language and ethnicity which involves the accommodation theory could be identified. The findings of this study can lead to future researches on language and ethnicity or how language and ethnicity in a multicultural society accommodates in communication across different cultures.

4.3 FINDINGS OF THE SURVEY

4.3.1 Quantitative Phase (Part 1 of the questionnaire)

The purpose of analyzing part 1 is to identify the age distribution of the respondents, which ethnicity the respondent belonged to, their gender and the languages they master. Since one of the aims of the research was to study the relationship between the forms of address and the language choice used in the communication between nurses and patients, it was important to identify the language spoken by the respondents and the ethnicity they belong to. Table 4.1 shows the age distribution of the respondents that took part in this survey.

Table 4.1: Age distribution of the respondents

Age range	Frequency
25 -29	8
30-34	6
35-39	5
40-44	5
45-49	5
50-54	1

Figure 4.1 shows the same distribution in the form of pie chart.

Figure 4.1: Age distribution (%) of the respondents

Figure 4.2 shows the distribution of ethnicity among the respondents who took part in this research. The majority of the respondents were Malays with the total number of 19. Indians and Chinese make up 7 and 4 respectively.

Figure 4.2: Distribution of ethnicity among the respondents

The respondents were both males and females. But there were very few male respondents compared to the females. Out of the 30 respondents, there were only 2 males. The rest of the respondents were females. Figure 4.3 illustrates this distribution.

Figure 4.3: Gender distribution among the respondents

The last question of Part 1 investigated the language spoken by the respondents. The data shows that all of the respondents   spoke two or three languages. Table 4.2 shows the distribution of languages spoken among the respondents. Majority of the respondents spoke Malay and English while nine of the respondents spoke Malay, English and Mandarin. The remaining seven respondents spoke Malay, English and Tamil. Thus 14 of them spoke two languages while 16 of them spoke three languages. This is related to ethnicity since Chinese and Indians in Malaysia have to learn Malay as the countries national language, and their ethnicity requires them to speak either Mandarin or Tamil.

Table 4.2: Language spoken among the respondents

Languages spoken	Frequency
Malay/English	14
Malay/English/Mandarin	9
Malay/English/Tamil	7

4.3.2 Quantitative Phase (Part2 of the questionnaire)

Part 2 of the questionnaire contained two sections. The findings of these two sections are reported separately in this subtopic.

Section A

Section A reported on how the nurses address their patients according to their age group. The relation is many to many types, where more than one nurse, uses more than one forms of addresses to address the patients. The patients are divided into age groups namely: children, younger patients and older patients.

Table 4.3 shows how the respondents generally addresses children and the frequency of each forms of addresses used.

Table 4.3: Frequency of the terms used by the respondents to address children

Terms	Frequency
Names	21
Adik	18
Lengloi	1
Lengchai	1
Thambi	1
Dik	4
Dei	1
Sayang	1
Hi	1
Boy	1
Hey	1

The table shows various languages used by the respondents when addressing children in the ward. The most commonly used term would be the children’s names. The frequency of using names is 21 times; which is the highest. Then the respondents tend to address children as Adik. This was shown by 18 responses. Another term with the same meaning as Adik which is Dik was the next commonly used term with a frequency of four. Some other terms found in this survey which are not so commonly used are Lengloi, Lengchai, Thambi, Dei, Sayang, Hi, Boy and Hey. These groups of patients were much younger than the respondents causing the respondents to be more jovial.

Table 4.4: Frequency of the terms used by the respondents to address younger patients

Terms	Frequency
Names	20
Adik	20
Dik	3
Hello	1
Hi	1

Table 4.4 shows the forms of addresses used by the nurses to address younger patients. It was observed that most of the terms used to address the children are not used when addressing the younger patients. Those terms are Lengloi, Lengchai, Thambi, Dei, Sayang, Boy and Hey. This showed that the respondents practice more formality when approaching the older patients. The age compatibility could be the reason since most of the respondents were in the group of 25 to 29 years old. In this scenario, the patients’ names are still the most preferred way of addressing the patients. The frequency of using names to address was equivalent to the frequency of using Adik (20 times). The less formal forms were used for this age group where a more formal word Adik was used more often. At the same time the form of address Dik was still used with a frequency of four. As mentioned earlier, both the words Adik and Dik are from the same language and carry the same meaning. It is just a norm or by preference that some respondents used one word instead of another (See 2.6.2, 2.7 and 2.8). Very seldom the respondents address the younger patients with Hello and Hi which are classified under greetings. The frequency is only one for each of these address forms.

Next in the list are the forms of address used by the respondents to address older patients. The terms used and the frequencies at which those are used are summarized in Table 4.5. The formality practiced in approaching the younger patients seemed diminishing and more when the respondents approach older patients.

Table 4.5: Frequency of the terms used by the respondents to address older patients

Terms	Frequency
Uncle	26
Aunty	26
Abang	5
Kakak	2
Pakcik	7
Makcik	7
Kak	8
Brother	2
Sister	3
Miss	1
Akka	3
Anne	2
Names	3
Bang	4
Hi	1
Hello	1

It can be observed that the form Uncle and Aunty are most commonly used; 26 times each. The word Abang was used more often compared to Kak. These two terms were the most commonly used words after the terms Uncle and Aunty with a frequency of five and eight each. Bang has exactly the same meaning as Abang but it is the individual’s preference to omit the first letter when addressing older people. The frequency for the form Bang was four. The forms Pakcik and Makcik carry the same meaning as Uncle and Aunty respectively (See 2.6, 2.7 and 2.8). These two are next commonly used with a frequency of seven each. It is just the individual’s preference and ethnicity variance that makes the respondents to choose either Uncle or Pakcik or Aunty or Makcik. The forms Brother and Sister are the translation of Abang and Kak  from Malay to English. Few respondents stated that they address older patients by using the forms Brother and Sister. The frequency of this form of address is two and three respectively. At the same time, the term Kak is pronounced as Akka and Abang pronounced as Anne once translated to the Tamil language.  These two forms were used at a frequency of three and two respectively.

The frequencies of using names were very few for this age category (three). Again, the age is the factor that contributes to such result. The majority of the nurses working in the ward were younger compared to the patients being handled. As such it is less likely for them to use the patients’ names to address them. The frequency reported for the forms of using Miss, Hi and Hello is only one for each. This quantitative study shows that nurses prefer using ‘kinship’ terms to address their patients compared to honorifics. This can be related to the nurses’ desire to maintain the relationship between themselves and their patients.

Section B

This section consisted of four questions a, b, c and d. The responses for each of these questions were analyzed.

Question a

Question a required the respondents to select a scale for three different statements and provide a reason as a supporting answer. The scale is a 5 level Likert scale, with 5 = always, 4 = often, 3 = sometimes, 2 = seldom and 1 = never. Table 4.6 and figure 4.4 show the summary of the responses on the likert scale while table 4.7 shows the reasons for all the three statement according to the scale they chose. The respondents that gave the same reasons, were compiled as a single entry in table 4.7.

Table 4.6: Summary of using address forms at different stages of conversation

Using address forms	Often	Sometimes	Seldom
Beginning of the conversation	19	6	5
End of the conversation	18	6	6
Throughout the conversation	13	4	13

Based on the analysis, the majority of the respondents often used a kind of address form when communicating with patients at all stages of the conversation. But it is apparent that a lower number of respondents use the forms of addresses throughout the conversation even though they admit that they often use the address forms. There are 19 out of 30 respondents who often use the forms of addresses in the beginning of the conversation, 18 uses at the end of the conversation and 13 who used them throughout the conversation.

The overall distribution of using the address forms only sometimes at all three different stages of conversation is obviously lower compared to the often usage. It is observed that only six respondents stated that they use address forms at the beginning of the conversation and at the end of the conversation and four respondents responded that they use address forms throughout the conversation. Only five and six out of the 30 respondents stated that they seldom use address forms in the beginning of a conversation and end of a conversation while 13 of the respondents stated that they seldom use address forms throughout a conversation.