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Evid Based Nurs 10:100-103 doi:10.1136/ebn.10.4.100
  • EBN notebook

How to write a commentary—an editor’s perspective

  1. Andrew Jull, RN, MA
  1. Co-Editor, Evidence-Based Nursing
 Clinical Trials Research Unit, University of Auckland
 Auckland, New Zealand

      Ever been trapped in the reader’s equivalent of Groundhog Day, stuck reading the same paragraph over and over? Some research papers can tie up the reader for unnecessary periods of time. Synoptic sources, such as Evidence-Based Nursing, reduce the effort needed to be well-informed by selecting high quality studies from a wide range of journals, abstracting the studies, and adding value with an expert commentary. A commentary is an extended note that sets forth an expert’s take on the meaning of a study. At issue is whether the evidence from the study or review is sufficient to inform practice. Any study or review offers only a provisional truth, and a commentary is always based on imperfect knowledge. While caution may be justified, practitioners still need to integrate the new knowledge. An expert commentary is an opportunity to help readers with the integration process. This Notebook aims to provide some useful pointers on writing commentaries for Evidence-Based Nursing.

      SCENARIO

      In the halcyon days after completion of your thesis, you attended a conference on evidence-based practice and signed up to become a commentator for Evidence-Based Nursing. Now, 4 months later, you have received an email request from the journal inviting you to write a commentary for the first time. It seems like an easy opportunity to get published, but you feel some trepidation. Knowing that you could influence practice, you want to get it right and do a really good job, but how to proceed?

      ON BEGINNING

      Commenting on an abstracted study may appear, at first glance, to be a relatively simple task. Evidence-Based Nursing commentaries are short, and experienced nurses are likely to have views on many subjects within their fields. But talking among a group of colleagues and writing are quite different activities.

      The role of an EBN commentator is to translate the findings into guidance for readers. To do this, the commentator needs to shift perspective from study content, as described in the abstract, to its clinical meaning. However, the clinical meaning may prove illusive and expressing an expert opinion, overwhelming. Margaret Atwood1 writes of stories as being in the dark, and the writer having to go into a downward hole, needing that flash of light to bring stories in from the dark. Such a process reveals just how much thinking and reflection is involved in writing. Writing narrative for science may be a somewhat simpler process than writing fiction, but a blank page is no less daunting.

      Weak approaches to writing involve waiting for inspiration or trying to write a perfect first draft. These strategies will create more pressure on the writer as the deadline for submission approaches. A more productive strategy involves breaking down the work into achievable steps, such as reading and generating ideas, organising ideas, preparing a first draft, revising drafts, and submitting a final draft. These steps can be taken one at a time, or several at a time, depending on the time available. The steps are not necessarily linear but may be cyclical as you become more involved in writing your commentary.

      Reading always begins the process of writing a commentary, whether that means starting with the study itself or the background material provided with the study. A common example of background material is an editorial that may accompany the original study article and addresses the study and its implications. However, you might feel that such information could bias your first impressions of the study. If so, then your starting point will be the original article reporting on the study. Familiarity with the study is essential. A brief first read will help to identify the key message of the study. Reading the opening sentence of the discussion section in a paper can help by drawing your attention to the study’s meaning. For instance, regarding their study on the cost-effectiveness of 2 different pressure-relieving surfaces, Iglesias et al2 stated the following in their discussion:

      
 Alternating pressure mattresses to prevent pressure ulceration in patients admitted to hospital are associated with lower costs and greater benefits and are more likely to be cost-saving than alternating pressure overlays.

      Such sentences are similar to the beginning of a newspaper lead. A lead answers the “who, what, when, where, why, and how” in an article. This heuristic can provide the essence of a commentary. Sentences, such as the above example, provide the what, where, and some of the who, but the remaining elements must also be considered. A typical newspaper lead is not the only rule of thumb to follow when writing a commentary. An alternative heuristic might be “what is already known, what is new, and what now.” This heuristic can also provide the structural beginnings of a commentary. Some general questions to consider when writing a commentary are listed in the box.

      Questions to consider when writing a commentary

      • What is the best way share this information with patients?

      • How would this evidence assist with integration of services?

      • What is the best way to embed this evidence in everyday practice so that it can be easily applied?

      • Who would benefit from knowing this evidence (consider both practitioners and patients)?

      • Where might this evidence be best applied (which practice settings, what type of country)?

      • Which subgroups of patients that might benefit most from knowing this evidence?

      • What impact does the evidence have on practitioners’ roles?

      • What impact does this information have on performance monitoring?

      • What are the specific barriers to implementing this evidence?

      • What other information needs to be known?

      Whichever heuristic is followed, a commentator needs to focus on what he or she believes is essential before beginning writing. Ideas will come to you as you read, and it is worth noting these as you read, rather than waiting until you have finished reading. Don’t censor these thoughts, even if they appear irrelevant or inarticulate. They are an important first step in getting into the zone of writing. A second more detailed read of the study will generate more ideas and start to firm up your thoughts about the study. This process can be assisted by suggestions provided by the EBN Associate Editor. An Associate Editor is assigned to each study that is abstracted in Evidence-Based Nursing. The role of the Associate Editor is to provide clinical and methodological perspective and direction in the preparation of the abstract and commentary. The Associate Editor will have reviewed the original article and the structured abstract prepared by the journal staff. As such, he or she will have formed a view on the direction a commentator should pursue. Such views are not necessarily prescriptive but are often intended to provoke thoughtful responses. The Associate Editor’s views should be considered during second and third readings of the original article, as you move towards the specifics of your commentary.

      The cycle of reading and thinking is only the first of 3 phases involved in completing a final draft. The remaining phases involve creating a first draft and then making revisions to a final draft.

      ON FIRST DRAFTS

      It is very rare to be inspired to write. Writing is quite simply the discipline of “getting on with it.” Awaiting inspiration will inevitably lead to blocking and avoidable stress. In a first draft, it matters little how you start. What matters is that you start and that you set aside regular sessions for writing until you have finished.

      When you are getting ready to write a first draft, you may be full of inklings about what you might say, but you need to transform these unformed ideas into a more concrete view of the study. To focus in on your responses to a study, you can engage in some simple exercises such as the following:

      • Consider how you would describe the study in 1 sentence to your best friend.

      • Consider what would be the most convincing finding for a sceptical colleague.

      • Describe the findings to yourself in 5 words, then 3 words, then 1 word.

      These exercises can also help you to formulate your conclusion.

      A first draft is a fuller exposition of your ideas than simple notes. Generating a plan from the list of ideas you jotted down as you read the study is a good start. Such a plan can be a simple mind map of your notes rather than an outline of what you write. Such maps may also expose gaps in your thinking and lead to further notes. To move beyond notes, your ideas need to be translated into sentences. Your first sentences do not have to relate to the structure of your commentary. Begin at the beginning, the middle, or the conclusion of your commentary. Just start writing. Put sentences with meaningful links alongside each other. If you have an overall view of the study that you can describe in a single sentence, you may have the conclusion of your commentary at hand. Write on paper, or on computer, whichever is most familiar to you. Some may find it difficult to compose directly onto a computer screen and prefer to write it out on paper first. It matters not where the writing begins, so long as it begins.

      Do not censor or revise during your first draft. This draft is the gravel, not the polished gem. A first draft is written only for yourself, and nobody else need see your first efforts. Stephen King believes that first drafts are best written behind closed doors.3 Only later drafts escape for others’ purview. Do not revise even if you change you point of view during writing. Keep going until you reach your conclusion. It may take a couple of sessions to get to a completed first draft, but then stop writing. Rest and incubation are essential parts of writing. Sleep on it.

      ON REVISION

      Once you have a first draft, your work is 70% complete. In the light of a new day, your first draft may seem awful, but revision is not a new start. There will be phrases and sentences that you will keep in your second draft. If writing on paper, this is a good time to enter your writing into a computer. Such a process will promote revision. The best writers go through the same process. John Maxwell Coetzee, a Nobel Prize winner, has a character describe the process:

      
 Surely you don’t scribble down the first thing that comes into your head and email it off to your publisher. Surely you wait for second thoughts. Surely you revise. Isn’t the whole of writing a matter of second thoughts—second thoughts and third thoughts and further thoughts?4

      Once you have a second draft that captures your thoughts about the study, some final polishing is necessary.

      Your most important consideration should be to make every word meaningful. Search out and remove fluff. Be ruthless. Fluff does not contribute, it annoys. Meaningless words and phrases litter bad writing. Check the dictionary if unsure of a word’s meaning. No matter how proud you are of a word, if it is not accurately used, it is fluff. Delete it. Clichéd phrases are fluff: “Further research is needed,” “The reality of clinical practice is…” and “In actuality …” Adverbs are fluff. Adverbs often end in “…ly.” “Nurses care deeply…” is a bumper sticker, not part of a commentary. Hunt out jargon. Technical language is fine, but jargon will exclude the very readers you are trying to inform.

      Commentaries are non-fiction and thus need complete sentences, not fragments. A complete sentence uses a noun and a verb. It need not be long. “Nurses care” is a complete sentence. Whether such sentiments are accurate is another question. Vary your sentence length to keep readers interested. By now you may be thoroughly sick of revising your draft. That’s a good sign. You now have a final draft.

      ON STRUCTURE

      Earlier, I mentioned that the heuristic “what is already known, what is new, and what now” can provide a structural outline for commentaries. Such a structure is linear and not the only possible structure. It is relatively easy to experiment with form in a commentary. Cinematic film provides instruction on how to vary structure. Just as an opening shot might be a pan of the wider landscape that focuses in on a detail that opens the story, a commentary might move from context to specific details. For instance, Peter Griffiths introduces his commentary of a study investigating early discharge and home-based rehabilitation for stroke by stating:

      
 Stroke is a major cause of long term disability. Much research has been done to determine the best way of delivering care after a stroke.5

      Thus, the context is set, with stroke being identified as a major health issue, and the organisation of care being a topic of considerable research. Griffiths then goes on to address what is new about the particular study he is considering.

      Another approach to an opening is to move from specific to wider concerns, much like a very tight shot pulls back from the detail to pan the scene. David Thompson provides such an example by first describing the study and its key finding when commenting on a study of aspirin for primary prevention of cardiovascular disease:

      
 The landmark 10 year study by Ridker et al of nearly 40 000 initially healthy women found that taking prophylactic low dose (100 mg) aspirin every other day did not confer the same benefits to women as it did to men. Few therapies have separately analysed effects by sex, and the findings lead us to ponder why many of the therapies used for women are not effective or are even harmful.6

      By first stating the study’s findings, Thompson can emphasise important details and then draw back to consider the wider implications of this study and others that have conducted sex-specific analyses.

      While the opening needs to keep readers engaged and draw readers through the middle of your commentary, the ending is the most important part of a commentary. It is your final opportunity to make a lasting impact on readers. A good ending will reinforce your points and resonate in the minds of readers. Margaret Heaton, commenting on a review of pre-operative hair removal, wrote:

      
 Practitioners should ask why evidence should not be applied, rather than why it should be applied. Policies can create room for such questioning by promoting the use of clipping or depilatory cream when individual practitioners believe it is appropriate. Shaving, whether wet or dry, should always be avoided.7

      Heaton’s concluding sentence is so forceful, it is difficult to see how she avoided using an exclamation mark. The “take home” message is very clear and will stay with readers.

      The choice of whether to advise practitioners to use the evidence is at the centre of every commentary. We encourage commentators to make such choices. Many studies will merit a more diffident conclusion than that offered by Heaton, but that should not preclude clarity. In studies where there are gaps in the evidence, use of consensus statements and guidelines offer commentators a sensible conclusion. Julie Betts took just this approach to conclude her commentary on a review of dressings for venous leg ulcers:

      
 Given the current absence of evidence, clinical choice of dressing should initially be that which is simple, inexpensive, and acceptable to patients.8

      Flow

      An important element of any writing is its flow. Flow and structure are inseparable. The ideas a commentator wants to convey are crucial to the structure and flow of a commentary. Flow is built out of the linking and logic of your ideas. It is likely that you will use 2–4 paragraphs in your commentary. Each successive paragraph must build upon the preceding paragraph, and within each paragraph, each sentence must build upon the preceding sentence. Linda Patrick demonstrates superb linking between sentences following an opening about the burden of disease management:

      
 Achieving optimal glycaemic control in type 2 diabetes can be complicated by the progressive nature of the disease, warranting more treatment over time to minimise complications. Patients are often reluctant to move to insulin injections, perceiving them as punitive for failed attempts at diabetes management. Alternatives such as inhaled insulin are seductive because of their potential to improve patient acceptance of treatment options, but the need for clinical trials to establish their safety and effectiveness cannot be understated. Studies such as the one by Rosenstock et al are necessary before we can promote widespread use of inhaled insulin.9

      The first sentence establishes the need for vigilant monitoring and increased treatment. The second sentence reveals why some patients are reluctant to change their regimen to injected insulin, setting the scene for the alternative regimen raised by the third sentence and the need for evidence before promoting such regimens in the fourth sentence. The variations in sentence length and internal structure also serve to produce a consistent flow in the commentary toward the concluding sentences.

      Reading from hard copy rather than the computer screen and reading the commentary out loud are exercises that will help you to improve flow.

      ON WRITING STYLE

      Good science writing keeps the audience at the fore. Your readers will include other experienced clinicians, people new to the field, and curious generalists. A commentary must cater to all of these readers, and it is important to use language that promotes understanding. The commentary by Dawn Kingston on a smoking cessation intervention is a good example:

      
 Tobacco smoking is a leading cause of death worldwide. Interventions to prevent the uptake of smoking are urgently needed. The study by Hollis et al is an important addition to the evidence.10

      The extent and urgency of the problem is outlined, and the importance of the study findings is asserted in brief, clear sentences. The style is akin to that of a newspaper editorial, and its staccato approach creates an urgency that reinforces Kingston’s points. This commentary reflects passionately held views.

      A more academic style can also be used. Jane Joy, commenting on a review of therapies for constipation, employs technical terms, but without reducing clarity or excluding readers:

      
 Constipation is defined by the passage of infrequent hard stool and is associated with bloating, flatulence, abdominal pain, and a feeling of incomplete evacuation. Specific patient groups, such as those with terminal illness, are at high risk of constipation, but the condition is also a common reason for consultation in general practice, especially for the young and old.11

      The term is defined, symptoms reviewed, and the patient populations identified, so that readers learn in the first sentence whether they need continue. The stylistic differences between Kingston and Joy also reflect the personal voice of the commentators. For instance, the tone in Joy’s passage is gentler as it courses towards a conclusion, perhaps reflecting a little more authorial distance from the topic.

      ON EDITING

      Once you have submitted your commentary to the EBN editorial office, it will undergo several levels of editing. First, all commentaries are edited for journal style and format. Evidence-Based Nursing is publication of the BMJ Publishing Group and the Royal College of Nursing Publishing. It follows BMJ house style, which includes, for example, UK spelling. As well, because Evidence-Based Nursing is an abstract journal and each abstract and accompanying commentary must fit on a single printed page, there are several style conventions that are unique to Evidence-Based Nursing. For example, because of space restrictions, numbers within the narrative text of the abstract and commentary are almost always written out as numerals, even if they appear at the beginning of a sentence. Given the space limitations of the journal, commentaries that are too long must be edited for length. This is usually done within the context of the next level of editing described below.

      Each commentary will also be reviewed and edited for content, structure, and writing. During this process, members of the editorial team (ie, the Research Associate, Associate Editor, and Co-Editor) act as representatives of the readers of the journal.12 That is, they read the commentary from the perspective of a naïve reader and consider the various points that were raised throughout this Notebook. Look for more on editing of commentaries in future Notebooks. For now, the main point is to expect that your commentary will be edited—try not to be disheartened by these edits. All commentaries submitted to Evidence-Based Nursing, even in final draft, are still just that—drafts, which can be polished and crafted. The structured abstracts that are written by the journal staff also go through similar levels of editing. This doesn’t diminish the efforts of the commentator to put pen to paper—we respect those efforts and only want to help to make your message clearer.

      CONCLUSION

      Every commentary is ultimately about choice—it seeks to address the question “What is the value of this evidence?” Clinical practice will proceed without perfect knowledge, but we believe that expert commentaries are a useful opportunity to help clinicians synthesise evidence in the face of imperfect information. Commentaries that, in simple prose, lay out a few key ideas in clear sentences that flow from one to the next with a clear take-home message will be good commentaries. Commentaries require some effort to produce, but when approached by Evidence-Based Nursing, we hope that you will take the opportunity to help us and your colleagues.

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