Improving Discharge Education Using Pictographs

A significant portion of older adults are discharged unprepared and return to their homes with a limited understanding of discharge instructions (Aminzadeh & Dalziel, 2002; Camargo, Pallin, Weiner & Ginde, 2008; Flacker, Park & Sims, 2007; Makaryus & Friedman, 2005; Maniaci, 2008). This limited understanding has resulted in noncompliance with discharge instructions (Lindau, Basu & Leitsch, 2006; Vermeire, Hearnshaw, Van Royen & Denekens, 2001), leading to high complication rates, costly return visits, and increased use of emergency rooms (Aminzadeh & Dalziel, 2002; Baker et al., 2004; Strunin, Stone & Jack, 2007; Witherington, Pirzada & Avery, 2008). Furthermore, older adults suffer from delays or inability to regain their former level of mobility and independence after discharge, leading to a reduced quality of life and premature death (Hall, Williams, Senior, Goldswain & Criddle, 2000). The primary factor often cited for this lack of understanding is inadequate discharge education materials, which are not created in a format that older adults can read and understand (Lindquist et al., 2012; Samuels-Kalow, Stack & Porter, 2012). Discharge education instructions have consisted of recommended healthcare actions—“dos” and “don’ts. ” These healthcare actions are, however, provided in written text-based instructions and are often difficult for older adults, especially those with low literacy skills (i.e., sixth grade or lower reading level), to follow accurately at home. Written text alone is not appropriate for presenting lengthy, complex discharge instructions with multiple actions to be followed. Also low literate older adults are likely to read word for word, take the words literally, focus exclusively on accessory details, and plow the text line by line, thereby giving a narrow field of view, and skipping over large amounts of information (Doak, Doak, Friedell & Meade, 1998; Doak, Doak & Root, 1996). Therefore, easy-to-read, text-based instructions can only marginally improve these older adults’ discharge learning. Without effective strategies addressing low literacyrelated, action-based discharge education materials, these older adults will continue to be at high health risk and accrue unnecessary healthcare costs. The purpose of this article was to introduce nurses in rehabilitation practice to an effective strategy to address low literacy, pictograph-based discharge instructions. Pictographs are simple line drawings showing explicit discharge care actions (Houts, Doak, Doak, and Loscalzo, 2006; Houts et al., 1998). Using stick figures, pictographs can illustrate a step-by-step sequence of complex discharge instructions, thereby making an entire series of actions easy to learn. Pictographs also direct patients’ attention to key information and reduce heavy reliance on complex textual information. To illustrate the use of pictographs in discharge instruction, we chose discharge education after hip replacement surgery. Hip replacement surgery is one of the most challenging procedures for older adults as well as for nurses in rehabilitation practice because of the high rates of readmission following discharge and the high mortality rates for readmitted patients (Brauer, Coca-Perraillon, Cutler & Rosen, 2009; Hahnel, Burdekin & Anand, 2009; Hall et al., 2000; Leibson, Tosteson, Gabriel, Ransom & Melton, 2002; Lie et al., 2010). As noncompliance with discharge instructions can easily result in costly chronic conditions, subsequent increases in reoccurrence, and prolonged disability,