Achieving universal health literacy is as simple as treating all patients as if they are at risk of not understanding health information, according to Deborah Christensen, MSN, APRN, AOCNS, HNB-BC.
In a national survey of 19,000 English-speaking adults, only 1 in 10 had adequate health literacy, leaving 90% at risk for navigating the healthcare system and their own health, reported Ms Christensen, an oncology nurse navigator at Dixie Regional Medical Center in Saint George, UT.
“I consider nurses and navigators to be bilingual in that we understand medical language, but we also understand the language of people,” she said. “We know that when we’re better communicators, we deliver better care, and better care leads to better outcomes.”
Components of Health Literacy and Communication
Care coordination and patient engagement are at the heart of the nurse navigator role. At the core of engagement is health literacy, or the ability to obtain medical information, she told attendees at the Academy of Oncology Nurse & Patient Navigators 7th Annual Navigation & Survivorship Conference.
She noted that patients often obtain health information from the Internet, but it is the navigator’s responsibility to translate that information and separate the reliable from the unreliable sources. She said nurses and the general medical community tend to overestimate patients’ health literacy, but patients need to be able to process information, communicate their knowledge, and understand how it applies to their diagnosis in order to act on it.
Communication involves a sender, a receiver, and a message. Interference, or “noise,” might arise in the form of uncertainty, fear, or emotional turmoil on the part of the patient, so it is crucial to obtain feedback to confirm understanding. She offered the example of a patient receiving her pathology results and misunderstanding “positive lymph nodes” to be a good thing, noting that typically, when a patient asks very few questions, he or she likely has lower health literacy.
It is vital to customize health-related education material to the individual patient’s reading level. Various healthcare organizations recommend between a 5th and 8th grade reading level for patient education materials, and readability formulas (Flesch-Kincaid, Gunning Fog, SMOG) can determine if materials are too advanced for your patients.
Research clearly shows that patients prefer face-to-face interaction, and for the navigator, deciphering nonverbal communication such as body language and tone of voice is part of patient assessment, she said, adding that patients appreciate printed material summarizing the key points of their visit and visual interpretations of statistical information.
Other healthcare barriers encountered in day-to-day interactions with patients can be patient-related (physical/emotional state, previous healthcare experience), provider-related (use of medical jargon, time constraints), or systems-related (noisy atmosphere, understaffing), but evidence-based communication and health literacy strategies can aid the navigator in overcoming these common obstacles to understanding.
Improving Health Literacy and Patient Engagement
“Adults learn best when teaching progresses from the known to the unknown,” said Ms Christensen. She said one simple strategy is to ask patients what they do know—about their diagnosis, chemotherapy, financial resources, etc—and then build on that knowledge.
“Ask Me 3” is a communication tool that can help navigators hone in on important communication information in a very simple way. It consists of simply asking the patient, “What is your main problem?” “What do you need to do?” and “Why is it important that you do this?” Another effective method is the “chunking strategy,” which consists of breaking down large amounts of information into smaller chunks and grouping similar information together, she said.
Statistics show that between 40% and 80% of information given to patients is forgotten immediately, and of what they remember, 50% is remembered incorrectly. “The ‘teach back/show back’ method is really the only way to gauge what the patient understands,” she said. “It is a key component to communication.” She added that while analogy and metaphor can be useful in certain situations, they should be used with caution, as people with limited health literacy might struggle to understand figurative speech. For example, using the dimples in a golf ball as an analogy for overexpression of HER2 in breast cancer would not be understood if a person has never picked up a golf ball. The same is true for units of measure; “the size of a quarter” might be better understood than “2 centimeters.”
Motivational interviewing creates an atmosphere in which a client generates his or her own reasons for change. Developing rapport with a patient creates a longer learning curve and allows the patient to feel supported and open to asking questions, she said, and “listening to understand rather than to respond is key.”
She said to remember the “OARS” when conducting motivational interviewing: Open-ended questions that can’t be answered with “yes,” “no,” or “maybe”; Affirming and supporting; Reflective listening (“what I hear you saying is this…”); and Summarizing.
Medical language can be a barrier; to improve health literacy, she urges using only plain language and simple terms in all communication. She recommends a CDC resource called Simply Put: a guide for creating easy-to-understand materials, as well as the website cdc.gov/healthliteracy, health communication–related apps, and vengage.com for free infographic design.
“Evidence-based strategies have the potential to change the way you communicate with patients,” she said.