Abstract
Health literacy promotion techniques are important for the school nurse’s toolkit. Health literacy, an Institute of Medicine objective, is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” Forty-three percent of the adult population has difficulty understanding basic health information. This article is the first of two articles that will describe techniques for improving verbal (part 1) and written (part 2) health communication.
Clear, ongoing, and thorough communication with parents is essential to improving health outcomes and learning for students. Most school nurses have experienced health history forms not being completed correctly or never returned, medications incorrectly administered at home, or children with fevers returning to school after being sent home the previous day. As frustrating as it may seem to the school nurse, what is perceived as non-compliance may in actuality be misunderstanding. Health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Institute of Medicine Committee on Health Literacy, 2004, p. 31). Reflecting the increase in awareness of the importance of health literacy in the last decade, Healthy People 2010 and Healthy People 2020 (U.S. Department of Health & Human Services, 2010) identified health literacy objectives (see Table 1). A school nurse’s knowledge of the importance of health literacy and use of commonly used health literacy tools in his or her practice can dramatically change both verbal and written interaction with parents and will undoubtedly lead to an increase in “compliance.”
Healthy People 2020 Communication Objectives
In June 2011, an NASN quick poll asked, “Are you using any of the following health literacy guidelines in your school nursing practice?” regarding three evidence-based health literacy techniques. Of the 167 nurses who responded, 9% use “Health Literacy Universal Precautions,” 6% use “Teach-Back,” and 2% use “Ask Me 3.” A staggering 83% replied “none of the above.”
The Scope of the Problem
It comes as a surprise to many health care professionals that most consumers need assistance in interpreting and understanding medical information, not just the poorly educated. In fact, only 50% of all patients take their medications as directed (Center for Health Care Strategies, Inc., 1997). Regardless of reading level, consumers prefer easy-to-read materials. Busy people, even the most highly educated, want and need easy-to-read materials; otherwise, they will put it aside for “when they have time.” In addition, for those with low literacy skills, easy to read is essential (National Patient Safety Foundation [NPSF], 2011a). It is not that Americans cannot read but that they poorly read. Doak, Doak, and Root (1996), the seminal voices in health literacy, described that 20% of adults read at a fifth-grade level or below; the average reading level of U.S. adults is eighth to ninth grade; and two out of five older, inner city, or rural adults read below fifth grade. With a school nurse’s experience, she or he would reasonably expect the older, inner city, and rural adult groups to be at risk for low health literacy. On the other hand, being young or well educated does not make someone health literate. How often is the school nurse called upon by a staff member to interpret a lab test or asked questions about a recent doctor visit? Most staff members in the educational arena are at least baccalaureate educated, many master’s and doctorate prepared, but they do not have equivalent health literacy skills. Highly educated people can be very poorly health literate (Weiss, 2003).
Weiss (2003) found that a person’s literacy skills are a much stronger predictor of health status than age, income, employment status, education level, or race and ethnicity. Additionally, minority literacy rates (Hispanics, 50%; Blacks, 40%; and Asians, 33%) are disproportionate to the overall U.S. population (NPSF, 2011a). As a practical example, it takes a 6th-grade reading level to understand a driver’s handbook, an 8th-grade level to decipher frozen dinner instructions, and a 10th-grade level to interpret the instructions on over-the-counter pain reliever (Doak et al., 1996).
The 2004 Institute of Medicine report, Health Literacy: A Prescription to End Confusion, recommends not only that health care systems address the negative effects of limited health literacy but that health knowledge and skills be incorporated into kindergarten through 12th grade, adult, and community education programs. The American Medical Association said it best in its summary of studies: “Literacy skills are a stronger predictor of an individual’s health status than age, income, employment status, education level, or racial/ethnic group” (Weiss, 2003, p. 13).
Measuring Adult Literacy
In a perfect world, school nurses would assess their learners before creating an education plan. Literacy and health literacy are measured differently. Three assessments designed specifically to identify learners’ health literacy levels include the Wide Range Achievement Test (WRAT) for word recognition, the Rapid Estimate of Adult Literacy in Medicine (REALM) for medical word recognition, and the Test of Functional Health Literacy in Adults (TOFHLA) for health information comprehension and numeracy. However, each test takes 20 minutes to an hour to perform. Recently, Pfizer’s (2011) health literacy program described a brief new test to assess health literacy called The Newest Vital Sign, based on the nutrition label from an ice cream container. Patients are given the label and then asked six questions about it. Although this innovative screening tool takes only three minutes to perform, school nurses do not have even this short a period to assess their parents’ literacy levels, nor is it appropriate.
Research has provided clear data regarding the scope of the problem, that is, 43% of the adult population would have trouble reading a prescription medication label and knowing how to take their medicine in relation to food (Kirsch, Jungeblut, Jenkins, & Kolstad, 1993). Additionally, a school nurse’s time-limited day does not allow for time-intensive literacy assessment procedures; therefore, the concept of “Health Literacy Universal Precautions” (Agency for Healthcare Research and Quality [AHRQ], 2010) makes perfect sense. Universal blood-borne precautions assume that all patients are infectious; so, health care staff take precautions to minimize the risk of spreading blood-borne disease by using gloves and sharps containers for ALL patients. Applying this to the school environment, universal precautions for health literacy assume that all parents may have some difficulty understanding health instructions, so school nurses should then take measures to maximize understanding to the largest possible audience. In addition, what applies to parents applies to the learning needs of students, especially secondary students, as school nurses teach them to take responsibility for their own health.
The remainder of this article will focus on improving health literacy through adapted verbal communication with parents and staff, using evidence-based interventions including Universal Precautions, Ask Me 3, and Teach-Back. Part 2 of this topic, in a future issue, will focus on evaluating and adapting written materials for greatest readability.
Improving Verbal Communication
With the increased awareness of the importance of improving health literacy, multiple excellent resources are available to review. The aforementioned American Medical Association program by Weiss (2003); Simply Put from the Centers for Disease Control and Prevention (CDC, 2009); Pfizer Principles for Clear Health Communication (Doak & Doak, 2004); and the AHRQ’s (2010) Health Literacy Universal Precautions Toolkit, all available online, are excellent places to start. In assuring that the school nurse’s verbal instructions and communications hit the mark, the first step is to review what was learned about effective communication in nursing school. It may be in the nurse’s skill set, but in a busy office, when there are four sick students and the mother comes in to pick up her child with pink eye, it is easy to get distracted, be rushed, and forget the basic clear communication principles.
Warm Greeting, Eye Contact, and Time Management
Make sure you greet your parents (and students) with a smile and a welcoming attitude, even if it is over the phone. Sit down and face them. Alternatively, stand at the same level. Moreover, watch your body language. Are you crossing your arms? Continuing to work on paperwork? Be sure and speak clearly, with a moderate pace—too slowly and it may appear condescending, too fast and your parent feels unimportant. You may feel rushed, but slow down your speech. This is often very hard to do! Let your parent or student speak uninterrupted. In one primary care study, patients who were allowed to talk without interruption for as long as they liked spoke for an average of only 1 minute 40 seconds (Marvel, Epstein, Flowers, & Beckman, 1999).
Limit the Content and Repeat
It is natural to want to share your knowledge with families. School nurses want to tell them everything. Nevertheless, nurses must remember that parents cannot possibly remember everything told to them. They are rushed to get out of the office with the sick child or off the phone and back to work. So, work to limit the content of your conversation to three to five concepts, or the most important pieces of information they need to hear. Write an actual list of what they need to know before calling home. Cut that list down, and then cut it down some more. What three to five things does the parent (or you) need to know right now? What is NEED to know and what is NICE to know (AHRQ, 2010; Weiss, 2003)?
After limiting the content, think about how you can repeat it at least three times in different ways, being both specific and concrete. For our pink-eye student case model from earlier, be specific in your questions: “Were her eyes stuck together when she woke up?” Be concrete: “Stay home from school until 24 hours after the first time the drops are used.” This is much preferred over “Stay home from school for 24 hours,” and then the child comes back to school the next day without treatment. Word your message in different ways, making sure to repeat important content at least three times: “Was there thick stuff in the corner of her eyes? Were her lashes stuck together? Was the stuff in her eyes clear or colored?”
Employ the Teach-Back Method
Forty to eighty percent of the medical information that providers give to patients is forgotten immediately (Rost & Roter, 1987). To help parents and students remember what you have told them after they have walked out the door, first use the concept of “chunk and check.” Rather than giving your learner all the information at once, pause and check for understanding. In addition, it is important to steer clear of asking yes or no questions, for example, avoid the sentence “Do you have any questions?” Yes or no questions end the interaction. A better way is to design your questions to foster interaction, such as, “What questions do you still have?” Another option, which can reduce feelings of inadequacy or self-consciousness, is to anticipate questions (AHRQ, 2010). Try using the language, “Some people ask me. . . .” Using the previous conjunctivitis situation, you might say, “Some people ask me if their child’s eyes have to be red to have pink eye.” Or “Some people wonder if other people in the household will catch it.” Use Teach-Back principles to check in with the learner and make sure you are understood. Ask questions in a non-shaming or non-threatening manner, framed in a way that makes it clear that you as the nurse provided the right information, not that it is a test of what the recipient has learned (AHRQ, 2010; Weiss, 2003). For the eye with a drainage situation, you might say,
“I want to be sure I went over everything—when can your daughter come back to school?” or “Just to check if I’ve covered everything—tell me what you will say to your husband when he gets home from work,” or “So just to be sure I was clear—tell me when Laura can return to school.”
Use Ask Me 3
Ask Me 3 is a patient education program designed to promote communication between health care providers and patients in order to improve health outcomes. The program encourages patients to understand the answers to three questions: (1) What is my main problem? (2) What do I need to do? (3) Why is it important for me to do this? The Ask Me 3 program suggests that patients be taught to Ask Me 3 when they see their doctor, nurse, or pharmacist; when they prepare for a medical test or procedure; and when they receive their medicine (NPSF, n.d.).
Ask Me 3 is an ideal way to involve the learner in the interaction and check for understanding at the same time. The best use of the Ask Me 3 principles for the school nurse is to anticipate and answer these questions in your instruction during each parent and older student interaction. Translating them into a teaching template, they become (1) “Your child has/is . . .”; (2) “What you need to do is . . .”; and (3) “This is important because. . . .” Last, at the end of the teaching interaction, use Teach-Back to ensure that you have provided the answers to these questions. Once again using the child with conjunctivitis, this could look like:
“
“
“
A second example of use would be an explanation of treatment and school policy:
“
“
“
Use Plain Language
The importance of using plain language in providing health information is well described in a number of print and online publications (AHRQ, 2010; CDC, 2007; Doak & Doak, 2004; Doak et al., 1996; NPSF, 2011b; National Institutes of Health, 2012). Interactions, whenever possible, should be in the learner language of choice, using an interpreter when necessary. Regardless of language, it should be the everyday living room language we normal speak. For example, although saying “keep your glucose in a normal range” makes perfect sense to a health care provider, the lay person may have no idea what “glucose” is, and even if he did, he would struggle with the concept of keeping it in the only “normal range” he is aware of, the kitchen stove. This statement is too abstract to be meaningful.
Use Concrete Terms
Normal is not a concrete word. Translating the statement above into more universally understood terms means focusing on concrete language. For example, instead of “normal range,” you could use “between 70 and 110 on your meter.” The CDC’s (2007) Plain Language Thesaurus and NPSF’s (2011b) Words to Watch are excellent resources for alternate terms for school nurse speak. Language to be careful of includes medical jargon, concept words, category words, and judgment words (NPSF, 2011b). Table 2 shows examples of words to be careful of and possible replacements. For example, one of the author’s favorite words is lesion. It covers a plethora of rashes and wounds. However, even the well-educated public does not understand this medical jargon. Better would be more specific terms like sore, infected area, burn, or rash.
Examples of Words to Avoid for Better Communication
Source: Adapted from National Patient Safety Foundation (2011b).
It is often difficult for the experienced school nurse to “dial back” the medical jargon. Nurses learn medical terms because they are much more efficient ways of communicating. “Referral” is more succinct than “ask you to see a doctor.” However, referral can mean many things to a parent, including “turning them in” to child and family services for suspected abuse. Often, it is necessary to use more, but simpler, words to be sure you are clear in your message, especially when trying to get across an abstract concept.
Category words are another area of confusion. In the author’s practice, parents can rarely correctly identify foods in the category protein. Instead, it is much more conducive to clear communication to describe a list of foods that contain protein.
The final group of words that contribute to medical miscommunication includes judgment words such as significantly and adequately. Instead of the word significantly, use a concrete example: “If Jill is not up to playing video games or asking to talk to friends, she should stay home another day.” Instead of adequately, you might say, “If Sam is not peeing at least five times per day, call the doctor.”
Graphics
Although impossible in a telephone conversation, graphics can add important reinforcement to your message in a one-on-one interaction. Draw pictures or use illustrations, photographs, or 3D models to help reinforce your content (Doak & Doak, 2004; Doak et al., 1996). One study examining the use of pictographs to enhance the recall of spoken medical instructions found that the mean correct recall several days later was 85% when pictographs were used, versus 14% when only spoken instructions were provided (Houts et al., 1998). When teaching parents about the management of a lice infestation, using photographs of lice and nits can be very helpful for parents to be able to discriminate viable from non-viable nits or dead scalp cells. But be careful that the photos are not too realistic and that the image has some elements for comparison.
Photo 1 is effective because it compares the sizes of the nit, nymph, and adult louse to the penny. Photo 2 is poor for parent use as there is no size comparison, the louse looks huge, and its engorgement of blood makes it very scary indeed. Preferred lice education graphics to use with parents include an actual louse, a viable nit, and an old nit, still attached to a hair shaft, all taped to an index card.
Summary
Research has shown repeatedly that poor health literacy is associated with poor follow through, poor caregiving and self-care behaviors, and a lack of understanding of the importance of the health instruction. Critical for school nurses is the realization that parents and other caregivers of children with poor literacy skills have children with poorer control of asthma and diabetes compared to caregivers with above average literacy (AHRQ, 2010). Being cognizant of the critical health literacy principles, along with using the tips listed in Table 3, will ensure that the message is heard in every parent and student interaction. This is essential to building trusting relationships with families, resulting in improved compliance and, most important, improved health outcomes. ■
Summary of Tips to Improve Verbal Health Information Communication
Footnotes
Author’s Note
This is part 1 of a two-part series on health literacy. This article focuses on verbal communication. Part 2 will describe techniques to improve written communication.
Deborah has been the health services coordinator/chief school nurse at Pershing County School District in Lovelock, Nevada, since 1999. She recently completed her term on the NASN Board of Directors from Nevada, and a term on the NASN Executive Committee.