Nonadherent patients may not understand

Keep your message easy to comprehend

When patients don't follow their discharge instructions and end up back in the hospital, it may be that they simply don't understand what they were supposed to do at home.

"Today's health care professionals are busy and give the discharge information quickly without making sure that the patient gets it. Patients want to do what they need to do to get better. When they are noncompliant, it may be that they just don't understand," says Gloria Mayer, RN, EdD, CEO for the Institute for Healthcare Advancement based in LaHabra, CA.

People who are discharged from the hospital are still really sick and have a difficult time learning and remembering a lot of material, adds Helen Osborne, MEd, OTR/L, president of Health Literacy Consulting, a Natick, MA, firm.

"That's why case managers must make sure that patients and family members understand what they should do after discharge and why it's important," she adds.

Medical professionals tend to use medical jargon when they speak to patients, which creates a tremendous health care literacy problem, Mayer says.

"When patients aren't familiar with the terminology the case manager uses, they miss the message and they don't understand what they need to do, so that translates into nonadherence," she says.

For instance, people who are told they have "hypertension" sometimes think that means they are hyperactive, but they may understand the term "high blood pressure." Instead of using terms such as "myocardial infarction," use "heart attack" and say "X-ray" instead of "radiology," Mayer suggests.

When you talk to patients, avoid medical jargon and technical terms you don't need to use, Osborne suggests.

"On the other hand, case managers have a responsibility to use the correct word when it's needed and explain it clearly," she says.

For instance, words such as "chemotherapy" or "dialysis" are complicated words, but there are times when people need to know what they mean, Osborne adds.

Remember that idiomatic terms such as "draw your blood" may not be understood by people who are new to the language.

Confirming understanding is an essential step in communication and one that often gets left out, Osborne says.

Teach patients as clearly and simply as you can, and ask open-ended questions on key points to make sure that they understand, she says.

Using the teach-back technique is key in ensuring that your patients understand what they should do when they leave the hospital, Osborne says.

"We as health professionals do our best to use plain language, but doing that alone is not sufficient. We need to make sure our message is understood," she says.

When you talk to your patients and their family members, create a feeling of partnership. Use phrases such as, "I want to make sure we're on the same page," or "Let's work together to make sure you do everything you need to do after discharge."

Assess your patients' comprehension after you give them key points or new information.

Always ask open-ended questions, putting the responsibility for comprehension on you.

Say, "I want to make sure I've given you the right information."

Don't say, "Do you understand?" because the only answer is yes.

Narrow your focus when you ask questions, Osborne suggests. For instance, say, "The doctor said you need to be on a high-fiber diet. When you go grocery shopping, which cereals would you buy?"

After the patient and family members repeat what you've told them, reinforce that they have the information correct, or correct it if their answer indicates that they don't understand, Osborne says.

Try different strategies and ways of learning, such as bringing in pictures or giving examples, she says.

"If you find the person really does not understand, try to determine why they are having so much trouble. Is the issue hearing, language, anxiety, or learning skills? Think of alternate ways to teach the patient. Make another appointment and invite the family members to participate or arrange for a few visits from a home care nurse who can reinforce the teaching," she says.

Remember that patients can absorb only two or three things at a time. If multiple items need to be covered, break them into small portions, Mayer suggests.

"If people are sick, they are even less likely to understand everything you are telling them," she adds.

Limit your teaching to three concepts at a time and include the family whenever possible, Mayer suggests.

"If medication is the most important thing, teach them about medication. If they need a follow-up appointment, write down the name and telephone number of the doctor and be very specific. Tell them to call Monday and see the doctor within a week," Mayer says.

Be specific with your instructions, she says.

For instance, with congestive heart failure patients, go beyond saying, "Weigh yourself every day," because weight can vary depending on the time of day and what the patient is wearing.

Say, "Weigh yourself when you get up in the morning before you put on your clothes."

Make sure that your written instructions are simple and legible. Keep in mind that people who are just learning to read English may not recognize script and print the instructions, Mayer suggests.

Most health education materials are written between the eighth grade and college level, and about 90 million Americans read at the fifth-grade level or below, Mayer says.

Don't use pharmaceutical company handouts. They tend to be far too complicated for the average person to understand, she adds.

Mayer suggests that hospital case managers review the materials they are handing out and make sure they are simple and to the point so every client can understand them.

"Some people argue that college-educated patients would be insulted by easy-to-read materials, but in fact, nobody ever complains that something is too easy to understand," she says.