The recording of information that concerns the current shift
largely requires verbs in the present simple, present perfect or
past simple tenses, i.e. ‘eats’, ‘has eaten’ or ‘ate’ respectively,
and adverbs of time such as ‘this morning’ and ‘12 noon’ and the
like. Notes intended for the next nurse on duty make it natural for
the reporting nurse to express the future using verbs such as
‘shall’, ‘can’, ‘must’ and ‘should’, and expressions of time such
as ‘this evening’ or ‘next week’.
Notes that refer to the preceding shift require the nurse to use
past forms such as the past simple ‘ate’ or the past perfect tense
to show that something happened before something else, for example,
‘had just eaten when he felt pain’. The verb tense used in this
example was previously referred to as the pluperfect. Even foreign
languages that are closely related to Norwegian, such as English,
German, French and Spanish, express the past fairly
Languages such as Vietnamese and Chinese (Mandarin) do not
express the past by means of different verb endings like Norwegian
åpner – åpnet/åpna) or changes in the vowel (
stå – sto), but use time markers, for example ‘this
morning’ and ‘during the visit’ (23). Such language differences can
explain some of the findings. Therefore, the linguistic challenges
we have revealed may vary according to the native language of the
nurse, or where he/she completed their nursing education.
The fact that Norwegian is a foreign language not spoken by many
people may make a difference for nurses who have probably learned
it as adults. They have been exposed to Norwegian for a far shorter
length of time and to a lesser degree than to world languages such
as English and Spanish. This may lead to considerable challenges in
communication with patients and in interaction with other
healthcare personnel. However, on the basis of the findings in the
study, we have no evidence to comment on such challenges.
The employer is responsible for the training
We cannot draw conclusions as to whether there is any
correlation between language skills and possible deficiencies in
the direct treatment and follow-up of patients. The objective of
the study has not been of a normative character – i.e. meant to
evaluate whether one group of nurses is better than the other. We
have focused on describing linguistic similarities and
There may be reason to reflect on the findings in a broader
cultural context, with information culture in the foreground (16).
Precision in descriptions and a smaller register of words and
expressions to describe professional assessments, actions and
measures may then be significant.
Regardless of the reason for these linguistic challenges, the
employer has a duty to ascertain that the language skills of
second-language speakers are on a level that ensures that they can
record information accurately and succinctly so that nursing
services are sound (24).
Developing nursing terminology
International efforts have been made to develop terminology for
use in nurses’ patient record documentation, which may alleviate
some of the challenges (25, 26). Efforts are being made nationally
to develop and introduce nursing terminology, and the Norwegian
Directorate of eHealth recommends the use of the ICNP
(International Classification for Nursing Practice). When the
nurses used specialist terminology, the content was more complete
However, nursing diagnoses can be seen as enriching, linguistic
constructions (6). Therefore, we need studies that address whether
the use of specialist terminology helps to support nurses who are
second language speakers.
Limitations of the study
The study has several limitations. We do not know if the
differences are caused by language proficiency alone or by nursing
competence and cultural background in addition (1). More knowledge
is needed about the actual quality of patient record documentation
through more comprehensive and robust studies. An interview survey
giving more in-depth insight is also recommended.
Our study builds on a limited number of handover reports. Since
we found no previous studies on this topic, we used a method that
enabled us to compare the scope and linguistic nuances of the two
groups. The fact that we analysed the material across functional
areas is a strength because it gives a deeper understanding of the
Ten of the second-language speakers had completed their nursing
education in Norway while the remaining seven were educated in
other countries. We found small differences when comparing these
groups so we chose to include them in the same group. However, the
findings must be seen in light of the fact that we were unable to
control for the characteristics of the informants. The body of
material was too small.
The findings must also be considered in light of the fact that
we have no information about how many patients were represented in
the reports. In addition, we had to take ethical considerations
into account. Since the number of informants in the sample is
small, we cannot state the country of origin of nurses with
Norwegian as a second language due to anonymity requirements.
The fact that nurses who are second language speakers have a
smaller vocabulary in writing does not mean that we can draw
conclusions about the quality of their direct patient care or their
competence as nurses. We do not know whether there was an oral
information transfer between the shifts and whether this helps to
compensate for deficiencies in written information. However, an
oral report does not necessarily solve all the language challenges
Nor do we know whether the participants in this study felt
pressurised to participate. If cultural factors indicate that they
feel inferior (2), this may mean that our group is not
representative. Furthermore, we have no information about the
content or quality of the reports written by the nurses who chose
not to participate, and this may affect the results.
Native language nurses and second language nurses record almost
the same amount of numerical information but there are clear
differences between the groups in terms of their language
repertoire and register. Nurses who are native speakers use a
larger and more nuanced repertoire than those who are second
language speakers. The study does not provide a basis for
concluding that nurses who are native speakers record nursing
The study should be followed up by a larger and more broadly
based study in the specialist and primary health services and in
the education sector. It is a managerial responsibility to ensure
that employees receive language and professional follow up to
prevent risk to patients. The study can help to implement relevant
measures that may make patient record documentation easier for a
growing group of nurses that Norway needs.
Thanks to quality assurance staff at the hospital for their
help in the implementation of the project, and to Else Ryen for
vital input in the final phase.
Lasse Morten Johannesen died before the article was published.
The article is published in agreement with his family.
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