Journal of Nursing Education

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The Composing Processes of Nursing Students in Writing Nurses' Notes

Jeanne Merkle Sorrell, DAEd, RN

Abstract

ABSTRACT

In this exploratory research, a microethnographic approach was used to investigate how nursing students learn to write nurses' notes. The research focused on the perceptions and behaviors of first-year nursing students as they learned to write nurses' notes in the classroom, campus lab, and hospital. Aspects of the environment were identified that facilitated or hindered the process of learning to write nurses' notes. Adoption of a mental organizing framework by the students appeared to facilitate the composing process. The use of a standard flow sheet appeared to hinder the writing-to-learn and writingto-remember aspects of the composition of nurses' notes. Students were aware of a hostile authence for their nurses' notes - a court of law. The study provides important information on the assessment and decision-making processes that students use in learning to write nurses' notes, as well as the various environmental influences that must be considered in on-the-job writing. Findings suggest that nurses and educators should consider how to restructure the learning environment to facilitate composition of effective nurses' notes.

Abstract

ABSTRACT

In this exploratory research, a microethnographic approach was used to investigate how nursing students learn to write nurses' notes. The research focused on the perceptions and behaviors of first-year nursing students as they learned to write nurses' notes in the classroom, campus lab, and hospital. Aspects of the environment were identified that facilitated or hindered the process of learning to write nurses' notes. Adoption of a mental organizing framework by the students appeared to facilitate the composing process. The use of a standard flow sheet appeared to hinder the writing-to-learn and writingto-remember aspects of the composition of nurses' notes. Students were aware of a hostile authence for their nurses' notes - a court of law. The study provides important information on the assessment and decision-making processes that students use in learning to write nurses' notes, as well as the various environmental influences that must be considered in on-the-job writing. Findings suggest that nurses and educators should consider how to restructure the learning environment to facilitate composition of effective nurses' notes.

Introduction

Nurses' notes constitute a very important type of writing for nurses in the clinical setting. The nurse must be able to decide what information is significant in order to communicate this information effectively in a written format dictated by the institution.

The nursing literature contains little information about how nurses learn to write nursed notes, even though nursing instructors spend many hours in the classroom, campus lab, and health agencies teaching students how to compose these documents. Nursing texts dealing with nurses' notes provide information about appropriate and inappropriate content but do not discuss the process that the student engages in to produce the document.

Research on the Composing Process

Most early studies of composition concentrated on what the teacher did, not on what the student writer was experiencing (Emig, 1983). Teachers assumed that students who adhered to prescribed rules would produce appropriate writing (Beach & Bridwell, 1984). A new focus for composition emerged after Emig (1971) carried out formative research describing the process that occurs with writing. In a study of eight student writers, Emig concluded that teachers greatly oversimplify the process of composing. Researchers now distinguish between a theoretical "knowing what" and a "knowing how" linguistic competence (Lunsford, 1979).

Most research in composition has been done in academic settings. Odell and Goswami (1984) noted the need to examine more carefully the writing done in nonacademic settings, especially the writing that adults do as a regular part of their daily work. Surprisingly little information is available about the nature and functions of on-the-job writing, and about the types of stylistic and substantive choices writers make in the work environment. The assessment and decision-making processes involved in learning work-related writing have received little systematic study.

Research on the Composing of Nurses' Notes

The only research studies related to the composing of nurses' notes found in the nursing literature were those by Shine (1982a, 1982b). Shine (1982a), in a survey of graduate nursing students and faculty, found that students and faculty shared similar perceptions regarding content, authence, and preferred format. Faculty, however, perceived the notes as most valuable for planning and evaluating nursing care; they viewed the notes as a dynamic tool for patient care. In contrast, students listed the most important purpose of the notes as a written record for legal accountability. Thus, they perceived writing the notes as an isolated activity for documentation of patient care.

In a second study, Shine (1982b) described the composing processes of nursing students in a clinical setting. Observations of four students as they wrote nurses' notes led to the conclusion that students used a modeling approach when learning how to compose the notes; students mimicked the style and language in the existing chart when writing nurses' notes.

Focus of Study

The present study was undertaken to build on Shine's foundational research on nurses' notes. The purpose of this research was to describe the process by which nursing students learn to write nurses' notes, in order to identify characteristic patterns of the learning process. An important proposition for exploration in the study was whether students use different strategies in different environments for seeking out information to facilitate learning to write nurses' notes.

The following research questions provided the focus for the study:

* What information do students seek out after exposure in the classroom to a lecture related to nurses' notes?

* How do students interact with the environment to get the information they need to write nurses' notes?

* Do composing processes differ for nursing students in a simulated laboratory setting and in an actual clinical setting?

* What aspects of the environment facilitate or hinder the composing of nurses' notes?

Method

The microethnographic approach was used for this study. Microethnography can be characterized as a focused ethnography (Erickson & Mohatt, 1982). Traditional ethnography is like a camera that takes in a wide scope of a culture, attempting to provide a picture of components fitting together in a unified whole. In microethnography, the "camera" zooms in on a much narrower segment of the culture - usually one scene within an institutional setting. Microethnography often analyzes the processes of face-to-face interactions that produce observed outcomes, using participant observation and interviews to understand the context of the cultural scene selected for study.

In this study, first-year nursing students in a private college in northern Virginia were observed in face-to-face interactions with instructors and peers. These interactions took place in the initial stages of learning to write nurses' notes in three different environments - the classroom, the campus lab, and the hospital. Each environment constituted a successive stage of the learning process for the students. Initially, students received information related to nurses' notes in a classroom lecture. During the following week, the students participated in a campus lab where they practiced writing hypothetical nurses' notes. At the end of that week they moved to the "real world" of the hospital, where they wrote actual nurses' notes.

All 62 first-year students were observed in the classroom. Seventeen students were observed in the campus lab. The researcher acted as a nonparticipant observer in the classroom and campus lab environments.

In the hospital, 18 students were observed during 3 successive weeks of writing nurses' notes (charting). These students comprised two clinical groups, each with nine students and a separate instructor. Students spent 4 hours in the hospital each week during this time. Each student was assigned to one patient during the 4-hour period and charted only on the assigned patient. The researcher acted as a participant observer in the clinical setting, writing field notes on observed interactions of the students and conducting brief interviews with the students.

Data were analyzed at each stage of data collection to identify characteristic patterns emerging from the data in relation to the research questions. This analysis of data was then used as a guide to data collection at the next stage.

The classroom setting

Instructor behaviors. In the classroom, the instructor described general rules for writing nurses' notes in a 75-minute lecture. She emphasized the need for "defensive charting" - charting to "cover" the nurse by documenting that an appropriate action was carried out, such as calling the doctor about a problem, or noting that a patient refused a treatment.

Analysis of content presented by the instructor in the classroom resulted in identification of three main categories of emphasis:

* The use of appropriate terminology and form (e.g., avoiding words such as "patient," writing in ink, and signing each entry).

* The use of objective, rather than subjective, terminology (e.g., recording facts and avoiding interpretations).

* The legal aspect of nurses' notes (e.g., nurses' notes might be used as evidence in court).

Student behaviors. The students were, for the most part, passive learners in the classroom. They appeared attentive, but raised few questions. Questions that did arise concerned technical aspects of charting, such as a specific way to say "patient asleep" or "patient died."

Student/instructor interactions. The social interaction in the classroom conveyed a novice/expert relationship between student and instructor. The students looked to the instructor as the authority on nurses' notes. This relationship was reinforced by the instructor, who stated several times that students would need to practice often to learn how to write good nurses' notes. The implication was that the instructor was the expert in knowing what good nurses' notes look like; it was now up to the students to learn how to produce them. Thus, social interaction in the classroom appeared to facilitate the students' obtaining information about what to write, but not necessarily how to write.

The campus lab setting

Instructor behaviors. The lab instructor assumed a nondirective role during most of the campus labs, encouraging students to work independently on nurses' notes for hypothetical patient situations. The instructor reinforced the rules of charting that had been presented to the students in the classroom, emphasizing legal aspects of charting, as well as the need to use appropriate terminology and objective statements of fact, and the need to be concise. Students sometimes wrote information in the hypothetical nurses' notes that they felt was important to document, but which the lab instructor stated should be recorded on the flow sheet.

Student behaviors. Students averaged 10 to 15 minutes to complete the nurses' notes for the three hypothetical situations. Students wrote directly on the form for nurses' notes without making a practice draft. Students seldom revised their notes. Occasionally, they crossed out a word and wrote "error" above it with their initials, as they had been instructed. Even when the instructor pointed out some aspects of the notes that should be changed, the students did not rewrite the notes.

Student/instructor interactions. A student would often pause during the writing to ask a question. Almost all of the students' questions were concerned with what to include in the notes, and where to write it. Student interactions revealed that students were beginning to realize that decisions about what to write varied considerably according to specific situations. They experienced frustration at the many "gray areas" in the rules of charting, which had been presented to them in the lecture as clearly defined guidelines. The example below illustrates the confusion students experienced in interpreting the rules of charting:

Lab instructor: You didn't chart that this patient is awake and restless. You need to document that.

Student: But I put it on the flow sheet. I checked *sleep interrupted." We were told not to put something in both places.

Lab instructor: But in this case it's a significant change, so it should be in the nurses' notes.

Thus, students in the campus lab appeared to be searching for information that would help them bridge the gap between knowledge of the rules of charting, which they had learned in the classroom, and the application of these rules in writing nurses' notes for hypothetical patients in a variety of situations.

Social interactions with peers and the instructor were more active than in the classroom environment, and had less of the novice/expert character observed in the classroom. The instructor readily acknowledged the difficulty in learning to apply a standard set of rules to varied situations. The campus lab environment appeared to facilitate the composing of nurses' notes when the instructor provided a structure in which students worked independently, questioning each other or the instructor as needed to move the writing forward. When the instructor assumed a directive role in the lab, the environment appeared to take on a character very similar to the classroom setting, in which the lab instructor lectured, the students listened passively, and the novice/expert relationship was resumed. This change in structure appeared to hinder the composition process, in that students stopped writing.

The hospital setting

Instructor behaviors. Each instructor held a 15- to 20-minute conference with students at the beginning and end of each 4-hour period in the hospital. During the first preconference, each instructor reviewed the rules of charting. She told students to write their nurses' notes on a practice form, and to have their notes checked before transcribing them to the patient's chart. At the postconference, the instructor encouraged students to share feelings and raise questions about their first experience in charting. In the succeeding 2 weeks, the preconferences and postconferences focused on topics other than nurses' notes, but the instructor provided opportunities for the students to ask questions or comment about their experiences in charting.

Student behaviors. The two places on the unit where students frequently sought information for their nurses' notes were the chart room and the patient's room. Students stated that they used the time in the patients' rooms to collect information to use in their nurses' notes.

A common pattern characterized the informationgathering process for writing nurses' notes in the hospital. The chart was used as a model for what information to gather and how to record it. In essence, the chart became the paradigm for the students' observations. The patient was sought out to validate information and to answer questions that arose from reading the chart.

Student/instructor interactions. The students interacted frequently with the instructor, but these interactions usually focused on specific aspects of providing nursing care for their patients, rather than as a means of acquiring information for charting. The instructor discussed students' notes after they were written and made suggestions for improvement. The instructors and students in the hospital setting appeared to interact in a more collegial manner than in the other two environments studied.

Overview of Findings

On-the-job writing

Findings from analyses of data indicate that the "real world" of the hospital made the process of writing nurses' notes very different from that in the campus lab.

The students described it this way:

I knew that basically we needed to chart in concise, clear sentences. I knew there were basic rules. But my problem was to know exactly what information should be there and what shouldn't. When you had a real patient, it was different. I don't think the lab was enough practice.

Students knew that rules for charting required them to chart only the significant aspects of patient care, but they expressed frustration at not knowing what was significant:

It's hard to know what's unusual. We don't know what's normal for a patient because we're not here everyday. We have a different patient every week and we only see him 3 to 4 hours. It's hard to determine what is a significant change for him.

In an attempt to resolve this frustration about not knowing what to write, students used nurses' notes on the chart as a model. Students read the chart not only to get information, but also to learn how to mimic the nurses' notes that they read in the chart.

Sometimes the students did not notice that the previous nurses' notes were no longer applicable to their patient, and they imitated the notes anyway. The fact that these students placed a greater emphasis on modeling other nurses' notes than on writing accurate notes suggests that the form and style of the notes were more important to them than the content.

Organizing framework

In their initial attempts at writing nurses' notes, students expressed frustration with the difficult task of selecting and organizing the vast amount of information they had collected. Students who used a framework for organizing their notes felt that it greatly facilitated the writing process.

Students were observed using two types of organizing frameworks. One of these was a narrative, time-sequence approach, in which students wrote down each important event as it occurred. A second framework, a body systems approach, appeared to be particularly helpful. With this framework, the student assessed the patient from "head to toe," visualizing each of the body systems in the process. Students who used this strategy for organizing their notes stated that it helped them determine how to start their notes and how to organize the information they wanted to include.

Focus on legal document

Students were very aware that the nurses' notes in the hospital comprised a legal document that could be produced as evidence in court. Students worried about implicating themselves:

I worry about charting incriminating things. I think about how everything I write might come up 2 years later, and will I remember it?

I think about maybe Fm putting down something I shouldn't that could come back later on to haunt me because they are legal documents.

Students demonstrated an unexpected strategy for dealing with their concerns about legal aspects of charting. Rather than revising their notes to ensure that they were as succinct, clear, and comprehensive as possible, they carried out what they called "double charting." One student described how she handled the problem:

I find myself double-charting. I'll check the flow sheet and then I'll write it in the nurses' notes anyway. It makes me feel more comfortable that I've documented what I've done.

Thus, the students' concerns about "covering" themselves caused them to adopt a strategy that interfered with their ability to write notes in a clear, succinct style. It may also have contributed to "writer's block" in the composing of the notes.

Writing to learn

Another unexpected finding emerged from analysis of data: interviews with students revealed that the writing of nurses' notes was not just a means to record information. The notes also served as a tool to enhance memory. Several students, as well as the instructor, expressed concern that merely placing a check mark on a flow sheet would not be adequate to help them remember the details of the patient situation years later if they were required to testify in court. They believed that writing out the nurses' notes helped them to clarify and remember the facts.

Conclusions and Implications Related to Patterns in the Composing Process

The four research questions provide a framework for describing conclusions and implications for the study:

* What information do students seek out after exposure in the classroom to a lecture related to nurses' notes?

Students appeared to master readily the rules for charting which were presented in the classroom. The type of information the students sought after the lecture related to how to apply these rules. Students needed to learn how to tell when something was significant enough to record, and how to determine the correct amount of information to record in order to protect themselves legally.

This conclusion supports findings from studies in composition research which demonstrated that knowing the rules about writing did not ensure competence in writing (Lunsford, 1979; Pianko, 1979). This has important implications for teaching the composing of nurses' notes. Nurse educators should not merely lecture on rules for charting, but should also provide a variety of opportunities for students to practice those strategies that have proved effective in composing, to help students gain confidence in their writing of nurses' notes.

* How do students interact with the environment to get the information they need to write nurses' notes?

One of the most common methods that students used to obtain information in the hospital was to seek out the patient's chart and to model their own notes after those they read in the chart. This finding suggests an important question to consider; Does the chart, as a model, limit the observations that students (and nurses) make related to the patient?

De Bono (1983) states that the relationship of perception to thinking is a critical one. He defines perception as the way in which one's mind makes sense of the world. Emig (1983) describes perception as an immensely complex and selective process. She notes that we use a "self-governing gaze" - a steady way of perceiving reality, and that we see what we choose to see.

In the present study, students sometimes modeled previous notes in a patient's chart so closely that they recorded information that was no longer accurate. This suggests that students may need to be taught to reverse the information-gathering process, i.e., to first seek out the patient, rather than the chart, as a primary data source. In this way, observations of the patient would not be limited by the self-governing gaze imposed by attempts to model notes on the patient's chart.

* Do composing processes differ for nursing students in a simulated laboratory setting and in an actual clinical setting?

Composing processes were noticeably different in the two environments of campus lab and hospital. In the campus lab, information for nurses' notes was presented to the students in a neat, concise package of a hypothetical situation. These students knew the nurses' notes were practice exercises. In the hospital, the task of assimilating similar information from a variety of sources over a longer period of time seemed overwhelming to some students. They were aware that their notes would be available for hospital personnel to read and to criticize, and that the notes might reach a potential hostile authence - a court of law. The public nature of the nurses' notes in the hospital and the potential threat of their being used as evidence in court created an intimidating situation for the student.

These findings suggest that educators should identify strategies for assisting students to bridge the gap between learning to write nurses' notes in hypothetical situations and in the "real world" of the hospital. Classroom and campus lab writing sessions should emphasize not only documentation for legal accountability, but also the various purposes of nurses' notes. Learning activities should simulate more closely the information-gathering carried out in the hospital.

* What aspects of the environment facilitate or hinder the composing of nurses' notes?

Factors facilitating the composing process. The use of a mental organizing framework appeared to facilitate the composing process for students in this study. Initially, the students used a narrative framework in their writing. Flower (1981) noted that inexperienced writers use a narrative framework as a substitute for analytic thinking. The temporal pattern of the narrative, however, encourages writers to record details of what happened next, even if the details are irrelevant. Flower found that the narrative framework served to submerge ideas under events that precipitated them; events are described, but important logical relationships between ideas may be obscured.

Flower noted that writers who organize data and details under larger guiding ideas, placing these ideas in an integrated framework, are able to articulate more clearly the meaning they see in the data. In this study, learning how to integrate information from the patient and chart into a data base with an organizing framework such as the body systems approach helped the student compose comprehensive nurses' notes. The use of such a framework may also help students to understand and to retain the meaning of the data they record.

Factors hindering the composing process. The use of the flow sheet as an alternative to traditional nurses' notes appeared to hinder the composing of nurses' notes. Students in the hospital were able to differentiate between information that should be recorded on the flow sheet and on the nurses' notes, but many students still recorded information in both places. They stated that the process of writing the information on the nurses' notes helped them to remember the information.

This supports findings from composition research which suggest that learning of information can be enhanced, and perhaps retained longer, when students write about what they are studying (Allen, Bowers, & Diekelmann, 1989; Thaiss, 1983). Emig notes, "Writing represents a unique mode of learning - not merely valuable, not merely special, but UnIqUe* (1983, p. 123). In view of these findings, nurses need to evaluate carefully the rationale for using tools such as flow sheets and computer codes as substitutes for written nurses' notes.

The composing of nurses' notes may serve a writing-tolearn and a writing-to-remember purpose that may be hindered by simplified recording systems such as flow sheets and computers. If the act of writing helps the writer to think, organize, and remember, then time-saving methods for recording observations may actually be time- wasting and ineffective.

This was an exploratory study, limited to a convenience sample of first-year nursing students in one school of nursing. All observations of student behaviors were made by the investigator. In order to decrease the possibilities for investigator bias in the observational process, a standardized form was use for recording observations.

Although the microethnographic approach provided effective opportunities for focusing on a narrow set of nursing students' composing behaviors in a natural context, further research with a wider focus of study is needed in order to generalize findings of this research to other populations. The patterns that were identified in the process of learning to compose nurses' notes in this student population indicate the need for further research related to the question: How can the environment be structured to facilitate learning to write nurses' notes - and to use nurses' notes to facilitate learning?

References

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  • Shine, M.S. (1982a). Teaching student nurses to write nursed notes. In D. Gallehr, R. Gilstrap, A. Legge, M. Mohr, & M. Wilson Nelson (Eds.), Writing processes of college students: Vol. 1 (pp. 100-111). Fairfax, Va: Northern Virginia Writing Project.
  • Shine, M.S. (1982b). The composing processes of nursing students in clinical writing. In D. Gallehr, R. Gilstrap, A. Legge, M. Mohr, & M. Wilson-Nelson (Eds.), Writing processes of college students: Vol. 2 (pp. 49-57). Fairfax, Va: Northern Virginia Writing Project.
  • Thaiss, C. (1983). Writing to learn: Essays and reflections on writing across the curriculum. Dubuque, Iowa: Kendell/Hunt.

10.3928/0148-4834-19910401-07

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