The real health literacy issue is not the lack of information, but rather the ability of the healthcare consumer to access and process the information. The human brain is miraculous in its structure and capacity. It has literally millions of cells and neurons that work together to enable learning to occur. Although the brain is a basic structure in each human being, no two brains are identical. These differences can affect how individuals learn and influence their level of health literacy. The United States Department of Health and Human Services (U.S.DHHS) in the Healthy People 2010 (2000) document defined health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.” This document has explained that health literacy includes activities, such as the ability to understand instructions on prescription bottles, appointment slips, health-related brochures, provider’s directions, and consent forms, as well as the ability to navigate and negotiate complex health systems. Health literacy requires more than the ability to read. It also requires a complex group of reading, listening, analytic, and decision-making skills, and the ability to apply these skills to health situations.

Nutbeam (2000) contributed to our understanding of health literacy by identifying three distinctive health-literacy levels. Basic or functional literacy involves having “sufficient basic skills to read and write to function in everyday situations” (p. 263), while the second level, communicative or interactive literacy, involves the ability to use existing social skills to actively extract information and draw meaning from a variety of communication methods and ultimately to apply new knowledge to changing circumstances (p. 264). The third level, called critical literacy, involves the ability to critically scrutinize information from a variety of sources, thus empowering the individual to make more informed decisions.

Shapiro and Hughes (1996) introduced the concept of information literacy, which they defined as "a new liberal art that extends from knowing how to use computers and access information to critical reflection on the nature of information itself, its technical infrastructure, and its social, cultural, and philosophical context and impact" (p. 3). Information literacy includes the ability to determine information that is needed, understand how the information is organized, and identify the best sources for a specific need. It also includes the ability to locate and critically evaluate various sources. Information literacy is becoming more and more challenging as the amount of information that one needs to ‘sort through’ increases (Shapiro & Hughes).

Regardless of patients’ health literacy levels, their ability to understand health information may be limited by the often disturbing aspects of the healthcare system and/or the illness itself and the anxiety associated with these concerns. Other factors that influence one’s ability to understand explanations include the many changes that occur with age, along with an individual’s psychological/emotional makeup, educational and socio-cultural background, and life experiences (Lawson, 2002).

Healthcare organizations have been relatively proactive in their attempts to increase the accessibility of healthcare information. Substantial amounts of health-related educational material are now posted on the web sites of most healthcare organizations and/or offered in the form of print materials. Some of the impetus for this proactive stance comes from regulatory and accrediting organizations, such as The Joint Commission (TJC), which has published a “white paper” on health literacy. The Joint Commission’s accreditation standards have underscored the need for patients to receive, both orally and in writing, information about their care that is presented in an understandable manner (TJC, 2007).

However, as chronic conditions become more prevalent in our society, the need for patients to be able to interpret the health-related information provided becomes increasingly important. Providers today are sensing an increase in patient visits that seem to be the result of so-called ‘noncompliance.’ Although multiple patient visits for the same issue may seem to indicate noncompliance, they may also due to the fact that the patient did not understand the information provided. The real health literacy issue is not the lack of information, but rather the ability of the healthcare consumer to access and process the information. The ability to understand the complexities of many health issues requires not only the ability to read and write, but also the ability to discuss and clarify confusing issues. In this article I will describe how healthcare providers can promote health literacy through storytelling. First I will discuss two different ways of learning, namely linear learning and experiential learning; then I will advocate for storytelling as an intervention that is especially effective for experiential learners.

Linear and Experiential Learning

...linear learners benefit from clearly explained and defined activities, schedules that denote deadlines, and ‘how to’ props, such as pictures and/or examples...[in contrast] the more experiential and global learners...value learning through experience and reflection. The educational literature describes various ways of learning, each of which influences the most appropriate manner in which to present health education information to a given patient. Two of these ways of learning include the linear and the experiential styles of learning.

The linear learning style describes a manner of learning that is often associated with high activity in the left side of the brain. The left brain is analytical; it is the site where logical thinking, language and mathematical processing, sequencing, and analyzing take place. Adults who are left-brain dominate tend to learn best in a step-by-step process; they are sometimes referred to as a sequential or linear learner (Felder & Spurlin, 2005). If these learners are in an environment where the information presented is well organized, structured, and logically sequenced, they do well. In general, linear learners benefit from clearly explained and defined activities, schedules that denote deadlines, and ‘how to’ props, such as pictures and/or examples.

In contrast to linear learners are the more experiential and global learners who value learning through experience and reflection. This style is often associated with high activity on the right side of the brain. These learners enjoy being able to take a concept and explore applications of the concept so as to find new ways of looking at the world. These learners like to first watch and listen to others, and then perform an activity on their own. They are motivated by discovering new knowledge and understanding. Merriam, Caffarella, and Baumgartner (2007) have described how the learner takes a new event, applies its meaning to past experiences, and visualizes future possibilities. Experiential learners take in information, reflect on how it will impact some aspect of their life, compare the information with their own experiences, and arrive at new ways of thinking about the information. Reflection plays an important role in the experiential process by providing a bridge between the theoretical model or example and its application to one’s own situation. Experiential learners seek to integrate theoretical and practical elements of learning for a ‘whole person’ approach, emphasizing the significance of experience for learning.

Encouraging Health Literacy through Storytelling

...storytelling can be beneficial for both teaching and motivating change...[it] is humankind’s oldest form of teaching and motivating change. Osborne (2008) has noted that “when you tell a good story, you can frame important messages in ways that make them memorable for your listeners.” One reason that purposeful storytelling works is because it brings across factual information along with a human interest perspective drawing upon emotions. Emotions in adults are generally derived from past or current events. As adult learners these emotions play a significant part in the ability to grasp new ideas. Positive emotions contribute to self-esteem, which increases learners’ ability and motivates them to learn. Telling the right story at the right time can help a patient understand the importance of adherence to a treatment plan or move from a pre-contemplative state to a contemplative one during the process of making lifestyle changes. Hence, storytelling can be beneficial for both teaching and motivating change.

Experiential learning theory defines learning as "…the process whereby knowledge is created through the transformation of experience. Knowledge results from the combination of grasping and transforming experience" (Kolb, 1984, p. 41). Experiential learning in this respect involves observing the event and doing something significant with the observations through active participation. Storytelling allows hearers to reflect on the story told and actively apply it to their life situation. An intervention, such as storytelling, can help people of all ages increase their health literacy.

Storytelling is one of the ways in which experiential learning can be incorporated into the formal learning environment. Storytelling is humankind’s oldest form of teaching and motivating change. Personal storytelling, case studies, role-playing, games, and even reflective personal writings all help to tell a story. All of these examples contain a common thread of learning from experience, reflecting both emotionally and intellectually, and applying what was learned to one’s own life.

Stories can also be valuable to the person telling the story. I have found in my years of nursing experience that storytelling is a powerful method of patient education. The telling of a story can help explain needed healthcare-lifestyle changes. Stories can provide encouragement and new insights into health-related needs and concerns as described below.

Stories can also be valuable to the person telling the story. Sometimes the tables are turned and healthcare providers need to hear stories from patients. This may happen while obtaining the patient’s history. With a little prodding and the asking of relevant questions, providers can elicit personal stories from their patients while taking their histories. To hear these unique stories healthcare professionals must remain open to taking the time to listen to patients' personal stories. These patient stories include the components that are seen in all stories, such as character(s), actions (or inactions), settings, and messages. Restrepo and Davis (2003) have noted that the values and cultural practices that are elicited through the history-taking can guide the plan of care. The patient’s cultural perspective regarding health becomes more real as the caregiver listens to the patient’s story. Adjustments in care can then be made to accommodate these cultural practices. In this way tolerance, empathy, and culturally sensitive care can be augmented by storytelling.

Examples of Storytelling to Increase Health Literacy

Storytelling allows hearers to reflect on the story told and actively apply it to their life situation. As noted above, stories allow an individual to share in the experiences of other and see the situation through the eyes of another. One idea for developing patient stories is to have patients with a specific health problem create a ‘book.’ For example, patients with End Stage Renal Disease (ESRD) face major lifestyle changes due to their need for ongoing hemodialysis to sustain life. To create a book, a story, about ESRD patients, the nurse could find patients and/or families interested in sharing thoughts, experiences, and tips for maintaining a normal lifestyle in spite of the ongoing need for dialysis. These stories could address, for example, ways to cope with dietary restrictions in social situations, travel helps, day-to-day survival tips, and steps to avoid unnecessary complications. In addition to using words in the story, the nurse could use pictures to represent the story of what happens in the dialysis center or a step-by-step illustration of the peritoneal dialysis procedure. This format would be valuable both for highly educated patients and for those who are less literate.

Stories can also be told in support groups. Support groups allow for the sharing of information through storytelling in a way that helps all group members learn how to better care for their specific condition. These groups also provide the support needed as patients and families realize the implications of the disease.

Consider the case of new diabetic patients who are often overwhelmed by the lifestyle changes that must be made to cope with this condition. The initial reaction to the diagnosis of diabetes is often one of denial and asking “why me?” The impact of diabetes can also create feelings of guilt over not having practiced better health habits in the past. Generally we try to help these patients cope with these challenges by bombarding them with information about the clinical aspects of the condition and the treatments with which the patient must comply. We tell them about what they must eat, the medications that must be taken, and the checking and interpretation of blood glucose levels that need to be done on a regular basis. All this information is simply too much to absorb. It agonizes them, and they often suffer this overwhelming agony alone.

Support groups can help new diabetic patients learn to cope with these needed lifestyle changes and the feelings of despair that can arise when they realize the implications of this life-long illness. The newly diagnosed diabetic patient can learn from the stories told by other group members regarding what they found helpful in making the best food selections both in the grocery store and at local restaurants. Sample menus can show what entrees would be good choices when eating out, and the grocery store flyer can be used to tell how others have decided what foods to purchase. There might also be stories of how to locate needed resources or supplies that would make dealing with diabetes much simpler and perhaps even less expensive. Hearing the stories of others, reflecting on these stories, and determining how these stories can be applicable to one’s life may be more beneficial than simply reading written information or watching an educational video. The interaction with the storyteller, who is a more experienced diabetic patient or a family member, can also provide encouragement and support. Encouragement from group members can bring about a change in thinking from a negative perspective to a more positive and productive outlook, helping the patient to think “I can do this.”

Another area where storytelling can be helpful is in situations in which patients and/or their families are dealing with the devastating news that the patient has a limited time to live. On a personal level, I learned to share my story of dealing with my mother’s stroke and its catastrophic impact. Strokes, like many other life-threatening problems, are frequently very sudden, physically devastating, and emotionally tearing. I wrote my story to share some of the overwhelming feelings of inadequacy that I, not only as a family member but also as a nurse, had in dealing with the situation. As the minutes of watching and waiting became days, it became obvious that recovery from this major assault on Mom’s brain would not occur. It was heartbreaking to realize that there was not realistic hope of long term survival. I journaled. I wrote my story, which was later published in our hospital newsletter (Day, 2009), from the perspective of my roles as both nurse and daughter, sharing through this story the devastation a stroke can bring when it strikes someone you love.

What was the impact of telling my personal story? After the story was published in the hospital newsletter (Day, 2009), there was an outpouring of support from my colleagues as well as from other hospital employees. The story also provided the medium to engage in dialogue with colleagues about some of the real issues that our patients and their families face when given devastating, health-related news. The dialog often began with questions, such as “How did you cope?” and “What did you learn about how we can deal with death and tying more effectively?” The ensuing dialog frequently opened up discussions about coping with the realities that we as nurses face every day. I found my story telling to be both liberating and healing; so did many of my colleagues.

Conclusion

As healthcare professionals we have a responsibility to the public to ensure that they are able to understand what they need to do to address their healthcare needs. This article has noted that a patient’s individual learning preferences can guide healthcare providers in selecting an appropriate teaching approach for each patient. It has also encouraged the use of storytelling to individualize patient teaching and thus promote health literacy, especially with patients who prefer an experiential learning approach.

Author

Vivian Day, BSHCA, MHA, RN
E-mail: dveday@dnlt.com

Vivian Day is currently employed at Martin Memorial Health System in Stuart, Fl as an Administrative/Clinical Supervisor. Her 35 years of nursing experience include positions in staff nursing, primarily in critical care and telemetry units; long term care administration; nursing management; and healthcare and software consulting. She received her nursing education at LaBouré College in Boston, MA, and her Bachelor of Science and Health Care Administration (BSHCA) and Master of Health Administration (MHA) at St. Joseph’s College, Windham, ME. She is currently completing a PhD degree at Capella University, Minneapolis, MN.

Of particular influence throughout Ms. Day’s youth was the impact that storytelling had on her. One of her earliest recollections as a child was her mother gathering her brothers and herself together on the floor of the living room for “story time.” She became motivated to write this article after talking with colleagues who freely shared their desire to make the process of patient education more captivating and memorable. Ms. Day recognized early on that although factual information is a necessity to ensure that critical components of relevant content are thoroughly and effectively presented, it is also necessary that the learning experience be enjoyable and inspirational. This article was developed to emphasize that story telling can help our healthcare teaching to be not only factually correct but also appealing and captivating.

© 2009 OJIN: The Online Journal of Issues in Nursing
Article published September 30, 2009