Nurses need to put pen to paper

In writing about “writing”, I would like to thank the publisher and Editor of this exciting new journal for diabetes nursing. Their invitation to write this article has led me to rediscover poetry, and to delve into the world of language – a whole new horizon in my professional and personal life.

In the study of written and spoken language, written communication reigned supreme for many centuries. Writing became the medium of literature, a source of standards of linguistic excellence, providing language with permanence and authority. The spoken language was not considered worthy of study as it lacked rules, care and organisation.

Communication
It was not until the early part of the 20th century that ideas truly began to change. It was recognised that speech is many thousands of years older than writing and that it develops naturally in children, whereas writing has to be learned. Speech became the dominant object of study as the primary medium of communication. Writing fell into disrepute and became an optional, special skill used by the minority only for sophisticated purposes such as scientific or literary expression.

There is no doubt that whatever the historical relationship, in current society, writing and speech provide us with two very different communication systems, each fulfilling a special purpose. They complement each other, but one cannot be substituted for the other as each offers a particular mode and medium of expression in everyday life (Crystal, 1992).

In nursing, and in particular diabetes nursing, our relationships with people with diabetes, their families and other healthcare professionals are built and maintained through personal contact and the spoken word. As we gain knowledge, skill and experience, much is learned. Sadly, however, this is all too rarely shared for the benefit of our colleagues and the wider community. Nurses have creative talents and the ability to use them, for these are inherent in the art of nursing. However, they lie dormant, subdued by the ever-increasing pressures both at work and outside it.

The need to write
Nurses need to write about what they do. So much course work is now written up as projects and dissertations, for example, that never see the light of day once finished. There are so many good ideas about patient care and new areas of practice to be shared – just waiting for you to take up the challenge and write about them.

It was, after all, through her writing that Florence Nightingale established her reputation and was able to spread her influence. She wrote extensive memoranda, reports, reviews and was the first person to demonstrate the use of practical statistics in healthcare, portraying data for the first time in pie-chart form. Her book, Notes on Nursing (1860), is a masterpiece of written expression, describing the philosophy and art of nursing. She also manages to incorporate humour and practical advice into this definitive work.

Composition
There is little knowledge of the process of composition of written text. The creative times may be lengthy. Turning ideas into an accessible form on the page is agony for some and easy for others. The more you do, however, the easier it becomes. Although, in my own writing, I still contemplate the blank page with dismay, I know that once a few words are written, the barrier is lifted and each line’s completion represents another step in the process.

In reading the end product, it is often difficult to see how it evolved: processes of thought, alterations in language construction, revision and re-revision are no longer apparent. Those people who are fluent writers may be unaware of what they do; little is known about what is going on “beneath the surface”.

The art of expression in writing is the subject and life of poetry and poets, playwrights and diarists (Table 1). 

The writing process
There is a diversity of individuality in the writing process, and, in general, three factors are fundamental for success. 

1. There is a stage of planning in which thoughts are organised and an outline (sketch) is prepared. To do this you need to consider:

• What you want to say.
• Who you want to say it to.
• What they need to know to understand your message.
• What effect you want it to have on your reader.

2. Follow accepted rules of grammar and punctuation.

3. Re-writing is an art in itself, and many drafts may be needed before the final version is reached. In general, you want your writing to be:

• Readable.
• Clear.
• Logical.

One of the most difficult aspects of writing is making the text flow from one phrase to another. Artists draw your gaze into and around their painting until you absorb the whole picture. Your writing should aim to do likewise for your readers, guiding them down all the paths you have laid until they reach their destination.

Writing is not simply a mechanical task in which the spoken word is put down on paper. To write well you need to read and learn how others write. Reading must surely be the most important prerequisite to writing. Writing is a creative process – an act of discovery.

Writing for publication
If you have a viewpoint to put across, or some research you wish to submit for publication, you need to decide who your audience should be. In other words, who will learn from your message? This will help you to decide which journal you should write for.

If you are commissioned to write for a particular journal, you will be given a brief as to content, perhaps a title, and a word limit. One sheet of typewritten, single-spaced A4 paper yields about 250 words. By looking at back copies of the journal, you can see the format of the articles used.

Presentation is important, as your article will be read and judged, often by two external reviewers, as well as an in-house editor. It is worthwhile making this process as easy as possible for them. All submissions should be typed in double spacing with a print size and typeface that is easy to read. You need to find out the journal’s preferred method of referencing, usually Harvard, although it is simple to adjust to either of the two styles in common usage (Harvard or Vancouver). 

Submitting your research for publication
Research articles tend to follow an accepted format. All you have to do is add the ingredients (Table 2).

Figures, tables and graphs
Wherever possible, figures, tables and graphs should be used when presenting the results of your research, audit or any nursing process. They break up the text and, more importantly, present information that is easy to assimilate. 

All graphics should be appropriately referred to and clearly labelled, and the information they provide should not be repeated in the text. When submitting your work for publication, graphics should be placed at the end of your script in the order of mention – and one per sheet only.

Illustrations and photographs
Illustrations and photographs also break up the text, providing a focus for your important messages. The following points are worthy of note:

• The editor will need to know whether the photographs are landscape or portrait in shape, so that they can judge how to fit them into the text and the space available.
• If you want to submit colour photographs, it is worth checking whether they will be published in colour or in black and white. If you discover, for example, that the journal you are writing for never uses colour pictures, you may want to think about changing your photographs.
• The choice of colour or black and white is also important when presenting artwork such as graphs and flow diagrams, since these may depend, for meaning, on the reader being able to differentiate one colour from another. The problem can sometimes be resolved by providing graphs that have, for example, lines distinguished by being broken, dotted or complete, rather than in colour.

Peer review
Most published material will have been peer reviewed. This process involves your article being sent anonymously to one or more reviewers, who may or may not be members of the editorial board of the journal. They will be involved in the same professional field as you, and will have a special interest in your subject. Their role is to make amendments and suggestions that are helpful to both the author and the editor. Contrary to what many people believe, good reviewers are looking to help you get your article accepted for publication, even if it needs to be revised beforehand.

It is worth remembering, however, that a rejection does not necessarily mean your article received a poor review. It may simply have been that the journal had already accepted several articles on the subject or had just commissioned someone else to write one; or that the journal may not be the most suitable publication for your work.

Proofreading
You will be sent proofs for checking just before the article is to be published. There are two reasons for this: to give you a chance to see what has been done to your article, and to give the editors the opportunity to ask you to answer any problems they might have with the piece.

The turnaround time you are given may be short, sometimes as little as 24 hours. At this stage, amendments should be kept to a minimum. This is not an opportunity to sit down and rewrite large chunks of text because you suddenly see a way of explaining something better (unless the editor has asked you to do so).

It is advisable to get someone else to look through the proof as well as yourself. It is all too easy to miss small errors or typographical mistakes when you have become over-familiar with the article.

Conclusion
Writing carries with it rewards. These may be financial, but most of all they stem from the satisfaction of creation, of sharing your ideas and yourself with others, and of giving important messages about healthcare in your role as a diabetes nurse. Put aside some time in a quiet place with perhaps a little music, not too loud, and start to write… 

“Every great and original writer, in proportion as he is great and original, must himself create the taste by which he is to be relished.” William Wordsworth (1770–1850), Letter to Lady Beaumont