Chloé Woodward, author
Dr. Heather Lettner–Rust, faculty advisor
awarded first place for best social science paper
As a first year nursing student, I was interested in how academic writing in college was applicable to the writing in the nursing workplace, specifically how inquiry based research writing applied. I was also curious if there were any other forms of writing in the nursing workplace, other than documentation. This study aims to investigate the connection between writing in an academic setting and writing in the nursing workplace. The results of the study suggest that writing in the nursing workplace is mainly documentation, but can include academic journal writing. The process of becoming a writing expert in the nursing field is an evolution that spans from high school to early employment, taught through the use of models and the process of doing.
In college, students learn to compose for many writing assignments including research, reports, and reflective assignments. This is important to learn for success in future classes. However, the discourse community of nursing requires knowledge of specific forms of writing that are not specifically taught in academic classes. How should a student bridge this gap between the academic settings’ writing and their new workplace’s writing requirements? Is it feasible for a student to do on their own? This study will attempt to examine how students should bridge this gap, and whether or not is being successfully done.
Nursing can be defined as a discourse community using John Swales’ (1987) criteria. He defines discourse communities through six characteristics:
Broadly agreed set of common public goals, mechanisms of intercommunication among its members, uses participatory mechanisms to provide information and feedback, utilizes and possesses one or more genres, has acquired a specific lexis, and has a threshold level of members with a suitable degree of relevant content and discourse expertise. (pp. 5-6)
Nursing meets every criteria he set forth.
Using Swales’ text to define nursing as a discourse community, his concept then asserts that writing in the nursing workplace will be different than writing in any other discourse community or areas of academia, because of the lexis and mechanisms of communication that define the community. However, there are some features that are shared by nursing and academia. Melissa Craft’s (2005) study demonstrates this by explaining the importance of criticality, evidence, and impersonality in the nursing discourse community. Criticality is the inclination to be suspicious of any information obtained, evidence is the ability to find and cite any previous knowledge that may impact decisions with the patient, and impersonality is the action of eliminating bias within any decisions or writing, in order to properly help the patient to the fullest. All of these are accepted and enforced lexis and mechanisms of communication that reinforce that nursing is a discourse community. These common features then help to determine what will be taught in the preceding academic setting, college, in order to try and prepare the student for their intended career’s discourse community, in a general manner.
What nursing undergraduate professors are looking for in writing, as well as the problems that students encounter when learning how to write in nursing, is articulated in Julio Gimenez’s (2011) article. He concludes:
From a political perspective, examining the relationship between epistemologies, attributes, and spoken and written communication can provide ways in which less seasoned members of a discipline can gain access to the discipline-specific discourse and thus become more central members of their professional community. (p. 419)
He suggests that students must understand the expectations within the discourse community in order to be successful. Examples of epistemologies in nursing would be empirical knowledge, intuitive knowledge, or even metaphysical knowledge.
Gimenez used a questionnaire, ten in-depth interviews, two focus groups (one for investigating nursing and one for midwifery), and a number of texts written by the students (p. 406). These data examined how each student of the discipline differently viewed problems, the different disciplinary epistemology as defined by the students, as well as traits that are associated with nursing and midwifery writing. It was found that nursing used more empirical knowledge, while midwifery used more intuitive knowledge. Knowing the epistemology of the nursing discipline influences what and how students are taught at the undergraduate level, in addition to discourse community lexis and mechanisms.
The discussion of whether models or mentoring is effective is demonstrated in Dorothy Winsor’s (1990) study of engineering students compares the perceived effectiveness of models verses mentoring on engineering students who are new to the field. The students found a list of rules least helpful, and models as the most helpful. As such, models can be found throughout nursing in order to teach as well as in the workplace. Kathleen Haig, Staci Stutton, and John Whittington (2006) identify the SBAR: Situation, Background, Assessment, and Recommendation as a shared mental model used to improve the communication within the discourse community of clinicians and within nursing. In addition, Claire Mavin and Gillian Mills (2015) discuss using a model across an entire hospital to improve care regarding the prevention of catheter-associated Urinary Tract Infections. The Mavin and Mills study suggests that the use of models and academic writing would help all members of the discourse community operate effectively, in order to achieve the set of public common goals and maintain their level of community expertise. Will this suggestion apply to the academic setting, in order to prepare the student for the workplace? This study aims to determine whether or not models are being used at the academic setting to improve understanding among nursing students.
To aid this study regarding the connection between academic writing and writing in nursing, I conducted interviews with a nursing student and nursing professor, who will be referred to using pseudonyms. Using interviews allowed me to study the opinions on the prevalence of writing within nursing, academically or in the workplace, and whether or not students leaving college feel prepared. Entering this study, I expected to discover that academic writing was absent in the nursing workplace, and that the curriculum of academic writing did not prepare the average nursing student for workplace success.
Through coding, I noticed the frame of Evolution as a theme in the codes. Within the field of nursing, the writing that is done by the members of the discourse community goes through a number of changes, until it reaches the community’s standards. Within the larger frame of Evolution, the codes of Preparation, Transformation, and Adjustment emerged. Preparation describes all previous knowledge that a student brings to college about writing. This knowledge is then taken and applied to the nursing field. Transformation is the process by which the student applies the previous knowledge of writing techniques from high school to writing in college, sometimes through models of documentation. Adjustment is the final stage of the evolution, which occurs when the student leaves college, and enters into the workforce. There, the student learns through trial and error about the writing styles that the workplace demands, and once mastered, the student will finally become a writing expert within the discourse community.
Preparation. During their interviews, the nursing professor and student mentioned the need to write a certain way within the discourse community. Professor S stated, “The academic writing of papers in APA format, like research papers, philosophy statement papers, [are] a completely different world and completely different entity than actually sitting down and [doing] shorthand and using medical terminology.” Similarly, Student A stated, “it’s kind of a different kind of writing.” Within the interviews, the specific characteristics that made the writing different were identified. The coding of the preparation category suggests that there is the need for a previous understanding of the terms: style, format, and purpose, in order to properly meet these mentioned standards and characteristics of the discourse community. This prior knowledge is commonly learned within the early stages of education, mainly high school.
Style characteristics of writing within nursing include specificity, defensiveness, summarization, and no bias. An example of summarization, specificity, and defensiveness discussed within nursing was, “Start writing out very specific, defensively, [say] what’s wrong with your patient. For whatever it may be for that day, or that moment,” within documentation (Professor S, personal interview). Defensiveness is the way in which a nurse writes in order to communicate efficiently at the standard at which those she is writing for can understand at a level that will only aid her patient. An example of the lack of bias that is required within the documentation was seen in a document where Student A, a sophomore within the Longwood Nursing Program, has written on a model of SOAP notes, “Make sure there are no opinions.”
Format characteristics in nursing include a use of abbreviations, correct grammar, and use of quotations. As spoken by Student A, “It’s kind of like an interview. You have to use quotes, just because of the liability.” This is an example of how format within the nursing field is influenced by the style, and defensive documentation, previously mentioned by Professor S. By taking direct quotations, and documenting them, the nurse is then protecting his or herself from potential conflict between nurse and patient, in reference to complaints about experiences. Student A continues about characteristics of format, “So, it’s kind of a different kind of writing. Because it’s not always complete structured sentences…you use a lot of abbreviations, which you can’t do in English [class].” She then provides examples of abbreviations within nursing, “So for like patient we just write ‘PT’ or chief complaint is just ‘CC’.”
Lastly, purpose characteristics within nursing include using writing as a mode of communication, and a presentation of information; both are avenues to improve patient care. These ideas of purpose affecting writing style and format are instilled in high school. Professor S introduced that the purpose of specificity and defensiveness within the forms of communication SBAR and SOAP note is to better the care of the patients. Professor S explains in regards to SBAR, “So that when you’re talking about giving report [because] there’s a change in your patient’s clinical condition, how you present that information to the physician, the therapist, the surgeon, whatever the case may be…improved communication is going to occur to improve patient care.” This example is using the type of style and format implemented, in order to achieve the purpose for writing. Then, Professor S gave an example of academic writing within nursing, which is rarely implemented on a daily workplace basis, but is used to improve patient care.
Academics has a significant value when it comes to writing research that could improve patient care. One of the examples, and this is a true story, when we put Foley Catheters into patients female or male, mostly females, if we don’t do it sterilely, and its invasive, we can cause a bladder infection. Or urinary tract infection, especially in older females, due to changes to our anatomy as we get older. So what was happening on a particular unit was the nurses started realizing that when they put in Dueling Foley Catheters in their patients, they were having increased incidences of UTI. So, one of the nurses on the floor decided, ‘Well let’s start a study, let’s start a –. Gathering data to see, in effect, are we doing these techniques sterilely and correctly’. What she found was no, nurses were not doing it sterilely. So, she put together an algorithm of when to insert a Foley Catheter, and then she set up a workshop to reteach the nurses how to do it, sterilely. Then she started collecting data again, after the workshop, [and] the incidences of UTI dropped dramatically, because nurses were putting the catheters in [correctly]. That’s evidence, based on research, improving care. And she wrote that up in academic format, submitted it to an online journal of nursing, and got it published.
Knowing all of the fundamental characteristics of types of writing from previous schooling, high school or other contexts, could help the students’ transformation from academic writing into this workplace writing smoother.
Transformation. The transformation section of the evolution is the application of this previous knowledge, in college nursing classes. In an interview, Student A discussed writing assignment frequency in the nursing program, “this semester I haven’t written a paper”. She mentioned a writing assignment within the Longwood Seminar class that is required for all students, but did not mention any other academic paper assignments. However, Student A discussed in detail SOAP notes, which is an acronym for subjective, objective, assessment, plan. She explained that although there are no papers, “You write a lot…[of] SOAP notes, and documentation…the biggest part. When you get into clinicals, you have to do all the documentation paperwork.” This is a form of communication of knowledge that is used between nurses to evaluate the patient’s status, that is introduced more in depth in college, to teach students how to improve patient care once in the workplace. A model of SOAP notes that was supplied by Student A is a worksheet which showed exactly how to fill them in, and what is expected within the writing that is done within the form in order to communicate properly.
During the interview Professor S also mentioned another form of communication taught in the nursing program, SBAR. She differentiated SBAR from the previously mentioned SOAP note in an interview, “There’s something called SBAR… It’s Situation, Background, Assessment, and Recommendation. I teach that in fundamentals. The SOAP note is the actual assessment of the patient based on a particular problem.” In laymen’s terms, SOAP note is what nurses’ use while examining the patient in order to determine health, while the SBAR is total overview of the patient’s past, present, and what should take place in the future. These two forms of documentation are taught during college, the transformation process, by ways of models in order to prepare the student for workplace writing.
Adjustment. In the interviews conducted, several forms of writing were mentioned by Professor S as forms of writing done on a daily basis in the nursing workplace. Some of these were, “SOAP note[s],”, “documentation for clinical purposes,”, “SBAR”, “Electronic Medical Records”, and rare but important, “Evidence Based Practice…[which] is academic writing” (Professor S, personal interview). SBAR and SOAP notes were mentioned as being forms of writing taught at the academic level; however, Electronic Medical Records were not mentioned by Professor S nor Student A as something fundamentally taught within the program. Evidence Based Practice, although not mentioned to be taught within nursing specific classes, is commonly taught within other academic classes, as well as within high school. Although most of the forms of communications listed above are taught within the college curriculum, students are finding that they are having to change the way they write for documentation when they enter the workplace.
During the interview, Professor S discussed feedback that students were giving to her once they had entered the workplace, “What I’m getting back from the grads in the sense of what they’re seeing in the health care arena…The way [documentation] was being taught was too generic. It wasn’t specific enough.” Therefore, once the student had been taught how to apply their previous knowledge about writing (Preparation label) to nursing field documentation, through college education (Transformation label), they were still having to alter their knowledge of stylistic characteristics in order to properly communicate within their workplace (Adjustment label).
This study suggests that writing in nursing is dictated by the purpose for which the writing is occurring, which is supported by Gimenez’s identification of the cause and effect relationship between what the community is trying to achieve, and the characteristic of writing done in the field.
This study also suggests that becoming an expert at writing within nursing is a process of evolution, and the most common form to help the evolution processes are models, as seen in Student A’s worksheet. Many students learn best through a use of models, as well through the process of actually doing the action that the workplace requires of them (Winsor). This study suggests that students will only truly be experts in their field once they have been in the workplace, learned the standards, and adjusted their writing to the discourse community.
Furthermore, this study suggests a disconnect between what students perceive they are to achieve in their writing in college, and what they are to achieve in the workplace. However, more research needs to be done concerning this disconnect.
This study has limitations, in regards to the number of interviews that were conducted, as well as the bias that the interviewees may have held. With only two interviews conducted, and artifacts retrieved from the same subjects, this study is more like a case study, and therefore is not as representative as a random survey or large scale inquiry. In addition, Student A is only a sophomore, and may not completely represent the degree to which writing is done within the program.
As a researcher, I’m interested in the broader implications for all nursing students entering, and leaving college. Understanding that nursing students will learn how to write within their field, in theory, but without direct application within a specific workplace, can possibly alter the way a student approaches the workforce, as well as their willingness to receive criticisms during the first months of employment. This study suggests students who are more flexible and willing to adapt what they have learned in previous years to current situations, will excel more readily than students who are focused on adhering to rules and regulations previously taught.
Craft, M. (2004). Reflective Writing and Nursing Education. Faculty Forum, 44(2), 53-57.
Gimenez, J. (2011). Disciplinary epistemologies, generic attributes and undergraduate academic writing in nursing and midwifery. Higher Education, 401-419.
Haig, K., Sutton, S., & Whittington, J. (2006). SBAR: A Shared Mental Model for Improving Communication Between Clinicians. Journal on Quality and Patient Safety, 32(3), 167-175.
Mavin, C., & Mills, G. (2015). Using quality improvement methods to prevent catheter-associated UTI. British Journal of Nursing.
Swales, J. (1987, March 19). Approaching the Concept of Discourse Community. Lecture presented at Annual Meeting of the Conference on College Composition and Communication, Atlanta, GA.
Winsor, D. (1990). Joining the Engineering Community: How Do Novices Learn to Write Like Engineers? Technical Communication, 37(2), 171-172.