Journal of Nursing Education

Major Article Supplemental Data

Health Literacy Education in Health Professions Schools: An Integrative Review

Coleen E. Toronto, MSN, RN, CNE; Barbara Weatherford, PhD, RN, CNE

Abstract

Background:

Most Americans lack the health literacy skills to function in today's health care environment. The Institute of Medicine's Health Literacy: A Prescription to End Confusion report recommended that health professionals be trained to effectively communicate with patients with low health literacy.

Method:

An integrative review was conducted, using six electronic databases: CINAHL, ERIC, MEDLINE, PsycINFO, SocINDEX, and Web of Science.

Results:

Nine articles met the inclusion criteria. Educational interventions include multimodal approaches using didactic content, followed by active learning strategies. Evaluative methods in the classroom were used in all studies; however, only one study assessed students' health literacy skills.

Conclusion:

Findings support research efforts that (a) clarify where health literacy should be taught, (b) target the assessment of students' health literacy skills, (c) perform rigorous psychometric testing of evaluative instruments used, and (d) create interprofessional learning opportunities. [J Nurs Educ. 2015;54(12):669–676.]

Abstract

Background:

Most Americans lack the health literacy skills to function in today's health care environment. The Institute of Medicine's Health Literacy: A Prescription to End Confusion report recommended that health professionals be trained to effectively communicate with patients with low health literacy.

Method:

An integrative review was conducted, using six electronic databases: CINAHL, ERIC, MEDLINE, PsycINFO, SocINDEX, and Web of Science.

Results:

Nine articles met the inclusion criteria. Educational interventions include multimodal approaches using didactic content, followed by active learning strategies. Evaluative methods in the classroom were used in all studies; however, only one study assessed students' health literacy skills.

Conclusion:

Findings support research efforts that (a) clarify where health literacy should be taught, (b) target the assessment of students' health literacy skills, (c) perform rigorous psychometric testing of evaluative instruments used, and (d) create interprofessional learning opportunities. [J Nurs Educ. 2015;54(12):669–676.]

Only 12% of adults in the United States exhibit proficient health literacy skills (Kutner, Greenberg, Jin, & Paulson, 2006). Health literacy should be a concern for health professionals involved in health promotion, disease prevention, and the management of chronic disease (Parnell, 2015). It has been more than 10 years since the release of the seminal report by the Institute of Medicine (IOM), Health Literacy: A Prescription to End Confusion (2004). This landmark report explicitly recommends that health professionals be trained to effectively communicate with patients with limited health literacy (IOM, 2004). However, few official requirements or curricula address health literacy in health professions schools (IOM, 2004). Inadequate time is devoted to health literacy education due to the content-laden curricula of the health professions (Harper, Cook, & Makoul, 2007; Owens & Walden, 2007).

Improved education in health literacy is critical to the development of competent health professionals who can help to improve health literacy and mitigate the negative effects of limited health literacy among patients (IOM, 2004). Effective health communication is a major goal of Healthy People 2020 (U.S. Department of Health and Human Services, 2014). Seven objectives of Healthy People 2020 specifically focus on improving health providers' communication skills (Table). Those objectives charge health professionals to determine when a lack of understanding exists and to provide health information in a format that patients can understand.

Healthy People 2020: Health Communication Objectivesa

Table:

Healthy People 2020: Health Communication Objectives

The purpose of the current integrative literature review is to evaluate the response of nursing and other health professions schools to the IOM's recommendation regarding preparing students on how to take care of patients with low health literacy.

Background and Significance

Health literacy, which encompasses more than just basic reading skills, is rapidly gaining recognition as a major health care problem in the United States. A commonly cited definition for health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (IOM, 2004, p. 32).

Low health literacy has been linked to adverse health outcomes, such as higher rates of emergency department visits, decreased capacity to manage chronic disease, lower rates of medication adherence, and higher rates of hospitalization and death (Baker, Wolf, Feinglass, & Thompson, 2008; Keller, Wright, & Pace, 2008; Murray et al., 2009; U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, 2010).

The concept of literacy is not new; however, the prevalence of low literacy skills in the United States came to the forefront following the 1992 National Adult Literacy Survey (Parker, Baker, Williams, & Nurss, 1995). As a result of that study, the first profile of adult literacy was completed, and it found that 40 million American adults scored within the lowest literacy categories (Kirsch, Jungeblut, Jenkins, & Kolstad, 1993).

In terms of health care, the above results suggest that adults with low literacy scores do not possess the basic skills required to function within the 21st century health care system. This includes completing basic tasks such as reading prescription drug labels, reading appointment cards for follow-up visits with health care providers, interpreting instructions, and parents managing their children's health, such as reading food labels, getting their children immunized, taking them for wellness checks, and determining the need for medical care for childhood illnesses (Hoover et al., 2012; Kutner et al., 2006; Yin et al., 2009).

The significance of the 1992 National Adult Literacy Survey report (Parker et al., 1995) prompted a follow-up assessment of adult literacy in the United States, which was conducted in 2003 (Kutner, et al., 2006). The National Assessment of Adult Literacy survey provided valuable information on the state of adult health literacy in America by identifying at-risk populations. Populations most at risk for low health literacy are older adults; individuals with cognitive decline, low education levels, and low socioeconomic status; minorities; and individuals with limited English proficiency (IOM, 2004; Kobayashi, Wardle, Wolf, & von Wagner, 2015; Kutner et al., 2006).

Despite the facts on adult literacy in the United States currently, most health care settings still administer materials written at a 10th grade to graduate school–level, instead of the recommended fifth- to sixth-grade reading level (Agency for Healthcare Research and Quality, 2010; American Medical Association Foundation, 2007; Weiss, 2003). Patients who have difficulty reading health care instructions often fail to report this difficulty to their health care provider due to the shame and embarrassment associated with poor reading skills (Parikh, Parker, Nurss, Baker, & Williams, 1996; Parnell, 2015). Consequently, health care information provided to many patients is often misunderstood, which is a factor that may contribute to reduced adherence with the plan of care and poor health care outcomes (Gazmararian, Williams, Peel, & Baker, 2003; Hoover et al., 2012). Providing oral and written health care information that is understandable empowers individuals to make informed decisions regarding their health care and is considered by many to be an ethical responsibility of all health care providers (American Nurses Association, 2013; Cormier & Kotrlik, 2009; Nutbeam, 2000).

To date, the majority of literature on health literacy has focused on patient factors, with minimal emphasis on the communication skills and practices of health care professionals. Researchers have shown that significant education and practice gaps related to health literacy exist among nurses, pharmacists, physicians, and other health professionals (Coleman, Hudson, & Maine, 2013; Jukkala, Deupree, & Graham, 2009; Payne, 2009; Schwartzberg, Cowett, VanGeest, & Wolf, 2007). Recent literature shows that U.S. health professions schools need to improve their preparation of students to include the knowledge and experiences required to assist patients with low health literacy skills (Cellary, 2014; Coleman, 2011; Cormier & Kotrlik, 2009; Speros, 2011).

In response to the need to focus on health literacy in nursing education, The Essentials of Baccalaureate Education for Professional Nursing Practice (American Association of Colleges of Nursing, 2008) recommended that baccalaureate nursing programs prepare graduates to assess the health literacy of individuals, families, and groups served.

Method

The current integrative literature review used a methodology that followed five steps: (a) identifying the problem, (b) conducting a structured literature search, (c) appraising the quality of data, (d) extracting and analyzing the data, and (e) synthesizing and presenting the findings (Whittemore & Knafl, 2005).

Problem Identification

The questions guiding the current review were:

  • How are health professions schools incorporating health literacy into their curricula?
  • What content is being addressed?
  • What teaching methods for health literacy are used?
  • How is student learning evaluated?

Search Strategy

To retrieve relevant literature published from January 2004 to June 2014, computerized searches were conducted using the following electronic databases: the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), ERIC, MEDLINE®, PsycINFO®, SocINDEX, and Web of Science®. The selection of 2004 was based on the release of the seminal IOM report Health Literacy: A Prescription to End Confusion (2004). Search terms included health literacy, nursing, student, assessment, communication, competencies, practices, evaluation, curriculum, education, teaching methods, and outcome. Ancestry searches were conducted to identify work that was relevant to the specific purpose of the current review, which may not have been found in the database search. In addition, a hand-search of the Journal of Nursing Education, Nursing Education Perspectives, Nurse Education Today, and Nurse Educator was performed. The computerized searches, ancestry searches, and hand searches were conducted between September 2013 and June 2014.

Inclusion and Exclusion Criteria

Studies were included in the sample if (a) the focus included peer-reviewed empirical research on methods for teaching and evaluating health professional students, related to learning about health literacy; (b) they were published between January 2004 and June 2014; (c) they reported institutional review board (IRB) approval (ensuring ethical treatment of students as research participants); and (d) they were published in English. Exclusion criteria were consensus studies, project implementation reports, expert opinions, case reports, abstracts, editorials, theoretical articles, dissertations, and unpublished manuscripts. The search strategy resulted in the identification of 32 articles, of which nine articles met the inclusion criteria. The final sample included nine studies (Figure).

Integrative review search strategy diagram.

Figure.

Integrative review search strategy diagram.

Quality Appraisal

Quality appraisal involves a systematic, unbiased, careful examination of all aspects of the studies (Groves, Burns, & Gray, 2013). Because of the diverse representation of the empirical studies, the quality of the data was evaluated according to the following two criteria: (a) data relevance and (b) methodological rigor (Whittemore & Knafl, 2005). Data relevance refers to the extent to which the study was relevant to the identified research questions. The methodological review included an evaluation of the research design, sample selection, ethical integrity, and reliability and validity. Using a modified data appraisal protocol, studies with lower rigor or relevance to the chosen questions were rated as 1 (low), and those with acceptable rigor and relevance were rated as 2 (high; Hawker, Payne, Kerr, Hardey, & Powell, 2002). A review of potentially eligible studies ensured that they met the inclusion and exclusion criteria and that the study methodology and findings were reported in detail sufficient to describe and evaluate in the current review.

Data Analysis

Analysis of the studies was guided by following six steps:

  • Studies were analyzed to identify preliminary key ideas related to each question.
  • Each article was examined separately in relation to identified questions.
  • Articles were compared, noting patterns and key points.
  • A data matrix was constructed to display the categorized data so that studies could be more easily compared.
  • Synthesis and summation of the key points related to each question were completed.
  • Agreement between both authors (C.E.T., B.W.) was reached on patterns and key points.

Findings

Of the nine studies included, seven were quantitative (n = 7) and two were qualitative (n = 2). The sample sizes ranged from 31 to 303 participants, with mean ages from 22 to 28 years. The studies included more female (50% to 94%) than male participants, and the majority of participants were Caucasian (77% to 83%). Five of the nine studies included pharmacy students, three included nursing students, and one included internal medicine residents. None of the studies used an interprofessional sample. The search strategy used by the primary author (C.E.T.) identified published studies beginning in 2005 and limited to the United States.

Themes

Curriculum Placement

Health literacy content was found in a variety of courses and in different levels of education (Chen, Noureldin, & Plake, 2013; Devraj, Butler, Gupchup, & Poirier, 2010; Ha & Lopez, 2014; McCleary-Jones, 2012; Sand-Jecklin, Murray, Summers, & Watson, 2012; Shieh, Belcher, & Habermann, 2013; Sicat & Hill, 2005). No studies identified that health literacy was being addressed across a program's curriculum. Only one study reported having conducted a targeted curricular needs assessment to determine students' baseline health literacy skills (Green, Gonzanga, Cohen, & Spagnoletti, 2014). Findings from the current review demonstrated that health literacy is generally being taught in a single class, usually in the second or third year of entry-level health professional students (Table A; available in the online version of this article).

Health Literacy EducationHealth Literacy EducationHealth Literacy EducationHealth Literacy EducationHealth Literacy EducationHealth Literacy EducationHealth Literacy EducationHealth Literacy EducationHealth Literacy EducationHealth Literacy Education

Table A:

Health Literacy Education

Educational Interventions

Health literacy interventions addressed in health professions education were grouped into three categories: lecture (content; n = 8), active learning strategies (n = 9), and out-of-class assignments (n = 5).

Content

Lecture presentation is the most efficient way to cover complex material (Billings & Halstead, 2009). Eight studies used lecture of 20- to 50-minute duration within a single class. The lecture content ranged from defining and addressing health literacy concepts such as prevalence and incidence, the impact of low health literacy on patient outcomes, and strategies to help patients understand health information (Shieh et al., 2013; Wilcoxen & King, 2013).

Several studies addressed subjective and objective assessment methods for low health literacy. Researchers have shown that patients with low health literacy may not want to be formally assessed for literacy or have the results recorded in their medical record (Wolf et al., 2007). Because no widely accepted approaches to identify patients with low health literacy currently exist, educational efforts generally focus on the subjective assessment of behavioral cues, such as poor adherence with medication, putting off reading written health information, and lack of follow-through with medical appointments (Chen et al., 2013; Devraj et al., 2010; McCleary-Jones, 2012; Sand-Jecklin et al., 2010; Sicat & Hill, 2005). Several studies instructed students on the use of health literacy assessment measures, such as the Rapid Estimate of Adult Literacy in Medicine, the Newest Vital Sign, the Test of Functional Health Literacy in Adults-Short Form, and the Chew instrument (Chen et al., 2013; Devraj et al., 2010; McCleary-Jones, 2012; Sand-Jecklin et al., 2010; Wilcoxen & King, 2013).

Patients are often asked to read instructions during health care encounters. A patient's reading level is often below the reading level of material given to them. Researchers suggested that health care practices using materials that are easier to read may influence the chance a patient will follow directions correctly and experience better outcomes (Agency for Health care Research and Quality, 2010; Katz, Kripalani, & Weiss, 2006).

Few studies addressed methods to identify, assess, and tailor appropriate written patient education materials. Instruction methods included assessing the reading level of written materials, using readability formulas such as the Fry readability formula, the Simple Measure of Gobbledygook, and the Flesch-Kincaid Readability Scale tool in Microsoft® Word (Chen et al., 2013; Devraj et al., 2010; Sicat & Hill, 2005). Additional factors, such as analyzing font size, color contrast, unfamiliar context, and concept density using the Suitability Assessment of Materials method, were noted (Chen et al., 2013; Devraj et al., 2010). One study addressed the use of pictorial aids to enhance patients' understanding (Chen et al., 2013).

Finally, the power of the spoken word is a useful strategy to aid in mitigating poor patient understanding. Communicating effectively with patients is needed to ensure patient safety and self-management (Agency for Healthcare Research and Quality, 2010). In class, several studies covered clear verbal communication strategies such as avoiding medical jargon (Devraj et al., 2010; Green et al., 2014; McCleary-Jones, 2012); use of teach back, where patients repeat back information in their own words to confirm understanding (Chen et al., 2013; Devraj et al., 2010; Green et al., 2014; Wilcoxen & King, 2013); and the use of open-ended questions, instead of closed questions (Green et al., 2014).

Active Learning Strategies

Most studies favored a multimodal approach in which learners were first offered didactic content, followed by opportunities to practice using case studies, reflection, role-play, and standardized patients. A goal for these activities is to enhance students' knowledge and confidence to identify and interact with patients with low health literacy.

Case Studies. Case studies analyze a real-life event as a way to promote immediate application of didactic content (Billings & Halstead, 2009). Case-based learning was used in the classroom (Devraj et al., 2010; Ha & Lopez, 2014) and online, using an unfolding case to promote learning (McCleary-Jones, 2012).

Reflection. Written reflection requires students to detail personal experiences and connect them to the theoretical concepts addressed in the classroom (Billings & Halstead, 2009). Two studies took two different approaches for their reflective educational activities. In the first study, nursing students reflected on significant health literacy clinical experiences. Qualitative analysis revealed several themes. One theme showed that students relied heavily on assessing behavioral red flag cues to alert them of patients with low health literacy. Another theme demonstrated that students would often use clear verbal communication techniques to help patients understand health information (Shieh et al., 2013).

In comparison, another study requested pharmacy students to reflect on a learning activity, requiring them to write health literacy level–appropriate patient education material. Findings revealed that students found it challenging to simplify the warnings and side effects sections of a patient education leaflet because it contained the most medical terminology and complex directions (Chen et al., 2013).

Role-Playing. Role-play is a learning method in which individuals (i.e., students, faculty) assume the role of others. Through observation, students analyze and interpret the scene played out (Billings & Halstead, 2009). Three pharmacy studies used role-play in the classroom setting with a variety of methods (Devraj et al., 2010; Sicat & Hill, 2005; Wilcoxen & King, 2013). The first study (Wilcoxen & King, 2013) had students analyze a counseling session between two actors—a pharmacist and a patient possessing low health literacy. During role-play, the pharmacist intentionally made errors, and the student groups needed to identify the mistakes. After error identification was achieved, the role-play occurred again, with proper modeling of the counseling session (Wilcoxen & King, 2013). Students in the other two studies (Devraj et al., 2010; Sicat & Hill, 2005) were assigned to the roles of pharmacist, patient, or evaluator, while working in groups. The students in the pharmacist role would counsel a patient on new medications. The observers were asked to evaluate whether the pharmacist's communication techniques were clear.

Standardized Patients. The use of standardized patients (SPs) involves “structured educational simulations using live actors/educators to portray patients in a real-life clinical scenarios” (Carter, Wesley, & Larson, 2006, p. 262). One study used SPs as a teaching strategy. The medical residents needed to explain a new diagnosis of diabetes to the SP, counsel the SP on lifestyle changes, and provide instructions for an oral glycemic agent. Feedback was provided to each resident by observing peers and instructors and the SP (Green et al., 2014).

Out-of-Class Assignments

Several active learning activities occurred beyond the classroom walls, where students were given out-of-class assignments to help reinforce the content taught and to promote health literacy skills. Two studies involved direct patient contact. The first required nursing students to administer the Chew instrument during their clinical experience to assess patients' health literacy (Sand-Jecklin et al., 2010). The second clinical experience involved medical residents videotaping their communication with patients encountered in clinic (Green et al., 2014).

Students in two studies practiced administering an assigned health literacy assessment tool (the Rapid Estimate of Adult Literacy in Medicine, the Newest Vital Sign, or the Test of Functional Health Literacy in Adults) to an individual face to face who was not a patient or pharmacy student (Devraj et al., 2010; Wilcoxen & King, 2013).

In the study by Devraj et al. (2010), pharmacy students were given an assignment to determine a layperson's understanding of health education materials. Students looked at magazines or Web sites for patient information about any type of medication, and then had two nonhealth care individuals read and assess the information. Students needed to assess what information these individuals did not understand and suggest ways to make the material easier to comprehend (Devraj et al., 2010).

Evaluative Methods

Evaluative methods were used in all studies. Several studies assessed for some combination of knowledge, attitudes, and skills related to a health literacy intervention (Devraj et al., 2010; Green et al., 2014; Sicat & Hill, 2005). Seven studies administered knowledge pre- and posttests related to lecture content (Devraj et al., 2010; Green et al., 2014; Ha & Lopez, 2014; McCleary-Jones, 2012, Sand-Jecklin et al., 2010; Sicat & Hill, 2005; Wilcoxen & King, 2013). Six studies assessed attitudinal changes after a health literacy educational intervention (Chen et al., 2013; Devraj et al., 2010; Green et al., 2014; Ha & Lopez, 2014; Sicat & Hill, 2005; Wilcoxen & King, 2013). Only one study assessed for students' gains in skills of health literacy before and after implementation of an educational effort (Green et al., 2014).

Knowledge

Studies that assessed students' gains after an educational intervention used measurement tools created by other authors (Devraj et al., 2010; Green et al., 2014; Ha & Lopez, 2014; McCleary-Jones, 2012; Sand-Jecklin et al., 2010; Sicat & Hill, 2005; Wilcoxen & King, 2013). Only two studies reported internal consistency of knowledge instruments, with Cronbach's alphas ranging from .173 to .61 (McCleary-Jones, 2012; Sicat & Hill, 2005). Face validity was ensured in three studies. Two studies piloted their tools with 10 fourth-year pharmacology students (Devraj et al., 2010; Wilcoxen & King, 2013), and one study used two communication experts (Green et al., 2014). Only one study ensured content validity, using a test blueprint (McCleary-Jones, 2012).

All studies that measured knowledge reported significant improvements in students' knowledge (Devraj et al., 2010; Green et al., 2014; Ha & Lopez, 2014; McCleary-Jones, 2012; Sand-Jecklin et al., 2010; Sicat & Hill, 2005).

Skills

Only one study reported assessment of health literacy skills with medical residents during outpatient clinic patient encounters (Green et al., 2014). Those authors created a communication skills checklist derived from the literature. Two communication experts were consulted to assess face validity of the instrument. Content validity index and interrater and intrarater reliability were not reported. Faculty compared videotaped communications between residents and patients before and after health literacy training. Increase in the use of plain language, teach back, and open-ended questions during the postintervention sessions was noted. Only the increase of plain language use reached statistical significance (Green et al., 2014).

Attitude

Most studies measuring attitudinal changes showed significant improvements in student confidence using health literacy interventions with patients (Devraj et al., 2010; Green et al., 2014; Ha & Lopez, 2014). Student comfort with assessing patients for low health literacy varied, ranging from a low percentage of first-year students feeling comfortable identifying patients with low health literacy (Sicat & Hill, 2005) to gains in third-year students' confidence using health literacy assessment instruments (Devraj et al., 2010).

Assessing changes in attitudes, using an open-response format, related to an educational intervention or experience were reported in two studies. Both methods provided information about students' knowledge, skills, attitudes, and confidence related to providing health literacy practices (Chen et al., 2013; Shieh et al., 2013). One study reported psychometrics testing of an attitudinal measure, with Cronbach's alphas of .72 at pretest and .70 at posttest (Wilcoxen & King, 2013).

Discussion

The current integrative review suggests that health professions schools have begun to respond to the IOM's (2004) call to incorporate health literacy in health professional education. A major strength of the current review is the interprofessional focus, representing pharmacy, nursing, and medicine. Limitations of the current review include difficulty in comparing studies, given that the included studies varied widely in population, setting, and sample size. Convenience sampling and reliance on self-reported data may influence the generalizability of the results.

It is unclear from the findings whether health literacy should be taught as a stand-alone lecture or integrated throughout a program of study. The wide variability of health literacy content placement suggests its ability to be broadly applied within a health professions education program. Adding to the challenge is the fact that health literacy overlaps with the topics of cultural competency, health education, and communication. Researchers are beginning to survey health professions schools regionally and nationally to determine how health literacy is being integrated within curricula (Ali, 2013; Cellary, 2014; Coleman & Appy, 2012).

Many studies used a multimodal approach in teaching health literacy, where learners were offered didactic content, followed by active learning strategies using case studies, reflection, role-play, and SPs. Although a variety of methods were implemented, little empirical evidence exists to suggest that any one methodology for teaching health literacy to health professional students produces significantly better outcomes.

Further refinement is needed for instruments that measure the health literacy knowledge, skills, and attitudes of students after an educational intervention, as well as the consistent reporting of psychometrics when measures are used in educational research. Three studies reported using face validity with either experts or students when addressing content validity. This face validity method is an important first step but has inherent subjectivity. Researchers need to use stronger psychometric testing when ensuring the reliability and validity of new instruments, such as test–retest, interreliability, intrareliability, content validity index (when using a group of content experts), and construct validity (when using a theoretical framework) methods (Streiner, Norman, & Cairney, 2015). The common methods to assess reliability of knowledge measures use Cronbach's alpha and Kuder-Richardson coefficients (McDonald, 2014). One of the few studies that analyzed for internal consistency of the test used reported a Cronbach's alpha of .173 (McCleary-Jones, 2012); however, the author did not address this as a limitation. It is important to note that the study by McCleary-Jones (2012) used a homogeneous sample of students who were given 2 weeks to complete the posttest online. One reason for the low value may be due to the measure consisting of only five items. An increase in the number of items would increase the value. In addition, low reliability values are often due to an excess of very easy or very hard items, items that do not discriminate, or items that do not represent the unified body of knowledge (McDonald, 2014).

Implications for Nursing

Essential communication skills of health care providers are indicated as objectives in Healthy People 2020 (U.S. Department of Health and Human Services, 2014). However, currently, no established health literacy competencies specific to nursing have been published. Without these competencies, it is difficult to develop a standardized assessment method to give feedback on health literacy skills to students. A consensus agreement among health professionals is in development, with efforts to establish common competencies that address health literacy, cultural competence, and communication (Coleman et al., 2013; Lie, Carter-Pokras, Braun, & Coleman, 2012).

To date, evidence supporting formal health literacy screening of patients has not been established (Paasche-Orlow & Wolf, 2008). Health care providers do not always know when patients have limited health literacy. Given the current lack of an available gold-standard measure of health literacy, students should be encouraged to use a health literacy universal precaution approach with their patients, using the assumption that everyone may have difficulty understanding health care information and to teach patients by using simple, plain language (Agency for Healthcare Research and Quality, 2010).

In the current review, the majority of studies described the teach-back method in class but often did not provide opportunities for students to practice. The teach-back strategy in theory may seem simple, but the art of using teach back correctly often requires practice and feedback. A recent study that assessed an educational intervention's effect on nurses' use of teach back for educating patients found that many nurses required remediation and reinforcement of teach-back content (Mahramus et al., 2014). In class role-play could be an efficient teaching strategy, allowing students the ability to practice teach back and then receive feedback by classmates and faculty. Current research suggests that undergraduate nursing students find health-teaching simulations and positive role modeling of nurses and faculty to be helpful in developing their skills when promoting health literacy with individuals and groups (Zanchetta et al, 2013).

Interprofessional education opportunities can provide nursing students with an awareness of their role in teams when addressing health literacy issues with patients. Nurse educators should seek opportunities for interprofessional learning. For those schools not affiliated with other health professions programs, organizations such as The Josiah Macy Jr. Foundation (2013) currently work with schools by helping them to make connections to other schools or to seek out other learners in their community.

Implications for Researchers

Education research is needed to advance education practices. Researchers need to demonstrate strength of their research by reporting rigorous methods and procedures. Future research of health literacy teaching interventions needs to be theoretically based to connect findings to the existing body of knowledge (Groves et al., 2013). Only one of the studies reviewed (Wilcoxen & King, 2013) used a conceptual framework as a foundation for the pedagogical approach described in the reported articles.

Another important procedure is to obtain IRB approval. All research that involves human subjects must receive approval from the IRB. Faculty-conducted research using student participants may place students at risk due to their relationships with education researchers (Ridley, 2009). Studies were excluded from the current review if the authors did not state in the article that IRB approval was obtained. Several strong educational articles were excluded due to the lack of reported IRB approval.

Clear ongoing and thorough communication with patients is essential to improving health outcomes. Researchers have begun to demonstrate positive findings in studies that use virtual training for developing and evaluating health professions students' communication skills (Lowes, Hamilton, Hochstetler, & Paek, 2013; Miller & Jensen, 2014). Novel methods of clear communication instruction and evaluation related to health literacy should be researched. This might include the use of avatars in Second Life®, Shadow Health, and other virtual worlds. As the educational setting moves beyond the classroom walls to a virtual one, research is needed to support and evaluate this change.

Conclusion

More than 10 years have passed since the IOM first emphasized the importance of incorporating health literacy training into health professions education. Although findings reveal that some progress has been made, greater attention to health literacy is still needed in health professionals' education. Areas to address include the development of health literacy competencies to guide teaching and evaluation methods that address the knowledge, skills, and attitudes of students.

References

  • Agency for Healthcare Research and Quality. (2010). AHRQ health literacy universal precautions toolkit. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html
  • Ali, N.K. (2013). Are we training residents to communicate with low health literacy patients?Journal of Community Hospital Internal Medicine Perspectives, 2, Article 19238. http://dx.doi.org/10.3402/jchimp.v2i4.19238 doi:10.3402/jchimp.v2i4.19238 [CrossRef]
  • American Association of Colleges of Nursing. (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche.edu/education/pdf/BaccEssentials08.pdf
  • American Medical Association Foundation. (2007). Removing barriers to better, safer care: Health literacy and patient safety: Help patients understand. Chicago, IL: Author.
  • American Nurses Association. (2013). Public health nursing: Scope & standards of practice (2nd ed.). Silver Spring, MD: Nursesbooks.org.
  • Baker, D.W., Wolf, M.S., Feinglass, J. & Thompson, J.A. (2008). Health literacy, cognitive abilities, and mortality among elderly persons. Journal of General Internal Medicine, 23, 723–726. doi:10.1007/s11606-008-0566-4 [CrossRef]
  • Billings, D.M. & Halstead, J.A. (2009). Teaching in nursing: A guide for faculty (3rd ed.). St. Louis, MO: Saunders Elsevier.
  • Carter, M.B., Wesley, G. & Larson, G.M. (2006). Lecture versus standardized patient interaction in the surgical clerkship: A randomized prospective cross-over study. American Journal of Surgery, 191, 262–267. doi:10.1016/j.amjsurg.2005.06.045 [CrossRef]
  • Cellary, K. (2014). Assessment of health policy literacy curricula in physician assistant programs (Master's thesis, Thomas Jefferson University). Retrieved from http://jdc.jefferson.edu/mphcapstone_presentation/122
  • Chen, A.M., Noureldin, M. & Plake, K.S. (2013). Impact of a health literacy assignment on student pharmacist learning. Research in Social & Administrative Pharmacy, 9, 531–541. doi:10.1016/j.sapharm.2013.05.002 [CrossRef]
  • Coleman, C. (2011). Teaching health care professionals about health literacy: A review of the literature. Nursing Outlook, 59, 70–78. doi:10.1016/j.outlook.2010.12.004 [CrossRef]
  • Coleman, C.A. & Appy, S. (2012). Health literacy teaching in US medical schools, 2010. Family Medicine, 44, 504–507.
  • 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]
  • Cormier, C.M. & Kotrlik, J.W. (2009). Health literacy knowledge and experiences of senior baccalaureate nursing students. Journal of Nursing Education, 48, 237–248. doi:10.9999/01484834-20090416-02 [CrossRef]
  • Devraj, R., Butler, L.M., Gupchup, G.V. & Poirier, T.L. (2010). Active-learning strategies to develop health literacy knowledge and skill. American Journal of Pharmaceutical Education, 74(8), Article 137. doi:10.5688/aj7408137 [CrossRef]
  • Gazmararian, J.A., Williams, M.V., Peel, J. & Baker, D.W. (2003). Health literacy and knowledge of chronic disease. Patient Education & Counseling, 51, 267–275. doi:10.1016/S0738-3991(02)00239-2 [CrossRef]
  • Green, J.A., Gonzanga, A.M., Cohen, E.D. & Spagnoletti, C.L. (2014). Addressing health literacy through clear communication: A training program for internal medicine residents. Patient Education and Counseling, 95, 76–82. doi:10.1016/j.pec.2014.01.004 [CrossRef]
  • Groves, S.K., Burns, N. & Gray, J.R. (2013). The practice of nursing research: Appraisal, synthesis, and generation of evidence (7th ed.). St. Louis, MO: Elsevier.
  • Ha, H. & Lopez, T. (2014). Developing health literacy knowledge and skills through case-based learning. American Journal of Pharmaceutical Education, 78(1), Article 17. doi:10.5688/ajpe78117 [CrossRef]
  • Harper, W., Cook, S. & Makoul, G. (2007). Teaching medical students about health literacy: 2 Chicago initiatives. American Journal of Health Behavior, 31, S111–S114. doi:10.5993/AJHB.31.s1.14 [CrossRef]
  • Hawker, S., Payne, S., Kerr, C., Hardey, M. & Powell, J. (2002). Appraising the evidence: Reviewing disparate data systematically. Qualitative Health Research, 12, 1284–1299. doi:10.1177/1049732302238251 [CrossRef]
  • Hoover, E.L., Pierce, C.S., Spencer, G.A., Britten, M.X., Neff-Smith, M., James, G.D. & Gueldner, S.H. (2012). Relationships among functional health literacy, asthma knowledge, and the ability to care for asthmatic children in rural dwelling parents. Online Journal of Rural Nursing and Health Care, 12(2), 30–40.
  • Institute of Medicine. (2004). Health literacy: A prescription to end confusion. Washington, DC: National Academies Press.
  • The Josiah Macy Jr. Foundation. (2013). Interprofessional education and nursing: A conversation with AACN's Polly Bednash. Retrieved from http://macyfoundation.org/news/entry/interprofessional-education-and-nursing-a-conversation-with-aacns-polly-bed
  • Jukkala, A.M., Deupree, J.P. & Graham, S. (2009). Knowledge of limited health literacy at an academic health center. The Journal of Continuing Education in Nursing, 40, 298–302. doi:10.3928/00220124-20090623-01 [CrossRef]
  • Katz, M.G., Kripalani, S. & Weiss, B.D. (2006). Use of pictorial aids in medication instructions: A review of the literature. American Journal of Health-System Pharmacy, 63, 2391–2397. doi:10.2146/ajhp060162 [CrossRef]
  • Keller, D.L., Wright, J. & Pace, H.A. (2008). Impact of health literacy on health outcomes in ambulatory care patients: A systematic review. Annals of Pharmacotherapy, 42, 1272–1281. doi:10.1345/aph.1L093 [CrossRef]
  • Kirsch, I.S., Jungeblut, A., Jenkins, L. & Kolstad, A. (1993). Adult literacy in America: A first look at the results of the National Adult Literacy Survey. Washington, DC: National Center for Educational Statistics, U.S. Department of Education.
  • 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:10.1007/s11606-015-3206-9 [CrossRef]
  • Kutner, M., Greenberg, E., Jin, Y. & Paulson, C. (2006). The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy (NCES 2006-483). U.S. Department of Education. Washington, DC: National Center for Education Statistics.
  • Lie, D., Carter-Pokras, O., Braun, B. & Coleman, C. (2012). What do health literacy and cultural competence have in common? Calling for a collaborative health professional pedagogy. Journal of Health Communication, 17(Suppl. 3), 13–22. doi:10.1080/10810730.2012.712625 [CrossRef]
  • Lowes, S., Hamilton, G., Hochstetler, V. & Paek, S. (2013). Teaching communication skills to medical students in a virtual world. The Journal of Interactive Technology & Pedagogy, 3, 1. Retrieved from http://jitp.commons.gc.cuny.edu/teaching-communication-skills-to-medical-students-in-a-virtual-world/
  • Mahramus, T., Penoyer, D.A., Frewin, S., Chamberlain, L., Wilson, D. & Sole, M.L. (2014). Assessment of an educational intervention on nurses' knowledge and retention of heart failure self-car principles and the teach back method. Heart & Lung, 43, 204–212. doi:10.1016/j.hrtlng.2013.11.012 [CrossRef]
  • McCleary-Jones, V. (2012). Assessing nursing students' knowledge of health literacy. Nurse Educator, 37, 214–217. doi:10.1097/NNE.0b013e318262ead3 [CrossRef]
  • McDonald, M.E. (2014). The nurse educator's guide to assessing learning outcomes (3rd ed.). Burlington, MA: Jones & Bartlett.
  • Miller, M. & Jensen, R. (2014). Avatars in nursing: An integrative review. Nurse Educator, 39, 38–41. doi:10.1097/01.NNE.0000437367.03842.63 [CrossRef]
  • Murray, M.D, Tu, W., Wu, J., Morrow, D., Smith, F. & Brater, D.C. (2009). Factors associated with exacerbation of heart failure include treatment adherence and health literacy skills. Clinical Pharmacology and Therapeutics. 85, 651–658. doi:10.1038/clpt.2009.7 [CrossRef]
  • Nutbeam, D. (2000). Health literacy as a public health goal: A challenge for contemporary health education and communication strategies into the 21st century. Health Promotion International, 15, 259–267. doi:10.1093/heapro/15.3.259 [CrossRef]
  • Owens, L. & Walden, D. (2007). Health literacy: The new essential in nursing education. Nurse Educator, 32, 238–239. doi:10.1097/01.NNE.0000299472.26691.f6 [CrossRef]
  • Paasche-Orlow, M.K. & Wolf, M.S. (2008). Evidence does not support clinical screening of literacy. Journal of General Internal Medicine, 23, 100–102. doi:10.1007/s11606-007-0447-2 [CrossRef]
  • Parikh, N.S., Parker, R.M., Nurss, J.R., Baker, D.W. & Williams, M.V. (1996). Shame and health literacy: The unspoken connection. Patient Education and Counseling, 27, 33–39. doi:10.1016/0738-3991(95)00787-3 [CrossRef]
  • Parker, R.M., Baker, D.W., Williams, M.V. & Nurss, J.R. (1995). The test of functional health literacy in adults: A new instrument in measuring patient's literacy skills. Journal of General Internal Medicine, 10, 537–541. doi:10.1007/BF02640361 [CrossRef]
  • Parnell, T.A. (2015). Health literacy in nursing: Providing person-centered care. New York, NY: Springer.
  • Payne, L. (2009). Registered nurses' use of teaching techniques to mitigate low health literacy: Frequency, perceived effectiveness and correlations (Doctoral dissertation, University of Houston).
  • Ridley, R.T. (2009). Assuring ethical treatment of students as research participants. Journal of Nursing Education, 48, 537–541. doi:10.3928/01484834-20090610-08 [CrossRef]
  • Sand-Jecklin, K., Murray, B., Summers, B. & Watson, J. (2010). Educating nursing students about health literacy: From the classroom to the patient bedside. The Online Journal of Issues in Nursing, 15(3). doi:10.3912/OJIN.Vol15No03PPT02 [CrossRef]
  • Schwartzberg, J.G., Cowett, A., VanGeest, J. & Wolf, M.S. (2007). Communication techniques for patients with low health literacy: A survey of physicians, nurses, and pharmacists. American Journal of Health Behavior, 31(Suppl. 1), S96–S104. doi:10.5993/AJHB.31.s1.12 [CrossRef]
  • Shieh, C., Belcher, A.E. & Habermann, B. (2013). Experiences of nursing students in caring for patients with behaviors suggestive of low health literacy: A qualitative analysis. Journal of Nursing Education and Practice, 3, 75–85. doi:10.5430/jnep.v3n2p75 [CrossRef]
  • Sicat, B.L. & Hill, L.H. (2005). Enhancing student knowledge about the prevalence and consequences of low health literacy. American Journal of Pharmaceutical Education, 69, 460–466. doi:10.5688/aj690462 [CrossRef]
  • Speros, C.I. (2011). Promoting health literacy: A nursing imperative. Nursing Clinics of North America, 46, 321–333. doi:10.1016/j.cnur.2011.05.007 [CrossRef]
  • Streiner, D.L., Norman, G.R. & Cairney, J. (2015). Health measurement scales: A practical guide to their development and use (5th ed.). Oxford, UK: Oxford University Press.
  • U.S. Department of Health and Human Services. (2014). Healthy People 2020: Health communication and health information technology. Retrieved from http://www.healthypeople.gov/2020/topics-objectives/topic/health-communication-and-health-information-technology/objectives
  • 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.
  • Weiss, B. (2003). Health literacy: A manual for clinicians. Washington, DC: American Medical Association Foundation and American Medical Association.
  • Whittemore, R. & Knafl, K. (2005). The integrative review: Updated methodology. Journal of Advanced Nursing, 52, 546–553. doi:10.1111/j.1365-2648.2005.03621.x [CrossRef]
  • Wilcoxen, K. & King, S.R. (2013). An educational strategy to enhance pharmacy students' attitudes toward addressing health literacy of patients. Currents in Pharmacy Teaching and Learning, 5, 85–92. doi:10.1016/j.cptl.2012.11.001 [CrossRef]
  • Wolf, M.S., Williams, M.V., Parker, R.M., Parikh, N.S., Nowian, A.W. & Baker, D.W. (2007). Patients' shame and attitudes toward discussing the results of literacy screening. Journal of Health Communication, 12, 721–732. doi:10.1080/10810730701672173 [CrossRef]
  • Yin, H.S., Johnson, M., Mendelsohn, A.L., Abrams, M.A., Sanders, L.M. & Dreyer, B.P. (2009). The health literacy of parents in the United States: A nationally representative study. Pediatrics, 124(Suppl. 3), S289–S298. doi:10.1542/peds.2009-1162E [CrossRef]
  • Zanchetta, M., Taher, Y., Fredericks, S., Waddell, J., Fine, C. & Sales, R. (2013). Undergraduate nursing students integrating health literacy in clinical settings. Nurse Education Today, 33, 1026–1033. doi:10.1016/j.nedt.2012.05.008 [CrossRef]

Healthy People 2020: Health Communication Objectivesa

Increase the proportion of persons who report that their health care provider always gave them easy-to-understand instructions about what to do to take care of their illness or health condition. Increase the proportion of persons who report that their health care provider always asked them to describe how they will follow the instructions. Increase the proportion of persons who report that their health care providers always listened carefully to them. Increase the proportion of persons who report that their health care providers always explained things so they could understand them. Increase the proportion of persons who report that their health care providers always showed respect for what they had to say. Increase the proportion of persons who report that their health care providers always spent enough time with them. Increase the proportion of persons who report that their health care providers always involved them in decisions about their health care as much as they wanted.

Health Literacy Education

Author, Year, and CountrySampleAimQuality RatingStudy Design/Teaching Method(s)Instrument(s)Findings
Sicat & Hill, 2005 USAN = 108 Convenience First-year pharmacy students Communications in pharmacy practice course 68% female 77% Caucasian Median age = 24 yearsEvaluate the impact of an educational approach to enhance instruction of low health literacy (HL)2 (high)Quasi-experimental

-Lecture

-Small groups

-Active learning activities

-Role-play

Author-created, 20-item pre- and posttest evaluated students' HL knowledge Students' comfort with using HL strategies was assessed with four questions, using a 4-point Likert scale. Cronbach's alphas were .34 for the pretest and .61 for the posttest. Test publishedSignificant increase in HL knowledge for most items except for four. Postintervention: 43% of students felt comfortable identifying patients with low HL.
Sand-Jecklin, Murray, Summers, &Watson, 2010 USAN = 112 Convenience Second-year baccalaureate nursing students Beginning-level clinical nursing course 91% female Majority direct entry from high schoolEvaluate the impact of an educational approach to enhance instruction of low HL Secondary aim was to identify prevalence of limited HL among hospitalized patients.1 (low)

-Quasi-experimental

-Lecture

-Out-of-Class assignment

-Assess patients' HL level using the Chew instrument during clinical experience

Author-created, 10-item pre- and posttest which evaluated students' HL knowledge Evaluation of students' skill to administer the HL assessment instrument in clinical not reported. Cronbach's alpha not reported. Test not publishedSignificant increase in HL knowledge posttest scores (t −15.48= 102, p < .000).
Devraj, Butler, Gupchup, & Poirier, 2010 USAN = 76 Convenience Third-year pharmacy students Health promotion and literacy course 62% female 79% Caucasian Mean age = 23 yearsEvaluate the impact of an educational approach to enhance instruction of low HL Secondary aim was to assess its effects on students' confidence in their ability to identify and communicate with patients with low HL2 (high)

-Quasi-experimental

-Lecture

-Small groups

-Active learning activities

-Role-play

-Out-of-class assignments:

Perform an objective HL assessment with an individual not associated with the school;

Have an individual read a written health information material and assess what the individual found difficult to understand and suggest ways to improve content understanding

Adapted Sicat & Hill (2005) 20- item pre- and posttest instrument evaluating students' HL knowledge Students' confidence to identify and communicate with patients with low HL was assessed pre- and postintervention, with five questions using a Likert scale Cronbach's alpha not reported Instrument was piloted to fourth-year pharmacology students (n = 10) to assess face validity Test and survey publishedAll sets of comparisons were significant (p < .01) except for one. Responses to survey items showed significant improvements in students' confidence in their ability to use various HL strategies.
McCleary-Jones, 2012 USAN = 53 Convenience Second-year baccalaureate nursing students Pharmacology course 94/% female 83% Caucasian Mean age = 22 yearsEvaluate the impact of an educational approach to enhance instruction of low HL The secondary aim was to use information in future curriculum planning.1 (low)

-Quasi-experimental

-Asynchronous online PowerPoint®

-Unfolding online case study

-Author-created, five-item pre- and posttest evaluating students' knowledge of HL Cronbach's alpha for the test was .173. Students were given 2 weeks to complete the posttest online. Content validity was addressed using a test blueprint to ensure that test items correlated with objectives and content presented Test publishedThere was a significant increase in HL knowledge (t −10.015 = 52, p < .001).
Chen, Noureldin, & Plake, 2013 USAN = 303 Convenience Third-year pharmacy students Pharmacy administration course Demographics not reportedEvaluate the impact of an HL approach on student perceptions about HL, their ability to write health literate–level patient education material and their success in using these skills in future pharmacy practice2 (high)

-Qualitative content analysis

-Lecture Small groups Active learning activities

Author-created, four-item, open-ended questionnaire on what the student learned from the HL educational experience Reflection questions publishedMajor themes identified:

Students learned about the challenges, importance and methods of communicating in a health literate manner;

students found it challenging to simplify written information; and

students used various strategies to make patient information understandable.

Wilcoxen & King, 2013 USAN = 40 Convenience Third-year pharmacy students and N = 42 second-year pharmacy students (control group) Patient assessment course (third-year pharmacy students) 50% female 82.5% Caucasian 92.5% were aged 20 to 30 yearsEvaluate the impact of an educational approach based on the theory of planned behavior on students' attitudes toward health literacy, perceived behavioral control, and intentions concerning communication with patients possessing low health literacy.2 (high)

-Nonrandomized control study

-Lecture Small groups Role-play Out-of-class assignment: Perform an objective health literacy assessment with an individual not associated with the school

Adapted Sicat & Hill (2005) 20-item pre- and posttest knowledge instrument Authors created a 26-item tool, using three scales and a 7-point Likert scale to assess the theory of planned behavior constructs (attitudes, perceived behavior control, and intentions). Instrument was piloted with fourth-year pharmacology students (n = 10) to assess face validity. Cronbach's alphas of the attitudes, perceived behavioral control, and intentions scales were .72, .70 and .87, respectively, and with reported Cronbach's alphas = .70, .74, and .88 at posttest Construct validity not performed Survey instrument available upon requestSignificant improvements reported over time with the experimental group for attitudes toward health literacy (p = .033) and perceived behavioral control when communicating with patient with low health literacy (p = .033). Third-construct intentions to communicate were high for both groups at pretest, so there were no significant gains at posttest. Authors did not report HL knowledge gains measured by the adapted Sicat & Hill (2005) instrument.
Shieh, Belcher, & Habermann, 2013 USAN = 59 Convenience Third-year baccalaureate nursing students Research course Majority female Majority Caucasian Mean ages between 25 and 29 yearsExplore the impact of previous students' clinical experiences in caring for patients with low HL2 (high)

-Qualitative content analysis

-Lecture

-Reflection

Author created, one-item, open-ended questionnaire Question publishedStudents described assessing for low HL, using behavioral cues and clear communication strategies, but did not assess the readability of written educational material.
Ha & Lopez, 2014 USAN = 97 Convenience Third-year pharmacy students Laboratory course Demographics not reportedEvaluate the impact of an educational approach to enhance instruction of low HL2 (high)

-Quasi-experimental

-Small groups

-Case studies

Laboratory faculty created 10-item, pre- and posttest HL knowledge test. Pre- and posttest instrument validity and reliability not described Test questions not publishedIncrease in test scores were significant (p < .001).
Green, Gonzanga, Cohen, & Spagnoletti, 2014 USAN = 31 Convenience Second-year internal medicine residents Ambulatory care rotation 52% female Mean age = 28 years Race/ethnicity not reportedEvaluate the impact of a clear health communication curriculum to improve residents' knowledge, skills, and attitudes regarding health literacy2 (high)

-Quasi-experimental (pilot)

-Lecture

-Small groups

-Standardized patients

-Out-of-class assignment:Videotaping encounters with real patients

Author-created, eight-item pre- and posttest HL knowledge and four-item (5-point) Likert survey to assess students' attitudes concerning the concept of HL and communication skills was assessed pre- and postintervention Testing was done at baseline and post 3-week intervention. Pre and posttest instrument validity and reliability not reported Communication skills were assessed, using a standardized checklist developed by study authors. Skills were based on review of literature by study authors Face validity was determined by two local communication experts.Interrater or intrarater reliability not reported Test questions and communication skills checklist publishedHL knowledge scores increased significantly (p < .001). There were also significant improvements for students' attitudes. Only one clear communication skill reported significant gains: Use of plain language (p < .023). Use of teach back did not report significant findings (p < .116) or use of open-ended questions (p < .502).
Authors

Ms. Toronto is a doctoral student, and Dr. Weatherford is Assistant Professor of Nursing, University of Massachusetts Dartmouth, North Dartmouth, Massachusetts.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Coleen E. Toronto, MSN, RN, CNE, 163 Prospect Street, Holliston, MA 01746; e-mail: ctoronto1@verizon.net.

Received: January 13, 2015

Accepted: July 08, 2015

10.3928/01484834-20151110-02

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