Assess patients’ reading levels

Does it ever seem that patients are ignoring educational materials and discharge instructions? This may be due to an inability to read those materials, according to Margaret M. Duffy, RN, EdD, CNN, former clinical educator at Medical University of South Carolina Medical Center in Charleston. "The reading level of your handouts may be way too high for your patient population," she says.

A recent study at Medical University of South Carolina Medical Center’s ED found that literacy levels of many adult patients were too low to understand ED discharge instructions.1 The study found that 29 of 110 patients sampled read at a sixth-grade level or lower, while the patient educational materials used in the ED were at a higher reading level.

Only 50% of patients tested could read at a high school level, and 9% could not read at all, reports Duffy, the study’s principal investigator. Of the 26 reading materials used in the ED, only one item was at the eighth-grade level, and the others were more complex. Thus, half of the patients in the sample would only be able to read one of the materials tested, she notes.

"In the ED, you only have one visit to educate patients, so whatever information you give them may be all they are going to have," Duffy says.

Here are ways to ensure patient reading levels are not lower than the educational materials you provide:

• Assess reading levels of ED patients. At Medical University of South Carolina, 110 patients were given a literacy test. "We told patients that we needed to develop materials appropriate for them and wanted to know what their reading levels were. Everyone agreed to take the test," says Duffy.

The Rapid Estimate of Literacy in Medicine (REALM) test was used to determine patient reading levels. The test can be completed in 90 seconds, says Duffy. The REALM measures a patient’s ability to pronounce medical terms in ascending order of difficulty and consists of three columns of 22 words each. The patients were asked in private, behind a curtain,
or in the treatment room to read the words in each column. (See REALM test, inserted in this issue.)

"The test is quick and easy to score," says Duffy.

Test patients from different times and days to determine the general reading level of the group, recommends Duffy.

• Use materials geared toward lower reading levels. Medical University at South Carolina Medical Center has developed a Web site with 250 patient education materials that are all at the 6th to 8th grade reading level, Duffy reports. They are available at no charge (

The reading level of the materials have been evaluated by Prose: The Readability Analyst, manufactured by MicroBrothers Software in Boulder, CO. The reading grade level is listed next to the material, Duffy says.

• Keep it simple. Any materials that use jargon or too many undefined medical terms are ineffective, says Jean R. Moss, PhD, RN, PNP, patient education specialist at Dartmouth-Hitchcock Medical Center in Lebanon, NH. "Avoid written materials that go into too much detail," she says. "Think about what the patients needs to know, not what is nice to know. A pamphlet packed with text will probably not be read."

Too much information can be intimidating, especially for patients with marginal reading skills, says Jean Proehl, RN, MN, CEN, CCRN, immediate past president of the Emergency Nurses Association, based in Des Plaines, IL. "We need to focus on the most important information to get them through the next few days. Complex teaching on anticoagulants or diabetes management is best left for a future date."

ED patients are stressed and not in the best frame of mind to absorb complicated material and psychomotor skills (such as self-injection of medications), notes Proehl. "This has really become a problem with the recent surge in home treatment of deep venous thrombosis with injectable anticoagulants," she notes.

For more advanced education, try to arrange follow up through a home health agency, Moss suggests. "Or call the patients at home to make sure they are following instructions and to answer any questions," she says. "If they are unable to follow through, encourage them to call their family physician for an appointment."

• Offer a range of materials. If possible, put a wide variety of educational materials in a display area, suggests Duffy. "If the patients have a range of materials to choose from, they are more apt to pick the one they can read," she says.


1. Duffy MM, Snyder K. Can ED patients read your patient education materials? J Emerg Nurs 1999; 25:294-297. n

The Rapid Estimate of Adult Literacy in Medicine test and an administration manual is available for $50, including shipping and handling. To order, contact:

Terry Davis, PhD, Department of Medicine, Louisiana State University Health Sciences Center, 1501 Kings Hwy., Shreveport, LA 71130. Telephone: (318) 675-5813. Fax: (318) 675-4319. E-mail: