When I was 20, I got my first job as a public health nurse for the Philippine National Cross.
For a monthly salary of $41 (in 1987 dollars), I was charged to train local villagers in remote rural communities on the basics of first aid, sanitation, and to spread the word on the principles of the red cross and its many services. In short, I was a public health educator. Given my non-existent teaching skills and limited life experience, I became an avid observer and absorber of practical advice from seasoned health educators.
One of my early tutors was an affable educator with the brisk cheerfulness of a Disney cruise director who talked about a time teaching family planning. He told me about how he explained the contraceptive powers of a condom by showing his audience how to use it using his thumb as a stand-in for the male genitalia. A few months later, a disappointed audience member informed the educator that his wife got pregnant, in spite of his fidelity to sheath his thumb with a condom during intercourse.
Whether this anecdote is true or fabricated, it does not matter. My time teaching ordinary people brought me extraordinary memories – and later, skills, that I still depend on today. It was the incubation period of my nascent fascination with teaching. Nurses, no matter where they practice, will always be, in one form or other, instructing patients and their peers. Here I’d like to share some of my teachable moments in patient interactions.
In the semi-darkness of the hospital room, I handed the patient her dose of theophylline. Squinting her eyes, she scrutinized the medicine cup and declared, “I can’t see it.”
“It is transparent” was my reply.
The patient then cupped one of her hands, anticipating a touchdown of a transparent pill as she tipped over the cup, only to discover the syrupy run of a transparent liquid between her knuckles. This experience taught me two things: put the light on when giving meds and be explicit in my instructions. If I had said it was a transparent liquid, the impromptu gown change could have been prevented and the patient’s dignity preserved. One study has shown that the correct understanding of medication regimen was significantly enhanced by changing the pill bottle instruction from “Take two tablets by mouth twice daily” to “Take one tablet in the morning and one at 5 p.m.” It turns out “twice daily” is doubly harder to comprehend for the average reader.
The reason I’m asking…
Behind closed curtains I heard the following conversation between a nurse and a patient of a certain age, suspected to have a cognitive impairment.
Nurse: Can you tell you where you are?
Patient: I’m in the hospital.
Nurse: Which hospital?
Patient: In the hospital where you work! (with a hint of irritation)
Made sense to me. In this exchange (one might say cross examination), the patient, who did have mild dementia, seemed lost in the GPS-related line of questioning because she did not understand why her memory was on trial. It is always a good thing to explain why a question is being asked. For optimal comprehension, conversations and patient education materials should be written at a sixth-grade or lower reading level. Special attention must be given to older adults with sensory and cognitive deficits.
Keep it short and teach-back
Pneumonoultramicroscopicsilicovolcanoconiosis is longest word in the in the Oxford English Dictionary. Or, one can also just simply say silicosis. Hospital-speak is full of jargons and healthcare workers are prolific coiners, enough to make Shakespeare jealous. I recall a student asking me what I meant by “dusky” when I was describing a patient with an ominous grayish appearance. In speaking with patients, even those with college degrees, it is best to use plain language and words with fewer syllables. “Walk” is better understood than “ambulation.” Heart disease is the plain language substitute for cardiovascular condition. Say “yearly” instead of “annual basis.” To learn more on how to use concise language, access the Plain Language website at https://www.plainlanguage.gov/guidelines/concise/
To further ensure understanding, the teach-back method can also be used. It seems weird at first, but with consistent use, asking the patient “I want to make sure I explained it correctly, can you tell me in your own words…” becomes more natural. Come to think of it, asking the surgical patient if they passed gas also seemed embarrassing at first.
Picture this and ask questions
People learn in multiple ways, and the internet (YouTube, anyone?) has made the wired masses visual learners. Whenever possible, use simple drawings, pictures, moving images, models, and demonstration during patient teaching. While teaching nursing online, whenever I would discuss about providing certain patients with low-flow oxygen, I would physically put a nasal cannula on myself. This, I think, enhanced the students’ engagement and recall of the material. With images, the students (and patients) might be able to come up with relevant questions to ask.
People with low literacy tend to ask fewer questions. The clinician can give the patient and their loved ones an opportunity to ask questions or provide them open-ended prompts to answer.
A patient once told me that the reason he likes the hospital staff is they give him undivided attention. Can you imagine teaching a patient about their prescription while busily texting? In our masked world, it is already tough for patients to lip-read; denying them eye-contact while tethered to a mobile device is rude and disrespectful. Turning the computer screen away, or closing a laptop is a simple way to reduce distraction. It is also important to be mindful not to interrupt the patient while they are talking, and to intentionally listen to understand. I read somewhere that if we listen long enough to our patients, they’ll give us the diagnosis.
Nurses can harness the richness and dexterity of language and consider a patient interaction not just an opportunity to enhance health literacy, but also a chance to comfort the grieving, reassure the fearful, and give expression to a shared happiness in small mercies – after all, not everything in healthcare is bad.
Glick AF, Brach C, Yin HS, Dreyer BP. Health Literacy in the Inpatient Setting: Implications for Patient Care and Patient Safety. Pediatr Clin North Am. 2019;66(4):805-826. doi:10.1016/j.pcl.2019.03.007.
Wolf MS, Davis TC, Shrank W, et al. To err is human: patient misinterpretations of prescription drug label instructions. Patient Educ Couns. 2007;67(3):293-300. doi:10.1016/j.pec.2007.03.024.
Fidelindo Lim is a clinical associate professor at New York University – Rory Meyers College of Nursing.