It’s on paper, but do they understand it?

Simple testing gets written handouts on target

Don’t assume that the education materials your staff wrote for the average national level are right for your facility. The reading level of patients from area to area varies widely; therefore, many patient education managers are evaluating their patient groups.

"We assumed that our population would fit into that national average range [seventh- and eighth-grade reading level] so we kept writing right at that national average level," says Kathy Ordelt, RN, CRRN, CPN, patient and family education coordinator at Egleston-Scottish Rite Children’s Healthcare System in Atlanta.

However, the hospital had never surveyed its population to be sure. Therefore, in 1998 staff in the education department decided to verify their hunch that the materials were written at the correct level. They purchased the Rapid Estimate of Adult Literacy in Medicine (REALM) test to help determine the reading level of the hospital’s patient population. (For information on REALM see the resource box at the end of this article.)

Educators at Medical University of South Carolina in Charleston also wanted to know the average reading level of the patients who were hospitalized, yet they had not made an estimate. With South Carolina trailing the nation in literacy, providing educational materials patients could understand had been an ongoing problem.

"Educators need to be a lot more creative and they need more time to teach when you have patients who can’t read," says Margaret M. Duffy, EdD, RN, CNN, CCM, clinical educator at Medical University. The REALM test helped them determine that 47% of the patients who come to the emergency department are not able to read the handouts at the level they are written.

Assessing the reading level of your patient population provides valuable information, agrees Carol Maller, MS, RN, CHES, patient education coordinator at the Veterans Medical Center in Albuquerque, NM. She worked on a project where about 300 patients were interviewed to evaluate literacy skills and determine the overall reading level of the medical center’s population. The Wide Range Achievement Test (WRAT) was used to evaluate literacy within the medical center’s patient population. (For more information on WRAT, see the resource box at the end of this article.)

"We found that the average reading level of our patients was beginning seventh grade and that was valuable information as far as targeting print materials for the appropriate grade level," says Maller.

Some materials need rewrites

Often, such projects reveal that written materials must be rewritten at a lower grade level, says Mary Jean Kotch, BSN, CRRN, patient education coordinator at John Heinz Institute of Rehabilitation Medicine in Wilkes-Barre, PA. High-frequency, interdisciplinary patient education materials were evaluated using the SMOG readability scale, introduced by McLaughlin. During the nursing assessment, nurses ask patients what grade level they have completed. In reviewing more than 200 charts, the average grade level of these patients was 10.45, yet a handout on advance directives that all patients received was written at a 16th grade reading level.

Designing a project to assess the reading level of your patient population is not difficult. One drawback, however, is time. "Someone has to have the time to do the sampling," says Ordelt.

Following are the steps Ordelt and others took to assess the reading level of their patient population to improve written materials:

Determine patient sample.

To verify that the average reading level of adults at Egleston-Scottish Rite was seventh- to eighth-grade level, people were interviewed in every department except the emergency department. "We thought that the area [emergency department] was too high-stress to ask people to take tests," says Ordelt. Candidates were approached in the waiting rooms of such areas as clinics, day surgery, and even intensive care units.

Staff at Medical University of South Carolina targeted the emergency department because 40% of those patients are admitted to the hospital and they determined that would give them a rough estimate of the reading level of the inpatient population. (For information on how to get people to participate in a literacy survey, see article, p. 9.)

Select an assessment tool.

Before choosing a tool to assess the reading level of patients, Ordelt read several journal articles that discussed various methods. She wanted a tool that was inexpensive, easy to use, and did not take a lot of time to administer. She decided REALM fit those criteria.

Duffy was familiar with REALM, because she had taught several nurses to use the tool. "We debated on whether to have the nurses use the tool with each patient, but they have to do so much already," says Duffy. The tool is available to use with individual patients but it is not mandatory.

Find a person to survey patient groups.

An emergency department nurse conducted the readability tests at Medical University of South Carolina. She selected patients to interview who were not heavily stressed, conducting about six interviews throughout each 12-hour shift. The nurse conducted a sampling of 110 patients.

At Scottish Rite, a child life specialist intern conducted the REALM tests. "We did a sampling of 50 adults and will repeat the sampling of 50 after the first of the year [in 1999]. We might do this every year," says Ordelt.

Make use of the information.

As part of a performance improvement project, the patient education department at John Heinz Institute of Rehabilitation Medicine undertook the task of rewriting the advance directives brochure at a lower reading level. "The patient education department simplified the information and made a much more appealing brochure to read. We included pictures, increased the font size, and rewrote the copy to a 10.3 grade reading level," says Kotch.


For more information on assessing the reading level of your patient population, contact:

Margaret M. Duffy, EdD, RN, CNN, CCM, Clinical Educator, Medical University of South Carolina, 171 Ashley Ave., Charleston, SC 29425. Telephone: (843) 792-5078. Fax: (843) 792-5972. E-mail:

Mary Jean Kotch, BSN, CRRN, Patient Education Coordinator, John Heinz Institute of Rehabilitation Medicine, 150 Mundy St., Wilkes-Barre, PA 18702. Telephone: (717) 826-3830. Fax: (717) 830-2028.

Kathy Ordelt, RN, CRRN, CPN, Patient & Family Education Coordinator, Scottish Rite Children’s Medical Center, 1001 Johnson Ferry Road, NE, Atlanta, GA 30342. Telephone: (404) 250-2757. Fax: (404) 250-2255. E-mail: Kathy_Ordelt

REALM (Rapid Estimate of Adult Literacy in Medicine). This test consists of three separate lists of words that progress in difficulty. People are asked to read the lists to determine their reading level range. The kit costs $10 total. Address inquiries to: Terry C. Davis, PhD, Department of Medicine and Pediatrics, Louisiana State University Medical Center, 1501 Kings Hwy., Shreveport, LA 71130. Telephone: (318) 675-5318. Fax: (318) 675-4319. [Send no money, an invoice will be included with the order.]

WRAT (Wide Range Achievement Test). This test consists of three components — reading, spelling, and arithmetic. It not only tests people’s ability to pronounce printed words but their ability to count, read number symbols, and do computation. A starter set costs $110.00 with additional aids available at varying prices. Scoring software, for example, is an additional $99.00. Shipping and handling is 10% of domestic orders. For additional information, or to order: Wide Range, 15 Ashley Place, Suite 1A, Wilmington, DE 19804-1314. Telephone: (800) 221-9728 or (302) 652-4990. Fax: (302) 652-1644.