I Can’t Read That! Improving Perioperative Literacy for Ambulatory Surgical Patients LAURA TRAYLOR LIEBNER, MSN, RN
ABSTRACT Low literacy and low health literacy are surprisingly rampant problems facing health care providers. Patient educators in all settings should consider the need for improved patient education materials that are easy to read and understand for the majority of patients. In the ambulatory surgery setting, patients often have time to prepare for scheduled outpatient surgery, yet education is provided primarily in the postoperative period. This article highlights the need for incorporating education into all phases of the perioperative process, beginning in the preoperative period. Perioperative educators should address all learning styles that provide education in a simple and cost-effective way to appeal to all patients and help to reduce postoperative complications and increase patient satisfaction in the ambulatory surgery setting. AORN J 101 (April 2015) 416-427. ª AORN, Inc, 2015. http:// dx.doi.org/10.1016/j.aorn.2015.01.016 Key words: perioperative education, patient education materials, online education, patient education, ambulatory surgery, low literacy, low health literacy.
http://dx.doi.org/10.1016/j.aorn.2015.01.016 ª AORN, Inc, 2015
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n the United States, approximately 75% of surgeries are performed in the outpatient or ambulatory setting.1 In the ambulatory surgery setting, nurses frequently provide postoperative patient education only. Patients often must rely on family members and visitors to remember information given to them at this time because they are still experiencing the effects of anesthesia (eg, retrograde amnesia) or because surgeons commonly give a patient’s family members verbal instructions after surgery in the surgical waiting area. Although education in the postoperative period often is necessary, Krizik1 indicates that providing educational interventions throughout the perioperative process, beginning in the preoperative period, is the best approach to educating patients undergoing ambulatory surgery. By initiating education in the preoperative period, patient outcomes can be improved by
decreasing anxiety, decreasing lengths of stay, preparing the patient to better anticipate postoperative pain that may be experienced, and increasing patient and family member satisfaction.1 Many American adults have low literacy levels so they function at below-basic reading and comprehension levels.2 People often read two to three grade levels below their last completed year of school.3 People living in poverty typically have even lower literacy levels, often reading four grade levels below their highest obtained education.3 Therefore, those most at risk for low literacy are people with less education or those who are economically disadvantaged. However, most consumers report that they need help understanding health care information, regardless of education or economic status, especially those who have had infrequent encounters with the health care system.2 Therefore, anyone can be at risk for low health literacy. According to Krizik,1 research evidence shows that patient outcomes are tied directly to the provision or lack of patient education. Inadequate preoperative education for surgical patients leads to avoidable postoperative complications or complaints, including unexpected pain, fatigue, and the inability to care for oneself.1 If patients anticipate the inability to perform normal activities of daily living in the immediate postoperative period, they can arrange for assistance and help avoid these complications. Patient education should be available in many forms to accommodate multiple learning styles of patients; nurses should ask the patient what way he or she learns best and should provide patient education primarily in the patient’s preferred form.1 Patients may be auditory, visual, kinesthetic, or tactile learners or a combination of these learning modalities.4 Different approaches to education in the perioperative process can include
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the traditional forms of verbal and written communication, but the nurse also can provide demonstrations, after which he or she asks the patient to provide a return demonstration to confirm that the information has been correctly understood. Pictographs, videos, and web-based information are also helpful.
PURPOSE The purpose of this project was to analyze the health literacy level of preoperative and postoperative ambulatory surgical patient education materials; develop patient-centered, evidence-based materials to facilitate learning and improve patient outcomes; and create a web-based intervention that patients can easily access throughout the preoperative and postoperative process, beginning in the preoperative period. Health care providers who alter the type of information and the way they deliver information to ambulatory surgical patients can improve patient outcomes. These changes should incorporate diverse methods, including web-based, easy-tounderstand information and graphics; include appropriate hard-copy patient educational materials for patients of all backgrounds and literacy levels; and provide preoperative and discharge education.
LITERATURE REVIEW
We conducted a review of the literature using CINAHL Plus With Full Text for 2006 through 2014. We focused on how literacy affects patient education, the use of available patient educational materials, and the use of web-based educational interventions in health care. We used the following key words and key word strings, alone and in combination: perioperative education, patient education materials, literacy, preoperative education, and postoperative education.
Patient Literacy A surprisingly high number of American adults function at a below-basic reading and comprehension level.3 According to DeYoung,3 a common average reading level is sixth to eighth grade (depending on region and area). DeYoung3 explains that people often read two to three grade levels below the last completed year of school; therefore, many people may function at less than the fourth-grade reading level. Guidelines from the US Department of Health and Human Services5 and the National Cancer Institute6 recommend that all written materials prepared for patients be on a third- to fifthegrade reading level. For instance, people reading at a sixth- to AORN Journal j 417
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eighthegrade level (vs a fourth- to sixthegrade reading level) are able to process more complicated statements, compound sentences, longer sentences, and sentences with multiple phrases. Therefore, to reduce the reading level of patient education materials, statements must be made as simple and short as possible, using common one- and two-syllable words whenever possible.4 Furthermore, according to the Institute of Medicine7 and the Agency for Healthcare Research and Quality,8 only 52% of American adults are considered literate (the rest being illiterate or marginally illiterate) and even fewer people are estimated to have functional health literacy. According to the National Adult Literacy Survey, 23% of American adults who are described as having below-basic literacy skills are high school graduates.9 This means that even people who have graduated from high school may be somewhat illiterate where health information is concerned. According to the National Patient Safety Foundation,2 most consumers need help understanding health care information regardless of age, race, or income level. Therefore, all health information should be presented as simply as possible.2
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have undergone general anesthesia and could still be experiencing its effects; have low health literacy, as could family members; or be unable to understand the materials because they are too complicated for the patient or his or her family members.4 Many postoperative educational materials that have been developed by personnel at surgeons’ offices may not take into consideration low literacy level. This often results in patient confusion.
AVAILABLE METHODS TO IMPROVE COMPREHENSION When used in conjunction with verbal instructions and demonstrations, written educational materials can be valuable and cost-effective in providing patient education.5 However, because research indicates that many patient education pamphlets, booklets, information sheets, and consent forms used in health care exceed the literacy level for many people, written patient educational materials are not always helpful.5
Patients who do not comprehend the information presented are more likely to be noncompliant.
Effect of Literacy on Education Current methods of providing ambulatory surgery education include written informational pamphlets and verbal instruction after surgery. Patients who do not comprehend the information presented are more likely to be noncompliant or to guess about what they do not understand, with potentially harmful results to their health.4 Patients may appear to comprehend the instructions, but may not truly understand what is being taught because of anxiety, language barriers, or low literacy.1 Patients with low literacy also may have trouble comprehending information, especially information presented in pamphlets. Low literacy, low health literacy, and a lack of appropriate educational materials for patients also contribute to complications, as well as the additional costs incurred from these complications. Furthermore, “people with low literacy skills put off disease prevention actions and tend to wait longer before seeking medical help.”4(p59) If patients are not able to understand the information presented, it is of very little value.4 This lack of comprehension may be multifactorial. For example, the patient may
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Often, text-based instructions are difficult for patients with low literacy skills to follow at home. After reviewing 44 articles, Choi10 determined that pictographs using simple line drawings combined with simplified text are the most efficient and effective tool to improve discharge education. Pictographs can even be used to show a step-by-step procedure consisting of multiple actions described in complex and lengthy discharge instructions, thus making an entire action sequence easier to learn.10 Therefore, by using pictographs with simplified text, health care educators can improve discharge instructions for low-literate older adults. Furthermore, they are even helpful for patients who speak English as a second language and may be helpful for all patients regardless of their literacy level.10 To assess the current patient educational materials being used at an ambulatory surgical facility, we used the simplified measure of gobbledygook (SMOG)11 formula to determine the readability by grade level of these documents. The SMOG formula offers simple and fast computation by calculating the number of words at the beginning, middle, and end of a written piece and the number of polysyllabic words. A mathematical formula can then be used
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to determine the grade level and readability of a document.11 It is considered one of the most valid tests of readability.4,11
What Affects Readability? The reading level of printed educational materials is not the only factor that plays into readability. Numerous factors affect the reader’s ability to comprehend the information, such as
content organization, second-person and active voice, complexity, acronyms, value terms, text crowding, font size and type, key points, and graphics.5
Content organization Information must be organized into segments that follow a logical sequence and should be prioritized to include the most important information first. Organizing information into chunks improves recall.2
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Value terms Value words, such as “frequently” or “regularly,” should be defined by using specific numbers instead.4 For instance, instructions regarding fluid intake should not be written vaguely (eg, drink water regularly), but should be very specific (eg, drink at least eight full glasses of water a day).
Crowded text Do not use more than 30 to 40 characters per line to avoid crowding the page with text and thus overwhelming the reader.4 According to Bastable,4 patient educational materials should have plenty of white space in the margins, with double-spaced lines and generous spacing between paragraphs.
Font size and type Font should be 14- or 16-point size, but font type also is important. For instance, sans serif fonts (eg, Calibri) do not give the eye any “handles” to visually grasp, so the eye tends to slip off the line of type; which can be difficult for even good readers to follow.12 On the other hand, mixed-case serif fonts (eg, Times New Roman) are the easiest of all typefaces to read because they have little bars on the bottoms and tops of letters that make the letters stand out.12
Key points Second-person and active voice Patient educational materials should not be written in a formal or professional style. A conversational style should be used when creating patient education materials. This style uses the pronouns “you” and “your” to make the message more personal, more interesting, and easier to understand. Using active voice (eg, Do not eat spicy food) ensures that ambiguity is avoided (eg, It is better not to eat spicy food).
Complexity Short words with one or two syllables should be used whenever possible. It is important to use correct terminology rather than slang (eg, breasts vs boobs), and medical terms should be defined.4 Short sentences (ie, no more than 20 words) also are best because they are easier to read and understand, especially for clients with short-term memory problems.
Acronyms Abbreviations or acronyms should not be used4 unless they are common and are terms the patient is familiar with. If an acronym is used, an explanation should be provided; for example, after defining the acronym CPAP as a continuous positive airway pressure, CPAP can be used because patients typically use the acronym rather the full term.
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Do not use all capital letters to emphasize points; instead, use both capital and lowercase letters as appropriate. To emphasize important points, put the information in a box or Use typographic cues such as bolding, underlining, size, and color to emphasize key points. Use visual cues like shading, boxes, and arrows to direct the reader’s attention to specific points or key content. Use color to highlight, add clarity, differentiate, focus the eye, and make images more realistic but use color carefully. It should support, not detract from, the message. When using color, keep in mind that age, gender, and ethnic preferences for color vary markedly.12(p35)
Graphics Pictures and graphics are helpful supplements to include in written patient educational materials.4 Visuals should be relevant, meaningful, and appropriately located.5 Illustrations should be simple and depict adult rather than childlike images when applicable. The illustrations should have captions and each visual should be directly related to one message.5 Cues can also be used, such as circles or arrows, to point out key information.5
Using Web-Based Educational Interventions in Health Care According to Atack and Luke,13 a web-based educational intervention would be a cost-effective and highly accessible AORN Journal j 419
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preoperative intervention for patients who are scheduled for surgery. However, information available on the Internet varies widely in accuracy, and correct information is not always readily accessible or identifiable to patients.13 One study reviewing patient education resources on peripheral neuropathy found that even after using two different reading level scales, the patient information from many popular search results, such as www.Neuropathy.org and the Mayo Clinic, were unsuitable based on reading difficulty.14 Of the nine popular and reliable web sites reviewed, only the US National Library of Medicine scored low enough on reading level (ie, fifth grade) to benefit the average American.14 Therefore, this web site would be a valuable resource for developers of education materials to review before creating a web-based educational intervention for surgical patients to ensure better understanding from its viewers.14 One online preoperative educational intervention that is available for orthopedic surgery encourages patients to submit questions for review before their procedures.15 Findings from a study evaluating this web-based education showed that approximately
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practice for education throughout the ambulatory surgical process for web-based as well as hard-copy instructions for patients. To appeal to all types of adult ambulatory surgical patients, the educational interventions must be patient centered by considering the specific learning needs of adult learners. The Adult Education Theory (ie, andragogy) by Malcolm Knowles (1980) is the theoretical framework for this project. According to Knowles,16 adults learn best when they apply new knowledge to past experiences to solve personally relevant, important problems. This is important to ambulatory surgical patients because these patients will be motivated to learn the new knowledge and skills necessary to help ensure that the surgical experience is successful, such as how to take medications, how to change dressings, and how to empty drains. Adult learning is problem centered, meaning that adults’ prime motivation to learn is to be able to readily apply knowledge
Adults learn best when they apply new knowledge to past experiences to solve personally relevant problems.
one-third of patients had questions preoperatively after viewing the material, and this program allowed patients and family members to ask questions about the procedure, condition, risks, and benefits beforehand.15 This is a valuable example of an existing preoperative educational intervention. There are other alternatives to the idea of questions being answered online that should be explored and considered for the preoperative period. For example, preoperative instructions could suggest that patients have questions ready when they arrive the day of their surgery. Questions could also be answered by other means of technology, such as during the preoperative telephone call reminding patients of their appointments, or by appealing to younger or more technologically savvy patients by providing an avenue of questioning via text messages.
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and skills to solve immediate problems, such as needing to apply knowledge to an upcoming surgery.3 Additionally, Knowles16 stated that important characteristics of adult learners are that they have a variety of life experiences, preferred learning styles, and different life situations and social contexts that affect their learning. For example, some patients may have had surgery in the past or may even be repeating the same surgery, so their learning needs would be different from the needs of patients having surgery for the first time.
PROJECT IMPLEMENTATION THEORETICAL FRAMEWORK This project aims to incorporate these evidence-based educational intervention recommendations to provide best
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During our project, we revised current patient educational materials in circulation at the project facility using visual, auditory, and kinesthetic/tactile strategies to address all
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Perioperative Patient Literacy
Figure 1. Preoperative instructions revised to lower literacy level for improved comprehension and compliance. learning styles.4 We also took into consideration existing preoperative educational interventions when building the web-based intervention for this project. We focused the implementation of this project on two phases. First, we
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assessed the patient educational materials currently being used at the project facility and revised them as needed to be more readable. Second, we developed a web-based intervention in the form of a blog. AORN Journal j 421
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Figure 2. General surgery postoperative information revised to lower literacy level for improved comprehension and compliance.
Ambulatory Surgery Perioperative Education Ambulatory surgery is defined as outpatient surgery in which the patient is discharged home the same day he or she undergoes a surgical procedure.17 Typically, a preoperative 422 j AORN Journal
ambulatory surgical patient is admitted to the surgical department, usually from outside the hospital, and postoperatively is discharged home to self-care.17 According to Berg et al,18 both the ambulatory nature of patients and postoperatively discharging the patient home put a high
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Figure 2. (continued). demand on the patient and family members for providing care in the postoperative period that requires education and support before discharge. This project took place in a hospital system that has several locations for surgical procedures; the focus of the project was on one location in the hospital system where ambulatory surgery is provided primarily for women’s surgeries and several other disciplines, such as ear, nose, and throat surgery (eg, tonsillectomy); plastic surgery (eg, breast augmentation); obstetrics and gynecology (OB/GYN) surgery (eg, endometrial ablation); and minor orthopedic surgery (eg, lumbar epidural steroid injections). Currently, educational interventions for this location include giving the ambulatory patient general preoperative patient educational materials at the preoperative appointment and postoperative patient educational materials after surgery.
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Assessing and Revising Current Educational Materials None of the preoperative or postoperative instructions available at the surgical facility had pictures or diagrams to help explain concepts to patients. The font was too small on all patient educational materials, and the pages appeared crowded because there were too many characters per line. Sentence length was too long, and many words were all caps rather than underlined or bolded for emphasis, which could cause trouble for patients who have difficulty reading. Furthermore, medical terms, such as anesthesia, were not defined for low health literacy readers.4 We revised the patient educational materials to address these problems. The revised instructions highlight the most important points with pictures, use 14-point type size for body text with bolded text for headlines and key points, and use wider margins AORN Journal j 423
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Figure 3. Obstetrics and gynecology postoperative information revised to lower literacy level for improved comprehension and compliance. and line spacing for easier readability. We determined the reading level of the current general preoperative instructions given to ambulatory surgical patients to be at a ninth-grade reading level, but we revised them so that they are now at a fourth-grade reading level (Figure 1). The reading level of the general postoperative instructions was at a twelfth-grade reading level, but we revised them to be at a fifth-grade reading level (Figure 2). The reading level of the OB/GYN postoperative instructions was at an eleventh-grade reading level, and now is at a fifth-grade reading level (Figure 3).
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Developing a Blog We developed a web-based intervention in the form of a blog for this project to appeal to more patients’ learning styles, which could be used in conjunction with written patient educational materials. A blog is defined as a personal web site or web page on which a person records his or her opinions and links to other sites on a regular basis.19 The blog allows for learning to occur no matter what the patient describes as his or her preferred learning style. People learn in different ways, but there are three primary types of learners: visual learners,
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Figure 3. (continued). auditory learners, and tactile/kinesthetic learners.4 By approaching the information from the perspective of all three learning styles, more people will learn the information being taught.4 For this project, we developed a blog for the facility: http:// outpatientsurgeryinfo.blogspot.com. This blog addresses all learning styles by having information presented in print with visuals for visual learners, audio for auditory learners, and links to videos with demonstrations for kinesthetic learners. According to Krizik,1 it is best to present educational materials in a variety of learning styles throughout the surgical process, beginning in the preoperative period and extending through
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the postoperative period. The blog allows patients with any learning style to revisit the information being provided at any time. This goes beyond what patient educational materials can provide by offering more than just printed material with visual aids. A limitation of the blog is that it requires patients to have access to the Internet; however, patients without Internet access could be encouraged to view the blog from other locations, such as a library. Although people at an economic disadvantage might not have access to or know how to use a computer, many people would still benefit from this option and increase their understanding of their health problems and perioperative education in this way. AORN Journal j 425
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The types of surgeries being performed at this location are of a nonspecific nature, so we developed the blog with two basic areas for patients to visit depending on their type of surgery: general or OB/GYN surgery. The blog is accessible to the patient at any time during the perioperative process, but patients are encouraged to first view the blog from home before their procedure to be better prepared and familiarized with the perioperative process. Included in the blog’s information are preoperative instructions, what to expect at the hospital the day of surgery, and postoperative instructions. Patients also are able to print their preoperative and postoperative instructions from the blog if they want them ahead of time or if their instructions are misplaced.
DISCUSSION The blog is in its infancy, so there are many areas that can be improved and expanded to involve more specific instructions, as well as involving other disciplines. For example, when patients begin viewing the blog, their feedback about how successful it was can help us to improve the blog and make it more effective. Also, the perioperative educator can review the individual instruction sets for readability and then make them available on the blog. This would allow patients to search for specific instructions from their respective surgeons by searching for their surgeon or searching within that discipline (eg, ear, nose, and throat; OB/GYN). The most challenging part of this project was developing audiovisual technology. Audiovisual records were timeconsuming and confusing to produce, particularly because the project manager had no prior experience building a blog, creating audiovisual products, or using the blog software. The novice-level equipment used for these endeavors was a home camcorder, a computer, and basic microphone, leaving much room for improvement. Better audiovisual products can be produced by involving either professionals or semi-professionals for future expansion of the project. For example, hospital administrators could solicit and collaborate with information technology students at a local college to help improve audiovisual records. After fully implementing this project, research will be needed to identify how helpful it is to patients (eg, level of user-friendliness, how effective it is at reducing postoperative complications). One method to objectively measure the project’s effectiveness is to monitor the portion of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, “Clear Discharge Instructions.”20 The HCAHPS survey is a standardized nationwide patient perception survey, and its “Clear Discharge Instructions” area currently is the lowest-scoring area for the surgical services setting in which this project is being 426 j AORN Journal
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implemented. Monitoring HCAHPS scores is one way we plan to evaluate the effectiveness of this project, with the goal of the “Clear Discharge Instructions” category of the survey to show improvement in its scoring. Hospital management personnel monitor these results routinely and even monetarily incentivize hospital employees to meet goals in each category.
CONCLUSION Low literacy and low health literacy are problems facing patients of all demographics. Therefore, patient education throughout the perioperative process that is easy to understand and presented in all learning styles is needed in the ambulatory surgery setting. By implementing simple and cost-effective educational initiatives, nurses can enhance current educational practices focused on reducing postoperative complications and increasing patient satisfaction in the ambulatory surgery setting. Achieving this requires revising current patient educational materials and developing easily accessible webbased interventions.
Editor’s note: CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL.
References 1. Krizik N. Benefits of preoperative education for adult elective surgery patients. AORN J. 2009;90(3):381-386. 2. Health literacy: statistics at-a-glance. National Patient Safety Foundation. http://www.npsf.org/wp-content/uploads/2011/12/ AskMe3_Stats_English.pdf. Accessed November 14, 2014. 3. DeYoung S. Teaching Strategies for Nurse Educators. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 2009. 4. Bastable SB. Nurse as Educator: Principles of Teaching and Learning for Nursing Practice. 3rd ed. Sudbury, MA: Jones & Bartlett; 2008. 5. Toolkit for making written material clear and effective. Section 4: special topics for writing and design. Part 7: using readability formulas: a cautionary note. US Department of Health and Human Services. Centers for Medicare & Medicaid Services. http://www.cms.gov/ Outreach-and-Education/Outreach/WrittenMaterialsToolkit/down loads/toolkitpart07.pdf. Accessed November 14, 2014. 6. Clear & simple: developing effective print materials for low-literate readers. National Cancer Institute. http://www.cancer.gov/cancer topics/cancerlibrary/clear-and-simple/page1/AllPages. Accessed November 14, 2014. 7. Committee on Health Literacy; Board on Neuroscience and Behavioral Health; Institute of Medicine of the National Academies In: Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004. 8. Agency for Healthcare Research and Quality. Research findings: patients with low literacy have poorer health outcomes. In: Health Literacy: Program Brief. Rockville, MD: Agency for Healthcare Research and Quality; 2007:1.
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April 2015, Volume 101, No. 4 9. Kirsch IS, Jungeblut A, Jenkins L, Kolstad A; National Center for Education Statistics. Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey. Washington, DC: US Department of Education; 2002. 10. Choi J. Literature review: using pictographs in discharge instructions for older adults with low-literacy skills. J Clin Nurs. 2011;20(21-22):2984-2996. 11. The SMOG Readability Formula. Readability formulas. http://www .readabilityformulas.com/smog-readability-formula.php. Accessed December 5, 2014. 12. Jacobson KL, Cucchi PS, Morton FJ. Clear and Effective Patient Education. A Guide for Improving Health Communications in the Hospital Setting. Atlanta, GA: Emory University, Rollins School of Public Health; 2005. 34. 13. Atack L, Luke R. The impact of validated, online health education resources on patient and community members’ satisfaction and health behaviour. Health Educ J. 2012;71(2):211-218. 14. Hansberry DR, Suresh R, Agarwal N, Heary RF, Goldstein IM. Quality assessment of online patient education resources for peripheral neuropathy. J Peripher Nerv Syst. 2013;18(1):44-47. 15. Mora M, Shell JE, Thomas CS, Ortiguera CJ, O’Connor MI. Gender differences in questions asked in an online preoperative patient education program. Gend Med. 2012;9(6):456-462.
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Perioperative Patient Literacy 16. Knowles MS. The Modern Practice of Adult Learning. Chicago, IL: Follett; 1980. 17. Billings DM, Halstead JA. Teaching in Nursing: A Guide for Faculty. St Louis, MO: Elsevier Saunders; 2012. 18. Berg K, Arestedt K, Kjellgren K. Postoperative recovery from the perspective of day surgery patients: a phenomenographic study. Int J Nurs Stud. 2013;50(12):1630-1638. 19. Blog. Oxford Dictionary. http://www.oxforddictionaries.com/us/ definition/american_english/blog. Accessed November 14, 2014. 20. HCAHPS: Patients’ Perspectives of Care Survey. CMS.gov. http:// www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/HospitalHCAHPS.html. Accessed December 8, 2014.
Laura Traylor Liebner, MSN, RN is a preoperative nurse for surgical services at Huntsville Hospital for Women and Children, Huntsville, AL. Ms Liebner has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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ABSTRACT Low literacy and low health literacy are surprisingly rampant problems facing health care providers. Patient educators in all settings should consider the need for improved patient education materials that are easy to read and understand for the majority of patients. In the ambulatory surgery setting, patients often have time to prepare for scheduled outpatient surgery, yet education is provided primarily in the postoperative period. This article highlights the need for incorporating education into all phases of the perioperative process, beginning in the preoperative period. Perioperative educators should address all learning styles that provide education in a simple and cost-effective way to appeal to all patients and help to reduce postoperative complications and increase patient satisfaction in the ambulatory surgery setting. AORN J 101 (April 2015) 416-427. ª AORN, Inc, 2015. http:// dx.doi.org/10.1016/j.aorn.2015.01.016 Key words: perioperative education, patient education materials, online education, patient education, ambulatory surgery, low literacy, low health literacy.
http://dx.doi.org/10.1016/j.aorn.2015.01.016 ª AORN, Inc, 2015
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n the United States, approximately 75% of surgeries are performed in the outpatient or ambulatory setting.1 In the ambulatory surgery setting, nurses frequently provide postoperative patient education only. Patients often must rely on family members and visitors to remember information given to them at this time because they are still experiencing the effects of anesthesia (eg, retrograde amnesia) or because surgeons commonly give a patient’s family members verbal instructions after surgery in the surgical waiting area. Although education in the postoperative period often is necessary, Krizik1 indicates that providing educational interventions throughout the perioperative process, beginning in the preoperative period, is the best approach to educating patients undergoing ambulatory surgery. By initiating education in the preoperative period, patient outcomes can be improved by
decreasing anxiety, decreasing lengths of stay, preparing the patient to better anticipate postoperative pain that may be experienced, and increasing patient and family member satisfaction.1 Many American adults have low literacy levels so they function at below-basic reading and comprehension levels.2 People often read two to three grade levels below their last completed year of school.3 People living in poverty typically have even lower literacy levels, often reading four grade levels below their highest obtained education.3 Therefore, those most at risk for low literacy are people with less education or those who are economically disadvantaged. However, most consumers report that they need help understanding health care information, regardless of education or economic status, especially those who have had infrequent encounters with the health care system.2 Therefore, anyone can be at risk for low health literacy. According to Krizik,1 research evidence shows that patient outcomes are tied directly to the provision or lack of patient education. Inadequate preoperative education for surgical patients leads to avoidable postoperative complications or complaints, including unexpected pain, fatigue, and the inability to care for oneself.1 If patients anticipate the inability to perform normal activities of daily living in the immediate postoperative period, they can arrange for assistance and help avoid these complications. Patient education should be available in many forms to accommodate multiple learning styles of patients; nurses should ask the patient what way he or she learns best and should provide patient education primarily in the patient’s preferred form.1 Patients may be auditory, visual, kinesthetic, or tactile learners or a combination of these learning modalities.4 Different approaches to education in the perioperative process can include
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the traditional forms of verbal and written communication, but the nurse also can provide demonstrations, after which he or she asks the patient to provide a return demonstration to confirm that the information has been correctly understood. Pictographs, videos, and web-based information are also helpful.
PURPOSE The purpose of this project was to analyze the health literacy level of preoperative and postoperative ambulatory surgical patient education materials; develop patient-centered, evidence-based materials to facilitate learning and improve patient outcomes; and create a web-based intervention that patients can easily access throughout the preoperative and postoperative process, beginning in the preoperative period. Health care providers who alter the type of information and the way they deliver information to ambulatory surgical patients can improve patient outcomes. These changes should incorporate diverse methods, including web-based, easy-tounderstand information and graphics; include appropriate hard-copy patient educational materials for patients of all backgrounds and literacy levels; and provide preoperative and discharge education.
LITERATURE REVIEW
We conducted a review of the literature using CINAHL Plus With Full Text for 2006 through 2014. We focused on how literacy affects patient education, the use of available patient educational materials, and the use of web-based educational interventions in health care. We used the following key words and key word strings, alone and in combination: perioperative education, patient education materials, literacy, preoperative education, and postoperative education.
Patient Literacy A surprisingly high number of American adults function at a below-basic reading and comprehension level.3 According to DeYoung,3 a common average reading level is sixth to eighth grade (depending on region and area). DeYoung3 explains that people often read two to three grade levels below the last completed year of school; therefore, many people may function at less than the fourth-grade reading level. Guidelines from the US Department of Health and Human Services5 and the National Cancer Institute6 recommend that all written materials prepared for patients be on a third- to fifthegrade reading level. For instance, people reading at a sixth- to AORN Journal j 417
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eighthegrade level (vs a fourth- to sixthegrade reading level) are able to process more complicated statements, compound sentences, longer sentences, and sentences with multiple phrases. Therefore, to reduce the reading level of patient education materials, statements must be made as simple and short as possible, using common one- and two-syllable words whenever possible.4 Furthermore, according to the Institute of Medicine7 and the Agency for Healthcare Research and Quality,8 only 52% of American adults are considered literate (the rest being illiterate or marginally illiterate) and even fewer people are estimated to have functional health literacy. According to the National Adult Literacy Survey, 23% of American adults who are described as having below-basic literacy skills are high school graduates.9 This means that even people who have graduated from high school may be somewhat illiterate where health information is concerned. According to the National Patient Safety Foundation,2 most consumers need help understanding health care information regardless of age, race, or income level. Therefore, all health information should be presented as simply as possible.2
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have undergone general anesthesia and could still be experiencing its effects; have low health literacy, as could family members; or be unable to understand the materials because they are too complicated for the patient or his or her family members.4 Many postoperative educational materials that have been developed by personnel at surgeons’ offices may not take into consideration low literacy level. This often results in patient confusion.
AVAILABLE METHODS TO IMPROVE COMPREHENSION When used in conjunction with verbal instructions and demonstrations, written educational materials can be valuable and cost-effective in providing patient education.5 However, because research indicates that many patient education pamphlets, booklets, information sheets, and consent forms used in health care exceed the literacy level for many people, written patient educational materials are not always helpful.5
Patients who do not comprehend the information presented are more likely to be noncompliant.
Effect of Literacy on Education Current methods of providing ambulatory surgery education include written informational pamphlets and verbal instruction after surgery. Patients who do not comprehend the information presented are more likely to be noncompliant or to guess about what they do not understand, with potentially harmful results to their health.4 Patients may appear to comprehend the instructions, but may not truly understand what is being taught because of anxiety, language barriers, or low literacy.1 Patients with low literacy also may have trouble comprehending information, especially information presented in pamphlets. Low literacy, low health literacy, and a lack of appropriate educational materials for patients also contribute to complications, as well as the additional costs incurred from these complications. Furthermore, “people with low literacy skills put off disease prevention actions and tend to wait longer before seeking medical help.”4(p59) If patients are not able to understand the information presented, it is of very little value.4 This lack of comprehension may be multifactorial. For example, the patient may
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Often, text-based instructions are difficult for patients with low literacy skills to follow at home. After reviewing 44 articles, Choi10 determined that pictographs using simple line drawings combined with simplified text are the most efficient and effective tool to improve discharge education. Pictographs can even be used to show a step-by-step procedure consisting of multiple actions described in complex and lengthy discharge instructions, thus making an entire action sequence easier to learn.10 Therefore, by using pictographs with simplified text, health care educators can improve discharge instructions for low-literate older adults. Furthermore, they are even helpful for patients who speak English as a second language and may be helpful for all patients regardless of their literacy level.10 To assess the current patient educational materials being used at an ambulatory surgical facility, we used the simplified measure of gobbledygook (SMOG)11 formula to determine the readability by grade level of these documents. The SMOG formula offers simple and fast computation by calculating the number of words at the beginning, middle, and end of a written piece and the number of polysyllabic words. A mathematical formula can then be used
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to determine the grade level and readability of a document.11 It is considered one of the most valid tests of readability.4,11
What Affects Readability? The reading level of printed educational materials is not the only factor that plays into readability. Numerous factors affect the reader’s ability to comprehend the information, such as
content organization, second-person and active voice, complexity, acronyms, value terms, text crowding, font size and type, key points, and graphics.5
Content organization Information must be organized into segments that follow a logical sequence and should be prioritized to include the most important information first. Organizing information into chunks improves recall.2
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Value terms Value words, such as “frequently” or “regularly,” should be defined by using specific numbers instead.4 For instance, instructions regarding fluid intake should not be written vaguely (eg, drink water regularly), but should be very specific (eg, drink at least eight full glasses of water a day).
Crowded text Do not use more than 30 to 40 characters per line to avoid crowding the page with text and thus overwhelming the reader.4 According to Bastable,4 patient educational materials should have plenty of white space in the margins, with double-spaced lines and generous spacing between paragraphs.
Font size and type Font should be 14- or 16-point size, but font type also is important. For instance, sans serif fonts (eg, Calibri) do not give the eye any “handles” to visually grasp, so the eye tends to slip off the line of type; which can be difficult for even good readers to follow.12 On the other hand, mixed-case serif fonts (eg, Times New Roman) are the easiest of all typefaces to read because they have little bars on the bottoms and tops of letters that make the letters stand out.12
Key points Second-person and active voice Patient educational materials should not be written in a formal or professional style. A conversational style should be used when creating patient education materials. This style uses the pronouns “you” and “your” to make the message more personal, more interesting, and easier to understand. Using active voice (eg, Do not eat spicy food) ensures that ambiguity is avoided (eg, It is better not to eat spicy food).
Complexity Short words with one or two syllables should be used whenever possible. It is important to use correct terminology rather than slang (eg, breasts vs boobs), and medical terms should be defined.4 Short sentences (ie, no more than 20 words) also are best because they are easier to read and understand, especially for clients with short-term memory problems.
Acronyms Abbreviations or acronyms should not be used4 unless they are common and are terms the patient is familiar with. If an acronym is used, an explanation should be provided; for example, after defining the acronym CPAP as a continuous positive airway pressure, CPAP can be used because patients typically use the acronym rather the full term.
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Do not use all capital letters to emphasize points; instead, use both capital and lowercase letters as appropriate. To emphasize important points, put the information in a box or Use typographic cues such as bolding, underlining, size, and color to emphasize key points. Use visual cues like shading, boxes, and arrows to direct the reader’s attention to specific points or key content. Use color to highlight, add clarity, differentiate, focus the eye, and make images more realistic but use color carefully. It should support, not detract from, the message. When using color, keep in mind that age, gender, and ethnic preferences for color vary markedly.12(p35)
Graphics Pictures and graphics are helpful supplements to include in written patient educational materials.4 Visuals should be relevant, meaningful, and appropriately located.5 Illustrations should be simple and depict adult rather than childlike images when applicable. The illustrations should have captions and each visual should be directly related to one message.5 Cues can also be used, such as circles or arrows, to point out key information.5
Using Web-Based Educational Interventions in Health Care According to Atack and Luke,13 a web-based educational intervention would be a cost-effective and highly accessible AORN Journal j 419
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preoperative intervention for patients who are scheduled for surgery. However, information available on the Internet varies widely in accuracy, and correct information is not always readily accessible or identifiable to patients.13 One study reviewing patient education resources on peripheral neuropathy found that even after using two different reading level scales, the patient information from many popular search results, such as www.Neuropathy.org and the Mayo Clinic, were unsuitable based on reading difficulty.14 Of the nine popular and reliable web sites reviewed, only the US National Library of Medicine scored low enough on reading level (ie, fifth grade) to benefit the average American.14 Therefore, this web site would be a valuable resource for developers of education materials to review before creating a web-based educational intervention for surgical patients to ensure better understanding from its viewers.14 One online preoperative educational intervention that is available for orthopedic surgery encourages patients to submit questions for review before their procedures.15 Findings from a study evaluating this web-based education showed that approximately
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practice for education throughout the ambulatory surgical process for web-based as well as hard-copy instructions for patients. To appeal to all types of adult ambulatory surgical patients, the educational interventions must be patient centered by considering the specific learning needs of adult learners. The Adult Education Theory (ie, andragogy) by Malcolm Knowles (1980) is the theoretical framework for this project. According to Knowles,16 adults learn best when they apply new knowledge to past experiences to solve personally relevant, important problems. This is important to ambulatory surgical patients because these patients will be motivated to learn the new knowledge and skills necessary to help ensure that the surgical experience is successful, such as how to take medications, how to change dressings, and how to empty drains. Adult learning is problem centered, meaning that adults’ prime motivation to learn is to be able to readily apply knowledge
Adults learn best when they apply new knowledge to past experiences to solve personally relevant problems.
one-third of patients had questions preoperatively after viewing the material, and this program allowed patients and family members to ask questions about the procedure, condition, risks, and benefits beforehand.15 This is a valuable example of an existing preoperative educational intervention. There are other alternatives to the idea of questions being answered online that should be explored and considered for the preoperative period. For example, preoperative instructions could suggest that patients have questions ready when they arrive the day of their surgery. Questions could also be answered by other means of technology, such as during the preoperative telephone call reminding patients of their appointments, or by appealing to younger or more technologically savvy patients by providing an avenue of questioning via text messages.
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and skills to solve immediate problems, such as needing to apply knowledge to an upcoming surgery.3 Additionally, Knowles16 stated that important characteristics of adult learners are that they have a variety of life experiences, preferred learning styles, and different life situations and social contexts that affect their learning. For example, some patients may have had surgery in the past or may even be repeating the same surgery, so their learning needs would be different from the needs of patients having surgery for the first time.
PROJECT IMPLEMENTATION THEORETICAL FRAMEWORK This project aims to incorporate these evidence-based educational intervention recommendations to provide best
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During our project, we revised current patient educational materials in circulation at the project facility using visual, auditory, and kinesthetic/tactile strategies to address all
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Figure 1. Preoperative instructions revised to lower literacy level for improved comprehension and compliance. learning styles.4 We also took into consideration existing preoperative educational interventions when building the web-based intervention for this project. We focused the implementation of this project on two phases. First, we
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assessed the patient educational materials currently being used at the project facility and revised them as needed to be more readable. Second, we developed a web-based intervention in the form of a blog. AORN Journal j 421
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Figure 2. General surgery postoperative information revised to lower literacy level for improved comprehension and compliance.
Ambulatory Surgery Perioperative Education Ambulatory surgery is defined as outpatient surgery in which the patient is discharged home the same day he or she undergoes a surgical procedure.17 Typically, a preoperative 422 j AORN Journal
ambulatory surgical patient is admitted to the surgical department, usually from outside the hospital, and postoperatively is discharged home to self-care.17 According to Berg et al,18 both the ambulatory nature of patients and postoperatively discharging the patient home put a high
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Figure 2. (continued). demand on the patient and family members for providing care in the postoperative period that requires education and support before discharge. This project took place in a hospital system that has several locations for surgical procedures; the focus of the project was on one location in the hospital system where ambulatory surgery is provided primarily for women’s surgeries and several other disciplines, such as ear, nose, and throat surgery (eg, tonsillectomy); plastic surgery (eg, breast augmentation); obstetrics and gynecology (OB/GYN) surgery (eg, endometrial ablation); and minor orthopedic surgery (eg, lumbar epidural steroid injections). Currently, educational interventions for this location include giving the ambulatory patient general preoperative patient educational materials at the preoperative appointment and postoperative patient educational materials after surgery.
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Assessing and Revising Current Educational Materials None of the preoperative or postoperative instructions available at the surgical facility had pictures or diagrams to help explain concepts to patients. The font was too small on all patient educational materials, and the pages appeared crowded because there were too many characters per line. Sentence length was too long, and many words were all caps rather than underlined or bolded for emphasis, which could cause trouble for patients who have difficulty reading. Furthermore, medical terms, such as anesthesia, were not defined for low health literacy readers.4 We revised the patient educational materials to address these problems. The revised instructions highlight the most important points with pictures, use 14-point type size for body text with bolded text for headlines and key points, and use wider margins AORN Journal j 423
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Figure 3. Obstetrics and gynecology postoperative information revised to lower literacy level for improved comprehension and compliance. and line spacing for easier readability. We determined the reading level of the current general preoperative instructions given to ambulatory surgical patients to be at a ninth-grade reading level, but we revised them so that they are now at a fourth-grade reading level (Figure 1). The reading level of the general postoperative instructions was at a twelfth-grade reading level, but we revised them to be at a fifth-grade reading level (Figure 2). The reading level of the OB/GYN postoperative instructions was at an eleventh-grade reading level, and now is at a fifth-grade reading level (Figure 3).
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Developing a Blog We developed a web-based intervention in the form of a blog for this project to appeal to more patients’ learning styles, which could be used in conjunction with written patient educational materials. A blog is defined as a personal web site or web page on which a person records his or her opinions and links to other sites on a regular basis.19 The blog allows for learning to occur no matter what the patient describes as his or her preferred learning style. People learn in different ways, but there are three primary types of learners: visual learners,
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Figure 3. (continued). auditory learners, and tactile/kinesthetic learners.4 By approaching the information from the perspective of all three learning styles, more people will learn the information being taught.4 For this project, we developed a blog for the facility: http:// outpatientsurgeryinfo.blogspot.com. This blog addresses all learning styles by having information presented in print with visuals for visual learners, audio for auditory learners, and links to videos with demonstrations for kinesthetic learners. According to Krizik,1 it is best to present educational materials in a variety of learning styles throughout the surgical process, beginning in the preoperative period and extending through
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the postoperative period. The blog allows patients with any learning style to revisit the information being provided at any time. This goes beyond what patient educational materials can provide by offering more than just printed material with visual aids. A limitation of the blog is that it requires patients to have access to the Internet; however, patients without Internet access could be encouraged to view the blog from other locations, such as a library. Although people at an economic disadvantage might not have access to or know how to use a computer, many people would still benefit from this option and increase their understanding of their health problems and perioperative education in this way. AORN Journal j 425
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The types of surgeries being performed at this location are of a nonspecific nature, so we developed the blog with two basic areas for patients to visit depending on their type of surgery: general or OB/GYN surgery. The blog is accessible to the patient at any time during the perioperative process, but patients are encouraged to first view the blog from home before their procedure to be better prepared and familiarized with the perioperative process. Included in the blog’s information are preoperative instructions, what to expect at the hospital the day of surgery, and postoperative instructions. Patients also are able to print their preoperative and postoperative instructions from the blog if they want them ahead of time or if their instructions are misplaced.
DISCUSSION The blog is in its infancy, so there are many areas that can be improved and expanded to involve more specific instructions, as well as involving other disciplines. For example, when patients begin viewing the blog, their feedback about how successful it was can help us to improve the blog and make it more effective. Also, the perioperative educator can review the individual instruction sets for readability and then make them available on the blog. This would allow patients to search for specific instructions from their respective surgeons by searching for their surgeon or searching within that discipline (eg, ear, nose, and throat; OB/GYN). The most challenging part of this project was developing audiovisual technology. Audiovisual records were timeconsuming and confusing to produce, particularly because the project manager had no prior experience building a blog, creating audiovisual products, or using the blog software. The novice-level equipment used for these endeavors was a home camcorder, a computer, and basic microphone, leaving much room for improvement. Better audiovisual products can be produced by involving either professionals or semi-professionals for future expansion of the project. For example, hospital administrators could solicit and collaborate with information technology students at a local college to help improve audiovisual records. After fully implementing this project, research will be needed to identify how helpful it is to patients (eg, level of user-friendliness, how effective it is at reducing postoperative complications). One method to objectively measure the project’s effectiveness is to monitor the portion of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, “Clear Discharge Instructions.”20 The HCAHPS survey is a standardized nationwide patient perception survey, and its “Clear Discharge Instructions” area currently is the lowest-scoring area for the surgical services setting in which this project is being 426 j AORN Journal
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implemented. Monitoring HCAHPS scores is one way we plan to evaluate the effectiveness of this project, with the goal of the “Clear Discharge Instructions” category of the survey to show improvement in its scoring. Hospital management personnel monitor these results routinely and even monetarily incentivize hospital employees to meet goals in each category.
CONCLUSION Low literacy and low health literacy are problems facing patients of all demographics. Therefore, patient education throughout the perioperative process that is easy to understand and presented in all learning styles is needed in the ambulatory surgery setting. By implementing simple and cost-effective educational initiatives, nurses can enhance current educational practices focused on reducing postoperative complications and increasing patient satisfaction in the ambulatory surgery setting. Achieving this requires revising current patient educational materials and developing easily accessible webbased interventions.
Editor’s note: CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL.
References 1. Krizik N. Benefits of preoperative education for adult elective surgery patients. AORN J. 2009;90(3):381-386. 2. Health literacy: statistics at-a-glance. National Patient Safety Foundation. http://www.npsf.org/wp-content/uploads/2011/12/ AskMe3_Stats_English.pdf. Accessed November 14, 2014. 3. DeYoung S. Teaching Strategies for Nurse Educators. 2nd ed. Upper Saddle River, NJ: Prentice Hall; 2009. 4. Bastable SB. Nurse as Educator: Principles of Teaching and Learning for Nursing Practice. 3rd ed. Sudbury, MA: Jones & Bartlett; 2008. 5. Toolkit for making written material clear and effective. Section 4: special topics for writing and design. Part 7: using readability formulas: a cautionary note. US Department of Health and Human Services. Centers for Medicare & Medicaid Services. http://www.cms.gov/ Outreach-and-Education/Outreach/WrittenMaterialsToolkit/down loads/toolkitpart07.pdf. Accessed November 14, 2014. 6. Clear & simple: developing effective print materials for low-literate readers. National Cancer Institute. http://www.cancer.gov/cancer topics/cancerlibrary/clear-and-simple/page1/AllPages. Accessed November 14, 2014. 7. Committee on Health Literacy; Board on Neuroscience and Behavioral Health; Institute of Medicine of the National Academies In: Nielsen-Bohlman L, Panzer AM, Kindig DA, eds. Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press; 2004. 8. Agency for Healthcare Research and Quality. Research findings: patients with low literacy have poorer health outcomes. In: Health Literacy: Program Brief. Rockville, MD: Agency for Healthcare Research and Quality; 2007:1.
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April 2015, Volume 101, No. 4 9. Kirsch IS, Jungeblut A, Jenkins L, Kolstad A; National Center for Education Statistics. Adult Literacy in America: A First Look at the Findings of the National Adult Literacy Survey. Washington, DC: US Department of Education; 2002. 10. Choi J. Literature review: using pictographs in discharge instructions for older adults with low-literacy skills. J Clin Nurs. 2011;20(21-22):2984-2996. 11. The SMOG Readability Formula. Readability formulas. http://www .readabilityformulas.com/smog-readability-formula.php. Accessed December 5, 2014. 12. Jacobson KL, Cucchi PS, Morton FJ. Clear and Effective Patient Education. A Guide for Improving Health Communications in the Hospital Setting. Atlanta, GA: Emory University, Rollins School of Public Health; 2005. 34. 13. Atack L, Luke R. The impact of validated, online health education resources on patient and community members’ satisfaction and health behaviour. Health Educ J. 2012;71(2):211-218. 14. Hansberry DR, Suresh R, Agarwal N, Heary RF, Goldstein IM. Quality assessment of online patient education resources for peripheral neuropathy. J Peripher Nerv Syst. 2013;18(1):44-47. 15. Mora M, Shell JE, Thomas CS, Ortiguera CJ, O’Connor MI. Gender differences in questions asked in an online preoperative patient education program. Gend Med. 2012;9(6):456-462.
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Perioperative Patient Literacy 16. Knowles MS. The Modern Practice of Adult Learning. Chicago, IL: Follett; 1980. 17. Billings DM, Halstead JA. Teaching in Nursing: A Guide for Faculty. St Louis, MO: Elsevier Saunders; 2012. 18. Berg K, Arestedt K, Kjellgren K. Postoperative recovery from the perspective of day surgery patients: a phenomenographic study. Int J Nurs Stud. 2013;50(12):1630-1638. 19. Blog. Oxford Dictionary. http://www.oxforddictionaries.com/us/ definition/american_english/blog. Accessed November 14, 2014. 20. HCAHPS: Patients’ Perspectives of Care Survey. CMS.gov. http:// www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/HospitalHCAHPS.html. Accessed December 8, 2014.
Laura Traylor Liebner, MSN, RN is a preoperative nurse for surgical services at Huntsville Hospital for Women and Children, Huntsville, AL. Ms Liebner has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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