by Denise Henry
Illustration by Christina Sponselli
October 29, 1998

Illiteracy can be deadly.

When a patient cannot read or understand instructions, nurses must find creative ways to communicate. This challenge prevails in some communities where literacy skills fall short.

In the farming town of San Joaquin, where 41 percent of adults have low-level literacy skills, Bill Valenzuela, RN, faces this obstacle. But he is optimistic nurses can overcome it. "There is always a way to communicate with someone who is illiterate," said Valenzuela, clinical coordinator for Valley Health Team Inc.’s San Joaquin Health Center and Kerman Health Center.

Valenzuela marks sample syringes with tape to show diabetic patients who can’t read numbers how much insulin to use. He draws simple sketches of the heart and its chambers to educate heart patients. He color-codes time charts to show patients when they should take their medication and takes advantage of ready-made diagrams when possible.

Pinpointing the problem

When it comes to assessing illiteracy, Valenzuela doesn’t mince words. He routinely asks patients about their education level. "In the admission process we explain that some questions may be personal, but the more we know about you, the better we can take care of you," he said. "It doesn’t bother people to tell us about their education. We do this on a one-to-one basis, so it’s confidential and patients are not afraid."

The straightforward approach, however, may not always work. Patients can sometimes skirt outright requests for education information. Darlene Williams, RN, assistant administrator for Memorial Medical Center-Livingston in Texas, approaches educational assessment subtly and looks for signs of illiteracy. Patients asked to sign and read forms out loud may complain of poor eyesight, turn their heads away, or simply say they don’t like to read, she said.

"We’ll ask, ‘What is the best method for you? Do you learn better by watching a movie, hearing a tape, or with verbal instruction or with pictures?’ " Williams said.

Memorial Medical Center adapts medical information to patient needs and designs its printed patient materials at no higher than a sixth-grade reading level. Staff nurses also relay information to patients in person and ask them to explain in their own words what they’ve been told.

Cultural concerns

Karen Mountain, MBA, MSN, RN, chief executive officer of the Migrant Clinicians Network in Austin, Texas, said printed materials for low-literacy patients sometimes require cultural adaptation. "For farmworker populations we need to show situations that depict their lifestyle. We cannot use information that instructs patients to put their feet in warm water and rest for three weeks when the majority of them can’t stay away from work that long and don’t even have hot water."

For patients unable to read or write in English or in their native language, Migrant Clinicians Network uses pictures, videos, and icons. An icon to educate women about domestic violence, for instance, includes an image of a man harming a woman with a slash through it. Health providers spread the message by employing women farmworkers trained as advocates against domestic violence.

"This is the kind of sensitive information women victims are more likely to tell another member of their own community," Mountain said. "We can help give them skills and tools to be able to understand what the problem is and what resources are available."

Talking it through

A well-trained, multilingual staff may find oral instruction the best form of communication. At Clinica Sierra Vista in Lamonte in Kern County, almost every employee is bilingual.

"We face this problem constantly. Most of our patients do not speak English and also may not be able to read," said supervisor Sarai Moore, RN. "When we find a patient is just not understanding, we use our ‘silver-tongued’ people, who are very good at communicating. They may repeat [a message] 15 times until they know a patient understands it."

The clinic’s healthcare team even makes an occasional house call to follow up with patients and ensure they understand instructions.

Careful words

Healthcare providers with low-literacy patients agree a direct approach usually works best. Choose words carefully and avoid jargon. Consider, for instance, the patient who hears HIV-positive and mistakes the word positive to mean good, said Faun Ryser, MSN, RN, assistant professor of clinical nursing at the University of Texas-Houston Health Science Center School of Nursing.

"After you do your teaching or give instructions, ask patients questions," Ryser said. Discuss their treatment and tell them about signs and symptoms they should be aware of and physician recommendations, she said. "Be careful with words. Sometimes healthcare workers assume patients know about certain things, and they don’t."

Previous Stories

A hazard to your health
Advocating for a safer workplace environment

How to work with patients of all ages

Has your company's soul been sold?

Are netizens really that sad?
A new study questions the Internet's impact on its users.

Assisted Suicide
What is your role as a healthcare professional?

Juggling Act
Ten tips for balancing work, school, and family.

The 1998 Career Guide