To improve communication, make literacy a priority

Teach staff to write readable documents

Finding a solution to the literacy problem that plagues the health care industry is not a simple task. Although much has been written on the topic, few researchers and authors offer a blueprint for change, saysHelen Osborne, MEd, OTR/L, director of health education at Carney Hospital in Boston. Yet in 1996, the hospital’s patient and family education committee selected literacy as a priority project.

"Our goal is to change how an organization, not just an individual or department, approaches health and literacy," she explains.

The issue was brought to light when an article was published in the local newspaper in December 1995 about the results of a study researchers at Emory University School of Medicine in Atlanta had conducted on literacy. Out of 2,600 patients who participated in the study, 41% were unable to comprehend directions for taking medication on an empty stomach. Another 26% were unable to understand information regarding when their next appointment was scheduled, and 59.5% could not understand a standard informed consent document.1

"The study was done in Atlanta and Los Angeles, but I saw no reason to think that those statistics would not be the same in Boston," says Osborne.

In addition, Osborne and her colleagues on the patient and family education committee had experienced situations in which health care was impacted by the patient’s inability to read. For example, Osborne had worked on a psychiatric unit where a young man was repeatedly admitted. His treatment was never successful because he would not go to group therapy and did not follow his recommended outpatient treatment plan. Finally, one health care professional determined that he was noncompliant because he could not read. They put him in contact with an organization that could help him learn to read, and as a result, he was admitted less frequently.

Recognizing that there is a problem that needs to be addressed by the health care industry, the committee asked members to volunteer to serve on a task force to devise and implement a plan. Following are the steps the task force took to make an impact on literacy at the organizational level:

Perform extensive research.

Osborne got a copy of the original Emory University research article that had been published in the Journal of the American Medical Association (JAMA). Then she found copies of all the references listed in the JAMA article and continued the process getting copies of all the references listed at the end of each article she read. Sometimes, she would call the authors. Through this process, she uncovered organizations that were working to find solutions to the literacy problem. These included the Philadelphia-based Health Promotion Council and World Education in Boston.

Determine a starting place.

To determine the extent of the problem and practice evaluating the reading level of written materials, the Literacy Task Force decided to conduct a readability assessment on several documents at Carney. They looked at 35 documents and found the average reading level was at the 11th grade.

Out of the 35 documents, the committee chose to rewrite the Informed Consent for Routine Treatment and Care form because it had a reading level beyond college level, and it was given to all patients. The project goal was for committee members to learn the process and teach others to increase awareness and improve skills in communicating with patients at all literacy levels. (For details on how the task force revised the informed consent document, see story, at right.)

Promote literacy hospitalwide.

To help make staff aware of literacy as a factor in good health care, the hospital hosted a one-day seminar. It covered general information, such as tools for assessing reading levels, and provided hands-on workshops.

Now members of the task force teach half-day writing workshops for staff that cover how to assess readability, create easy-to-read materials, and test for comprehension. (For details on what is taught in the workshop, see story, p. 19.)

The task force will continue to train staff in the skills needed to write materials at a fifth- to eighth-grade level and increase awareness about literacy among staff.

Nancy Borden, RN, BSN, CETN, Enterostomal Therapy nurse clinician at Carney Hospital and a member of the Literacy Task Force, says, "Increas-ing people’s awareness makes a difference. People who have come to the classes have said, I don’t stop and figure out the literacy level of everything I’m using, but I am much more aware of making sure that the patient really understands.’ They are asking for more feedback from the patient and using a variety of teaching methods."


1. Williams MV, Parker RM, Baker DW, et al. Inadequate functional health literacy among patients at two public hospitals.JAMA 1995; 274:1,677-1,682.