As the profession of nursing continues racing toward greater technological complexity, nurses are providing care for patients at even higher levels of acuity, yet the true essence of the profession continues to be measured in basic accomplishments. Nursing "basics" necessitate an intricate balance between highly technical skills and comforting care; emotional support and effective communication; and active listening and successful patient teaching. Ask any nurse and you'll hear that many daunting challenges lie in those important yet mundane tasks.
With regard to patient teaching, how can healthcare personnel be certain that patients understand concepts basic to informed consent, hospital safety, dietary restrictions, and prescription information—or even how to follow through with self-administration of medications or a scheduled, postdischarge appointment? What professional liabilities may be attached to that certainty or lack thereof?
In planning for discharge, how do healthcare professionals effectively teach a home nursing skill or communicate critical information to a patient with low literacy skills? How do we determine the best approach to use? Is it possible to make certain that the patient actually understands and can safely implement what has been taught? And finally, how do we decide that the patient is motivated enough to comply with instructions and actively participate in positive healthcare behaviors?
The scope of the problem
As many as 27 million American adults, one in five, are likely to be unable to read basic discharge instructions.1 The National Center for Educational Statistics estimates that approximately 40 million U.S. adults have literacy skills at the "lowest level."2 And an even more alarming report from the Institute of Medicine (IOM) states that nearly half of all adult U.S. citizens, or 90 million people, have difficulty accessing, understanding, and using basic health information.3 Population literacy deficits are estimated to cost the U.S. healthcare system 50 to 73 billion dollars annually.4 Research also finds an "important relationship" between low literacy and lack of desire to participate in medical decision making.5
Compounding the literacy challenge is the fact that the less literate are more often poor and unemployed, or underemployed in jobs unfavorably linked to economic downturns.6 Negative outcomes directly linked to illiteracy are higher healthcare costs, noncompliance or limited compliance with the instructions of the healthcare provider, and the potential for errors after discharge, especially medication errors. Several studies have demonstrated a direct correlation between low literacy skills and chronically poor health status. And in addition to all other health and illness challenges, illiteracy becomes a "silent disability."1
There are also well-documented misconceptions commonly held by some healthcare providers who recognize poor literacy as a challenge to health and illness care: Patients with low literacy skills are cognitively impaired or slow to learn; most adults with low literacy are immigrants and/or members of a minority; the number of years of formal schooling will help predict literacy; and patients will inform us if they can't read or understand directions, and they'll seek assistance when it's needed.6 As members of the healthcare team we often use "years of school" as part of our assessment, as if reading skills are inextricably linked to one's educational level. According to several studies, this is a faulty assumption. It's estimated that half of all consumers of hospital services, whether they've graduated from high school or not, can't read at the 5th grade level.2
Since research also supports that low literacy is linked to increased healthcare problems and concomitantly more hospitalizations, it follows that these are the individuals that we, in the healthcare professions, are currently seeing and treating in numbers disproportionate to the rest of the population.6 These are the patients that nurses must reach quickly and somehow engage in a meaningful exchange of critical information. As the director of the Agency for Healthcare Research and Quality (AHRQ) reminds us: "The main currency of healthcare is communication."
For the last decade, hospitalization and posthospitalization healthcare issues have become increasingly problematic. The discharging patient has often been more critically ill, in the acute care facility for only a brief time, and is more likely to be sent home on a regimen of medications that would daunt even the most knowledgeable patient. In one situation, a patient, age 60, has been discharged after 2 days in the hospital for newly diagnosed congestive heart failure. He's prescribed the following: furosemide, 40 mg BID; potassium supplement, 20 mEq BID; digoxin, 0.125 mg daily; a restricted diet, plus orders to exercise daily, and return to the physician's office in 2 weeks. Where will the nurse begin teaching, and how will success be measured? Is there hope for even minimal compliance? What responsibility do the health professionals retain for his safe self-care following discharge? Obviously literacy skills are just one part of the complicated compliance puzzle, but as stated by a past president of the American Medical Association (AMA): "If you can't read about it or understand it, you can't participate in the doctor-patient relationship."7
Nurses understand that assessment is the first step in addressing any patient problem. Assessment related to patient teaching should ask and answer four questions: (1) What does the patient know right now? (2) What must he know when he's home? (3) What will motivate him toward compliance and active participation? (4) How can he be taught the critical information that will keep him safe? But it's not really that simple. With literacy questions unanswered, the nurse must also establish how this patient best learns. So what, besides reading, exactly determines literacy? Why is this concept critical to the process of learning, and how do nurses look for indicators to adequately address the needs by which it's defined?
Health literacy defined
Some define literacy as the accurate interpretation and use of information for the intended advantage of that information.3 The AHRQ defines literacy as "an individual's ability to read, write, and speak in English and compute and solve problems at levels of proficiency necessary to function on the job and in society, to achieve one's goals, and to develop one's knowledge and potential."8
Functional health literacy encompasses the ability to use reading, writing, computation, and communication skills to a degree that allows full participation in the planning and implementation of a therapeutic regimen.9 Nurses know that patient education, when done effectively, is multifaceted and crafted to meet the needs of each individual learner. According to the IOM, "health literacy" involves more than an ability to read, but also to accurately interpret and use health information for its "best benefit."3 Healthy People 2010 added that health literacy includes the capacity of a person to "obtain, process, and understand information and services required to make appropriate decisions regarding health" and "the ability to understand ... consent forms and negotiate complex healthcare systems."7
The AMA Council of Scientific Affairs defines functional health literacy as "the ability to read and comprehend prescription bottles, appointment slips, and other essential health-related materials to successfully function as a patient." Health literacy, therefore, is a collection of skills within which some authors include analytical decision-making, a working knowledge of disease processes, self-efficacy, and the motivation necessary for compliance.
According to Healthy People 2010, the skills necessary for true health literacy may include:
- evaluating information for credibility and quality.
- analyzing relative risks and benefits.
- calculating dosages.
- interpreting test results.
- locating health information.10
In order to accomplish these tasks, individuals "may also need to be:"
- visually literate (able to understand graphs, lab values, and other visual information).
- computer literate (able to operate a computer).
- information literate (able to obtain and apply relevant information).
- numerically literate (able to calculate and reason numerically).10
With the emphasis on evidence-based practice for all branches of healthcare, it's not surprising that Carolyn Clancy, director of the AHRQ, is actively pursuing the issue of health literacy. A general audit of 684 articles by the AHRQ, followed by a detailed review of 73 of those articles, closely examined the role that low literacy plays in healthcare inequality and errors. This "best evidence" research concluded that those with low literacy skills have difficulty understanding how to self-administer medications and inadequate comprehension of hospital discharge instructions. These individuals are more likely to misinterpret informed-consent forms, have inadequate knowledge of their children's diagnoses and treatment plans, and are also less likely to understand the health effects of smoking, diabetes, asthma, and postoperative care—implications for long-term detriments to health and the impact on healthcare. The AHRQ is also calling for future research to determine if poor literacy skills are a primary cause of adverse health outcomes or if those outcomes are markers for other problems such as low socioeconomic status, poor access to care, or mistrust in the healthcare delivery system.
Assessing indicators of poor literacy
These indicators often include a recurrent pattern of missed appointments, and noncompliance with prescribed medications, diet, and exercise programs. Consider assessing carefully for the patient who may:
- have difficulty relating an incident clearly and concisely.
- change the story of his or her illness or condition often.
- seem nervous or appear to lack confidence in ability to read, interpret, and understand simple directions.
- avoid eye contact (outside of a cultural context).
- ask questions about what has already been explained or that which is clearly defined in given reading material or on a label.9
Patients with low literacy skills may also:
- appear uncomfortable when asked if they understand a permit, but will often sign rather than admit to having a reading problem or questions.
- demonstrate or verbalize unusual problem-solving skills or approaches to thinking things through.
- provide unusual or irrelevant answers to questions, or ask questions that appear irrelevant to the situation or problem at hand.9
Given the scope of the literacy issue, there will be no simple, unidirectional solution. If the issue is merely increasing patient recall and understanding of some small quantity of critical information, consider organizing information into "logical blocks." Make the message simple and specific for the patient to understand, summarize the message, and check understanding by asking the patient to restate the information in his or her own words or perhaps to return a demonstration of a skill.6 Check the verbal feedback and/or the return demonstration for accuracy and completeness and emphasize any critical data. (For additional information and proposed solutions to the complex health literacy issue, see Available resources.)
Health Literacy, American Medical Association Foundation
Ask Me 3
Health Literacy Studies, Harvard School of Public Health
Health Literacy Institute, University of New England
Literacy and Health Project, Ontario Public Health Association
Health Information Literacy, Medical Library Association
Canadian Literacy and Learning Network
Literacy Information and Communication System
Office of Minority Health
World Education, Health and Literacy Initiative
Bibliographies, webliographies, and web resources
Understanding Health Literacy and its Barriers, National Library of Medicine
Current Bibliographies in Medicine 2004–1
Proceedings of the Surgeon General's Workshop on Improving Health Literacy
Annotated Bibliographies: Health Literacy Links
Health and Literacy Compendium
Health Communication, Partners in Information Access for the Public Health Workforce
Source: National Network of Libraries of Medicine. Health Literacy Organizations and Programs. http://nnlm.gov/outreach/consumer/hlthlit.html#A7.
1. Conlin K, Schumann L. Literacy in the health care system: a study of open heart surgery patients. J Am Acad Nurse Pract
2. Horner S, Surratt D, Juliusson S. Improving readability of patient education materials. J Community Health Nursing
3. Young D. Low health literacy is high among Americans. Am J Health Syst Pharm
4. Weiss B, Palmer R. Relationship between health care cost and very low literacy skills in a medically needy and indigent Medicaid population. J Am Board Fam Prac
5. DeWalt D, Boone R, Pignone M. Literacy and its relationship with self-efficacy, trust and participation in medical decision making. Am J Health Behav
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6. Roter D, Rudd R, Comings J. Patient literacy: a barrier to quality care. J Gen Intern Med
7. Krisberg K. Millions of Americans suffer from low health literacy. Nations Health
8. Agency for Healthcare Research and Quality. Health literacy interventions and outcomes: an updated systematic review
9. Degazon C. You make the diagnosis: diagnoses and intervention with low literacy. Nurs Diagn
10. U.S. Department of Health and Human Services. Healthy People 2010