Emphasizing Health Literacy in Nursing Education: Equipping Nursing Students with Literacy Skills to Improve Patient Outcomes

Health Literacy

Health literacy is a broad term which encompasses a patient’s ability to manage their personal health issues. High level health literacy skills include the ability to read instructions and interpret labels, effectively communicate health concerns in a timely manner, and manage individual care needs according to prescribed orders. The ability to read medication labels and follow the directions precisely is examples of strong health literacy skills [1]. Health literate individuals are equipped with the knowledge and skills needed to make educated decisions Perspective involving their health. They are able to accurately calculate medication doses, review food labels to ensure safe consumption when managing food allergies, and they will be able to follow directions such as with preparation instructions for procedures such as fasting before blood work. A patient with strong health literacy skills will have an awareness of the inner workings of the health care environment and will be able to navigate the health care delivery system. A health literate individual has the ability to advocate for their health needs and will articulate questions directed to the appropriate health care professional. In addition, the astute health literate individual knows the value of well patient office visits to their primary health care provider and knows the importance of keeping current with health screenings and vaccinations [2].

Populations at Risk for Low Health Literacy

Unfortunately, the vast majority of patients struggle with health literacy and a staggering 9 out of 10 adults are said to have low level health literacy skills [3]. In a study conducted by Shahid, et al. [4], it was determined only 50% of hospitalized medical-surgical patients had adequate health literacy, thus 50% of hospitalized medical-surgical patients experience challenges with reading, comprehending and interpreting health information. A study conducted among Danish adults, it was determined that 4 out of 10 adults have problems addressing their complex health issues [5]. It is also important to note, the study findings were consistent with eight other European countries where the population average of 47.6% identified as having subpar health literacy skills [5].

Factors associated with low health literacy include advanced age, diverse cultural backgrounds, marital status, low socioeconomic class, and limited education [1]. Advanced age is associated overall cognitive decline thus inhibiting the ability to navigate printed materials and access electronic resources. According to the Centers for Disease Control and Prevention (CDC) [6], 71% of adults over the age of 60 struggle with printed materials, and 68% of this population have great difficulty understanding numbers and performing calculations. Language barriers due to limited- English proficiency are a major factor to consider when working with patients from diverse cultural backgrounds. When patients and their clinicians do not speak the same language, patients experience more diagnostic testing, increase days admitted for inpatient care, and increased rates of readmissions. Failure to deliver patient centered care to this at-risk population intensifies patient suffering and mental anguish [7]. Lack of personal support systems which are comprised of family and concerned friends can contribute to low health literacy. Additionally, households of low-socioeconomic status are at high risk for low health literacy due to the limited educational opportunities and reduced access to health care resources [8]. In a study conducted from 2012-2018 which examined health literacy levels and trends in health, 51% of individuals reported low health literacy in 2018, which is a decrease from 67% in 2012. The study participants were young adults ranging in age 18-24 years old. This population also identified as multiracial, separated, note graduated from high school, out of work for from more than 1 year, and had a household income of less than $10,000 [9]. Warning Signs of Low Health Literacy Skills There are many red flags associated with low health literacy skills that health care professionals must be aware of. Health care professionals would be wise to pay particular attention to the warning signs associated with low health literacy as there is great potential patients could suffer serious health consequences. Patients that often miss office appointments or cancel frequently are cause for concern. Low health literacy should be considered when patients are unable to complete registration forms or important documents, or have gaps in their medical histories. Health literacy skills should also be evaluated closely in patients who cannot name their medications or do not ask questions when meeting with health care professionals [10]. Increased levels of anxiety and frustration along with confusion and nervousness are signs a patient with low health literacy could display. According to Hickey, et al. [11], studies have shown inadequate health literacy is attributed to increased risk of medication errors as patients misread their medication labels and miscalculate dosage orders. Low health literacy is also attributed to adverse health issues due to misinterpretation of health information and health instructions such as with taking medication with or without food [11].

Significance of Low Health Literacy

The consequences of low health literacy will certainly impact the individual, but will also pose detrimental economic and societal consequences. Patients with chronic health issues and low health literacy skills are at significant risk for negative health outcomes. There are higher rates of morbidity and mortality and the cost for healthcare is exponentially higher in this population. These patients often seek health care for non-urgent matters in local emergency departments [4]. The misappropriation of health care resources will result in increased financial burden to health care agencies and also severely reduce access to necessary lifesaving resources thus posing great danger to society at large. Patients with low health literacy also place society at increased risk as those with low literacy tend to avoid vaccinations or do not partake in vaccinations and other means of preventative health care due to knowledge deficits. There is also increased burden on the United States healthcare system as low health literacy adds additional $106-$238 billion costs to health care systems [4]. According to United Health Group [12], hospital readmissions, avoidable hospitalizations, and non-urgent visits to emergency rooms are all indicators of deficiencies in health care stemming from low health literacy. Despite the extreme ramifications associated with low health literacy among the individual and society, health care professionals are not routinely evaluating patient health literacy and are often unaware of their patient’s limitations. Important to note, the medical record and administrative data are lacking this important indicator which places patients at risk for poor health outcomes [4]. Interestingly, if each county in the United States focused efforts on improving health literacy levels, there would be 993,000 fewer hospital visits each year and a projected savings of $25.4 billion dollars [12].

Nurses and Health Literacy

It’s long been recognized that nurses are the lifeline which keeps health care operational. Nurses are perfectly positioned to make enormous strides to improve patient health literacy. It’s also been well established that the public values nurses and the nursing profession. According to Gallup’s annual poll, the nursing profession is the most trusted profession [13]. For their dedication, courage, and commitment to promoting optimal health, nurses have earned this great honor. Nurses spend the most time with patients in comparison to other members of the interdisciplinary team. Nurses are afforded numerous opportunities to interact with patients a daily basis as it is estimated that 54% of their shift, or approximately 7 out of 12 hours is spent at the bedside where patient centered care is delivered.

Nursing care which aims to assess and address health literacy begins with effective communication skills. Like any skill, nurses need adequate training to be effective communicators, and this training should commence in undergraduate nursing programs. According to the CDC [6], health care professionals should be well versed in communicating familiar concepts, words and phrases, and avoid using jargon. It is also important to note that nurse- patient interactions must not be rushed as patients do not feel valued during haphazard exchanges. Patient hesitancy during forced exchanges will inhibit the development of trusting and therapeutic relationships, which is central to providing patient centered care [14]. Establishing therapeutic nurse- patient relationships through open dialogue will foster and forge exchanges aimed at enhancing health literacy [15]. During patient interactions, nurses must assess patient skill levels and uniquely tailor the educational experiences using a variety of resources. A creative approach is encouraged as patient involvement and engagement is imperative. Establishing therapeutic nurse-patient relationships through open dialogue will foster and forge exchanges aimed at enhancing health literacy [15].

Nursing Academia to Emphasize Health Literacy in Undergraduate Curriculum

Nurses play a crucial role in elevating patient health literacy, therefore it’s critical that nurses receive adequate training [16]. Nursing baccalaureate programs should emphasize health literacy in curricula with health literacy being introduced in the first nursing courses. Health literacy should be a theme within the undergraduate nursing program and must be incorporated into each nursing course. Health literacy assessment should be delivered in a formative and summative manner, which will support the nurse’s role in as patient educator. The topic of health literacy needs consistent enforcement in the clinical experiences and health literacy objectives must be incorporated in the clinical evaluation forms and clinical pre/post written assignments [17].

Nurse educators can create opportunities for students to develop their skills teaching patients. Learning experiences which incorporate creative approaches such as with the use of medical models or visual aids, allowing students to do role play exercises along with incorporating occasions for students to ask for return demos [18]. It’s important for nursing students to develop an awareness and sensitivity to experiences which prevent the patient from functioning at higher levels. These barriers may be associated with advanced levels of pain, loneliness, isolation, and despair. Student nurses should also be provided with opportunities to observe and participate in health literacy to gain experience and increase comfort and skill level. Efforts should be taken in nursing academia to introduce mentoring programs for student nurses which focus on addressing patient health literacy needs [19]. Nurse educators can start the momentum by meeting with stakeholders, such as health care agencies, nursing accrediting bodies, and professional organizations so that collaborative efforts can be initiated to address the health literacy needs of diverse populations. Recommendations stemming from research performed by Melariri, et al. [20], suggest undergraduate nursing programs incorporate rigorous learning opportunities to prepare them for their role as skillful health literary agents. Government agencies, professional organizations, and accrediting bodies must be included in the dialogue to influence policy which will support adequate training for student nurses and continual training opportunities for practicing nurses.

Future Research Endeavors

The nursing profession is best aligned to address and improve patient health literacy. Patient centered care offered delivered by nursing professionals who possess and demonstrate health literacy competencies are best positioned to make significant advances in patient outcomes [21]. Nursing schools must incorporate ample learning opportunities for nursing students to develop necessary knowledge and skills to deliver quality patient education to address complex health issues. It is imperative to conduct research to determine if student nurses and graduate nurses are equipped with the knowledge and skills necessary to serve in the to promote health literacy. It is also imperative to conduct research to determine patient perspectives regarding their health literacy needs and determine how nursing can address patient health literacy [22].