Nearly half of all adults in America cannot read or comprehend material if it is written at or above the eighth grade level. Many of these functional illiterates and marginal literates are our patients. Some of them are our coworkers. However, the true scope of this problem stays hidden because people who do not read well are very good at masking their poor reading skills.
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I first noticed this serious problem when I was 19 years old and working at a grocery store.
One of my coworkers, a middle-aged mother of three who had been married for 15 years, asked for my assistance with reading and properly completing a time-off request form. "I am not good at writing things," she chimed with a smile on her face. She added, "I forgot my glasses, so I can't see this paper too well today."
While helping her with the form, which was written at a fifth or sixth grade level, I made some silent observations. First of all, this woman was a high school graduate. Moreover, I never saw her wearing eyeglasses during the entire year that I worked with her. Her excuses of being a bad writer and forgetting her glasses were likely intended to mask an awful truth.
My coworker did not know how to read very well.
When I started working as a nurse, I suspected that some of my coworkers lacked basic literacy skills. For instance, a middle-aged nursing assistant with whom I once worked started crying one afternoon several years ago after staring at a letter that had been given to her by the human resources manager. The assistant asked, "What is this paper? Are they going to fire me?"
After glancing at the letter, I determined within a few seconds that it was the same preprinted memo that every employee in the facility had received regarding yearly open enrollment for health insurance. I reassured her and gently told her about the letter's contents, and she thanked me. I also surmised that this woman would have never cried over the memo in the first place if she was comfortable reading the written word.
Many people do not read very well. According to the 2003 National Assessment of Adult Literacy, 63 million adults in the U.S. do not read proficiently enough to comprehend an article written at the eighth grade level and another 30 million people read at or below a fifth grade level. In other words, a whopping 93 million people possess low levels of literacy. This is almost half of all adults in America! However, the true scope of this problem lurks in the shadows because functional illiterates and marginal literates are usually very astute at covering up their poor reading skills.
It's a sad fact of life that many of our patients and some of our coworkers do not read well. For example, a patient who delays signing consent paperwork because he's tired or forgot his glasses (even though he denied wearing eyeglasses during the initial assessment) might be an illiterate. The CNA at the nursing home who procrastinates when asked to write a statement regarding a fall and always requests help from others to complete her flow sheets might be a nonreader. Since many people who do not read are well-dressed, articulate and work in respectable occupations, it is a problem that cannot be detected by simply looking at a person or studying one's demographic information. In addition, people with poor reading skills have spent much of their lives learning creative ways to hide their inadequacies from others.
Low literacy skills can negatively affect patient outcomes. First of all, the marginally literate patient might cheerfully nod, pretend to understand, and simply sign written discharge instructions when he did not comprehend the paperwork. In one case, a patient was given full-sized 8x11 inch papers that were light blue in color and did not realize that these were prescriptions because he could not read them well enough. Some patients are readmitted for the same chronic illnesses repeatedly. While noncompliance might be a major part of these readmissions, one must wonder if these people really understand what we're telling them.
There are no simple solutions to this complex problem. However, nurses can help in small ways by providing clear verbal discharge instructions and taking great care to avoid medical jargon. The nurse should check for understanding by requesting that the patient repeat the instructions in his own words and watch as the patient demonstrates any hands-on skills that he was taught by staff. Patients who are marginally literate can read and comprehend pamphlets if they are written at a sixth grade level.
If you suspect that a subordinate coworker who reports to you is unable to read well, use simple verbal directives, keep explanations short, and ask the person to restate the directions in his/her own words to ensure comprehension. Do not confront the coworker on the alleged inability to read or do anything to embarrass him/her.
