The vision for a culture of health (Robert Wood Johnson Foundation, 2017, para. 1) is based on 10 principles:
- Good health flourishes across geographic, demographic, and social sectors.
- Attaining the best health possible is valued by our entire society.
- Individuals and families have the means and the opportunity to make choices that lead to the healthiest lives possible.
- Business, government, individuals, and organizations work together to build healthy communities and lifestyles.
- No one is excluded.
- Everyone has access to affordable, quality health care because it is essential to maintain, or reclaim, health.
- Health care is efficient and equitable.
- The economy is less burdened by excessive and unwarranted health care spending.
- Keeping everyone as healthy as possible guides public and private decision making.
- Americans understand that we are all in this together.
A culture of health requires all individuals, families, communities organizations, professionals and cities to make decisions promoting a healthy society. At the individual level, health literacy (i.e., the degree to which individuals have the capacity to obtain, communicate, process, and understand basic health information and services so they may make appropriate health decisions [Centers for Disease Control and Prevention, 2013]) is a necessary precursor to assist individuals in achieving a higher level of health. Collaborating with a commitment to health literacy will assist in eliminating barriers and improving access to understandable and actionable health information so everyone can achieve better health (U.S. Department of Health and Human Services, 2010).
Several federal reports have proclaimed the importance of health literacy from a public health or population health perspective (Agency for Healthcare Research and Quality, 2017; The National Academies of Sciences, Engineering, and Medicine, 2015; U.S. Department of Health and Human Services, 2010). However, few have provided strong guidance for nurses within the acute care environment. Therefore, we must look at emerging research on health literacy and identify key nursing competencies and essential practices to promote health literacy among hospitalized patients.
Survey findings from the past 10 years show the U.S. health care system has not prioritized health literacy as an essential component of health care delivery. More than one third of adults in the United States still demonstrate low health literacy; for example, 77 million people have difficulty following directions on a prescription (Centers for Disease Control and Prevention, 2013; U.S. Department of Health and Human Services, 2010). Health literacy is foundational for individuals' ability to assume responsibility for their health care, as well as the health of their family and community. Low health literacy leads to a continuum of poor outcomes, including “poorer ability to demonstrate taking medications properly and interpret medication labels and health messages and, among elderly persons, poorer overall health status and higher mortality” (Berkman, Sheridan, Donahue, Halperin, & Crotty, 2011, p. 7). By contrast, patients and families engaged in their care have improved health outcomes (Carman et al., 2014; Pelletier & Stichler, 2013).
Exploring Who Is at Risk
Previous researchers have identified “at-risk populations” for limited health literacy to include older adults, minorities, and individuals with cognitive decline, low education levels, low socioeconomic status, and limited English proficiency (Kobayashi, Wardle, Wolf, & von Wagner, 2015). However, health literacy does cross all age groups and ethnicities, and, at times, even those who may typically have high literacy are challenged with medical terminology, the anxiety or confusion of the moment, or the complexity of the issue at hand. The National Academies of Sciences, Engineering and Medicine, Health and Medicine Division (2016) noted even those with strong health literacy can struggle with recall of information presented verbally, as there are two parts in understanding the complexity of health literacy. The first is communication (written and verbal), and the second is numeracy (numbers, graphics, and diagrams) (Palumbo, 2016).
Nurses can engage in health literacy practices and competencies, which are patient-centered standards designed to minimize the negative outcomes of low or limited health literacy and improve health-related outcomes (Barrett, Puryear, & Westpheling, 2008). In a recent Delphi study, Coleman, Hudson, and Maine (2013) achieved consensus on 24 knowledge competencies, 27 skill competencies, 11 attitude competencies, and 32 practice competencies in health literacy that all health care professionals should achieve. The practices range from eliciting a full range of the patient's concerns at the onset of the visit to negotiating a mutual agenda at the first interaction, speaking slowly and clearly using plain language or an interpreter as needed, to routinely referring the patient to resources to enhance his or her literacy (Coleman et al., 2013). However, dissemination of these competencies to staff nurses has been inconsistent.
A Conceptual Model of Health Literacy
The health literacy tapestry model provides the structure for organizing potential nursing practices and competencies to support health literacy (Parnell, 2015). Parnell, Stichler, & Barton (2017) described the health literacy tapestry using a holistic nursing approach that fosters a partnership that affects individuals, nurses, and the health care system and is illustrated by interwoven threads (antecedents) and fibers (domains). The three basic domains of health literacy are oral communication, written communication, and environmental communication, which comprises access to care and navigation within the health care delivery system. These domains are centered on the existence of misconceptions and unconscious bias that may influence provider–patient interactions from both perspectives. The threads of the model consist of contextual factors that may influence an individual's level of health literacy and include the media and marketplace, health knowledge and experience, demographics, overall health status, community support, and cultural, spiritual and social influences.
To make the model “actionable” for nurses in health care settings, the Table provides a cross-walk of health literacy practice competencies identified by Coleman et al. (2013) within the health literacy domains of oral communication, written communication, and environmental communication. Competencies for oral and written communication include use of clear and simple language and eliminating the use of jargon. Use of the teach back method is essential so that patients demonstrate what they have been taught. Competencies concerning environmental communication include navigation within a hospital or clinic, instructions for follow-up, and links to community resources.
Cross-Walk of Health Literacy Practice Competencies Within Tapestry Model Domains
The central competency is the use of a universal precautions approach to health literacy. The Agency for Healthcare Research and Quality (2017) identified the term health literacy universal precautions in the creation of a health literacy “universal precautions toolkit.” Even though use of the term, universal precautions, may generate confusion in its association with blood and body fluids precautions, the notion that everyone may have difficulty understanding health information and accessing health care services is important for nurses to embrace. The practice of health literacy universal precautions is as important for nurses to embrace as good hand washing practices.
The Health Literacy Tapestry model recently has been expanded to include the concepts of patient empowerment, engagement, and activation (Parnell et al., 2017). “Empowerment relates to providing patients with access to information, education, support, and skills that facilitates their role as partners with providers in decisions and actions in their own care” (Pelletier & Stichler, 2013, p. 52). Once patients are empowered, they are more likely to be engaged in their health journey and part of the decision making process. Health literacy enhances engagement at all levels and provides a level of activation for patients to successfully manage their health. The lower section of the Table lists the health literacy practice competencies that map to the concepts of patient engagement, empowerment, and activation. The competencies listed facilitate a collaborative approach to teaching and initial efforts at shared understanding.
Role of Professional Development in Ensuring the Health Literacy Competency of Care Providers
The National Academies of Sciences, Engineering and Medicine, Health and Medicine Division (2016) noted that health literacy is not only about patients' abilities to make decisions during episodic or chronic care but also about health and fitness, nutrition, prevention, and other behaviors and decisions influencing optimal health and well-being. To build a culture of health care enhancing patients, families, and communities' health literacy is a challenge for all members of the health care team. As we move to a health care system focused on health promotion, we again revisit the challenge of ensuring health literacy. Therefore, nurses and other care providers need enhanced knowledge and skills in implementing health literacy strategies to meet the diverse needs of all patients and to support improved patient outcomes. The following link highlights the skills needed for all health professionals via a brief tutorial and quiz for the health team members: https://www.cdc.gov/healthliteracy/training/page669.html (Centers for Disease Control and Prevention, 2013).
In exploring the complex concept of health literacy, we acknowledge the need for integration of health literacy knowledge and competency skills into nursing education curricula. In addition, continuing professional development is essential to employ evidence-based findings given the relationship of health literacy to patient safety and outcomes, patient-centered care, engagement, and the movement to a culture of health.
For nurses, health literacy is not addressed adequately by checking a box on the health record after asking the patient and family how best they learn. Health literacy is an old concept in nursing and health care, but it is also a complex issue as the United States continues to experience a demographic transformation and a health care system that is uncertain and shifting to a value-based payment model. The result is a new sense of urgency for nurses to promote health literacy. Therefore, nurses need to learn actionable practices to change clinical practice and enhance patient outcomes. We recommend health literacy be considered in every type of patient education to enhance the patient's ability to access, understand, and engage in self-management of their care. The mantra of “every patient, every time” should apply to health literacy practices.
Do your clinical nurses and other providers routinely assess patients' health literacy and use standardized nursing behaviors to promote health literacy and evaluate patient outcomes? One method to ensure all clinical nurses are routinely using a universal precautions approach and promoting health literacy strategies is using competencies and practices previously identified by Coleman et al. (2013) for all health professions. Further, cross-walking these competencies with the health literacy tapestry model (Parnell, 2015) can be extremely helpful in framing assessment, action steps, and outcomes for your clinical nurses as they assume responsibility for implementing health literacy strategies.
Practices and Competencies for the Promotion of Health Literacy
As key members of the health care team, nurses play a major role in boosting health literacy to move beyond the current “cycle of crisis care” system to the triple aim of improving the patient experience of care (including quality and satisfaction), improving the health of populations, and reducing the per capita cost of health care (Koh et al., 2012, p. 434). Nurses are employed across many areas of health care, public health, and community organizations and are uniquely positioned to create a cultural change in health care that will shift the focus to optimizing health and well-being (Parnell, 2014). Nurses must consider a patient-centered approach by respectfully asking patients, “What questions do you have?” rather than “Do you have any questions?” Asking patients about their preferred language to discuss health care, always speaking in plain language, and ascertaining whether they were clear in their teaching by incorporating the teach-back method are all health literacy principles that support patient centeredness. An awareness of what affects a patient's level of health literacy and the corresponding related nursing actions is foundational to providing safe, equitable health care.
Using these recommended practices in everyday patient interactions is only addressing one side of the health literacy challenge. Just as resources are needed to support patients in becoming health literate, the organization also must address health literacy. Organizations can start by considering the competencies within environmental communication and recognizing the challenges faced by patients with low health literacy within their walls (Palumbo, 2016).
Recommendations and Conclusion
Professional development nurse leaders have the responsibility of ensuring clinical nurses are implementing a health literacy universal precautions approach as a foundational nursing activity in every nurse–patient–family interaction. Advocating this universal approach to health care delivery is one method to ensure that all clinical nurses and other care providers use clear effective communication with all patients, regardless of their perceived health literacy skills (National Action Plan; U.S. Department of Health and Human Services, 2010) In addition, recommending that clinical nurses use the health literacy tapestry model cross walked with the competencies and practices identified by Coleman et al. (2013) in the Table will provide nurses with a model to follow when providing patient- and family-centered care.
- Agency for Healthcare Research and Quality. (2017). AHRQ health literacy universal precautions toolkit. Rockville, MD: Author. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html
- Barrett, S.E., Puryear, J.S. & Westpheling, K. (2008). Health literacy practices in primary care settings. Examples from the field. Washington, DC: The Commonwealth Fund.
- Berkman, N.D., Sheridan, S.L., Donahue, K.E., Halpern, D.J. & Crotty, K. (2011). Low health literacy and health outcomes: An updated systematic review. Annals of Internal Medicine, 155, 97–107. doi:10.7326/0003-4819-155-2-201107190-00005 [CrossRef]
- Carman, K.L., Dardess, P., Maurer, M.E., Workman, T., Ganachari, D. & Pathak-Sen, E. (2014). A roadmap for patient and family engagement in healthcare practice and research. Palo Alto, CA: Gordon and Betty Moore Foundation. Retrieved from http://patientfamilyengagement.org
- Centers for Disease Control and Prevention. (2013). Health literacy for public health professionals. Retrieved from https://www.train.org/cdctrain/course/1057675/
- Coleman, C.A., Hudson, S. & Maine, L.L. (2013). Health literacy practices and educational competencies for health professionals: A consensus study. Journal of Health Communication, 18, 82–102. doi:10.1080/10810730.2013.829538 [CrossRef]
- Kobayashi, L.C., Wardle, J., Wolf, M.S. & von Wagner, C. (2015). Cognitive function and health literacy decline in a cohort of aging English adults. Journal of General Internal Medicine, 30, 958–964. doi:. doi:10.1007/s11606-015-3206-9 [CrossRef]
- Koh, H.K., Berwick, D.M., Clancy, C. M., Baur, C., Brach, C., Harriss, L. M. & Zerhusen, E. G. (2012). New federal policy initiatives to boost health literacy can help the nation move beyond the cycle of costly “Crisis Care.”Health Affairs, 31, 434–443. doi:10.1377/hlthaff.2011.1169 [CrossRef]
- The National Academies of Sciences, Engineering, and Medicine. (2015). Health literacy: Past, present, and future: Workshop summary. Washington, DC: The National Academies Press.
- The National Academies of Sciences, Engineering and Medicine, Health and Medicine Division. (2016). Relevance of health literacy to precision medicine. Workshop in brief. Retrieved from http://nationalacademies.org/hmd/activities/publichealth/healthliteracy/Relevance-of-Health-Literacy-to-Precision-Medicine-SWIB.aspx
- Palumbo, R. (2016). Designing health-literate health care organization: A literature review. Health Services Research Management, 29, 79–87. doi:10.1177/0951484816639741 [CrossRef]
- Parnell, T.A. (2014). Nursing leadership strategies, health literacy, and patient outcomes. Nurse Leader, 12(6), 49–52. doi:10.1016/j.mnl.2014.09.005 [CrossRef]
- Parnell, T.A. (2015). Health literacy in nursing: Providing person-centered care. New York, NY: Springer.
- Parnell, T.A., Stichler, J. & Barton, A.J. (2017). Leading health literacy initiatives to optimize patient outcomes. Manuscript submitted for publication.
- Pelletier, L.R. & Stichler, J.F. (2013). Action brief: Patient engagement and activation: A health reform imperative and improvement opportunity for nursing. Nursing Outlook, 61, 51–54. doi:10.1016/j.outlook.2012.11.003 [CrossRef]
- Robert Wood Johnson Foundation. (2017). How we got here. Retrieved from https://www.cultureofhealth.org/en/about/how-we-got-here.html#ten-underlying-principles
- U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2010). National action plan to improve health literacy. Washington, DC: Author.
Cross-Walk of Health Literacy Practice Competencies Within Tapestry Model Domains
|Tapestry Domain||Health Literacy Practice Competency|
|Oral communication||Routinely recommends the use of professional medial interpreter services for patients whose preferred language is other than English|
|Consistently speaks slowly and clearly with patients|
|Routinely uses verbal and non-verbal listening techniques|
|Consistently avoids using medical jargon in oral communication with patients, and defines unavoidable jargon in lay terms|
|Routinely conveys numeric information, such as risk, using low numeracy approaches|
|Consistently uses health literacy universal precautions approach to oral communication with patients|
|Routinely uses short action-oriented statements, focused on answering patient's questions, “What do I need to do?”|
|Routinely documents in the medical record that a teach back, or closed communication loop technique has been used to check the patient's level of understanding at the end of the encounter|
|Written communication||Routinely puts information into context by using subject headings in written communication with patients|
|Consistently follows principles of easy to read formatting when writing for patients, including the use of short sentences and paragraphs, and the use of bulleted lists rather than denser blocks of text, when appropriate|
|Routinely writes in English at approximately the fifth to sixth grade reading level|
|Consistently writes or rewrites (i.e., translates) unambiguous medication instructions when called for during regular duties|
|Routinely encourages and facilitates patients to carry an updated list of their medications with them|
|Consistently uses a health literacy universal precautions approach to written communication with patients|
|Consistently avoids using medical jargon in written communication with patients, and defines unavoidable jargon in lay terms|
|Consistently locates and uses literacy-appropriate patient education materials, when needed and available, to reinforce oral communication, and reviews such materials with patients, underlining or highlighting key information|
|Environmental communication||Routinely anticipates and addresses navigational barriers within health care systems and share responsibility with patients for understanding and navigating systems and processes; attempts to make systems and processes as transparent as possible|
|Consistently treats the diagnosis of limited health literacy as “protected health information” requiring specific “release of information” for disclosure|
|Routinely refers patients to appropriate community resources for enhancing literacy or health literacy skills (e.g., adult basic literacy education) within the context of the therapeutic relationship|
|Routinely arranges for timely follow-up when communication errors are anticipated|
|Engagement, empowerment, and activation||Consistently elicits the full list of patient concerns at the outset of encounters|
|Consistently negotiates a mutual agenda with patient at the outset of encounters|
|When preparing to educate patients, routinely asks about patients' preferred learning style in a nonshaming manner|
|Routinely elicits patients' prior understanding of their health issues in a non-shaming manner|
|Routinely emphasizes one to three “need to know” or “need to do” concepts during a given patient encounter|
|Routinely makes instructions interactive, such that patients engage the information, to facilitate retention and recall|
|Routinely assesses adherence to treatment recommendations, and root causes for nonadherence, nonjudgmentally, before recommending changes to treatment plans|
|Consistently elicits questions from patients through a “patient-centered” approach (e.g., “What questions do you have?” rather than “Do you have any questions?”|
|Routinely ensures that patients understand at minimum: (a) what their main problem is, (b) what is recommended that they do about it, and (c) why this is important|
|Routinely uses a teach-back or “show me” technique to check for understanding and correct misunderstandings in a variety of health care settings, including during the informed consent process|