Here’s one of the responses I might offer:

Imagine you have been given some written material from a professional in a field you are totally unfamiliar with, yet your decisions based on this professional’s advice will seriously impact your life. For example, you might be facing financial ruin or imprisonment, and a lawyer hands you a document to sign.

Now, choose the professional behavior which you consider more condescending or offensive:

A) The document is written with words you have never seen before, with long sentences you cannot follow (“if this than that, or maybe this and that”). The type is small, the page is packed with unintelligible content. You have no idea what you’re agreeing to.

B) The document is written in clear language, in words you understand, and formatted to help you follow the ifs and thens. You understand it and agree this is what you want.

Are you offended by the clearly written document? Do you even notice it is clearly written, or do you just read it?
It is more likely you will be offended by the condescending attitude of a jargon-filled, unintelligible document, because its message is, “you are too stupid to understand this.”

Dumbing down implies oversimplifying, leaving out details, and adding a pat on the head.
By attending to health literacy, we are not dumbing down health information, but making it clear so learners can understand and apply it.

If you still feel the need to hand patients written materials filled with technical terms and jargon, consider this:
How do you see your job?
Is your focus to be brilliant in your specialized field?
Or is it to improve health outcomes?
Maybe that’s the problem.

You know many of our patients understand the components of a healthy lifestyle: good nutrition, activity, sleep, balance. However, many have difficulty applying this knowledge to their lives. Medicine doesn’t work if patients don’t take it. Surgery doesn’t change outcomes if the behaviors that brought on the problem continue. Health coaching can help them decide what changes they want to make, and then help them figure out how they might actually do it.

How do we create a health care system that supports healthy behaviors?

Behavior change is difficult, but it does happen every day, so it is very possible. Perhaps this is where we need to put more of our medical research dollars: learning how to effectively help folks make healthier choices.

What do you think?

Join a free phone conference, sponsored by the Health Care Education Association
on Thursday May 10, 2012
10 am Pacific time/1 pm Eastern time
Besides the printed page – alternative formats and technology for patient and family education

See the agenda and how to connect to the conference at:
http://www.hcea-info.org/html/unmeetings.html

Let’s move forward together!

Some factors that contribute to health outcomes are out of my control. For example, many studies correlate socioeconomic status and racial/ethnic disparities with poor health outcomes. Nice to know, but I can’t change those. Does that mean my goals need to be lower for those populations?

But now a study comes along that tells me no, we’re missing a root cause. Curtis and Wolf, et al. (2012) studied 353 adults aged 18-40 years with persistent asthma from 2004 to 2007. They assessed in person, at baseline: health literacy, socioeconomic status, and asthma outcomes including disease control, quality of life, emergency department visits, and hospitalizations. Then, every 3 months for 2 years they measured asthma outcomes by phone. They used multivariate analysis to assess racial and ethnic disparities in asthma outcomes, and looked at the effect of health literacy and socioeconomic status on these.

Compared with White participants, African American adults fared significantly worse in all asthma outcomes and Latino participants had lower quality of life and worse asthma control. Differences in socioeconomic status partially explained these disparities. Health literacy explained an additional 20.2% of differences in quality of life between Latinos and Whites, but differences in hospitalization rates between African American and White adults remained.

The authors concluded that health literacy appears to be an overlooked factor explaining racial and ethnic disparities in asthma. They proposed that comprehensive interventions should include evidence-based low literacy strategies for patient education and counseling.

This is good news. When you get that poor minority patient, you no longer have to sigh in resignation. Apply those interventions that address health literacy (Weiss, 2003), and you may have an impact on health outcomes:
• Slow down
• Use plain, non-medical language
• Show or draw pictures to enhance patient understanding and recall
• Limit the amount of information given at each visit — and repeat it
• Use the teach-back and show-me techniques
• Create a shame-free environment: Be respectful, caring, and sensitive
• Use patient-friendly written materials (consent forms and patient education handouts)

Sources:
Curtis, L. M., Wolf, M. S., Weiss, K. B., & Grammer, L. C. (2012). The impact of health literacy and socioeconomic status on asthma disparities. J Asthma, 49(2), 178-183.

Weiss, B. D. (2003). Health Literacy: A manual for clinicians Retrieved from http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf

©2012 Fran London, MS, RN

I continuously use free Internet tools to search for and send me the latest research and news relating to patient and family education. Then, whenever I get a chance, I can read a few of them in the limited time I have.

Recently, a systematic review appeared that looked at the most effective strategies for patient education for cardiovascular patients. Their findings were consistent with research findings in other patient populations:

1. Reinforcement: Programs that incorporate scheduled follow-up sessions as a core component are generally more effective than single-session interventions.
2. Focus on skills: Behavioral and clinical outcomes were better when interventions were designed to build skills: self-care, communication, and problem-solving skills, rather than those focusing on increasing knowledge.
3. Individualize: Compliance is best when teaching strategies are tailored to fit with the learner’s motivation, cognitive level, and learning style.

As I said in my book No Time to Teach, the research consistently boils down to involve and individualize. Involve the learner in the process, and individualize teaching methods and content to meet the needs of the learner.

Source: Commodore-Mensah, Y., Himmelfarg, C.R. (2012). Patient Education Strategies for Hospitalized Cardiovascular Patients: A Systematic Review. Journal of Cardiovascular Nursing, 27(2).

“If you can’t explain it to a six year old, you don’t understand it yourself.”
and
“Everything should be made as simple as possible, but not one bit simpler.”

It’s all about clarity, no?

Put the link to this funny 32-second video on your computer, phone, or iPad. Then, when you want to start a conversation on teach back, show it.

Here are a few points to consider:
• I would say, “Are you using your inhaler?” and “Why don’t you show me how your inhaler works.”
• I would not say, “Are you sure you’re using it right?” That’s there for the joke.
• It appears that, upon evaluating understanding, this physician was less than compassionate. It would be best if we don’t elicit the response the patient in the video had. Discuss how you might respond after this return demonstration to enhance the therapeutic relationship, rather than damage it.

This video can also be used to initiate conversations about health literacy, medication adherence, and the assumptions we make.

Enjoy!

Let me know how this works for you.

View the video at: http://www.youtube.com/watch?feature=player_embedded&v=akunCCxRVBk

http://www.youtube.com/watch?feature=player_embedded&v=akunCCxRVBk

©2012 Fran London, MS, RN

I was recently in Hawaii, and, among other things, took a week-long course in hula. After the second class I passed a classmate in the hotel hallway. She stopped me and started to complain about the class.

“What is wrong with us?” she said. “She made us do that one step for 45 minutes! But she never told us what we were doing wrong! She just kept telling us what to do differently!”

The student was very upset. “We couldn’t all have been that bad. Were we all doing it wrong? What were we doing wrong?” She ended with, “I just wanted to learn a hula!”

I didn’t get to say much in that conversation, but her reaction actually stunned me. That was not my response to that experience at all. Over the years I had taken many classes like this, such as ballet and tai chi. And it was not unusual for the teacher to repeat an essential element so you can explore the subtleties and get the basics right. In my experience, spending 45 minutes to learn one step was normal. I was comfortable with it.

So what’s my point here?

The hula teacher did a fine job, but lost a student because goals did not match. The student wanted to learn a hula, not how to do hula. She just wanted to go home knowing a little dance routine. The teacher wanted to share a deep understanding of the art; the dance routine was secondary to her. No one was right or wrong here. It was a mismatch, a lack of communication. Mutual goals were not established before the class began.

We probably lose folks in patient education for the same reason. But instead of exploring what happened, we label it non-adherence and decide it was their fault. But maybe that new diabetic perceived the teaching as sending a “you are bad” message. People don’t like to feel bad, so they remove themselves from situations that give them that message. We can avoid this with a conversation that discusses goals and human responses to change. This may take a little time, but it can improve compliance and outcomes.

In the next, third class, we learned the hula steps to an entire song. By the last class we were all able to do the dance on our own. But that fellow student never returned to get her needs met. She dropped out of the class. Too bad.

©2012 Fran London, MS, RN

Well, MedlinePlus.gov offers free, reliable, up-to-date health information in English and Spanish, with no advertisements. It’s called MedlinePlus Connect. This service lets health organizations and health providers to link patient portals and electronic health record (EHR) systems to MedlinePlus, an authoritative up-to-date health information resource for patients, families, and health care providers. Upon receiving a problem code request, MedlinePlus Connect returns relevant MedlinePlus health information.

Content includes:
— Information on hundreds of diseases, conditions and wellness topics
— Interactive tutorials, videos and other multimedia
— An illustrated medical encyclopedia, dictionary definitions, and health news
— Links to health information in over 40 languages

MedlinePlus Connect can also link your EHR system to drug and supplement information written especially for patients. When an EHR system sends MedlinePlus Connect a request that includes a medication code, the service will return links to the most appropriate drug information.

Doesn’t this sound too good to be true?
Access to good, clear health information for free!
What a great use of tax dollars!

For more information, send your IT expert to: http://www.nlm.nih.gov/medlineplus/connect/overview.html

An analysis of the outcomes (Morse, et al., 2011) concluded compliance with the home management plan of care component was not associated with fewer post-discharge ED visits or asthma-related readmissions. Handing a family a piece of paper did not change health outcomes.

Are you surprised?

Are we measuring the right things in patient education? What if that third measure was the family successfully taught back the contents of the Asthma Action Plan? When presented with a scenario, they were able to apply the information on how to respond appropriately? What if we asked how confident they were in their ability to obtain the prescription meds, have them always available, and follow the home management plan of care successfully?

Patient education may not be as simple as handing folks a piece of paper. But it’s not rocket science, either.

Source: Morse, R. B., Hall, M., Fieldston, E. S., McGwire, G., et al. (2011). Hospital-level compliance with asthma care quality measures at children’s hospitals and subsequent asthma-related outcomes. JAMA, 306(13), 1454-1460.

©2012 Fran London, MS, RN