WORK A Journal of Prevention, Assessment & Rehabilitation
ELSEVIER
Work 7 (1996) 31-36
Literacy in the health professions today James Carifio*a, Lorraine Dagostino b • University of Massachusetts-Lowell, 1 University Avenue, Lowell, MA 01854, USA b16 Royal Crest Road, Nashua, NH 03060, USA Received 19 December 1995; accepted 14 January 1996
Abstract Multiple literacies are needed to be successful in the health professions today. This article outlines five general types or spheres of literacies that health care workers, professionals and clients need to possess to some degree to function effectively in the current complexities and multiple areas of modern health. Examples of each kind or sphere of literacy are given as well as suggestions for how such literacies may be promoted in the workplace. Keywords: Literacy; Workplace literacy; Healthcare literacy
1. Introduction Multiple literacies are crucial for achieving successful independent and interdependent functioning in the workplace today. Without the skill to use language, individuals are dependent on others to learn new skills to complete routine aspects of their daily work. They also are limited in their capacity to grow and to adapt as the responsibilities of their job change. Achieving the literacy necessary for success in today's workplace is a continuous process, requiring that we view literacy as more than simply the basic skills associated with reading and writing. Understanding literacy as language and
* Corresponding author. Tel.: [email protected].
+ 1 508 9344609; e-mail: cari-
thinking processes consisting of mUltiple proficiencies provides a useful concept for understanding what it means and takes to be literate and competent in the workplace today. This article presents a changing model of literacy that is useful to understanding how literacy varies over time and situation as well as how the model shapes literacy in the workplace and applies to the health professions. 2. A model of literacy Achieving the literacies needed for the workplace today is a complex process. The model of literacy described should help clinicians understand the complexity of the process. As individuals move from one environment to another, they will need to develop or transfer the skills needed for the new environment as participation in each
1051-9815/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved. PII:S1051-9815(96)00185-4
32
1. Carijio, L. Dagostino / Work 7 (1996) 31-36
new work environment requires multiple proficiencies to ensure success. The spheres of literacy model (Dagostino and Carifio, 1994) is a concept that recognizes multiple kinds of literacy and the potential relationships between and among the spheres. Fig. 1 represents this spheres of literacy model. It shows how professionals as workers must master the multiple proficiencies implicit in the spheres. The spheres of literacy represents a set of skills, attitudes and proficiencies that are needed to function in most environments according to that specific environment's requirements. Each sphere is a subset of the spheres above it and, therefore, requires the skills and proficiencies of the additional sphere. Yet, each sphere is qualitatively different from the spheres that precede it. Each sphere is similar in many ways to a developmental stage, at least in terms of the differences in kind and complexities of those spheres that precede it. When workers are limited in the spheres in which they can function, they will be limited in how successful they can be in both their work and personal life as well as in attaining the proficiencies they need to participate in the higher spheres. Imagine several work environments where the degree of success in achieving literacy varies with the changing needs and expectations of each envi-
Fig. 1. The spheres of literacy
ronment according to the varying standards of each sphere. There are work environments and tasks where only functional skills are needed, and there are other situations where problems and failures will be highly manifest if one does not have specialized or multicultural literacies. This same point holds true for clients as well as workers. Professionals may overlook that clients must have multiple literacies to participate successfully in appropriately employing and consuming services. Our model, therefore, can be used to conceptualize and analyze 'customers' as well as self, coworkers or an organization. 3. Functional literacy This sphere represents a restrictive view of literacy. It has an expectation of minimal standards; that is, where people are expected to have specific, technical, almost mechanical skills related to reading, writing, speaking, minimal computation and other life 'basics' as measured most often by the standardized tests used in the schools, counseling and work readiness assessment. Students may be prepared to join the section of the work force which requires the most basic of skills, approximately at a fourth to eighth grade level. These individuals will be able to read street signs, newspapers and simple instructions or directions, do basic mathematics, solve simple problems, and employ basic life skills such as being on time, being polite, and having good personal hygiene. Individuals who are functionally literate will be able to comprehend basic messages that are conveyed in straightforward, explicit text (Anderson et aI., 1984; Kozol, 1985; NAEP, 1986). Generally, functional literacy means meeting minimal requirements for functioning in the home, in social situations and in the work environment. As a society advances what becomes minimal expectations increases either because the problems become more sophisticated and complex, or the basis of an economy or sociopolitical structure changes. Functional literacy is simply an initial level of literacy and changes constantly as the everyday functioning of individuals becomes more complex. What may have been a specialized liter-
J. Carijio, L. Dagostino / Work 7 (1996) 31-36
acy 10 years ago, has become a functional literacy today. Minimal skill with computers is an excellent example of this principle. 4. Specialized literacy In the second of the spheres, a sphere of specialization, we see individuals with the goal of assimilation into groups whose work skills and language often require the use of technical and professional terms, specific knowledge bases, and established ways of approaching problems. Scientific research and the legal profession have welldefined procedures for investigating problems or coming to justifiable decisions and judgments (Rutherford, 1990). With those procedures comes specialized terminology and concepts. Specialized literacy, however, is not simply workplace related. With all of the changes coming about in how we complete banking transactions or complete insurance and health-related paperwork, people must be familiar with many kinds of specialized literacies for everyday functioning now (Gagnon, 1989; Bianculli, 1992). Highly educated people may find themselves at a loss if the text and the language do not match their background knowledge. Here we see where literacy development is uneven across different domains of knowledge and the individual. As a society develops more knowledge and those knowledge bases become highly specialized, we will see more people dependent upon others for functioning in different specializations. People with specialized literacy will not be literate in other rapidly developing and proliferating specialization areas and this will (and now does) create various problems, including feelings of inadequacy and insularity. Much of this problem will mean constant retraining and upgrading of literacy skills in almost every work environment (Skagen, 1984). The need for development of cooperative learning and functioning skills and attitudes as necessary changes will be exponential and rapid from now on for awhile at least. From this perspective of specialized literacy, the next sphere of literacy becomes more important.
33
5. Cultural and multicultural literacy In cultural and multicultural literacy people are able to assimilate the meanings, values and views of various cultures and subcultures where appropriate (Diamond et aI., 1995). In the narrowest sense, this literacy may mean one has read the books selected as classic and representative of a specific culture. In a broader sense, it can mean a knowledge of the different ways people from different cultures see topics and issues that emerge in all cultures. In the broadest view, we see many cultures legitimized. We see a world that is rich in its interpretation of life rather than limited by intolerant and exclusionary boundaries. Multicultural literacy is a broader view of cultural literacy where minorities share the right to express their opinions and have a say in the way they are governed and what is valued in a particular society (Spear et aI., 1990). The pluralism generated by the development of multicultural literacy is key to maintaining a democratic state as is the cultivation of the fourth sphere of literacy-critical literacy. 6. Critical literacy Critical literacy is an outgrowth of critical thinking; that is, the individual is able to evaluate the message and the means of communication. In this process the individual evaluates the accuracy, the reasoning, the value and the appropriateness of the 'text' for the situation. In the sphere of critical literacy, we also see the power of language and knowledge transformed into political tools that can change and improve the quality of an individual's life. The sphere of critical literacy has the potential for enlightenment because the individual learns to entertain multiple points of view on many topics and issues. Individuals who are critically literate are cognitively and affectively open and seldom passively accept what is presented. Dialogue and questioning are encouraged and seen as unavoidable. Individuals view themselves as choicemakers rather than having choices made for them. Almost all environments in the modern world require this kind of literacy today
34
1. Carifio, L. Dagostino / Work 7 (1996) 31-36
(Brodkey, 1986). Health and helping occupations and professions have a high demand and need for critical literacy today in terms of both clients and workers, but critical literacy is also becoming increasingly important in a vast number of other jobs and areas of our economy where workers must analyze and make choices about jon-related health hazards and risks and environmental and psychological consequences of actions, such as depleting the ozone layer and the effects of a given therapeutic strategy. Critical literacy is needed and demanded in high stakes contexts and activities. 7. Composite environment The final sphere in our model represents an ideal standard and total expectation of skill in literacy. As a society becomes more complex individuals will have to be able to function using skills, attitudes and proficiencies represented by all of the spheres. People will have to be able to shift rapidly from simply reading to get the literal meaning of basic text to evaluating a more complex piece of writing or a speech in terms of its relevance and appropriateness for a particular audience or situation. Making decisions where the stakes are high will require people to know more about specialized fields and cultures as well as having very good critical thinking and valuing skills. Having the flexibility to move rapidly from one sphere of literacy to another independently will become crucial in the modern world. Literacy will not be a static state; it will change with every advance a society makes. Therefore, being literate once will not be enough, nor will having only one kind of literacy suffice. 8. Literacy in the workplace of the health professions The workplace usually demands some form of each of the literacies and the mUltiple proficiencies associated with each sphere. The health and helping professions are not exceptions. As we examine the tasks required in the health professions we see some parallels to the spheres of literacy. First, many administrative tasks, forms
or reports could be considered examples of material representing functional literacy as it appears in hospital or home health care facilities. Receptionists and people working in business offices must be able to handle a variety of admittance forms, billing records, claims and health agency or insurance agency material. Aside from demographic information, these materials often use terms indicating distribution of pharmaceuticals or administration of specific medical procedures. The more these workers know, the more effective and efficient they can be. The meticulousness of medical histories and patient records depends upon doctors and their assistants to record information systematically and accurately. The more organized and simple these forms are, the less room for errors. Good medical histories and patient records should quickly reveal patterns of illness and treatment over time, by physician and by institution. Causal relations between treatment and patient well-being should be evident. These two latter examples are instances of specialized literacies and the shift to the next sphere. Health care professionals also need to find ways to digest a great deal of information about guidelines and policies of various health-administering agencies and institutions as well as legal contingencies for doing a job. Tl1ese reports and guidelines should be written as straightforwardly as possible so that multiple interpretation is minimized. These tasks, along with others, are basic to functioning in healthcare environments and also reflect how individuals without specialized education must develop some. level of specialized knowledge. As we move on to tasks and material that have greater scientific substance, we see the need for skill in specialized literacy. Initial training for this type of work is more extensive, and the need to update knowledge and skills is continuous. Beginning with lab technicians and nursing aides, there is a need for training to follow specific procedures and techniques that have a scientific or medical basis. Technicians are required to learn about new tests, conduct experiments, use new equipment and read and write technical reports on a regular basis. Aides must learn to use new equip-
1. Carifio, L. Dagostino I Work 7 (1996) 31-36
ment as often as a medical supply salesment visits a facility. Nurses and doctors must stay abreast of the pharmaceuticals available so that medications are prescribed and administered properly. Reliance on the pharmaceutical sales person is not the best way to update knowledge. New equipment requires transforming skills and approaches for diagnosing all kinds of medical problems. Adjusting skill in reading graphs, charts or other forms of reporting test results or monitoring patient behaviors is another area of concern. Reading journals and evaluating the information of specialized areas of medicine is still within the responsibility of the primary care physician and health care practitioner so that appropriate referrals can be made. Constant reporting and reviewing of this information is necessary so that health care professionals can share even anecdotal information about their experiences. What has been said here about specialized literacies for healthcare and helping professionals could also be said of engineers, technologists, teachers, lawyers and salespersons. Todays' world demands continuing updated specialized literacies even at McDonald's. Today's world is also demanding more and more multiple specialized literacies which means more update training time and better cooperative learning and working skills. The sphere of cultural/multicultural literacy parallels some concern with the pragmatics of communication as well as culturally different points of view about health and medicine. In the case of pragmatics, health professionals need to attend to interpersonal relationship skills such as channels of communication within organizations as well as how people from other cultures communicate or what they believe about medicine, religion and life in general. Understanding about alternative medicines, particularly as they are culturally-based is a second concern. When we consider the pragmatics of communication we are making decisions about what, where, who, how and why we tell people what we do. Often this requires a sensitivity to the organization of an institution, a relationship of the people communicating with patients, ethnic and cultural differences and views about western and eastern forms of medicine and death or other means of tran-
35
smitting information. Condescension clearly has no place in any form of communication, even though knowledge bases or rank may vary widely. Cultural or multicultural literacy has been getting attention in the workplace recently. Finally, critical literacy, or the evaluation of messages, proposals, situations, cases and language in the workplace is key to effective functioning relative to most tasks encountered in the workplace above entry level jobs and tasks. People in the health profession, like those in any profession, must have the critical thinking skills necessary to make decisions and judgments based upon multiple sources of information. This simple fact means that both cognitively and affectively they must be open to rethinking and evaluating what they do and how they do it constantly. This attitude of openness and careful skepticism is crucial to reviewing proposed changes in administrative policies as well as medical and technological advancements. Many individuals must be willing to share knowledge and views on a range of significant issues. Being open to alternatives for providing and receiving healthcare not previously available often creates situations requiring ethical considerations not necessary in earlier times. The value systems and philosophies guiding healthcare facilities may conflict with the patient's beliefs and desires. Patients must learn to make choices, often with inadequate understanding of specialized knowledge. Critical judgment and sensitive communication are crucial to serving a patient well. Professionals in the health and helping fields as well as the clients they serve must have access to mechanisms that support constant reassessment and learning for making intelligent choices and informed decisions about healthcare. Patients must be able to get adequate information about their own health status as well as about health insurances and hospital practices. This means doctors and agencies must learn to communicate technical and specialized knowledge to people of a variety of backgrounds who have little or no knowledge of what is available to them. Achieving this goal is linked to the quality and nature of the training provided for healthcare professionals at every level. In conclusion, the need for recogniz-
36
J. Carifio, L. Dagostino / Work 7 (1996) 31-36
ing and developing the multiple proficiencies and literacies required by the professional and the client is high. Some suggestions, therefore, may be helpful. Training administrative staff who will work directly with clients on issues regarding health insurances and agencies would serve the health care facility and also educate the patient. These workers will not simply do the paperwork but they will be well-informed enough to help clients make informed decisions where possible. This becomes very important as outpatient services grow and this staff is the client's primary link to the facility and services, other than the doctor. Key in this training is developing a helpful, understanding attitude toward the client. As administrative staff begin employment and as new procedures or forms are brought into use, health care facilities should consider small group training sessions to learn to handle the paperwork and the interpersonal skills needed for the job. Assuming each employee will learn on his or her own is presumptive. Sessions might be held to update employees about changes in guidelines and policies of an agency they work for and those that agency works with. Since communication is key to the growing number of collaborative diagnoses and treatments of out patient services both written and oral skills of employees should be reviewed regularly. Forms regularly used should be reviewed for improvement. For example, technicians should be using forms that report clearly all test findings and possible interpretations. They also would benefit from training in writing technical reports. Supervisors would benefit from instruction in interpersonal skills and writing memos and annual reports. Regular presentations about recent use of new pharmaceuticals would be helpful. The distribution of the results of significant studies about controversial drugs and experimental procedures should be the focus of discussion groups for all involved. Healthcare practitioners need to have better and constantly updated training about
medical practices, particularly diagnosis, treatment and after-care followup work. Training in interpersonal skills with minority populations is becoming important. Recognizing cultural and language differences is crucial to good services. Getting patients to accept care from minority professionals and other caretakers is important too. Breaking through attitudinal barriers is crucial training in many healthcare facilities. These are a few possibilities for training people in the health and helping professions suggested by our model of the spheres of literacy. The spheres of literacy model can guide the development of training programs to accommodate the many facets of communication implicit in the health and helping professions by suggesting who needs what kind of literacy for their job responsibilities. Each of the spheres delineates clearly areas of concern, and they remind us of the complexity of the issues related to literacy in the workplace today. References Anderson, R. et al. (1984) Becoming A Nation of Readers: The Report of the Commission on Reading. Washington, DC: The National Institute. Bianculli, D. (1992) Teleliteracy: Taking Television Seriously. NY: Simon and Schuster. Brodkey, L. (1986) Topics of literacy. J. Educ. 168(2),47-54. Dagostino, L. and Carifio, J. (1994) Evaluative Reading and Literacy: A Cognitive View. Boston: Allyn and Bacon, Inc. Diamond, J. B. and Moore, M.A. (1995) Multicultural Literat.'y: Mirroring the Reality of the Classroom. NY: Longman. Gagnon, P. (Ed.) (1989) Historical Literacy: The Call for History in American Education. Boston: Houghton Mifflin. Kozol, J. (1985) Illiterate America. NY: Anchor Press. NAEP (1986) Profiles of Literacy: An Assessment of Young Adults. Princeton, NJ: Educational Testing Service. Rutherford, F.J. and Ahlgren, A. (1990) Science For All Americans. NY: Oxford University Press. Skagen, A. (Ed) (1986) Workplace Literacy. NY: American Management Association. Spear, A. et al. (1990) Multicultural literacy: A context for composition. Teaching English in the Two-Year College 17(4) (December 1990), 247-252.
ELSEVIER
Work 7 (1996) 31-36
Literacy in the health professions today James Carifio*a, Lorraine Dagostino b • University of Massachusetts-Lowell, 1 University Avenue, Lowell, MA 01854, USA b16 Royal Crest Road, Nashua, NH 03060, USA Received 19 December 1995; accepted 14 January 1996
Abstract Multiple literacies are needed to be successful in the health professions today. This article outlines five general types or spheres of literacies that health care workers, professionals and clients need to possess to some degree to function effectively in the current complexities and multiple areas of modern health. Examples of each kind or sphere of literacy are given as well as suggestions for how such literacies may be promoted in the workplace. Keywords: Literacy; Workplace literacy; Healthcare literacy
1. Introduction Multiple literacies are crucial for achieving successful independent and interdependent functioning in the workplace today. Without the skill to use language, individuals are dependent on others to learn new skills to complete routine aspects of their daily work. They also are limited in their capacity to grow and to adapt as the responsibilities of their job change. Achieving the literacy necessary for success in today's workplace is a continuous process, requiring that we view literacy as more than simply the basic skills associated with reading and writing. Understanding literacy as language and
* Corresponding author. Tel.: [email protected].
+ 1 508 9344609; e-mail: cari-
thinking processes consisting of mUltiple proficiencies provides a useful concept for understanding what it means and takes to be literate and competent in the workplace today. This article presents a changing model of literacy that is useful to understanding how literacy varies over time and situation as well as how the model shapes literacy in the workplace and applies to the health professions. 2. A model of literacy Achieving the literacies needed for the workplace today is a complex process. The model of literacy described should help clinicians understand the complexity of the process. As individuals move from one environment to another, they will need to develop or transfer the skills needed for the new environment as participation in each
1051-9815/96/$15.00 © 1996 Elsevier Science Ireland Ltd. All rights reserved. PII:S1051-9815(96)00185-4
32
1. Carijio, L. Dagostino / Work 7 (1996) 31-36
new work environment requires multiple proficiencies to ensure success. The spheres of literacy model (Dagostino and Carifio, 1994) is a concept that recognizes multiple kinds of literacy and the potential relationships between and among the spheres. Fig. 1 represents this spheres of literacy model. It shows how professionals as workers must master the multiple proficiencies implicit in the spheres. The spheres of literacy represents a set of skills, attitudes and proficiencies that are needed to function in most environments according to that specific environment's requirements. Each sphere is a subset of the spheres above it and, therefore, requires the skills and proficiencies of the additional sphere. Yet, each sphere is qualitatively different from the spheres that precede it. Each sphere is similar in many ways to a developmental stage, at least in terms of the differences in kind and complexities of those spheres that precede it. When workers are limited in the spheres in which they can function, they will be limited in how successful they can be in both their work and personal life as well as in attaining the proficiencies they need to participate in the higher spheres. Imagine several work environments where the degree of success in achieving literacy varies with the changing needs and expectations of each envi-
Fig. 1. The spheres of literacy
ronment according to the varying standards of each sphere. There are work environments and tasks where only functional skills are needed, and there are other situations where problems and failures will be highly manifest if one does not have specialized or multicultural literacies. This same point holds true for clients as well as workers. Professionals may overlook that clients must have multiple literacies to participate successfully in appropriately employing and consuming services. Our model, therefore, can be used to conceptualize and analyze 'customers' as well as self, coworkers or an organization. 3. Functional literacy This sphere represents a restrictive view of literacy. It has an expectation of minimal standards; that is, where people are expected to have specific, technical, almost mechanical skills related to reading, writing, speaking, minimal computation and other life 'basics' as measured most often by the standardized tests used in the schools, counseling and work readiness assessment. Students may be prepared to join the section of the work force which requires the most basic of skills, approximately at a fourth to eighth grade level. These individuals will be able to read street signs, newspapers and simple instructions or directions, do basic mathematics, solve simple problems, and employ basic life skills such as being on time, being polite, and having good personal hygiene. Individuals who are functionally literate will be able to comprehend basic messages that are conveyed in straightforward, explicit text (Anderson et aI., 1984; Kozol, 1985; NAEP, 1986). Generally, functional literacy means meeting minimal requirements for functioning in the home, in social situations and in the work environment. As a society advances what becomes minimal expectations increases either because the problems become more sophisticated and complex, or the basis of an economy or sociopolitical structure changes. Functional literacy is simply an initial level of literacy and changes constantly as the everyday functioning of individuals becomes more complex. What may have been a specialized liter-
J. Carijio, L. Dagostino / Work 7 (1996) 31-36
acy 10 years ago, has become a functional literacy today. Minimal skill with computers is an excellent example of this principle. 4. Specialized literacy In the second of the spheres, a sphere of specialization, we see individuals with the goal of assimilation into groups whose work skills and language often require the use of technical and professional terms, specific knowledge bases, and established ways of approaching problems. Scientific research and the legal profession have welldefined procedures for investigating problems or coming to justifiable decisions and judgments (Rutherford, 1990). With those procedures comes specialized terminology and concepts. Specialized literacy, however, is not simply workplace related. With all of the changes coming about in how we complete banking transactions or complete insurance and health-related paperwork, people must be familiar with many kinds of specialized literacies for everyday functioning now (Gagnon, 1989; Bianculli, 1992). Highly educated people may find themselves at a loss if the text and the language do not match their background knowledge. Here we see where literacy development is uneven across different domains of knowledge and the individual. As a society develops more knowledge and those knowledge bases become highly specialized, we will see more people dependent upon others for functioning in different specializations. People with specialized literacy will not be literate in other rapidly developing and proliferating specialization areas and this will (and now does) create various problems, including feelings of inadequacy and insularity. Much of this problem will mean constant retraining and upgrading of literacy skills in almost every work environment (Skagen, 1984). The need for development of cooperative learning and functioning skills and attitudes as necessary changes will be exponential and rapid from now on for awhile at least. From this perspective of specialized literacy, the next sphere of literacy becomes more important.
33
5. Cultural and multicultural literacy In cultural and multicultural literacy people are able to assimilate the meanings, values and views of various cultures and subcultures where appropriate (Diamond et aI., 1995). In the narrowest sense, this literacy may mean one has read the books selected as classic and representative of a specific culture. In a broader sense, it can mean a knowledge of the different ways people from different cultures see topics and issues that emerge in all cultures. In the broadest view, we see many cultures legitimized. We see a world that is rich in its interpretation of life rather than limited by intolerant and exclusionary boundaries. Multicultural literacy is a broader view of cultural literacy where minorities share the right to express their opinions and have a say in the way they are governed and what is valued in a particular society (Spear et aI., 1990). The pluralism generated by the development of multicultural literacy is key to maintaining a democratic state as is the cultivation of the fourth sphere of literacy-critical literacy. 6. Critical literacy Critical literacy is an outgrowth of critical thinking; that is, the individual is able to evaluate the message and the means of communication. In this process the individual evaluates the accuracy, the reasoning, the value and the appropriateness of the 'text' for the situation. In the sphere of critical literacy, we also see the power of language and knowledge transformed into political tools that can change and improve the quality of an individual's life. The sphere of critical literacy has the potential for enlightenment because the individual learns to entertain multiple points of view on many topics and issues. Individuals who are critically literate are cognitively and affectively open and seldom passively accept what is presented. Dialogue and questioning are encouraged and seen as unavoidable. Individuals view themselves as choicemakers rather than having choices made for them. Almost all environments in the modern world require this kind of literacy today
34
1. Carifio, L. Dagostino / Work 7 (1996) 31-36
(Brodkey, 1986). Health and helping occupations and professions have a high demand and need for critical literacy today in terms of both clients and workers, but critical literacy is also becoming increasingly important in a vast number of other jobs and areas of our economy where workers must analyze and make choices about jon-related health hazards and risks and environmental and psychological consequences of actions, such as depleting the ozone layer and the effects of a given therapeutic strategy. Critical literacy is needed and demanded in high stakes contexts and activities. 7. Composite environment The final sphere in our model represents an ideal standard and total expectation of skill in literacy. As a society becomes more complex individuals will have to be able to function using skills, attitudes and proficiencies represented by all of the spheres. People will have to be able to shift rapidly from simply reading to get the literal meaning of basic text to evaluating a more complex piece of writing or a speech in terms of its relevance and appropriateness for a particular audience or situation. Making decisions where the stakes are high will require people to know more about specialized fields and cultures as well as having very good critical thinking and valuing skills. Having the flexibility to move rapidly from one sphere of literacy to another independently will become crucial in the modern world. Literacy will not be a static state; it will change with every advance a society makes. Therefore, being literate once will not be enough, nor will having only one kind of literacy suffice. 8. Literacy in the workplace of the health professions The workplace usually demands some form of each of the literacies and the mUltiple proficiencies associated with each sphere. The health and helping professions are not exceptions. As we examine the tasks required in the health professions we see some parallels to the spheres of literacy. First, many administrative tasks, forms
or reports could be considered examples of material representing functional literacy as it appears in hospital or home health care facilities. Receptionists and people working in business offices must be able to handle a variety of admittance forms, billing records, claims and health agency or insurance agency material. Aside from demographic information, these materials often use terms indicating distribution of pharmaceuticals or administration of specific medical procedures. The more these workers know, the more effective and efficient they can be. The meticulousness of medical histories and patient records depends upon doctors and their assistants to record information systematically and accurately. The more organized and simple these forms are, the less room for errors. Good medical histories and patient records should quickly reveal patterns of illness and treatment over time, by physician and by institution. Causal relations between treatment and patient well-being should be evident. These two latter examples are instances of specialized literacies and the shift to the next sphere. Health care professionals also need to find ways to digest a great deal of information about guidelines and policies of various health-administering agencies and institutions as well as legal contingencies for doing a job. Tl1ese reports and guidelines should be written as straightforwardly as possible so that multiple interpretation is minimized. These tasks, along with others, are basic to functioning in healthcare environments and also reflect how individuals without specialized education must develop some. level of specialized knowledge. As we move on to tasks and material that have greater scientific substance, we see the need for skill in specialized literacy. Initial training for this type of work is more extensive, and the need to update knowledge and skills is continuous. Beginning with lab technicians and nursing aides, there is a need for training to follow specific procedures and techniques that have a scientific or medical basis. Technicians are required to learn about new tests, conduct experiments, use new equipment and read and write technical reports on a regular basis. Aides must learn to use new equip-
1. Carifio, L. Dagostino I Work 7 (1996) 31-36
ment as often as a medical supply salesment visits a facility. Nurses and doctors must stay abreast of the pharmaceuticals available so that medications are prescribed and administered properly. Reliance on the pharmaceutical sales person is not the best way to update knowledge. New equipment requires transforming skills and approaches for diagnosing all kinds of medical problems. Adjusting skill in reading graphs, charts or other forms of reporting test results or monitoring patient behaviors is another area of concern. Reading journals and evaluating the information of specialized areas of medicine is still within the responsibility of the primary care physician and health care practitioner so that appropriate referrals can be made. Constant reporting and reviewing of this information is necessary so that health care professionals can share even anecdotal information about their experiences. What has been said here about specialized literacies for healthcare and helping professionals could also be said of engineers, technologists, teachers, lawyers and salespersons. Todays' world demands continuing updated specialized literacies even at McDonald's. Today's world is also demanding more and more multiple specialized literacies which means more update training time and better cooperative learning and working skills. The sphere of cultural/multicultural literacy parallels some concern with the pragmatics of communication as well as culturally different points of view about health and medicine. In the case of pragmatics, health professionals need to attend to interpersonal relationship skills such as channels of communication within organizations as well as how people from other cultures communicate or what they believe about medicine, religion and life in general. Understanding about alternative medicines, particularly as they are culturally-based is a second concern. When we consider the pragmatics of communication we are making decisions about what, where, who, how and why we tell people what we do. Often this requires a sensitivity to the organization of an institution, a relationship of the people communicating with patients, ethnic and cultural differences and views about western and eastern forms of medicine and death or other means of tran-
35
smitting information. Condescension clearly has no place in any form of communication, even though knowledge bases or rank may vary widely. Cultural or multicultural literacy has been getting attention in the workplace recently. Finally, critical literacy, or the evaluation of messages, proposals, situations, cases and language in the workplace is key to effective functioning relative to most tasks encountered in the workplace above entry level jobs and tasks. People in the health profession, like those in any profession, must have the critical thinking skills necessary to make decisions and judgments based upon multiple sources of information. This simple fact means that both cognitively and affectively they must be open to rethinking and evaluating what they do and how they do it constantly. This attitude of openness and careful skepticism is crucial to reviewing proposed changes in administrative policies as well as medical and technological advancements. Many individuals must be willing to share knowledge and views on a range of significant issues. Being open to alternatives for providing and receiving healthcare not previously available often creates situations requiring ethical considerations not necessary in earlier times. The value systems and philosophies guiding healthcare facilities may conflict with the patient's beliefs and desires. Patients must learn to make choices, often with inadequate understanding of specialized knowledge. Critical judgment and sensitive communication are crucial to serving a patient well. Professionals in the health and helping fields as well as the clients they serve must have access to mechanisms that support constant reassessment and learning for making intelligent choices and informed decisions about healthcare. Patients must be able to get adequate information about their own health status as well as about health insurances and hospital practices. This means doctors and agencies must learn to communicate technical and specialized knowledge to people of a variety of backgrounds who have little or no knowledge of what is available to them. Achieving this goal is linked to the quality and nature of the training provided for healthcare professionals at every level. In conclusion, the need for recogniz-
36
J. Carifio, L. Dagostino / Work 7 (1996) 31-36
ing and developing the multiple proficiencies and literacies required by the professional and the client is high. Some suggestions, therefore, may be helpful. Training administrative staff who will work directly with clients on issues regarding health insurances and agencies would serve the health care facility and also educate the patient. These workers will not simply do the paperwork but they will be well-informed enough to help clients make informed decisions where possible. This becomes very important as outpatient services grow and this staff is the client's primary link to the facility and services, other than the doctor. Key in this training is developing a helpful, understanding attitude toward the client. As administrative staff begin employment and as new procedures or forms are brought into use, health care facilities should consider small group training sessions to learn to handle the paperwork and the interpersonal skills needed for the job. Assuming each employee will learn on his or her own is presumptive. Sessions might be held to update employees about changes in guidelines and policies of an agency they work for and those that agency works with. Since communication is key to the growing number of collaborative diagnoses and treatments of out patient services both written and oral skills of employees should be reviewed regularly. Forms regularly used should be reviewed for improvement. For example, technicians should be using forms that report clearly all test findings and possible interpretations. They also would benefit from training in writing technical reports. Supervisors would benefit from instruction in interpersonal skills and writing memos and annual reports. Regular presentations about recent use of new pharmaceuticals would be helpful. The distribution of the results of significant studies about controversial drugs and experimental procedures should be the focus of discussion groups for all involved. Healthcare practitioners need to have better and constantly updated training about
medical practices, particularly diagnosis, treatment and after-care followup work. Training in interpersonal skills with minority populations is becoming important. Recognizing cultural and language differences is crucial to good services. Getting patients to accept care from minority professionals and other caretakers is important too. Breaking through attitudinal barriers is crucial training in many healthcare facilities. These are a few possibilities for training people in the health and helping professions suggested by our model of the spheres of literacy. The spheres of literacy model can guide the development of training programs to accommodate the many facets of communication implicit in the health and helping professions by suggesting who needs what kind of literacy for their job responsibilities. Each of the spheres delineates clearly areas of concern, and they remind us of the complexity of the issues related to literacy in the workplace today. References Anderson, R. et al. (1984) Becoming A Nation of Readers: The Report of the Commission on Reading. Washington, DC: The National Institute. Bianculli, D. (1992) Teleliteracy: Taking Television Seriously. NY: Simon and Schuster. Brodkey, L. (1986) Topics of literacy. J. Educ. 168(2),47-54. Dagostino, L. and Carifio, J. (1994) Evaluative Reading and Literacy: A Cognitive View. Boston: Allyn and Bacon, Inc. Diamond, J. B. and Moore, M.A. (1995) Multicultural Literat.'y: Mirroring the Reality of the Classroom. NY: Longman. Gagnon, P. (Ed.) (1989) Historical Literacy: The Call for History in American Education. Boston: Houghton Mifflin. Kozol, J. (1985) Illiterate America. NY: Anchor Press. NAEP (1986) Profiles of Literacy: An Assessment of Young Adults. Princeton, NJ: Educational Testing Service. Rutherford, F.J. and Ahlgren, A. (1990) Science For All Americans. NY: Oxford University Press. Skagen, A. (Ed) (1986) Workplace Literacy. NY: American Management Association. Spear, A. et al. (1990) Multicultural literacy: A context for composition. Teaching English in the Two-Year College 17(4) (December 1990), 247-252.
