NUR 545 Module 6 Patient Education Handout Example

From Grade 12 to a Card in a Lunch Bag: Writing and Testing a Plain-Language Handout on High Blood Sugar

[Student Name]

Southern New Hampshire University

NUR 545: Advanced Health and Literacy Assessment

Patient Education Handout

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

From Grade 12 to a Card in a Lunch Bag: Writing and Testing a Plain-Language Handout on High Blood Sugar

Most patient handouts are written by people who read well for people who may not. National guidance recommends that written materials be tested for understandability and actionability rather than judged by their authors (Brega et al., 2015). This paper revises the health center's existing text on high blood sugar into a handout for a composite 58-year-old patient with new type 2 diabetes, a night-shift schedule and difficulty with calculation. It reports readability scores for both versions, rates the revision with the Patient Education Materials Assessment Tool (PEMAT) and tests it with the patient. It argues that the revision works not because its grade-level score is low but because every line tells the patient something to do at a time he is actually awake, in a form that does not require arithmetic.

The Original Text

The center's standard sheet contained this paragraph: "Hyperglycemia occurs when the concentration of glucose in the bloodstream exceeds the target range recommended by your health care provider. Persistent elevation of blood glucose can result in serious complications affecting the eyes, kidneys, nerves and cardiovascular system. Monitor your blood glucose as directed and document the results in your logbook. Contact your provider if your blood glucose exceeds 300 mg/dL or if you experience nausea, vomiting or symptoms of dehydration."

Calculated with the standard Flesch-Kincaid grade-level formula (Kincaid et al., 1975), the paragraph scores at grade 12.7, with a Flesch Reading Ease of 35.8, in the difficult range. The number only begins to describe the problem. The paragraph uses words the patient does not use, such as hyperglycemia, concentration and cardiovascular. It tells him to monitor as directed without saying when. It asks him to compare readings with 300 mg/dL, which requires him to interpret a number. And nothing in it connects to his day, which begins at 2 p.m. and has its main meal at 3 a.m.

Design Decisions

Five decisions shaped the revision. Content was cut to the three actions taught in the teach-back session and one warning, because a handout that covers everything supports nothing. Every instruction was written in the active voice, starting with a verb. Everyday words replaced clinical terms, so hyperglycemia became too much sugar in your blood. Numbers the patient would need to interpret were replaced by a green, yellow and red card that he compares with his meter reading, keeping the single number he must notice, 300, printed in the red band. Finally, every instruction was tied to a moment in his work night, so the handout reads in the order he lives it.

The Revised Handout

Your sugar and your work night

Too much sugar in your blood can hurt your eyes, feet, heart and kidneys over time. Your tablets and a few changes help bring your sugar down.

Each work night, do these 3 things.

1. Take 1 metformin tablet with your meal at 3 a.m.

2. Check your sugar before you eat, 3 nights a week. Wash your hands first. Write the number on your card.

3. Look at the color on your card. Green means your sugar is where we want it. Yellow means it is high. Keep taking your tablets. We will look at it at your next visit. Red means it is over 300. Call us.

Call us any time if you throw up and cannot keep food down.

Drink water or diet soda at work, not regular soda.

Our number is on the back of your card. Someone answers day and night.

Readability Scores

Scored with the same Flesch-Kincaid formula, the revised handout comes out at grade 1.2, with a Flesch Reading Ease of about 100, the easiest end of the scale. That result needs a caution. Readability formulas count only sentence length and syllables, and short list items count as short sentences, so formatted handouts can score far lower than their true difficulty. A grade-level score cannot tell whether a patient understands a color code, whether instructions are in a sensible order or whether a word such as metformin, which must stay because it is on the bottle, will be recognized. The score shows that the words and sentences are no longer a barrier; it does not show that the handout works.

PEMAT Ratings

The PEMAT was developed to fill that gap by rating understandability and actionability separately, and in its validation, materials rated as more actionable produced better comprehension among consumers (Shoemaker et al., 2014). Table 1 summarizes my ratings of both versions, expressed as the percentage of applicable items met.

Table 1

PEMAT Ratings of the Original and Revised Text

Note. Ratings by the author using the PEMAT for printable materials.

Testing With the Patient

The final test was the patient. At his follow-up visit, he was given the handout and asked, without coaching, what he would do on his next work night. He described all three actions in order, pointed to the color on his card for his most recent reading and said he would call if the meter showed red. He asked whether diet soda was really acceptable, which led to one change: the line now names water first. His daughter asked for a copy for the refrigerator. This kind of direct testing with the intended reader, combined with teach-back, is what the AHRQ toolkit recommends for confirming that materials work (Brega et al., 2015).

Limitations and Next Steps

This handout was designed for one patient, and its strength, being tied to his work night, limits its use for others. The center could adapt it into a template with a blank schedule filled in with each patient. It should also be translated and tested in Spanish, since many of the center's patients prefer Spanish, and a simple picture of the meter and card would lift its understandability further. Finally, the PEMAT ratings were made by one rater; a second rater would make them more reliable.

Conclusion

The clinic's paragraph on high blood sugar was accurate and unusable for this patient: twelfth-grade language, no actions and numbers he could not interpret. The revision tells him what to do, when, and how to recognize trouble without arithmetic. Its grade-level score fell from 12.7 to 1.2, but the stronger evidence is that the PEMAT ratings rose and the patient could explain his night's routine from the handout alone.

References

Brega, A. G., Barnard, J., Mabachi, N. M., Weiss, B. D., DeWalt, D. A., Brach, C., Cifuentes, M., Albright, K., & West, D. R. (2015). AHRQ health literacy universal precautions toolkit (2nd ed., AHRQ Publication No. 15-0023-EF). Agency for Healthcare Research and Quality.

Kincaid, J. P., Fishburne, R. P., Rogers, R. L., & Chissom, B. S. (1975). Derivation of new readability formulas (Automated Readability Index, Fog Count and Flesch Reading Ease Formula) for Navy enlisted personnel (Research Branch Report 8-75). Naval Technical Training Command.

Shoemaker, S. J., Wolf, M. S., & Brach, C. (2014). Development of the Patient Education Materials Assessment Tool (PEMAT): A new measure of understandability and actionability for print and audiovisual patient information. Patient Education and Counseling, 96(3), 395-403. https://doi.org/10.1016/j.pec.2014.05.027