Nurse with face mask explaining information to face-masked male patient in wheelchair
HealthFebruary 16, 2021

Health literacy and importance to prelicensure nursing students

By: Denise Isibel, DNP, MSN, RN, CNE
Communication is considered a central concept of nursing practice. It is a principle of person-centered care. Communication in nursing encompasses all the various ways people interact with each other including verbal, written, behavior, body language, touch, and emotion.

Effective communication between nurses and patients and between nurses and other health professionals is necessary for the delivery of high quality, individualized nursing care. The baccalaureate essentials require the generalist nurse to be able to communicate with and educate patients and caregivers regarding health, wellness, and disease management and prevention.

Despite the focus and emphasis on communication in nursing programs, there is little formal education on how to speak with patients in pursuing health education, health promotion and health prevention. Nurses need to be informed about effective strategies in healthcare communication. In prelicensure programs, these topics are taught as part of health education, discharge planning and community health focusing on the population health. Health literate care is fundamental to individualized, patient-centered care. Translated, this means that every patient is approached as if at-risk for not understanding the information being provided. Rather, what is needed is a broader, formal organizational approach to establishing a health literate environment to overcome the often-confusing encounters patients have accessing and receiving care. Today, most people use technology to seek information to make decisions about their health and healthcare. To benefit from this information and care offered, patients must understand and act upon the information given. Kutner, Greenburg and Paulsen (2006) found only 26% of patients were able to successfully navigate a health care system and act upon the information provided.

What is health literacy?

Health literacy is demonstrated when individuals have the capacity to gather, process and understand basic health information and services to make appropriate health decisions (Kindig, Nielson-Bohlman & Panzer, 2004). Although a patient may possess basic literacy skills, health literacy emphasizes the skills necessary to understand important health information that is dense, technical and jargon filled. Health literacy, then, is when a patient has the ability to understand printed and verbal health information, and the ability to ask questions about all of these.

Why is health literacy important to undergraduate nursing programs?

Effective communication is an essential part of nursing care. Our words teach, inform and explain healthcare information to help patients meet their healthcare goals. Our words also comfort, support and advocate. Undergraduate nursing students learn about communication early in their programs but not necessarily about health literacy. Often, health literacy is not formally taught. Health literacy should be in all nursing curricula in a formative and summative manner. Becoming knowledgeable about the prevalence of low health literacy and its impact on patients can make a difference for positive patient outcomes. Including health literacy information in undergraduate nursing education supports nursing professional responsibility to provide effective patient teaching. It is not enough to just provide patients with health care information, we have an ethical duty to teach patients effectively and evaluate their understanding and ability to utilize health information.

Since 2010, the Healthy People Initiative has included objectives to improve health literacy (USDHHS, 2011). The Institute of Medicine’s Health Literacy: A Prescription to End the Confusion notes that nearly half of the American adult population has difficulty comprehending health information (Kindig et al., 2004), and A National Action Plan to Improve Health Literacy supports a universal precautions approach to health literacy (USDHHS, 2010) suggesting that all patients be approached with clear verbal and written communication, and easy to use forms and instructions.

Despite these national directives, both providers and patients still struggle with health literacy, and this can result in poor outcomes for patients. Patients who cannot understand or read healthcare directions may have difficulty engaging in self-care behaviors, which can lead to lower self-efficacy and a lower quality of life. Effective, safe care at home can be linked to behaviors such as medication adherence or understanding instructions about when to call a provider. When patients do not demonstrate self-care behaviors or follow health care regimens (for example, adhering to their medication regimen), the likelihood of hospitalization increases, further complicating care.

The most vulnerable patients often have multiple chronic medical problems. Without active management, diagnoses such as hypertension, obesity and diabetes may lead to more serious problems such as congestive heart failure, myocardial infarction, or stroke. In practice, we find patients with limited health literacy are often associated with hospitalizations, emergency department use, missed dialysis treatments, and increased cardiovascular events. Patients with low health literacy have poorer outcomes, use more health care services, demonstrate lower adherence to health care instructions, use fewer preventive services, experience delayed diagnosis and perform fewer self-management activities. If we know that many patients have difficulty understanding healthcare information and only about a third can successfully navigate a health care system and act upon the information provided, then what does this mean for prelicensure nursing students.

Including health literacy in a pre-licensure curriculum

Health literacy applies to all interactions nurses have with their patients. Health literacy is a topic that should be formally introduced, threaded throughout a curriculum, and consistently reinforced in all clinical experiences. By consistently teaching health literacy across a nursing program, the concepts and tools of health literacy will not only be enforced in the program but also become a natural part of that nurses’ professional practice.

Undergraduate nursing programs create an expectation to learn important medical terminology to understand and function in healthcare. It can be difficult for students to use and understand medical terms amongst their professional peers and then be expected to use plain language with their patients. Learning about health literacy starts in the first foundational classes. These classes can introduce health literacy in a variety of ways:

  • What is health literacy, how to assess it in patient scenarios?
  • Including plain language when Using therapeutic communication.
  • Describing and discussing the social determinants of health (Health literacy is considered one).
  • Exercises in using medical terminology in work and how to translate these terms into plain language.

As students move into clinical classes in adult health, pediatrics, and maternal-child health many opportunities are created to include health literacy in both didactic content and clinical experiences. These include:

  • Review what is health literacy, how it affects discharge planning and health education
  • Using plain language when talking to patients
  • Doing a health literacy assessment with all patients
  • Discharge planning to match the needs of the patient
  • Assessing and working with printed materials to address all levels of health literacy

Students should be encouraged to use a health literacy universal precaution approach with their patients, using the assumption that every-one may have difficulty understanding health care information and to teach patients by using simple, plain language.

Simulation can be used to practice discharge instructions to a patient with low health literacy. The teach-back strategy is commonly used in discharge planning and patient education but using the strategy takes practice. Anyone learning the teach-back strategy benefits from feedback during practice sessions. Role-playing is an effective teaching strategy for students to practice the techniques of teach-back and for getting feedback for improvement.

In community/public health nursing courses health literacy becomes central to working with patients and populations. The encounters students have with community agencies and vulnerable populations show a different aspect of health literacy. In this environment, nurses are challenged can continue to assess health literacy for a population, analyze written material, create written material in accordance with determining health literacy levels. The social determinants of health come front and center.

Classes related to research and evidence-based practice and nursing management can engage students to look at best practices for health literacy. Including health literacy in these classes draws the student to a more organized approach to health literacy as:

  • Develop projects connected to health literacy and patient outcomes and patient behavior.
  • Assignments analyzing, local state and federal policies related to health literacy.
  • Assignment examining how in nursing management, make health literacy priority in their units and in the organizations. Focusing on health literate organizations.
  • Use the Agency for Healthcare Research and Quality Health Literacy Universal Precautions Toolkit (Brega et al.2015).


An implication for incorporating health literacy into a nursing curriculum across it is the available resources to do this. Nursing faculty are regularly updating course materials to address changes in practice. It is the ease to do this that matters. No one wants to search hunt and go crazy finding this information. There is little on texts related to just health literacy, some texts address it as a social determinant of health or a few paragraphs supporting health education be health literacy. Resources are important to implement. One does not want to re-invent the wheel to include the content. There is much out there to assist with implementing Health literacy in our curriculum and across other health care specialties. These links have many tools for incorporating health literacy into healthcare curriculums.

For improved patient outcomes in practice, nurse educators need to take a hard look at established nursing curricula to determine whether they are providing nursing students with the knowledge and experiences that are required to provide health care to individuals with low health literacy skills. When these nurses graduate from their programs and enter the nursing profession as new practitioners, they will be equipped with the tools to improve quality patient outcomes and meet the needs of health care organizations where they are employed.

Denise Isibel, DNP, MSN, RN, CNE
Expert Insights Contributor for Wolters Kluwer, Nursing Education
  1. Brega A.G., Barnard J., Mabachi N.M., Weiss B.D., DeWalt D.A., Brach C., . . . West, D.R. (2015). AHRQ Health Literacy Universal Precautions Toolkit, 2nd ed. (Prepared by Colorado Health Outcomes Program, University of Colorado Anschutz Medical Campus under Contract No. HHSA290200710008, TO#10.) AHRQ Publication No. 15-0023-EF) Rockville, MD: Agency for Healthcare Research and Quality.
  2. Kindig, D. A., Nielson-Bohlman & Panzer, A. M.(Eds.). (2004). Health literacy: A prescription to end the confusion. Washington, DC: National Academies Press.
  3. Kutner, M., Greenburg, E., Jin, Y., & Paulsen, C. (2006). The health literacy of America’s adults: Results from the 2003 national assessment of adult literacy. NCES 2006-483. National Center for Education Statistics. pubsinfo.asp?pubid=2006483
  4. United States Department of Health and Human Services. (2010). National action plan to improve health literacy. Washington, DC: Author. Retrieved from
  5. United States Department of Health and Human Services. (2011). Healthy People 2020: Health communication and health IT objectives HC/HIT-1, and HC/HIT-2. Washington, DC: Author.
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