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We are keen to include more reports of experience of quality improvement: what works and what does not, how changes affect patient care, and how we can translate what we know into practice. But many of those involved in interesting projects tell us that they find it hard to start writing because, for example, they have insufficient time or are unfamiliar with the process. We asked Tim Albert, who provides courses and support programmes to those who wish to publish, to explain how to overcome such obstacles.
We know, often from bitter personal experience, that writing a paper can be a long and complex task, involving all kinds of skills (such as time management, negotiation skills and writing in simple language) that aren’t necessarily taught to health professionals. But we want you to persevere because we feel there is a lot of interesting work going on out there that doesn’t see the light of day. So the purpose of this article is to give added impetus to those who want to write for this journal but aren’t quite sure how.
First, clarify your message. What is the story you want to tell? Express it in a single sentence of 10–14 words using simple language. Write it down. Ask your co-authors to help you to define and refine this message. Far from making your writing “simplistic”, this will ensure precision and clarity; it will involve, for instance, making choices between small but important words such as “could”, “should”, and “will” that will make all the difference to the final article. Make sure you all agree before you move forward. If you cannot agree on 12 words now, you certainly will not be able to agree on 2000 later, and the importance of this step cannot be overstated. Get it right and you will sail on towards publication; get it wrong (or more likely fudge the issues) and you will invariably founder.
Once you have agreed on the message, find out which editor is likely to be interested in publishing it. A literature search will show which journals have published on this topic before: try to come in on the end of an ongoing debate. Read some back copies and get a feel for how articles are treated. Use any (legal) means to find out what the editors really want. The editors of QSHC have clear views: “There should be an ‘Ah-ha!’ factor” they say. “The people we want to read this journal include clinicians, the director of nursing, the medical director, and the chief executive—and we want to hear of them fighting over the latest issue because there is something in it for them … We want papers that say something about improving the quality and safety of health care, that have a clear message for people in other units”. If targeting this journal, try writing a summary for the Action Points section on the back page; if your question is fuzzy and your action points non-existent, then your time will probably be better spent on other things. No amount of work can turn a coffee bean into a tea bag.
Once you have decided on your target journal, analyse the structure of articles already published in it. Many articles, including some in this journal, use the traditional IMRaD format. This is a tried and tested (though not overtly reader friendly) model which has four main sections:
Introduction: 2–3 paragraphs, typically starting with a description of the topic and ending with a description of the intervention.
Methods: 7–8 paragraphs describing what they did.
Results: 7–8 paragraphs describing what they found.
Discussion: 6–7 paragraphs starting with a summary of what they found and ending with what it all means—in other words, the message.1
This structure is not always appropriate for quality improvement articles, and in 1999 the editors decided to introduce an alternative structure for writing about local quality improvement work.2 Our advice is to choose the one with which you feel more comfortable and fits your work. Decide how many sections you will need, the number of paragraphs in each, and where the key sentences should appear. Use this as a template to construct your own brief plan.
Then write. One way is to construct a cosy nest lined with your data and references, block off 3 or 4 hours of valuable time, and painstakingly construct the article by transferring words and numbers from one piece of paper to another. A better way is to find a quiet corner, block off about 10 minutes, and “free write” each of your sections at a time without hesitation, leaving blanks where necessary. This is a creative activity and some people admit they enjoy it. This “free writing” technique3 may make you profoundly uneasy, but you will find that what your first draft lacks in details (easily inserted later) it makes up for with focus and structure.
After a sensible interval (at least overnight) to increase the chances of objectivity, you will have to rewrite. Check your facts (and check them again—there is nothing that puts off an editor so much as a column of figures that does not add up!). Insert your references: doing them at this stage will ensure that they are used for their rightful purpose, which is to back up your statements. Make sure you have a “good English style”, which is harder than it sounds because your co-authors will have different views. So follow the advice of the recognised masters4–,6 and keep your sentences short and active (“We did this” rather than “This was done”). Use short and familiar words rather than the long and pompous (“had” rather than “possessed”; “met” rather than “encountered”). Make every word count.
So far, relatively easy. Now you will need courage as you release your offspring into the wicked world of co-authorship and then submission. Other people will reward your efforts with countless marks in red ink. Don’t be discouraged: they do this because this is what they are expected to do rather than for any failure on your part. Keep your nerve: use their comments sensibly to improve the chances of persuading the editors that this paper will be the one in three that they accept for publication. If your co-authors insist, for example, that writing must be long and pompous, show them this article. Keep focused on the main task, which is to send the article off as soon as the co-authors can agree. Don’t hold out for perfection. Aim for submission, and when you achieve that aim, celebrate.
Conflict of interest: Tim Albert makes his living by running courses on writing and editing skills for health professionals.
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