An evaluation of staff experiences of the Royal Literary Fund writer-in-residence service to support improvements in written communication in healthcare

Abstract

Written communication is essential to staff and patient experience in healthcare. The Royal Literary Fund has hosted a writing fellow in an NHS Trust since 2018 providing professional writing training. The aim of this evaluation was to explore the experiences of staff using the service. Semi-structured interviews were conducted with 21 staff members from a range of professions who had accessed the service. Data were analysed using thematic analysis. Findings: The writing service was highly valued. Three themes emerged: feelings about writing at work, reported benefits of attending sessions, and perceived barriers to accessing them. Staff felt underskilled in professional writing and described the wish to write more succinctly and reflectively. Self-reported confidence increased after sessions. Stigma around writing skills prevented some staff from recommending the service. Wider adoption of professional writing skills training through the NHS could have benefits in terms of increasing self-perceived skills and confidence.

Introduction

The Royal Literary Fund (RLF) was established as a benevolent charity in 1790. Its Royal Charter requires it to support writers and provide public education. It has had a presence in United Kingdom (UK) universities for over twenty years, providing support for academic writing. More recently, it has expanded into the social sector. Today, it facilitates “workplace writing development and community-based workshops. The participants for these workshops are staff in work settings such as the NHS [National Health Service], Unions and voluntary and community sector organisations” (Young, 2022, p.1). Writers working for the RLF have varied backgrounds as authors, script writers, and journalists. They facilitate workplace discussions identifying the writing needs of individuals and the communication challenges experienced by staff, aiming to “increase confidence and support improvements in the quality and effectiveness of workplace/professional writing” (Young, 2022, p.1).

The RLF has provided a writing fellow at an acute London hospital for two days per week since 2018. This model is currently a unique arrangement in the NHS. Approximately 15 other hospitals in the UK have received ad hoc writing support from the RLF, including support with writing case studies, preparing funding applications, and drafting responses to complaints. The writing fellow service at the acute hospital is available to all levels of staff, clinical and non-clinical and has been accessed to date by over 1000 employees. A range of workshops and customized sessions, provided for groups and individuals, cover subjects such as boosting confidence and writing “tips and tricks.” Reflective writing sessions are also available and were particularly beneficial during the pandemic, enabling staff to write their “Covid story.” All sessions are advertised through staffwide email alerts, and staff contact the writing fellow directly to attend or arrange a session. Attendance is confidential and managers are not informed if their staff participate. The Staff Psychology and Welfare Service also advertises and recommends the reflective writing sessions. Sessions were initially held face-to-face, but have remained online since the start of the pandemic. Each writing fellow placement is for two years. The third placement was appointed in the autumn of 2022; on this occasion, two fellows with complementary backgrounds were assigned to work one day per week each at the hospital.

Literature review

Writing provides a way to form our thoughts and ideas into messages that others can understand and act on (Miller et al., 2018; Mitchell, 2018). Clinical documentation is at the center of care (Rosenbloom et al., 2011) and has been described as occupying a pivotal position in patients’ care. Writing synthesizes knowledge, data, and opinion which may be used by various readers for a range of purposes (Rosenbloom et al., 2011). Other written formats – operational policies, reports, email correspondence – constitute a large part of the work in both patient-facing and nonclinical roles, and the ability to write well has been identified as a key tool for staff (Addison et al., 2015).

However, clinical writing by nurses and doctors, both qualified and in training, suggest there is room for improvement (Okaisu et al., 2014; Sondergaard et al., 2017; Tower, 2012). Nursing documentation has sometimes been described as random and inconsistent (Sondergaard et al., 2017), and medical notes can present information in a disorganised way, which can be irritating for the reader and cause potential clinical risks (Belden et al., 2017). Gaps in the quality of written communication can adversely impact patients (Hanson et al., 2012), leading to missed and delayed interventions, inadequate discharge information, and substandard patient education (Tower, 2012).

Multiple factors can impact the effectiveness of clinical writing. It may be written for multiple audiences, including clinical and non-clinical staff as well as patients, who have varying literacy needs. This includes patients’ understanding their own condition, planning care, collating data for financial reimbursement, and answering complaints. Yet producing documentation often happens in a busy, time-pressured environment with frequent interruptions. These factors can increase the cognitive load on the writer and reduce the quality of output (Jamieson et al., 2017). The short amount of time professionals spend reading clinical letters emphasizes the importance of clear headings, conciseness, and good sentence structure to reduce the risk of missing important information (Addison et al., 2015).

The characteristics of good writing have been described as including clarity, brevity, comprehensible syntax, completeness, and telling a continuous story (Hanson et al., 2012). Proposals to address poor clinical writing often focus on providing electronic checklists and structured letter formats, aiming to design out error. However, the importance of achieving a balance between structure and narrative is highlighted in the literature (Addison et al., 2015; Belden et al., 2017). Jamieson et al. (2017) demonstrated the continued importance of free text and found clinicians wrote more using electronic health records (EHR) than on paper notes. Rosenbloom et al. (2011) described how structure was highly valued when it was paired with complementary narrative-style entries in the free-text section, allowing complex, uncertain, and unique aspects of a case to be conveyed through nuanced writing.

Several studies reflect on the importance of writing as an iterative process during which thoughts are synthesised (Arail et al., 2013; Jamieson et al., 2017). Other studies, comparing clinical documentation to essay writing, have noted that while both are iterative processes, the busy work environment precludes valuable prethinking. Typing facilitated by EHR allows more postthinking and re-writing by the clinician with the potential for higher quality prose (Jamieson et al., 2016). Broad benefits have been found by improving clinical staff’s writing skills. Individualised writing tuition during university-based training increased critical thinking, reflection, and empathy in the clinical setting (Arail et al., 2013).

Despite recognition of what constitutes good writing in healthcare settings, its broad benefits to care and the existing barriers to writing well in a busy setting, there is no universal approach to improving written communication. While some interventions have reported positive outcomes (Arail et al., 2013), there is limited evidence to support the effectiveness of existing interventions across the range of writing required by clinical and non-clinical staff (Dehgan et al., 2013; Jeffries et al., 2012; Okaisu et al., 2014; Miller et al., 2018).

Aim

The aim of this project was to evaluate the RLF writing fellow post based within an NHS acute hospital. The RLF invests significant funds into these roles, so we wanted to show the benefit, providing them evidence for increasing the number of hospitals they provide this service to.

Materials and Methods

Study design

This was a service evaluation study using qualitative methods. A qualitative design was chosen because there had not been any previous evaluation of the service, and this would be a way of exploring the experiences of using the service in more depth.

Sample and setting

Purposive sampling was used to capture experiences of staff who had attended sessions with the current and previous writing fellow. Staff who had used the writing fellow service were initially contacted by the writing fellow who provided information about the study and contact details for the intern who was conducting the evaluation. This was to ensure anonymity of staff using the writing service and for those taking part in the evaluation. Further targeted emails were sent to staff representing underrepresented key characteristics, e.g., levels of seniority and gender.

Twenty-one members of staff participated in interviews between February and April 2022. Interviewees came from a range of professions including nursing, radiography, medicine, midwifery, core services, and physiotherapy. Participants were ethnically diverse, representing nine ethnic categories. One-third of the participants spoke English as a second language. All were educated to at least first-degree level, and seventeen had a higher degree.

The Health Research Authority (HRA) has the Research Ethics Service as one of its core functions, and they determined the project was exempt from the need to obtain approval from an NHS Research Ethics Committee (HRA, 2021). However, the evaluation was conducted in accordance with the UK Framework for Health and Social Care Research (HRA, 2017).

Data collection

Interviews were conducted digitally via Microsoft Teams at a time and setting convenient to participants. All interviews were undertaken by one researcher, and verbal consent was recorded electronically at the start of the interview. The semi-structured interview questions were informed by a scoping literature search and included key issues identified in discussion with the RLF Outreach Manager and writing fellow. Interviews were recorded and transcribed verbatim using AI software (Otter.ai) and checked for accuracy. The Teams recordings were then deleted.

Data analysis

One researcher undertook framework analysis to identify emerging themes and key concepts in a five-step approach (Richie & Spencer, 1994). After familiarising with the transcripts, the data were coded using a “in vivo” method which coded participants’ words directly, “values” coding which coded participant attitudes and perceptions of the writing service, and “descriptive” codes which aligned with participants’ writing activities (Skjott Linneberg & Korsgaard, 2019). The recurrence and alignment of codes enabled recognition of pertinent themes; irrelevant codes outside this formation were omitted.

The framework (index) was developed inductively based on the interview schedule. This index was organized according to overarching themes and subthemes and developed in line with new emerging information; i.e., additional themes and subthemes were added, and previous transcripts were re-reviewed to ensure the new themes had not been missed. Each theme in the framework formed a new worksheet, and the subtheme(s) became the column headings.

The third stage—charting—involved entering the information from the transcripts into the relevant cells in an Excel file; each row represented a participant. The index/framework had many themes and subthemes, and, therefore, these were mapped to examine where there was convergence and divergence which, in turn, enabled the development of key themes. The text in each of the columns reflected the subtheme heading, using the original text from the transcript. This mapping underpinned the collective narrative, and key quotes were used to support all themes. Transparency with framework analysis ensured there was rigor in the analysis. The transcripts were reviewed by two other researchers against the framework to check that there was no over-interpretation of data and that the themes accurately reflected the content.

Findings

We identified three themes: writing at the heart of healthcare, the perceived value of the writing fellow and barriers to accessing the service. Each theme is discussed below with supporting quotes.

Writing at the heart of healthcare

Participants acknowledged that writing formed a large part of their day-to-day activities, whether as clinical documentation, composing emails, or report writing. They shared a strong sense that their professional role required them to write well, and much depended on what they wrote. For their writing to be effective and have an impact, participants believed that both skill and confidence were required on the part of the writer, and participants felt that these attributes were often lacking in day-to-day writing. They identified this skill deficit in themselves and in colleagues, for example:

You know, in cancer, we have, you know, advanced communication skills training and, and all these things which is about verbal communication and nonverbal communication. But we don’t really have any training about how to write a clinic letter or how to write an email or how to write a, you know, even patient information. You don’t ever get any training [on] how to write that. So I think, you know, it’s that importance in the NHS, isn’t there, even though we use writing all the time.

Good writing was crucial for accurate documentation and safe-care provision. Staff reflected on the importance of individual word choices when summarizing a consultation with a patient, as well as the benefits of well-written correspondence for time-poor, multidisciplinary colleagues collaborating on a case or receiving a referral;

The worst thing is that both of you can’t understand each other when it comes to clinical matters. It’s really important that information is distilled, you know…. I find people write reams and reams of stuff. And you’re just trying to get to the crux of it…. You’re just trying to get to the nitty gritty of what was he actually doing for this patient. I can only imagine a patient reading this thing. They will get lost in it.

However, one participant commented on the fact that clinicians often saw the same patient repeatedly at intervals of several months and needed to be able to understand the notes they had written themselves at an earlier visit to ensure continuity of care at future visits.

Writing was also recognized as being important for staff experience, having the potential to positively or negatively impact teamwork and staff satisfaction. For example, participants referenced the tone of emails as a frequent concern. The majority had been offended by an email, while some had received feedback that they had inadvertently offended others through email communication. Staff acknowledged they needed to be careful with their writing, reflect on what they had written, and be as sure as possible that what they meant to say was going to be understood by the reader. Participants felt these were skills that could be taught and sharpened: “Emails can be misconstrued as well, you know, you can come across as being, you know, aggressive or rude or unhelpful? So you really have to stop and think about what you’re writing in your email.”

Perceived value of the writing fellow

Staff reported having a positive reaction on first hearing about the writing service. Some were slightly hesitant, as it was a new service; they were not sure what the sessions would involve. Others expressed a sense of amazement that this was available in the NHS and were excited at the possibility of being able to address an unmet need.

Participants described gaining practical techniques from the sessions that they could keep with them and continue to use. They felt these made a real difference to their writing and felt increasingly skilled in areas such as succinctness and conveying meaning unambiguously. An improved feeling of confidence meant they were able to write more quickly and, hence, more efficiently. Whether producing clinical or managerial written communication, they felt the writing fellow sessions made a tangible difference, and they could see a change in their writing:

It helped me to see that…. Look, it’s not enough to be in your head. It needs to be clear on the paper…. The most important thing [is] that what I want to say is actually being said, and it is said in a way that is understood by the reader.

With increased skill and confidence, staff felt able to do their job better. This was particularly important for recently promoted staff who noted that promotion usually came with a requirement to write at a higher standard or to perform new kinds of writing for which there was rarely any training. And staff who had initially struggled with writing at a higher level benefitted from sessions with the writing fellow; they felt more confident and able to achieve in their new roles.

Importantly, the writing fellow support was beneficial for staff who did not have English as their first language. Several participants commented that improving their writing skills had also improved their confidence in speaking at work, and increased confidence was reported by native and non-native English speakers:

But when you get to a certain level, people expect your writing to be reaching a particular level of proficiency. So, if I compare myself with a native speaker at a similar level as my role currently is, what I would say that I feel my English writing is really not up to the level I want it to be.

Participants reported the sessions were conducted in a non-judgemental, supportive way, creating what felt like a safe space. The fellow was a lay person, from outside the organization, and this, combined with the fact that staff could self-refer to the service without requesting permission from a manager, meant the sessions were felt to be a safe space. The writing fellow was also outside the NHS hierarchy, and this seemed to be especially beneficial to nurses and allied health professionals who felt that the fellow had a neutral, objective view of them and encouraged them to think of themselves as having as much right and ability to publish or write a clinic letter as the medical staff:

I guess we just we never think when we’re nursing, we’re going to publish. And I think that he [RLF fellow] was very pro nurses publishing, or even a receptionist publishing if they have something interesting to say. He wanted anyone’s expertise to be out there.

This combination of new skills, increasing confidence and a supportive atmosphere, led to staff members feeling that writing well could take them a long way and could enable them to break through some traditional barriers. They found writing empowering and an equalizing force that had the potential to enable a wider range of voices to be heard, as one participant put it:

But I think having [RLF fellow] there as well also really emphasises the fact of nurses that, well, and all healthcare professionals, that the NHS, and specifically your employer, does value your writing skills, and it values the fact that you should be saying, well, actually, I could publish my work. And there’s someone here that can help you to do that. So, I think it’s good from the trust side to be able to showcase that. Because otherwise, how do you know how to do that? Like, how would you know how to write an article for publication? No one tells you that in your day-to-day job.

Motivators and barriers to accessing the service

Staff accessed the service for a variety of reasons. Some were motivated by well-being, attending reflective writing sessions which were ran in collaboration with the Trust’s staff psychology department. Others were primarily interested in support for academic writing while attending a course or preparing an article for publication. Some participants described themselves as very open minded and willing to try something new.

A small number reported being told to improve their writing skills by their manager. This group was grateful to be able to access the writing fellow service and have a way to improve their performance, having found conversations about writing abilities distressing. After attending sessions, they reported feeling more able to achieve in their roles.

The most common motivator for accessing the service, however, was a general desire to be a better, more effective writer. Participants identified deficiency in their writing ability which they wanted to improve and were pleased to have the opportunity to do so: “If we could actually say, ‘Well, I really struggle with this, but I’m embarrassed to tell you. I don’t know when to do this. I don’t know when to do that.’ Right?”

In terms of barriers, participants identified factors which had either caused them to hesitate before using the service or that might deter others. The most frequently mentioned of these was lack of time. Clinical services were under a great deal of pressure, i.e., high volume of patients and shortages of staff, and it was hard to release frontline staff, especially for non-mandatory training. Staff felt that those whose roles gave them more autonomy over their time would find it easier to attend. They also felt that the service was not promoted enough within the Trust. Staff were concerned that frontline colleagues, especially those on lower grades, could potentially miss out on email publicity, as they spent less time at a computer.

Staff also reported that because it was a novel service, they had not understood what it would entail and what it could offer them. They felt this could be explained more clearly in publicity material. Some staff thought it was aimed at the functional literacy level, while others assumed it was for high achievers writing for publication, as one person reported: “The main issue is with staffing and having that protected time to work on, you know, skills like writing which we don’t, unfortunately, have at the moment.”

Furthermore, there was a sense of shame and stigma about asking for help with writing. While many participants saw improving their writing skills as a positive development opportunity, some who had enjoyed the sessions themselves had not recommended them to others because they worried that their colleagues might feel insulted by a suggestion that they could benefit from improving their writing skills:

I mean, any suggestion that someone needs development could feel embarrassing. Someone might think that they know. So it’s.... I think it’s probably how you have that conversation with kindness and in a supportive way rather than a critical way.

Participants suggested ways to potentially overcome these barriers, placing the responsibility on senior managers who they felt should understand the value of the writing classes and the need to improve staff writing. Some participants suggested that encouragement from senior management should be cascaded through their teams, making use of pre-existing forums such as regular team meetings and clinical governance sessions. The service could also be made available on the internal Learning Portal so that staff could find it there and be guided on how to contact the fellow. Participants felt that appraisals were an appropriate forum to raise the wish to improve writing skills and that they could form part of personal development plans; however, no interviewees had so far done this, and it did not seem to be current practice: “I think definitely making more managers aware. So they put it in people’s, you know, discuss it in appraisals and their PDPs [personal development plans]. I think that’s really good to do.”

Discussion

Our evaluation shows that staff welcomed the unusual opportunity provided by the RLF writing fellow to improve their writing skills. They felt writing was an essential, but undervalued, skill for healthcare staff. Much depended on clinical and non-clinical written communication, but staff believed they lacked skills for effective and impactful writing. This could have a detrimental effect on teamwork, quality of care, and the ability to succeed in a role. Sessions with the fellow were felt to improve skills and increase confidence, which led to an improved sense of efficiency in the delivery of care and broadened career options. These wider personal and professional benefits suggest that the innovative service addressed significant unmet needs.

Our study employed methods inquiring about staff experiences of writing in the workplace and in taking a broad approach to writing which included clinical, professional, and academic formats. This contrasts with studies where writing support focused specifically on academic work or on improving clinical documentation (Ariail et al., 2013; Belden et al., 2017). In addition, the RLF sessions took an approach that was both individualized and applicable across all areas of writing, enabling staff to access the level of support they needed and then make use of new techniques whenever their respective roles required writing.

However, the principal qualities of good writing described by other authors are the same as those promoted by the RLF and identified by participants throughout this study (Hanson et al., 2012, Rosenbloom et al., 2011). Staff understood that they and their colleagues often lacked these qualities and were inadequately equipped to perform the range of writing required for optimum care provision and organizational effectiveness. They felt strongly about the current standard of written communication at work and were frustrated that the subject remained hidden in plain sight and was rarely mentioned or addressed. The writing fellow service itself was felt to have a low profile among staff, having been introduced by a small research department, rather than as part of a centralized training program. Professional writing skills can, thus, be seen as having marginal status and may be omitted from training even when the activity requires them (Healy & Drayton, 2021).

This study suggests that NHS managers should be aware of the value of training staff to write well. Professional writing skills should be recognized as an essential competency and incorporated into professional development, with healthcare identified as a writing-intensive profession (Henry & Austin, 2021). For example, scholarship describes the centrality of clinical documentation to care (Jamieson et al., 2017; Rosenbloom et al., 2011), and Hanson et al. (2012) described writing as a “primary tool” in clinical areas. Indeed, the importance placed by staff on non-clinical writing was a significant finding in this study and was not widely noted in the literature.

This study also suggests that provision of writing skills training has an important part to play in improving areas as diverse as rates of incident reporting, patient information, and well-constructed job advertisements, as well as potentially having a beneficial effect on satisfactory conclusion to patient complaints and preparation of court documents. While this evaluation supports findings by Hanson et al. (2012) that well-written clinical documentation is important, it also recognises the broader and deeper benefits that may result from targeted writing skills training. This may be because of the mix of roles held by interview subjects and the relatively high professional status of interviewees. It is possible that lower grade clinical staff would be less exposed to non-clinical writing such as reports and business cases, and further research into the views of this group would be helpful.

In addition to allowing a broad discussion of writing at work, our use of a qualitative approach allowed staff to describe their experiences of written communication and the importance to safe delivery of healthcare. This study is unusual in giving an insight into how poor writing and poor writers are viewed by colleagues—with exasperation or derision— while good writers were sought out and appreciated. This day-to-day awareness of the impact of writing is not generally captured in the literature; neither is the negative personal impact of being an unconfident writer at work, even by those in high status roles and professions. In comparison, the strength and enjoyment staff found through the writing fellow sessions at both personal and professional levels was powerfully expressed. Of particular interest is the finding that nurses and allied health professionals felt writing helped provide them with a sense of equality with medical colleagues in terms of academic output and clinical documentation.

Writing support can also play a role in equalizing opportunity for staff who have English as an additional language. By increasing the confidence and skill set of this group, it can facilitate promotion to higher professional levels where expectations of written English are greater. This reflects the increasing importance placed by the NHS on equality and diversity as well as enabling organizations to retain and develop their staff. It should be noted that native English speaking medical staff, who might be thought least likely to need training on written communication, were also among the groups identified in this study lacking confidence and appreciate the ability to learn from an expert.

Increased confidence in writing because of RLF sessions raised staff satisfaction across professions. Some interviewees described it as setting their organisation apart and being a reason to choose to work there. In the current period of large-scale vacancies and burnout among healthcare staff, services that boost morale and make staff feel empowered have a high value and should be extended.

Ariail et al. (2013) described the excitement that students felt due to expert, individualized writing training in a university setting and found that better writing could translate to increased critical thinking skills, with more reflective and empathic practice. Similarly, the RLF writing fellow model was also valued for its individualized approach, and staff were surprised to find such a service in a workplace setting, reflecting the lack of attention currently paid to professional writing.

The general benefits of the RLF teaching led to staff reporting their confidence and skills increasing in areas other than those for which they had originally sought help. Some described the sessions as having an almost alchemical effect which was hard to define, but is perhaps the result of being taught by an expert. Further research is needed to determine whether this type of tuition can be applied to large enough numbers of staff to affect an organizational change and to consider whether different styles suit different learners and needs.

Absence of discussion around writing skills at work contributes to a continued sense of shame felt by some staff when admitting they want help with writing, and consequently participants particularly valued the confidential, lay nature of the writing fellow. A more open acknowledgement of the current state of professional writing, coupled with recognition of the deep and broad benefits of improvements, could lead to a removal of stigma and increased willingness of staff at all levels to self-identify a learning need in this area. Bringing writing training into the fold of professional development could increase access to and raise awareness about the subject, while staff who were early adopters of the service could volunteer to discuss its benefits with more hesitant colleagues.

Limitations

This evaluation had several limitations. While we were able to explore the subjective perceptions of staff who had used the service, we were not able to objectively measure if writing skills had improved after using the service. This could be something that could be explored in future evaluations. In addition, all those who participated in the evaluation were educated to degree level or above and reported that their roles had a degree of autonomy. While it is interesting that those educated to this level still expressed anxieties and valued support, more work is required to see if the writing service is helpful for those with lower levels of education. Despite these limitations, this is the first evaluation of the writing support model provided by the RLF to the NHS.

Conclusions

This qualitative evaluation indicated that professional writing support brought a wide range of benefits to staff and the hospital and that there was value to investing in it. Within the clinical sphere, these may include improvements to documentation, inter-staff communication and incident reporting. Accompanying these benefits, and important for staff satisfaction, are increased opportunities for career development, research, and effective service improvement. Wider application of the RLF writing fellow model may be limited by under-appreciation of its benefits at management level. However, written communication is at the heart of healthcare, and facilitating professional writing skills can be seen as an important part of improving healthcare delivery.

While we have shown the value to staff of having a writing support service, we have not documented the full consequences of poor written communication or explored how, or if, this RLF writer-in-residence service equates with improvements in patient care. Through this evaluation, we have discovered an important, but under-researched, aspect in the delivery of care. Clear written communication is of paramount importance, but staff lack confidence and often do not feel educated enough to fulfill this aspect of their role. The significance of carers’ written communication and the relevance of quality and clarity in their output should be sensitively and prominently highlighted in professional training pathways so writing can be identified and supported as a key quality characteristic within healthcare.

Implications for practice

Based on the findings of this evaluation we make the following recommendations: i) professional writing should be recognised as an essential skill for all healthcare staff and should be included in mandatory training, ii) writing skills training should be included in existing professional development courses for specific aspects of writing, e.g., incident reporting and taking minutes, and iii) stigma around writing skills should be reduced by normalizing training as part of professional development and included in appraisal discussions.

Funding Statement

Funding: This evaluation was conducted as part of a Chief Nurse Research Internship funded through UCLH Charity. Rachel Taylor is funded through UCLH Charity, and the National Institute for Health and Care Research (NIHR), and Carolyn Spring is funded through UCLH Charity. The views expressed in this article are those of the author and not necessarily those of UCLH Charity, the NIHR, or the Department of Health and Social Care.