The composing processes of nursing students in writing nurses' notes

In this exploratory research, a microethnographic approach was used to investigate how nursing students learn to write nurses' notes. The research focused on the perceptions and behaviors of first-year nursing students as they learned to write nurses' notes in the classroom, campus lab, and hospital. Aspects of the environment were identified that facilitated or hindered the process of learning to write nurses' notes. Adoption of a mental organizing framework by the students appeared to facilitate the composing process. The use of a standard flow sheet appeared to hinder the writing-to-learn and writing-to-remember aspects of the composition of nurses' notes. Students were aware of a hostile audience for their nurses' notes--a court of law. The study provides important information on the assessment and decision-making processes that students use in learning to write nurses' notes, as well as the various environmental influences that must be considered in on-the-job writing. Findings suggest that nurses and educators should consider how to restructure the learning environment to facilitate composition of effective nurses' notes.