“Nurses at a large maximum security prison are teaching patients about sexually transmitted diseases. While the inmates await their chronic care appointment in the clinic holding area, they are given written material printed from the Centers for Disease Control website. During the nurse portion of the chronic care visit, each inmate is asked if they received the material and if they have any questions. If they have no questions, the nurse documents successful patient teaching on the topic in the medical record.”
This example (page 11) from the Essentials of Correctional Nursing invites us to think about the situation and to “Describe flaws in this process and suggest improvements in the teaching method.” Last week’s post pointed out that at least 36% of the population have limited health literacy. The following are “best practices” to improve health communication. How many would apply to the case example above?
Identify the audience and focus the message: Our ability to understand and act upon communication is effected by the factors listed below:
Communication of health information will be more relevant if it is sensitive to the characteristics of the intended audience. For example, would youth at a detention facility prefer to receive information about basic oral hygiene via a cartoon with rap music or in a film of a dentist in an office setting brushing a large set of false teeth? These options and many more are available for free on Youtube, just type in the search term, oral hygiene. The more the information and it’s delivery can be tailored to the preferences of the audience the more successful the communication will be.
Best Practices for Oral Communication: The problem with verbal information is that patients only retain about half of what they are told and they are uncomfortable asking to have information repeated. To increase patients’ retention the following are considered “best practices”:
- speak slowly and keep the message simple
- limit the amount of advice to no more than 4 points
- cover the most important point first
- advice should focus on patient behavior that is the most important to a good outcome
- organize information logically with the simplest coming before more complicated information
- give concrete, specific and vivid instructions; avoid abstract or general statements
- use active rather than passive voice
- use plain language and a thesaurus to avoid medical terminology or jargon
Best Practices for Print Communication: Patients prefer to have pictures or graphics accompany written information. Pictures also improve comprehension. Printed material should not replace personal interaction and is most effective when it reinforces verbal information. Patients prefer information presented with simple visuals especially when ill or adjusting to a new diagnosis. The following are “best practices” for print communications:
- the most important point should appear first
- use 12 point font, limit sentences or lines to 40-50 characters.
- use headings and bullets to break up text
- avoid using all capital letters (this is akin to shouting), italics or fancy script
- use a lot of white space in the margins, between points and to separate paragraphs or ideas
- avoid decoration; all print material should be specifically relevant to the point being made
- pictures are encouraged when the picture
is linked to the text
is concrete, not complex
supports key points
is without unnecessary detail
Evaluate the Patient’s Understanding of the Message: Don’t assume that the patient understands if they don’t ask any questions. In fact asking patients to restate what they have been told is among the top patient safety practices recommended by the Agency for Healthcare Research and Quality in their 2001 report. This technique, referred to as “teach-back”, improves retention and allows the nurse to correct misunderstandings. The following are tips on how to evaluate patient comprehension:
- Ask open ended questions. In the example above it would be better if the nurses asked “What questions do you have about sexually transmitted diseases?” rather than “Do you have any questions about STDs”
- Questions that start with “what” or “how” are more likely to be open ended.
- Ask the patient to tell you in their own words what they understand. One way to do this is to say “I want to make sure I didn’t leave anything out so would you please tell me in your own words what we have discussed” or “What will you tell your (family member) about your condition?”
- Present the patient with a problem or scenario to see if the patient can apply the information. The nurse might ask the patient receiving STD education “What should you do if you experience pain and burning upon …”
- If the patient is unclear about one of the points, re-phrase the information rather than repeat it.
The flaws in the example at the beginning of this post are:
- the material provided does not appear to have been selected with a specific audience in mind
- printed material was used in lieu of oral communication
- there was no evaluation of the patient’s understanding of the information given
Here are some tools and resources to address health literacy:
1. Clear Language and Design evaluate readability, examples, online Thesaurus http://www.eastendliteracy.on.ca/ClearLanguageAndDesign/start.htm
2. Plain language thesaurus http://depts.washington.edu/respcare/public/info/Plain_Language_Thesaurus_for_Health_Communications.pdf
3. More on Plain Language http://plainlanguage.com/
4. Creating easy to understand materials http://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf
5. Clear & Simple: Developing Effective Print Materials http://www.cancer.gov/cancertopics/cancerlibrary/clear-and-simple
6. Health Literacy Tools http://www.health.gov/communication/literacy/#tools
7. Gateway to Health Communication and Social Marketing http://www.cdc.gov/healthcommunication/cdcynergy/editions.html
8. Health Communication, Health Literacy, and e-Health http://www.health.gov/communication/
What resources have you found particularly helpful in addressing the care of patients with low health literacy? Please tell about your experience, success and resources addressing health literacy in the correctional population by responding in the comments section of this post.
To read more about correctional nursing practice order your copy of the Essentials of Correctional Nursing directly from the publisher. Use promotional code AF1209 for $15 off and free shipping.
Photo Credit: Catherine Knox 2/28/2013