Vol. 6 Issue 12
The Learning Scope
Patient Education Materials
When preparing written pieces for patients/family members, use a reader-friendly format and keep it simple
This offering expires in 2 years: May 24, 2006
The goal of this CE offering is to give nurses current information on preparing patient education materials they can apply to their practice. After reading this article, you will be able to:
1. Explain the importance for nursing to write effective education materials for patients and their family members.
2. Identify the concepts important to consider when preparing a written piece for patients/family members.
3. Describe writing techniques useful to make reader-friendly educational materials.
You can earn 1 contact hour of continuing education credit in three ways: 1) For immediate results and certificate, go to www.advanceweb.com. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. Make checks payable to Merion Publications Learning Scope (any checks returned for non-sufficient funds will be assessed a $25 service fee). 3) Fax the answer sheet (available with credit card payment only) to 610-278-1426. If faxing or mailing, allow 45 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 011-3-H-04), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. also is an approved provider in California (No. 13230) and Florida (No. 3298).
"Good morning," Sally said to Liz as she sat down in the hospital cafeteria for a morning cup of coffee. "You look like you have something important on your mind what's up?"
Liz, an RN in the ambulatory procedure unit, sighed and said, "I see a lot of patients each week, and go through the same spiel about how they should prepare for their procedures, but many of them still show up without the proper prep. It is really frustrating. I don't know how many times I've needed to reschedule patients because they ate when they were not supposed to, didn't do their prep correctly or didn't bring someone to take them home.
"What am I doing wrong?" she continued. "Why don't they follow the instructions I give them? I hand them a flier that explains everything I told them. I ask them to take it home and review it again. What is wrong with them can't they read?"
Unfortunately, the truth is many patients cannot read the materials given to them by their healthcare providers because they are written at a higher reading level than they can understand. Although most nurses receive classes on the principles of teaching/learning, and include assessment of willingness and ability to learn before starting any teaching session, many nurses still give patients materials that are written well beyond their abilities to understand the content contained in them. Learning to recognize and write consumer-friendly patient education materials is a skill many nurses need.
The goal of this CE offering is to review the components of well-written, reader-friendly health education materials. Nurses can apply these concepts when preparing materials to give to patients and their family members, or when reviewing materials for appropriateness for patient use. It will address the issues and concerns related to health literacy. Health literacy is defined by the Center for Health Care Strategies Inc. as the "ability to read, understand and act on healthcare information."
To Inform and Instruct
Liz is in good hands. Sally is the patient/family health education coordinator, and part of her role is to mentor nurses through the process of preparing patient/family education materials so their desired outcome is achieved.
"Liz, I think I can help," Sally said. "Tell me how you explain things to patients and let me look at what you give them. Maybe I can offer some suggestions to help you prepare materials so your patients will better understand the instructions you give them."
Later that day, Sally met with Liz and shared some helpful hints.
"Liz, there are many reasons nurses teach patients and their family members and give them written materials. In this case, your primary reasons for giving the patient written materials are to inform and instruct, and enhance the information you have given verbally. In this instance, your goal is that you want the patient to take action and follow instructions. The questions that need to be kept in mind as you prepare both your verbal and written instruction need to be: What do you think is most important for the patient to know? And what is the clearest way to get this information across?"
Sally worked with Liz to help her:
• define her audience;
• list key points she believed needed to be made;
• determine the tone; and
• ascertain the materials are easy to read and understand.
Let's review each of these components of creating consumer-friendly written materials, as Sally would have explained them to Liz.
Understanding the needs of your audience is of utmost importance when writing patient education materials. Patients with language barriers, learning difficulties and low health literacy skills will read health education materials. The material needs to be clearly written in language the patient can understand. Materials may need to be written in larger print for those with visual difficulties, and translated into other languages for those whose first language is not English.
Many patients are anxious and feel self-conscious when communicating with healthcare providers. Patients who are very anxious may not be able to concentrate enough to listen to what is said to them or to read materials given to them. Again, clear, concise and friendly materials work best.
Communication patterns, emotional expression and learning styles may differ depending on a person's culture. Ways to reduce the possibility of committing a cultural faux pas when preparing written materials is to avoid using culturally dependent language, examples or illustrations. For example, symbols of victory or good luck acceptable in our culture may not apply to other cultures. Instead, use examples and illustrations that pertain to the topic, or activities of daily living.
Listing the key points you want patients to remember keeps you focused on the purpose of the written material. Veering off course confuses the reader. Lost readers are hard to get back. For example, the key points in preparing for an ambulatory care procedure may include: not eating or drinking for a specific time period before the procedure, making sure patients have someone with them to help transport them home after the procedure, and making certain patients have the supplies needed to care for themselves after the procedure.
It is best to keep the focus of the material limited to a few important key points. Answer the questions patients are most likely to ask. You may want to ask other nurses what confuses patients the most or what questions they ask most often to help you compile a list of key points.
Effective consumer health education materials are reader-friendly, address the needs of the patient and focus on the patient, not the healthcare provider. Some things to consider about tone:
• Capture and hold the reader's attention. Using medical jargon and too much detail, and including extraneous information is guaranteed to lose your reader.
• Be realistic but reassuring. State the facts but do so in terms that reassure rather than frighten.
• Tell the truth but keep it hopeful. If you need to state a procedure may cause discomfort, follow with how long the discomfort is expected to last, and ways healthcare providers will attempt to relieve it.
• Avoid negatives. State things in a positive way. It is much better to write, "Avoid smoking" than "DO NOT SMOKE." In addition, using all capital letters is considered shouting, offends some people and is hard to read.
Readability refers to how easy a written document is to read and understand. Some people may be able to express themselves very well verbally but cannot read well. The recommended presentation for patient health education materials is a sixth-grade reading level. Most higher level readers still prefer to have unfamiliar material presented to them at a lower reading level than they are accustomed. They will not think they are being talked down to; instead, they will thank the writer for an easy-to-read document.
One way to be certain the information you are presenting is clear is to read it aloud. If it sounds like a textbook, it is too high level. Ask yourself if your neighbor or a high school student would understand it. Write the way you talk. Use words that are commonly used in everyday speech.
Forms of Address
Readability and friendly language go hand-in-hand. Here are some additional hints on how to make materials more attractive to the reader.
Use second person forms of address to engage your reader. Use second person ("you") or even first person ("I" or "we") as a way to draw in readers and involve them in the discussion. For example, "Many of us have a problem overeating at restaurants that serve meals buffet style." Or, "We are happy to help you through this procedure, and want you to be as comfortable as possible."
Always use second person when you give directions. For example: "You will be asked to take off your shirt."
Use third person to create distance. Use third person ("he," "she" or "patients") to create distance when the material being presented may cause a negative reaction, or when the issue under discussion may not apply to everyone. To avoid using "his/her," use plurals. For example: "Many people with this condition have trouble sleeping. They are encouraged to use nonmedication sleep aids such as relaxation exercises and soothing music tapes at bedtime."
It's OK to switch back and forth between first and second person or between second and third person. Make sure doing so does not confuse the reader. Here is an example of when it makes sense to change person: Some people with depression do not know they have it. They misread the signs of depression. If you have problems falling asleep at night, wake up early in the morning without feeling rested and have problems with your appetite, you may be depressed and not know it.
Simple ways to make your piece more readable is to:
• Use shorter sentences. But not so short that when reading them out loud they seem choppy. Limit each sentence to one idea.
• Replace words of three or more syllables with common one- or two-syllable words.
• Keep your paragraphs short. Make sure you have one strong topic sentence (usually the first sentence) for each paragraph.
• Use transitional sentences (bridges) between paragraphs. Transitional sentences lead the reader through the material.
Voice, Tense and Sequencing
Other ways to make patient education material more reader-friendly include the following.
• Use active voice (subject verb object). Passive voice is harder to read. For example:
Active voice: The nurse will measure your blood pressure when you arrive.
Passive voice: Your blood pressure will be measured by the nurse when you arrive.
• Use present tense when defining, explaining or instructing: "Clean the site with warm tap water." Use future tense when writing about things to be expected: "You will be asked to change into a hospital gown."
• Sequencing of material is important to enhance understanding. Sequence from simple to complex; already known to new information.
• Avoid abbreviations and acronyms except when commonly understood, e.g., AIDS. If you need to use an unfamiliar term, explain it first and then introduce the term in parentheses. Spell it out phonetically for the reader.
Formatting the Material
Sally explained some concepts related to choosing the format of an educational piece. She shared that "clear and concise content is best presented in a format pleasant to the eye. A friendly, pleasing format helps the reader stay focused and maintain interest."
Here are some hints Sally gave Liz about format:
• Write a straightforward and catchy title. Put it at the top of the piece.
• Start with a few forceful sentences. These grab the reader's attention.
• Use examples whenever possible.
• Use illustrations to enhance the document's educational content. Use graphics wisely; they should not steal the show. Keep them simple. Many graphics found on the Internet are tempting to use but may be copyright protected. Check government Web sites for illustrations within the public domain.
• Present some material in tables, diagrams, drawings and photographs.
• Keep page layout simple. Give readers an obvious sequence of material to follow.
• Use a ragged (unjustified) right margin to keep consistent space between words.
• Choose a font (like Times New Roman) that has little "feet" on the letters (serifs). Those little feet make for easier reading. Choose fonts like Helvetica, Arial or Univers that do not have little feet (sans serif) for headings, tables and figures.
• Use bulleted lists to reduce reading time, capture complex information at-a-glance and highlight key points. Make a list that only includes similar things. Example: signs and symptoms of a certain disorder. Always title the list or write a lead-in sentence so the reader knows what to expect. And make sure you have a logical order for your list if there needs to be one. Number the bulleted lists if there is an ordered sequence to follow. Do not number the list if it is simply a list of items in no particular order.
People who are colorblind may not be able to distinguish among red, green, brown, purple and orange. Use black ink on light-colored paper (white or light yellow) whenever possible. Use a heavy, dull-coated (matte) paper. Glossy paper causes glare and "ages" quickly. Likewise, use matte ink.
A few weeks later, Liz called Sally to tell her how delighted she was with the success she was experiencing with her new way of presenting written materials for procedure preparation.
"Sally, I can't believe it," Liz said. "I talked with some of the other nurses on the unit and we came up with a list of questions we heard most often and items that seemed to confuse patients the most. Then we role-played one of us played the patient and the other the nurse doing the teaching. A third nurse jotted down notes of how we presented the material. We got together and looked at the notes and changed our written materials to use the words that we used when we taught verbally. What a change!"
"How did you present the written materials?" Sally asked.
"Oh, that's the best part," Liz replied. "After we thought about it, we decided we tried to present way too much information on the written materials we handed to patients after our verbal instructions. So we changed the handouts to a check off list of what we wanted them to do and when. We sequenced it in the order they needed to complete each step and then put boxes to check off as they completed each step. We also included brief explanations but only what the patient really needed to know. Simple is better."
Success stories like Liz's can be yours if you use the concepts presented in this article when preparing or choosing patient education materials. Critiquing and writing patient education materials through the eyes of the patient helps you maintain a focus that improves understanding and compliance.
American Medical Association Foundation. (2003). Health literacy. Retrieved May 5, 2004 from the World Wide Web: http://www.ama-assn.org/ama/pub/category/8115.html
Best, J.T. (2001). Effective teaching for the elderly: Back to basics. Orthopedic Nursing, 20(3), 46-52.
Center for Linguistic and Cultural Competence in Health Care. (2003). What is culturally competent care? Retrieved May 5, 2004 from the World Wide Web: http://www.omhrc.gov/cultural/whatsnewbox1.htm
Davis, L.A., & Chesbro, S.B. (2003). Integrating health promotion, patient education, and adult education principles with the older adult: A perspective for rehabilitation professionals. Journal of Allied Health, 32(2), 106-109.
Lorenz, J.M. (2003). Writing patient education materials. Tampa, FL: James A. Haley Veterans' Hospital.
Lorenz, J.M., et al. (2004). Manual for writing patient education materials. Tampa, FL: James A. Haley Veterans' Hospital.
Potter, L., & Martin, C. (2003). Health communication and cultural diversity. Retrieved May 5, 2004 from the World Wide Web: http://www.chcs.org/publications3960/publications_show.htm?doc_id=213135
Potter, L., & Martin, C. (2003). Tools to evaluate patient education materials. Retrieved May 5, 2004 from the World Wide Web: http://www.chcs.org/publications3960/publications_show.htm?doc_id=213134
Schloman, B. (2004, February). Information resources column: "Health literacy: A key ingredient for managing personal health" Online Journal of Issues in Nursing. Retrieved May 5, 2004 from the World Wide Web: http://www.nursingworld.org/ojin/infocol/info_13.htm
Stern, E. (2003). Writing and designing materials for patient education. Core curriculum workshop for American Medical Writers Association.
Sullivan, E. (2000). Health literacy. Retrieved May 5, 2004 from the World Wide Web: http://www.nnlm.gov/scr/conhlth/hlth.lit.htm#Health%20Literacy%20Listservs
Joan M. Lorenz is patient/family health education coordinator, ambulatory care, James A. Haley Veterans' Hospital, Tampa, FL.
Why Nurses Write Consumer Health Materials
• To inform and instruct
• To persuade and empower
• To prevent problems and complications
• To enhance quality of life
• To supplement information given verbally