A Systemic Functional Linguistics Analysis of Cohesion and Coherence in Written Nursing Care Reports

This study analyses 25 nursing care reports written by nursing students majoring in the International Class of Nursing Diploma at a higher education institution in Indonesia. The main research focus is to assess the cohesion and coherence of nursing care reports in relation to their grades. The Systemic Functional Linguistics framework, with a focus on the textual metafunction, serves as a tool for analyzing cohesion, Thematic structures and Thematic development of the texts. The analysis of text cohesion revealed that all texts predominantly used lexical cohesion and reference to build internal ties within the texts. Reiteration of the same lexical items throughout the texts and heavy use of personal pronouns indicated the exploitation of these systems. In terms of coherence via Thematic structure, it was found that textual Themes were predominantly used. All the texts relied heavily on unmarked Themes, with no evidence indicating a proportional use of marked and unmarked Themes. In terms of Thematic development, Theme reiteration was the main method of text development for all texts. However, a few instances of Zig-zag Thematic development were found in texts in the higher graded categories. None of the texts used multiple Rheme patterns as an alternative method of text development.


INTRODUCTION
Globalisation has significantly advanced the status of English in professional workplaces. Evans (2010) states that globalization and decolonization are two influential factors contributing to the primacy of English as a professional language. Evans points to Hong Kong as an example of a country that relies heavily on the use of English as a tool of communication in economic activity and a means of integration into global economies. Such incentives have brought English to the center of the global system as the means of formal written communication in professional workplaces (Graddol, 2006in Evans, 2010. One instance of the growing status of English as the language of professional communication is the need for English skills in the healthcare sector. English plays an important role for nurses seeking a job in Western countries. As professional healthcare workers, nurses are required to meet a certain level of English proficiency to be hired in LQWHUQDWLRQDO KRVSLWDOV $ VWXG\ FRQGXFWHG E\ 2 ¶1HLOO KLJKOLJKWV WKH ZD\V LQ which international nurses who use English as second or foreign language adapt and integrate themselves into the Australian workforce. The study involved ten participants, of whom five were Indian, four Chinese and one Nepalese. The result showed that these nurses faced difficulty in managing their roles as language learners and professional health workers. The participants responded that they were not supported by sufficient language knowledge and social and cultural information. These findings are in line with the statements of Nickerson (2015) on the influence of the language and culture of the country of destination on the use of language in a workplace.
For international nurses, the problems of developing English skills are inseparable from the English courses provided to them by their former educational institutions. A study by Saragih (2014) conducted in Indonesia reveals that there is no designated ESP curriculum in nursing programs run in nursing colleges in Indonesia. 50 Nursing students from 5 different nursing colleges, 5 ESP lecturers, and 2 Indonesian nurses working in English speaking countries were respondents for this study. From the interview, Saragih noted that the majority of the ESP lecturers used no specific curriculum. Different institutions have their own ESP courses for nursing, with differing standards of competency. Consequently, ESP lecturers are obliged to use relevant sources taken from the internet or books in which most of the content is in general and academic English. Ideally, English for nursing curricula should contain specific materials to meet the specific learning needs of specific learners.
Within the present research context²that of nursing students majoring in the International Class Program at a higher educational institution in Indonesia²the necessary subject content of English for Nursing education is the field of nursing care. Nursing students in this international program are trained to be able to provide clients with standard nursing care. Besides the provision of care itself, all actions taken by nursing students must be documented in a nursing care report which is written in English. This is because the nursing care reports will be read by other nurses and health practitioners from the practice hospital which is based in Kuching, Malaysia. To ensure the readers to get access to the information, therefore, English is chosen as the official language for communication.
As a written text, the nursing care report relies on its coherence and cohesion as a means of delivering the intended messages.  A number of studies on cohesion and coherence have been conducted by investigating  the use of Theme±RhHPH DV D IUDPHZRUN IRU DVVHVVLQJ FRKHUHQFH LQ VWXGHQWV ¶ ZULWLQJ  (see Arunsirot, 2013;Aziz, 1988;Ebrahimi & Khedri, 2012;Hawes, 2015). Comprehensive research on this topic was undertaken by Wei (2016)

Research Design
This study uses discourse analysis as its research method, within which an SFL framework, with a focus on the textual metafunction analysis, serves as a tool for analyzing and interpreting the data. From this perspective, a clause is always a representation of (i) the experiential meaning that the author intends to express, (ii) a form of interaction between the author and the reader and (iii) a means of organising a structured text, telling the readers about the writer's experience of the world and inviting them to experience it also.
The analysis highlights cohesion in the text through the identification of specific language systems, such as reference, conjunction, substitution, ellipsis and lexical cohesion, which are exploited by text makers. In addition to cohesion, the coherence of text is also identified. From an SFL perspective, text coherence is achieved through the appropriate deployment of Theme±Rheme structure and Thematic development 7KHPDWLF SURJUHVVLRQ $ WKHPH DV µWKH VWDUWLQJ SRLQW IRU WKH PHVVDJH +DOOLGD\ Matthiessen, 2004), is the first constituent in the clause and tells the reader what the clause is about. Rheme is remainder of the clause that comes with the Theme.
In terms of Thematic structure, three kinds of Thematic organizations are investigated in this research: topical, interpersonal and textual Themes (Eggins, 2004 (Eggins, 2004, p. 302). The last type is textual Theme, which shows a cohesive tie within a clause which is realized through the use of continuity adjuncts, such as µRK ¶ µZHOO ¶ µ\HDK ¶ DQG µQR ¶ and conjunctive devices (Eggins, 2004).
Another element that needs to be analyzed in relation to the coherence of text is Thematic development or Thematic progression. This concept refers to the ordering of Theme and Rheme throughout a text. In other words, the order of Theme-Rheme in a text determines the category of Thematic progression being used and this choice affects the text coherence. Eggins (2004) categorizes Thematic development into three types: Theme reiteration, the Zig-zag pattern, and the multiple Rheme pattern. Theme reiteration is shown through the reiteration of the same topical Theme throughout the paragraph, while the Zig-zag pattern places an element that made up the Rheme in the previous clause as the Theme in the next clause. The multiple Rheme progression takes place when the Rheme of the first clause comes with an element that can then be split up and used in the Themes of the clauses that follow (Droga & Humphrey, 2002).

Setting and Research Objects
The present study used a sample of 25 nursing care reports written by nursing students majoring in the International Class Program at a higher educational institution in Indonesia. A small set of data was taken from the Case Description section of these nursing care reports; this section elaborates on the client's identity, history of illness, past medical records and family's history of illness. This information functions as a guide for a nurse in performing a further assessment and taking actions to care for the client. More importantly, in the educational context, this section offers a picture of students' real writing ability, since students are required to describe and report in their own words what they have done during preliminary clinical observation. Students are not required to quote from external sources in these texts. As an academic piece of writing, the text should be written in the correct format and present clear information to readers, nurses or other healthcare practitioners. Failure to write this report appropriately may create difficulty for stakeholders in understanding the intended messages.

Data Collection Method and Analysis
The data were taken from 25-photographed case description-sections of the nursing care report. At the time of the investigation, the soft files of the documents were not accessible due to the library only has hard copies of the documents. So, the data were only possible to be garnered through photographs. The data were classified into three achievement grades: Grade A, Grade AB and Grade B because the reports were graded and marked. The grading was compiled with the Guidance of Assessment of Nursing Care Report of that institution. Below is the marking system quoted from the division of Evaluation and Assessment of that institution.  The analyses were undertaken in two steps: the analysis of text cohesion and the Theme±Rheme analysis. More specifically, the analysis followed the steps below: 1. Locating and numbering each T-unit; Identifying the Theme±Rheme division in each T-XQLW XVLQJ D VODVK µ ¶ Identifying Thematic structures and Thematic progression types in each sample of text; Counting the raw numbers and calculating percentages; Tabulating and presenting the data; Conducting discourse analysis using SFL framework; and Making inferences and conclusions.

Outcomes of the Text Cohesion Analysis
The findings encapsulate how the exploitation of the systems of reference, lexical cohesion, conjunction, ellipsis, and substitution contribute to the cohesion of the nursing care reports. that describe the use of reference within nursing care descriptions: personal, demonstrative and comparative reference.
The following example illustrates how personal reference was used throughout the texts. Client (P) said that her family (P) does not have any disease such as a cyst or a tumor and client (P) also has no tumor disease in advance. Client (P) said in her family also there was no sufferer hereditary disease such as (C) hypertension, diabetic mellitus, etc. &OLHQW ¶V KXVEDQG 3 said that in their family (P) also there were no sufferer breast cancer and any other cancer. Client (P) said that only she (P) in her family that sufferer this (D) cancer.
Note: P = Personal reference, D = Demonstrative reference, C = Comparative reference.
From that example, there is only one instance for each of demonstrative and comparative references, while the remainder of the text is cohesively linked through the use of personal references.
The present study further delves into semantic ties within the elements of the clause by examining word repetition and the relationships of synonymy, antonymy, hyponymy and meronymy that occur within the text. The nursing students demonstrate the ability to use specific language features indicating semantic ties between the elements of the text, even though, to some extent, their skill in this area is limited and inflexible. Repeating similar words throughout the text is a common issue for students. On the other hand, competence in using other resources, such as synonymy, antonymy, hyponymy, and meronymy, is still below the expectation. This skill is very limited and does not reflect a sufficient command of language proficiency in relation to building a cohesive English text among these students. The following excerpt is evidence of this issue: The textual Themes in those three texts are realized in the use of conjunctive devices: when, before, after, next, but and.
Other resources that are used by the students to produce a cohesive text are ellipsis and substitution. The use of these resources aims to avoid redundancy and repetition in a text.  Referring to that table, four examples of ellipsis are found in all samples, whereas no instance of substitution is found. Although the Grade AB texts contain ellipsis and substitutions, the ellipsis is still the most frequently used resource. There is no significant comparison to be made between ellipsis and substitution in the Grade B texts since there is only one example of each item.  Although the result shows that the highest frequency belongs to the use of topical Themes in nursing care reports, this is not the case for comparison. The study has merely considered the instances of textual and interpersonal Themes as key elements to determine how the students structured their texts. According to the data, the students demonstrate limited ability to use textual Themes to structure their writing. This is indicated by the small proportions of textual Themes of the total: 52 textual Themes out of 314 were found in the Grade A texts, 191 out of 922 in Grade AB, and 14 out of 93 in Grade B. However, there were no incidences of interpersonal Themes found in any of the texts. Grade AB seems to represent texts using more textual Themes than the other grades. In relation to text organization, the analysis also highlights markedness of Theme as a µVWDQG RXW IHDWXUH RI WH[W FRKHUHQFH 'URJD DQG +XPSKUH\ DUJXH WKDW PDUNHG Themes that are chosen by a competent writer or speaker may contribute to the information that the writer tries to focus on and shape a distinctive text organization. From the data in Table 5  The coherence of the text can be further examined through the use of Thematic progression. Thematic progression determines how the text develops and reveals the logical thought patterns of the author. The data below describe how patterns of Thematic progression differ across the three grades. The underlined parts signal how these texts progress through the reiteration of those ZRUGV 7KH SUHGRPLQDQW XVH RI 7KHPH UHLWHUDWLRQ UHIOHFWV VWXGHQWV ¶ OLPLWHG FKRLFHV IRU text development. This limited choice of Thematic development may hinder the reader from engaging effectively with the text by rendering the texts more formulaic and monotonous. In contrast, Zig-zag patterns are more likely to attract the reader to engage with the text, since they introduce new information through the text progression: Eggins (2004) argues that this type of text progression promotes a sense of cumulative messages flowing to the reader.

The Most Common Cohesive Device Used in Nursing Care Reports
From the data, the analysis reveals lexical cohesion (semantic ties) to be the most frequently used cohesive marker, followed by reference as the second most frequently XVHG 5HLWHUDWLRQV RI WKH VDPH SHUVRQDO SURQRXQV FRQVWLWXWH RQH ZULWHU ¶V VWUDWHJ\ IRU creating semantic bonds between the elements of the clause. This semantic bonding is aimed to maintain focus on the main topic of each text. Khalil (1989) infers that the RYHUUHSUHVHQWDWLRQ RI OH[LFDO FRKHVLRQ LQ ()/ VWXGHQWV ¶ ZULWLQJ LV FUHDWHG E\ WKHLU excessive repetition of the same vocabulary. However, Halliday and Hasan (1976) point out that repetitive occurrence of lexical items such as pronouns, prepositions, and auxiliaries may lead to a less essential role of the lexical items in making cohesive text. Fewer cohesive ties would mean fewer semantic ties, and this may lead to a poorer quality of writing.
In addition to these issues of the cohesive device, the repetition and the overuse of personal pronouns by the nursing students may point to students' very basic level of skill in making meaning in a text. The reiterations of the same personal pronoun throughout the texts may enable students to keep the idea on the track, but, it is not the only strategy to make text cohesion. Halliday and Hasan (1976) argue that reference is the way to establish a context for lexical cohesion.
To logically organize a text, conjunction plays a crucial role. 7KH XVH RI µDQG ¶ in those sentences may bear a sense of a more structural than conjunctive relation. This type of conjunction merely coordinates clauses; this means WKDW WKH UHODWLRQ EHWZHHQ WKH FODXVHV LV OHVV FRKHVLYH HYHQ WKRXJK HYLGHQWO\ WKH µDQG ¶ LV used cohesively to link one clause to another. Thus, the use of conjunction is not only mechanically correct; to make a linkage between the clauses, but its use should be functionally appropriate.
In addition to the function of adding information, conjunctions were also used to represent time settings in the nursing care reports. However, the students still demonstrated low levels of ability to use a wide range of temporal conjunctions. The µZKHQ ¶ FRQMXQFWLRQ ZDV RYHUXVHG LQ DOPRVW DOO WH[WV 5DWKHU WKDQ JLYLQJ LQIRUPDWLRn about a specific timing, this conjunction signals that a procedure (an action) has been undertaken or would be undertaken by the participant in relation to another action. , or to relate the procedure following a problem (i.e. the patient took fever relief) to the occurrence of the problem (i.e. the patient experienced fever). Other temporal conjunctions such as after that, next, then, before and after are tangibly used in the texts, but their small frequencies of use may not be able to account for text cohesion.
To summarise, the nursing care reports build text cohesion through semantic ties by the extensive use of repetition of the same lexical items throughout the text. In using this strategy, students may expect that they can keep their ideas on track. The cohesive ties between lexical items are inseparable from the role of reference as a context setter. Further, the use of conjunction in the nursing care reports, to some extent, has been misplaced. The chosen conjunctions do not necessarily reflect the appropriate functions, and merely stress the internal connections between the clauses. There are very few instances indicating the role of conjunction in external connectors between the texts.

Types of Thematic Structure and Thematic Development Prevailing in Nursing Care Reports
As discussed in the findings section, the study reveals that only textual Themes were used by nursing students in addition to topical Themes for text coherence. Extensive use of this Thematic choice is not uncommon in academic texts; conjunctions, coordinate and subordinate clauses often take on the role of textual Themes. The present research outcomes are in line with EggiQV ¶V VXJJHVWLRQ WKDW LQWHUSHUVRQDO 7KHPHV UDUHO\ occur in scientific writing.
Moreover, the absence of interpersonal Themes may be due to the fact that these texts by their nature contain more facts than opinions. Thus, the writers do not need to LQIOXHQFH WKH UHDGHUV WR DOLJQ WKHPVHOYHV ZLWK WKH DXWKRU ¶V YLHZSRLQW 7KH DXWKRU ¶V WDVk LV VLPSO\ WR SURYLGH YDOLG LQIRUPDWLRQ UHJDUGLQJ WKH SDWLHQW ¶V KHDOWK UHFRUG DQG PHGLFDO treatments.
The textual Themes are mainly used to set up a chronological order of the events that the clients' experience (when, before, after, next) and to add information regarding the QXUVH ¶V DVVHVVPHQW RQ WKH FOLHQWV ¶ FRQGLWLRQ and). Because the case description section of the nursing report presents a narrative of facts about the client and the history of his/her diseases, the conjunction function may serve to link events that took place. In other words, conjunctions are used to signpost the narrative line of the case. This is VLPLODU WR +DZNLQV ¶V LQ )HUJXVRQ FRQFHSW RI QDUUDWLYH LOOQHVV ZKLFK follows a three-part progression comprising the pre-condition of the client, the crisis of the disease and the post-treatment. Conjunctions are needed to relay the narratives through these stages.
With respect to the use of topical Theme, it can be understood that the writing format of the nursing care reports is quite formulaic. The focus of the content is more on the client's particulars and the time settings of events rather than the development of the text based on the writer's arguments. Compared to an argumentative essay, this writing pattern lacks text development and does not prioritize engagement between the writer and the reader.
Another Thematic element that contributes to text organization is the markedness of Theme. The majority of instances of Thematic markedness represent circumstances of location that are positioned at the beginning of the clause. This Thematic choice SURYLGHV FOXHV DERXW µZKHQ WHPSRUDO RU µZKHUH VSDWLDO DQ HYHQW RU SURFHVV LV occurring. To illustrate this choice, the following example depicts how marked Themes are used in these texts.
At the assessment on 3rd of June 2015 at 9 am, the client said that he had a cough with sputum but it's steady and difficult to come out.
One day before, he entered the hospital. He also complained of a headache, difficult to breathe, and his body felt weak. The underlined marked Themes indicate the time at which the events (a cough, headache, difficult to breathe and weak body) occurred. By placing this temporal information at the point of departure, the author draws the reader's attention immediately to the things that the author wishes to emphasize.
Through accident and emergency unit, client transferred to ICCU ward but she refused to hospitalized in ICCU.
In Sampit Hospital, client's child said that her mother was hospitalized about 1 day.
The preceding constituents set a spatial setting where the action is taking place (transferred to ICCU, hospitalized in Sampit Hospital). Thus, the temporal and spatial aspects are two important pieces information that needs to be explicitly evident in a nursing care report, and thus become the starting points that direct the text orientation.
Coherence can also be achieved through the appropriate use of Thematic progression. Thematic progression dictates how Themes are structured in a text. Based on the findings, the nursing care reports used Theme reiteration as the most means of Thematic progression. The writers simply repeat an element of the clause throughout the text in order to make the text focused. Let us examine the following example: &OLHQW ¶V Fhild said that this is the first time for her mother got this disease. &OLHQW ¶V child said that her mother has the history of falling down about 5 years ago. &OLHQW ¶V child said that her mother complains of a headache sometimes. &OLHQW ¶V FKLOG said that her mother has a history of gastritis.
This is a very basic means by which a writer can keep the text on the track of its main topic. Reiterating the same participant (the client's child) maintains the continuity of the text, but a text with unchanging Theme not only risks boring the audience but also takes on a static feel. Constant repetition of the same element of the clause means that we are always departing from the same starting point, and the new information contained in the Rheme cannot go on to be further elaborated in the next clause. There is a significant relationship between the writer's choices concerning Theme and Thematic progression. Where topical Themes are constantly realized through placing pronouns (participants of the clause) in the subject position, it creates a method of text development that relies heavily on the constant repetition of the same participant as a point of departure. Consequently, resources for coherence are confined to the use of a single choice of Thematic organization.

CONCLUSIONS
Considering the challenges faced by nursing students in writing cohesion and coherent nursing care reports, several basic steps can be implemented in writing lessons. In the first place, Theme-Rheme system and Thematic progression need to be explicitly taught to the students as the key criteria for the coherence of text and their practical uses are highlighted. Additionally, a wide variety of cohesive devices need to be explicitly taught to the students, along with their functional roles as elements of meaning-making. Learners need to be taught how to orient their readers towards the topics of their writing, the participants involved in the text and the context that surrounds the text through the appropriate choice of Thematic development (Thematic progression).
In terms of the assessment of nursing care reports, it is essential to assess the coherence and cohesion of the text along with the elements of textual metafunction rather than focusing solely on the mechanical aspects, such as error correction in grammar, punctuation, and format. Language should be viewed as a system of meaning potential, where the meaning is very context-dependent. Examining how people use English in a specific context is much more important rather than relying heavily on the achievement of curriculum targets. Finally, collaborative writing, as a writing process, needs to be extensively implemented as a strategy of teaching and learning, since it may open up opportunities for students to learn contributively and mutually from one another.
Although this study has revealed certain findings in relation to coherence and cohesion in nursing care reports, it is not without limitations. The samples taken from a corpus of 25 nursing care reports might not yield a comprehensive picture of the features under investigation. Since the research only focused on the nursing care reports as the artifacts of social activity (i.e. the interaction between nurse and patient), the written language of the document could be productively explored further with assistance from the writers, that is, the nursing students. In addition, the outcome of this study may not be generalizable to other types of medical text, since each type has its own specific progression and structural complexity.