Using Plain Language When You Write
Nurse Author & Editor, 2020, 30(3), 3
Did you know that in 2010, President Obama signed a law informally called “The Plain Writing Act of 2010”? If this is news to you, you are in good company—many people I have mentioned this to are not aware of this act. Its full title, “An act to enhance citizen access to Government information and services by establishing that Government documents issued to the public must be written clearly, and for other purposes” pretty much sums up its purpose. Elements of the Plain Writing Act are starting to filter down from government documents to other types of materials for the public, such as incorporating its principles into writing for patient education materials, healthcare and academic education articles, nursing journals, and so on. Organizations such as the National Institutes of Health (NIH) and Centers for Disease Control and Prevention (CDC) want to reach everyone with “health information they can use and to communicate in a way that helps people to easily understand research results.”2 Certainly, it is hard to argue with making government documents and health information easier to understand!
Patient education is a cornerstone of the profession of nursing. State level Nurse Practice Acts, which regulate the profession of nursing throughout the US, have general statements that discuss the nurse’s responsibility for educating patients on “actual or potential health problems.”4 These guidelines provide the framework and expectation that nurses are frontline educators to provide patients with knowledge, understanding, and preparation for self-care management. Within their scope of practice, nurses have freedom to make decisions regarding education based on a patient’s needs and learning style. This is a crucial concept given our diverse patient population in the US. Roughly 44 million US citizens are illiterate (able to understand material at a fourth-grade level or below) and 50 million are classified as low literate (able to understand material between a fifth- and eighth-grade level). Nurses must be skilled in absorbing high-level health information and able to break it down into practical related information that patients can easily understand.6 Patient education materials have historically hovered around eighth- to tenth-grade level or higher. Additionally, patients can only recall about 40% of health information provided by nurses.7 Due to the low literacy and retention rates in the US, Plain Language5 provides a best practices approach to education materials for patients, so they can find what they need, understand what they find after they have read it the first time, and use the findings to meet their needs.
History of Plain Language
As noted on the Plain Language website, “Interest in making government documents clear has a long, but checkered, history in the United States.”5 Early attempts to use clear, direct language in government documents began after World War II. In the 1960s, an employee of the Bureau of Land Management, John O’Hayre, wrote a humorous handbook called Goobledygook Has Gotta Go (see Figure 1). If you are interested in reading it, the book is freely available at the Internet Archive (https://bit.ly/2DvHiOn)
In the 1970s, the federal government encouraged regulation writers to be “less bureaucratic.”5 It began with President Nixon decreeing that the Federal Register be written in layman’s terms. In 1977, the Federal Communication Commission issued rules and regulations for the Citizen Band Radios, which were written with personal pronouns, sentences in the active voice, and clear instructions, making it one of the first regulatory guides to appear in plain language.5 In 1978, Executive Orders were issued by President Carter, intending to make regulations more cost-effective and easy-to-understand by the individuals that were expected to comply with them. The Department of Education funded the Document Design Project that studied the problems with public documents and helped federal agencies write them with plain language. The book created by this group, Guidelines for Document Designers, was used as the handbook for government writers for years.5
In the 1980s, President Reagan revoked President Carter’s Executive Order. It became an agency-by-agency decision whether they would write rules and regulations in clear, plain language. However, during this time lawyers became interested in the benefits of plain language and the Social Security Administration made it a priority to use plain language when communicating with the public.5
The 1990s were an important time for plain language. Vice President Gore believed that plain language promoted trust in the government and that it was a civil right. He created and presented the “No Gobbledygook Award” monthly to federal employees that took bureaucratic messages and turned them into plain language that citizens could understand. The Plain Language Action and Information Network (PLAIN) website was launched in 1994; regular meetings began in 1995. This group was and remains the center of the US movement for plain language. President Clinton was an advocate and signed two executive orders and issued a Memorandum on Plain Language in Government Writing in 1998. PLAIN also issued guidelines for implementing the presidential memo. In Walters v. Reno (1998), the 9th Circuit Court came to the decision that the forms issued by the Immigration and Naturalization Service (INS) were so confusing and difficult to read that they violated a person’s due process.5 The Court ordered the INS to rewrite and format the forms for better communication.
During the 2000s, the Bush administration did not have a formal plain language initiative, however there was a mandate for communicating clearly with the public. Many agencies had strong, active plain language programs in place. Arthur Levitt, the chairman for the Securities and Exchange Commission (SEC), was a champion of plain language and helped create the SEC’s Plain English Handbook. In 2003, the Office of Management and Budget issued a policy directive about a standard format for grant announcements. In 2006, the Federal Emergency Management Agency issued an alert stating that plain language was a public safety matter.5
On October 13, 2010, President Obama signed the Plain Writing Act of 2010. Since 2012, the Center for Plain Language has presented Federal Report Cards to evaluate how well agencies are following the law. The report card has two categories: organizational compliance and writing quality. In 2019 there were 11 out of 21 Executive Branch agencies that received an A under organizational compliance but only 2 out of 21 agencies that received an A under writing quality.5 The key findings reported the growing gap between agencies that comply and those that do not. Now, there is an urgent call to for agencies to use plain language to promote the understanding of government documents, patient education materials, and healthcare academic education materials. There are 12 principles of plain language, which are shown in Table 1.
Table 1. Principles of Plain Language
|1. Write for your reader, not for yourself.||This means using language that your audience understands the first time they hear or read it. One should know the expertise of their readers. It is important to do your research, state what the audience needs to know and to write in a way that explains your knowledge.|
|2. Use pronouns when you can.||The use of pronouns will allow the reader to better understand what may be expected of them and what they can expect of others.|
|3. State your major point(s) first before going into detail.||This will allow the reader to gain a basic understanding before building on that understanding. The most important information should be in the beginning and background information should be included. The purpose should be stated and what you are trying to convey.|
|4. Stick to your topic.||Sticking to one topic will allow the reader to better follow along. The reader is already expected to have minimal knowledge on the subject. Writing in a manner that is difficult to follow will only lose the readers interest sooner due to possible frustration and confusion.|
|5. Limit each paragraph to one idea and keep it short.||Separating out ideas into separate paragraph will allow the reader to follow along better. It will also benefit the reader in case he/she needs to go back and reread a section.|
|6. Write in an active voice. Use a passive voice only in rare cases.||Active voice makes it clear who does what and is concise.|
|7. Use short sentences as much as possible.||Phrases and clauses should be avoided.|
|8. Use everyday words.||If you must use technical terms, explain them on the first reference|
|9. Omit unneeded words, be concise.||Omit redundancies.|
|10. Keep the subject and verb close together.||Use verbs to provide the reader direction, keeping the writing conversational.|
|11. Use headings, lists, and tables to make reading easier.||The information should be organized into sections, the typography should be simple, a serif and arial font should be used, headings, bullets and simple text should be used.|
|12. Proofread your work and have a colleague proofread it as well.||All writing should be free of errors. Proofreading is essential in the writing process.|
Principles Related to Healthcare
In order to achieve optimal health outcomes, the use of plain language in healthcare is necessary. Health literacy is defined as the “degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions.”1, p. 263 Only 45% of high school graduates are able to make good health decisions based on understanding and comprehending health information.1 For people to be health literate, it is important to utilize the principles of plain language. Using plain language can help people to clearly understand research findings and important health information, read medication information, and accurately complete health documents. By using the principles of plain language, health agencies and researchers are in a position to transform their health documents and research into language that consumers can use.
The Plain Writing Act of 2010 requires federal agencies to train their staff and to use plain language when they communicate with the public. With respect to healthcare, the CDC offers plain language materials and resources to make information easier for everyone to understand. At the CDC website you can find a search tool so that you can search jargon or plain language words and find alternatives and example sentences (https://www.cdc.gov/healthcommunication/everydaywords/). One example provided at the site is “disproportionate” with these example sentences:
CDC Original Sentence
- MSM continue to bear the greatest burden of HIV infection, and among races/ethnicities, African Americans continue to be disproportionately affected.
Plain Language Sentences
- Some groups are affected by HIV more than others. Men who have sex with men are most affected. African Americans are strongly affected, too.
The CDC also offers The Federal Plain Language Guidelines, Plain Language at NIH, and a Plain Language Planner (PLP-PC).2 Understanding that there are resources available and ways in which all individuals can access plain language materials is important.
Pros and Cons: Positive
There are a multitude of positive benefits, reasons, and costs for implementing plain language, the most obvious being an increase in understanding of the material by the intended audience. Use of plain language reduces confusion, as well as the number of questions being asked for clarification.5 If the material is too formal and difficult to understand, the intended reader can become frustrated and may not read the material at all. Utilizing plain language decreases confusion and leads to an increase in understanding, comprehension, patient satisfaction, and creates a positive image for the intended audience.5 Someone who thinks more positively about a topic is more likely to listen to what is being said and feel better about the decisions that are being made. The shorter and more concise, yet informative, a piece of writing is, the faster the message is able to get across and the more people will understand.5 Finally, use of plain language fast-tracks the time it takes for procedures and paperwork to be completed, saving both time and money.
Pros and Cons: Negative
Implementation of plain language has a few negative impacts as far as costs, reasons, and risks. First, despite being a long-discussed topic, it has only become an expectation and norm within the last decade. While younger generations now going into professional employment will be able to adapt easily if plain language is included as part of their education, the older generation of workers may struggle. This leads to costly re-education and trainings on how to utilize plain language. While the idea of plain language as a general concept seems simple enough on the surface, there really is a lot to it in order for it be successful. Each of the principles of plain language personalizes the written information to the specific situation. Every situation is going to have a different intended audience, which complicates the level of layman’s terms needed in order to properly convey the message. If patient education materials are not designed for the right audience, it does not matter how short your sentences are or how active the voice is.
Another negative of plain language is the time it takes to “translate” information as well. After the information is produced, public understanding is increased, and procedures and paperwork may be completed more quickly. However, the effort, training, and time that go into creating the information can be resource intensive and expensive. Despite all of this, the positives outweigh the negatives. Use of plain language heavily increases comprehension and understanding of the audience, while decreasing the time it takes to achieve this understanding.5 This means that there is little need for re-explaining the information again and again, and there is an increased ability to understand the information on the first read.
Plain Language in Journal Writing
So far this discussion has focused on health education and patient materials. What about scholarly writing, such as journal articles or student papers. Should these be written in plain language, too?
The 12 principles of plain language can certainly apply to any writing situation. Omitting unnecessary words, making sure every paragraph contains a single idea, and proofreading are all important concepts that all writers should embrace. The APA Manual has stressed using active voice in both the 6th and 7th editions. Perhaps the one point where I would offer caution is the use of pronouns. Although pronouns such as “I” and “we” are becoming more common in journal articles, you need to be careful about how these appear in the text. Chinn3 offers good examples of how to write in an active voice without overly relying on personal pronouns.
Journal articles, by their nature, will have longer, more complicated sentences, multi-syllabic words, and technical terms. These items will increase the reading level of the document—most journal articles are written at the tenth-grade level and above. Even so, plain language and scholarly writing are not concepts in opposition to each other. You can, and should, think about plain language principles in all of your writing, whether a letter, a memo, or an article.
The Plain Writing Act of 2010 was originally intended for use in federal government documents and agencies. However, principles from the act are filtering down to the state and local level and branching out beyond government. I encourage all authors to become familiar with the law and work to implement plain writing in all facets of their written communications.
- Bastable, S.B. (2019). Nurse as educator: Principles of teaching and learning for nursing practice(5th ed.). Sudbury, MA: Jones and Bartlett Publishers.
- Centers for Disease Control and Prevention [CDC], 2020. Health literacy. Retrieved from https://www.cdc.gov/healthliteracy/developmaterials/plainlanguage.html
- Chinn, P. L. (2017). Finding your voice and writing well: Situating yourself within your text. Nurse Author & Editor, 27(2), 5. https://naepub.com/wp-content/uploads/2017/05/NAE-2017-27-2-5-Chinn.pdf
- National Council of State Boards of Nursing [NCSBN] (2020). Retrieved from https://www.ncsbn.org/
- Plain Language Action and Information Network [PLAIN] (2020). Retrieved from https://www.plainlanguage.gov/
- Russell, K.A. (2017). Nurse practice act guide and Govern: Update 2017. Journal of Nursing Regulation, 8(3), 18-25.
- Selic, P., Svab, I., Repolusk, M., & Gucek, N. K. (2011). What factors affect patients’ recall of general practitioners’ advice? BMC Family Practice, 12, 141. https://doi.org/10.1186/1471-2296-12-141
About the Author
Kara Evans, PhD, RN, Professor of Practice in the Department of Nursing, Purcell School of Professional Studies, Le Moyne College. Kara has taught undergraduate and graduate courses in Nursing Research and Principles of Teaching and Learning. Kara is a contributor to Nurse as Educator: Principles of Teaching and Learning for Nursing Practice (4th & 5th edition) and Essentials of Patient Education (2nd edition). Email: firstname.lastname@example.org
Copyright 2020: The Author. May not be reproduced without permission.
Journal Complication Copyright 2020: John Wiley and Son Ltd.