JONA Volume 45, Number 12, pp 636-641 Copyright B 2015 Wolters Kluwer Health, Inc. All rights reserved.
THE JOURNAL OF NURSING ADMINISTRATION
Successfully Coaching Nursing Staff to Publish Outcomes Barbara Molina Kooker, DrPH, RN, NEA-BC Renee Latimer, MS, RN, PMHCNS-BC Debra D. Mark, PhD, RN
There is a need for bedside nurses to disseminate the results of evidence-based practice quality initiatives to a wider audience through publications in peer-reviewed journals. Barriers to publication are common and include lack of time, skills, experience, confidence, and tangible support. This article describes the structured approach, timeline, writing activities, and coaching guidance used to support the publication of 12 quality improvement articles in 1 nursing journal. Although publishing nursing science has historically been in the academic domain, bedside nurses are increasingly being encouraged to publish, sometimes as a result of increasing levels of nursing education1 or Magnet designation. In addition, there is an increased need for nurses to incorporate evidence into practice. The Institute of Medicine_s initiative on the Future of Nursing defines a model healthcare system as ‘‘seamless, affordable, quality care that is accessible to all, patient centered, and evidence-based and leads to improved health outcomes.’’2 Nurses are positioned to make this goal a reality if they have access to information. According to Keen,1 ‘‘Published evidence is subsequently required in order to review and, if necessary, adjust existing nursing practice.’’1(p384) The Queen_s Medical Center, a Magnet-designated facility in Honolulu, Hawaii, acknowledges that the A
Author Affiliations: Nurse Researcher (Dr Kooker) and Director (Ms Latimer), The Queen_s Medical Center, Queen Emma Nursing Institute, Honolulu, Hawaii; and Associate Professor (Dr Mark), School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu. The authors declare no conflicts of interest. Correspondence: Dr Kooker, The Queen_s Medical Center, 1301 Punchbowl St, Honolulu, HI 96813 ([email protected]). DOI: 10.1097/NNA.0000000000000277
636
need for nurses to publish is driven by many factors, such as the increasing recognition of the importance of quality care and patient safety. Healthcare facility certification and accreditation sometimes include a requirement for disseminating new knowledge and process improvements related to quality and patient safety. For example, Magnet-designated organizations must provide examples of evidence-based practice (EBP) and research initiatives in their recertification applications, including the requirement that nurses disseminate their organization_s innovations both internally and externally through presentations and publications.3 The Hawaii State Center for Nursing (HSCFN) was established in 2003 with a legislative mandate to conduct research on best practices and quality outcomes. HSCFN has a 7-year history of partnering with various healthcare facilities across the state to develop a nursing workforce competent in EBP and improve the quality of nursing care to Hawaii_s citizens. The program consists of an annual workshop followed by a 12-month internship experience and has successfully engaged 60 EBP teams from 15 healthcare facilities to implement evidence-based nursing practices.4 An outgrowth of this successful state-wide EBP partnership was the initiative to encourage dissemination through publication of the completed EBP projects. While the outcomes of the statewide EBP program have been circulated locally, little information has been disseminated in professional literature. A consultation with Dr Marita Titler, who has a long-standing relationship with the program, resulted in dedicating an entire issue of the Nursing Clinics of North America (NCNA) journal to Hawaii_s EBP program. The purpose of this article is to describe the approach, timeline, writing activities, and coaching guidance to support the
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
publication of solicited quality improvement articles in a national nursing journal.
Evidence for Practice Improvement A thorough review of the literature was conducted to document the need for increasing publications among staff nurses for disseminating outcomes of EBP projects. Several approaches appear in the literature with varying levels of success. Scholarly writing groups as a means to increase publications have been described in the literature.5 A variation on this approach is the writing retreat as described by Jackson.6 Retreats for a varied group of Australian nurses working in different settings (eg, academic, practice) led to positive outcomes including publications and collaboration.6 Keen1 discussed the increased pressure to publish in nonacademic settings and suggested strategies that could help nurses be successful, including academic writing courses, use of experts and coaches, collaborative writing, and writing groups.1 Shatzer et al7 focused on improving self-efficacy for scholarly writing. By using individual mentoring sessions addressing situational and personal barriers, this study aimed to improve nurses_ self-efficacy for writing. Although improvements in self-efficacy were noted in this small sample, there was no correlation with manuscript completion.7 There have been several previous efforts to encourage nurses to publish papers highlighting their patient care activities at this facility in Hawaii. Examples include offering hour-long breakout sessions at the annual Research Day and multisession writing workshops over a 3-month period. Neither strategy resulted in publications, despite good intentions and verbal commitments to complete papers. A more successful model was the establishment of a small writing group that met monthly with a writing coach to develop a publishable paper of their research project. Introducing a coach who was not a regular member of the project team appeared to increase writer accountability, resulting in a paper that was submitted to a peer-reviewed journal. Based on the existing literature and experiences of the EBP faculty, it was determined that an EBP writing workshop could fulfill the requirements and deadline of the NCNA journal. It would also disseminate successful EBP projects and fulfill Magnet requirements.
Implementation Strategies Conceptual Framework Adult Learning theory served as the theoretical basis for the EBP writing workshop series. Malcolm Knowles,8
an American educator, coined the term ‘‘andragogy,’’ the art and science of adult learning (Table 1). The Knowles theory is based on 4 principles. First, adults need to be involved in the planning and evaluation of their instruction. Second, adults learn experientially so experience should provide the basis for their learning activities. Next, adults are most interested in learning content that has immediate relevance to their jobs. Finally, adult learning is problem centered rather than content oriented.9 Application of Principles Application of Knowles_8 4 principles was demonstrated through various elements of the writing workshop. The method was implemented by continually reviewing the curriculum to ensure that it was meeting the needs of the group, revising as needed. The teaching method emphasized the use of experiential learning. Participants learned by doing, writing, and critiquing both during and between sessions. The relevance of the content to the individual_s professional life impacted the motivation of the participants. Participants had been involved in the design and implementation of the EBP projects described in each manuscript. The teams were eager to disseminate their results. The sessions were designed to help teams ‘‘solve the problem’’ of writing a manuscript for publication, a task none of the participants had accomplished before. Coaching Previous experience with different types of support for writing manuscripts indicated 1 of the most important strategies was the use of a writing coach. The role of the writing coach has been described as providing support and encouragement to a motivated individual in order to help him/her meet particular goals.6 Literature supports the necessity of self-motivation; ergo the coach serves on the sidelines but is not pushing or prodding the individual toward the finish line. Successful coach characteristics include the ability to encourage and validate the writer, as well as the skills to provide written and verbal feedback and experiencebased guidance.10 Other important elements described by Baldwin and Chandler10 are the ability to empathize with the difficulties of writing by reassuring potential authors that writing can be learned and is not innate. In addition, it is important for the coach to have sound knowledge of the writing process including a successful publication record. A coach must also give specific writing tips, such as those related to voice, tense, organization of the manuscript, and reference citations.10 The writing coach selected for this initiative is a professor emeritus from 1 of the local schools of nursing who had also worked at the Magnet facility as a
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
637
Table 1. Knowles_8 4 Principles of Andragogy Principle Principle Principle Principle
1 2 3 4
Adults need to be involved in the planning and evaluation of their instruction. Adults learn experientially so experience should provide the basis for the learning activities. Adults are most interested in learning subjects that have immediate relevance to their job. Adult learning is problem centered rather than content oriented.
nurse researcher and had facilitated several writing workshops and groups over the past 5 years. She has a sound record of publications and a history of working with bedside nurses on various initiatives. After a discussion about author order and responsibilities, each writing team identified 1 person as the 1st author and as the lead who collected and managed the contributions of the different writers. Using a team approach meant that multiple authors contributed to the manuscript at different times, resulting in a situation where members may not have reviewed the assignment that was submitted for each workshop session. A major challenge for the workshop writing coach was to find ways to bridge the time and contribution gaps among writers within a team during the sessions. Writing Sessions The editorial deadline for submission to the special issue of NCNA was the impetus driving the timeline of the process. There were 6 months of workshop sessions. Teams were selected on the basis of 2 main criteria. First, each team must have completed its EBP project and prepared a 1-page project summary. Second, team members had to indicate commitment to completing the manuscript by the journal deadline. After an introductory session where participants presented their topics, the workshop content was divided into 6 short segments to guide the budding authors with their work. Small, manageable monthly assignments were designed to minimize feeling overwhelmed by the writing process. The logistics of the workshops were designed to meet the needs of the participants. For example, sessions were held at 2 different facilities for ease of access, parking availability, presentation/logistical support, and promotion of small-group communication. To accommodate work schedules, session times alternated between afternoon and evening hours. Perhaps most importantly, access to food/snacks at the start of the sessions was considered. Dr Titler provided a topical outline for the manuscripts based on the Iowa Model of Evidence-Based Practice to Promote Quality Care.11 There were 6 major elements to address: introduction, evidence for practice improvement, implementation strategies, evaluation, lessons learned, and conclusion. Because most
638
participants had been involved in the EBP internship program, a clear link between the manuscript topical outline and the structure of the Iowa Model was made to ease the transition to the manuscript format. This became the structural framework for the paper (Table 2).
Curriculum The introductory session focused on the project overview. Thereafter, the curriculum content was divided into 3 main areas, which left 2 sessions at the end of the series to refine manuscript drafts (Table 3). In session 1, each writing team shared its 1-page project overview with the whole group. In session 2, the focus was on developing the Introduction and Evidence for Practice Improvement sections. Session 3 was devoted to Implementation Strategies and Evaluation. Writers needed to be very detailed in their descriptions so anyone who read the article could replicate the project in their his/her facility. Session 4 incorporated Lessons Learned and Conclusion sections. Lastly, sessions 5 and 6 were spent on feedback and refining manuscripts in preparation for submission to the journal editorial staff. During the last session, final drafts were reviewed, and participants evaluated the workshop. Each manuscript was reviewed a total of 9 times. The writing coach reviewed and edited the individual sections of the papers as they were being developed. Once these sections were combined into complete drafts, 3 subsequent submissions were reviewed and edited by 3 workshop faculty: the writing coach, the EBP workshop director, or the clinical facility director. Two final reviews were conducted by 2 of the 3 editors of the journal issue. Editorial Tips For each session, feedback was provided in writing using the ‘‘track changes’’ and ‘‘new comment’’ features of Microsoft Word (Microsoft, Seattle, Washington). Writing teams were given hard and soft copies of their documents with visible track changes and another copy of their document with changes accepted for improved readability. Teams were also provided opportunities for direct verbal feedback from reviewers during or after workshop sessions.
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Table 2. Structural Framework for Paper Iowa Model Steps
Article Outline (M.Titler)
& Identify Topic & Form Team & Find & Critique Literature & Determine Evidence & Pilot Changes & Institute EBP Changes & Evaluate Change
& Introduction (describe practice issue, purpose of paper) & Evidence for Practice Improvement & Implementation Strategies (how was the practice change implemented) & Evaluation (what was the impact) & Lessons Learned and Recommendations for others & Conclusion
Source: Kooker B, ‘‘Structural Framework for Paper [handout] EBP Writing WorkshopSession 1, Goal, Requirements, Project Descriptions,’’ The Queen’s Medical Center and the Hawaii State Center for Nursing; 2013.
revisions as a group. This was helpful because team members usually worked asynchronously on different sections of the paper. The lead author would revise the manuscript based on feedback from the team. Because not all team members were present at each workshop session, this activity also was helpful as a means to bring all team members up to date with the latest revisions. Monitoring Progress A tracking tool was designed to monitor progress of the writing teams. The tool was used to monitor submissions, track monthly progress, indicate late or missing work, and ensure distribution among reviewers (Table 4).
Evaluation Read Aloud A major part of each workshop session was the Read Aloud (RA) activity. RA is a recognized tool to improve reading comprehension in children.12,13 RA has been shown to result in better comprehension than silent reading.14 During the RA activity, use of strategic questions guided the reader to better focus on what was read for factual, inferential, and predictive analysis.14 Beltchenko indicated that RA not only increased the ability to make connections while reading, but also encouraged thinking aloud during which readers verbalized their thoughts while reading, thus encouraging further analysis of the content and context.15 An RA group activity was designed for each workshop session. Specific instructions were devised to guide the work of each team (Figure 1). Members of each writing team read the revised sections of their manuscript to each other, making note of comments, questions, and hesitations while reading. Members shared their detailed feedback, discussing points of confusion, and negotiating clarifications/
Process Workshop faculty kept track of such process elements as session attendance by at least 1 team member and submission of assignments on time. Participants were
Table 3. Curriculum Content per Workshop Session Session 1 Session 2 Session 3 Session 4 Session 5 Session 6
& & & & & & & & & & &
Project Overview Introduction Evidence for Practice Improvement Implementation Strategies Evaluation Lessons Learned Conclusion Draft feedback Draft refinement Draft feedback Draft refinement
Figure 1. Read aloud group activity. Source: Kooker, B. (2013) Read Aloud Group Activity [handout] EBP Writing Workshop, Session 2, Project description critique, Manuscript development plan, The Queen’s Medical Center and the Hawaii State Center for Nursing. 7/11/2013.
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
639
Table 4. Writing Assignment Tracking Tool Journal Writing Assignment Due Dates Manuscript Topic Facility, Authors Paper Paper Paper Paper Paper Paper Paper Paper Paper Paper Paper
A B C D E F G H I J K
6/6
7/3
7/25
8/29
9/26
10/31
11/29
1-Page Project Overview
Introduction and Evidence for Practice Improvement
Implementation Strategies and Evaluation
Lessons Learned and Conclusion
Draft 1
Draft 2
Draft 3
X X X X X X X X X X X
X X X X Sick 7/5 X X X X 7/10 X Intro only X X 7/5
X X X 7/31 X 7/31 X X Sick 8/2 V X X X V
X X X V X 8/31 X X X X X X
1 1 1 X 9/30 1 1 V 1 1 1 1
Reviewer 3 1 2 1 1 2 2 3 1 3 3
1 3 1 3 2 3 3 1 2 1 2
X indicates assignment submitted; V, assignment not submitted.
engaged during each session and communicated with faculty in between sessions when issues arose. Workshop faculty were actively engaged in process evaluation. They met before each session to review and refine materials and activities developed by the writing coach to cover the curriculum content. They met after each workshop session to debrief and analyze the session and make preliminary plans for the next one. Periodically, the EBP workshop director and the facility director met with Dr Titler and the NCNA journal editorial staff to apprise them of progress and seek clarification and updates from them. Participant evaluation was formally obtained via verbal feedback at the last session. Workshop faculty led the discussion and recorded comments on chart paper so everyone could review and contribute. Participants viewed structure and logistics of the workshop sessions as positives. They liked the alternating times and locations of the sessions and appreciated the manageable assignments. Peer support, including gentle peer pressure, was also seen as a positive aspect. Several participants also voiced their appreciation of timely coaching and support from workshop faculty. Two main challenges were identified by the participants. The 1st related to the mechanics of writing, which included learning the technical aspects of ‘‘track changes.’’ The 2nd was finding time to write. Participants had 3 main recommendations for future workshops. First, they requested that structured time during the workshop be devoted to actual writing. Next, they asked for samples of completed papers and more detailed outlines to serve as guides for their own writing. Finally, suggestions were made for electronic storage of files with guidelines for keeping track of different drafts.
640
Outcomes The writing workshop started with 12 teams committed to preparing their manuscripts. Since the results of a research study had prompted one of the EBP projects, those authors joined the workshop after the 3rd session. Thirteen manuscripts were submitted for the final editorial review, and 12 were accepted for publication.4 The 13th manuscript was found to be lacking an adequate evidence base for the specific intervention and was inconsistent with editorial guidance and other manuscripts in the issue. It is unfortunate these authors had their manuscript rejected, but they are now revising it for submission to another journal. Therefore, a total of 12 manuscripts were completed as a result of the writing workshop; 82% of the assignments were completed on time.
Lessons Learned The success of this endeavor depended on important components of the approach used. First, the most important component was setting an expectation that teams would meet the external deadlines imposed by the journal editor. Knowing that final submission of each paper was needed by a set date to meet the publication date encouraged author adherence to interim deadlines. The authors committed to these deadlines at the 1st meeting of the writing group. Other external factors also influenced adherence to deadlines, including applications to the clinical ladder at the Magnet facility and application deadlines for advanced-degree programs and certification applications. A 2nd lesson learned was the importance of commitment to a person known and respected by the group;
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
in this case, the lead guest editor was Dr Marita Titler. Dr Titler was well known to the authors as the lead facilitator of the EBP workshop held to kick off the EBP projects. She provided interim guidance and support throughout the life of the projects. The writing teams wanted to show their respect and gratitude to this nursing scholar by publishing their manuscripts. The importance of having a clearly defined process for selecting writing teams was the next lesson. Teams whose projects were completed and who had expressed interest and commitment were invited to participate in the workshop. In retrospect, having more robust criteria for project selection would have avoided the last-minute realization that one of the projects was not adequately evidence based and could not be published in this journal edition. Because each team had submitted a final project summary, a closer examination of these summaries using selection criteria might have avoided this situation. The 4th lesson was to keep in mind that the members of the writing teams were all novice authors. Workshop faculty needed to attend to details of the submission process and double check each step. No assumptions could be made about completing the intricate online manuscript submission, including title page format, correct spelling of author names, and proper placement of tables/graphs. Although coaching novice authors was a resource-intensive process for workshop faculty, the completion of all manuscripts made it a worthwhile endeavor. As enticing as success of this workshop was, the final lesson learned was to hold the workshops every other year rather than annually, using the alternate years to improve the process. For example, criteria for team selection could be clarified and distributed,
teams could develop more detailed project summaries, and faculty could prepare resource guides for submission of papers to various journals.
Conclusion Based on evaluation of the EBP writing workshops, the faculty offered several suggestions for improvements for the next workshop series. First, dedicated time during the workshop needs to be set aside for actual writing by the team members. Second, writing team members need technical assistance with drafting and editing skills such as ‘‘track changes,’’ electronic sharing of documents, and techniques to track different manuscript versions. Finally, the application process for selection of EBP projects and teams must be more rigorous, clearly stated, and widely distributed among all EBP teams who want to be considered. During the next writing workshop series, the EBP teams will be writing their manuscripts for different journals as appropriate to their specialty areas. Therefore, time and content must be devoted early in the workshop sessions to selecting the proper journal for each project and addressing ‘‘author guidelines’’ appropriate to the particular journals. The Center, in collaboration with The Queen_s Medical Center, will continue its work and expand efforts to promote and disseminate findings from EBP projects. As use of EBP to improve care in the clinical setting becomes the standard, the next challenge is to normalize dissemination of findings. The success achieved in Hawaii through this EBP writing workshop provides a road map that others can use to obtain similar results with dissemination. In this way, the true intent of EBP, which is improvement of patient care, can be realized.
References 1. Keen A. Writing for publication: pressures, barriers and support strategies. Nurse Educ Today. 2007;27(5):382-388. 2. IOM future of nursing report recommendations are in: now what? Implications for nursing. N J Nurse. 41(3):10. 3. ANCC. 2014 Magnet Application Manual. Silver Spring, MD: American Nurses Credentialing Center (ANCC); 2013. 4. Mark DD, Latimer RW, White JP, Bransford D, Johnson KG, Song VL. Hawaii_s statewide evidence-based practice program. Nurs Clin North Am. 2014;49(3):275-290. 5. Bauer-Wu S, Epshtein A, Reid Ponte P. Promoting excellence in nursing research and scholarship in the clinical setting. J Nurs Adm. 2006;36(5):224-227. 6. Jackson D. Mentored residential writing retreats: a leadership strategy to develop skills and generate outcomes in writing for publication. Nurse Educ Today. 2009;29(1):9-15. 7. Shatzer M, Wolf GA, Hravnak M, Haugh A, Kikutu J, Hoffmann RL. A curriculum designed to decrease barriers related to scholarly writing by staff nurses. J Nurs Adm. 2010; 40(9):392-398.
8. Knowles M. The Adult Learner: A Neglected Species. 3rd ed. Houston, TX: Gulf Publishing; 1984. 9. Kearsley G. Andragogy (M. Knowles). The theory Into practice database. http://www.instructionaldesign.org/theories/andragogy. html. Accessed June 9, 2014. 10. Baldwin C, Chandler GE. Improving faculty publication output: the role of a writing coach. J Prof Nurs. 2002;18(1):8-15. 11. Titler MG, Kleiber C, Steelman VJ, et al. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. 2001;13(4):497-509. 12. Dhaif H. Reading aloud for comprehension: a neglected teaching aid. Read Foreign Lang. 1990;7(1):457-464. 13. Trelease J. The Read Aloud Handbook. 5th ed. London: Penguin Books; 2006. 14. Lane HB, Wright TL. Maximizing the Effectiveness of Reading Aloud. International Reading Association; 2007. 15. Beltchenko L. The components of effective read alouds. http:// www.d118.org/district/curriculum/initiatives/componentseffective-read-alouds.pdf. Accessed February 1, 2014.
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
641
THE JOURNAL OF NURSING ADMINISTRATION
Successfully Coaching Nursing Staff to Publish Outcomes Barbara Molina Kooker, DrPH, RN, NEA-BC Renee Latimer, MS, RN, PMHCNS-BC Debra D. Mark, PhD, RN
There is a need for bedside nurses to disseminate the results of evidence-based practice quality initiatives to a wider audience through publications in peer-reviewed journals. Barriers to publication are common and include lack of time, skills, experience, confidence, and tangible support. This article describes the structured approach, timeline, writing activities, and coaching guidance used to support the publication of 12 quality improvement articles in 1 nursing journal. Although publishing nursing science has historically been in the academic domain, bedside nurses are increasingly being encouraged to publish, sometimes as a result of increasing levels of nursing education1 or Magnet designation. In addition, there is an increased need for nurses to incorporate evidence into practice. The Institute of Medicine_s initiative on the Future of Nursing defines a model healthcare system as ‘‘seamless, affordable, quality care that is accessible to all, patient centered, and evidence-based and leads to improved health outcomes.’’2 Nurses are positioned to make this goal a reality if they have access to information. According to Keen,1 ‘‘Published evidence is subsequently required in order to review and, if necessary, adjust existing nursing practice.’’1(p384) The Queen_s Medical Center, a Magnet-designated facility in Honolulu, Hawaii, acknowledges that the A
Author Affiliations: Nurse Researcher (Dr Kooker) and Director (Ms Latimer), The Queen_s Medical Center, Queen Emma Nursing Institute, Honolulu, Hawaii; and Associate Professor (Dr Mark), School of Nursing and Dental Hygiene, University of Hawaii at Manoa, Honolulu. The authors declare no conflicts of interest. Correspondence: Dr Kooker, The Queen_s Medical Center, 1301 Punchbowl St, Honolulu, HI 96813 ([email protected]). DOI: 10.1097/NNA.0000000000000277
636
need for nurses to publish is driven by many factors, such as the increasing recognition of the importance of quality care and patient safety. Healthcare facility certification and accreditation sometimes include a requirement for disseminating new knowledge and process improvements related to quality and patient safety. For example, Magnet-designated organizations must provide examples of evidence-based practice (EBP) and research initiatives in their recertification applications, including the requirement that nurses disseminate their organization_s innovations both internally and externally through presentations and publications.3 The Hawaii State Center for Nursing (HSCFN) was established in 2003 with a legislative mandate to conduct research on best practices and quality outcomes. HSCFN has a 7-year history of partnering with various healthcare facilities across the state to develop a nursing workforce competent in EBP and improve the quality of nursing care to Hawaii_s citizens. The program consists of an annual workshop followed by a 12-month internship experience and has successfully engaged 60 EBP teams from 15 healthcare facilities to implement evidence-based nursing practices.4 An outgrowth of this successful state-wide EBP partnership was the initiative to encourage dissemination through publication of the completed EBP projects. While the outcomes of the statewide EBP program have been circulated locally, little information has been disseminated in professional literature. A consultation with Dr Marita Titler, who has a long-standing relationship with the program, resulted in dedicating an entire issue of the Nursing Clinics of North America (NCNA) journal to Hawaii_s EBP program. The purpose of this article is to describe the approach, timeline, writing activities, and coaching guidance to support the
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
publication of solicited quality improvement articles in a national nursing journal.
Evidence for Practice Improvement A thorough review of the literature was conducted to document the need for increasing publications among staff nurses for disseminating outcomes of EBP projects. Several approaches appear in the literature with varying levels of success. Scholarly writing groups as a means to increase publications have been described in the literature.5 A variation on this approach is the writing retreat as described by Jackson.6 Retreats for a varied group of Australian nurses working in different settings (eg, academic, practice) led to positive outcomes including publications and collaboration.6 Keen1 discussed the increased pressure to publish in nonacademic settings and suggested strategies that could help nurses be successful, including academic writing courses, use of experts and coaches, collaborative writing, and writing groups.1 Shatzer et al7 focused on improving self-efficacy for scholarly writing. By using individual mentoring sessions addressing situational and personal barriers, this study aimed to improve nurses_ self-efficacy for writing. Although improvements in self-efficacy were noted in this small sample, there was no correlation with manuscript completion.7 There have been several previous efforts to encourage nurses to publish papers highlighting their patient care activities at this facility in Hawaii. Examples include offering hour-long breakout sessions at the annual Research Day and multisession writing workshops over a 3-month period. Neither strategy resulted in publications, despite good intentions and verbal commitments to complete papers. A more successful model was the establishment of a small writing group that met monthly with a writing coach to develop a publishable paper of their research project. Introducing a coach who was not a regular member of the project team appeared to increase writer accountability, resulting in a paper that was submitted to a peer-reviewed journal. Based on the existing literature and experiences of the EBP faculty, it was determined that an EBP writing workshop could fulfill the requirements and deadline of the NCNA journal. It would also disseminate successful EBP projects and fulfill Magnet requirements.
Implementation Strategies Conceptual Framework Adult Learning theory served as the theoretical basis for the EBP writing workshop series. Malcolm Knowles,8
an American educator, coined the term ‘‘andragogy,’’ the art and science of adult learning (Table 1). The Knowles theory is based on 4 principles. First, adults need to be involved in the planning and evaluation of their instruction. Second, adults learn experientially so experience should provide the basis for their learning activities. Next, adults are most interested in learning content that has immediate relevance to their jobs. Finally, adult learning is problem centered rather than content oriented.9 Application of Principles Application of Knowles_8 4 principles was demonstrated through various elements of the writing workshop. The method was implemented by continually reviewing the curriculum to ensure that it was meeting the needs of the group, revising as needed. The teaching method emphasized the use of experiential learning. Participants learned by doing, writing, and critiquing both during and between sessions. The relevance of the content to the individual_s professional life impacted the motivation of the participants. Participants had been involved in the design and implementation of the EBP projects described in each manuscript. The teams were eager to disseminate their results. The sessions were designed to help teams ‘‘solve the problem’’ of writing a manuscript for publication, a task none of the participants had accomplished before. Coaching Previous experience with different types of support for writing manuscripts indicated 1 of the most important strategies was the use of a writing coach. The role of the writing coach has been described as providing support and encouragement to a motivated individual in order to help him/her meet particular goals.6 Literature supports the necessity of self-motivation; ergo the coach serves on the sidelines but is not pushing or prodding the individual toward the finish line. Successful coach characteristics include the ability to encourage and validate the writer, as well as the skills to provide written and verbal feedback and experiencebased guidance.10 Other important elements described by Baldwin and Chandler10 are the ability to empathize with the difficulties of writing by reassuring potential authors that writing can be learned and is not innate. In addition, it is important for the coach to have sound knowledge of the writing process including a successful publication record. A coach must also give specific writing tips, such as those related to voice, tense, organization of the manuscript, and reference citations.10 The writing coach selected for this initiative is a professor emeritus from 1 of the local schools of nursing who had also worked at the Magnet facility as a
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
637
Table 1. Knowles_8 4 Principles of Andragogy Principle Principle Principle Principle
1 2 3 4
Adults need to be involved in the planning and evaluation of their instruction. Adults learn experientially so experience should provide the basis for the learning activities. Adults are most interested in learning subjects that have immediate relevance to their job. Adult learning is problem centered rather than content oriented.
nurse researcher and had facilitated several writing workshops and groups over the past 5 years. She has a sound record of publications and a history of working with bedside nurses on various initiatives. After a discussion about author order and responsibilities, each writing team identified 1 person as the 1st author and as the lead who collected and managed the contributions of the different writers. Using a team approach meant that multiple authors contributed to the manuscript at different times, resulting in a situation where members may not have reviewed the assignment that was submitted for each workshop session. A major challenge for the workshop writing coach was to find ways to bridge the time and contribution gaps among writers within a team during the sessions. Writing Sessions The editorial deadline for submission to the special issue of NCNA was the impetus driving the timeline of the process. There were 6 months of workshop sessions. Teams were selected on the basis of 2 main criteria. First, each team must have completed its EBP project and prepared a 1-page project summary. Second, team members had to indicate commitment to completing the manuscript by the journal deadline. After an introductory session where participants presented their topics, the workshop content was divided into 6 short segments to guide the budding authors with their work. Small, manageable monthly assignments were designed to minimize feeling overwhelmed by the writing process. The logistics of the workshops were designed to meet the needs of the participants. For example, sessions were held at 2 different facilities for ease of access, parking availability, presentation/logistical support, and promotion of small-group communication. To accommodate work schedules, session times alternated between afternoon and evening hours. Perhaps most importantly, access to food/snacks at the start of the sessions was considered. Dr Titler provided a topical outline for the manuscripts based on the Iowa Model of Evidence-Based Practice to Promote Quality Care.11 There were 6 major elements to address: introduction, evidence for practice improvement, implementation strategies, evaluation, lessons learned, and conclusion. Because most
638
participants had been involved in the EBP internship program, a clear link between the manuscript topical outline and the structure of the Iowa Model was made to ease the transition to the manuscript format. This became the structural framework for the paper (Table 2).
Curriculum The introductory session focused on the project overview. Thereafter, the curriculum content was divided into 3 main areas, which left 2 sessions at the end of the series to refine manuscript drafts (Table 3). In session 1, each writing team shared its 1-page project overview with the whole group. In session 2, the focus was on developing the Introduction and Evidence for Practice Improvement sections. Session 3 was devoted to Implementation Strategies and Evaluation. Writers needed to be very detailed in their descriptions so anyone who read the article could replicate the project in their his/her facility. Session 4 incorporated Lessons Learned and Conclusion sections. Lastly, sessions 5 and 6 were spent on feedback and refining manuscripts in preparation for submission to the journal editorial staff. During the last session, final drafts were reviewed, and participants evaluated the workshop. Each manuscript was reviewed a total of 9 times. The writing coach reviewed and edited the individual sections of the papers as they were being developed. Once these sections were combined into complete drafts, 3 subsequent submissions were reviewed and edited by 3 workshop faculty: the writing coach, the EBP workshop director, or the clinical facility director. Two final reviews were conducted by 2 of the 3 editors of the journal issue. Editorial Tips For each session, feedback was provided in writing using the ‘‘track changes’’ and ‘‘new comment’’ features of Microsoft Word (Microsoft, Seattle, Washington). Writing teams were given hard and soft copies of their documents with visible track changes and another copy of their document with changes accepted for improved readability. Teams were also provided opportunities for direct verbal feedback from reviewers during or after workshop sessions.
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Table 2. Structural Framework for Paper Iowa Model Steps
Article Outline (M.Titler)
& Identify Topic & Form Team & Find & Critique Literature & Determine Evidence & Pilot Changes & Institute EBP Changes & Evaluate Change
& Introduction (describe practice issue, purpose of paper) & Evidence for Practice Improvement & Implementation Strategies (how was the practice change implemented) & Evaluation (what was the impact) & Lessons Learned and Recommendations for others & Conclusion
Source: Kooker B, ‘‘Structural Framework for Paper [handout] EBP Writing WorkshopSession 1, Goal, Requirements, Project Descriptions,’’ The Queen’s Medical Center and the Hawaii State Center for Nursing; 2013.
revisions as a group. This was helpful because team members usually worked asynchronously on different sections of the paper. The lead author would revise the manuscript based on feedback from the team. Because not all team members were present at each workshop session, this activity also was helpful as a means to bring all team members up to date with the latest revisions. Monitoring Progress A tracking tool was designed to monitor progress of the writing teams. The tool was used to monitor submissions, track monthly progress, indicate late or missing work, and ensure distribution among reviewers (Table 4).
Evaluation Read Aloud A major part of each workshop session was the Read Aloud (RA) activity. RA is a recognized tool to improve reading comprehension in children.12,13 RA has been shown to result in better comprehension than silent reading.14 During the RA activity, use of strategic questions guided the reader to better focus on what was read for factual, inferential, and predictive analysis.14 Beltchenko indicated that RA not only increased the ability to make connections while reading, but also encouraged thinking aloud during which readers verbalized their thoughts while reading, thus encouraging further analysis of the content and context.15 An RA group activity was designed for each workshop session. Specific instructions were devised to guide the work of each team (Figure 1). Members of each writing team read the revised sections of their manuscript to each other, making note of comments, questions, and hesitations while reading. Members shared their detailed feedback, discussing points of confusion, and negotiating clarifications/
Process Workshop faculty kept track of such process elements as session attendance by at least 1 team member and submission of assignments on time. Participants were
Table 3. Curriculum Content per Workshop Session Session 1 Session 2 Session 3 Session 4 Session 5 Session 6
& & & & & & & & & & &
Project Overview Introduction Evidence for Practice Improvement Implementation Strategies Evaluation Lessons Learned Conclusion Draft feedback Draft refinement Draft feedback Draft refinement
Figure 1. Read aloud group activity. Source: Kooker, B. (2013) Read Aloud Group Activity [handout] EBP Writing Workshop, Session 2, Project description critique, Manuscript development plan, The Queen’s Medical Center and the Hawaii State Center for Nursing. 7/11/2013.
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
639
Table 4. Writing Assignment Tracking Tool Journal Writing Assignment Due Dates Manuscript Topic Facility, Authors Paper Paper Paper Paper Paper Paper Paper Paper Paper Paper Paper
A B C D E F G H I J K
6/6
7/3
7/25
8/29
9/26
10/31
11/29
1-Page Project Overview
Introduction and Evidence for Practice Improvement
Implementation Strategies and Evaluation
Lessons Learned and Conclusion
Draft 1
Draft 2
Draft 3
X X X X X X X X X X X
X X X X Sick 7/5 X X X X 7/10 X Intro only X X 7/5
X X X 7/31 X 7/31 X X Sick 8/2 V X X X V
X X X V X 8/31 X X X X X X
1 1 1 X 9/30 1 1 V 1 1 1 1
Reviewer 3 1 2 1 1 2 2 3 1 3 3
1 3 1 3 2 3 3 1 2 1 2
X indicates assignment submitted; V, assignment not submitted.
engaged during each session and communicated with faculty in between sessions when issues arose. Workshop faculty were actively engaged in process evaluation. They met before each session to review and refine materials and activities developed by the writing coach to cover the curriculum content. They met after each workshop session to debrief and analyze the session and make preliminary plans for the next one. Periodically, the EBP workshop director and the facility director met with Dr Titler and the NCNA journal editorial staff to apprise them of progress and seek clarification and updates from them. Participant evaluation was formally obtained via verbal feedback at the last session. Workshop faculty led the discussion and recorded comments on chart paper so everyone could review and contribute. Participants viewed structure and logistics of the workshop sessions as positives. They liked the alternating times and locations of the sessions and appreciated the manageable assignments. Peer support, including gentle peer pressure, was also seen as a positive aspect. Several participants also voiced their appreciation of timely coaching and support from workshop faculty. Two main challenges were identified by the participants. The 1st related to the mechanics of writing, which included learning the technical aspects of ‘‘track changes.’’ The 2nd was finding time to write. Participants had 3 main recommendations for future workshops. First, they requested that structured time during the workshop be devoted to actual writing. Next, they asked for samples of completed papers and more detailed outlines to serve as guides for their own writing. Finally, suggestions were made for electronic storage of files with guidelines for keeping track of different drafts.
640
Outcomes The writing workshop started with 12 teams committed to preparing their manuscripts. Since the results of a research study had prompted one of the EBP projects, those authors joined the workshop after the 3rd session. Thirteen manuscripts were submitted for the final editorial review, and 12 were accepted for publication.4 The 13th manuscript was found to be lacking an adequate evidence base for the specific intervention and was inconsistent with editorial guidance and other manuscripts in the issue. It is unfortunate these authors had their manuscript rejected, but they are now revising it for submission to another journal. Therefore, a total of 12 manuscripts were completed as a result of the writing workshop; 82% of the assignments were completed on time.
Lessons Learned The success of this endeavor depended on important components of the approach used. First, the most important component was setting an expectation that teams would meet the external deadlines imposed by the journal editor. Knowing that final submission of each paper was needed by a set date to meet the publication date encouraged author adherence to interim deadlines. The authors committed to these deadlines at the 1st meeting of the writing group. Other external factors also influenced adherence to deadlines, including applications to the clinical ladder at the Magnet facility and application deadlines for advanced-degree programs and certification applications. A 2nd lesson learned was the importance of commitment to a person known and respected by the group;
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
in this case, the lead guest editor was Dr Marita Titler. Dr Titler was well known to the authors as the lead facilitator of the EBP workshop held to kick off the EBP projects. She provided interim guidance and support throughout the life of the projects. The writing teams wanted to show their respect and gratitude to this nursing scholar by publishing their manuscripts. The importance of having a clearly defined process for selecting writing teams was the next lesson. Teams whose projects were completed and who had expressed interest and commitment were invited to participate in the workshop. In retrospect, having more robust criteria for project selection would have avoided the last-minute realization that one of the projects was not adequately evidence based and could not be published in this journal edition. Because each team had submitted a final project summary, a closer examination of these summaries using selection criteria might have avoided this situation. The 4th lesson was to keep in mind that the members of the writing teams were all novice authors. Workshop faculty needed to attend to details of the submission process and double check each step. No assumptions could be made about completing the intricate online manuscript submission, including title page format, correct spelling of author names, and proper placement of tables/graphs. Although coaching novice authors was a resource-intensive process for workshop faculty, the completion of all manuscripts made it a worthwhile endeavor. As enticing as success of this workshop was, the final lesson learned was to hold the workshops every other year rather than annually, using the alternate years to improve the process. For example, criteria for team selection could be clarified and distributed,
teams could develop more detailed project summaries, and faculty could prepare resource guides for submission of papers to various journals.
Conclusion Based on evaluation of the EBP writing workshops, the faculty offered several suggestions for improvements for the next workshop series. First, dedicated time during the workshop needs to be set aside for actual writing by the team members. Second, writing team members need technical assistance with drafting and editing skills such as ‘‘track changes,’’ electronic sharing of documents, and techniques to track different manuscript versions. Finally, the application process for selection of EBP projects and teams must be more rigorous, clearly stated, and widely distributed among all EBP teams who want to be considered. During the next writing workshop series, the EBP teams will be writing their manuscripts for different journals as appropriate to their specialty areas. Therefore, time and content must be devoted early in the workshop sessions to selecting the proper journal for each project and addressing ‘‘author guidelines’’ appropriate to the particular journals. The Center, in collaboration with The Queen_s Medical Center, will continue its work and expand efforts to promote and disseminate findings from EBP projects. As use of EBP to improve care in the clinical setting becomes the standard, the next challenge is to normalize dissemination of findings. The success achieved in Hawaii through this EBP writing workshop provides a road map that others can use to obtain similar results with dissemination. In this way, the true intent of EBP, which is improvement of patient care, can be realized.
References 1. Keen A. Writing for publication: pressures, barriers and support strategies. Nurse Educ Today. 2007;27(5):382-388. 2. IOM future of nursing report recommendations are in: now what? Implications for nursing. N J Nurse. 41(3):10. 3. ANCC. 2014 Magnet Application Manual. Silver Spring, MD: American Nurses Credentialing Center (ANCC); 2013. 4. Mark DD, Latimer RW, White JP, Bransford D, Johnson KG, Song VL. Hawaii_s statewide evidence-based practice program. Nurs Clin North Am. 2014;49(3):275-290. 5. Bauer-Wu S, Epshtein A, Reid Ponte P. Promoting excellence in nursing research and scholarship in the clinical setting. J Nurs Adm. 2006;36(5):224-227. 6. Jackson D. Mentored residential writing retreats: a leadership strategy to develop skills and generate outcomes in writing for publication. Nurse Educ Today. 2009;29(1):9-15. 7. Shatzer M, Wolf GA, Hravnak M, Haugh A, Kikutu J, Hoffmann RL. A curriculum designed to decrease barriers related to scholarly writing by staff nurses. J Nurs Adm. 2010; 40(9):392-398.
8. Knowles M. The Adult Learner: A Neglected Species. 3rd ed. Houston, TX: Gulf Publishing; 1984. 9. Kearsley G. Andragogy (M. Knowles). The theory Into practice database. http://www.instructionaldesign.org/theories/andragogy. html. Accessed June 9, 2014. 10. Baldwin C, Chandler GE. Improving faculty publication output: the role of a writing coach. J Prof Nurs. 2002;18(1):8-15. 11. Titler MG, Kleiber C, Steelman VJ, et al. The Iowa Model of Evidence-Based Practice to Promote Quality Care. Crit Care Nurs Clin North Am. 2001;13(4):497-509. 12. Dhaif H. Reading aloud for comprehension: a neglected teaching aid. Read Foreign Lang. 1990;7(1):457-464. 13. Trelease J. The Read Aloud Handbook. 5th ed. London: Penguin Books; 2006. 14. Lane HB, Wright TL. Maximizing the Effectiveness of Reading Aloud. International Reading Association; 2007. 15. Beltchenko L. The components of effective read alouds. http:// www.d118.org/district/curriculum/initiatives/componentseffective-read-alouds.pdf. Accessed February 1, 2014.
JONA Vol. 45, No. 12 December 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
641
