It is the ethical right of patients to have input into their medical treatment and end-of-life decisions. Luptak and Boult (1994) state:
Over the past 2 decades, opportunities have increased for elderly people to retain more control over their health care by recording advance directives. An advance directive allows a competent adult to state how medical decisions should be made if he or she becomes mentally or physically unable to choose options or to communicate his or her wishes (p. 409).
The increasing complexity of health care technology has made these decisions harder than ever before. The enactment of the Patient SeIfDetermination Act (PSDA) in 1991 mandated health facilities to provide information regarding patients' rights concerning health care decisions. The target population most in need of this information is elderly individuals. At the time of admission to a health care faculty or an HMO, patients are given written information about advance directives. The time of admission is known to be anxiety-provoking and does not lend itself to comprehension of the written material nor to making sound judgments about such serious matters (Evans & Clarke, 1993).
The emotional upheaval of people in this situation, as well as problems with the written materials presented to them, may account for the low percentage of people drafting advance directives (Steher, Elliot, & Brouno, 1992). One of the major problems is that the printed material frequently is not at the appropriate readability level for the average adult (Bernier, 1996). A recent study of 10 advance directive documents from various sources found the average readability level was 11.3 using the Flesch-Kincaid Grade Level and 18.2 using the Gunning's Fog Index (Ott & Hardie, 1997). This may explain, in part, why so few people draft advance directives.
THE BERNIER INSTRUCTIONAL DESIGN SCALE 2
Another problem that needs to be addressed is the appearance of the written brochure. The print style and size, space between lines of text, use of illustrations, color, and paper texture all are factors that contribute to the ease of reading and the level of understanding of the information (Adler, 1993; Courson, 1995).
To address these issues, an advance directive brochure for the well-elderly titled, "You Have the Right to Choose - A Guide to Preparing Your Advance Directive" was developed (Husted et al., 1997). The brochure incorporates information gained from prosumer focus groups as well as information gained from the literature on preparing educational materials. The term prosumer refers to a person who not only provides a service but is the consumer of that service (Borkman, 1990). Both content and appearance of the brochure were considered in its development. A nurse lawyer read the brochure for accuracy of information. Minor changes were made according to her suggestions. This article cites the results of a pilot test of the educational brochure using a purposive sample of wellelderly people living independently in two sites. It was conducted to test for interpretation of content contained within the brochure as well as to gain knowledge regarding which characteristics of the brochure enhanced the understanding of the information.
DEMOGRAPHIC CHARACTERISTICS N = 20
BROCHURE READABILITY MEASUREMENT
After the brochure, "You Have the Right to Choose - A Guide to Preparing Your Advance Directive," was developed, readability was calculated using four methods. According to the Fry Readability Graph (Fry, 1968) and Flesch Reading Ease (Flesch, 1949) the readability of the brochure was at the seventh-grade level. On the Gunning Fog Index (Gunning, 1952), the reading level was fifth grade. The SMOG readability index placed the reading level at ninth grade. The SMOG index allows for the omission of a multisyllable word that must be used in the text. Thus the SMOG index again was calculated, omitting the three syllable word "directive" (McLaughlin, 1969). This brought the reading level down to the eighth grade.
READABILITY LEVELS AND COMPREHENSION CORRELATION
It can be problematic to use only one readability index. None are 100% accurate; therefore, it is helpful to use a number of indexes (Dowe, Lawrence, Keyserling, & Carlson, 1992). Most indexes address only the length of sentences and the number of syllables in each word. The combination of the material and each individual reader produces an almost infinite number of variables such as:
syntactic complexity, concept density, abstractness, organization, coherence, sequence of ideas, page format, length of line of print, length of paragraph, punctuation, illustrations, color, and reader interest (Koenke, 1987, p. 674).
Furthermore, any target population such as the well-elderly does not assure a stable reading level ability. Therefore, even when educational material is written at a level deemed appropriate (sixth-grade level is deemed appropriate for adult patient populations), comprehension is not assured (Reid et al., 1995). However, the SMOG index tends to measure comprehension, while others tend to measure the level at which an individual is reading. Thus, the SMOG index is frequently preferred when the elderly person (or any learner) is expected to learn from the material (Vaughan, 1976).
BERNIER INSTRUCTIONAL DESIGN SCALE 2
In 1993 Bernier became interested in the process of developing and evaluating printed education materials (PEMs). In 1996 she conducted
a study establishing the psychometric properties of a quality standard for quantifying the presence (or absence) of instructional design/learning principles contained in PEMs... (Bernier, 1996, p. 283).
RESULTS FROM SURVEY QUESTIONS FOR THE ADVANCE DIRECTIVE BROCHURE N = 20
The study was performed in four stages and resulted in 35 instructional design principles that can be used as a checklist (i.e., The Bernier Instructional Design Scale [BIDS]) to facilitate the ratings of PEMs used with patients or families. In 1996 additional research yielded a shorter version of the scale (i.e., Bernier Instructional Design Scale 2 [BIDS2]). The researchers asked 10 nurses, some educators, and some clinicians to evaluate the brochure, "You Have the Right to Choose - A Guide to Preparing Your Advance Directive." This evaluation was performed prior to using the brochure for the study. See Table 1 for results of the evaluation.
The total number of possible points (if every nurse scored each Principle as 2, meaning it fully met the criteria) was 280. The total number of points obtained from the participants using the BIDS2 was 244.
The contrast between ink and paper (Principle 1), font size (Principle 2), vocabulary (Principle 5), active voice (Principle 7) , content (Principles 11 and 13) each received the optimum number of points. The total response to Principle 6 was 1 point less than the optimum number. The authors, along with 9 of 10 nurses who evaluated the brochure, believed relevant terms had been defined. The responses to Principles 8 and 9 regarding learning objectives resulted in the majority stating the principles were met entirely and only three stating principles were partially met or not met at all. For Principle 14, 8 individuals indicated the readability level was appropriate for the target group, and 2 indicated it was met only partially. For both Principles 10 and 12 (amount of information and bridge-gapping examples), 7 stated it was met entirely, 2 believed it was partially met, and 1 in each case said it was not met. For Principles 3 and 4 (illustrations), only 5 reported the principles were met. Ten stated they were only partially met, and 4 believed they were not met at all. (One response was missing from Principle 4). Because there were no content drawings or illustrations in the brochure, the authors believed a not applicable (N/A) response would have been appropriate for Principles 3 and 4. On the basis of the results of the study, drawing or illustrations did not seem necessary for understanding the information.
RESEARCH DESIGN AND METHODS
The research is a descriptive study using an advance directive brochure developed from the data collected in a previous research study. An objective questionnaire was used as a guideline for the semistructured interviews conducted with participants after they had the opportunity to read the brochure.
Subjects and Sites
The subjects for the study were a convenience sample of well-elderly people from independent Uving sites. The well-elderly are defined for this study as people age 65 and older who are well enough to function in independent housing. Additional criteria include the ability to speak and read English and to be oriented to person, place, and time. The settings were a private apartment complex and a government-funded independent Uving site. Every attempt was made to include both genders, a cross-section of ethnic and racial groups, and various educational levels.
Twenty people agreed to participate in the study. Two participants were men, and the remainder were women. Seventeen participants had a minimum of a high school education. A few had some college credit. Three had more than an eighthgrade education but did not graduate from high school. None remembered receiving a brochure on advance directives. See Table 2 for further demographic information.
1. What characteristics of this brochure enhance understanding of the information? For example, size of print, contrast between paper and print, manner in which the information is presented, and ease of handling the brochure.
2. How well are the participants able to understand the information contained within the brochure?
INTERVENTION PLAN/DATA COLLECTION PROCEDURE
Prior to data collection, Institutional Review Board permission was granted by Duquesne University, and permission was obtained from the appropriate people at both sites. Data were collected through individual interviews to answer the research questions. Participant volunteers for the study were accessed through advertising signs placed in common gathering areas, mailrooms, and dining areas. Those people who expressed a desire to participate in the study had the study further explained to them and then were asked to read and sign a consent form. They were told that refusal to participate in the study would in no way affect their living situation, and they could withdraw from the study at any time. Before the participants received the brochure, they were asked to complete a short demographic profile.
The data collection procedure involved talking individually to all participants and asking them to read the brochure. Participants then were asked to share their comments on the ease of readability and their understanding of the information in the brochure. This was facilitated by the use of yes and no questions read to them by the interviewer (See Appendix). Following the interview, all participants were given the opportunity for individual assistance in drafting an advance directive if they so desired. Some availed themselves of this service.
Analysis of the data was a simple reporting of how the participants responded to the questions. No attempts were made to code the data. The brochure would be determined to be a success if a simple majority responded favorably to Questions 1 through 5, and the participants understood more than 70% of the information, as represented by Questions 6 through 15.
Research Question 1
Ail the participants answered yes in response to survey Questions 1 through 5 (Table 3). This indicates the print was large enough and was not difficult to read. The brochure was easy to handle, and the presentation of the material was easy to follow. The participants reported they understood the information presented in the brochure. This was substantiated by the responses to Questions 6 through 15.
Research Question 2
Survey Questions 6 through 15 (Table 3) were specific regarding the information contained in the brochure. The overall percentage of correct responses was 90.5%. It appears the participants understood what they were reading and were able to correctly respond to the questions asked. The only question that the respondents scored below the 17th percentile was Question 14: Do all states have living wills? Eleven (55%) answered the question correctly. Eight (40%) answered incorrectly, and 1 (5%) was undecided. For Question 12 (Do you need a lawyer to complete an advance directive?), 16 (80%) responded correctly, 4 (20%) responded incorrectly. For Question 7 (Is an advance directive a legal document?), 17 (85%) answered correctly, 2 (10%) answered incorrectly, and 1 (5%) was undecided. For Questions 8 (Can you have both a living will and a durable power of attorney for health care?) and 10 (Do you need an advance directive to receive quality care?), 19 (95%) responded correctly, and 1 (5%) was undecided for each question. For Question 9 (Is it true that an advance directive only goes into effect when you cannot make decisions yourself?), 19 (95%) responded correctly, and 1 (5%) responded incorrectly. For all other questions (Questions 6, 11, 13, and 15), all responses were correct.
Nurses, as caregivers, must constantly search for opportunities to promote worth, dignity, and, if possible, meaning, for elderly people (Everett, 1993). Nurses are uniquely positioned to do this. This is especially true because nurses attend to patients 24 hours a day, and they are readily trusted by the people for whom they care (Bailly & DePoy, 1995). However, before the advance directive can or should be drafted, elderly people (or any individuals) need to be assisted in assessing personal values. It is from these values that the choices and decisions should be made (Winland-Brown, 1998). Nurses have the opportunity to see people at various times and in various situations. Nurses usually watch patients interact with family and significant others. This gives nurses a better perspective and helps them to guide individuals to articulate their desires. They may help the individual draft an advance directive or talk with loved ones about what the elderly person wants. This is important because the problem of interpretation - understanding what a specific patient would want in a specific situation - is difficult even with an advance directive. Nurses must discuss advance directives with their elderly patients and, if possible significant others, to discover what the patients want and if they understand what the advance directive means. Without discussing this, drafting an accurate advance directive becomes "chancy" or impossible (Husted & Husted, 1995).
A brochure designed specifically for the elderly population and tested for its comprehensibility is of particular use to nurses. Nurses can use it to impart information to elderly people and then follow up reading the brochure with a discussion. Numerous authors believe there is a need for discussion if the drafting of advance directives is to be increased (Duffield & Podzamsky, 1996; Foley, Miles, Brock, & Phillips, 1995; Spears, Drinka, & Voeks, 1993). In an unpublished dissertation using the elder-sensitive brochure, a significant relationship was found between discussion and the drafting of advance directives by elderly people (Brown, 1998). Following a discussion about advance directives, it would be helpful for elderly people to receive a document, such as the elder-sensitive brochure, to take home to use as a reference in making a decision to draft or not to draft an advance directive.
The overwhelming positive results obtained from this study are a result of the process used to develop the brochure. Initially, the researchers collected information from the prosumers which helped assure their needs were recognized. The next step was a literature search on preparing written materials. This information along with the prosumer information was incorporated into the development of the brochure. After the brochure was developed, a lawyer examined it for legal accuracy. One change was made in response to her counsel. Next, the brochure was given to 10 nurses who evaluated it according to BIDS2 (Bernier, 1996). The rating from the nurses using the BIDS2 was generally favorable.
The sample was small; therefore, caution should be exercised when applying these results to wellelderly people in general. However, the researchers believe the process followed in conducting this study gives credence to the results.
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THE BERNIER INSTRUCTIONAL DESIGN SCALE 2
DEMOGRAPHIC CHARACTERISTICS N = 20
RESULTS FROM SURVEY QUESTIONS FOR THE ADVANCE DIRECTIVE BROCHURE N = 20