I am very excited about my research this week. First, I have expanded my annotated bibliography for another class to include appropriate literature that could apply to that class on research and this independent study. Two books that need to be included are Osbornes's Health Literacy from A to Z Practical Ways to Communicate Your Health Message and the other Polit's and Beck's book, Nursing Research Principles and Methods. Both offer great info for the nurse researcher and the staff nurse. Reading both of these books re enforce the belief that there should be no reason why a practicing staff nurse can not validate what that nurse has seen as effective nursing practice.
Next, this research shows me the value of the role of the nurse as an educator might occur daily in the practice of nursing, but the research literature often takes on the privileges of academia discounting the front line experiences.
This brings me to the issues of hierarchy within the hospital setting.When the evaluation of available patient teaching material is done, who has the power to investigate, suggest, and decide upon the materials to be utilized? How is any input by floor nurses utilized in the actual purchasing of information? Then to do to the post-use evaluation: how is the patient and the nurse approached? How flexible are the procedures and policies already in place?
On another note, Rima Rudd's work with Study Groups involving the Navigation of Health care is taking on a new note.
Parade Magazine, 3/29/09 Page 10 has a little blip "Helping you through the Medical Maze". In this section the new job category of Patient Navigator(PN) is designed to help people acquire the best medical care they can and " improve the lives of patients, especially those among the socially disadvantaged". In the growing world of complex medical care, the Patient Navigator addresses the multitude of reasons (not just health care literacy) that addresses why patients might not be compliant. Never to be removed from the mix is the responsibility of patients to assume some of the responsibility for successful medical treatment.
Monday, March 30, 2009
Tuesday, March 17, 2009
Re-invention of the Wheel
I have been involved with looking at many brochures, pamphlets, and other teaching materials lately given to patients for educational purposes. User-friendly and patient specific should be the goal of any information given when added to a face-to-face session with a medical professional. The timing of the written information should be appropriate with adequate time allowed for follow up. Patients should be encouraged to write questions as they think of them. Some facilities provide folders that include pens and paper as well as a place to collect all information given upon admission, during the stay, and at discharge. That folder can become the place to keep medical information such as history and current medications. The folder makes patients active in deciding on their health care.
A bad example of a brochure would be one that includes too much information on too many topics with confusing medical jargon that is inappropriate for a specific patient.
The question of availability of information and education of information will need to be addressed. What will constitute providing education that can be utalized by a specific patient and the documentation of that education?
A very user friendly web site for medical professionals and lay people can be found on the Centers for Disease Control and Prevention website www.CDC.gov. under the Dept of Health and Human Services. Access can be obtained @work, @home, @schools, and @ libraries. Of course, the recent PA cuts to library funding affect those looking for information that may not have daily access to a personal computer. The use of the computer also requuires skills. THE GAP then becomes not only between Patient and Physician but financial, age, education, and access ability.
Sometimes after 35 years of nursing, the impact of lacks of the gap seem to be re-discovered.
A bad example of a brochure would be one that includes too much information on too many topics with confusing medical jargon that is inappropriate for a specific patient.
The question of availability of information and education of information will need to be addressed. What will constitute providing education that can be utalized by a specific patient and the documentation of that education?
A very user friendly web site for medical professionals and lay people can be found on the Centers for Disease Control and Prevention website www.CDC.gov. under the Dept of Health and Human Services. Access can be obtained @work, @home, @schools, and @ libraries. Of course, the recent PA cuts to library funding affect those looking for information that may not have daily access to a personal computer. The use of the computer also requuires skills. THE GAP then becomes not only between Patient and Physician but financial, age, education, and access ability.
Sometimes after 35 years of nursing, the impact of lacks of the gap seem to be re-discovered.
Getting Through the Gobblydegok
My Mock Literacy Research survey "Addressing the Nurse to Patient Education in the Hospital Setting" has become quite an undertaking. The purpose was to address the comfort level of nursing staff in educating patients to allow the patient to have the information they want and need to participate in making informed choices regarding their health care.
First, I would like to comment on the comments of my non-nursing classmates who took on the role of criticising the survey. Their comments prove that "you can not tell a person's health care literacy by education level or profession. The jargon often gets in the way of the message.
Next, my nursing colleagues appeared to immediately see where the survey was headed. Some commented "who is doing this survey and what will I be required to do NOW?". Others thought the survey could be useful for in services (particularly with new Joint Commission and Nursing Board CEU requirement). Still others said, "there is just not enough time why do we nurses ALWAYS have to provide information?".
The gap between physician and patient often requires a nurse to intervene in health care knowledge. The Columbia University School of Nursing website is a stellar example of nurses taking control. The weakness in all of the assessment tools appears to be "the exceptions". Barriers such as willingness to learn, ESL, cognitive challenges (dementia, hearing, etc.), often seem to go hand in hand with compliance to a prescribed health care regime either through personal commitment or financial considerations. There is always THE TIME FACTOR.
Perhaps follow up phone calls by the facility would be beneficial for those who do not qualify for home health care follow through. The hospital could expand community out reach topics. Bottom line-nurses must be provided the skills, tools, and time to educate if financial re-reimbursement is to be considered tied into the discharge instruction mix. The other possibility is a return to the Primary Nurse responsibilities that offered a continuing education. Yet the weakness in that scenario is the present 23 hour observation status of many patients.
I return to the ASKme3 program that provides basic information while allowing for an expansion IF THE PATIENT DESIRES. A timely article is Safeer and Keenan's "Health Literacy: The Gap Between Physicians and Patients", American Academy of Family Physicians. 2005.
My bottom line as a nursing professional is that nurses (and hospitals) should not be penalized for patient non-compliance when the patient makes an active informed choice to not live with a prescribed health care regime.
First, I would like to comment on the comments of my non-nursing classmates who took on the role of criticising the survey. Their comments prove that "you can not tell a person's health care literacy by education level or profession. The jargon often gets in the way of the message.
Next, my nursing colleagues appeared to immediately see where the survey was headed. Some commented "who is doing this survey and what will I be required to do NOW?". Others thought the survey could be useful for in services (particularly with new Joint Commission and Nursing Board CEU requirement). Still others said, "there is just not enough time why do we nurses ALWAYS have to provide information?".
The gap between physician and patient often requires a nurse to intervene in health care knowledge. The Columbia University School of Nursing website is a stellar example of nurses taking control. The weakness in all of the assessment tools appears to be "the exceptions". Barriers such as willingness to learn, ESL, cognitive challenges (dementia, hearing, etc.), often seem to go hand in hand with compliance to a prescribed health care regime either through personal commitment or financial considerations. There is always THE TIME FACTOR.
Perhaps follow up phone calls by the facility would be beneficial for those who do not qualify for home health care follow through. The hospital could expand community out reach topics. Bottom line-nurses must be provided the skills, tools, and time to educate if financial re-reimbursement is to be considered tied into the discharge instruction mix. The other possibility is a return to the Primary Nurse responsibilities that offered a continuing education. Yet the weakness in that scenario is the present 23 hour observation status of many patients.
I return to the ASKme3 program that provides basic information while allowing for an expansion IF THE PATIENT DESIRES. A timely article is Safeer and Keenan's "Health Literacy: The Gap Between Physicians and Patients", American Academy of Family Physicians. 2005.
My bottom line as a nursing professional is that nurses (and hospitals) should not be penalized for patient non-compliance when the patient makes an active informed choice to not live with a prescribed health care regime.
Monday, March 2, 2009
Taking a Step Back...
After some discussion with co-workers (those front line nurses left responsible for co-ordinating and ensuring that patients have adequate knowledge of personal health care education); I needed to take a step back and evaluate methods of giving health care education. The bigger, first question became "what are the principles of adult education?".
So...I decided that I had to look at the key elements of andragogy. Looking at adult learning principles has been my quest over the past week.
As always I will be using the standard definition of health literacy that maintains providing individuals with the skills, resources, and motivation to obtain, process, and understand basic health information allowing the individual to make appropriate health care decisions relevant to the individual.
I am excited, The Facility-wide diabetes education committee has requested that I give a 15 min or so presentation regarding health care education and adult learning principles.
On another note: My question for the project has been refined: "How does the composition of health care patient educational materials affect health care conversations between nurses and patient?"
So...I decided that I had to look at the key elements of andragogy. Looking at adult learning principles has been my quest over the past week.
As always I will be using the standard definition of health literacy that maintains providing individuals with the skills, resources, and motivation to obtain, process, and understand basic health information allowing the individual to make appropriate health care decisions relevant to the individual.
I am excited, The Facility-wide diabetes education committee has requested that I give a 15 min or so presentation regarding health care education and adult learning principles.
On another note: My question for the project has been refined: "How does the composition of health care patient educational materials affect health care conversations between nurses and patient?"
Sunday, February 22, 2009
Personal Angst
I just love that word "angst". My personal belief is "since I am old and wandering through my life" much like teen agers do, I can bring a new perspective to the term and make it my own.
Three things that are becoming apparent in my literacy search and personal experiences:
first: My research building through professional observations take on a special meaning of communication between health care providers. Weaknesses, strengths, biases, and personalities appear to intertwine with time, tasks, facilitiy mission, best practices, needs of the patient, and continuity.
If we as professionals can not communicate between ourselves, how can we communicate to patients and families. Importantly, after the communication, how is implimentation to be encouraged and expected?
Second: How will we as professional deal with those patient's who have needs that we might not recognize? The purpose of a literacy test(based on a very informal discussion) seems threatening to even the "educated". I do not know if the Ask me 3* is all that we need for all levels of literacy. Other tools such as STOFHLA, REALM, Newest Vital Sign,and others appear to provide a guide-ONLY and ONLY IF the participants are willing.
What is my main problem?
What do I need to do?
Why is it important for me to do this?
These three questions seem to transform the needs of the patient and the words of the health care provider into daily function for life.
Third: Using the Teach-Back/Show-Me Method (from Doctor D. Schillinger's work in health care literacy) appears a best practice method. The weakness lies in utalizing ONLY this method in complex medical instructions with limited time resources seems to require perfection.
Speaking personally, my MD will talk to you following all the standards, sitting at equal level, telling and asking, repeating, etc. ...but forgetting specific needs of a specific known patient while in the examining room. Then when the patient leaves a copy of the front page is given as a receipt...all instructions are on the flip side. Go figure?
Then there was one time in a rushed, crowded waiting room (where was HIPPA?) personal infomation and instructions were given without time for contemplation.
Three things that are becoming apparent in my literacy search and personal experiences:
first: My research building through professional observations take on a special meaning of communication between health care providers. Weaknesses, strengths, biases, and personalities appear to intertwine with time, tasks, facilitiy mission, best practices, needs of the patient, and continuity.
If we as professionals can not communicate between ourselves, how can we communicate to patients and families. Importantly, after the communication, how is implimentation to be encouraged and expected?
Second: How will we as professional deal with those patient's who have needs that we might not recognize? The purpose of a literacy test(based on a very informal discussion) seems threatening to even the "educated". I do not know if the Ask me 3* is all that we need for all levels of literacy. Other tools such as STOFHLA, REALM, Newest Vital Sign,and others appear to provide a guide-ONLY and ONLY IF the participants are willing.
What is my main problem?
What do I need to do?
Why is it important for me to do this?
These three questions seem to transform the needs of the patient and the words of the health care provider into daily function for life.
Third: Using the Teach-Back/Show-Me Method (from Doctor D. Schillinger's work in health care literacy) appears a best practice method. The weakness lies in utalizing ONLY this method in complex medical instructions with limited time resources seems to require perfection.
Speaking personally, my MD will talk to you following all the standards, sitting at equal level, telling and asking, repeating, etc. ...but forgetting specific needs of a specific known patient while in the examining room. Then when the patient leaves a copy of the front page is given as a receipt...all instructions are on the flip side. Go figure?
Then there was one time in a rushed, crowded waiting room (where was HIPPA?) personal infomation and instructions were given without time for contemplation.
Wednesday, February 4, 2009
Interesting discoveries
First, it has been great speaking with my advisor...great to share my thoughts and receive some clarification from Dr. J.
So moving right along two things:
Storyboards as education tools for nursing staff pose some unique challenges. There are set forms provided by the individual facility. Many topics for education either are for new information or as reviews. The audience includes RNs, LPNs, and CNAs. There might be specific protocol for each hospital that needs to be examined. Most facilities even have a set form for the introduction of why,how, and what of expected outcomes. Storyboard (self-learning packets) require a post-test.
Technical writing places an important part in the presentation of the material. At my meeting Dr. J. offered some valid and welcomed suggestion. For my dry run storyboard, I had been most concerned with clarity of the information, content, and the who, what, how, and why...she added more detailed application (why)into the mix. Also the use of color might be more effective co-ordinated differently with more visuals and varied fonts.
I nixed the idea of statistics because practical experience has shown me statistics BORE us nurses.
I have been looking at tools for evaluating the content of patient education materials as well as tools for evaluating health care literacy.
For the material evaluation, SMOG (simple measure of gobblydegook)and Lextile will require more evaluation over the next few weeks. This may prove useful for my evaluation of patient information pertaining to Coumadin(my selected topic for evaluation because of its importance to Joint Commission and my frequent responsibility in my work.
Preliminary research on literacy tools, Newest Vital Sign and REALM appear to have very limited, specific audience. NVS requires math and critical thinking skills along with reading. For NVS, the patient does not look at the questions and is offered no scrap paper. While looking at an ice cream label, 5 questions are scored by the tester. REALM appears to correlate word recognition with familiarity of the definition of the word spoken. I believe the label reading would be very important for patients with specific medical conditions such as diabetes, renal failure, congestive heart failure. The REALM in my experience of vocabulary and meanings might be limited. (This is even more apparent with a review of Clear Language and AMA recommendations of words to avoid). Both are English oriented, although I believe NVS now has a Spanish version. How will the needs of cognitively and developmentally challenged placed. How about those with learning, speech, and hearing difficulties? I do want to contact Dr. TD regarding these lackings.
Interesting sidebar: many hospitals are now using a special translation phone to provide access to many languages taking the place of in-house translators or the regular phone translators where the nurse states the question to the translator on the phone, then the translator addresses the patient, finally the patient can ask questions of the nurse through the translator on the phone. This would not be a very efficient or safe method for use of the "Teach Back" method.
All of these issues will be continued to be investigated as well as work on annotated bibliography.
So moving right along two things:
Storyboards as education tools for nursing staff pose some unique challenges. There are set forms provided by the individual facility. Many topics for education either are for new information or as reviews. The audience includes RNs, LPNs, and CNAs. There might be specific protocol for each hospital that needs to be examined. Most facilities even have a set form for the introduction of why,how, and what of expected outcomes. Storyboard (self-learning packets) require a post-test.
Technical writing places an important part in the presentation of the material. At my meeting Dr. J. offered some valid and welcomed suggestion. For my dry run storyboard, I had been most concerned with clarity of the information, content, and the who, what, how, and why...she added more detailed application (why)into the mix. Also the use of color might be more effective co-ordinated differently with more visuals and varied fonts.
I nixed the idea of statistics because practical experience has shown me statistics BORE us nurses.
I have been looking at tools for evaluating the content of patient education materials as well as tools for evaluating health care literacy.
For the material evaluation, SMOG (simple measure of gobblydegook)and Lextile will require more evaluation over the next few weeks. This may prove useful for my evaluation of patient information pertaining to Coumadin(my selected topic for evaluation because of its importance to Joint Commission and my frequent responsibility in my work.
Preliminary research on literacy tools, Newest Vital Sign and REALM appear to have very limited, specific audience. NVS requires math and critical thinking skills along with reading. For NVS, the patient does not look at the questions and is offered no scrap paper. While looking at an ice cream label, 5 questions are scored by the tester. REALM appears to correlate word recognition with familiarity of the definition of the word spoken. I believe the label reading would be very important for patients with specific medical conditions such as diabetes, renal failure, congestive heart failure. The REALM in my experience of vocabulary and meanings might be limited. (This is even more apparent with a review of Clear Language and AMA recommendations of words to avoid). Both are English oriented, although I believe NVS now has a Spanish version. How will the needs of cognitively and developmentally challenged placed. How about those with learning, speech, and hearing difficulties? I do want to contact Dr. TD regarding these lackings.
Interesting sidebar: many hospitals are now using a special translation phone to provide access to many languages taking the place of in-house translators or the regular phone translators where the nurse states the question to the translator on the phone, then the translator addresses the patient, finally the patient can ask questions of the nurse through the translator on the phone. This would not be a very efficient or safe method for use of the "Teach Back" method.
All of these issues will be continued to be investigated as well as work on annotated bibliography.
Wednesday, January 28, 2009
The Project
Already the issue of the study changed by placing the nurse in a dual role of "speaker" and "listener" as well as the dual role of the patient as "listener' and "speaker". The dual roles allow the nurse to evaluate barriers to the information provided that might hinder a patient's personal health care literacy.
Study objectives include:
Background Information
1. Define health care literacy/illiteracy
2. Develop an annotated bibliography of current medical profession initiatives for the promotion of health care literacy.
3. Use The Fifth Vital Sign and REALM as a class project in a non HIPPA/IRB situation.
Compliance with 2009 Joint Commission Patient Safety Goals by promoting effective communication among caregivers and stimulating patient (and family) involvement.
4.. Survey practicing nurses regarding their adaption methods to individualize their patient teaching following role-playing exercises.
5. Develop a Story Board self-education packet promoting improved nurse/patient communication to be used in a hospital setting.
Examining compliance to the 2009 Patient Safety Goal Safe Use of Anticoagulants
6. Make a textual analysis of frequently utilized educational brochures and information sheets for Coumadin, one commonly prescribed anticoagulant.
I have research material and preliminary dialogue with practitioners in the fields of nursing, literacy, sociology, and public health.
I am expanding my bibliography base into nurse specific research-based literature.
I have developed a plan to administer the FVS and am awaiting the REALM Kit to proceed.
I was going to use SMOG for measuring the gobbledygook in the textual analysis, but following Dr. K's recommendation I will be looking at the information through a Technical Writing Graphic evaluation as well as following Dr.D. suggestion for checking out "Lexile".
Two situations peaked my interest in this study that may provide entry anecdotal entry into any write up of my study. One was the method information was given to my 23 year old son with learning disabilities. The other was overhearing colleagues "educate" patients. I believe we, as nurses, can do better in educating patients while allowing them to participate in their health care. Knowledge, choices, and reason all center around a health care literacy that clarifies what the problem is, what needs to be known, and what happens if guidelines are not followed.
Study objectives include:
Background Information
1. Define health care literacy/illiteracy
2. Develop an annotated bibliography of current medical profession initiatives for the promotion of health care literacy.
3. Use The Fifth Vital Sign and REALM as a class project in a non HIPPA/IRB situation.
Compliance with 2009 Joint Commission Patient Safety Goals by promoting effective communication among caregivers and stimulating patient (and family) involvement.
4.. Survey practicing nurses regarding their adaption methods to individualize their patient teaching following role-playing exercises.
5. Develop a Story Board self-education packet promoting improved nurse/patient communication to be used in a hospital setting.
Examining compliance to the 2009 Patient Safety Goal Safe Use of Anticoagulants
6. Make a textual analysis of frequently utilized educational brochures and information sheets for Coumadin, one commonly prescribed anticoagulant.
I have research material and preliminary dialogue with practitioners in the fields of nursing, literacy, sociology, and public health.
I am expanding my bibliography base into nurse specific research-based literature.
I have developed a plan to administer the FVS and am awaiting the REALM Kit to proceed.
I was going to use SMOG for measuring the gobbledygook in the textual analysis, but following Dr. K's recommendation I will be looking at the information through a Technical Writing Graphic evaluation as well as following Dr.D. suggestion for checking out "Lexile".
Two situations peaked my interest in this study that may provide entry anecdotal entry into any write up of my study. One was the method information was given to my 23 year old son with learning disabilities. The other was overhearing colleagues "educate" patients. I believe we, as nurses, can do better in educating patients while allowing them to participate in their health care. Knowledge, choices, and reason all center around a health care literacy that clarifies what the problem is, what needs to be known, and what happens if guidelines are not followed.
Thoughts Post Dr. K. meeting
CLARIFICATION OF THE USE OF THIS BLOG: TO JOURNAL THOUGHTS, RESEARCH, AND FOCUS.
Thanks to Dr. Dean Schillinger for coining the phrase "closing the loop" based on the "teach back method" used in the field of education.
What came to the forefront after my meeting with Dr. K. is the realization that I will have to remain focused. I will have to evaluate my information as what is interesting for examination at a later time, and what is essential for this study.
The main questions centers around understanding and efficiency of information disseminated by the nurse to the patient.
I will add the following caveats:
1. this independent study assumes adequacy of staffing ratios and time allotted for education within the hospital setting (I acknowledge that practicing nurses recognize the day to day variances in staffing and duties that can hinder education teaching)
2. this study assumes compliance with accepted standards of practice where physicians, Registered Nurses, or delegated other discipline representatives (Registered Dietitians, Diabetic Educators, etc) provide the initial education and the Licensed Practical Nurse provides re-enforcement. This clarification complies with scopes of practice as defined by PA State Board of Nursing.
3. Further, this study will NOT examine lack of compliance due to financial considerations. That topic is beyond the scope of this independent study. I leave that discussion to those outside the nurse-patient-education paradigm.
A combination of rhetorical and compositional evaluation of how the nurse and patient put together all the "pieces of information" that hopefully will allow for optimal health care literacy that maintains, improves, and explains an individual patient's specific health care needs.
Hopefully the blog will be a way to summarize my research to date and discuss future steps as well as evaluating what has been completed and what has not been completed.
Thanks to Dr. Dean Schillinger for coining the phrase "closing the loop" based on the "teach back method" used in the field of education.
What came to the forefront after my meeting with Dr. K. is the realization that I will have to remain focused. I will have to evaluate my information as what is interesting for examination at a later time, and what is essential for this study.
The main questions centers around understanding and efficiency of information disseminated by the nurse to the patient.
I will add the following caveats:
1. this independent study assumes adequacy of staffing ratios and time allotted for education within the hospital setting (I acknowledge that practicing nurses recognize the day to day variances in staffing and duties that can hinder education teaching)
2. this study assumes compliance with accepted standards of practice where physicians, Registered Nurses, or delegated other discipline representatives (Registered Dietitians, Diabetic Educators, etc) provide the initial education and the Licensed Practical Nurse provides re-enforcement. This clarification complies with scopes of practice as defined by PA State Board of Nursing.
3. Further, this study will NOT examine lack of compliance due to financial considerations. That topic is beyond the scope of this independent study. I leave that discussion to those outside the nurse-patient-education paradigm.
A combination of rhetorical and compositional evaluation of how the nurse and patient put together all the "pieces of information" that hopefully will allow for optimal health care literacy that maintains, improves, and explains an individual patient's specific health care needs.
Hopefully the blog will be a way to summarize my research to date and discuss future steps as well as evaluating what has been completed and what has not been completed.
Monday, January 19, 2009
"Closing the Loop": Promoting Healthcare Literacy
This blog will become a journal of my journey to discover a method of communication clarity of health care information that can be used by Nurses. Specifically, I will look at how connections can be made between the responsibility of the Nurse as "speaker as well as listener" and the responsibility of the patient as "listener as well as speaker".
Because of my 35 years experience as a nurse and my exposure to the on-going attempts of my colleagues to provide clear, useful, and relevant information, I hope to place the NURSE as one of the most important front line communicators.
I hope to examine the following questions:
Is the nurse clear, logical, and thorough in the presentation of medical information?
Have barriers to learning been identified, adapted, and addressed?
Is there a way for the nurse to evaluate the patent's response to the discussion of the information?
How can the Nurse ensure the information given is incorporated into the personal health care literacy of the patient?
According to the National Center for Educational Statistics (NCES)
about 1 in 20 adults in the US is not literate in English
11 million Americans lack the skills to handle many everyday tasks
Literacy is learned
Learning the visual, written, and numerical skills of health care management allows patients to make informed choices regarding their health. Nurses are often on the frontline of providing information.
I believe the information a Nurse provides for a Patient allows for a literacy that enables entry into a dialogue of the personal, private, and public worlds of health care.
These will be some of the questions, research, and observations of my journey.
Because of my 35 years experience as a nurse and my exposure to the on-going attempts of my colleagues to provide clear, useful, and relevant information, I hope to place the NURSE as one of the most important front line communicators.
I hope to examine the following questions:
Is the nurse clear, logical, and thorough in the presentation of medical information?
Have barriers to learning been identified, adapted, and addressed?
Is there a way for the nurse to evaluate the patent's response to the discussion of the information?
How can the Nurse ensure the information given is incorporated into the personal health care literacy of the patient?
According to the National Center for Educational Statistics (NCES)
about 1 in 20 adults in the US is not literate in English
11 million Americans lack the skills to handle many everyday tasks
Literacy is learned
Learning the visual, written, and numerical skills of health care management allows patients to make informed choices regarding their health. Nurses are often on the frontline of providing information.
I believe the information a Nurse provides for a Patient allows for a literacy that enables entry into a dialogue of the personal, private, and public worlds of health care.
These will be some of the questions, research, and observations of my journey.
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