Clinical smarts work like me to put our shoulders to the rock and modern healthcare every day pushing up the hill. So, talk of the vote about what our current Healthcare System and how challenging it is to be a nurse in the system today. Guest that image came to me because i really feel that way a lot at work that there is a giant rock and we come in every day and have to move to the top of the hill and then come back to that same rock and same job because of care is so complicated now and not really focused very well on coordination that it can often take a tremendous amount of time and energy for basic ordinary things to happen. So, for example one of the patients in the book who was misdiagnosed with a classic thing that happens they come to the Emergency Department with a medical problem that is perceived to the medical floor and it turns out she turns out she actually has a very serious surgical problem, and i was talking with one of the surgeons involved in on my behalf i felt so angry and they said it happens all the time. Host i dont think the public can appreciate how competed it can be to even try to work harder at coordination. Guest and i dont want to scare people and make them think hospital is a chaotic mess. Thats not the case. Host but it takes a lot of work. Especially nurses who are there every day. Guest and that is a lot of what motivated me to write this book because the average person doesnt know how important verses are to quality patient care and if you do well in the hospital its likely that some of that is going to have to do with your nursing care. Host so the practice in the book is a cancer ward. When i was in the next practice by practicing pediatrics and i sometimes would have people say to me i dont know how you take care of the kids. Im guessing from people that say to you i dont know how you take care of patients that have cancer it seems so depressing. Guest that is exactly what they say. Host but im also struck by the use of humor and health care and in the setting that you normally think of as depressing and difficult, but patients and families and nurses and Healthcare Teams use humor. Talk little bit about the use of humor to talk about the difficulties. Guest i think people not in healthcare can find it offputting but i dont think it comes out of being callous or uncaring. So giving the patient, i didnt know him very long but i got attached to him and i felt this very profoundly. After he died he had a bout of narcotics left over so i needed to get rid of it and another nurse helped me. You have to give a reason why you are wasting. And patient died is not one of the reasons. So together we decide to patient refused to which struck us as hilarious. We were laughing so hard people hurt us in the hallway. Somehow it helped with my grief to the do that. Host you talk about what its like to work in Healthcare System that seems to forget it is working with human beings and that sometimes we are caught up in the bureaucracy and focus on healthcare as a business. See say more about the empathy that is needed to get direct care to patients and the toughness that it may take to be a nurse. Talk about that. Guest its so important to totally be there and its incredibly difficult because we are constantly getting pulled away. The phone is ringing and alarm is going off and when someone needs Something Else from you, that is a constant challenge because sometimes the patient just needs you to be there for them either because they are in pain or scared or all kinds of things. And being able to come to the patient with your whole heart and then at the same time being able to constantly go through door to do list is very, very difficult. And good nurses have to be really good at that turning on a dime. Host is a challenge we hear from patients and former patients who feel the nurses field so busy they dont want to ask them for things that are important even if it is just spending a few minutes with them to explain one of their medications or host and thats tough. I ever member talking to another nurse one day saying if you dont have time to do all the Little Things and she said thats right these are the things that make you feel like youve contributed. Host but shifted to the hospital you talk about that at various points in the buck and we know that their research on the research on staffing has made it pretty clear the more patients a nurse as it is very dependent on how sick the patients are, what the skill level is from the various nursing staff on the unit that they. We know that number may contribute to an increased likelihood of Patient Outcome and about patients who can die. So it is an ongoing concern at the investigation its been a lot of our work in the last few years that we have worked with congress to reintroduce the staffing act. So, talk about how the staffing and Practice Nurses and their patient. Patients. This is a great question and issue and i really applaud them for their supportive work. I picked for patients that is a standard load on the floor but i start with. With four im just hoping all the time and i really want people to understand that because i think initially some people said for patients, whats that, that sounds bad, that sounds like nothing. Then they said now i really get it. And the scary thing to me is ive been doing it for a number of interviews and ive never had fewer than eight patients. Its very distressing to me to think they might be worrying about how to meet all those needs. Host it is difficult and get with the constraints and funding for health care these days, we have defined the right balance to get. It can contribute to bad outcomes and additional work is needed for sure. Do you think patients understand how stressed versus can be and what have you had them say to you in that regard, and maybe how can we engage patients or even individuals who are involved in the Health Care System to better advocate tax guest that thats a great question. I think a lot of patients get it. Youre busy, and ive had others say dont give me that expletive about a change in the shift. So come in either case is really great for the patient to be so frustrated certain needs are not met because i am too busy. So, what i would like is people read my book or learn more about nursing and see how important we are and then if they are going to write to the legislators or make a point about how to improve hospital care, that they talk about the nursing care. We are very focused on Patient Satisfaction now which there is a value in talking about that and also having enough nurses lead to having enough satisfied patients and a creation of enough good nurses able to do the job and patients doing well needs to be even more solidly established into the public to say this is what we want. But i think there are increasing ways to educate the public around what kind of questions they should be asking before they have to go into the hospital or maybe one of their family members has to, whether they have a magnet designated hospital in their area were even a simple question about what is the average staffing, what is the average Nurse Staffing for a unit. So theres a great deal of work but i think we are all engaged in right now about what are those measures, particularly related to nursing care that we would like to see publicly reported that patients can go to or individuals can go to and book online if we are getting staffed in that accessing information online. And what would they want to know especially when they have the ability to compare different hospitals, Different HealthCare Healthcare providers, different facilities . Guest that kind of transparency would make a huge difference, because then hospitals would go out of this. The hospital across town has more nurses in general than we do on the floor. We cant tell people how much an mri will cost were in appendix b. For complicated reasons, but surely we can find a way to tell them how to nursing care is. Host absolutely. Im going to shift the image of nurses. You talk about various things in the book that get at the image with relationship among the Health Care Professionals and you give an example about Nurse Practitioners and the practice listed on the board thats up on the walls of individuals cant he who is caring for whom, who is assigned to whom and how those individuals as well as nurses are often listed by first name. So, we use physicians, residents can often listed by their last name. So, say more about the relationship among individuals and what kind of issues to be half an hour settings that keep this challenge as we work on nurse physician relationships or respect among the Healthcare Team understanding about what healthcare members do. Guest there is a clear hierarchy. There is a legal hierarchy in the one sentence of the authority that they do not have, that there is a bigger problem with hierarchy in the nurses find themselves in situations where we feel like our contribution is not fact of being significant and so the doctors are only seeing doctor brown and the nurses seeking to visa it reinforces the sense that the doctor is the Expert Committee authority, and the nurse is something between a waitress and a best friend. I dont mind at all having patients call me treats in fact i like it. I would like the formality that doctors work with them to be dropped and i find it so strange he then you will be talking to a physician and talk about another doctor and sometimes it is a really common last name like doctor brown or doctor miller, and you have no idea who they are talking about. So, on a very basic level, this reinforcing of the hierarchy with titles can get in the way of elementary things about who is the doctor and how do i call that person. Host another example you used in the book is how nurses are certainly trusted to administer a drug that could be very damaging for an individual particularly for an oncology cancer unit. Youre administering medication through the veins, and even countered that example how youre not quite mature enough to use google without filters, so we have we have this dynamic of the trust and yes we have these bigger years that seem to impact the respect we would have for a professional. Host that is a great contrast. On the other hand we are very skilled technicians and despite extensive classes my job provided to give patients therapy, many drugs require very specific knowledge and how we carry a lot of that around with us. Thats quite a responsibility. But then on the other hand, yes sometimes i would try to look at things at the hospital. Like i did look up something about a chemotherapy drug and i wouldnt be able to use google, and it seemed to come and go, that authority. And then another another found out was the way that you could pull up and ekg and use that to circumvent it and somebody found that out. [laughter] but the idea that we are in intelligent people that might actually needed to look something up, no the point is to keep us from getting on facebook i guess. And i just didnt see that happening a lot. Host a little too busy. Guest yes. Host so beside this issue of first name, last name were respect and access to the internet resources that may be needed for patient care, are there any other areas that you can think of them anything else that you have had in your experience in which nurses need to be focused about engineering more respect for their positions and who they are as a key member of the health party . Guest nurses are notorious for this ugly phrase versus either young and i have experienced that. Its really horrible. But we could change that. I think that it happens out of a sense of frustration at not speaking speaking with them too and not being taken seriously. And that anger has to go somewhere. So then some take it out on each other and ive heard all kinds of combinations that can be younger nurses against older nurses, older nurses against younger nurses, new, any combination you can think of as possible and its just bullying that we could stop it if he really looked at it as a management problem in a Work Environment problem. Host y. Arvs nurses so frustrating . You do a great job in about talking about your relationship with obese patients and even some other patients you alluded to that you care you care for you for and youve been in the units previously. Our relationship with patients particularly those that sometimes would come in and out of the hospital so you get to know them more than just a single episode. Our relationships with patients coming in to talk more about that particularly once we have the challenges and Patient Satisfaction scores and the dynamics and we know that for the period of time you send them off and as you say in the book in a cancer ward you hope to never see this again. Guest and we say that to people and ive had people say that to me. To become heart to hearts with people and number as a nurse talking about this with another doctor and she said if you stop caring that when you need to get a different job and i really took that to heart as well. Its going to be really painful sometimes when you get attached to people. Its part of the job. And if that idea i go in and do my best ive done my bit and then i leaned. Say how is mr. Jones doing and then someone who is every bit as good as you are will take care of you. Host youve also talked about other things that impact patient care, paperwork. There is an example of one want to talk about and read from about and as you just mentioned a moment ago you just cant stop bothering her, can you commit a secretary the secretary calls out loud enough standing nearby and this is the moment i find that refuses difficult but when i feel it then i feel it upset. Im not adhering to the expected relationship. Shouldnt that feel a sort of and responsible and instead arent those values for all healthcare professionals. Talk about the physician and nurse a physician and nurse relationships, paperwork that impacts those things that get in the way of you doing the care that we know our patients need. The balance of needing to feel pushy. I will describe my self like being a pushy nurse and my husband says youre not being pushy contest your job. Why dont i just see myself as assertive. As nurses we can be hard on ourselves and the environment doesnt always reward. I thought no, dont say that. He is advocating for his or her patients. Paperwork is a more complicated issue. Its a constant demand to never get away from it but its for the entire shift to be one of the full suspense. And because you didnt have time to do it before. So a lot of nurses feel like more and more paperwork requirements are being placed on it and none of them drop off the dropped off the other end, so we are spending more and more time at the computer and i know that physicians feel this way and respiratory therapists and even chaplains ive heard can feel this way. So we are not alone in this, but again, as a society we need to be thinking about all these paperwork requirements and thinking about how we can streamline them and make them more efficient. What is it we want to know and need to know and say that the paperwork is never going to be more important than actually being with your patient, thats what matters. Host i sometimes think we need to ask ourselves the question how are we going to use this information from the Electronic Health record we are really looking a lot at can we extract information from the record, not a single patient across the board tuesday are there certain things we are doing or arent doing that may contribute to good patient care and negative false patients into those kind of things but there is a lot of documentation. You talk about spending time with sheila and her family. It wasnt on the to do list. It wasnt on your dropdown menu on the Electronic Health record in the patients with lifethreatening diagnosis. So unfortunately, it was like that wasnt one of those waiting to be cut things but we understand from the legal perspective of things certainly need to be documented. But the balance of that balance up out of the balance documentation that care because we know that Patient Value thats what they look for and often thats what they talk about when they leave. Guest thats right that is very important for the patients and their family members and its what nurses are so good at. Its what we are there for. We feel like it isnt legitimate and the paperwork that we wont have time for it because of things like when you take the iv down and on and on. Host exactly. You also talk about how in this day and age i finish Nursing School and did my earliest. I think to a large extent. They are doing classes together better understanding but i think for the most part, and you talk about this in the book they have little idea of what nurses actually do when we check the orders and they dont necessarily understand that they are performing a really independent function. Its the right drug to the right patient and why that is so important making sure the patient is ready for that medication and how you use the phrase our used the phrase our work is often visible to each other. So come see more about that dynamic and what you think we can do to improve that. We talk about respect earlier. But talk about the actual need to understand each others role and work well together to optimize the care that we are giving both in different roles to the patient. Host its so important and that strikes me as very strange nurses dont learn how to work with doctors and doctors dont learn in medical school how to work with nurses. But then you put these two groups together and that is how patient care happens so im not sure how anyone thinks that this is the best way to achieve the results possible. As you said there are programs that are now starting to focus on the interpretation of education. And that is a great start. I think for each of us to have empathy for the other makes a huge difference. Partly to know what they are thinking and what they are doing. And i would love it if doctors would look at writing by nurses and to try to find out what is it that we are actually doing all day, get a sense of how we are training or how we are able to accomplish. I mean, i am thinking of a story where we had a patient who was doing very badly and didnt want to go to the icu but we didnt have a do not resuscitate form but that was okay. Host and explained that means. Guest at this point the patient was basically making the choice between doing once more aggressive treatment or do i want to just have my symptoms managed and that is more direction Going Forward hospice. With the patient wanted was to not have aggressive treatment that without this form is that we dont want to be aggressive treatment, our hands were tied. So, we were calling the interim residence and the younger doctors who were learning the job and they kept putting this off and putting this off and i was helping a nurse and of course the issues that we agree we need you here whats going on and she said we are dealing with a crisis across the hall and was so helpful because we knew they were not just in a meeting they were actually in the middle of something that was hard for them that we were going through at the same time and then because she told me we can work out a plan and taking over as soon as we could and got the form figured out and it worked but neither side was revealing. Neither group is all that good at explaining to the other what is going on in a different correction. And i think the perfect example sometimes just explaining that and helping on either end of helping them understand can go a long way. Lets shift to the worklife balance. You spend a lot of time thinking about your shift over from your family life in the morning and getting to work and dont call your family while you are at work unless you have to because you want to stay in control then you talk about the shift as you leave the hospital and try to get focused on your family. Say more about how the demand impacts your life and the life of that you have with your family. Asked cody always end up being long days and i leave before everyone is up and get how after dinnertime but they would wait to have dinner with me so that was nice. But the stress of the day would be emotional fatigue i would come home and not be able to be a mom for my kids and i have a great husband, so he is a great father and it definitely is challenging to have so many demands put on you that when you come home you cant just turn that off right away. But the interesting thing is no matter how many i have every day when i was at the hospital its okay now im ready to go. Maybe we just get a turned into us. Its exhausting. Host and im sure theyre saying is that the only profession that does this but i think that especially since we know that weve turned over to care to someone else i used to find myself on my drive home kind of going through a mental checklist of did i do this and that. Every once in a while i would call back to the unit andsign my name on this form of word. Guest as i said in the book i ride my bike to work and home and its downhill going and uphill back because having to work that hard to get stressed out, but that is exactly i would call at the phone calls are not really that helpful and its just me. Its conscientious not being able to let go. Host you do a great job of working to shed the day so to speak. In your chapter you talk about the work demand and the need not to be vulnerable, and you you especially in front of someone who has power over you you want to show that you can do it all and you want to show that you can be that good but we know that one of the key issues or factors on any job in particular if we dont have control over the Work Environment. Not because they cant control. But there is so much of the system in delivering care. So are the expectations really high and how do we leave it to that other than you used the example use the example how we dont want to show vulnerability how does that impact us longterm staying in the profession . Guest its not good for you. I remember starting and thinking im never going to learn how to do this and then i did. What needs to happen at this time wait i just find out something that throws the whole schedule out of the window and the schedule that is in place is incredibly taxing because they feel such a credible responsibility for the patient. So we do ask a lot of nurses and others worries now are we going to have enough nurses to be looking about and how can we make that Work Environment better . Theres so much we cant control, thats right but for example the no time for lunch, wouldnt it be huge if every nurse knew he would get lunch, and i think that sometimes it is too simplistic for people to say really, youre complaining about not having a lunch hour but its not just about the outcome is about the mental break that we need to have two really keep up the pace of getting patient care for things that are so important to the patient delivering the right medication, giving them the care that they need for all those things kind of juggling those and so in some ways it is almost a proxy for how we have to allow time to keep the pace up. Particularly when you are doing a whole 12 hours shift i think that it can be relentless and i its hard to do when you think about. Guest if the patient gets quoted in the the look the looks of things that suddenly takes a very severe turn for the worst and bring in a Rapid Response team and then i remember a code in the hospital where one of the ministers ends up coming up later in the book and likes this particular woman and she said im trying to talk to people can we talk about what happened and i said yeah we would really like to talk about what happened but i cant right now and she came back half an hour later and said he wanted. What happened and i said i would like to and i think she came back three or four more times. I think that its so hard to see someone you care about two really not be doing well and we dont get breaks when that happened. We havent done a good job i think that we are doing a better job in some places about that. I think Emergency Departments are notorious about dealing with the problem of issues and moving on and not really allowing or trying to carve out time to let people work through what happened and how to cope with the great example that sees the need to provide those resources but as you say the pace can be relentless for sure. Guest i would rarely cry at work and again i think that is part of Holding Things in and i remember going to see one particular patient and hiding in the bathroom to cry, one of the few times ive ever cried in the hospital and i thought i dont have time for this and i dont have the space to be here for other people. Host sometimes i would find myself in the car ride to process some of those things and you just dont have the time while you are there. Host you made reference to a job and susie who is a good person and you dont want her to be part of the 20 of people that leave us a talk about the talk about other than some things we mentioned already like adding lunch breaks and issues of respect are there other things we need to be doing and i will talk in a minute about some of the resources that maybe we are and need to be provided to help nurses to feel supported in that environment on anything you can think of specifically . Guest it is a sink or swim mentality. Nobody is going to go out of their way necessarily to help new nurses along. Some people will but its not built into the institution at least in my experience from what ive heard from others. In a training capacity they are not actually doing the job and then they are much better prepared to start the actual job when they get their. Having the real mentorship programs or the nurses to check in with people and they know they will be safe and how did this happen i think i made a mistake, how should we have handled it, and then that person can counsel them and about how to cope with situations like that lets look at it and see how you might do it next time. Also i know at the Cleveland Clinic if they feel like a nurse is sufficient in terms of skills when she starts to get out of school, they will actually do a week of special training in a Simulation Lab to bring vendors to speed, and i think that is so incredible instead of saying if you dont make it your gone. Or you will learn on the job center speak. There is a need for consistency acrosstheboard. We all know good examples of where they do get it and as the increasing need for nurses will increase and baby boomers start ramping up the retirement and the nerd elite can could need for the nurses we have to address this we cant keep losing 20 every year in the hospital and certainly some of them find their way to other settings, they go to primary care, School Health nurses, Public Health to find other settings and i think thats wonderful. Ive lived my whole career moving in and out of different settings and that is an advantage for nursing but currently we stored somewhere in the range of almost 60 of nurses that actively work in a hospital setting so we have to make it positive for those resources. Its expensive for hospitals to train a nurse and have her leave in six months or a year not that money should be the motivator but it is real money. Host is one of the major factors of cost constraints. The association is focused on the developing resources to help the worklife balance and also deal with the work issues so we have resources on fatigue and the Workplace Violence to be wealthy enough on average they are less healthy than the average public i think that we internalize too much and we dont practice what we preach sometimes, so we need to be better at that. Arent there other things that come to mind always need to make sure that they unveil themselves were where the resources can look into how they can bring them into their own practice setting to their own facilities because we want them to be fit for their work as well as goodwill models for their Family Healthcare is becoming more and more complex and specialized in so nursing now isnt what it was a say in 1950. That seems again obvious thing to say that what it means is that demand on each individual to increase the expectations are higher because there are so many things that go on in the hospital and so we need to value ourselves as professionals and also expect the Larger Community to value us value us in real value us in real life healthcare is only going to get more and more complex. And we are just going were just going to need better and better nurses to meet all of the complex needs. So thinking about how to keep us strong and healthy and encouraging that is huge. We sort of give lip service to that but we dont really emphasize it. Host back to this issue of empowerment and your example of being an opinionated nurse do you think thats that nurses feel empowered in their role for those that do or dont what to you think enables that or doesnt do you think that many use the phrase im sure we both hate which we see sometimes so talk about the lack of empowerment or what needs to be occurring or maybe theres things that are shifting. Guest a lot of nurses do not feel empowered for them or for patients and it comes from the humiliation of having moments when you try to have an opinion or bring something up because it was important and and that physicians put you off and even if it only happens one out of every ten times it has quite a Chilling Effect on your assertiveness and wanting to dive in because why should should i buy a van if i am just going to be knocked down and there can also be the worry and i going to look ridiculous . My answer patient is stupid. So there are nurses that earn that respect doctors are going to listen to them but they earn that respect. We should all get that respect. It shouldnt have to be something that is earned so again to me it goes back to the physician training and being taught to recognize us as colleagues. Host i am very interested in the very glad to know that we are finding some educational colleges and universities really starting to look at this and its going to be important. They really emphasize where we will have this as an organization a focus next year as we roll out the programmatic work on the culture of safety comes to developing within the healthcare setting that need to focus as an entire culture on the safety of patients what we can do to support it and use some examples in the book around safety issue is whether it getting the right medication, some of the checks of giving blood and blood products. Can you talk about that and the importance of that culture within hospitals and the challenge of doing that . Guest this goes back to the documentation as i say in the book we spend all this time in the assessment how much of a fall risk and i could be spending their time talking to them about what we can do together to keep them from falling. So, having the paperwork there to keep people safe, thats one problem. But i think we also can get so up in the system this has to happen and this has to happen that really obvious safety things like hand washing we all know how important and washing is and every hospital now. It doesnt even have been in some situations. And its so simple and important. I think of an example in one of the medication rooms there was a refrigerator that opened and you could walk in the door to the room on one side of the refrigerator or the other and the door to the refrigerator open so that if it was open nobody could get to the system it doesnt make sense in having someone use the narcotics dispenser when i first started working as a nurse that would have really bothered me but i dont think it bothered me. Theres obvious things weve gotten so used to thinking this doesnt work. Host they almost become invisible to you because you have adapted your self which is not ideal if you want to really keep the focus on building that culture. The book takes place over a 12 hour period and you talk about holding these in your hand. In the ever shifting day that comes and goes to stay focused on the patient of human beings and the care they need. Guest i wanted them to get a sense of how important nurses are inpatient in patient care and to give them a title. Writing the book that was one shift being a great way to do that. At the end of the day you would more or less find out how they did. We note know that the shift is really like. Host we had recently social media that has a flare up of talkshow hosts talk show hosts talking about stethoscopes and not really understanding the role of nurses and what they do and im very pleased to have tens of thousands of nurses go on social media and really focused to try to educate the public about the work that we do and try to help them understand the value of nursing to their care. So, great examples in the book and great recent example to social media and that opportunity we all have to take advantage of an education. Host thats what i do hope i inspire more nurses to talk about what you do. Host thanks so much. I enjoyed reading the book. You did a great portrayal. As i understand you have shifted from the hospital and you are focused on getting care in the home. Host guest i wanted to see what i could do to make the hospital better. Host thinks, thanks, theresa. I appreciate it. Authors of the latest nonfiction books are interviewed. Watch after words programs online that booktv. Org. Linda what gave you the idea to write about Sandra Day Oconnor and Ruth Bader Ginsburg . Guest i write books about social movements. So i was interested in how women have achieved the goal a quality which is a happy story and happy ending. You cant think about that subject. What is obvious if you think about it its second. Sandra day oconnor came to the Supreme Court first she was a symbol in the icon that women provide for the highest jobs and their land so she did a lot for the women equality so i thought do they know each other for lunch and shopping and shoes they know each other but they do not go Grocery Shopping together but they made an alliance to the section of the alliance which made both of them more powerful. So they did the decisions helping women to be equal but the way that they have helped each other, its okay to be the first but i do not want that and she paved the way. She was so successful and when ginsburg came, he was so she was so excellent at her job she that she would be another successful women just like oconnor. So i wrote about what they did for women and how they acted together which is a model for women in the future to know that you can be allies and how you can together make the world better than either one of you thought you could allow it. And when i started it turns out the cases were very interesting so i wanted to be able to understand how they did it case by case. Its going to come this june will have a lot of spin court decisions. To understand how these women did it and how they changed the law for women. Host did you find a 62nd case they each wrote opposing opinions . Guest there was a case they disagreed. There were a couple. Theres one where they struck down a constitutional violence against women act. Oconnor is very conservative and comes from a republican president and was very conservative for the state and for the federal government so she said it was unconstitutional and Ruth Bader Ginsburg said that it meant the constitutional standards. That was one of the very few cases about women where they disagreed. They agreed there mustve must have been 25 cases they saw together, and they agreed on all but two of them say see the one was republican and one was democrat a very important distinction one came from arizona and proclaimed the womens issues. So it is a pretty good record reflection of what they knew was at work for them to do it. Did they grant interviews . It tells the story of the state or ginsburg starts at the aclu and then goes to the circuit and oconnor picks up the baton and carries the women to quality forward while shes on the Supreme Court of the United States that may come to the spin court and now since 2005, ginsburg has been carrying the torch, so i was able to go back and forth between them without much difficulty as a writer because its not that different from one to another in a very orderly way