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Issues up close


Before nurses begin teaching patients about a new medication or other health-related regimen, they might want to consider this: A recent British study published in BMC Family Practice revealed that more than half of survey participants could not properly locate the heart on a diagram of the human body. Many could not make heads or tails of the location, shape, or size of other organs. On this side of the Atlantic, the Institute for Safe Medication Practices highlighted a study showing that 70% of some 300 parents gave the wrong acetaminophen dose to their children using a dosing cup with printed markings.

Louisiana State Nurses Association (LSNA) member Melissa Stewart, DNP, RN, CPE, is not surprised about the need to educate patients and consumers about health issues in a more meaningful, individualized, and patient-oriented way. Stewart’s passion for increased literacy led her to bring a resolution to ANA’s recent House of Delegates (HOD) to spur more action by nurses on this issue.

“We pontificate patients to death about what they should or shouldn’t do,” says Stewart, a nationally recognized expert in patient education and literacy. “But we are not ‘patient literate.’”

She believes that too often nurses and other healthcare professionals fail to determine where patients are in terms of their learning needs, values, priorities, and lifestyle factors. “Every time a patient leaves any healthcare access point—from hospital to office—that patient should leave with more knowledge,” Stewart says. “If they don’t understand the information nurses and other providers are offering or are not given a rationale for lifestyle-change recommendations, their decisions will be made with limited knowledge that can impact their health and quality of life and could even cost them their lives. Bringing patients to a level of personal understanding is morally and ethically the right thing for nurses to do.”

Inside the resolution

As the nation moves toward a patient-centered, proactive, and preventive model, consumers must understand their health status and provider’s instructions so they can make truly informed decisions, according to a background report that accompanied the resolution submitted by LSNA and authored by Stewart.

Yet patient education, which is a shared responsibility of nurses and other healthcare providers, often is “assumed, overlooked, ill-planned, and undervalued,” the report states. “The nation’s patients and consumers of healthcare services need their most trusted professionals— nurses—to drive substantial initiatives to address health literacy concerns.”

To accomplish that goal, nurse delegates at ANA’s 2010 HOD approved the literacy resolution, which calls for ANA to implement the following:

  • Promote collaborative nursing initiatives to address health literacy problems.
  • Use existing research findings to strengthen health literacy knowledge and skills in nursing school curricula and in RNs’ workplaces.
  • Advance nursing research to identify evidence-based practices that promote optimum health literacy.

    Barriers to understanding

    Renee Gecsedi, MS, RN, director of Education, Practice and Research at the New York State Nurses Association (NYSNA), recommended the New York delegation support it—in part because it’s in line with longstanding NYSNA policy emphasizing nurses’ crucial role in patient education.

    “As RNs, it’s our responsibility to provide patients with the information they need,” Gecsedi says. And nurses and other healthcare professionals should present that information using everyday layman’s language, free from medical lingo.

    But that’s not always what happens. Even instructions accompanying over-the-counter medications can be confusing or incomplete. For example, packaged instructions may list one dose for children younger than 3 months and another dose for those from 3 to 9 months, Gecsedi says. So which dose should parents give their 3-month-old child?

    Language and cultural issues also come into play. Georgia Nurses Association board secretary and HOD delegate Rebecca Wheeler, MA, BSN, RN, is a former Spanish and French teacher who has lived in Spain and Mexico and has traveled extensively throughout Latin America. She ran into communication difficulties when she became ill and needed urgent care while traveling.

    “I was fluent in Spanish, but I was so stressed out that I wasn’t really listening to what they [healthcare providers] were saying,” says Wheeler, who spoke in favor of the resolution. “And although you can know the words and tenses, there are a lot of nuances in language. And simple words can take on different meanings in different cultures.”

    She also recalls potential patient education barriers when working in a fast-paced Georgia hospital emergency department. “Sometimes I was sending people home wondering if they really got what I was telling them,” Wheeler says. “Even if they had a grasp of the language, they were in pain or scared,” says Wheeler, noting that those conditions are far from optimal for learning.

    Gecsedi adds, “Acute care nurses do their best, but there often isn’t time to evaluate whether the patient or the patient’s family understand what nurses have taught them. That’s a huge piece that gets dropped.”

    To address this, NYSNA’s policy statement urges that “RN patient care must be created to afford the time necessary to assess, plan, implement, and evaluate patient education.”

    Another problem is that there can be a big gap between what patients are taught while hospitalized and what content is evaluated or provided once they become outpatients, Gecsedi says.

    Starting with the patient

    When nationally renowned health literacy expert and Florida Nurses Association member Cathy Meade, PhD, RN, FAAN, was working at a county hospital in the 1980s, she realized nurses and other healthcare professionals were providing patients with a great deal of patient literature—from discharge instructions to medication sheets.

    “But there was a real disconnect between the ability of patients to read and the readability of health information,” says Meade, who served on the Institute of Medicine committee that released a 2004 report recommending strategies to improve health literacy. “Whether patients have a lot of education or just a few years of schooling, when they come into the healthcare arena, they often are entering terrain that is unfamiliar.

    “The whole goal [of patient education] is to impart information to patients so they can make informed decisions. And nurses, by virtue of the time spent with patients and their families, are best poised to quickly decipher information patients need and determine the most salient way to present it so it makes sense.”

    Meade says nurses are good communicators and content experts. But she and other interviewed nurses offered some key strategies to help RNs improve patient learning and health literacy:

    • Make no assumptions that a patient already understands a particular topic, such as high blood pressure.


  • Listen to patients and create a plan together that reflects their values, lifestyle factors, resources, and health goals.
  • Refrain from asking “yes or no” questions, such as “This medicine is for your heart, right?”. Instead ask open-ended questions, such as “Can you tell me what this medication is used for and how do you usually take it?”. Make the connection of health information to patients’ everyday lives.
  • Don’t try to teach everything at once. Choose the most important issues to tackle first, and then work with the patients, their family, and other providers to determine follow-up patient education content and evaluation.
  • Use a variety of teaching methods and modalities, and determine which are the most effective for the learning needs of individual patients or a target audience. For example, Meade suggests using photo novellas to improve Hispanic farmworkers’ understanding of colorectal screening, using a “Wheel of Education” game format to verify community members’ understanding of cancer facts at a heath fair, or conducting hospital tours to enhance understanding of emerging technologies, such as biobanking.
  • Enlist patients as partners and try to help them develop their critical thinking so they can problem-solve health issues.Nurses also offered suggestions that can improve health literacy across facilities, communities, and the nation. Meade suggests nurses share with each other effective tools they’ve developed when working with patients, such as simple glossaries about a particular condition.Wheeler says it’s also important for nurses to advocate for more funding for public health services and school nursing, where many gains in preventive care and health literacy can be reaped.

    And Stewart, who trains healthcare providers on how to teach patients according to her Medagogy© model and is the developer of the Understanding Personal Perception (UPP) patient understanding assessment tool, says it’s crucial that more nurses gain the specialty knowledge it takes to become more competent patient educators.

    For more information on health literacy, go to www.health.gov/communication/literacy/quickguide/resources.htm and www.health.gov/communication/HLActionPlan/.

    Susan Trossman is the senior reporter in ANA’s communications department.

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