By Heather Stringer
Health literacy has become a hot topic in healthcare in the past decade. In 2003, the National Center for Education Statistics published results of a survey revealing that only 12% of adults in the U.S. had proficient health literacy skills. This meant the vast majority of American adults lacked the skills needed “to obtain, process and understand basic health information and services to make appropriate decisions regarding their health,” according to the Institute of Medicine.
Since then, organizations such as the National Institutes of Health, the IOM and U.S. Department of Health and Human Services have launched programs and initiatives aimed at addressing this gap. In more recent years, there has been a shift in the understanding of health literacy, said Terri Ann Parnell, DNP, RN, principal and founder of Health Literacy Partners in New York.
“The definition implies that the onus is on the patient, but it’s become clear that it is a shared responsibility, and includes the skills or lack of skills of the health professional and healthcare system,” Parnell said. “As the patients we care for become increasingly diverse in age, race, ethnicity, socioeconomic status and proficiency in English, we need to expect and adapt to that reality when we deliver care because health literacy impacts patient safety and outcomes.”
According to the NCES report, Hispanic adults had lower average health literacy than adults in any other racial or ethnic group, and adults who were 65 and older had lower average health literacy than adults in younger age groups.
“When we age our cognitive skills can deteriorate, along with vision and hearing,” Parnell said. “With the graying of America, changing demographics and increased access to care from the Affordable Care Act, it’s extremely important to find ways to improve health literacy.”
What’s happening now
In January 2015, the Agency for Healthcare Research and Quality released the second edition of the Health Literacy Universal Precautions Toolkit, which provides several best-practice interventions to address health literacy.
One of the included tools is the teach-back method, a strategy in which healthcare providers ask patients to explain in their own words what they need to know or do. “It’s really important, though, for nurses to understand that this is not a quiz for the patient,” Parnell said. “Instead, it is a way to make sure the nurse explained information clearly.”
Rather than saying “Do you understand how to take your medication?” a nurse could say “Can you tell me when you go home what you will tell your wife about how you are going to take your medication? I want to be sure I was clear in my explanation.”
A second strategy in the toolkit focuses on limiting information to three to five main points during a conversation rather than overwhelming patients with numerous instructions. “I tell nurses to pick out three or four things a family member really needs to know about medication, or three or four symptoms they need to watch for that are signs of an infection,” Wayne Neal, RN, a patient and family education manager at Children’s National Medical Center in Washington, D.C., said. “I also encourage nurses to start the education process early during a patient’s stay rather than waiting until discharge to cover everything.”
Creating a “shame-free environment” also increases the odds patients will feel comfortable asking questions and engaging as active partners in their healthcare, according to the AHRQ. Nurses can cultivate this type of environment by using wording that creates an expectation that patients can ask questions, such as “What questions do you have?” or “We discussed a lot of information. What can we review again?” The toolkit also encourages providers to sit at the same level as patients while talking, rather than standing.
Neal also uses a strategy from the toolkit known as using plain language, or explaining concepts or instructions in terms that are not medical jargon. For example, she says “pain in the joints” rather than “arthritis,” or “high blood pressure” rather than “hypertension.”
How it affects nursing practice
Parnell, who in the past served as the vice president for health literacy and patient education at North Shore-LIJ Health System in New York, now consults with healthcare organizations nationwide to integrate healthcare literacy principles into the services they provide. “Nurses are perfectly positioned to focus on health literacy as an essential component of care because they are a consistent member of a patient’s team,” she said. “Many other members of the healthcare team have only brief visits with patients.”
Although initially it might seem time-consuming to train caregivers how to use new strategies that enhance health literacy, Parnell believes ultimately it saves nurses time to use these tools. Nurses will be providing clearer, more concise information rather than covering too many instructions that patients might not understand.
Nurses like Neal also are simplifying the education process by creating standardized teaching materials. For example, she noticed nurses in her hospital were spending time teaching parents how to use a nasogastric tube to feed their children, but parents were not always competent in this area when they left the hospital. She facilitated the development and implementation of a guide for nurses that scripted what they should cover each day using language that followed health literacy principles. Similar guides also were developed for nurses educating parents about home care after a tracheostomy, a leukemia diagnosis or a NICU stay.
The written education materials patients take home also should be crafted to promote health literacy, said Kathy Ordelt, RN, CPN, FAHCEP, a patient education consultant who formerly headed the patient education office at Children’s Healthcare of Atlanta. She taught a “Writing for Patients and Families” class, and explained to participants material should be written below an eighth-grade reading level and include pictures to offer visual ways of learning.
What to watch for in the future
As healthcare becomes increasingly electronic, Ordelt predicts a need to incorporate e-health literacy into patient care. “We need to train patients how to navigate their electronic health records to find appointments and lab tests, and how to use the web to find credible information,” she said.
In the coming years, health literacy education should be integrated into nursing school curriculum, Parnell said, and these techniques can be reinforced during nurse residency programs at hospitals. Parnell can broach similar ideas with other members of the IOM Roundtable on Health Literacy, which is a consortium including organizations such as Kaiser Permanente, HHS, AHRQ and the Health Resources and Services Administration.
“We’re making progress toward bridging the health literacy gap that exists in this country, but there is also tremendous opportunity for improvement,” she said. “Providers want to deliver the best care to their patients, but I think many times they don’t even realize there was a disconnect. Focusing on health literacy as an essential component will help provide care that is meaningful, understandable and accessible, and will help promote the positive outcomes we are striving for.”
Heather Stringer is a freelance writer.
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