Diabetes education for low-literacy patients at St. Vincent's Hospital

¶ … hospital community group with high incidence of diabetes and low literacy presents to the teaching efforts of a hospital nurse.

Description of the selected adult learner, learning topic and related hospital circumstances

I am a registered clinical nurse in St. Vincent's hospital. We are a medium-sized hospital located in a highly diverse part of the town. We have a sizeable domestic and Spanish inpatient population with diabetes, including people with long-standing diabetes related complications and co-morbidities requiring inpatient expertise. Today, that population seems to be increasing. Almost 80% of all our adult patients lack literacy referring to the ability to read and write as well as knowledge about the topic of diabetes literacy. It is not only the printed word that challenges these patients with inadequate literacy; writing, speaking, listening numeracy, and conceptual knowledge is often impaired as well. About 2/3 of these illiterate patients are Latinos and the majority of these does not speak English. Our patient average age is between 50 years and 60 years.

Because diabetes is almost always a secondary diagnosis in secondary and tertiary care settings, there is not a constituent base of staff nurses dedicated to diabetes care, as once was the case. Previously, at our institution, patients were admitted to an endocrine unit for prolonged stays for diabetes control and education. This unit no longer exists, and diabetes patients are now found everywhere in our hospital. However, at times, one can find a cluster of patients with diabetes on the general medical units (primary diagnosis, in some cases) or on the cardiology unit for example.

There is no diabetes teaching protocol in our hospital. We only have a written diabetes education plan (see below). The hospital management has obliged staff nurses to make themselves familiar with the education plan in order to be able to teach our diabetes patients about the risks of the disease and how a proper nutritional and exercise protocol can drastically improve their health in addition to the medication prescribed to them.

Only very little communication exchange takes place in the teaching process. The plan relies heavily on a one-sided approach because of the difficulty to reach patients with inadequate literacy at all. The plan does not encourage questioning the patients about lifestyle habits, nutritional preferences etc. And not surprisingly in turn patients very rarely address any questions to us nurses.

The hospital does not have a registered dietitian to bring into the mix to educate patients about how a healthy diet can have a positive impact on their diabetes and how a not so healthy one can have a negative impact. We also do not have a trained translator to facilitate communication with the only Spanish speaking patient community.

Critique of the current plan

In general, I would criticize that the current plan -- with all its flaws -- is only an "education" plan and not (also) a "learning" plan. Successful teaching requires successful learning and this is missing here at all. I would furthermore find fault with the following: Cultural variation in learning styles is an important consideration in patient education (Reimer & Kelley (2001), p. 13). The current education program disregards this finding.

The education plan provides far too much (unnecessary and patient-confusing) detail on medical science related to diabetes at the expense of essential information on daily management of diabetes. The illiterate Latino patients are certainly overwhelmed by this approach and -- if there had been any initial interest in learning about the disease -- it will dissipate in the shortest when being confronted with medical jargon on the disease even if the nurses aim to "translate" it to the patients' needs.

Following the recommendations of Reimer and Kelley (2003) I would give much more focus on patient information on a healthy lifestyle nutritional and exercise regime instead of its scientific bases. The education program should be tailored to the needs of each patient because each patient has different needs. Subjecting a patient under a generalized diabetic education and learning plan does not address his particular needs and therefore not prove helpful. Instead it is a waste of precious hospital time of all persons involved and will cause unnecessary healthcare costs.

Against this background, I would criticize that the learning plan does not stipulate to interview the patients' support surrounding about his/her health beliefs, preferred learning styles, lifestyle, nutritional and exercise practices, and community context before initiating the education program. Certainly I would ask these people for cultural information that can be well incorporated here as it relates to the area of health education. For example, if my intervention is nutrition counseling, I find inclusion of common foods, methods of preparation and typical units of food measurement necessary.

Using written diabetes education materials in English language certainly goes nowhere with illiterate or low literate patients. With regard to patients of different ethnicity and culture, research has shown that written diabetes educational materials need to be culturally congruent in language, beliefs; perceptions in order to reach these patients (see Reimer & Kelley (2001), p. 14). The English written booklets on diabetes that are given out to the only Spanish speaking Latino patient community at the hospital do not even try to adjust educational messages according to the patient's ability to absorb and apply to personal lifestyles.

Ways to improve the plan

The goals of diabetes management are to reduce the personal tragedy and public health cost of diabetes and its complications and to enhance the quality of life for people with diabetes. People with diabetes need sufficient self-care knowledge to manage their diabetes effectively (Davis (2000), p. 4). Patients' self-management practices have substantial consequences on morbidity and mortality in diabetes (Heisler et al. (2002), p. 243). Patients may lack the essential knowledge unless they receive education. Medical education should follow the principles of adult learning (Schwenk, p. 2). Note: If possible, please fill in here some principles of adult learning that you might have been introduced to in class.

In my opinion, successful diabetes care requires two-way communication between health care provider and patient, involvement of patients in treatment decisions, and active participation of patients in self-care and goal setting. Yet patients with inadequate literacy may lack the skills to accomplish such tasks and find it difficult or impossible to access and understand health care information and instructions or to implement recommended behaviors (Nath (2007), 43). Scholars differentiate between general literacy as mentioned above and so called "health literacy" (see Nath (2007), p. 43). Adequate health literacy implies problem-solving and decision-making skills that enable a person to apply new information in order to navigate the health care system and function successfully as a health care consumer. A person with adequate health literacy can read, understand, and act appropriately on health information. Researchers have shown that health literacy is a stronger predictor of health status than is socioeconomic status, age or ethnic background.

The consequences of inadequate health literacy include poorer health status, lack of medical care knowledge, impaired comprehension of medical information, lack of knowledge about medical conditions, lack of understanding and use of preventive services, poorer self-reported health, poorer compliance rates with treatment modalities, increased hospitalizations, and increased health care costs (Pawlak (2005), p. 1).

People with inadequate health literacy have difficulty understanding written or oral health care information. Moreover, they have less knowledge about diabetes than do people with adequate literacy, even after diabetes education classes (Nath (2007), 44).

A 2005 National Assessment of Adult Literacy (NAAL) survey incorporated health-related tasks for the first time. The researchers found that approximately 14% of adults who were given directions on a printed sheet could not perform simple tasks, such as determining the appropriate dose based on the label information or identify which drinks were permitted before a medical test (Nath (2007) ibid).

Numerous studies have confirmed an association between inadequate health literacy and adverse outcomes in patients with diabetes (Nath (2007), p. 45). Effective health education is a prerequisite for effective self-management of diabetes. A better understanding of diabetes may improve outcomes in certain populations that have large knowledge deficits, because under these circumstances even a small increase of knowledge may contribute to increased self-care (Nath (2007) ibid).

Cultural appropriateness and clearness of the education program seems to be particularly important when attempting to tailor a diabetes learning/education plan to the needs of the illiterate patient. The barriers for patients with inadequate general illiteracy and health illiteracy will remain unless nurses and other hospital personnel make conscious efforts to simply educational efforts and reduce the complexity of diabetes care.

This being said I think that the current learning plan could be improved and reasonably resolved in the following ways: Already from the starting point of the hospital's current diabetes education program I find it critical for its success that the following parameters are taken into consideration:

The dietary goals should be clearly articulated because otherwise illiterate patients will not be able to understand them.

The diet regimen should be related to patients' cultural and economic situation because patients otherwise are very likely not to stick to it.

The dietary recommendations should be represented in ways that are easy for illiterate patients to understand and implement because otherwise they are not even able to start a better nutritional program.

Furthermore, the following issues would need to be taken into consideration in order to improve the plan and resolve it:

Self-efficacy:

Research has shown an association between self-efficacy and self-management that persisted across ethnic groups and health literacy levels (see Nath (2007), p. 46). This finding suggests that healthcare providers improve self-management by increasing patients' understanding of their conditions and treatments as well as self-confidence in their own self-care abilities (self-efficacy) both of which have been shown positively related to treatment adherence (see Heisler et al. (2002), p. 244). Several strategies contribute to self-efficacy and improve education outcomes for adults with diabetes. Nurses can work to involve patients in their own care and guide them in actively learning about their disease. Patients with diabetes should also be encouraged to explore their feelings about having this disease. By teaching patients the skills necessary to adjust their behaviors, nurses can help patients control their own health outcomes, Practical, interactive exercises should focus on developing specific skills. For example, the nurse should ask the patient to select the most appropriate of several between meal-snacks and discuss the pros and cons of the various choices.

Assessment of the patient's learning needs and capacities

All appropriate sources of information, e.g., patient's records, should be reviewed and the history of medical problems as well as diagnoses be read in order to assess the patient's learning needs. His emotional and intellectual readiness to learn should be assured. ). Be able to evaluate and select appropriate patient education materials, taking into account the patient's background, including educational level, literacy, cultural background, etc. (Patient Education, p. 2). Making sure that the patient is a partner in the teaching-learning process gives adult learners the sense of control that they are accustomed to in their daily living (Steps in the teaching-learning process (2008), p. 1).

Communication:

There are many techniques that can improve the communication between hospital personnel, such as nurses and patients with inadequate literacy. Nath (2007 ibid) in this regard points out that making more use of oral and visual instructions; limiting instructions to essential information only; making instructions interactive, with patients demonstrating their understanding of the topic; and encouraging the assistance of surrogate readers present during the one-to-one education sessions to assist the illiterate patient are helpful tools .Another suggestion would be to make use of a "teach-back" approach in an interactive educational strategy in which patients are called to paraphrase their understanding of information (see Schwenk, p. 3). A study has shown that this strategy improves recall and comprehension in patients with low literacy (see Nath (2007), p. 46). Determine patient's preferred learning style: visual auditory, experiential; and use of appropriate teaching modality (talking circles, one-on-one, didactic) might also prove useful (see Reimer & Schwenk (2001), p. 4

For future work in the hospital I would suggest the following:

Attempts should be undertaken to increase health care professionals' sensitivity to the problem of inadequate general literacy and health literacy. Research about literacy should be conducted and a literacy-assessment protocol be developed. Diabetes education materials for target populations should be created and evaluated. Attributes of the hospital health care system and hospital-patient relationships that reduce literacy-related disparities need to be identified. These attributes should then be included in the curricula of all health disciplines. Curricula should also include health literacy, means of assessing it, strategies to reach high-risk patients and groups, and interventions that limit the negative effects of inadequate literacy (see Nath (2007), p. 47).

A registered dietitian should be hired to educate patients about how a healthy diet can have a positive impact on their diabetes.

Use of a professional interpreter

Equal access to services requires effective communication, which may not be available when healthcare providers are not proficient in a patient's preferred language. For people who use languages other than English, having a basic understanding is not sufficient to understand health care information, especially in stressful situations (Reimer & Kelley (2001), p. 10). Understanding what has been said by the hospital personnel is of primary importance when diabetes education is involved. I would therefore suggest that a professional interpreter be available for all encounters with the diabetes patients. I also think that nurses should be knowledgeable of techniques to facilitate an interpreted patient encounter, such as speaking directly to the patient, using short sentences and non-technical language, allowing sufficient time, and not asking the interpreter to make judgments or provide information about which they have no expertise Our hospital's written information, e.g. booklets on diabetes, should be provided in English and in our patients' primary Spanish language, so that the information is available to people in our illiterate patients' support system (see Reimer & Kelly (2001) ibid.

List of References

Davis, E. (2000). A quality improvement project in diabetes patient education during hospitalization. 1-6. Diabetes Spectrum Volume 13 Number 4, 2000,-Page 234.

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Nath, C. (2007). Literacy and diabetes self-management. 43-49. AJN June 2007,

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Patient Education. 1-8. Accessed 3 October 2011.

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Pawlak, R. Economic considerations of health literacy. (2005). 1-2.

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Schwenk, T.L. Clinical teaching. 1-7. Accessed 3 October 2011.

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