Writing in Nursing

By September 28, 2016Writing about Writing

As a new UCWbLer, and specifically as the first ever UCWbLer who is a nursing student, I have spent my first couple weeks of tutoring shifts and WRD classes completely reassessing my view on how writing is important in my learning (and in my life).

How is Writing Important to Nursing?

During our first class meeting, in pondering the ways writing is important to nursing as a profession, the first thing I thought was about the endless scientific writing I do. It feels like I am constantly doing research on this disease, or that type of patient care, and subsequently conveying that research into an APA-formatted document.

It took me a bit to realize that research papers are only the tip of my proverbial iceberg. I write in many smaller, but possibly more significant, ways almost daily. Once a week, for example, I write a care plan to synthesize patient information, potential diagnoses, problems, and treatment plans.

Possibly most important, though least considered, is when writing enters nursing in the form of charting—a way to log a patient’s condition when they’re admitted and what happens to them while they’re in the hospital. We are taught the nuances of charting day in and day out, thought it was not until I began clinical rotations that I realized these nuances embody differences that may draw a line between life and death.

Charting: The Consequences of Doing it Wrong

Ineffective charting, also known as “communication breakdown,” is often a direct cause of unwanted patient incidents. A nurse giving a patient one dose of morphine and forgetting to document doing so, for instance, is an obvious example of where danger may lie.

There is danger in the less obvious mistakes as well, though. Writing “Mr. X has one wound,” is much different than writing “Mr. X has one stage 3 wound on the posterior side of his left shoulder.” The nurse who reads the former may go to turn Mr. X and accidently jab her hand directly into his wound since they do not know where it is located.

Errors like these do more than cause some bleeding from Mr. X’s shoulder. When patients come into the hospital, they always receive a full head to toe assessment, and a critical part of this is an evaluation of their skin. It is crucial that any preexisting wounds, scrapes, bruises, and paper cuts are documented accurately. Medicaid (and presumably, various other forms of insurance) will actually refuse to pay for the care of a wound that is acquired in the hospital! So, maybe Nurse Jackie saw the wound on Mr. X but forgot to chart it. Next week, when Nurse Florence wants to put some band-aids on Mr. X’s bleeding shoulder, his insurance will say “Nope, can’t help you, we won’t pay for those band-aids” since they now must assume the wound was caused by the staff’s lack of medical attention.

Nurses do Cool Stuff with Writing Too.

The moral of my story here is that nurses write more than long-winded research papers. Charting is a large slice of the pie chart that is nursing, and learning how to do it well is easier said than done. Sometimes it may take an instance of making the mistake, and learning that Mr. X was bleeding from the shoulder as a result, to remember how to do better next time. But you don’t have to make that mistake since I already told you about it.