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tThe human papilloma virus (HPV) vaccine can prevent the majority of cases of cervical cancer, a serious and potentially life-threatening dis-ease. Yet, decisions about the vaccine by parents, teens and young women have been complicated by intense media focus on the vaccine ever since it received FDA approval in June 2006. HPV vaccination is only one of a multitude of health care decisions women are faced with regularly. Across the lifespan, women are faced with deci-sions about contraception, pregnancy, genet-ic screening, menopause symptoms and health prevention and screening options. The deci-sions they make have potentially life-changing consequences for themselves and their fami-lies, including their children. Acute and chronic

conditions bring even more decisions related to tests, procedures and treatments.

Making Health Decisions in a Complex WorldDecision-making is set against the backdrop of the larger social, cultural, economic, geographic and political milieu. Media coverage of health issues and scientific developments is part of this backdrop. People can sift through a vast amount of health information—of varying quality and from a variety of sources—on the Internet, be-fore they even see a health care provider. A per-son’s age, gender, current physical and emotion-al health, personal and family medical history, ethnicity, family support, economic status,

Nurses who can

communicate

risk effectively

to their patients

will facilitate

informed and

efficient decision-

making, and

strengthen their

partnerships with

patients

Communicating Risk

Rationale and Strategies

Catherine Ruhl, CNM, MS

72 Nursing for Women’s Health Volume 14 Issue 1

beliefs and values may influence decisions (O’Connor, Jacobsen, & Stacey, 2002).

Communicating RiskWomen’s health nurses are very familiar with the need to effectively counsel women to assist them in making health care decisions. Inherent in these decisions are assessments of risk by both clinicians and patients. Nurses who can commu-nicate risk effectively to their patients will facili-tate informed and efficient decision-making, and strengthen their partnerships with patients.

Risk communication generally involves pro-viding numerical estimates of risk. Practical and efficient principles for communicating these numbers have been put forth and can be simple and cost-effective to put into practice. Risk com-munication is an essential component of obtain-ing informed consent. It’s recommended that providers discuss the components listed in Box 1 in order for informed consent to stand up to legal scrutiny (Mahlmeister, 2009). Discussion of risks, benefits and outcomes is involved at almost every step.

Individualized CounselingThe Association of Women’s Health, Obstetric and Neonatal Nurses’ Standards for Profession-al Nursing Practice in the Care of Women and Newborns, 7th edition, (2009) states that nurses should use health teaching methods that are appropriate to the patient’s developmental level, learning needs, readiness, ability to learn, lan-guage preference and culture. A woman’s health literacy is also a factor. Health literacy is a new-er concept that describes the ability of patients to understand health information and use this information to make informed health care de-cisions (Shieh & Halstead, 2009). One part of health literacy is quantitative literacy, which re-fers to skills with numbers. A woman’s under-standing of statistical explanations of risks can influence her present and future choices. For ex-ample, a study of breast cancer survivors dem-onstrated that women with lower health literacy had a less accurate understanding of the risk of their cancer recurring than those with higher health literacy (Brewer et al., 2009). Accurate understanding of recurrence risk could contrib-ute to a woman’s likelihood to seek future can-cer screening or comply with other preventive treatments.

Nurses who understand the many factors in-fluencing patients’ decisions as well as patients’ level of comprehension of health information will be better prepared to explain and clarify this information. Nurses can use this knowledge to tailor risk communication appropriately to indi-vidual patients.

Framing DiscussionsRisk explanations often involve rates, ratios and probabilities. It may be useful to compare the likelihood of one event or outcome happening versus another. Such explanations involve num-bers, and health care professionals may be chal-lenged in providing the most useful presenta-tions of this information in ways that a patient, who may be challenged with numerical under-standing, can easily grasp. A review of the lit-erature reveals that health care professionals, including nurses, have not extensively studied the topic of the best ways to communicate risk related to health care decision-making. For the most part, existing recommendations are based on expert opinion (Lipkus, 2007).

Quantitative Versus Descriptive TermsA good first step is to frame discussions of risk from the starting point that all decisions, whether a treatment is accepted or declined,

Catherine Ruhl, CNM, MS, is director of women’s health programs at AWHONN in Washington, DC. Address correspondence to: cruhl@awhonn.org.

DOI: 10.1111/j.1751-486X.2010.01510.x

A good first

step is to frame

discussions of

risk from the

starting point

that all decisions,

whether a

treatment is

accepted or

declined, involve

risk

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Box 1.

Informed Consent Components• Nature of problems and potential

diagnoses

• Nature of treatments and proce-dures

• Risks and benefits of the intended treatments and procedures

• Alternative therapies including their risks and benefits

• Expected benefits and outcomes of intended treatments and procedures

• Probability or likelihood of a suc-cessful outcome

• Risks of not undergoing the treat-ments or procedures

Source: Mahlmeister (2009).

February | March 2010 Nursing for Women’s Health 73

all settings who effectively communi-cate risks and benefits, in ways that are meaningful and useful, support and empower the women and families they serve. NWH

ReferencesAssociation of Women’s Health, Obstetric

and Neonatal Nurses. (2009). Standards for professional nursing practice in the care of women and newborns (7th ed.). Washington, DC: Author.

Brewer, N. T., Tzeng, J. P., Lillie, S. E., Edwards, A. S., Peppercorn, J. M., & Rimer, B. K. (2009). Health literacy and cancer risk perception: Implications for genomic risk communication. Medical Decision Making, 29(2), 157–166.

Cohen, I. B. (1984). Florence Nightingale. Scientific American, 250(3), 128–137.

Lipkus, I. M. (2007). Numeric, verbal and visual formats of conveying health risks: Suggested best practices and future rec-ommendations. Medical Decision Mak-ing, 27(5), 696–713.

Lipkus, I. M., & Hollands, J. G. (1999). The visual communication of risk. JNCI Monographs, (25), 149–163.

Mahlmeister, L. (2009). Partnering with patients to enhance informed decision-making. Journal of Perinatal and Neona-tal Nursing, 23(3), 213–216.

Malenka, D.J., Baron, J.A., Johansen, S., Wahrenberger, J.W., & Ross, J.M. (1993). The framing effect of relative and absolute risk. Journal of General In-ternal Medicine, 8(10), 543–548.

O’Connor, A. M., Jacobsen, M. J., & Sta-cey, D. (2002). An evidence-based ap-proach to managing women’s decisional conflict. Journal of Obstetric, Gynecolog-ic, & Neonatal Nursing, 31(5), 570–581.

Paling, J. (2003). Strategies to help pa-tients understand risks. British Medical Journal, 327(7417), 745–748.

Shieh, C., & Halstead, J. A. (2009). Un-derstanding the impact of health litera-cy on women’s health. Journal of Obstet-ric, Gynecologic, & Neonatal Nursing, 38(5), 601–612.

involve risk (Paling, 2003). There-fore, an accurate understanding of the amount of risk involved, no mat-ter what choice is opted for, is needed. It’s also a good idea to use quantitative rather than descriptive terms. Terms such as “low” or “high” may have dif-ferent meanings to clinicians and pa-tients. Describing both the positive and negative effects of a treatment or proce-dure gives the patient a more complete context for decision-making. Hearing that 3 in 100 people have experienced a certain side effect from a treatment is one side of the story. Explaining that 97 out of 100 had no side effects and received benefits of the treatment pro-vides balance (Paling).

Relative Versus Absolute TermsGiving risk information in terms of ab-solute numbers may provide greater clarity than giving relative risk (Lip-kus, 2007; Paling, 2003). For example, it may sound more frightening to hear that opting to take a medication triples the subsequent risk for breast cancer (relative risk) than it does to hear that while 3 women in 1,000 who took the medication went on to develop breast cancer, 1 woman in 1,000 who did not take the medication also developed breast cancer during follow-up (abso-lute risk). Relative risk can also give a false impression that might lead pa-tients to choose a treatment based on an inaccurate understanding of the benefits. Patients in one study (Malen-ka, Baron, Johansen, Wahrenberger, & Ross, 1993) were found to be more likely to choose a certain medication when benefits were expressed in rela-tive rather than absolute terms, because they understood the benefits to be greater than when they heard the abso-lute numbers.

ConsistencyIt’s recommended that risk estimates involving numbers be presented in the same format to patients. For example,

when comparing side effects of treat-ments, don’t present risk as a percent-age in one case and as odds in anoth-er. When discussing odds, such as 1 in 10, use consistent denominators. Not everyone understands that 1 in 10 is a greater risk than 1 in 25 (Lipkus, 2007; Paling, 2003).

Visual AidsFinally, making numerical risk expla-nations visual can be a useful accom-paniment to verbal explanations of risk (Lipkus, 2007). Florence Nightingale was an early proponent of represent-ing statistical data in a visual format. Her sophisticated version of a pie chart, called a polar area diagram, helped convince the British army to reform its entire military hospital system (Cohen, 1984).

Bar graphs are helpful to compare risks of various treatments. Pie charts are useful for showing the relation of parts to a whole, for instance in show-ing the likelihood of all possible out-comes of a treatment. A format that uses dots and x’s or a jar of marbles of two colors can show the numbers of those affected and not affected by a cer-tain condition or treatment. Patients may have an easier time comprehend-ing their risks if they can visualize them in these various formats (Lipkus, 2007; Lipkus & Hollands, 1999; Paling, 2003).

ConclusionThere is much discussion these days about the importance of health care professionals partnering with their pa-tients to achieve optimal health out-comes. Effectively explaining risks and benefits in order to support and facilitate decision-making promotes partnerships. More research is need-ed on how nurses can use simple risk communication techniques, especial-ly involving numbers, and how better risk communication affects preven-tion, screening and treatment choices and adherence and, ultimately, health outcomes. Women’s health nurses in

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