Q: Wonderful. And how long has it been since you graduated from undergrad?

A: I graduated from undergrad in 2014, May of 2014.

Q: Okay, okay. So about four years. And how long have you worked in nursing?

A: Eight and a half years. I had my associate’s before I had my bachelor’s.

Q: Great, okay, perfect. So could you provide sort of a brief description of your primary job functions as a floor nurse?

A: So as a staff nurse on labor and delivery specifically, my primary job would be to care for generally one to two patients in the labor, delivery, and recovery setting, which can be everything from giving emotional, physical support to the laboring woman, providing them with medications, whether it be for pain control or to augment labor, to stop labor. We also had a high-level NICU at our hospital, so I would care for high risk antepartum patients – so patients who are pregnant but not trying to deliver at the time – and generally your function there is to provide medication and monitoring to assess the wellbeing of mom and baby, and the safety of them, and hopefully to stall their labor if you could. And we also have three operating rooms, so we also cared for and circulated in c-section cases, and had a recovery unit for that.

Q: Wonderful, okay. Could you estimate, in an average week, what percentage of that job required writing?

A: How many words together counts as writing [laughter]?

Q: I’ll say two [laughter].

A: Two, okay [laughter]. Okay. How many hours in a week?

Q: What percentage of the week?

A: Umm, let’s say maybe 20 percent of my working time?

Q: Okay, and could you tell me a little bit about the forms or types of documents that you were writing?

A: So most of the writing that takes place as a staff nurse is on an electronic medical record, where we joke that it’s an elaborate billing system, because it is [chuckle], but they try to make it as easy for the billers to use as possible, and as easy for you to not get yourself in trouble as possible. So they do a lot of like, selecting options for charting, so it’s like a column where you select options, you can type in things like, you know, blood pressures, or temperatures, and then you can select options for pain levels, or assessment findings, like color of the skin, they’ll give you options like, “appropriate for ethnicity, warm, dry, clammy, red, hot, weeping”, like tons of different options. And then also an option to click and write a comment, so if you were writing something that was a like deviation from expected, you’d probably want to put a comment to explain why, or what you did about it. And there’s also notes you write that are more narrative. Generally you would write a minimum of one of those a shift, but depending on what you were doing that shift, especially if it was a more complicated patient, you could have like ten.

Q: I see, okay. And so, could you tell me a little bit more about what those narrative pieces sort of look like or sound like?

A: You have to be really careful when you write a narrative in the chart, because you definitely don’t want to double chart, because that’s a waste of your time, but also because you are trying to make sure that you’re staying consistent. And it’s really easy when you’re using click boxes to fill in your answers to, if you’re not being careful, just fill in like your normal answers, like the standards, and then if you write something different in a note, and it contradicts what you already charted, it makes it look like you’re not competent. So you’re trying to make sure that you’re being consistent with what you’re writing unless it’s actually discussing a change. And you have to be careful when you’re writing it to not, as a registered nurse, not make any medical diagnosis, and also not to like throw any other providers under the bus. So a lot of the notes were intentionally vague, in writing things like, if I was concerned about a patient, let’s say she had chest pain after delivery, and I was concerned, and I took some vital signs and everything was normal, and her bleeding was all normal, and everything was great. But I’m still going to definitely go the physician, and let the physician know, “Hey, she’s having chest pain. This is her blood pressure, this is her heart rate, this is her temp, this is what her bleeding is like.” And if they say like, “I’m not worried about it.” And then I’m like, “Well, don’t you want an EKG?” If the provider’s like, “No, I don’t.” Okay, so I don’t want to write a note that says that exactly, because it makes them look like they’re not doing their job, even if I feel that way. So I have to write, for example, that note would say, “Patient complained of chest pain.” I might like list the vital signs, “Provider notified, no new orders,” [laughter].

Q: Interesting. So this vagueness is to make it cover yourself while making sure you’re not throwing someone else under the bus?

A: Right. To say, “Look, I did my job. I followed through, but I can’t speak to whether this other person did.” And if it’s really a safety issue, I mean to be 100 percent honest, there’s obviously a chain of command you follow. So if I really didn’t agree with what that provider said, there’s another physician above that one that I can always go to. So I don’t want to like, speak to them [crosstalk 6:53] with that, but that’s like a really easy example of how and when you would write it.

Q: That makes perfect sense, yeah. And to be clear, you talked about this system being sort of like an elaborate billing system. Obviously the billing folks aren’t the only audience, who else would look at these notes? Both the narrative and the sort of standardized pieces?

A: I would say your most common audience for that would be your other nurses. It’s really common when you start a shift to kind of – you get a report, generally we would do bedside handoff, so you would discuss the patient’s care side to side, at the bedside, with the patient so they can speak up if they’re awake – but then it’s a really good idea to go through and take a look at the notes. And especially when you’re working with a patient who’s been there for a long time, it’s really easy for stuff to get missed. So going through and reading the narratives can say a lot more about what has and hasn’t happened, and what’s been tried and what hasn’t been tried, and how things are responding, than just looking at the – we call them flowsheets – like the excel spreadsheet that has values in it.

Q: I see, okay. That makes a lot of sense. And to clarify, those narrative pieces – it sounds like they’re relatively brief, even though they’re pretty important?

A: Generally. There are probably some nurses who write longer narratives, but most of what you should be writing should be like, especially nowadays, should be easily found in the flowsheet, and that’s the prefered way to document, because it’s an easy way for the system to keep track of what’s going on, and you can’t do metrics, for example, from notes. So if someone in the background from the education department is trying to track a new kind of epidural medication, for example, and I’m just writing notes about a pain level, you can’t just pull that up and track it. So I’m only writing notes about things that, or making comments about things that are maybe a deviation from normal, or it’s something that really needs to be explained.

Q: Got it, got it. And one more follow-up question. You said you also have to be careful not to make any sort of medical diagnosis. I didn’t realize that that was a position that a nurse is in. Can you talk a little bit more about that?

A: Yes [chuckle], so in nursing school, you learn a lot about nursing diagnosis, which just really a fancy way of describing symptoms. But making a medical diagnosis is practicing medicine, and that’s reserved for people who are licensed to practice medicine, so your nurse practitioners, midwives, physicians, etcetera. So if you are handling a patient who looks like they have the flu, and they clearly like, have the flu, as a nurse I can’t write a note that says, “Patient presents with the flu,” unless it’s been diagnosed by a provider. I can say, “Patient presents with fever, runny nose, body aches,” you know, malaise is a nursing diagnosis, which means not feeling well [laughter]. So I can describe it all, but I can’t say, unless it’s been diagnosed by somebody else, I can’t literally say that they have the flu.

Q: That’s fascinating. Okay, okay. I’m sure that makes writing especially tricky, because you’re sort of talking around this really obvious thing that you know, right?

A: Yes. Yeah, absolutely.

1. That’s really interesting, okay. So, as you are writing these sort of typical documents – let’s talk about that narrative piece, because that seems like you have sort of the most leeway in those–

A: Yeah.

Q: –when you are writing those, is there any preparation or steps that you take prior to writing?

A: Yeah, and especially depending on what the note is talking about or how maybe sensitive the issue is, I am probably going to be looking through the previous notes to make sure that I’m not, again, contradicting something really obvious, unless I have to. So, a big example was for a while, we had some anesthesia staff who would use an incorrect method of measuring a patient’s temperature – not that it wasn’t like, it was a fine measurement for temperature, but our unit had made a policy against using this temporal scanner, because we didn’t find it to be as accurate – and we had some anesthesia staff who were still using it because they liked it, and it was faster, and it would give them slightly warmer values on a patient coming out of the operating room; and one your risks after having surgery is having a low body temperature. So having anesthesia write in their flowsheet that the temperature was 97.4, and I’m getting a temperature of 96, I need to make sure that I see what they charted, what time they charted it, and then I have to be careful with how I chart it, and I might want to explain like, in my note, you know, “rechecked temperature after anesthesia, value 96.0 orally,” and make a note explaining what I had to do thereafter, without having to say like, “they were wrong or used incorrectly equipment,” or something like that. So I have to like, review what they actually charted, when they charted it, and make sure that my note kinda goes along with it without, you know, saying anything negative. So it’s a lot of previous chart review.

Q: And when you’re trying to be really diplomatic in these notes, what are the repercussions if you were not diplomatic? If you did call someone out for something like that?

A: Probably most of the time nothing. The issue’s going to come if they’re– I mean, maybe the physician reads it, but a lot of the times their notes, like I don’t know that a lot of their– like, they have to go look for our notes because the way that their system loads, it’s not as obvious to them. And so they might go through and reread them, and get upset with me, which could damage the relationship, but the biggest risk is if this was audited for court, for example, so if there was a complication and the patient wanted to bring it to court, anyone who’s touched the chart, it keeps a log of everyone who’s logged in and clicked and opened that chart, and anyone who’s written in the chart is probably going to get subpoenaed, and possibly deposed for this court case. And so I have to, you know, show that I’ve done my job, but I also– many court issues end up getting– like if there was incorrect care or something, a lot of times in nursing you’re taught it gets pushed back down to nursing, even if it’s not really in your control, because you’re like the last line of defense, right? So you don’t want to say in your note, you have to prove that you didn’t willfully ignore something, that you gave good, fair care, but you don’t want to provide any ammunition for – this is sounding terrible [laughter] – you know, someone trying to prosecute you saying you didn’t do your job, or the physician didn’t do their job when you know you did. And most of the time, I mean most cases have great outcomes, most cases don’t go to court, but even when they do, most of the situations that are brought to court aren’t because of any negligence or you know, it’s like something crappy happened, that couldn’t be avoided, and it wasn’t in anyone’s control, but no one wants to feel that way, you know? And so you want to make sure that you’re writing these intentionally vague notes so that no one gets in trouble for doing something wrong when most of the time things aren’t being done wrong. Does that kind of make sense?

Q: Got it, yeah that makes a lot of sense. Yeah, that’s really clear actually. That makes a lot of sense. There’s so much nuance to this. So how did you know how to perform these types of writing?

A: That’s a good question [laughter], I need to think about that one. I guess we talked about it some in nursing school, but not a ton. A lot of it comes from working on the floor, and just having to practice when you’re kind of, maybe like one of the first times that you’re put into a touchy situation, where maybe there isn’t a right answer, or you don’t agree, but the person who’s giving you orders isn’t technically wrong or something, and you have to write a note about it, you probably are learning more from your more experienced coworkers. It’s like a skill that’s passed down, because your first intention is just to want to write this like, long narrative note that explains every detail and everything, and then you’re probably doing it with someone with you know, 10 or 20 years more experience looking over your shoulder saying, “Delete that, delete that, delete that, delete that! You already charted that,” [laughter]. So a lot of practice. I do remember starting as a nurse, working in like med/surg–

Q: What is med/surg?

A: Oh, it’s like a medical/surgical floor. So if you’re admitted to the hospital for something, it’s probably where you’re going to go, unless you need like a specialty floor. So if you’re having general surgery for like appendicitis, you’re going to med/surg. If you are– on our unit we did a lot more surgical than medical, but let’s say you have pneumonia and you’re really, really sick and have to go the hospital but you don’t need the ICU, you’re probably going to go to med/surg. So it’s like a general hospital floor. I feel like situations, I remember having to sit there and write notes with people, and you would always seek out like someone you felt comfortable with and saying, “Can you help me write this note? This difficult thing happened.” Like generally then, it had to do with pain management, and you couldn’t get anesthesia to get there on time, or something like that, right?. Patient’s in pain, you’re out of pain medicine, anesthesia isn’t coming, it took an hour, your patient hates you now, you know, something like that [laughter], and you have to careful not to write, “I called anesthesia a hundred million times and they didn’t want to come, because they didn’t like the page,” like, you can’t write that, right? So it’s like going back in time and someone you know, teaching you how to write, okay, write a note for the first time that you notified anesthesia. And then write another note that says, “notified anesthesia.” Write another note that says, “notified anesthesia, anesthesia now in rounds,” you know, and you write it that way. Like these little one line notes that say, “Hey, I did it. Hey, I did it. Hey, I did it.” And as someone showing you, instead of writing one long note, it shows this persistence, for example.

1. I see, without having to say, “They didn’t show up, I had to follow up.” Yeah, got it.

A: Yeah. It’s obvious by, you don’t have to say it, because it’s obvious by how many times you had to follow up, for example. But that’s like a learned skill from your other nurses.

Q: Absolutely. That’s really, really interesting. Are there other things that you did besides seeking out more experienced nurses to learn how to perform these types of writing?

A: That like I, that I intentionally did?

Q: Yeah, yeah. Are there any other sort of strategies that you utilize to, you know, learn the nuances of this and improve?

A: I don’t know. I guess I can think of a few situations where, a lot of times the nursing managers or the units will have someone specific to call and check up on patients after they’re discharged home to see how they’re doing, and to get like a general idea of what we can do better and what we did really well, for example. And then they would, you know, give you follow up in staff meetings and stuff to talk about, “Well, this patient said that they asked for pain medicine a hundred times and were never given pain medicine,” but I can see from the charting where you called anesthesia, and gave them pain medicine, and reassessed their pain, for example. So you get feedback like that, where you learn you have to prove everything you’ve done.

Q: That’s really interesting, yeah.

A: And there’s a nursing addage of, “If it isn’t documented, it isn’t done.” So that gets beaten into your head as well [laughter].

Q: Got it, yeah, yeah. This is fascinating. Okay, so does anyone oversee your writing? You talked about other nurses reading these, and you talked about how you know, in a specific situation, a doctor might seek out your narrative, or your notes, but is there anyone who actually oversees your writing directly?

A: No.

1. Okay, alright. And how long do you typically have to complete one of these narratives?

A: So your charting should be done– okay, so the goal is always real-time charting. So real-time charting should be done within two hours of whatever event. But real life, it doesn’t always work like that if you’re in a really, let’s say you’re in a patient’s room and something changes and you have to go have an emergency c-section, well that whole process can take four hours, between the emergency in the room, going for the c-section, recovering the patient, getting them upstairs, and sitting back down, where you haven’t stopped moving, right? So in that kind of case, it can take a little bit longer. I think most of the applications won’t let you chart things that are older than 24 hours, and if you’re writing them really delayed like that, you should start them with like a phrase that says, “late entry,” or something, to show that, you know, if you’re really writing a, like maybe you wake up at midnight, and you’re like, “Oh no! I didn’t write this note about this thing that happened!” So you show up the next morning and you go to their chart and you write, “late entry” for the time it actually happened. And then how much time you’re given to do it – I mean, I guess as long as it takes to write it, I don’t know.

Q: Okay. if you, let’s say, like if it is happening in real time with a typical patient, without any sort of crisis within that, how long do you usually spend you know writing your one narrative for that shift about that patient?

A: Oh, I don’t know, like some seconds [laughter].

Q: Okay, perfect. Some seconds, perfect, okay [laughter].

A: If it’s like a really simple day, I’m not doing anything above and beyond, everything should be captured in that flowsheet. So my note might be like, something about like, it might just be comments I’m making – like in the fields, you can right-click and make a comment about something – like for a slightly elevated temperature, “reassessed in their axillary,” or something like that, you know?. So it could be really, really simple, or you know, “Spouse to bedside”, I don’t know, like really simple stuff like that, if it’s a really simple day, yeah.

Q: Got it, okay. What kinds of writing do you remember being asked to create as a student?

A: As a student, if you go all the way back to the beginning of nursing school, a lot of your writing is in the form of care plans, which is something nursing school really focuses a lot on still, and the idea is to be able to understand and write these nursing diagnoses, which you don’t ever use in real life. But like a true nursing diagnosis goes something like, let me think, like, “malaise secondary to spoiled milk ingestion following something.” It’s like this really silly string of words and modifiers [chuckle] that you just don’t use it, it doesn’t make any sense, no one’s looking for it, but it’s one of those things that the nursing profession really wanted to have included in part of the education. And then your careplan is based on those nursing diagnoses that you’ve made in writing like what the symptoms of the malaise are in that category, and then what you’re doing for it, and what the expected outcome should be following it. And I think the idea is supposed to be like, big picture thinking, you know, like not just saying, “Oh, okay, so they have a fever, let’s just do Tylenol. The end.” You know? High level thinking, like, “Okay, so they have an elevated temperature, and an elevated heart rate, and shortness of breath. And so I’m considering that they might not be perfusing their lungs as well, and so I’m going to follow up with the MD for XYZ.” So it’s to get you thinking like big picture, what are the causes and effects of different things. That was most of nursing school, was these really crazy mind maps and venn diagrams or something, and I don’t know.

Q: That’s really interesting.

A: I don’t think very well like that.

Q: Yeah, so it was more to get you to a certain way of thinking, rather than to you have you practice writing the kind of document you’d be writing on the job.

A: Right, exactly.

Q: Got it, interesting. And so how do you feel like that did prepare you for the actual writing you do at work?

A: I don’t remember it very well, so maybe not great [laughter]. I think it did do a good job of helping you get out of the habit of looking at medical diagnoses though, as a nurse, and get really good at describing what’s going on. Like describing someone who looks like they’re having a pulmonary embolism, instead of saying, “I think they might have a pulmonary embolism,” or, you know? So it does help you with that. But besides that, I don’t know, that kind of felt like busy work.

Q: Got it, okay. And are there things that you wish you had learned in school that would have set you up to be a more effective writer on the job?

A: Let me think for a second. So I did a lot of like educating new hires for example, and training them on the units I worked on for a long time. And I know some of the focus has really changed. When I was in school, there was definitely a focus on, you know, if you didn’t document it, you didn’t do it. And you had to learn how to write in like a paper chart, so you did do a couple examples of writing little notes in paper charts and reading your notes in paper charts, but now the focus seems to be a lot more on the immediacy of charting, because the electronic medical records are everywhere in this area, at the very least. And so for myself, I don’t, I guess maybe more of an emphasis or some more education on how language can be used in like court system, or chart reviews. Or when the hospital can get reviewed by the Joint Commission to makes sure that they’re following standards of care, for example, so you kind of have like a bigger understanding of why you’re charting what you’re charting when some stuff just seems so silly, because you’re just hitting these like charting requirements for the day that don’t have any meaning or impact on what you’re actually doing for the patient, but it’s some bigger company’s proof of what you’ve been doing. So I wish I had learned about what the Joint Commission was, and what they were looking for, so that way I wouldn’t feel so bitter when I was a new nurse about spending extra time filling in these [chuckle] silly paperwork. And I wish that, well the nursing schools it seems like from the nurses who I’ve been training, they really come out wanting to chart everything the moment it’s happening, which is great, but they are so busy charting that they will forget to actually care for their patient. So I find myself saying a lot, like, “the computer’s not your patient,” because that’s what their emphasis is in nursing school, it’s just so hardwired that you have to make sure everything is documented, you know, documentation has to be perfect, etcetera. Which, a lot of what you do is already in the chart, you don’t have to like constantly be in it, you need to be focusing on your patient first. So I wish that was a change too, I wish they really pushed patient first, rather than chart first.

Q: That’s wonderful. Yeah, that’s really fascinating. Um, this next question is sort of a big picture question, we touched on it earlier – but what is at stake in your writing?

A: Oh, I mean, I guess if I am in inappropriate with the kind of notes I write, or if I don’t write something that I’ve done that’s really important, that proves I was doing my job, that proves the provider was doing their job, that we were working as a team for example, and there is a negative outcome, and we all go to court, like I could lose my license [chuckle], yeah.

Q: Yeah, pretty big impact, okay.

A: I mean charting isn’t going to save, I mean I guess in theory charting could really impact someone’s care if you don’t chart that you’ve done something, I mean that becomes bigger with proving that you’ve passed your medications and stuff like that, but as far as narrative writing, it’s mostly going to be proof that I’ve followed up on things, and acknowledged things, and noticed changes.

Q: That makes perfect sense, yeah. And what is the most difficult or challenging thing about writing in that particular position?

A: A lot of times you’re doing so many things at one time, and you’re following up on like if you notice a change in someone’s status, and you’re following up on it, and your provider’s following up on it, and they’re getting specialists involved, and you know, you’re like trying to keep track of everything that’s happening, while also making sure you’re patient’s safe, you could definitely just forget to write something, you know? And that’s your proof that it was done.

Q: Right, okay, okay. You talked a little bit about seeking out more experienced nurses early on in your career – is there anyone else who’s helped you with your writing, formally or informally, since you’ve been on the job?

A: Like in my nursing writing?

Q: Yeah.

A: No, I guess not really. Because no one really follows up on it unless you’re not charting that you did something.

Q: Okay, okay. And how do you believe you’ve evolved or improved as a writer over the course of your career?

A: I’ve gotten a lot more efficient [chuckle]. I am really good at saying as little as possible to get my point across [laughter].

Q: And to what extent do you think that writing is valued in that position?

A: I would say among other nurses, you know, you definitely have opinions about how people chart, and there’s definitely lazy charters, which isn’t so much a big deal, unless they’re not really saying things like, that they’ve called case management, or whatever, and it’s making your day extra busy because you’re doing stuff they already did, so. I think it makes a big difference between the other nurses that you’re working with, to know what’s going on.

Q: Got it, got it. So sort of your reputation as a nurse also has to do with it?

A: Yeah, your like reputation as a nurse, and also the, how– how do I say it? Like how easy it is to care for the patient can be impacted by how willing someone was to sit down and type something out.

Q: Got it, got it. Okay. And this is my last couple of questions here. So how would you have defined successful writing when you were a student, versus how do you define successful writing in this job that you’ve recently left?

A: So especially working on my bachelor’s after I had my associate’s, the focus what a lot more on paper writing, and writing, I don’t know, a bunch of, I felt like the same essay again and again. So doing well on the essay, right, was really important, and what really became hard, because I was already working as a nurse, was when you had a word count that you had to hit; you’re getting really really good at mincing your words and being really succinct, and then you’re given a word count that’s longer, like hitting a word count becomes really hard [chuckle]. So the big difference is that, is in nursing you’re– wait, is that what you asked, I’m sorry?

Q: It is. How did you define successful writing then versus now, yeah.

A: Okay, yeah. So then, it was a lot more about hitting word counts, and saying you know, what they wanted to hear, and sometimes just being more verbose. And then now it has a lot more to do with how quickly and efficiently can I say the bare minimum to show that I did my job?

Q: That makes perfect sense. That’s so interesting. And I’m sure that’s– I don’t know how typical that path is for other nurses, but it seems especially tricky, because I guess most nursing in doing a bachelor of nursing have not worked as a nurse in the past? Is that a fair statement, or no?

A: At least in this area, that’s probably true. It depends on where you are in the country. Associates-prepared nurses, I mean this area still has associates programs, and throughout the program some places really rely heavily on associates prepared nurses.

Q: Gotcha, okay.

A: Yeah.

Q: And my final question – would you say that you are a successful workplace writer?

A: Yeah, I think I’m a good note writer. People come to me for help with their notes.

Q: Excellent.