We’re all struggling to stay well — to stay as far away from the health care system as possible. For some, however, it’s a struggle complicated by learning disabilities (LD). Can you imagine how hard it must be for a newly diagnosed diabetic, who, because of learning problems can’t do simple math, yet must count carbohydrates and calculate sliding scale insulin doses? Or how a patient diagnosed with HIV will manage a mind-boggling range of medicines when he suffers from attention deficit hyperactivity disorder (ADHD) on top of it?

According to the National Joint Committee on Learning Disabilities, LD are “a heterogeneous group of disorders manifested by significant difficulties in the acquisition and use of listening, speaking, reading, writing, reasoning, or mathematical abilities. These disorders are intrinsic to the individual and presumed to be due to central nervous system dysfunction, and may appear across the lifespan.”¹ Not included in this population are learning problems that result from vision, hearing, or motor handicaps; mental retardation; and cultural differences.

Characteristics of persons with LD can include attention deficit, hyperactivity, social skills problems, and difficulties with reading, writing, or math despite the typical school program. Today, children who receive appropriate special educational support can progress well in school. Before the 1970s, though, children with LD may not have received remediation in public schools. Consequently, as adults, many in this population are disadvantaged as consumers of health care.

Consider these seemingly simple issues, but view them through the eyes of an adult with LD: selecting an insurance plan, signing an informed consent document, or learning self-management of asthma. Shame and embarrassment often prevent these patients from asking for help with forms or for a repeat explanation. This, complicated by the rushed atmosphere we are all subjected to these days, has patients with LD often leaving the office or hospital in a state of confusion.

The scope

Statistics about LD prevalence are based on the number of children enrolled in special education programs in schools. More than 10% of public school children are in special education programs, and half of them have LD.¹ The prevalence of LD in adults, however, is not known. Literacy studies of selected populations do give some insight. According to Literacy Volunteers of America, Inc., about 44 million Americans are functionally illiterate. The majority can read a little “but not well enough to fill out an application, read a food label, or read a simple story to a child…they lack the foundation they need to find and keep decent jobs, support their children’s education, and participate actively in civic life.”² One-half of the elderly tested in a national study were found to be functionally illiterate.³

Health literacy is an application of basic literacy skills in a health care setting, such as reading food labels and following preop instructions at home. More than 200 papers researching health literacy were reviewed and summarized by the Ad Hoc Committee for Health Literacy, summoned by the American Medical Association. Their landmark report reached the following conclusions —

1. Many patients do not understand self-care regimens.
2. Physicians rarely test patient understanding of medical instructions.
3. Patients with low health literacy may not know they’re giving consent when they sign informed consent documents.
4. Much research is needed to understand how to assess health literacy and improve patient education methods.³

Literacy and health education

Mr. Marks, age 37, comes to the clinic with severe anxiety. His symptoms of tremulousness, darting eyes, and restlessness are immediately apparent and unsettling. He comes alone and brings his two prescription bottles. His nurse learns that he does not understand his drug routine. He cannot read the labels or anything else. One look in the bottles confirms the nurse’s suspicion that he has not been taking his medicine as prescribed.

The highest grade your patient achieved in school is not a reliable indicator of literacy. Reading levels may be many grades below grade levels, especially in adults without a high school diploma.⁴ Reading problems are pervasive in LD — a critical and sometimes life-threatening matter when it comes to health care. But who has the time and resources to perform reading assessments on patients? There are, however, clues to literacy problems, such as the inability to restate a medication schedule, having too many pills left over, struggling with written materials, and poor self-management of chronic diseases, such as asthma.

Well-controlled studies, reviewed and summarized by the Committee for Literacy, have shown that adults with functional illiteracy have a poorer health status.³ And this hits the system right in the pocketbook. In a Medicare sample, it was determined that recipients with reading deficits had medical bills 25% to 50% higher than those who could read.⁵

Teaching persons with LD requires more than rewriting brochures with simpler words and more pictures. Studies have shown that these materials written at a more basic level do not necessarily improve patient comprehension of health materials.³ Techniques for educating patients with low literacy include the following, and remember to look for clues to poor reading before teaching any patient:

1. If the setting allows, test the reading level of a sample of patients, use the results to create awareness among staff, and adjust written materials. (For an excellent guide to testing, see Nursing Spectrum’s CE 195, “Improving Patient Education for Poor Readers,” online at http://nsweb.nursingspectrum.com/ce/ce195.htm.)
2. Teach directly, face to face, and with time for repetition of information. Allow for frequent “show and tell” to assess and confirm understanding.
3. Break the material into manageable pieces. Most people can remember no more than seven new facts. Adults with LD may only recall three.⁶ Teach essentials in a logical progression that allows reinforcement of previously learned facts; give feedback often.
4. Use visual cues, such as color-coded stickers on a clock that match the pill bottles as reminders. Patients can tape pictures to the bathroom mirror or refrigerator, keep pill organizers on the counter, and keep handy a series of photos or picture cue cards that demonstrate a skill. Use a highlighter pen when reviewing blood sugar records or food diaries with diabetics; think aloud as you model pattern recognition.
5. Rely on oral methods rather than written words. Use simple words for medical terms. The use of “story scripts,” for example, giving a fictional example of how another person could manage the same problem, makes the instruction more memorable and meaningful.⁷
6. Refer to Proliteracy Worldwide organization’s website for more information at www.proliteracy.org. When appropriate, patients can be sent to a local literacy center for tutoring.
7. Use audio/video tapes to provide information in a nonwritten form. Be sure the spoken words are at the appropriate level to ensure comprehension. Speak slowly when taping to improve auditory processing of new information. If possible, the nurse can tape a lesson, then give the tape to the patient for reinforcement at home.⁶

Confounding numbers

Josh Oren, 57, cares for his ailing 84-year-old mother. Mrs. Oren has hypertension, chronic obstructive pulmonary disorder, and glaucoma. She takes oral meds QD, BID, and TID. Her inhalers are BID and prn. Eye drops are BID as well. Josh works the night shift, caring for her between catnaps during the day. Although he can read the words on the labels, he cannot figure out how to schedule all of her medications, and many doses are missed as a result.

Difficulty with math goes beyond paper and pencil computations. Numeracy — the use of basic math skills — affects the self-management of a diabetic diet and insulin calculations, the self-monitoring of asthma, the understanding of Nutrition Facts labels, and the figuring out of complex medication schedules. Adults with poor math and science skills struggle with medical bills, dose calculations for over-the-counter drugs, and the preparation of infant formula. Nurses in every setting can give examples of similar problems.

When medications are prescribed for multiple times, a patient is instructed to space them evenly. Sounds straightforward. However, it requires fraction skills to divide one’s waking hours into equal intervals; complex drug schedules like Mrs. Oren’s are difficult. The addition of self-monitoring and record keeping can be overwhelming. Consider these strategies —

1. Look for the patient’s strengths and make the most of them. If he or she can tell time well, use the face of a clock on a piece of paper and tape the pills to the correct times. If he or she has routine eating/sleeping habits, help link pill times with meals and bedtime.
2. Teach with the patient’s own prescription bottles, monitors, and/or recording logs in an interactive “show-me” manner. Give facts without long explanations and have the patient repeat the routine several times. Try to reply with immediate feedback to correct mistakes and to encourage.
3. Schedule teaching sessions at frequent intervals to assess competency.
4. With the patient’s permission, include family members when possible for support at home. Identify each member’s strengths in math and reading; enlist their talents.

Diabetes self-management requires so much math that it’s common to give a basic math test to a newly diagnosed patient. Carbohydrate counting requires computations in multiples of 15; the exchange diet uses fractions. Sliding scale dosing of insulin and intensive therapy demand competence with all major math operations.

So how can you help?

1. Use food models and the food pyramid with detailed photos to teach diet.
2. Bring some measurable foods (e.g., rice, pasta) and measuring utensils to a session to make learning interactive and concrete. A half cup can be marked with a red paint dot for a serving of carbohydrate; a cup could be green for berries and vegetables. Mark with shapes if your patient is color-blind.
3. Get menus from local restaurants and “do lunch” together, pretending to make healthy choices. As always, give frequent feedback to correct and reinforce.
4. For patients with no literacy skills or poor motivation, teach the “hand jive.” One serving of starch equals a person’s own fisted hand. A meat serving is the shape of his palm and the thickness of the little finger. Vegetable serving size equals both hands slightly cupped together, palms up. A cheese serving is the size of his thumb, and butter, a fingertip-size piece.
5. Take a “field trip” with the patient and family to their local grocery store. Identify ingredient and Nutrition Facts labels; make healthy food choices. For hospitalized patients, bring empty food packages along as teaching tools. In a patient’s home, the community health nurse and patient can go into the food cupboard together to discuss healthy choices and portion sizes.
6. Avoid suggesting the use of charts and graphs to record personal data, such as blood sugars, weights, or peak flows, as they are difficult for persons with poor math skills. A simple dated list will do.

Attention deficit disorder

Jayne, a 21-year-old college student, is hospitalized for control of her new-onset, type-1 diabetes. She is medically stable and ready for discharge to her dormitory; the nurse, however, has concerns about her ability for self-management. During teaching sessions, Jayne is constantly distracted. She shows poor short-term memory and is unable to repeat the principles necessary for controlling her blood sugar. Her family is out of state, and she has had few visitors.

It has been estimated that about 3% to 7% of all school children have attention deficit (the inability to attend to a task) and hyperactivity (high rates of purposeless movement).⁸ Other characteristics include impulsivity; poor organizational skills; excessive procrastination; delayed task initiation and completion; forgetfulness; and frequent losing of belongings.⁹ Fortunately, many children with ADHD are provided with special accommodations in school that enhance their ability to learn.

Statistics state that 2% to 4% of adults have the disorder. Seventy percent of children with ADHD will have some symptoms as adults.⁸ Although not all persons with ADHD have LD, about 60% do.⁹ College students with ADHD may have accommodations in college classrooms; however, in the hospital these learning differences are likely not understood.¹⁰ Nurses caring for middle-aged and older Americans with ADHD may observe poor recall of instructions, lack of focus during health teaching, easy distractibility in the hospital setting, and a low threshold of frustration.

When it comes to teaching adults with symptoms of ADHD, try these tips:

1. Monitor a patient on ADHD-related medications. Understand drug actions, adverse reactions, and potential drug interactions. Ask the patient about what drugs have helped most in the past; take the patient’s history about positive and negative experiences with medications for ADHD.
2. Ask the patient about nonpharmacological therapies and activities that may have been successful at improving focus and impulse control, such as sports, background music, the use of headphones to screen out background noise, chewing gum, avoidance of caffeine, and frequent activity breaks during work or school. Add these effective techniques to the patients’s regimen if possible.
3. Present new material in a highly structured manner. Prepare your patient for each session with concrete goals, including what skills will be assessed. Aggregate new material into manageable pieces. Provide repetition and opportunities to practice new skills with health experts to demonstrate mastery.
4. Minimize environmental distractions. In a hospital room, turn off the television, draw the curtains, and schedule teaching sessions to avoid interruptions by meals, visitors, and other professionals.
5. Follow a predictable routine of teaching the patient at the same time of the day or week. Keep sessions short. Help the patient incorporate new skills and/or medications into the structure of his or her routine at home and work.
6. Adults with ADHD may struggle with organizational skills. Select only essential brochures; avoid using a cluttered folder of papers. Simplify the number of steps in a procedure (e.g., the use of combination or long-acting medications when appropriate).
7. Refer a patient for vocational counseling when ADHD symptoms interfere with employment. Psychotherapy is helpful for adults with ADHD when interpersonal relationships are affected. Support groups for patients and family members can be located through the Children and Adults with Attention-Deficit/ Hyperactivity Disorder website www.chadd.org.
8. For an excellent resource on ADHD see Nursing Spectrum’s CE 82B, “Attention Deficit Hyperactivity Disorder,” online at http://nsweb.nursingspectrum.com/ce/ce82.htm.

Social skills

George, age 45, is hospitalized after a bike accident left him with fractures of his pelvis, ribs, and wrist. He has been on the unit for a week and is preparing for discharge. The nurses will be relieved because he is “difficult”; George screams for a nurse when he needs help, touches staff members inappropriately, and is withdrawn during physician visits. There have been no visitors, and he lives alone.

Some patients with LD have poor social skills. Just as they have difficulty reading and comprehending words, they can have problems reading facial expressions, body language, and social cues from other people.¹¹ As children, they may have been teased or isolated from same-age peers, thereby missing out on valuable experience in learning social skills. Like George, they need attention and friendship; often, they are misunderstood and lonely. In an unfamiliar hospital setting, adults with social skill deficits may feel stressed out and unable to interpret the demands being made on them.

When a patient’s behavior seems inappropriate, immature, or difficult, try these positive steps:¹²

1. Give immediate feedback when behavior is inappropriate or when there is a misunderstanding to let the patient know that something is wrong.
2. Provide encouragement and praise often, when appropriate.
3. Encourage your patient to share his or her feelings about being alone or misunderstood.
4. Model appropriate behavior and rehearse social skills, such as how to ask questions of the physician, how to get the nurse’s attention, or how to garner assistance for personal care.
5. When a patient’s behavior is inappropriate, immediately consider what may have provoked the incident and how it may have been reinforced. For example, if a patient consistently screams for a nurse instead of using a call button, and a nurse appears immediately, realize that the behavior (screaming) is being reinforced by the consequence (quick arrival of the nurse). Consider how long the patient has been without staff attention, then shorten the intervals of nursing care to reduce the incidence of screaming for the same patient.
6. Refer your patient to a social worker, psychologist, or chaplain who may know of a social skill development program in the community.

Nurses are the primary teachers for patients in health care settings. There is much to learn from the professionals who teach children in the field of special education. Through careful assessment and the use of special techniques, nurses can help adult patients with learning difficulties manage their own health care needs and those of loved ones.