writing nursing journal articles

Writing clinical articles: A step-by-step guide for nurses

Focus on your audience and narrow your topic. .

Editor’s note: Dissemination 101 is a series designed to help nurses share their expertise. To read other articles in the series, visit myamericannurse.com/category/dissemination-101 . 

  • Writing for publication allows you to contribute to nursing practice and help build nursing and healthcare knowledge.
  • Taking a step-by-step approach to writing a clinical article can help increase the chances for acceptance.

Are you thinking about writing a clinical article for publication? You can write for a general interest nursing journal that addresses a broad audience or a specialty journal that caters to nurses focused on caring for a specific patient population (for example, oncology or wound care). Most clinical articles published in general interest journals aim to help nurses understand the clinical presentation and progression of a disease or health issue and the subsequent care for a specific patient population.

To increase your chances of article acceptance for publication, take a step-by-step approach, as recommended by Mee.

Start with what you know

Write about what you’re most familiar with. Are you working on a hemodialysis unit and recently managed a patient who experienced a cardiovascular event? Then consider writing about managing cardiovascular emergencies in this patient population. Are you an endoscopy nurse who works with patients receiving endoscopic retrograde cho­lan­giopancreatography? Focus your article on the nursing implications of caring for patients after this test.

Strive to keep your topic focused so you can control manuscript length and ensure you deliver relevant content to the reader. For example, an article about caring for patients with pancreatic disorders is too broad. A narrower-focus article might cover cystic fibrosis, specifically on the impact of this condition on health-related quality of life. You can narrow the topic further by a concentrating on adolescents.

Solo vs. team writing

Are you going to write alone or with a team? Pros and cons exist for each. When writing alone, you may have better control of your timeline and content. However, compared to writing with a team, you might miss an opportunity to present a more diverse perspective of the topic. Another advantage of writing with a team includes having more access to resources, including a network of colleagues to interview. With a team, you can distribute the work among the authors and even have more proofreaders. However, delays may arise if one team member lags behind schedule or conflict emerges within the group. When writing with a team, establish authorship early in the process. The International Committee of Medical Journal Editors developed a set of four criteria to establish authorship: authors should make substantial contributions to the manuscript, draft or revise it, have final approval of the published version, and agree to be accountable for all aspects of the work.

Journal selection

Before selecting a journal, establish your intended audience. For example, are you writing for staff nurses, clinical nurse specialists, nurse practitioners, or nurse midwives? Write for the selected audience, keeping in mind what they already know about the topic.

Now you can narrow your journal choices to those that are a good match for your topic and intended audience. You can expect immediate rejection if your manuscript doesn’t match a journal’s purpose and readership. Read at least three to four issues, and explore the table of contents for similar articles related to your topic. An article on a disease or condition similar to your topic doesn’t necessarily make yours ineligible for publication. Your topic may have a different focus.

After you select the target journal, carefully read the author guidelines, which usually can be found on the journal’s website. Follow directions for formatting the manuscript, and comply with page or word limitations. Consider querying the journal editor before submitting your manuscript (in fact, many journals require this step). Querying can help ensure your topic is appropriate for the journal. In addition, the editor may provide feedback to help you focus the manuscript accordingly before submission.

Article type

Elements of a clinical review article.

Clinical review articles typically include the following sections:

  • Etiology. The cause or origin of the disease.
  • Pathophysiology. The pathologic and physiologic processes associated with the disease.
  • Epidemiology. Discussion of disease frequency (number of new cases in a given population) or prevalence (number of cases present at a point in time).
  • Clinical presentation. What are the signs and symptoms of the disease?
  • Diagnostics. This includes relevant tests and normal and abnormal laboratory values.
  • Treatment and interventions. Depending on the journal guidelines, this section might include medications, medical and nursing procedures, and key nursing considerations.
  • Patient education. This section focuses on key points for patient education. If your article discusses best practices in your setting, consider including a patient education handout that can be incorporated into any organization.
  • Nursing implications. Includes the nursing process from assessment to interventions and outcomes. Some journals want a separate section devoted to nursing implications.

Case studies 

Most nurses are familiar with case studies, first from learning how to write them in nursing school and then in clinical practice when reading progress notes. If you’re a novice writer, you’ll find reading case studies in journals to be helpful.

Published case studies can evolve from real case reports or be a simulated, fictional case. If you choose to write about a real case, obtain permission from the patient and your organization. Although the patient’s identity will be concealed in your article, you may run the risk of readers identifying the patient. Also, don’t choose a case that’s so rare that the reader may never encounter such a situation.

Case studies typically begin with the patient’s health history followed by a discussion of the common clinical presentation, pathophysiology, nursing process, psychosocial considerations, and treatments. Keep in mind that you’re using the case to teach readers, not merely reporting what you experienced.

How-to articles 

How-to articles focus on teaching a skill, procedure, or intervention. For example, caring for patients with a colostomy, proning patients with COVID-19 who haven’t been intubated, or attending to patients after cardiac catheterization. When writing a how-to article, focus on what’s most meaningful to nurses who provide direct care, such as patient and family education, and cite evidence-based recommendations.

Do your research

A fundamental motto for writing is “Read. Read. Read. Write. Write. Write.” In other words, do your research. When you read a wide range of literature on your topic, including relevant nursing models or theories, and access key databases, you’ll soon be ready to write. Organize your notes (paper or digital) and maintain a complete and accurate account of your references, which should be as current as possible.

Create an outline

Use an outline to organize your thoughts and help you stick to one main focus or purpose that’s appropriate for the intended audience. At this stage, you’ll also want to consider what information can be best covered in tables or figures rather than in text. For example, you can create a table that lists signs and symptoms in column one and related pathophysiology in column two. Such a table can effectively present a large amount of information that doesn’t need to be repeated in the text of the article.

Writing and editing

Knowing where to start can be daunting. Consider starting on the section you know best or one for which you have the most information to help build your confidence and spur development of other sections. Other writing tips that can enhance the chances your article will be accepted for publication and engage readers include the following:

  • Passive: The patient’s medications were reviewed by the nurse before discharge.
  • Active: The nurse reviewed the medications with the patient before discharge.
  • Cite relevant references. Support statistics and practice guidelines with appropriate recent references. Follow the journal’s author guidelines for number of references and style.

After completing your manuscript, let a day or two pass and then read it again and start editing. Note that your overall goal during editing is to make the manuscript concise and meaningful for the reader. Check that it aligns with the journal’s author guidelines and requirements. Ask colleagues (including an expert, novice, or someone who’s not familiar with your topic) to read your manuscript, and request their honest feedback. Review tables, figures, and other graphics to ensure they provide relevant information and that they adhere to the journal’s author guidelines. Consider including a box with key points, such as nursing implications.

Follow the journal’s article submission guidelines. Some journals request submission through an author portal that requires you to create an author account, while others prefer to receive submissions via email. Most journals require that you attach a cover letter, sign copyright release and conflict-of-interest forms, and submit information about all authors.

Advance nursing practice and science

When you publish, you contribute to nursing practice and help build nursing and healthcare knowledge by providing guidance for practitioners and future researchers. Regardless of the type of article, include implications for nursing practice and, when appropriate, education, policy, and research. Writing involves hard work, but it’s rewarding and a great way to build your credentials.

Rhoda Redulla is director of nursing excellence and Magnet Recognition at NewYork-Presbyterian in New York, New York, associate editor of Gastroenterology Nursing Journal, and author of Fast Facts for Making the Most of Your Career in Nursing . 

Eldh AC, Almost J, DeCorby-Watson K, et al Clinical interventions, implementation interventions, and the potential greyness in between – a discussion paper. BMC Health Serv Res. 2017;17(1):16. doi:10.1186/s12913-016-1958-5

International Committee of Medical Journal Editors. Defining the role of authors and contributors.

Mee C. Writing the clinical article. In: Saver C ed. Anatomy of Writing for Publication for Nurses. 4th ed. Indianapolis, IN: Sigma; 2021.

Morton P, Ketefian S, Redman R. Writing the research report. In: Saver C, ed. Anatomy of Writing for Publication for Nurses. 4th ed. Indianapolis, IN: Sigma; 2021.

Oermann MH, Ingles TM. Writing manuscripts about quality improvement: Squire 2.0 and beyond. Health. April 30, 2019.

Roush K. What types of articles to write. Am J Nurs. 2017;117(5):68-71. doi:10.1097/01.NAJ.0000516278.97098.02

2 Comments . Leave new

I could have used this when I was writing articles years ago. Excellent resource

Thank you for this helpful article. I believe that when we publish good articles, we help healthcare providers to give a high quality of care to patients. I encourage all knowledgeable healthcare to write and publish many articles in order to help others for the betterment of patients. Thank you

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Tips for Writing Nursing Journal Articles

October 29, 2021

View all blog posts under Articles | View all blog posts under Master of Science in Nursing

A nurse in purple scrubs poses with a nursing journal.

Benefits of Writing Nursing Journal Articles

It’s exciting for nursing professionals to see their names in print in a reputable nursing journal. Yet the benefits of writing nursing journal articles extend far beyond the thrill of a byline. Journal articles provide critical information that nurses can apply to their own practice. Ultimately, the information may uncover vital insights into health care concepts that could lead to higher-quality care and improved patient outcomes.

Writing nursing journal articles has practical benefits. For instance, these articles can provide extra sources of income, as journals will pay authors for the rights to publish their work. Rates vary from journal to journal, so nurses should research these rates before submitting an article for publication.

Furthermore, publication in a nursing journal gives nurses a potential advantage when applying for a new position. While an advanced degree may demonstrate an applicant’s deep knowledge and refined skill set, a published article can provide prospective employers with a written example of a candidate’s strengths.

Tips for Success

Writing a nursing journal article isn’t as simple as putting ideas on a piece of paper and sending it off to a publication. There are several steps nursing professionals can take to improve their chances of getting published.

Draw on Your Expertise

When writing an article for a nursing journal, adhering to the adage “write what you know” is critical. Journals allow nursing professionals to share their expert knowledge on a subject, which could lead others to develop new strategies, possibly resulting in the more efficient or effective delivery of health care. For example, a nurse practitioner with a specialization in gerontology could write an article on the potential use of artificial intelligence in palliative care, which could inspire other nurses to create innovative end-of-life care strategies. That said, it’s important to make sure that the article avoids plagiarism and adds a unique perspective to what exists in other journals. To this end, professionals can read up on various nursing journals to become familiar with current health care theories and philosophies.

Do Your Research

Extensive research is the backbone of any professional journal article. While it’s common to cite other sources, such citations must support the author’s original research. If the article hinges on physical research, such as lab work or similar testing, the article must contain a detailed description of the methodology, such as the test setup and equipment used; carefully curated analysis; accurately represented results; and a logical, well-constructed discussion that presents the article’s hypothesis in a neutral tone. These elements are unwavering, and no level of writing quality can compensate for inadequate or biased research.

Become Familiar with Nursing Journals

Before writers submit an article to a nursing journal, it’s important that they become familiar with the types of articles that particular journal tends to publish. Some journals focus on a specific health care topic, such as women’s health or oncology. Others may feature theoretical explorations of care concepts, such as an emerging health care technology. It’s key for nurses to develop a thorough understanding of what suits a particular publication. Doing so may prevent authors from spending time and energy on approaching a journal that’s a poor fit for their work.

Choose an Article Type

Authors can explore several kinds of journal articles. Again, an article can focus on original research conducted to prove a hypothesis or test the parameters of a given process or procedure. It can also be a review of an existing piece of care-related literature. Additionally, nursing journal articles can share detailed descriptions of a practice or procedure. Finally, an article can explore the impact of existing and emerging care policies. Each of these article types requires thorough research and evidence to support any proposed theories.

Make a Difference in Health Care

Publishing articles in nursing journals can give nurses a modest extra income and another way to demonstrate their competency to potential employers. Publication can also help nurses impact care. Articles that share carefully researched data and uncover new insights can prompt readers to rethink their approaches to health care, possibly leading to higher-quality care and improved patient outcomes. Learn how Regis College’s post-master’s certificate program can offer you the knowledge needed to write these authoritative, game-changing articles.

Recommended Readings Degrees Defined: What Does MSN Mean? The Importance of Teamwork and Collaboration in Nursing Using Nursing Skills to Provide Primary Care

Sources: American Journal of Nursing, “What Types of Articles to Write” Elsevier, The Journal for Nurse Practitioners The Journal for Nurse Practitioners, “How to Increase Your Odds of Getting Published” RCNi, RCNi Guidance on Writing and Submitting Articles for Publication

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Writing and submitting articles for publication with RCNi

A guide for nurses on how to write and submit articles for publication in an RCNi nursing journal

The journals, in print and online, support the sharing of knowledge and experience within the nursing community. We commission articles but also welcome unsolicited clinical articles, literature reviews, and reports of original research and service innovations, as well as comment on issues in practice, education, policy or management.

Articles need to be informative, of interest to a journal’s readership, have something new to say or offer a fresh approach to an old subject, challenge current thought or practice, predict future trends or review current thinking.

One of the best ways nurses can understand how to write for publication is to read a selection of articles published in the journals. There are various kinds of articles that may suit the topic you are considering.

What nurses can write about

If you have an idea but are unsure how to proceed or whether readers will be interested, contact the editor, who will tell you whether your planned article will be appropriate for the journal. If it is not, the editor may suggest another journal that might be more suitable. It is also important to get advice if you are planning to base your article on an essay or dissertation because you will need to adapt the length and style of writing to suit the journal.

Types of nursing articles that are published in ‘evidence and practice’ include:

Description of practice

This is an article that describes logically and informatively a particular nursing procedure, the work of a ward or unit, or the role and function of a nursing post or specialty. The relevance of this work to other nurses should be discussed.

Literature review

This is a thorough and comprehensive review of current writing on a particular aspect of nursing. Up-to-date referencing is essential, as is a strong conclusion to bring the subject together. Implications for practice need to be explicitly stated – that is, how is this relevant to readers?

Original research

This should be written in classic research style, that is, abstract, introduction, literature review, aims, method, results/findings, discussion and conclusion.

Case studies are a form of evidence and can be used to introduce or illustrate specific points in an article. Even though you will anonymise the case study, you should get permission from the subject for publication of such material.

Informing or updating article

Readers appreciate summaries and updates on specific topics including new policy or practice guidelines. Check that the topic has not been addressed in depth recently. For some topics, a continuing professional development (CPD) article may be appropriate, particularly if you want to convey mainly factual information. Check with the editor before you embark on this kind of article.

But they also publish:

The journal provides opportunity for comment on issues current in the field of practice. Writers should express a definite opinion rather than simply restate commonly known arguments. And while there is scope to be provocative and partisan, opinions should be based on fact.

Letters to the editor

These are a useful medium through which to comment on articles that have been published or to inform readers of practice developments or issues in your area in a more informal way than writing a feature article.

Book reviews

Please contact the editor if you are interested in becoming a book reviewer, specifying your area of practice and interests.

How much to write

Talk to the editor of the journal about the word count for your chosen style of article. As a guide, opinion pieces range between 600 and 700 words. For evidence & practice articles, general articles should be no more than 4,800 words in total and CPD and research articles no more than 5,400 words in total, including references.

Preparing your manuscript

Articles should be prepared in a Word document or text file. There can be problems translating some computer commands so please keep these to a minimum.

  • Use only one space after full stops.
  • Do not use more than one space.
  • Use only one return to denote the end of a paragraph.
  • Do not use bold, underline or italic type.
  • Do not start a new page for sections.
  • Do not use block capitals. Use sentence case, capitalising only the first work and any proper nouns.
  • Please put text for all boxes, tables and figures at the end of the article and clearly label them. Please also indicate where they should appear in the main body of the text.

If you have a query about preparing your manuscript, contact the editor of the journal or administration manager Helen Hyland on 020 8872 3138 or email [email protected]

Checking your manuscript

You should carefully check your article before submitting it:

  • Have you checked the spelling using a UK spell-check program?
  • Have you checked statistical calculations?
  • Have you had a friend or colleague read the article for clarity and sense?
  • Are the references in the reference list complete and in style? If you have rewritten or edited the copy, do you need to take out references from, or add any to, the reference list?
  • Have you included all the information for any boxes, tables or figures? Are boxes, tables and figures cited in the text?
  • Do you need to include photographs or other illustrations?
  • Have you gained the necessary permission to reprint photographs? Are they good enough quality and size?
  • Have you declared any potential conflict of interest?

Submitting your manuscript

All contributions should be submitted through the online submission system.

A tutorial to help authors use the system is available through the ‘Instructions for authors’ link on that page. The registration and submission process will ask for all your contact details and the following information for all other authors of your article: full name, job title, institution, email address and country.

Please note that your manuscript must be sent to one journal only. It is considered unethical to send it to more than one, and doing so will not increase your chances of publication because editors will not consider articles that have been published elsewhere.

What happens next

All manuscripts submitted to the journal are acknowledged.

The article is then assessed internally before being sent to an external clinical expert for peer review. This is usually double-blind, which means that the reviewers do not know who the authors are and the authors are not informed who the reviewers are.

Some people think this helps to ensure the manuscript is given an objective and unbiased review; others see open, as opposed to double-blind, review as being more honest. Nursing Children and Young People, for example, operates an open peer review system. More information about this can be obtained by contacting the editor: please see the contact information in Exploring our journals.

Reviewers advise the editor who is responsible for the final decision. To be accepted the article needs to be:

  • Have a message that is important to the readership.
  • And, in the case of original research, demonstrate appropriate rigour.

Reviewers give an informed or expert opinion on the work of an informed or expert author, which is why it is called ‘peer’ review.

It takes about 12 weeks from acknowledgement to receive a response. Responses may be:

  • Acceptance without revision.
  • A request for minor or major revision.
  • A letter explaining that your manuscript has not been accepted for publication.

Requests for revision. In most cases, authors are asked to revise their manuscripts in the light of the comments made by external reviewers and editorial staff. These comments are intended to be constructive and useful and to help to produce a high-quality article. The manuscript will be returned to you by email with a copy of the reviewers’ comments and a deadline for re-submission. Revised manuscripts may be returned to the original reviewers to ensure the changes made are satisfactory.

Not accepted for publication. There are many reasons why your manuscript may not be accepted for publication and these may not necessarily reflect the quality of the submission. Where possible, we will to try to explain why but we retain the right not to engage in further correspondence on the matter.

The review process may be a bit uncomfortable when you have spent many hours labouring over your first or even your tenth article but it is a healthy and constructive process that ensures quality in the journal. The author does not have to accept all the views in the review report. Most find the comments helpful but authors are free to respond with reasons for not making one or more of the changes suggested. Please contact the editor to discuss any questions that you have about your review feedback.

RCNi offers continuous online publishing so that, once your manuscript is accepted for publication, it will be published online first. Peer-reviewed articles will be posted as soon as they are accepted and edited to ensure that readers have access to new content as soon as possible. Please note that not all articles we publish online will appear in print.

Bear in mind that RCNi subscribers can read your article online even if they subscribe to another RCNi journal. This is because they can access ten free articles from other RCNi journals every month. So publishing online rather than only in print can mean that even more people can read, and act on, what you have written. 

Plagiarism detection

Articles that are accepted are checked using antiplagiarism software. This generates a ‘similarity report’ which shows any matches between text in your article and text in other published articles. If lengthy verbatim or unreferenced passages from previously published articles are identified during this check, you may be asked to revise the passages, including any from published articles that you have authored. The article may also be rejected based on the report.

Editing and production

Accepted articles are then edited, for example, for sense, flow and grammar and to check that the article is in-house style.

If any queries arise or are outstanding at this stage, you may be emailed directly by an editor, perhaps with an attached Word document of the edited article with the queries highlighted. The editor may also explain a particular format to use in answering the questions.

Otherwise, the article is prepared by members of the RCNi production team. They will send you this draft in Word form, along with images or figures that you have provided and have been redrawn.

At this stage, there may still be unresolved editorial queries, which will be highlighted. This is also your chance to check the accuracy of the text of the article and any images or figures, for example, the labelling of anatomical drawings.

Please list any amendments separately from the article in an email to the production editor, whose details you will now have. Do not try to amend the PDF or resubmit an amended Word document.

Where payment is due for an article, for example for a continuing professional development (CPD) article, it should be received within between eight and ten weeks of publication.

The publisher’s agreement that you are asked to sign when your article is accepted assigns copyright of your paper to the RCNi Company. This protects you from someone else taking your work and using it ‘unfairly’. If someone wants to reprint or adapt your work or place it on a website, they will need to obtain permission from us and credit you as the original author. We do not usually allow articles published in our journals to appear on third-party websites. We would generally support reprinting provided the proposed use was appropriate. If you have any specific questions, email  Helen Hyland

  • How to Write in Plain English from the Plain English Campaign (Last accessed: 7 May 2017.)
  • Nurse Author & Editor is an international publication dedicated to nurse authors, editors and reviewers. It was first published in 1991 as a print publication but it is now published by Wiley-Blackwell as a free quarterly online publication. To access, click here  (Last accessed: 7 May 2017.)
  • Albert T (2009) Winning the Publications Game. Third edition. Radcliffe Publishing, Abingdon.
  • Happell B (2008) Writing for publication: a practical guide. Nursing Standard. 22, 28, 35-40.
  • Happell B (2012) A practical guide to writing clinical articles for publication. Nursing Older People. 24, 3, 30-34.
  • Leary A (2006) Nursing a Secret. To access, click  here (Last accessed: 7 May 2017.)
  • Orwell G (2000) Politics and the English Language. In Orwell G. Essays. Penguin Classics, London.
  • Turnbull A (2001) Plain Words for Nurses; Writing and Communicating Effectively. Foundation of Nursing Studies, London.

Further reading

  • RCNi writing style guidance
  • RCNi guidance on planning and structuring articles
  • Become a reviewer for RCNi
  • Explore our journals

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Writing in Nursing

Graduate Student Resource Center

Writing as a Student

Ely, C., Nicol, M., & Scott, I. (2007). Essential study skills for nursing . Mosby/Elsevier.

Garrard, J. (2017). Health sciences literature review made easy: The matrix method (5th ed.). Sudbury, MA: Jones and Bartlett.

Gimenez, J. (2011). Writing for nursing and midwifery students . Palgrave Macmillan.

Lang, T. (2010). How to write, publish, and present in the health sciences: A guide for clinicians and laboratory researchers. Philadelphia, PA: American College of Physicians.

Scullion, P., & Guest, D. (2007). Study skills for nursing and midwifery students. Open University Press.

Roush, K. (2015). A nurse's step-by-step guide to writing your dissertation or capstone. Indianapolis: Sigma Theta Tau International.

Taylor, D.B. (2014). Writing skills in nursing and health care: A guide to completing successful theses and dissertations. London: Sage.

Whitehead, E., & Mason, T. (2008). Study skills for nurses (2nd ed.) London: Sage.

Witte, F. (2003). Basic grammar and usage for medical communicators . Rockville, MD: American Medical Writers Association.

Writing in Nursing : Resources to help nursing students with writing from Purdue OWL.

Literature Searching for Nursing Students : A bibliography of articles on researching and writing literature reviews in nursing, compiled by the Nursing and Allied Health Resource Section of the Medical Library Association.

Writing for Publication

Nurse Author & Editor : A free online journal with articles on writing manuscripts, editing, publishing, and avoiding rejection. Volume 19.2 (March 2009), for example, contains articles on converting a poster into a paper and on writing a PhD proposal. This page lists all of the articles written for authors (as opposed to publishers or editors). See also their free e-book, listed below. Note: You will need to register with the website to view articles.

Webb, C. (2008). Writing for publication . Wiley-Blackwell. A free e-book posted on Nurse Author & Editor’s website that covers writing for publication; writing review articles, clinical articles, and research papers; presenting tables and figures; publishing a thesis; writing style; finishing touches such as the abstract; impact factor; and copyright.

Fondiller, S. (1999). The writer’s workbook: Health professionals’ guide to getting published (2nd ed.). New York: Jones & Bartlett.

Oermann, M. H. (2016). Writing for publication in nursing (3rd ed.). Philadelphia: Lippincott Press.

Saver, C. (2017). Anatomy of writing for publication for nurses (3rd ed.). Indianapolis, IN: Sigma Theta Tau International.

Writing on the Job

Turnbul, A. (2001). Plain words for nurses: Writing and communicating effectively . London: The Foundation of Nursing Studies.

Writing to Get a Job

Nursing Samples and Resources : Examples of resumes, cover letters, thank-you letters and interview questions, by and for nurses at the University of California, San Francisco.

Resources for International Students

Allum, V., & McGarr, P. (2008). Cambridge English for nursing: Intermediate. Cambridge: Cambridge University Press.

Bosher, S. D. (2008). English for nursing, academic skills (2nd ed.). Ann Arbor, MI: University of Michigan Press. (for advanced English learners)

Graf, J. (2008). Handbook of biomedical research writing . Hanyang University Online Writing Lab. Written for Korean scientists in the biomedical sciences, this handbook covers writing journal article and clinical case reports.

McCullagh, M., & Wright, R. (2008). Good practice: Communication skills in English for the medical practitioner . Cambridge: CUP.

Ribes, R., & Ros, P. R. (2006). Medical English . Springer: New York.

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  • v.4(4); 2017 Oct

Writing self‐efficacy in nursing students: The influence of a discipline‐specific writing environment

Kim m. mitchell.

1 Nursing Department, School of Health Sciences and Community Services, Red River College, Winnipeg, MB, Canada

2 College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada

Tom Harrigan

Diana e. mcmillan.

To explore if writing self‐efficacy improved among first‐year nursing students in the context of discipline‐specific writing. The relationship between writing self‐efficacy, anxiety and student grades are also explored with respect to various learner characteristics such as postsecondary experience, writing history, English as a second language status and online versus classroom instruction.

A one group quasi‐experimental study with a time control period.

Data was collected over the 2013–2014 academic year at orientation, start of writing course and end of writing course.

Writing self‐efficacy improved from pre‐ to post writing course but remained stable during the time control period. Anxiety was negatively related to writing self‐efficacy but remained stable across the study period. Inexperienced students and students with less writing experience, appeared to over‐inflate their self‐assessed writing self‐efficacy early in the programme. This study gives promising evidence that online and classroom delivery of instruction are both feasible for introducing discipline specific writing.

1. INTRODUCTION

Self‐efficacy is a concept that has received an enormous amount of attention since the development of Bandura's theory (1977) but exploring self‐efficacy from the perspective of writing has received sparse consideration. Self‐beliefs are thought to predict academic success and influence career choices and self‐efficacy may be a better predictor of performance than actual ability (Pajares & Valiante, 2006 ). In nursing, scholars are only beginning to discuss the role of writing self‐efficacy and its relation to student success (Miller, Russell, Cheng, & Skarbek, 2015 ; Mitchell, Harrigan, Stefansson, & Setlack, 2017 ) and more research is required to inform this important educational discussion.

Writing self‐efficacy (WSE) can be defined as a writer's belief about their ability to write in a specific context. Bandura's self‐efficacy theory, emphasizes that context critically influences self‐efficacy perceptions (Bandura, 1997 ). Discipline‐specific writing instruction has been acknowledged as the preferred method for introducing students to nursing's unique discourse through allowing opportunities to practice higher level thinking strategies such as critical analysis. (Andre & Graves, 2013 ; Luthy, Peterson, Lassetter, & Callister, 2009 ; Oermann et al., 2014 ) However, empirical testing of this relationship is lacking likely because so few discipline‐specific writing courses are offered in nursing curriculums. Andre and Graves ( 2013 ), who investigated the nature of writing instruction in nursing programmes in Canada, identified that only 6% of programmes included a discipline‐specific course. Close to half of programmes had no required writing course and the remainder required a generic writing course, an English literature course, or both. Thus, research evidence is required to establish the benefits of discipline‐specific writing.

The purpose of the present investigation was to explore, via quasi‐experimental methods, if WSE improved among first‐year nursing students in the context of discipline‐specific writing in one college baccalaureate nursing programme. The relationship between WSE, anxiety and student grades are also explored with respect to various learner characteristics including, past postsecondary educational experience, writing history, English as a second language (ESL) status and online versus classroom instructional environment.

2. BACKGROUND

Nursing student populations have been the focus of inquiry in two studies: Miller et al. ( 2015 ), who explored writing in a cohort of post‐RN students near the end of their programme in a discipline‐specific environment and Mitchell et al. ( 2017 ), who described WSE and anxiety in first‐year nursing students pre and post a discipline‐specific writing course. Thus, given the limited research in nursing on discipline‐specific writing, this literature review will take the approach of an interdisciplinary examination of writing self‐efficacy as it relates to writing performance assessment, improvement in WSE pre‐ to post intervention or course specific strategy and the relationship between WSE and anxiety.

2.1. Writing performance

WSE's relationship with writing performance has received attention from various researchers as it correlates with or predicts student grades. A variety of writing activities have been used to define writing performance including on‐demand essays of 30‐minutes or less (Pajares & Johnson, 1994 ; Shell, Murphy, & Bruning, 1989 ; Woody et al., 2014 ), final grades or grade point average (Goodman & Cirka, 2009 ; Martinez, Kock, & Cass, 2011 ; Williams & Takaku, 2011 ; Zimmerman & Bandura, 1994 ), computer scored essays (Jones, 2008 ), scaffolded writing assignments and/or papers across a term (Miller et al., 2015 ; Woodrow, 2011 ) and complete essays (MacArthur, Philippakos, & Graham, 2016 ; Mitchell et al., 2017 ; Prat‐Sala & Redford, 2012 ; Sanders‐Reio, Alexander, Reio, & Newmann, 2014 ).

WSE, using various measurement instruments, has only partially been able to predict writing performance in most studies, usually predicting less than 10% of variance in grades (Prat‐Sala & Redford, 2012 ; Shell et al., 1989 ), with some studies finding a negligible relationship (Jones, 2008 ; MacArthur et al., 2016 ) and only one researcher identifying a “powerful effect” in a population of Chinese students learning to write in English (Woodrow, 2011 ). Differences in findings may be due to inconsistent methods of assessing performance or to the remote proximity of the WSE measurement to the evaluation of the writing outcome (Pajares & Johnson, 1994 ).

The study by Williams and Takaku ( 2011 ) compared ESL and non‐ESL students in terms of help seeking and writing performance. These authors found that ESL students scored lower than domestic students at the beginning of their freshman year but eventually outperformed domestic students by the end of their sophomore year. Higher self‐efficacy predicted writing centre use and writing centre use became the mediator between WSE and the grade the student ultimately achieved.

2.2. Writing self‐efficacy improvement from pre‐ to postwriting course

Among researchers who assessed change in WSE from pre‐ to postwriting course (Goodman & Cirka, 2009 ; Jones, 2008 ; MacArthur et al., 2016 ; Miller et al., 2015 ; Mitchell et al., 2017 ; Van de Poel & Gasiorek, 2012 ; Woody et al., 2014 ; Xu, Park, & Baek, 2011 ) all identified a statistically significant improvement in WSE. Given that each of these studies explored different populations using a variety of instructional strategies and different instruments to measure WSE, the consistency of this finding is evidence that WSE can be successfully influenced with positive instruction. Mitchell et al. ( 2017 ), providing a course design example, described the role of the instructor in the scaffolding process as including but not limited to anxiety control, simplifying the task demand, providing feedback, ensuring students stay on task and on the specific focus of the assignment, reviewing outlines or drafts of papers and providing models of successful student past writing efforts for current students to follow. Literature describing scaffolding as an instructional model also emphasizes the importance of an instructor “stance” that supports a collaborative instructor–student relationship (Benko, 2013 ).

2.3. The relationship between writing self‐efficacy and anxiety

One instructor role in writing instruction would be to normalize and alleviate writing anxiety. Writing anxiety is a common emotional response to writing tasks no matter the experience level of the writer (Zimmerman & Bandura, 1994 ). Anxiety, assessed using various measures (Martinez et al., 2011 ; Mitchell et al., 2017 ; Woodrow, 2010) and writing apprehension, assessed using Daly and Miller's writing apprehension scale (Goodman & Cirka, 2009 ; Pajares & Johnson, 1994 ; Sanders‐Reio et al., 2014 ) were the most common methods of assessing the emotional arousal component of self‐efficacy theory. Pajares and Johnson described writing apprehension as a form of writing anxiety. Correlations between apprehension or anxiety and WSE are consistently negative regardless of measurement tool used (Martinez et al., 2011 ; Mitchell et al., 2017 ; Pajares & Johnson, 1994 ; Sanders‐Reio et al., 2014 ). Through use of statistical modelling, researchers have demonstrated that anxiety's role in influencing academic performance is mediated through self‐efficacy (Goodman & Cirka, 2009 ; Martinez et al., 2011 ; Woodrow, 2011 ). Evaluation of change in apprehension from pre‐ to post writing course has been inconsistent with some authors identifying a statistically significant improvement in apprehension in pre‐ to post course methods (Goodman & Cirka) and others finding that apprehension remains constant even when self‐efficacy shows improvement (Pajares & Johnson).

3. THE STUDY

3.1. participants.

Participants in this study either directly enrolled in the Baccalaureate nursing programme (minimum entry requirement: 60% average in prerequisite courses) or entered through a college preparation programme designed to help mature students update their educational prerequisites. All 192 students registered in three sections of the required course “Scholarly Writing” were eligible to participate. Course sections were offered in both the first and second term of the 2013–2014 academic year. From 192 students, 132 participants (68.8%) provided useable data for analysis. Of the participating students, 27 (20.5%) were enrolled in an online‐only section offered in the first term of the nursing programme, 35 (26.5%) were in an online section in the second term of the programme and 70 (53.0%) were in a second term classroom section.

From the original 192 possible participants, 60 students failed to return sufficient questionnaires (31.2%). An assessment of paper percent grade, using an independent t test, comparing participants (mean = 69.85, SD = 18.10) to non‐participants (mean = 56.71, SD 23.88) found significantly lower grades in non‐participants , t (187) = 3.72, p  <   .001. A similar significant difference was observed between participants (mean = 5.85, SD 12.97) and non‐participants (mean = 64.48, SD = 19.40) on final percentage grade, t (187) = 4.05, p  <   .001.

3.2. Design

The study employed a one‐group quasi‐experimental pre‐test/posttest design with a time‐control period in the term prior to participation. A time‐control was added to rule out possible changes in WSE and anxiety unrelated to participating in a writing course. Figure  1 outlines the study groups that emerged given the varying degrees of participation of students in the context of collecting data over two academic terms in various course sections. Because a time‐control period was not possible for the students registered in the online section offered in the first term of the programme, these students were included as “experiment‐only” participants ( n  =   30)—three additional participants in this group were students in the other sections who did not return the first questionnaire.

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Study groups and context of participation over three measurement time points. Data was collected at T1 (T2 for online term 1 participants) during their first year orientation. T2 data was delivered and collected during the first classroom session for the classroom group and by email for the online group. T3 questionnaires were delivered and returned by email for all groups

3.3. Ethical approval and study procedures

Ethical approval was obtained from the Research Ethics Board at the instructional institution. Informed consent was secured by presenting all participants with a letter attached to the front of a questionnaire package following a presentation about the study during their first‐year orientation (T1). Return of questionnaire was considered consent to participate. Bonus marks, amounting to 2% of the final grade, were offered to students as a reward for participation to help reduce attrition. The pre‐course questionnaire (T2) was distributed on the first day of class for the second term online section and requested by email from the second term online students.

The post course questionnaire (T3) was requested via email from all students following completion of the academic paper assignment but prior to grades being released. This timing was chosen to avoid having student's knowledge of grading and feedback as an influencing factor on their internalized perception of their WSE. Students who did not return the post course questionnaire were included as “time‐control only” participants ( n  =   36). The main analysis was performed on students who completed all three questionnaires, referred to as “full participants” ( n  =   66). Online or classroom course section enrolment was self‐selected, however, students in the second term groups were given the general advice to choose the online section only if they felt confident with their writing skills. Students in the first term online section were required to have completed course credits in at least two other first term courses as this section was only added to decrease the class size for second term.

3.3.1. Scholarly writing course description and environment

The course was developed using scaffolding strategies (Benko, 2013 ; Gazza & Hunker, 2012 ; Vanderburg, 2006 ). A complete description of the course learning outcomes and instructional strategies has been presented elsewhere (Mitchell et al., 2017 ). The main outcome of the course required students to produce a final academic paper worth 60% of their final grade. The instructor provided three to five topic choices. First term students chose from topics such as binge drinking, victim blaming and energy drinks. The second term groups chose from narcotics addiction in health care workers, immunizations, kids and electronic devices, cyber bullying and healthy relationships.

3.4. Measures

3.4.1. self‐efficacy scale for academic writing.

The Self‐Efficacy Scale for Academic Writing (SESAW) was designed by the first author of this study. The SESAW is a 10‐item 4‐point Likert scale with response options ranging from strongly agree to strongly disagree. Scale items are presented in Mitchell et al. ( 2017 ). Cronbach's alpha for the SESAW was assessed as .82–.85 for this study and .85–.90 for a previous cohort. Concurrent comparisons with the General Self‐Efficacy Scale (Schwarzer & Jerusalem, 1995 ) were .50 and .53 at pre‐test and posttest, respectively, in previous use.

3.4.2. State‐trait anxiety inventory

The STAI is a two‐part questionnaire measuring anxiety as a stable personality trait (trait anxiety) and as a result of transitory anxiety producing circumstances (state anxiety) (Spielberger, 1983 ). The STAI has demonstrated acceptable reliability and validity in nursing and education populations. In college students, the test‐retest scores for the trait scale are reported to be .73–.86 but proved less stable in the state scale ranging from .16–.62, which, according to Spielberger, was expected because the state scale should be sensitive to situational factors on a given day. Cronbach's alpha is reported at greater than 0.90 in both scales in a college student population (Spielberger).

3.4.3. Grammar and APA knowledge test

This researcher designed knowledge test was created to assess improvement in recognition of errors in grammar and American Psychological Association (APA) style guide usage. The 10 questions were formatted as written statements that contained one error, or no errors. Errors in punctuation and spelling were not included. Error types included: use of & rather than “and” in an unbracketed APA citation with two authors; two examples where no page number or paragraph number was included with a direct quotation; a then/than grammar error; a sentence fragment; a date separated from its author in citation; two examples involving a word misuse of your/you're or its/it's; and two correct statements. Risk taking was rewarded in the scoring strategy. An unanswered question scored 0, a correct answer scored 2 and an incorrect or partially correct answer scored 1, for a total possible test score of 20. Participants were not informed of the scoring process for this knowledge test.

3.4.4. Assessment of writing

The two course instructors graded the scholarly paper assignments in the first term students. The second term sections required seven graders, including the two course instructors. The department chair assigned five additional markers, who were also classified as instructors in the nursing programme, to assist with the process. These five graders were all provided with the same training by the first author as to how to use the rubric found in Table  1 . A printed instruction sheet was supplied to all graders to help ensure consistency. The two course instructors (including the first author) were available for consultation during the process of grading as required and the first author completed a spot check of each external grader to assess for consistency.

Rubric for grading scholarly paper assignment a

3.5. Analysis

Data was analyzed using the Statistical Package for the Social Sciences version 22.0. Statistical tests performed are identified in the results section. Power was calculated for the main effect of change in self‐efficacy in the full‐participant group using an effect size of .5 and alpha of .05. For this study a sample size of 63 would yield a power of greater than 98%.

The demographic characteristics of the sample are presented in Table  2 for the total sample and by study group. One‐way Analysis of Variance (ANOVA) failed to identify any statistically significant demographic differences based on study participation level other than the experimental‐only group was significantly younger ( p  =   .042). Table  3 describes the sample by mean grades, SESAW, APA and grammar score and STAI scores at all three time points. No statistically significant differences were noted between the three study groups, using t tests or ANOVA, except in final course percentage grade where the time‐control only group achieved the lowest final grades.

Demographic characteristics of the sample by participation group

Grades, SESAW, APA and grammar and STAI scores by participation group at all time points

4.1. Change over time

Table  4 presents the results of the time effect on the key study variables using repeated measures ANOVA or dependent t tests. In the full participant group, as expected, SESAW scores were statistically non‐significant in the control period but significantly improved from pre‐ to post course ( p  <   0.001). SESAW scores did not achieve statistical significance in either the control‐only participants or the experiment‐only participants during the study period. There was no change in either state or trait anxiety at any time period in any of the three groups. APA and grammar knowledge improved significantly and were different at all three time periods in full participants ( p  <   0.001) and also improved in the time control‐only group ( p  =   0.03) and the experimental‐only group ( p  <   0.001).

Change in SESAW, APA and grammar knowledge and STAI scores across three time points by participation group

4.2. Correlations between SESAW and anxiety

Pearson's r calculated negative correlations, as expected, between SESAW and both state and trait anxiety with the exception of state anxiety at T3. Using Pearson's r , correlations with SESAW at T1 were r  = −.33 ( p  <   .001) for state anxiety and r  = −.24 ( p  <   0.05) for trait anxiety. At T2, SESAW negatively correlated with state anxiety, r  = −.48 ( p  <   .001) and trait anxiety, r  = −.53 ( p  <   0.001) and at T3 these negative relationships were maintained with state, r  = −.17 (n.s.) and trait, r  = −.23 ( p  <   0.05).

4.3. Correlations between SESAW and paper and final percentage grades

As expected, using Pearson's r, both paper and final percentage grades were uncorrelated with SESAW measures more remote from their writing performance at T1 (paper percent r  = −0.004, p  = n.s.; final grade percent r  =   0.04, p  = n.s.) and T2 (paper percent r  =   0.04, p  = n.s.; final grade percent r  =   0.07, p  = n.s.) but achieved a statistically significant correlation at the SESAW measure most proximal to their performance at T3 (paper percent r  =   .24, p  <   0.05; final grade percent r  =   .25, p  <   0.05).

4.4. Online versus classroom instruction

The study hypothesis predicted no differences between the online and classroom experience in terms of grades, APA and grammar test scores and STAI and this hypothesis was observed in the data with the notable exception of final course grade. Using independent t tests, final percentage grade differences between the first term online section (mean   = 80.66, SD = 9.33), the second term online section (mean = 72.84, SD 13.09) and the second term classroom section (mean = 75.49, SD 13.73) grades were non‐significant by ANOVA, F (2,129) = 2.90, p  =   0.058, but post hoc tests identified a significant difference between the two online groups ( p  =   0.048). The SESAW was expected to be higher in the second term section of online students because students were guided to choose this section based on their self‐assessed confidence in writing. As expected, independent t tests showed SESAW at T1 to differ between the second term classroom (mean = 27.95, SD 3.44) and online sections (mean = 29.52, SD 3.26), t (96) = −2.16, p  =   0.033.

4.5. Education prior to nursing admission

Students entering the programme with only high school entry credits fared the worst in terms of their paper and final percentage grades but did not correspondingly differ on SESAW, APA and grammar test, or the STAI scores. This was an expected finding. ANOVA compared the paper percentage grades in high school entry students (mean = 59.83, SD 23.45) with students with previous degrees or diplomas (mean = 74.98, SD 16.79) as well as students with some postsecondary experience (mean = 69.05, SD 16.78) F (2, 128) = 4.36, p  =   0.015. This pattern mostly held when examining final percentage grades where high school entry students (mean = 67.11, SD 16.13) had lower grades than those with degrees or diplomas (mean = 80.32, SD 11.30) or some postsecondary experience (mean = 75.17, SD 12.22), F (2, 128) = 6.67, p  =   0.002. Post hoc Tukey test targeted that difference as being between high school entry and previous degrees for both paper ( p  =   0.012) and final ( p  =   0.001) percent grades. In addition, the findings neared significance between high school entry and some postsecondary education for final grades ( p  =   0.053).

4.6. ESL status and past writing experience

As hypothesized, independent t tests showed no differences between students who self‐declared English as their second language and those who did not with respect to paper and final percent grades, SESAW, STAI and APA and grammar knowledge. A similar lack of significant difference was observed when the assessment compared those reporting less writing experience to those reporting more writing experience.

5. DISCUSSION

This study is unique in the body of literature examining WSE for several reasons. First, it examines WSE both pre and post a course with efficacy‐building scaffolded instructional methods and rules out the possibility of a maturation effect during a control time period where no academic writing was required. Second, it compares online and classroom instructional environments. Third, it examines WSE in self‐identified ESL and non‐ESL students, which has important implications for the instruction of writing in diverse student groups including international students. Fourth, it contributes valuable information for consideration when establishing admission policies, because nursing students direct out of high school struggle with the academic writing demands required to achieve passing grades.

As expected, WSE remained stable during the time control period when no writing was required and improved from pre‐ to postcourse in full study participants. In the experimental‐only group WSE improved but was not statistically significant. Failure to find significance in this latter group may have occurred for two possible reasons. First, the sample size was small with only 30 students in this portion of the analysis. Second, the initial WSE measure on this group was taken without a time control preceding their student experience. This group would have been responding to the first questionnaire, unaware of the nursing writing context and academic rigour of nursing education and this may have contributed to an over inflation of their initial self‐reported WSE giving little room for statistical improvement. Prat‐Sala and Redford ( 2012 ) made a similar observation in their first‐year psychology cohort. However, given that term one online students ultimately demonstrated a high degree of academic skill achieving the highest course final grades, their high WSE may have been justified.

Anxiety and WSE were negatively correlated as expected matching the findings of others when using writing apprehension or anxiety as the emotional arousal factor (Martinez et al., 2011 ; Mitchell et al., 2017 ; Pajares & Johnson, 1994 ; Sanders‐Reio et al., 2014 ). Surprisingly, anxiety did not change as a result of participating in the scholarly writing course. This finding is similar to the resilience in writing apprehension observed by Pajares and Johnson ( 1994 ). In this study, because anxiety was measured with the STAI, the STAI may have not been specific enough to writing anxiety and students may have answered the questions while envisioning their more general academic anxieties.

The APA/Grammar knowledge test produced some interesting trends in student knowledge of these writing tasks because participants demonstrated improvement of their knowledge during the control period (unexpected) as well as pre‐ to post course (expected). The improvement in scores from the beginning to the end of the control period was unexpected because students were not taking any writing instruction, completing formalized writing assignments, or being asked to apply APA style during the control phase. The noted improvement during the control period is more likely due to scoring the test by rewarding risk taking responses. By the end of their first term of study, students were more likely to guess at questions they were unsure of answers for—a trait related to learning effective test taking strategies. In addition, course readings in nursing may have exposed them to the patterns of APA in published textbooks and journals.

The most concerning but, perhaps, not surprising finding with respect to writing performance was that students who entered the programme without any previous postsecondary experience achieved the lowest writing course and paper grades while reporting similar WSE and anxiety at all measurement periods. Walsh, Prokos, and Bird ( 2014 ) noted that it is not unusual for inexperienced students to overestimate their capabilities in contexts where writing complexity and the demands of evaluators are unknown. This explanation also rationalizes the failure to find significance between students who self‐reported extensive past writing experience compared with those with little or remote past writing experience. Those who reported little writing experience likely had overestimated their WSE. Self‐evaluation is not likely to be accurate when little frame of reference is present for the experience. Context of writing is critical to accurate WSE measurements (Pajares & Johnson, 1994 ).

5.1. Online writing instruction

This study provides preliminary evidence that writing can be successfully taught in an online environment to generic baccalaureate nursing students. The online and classroom sections in second term only differed in terms of WSE at T1 with the online group reporting higher WSE. This difference is likely an indication that students heeded advice in section selection to choose the online version of the course only if they felt comfortable with their writing ability. Paradoxically, the second term online group ultimately achieved the lowest average final percent grades in the course indicating there may have been a mismatch between their self‐reported WSE and their writing ability. An overinflated sense of self‐efficacy in relation to grades, in some students, has also been observed by other authors (Williams & Takaku, 2011 ). The second term online students may have found themselves weaker in self‐regulatory skills to independently stay on pace with course materials (e.g. avoidance of the course in face of a heavy second term course load). However, because paper percentage grades did not differ significantly in this group when compared with the other sections, this is an indication that their final grades were lower as a result of poor quality of or failure to submit the other weekly assignments that contributed to their final grade. This pattern may be evidence that the second term online students did not attend to the course materials all that closely without having weekly class attendance to keep them accountable. By contrast, the first term online group had the highest final grades. This pattern may be an indication that student self‐selection of course section and previous college course credits prior to admission (required for admission to the first term online course) had a greater impact on grades in these online environments than WSE or anxiety levels. Some authors have suggested WSE instruments may be useful tools to guide course placement (Zimmerman & Bandura, 1994 ), however, if beginning students are prone to overinflate their sense of WSE, using the tool to place students in sections may not have the desired effect of appropriately grouping students by writing ability when disciplinary requirements and rigour are unknown to the student.

5.2. ESL status, WSE and writing performance

Identifying no differences between self‐declared ESL students and non‐ESL student in writing self‐efficacy, anxiety and grades was an important finding and similar to the results reported in Williams and Takaku ( 2011 ). Nursing instructors must be careful to not assume that ESL students are worse writers than their domestic counterparts, or overly scrutinize their work for errors because they are known ESL students.

5.3. Practical implications for teaching writing

5.3.1. scaffolding.

Similar to an earlier study in this population (Mitchell et al., 2017 ), the results of this study contribute additional knowledge that scaffolding writing assignments in an introductory discipline‐specific writing course can enhance writing ability and WSE. Miller et al. ( 2015 ), in the only other published study examining WSE in nursing students, also used a scaffolding method of structuring their writing assignments. Their population was different from this study and from Mitchell et al. ( 2017 ) in that they explored nurse‐to‐degree students late in their nursing programme. Scaffolding combines two parallel processes: (i) structuring assignments so that they are completed in progressive stages over a term (Walsh et al., 2014 ) and, (ii) instructor involvement, where the instructor or the tutor act as the scaffold in the writing process, slowly withdrawing support as writers become more independent (Benko, 2013 ; Gazza & Hunker, 2012 ; Mackiewicz & Thompson, 2014 ).

Leveling assignments within a course and across a curriculum is achieved by increasing the complexity of written assignments. This approach requires the student to progressively demonstrate abilities in Bloom's taxonomy to first, summarize and describe and then synthesize, critically analyze and evaluate topics they are investigating (Gazza & Hunker, 2012 ). This process of reducing a major writing project into manageable relevant pieces may contribute to students being able to advance their thinking to higher levels of Bloom's taxonomy (Luthy et al., 2009 ). In the course described here, this process involved short writing assignments which began with reflection and then requested students summarize one source, followed by two more writing exercises where they were asked to synthesize two and then three sources on the same topic. Scaffolding also occurred in the scholarly paper assignment. The course prescripted a schedule which had students complete the major elements of the assignment in stages, first choosing their topic, searching for supporting research, learning to make notes from their sources and develop an outline and then writing and editing a rough draft in preparation for submission for grading (Mitchell et al., 2017 ).

5.3.2. Instructor influence

While scholars who discuss writing instruction in nursing agree that writing is important to critical thinking skills, reasoning and career trajectories, we agree with Miller et al.'s ( 2015 ) conclusion that writing competency in many nursing programmes is assumed rather than taught. But because writing skills develop slowly, a single discipline‐specific course is not sufficient to develop proficient writers. All instructors who include a writing assignment as an evaluation criterion in a course must consider themselves writing instructors. Instructor involvement includes teaching course content in such a way that it connects the writing assignment to prior learning and future needs (Benko, 2013 ).

The scholarly writing course requires a tremendous number of instructor hours to implement successfully with large classes. Instructors must be comfortable with their knowledge of the writing process and their ability to give advice and feedback to students in a writing process framework for benefits to be observed. Scaffolding in courses is effective for any type of writing assignment but must include the critical elements of ensuring an appropriate challenge, allowing for student choice to increase engagement with writing and providing students with the opportunity to say something of their own, all contained in a caring classroom environment where instructors can show interest in student's writing ideas (Benko, 2013 ).

5.4. Study limitations

While this study successfully demonstrated that a discipline‐specific scholarly writing course using scaffolding as an instructional method can improve WSE in first year nursing students, the study does have some limitations. First, the original proposal for this study intended to compare this cohort of nursing students to another group of students in the college environment who were required to complete a significant academic writing assignment without the benefit of writing instruction, however, discussions with instructors in other programmes identified that all courses were providing too much writing support to function as a true control. While the time control period enhances confidence that the scholarly writing course positively affected WSE levels, a comparison group would have been an additional strength. Second, the bonus marks for participation were included in an attempt to curb attrition from the study, however, attrition remained high and was concentrated among students who achieved the lowest grades. Thus these results cannot be generalized to students who demonstrate poor writing performance.

5.5. Areas for future research

While this study successfully demonstrated that WSE can improve early in a nursing programme when assessed in the context of discipline‐specific writing, the empirical relationship between WSE and its role in student performance remains tenuous. In part, this is due to the difficulty in consistently assessing and scoring writing performance. The successful measurement of writing performance and detecting improvements in writing performance over time, requires similar writing assessment activities in a given course. For example, in this study, a second three‐page academic paper would have needed to be assigned early in the study—a requirement that would have put tremendous burden on both the students and the course instructors/graders. In addition, requiring a second intensive writing assignment early in a course prior to writing instruction would have likely produced high anxiety and some academically disastrous results for some students. One possible solution would be to explore the changes in drafts of the same assignment over a term.

This study used a brief grammar and APA test which was not to be considered an assessment of writing performance. It is generally well accepted among writing experts and theorists that good grammar (and application of APA format) does not equate to good writing as it is far too limiting a criterion to be a parallel assessment for performance. It may be argued that using a substitute writing assessment such as an in‐class essay is also not an adequate assessment of writing performance as it denies the student the opportunity to research, reflect, polish and be creative in their writing approach. These spontaneous essays are not a mirror for the kinds of assignments we require of students with the goal toward improving critical thinking, learning the discourse of a discipline, or creating a synthesis of knowing.

Miller et al. ( 2015 ) were likely correct in exploring changes in different sub‐components of writing performance (e.g. organization, sentence fluency, voice, or ideas), rather than exploring performance in a more global fashion such as grades or GPA, in their search for improvement over time. Williams and Takaku ( 2011 ) have suggested that the relationship between WSE and performance is likely mediated by student choices in help seeking for their writing. This study provides support for the idea that past writing experience (and more specifically, previous postsecondary experience) likely has a strong influence on writing performance in the form of grade earned in an assignment or course. But given that both experienced and inexperienced students reported similar WSE levels, this study also provided preliminary evidence that levels of WSE may bear little connection to past experiences of writing as WSE is not a stable construct and will fluctuate according to context, expectations and task requirements. Even expert writers will experience bouts of low self‐efficacy under conditions of changing expectations, challenging evaluators (sometimes external and sometimes self‐imposed) and disciplinary circumstances. However, improving writing self‐efficacy may play a role in shutting down negative self‐regulatory behaviours that lead to writing avoidance, stop students from writing, prevent them from making career choices that require writing such as advanced degrees, or keep them from writing to advocate for policy changes that may influence the nursing profession as a whole. Intervening in writing self‐efficacy could be what keeps students and nurses writing. These proposed relationships require further study.

The exploration of writing self‐efficacy and how it influences writing performance is a research area in its infancy. It is unlikely that writing self‐efficacy will dramatically improve performance across a single term as writing development is a lifelong endeavor. The only way writing performance can improve is through ongoing progressively more challenging writing. Currently a long‐term follow up of the same cohort of students is being conducted examining WSE and anxiety in terms of stability or growth over a curriculum. Help seeking, engagement with instructors, revision practices, response to feedback and progression through the programme will be investigated for their WSE connections. An exploration of the relationship between writing self‐efficacy and clinical practice success is being included. In addition to this active study, a revision of the WSE questionnaire is required to assess its discipline specific elements. Qualitative research examining the writing experiences of undergraduate nursing students are also necessary for establishing targeted interventions in this population.

6. CONCLUSION

This study has demonstrated that discipline‐specific writing instruction can influence writing self‐efficacy in first year nursing students. A paucity of research exists in nursing populations to address the “problem” of student writing. Scaffolding as an instructional method is a promising solution to improving student writing but requires intense instructor involvement from instructors who are confident with their own writing and confident assessing the writing of undergraduate students. Discipline‐specific writing, given that nurses communicate in a shared professional discourse, is the current recommended approach to improving writing and critical analysis skills in students at all levels of nursing education.

CONFLICT OF INTEREST

No conflict of interest has been declared by the authors.

AUTHOR CONTRIBUTIONS

Ms. Mitchell: designed, implemented and coordinated the study through all phases, developed and implemented the writing course, and wrote the manuscript.

Dr. Harrigan: contributed to the study design, provided statistical analysis and insights into the relevance of findings, and reviewed and approved the manuscript.

Dr. McMillan: provided insights to the statistical analysis, relevance of findings, and reviewed and approved the manuscript.

ACKNOWLEDGEMENTS

The first author thanks Mr. Ashley Blackman, Director, Research and Planning at Red River College, for his support and advice during the initial planning phase of this study.

Mitchell KM, Harrigan T, McMillan DE. Writing self‐efficacy in nursing students: The influence of a discipline‐specific writing environment . Nursing Open . 2017; 4 :240–250. https://doi.org/10.1002/nop2.90 [ PMC free article ] [ PubMed ] [ Google Scholar ]

This study was funded by the Red River College Program Innovation Fund Award 240‐15001‐09

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