One of our goals this year is to improve our client's ability to take their own oral medications. Toward this end, we recognized the need to better educate our nurses to recognize their client's inability to read and/or write and to give you the tools to better serve this population with limited literacy levels.

Health literacy is the ability to read, understand and act, on medical information. It is up to the nurse performing home care to adequately assess the patient's literacy level in order to determine if they are taking their medications correctly. Limited health literacy is likely linked to medication errors. It is ultimately important to educate them to take their medications as ordered to keep them out of the hospital. The average American reads at an 8th grade level, we regularly impart information at a college level.

Assessing Literacy

Illiteracy is hard to spot, so pay attention to verbal and visual cues. Does your patient put off reading or filling out forms, or does she ask a relative or friend to read them for her? Does she tell you she can't find her glasses? Does she get defensive when you ask about material she should have read? When you hand her written instructions or forms, does she quickly put them aside or look at them upside down?

Ask your patient about her vision and reading skills; if necessary, use these techniques to assess her literacy level. Ask open-ended questions. Once you give her written instructions, try to find out if she's read and understood them by asking questions that require more than a yes-or-no answer. For example, instead of "Do you understand this consent form?" say, "Would you please describe what'll happen to you during this procedure?" If she can't answer or answers incorrectly, she may need more help to understand or she may be illiterate.

Informally test her skills. If you strongly suspect that your patient is illiterate but you're unsure, you might give her a written brochure on breast self-examination (BSE). Allow her 10 minutes alone to read it. Then ask her to demonstrate the technique. Or hand her an appointment slip or a medication insert from the pharmacy and ask her to read it aloud while you change her dressing. If your patient can't read aloud or demonstrate a technique, she'll probably be embarrassed. Keep things low-key and show that you care. Reassure her that she's not the first person to have a reading problem and that she can learn about her health in many other ways. Tell her that you'll keep her inability to read as confidential as possible but that you'll need to tell her health care provider and other nurses.

Teaching without written words

Okay. You've determined that your patient can't read or write. Now how do you teach her what she needs to know about her condition and care? Here are some common sense tips:

Speak simply. Keep your messages short, clear, and specific, and use active voice. For example, tell your patient, "If your heart rate goes below 60 beats a minute, call your health care provider before taking this pill," rather than "There could be a slowing effect on your heart." Put enthusiasm in your voice, gestures, and facial expressions to keep her interested. Just don't overdo it.

When you explain one of the patient's medications to them, tell them the name, the use, one effect and one side effect. Then have them repeat it back to you. Slow down. Don't speak so quickly so the patients can understand what you are saying. Patients can only remember 1, 2, or 3 things from a conversation. Ask them to repeat back to you what you have told them. Use language the patient can understand. Say high blood pressure, not hypertension. Convey only the most important concepts.

Use appropriate examples. Consider your patient's age, sex, occupation, and interests before giving examples. If she loves to cook, explain that 30 ml of potassium elixir equals 2 tablespoons. Repeat and question. Give her important information more than once and allow plenty of time for questions and answers. Keep asking: "What questions do you have?" and "What would you like me to go over?"

Ask for return demonstrations. Make sure your patient demonstrates each step of every procedure you teach her. Take the extra step of asking the patient to demonstrate back. When asking patients to "teach-back" or "show me", clinicians should preface their request by placing blame for poor understanding not on the patient, but on themselves (the treating clinicians). For example, phrasing the request as-"Can you show me how you're going to do this when you get home? I want to make sure I did a good job explaining this to you"-clearly places the onus of learning on the teacher, not just the learner. The teach-back method not only can uncover misunderstanding, but also can reveal the nature of the misunderstanding and thereby allow for corrective, tailored communication.

Involve the patient in your teaching. Show her the care plan and ask for her input. As you work through the problems and goals, ask for her perceptions. Treating her as a partner encourages cooperation.

Use pictures. Writing "Take each dose with two glasses of water" won't work with an illiterate patient, but she'll probably understand a drawing of a pill, a water faucet, and two filled glasses. Draw them yourself or look for art in brochures or online.

When you teach involve family members. Use visual aids in what is going on, use examples. Use a medication sheet, what med to take, what time to take med, what med is for. Don't say do you understand the medication. That will be the end of the conversation. Say, "tell me, what is the medication for? What is the side effect that is most common? Why do you take the medication? Employ teach back method. Have the patient teach you. Because of the tremendous variation in learning preferences, providing patients with a visual demonstration can enhance communication, but by no means guarantees future success.

Use a medication dispenser. You can teach a family member, or teach the patient. Use 1 dispenser for daily, use 2 daily dispensers for twice a day or use the 4 or 5 times a day x7 day dispenser. It is useful each time you finish filling the dispenser with one medication, to turn the bottle over to remind you that no longer need that med. Put the pills on a heavy weight paper sized (8 ½" x11") cardboard by gluing or taping them, to demonstrate one day of medication. This will only be useful if there is a limited amount of pills/day.

Give her videotapes. Videos may be available in your facility's library or you could make your own. Follow your facility's protocol for videotaping procedures for patient use. Make audiotapes. If commercial tapes aren't available, make your own. Turn on the tape player and clearly explain each step of a procedure as you perform it. You can also have your patient make a second tape explaining the steps in her own words as she performs them while you supervise. Audiotapes work for other types of teaching too. For example, if your patient's taking a new medication, tell her about common adverse responses, how to combat them, drug interactions, and dosages.

Document your teaching. Record your patient teaching and how you verified her understanding in the medical record. Helping any patient stay as well as possible can be challenging, but an illiterate patient is especially hard to reach and teach. By combining common sense and caring, you can break through the illiteracy barrier.