There are more than 25 000 students enrolled in DNP programs in the United States.1 Dols et al2 conducted a survey of DNP program directors (N = 90) who reported that from less than 5% to a majority of students lacked the required skills for graduate writing. To address the problem, directors described a variety of approaches including selective admissions to deny entry to students with poor writing skills, baseline writing assessments with support referrals, writing immersion courses, and campus writing centers with editing services, coaching, or writing advisors. There is currently no consensus on the best approach to prepare nursing students for the writing demands of graduate education.
Writing Skill Needs
Nursing educators need to address basic, intermediate, and advanced writing skill deficits to support graduate student success. Poor grammar and sentence structure are common among nursing students.3,4 In addition, educators identified that student writing lacked substantive content, evidence synthesis, an understanding of plagiarism, appropriate citation use, and proper formatting (typically American Psychological Association [APA]).2-10 Because these skills are essential to construct papers for class, doctoral projects, grant proposals, and publishable papers, students who lack them are at risk for course failure or program dismissal.
Although commonly discussed among nursing educators, writing problems are not unique to nursing students. According to Tyre,11 educators taught the rules of grammar, sentence structure, paragraph, and essay formation to US students in the 1960s. In the 1980s, educators adopted a new approach to teach writing. Lessons pertaining to traditional rules of writing were replaced by creative writing activities intended to improve student engagement in the writing process. Furthermore, many educators lack training to teach writing. In a survey of 482 third- to eighth-grade teachers, only 32% participated in courses dedicated to writing instruction, and 38% participated in professional development activities about writing in the previous 5 years.12 As a result, students in every discipline, nursing included, are at risk of experiencing writing challenges in higher education.
In nursing programs, faculty and administration might also miss opportunities to develop writing skills in students. Gazza et al13 indicated that doctoral students attributed their graduate education challenges to a lack of writing practice and limited feedback from prelicensure faculty.
Approaches to Writing Skill Development
A scoping search of PubMed and Cumulative Index to Nursing and Allied Health Literature was conducted using a keyword search and the terms “graduate,” “nursing,” and “writing.” The manual of references identified a limited number of publications that described specific writing development approaches that were applied within graduate nursing programs.3,4,6-8,14-18 The approaches were developed to address the needs of master's, DNP, and doctor of philosophy in nursing students in programs throughout the United States. The university-and program-level supports included online or face-to-face workshops or courses that addressed skills needed to write such as searching the literature and/or writing structure and format. The lengths varied from a single day to multiple weeks or semesters, and although the investigators described the content and delivery methods in detail, the outcomes varied. A select few reported objective outcomes such as the number of publications by students, but most focused on the description of the writing program with either no reported outcomes or anecdotal data regarding satisfaction or perceived effectiveness by faculty or students. Furthermore, the efforts of faculty who evaluate student writing skills from course to course were not measured as an outcome in the previous studies. The purpose of this study was to evaluate the use of individual-level writing skill development strategies implemented by faculty in an online DNP program and to observe their changes in use over a 5-year period.
Design and Setting
A prospective, repeated-measures design was used for this observational study. Outcomes were assessed annually over 5 years. The study was conducted in a school of nursing in the western United States. The DNP program offers 2 tracks: postmaster's and family nurse practitioner. Doctorally prepared faculty (N = 7) used writing assignments in 10 of 13 DNP courses with 3 faculty who taught 2 courses each. All DNP level courses were taught exclusively online, and each course was offered once annually. This project received exempt approval by the university's institutional review board.
Data and Procedures
Writing assignment instructions were examined annually for each of the 10 courses that included an original writing assignment. Course sites and syllabi were accessed via the university's learning management system (LMS).
In 2013, faculty shared preferred individual-level strategies for writing skill development. They selected, implemented, and changed strategies throughout the 5 years according to preferences, workload manageability, and perceived value for achievement of course learning objectives.
IBM SPSS version 25 (IBM Corp, Armonk, New York) was used for this descriptive analysis. The frequency of use for each strategy was calculated for all courses. The mean and standard deviation of total strategies used per course were also reported.
Twelve writing development strategies were identified (Table). They addressed skill development related to content, construction, format, and plagiarism or citation use. The annual frequency of use for each strategy from 2013 through 2017 was divided into strategies that decreased (Figure 1, Supplemental Digital Content, http://links.lww.com/NE/A521), remained unchanged (Figure 2, Supplemental Digital Content, http://links.lww.com/NE/A522), or increased (Figure 3, Supplemental Digital Content, http://links.lww.com/NE/A523) over time. The mean number of strategies used per course was also calculated (Figure 4, Supplemental Digital Content, http://links.lww.com/NE/A524).
There were 3 strategies that decreased in use between 2013 and 2017. Optional editing service use decreased from a high of 50% in 2013 to 30% in 2017. Similarly, requiring an early deadline decreased from a high of 40% in 2014 to only 20% in 2017. Although topic confirmation reached to a low of 30% in 2015 and 2016, it was used in 40% of courses in 2017.
The frequency of 4 strategies remained constant or varied minimally throughout the study. Required editing service was used in 10% of courses from 2013 to 2017. Similarly, requiring a minimum number of references was constant at 20%. Although the use of peer review and specifying the number of pages was mostly unchanged, faculty in half of the courses used these strategies throughout all 5 years.
The use of 5 strategies increased over time. From the initial year, points for APA and style increased to 60% in 2014 and 2015 but reduced to 50% again in the final 2 years of the study. Multistep assignments increased from 40% to 60% as well. The steadiest increase occurred with the use of an example, rising incrementally from 10% in 2013 to 60% in 2017. Of all strategies, plagiarism detection software and rubrics were used most frequently. Rates of use increased from 60% to 80% for plagiarism detection software and from 50% to 100% for rubrics between 2013 and 2017.
Number of Strategies Used Per Course
Faculty implemented multiple strategies in each course (Figure 4, Supplemental Digital Content, http://links.lww.com/NE/A524). The mean number of strategies used per course increased between the first and second years of the study, with faculty adding an average of 1 strategy per course. There was minimal variation in the overall mean per course thereafter, with a range of 3 to 10 strategies used per course by individual faculty.
The most frequently used writing development strategies included rubrics, plagiarism detection software, multistep assignments, and examples. The literature supported many strategies for content, construction, format, plagiarism, and citation skill development. The following discussion analyzes the results in the context of the literature as well as events that occurred within the university's DNP program over the course of the study. Recommendations for use of selected strategies are also discussed.
Diehl6 suggested that some student writing deficiencies result from a lack of familiarity with nursing literature. Using the multistep assignment, faculty were able to coach students about content needs early in the semester. Multistep assignment use increased over time and was most effective when revisions were required at each step.
Another content-focused strategy, the requirement of a minimum number of references, was possibly underused because it also has the potential to lessen writing difficulties resulting from inadequate knowledge of the literature. This strategy compels students to consume the research literature because it is a mandatory component of the assignment. In 1 course that used this strategy, a midsemester table of studies was required. Students received feedback on the quantity, quality, and results reported in the studies. As a result, final papers included substantive and evidence-supported content.
In 2017, construction-related strategies used to coach students included examples, peer review, and rubrics. Rubric use increased annually and reached 100% as a result of a course enhancement project that involved partnering DNP faculty with instructional design team staff to create a consistent between-course user experience for students, implement best online teaching practices, and establish performance expectations by clarifying instructions through the use of rubrics. This project also included the development of a 10-module online writing course (developed in collaboration with a writing consultant) that included interactive video content, quizzes, and brief writing assignments to promote skill development including, among other areas, basic grammar and style, APA format, plagiarism, proposal writing, and writing for publication. Rubrics were refined annually in every course. According to Martin-Kniep,19 this is an expectation, and with each refinement, the rubric guidelines should become more closely aligned with assessment goals.
Although faculty used peer review frequently (half of the courses), Schlisselberg and Moscou's20 study indicated that the traditional process of providing written feedback to a peer could be augmented by requiring students to read the paper aloud. College students in 2 courses participated in peer review, with the first group using the traditional process and the second group additionally reading papers aloud to peer reviewers. Students in the second group reported that reading aloud was more helpful than written feedback alone.
Faculty use of editing services (optional or required) was limited. Because 1 course required editing service use, every student in the course submitted a portion of a paper for review and feedback. After the initial use, only about half of the students voluntarily used the service again. It is possible that faculty and repeat student users found that the service was valuable for basic skills remediation or English-language support. Williams and Takaku21 reported that students who spoke English as a second language performed as well or better than native English speakers on writing assignments with this type of support service.
In a qualitative study of nursing students, Tyndall and Scott10 reported that 8 of 9 participants never used APA format. Although common, this issue can be addressed with limited time and resources. In Walker and Tschanz,18 master's nursing students received 1 hour of APA format instruction. In this study, faculty allotted points in 50% of the courses to incentivize its use. The weight given to APA format varied but did not exceed 20% for any assignment. In the initial years of the program, students received printed information and referral to resources on the university library's website. In the course enhancement project described earlier, students learned APA format within the online writing course that became a mandatory part of orientation in 2016.
Plagiarism and Citation Use
Faculty discussed the occurrence of plagiarism and its prevention frequently in the early years of the study, and as a result, they used plagiarism detection software in 8 courses. Although there was a slight drop in use in 2015, this was most likely the result of a problem with software integration within the LMS. Once the software was fully compatible, the use returned to previous levels and increased.
In addition, the writing course modules developed in 2016 included 2 modules pertaining to plagiarism. The first provided the definition and identified its various manifestations in scholarly work. The other module was more practice-oriented and reviewed case examples while allowing for practice with paraphrasing.
Lynch et al's9 integrative review on plagiarism in nursing education identified 2 types. Deliberate plagiarism resulted from the pressure to perform, low motivation, heavy workload, and insufficient time. Inadvertent plagiarism occurred because students lacked the ability to track information or to correctly cite sources. Although Lynch et al9 did not find that language skills contributed to plagiarism, others suggested that limited English skills and differing practices for use of an author's exact words could play a role in inadvertent plagiarism in non–Western-educated students.22,23 For either type, the authors recommended a proactive, nonpunitive response to prevent future occurrences through education and coordination of deadlines and workload for students.
Although this study did not include faculty training, the literature suggests that this could be an important component for any university writing development program. Giddens and Lobo24 studied grading practices in 47 master's nursing students in an education course. On the same mock assignment, participants assigned grades from A (91%) to F (14%). To prevent the confusion that such inconsistencies can create for students, Singleterry et al25 suggested that faculty collaborate in developing student assessment rubrics to help achieve the consistency needed for students to develop skills and succeed academically and professionally.
In addition to the academic implications, writing is an essential component necessary for professional communication. According to Tyndall et al,26 the need for scholarly writing ability relates to the nursing scholars' socialization and identity development into the profession, and overcoming writing challenges is viewed as a rite of passage. Shirey presented a set of recommendations for building writing capacity that included many of the previously mentioned recommendations such as providing knowledge, clarifying expectations for performance, and providing feedback. However, Shirey27 further recommends efforts to reduce student fears associated with writing and advocates for promoting writing competency as a professional responsibility to contribute to the development of nursing as a discipline.
There are some limitations of this study to consider. First, there were no objective outcome measures regarding student writing. According to McLeod and Soven,28 this is a common problem with writing development program evaluation. It is difficult to distinguish writing improvements that result from structured development activities from those that result from time, writing practice, or growing knowledge of the subject matter as students advance in their studies. Therefore, the goal of this project was to evaluate the extent that faculty implemented strategies that would be expected to result in writing skill development among students. With regard to student writing outcomes, there were some DNP students who failed to achieve course learning objectives (demonstrated through writing competency) on the first attempt. When that occurred, they revised and resubmitted the paper. At times, faculty required students to submit 1 or more revisions of a paper to pass a course. Although all students who submitted revisions eventually met the expectation, at times, the burden was significant for faculty.
Another limitation was that there was no measurement of the rationale for faculty choice of or changes in the use of a particular strategy. However, this study provides 5 years of data regarding the evolution of faculty-implemented writing development strategies within courses in a DNP program. It is likely that faculty discontinued the use of strategies they perceived as ineffective or burdensome, and they likely added or continued strategies that they perceived resulted in student writing improvements. The reason that faculty fluctuated in the number of strategies used is also unknown, but with a mean of between 4 and 6 strategies used per course (range, 3-10), this could indicate that a balance point exists there between the effort required to implement the strategies and the return on investment. Although the results might not generalize to other universities or programs because of the size or design of this study, the writing difficulties identified are similar to those described in other institutions, and these results could provide useful information to drive future research.
As a result of insufficient academic preparation, many nurses are underprepared for the rigors of writing in graduate education. While university- and program-level supports are important and necessary, the efforts of faculty at the individual level are less likely to be recognized and quantified. Because faculty interact with students and assess writing development firsthand, the evolution of their teaching practices over time can be an indicator of best practices with the potential to improve student writing outcomes. The results indicate that content, construction, and plagiarism were among the highest priority concerns of faculty in this study. Future research should explore ways to effectively and objectively measure writing skill development among students and the burden that writing support places on graduate faculty who must balance the need to achieve learning competencies for the content of the graduate program above and beyond writing skill development.
2. Dols JD, Hernandez C, Miles H. The DNP
project: quandaries for nursing scholars. Nurs Outlook
3. Cone PH, Van Dover L. Shaping how graduate nursing students write. Nurs Educ Perspect
4. Pintz C, Posey L. Preparing students for graduate study: an eLearning approach. Nurse Educ Today
5. American Psychological Association. Publication Manual of the American Psychological Association
. 6th ed. Washington, DC: American Psychological Association; 2009.
6. Diehl S. Developing students' writing
skills: an early intervention approach. Nurse Educ
7. Falk NL, Phillips KM, Hymer R, Acquaviva KD, Schumann MJ. Using a student-faculty collaborative learning model to teach grant development in graduate nursing education
. J Contin Educ Nurs
8. Heinrich KT, Neese R, Rogers D, Facente AC. Turn accusations into affirmations: transform nurses into published authors. Nurs Educ Perspect
9. Lynch J, Everett B, Ramjan LM, Callins R, Glew P, Salamonson Y. Plagiarism in nursing education: an integrative review. J Clin Nurs
10. Tyndall DE, Scott ES. Writing
development in associate degree in nursing-to-baccalaureate degree in nursing students: moving out of the comfort zone. J Nurs Educ
11. Tyre P. The writing
revolution. The Atlantic
12. Troia G, Graham S. Common core writing
and language standards and aligned state assessments: a national survey of teacher beliefs and attitudes. Read Writ
13. Gazza EA, Shellenbarger T, Hunker DF. Developing as a scholarly writer: the experience of students enrolled in a PhD in nursing program in the United States. Nurse Educ Today
14. Krishnamurthy M, Wood F. Promoting effective searches and use of information by DNP
students: getting the write start. Nurse Educ
15. Mackin LA, Macera E, Jennings D. Lessons learned from a mentored graduate program in gerontological nursing. J Prof Nurs
16. Roberts ST, Goss G. Use of an online writing
tutorial to improve writing
skills in nursing courses. Nurse Educ
17. Salani D, Albuja LD, Azaiza K. The keys to success in doctoral studies: a preimmersion course. J Prof Nurs
18. Walker M, Tschanz C. Stories are like water: an academic writing
workshop for nurses. Creat Nurs
20. Schlisselberg G, Moscou S. Peer review as an educational strategy to improve academic work: an interdisciplinary collaboration between communication disorders and nursing. Work
21. Williams J, Takaku S. Help seeking, self-efficacy, and writing
performance among college students. J Writ Res
22. Knowlton M, Collins SB. Foreign-educated graduate nursing students and plagiarism. J Nurs Educ
23. Pennycook A. Borrowing others' words: text, ownership, memory, and plagiarism. TESOL Quarterly
24. Giddens J, Lobo M. Analyzing graduate student trends in written paper evaluation. J Nurs Educ
25. Singleterry L, Kalkman B, Chrenka L, Courtright-Nash D. Nursing faculty development: building a common grading rubric to evaluate writing
. Nurse Educ
26. Tyndall DE, Flinchbaugh KB, Caswell NI, Scott ES. Threshold concepts in doctoral education: a framework for writing
development in novice nurse scientists. Nurse Educ
27. Shirey MR. Building scholarly writing
capacity in the doctor of nursing practice
program. J Prof Nurs