Getting Started

Barbara Holmes Gobel, RN, MS

Although nurse authors agree that writing for publication takes time and effort, the activity is very rewarding. Success in publishing can be achieved by writing about familiar topics, spending time reviewing information already written on the topic, and carefully targeting a journal to which to submit the manuscript. Publishing opportunities in nursing abound, ranging from newsletter contributions to journal articles. All nurses have valuable information to share, and writing for publication is a worthwhile professional accomplishment.

"Writing is easy. All you have to do is stare at a blank sheet of paper until drops of blood form on your forehead."

— Gene Fowler (1890-1960)

As a nurse and author who has written and published over the years, I must say that I agree sincerely with Gene Fowler about this writing business. It is not easy! Some individuals in the nursing profession make writing look very easy, as they are prolific writers and accomplished authors. However, after talking with many of these individuals, it is clear that writing for publication is a skill that takes plenty of work but one that gets easier with practice. Connie Henke Yarbro, MS, RN, FAAN, editor of Seminars in Oncology Nursing, told me that the first time that she was asked to write for a nursing publication she had to think about it long and hard "...because, truthfully, I had not given any thought to writing an article at that time...and wondered if I would do a good job" (C.H. Yarbro, personal communication, October 28, 2000). She also stated that after "numerous drafts" and review by an inspiring mentor (her boss, John Durant, MD), she developed both a good book chapter and a desire to continue writing.

If writing takes so much work, as Connie Henke Yarbro and so many other authors will attest to, then why write? There are probably a million answers to this question from every nurse who chooses to write. One answer to that question may be that some nurses have to write—publish or perish. This is a familiar adage heard in many academic settings in which master's and doctorally prepared nurses must write (and publish) based on their job descriptions. For most of us, however, the reasons for writing are more personal. For as much work as it is, I really enjoy writing. I appreciate the process that writing takes and feel that it is one of my best learning tools. I know that I will always learn new things in the process of writing, and then I am able to bring new information to the staff and patients with whom I work.

I asked Lisa Schulmeister, RN, MN, CS, OCN^®, editor of Clinical Journal of Oncology Nursing (CJON), why she makes a commitment to writing. Rather than paraphrase her response, which I found to be so poignant, I chose to present it in its entirety.

My commitment to writing began when two things happened. The first part of the commitment process for me was when I encountered clinical problems that affected the patients I cared for. In order to learn more about the symptoms my patients were experiencing, I read as much as I could find, and, in doing so, I realized that if I had a question or learning need about a particular topic, then chances were good that there were other nurses out there like me. So I started writing informational sheets for my nursing colleagues and sent one to a nursing journal just to see if they might be interested in publishing it. Much to my surprise, my little info sheet on skin cancer and some photos of patients I had taken appeared in print. Although having an article published was quite thrilling, I viewed it as my first-and-only publication. Why write another? My work and home life were busy and, besides, there just wasn't enough time to write. I also didn't think that many nurses read journal articles.

My attitude changed quickly when I received a letter from a nurse who wrote that she became alarmed about a mole on her husband's shoulder after reading my article. She then wrote that it was biopsied, found to be an early-stage melanoma, and thanked me for saving her husband's life. By the time I got to the end of the letter, I had goosebumps from my head to my toes. I never imagined that a three-page article could have this kind of impact (L. Schulmeister, personal communication, October 15, 2000).

In preparing this manuscript, I also asked Laurie Abel, RN, BSN, OCN^®, why she has made a commitment to writing and publishing. Laurie, who is fairly new at writing and publishing, was the recipient of the first CJON Marcia Liebman New Writer Award for her first article on prostate brachytherapy. Since receiving this award, she has published another article on a similar topic as well as a letter to the editor. Abel told me that the physician with whom she works is a well published author and has encouraged her and her nurse colleagues to write and publish. Abel stated that prior to her article, little information was available on the nursing management of patients with prostate cancer being treated with brachytherapy. Abel's group managed their patients by "trial and error" and then discovered what worked best for their patients. She wanted to share this information with other nurses so that other patients treated with brachytherapy could do as well (L.J Abel, personal communication, November 26, 2000).

Source of Topics

The sources of topics about which to write are practically limitless. Presumably, as a potential author, you will want to write for a nursing publication; therefore, your writing will need to take a nursing focus. Think of all of the procedures, techniques, medications, variety of illnesses, and reactions to those illnesses with which you work on a daily basis and you will begin to see the numerous topics that would be worthwhile sharing with other nurses in writing. Every time I open a nursing journal or textbook, I am amazed that an article, book chapter, or practice tip is included that is relevant to my nursing practice.

Most important when considering topics about which to write is writing what you know. Unlike author Stephen King (whom I believe must dream about his story lines), most of us do our best writing about things that we know. This does not mean that you have to be an industry expert on the topic, but you should have experience in working with or around the particular topic about which you are interested writing.

Another important consideration before dedicating yourself to a particular topic is to spend time reviewing journals and books on the topic. Do a literature search on the topic, going back about two years to find out if "your" article already has been published. If your topic is published in the only journal that you considered submitting it to, then you may need to reconsider your idea. Remember, however, that multiple nursing publications exist and another journal may well appreciate a contemporary slant on this particular topic. As Fondiller (1999) stated in her wonderful book, The Writer's Workbook: Health Professional's Guide to Getting Published, "Remember, all you need for one good article is one good topic" (p. 8).

Selecting and Narrowing a Topic

Once you decide that you would like to be a published author, you then must select a specific topic. Generally, a wise move for a novice writer is to narrow the topic as much as possible. If your topic is too complex or global, you may find it difficult to keep on track. For example, early in my writing career, I was interested in writing a manuscript about lung cancer and its treatment. I quickly realized that this topic would require a manuscript the size of a healthy book chapter (or even a book). Having only published one article for my Oncology Nursing Society (ONS) chapter newsletter, I then reviewed the various aspects of lung cancer about which I wanted more information. This process helped me to narrow the topic (with the help of my coauthor Patricia Lawler, MS, BSN) to a review of malignant pleural effusion and its management.

Fondiller (1999) recommended writing a thesis statement to help clarify your topic and be able to express it clearly. A thesis statement helps to explain to readers your main idea. This thesis statement evolves from the topic and addresses three main questions: (a) what is the point of the article? (b) how will the article be presented? and (c) why is the point of the article important? (Fondiller).

If you are a novice writer, you may want to write the answers to the above questions out. A more experienced writer may only need to think about these questions to help guide them in developing the topic and the ensuing work. The idea behind this exercise is to clarify to yourself what the topic is and why other people should read it. If the idea is not clear to you as the author, then the idea probably will not be clear to a potential editor. Editors of books, journals, and newsletters want to be able to provide fresh and exciting ideas to their readership. It is up to you to provide these great ideas!

Another important consideration in selecting and then narrowing a topic is deciding the target audience. The target audience will guide your style of writing, the depth to which you cover the material, and how you present the information. What does the audience care about, know, and want from your written work? Is your information suited to a general audience less knowledgeable about cancer, or does it appeal most to nurses who work primarily with patients with cancer? Each particular journal has a specific target audience. For example, American Journal of Nursing has a very large circulation, so the subject matter must be of a general interest to nurses practicing in a variety of specialties and settings. Conversely, CJON, which is a member benefit to all ONS members, has a target audience of oncology nurses who provide direct patient care. Once you have decided your target audience, familiarize yourself with the journal(s) that you are interested in submitting your manuscript to. Each has a particular style and focus. You also should become familiar with the length of the articles. Article length can vary among journals. Carefully review the "Information for Authors" page that describes specific manuscript requirements.

Developing the Manuscript

Research

Do not assume that you intuitively know enough about your subject, even if you have some recent references, to write an entire manuscript. Complete a thorough literature review, generally going back no further than five years. Because healthcare information is changing daily, authors must cite the most current references. In general, a reference should not be cited if it was published more than five years ago unless it is considered to be a "classic" reference. A classic reference (sometimes dating back several years) is when an original idea, hypothesis, or research finding was published that continues to bear reference on current information. When reviewing the research information for your manuscript, keep in mind that it is always best to learn more than you will write.

References

References are included to give credit to the original source, where information is not generally known, or the information could be questioned (Maxwell, 1995). References can help to guide readers to further information that can amplify ideas presented in a manuscript. Depending on the type of manuscript that you are writing, sometimes comments by authorities (i.e., personal communication) are appropriate. Personal communication may enhance a manuscript that offers information in a stepwise manner but would not be appropriate in a research manuscript.

Organizing reference materials is critical to the success of a manuscript. If you include information that must be referenced and you cannot locate the reference, then the information cannot be included in the manuscript. Authors must check all references against the original source prior to manuscript submission. (See "Researching and Referencing" on page 7.) Information referenced incorrectly gives an editor a reason not to accept an otherwise well written manuscript. I keep a copy of all of my references in a file during the manuscript development. If the reference is a book chapter, I copy the book cover and any of the appropriate reference information. Seasoned author Yarbro recommended saving all citations from an online literature search and transferring this information to a document. She said that the material may need to be reformatted but not necessarily retyped, which can save a great deal of time (C.H. Yarbro, personal communication, October 28, 2000). In addition, many software programs now are available that will take citations and put them in the required format.

Review a back issue of the journal to which you plan to submit your manuscript, and carefully prepare your references according to that journal's style. Most editors are thrilled to see a clean and accurate reference list, which is a positive factor in having your manuscript accepted for publication.

Outlining

The process of outlining is an exercise that a writer can use to impose a logical order to information that has been collected. This logical order will be guided by the writer's purpose and reason. Outlining lays out the plan for the manuscript and forces the writer to identify what information belongs where. It also provides an idea of the flow of information and how headings and subheadings work. This is one way to identify any missing gaps of information that still need to be collected (Fondiller, 1999).

For novice writers, using a detailed sentence outline is the most helpful. The outline follows a basic format, including an introduction, the body of the manuscript, and the conclusion. Each of these headings should be filled in with detailed information. You can save a lot of time if your information is detailed in outline form, as a strong detailed outline provides the template for the manuscript.

The introduction is the "bait" for readers. We all have so much information to read today, including books, journals, newsletters, and Internet communication, that the initial information presented in a manuscript must be able to grab readers. Why should readers want or need to read your manuscript? The body of the manuscript provides all of the background information, such as the literature review, and provides the message to readers. The conclusion wraps up the manuscript and provides a coherent ending to all of the information that has been presented in the manuscript. The conclusion also provides the author a place to identify future directions and further areas of study for the information that was presented. The conclusion is generally one or two paragraphs.

Point of View

Identify a point of view in which to write your manuscript. The point of view is the person: first person, second person, or third person. Review your target journal before you choose your person, as each journal has a general style or relationship with readers. Decide how personal you want to be with your audience. I was taught early on to write in an impersonal voice (third person) when writing any scientific material (e.g., "The nurse should...," "The patient feels the pain when ...," "Several studies have determined the cost effectiveness to be ..."). Third person may be necessary when reporting research findings, but it can be disengaging and lead to disinterest with readers. If you are writing from your personal experience, then first person may be appropriate, as well as more engaging for readers. For example, sentences written in the first person would include things such as "I first noticed a rise in infection rates when...." Information that provides a series of steps to a new procedure might be suited to second person (e.g., "First, apply gloves." "Wipe the area...."). The most important determinants of your point of view are the subject matter and the purpose of your manuscript. Once a point of view is established, attempt to maintain that point of view throughout as much of your manuscript as possible.

Visual Aids

Visual aids, including photographs, figures, and tables, work to enhance the manuscript. A manuscript that is strictly text is less visually appealing than one that is interspersed with visuals. Any visual that is used must be fully explained and directly connected to the textual material in the manuscript. For example, in a manuscript discussing disseminated intravascular coagulation (DIC), the author would likely review the causes of DIC in the text of the manuscript. A table that correlates with this information also would be visually appealing. Photographs most likely would not work well in a manuscript on this topic. However, a photograph of a clot associated with a vascular access device leading to superior vena cava syndrome would be a great visual aid in a manuscript about superior vena cava syndrome.

Grammatical Tips

Here is my "Top 10" list of grammatical tips that I and several experienced editors of nursing journals and texts have compiled.

1. Generally speaking, shorter words are better than longer words. Words such as utilize, parameter, likewise, or preferable add nothing to how a manuscript reads. Consider instead using "use" for utilize or "better" or "best" for preferable.
2. Lists of words in a manuscript read easier if they are written in order from the shortest word to the longest word. For example, write "pulse, blood pressure, oxygen saturation, and central venous pressure."
3. Use a combination of sentence structures when writing a manuscript, including simple, compound, and complex sentences. Many writers avoid using simple sentences, which can lead to long, drawn out, and sometimes difficult to read sentences.
4. Use plural nouns to avoid she/he/her/him clutter. For instance, the sentence, "The nurse uses his or her assessment findings." reads better as "Nurses use their assessment findings."
5. Avoid overuse of the words "nurses should" because they sound like the author is lecturing the reader. Instead, consider saying that "Nurses need to monitor blood pressure closely," or better yet, use an active voice and simply say, "Monitor blood pressure closely."
6. Use one word consistently; use of synonyms does not enhance flow. For instance, consider the following sentence: "When administering chemotherapy, nurses review the antineoplastic drug orders and recalculate the doses of the chemotherapeutic agents." In this sentence, three different words are referring to the same thing. Choose one word. It is best to use the most simple of the words (e.g., "chemotherapy") and use it consistently throughout the manuscript.
7. Be sure to use the words "that" and "which" correctly, as they should not be substituted for one another. "That" should begin a restrictive clause, one that restricts the meaning of the noun before it (e.g., "Diagnostic tests that evaluate internal hemorrhage include ultrasound, angiography, plain film radiographs, magnetic resonance imaging, and computerized tomography scans."). The word "which" is always preceded by a comma because it should begin a nonrestrictive clause, one that does not restrict or change the meaning of the noun (e.g., "Vascular access devices, which may be used to administer vesicant chemotherapy, provide access to the superior vena cava.").
8. Avoid the use of a dangling participle, as it has nothing to modify. Consider the following sentence: "Although potentially curable if detected early, 25% of patients present with metastatic disease." Metastatic disease is not curable, thus, it does not modify the participle that it precedes.
9. Remember that when using the adverb "hopefully" that the subject must be the one who is hoping. In the sentence "Hopefully the nurses agree to the upcoming contract," it is not the nurses who are hoping to agree to the contract. The sentence should read, "I hope that the nurses agree to the upcoming contract."
10. Learn to edit your own manuscript before you submit it, and try to make it as concise as possible. Consider changing phrases to single (i.e., simpler) words when appropriate. For instance, instead of "due to the fact of," write "because," or "prior to" could be changed to "before," or even changing "upon" to "on" (M. Goodman, personal communication, November 26, 2000; L. Schulmeister, personal communication, October 15, 2000; T. Shorr, personal communication, November 27, 2000; C.H. Yarbro, personal communication, October 28, 2000).

Getting Started and Staying Motivated

Getting started writing really boils down to one thing: getting started writing. Unfortunately, no magic formula exists to get you going or keep you on task. Some writers like to get up an hour early before work to write (my least favorite idea), whereas others schedule blocks of time to write. It takes awhile to figure out how, when, and where you write your best.

One definite consideration regarding scheduling time to write is whether you have a home computer. Not having a home computer requires more organization on your part to schedule computer time at work. I have a friend who did not have a home computer during her doctoral program. This friend went home after work, fed her children, put them to bed, and returned to her workplace to do her computer-related work. This was not an easy feat, but she did finish her doctoral degree.

As for myself, I consider myself to be an eclectic writer. I write when I can find the time. I try to schedule time for my writing, but with a husband, two busy teenagers, a dog, and a full-time job, my schedule needs to be flexible. I frequently find myself at the computer on a Friday or Saturday night (yes, I admit it), as this seems to be the most quiet time at the computer in our house.

Other writers have different approaches to getting started and then staying on task, but all agree that finding the time to write is always the challenge. Lisa Schulmeister told me that she writes whenever she can. She has found that writing frequently, even if only for short bursts of time, helps her to stay focused. She tries to write daily, knowing that these short bursts of writing add up and that eventually she will have a finished manuscript (L. Schulmeister, personal communication, October 15, 2000). Connie Henke Yarbro, on the other hand, needs blocks of time for her writing (e.g., half day, full day, an evening). She finds it helpful to block time periods on her calendar that she then will devote to the writing project at hand. She also states that she often does not write in order but may do different sections at different times and then put them together at the end.

Publishing Opportunities

Publishing opportunities in oncology nursing are almost as limitless as are the sources about which to write. Well more than 50 nursing and health-related journals are published in the United States alone. Information about approximately 150 nursing journals can be found at the Nurse Author and Editor Web site (http://members.aol.com/suzannehj/naed.htm/). The nursing journals that are dedicated to the care of patients with cancer include Cancer Nursing, Oncology Nursing Forum, Seminars in Oncology Nursing, and CJON. ONS also has an official newsletter, ONS News, as do most of the local ONS chapters nationwide.

Rather than writing a lengthy manuscript, you might consider submitting short pieces to the ONS News or other local ONS chapter newsletters, writing a letter to the editor in journals or newsletters, or writing columns for journals such as CJON (Schulmeister, 2000). Newsletter articles are a great way to start writing, as newsletter editors always are looking for articles and newsletters have a high acceptance rate. Other ways to get started in writing include writing articles for your hospital or group practice newsletter or even your place of worship newsletter. Everyone who cares for patients with cancer has valuable information to share with others, so get started writing now!

Mentors

Many authors have pointed out to me over the years and in the preparation of this article the importance of finding an experienced writing mentor. These authors have stressed the importance of trying to find someone who is willing to assist them throughout the process and review of the work and someone who doesn't necessarily have to have their name on the manuscript. Your writing mentor may be your supervisor, a peer, or someone who you know is just really good at writing. CJON has developed an outstanding writing mentorship program that links a novice writer with an experienced author. Applications for this program are available through the ONS Education Care Issues Team by calling 412-921-7373, ext. 273.

Summary

Writing for publication is a generous gift that you give to nurses, patients, and other healthcare providers. This gift, however, takes a great deal of time, effort, and energy. Whether you write a letter to the editor or an extensive review of a disease, you will have an audience that is grateful for your willingness and commitment to write. Your audience will be even more appreciative (and probably bigger) if your manuscript is well written. Spend the time to learn the process of writing for publication and the process of writing well. I promise you that you will never regret it. Most nurses that I know who have published manuscripts are like Laurie Abel—once the first article gets published, the second one already is planned!

References

• Fondiller, S.H. (1999). The writer's workbook: Health professional's guide to getting published (2nd ed.). Boston: Jones & Bartlett and National League for Nursing.
• Maxwell, M. (1995). The agony and the ecstasy: How to successfully write and publish your paper. Oncology Nursing Forum, 22, 557-566.
• Schulmeister, L. (2000). Do the write thing. Clinical Journal of Oncology Nursing, 4,109.

Rapid Recap

• Numerous publishing opportunities are available to nurses in more than 150 nursing journals and include articles, columns, and letters to the editor.
• Nurses knowledgeable about a particular topic and interested in learning more about that topic are well prepared to become published authors.
• Narrowing a topic is critical to the writing process; the author should be able to summarize the article's purpose in one sentence.
• A recent, thorough literature review will support the content of an article.
• An outline provides a framework for information flow and will help to identify missing gaps of information.
• Attention to detail is important; accurate references and correct spelling, grammar, and sentence structure increase the likelihood that a manuscript will be published.