Problems Related to Patient Literacy In Nursing Education
What are Myths, Stereotypes, and Assumptions
Rarely do people voluntarily admit that they are illiterate. Illiteracy carries a stigma that creates feelings of shame, inadequacy, fear, and low self-esteem (McCune, Lee, & Pohl, 2016; Paasche-Orlow & Wolf, 2007b; Weiss, 2007; Williams et al., 2002; Wolf et al., 2007). Most individuals with poor literacy skills have learned that it is dangerous to reveal their illiteracy because of fear that others such as family, strangers, friends, or employers would consider them dumb or incapable of functioning responsibly.
In fact, the majority of people with literacy problems have never told their spouse or children of their disability (Quirk, 2000; Williams et al., 2002).People also tend to under report their limited reading abilities because of embarrassment or lack of insight about the extent of their limitation. The NALS report revealed that most adults performing at the two lowest levels of literacy skill describe themselves as proficient in being able to read and/or write English (Ad Hoc Committee on Health Literacy, 1999).
Nursing Assessment and Patient Report About Literacy Problems
Because self reporting is so unreliable and because illiteracy and low literacy are so common, many experts suggest that all patients should be screened to identify those who have reading difficulty to determine the extent of their impairment (Andrus & Roth, 2002; Safeer & Keenan, 2005; Weiss, 2007; Weiss et al., 2005). Nurses must recognize that many patients would approach such testing reluctantly and be fearful of having their literacy report recorded in their health record (Paasche Orlow & Wolf, 2007b; Wolf et al., 2007). Most people with limited literacy abilities are masters at concealment.
Typically, they are ashamed of their limitation and attempt to hide the problem in clever ways. Often, they are resourceful and intelligent about trying to conceal their illiteracy and have developed remarkable memories to help them cope with family and career situations (Doak et al., 1996; Kanonowicz, 1993). Many have discovered ways to function quite well in society without being able to read by memorizing signs and instructions, making intelligent guesses, or finding employment opportunities that are not heavily dependent on reading and writing skills.
An important thing to remember is that many myths about illiteracy
exist. It is very easy for healthcare providers to fall into the trap of
labeling someone as illiterate or, for that matter, assuming they are literate
based on stereotypical images. Some of the most common myths about people who
struggle with literacy skills are outlined in TABLE 7-2 (Andrus & Roth,
2002; Doaket al., 1996; Weiss, 2007; Williams et al., 2002; Winslow, 2001) .
Clues to Look For Assessment In Nursing Education
Thus, the question remains: How does one recognize an illiterate
person? Identifying illiteracy is not easy because there is no stereotypical
pattern. This impairment is easily overlooked because illiteracy is not
visible and affects people of all ages, socioeconomic levels, and nationalities
(Cole, 2000; Hayes, 2000).
Nurses, because of their role with health care consumers, are in an
ideal position to determine the literacy levels of individuals (Cutilli, 2005;
Monsivais & Reynolds, 2003). Because of the prevalence of illiteracy,
nurses must never assume that a client is literate. Knowing a person's ability
to read and understand is critical in providing teaching-learning encounters
that are beneficial, efficient, and cost effective.
Nurses need to watch for informal clues or red flags that indicate
reading and writing deficiencies. A caveat applies, however: Do not rely on the
obvious, but look for the unexpected. In so many instances when someone does
not fit the stereotypical image, nurses and other health professionals have
never even considered the possibility that an illiteracy problem exists.
Overlooking the problem has the potential for serious consequences in treatment outcomes and has resulted in frustration for both patients and caregivers (Cole, 2000; Weiss, 2007). Unfortunately, healthcare providers are often hesitant to infer that a patient may have low literacy skills because there is an implication of personal inadequacy associated with the failure to have learned to read (Quirk, 2000).
When healthcare providers become aware of a
client's literacy problem, they must convey sensitivity and maintain
confidentiality to prevent increased feelings of shame (Quirk, 2000). During
assessment, the nursing educator should take note of the following clues that
patients with illiteracy or low literacy may demonstrate (Andrus & Roth,
2002; Carol, 2007; Davis, Michielutte, Askov, Williams, & Weiss, 1998;
Weiss, 2007) :
Reacting to complex learning situations by withdrawal, complete avoidance, or being repeatedly non compliant:
Using the excuse that they were too busy, too tired, too sick, or too sedated with medication to maintain their attention span when given a booklet or instruction sheet to read Claiming that they just did not feel like reading, that they gave the information to their spouse to take home, or that they lost. forgot, or broke their glasses
Camouflaging their problem by surrounding themselves with books,
magazines, and newspapers to give the impression they can read
Circumventing their inability by insisting on taking the information home to read or having a family member or friend with them when written information is presented. Asking you to read the information for them under the guise that their eyes are bothersome, they lack interest, or they do not have the energy to devote to the task of learning.
Showing nervousness because of feeling stressed by the possibility of getting caught or having to illiteracy .Acting confess confused, talking out of context, holding reading materials upside down, or expressing thoughts that may seem totally irrelevant to the topic of conversation.
Showing a great deal of frustration and restlessness when attempting to read, of ten mouthing words aloud (vocalization) or silently (subvocalization), substituting words they cannot decipher (decode) with meaningless words, pointing to words or phrases on a page, or exhibiting facial signs of bewilderment or defeat Standing in a location clearly designated for authorized personnel only:
Listening and watching very attentively to observe and memorize how things work Demonstrating difficulty with following instructions about relatively simple activities such as breathing exercises or operating the TV, electric bed, call light, and other simple equipment, even when the operating instructions are clearly printed on them
Failing to ask any questions about the information you received
Turning in registration forms or health questionnaires that are incomplete, illegal, or not attempted
Revealing a discrepancy between what is understood by listening and what is understood by reading
Missing appointments or failing to follow up with referrals Not
taking medications as prescribed or being non compliant
Literacy Level of Patient and Role of Nursing Educator
In summary, although it has been clearly pointed out that the level of completed formal education is an inaccurate presumption by which to predict reading level, it is certainly one estimate that nurses should incorporate into their methods of assessment. Also, negative feedback and clues from the client in the form of puzzled looks, inappropriate behaviors, excuses, or irrelevant statements may give the nurse the intuitive feeling that the message being communicated has neither been received nor understood.
Not only do illiterate people become confused and frustrated in their attempts to deal with the complex system of health care, which is so dependent on written and verbal information, but they also become stressed in their efforts to cover up their disability.Nurses, in turn, can feel frustrated when persons who have un-diagnosed literacy problems seem at face value to be unmotivated and non compliant in following self care instructions.
Many times, nurses wonder why patients make care giving so difficult for themselves as well as for the provider. It is not unusual for nurses to conclude, “He's too proud to bend,” “She's in denial,” or “He's just being stubborn it's a control issue.” Nurses in their role as educators must go beyond their own assumptions, look beyond a patient's appearance and behavior, and seek out the less than obvious by conducting a thorough initial assessment of variables to uncover the possibility that a literacy problem exists.
An awareness of this possibility and good skills at observation are key to diagnosing illiteracy or low literacy in learners. Early diagnosis enables nurses to intervene appropriately to avoid dis-service to those who do not need condemnation but rather support and encouragement.
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