does this happen to you? - wichita state...
TRANSCRIPT
7/10/2014
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Do patients read what I write?
Do they hear what I say?
Deborah J. Pontius, MSN, RN, NCSN
Kansas School Nurse Conference, 2014
Does This Happen to You?
Maybe it’s
not NON-COMPLIANCE
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What is Health Literacy?
“The degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”
Healthy People 2010
NASN Quick Poll Are you using any of the following health literacy
guidelines in your school nursing practice? (check all that apply)
Health Literary Universal Precautions (15) 9%
Teach Back (10) 6%
Ask-Me-Three (3) 2%
None of the above (139) 83%
NASN: July 28, 2011 - August 10, 2011 http://www.nasn.org/Home/NASNQuickPollResults
Objectives:
Introduction to Health Literacy
Reaching Parents:
Tips For 1:1 Verbal Communication
Tips For Written Communication
Forms for completion
Health promotion information
Tips for Group Presentation-Powerpoint
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Adult Illiteracy
Not CAN’T read but POORLY read
1 in 5 read at 5th grade or below
Average reading level is 8-9th grade
2 out of 5 older, inner-city, or rural, read below 5th grade
Doak & Doak; NPSF
6th grade
8th grade
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10th grade
Measuring Adult Health Literacy
Literacy vs. Health literacy
Adults Wide Range Achievement Test (WRAT): word recognition
Rapid Estimate of Adult Literacy in Medicine (REALM): medical word recognition
Test of Functional Health Literacy in Adults (TOFHLA): health information comprehension and numeracy
Newest Vital Sign
http://www.pfizerhealthliteracy.com/asset/pdf/NVS_Eng/files/nvs_flipbook_english_final.pdf
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2003 National Assessment Of Adult Health Literacy Kirsch et al
Intermediate
Basic
Below Basic
Proficient
14%
13%
44%
29%
93 Million Adults have Basic or Below Basic Literacy
Basic or Below
Basic
52% of H.S. Grads
61% of Adults ≥ 65
Kansas Adults Below Basic-2003
Kansas
Nevada
16%
8% Seward-32% Finny 24% Ford-12% Johnson-4% Comanche-6% Douglas-6% Pratt, Pawnee-6% Riley-6%
http://nces.ed.gov/naal/estimates/index.aspx
High Risk Groups
English as Second Language
Non high school graduates
Elderly
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What Does This Mean?
~ 15% of adults functionally illiterate
30% struggle with basic words
Can’t read newspapers
Most adult health & medical info is written well above the reading level of these folks
Doak & Doak
Those with Limited Literacy--are
less likely to:
Ask.
Seek.
Understand.
Health Literacy Universal Precautions Toolkit
“Someday, you’ll act like you understand”
Shame
Pts w/ low health literacy who admitted having trouble reading said:
67.2% had never told their spouses
19% had never disclosed to anyone
Parikh 1996:
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2010-2020
HHS National Action Plan to Improve Health Literacy
Healthy People 2010-2020
“Literacy skills are a stronger predictor of an individual’s health status than age, income, employment status, education level , or racial/ethnic group.”
AMA
http://www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf
So parents will hear you
Health Literacy Universal Precautions Toolkit
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Resources-NASN School Nurse
September 2013
Resources-H.L. Universal Precautions
Prepared for the Agency for Healthcare Research and Quality,AHRQ Publication No. 10-0046-EF
H.L. Universal Precautions
“Taking specific actions that minimize risk for everyone when it is unclear which patients may be affected.”
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Warm Greeting & Eye Contact
Greet with a smile and a welcoming attitude
Sit down
Same level
Body language
Slow Down
Clearly
Moderate pace
Let a person talk uninterrupted:
1 min 40 sec
AMA
Limit Content
3 to 5 concepts
Make a list
Cut it down
Cut it down some more
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NICE to know
NEED to know
Repeat Key Points
Be specific
Be concrete
Word in different ways
Repeat at least 3 times
Invite Pt Participation
40-80 % of the medical information is forgotten immediately
Ask parent to repeat in their own words what they need to know or do, in non-shaming way.
Ley, Communicating with patients: improving communication satisfaction, and compliance 1988 Rost, Predictors of recall of medication regimens and recommendations for lifestyle change in elderly patients 1987.
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Invite Interaction
Ask yes/no questions ?
“Do you understand?”
“Do you have any questions?”
Invite Patient Participation
What DOES work:
“What questions do you still have?”
Anticipate the questions,
takes away self consciousness
“Some people ask me…..”
Teach-Back/Checking Understanding
I want to be sure I went over everything:
When can your daughter go back to school?
Just to check if I’ve covered everything:
Tell me what you will say to your husband when he gets home from work.
So just to be sure I was clear:
Show me how you will help Johnny use his inhaler
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Ask Me 3
http://www.npsf.org/for-healthcare-professionals/programs/ask-me-3/
Ask Me 3
Teach your parents to Ask Me 3
When they see their PCP or pharmacist
When they prepare for a medical test or procedure
When they get their medicine
Ask Me 3
1. What is my child’s main problem?
2. What do I need to do?
3. Why is it important for me to do this?
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Ask Me 3
Template for your instruction
Primary Use for the
Primary Care Provider:
Ask Me 3
1. You/your child has/is…
2. What you need to do is…
3. This is important because…
Use Plain Language
Use the words they use
“Keep your glucose in the normal range”
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“Keep your blood sugar between 70 and 100.”
Use Plain Language
CDC-Plain Language Thesaurus
Pfizer –Words to Avoid
NPSF Ask Me 3-Words to Watch
Words to Watch- Medical Jargon
Problem Word Consider Using
Benign Not harmful, not cancer
Condition Problem, how you feel
Dysfunction Problem
Lesion Sore, wound, infected area
Oral Mouth
Procedure Operation, how we fix the problem
Pediculosis Lice
http://www.npsf.org/wpcontent/uploads/2011/12/AskMe3_WordsToWatch_English.pdf
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Problem Word Consider Using
Avoid Stay away from
Factor Other thing
Intake What you (she/he) drinks or eats
Option Choice
Referral Ask you to see a doctor
Words to Watch- Category Words Problem Word Consider Using
Activity Something you do, what you do in the day
Adverse (like reaction or outcome) Bad
Hazardous Dangerous, bad, not safe
Generic Product not sold by brand name, like ibuprophen for Advil (give example)
Non-cancerous Not cancer
Poultry Chicken, turkey, or things made with them
Protein (give examples) chicken, cheese, nuts, fish
Words to Watch- Judgment Words
Problem Word Consider Using
Adequately Example: 6-8 glasses of water a day
Adjust Change, fine tune
Increase gradually Add to Example (foods while ill):start with ½ cup of 7up every hr for 2 hours, then 1 cup every hr….
Routinely The same every day, how often Example: every week; every other day
Significantly Enough to make a difference, makes a big difference Example (smoking/heart disease): 2 times the chance of having heart disease
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Use Simple Graphics Draw pictures
Use Simple Graphics Draw pictures
Use illustrations
Use Simple Graphics Draw pictures
Use illustrations
Use 3D models
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Use Simple Graphics Draw pictures
Use illustrations
Use 3D models
Recall improvement:
85% recalled information with pictographs vs. 14% without.
Houts PS, Bachrach R, Witmer JT, Tringali CA, Bucher JA, Localio RA. Using pictographs to enhance recall of spoken medical instructions. Patient Educ Couns. 1998;35:83-88.
Simple Graphics
CDC-PHIL
Summary Verbal Tips
Warm Greeting
Eye Contact
Slow Down
Limit Content
Teach-Back
Repeat 3 times
Patient Participation
Plain, Non-medical Language
Use Graphics
Health Literacy Universal Precautions Toolkit
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Key Concepts
Need to know vs Nice to know
What is the problem?
What do they need to do?
Why is doing this important?
Primary Consideration:
What is the least amount of information I can give to
change behavior?
Doak & Doak
So clients will read what
you send home
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Written Materials
Hints for: Forms for completion
District policy information
Health care or promotion information materials
NASN School Nurse
January 2014
Doak and Doak Classic Text
1985-1996
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Harvard School of Public Health
http://www.hsph.harvard.edu/healthliteracy/practice/innovative-actions/index.html
Pfizer Principles for Clear Health Communication-2004
http://www.pfizerhealthliteracy.com/asset/pdf/PfizerPrinciples.pdf
Simply Put
http://www.cdc.gov/healthliteracy/pdf/Simply_Put.pdf
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CMS.gov
TOOLKIT for Making Written Material Clear and Effective
NOT in reference list
http://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/index.html
Health Hx Forms/ Notes Home
Hx-Only COLLECT essential information District Policies-Only INCLUDE essential
information Consents and Releases-Do not need to be in
legaleaze to be legal Samples
Information Releases Health histories Too Sick For School
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Basic Principles
Make it ACTUALLY easy to read
Make it LOOK easy to read
Language
Principles
Doak & Doak
Language and Style
Preferred language of audience, translate
Living room/grandma language
Include interaction Anticipate and answer questions
Fill in the blank
Practice worksheets
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Use Simple Language First things first
Avoid medical jargon
Use common words and short sentences
Give examples for new/hard words
Apply to things they already know-analogies
Write the way you talk; use active voice
Active Voice Sometimes the
preliminary test results are positive when a person is not infected. A positive AIDS test should be reconfirmed by a different lab technique to assure that it is accurate.
Grade 12
If your AIDS test comes back positive, you may not have AIDS. Have the test done again using another method. Sometimes the first test gives a false reading.
Grade 5
Active Voice
Take your medicine with your meals
Tell your doctor the names of your medicines
The social worker will arrange for visits
Medicine should be taken at mealtimes
Physicians should be told of any medicines family members are taking
Visitation will be arranged by the social worker
Better Poorer
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Rule of Zombies
“All medicine must be brought (by zombies) to the school nurse.” →Passive
“Bring (by zombies) all medicine to the
school nurse.”→Active
Rebecca Johnson, professor of culture and ethics at USMC
Short & Common Words
Children need clear and consistent boundaries and immediate consequences to violating prescribed boundaries.
Make clear rules.
Tell your child what will happen if the rules are broken.
Do what you say you will do when they break the rules--- right away.
Better Poorer *
Reading Level
Aim for no more than 8th grade
5-6th grade better
Reading level is not all, only one step
Fry. SMOG, Flesch-Kincaid,
40+ others
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SMOG Count number of
words with 3 or more syllables in 3 chains of 10 sentences.
Check chart
Predicts grade level +/-1.5 grades in 68 % of passages.
31-42
On Line Readability Tools MS Word
ATOS for shorter passages www.renlearn.com
Grammarly
Joe’s Tools
ContraCosta.edu How to assess using MS word and others
Read-able.com
Online & Word Processing Readability Tools Grade level highly variable per tool
Appropriate only for narrative text
Grade level only-ignores other factors that influence readability
“looks easy to read”
http://www.cms.gov/Outreach-and-Education/Outreach/WrittenMaterialsToolkit/index.html
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MS Word Tools
• Cons: Concerns about accuracy by experts
• Pros: easy, quick,
gives reasonable estimate
MSWord-Readability Statistics
Flesch-Kincaid Reading level
Flesch Reading Ease
Words per sentence
Passive voice
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Layout Principles
Layout
One page, but don’t crowd !
White space
Too much print, reader won’t even try
Extra space BEFORE heading, not after
Eye catchers, titles, captions, bullet points
7, 7, 7
Use Simple Graphics
Wound care instruction study:
Cartoons 46% accuracy
Text only 6%
Use photos for everyday activities
Simple line drawings for sensitive things
Free clip art—CDC -PHIL
Delp C, Jones J. Communicating information to patients: the use of cartoon illustrations to improve comprehension of instructions. Acad Emerg Med. 1996;3:264-270.
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Use Simple Graphics
Drink more water when it is hot outside
Fonts
Avoid cursive
Avoid condensed
Avoid
Avoid stylized
Avoid ALL CAPS- only use for single words
white on black
Fonts
Times Roman
Schoolbook
Courier
Century
Arial
Verdana
Apple Chancery
Script Brush
Curlz
Haettenschweiler
Mistral
Better Poorer
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Fonts
12 pt or larger Bold > underline or italics
Serif vs. san serif
S r
Ill vs. Ill
Contrast
Which is easier to read?
Which is easier to read?
Line Length
This is an example of line
of only 20-25 characters.
This is an example of the best line length.
This line length is 40-50 characters.
The line length is 70-75 characters. Words that spread across the page look packed and don’t give much white space on the page. It may be too daunting for a reader to even try to tackle reading.
< 40-50 characters,
<15 words per line/sentence
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Line Justification
This is left justified text
All lines are equal on the left
Right edge is ragged Shorter line length
This is centered text
It is harder to read
Ok for titles but not f o r regular text. T h i s is full justification
Compare this:
This slide uses full width of the page. It is more tiring to read than
the next slide.
This slide has way too much information. It is better to have two papers with more white space than one page with lots of print.
The print is also too small. You need to use larger print or poor readers will tire too easily
If you have too much print the person will not even try to read it because it looks too overwhelming.
To This:
This slide uses two columns to divide the text of the page. Even though the text is almost exactly the same, it is easier to read.
This slide has way too much information. It is better to have two papers with more white space than one page with lots of print.
If you have too much print
the person will not even
try to read it because it
looks too overwhelming.
It is more tiring to read
than the past slide.
The print is also too small.
You need to use larger
print or poor readers will
tire too easily across.
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Don’t Crowd! This slide has way too much
information. It is better to have two papers with more white space than one page with lots of print.
The print is also too small. You need to use larger print or poor readers will tire too easily
If you have too much print the person will not even try to read it because it looks too overwhelming.
Do you read long articles? Do you go to the articles that have the pictures and illustrations or are broken up with tables?
Use more paragraphs with more spaces in between the paragraphs
Make sure there is plenty of contrast. Only use as many words as you need to in order to get your message across.
Limit information to most important
Use large type
Too much is overwhelming
SHORT! Use graphics
Use white space
Use good contrast
Sample Website/Parent Information
Health Screenings
State Law requires the school department to provide annual screenings for vision in grade 7 and scoliosis in grades 6, 7, and 8.
It is our goal to conduct these screenings as early in the school year as possible in order to identify potential problems. Screening begins in the fall and will continue throughout the year until all screenings are complete.
Words per sentence: 20.3
Reading ease: 58.6
Reading grade level: 10.1
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Health Screenings
State Law requires the school to check vision (eye problems) and for scoliosis (sideways bending of the spine)
The school checks vision in grade 7.
The school checks for scoliosis in
grades 6, 7 & 8.
These checks begin in the fall and continue until finished. This way we can find problems early in the school year.
Words per sentence: 11.4
Reading ease: 85
Reading grade level: 5
Health Screenings State Law requires the school to
check vision (eye problems) and for scoliosis (sideways bending of the spine)
The school checks vision in grade 7. The school checks for scoliosis in
grades 6, 7 & 8. These checks begin in the fall and
continue until finished. This way we can find problems early in the school year.
The immunization regulations of the ---- State Department of Health in accordance with the provisions of Title 16 of the General Laws of ----- (state) shall prevail. In cases of non-compliance, parents/ guardians will be notified in writing that their child will be excluded from school until they provide proof of appropriate immunization.
Grade level-15
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What if my child does not have the required immunizations (shots)?: You (the parent or guardian) will receive a
written note that your child may not come to school until:
Your child has gotten the needed shots AND
You have given written proof to the school
This is according to ___ (state)Health Regulations (Title 16).
Grade level-7
Sample Parent Education Form
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Health Services Guidelines for Keeping Sick Children Home
Each day many parents are faced with a decision: should they keep their sick child at home or send them off to school? Often the way a child looks and acts can make the decision an obvious one. Please consider these guidelines: • Colds: Please keep your child at home if he/she has a fever over 100 degrees or is
experiencing discomfort that would interfere with his/her ability to perform in school. (i.e. uncontrollable coughing, severe lack of energy). If your child experiences green nasal discharge that continues throughout the day, or a cough lasting longer than ten days, or is accompanied by fever or chills and is productive of discolored sputum, consult with your physician.
• Diarrhea/Vomiting: A child with diarrhea and /or vomiting should stay at home and return to school only after being symptom-free for 24 hours.
• Fever: The child should remain at home with a fever greater than 100°. The child can return to school after he/she has been fever free for 24 hours (without fever-reducing medicine such as Tylenol or Motrin).
• Strep Throat: A child with strep throat may return to school 24 hours after antibiotic treatment has begun.
A sick child cannot learn effectively and is unable to participate in classes in a meaningful way. Keeping a sick child home prevents the spread of illness in the school community and allows the child an opportunity to rest and recover.
Grade 10
Grade 8
Test Your Document
Find a proofreader
Test on staff and actual clients
Fill out the form yourself
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Strive for BELOW 66h grade reading level
White space
Simple fonts
Active voice
Common words
Good contrast
Bullets and lists-7 or less
Graphics
Summary of Written Tips-see handouts
So people will listen,
understand and learn
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PowerPoint Hints
Everything applies
Use high contrast-Darker ok for slides
Use graphics, pictures, but don’t over do
Use LIMITED fancy animation
Fonts are Power
This is 40 point
This is 30 point
This is 20 point
San Serif OK
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Build the slide
Read faster than speak
Build the slide
One idea at a time
No more than 7 points
But not every slide
Dim the Slide
Use the “Dim” feature
To keep the focus
On the bullet point
You are talking about
Rule of Seven
Or Or
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Rule of Three
No more than
three font styles
three font colors
Don’t Crowd The Slide !
Complement the presentation,
not BE the information
Start with outline, reduce by at least 1/2
Don’t Just read from the slides!
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Change from 2010 Schedule
Changes in the previous schedule (see MMWR for footnotes) include the following;
Guidance has been added for the hepatitis B vaccine schedule for children who did not receive a birth dose
Information on use of co-valent pneumococcal conjugate vaccine has been added]
Guidance has been added for administration of 1 or 2 doses of seasonal influenza vaccine based upon the child’s history of monovalent 2009 H1N1 vaccination.
Use of tetanus and diphtheria toxoids, and acellular pertussis (Tdap) vaccine among children aged 7 through 10 years who are incompletely vaccinated against pertussis is addressed, and reference to a specified interval between tetanus and diphtheria toxoids (Td) and Tdap vaccination has been removed
Footnotes for the use of human papillomavirus (HPV) vaccine have been condensed.
A routine 2-dose schedule of quadrivalent meningococcal conjugate vaccine MCV4) for certain persons at high risk for meningococcal disease, and recommendations for a booster dose of MCV4 have been added
Guidance for use of Haemophilus influenzae type b vaccine in persons aged 5 years and older in the catch-up schedule have been condensed.
PCV13 The supplemental dose of PCV13 should be administered
at least 8 weeks after the previous dose of PCV7.
A single dose of PCV13 may be administered to children 6 through 18 years of age who have functional or anatomic aplastic anemia, HIV infection or other immunocompromising condition, cochlear implant or a cerebrospinal fluid leak
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PCV13 Previous PCV7 dose?
Consider repeat with of PCV13 IF:
Age 6-18 years AND
Aplastic anemia
HIV infection or
Otherwise immunocompromised
Cochlear implant
CS leak
Give at least 8 weeks after previous PCV7
PCV13 The supplemental dose of PCV13 should be administered
at least 8 weeks after the previous dose of PCV7.
A single dose of PCV13 may be administered to children 6 through 18 years of age who have functional or anatomic aplastic anemia, HIV infection or other immunocompromising condition, cochlear implant or a cerebrospinal fluid leak
Hearing Loss in
Children Understanding deafness
and hard of hearing
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DON’Ts to Keep in Mind •DON’T talk in in a loud voice or overly enunciate words
•DON’T talk excessively slowly or quickly
•DON’T change the topic under discussion without warning
•DON’T cover mouth
See to Hear
•Awake and alert
•Looking at you
•Ok to touch-attention
•Ok to point/gesture
•Closed eyes = fingers in ears
I Can’t Hear in the Dark!
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Remember—
It’s not about how educated or professional you sound
in your documents–
It’s about getting them READ!!
What questions do you still have?
Contact Information
Deborah J Pontius, MSN, RN, NCSN
P.O. Box 908, Lovelock, NV 89419
775 273 3642
www.pershing.k12.nv.us tab-district, nurse