Plain Style in Healthcare: too plain or not plain enough?

First aid: Cardiopulmonary resuscitation (CPR) 

Presented by Mayo Clinic

Proper health literacy is critical to the vitality of the patient as well as the formality of communication between healthcare workers and the public. Healthcare is a complicated mix of both scientific fact as well as communicational ethics. Complication arises when healthcare professionals and experts try to relay information to the public. This information must be simple enough so that the patient and/or the average person can comprehend the definitions and explanations being provided. In order to avoid detrimental confusions and avoidable mistakes, plain language must be incorporated effectively. With extensive science backgrounds and knowledge, it can be difficult to “dumb things down” when many textbooks and medical/nursing schools often teach and expect their students to use official style in both their written and spoken language.

A big thing I have seen others do, and have even done myself, is immediately run to WebMD searching for answers to their symptoms. Most of the time the internet diagnosis is cancer, death, or some disease name I have never heard of. It is very likely that this internet diagnosis is wrong and a real doctor would say the same. This is because the internet is either too plain in its style choices or too official. Health websites usually use scientific language that common users are unable to understand. These websites are also very vague in their descriptions of symptoms, oftentimes, giving too large of a list or too short of a list leading people to fit the mold of the condition too easily. The same idea goes for health websites that offer instructional advice and/or guidelines. If the instruction is too plain, readers might oversimplify their actions and if the instruction is too official, readers might not be able to understand it, leading to confusion.

            Mayo Clinic Health System has been ranked the #1 hospital in the nation and is top-ranked in twelve specialties (MayoClinic). People trust Mayo Clinic in their accurate medical diagnostics and procedures because of their well-established and kind-hearted nature. If Mayo Clinic is able to provide exceptional in-person assistance, are they able to do the same on an online platform?

            To determine the effectiveness of Mayo Clinic’s online platform, I analyzed their first aid webpage concerning cardiopulmonary resuscitation (CPR). On this website, created by Mayo Clinic staff, guidelines and instructions are given for techniques behind the basics of CPR (First aid: CPR).

In doing a basic reading of the webpage, there were numerous style strategies that stuck out to me. I noticed that the webpage information was split up into multiple short paragraphs, keeping information brief, yet, informative. In the beginning paragraphs, Mayo Clinic provides advice given from the American Heart Association (AHA) on steps to take if you are untrained, trained and ready to go, or trained but rusty. Providing information from the AHA installs credibility and trustworthiness that the material provided is valid and up-to-date. The website is also organized with the use of bolded headers to section off particular sets of information. The

Chest compressions

titles of these headers are parallel with the second word being a verb, for example, “Breathing: Breathe for the person.” These headers also go in an instructional order. Mayo Clinic advises that you remember to spell “C-A-B,” consequently, the headers go in this order too, “Compressions: Restore blood circulation, Airway: Open the airway, and Breathing: Breath for the person.” The webpage also displays illustrations of actioned instructions to help guide readers through the motions. These images, like the one on the right, provide specific examples, exemplum.

Additionally, I noticed some aspects of the webpage that could use improvements. The guidelines for an untrained individual states that 100 to 120 chest compressions should be performed per minute. How do you time this out? Trying to figure out the rate to perform each compression is not an easy task, and this guideline does not simplify it for the reader. The guidelines also state, “To learn CPR properly, take an accredited first-aid training course,” however, it also later states, “If you are untrained and have immediate access to a phone, call 911 or your local emergency number before beginning CPR.” There are two sets of instructions being given, which can lead to uncertainty in a reader. Another issue I found was the information lacking on the age ranges that differentiates a child from a baby. The vagueness of the ages provided can lead to mistakes, instead, a specific age range for both a baby and a child should be given so the reader is able to easily differentiate the two if attempting CPR. These were the most relevant features of the website I noticed in just my first read through.

            To analyze the website further, I explored the plain style strategies used in the excerpt that follows.

 “Breathing: Breath for the person:

1.     With the airway open (using the head-tilt, chin-lift maneuver), pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal.

2.     Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver and then give the second breath. Thirty chest compressions followed by two rescue breaths is considered one cycle. Be careful not to provide too many breaths or to breathe with too much force.

3.     Resume chest compressions to restore circulation.

4.     As soon as an automated external defibrillator (AED) is available, apply it and follow the prompts. Administer one shock, then resume CPR — starting with chest compressions — for two more minutes before administering a second shock. If you're not trained to use an AED, a 911 or other emergency medical operator may be able to guide you in its use. If an AED isn't available, go to step 5 below.

5.     Continue CPR until there are signs of movement or emergency medical personnel take over.”

The numbered steps give organization to the writing, giving the instructions in a step-by-step manner that can be easily followed in order. I have highlighted the present tense action verbs in yellow. These action verbs promote instructional action within the reader to act now. The sentences are giving the reader a simple, straightforward command to follow. The instructions are given a header title which acts as a form of metabasis to state what will follow. There is also parallelism evident in the text. The steps are given equal importance by having the inclusion of commanding action in each. The excerpt also provides examples, exemplum, for the reader to have a better understanding of what is being said. The examples, highlighted in green, give additional information to the reader by explicitly noting what an open airway means, what kind of breathing should be done, and how tightly the person’s mouth should be to yours. Without knowing this, the reader might not fully understand what having an open airways means and/or might not effectively assist the person with breathing, leading to possible complications. Distincto is also found in the example reading, “With the airway open (using the head-tilt, chin-lift maneuver,” because it tells the exact meaning of open airway to the reader. Another form of distincto is given when the text provides the full definition as well as the acronym for an automated external defibrillator (AED). This prevents ambiguity because some people may know one term but not the other. The portion of the excerpt, highlighted in blue, is where plain style is necessary but is lacking. Upon reading this sentence, the question arises, how many breaths are too many and how much force is too much force? This sentence is oversimplified and fails to provide the reader with necessary information. If exact information cannot be provided, information on how to tell if you have given too many breaths or used too much force should have been specified, instead.

            The use of plain style, in this situation, simplified the purpose of the writing and presented the information in an organized fashion. A readability test seemed to agree on this.   

Average # of words per sentence	Gunning Fog Index	SMOG	Flesch Reading Ease
15.23	10.94	10.75	63.19

 

Since the average U.S. adult reads at the 7th-grade level, this was obviously intended for a broader audience. The Flesch Reading Ease deems this writing as a standard style with an estimated 83 percent of U.S adults who could actually read and understand this (Principles of Readability). Even though it was graded as standard, the plain style being used is still not plain enough for all U.S adults to comprehend. The question arises, why isn’t this good enough and what were Mayo Clinic’s intentions in writing this article?

            Mayo Clinic’s presentation of first aid CPR is categorized under a tab labeled “Basics.” The article states, “The American Heart Association recommends that everyone — untrained bystanders and medical personnel alike — begin CPR with chest compressions.” Mayo Clinic’s hope is for the general public to educate themselves on the CPR techniques and the importance of it so that everyone is able to perform it in a given emergency. The AHA provides Mayo Clinic with standard protocols to follow and through this, Mayo Clinic is able to expand this knowledge to their staff and to the general public. The general public is expected to follow the instructions of medical experts and 911 operators and have a sense of awareness for the situation. The AHA, Mayo Clinic hospital systems, the staff/medical workers, the 911 operators, and the general public are all intertwined and expected to work together in medical emergencies.

            The expected role of the general public is to help as much as they can. They are not licensed to perform any significant tasks, however, until medical professionals can arrive, the job is in the hands of the general public. Mayo Clinic’s website article on first aid CPR was created to inform the general public as a learning experience, but not as an instructional guide to follow during a medical emergency. I understand that information is provided in a step-wise fashion, however, some sections of information are formatted into paragraphs that cannot be quickly read in an emergency. The article states that a person can die within 8 to 10 minutes after the heart stops beating, yet, it took me a little over 7 minutes to read this article. By this time, the person is likely to be brain dead. The information is accessible and in chronological order, however, the reading time creates an issue for someone in a situation of panic. If Mayo Clinic would intend this article to be used as on-site guidelines, the article should be made more accessible to a greater percentage of people and it should be more concise in its readability.  

Carly K. Baumann