Adopt the less-is-more principle of communication

Teach staff simple writing and speaking skills

Staff aren’t likely to strive for good health communication until they recognize that there’s a problem, says Sandra Cornett, RN, PhD, director of The Ohio State University Health Literacy Pro-ject in Columbus. "When educating health care professionals, first help them understand there is a health literacy problem and its extent," she advises.

An adult literacy survey conducted by the government in 1993 determined that 21% of U.S. adults read at a fifth-grade level and 26% read at an eighth-grade reading level. Add those figures, and you will find that 47% of the adult population reads at a basic level.

In addition to alerting professionals about the health literacy problem, they need to know that most written materials are done at a level too difficult for many Americans to read and understand. "There is a mismatch between the public’s reading level and the level different health materials are written at," explains Cornett.

Once they understand these facts, you can identify the elements in a written piece that make it easy to read, so when they write educational materials or select published materials they can choose what is best for the patient. The more syllables there are in the words and the more words there are in a sentence, the higher the reading level, says Cornett.

Easy-to-read materials are written in the active voice, concepts are well-defined, and important information is highlighted with bullets. The need to know information must be obvious because people who don’t read well will miss the point if a lot of nonessential information is included in the text, says Cornett.

The content must flow logically as well. For example, if the material covers a surgical procedure, it should first explain how to get ready for the procedure, continue with information on what happens during the procedure, and end with what to expect following the procedure.

To draw attention to essential information, use techniques like bold type or boxes around key points. Headings and subheadings help people quickly find the information they need. For example, a heading might read: "When to call your doctor," and then list five signs and symptoms that warrant a call. "Information sheets should look like a recipe card, not a novel," says Cornett.

In addition to text, consider the layout as well, advises Zeena Engelke, RN, MS, clinical nurse specialist for nursing staff development at the University of Wisconsin Hospital and Clinics in Madison. "We need to look beyond the words and be sure there is sufficient white space, skillful use of lists or charts, and appropriate graphics. Too often we are focused on counting three-syllable words and miss the point about ease of presentation," she explains. (For more information on the elements of easy-to-read materials, see article on p. 102.)

All levels of communication affected

Communication is much more than the written word, and health care professionals must be aware of the words and phrases they choose to explain medical concepts to ensure that patients understand their instructions. A good exercise during staff instruction on health literacy is to give class participants a list of words commonly used by medical professionals and have them choose an alternate word or sentence that is more readily understood, advises Cornett. For example, rather than using the term anti-inflammatory, the health care professional might say "a drug that will prevent redness, swelling, and all the signs and symptoms of infection."

Cornett often advises health care professionals to tape a conversation they have with a patient when providing instructions so they can hear how they answered questions and explained concepts. Most patients won’t mind if told why the conversation is being recorded.

Videos and other nonwritten methods of communication should frequently be used when low health literacy is suspected. "I watch for cues that might indicate literacy concerns. If I have an individual that I know or suspect is illiterate, I rely more heavily on verbal instructions, videotapes, audiotapes, and other nonwritten methodologies," says Engelke.

Cues to a person’s literacy level includes the kind of words they use, their use of language in general, and whether they have reading materials around. For example, "Did the person bring a book to read in the waiting room?" says Cornett.

During staff training on health literacy use lots of hands-on activities, advises Cornett. Role playing is a good way to practice plain communication with patients. There are also many exercises for sharpening material selection skills. "An exercise you can do with students is to give them brochures at various reading levels and ask them to select materials for different types of patients," she says. After teaching them to write in easy-to-read language, you also can give them a paragraph that is written at a 12th-grade level and have them rewrite it at a fifth-grade level.

It is important to set a standard at your facility so that staff know that a particular reading level is required. At the University of Wisconsin Hospital and Clinics, staff are encouraged to select or create materials that are no greater than an eighth-grade reading level. To aid staff, the health care facility has an author’s guide to reinforce its standard and provide strategies for decreasing reading level. (For a list of resources to aid in educating staff on health literacy, see p. 102.)

"Likely, the most important help comes when we edit and work directly with staff to help them bring down the reading levels," says Engelke.

For more information about teaching staff about clear health communication, contact:

Sandra Cornett, RN, PhD, Director, The Ohio State University Health Literacy Project, Office of Health Sciences, AHEC, 218 Meiling Hall, 370 W. 9th Ave., Columbus OH 43210-1238. Telephone: (614) 292-0716. Fax: (614) 688-4041. E-mail:

Zeena Engelke, RN, MS, Clinical Nurse Specialist, Nursing Staff Development, University of Wisconsin Hospital and Clinics, 3330 University Ave., Suite 300, Madison, WI 53705. Telephone: (608) 263-8734. E-mail: