269 Patient Education and Counseling, 15 (1990) 269-214 Elsevier Scientific Publishers Ireland Ltd.

Management Rounds

Patient Newsletter: A Teaching Tool

Marlene R. Venturaa, Karen Toddb, Karen Burchb, Mary Louise Graceb, Frances Crosbyb and Ginny Lohrb

“Nursing Research Veterans Administration Medical Center, 3495 Bailey Avenue, Buffalo, NY 14215 and bResearch Foundation, State University of New York, Buffalo, NY 14215 (U.S.A.)

(Received October 20th, 1989) (Accepted January Sth, 1990)

Abstract

A study was conducted at the Veterans Administration Medical Center, Buffalo, New York, to evaluate the impact of a behaviorally oriented nursing intervention upon well-being and health care utilization of VA patients with peripheral vascular disease (PVD). Incorporated into the intervention was the production and distribution of a patient newsletter which addressed topics related to PVD risk factor reduction. Experiences developing the newsletter for use with PVD patients are described. In addition to the anticipated benefit for the patients, nurses developing them have also derived sec- ondary gains. Guidelines for preparation, topics addressed and patients’ reactions are discussed. A formal patient evaluation of the newsletters indicated that 65% of the respon- dents reported the information contained in

M.R. Ventura EdD, RN is Associate Chief. K. Todd, BSN, RN is a Nurse Researcher. K. Burch, BSN, RN is a Nurse Researcher. M.L. Grace, MS, RD is a Registered Dietitian. F. Crosby, EdD, RN is a Research Associate. G. Lohr, BSN , RN is a Nurse Researcher.

the newsletter stimulated a positive change in behavior. This experience has relevance for patient education coordinators and others involved in developing patient education materials.

Keywords: Patient education; Patient news- letters; Peripheral vascular disease interven- tion.

Introduction

A number of approaches are currently used for patient education materials. These may include booklets, audio-visual materials, books and handouts. This article describes an experience with developing a patient newslet- ter as a teaching tool and method for sharing health related information with patients. This article has value for patient education coordi- nators and others involved in the develop- ment of appropriate materials.

The production of a patient newsletter is not difficult and has many advantages for managers. Even though this idea of a newsletter was developed for a research study, the use of it in clinical practice has much merit.

0738-3991/90/$03.50 0 1990 Elsevier Scientific Publishers Ireland Ltd. Published and Printed in Ireland

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The National Center for Nursing Research (NCNR) awarded a grant to the Nursing Ser- vice of the Veterans Administration Medical Center, Buffalo, New York, and the School of Nursing at the State University of New York at Buffalo, to study the effects of behavioral interventions on patients who have been diagnosed as having peripheral vascular disease (PVD). The intervention involved a patient education program incorporating patient participation in goal setting for risk reduction activities. Individualized health information, reinforcement, and modifi- cation are provided by a registered nurse. The risk factors associated with PVD that are addressed included smoking, limited activity, poor foot care, and hypercholesterolemia.

The patient intervention focused upon smoking cessation, walking and exercise, proper foot care, and nutritional counseling. In the first three areas, patient education booklets were developed [ 11. A specific book- let was not developed for nutritional interven- tions since patients have different dietary needs and individual diet counseling concern- ing cholesterol lowering activities, increasing fiber, and weight reduction was supplied to patients by a registered dietitian. It became clear that an additional mechanism would be useful to supplement and reinforce the overall educational program. A newsletter was selected as the method of choice.

Very little was noted in the literature on the use of patient newsletters in health care deliv- ery systems. Some references were made to newsletters sent to professional groups. Schroeder [2] referred to a newsletter as a means to describe new programs, materials or other learning resources for health professionals. This also included teaching tips for nurses of certain patient groups, or a description of current programs being devel- oped or evaluated in a health care agency.

The use of a newsletter had many advan- tages. A limited amount of information can be provided in patient booklets without their

becoming overly lengthy and costly to repro- duce. Once printed, it can be difficult to keep information updated. A newsletter can be easily and quickly prepared. It is short in length, usually l-2 pages, and designed to maintain reader interest at a basic reading level. A newsletter has a relatively low cost in terms of reproduction. Postage fees are mini- mal.

Newsletters have a flexible structure and can use current events as topics or themes to present health related information. Timeliness of topics keeps newsletters rele- vant. They can blend what is familiar and happening around a person with what is per- sonally and medically beneficial to that per- son. Newsletters also provided a regular ongoing method of communication with patients regardless of the frequency of personal contact. If a common need for patients becomes apparent, a newsletter is a quick way to respond. Managers will find this useful in providing ongoing, timely, current patient information.

Since newsletters are brief, reading them takes only a few minutes. They could easily be hung on a refrigerator for future reference, such as an exercise guide, or filed for use, such as a recipe. An additional advantage of newsletters is that preparation of them allows various staff members the opportunity to develop the content. This encourages the nursing staff to develop their skills in teaching and writing, and thereby take ownership in the development of materials related to patient education.

Incorporation of newsletter

Several factors were kept in mind in the planning of the PVD newsletter. The content presented in the newsletter was prepared for a basic reading level. When writing for the gen- eral public, a 7th4th grade reading level has been recommended to enhance com- prehension. The SMOG [3] method of deter- mining readability was the guideline used for

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Fig. 1. Sample page from PVD newsletter.

PVD FOOTNOTES**

August 1889

Salad Sense

Since fruits and vegetables are packed with nutrients, most people cons lder salads to be healthy food choices. Salads can be a nutrltlonlst’s dream come true. However, the added calories, fat and cholesterol of many salad dressings can detract from the nutritional benefits of a salad. There are a few things you can ‘do to keep your salads healthy. Read salad dresslng labels carefully. Use store bought dresslngs sparingly, or prepare your own low fat dresslngs. Include vegetables with a high soluble fiber content, I.e., kidney beans, garbanzo beans etc.

When purchasing a dresslng, scan the label for sources of cholesterol and saturated fat (egg yolks, cream, sour cream, cheese). Next, check the type .of vegetable 011 used.

The type of fat a vegetable 011 contains determines the effect It has on your blood cholesterol. Polyunsat - urated fat (PUFA) lowers “bad” (LDL) cholesterol but its effect ori “good” (HDL) cholesterol Is quest lonable. Monounsaturated fat (MUFA) lowers LDL cholesterol also, and maintains good (HDL). cholesterol levels. In addition, MUFA may help lower blood pressure. Based on this lnformat ion, the best oils for a cholesterol lower- Ing diet are: Puritan or canola 011, olive 011, corn oil, sunflower 011, soybean oil, and safflower oil, in thla order. Many types of olive oil are available. They may refer to t-he olive oil as “light”, “vlrgln” or “extra virgin”, etc. These refer to the maturity of the olives used, which affects taste but not fatty acid content. So choose a type that suits your taste.

Mary Louise Grace, M-S., R.D. Registered Dietitian. PVD Project VAMC Buffalo, New York

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the PVD newsletter. Strategies to encourage patient involvement were also considered. Personal format was used, i.e., “you” rather than “a patient”. Topics that patients recom- mended were presented. Patients have also been invited to make suggestions for future issues. A contest was conducted for patients to name the newsletter. The name selected, among the many good recommendations, by vote of project staff, was “PVD Footnotes**“. The winner was awarded four state lottery tickets.

Visual presentation was another factor considered. Early on, the principal investiga- tor of the NCNR grant met with a graphic artist in the Medical Media Service of the VA Medical Center, Buffalo, New York to dis- cuss the idea of a patient newsletter. A ready- to-use border board design was explored. The advantage of using a border board was that it was a time saving aid in the production of professional quality artwork for reproduc- tion. The newsletters have been printed in a variety of colors, including green, pink, yel- low and blue. An illustration of part of the four page newsletter has been provided in Fig. 1.

To date, 24 newsletters have been devel- oped and sent to patients in the intervention group of the PVD study. The first newsletter was published in December 1987. Every effort has been made to develop and distribute a newsletter every month. Topics were selected that were appropriate for the month or season, and related to PVD. Each newsletter provided current factual information about the topic in a brief, lay terminology format. Table I presents the topics that have been addressed. Each issue included an example(s) to operationalize the content, i.e., a recipe for a nutritional theme, an exercise for an activity theme, an “I Stopped Smoking” certificate for a smoking cessation theme.

Many changes have occurred in the devel- opment of the newsletter since the first was issued. Later newsletters contain more infor-

Table I. Dates and topics of PVD newsletters.

Date

December 1987 January 1988

February 1988

March 1988 March 1988

April 1988 May 1988

June 1988 July 1988

August 1988 September 1988 October 1988 November 1988

December 1988 January 1989 February 1989 March 1989 April 1989 May 1989 June 1989

July 1989 August 1989 September 1989 October 1989

Topic/area

Holiday food intake Role of a dietitian in PVD counseling Helpful hints on smoking cessation Facts about heart disease Importance of nutrition to health Spring is here BBQ to your heart’s content Spotlight on foot care Taking care of minor foot injuries Plan ahead activities Why exercise? Tricks or treats? Its hard to quit, but not impossible Holiday time Oat meals! Do you have a sweet tooth? National nutrition month What’s the scoop? Calling it quits Fiber foods: their place in your diet PVD-QUIZ Salad sense Exercise Listen to your feet

mation than earlier ones and many of them are two pages long. Later issues also included more graphics than earlier ones.

Patient evaluation of newsletters

In May, 1989, 42 patients who were in the intervention group of the research study were asked to evaluate the newsletters. They were sent a written evaluation form containing twelve items to elicit feedback regarding the newsletter. The first seven items were struc- tured, and identified characteristics about the newsletter, such as length, interest of topic, usefulness, clarity, overall reaction, any posi- tive behavior change, and what was done with

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Table II. Software packages for desktop publishing (DTP).

Software title

Newsroom

WordPerfect 5.0 5.1 Aldus PageMaker” (3.0)

Xerox Ventura Publisher (1.1) Ready-Set-Go” (4.OA)

Office Publisher’ (1.1)

Manufacturer

Springboard, Inc. 7808 Creekridge Circle Minneapolis, MN 55435

WordPerfect Corp. 1555 N. Technology Way Orem, UT 84057 Aldus Corp. 411 First Avenue S. Suite 200 Seattle, WA 98104 Xerox Corp. 9745 Business Park Ave. San Diego, CA 92131 Letraset USA, Inc. 40 Eisenhower Drive Paramus, NJ 07653 Office Publisher, Inc. 495 Seaport Court Suite 106 Redwood City, CA 94063

Hardware

Apple II, IIe, IIc Commodore 64 or 128 IBM PC Tandy 1000 IBM PC or compatible Tandy 2000 Zenith 2-100 IBM (PC,AT) IBM (PS2) Macintosh

IBM PC or compatible

Macintosh Macintosh Plus

IBM PC or compatible

“Mouse required.

the issue. Response options were presented from most positive to neutral to negative reactions. Items 8- 10 were open ended, and sought information about what was liked most, least, and future topic recommenda- tions. Item 11 asked for suggestions for the name of the newsletter. Item 12 listed all past issue titles, and requested the respondent to indicate his degree of interest in obtaining more information about the topic specified.

Twenty-six patients completed the ques- tionnaire for a 62% response rate. All but one respondent (n = 25) indicated that the length was appropriate. Of the respondents, 65% (n = 17) indicated that the newsletters were very interesting, and 35% (n = 9) said they were moderately interesting. Usefulness of infor- mation was divided between being very useful to 46% (n = 12) and somewhat useful to 50% (n = 13). Seventy-seven percent (n = 20) reported that the information was very

clear. No one reported that it was unclear. Sixty-nine percent (n = 18) liked the newslet- ters very much and the remaining number of patients reported that they liked it a little (n = 2) or that it was all right (n = 6). Sixty- five percent (n = 17) reported that the infor- mation stimulated a positive change in a health-related behavior, while 15% (n = 4) said they were not sure, and 19% (n = 5) said “no”. Seventy-seven percent (n = 20) of the respondents indicated that they save the news- letters. Twenty-eight percent of the respon- dents said that they share the newsletter with someone else. Only two patients indicated that they discard them after reading them.

The following ideas were suggested by patients for topics for future issues, not in order of importance: update about PVD control; medications for PVD; symptoms of PVD; nutrition; low cholesterol recipes; breakfast foods; activity vs. inactivity; foot

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care; walking routines; label reading/nutri- tion; healthy snacks; and smoking cessation.

Future directions

Future directions for the newsletter are being considered. Patient recommendations for topics will be addressed. The project staff will be exploring the use of computer soft- ware as an adjunct to the development of the newsletter. Several computer software pro- grams are available that have enhanced the preparation of reports and newsletters and are referred to as desktop publishing. Desk- top publishing allows for a high quality product of customized presentation of mate- rials at less cost. Desktop publishing allows the user to manipulate text and graphics on a page. It allows for instantaneous feedback and the opportunity to change text and be creative, and eliminates the tedious and the expensive process of seeking an outside ven- dor to produce a high quality newsletter. Desktop publishing can be useful in patient education for the production of newsletters, programs, flyers, brochures, and reports.

Thompson et al. [4] viewed and compared several desktop publishing software packages and the readers might find the report infor- mative. Some examples of desktop publishing programs have been noted in Table II. New software options are currently being devel- oped, with a focus on quality enhancements. In the future, greater emphasis will be placed on the access and use of these techniques.

Summary

In summary, patients have indicated a favorable response to the PVD newsletters.

They have been both an effective and efficient patient education tool. Nurses have enjoyed preparing them, and researching and develop- ing new topics have maintained their interest and increased their knowledge. Newsletters are relatively easy to prepare and inexpensive to distribute. In all aspects, this format of patient education has been a positive component of health education.

Acknowledgments

Work reported here was performed at the VA Medical Center, Buffalo, New York, supported by funds from the National Center for Nursing Research, National Institutes of Health, Bethesda, Maryland (Grant No. lRO1 NR01636). The authors wish to thank Mary Ann John for her creative efforts in preparing and illustrating the individual patient newsletters, and William Heaslip and Gerry Frenette of the VA, Informa- tion Resource Management Section for their review of the software component.

References

1 Lohr G, Ventura M, Crosby F, Burch K, Todd K: An experience in developing patient education materials. J Nurs Staff Dev 1989; 5: 218-224.

2 Schroeder B: Role of the patient education coordinator. In: Smith C ed. Patient Education: Nurses in Partnership With Other Health Professionals. Orlando, FL: Grune and Stratton, 1987, pp. 251-269.

3 How to perform readability tests. In: How to Evaluate Education Programs. Arlington, VA: Capital Publica- tions, 1981, pp. l-6.

4 Thompson K, Gruman G, Smith G: Product comparison: Info World reviews six high-end desktop publishing soft- ware packages. Info World 1988; June 20: 45-64.

Correspondence to:

M.R. Ventura Veterans Administration 3495 Bailey Avenue Buffalo NY 14215, U.S.A.