Patient Teaching and Health Literacy
Objectives
1. Identify the common causes of patient medication errors.
2. List some of the problems patients have when they cannot read or understand health instructions.
3. Describe the process of teaching patients about medications.
Key Terms
compliant (kŏm-PLĪ-ănt, p. 10)
concordance (kŭn-KŌR-dăns, p. 10)
health disparity (dĭs-PĂR-ĭ-tē, p. 11)
health literacy (LĪT-ĕr-ă-sē, p. 11)
literacy (LĪT-ĕr-ă-sē, p. 11)
noncompliant (NŎN-kŏm-plī-ănt, p. 10)
Overview
http://evolve.elsevier.com/Edmunds/LPN/
One of the basic parts of the nursing role is teaching patients. If patients are to have successful results with medications, they must learn all they can about the drugs and how to take them properly. The nurse must learn how to speak clearly as they teach. This can be very difficult when patients do not speak English or have poor reading or writing abilities. It is also hard if patients are not ready to learn.
The reason we teach patients about their diseases, their drugs, and what to expect when they take the drugs is to help them improve their health. Patients who do not clearly understand basic health information have less ability to carry out the treatment plan. Patients who are unable to carry out the treatment plan, for whatever reason, are at greater risk for having problems or not getting well.
Compliance, Noncompliance, and Concordance
Often a patient is said to be compliant when a plan of care is followed and noncompliant when it is not. A better term to use, one that does not judge the patient, is concordance. Concordance or agreement might be defined as the nurse, patient, family, physician, and pharmacist working together as a team to implement the treatment plan.
There are two basic reasons a patient has difficulty meeting treatment goals:
1. The patient does not understand what to do.
2. The patient understands what should be done but fails to do it, because he or she:
• may not believe the plan needs to be carried out.
• may believe something should be done but fails to carry out the plan.
• may believe something should be done but does not have money, time, or ability to do it.
In teaching the patient, focus on helping the patient make informed decisions about taking medications. (See Chapter 5 for other factors that might make it difficult for patients to follow treatment plans, including cultural and life span considerations.)
Communicating With the Patient
In the busy health care setting, it may be difficult to find time to talk with patients. In addition, many of our patients are from different countries or cultures and have different languages and beliefs that affect their ability to understand or talk about their health. Many nurses also are from different countries and cultures. This means that beliefs about what is important or harmful may not be the same. Even words used by both patient and nurse might have different meanings to each. A growing number of patients are older adults, with their own challenges to hearing, understanding, and acceptance of suggestions.
Although speaking clearly to patients is important, much of the teaching that patients need will be given in writing. Thus what is written and how it is written is very important if we wish to send the right message.
In the U.S. (per house style), we say that people are literate when they have the ability to read, write, and speak in English, to do math, and to solve problems at the level necessary to function on the job and in society. During the last 20 years, research has shown that many people in the United States do not have the basic level of literacy to allow them to do these tasks. In 2003, the latest National Assessment of Adult Literacy reported that 30 million Americans scored at Below Basic level of literacy, the lowest of four levels, and another 63 million were at Basic level of literacy, the second lowest level. People are placed in these two lowest levels if they have trouble finding pieces of information or numbers in a long text, putting many pieces of information together into one story, or finding two or more numbers in a chart and doing a math problem. These levels are roughly equal to being able to read at about the fifth-grade level.
While general literacy is a problem, we have also learned that many patients do not have high levels of health literacy—the ability to understand and use information that is important in keeping them healthy. Low literacy limits a person’s ability to deal with the health care setting, which has become more complex and uses written materials even more difficult to understand than those used in everyday life. This may mean patients cannot read a prescription to learn how many pills they should take, cannot figure out when their next appointment is, or cannot read a map to help them find a pharmacy or get where they need to go for their appointment. It often means they cannot read the information nurses or physicians send home with them explaining their disease, the medicines they are taking, and important things they need to know. Thus they often do not have the information they need to help them get well or stay well.
Even patients who read at college level have been found to prefer medical information written at the seventh-grade level. Recent research suggests that written information given to most patients should be written at a fifth- to seventh-grade level if we wish to make it more likely patients will understand it. This will be a challenge.
Although there may be large numbers of people in the United States with low literacy, research has documented that certain groups may have more problems than others. People who are older, are from minority races or ethnic backgrounds where English is not the dominant language, live in certain areas of the country, have a low income level, or are in prison tend to have lower literacy levels. Research about the reasons for these disparities has shown that frequently these individuals have not been able to stay in school and get an education.
It makes sense that people who have low literacy levels often have poor health outcomes. Because they cannot read or write they are at higher risk for disease and disability. This situation is called health disparity. Unfortunately, such individuals often die from a disease several years earlier than someone with higher literacy simply because of this difference in ability to read and write.
Because of these factors, there is no more important teaching than that given by the nurse to the patient about the patient’s disease and its drug treatment. This teaching is a big factor in whether the drug therapy ordered will be effective. When patients don’t understand and so cannot follow the treatment plan, there are often limitations in what the patient can do to take care of themselves. Accurate, careful teaching of the patient by the nurses involved in their care should help reduce such problems. This is very true when medications are involved, because drug information is usually complex and thus is often given in writing.
The Process Of Patient Education
Assessment Of Patient Education Needs
The fact that a nurse knows a patient should have information does not mean the patient is aware of that need or, in fact, expects to learn from the nurse. Patient education has to involve both teacher and learner and cannot be forced. Patients may show one of four types of behavior when seeking drug information, as shown in Table 2-1. Patients will go to the person they feel is the best source of information or with whom they feel most comfortable.
Table 2-1
Behaviors of People Seeking Drug Information
| CLASSIFICATION | PERCENTAGE | CHARACTERISTICS |
| Uninformed | 34% | This group tended to be older, was less likely to have received written or verbal counseling from a provider or pharmacist, and did not seem to recognize the results of improper drug use. |
| Rely on physician | 40% | This group took information as given from the physician and was most likely to get prescriptions filled at chain pharmacies. |
| Rely on pharmacist | 19% | This was the youngest group; they got information at the pharmacy and saw few barriers to getting information. |
| Questioners | 7% | This group included those who were more likely to receive information from books or magazines. They required clear information about specific questions and appeared to be the most difficult group to satisfy. |
Modified from Morris LA, et al: A segmentational analysis of prescription drug information seeking, Med Care 25:953-64, 1987.
There may be some differences between the information clinicians see as important and the information patients want. For example, it may be hard to discuss some of the serious side effects that might be caused by a drug. Nurses may not want to talk about some of these problems for fear of scaring patients to the point they won’t take the drugs. However, research has shown just the opposite result with many patients. Patients who are given more information feel more comfortable taking their drugs and can correctly recognize side effects, should they occur.
More emphasis is being placed on the use of computers, both in learning the needs of patients and in meeting those needs. In some situations, computers are even helpful in teaching patients with low literacy skills. Computers may be used for health surveys and have been shown to result in more honest reports of certain health behaviors. A few years ago, a study found that patients might actually be more comfortable revealing personal information on a computer than to a human being—even though they know the information will be seen later by health care workers.
The registered nurse has primary responsibility for patient teaching, but all nurses caring for the patient play a role. The important items to include in the patient-teaching process are the following:
Preparing A Teaching Plan
The patient’s need for information is based on the patient’s disease, the treatment plan, and the patient-nurse relationship. When a patient is first diagnosed with a problem, education must start with what has gone wrong in the body and what is likely to happen next. To consider what to do to return to good health, the patient must first understand what has led to illness in very general terms. The nurse teaches in simple terms and in line with their own understanding.
As patients begin any therapy, there is a good deal of information that needs to be shared: what they think, what they expect, and any choices they might have. For example, starting the patient on a new medication requires a lot of teaching. It is clearly not possible to provide all the information a patient might need in one teaching session. Instead, you need to have a plan in mind for the things that need to be covered, and this plan needs to be shared with the patient (Box 2-1). Additional teaching will be required when drugs are changed, when the dosage or schedule is altered, or when changes in patient condition warrant further adjustment in therapy. Therefore, teaching becomes specific to what the patient requires, but it is always given in quantities that the patient can handle.
Informed consent is something we assume in the process of giving a medication to a patient. The nurse shares a legal obligation with other health care providers to make certain that the patient understands the condition, the treatment, and the risks and benefits of treatment plans. The law requires that the amount and type of information provided to the patient be “reasonable.” It is up to the nurse who is given the task of teaching the patient to determine what is reasonable for a specific patient to understand; the nurse may be held legally responsible for failure to teach the patient this information.
In the clinic or hospital, teaching often happens in response to a patient’s question, and the nurse may need to respond quickly without time to prepare, plan, or consider overall what the patient needs to know. Using scientific or nursing language or jargon, giving too much technical detail, or being vague does not provide clear information. It is impossible to avoid answering questions, even if they take you by surprise—just do your best to answer. It is also important for there to be a written plan that covers what will be taught, how it will be taught, and how you will know when the patient has learned the material. This plan can be changed if necessary or if it makes sense to present some information earlier based on patient questions.
The plan developed by the nursing staff for teaching the patient should have specific objectives to guide teaching. The objectives must state the new behaviors that will occur because of changes in the patient’s thinking or understanding. The best objectives are clearly stated by describing the desired outcome and what makes it acceptable. Specific goals help clarify for patients what they are to do. For example, “Blood pressure will drop to diastolic reading less than 90 mm Hg within 3 months” is a specific, measurable goal based on national guidelines. As patients and nurses create objectives together, the nurse has a chance to evaluate the patient’s knowledge, understanding, and general desire to change behavior.
Implementing The Teaching Plan
Both the content of patient education and the process of patient education are important to think about in planning the specific teaching-learning objectives. Many patients are fearful when they first learn their diagnosis. Stress and anxiety increase the confusion they often feel and interfere with their ability to learn.
Teaching needs to be offered in a systematic manner to decrease stress. It needs to be provided in a timely way and in a quiet and unhurried setting that gives the patient a chance to ask questions. It is hard to find a setting like that in today’s busy health care system. Research has suggested that people are able to remember three major things they are taught in any one session. Also, they generally remember those three things in the order in which they are presented. If you keep this in mind when developing a teaching plan, you can set aside small periods to use for teaching a few very specific things. At future visits, you can review the information presented in an earlier session to find out how much the patient remembers before you move on to the next phase of teaching.
To help the patient accept what is taught, the nurse may use a variety of ways to give patients information about their medications. Some of these methods include telling patients the necessary information, reviewing written instructions with them, and using audiovisual aids such as audiotapes, videotapes, CD-ROMs, or computer teaching systems that may use animation, color, music, and action figures to help the patient learn the information.
Verbal Education
Verbal education is often direct teaching, with the nurse telling the patient information and then giving the patient a chance to ask questions. Patients who have extensive needs for teaching may also be brought together in small groups for part of their teaching experiences; these might be patients with chronic diseases such as diabetes or hypertension.
Written Information
Written information can include special labels for prescription bottles, materials inserted in the drug package, or specially prepared materials or booklets that accompany the medicine. Preprinted instructions about medicines are available from manufacturers, pharmacy associations or some medical associations, and private companies. This information is often written and a high school or college level. Written information may also be created by the nurse, hospital, clinic, or may come from a professional group such as the Arthritis Foundation or the Asthma and Allergy Foundation of America. Increasingly, professional materials are written at a lower education level and may even be marked as to grade level.
Many books and preprinted patient information materials are already available from commercial sources (Box 2-2). With the growing use of the Internet, information about new products is widely available and often may be downloaded by the nurse to create high-quality handouts that may be changed as necessary for specific patients. In fact, the problem is not in finding patient teaching materials, but in evaluating their quality and how they may be used. Many materials are written at a high grade reading level and thus are not very helpful to those with reading difficulties.
To see if published handouts would be helpful for your patients, keep the following in mind:
• Be sure the goals of the teaching are stated.
• Focus on the behavior they should have rather than the medical facts.
• Use common or familiar words and not medical words.
• Clear communication should use short, simple sentences without complex grammar.
• In some settings, handouts may be needed in several languages
Audiovisual Resources
Audiovisual programs such as slide-tape programs, videocassettes, and CD-ROMs are also available for patient teaching. Some patients will be able to use the Internet, and this allows patients to select what they want and download it for future reference.
Television ads that are created by drug companies for patients are called direct-to-consumer advertising. Patients may have many questions or inaccurate information because they have seen these ads. When patients raise questions because of these ads, this is a good opportunity for you to assess what they know and provide correct information.
Talking to patients and giving them written information, or talking to the patient along with showing audiovisual aids, is usually better than only giving the patient things to read. This is very important for patients with new prescriptions.
Nurse and Patient Use of the Internet
One of the biggest challenges for health care workers is finding up-to-date information to use in teaching. Textbooks and journal articles may be years or months old before being printed. New information is available every day, so it is essential to provide patients with the latest information. This task is easier than it has been in the past because of the Internet. The Internet is becoming a source of up-to-date health information, not only for nurses, but for patients as well. Many Internet sites meet the needs of both. A number of sites offer directions for using the Internet. They range from those which focus on the basics, to more advanced Internet courses (Table 2-2).
Table 2-2
Websites that Offer Information for Navigating the Web
| WEBSITE | URL ADDRESS |
| The Help Web | www.imagescape.com/helpweb |
| The Internet Learning Tree | www.walthowe.com/navnet/ |
| Internet Web Text Index | www.december.com/web/text |
| Navigating the Web | http://digitalenterprise.org/navigation/nav.html |
| Navigating the Web: Using Search Tools | http://healthlinks.Washington.edu/howto/navigating/ |
| Navigating the Web—Library Services | http://lib.mnsu.edu/research/navwebtext.html |
Although many business websites have accurate information, others may be more interested in selling something. Commercial or business sites use “com” near the end of their web addresses. They often scatter ads throughout their web pages, charge fees or dues, or talk about things to buy. The letters “org” identify a nonprofit group, “gov” a government agency, and “edu” an educational site.
Evaluation Of Learning
Patient education occurs to help change patient behavior and increase satisfaction. When objectives are written for each patient, the behavior change sought is clearly stated. Thus it should be simple to determine if learning has taken place. When blood sugar levels do not come down and stay down to the desired level, when blood pressure remains high, or when weight is not lost, there is failure somewhere in the education process. Sometimes the process breaks down when a patient does not understand what to do, cannot afford the treatment plan, or loses confidence in being able to change. Whatever the problem, the nurse must attempt to discover where the process went wrong.
You, as a licensed practical or vocational nurse, may be the teacher, or may just observe the teaching process. Active questioning and discussion helps the learner remember what was taught. You may follow up a more formal teaching session with your own comments and questions. As you have a chance to work with the patient you can provide active teaching with sensory involvement (like handling things, hearing things, eating something, and so forth) that will reinforce what the patient has learned in class and allows more effective learning to take place.
Throughout the teaching process, it is important for the nurse to summarize, repeat, and keep it simple. Check for understanding as the teaching continues by having the patient repeat back the important points. It is important not to create fear or stress when quizzing patients on information that has been discussed. Note in the patient’s record what has been taught—the important topics covered, what material was given to the patient, and your view of the patient’s level of understanding. List anything you believe shows the patient’s willingness to carry out the treatment plan.
Other factors that improve the success of drug treatment plans for most patients include developing plans that have frequent nurse-patient contacts, using reminder cards, giving blood tests for drug levels, making the plan fit the patient’s needs and culture, giving feedback and encouragement, and encouraging the patient to be actively involved in things like taking blood pressures at home or having a behavior contract with the nurse. Build these things into the written objectives.
