The Catamount’s Guide to
Writing in Nursing
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Tips for Writing as a Nurse
Your nursing career will involve a great deal
of writing. You will construct patient care
plans, write progress notes, and document
patient care. Writing in nursing is different
from writing in other sciences because the
art and practice of nursing are concerned
with human response to illness. Writers
must take this emphasis into consideration
for professional and scholarly writing. (S.
Hester, personal communication, March 3rd,
2014). Nurses not only deal with academic
concepts such as medications and math
equations, but also with sentient human
beings with thoughts, feelings, hopes, and
fears. As a result, it is immensely important
that you don’t reduce the patient to a just a
body needing medical care, but rather
consider their situation from a holistic
perspective (S. Hester, personal
communication, March 3rd, 2014). Holistic
nursing takes into consideration many
aspects of a patient’s life including medical,
spiritual, cultural, and psychosocial
contexts. This is the most important point
to keep in mind in your writing. Here we
will take a look at some tips on how to write
as a nurse, reviewing elements such as:
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How to be brief and precise
Legal issues you may encounter
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How to write a clear thesis
statement
APA style
The steps of the nursing process
How to write goals and
interventions
Tips on writing for publication
Brevity and Precision
Writing as a nurse, brevity and accurate
words are important concepts. A nurse
needs to pack as much meaning as possible
into his or her words. Although writing is
concise, do not compromise accuracy and
breadth.
For instance, if a patient experiences a
psychotic episode, do not write, “Patient
suffering from psychotic episode”
(Tompkins,, Tompkins, & Angeli, 2012).
While the statement is brief, it does not
fully explain the situation. Other members
of the healthcare team will have a more in
depth idea of the patient’s condition if you
document something more behaviorally
specific, such as:
“Patient , breathing heavily, crouched in the
corner with face buried in hands,
inconsolable crying, and complaining of
disembodied voices.”
Likewise, if you administer a drug to a
patient, such as a pain killer, do not write,
“Patient given morphine to ease his pain.”
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Be more specific; give the reader complete,
relevant information: medication name,
dosage, administration time,
administration route, and include a pain
assessment(Tompkins, , Tompkins. , &
Angeli, 2012). Here we see that there’s a
trade-off between brevity and precision; a
nurse’s job is to use his or her best
judgment on how to balance the two.
A nurse should always be objective
(Tompkins, Tompkins., & Angeli, 2012). Do
not inject any personal judgements or
prejudices into the writing. For instance,
don not write, “patient acted rudely.”
Instead, write something more objective,
such as “the patient approached nurses
station and spoke in a loud and forceful
manner.”
Legal Issues
The reason for keeping meticulous
documentation is twofold—it will help you
and your co-workers perform the job more
efficiently and accurately, and will protect
the nurse in the event of any legal issues. .
If a nurse were to be questioned in the
courtroom, his or her complete and
accurate documentation would stand as a
strong defense. Remember, all writing a
nurse performs is a legal document; keep
this in mind at all times. Do not write in a
manner that could potentially cause a court
to rule against you. This means the nurse
should have accurate, complete
documentation that follows institution
policy and is free of prejudice or inaccurate
information. It is also important to keep in
mind that nurses and all healthcare
personnel are bound by strict privacy laws.
no identifying information is to be used at
all within your documents, and Sharing
protected healthcare information with an
unauthorized source is a federal offense
and results in significant consequences. (S.
Hester, personal communication, March 3rd,
2014).
Thesis Statements
Another problem to avoid in writing is the
lack of a clear thesis statement. This may
seem like an obvious suggestion, but it
turns out to be a problem that is frequently
encountered (S. Hester, personal
communication, March 3rd, 2014). When
you write an academic paper, a clear thesis
makes the paper’s purpose clear. Without a
thesis, the author’s intent is unclear.
When constructing a thesis, think about the
paper as a whole, and what you plan to
accomplish within it. This is your chance to
form the main structure of the document.
Imagine that you’re writing a paper on why
you believe a certain cancer treatment is
more effective than another, and you want
to demonstrate to the medical community
why this is true. You believe that the
benefits of one drug outweigh the
detrimental side effects of another. In this
case, your thesis might be something along
the lines of, “Treatment X is more effective
than treatment Y, because it offers a more
efficient means of targeting cancer cells,
whereas treatment Y is a less efficient
means of targeting cancer cells, and leads
to more harmful side effects.” You would
then spend the rest of your paper providing
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a clear scientific rationale in support of your
thesis.
APA Style in Nursing Writing
APA is the style used consistently
throughout the nursing field (S. Hester,
personal communication, March 3rd, 2014).
Now is a good time to do some research on
APA guideline. It is the
documentation/citation style used
throughout nursing school. As an example,
sources for this document are cited in APA
format.
The Nursing Process
In many ways, the nursing process
resembles the scientific method that is used
by researchers. . The nursing process helps
to consider a patient’s care in a scientific,
experimental way. It consists of five steps:
assessment, diagnosis, planning,
implementation, and evaluation. Each step
is detailed below.
Assessment
The first step in the nursing process is
assessment. The nurse will assess his or her
patient on a continual basis and in a variety
of ways. In preparation for writing a
patient’s care plan, an initial and ongoing
assessment is performed by collecting
information on the patient, including their
age, any allergies they might have, any
surgeries they’ve undergone, medications
they’re taking, and the admitting diagnosis
(Luanne, n.d). Always take notes of any
other health issues the patient has, even if
it is not included in their admitting
diagnosis. A nurse needs to assess the
patient’s social setting and whom the
person has for support (S. Hester, personal
communication, March 3rd, 2014). A nurse
should include smoking, alcohol
consumption, and drug use in the initial
assessment. Be sure to closely examine the
patient’s medical record, taking note of any
information that might be medically
relevant. It’s helpful to do some data
clustering in this stage, where a nurse
breaks up different aspects of his or her
patient’s medical information into basic
human needs categories (Cerone, 2011a).
In the care plan’s assessment, a nurse will
be asked to make a distinction between
subjective and objective data. Recall that
subjective information is generally fuzzy
and opinionated, whereas objective data is
concrete and measureable. An example of
subjective data would be if a patient states,
“I broke my arm while playing soccer, and
there’s a sharp pain like I’ve been stabbed.”
The patient’s subjective data can be
vindicated objectively. To do this, write
something like, “X-Ray photograph shows a
clean fracture of the ulna, which is very
likely sending pain signals to the brain”
(Cerone, 2011a).
Diagnosis
Next, a nurse writes down his or her own
diagnosis. Whatever diagnoses he or she
feels are most appropriate for a patient’s
condition, he or she must make sure they
are approved by the North American
Nursing Diagnoses Association (NANDA). It’s
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Commented [S1]: I see where you are going with this but
this example is not nursing, it’s medical. We might do a
study on the cultural significance of nursing care for the
Chinese, so a paper on the best nursing interventions to
prevent pressure ulcers. Remember, nursing is deals with
the human response to illness. It would be best if you have
up with a different example.
important that diagnoses be NANDA
approved, because NANDA provides the
profession with a universal nursing
language. Think about each diagnoses, and
rank them by level of priority (Cerone,
2011c).
Planning
In this phase, determine what course of
action is best for the patient. What are the
best ways to provide care for this person?
Make sure to back these up with clear
scientific rationales, because it explains the
methods used to someone who may not
otherwise know. Make this section
adaptable, staying in line with the needs of
each individual patient (Luanne, n.d).
Implementation
Provide specific details on the interventions
that will be implemented to help the
patient. This will be done before clinical,
because what good is meeting with a
patient if a plan of action is not laid out
(Luanne, n.d)? Interventions are based on
each nurse’s professional opinion on the
best plan for that patient. It’s okay to
disagree with what a doctor is saying, but
make sure to provide a clear scientific
rationale as to why the disagreement exists
(S. Hester, personal communication, March
3rd, 2014).
Evaluation
In this stage, determine whether or not the
chosen interventions were effective. Did
the patient’s condition improve in a way
that was expected? Based on an evaluation
of how successful the nursing process was,
a reassessment of priorities for that
particular patient may need to take place.
Make sure to change the priorities for the
second day if it’s appropriate. The care plan
is a living document, and it should be
altered in light of new information (Luanne,
n.d).
Patient Goals and Interventions
Once a decision is made on the
diagnosis/diagnoses for a particular patient,
set some goals for that patient. Think about
what needs to be accomplished as a nurse
with a particular patient. Make sure that
these goals are both timed and measurable.
For instance, if a patient’s primary diagnosis
is hypertension, write something like, “By
the end of my shift at 5:00 PM, the patient
will have a blood pressure less than 130/95”
(Cerone, 2011d). Next, write down the
planned interventions. By the time the care
plan is finished, other nurses should be able
to look at it and properly take care of the
patients (Cerone, 2011d). It’s similar to the
concept in the sciences where other
scientists should be able to recreate results
in the lab by looking at someone else’s lab
report.
An intervention always begins with an
action. For instance, education will always
be a part of an intervention because there
is always something a nurse needs to teach
his or her patient about. Likewise,
interventions will always consist of an
assessment. Make sure that interventions
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start out with a verb, like administered,
replaced, or recorded (Cerone, 2011d).
These interventions will be based upon the
most appropriate care options for a
particular diagnosis.
Carefully document each patient’s progress.
It is okay if a goal or expectation is not filled
within the allotted timeframe because it
may have been that a goal was simply
unrealistic. But make sure that to take note
of this in the records (S. Hester, personal
communication, March 3rd, 2014).
Writing for Publication
Within a nurse’s career, he or she may seek
to have his or her writing published. In
addition, professors may assign projects to
prepare students for this writing style.
Nursing publications are important because
they contribute to the progress of the field;
when individual nurses share their own
findings on which interventions are best for
patient care, this helps to move the field
forward. Here we’ll take a look at the
writing process involved in these projects.
There are some general guidelines when
writing for publication in nursing. When
writing a paper for publication, it’s
important to keep the audience in mind. Is
the audience other nurses? Is the audience
the general public? The writing style
depends heavily on the intended audience.
If writing for a group of peers, technical
language, jargon, is acceptable. If writing
for the general public however, technical
terms need explanation (Oermann, 2002).
guidelines of a particular journal to make
sure its requirements are met. It’s helpful to
read from the piece of writing is being
submitted to, so that knowledge of a
particular journal’s writing style is known.
(Oermann, 2002).
Next, collect useful materials, and create an
outline. Outlines are helpful in any
academic writing, because they help to
provide a logical structure to a paper
(Oermann, 2002).
Once these previous steps are complete,
prepare the first draft of the paper. Make
sure to closely follow the guidelines of the
journal, and don’t forget to cite all of the
sources used.
Rewriting will be necessary throughout the
process of writing the paper. Rewriting
helps to clarify the points made within the
paper. It also helps to read a draft out loud
and correct things that may not sound right
(Oermann 2002). If the paper is not
accepted for publication, consider it
valuable advice to help improve the
writing’s quality.
Research is necessary for deciding on which
writing style to use. First, consult the
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Mosby‐Elsevier.
References
Ackley, B. J., & Ladwig, G.B. (2006). Nursing
diagnosis handbook: A guide
to planning care. St. Louis:
Mosby‐Elsevier.
Black, B., Chitty, J., (2007). Professional
Nursing: Concepts &
Challenges(6th edition). St. Louis,
Missouri: Saunders Elsevier.
Tompkins, J.C., Tompkins. E., & Angeli, E.
(2012, December 20). Writing as a
Professional Nurse: Three General
Rules. Perdue OWL. Retrieved
March 17, 2014, from
https://owl.english.purdue.edu/o
wl/resource/922/01/
Turnbull, A. (2001). Plain words for nurses:
Writing and communicating
effectively. Foundation of Nursing
Studies, London.
Cerone, L. (2011a, June 7). Constructing a
nursing care plan, part 1-4: Data
clustering. [Video file]. Retrieved
from
http://www.youtube.com/watch?
v=p1fS4QaOnQE&list=PLzTrjnoGF
2leE4CpLVLRwg7hiFNVUww5T
Feldman, H., Hallas, D. (2006). A guide to
scholarly writing in nursing.
National Student Nurses
Association.
Luanne, B. (n.d). The nursing student’s
practical guide to writing care
plans. Bristolcc.edu. Retrieved
February 7, 2014, from
http://www.bristolcc.edu/student
s/writingcenter/forms/PROJECT.p
df
Oermann, M.H. (2002) Writing for
Publication in Nursing. New York,
NY: Lippincott.
Potter, P. A., & Perry, A.
G. (2005). Fundamentals of
nursing (6th ed.). St. Louis:
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