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.
