FEATURE ON...

WRITTEN COMMUNICATION

When writing Nicoll (1996), I was constantly challenging and changing the way I compose initial assessment reports. I routinely sent copies of reports to parents, varying length and complexity depending on the desired effect. By the time I left clinical practice in 2002, I was writing all reports directly to parents / clients, with copies to professionals. My client-centred approach did not however bear much scrutiny as, although I had consulted colleagues about the content and style of a series of information leaflets, I had not asked the target group of parents for their thoughts. I wonder what I would do differently now - and how written communication will have changed in 10 years time? We use writing for so many purposes at work appointment letters, reports, advice sheets, information leaflets, posters, case notes - aimed at people from a range of backgrounds, abilities and interests. The environment is full of the written word. So how do the roughly 1 in 5 adults who have difficulty with basic literacy and numeracy (Moser, 1999, cited in DH, 2003) manage with daily activities as diverse as travel, interpreting food and medication labels, completing forms, applying for jobs and finding out and remembering something they want to know? And how do we enable everyone to access what they need without dumbing down? For Susanne Simms, a lecturer at UCE in Birmingham, dyslexia teacher and former private speech and language therapist, being able to say what you mean in writing is a fundamental but undervalued skill. She urges us to take responsibility: You have a message to get across. If you dont manage to do it, your report will not be as successful as you would like. An online toolkit (DH, 2003) provides guidance for anyone who produces written information for NHS patients, their carers and the public such as leaflets, booklets, single sheets or posters. All our communication must be clear, cost-effective, straightforward, modern, accessible, honest and respectful. Tips to make writing clear - use present and active tenses, lower case letters and a question and answer format - are included, along with checklists and templates to help you plan information leaflets. This guidance suggests planning and writing should come before consultation with service users - but there are advantages to starting with the consultation. Otherwise we risk turning people off by telling them what we think they should want to know, rather than what they actually need or want.

The write
In the Winter 04 issue we looked at how the profession can contribute to making new buildings more accessible. Here, Avril Nicoll continues the accessibility theme as she reflects on our approach to written communication

Pages from The Stroke and Aphasia Handbook (Parr et al, 2004).

The charity Mencap (2002) continues to develop its knowledge of accessibility by asking people with learning disabilities for their views. They suggest, Wherever possible involve your audience in the creative process. Seek the advice and ideas of people with learning disabilities as early as possible. When researching and developing the new Stroke and Aphasia Handbook, Parr et al (2004) noted that information is rarely given directly to the person with aphasia. So, as well as setting up an advisory panel of people with aphasia and getting ideas and feedback from other individuals and groups of people with aphasia and their relatives as the writing progressed, the book starts with the words: People with stroke and aphasia, this book is for you. Legislation and key policy developments drive changes in services, and user involvement, evidence based practice and accessibility are current themes. The Stroke and Aphasia Handbook really scores here, being full of respect for autonomy, the influence of time, the need to find out more,

and aphasia as a life-changing event. Sometimes, however, people putting changes into practice miss the point. While Kingston Primary Care Trust speech and language therapist Deborah Green considers the white paper Valuing People (DH, 2001) to be a watershed, the immediate effect was for her department to be swamped with requests to make leaflets more accessible. As Deborah says, How can you make a 50 page document accessible? Non Elias is a speech and language therapy support worker in a team for adults with learning disabilities in Wales. Her core work includes involving service users and making written information accessible. Projects have included daily schedule boards, menus, leaflets, shopping lists and information boards using photos and symbols.

Changing a culture
In Southwark, Petrea Woolards team got a new post to help services become more accessible to people with learning disabilities and to increase

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SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

FEATURE ON...WRITTEN COMMUNICATION

stuff?
involvement of service users. That therapist found out from service user forums how people should ask for their opinion and how the environment should be set up. The department also assists people with learning disabilities to become trainers of other organisations on how best to give information to service users. This training encourages people to recognise that accessibility is about interaction - and changing a culture to make it friendly and welcoming. It is important to realise that images help explain the text and are not just there to make the material look accessible (Mencap, 2002) and to consider whether a leaflet / brochure / CD / DVD / audiotape / person to person is the most appropriate medium. Deborah Green is enthusiastic about alternatives to leaflets. She understands that people with learning disabilities find the most helpful ways to receive information are 1. for someone to sit down with them and talk about it 2. a drama presentation 3. a video. She says, It is important to be creative, to think about how you can take someone into context and to have the opportunity to repeat three or four times. Her team now has an Easy Information Group of service users. Everything that has been designed to be accessible is brought to the group to road test in the way it is intended to be presented, and for feedback on what they think of it and what they understand by it. The vast majority are written documents which do not always produce expected comments, for example the frequent appearance of an ear symbol in an audiology document was interpreted as pork chops. Also, a leaflet (A4 folded in three) was read all the way across rather than in sections. The Easy Information Group was introduced through a presentation, followed by a role play, then the song, Nice N Easy. Deborah says, A year ago, wed never have been brave enough to make it real. I really feel for the first time in a long time service users are being involved and were making real changes together. However, she cautions that being person centred means not making assumptions about the level of involvement service users want to have. For example, when working on Health Action Plans, some clients just want to know that they can choose the colour of their folder before they talk about what might be in them. Differentiation is also important to Louise Scrivener, the first speech and language therapist in a womens forensic service in Birmingham. She wanted to find a way of doing an assessment report that would allow her client to take responsibility for her communication. The method she used also provided a model for other professionals

and raised the profile of speech and language therapy at the same time. Over a few sessions, Louise assessed her client then they analysed the results together. Louise wrote up the assessment in parts and went over it with the client, changing any words or sections she didnt understand. They then agreed who would be invited to a presentation to discuss the results. While the entire report was on overheads, the client also had a summary as a prompt. The process got good feedback from the other professionals who attended and the client has asked to work with Louise again.

Facilitative approach
Over at the University of Central England in Birmingham, Susanne Simms also believes that time spent explaining things to clients pays off as both the clients and other professionals can then access the information more easily. We cannot assume that coming from a medical or educational background means people interpret terms (even everyday words) in the same way. Explaining what the impact of a child or adults impairment will have in different contexts enables others to make sense of what you write more easily. Susanne sees a tension between the expert model where the speech and language therapist knows it all and the partnership model where the therapist and the client work together. The expert model moves the profession towards a focus on impairment, while the latter frees us up to think holistically. Susanne has been complimented by tribunals for her clarity in report writing. She believes this is because she explains what problems mean for the child, the family, the school, the therapist and other people, and uses language which enables people to access her meaning even if she isnt actually there. Alison Webb is another speech and language therapist whose general report writing has been influenced by her work with tribunals and Special Educational Needs & Disability Tribunal training. In a legal situation the stakes are high - and when a well-written report obviates the need for court proceedings, everyone benefits. Alison, an independent therapist in Peterborough, now avoids what the parent-led organisation Afasic calls weasel words - benefit from, opportunity to, access to, regular, input, contact, facilitated by - and is far more precise about everything including therapy setting, frequency, type, timescales, targets and reviews. She includes information about her qualifications and experience as well as evidence to back up her recommendations. (Mencap guidelines (2002) suggest putting your photograph at the end of a letter so the reader knows who you are.)

When composing reports or other information, advice from the Plain English Campaign can be useful - but putting it all into practice is easier said than done! This independent pressure group wants to see all public information written in a language that the intended audience can understand and act on from a single reading. The group defines public information as anything people have to read to get by in their daily lives. As well as listing alternative words (why use commence when start will do the same job more effectively?), the campaigners suggest you make writing clearer by using: short sentences mostly active verbs verbs rather than the nouns formed from them you and me words that are appropriate for the reader instructions (with a please) positive language. The Plain English Campaign says that if you spend more than an hour a day writing you are, to an extent, a professional writer. But what can we learn from the real professionals? Taking account of the readers perspective is meat and drink to copywriter Chris Gregory, and he has used this skill to help his wife - speech and language therapist Neera Malhotra construct leaflets and articles. Looking over his companys website, there are many suggestions for people in business which we could adopt, including: Research and preparation time is vital. Be personal - always consider that you are addressing an individual. If you can, visualise in your minds eye the person - or typical person you are writing to. It is usually fairly easy to list the features of a service - but, if you want to engage people, you need to make the benefits of these features clear. Decide on the key messages you want to convey. Allow time to get something down on paper, return to it after a couple of days, amend it, read it aloud and get it checked by other people. Chris says, In every communication, try hard to put a limit on the number of points you want to get across. Ideally, there should be one key point, with the others of a subsidiary and related nature. The more points you try to include, the less likely any one of them will be adequately communicated.

Louise...wanted to find a way of doing an assessment report that would allow her client to take responsibility for her communication.

SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005

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FEATURE ON...WRITTEN COMMUNICATION

Whatever it takes
Customer focus in business is driven by a wish to increase sales but the concept is not too far removed from a person centred speech and language therapist wishing to improve accessibility. As Evans (2002) says in discussing the background to Mencaps guidance, do whatever it takes to make your writing accessible to your audience. For Bethan Jones, who is developing advice leaflets for parents in Sandwell where literacy levels are low, this means focusing on soundbites, captions and cartoons and a video. For Vanessa Crowe it meant embarking on a training programme and producing a resource called Stickerpack (Crowe, 2003). She realised there were accessibility problems when swallowing guidelines in her Edinburgh elderly care stroke unit werent being adhered to. From discussion with staff, it seemed there were three elements - non-compliance, a need for training and limitations of the communication method used (a sheet of paper above a bed). Research told Vanessa that information is retained and remembered more easily if it is given in more than one way, for example written text and pictures. Taking road signs as a model, she gradually built up a collection of symbol stickers to go on a display board. Backed up by the speech and language therapy team and an ongoing training programme, there was an improvement in compliance, and it was noticeable that auxiliary workers who didnt have English as a first language learned the symbol meanings quickly. As Carole Pound and Susie Parr might say, the information stuck. They run a study day for Connect, the communication disability network, called A toolkit for making information stick. I was interested to hear how policy is being put into practice, particularly in the field of aphasia, and how greater user involvement and increased accessibility are part of a bigger picture of people taking - and being allowed - more responsibility for their own health and well-being. The course usefully includes rating scales for assessing information in your own setting, divided into three areas of clarity, process and tone. Reflecting the experiences of others in this article, the key messages are: Information is the foundation of involvement Information can be enabling or disabling Theres more to accessible information than large print or pictures Information is a dynamic, multi-faceted process The shape that information takes depends on the person, the time and the context.

Petrea Woolards team in London have given a lot of thought to shaping information, asking questions like, Who are the reports for? How are appointments being made? Is it essential that I write in this way? If so, how do I provide the person its about with something that is useful to them? Talking Mats (Murphy, 1998) is excellent for gathering opinions and goal setting with clients. Sometimes PowerPoint presentations are used for reports, and people with more complex difficulties who are leaving school get a CD ROM with video clips made, so the receiving service providers can meet the person before they actually meet them. Technology, such as the internet, is also used by Petreas team to look out and improve practice. Jan Roach, a speech and language therapist at St Andrews Hospital in Northampton, comments that life has changed enormously in the past two years with wider access to e-mail and the internet. She is very positive about the resulting opportunities to update more people more easily, reduce paper, and get immediate access to information discussed by clients. What advances in accessibility will technology produce in 10 years time? Ken Fee is a top interactive designer of software for games consoles. He is keen to research how the intuitive nature of games could be harnessed to benefit people with communication disabilities, but is concerned that funding bodies dont fully appreciate that a generation raised on electronic games will benefit hugely from research that needs to start now if it is to be applied in 10 years time.

Intuitive flow
Ken expects wireless technology and hand-held devices to take off, with less reliance on keyboards and modems. The intuitive flow offered by selection menus, with up/down buttons, means there will be less and less need to rely on user manuals. He believes we should exploit the opportunities of new media to promote interaction, and reminds us that, Anything that someone wants to show to someone else should be entertaining and involving for the person presenting it as well as the person receiving it. Writing is one way people demonstrate how clever they are. If I was back in clinic tomorrow, I would remind myself that cleverness in public information lies in increasing access to written communication and in asking whether it is the write stuff in the first place. In 10 years time, Petrea Woolard hopes that specialist services for people with learning disabilities will all have well supported forums where people can express their views, and that people accessing generic services will have an easier time of it - whether they have English as a second language, aphasia or any other communication difficulty. She says the ultimate test of our accessibility efforts will be whether or not someone providing a service realises, That isnt helpful - Ill need to change the way Im saying it.

References
Crowe, V.J. (2003) Stickerpack: Safe Eating and Swallowing. University of Stirling Dementia Services Development Centre. DH (2001) Valuing people: a new strategy for learning disability for the 21st century. Department of Health: London. DH (2003) Toolkit for producing patient information, Version 2.0. The Department of Health: London. Evans, S. (2002) Accessibility unit at Mencap. Bulletin of the Royal College of Speech & Language Therapists June 602: 20. Mencap (2002) Am I making myself clear? . http://www.mencap.org.uk/download/making_myself_clear.pdf Murphy, J. (1998) Talking Mats: speech and language research in practice. Speech & Language Therapy in Practice. Autumn: 11-14. Nicoll, A. (1996) Initial assessment reports have to fulfil many functions. Human Communication. Summer Supplement: 6-7. Parr, S., Pound, C., Byng, S., Moss, B. & Long, B. (2004) The Stroke and Aphasia Handbook. Connect Press, e-mail carolecross@ukconnect.org.

Practical points: written communication

1. Take responsibility for getting your message across 2. Consult service users as early as possible 3. Know your key messages 4.Allow time for planning and checking 5. Be clear, precise, straightforward, honest and respectful 6. Speak to individuals 7. Develop a friendly and welcoming culture 8. Use different media flexibly 9. Problem-solve and think holistically 10.Have vision

Resources
Afasic - see www.afasic.org.uk Chris Gregory - www.mortongregory.com Connect training courses - www.ukconnect.org or e-mail carolecross@ukconnect.org Ken Fee - e-mail albanart@aol.com Plain English Campaign - www.plainenglish.co.uk

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SPEECH & LANGUAGE THERAPY IN PRACTICE SPRING 2005