How to write about quality and safety and get published

1. How to write about quality and safety and get published Mary Dixon-Woods Department of Health Sciences University of Leicester

2. Decide on your story • What is the story you want to tell? • Write the abstract first – but keep writing it over and over and over • Can you explain the story clearly? • Imagine you are being interviewed on live TV What’s your story?

3. Where is the best place to tell your story? • Medical/health journals • Good for exposure • Helpful for healthcare professional careers • Often short word limits, can be a bit frustrating for some kinds of papers • Decide between specialist/generalist journals

4. Specialist/generalist health journals • Big, high impact journals (NEJM, Lancet, JAMA etc) • Speciality-specific journals (e.g. Pediatrics, Anaesthesia, Journal of Advanced Nursing, Journal of Clinical Pharmacy and Therapeutics) • Quality and safety journals (e.g. BMJQS, Implementation Science, Joint Commission Journal on Quality and Safety...)

5. Where is the best place to tell your story? • Social science journals • Good for credibility • Can be intellectually satisfying if you are a social scientist • Very demanding to write, long word limits • Needs theoretical sophistication • May be more limited in impact

6. Choosing a journal • High impact/high status? • Indexed on right databases? • Going to reach your audience? • Right requirements in terms of your story? • Reasonable time to decision and publication?

7. Be aware of your audience • If medical/health audience make sure there is a key set of practical messages • If social science audience need to demonstrate mastery of theory • If in doubt, explain concepts • Always prioritise clarity

8. Fit the structure to the study type • IMRaD is the basic structure for most health journals • Guidelines cover many study types (e.g. CONSORT for clinical trials) http://www.consort-statement.org/ • http://squire-statement.org/ for quality improvement reports

9. Don’t forget the abstract • Often given little time or effort by authors • But the busy editor is using it to screen likely candidates • It also sets the tone for the busy referee • And it may be the only bit of your paper that’s publicly, freely accessible • So work hard on it!

10. Structuring a paper: introduction • Intrigue the reader. Set up a problem you are going to solve. • Don’t go on too long – get to the point quickly. And don’t give a standard, boring introduction that everyone has read before. • Give us • Something general about the importance of the overall topic area. • Introduction of the particular content or problem being addressed by this particular paper • Statement of precisely the purpose or research question for the paper.

11. Introduction: Making the story work • Don’t just summarise previous literature • Get hold of your voice and make that literature work for your story • There is no point in even mentioning literature unless it contributes directly to your story

12. Structuring a paper: Methods and Results • Methods • Clear, explicit, honest and accurate account. • If you use technical terms, make sure you understand them and only cite literature you have read and understood. • Results • Use subheadings, tables, boxes as appropriate • Be coherent and concise • Generally don’t offer commentary at this stage in health journals

13. Structuring a paper: Discussion • Begin with a summary, highlighting the issues you want to draw out • Acknowledge limitations • Come to a conclusion, indicate policy or practice implications and directions for future research

14. Get the writing right • Good writing and good thinking are inseparable. • Spelling, grammar, punctuation, and sentence construction all really matter. Getting them wrong damages your credibility. • Avoid over-long, complex sentences. Avoid run-on sentences. Avoid using “however” unless you are absolutely sure you know what you’re doing. .{; &?“@!:“,}? ,]

15. Writing right • Use plenty of sign-posting, but try to do it in a light-handed way. Use plenty of sub-headings, even if you end up deleting a lot of them later. • Every para should contain a single idea, and transition seamlessly to the next. • Make points once. Don’t keep repeating them. WritingRight

16. Structure, structure, structure • Organising your material into a coherent narrative is the biggest challenge • Be ruthless – cut, cut, cut • Only include stuff that works for your story • Maintain a voice that is consistent throughout.

17. Be prepared to change and change again • May start off writing something but it mutates into something else • Constant redrafting • Keep coming back to abstract • Try getting story down to bullet points

18. Working in a team • Fraught with challenges • Decide on provisional authorship up front, but be prepared to revise • Different models • Strong leader • Federal (section-based)

19. Working in a team • Make sure everyone sees and agrees final version • And agrees with any revisions subsequently • Agree things like statement of contributorship

20. Authorship and contributorship • International Committee of Medical Journal Editors (ICMJE) http://www.icmje.org/ • Good idea to describe every author’s contribution, even if not required by the journal

21. Preparing a submission • Make sure you address journal-specific requirements • References in correct system • Comply with any journal requirements • Delete hangovers from previous submissions • Make sure you get acknowledgements right • Keep a note of when you submitted it; ok to start hassling editorial assistant after about 3 months – but do it nicely

22. Be prepared for harsh words and rejection • Major medical journals reject ~95% of submissions • Sometimes within hours of receipt • Major social science journals reject about 80% and up • Only appeal if you really are sure of your grounds • Most articles are rejected three or four times before getting published somewhere Rejected

23. Referees’ reports • May seem very hurtful, esp first few times • Try to move beyond emotional reaction • Sometimes seem incompetent or perfunctory • Often very helpful • Sometimes (often?) the reports contradict each other

24. Responding to referees’ reports • Amend your paper to address the points raised, as appropriate • Don’t feel you have to do everything they suggest • Give a point-by-point explanation – helpful if you number this. Indicate if there’s anything you would give way on. • Be respectful – make displays of deference

25. Next stages • If rejected, think about where to go next • If accepted, be very cooperative with copy-editing and proofing • Check re putting a pdf into your institutional archive • Put publication details on your website etc • Check if press office (either journal or your institution) would be interested

26. Things that go wrong • Team fights over where to send paper • Team cannot agree draft of paper • Team cannot agree order of authorship • You have a renegade on the team • Someone wins a point but then it gets rejected because referee supports other position

27. Plotting an academic paper

28. The 7 step programme • Problem • Desire • Opponent • Plan • Battle • Knowledge • New level

29. 1.Problem • Show that there is some issue that really needs tackling • Introduce it in an attention-grabbing way if you can • Make it an interesting problem • Show how it’s obstructing the achievement of important goals • Link it to a policy or practice objective • Show how it affects people’s lives

30. 2.Desire • Your desire is to put the problem right • Formulate your desire as a clear research question • At the early stages of a paper you may be working up towards posing this question • So use your literature strategically

31. A good research question • Is clearly stated • Is well defined (and will have defined its terms in the lead-in phase) • Is oriented to solving an empirical or theoretical trouble

32. 3.Opponent • The thing that is standing in your way of resolving the problem is (usually) that other research has failed • There is a gap in the literature • And you’re the one to fill it – you’re the (wo)man with the plan

33. Using the literature • Everything you do has to work to establish the problem, desire and opponent • DO NOT simply list studies and what they say • this is very boring and doesn’t help you build your argument • DO NOT start sentences with the name of the author • e.g. “Woodrow et al state that most patients avoid taking tablets that are difficult to swallow.”

34. Marshall the literature effectively • Identify ways in which the literature can be organised • Generate your own labels for these if needed • Use devices such as numbering • Four major approaches to explaining non-compliance with infection control can be distinguished. • One dominant way of understanding non-compliance is to examine behaviours. In this article, we propose an emphasis on values instead.

35. 4.Plan • State your aims clearly at the end of the Introduction, having convinced us there’s really a problem • Now outline your plan • This should be a good plan that is well suited to addressing the problem

36. 5.Battle • The battle is your efforts to implement your plan • It won’t always go perfectly • So show how well what actually happened matched your plan • Report response rate and the characteristics of who ended up in the study • Tell us anything that might be relevant to understanding plan implementation

37. 6.Knowledge • This is your results • Present them authoritatively and clearly, in a logical sequence – build a plot and keep us interested • Put things in tables if needs be, but then don’t repeat the material again the text. And don’t say “Table 1 reports…”

38. 7. New level • This is your Discussion • Start by restating your main findings • Reflect on the new level you’ve reached as result of your plan and battle to address the problem • Link to what is already known • Acknowledge the limitations • Tell us about the implications (what needs to be different now?) • Say what more needs to be done to sort the problem

39. The authorial voice • This needs to be constantly present • But not clumsy – you need to be confident and in control of the material, steering us towards your argument • Be assertive, be in charge, make us think you’re worth listening to • Use devices such as explaining what your argument is at the beginning • “we will argue that non-compliance is best understood as a problem of legitimacy, rather than one of unprincipled cognitive lapse”

40. Other plot devices • Use a short, authorial interjection from time to time • “All three of these approaches are deficient in the way they conceptualise non-compliance” • “Soandso’s (1993) approach offers perhaps the most thoroughly informed critique of the ‘cognitive lapses’ tradition”. • “Soandso’s proposal does little to address the problem that ‘cognitive lapses’ explain only a small proportion of non-compliance.”

41. Sleights of hand • When you need to acknowledge that there are lots of ways of thinking about something, but don’t want to go into them all • “Among the many approaches to conceptualising non-compliance, those that address professionals’ values are most persuasive.” • “Non-compliance escapes straightforward definition. For purposes of this study, we will adopt that used by Soandso, in her influential analysis.”

42. The signs of an amateur • Saying “in 1993, Soandso said that..” • Using ‘dollops’ of literature • Claiming the work is much more important/significant/original than it really is • Describing, not conceptualising • Being too passive

43. Questions?