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Dream of a Common Health Language

If Kimberly Clark, MBA, RRT-NPS, has her wish, respiratory therapists would end patient education not with the question "Do you understand?" but with open-ended ones designed to assess low health literacy.

"Patients are going to tell you what you want to hear," said Clark, program director of the respiratory care program at the University of North Carolina at Charlotte. "If they are confused, they're going to try and cover it up. They won't even tell their spouse, their family."

Therapists often assume patients comprehend information when the actual message is unclear. Even she used to take that for granted. Then Clark discovered data showing that one in five patients reads at the fifth-grade level while most health materials are written at the college level.

More than 80 percent of patients age 60 and older at public hospitals cannot read or understand basic materials like prescription labels, according to a 1995 study in JAMA. The crisis will only worsen in the future.

"This is a hot topic," she said. "With the baby boomers retiring, we're going to have a record number of elderly individuals in the next 10 years."

'Greek to Them'
Most patients will claim they read well because that is their perception, according to Clark. But it is important to consider the reality that people read several levels below their last attained education level. Thus, high school graduates often read at a ninth-grade level; college graduates, at a high-school level.

As a result, people with low health literacy receive less information from oral and written communication. As patients, they are more likely to be hospitalized and have longer stays. Afterward, they often experience worse outcomes and are deemed non-compliant with therapies, according to Healthy People 2010.

Low health literacy-the inability to read, understand and act on health information-carries a big price tag. Additional health care costs associated with illiteracy are estimated to be in the range of $106 to $236 billion annually in the United States, according to a report from the University of Connecticut.

Literacy affects health status more than age, income, employment status, educational level or racial or ethnic group. In short, improved communication means healthier people.

For Mari Jones, RRT, FNP, AE-C, the predicament hit home when she found her college-educated father struggling to understand his doctor's instructions. He had returned home knowing he should stop taking one of three medications. But he was unclear as to which one. He didn't want to admit he didn't understand.

"It humbled me to think that he needed a lot more help," she told delegates at the AARC Congress in 2006.

She urged RTs to go beyond mere lecturing: Ask questions and then listen to what the patient is truly saying; discover what concerns and goals they are voicing.

"Listening is a lost art, one we've got to think about," said Jones, a case manager in Wichita, Kan. "We can't rely just on patient handouts. It's Greek to them; most handouts mean nothing."

Vital Sign
Several diagnostic tests exist to measure health literacy yet don't discount simple observation. Patients who may be reluctant to express confusion often display nonverbal signs. For example, a patient who leaves sections blank on written forms may be struggling to read the material.

"Be mindful and pay attention," advised Clark.

For hospitals looking to provide health care practitioners with assessment tools, Rapid Estimate of Adult Literacy in Medicine, a copyrighted test, offers a quick measurement. The Test of Functional Health Literacy in Adults is more comprehensive, although it is time-consuming and less patient-friendly. Both are readily available, and anyone can administer them.

The Newest Vital Sign, a screening tool designed to identify patients at risk for low health literacy, is based on a nutrition label from an ice cream container. Patients are given the label and then asked six questions about how they would interpret and act on the information.

The test, which can be administered in three minutes, is available at no cost from Pfizer at www.pfizerhealthliteracy.com.

'Deer in Headlights'
In working with a patient who shows evidence of low health literacy skills, providers should use simple and clear health communication techniques.

Start by speaking in simple sentences of less than 15 one-syllable words, said Jones. Avoid jargon. Prioritize information, and repeat the most essential concepts. Use analogies and drawings to convey concepts.

Vary your information delivery and tailor it to the individual. Many patients will have a preferred learning style: oral, written or kinesthetic, said Clark.

Oral learners respond best to spoken information; written learners will want more hand-outs. The latter group is decidedly hands-on, needing the opportunity, for example, to handle the inhaler and demonstrate proper technique.

"Don't just rattle off 90 miles a minute and leave the patient looking at you like a deer in headlights," Clark said.

Jones stressed RTs should ask follow-up questions to ensure understanding. A young patient in her office once complained of being "out of air" despite no apparent struggle with his breathing. She asked what that term meant to him and learned he simply could not breathe out his nose.

"I gave him a nasal spray and never saw him again," she said. "Give the patient a chance to tell his personal story. It may spark something you didn't know."

Ask Me 3
Another free educational program hospitals can use is Ask Me 3. Designed to foster clear health communication, it encourages patients to ask and understand the answers to three simple questions:

·  What is my main problem?

·  What do I need to do?

·  Why is it important for me to do this?

Handouts, supporting information and other communication tips are available on the Web site at www.npsf.org/askme3.

Literature about the problems and consequences of low health literacy is vast. RTs certainly know the issues and what is at stake. But despite all of the interventions and strategies, the jury is still out on their effectiveness.

But even without double-blind, randomized trials, hospital surveys show caregivers who take extra time with education can increase patient satisfaction and understanding. It yields better outcomes too.

Remember though, it is important to create a shame-free environment for patients, one that doesn't judge. For example, RTs who unknowingly sigh at low test scores can unintentionally signal disappointment or impatience to patient.

Instead, strive to be understanding, express genuine concern and make patients feel adequate.

"The last thing they need is to feel like we are judging them," Clark explained.

Respiratory therapists are not merely lung health gurus. They are patient care experts as well. They see people everyday, and every day they work to improve patients' lives.

"We do a good job, for the most part, of being down to earth with our patients," she concluded. "Still, we are so busy seeing patients that sometimes we forget these simple things."

Shawn Proctor, associate editor and Web editor, can be reached at sproctor@merion.com.

Low Health Literacy: A Patient Safety Risk
When important health information is communicated using medical jargon and unclear language, ordinary patients are put at risk, according to a Joint Commission report. Furthermore, it undermines other efforts to improve patient safety.

"Everyone who has a role in health care-including practitioners, employers and regulators-must work together to pursue strategies for improving patient communication that will result in safer, more effective care," commented Ronald M. Davis, MD, director of the Center for Health Promotion and Disease Prevention at Henry Ford Health System in Detroit, in a statement.

The experts' report focused on making effective communications a priority in protecting the safety of patients; addressing patient communications needs across the spectrum of care; and pursuing public policy changes that promote better communications between health care practitioners and patients.

"Effective communication is a cornerstone of patient safety," said Dennis S. O'Leary, MD, president of the Joint Commission. "If patients lack basic understanding of their conditions and the whats and whys of the treatments prescribed, therapeutic goals can never be realized, and patients may instead be placed in harm's way."

Every patient "should be a full partner in his or her medical decisions," said Toni Cordell, panel member, health literacy expert and dyslexic. "This requires crystal-clear communication that is done with compassion and mutual respect."

Resources on Health Literacy:

Ask Me 3: www.npsf.org/askme3

Test of Functional Health Literacy in Adults: www.pfizerhealthliteracy.com

National Network of Libraries of Medicine: nnlm.gov/outreach/consumer/hlthlit.html

 


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