Educating Nursing Students About Health Literacy

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    Educating Nursing Students about Health Literacy: From the Classroom to the Patient

    Bedside

    Kari Sand-Jecklin, EdD, MSN, RN, AHN-BCBillie Murray, MSN, FNP-BCBarbara Summers, MSN, RN

    Joanne Watson, MSN, RN

    Abstract

    All nurses and nursing students today must be able assess patients for health literacy limitations

    and intervene to assure patient understanding of important health information. In this article theauthors discuss the significance of the health literacy problem and share strategies for identifying

    and intervening with patients who have limited health literacy. They also describe how they

    incorporated health literacy content into their nursing education program and assessed the impactof this brief, health literacy education session. The analysis and results of this assessmentindicated both a significant increase in student knowledge related to health literacy and the need

    for nurses to assess more fully patients understanding of what they have been taught. Patientinitiative in asking for assistance in understanding health-related information was limited.

    Discussion and implications of these findings for nursing education and nursing practice areprovided.

    Citation: Sand-Jecklin, K., Murray, B., Summers, B., Watson, J., ( July, 23, 2010) "Educating

    Nursing Students about Health Literacy: From the Classroom to the Patient Bedside " OJIN: TheOnline Journal of Issues in NursingVol. 15 No. 3.

    DOI: 10.3912/OJIN.Vol15No03PPT02

    Keywords: health literacy, nursing students, nursing education, health literacy assessment,teaching health literacy, Chew health literacy screening questions

    It is imperative that...providers recognize when patients are struggling to understand health-

    related instructions, identify patients usual means of compensating for health literacylimitations, and intervene appropriately... Todays healthcare environment is rapidly changing

    and becoming increasingly complex. For patients who must navigate this complex system, makeinformed healthcare decisions, and care for acute or chronic health conditions at home, the

    complexity of healthcare terminology, devices, and instructions can be overwhelming. If, inaddition to this complexity, patients have limited health literacy, managing their healthcare

    becomes even more difficult. Although low health literacy levels have been associated with poorer patient health outcomes, many healthcare professionals are unaware of which of their

    patients have health literacy limitations; and often they do not know how to interveneappropriately with these patients (Rogers, Wallace, & Weiss, 2006; Singleton, 2009). It isimperative that we as healthcare providers recognize when patients are struggling to understand

    health-related instructions, identify patients usual means of compensating for health literacy

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    limitations, and intervene appropriately to assure patients understanding of their healthconditions and required self-care behaviors. It is also essential that we incorporate health

    literacy-related content into the nursing education curriculum, so that new nurses will be skilledin communicating with patients having low health literacy levels.

    In this article we will discuss the significance of inadequate health literacy and ways to identifyand intervene with patients who have limited health literacy. We will describe how weincorporated health literacy content into a nursing curriculum and then assessed the impact of

    this education session on the students ability to master the content and apply it in the clinicalsetting. We will also present findings regarding the incidence of health literacy limitations

    among a sample of medical-surgical patients and report their preferred behaviors to compensatefor their lack of understanding of health-related information.

    Significance of the Health Literacy Problem

    Low health literacy is not uncommon among elderly adults. The Institute of Medicine (IOM)

    (2004b) defines health literacy as the ability to obtain, understand, and act on healthcareinformation and instructions. This includes activities such as taking prescribed medicationsappropriately, providing informed consent for medical procedures and tests, following

    instructions for self-care of a health condition, reading food labels in order to follow a prescribeddiet, and navigating the complex healthcare system (Cutilli, 2005; Hess & Whelan, 2009;

    Lorenzen, Melby, & Earles, 2008).

    Low health literacy is not uncommon among elderly adults. It is estimated that at least 36% ofadults in the United States (US) have limited health literacy (Kutner, Jin, & Jin, 2006). This

    percentage climbs to 59% for the U.S. elderly. It is also higher in minority (particularly Blackand Hispanic) and immigrant populations (Kutner et al., 2006; Rudd, 2007; Singleton, 2009).

    United State citizens covered by Medicare and Medicaid insurance, and those without insurancealso have lower health literacy levels (Kutner et al., 2006). Even patients who are well educated

    and highly literate, but who have limited healthcare experience, may struggle with thecomplexity of healthcare terminology and procedures (Cornett, 2009; IOM, 2004a).

    Patients with lower health literacy levels experience higher rates of hospitalization and

    emergency room use. Limited health literacy has been identified as having a significant impacton patient health. Patients with lower health literacy levels experience higher rates of

    hospitalization and emergency room use. They have overall poorer physical function, lessknowledge about managing their chronic health conditions, and less participation in the

    healthcare decision-making process. They also use fewer preventive care services (Baker et al.,2002; Baker et al., 2007; Dewalt, Berkman, Sheridan, Lohr, & Pignone, 2004; DeWalt, Boone,

    & Pignone, 2007; Katz, Jacobson, Veledar, & Kripalani, 2007). Low health literacy in the US iscostly, both in terms of poorer health and the financial burden on the healthcare system. It isestimated that yearly healthcare costs resulting from low health literacy levels range from 106 to

    238 billion dollars (Vernon, Trujillo, Rosenbaum, & DeBuono, 2007).

    Identifying and Intervening with Patients Who Have Limited Health Literacy

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    Although healthcare providers often think that they are able to identify patients with limitedhealth literacy levels, studies indicate that they fail to identify up to half of the patients who

    struggle to understand health information (Rogers, Wallace, & Weiss, 2006; Singleton, 2009).Some observable cues to health literacy limitations include: forgotten glasses that prevent

    patients from reading printed instructions or forms, missed appointments due to navigation

    problems or lack of understanding of directions, difficulty completing health forms, inability tolist and describe the purpose of prescribed medications, limited questioning of the healthcareprovider, and apparent lack of follow through on self-care instructions (Fernandez & Schillinger,

    2009; Katz et al., 2007).

    There are a number of health literacy tests that healthcare providers can use to assess a patientshealth literacy level. These tests include the Rapid Estimation of Adult Literacy in Medicine

    (REALM), the Test of Functional Health Literacy in Adults (TOFHLA), and the Newest VitalSign (TNVS) (Baker et al., 2007; Cutilli, 2005; Lehna & McNeil, 2008; Peterson, Dwyer,

    Mulvaney, Dietrich, & Rothman, 2007; Reeves, 2008; Rogers et al., 2006). However, all thesetests take several minutes to administer and score, limiting their usefulness in a busy clinical

    setting. In addition, patients may feel that health providers think they are stupid because theyare unable to answer the questions correctly. They may be ashamed of their limitations, or may

    even refuse to complete the tests (Cutilli, 2005; Paasche-Orlow & Wolf, 2008).

    There is...[an] another approach to identifying patients with health literacy limitations--one thatis more efficient to administer and may elicit fewer negative feelings among patients. There is,

    however, another approach to identifying patients with health literacy limitations--one that ismore efficient to administer and may elicit fewer negative feelings among patients. Chew has

    developed three specific screening questions that have been shown to identify patients with lowlevels of health literacy (Chew, Bradley, & Boyko, 2004). These questions, using a five-point

    Likert scale, ask patients: How confident are you in filling out medical forms by yourself?(response options range from Not at all Confident to Very Confident); How often do you have

    someone help you read hospital materials (responses range from Always to Never); and Howoften do you have problems learning about your medical condition because of difficulty

    understanding written information (options range from Always to Never). Chew (Chew et al.,2004; Chew et al., 2008) and Wallace (Wallace et al., 2007; Wallace, Rogers, Roskos, Holiday,

    & Weiss, 2006) have compared the results of these three questions with the TOFHLA andREALM tests, finding strong correlations between test scores. In a semi-structured interview

    with clinic patients from an urban, underserved family medicine residency clinic, participantsindicated that Chew and colleagues questions were generally acceptable, particularly if asked in

    the privacy of the examination room (Farrell, Chandran, & Gramling, 2008). All respondents feltthat health literacy screening was worthwhile.

    Although Chews three questions are effective in identifying patients having low health literacy,they, like the other tests, miss determining what patients do when they dont fully understand

    important health information or instructions, i.e., how they compensate for their lack ofunderstanding. In some cases, patient compensatory behaviors (described below) may contribute

    to the failure to understand important health information. Without this assessment data, it isdifficult for health professionals to either support patients in using compensatory behaviors that

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    will promote understanding or suggest behaviors that would better help patients understand vitalhealth information.

    Incorporating Health Literacy Content into Nursing Education Programs

    Many nurses and other healthcare professionals have not been adequately trained in identifyingand interacting with patients having lower health literacy levels (DeSilets & Dickerson, 2009;Speros, 2009; Vernon et al., 2007). Patient teaching is a core nursing responsibility. However, if

    patients do not understand what nurses have taught them, effective communication has not takenplace (Parker & Gazmararian, 2003). Mandates from the Institute of Medicine, Healthy People

    2010, and The Joint Commission (TJC) support teaching nurses about health literacy (IOM,2004b; TJC, 2005; U.S. Department of Health and Human Services, Healthy People 2010, 2000).

    However, nursing education programs often fail to specifically address health literacy issueswhen covering patient education content (Cornett, 2009), and currently, there is no standard for

    the depth of health literacy content to be included in undergraduate nursing education. A reviewof the literature revealed a gap in demonstration of the effectiveness of health literacy education

    in changing student knowledge and application of health literacy principles in practice.

    The purpose of the study described below was to determine the impact of a health literacy

    education session on student knowledge of health literacy concepts and ability to apply thisknowledge in the clinical setting. A secondary purpose of the study was to identify both the

    prevalence of limited health literacy among hospitalized patients and also the behaviors patientsuse to compensate for their lack of understanding health information.

    Assessing the Impact of a Brief Education Session on Health Literacy

    A brief education session about health literacy was planned for sophomore (beginning level)

    nursing students at a large Mid-Atlantic university. The sophomore class consisted of 112students (101 females and 11 males), all enrolled in the generic BSN program. The vast majority

    of students were traditional undergraduatesentering college directly after high school, andonly a few had previous healthcare experience in a nursing assistant-type role.

    Because no formal content related to health literacy had been presented previously, a pre-testwas given to assess student knowledge just before presentation of the content. Students were

    informed that the pre and post-test were for the purpose of determining the effectiveness of theinstruction session, and that the tests would not be included in their course grade. The education

    session consisted of 20 minutes of content covering the significance of the problem of low healthliteracy, identifying via behavioral cues those patients who may have health literacy issues,

    Chews three screening questions, and essential interventions in interacting with and teachingpatients who may have health literacy issues. A case study involving a patient with limited health

    literacy was then presented and discussed. At the conclusion of the education session, studentscompleted a post-test containing the same questions as the pre-test.

    In the corresponding beginning-level clinical course, content related to health literacy assessment

    was added to the assessment section of the care planning document that students were asked tocomplete while caring for a hospitalized patient. This added content included Chews three

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    screening questions and questions asking patients what they do when they have difficultyunderstanding either written or verbal health information/instructions. Students were asked to

    identify interventions they would take based on the collected health literacy assessment data.

    Informal review of the student pre- and post-test data, as well as patient assessment data,

    indicated that further analysis would be beneficial, and that reporting of the results may bevaluable. At that point an application was made to the West Virginia University InstitutionalReview Board (IRB) for a retrospective study of the data. After IRB approval and de-

    identification of student names on pre- and post-tests, the data were coded and analyzed.

    Analysis and Results

    One hundred three students completed the pre and post-test knowledge assessment. Paired t-test

    comparisons indicated a significant increase in student knowledge about health literacy after thebrief educational session (see Table 1). Mean test scores increased from 6.5 to 8.4 on the 10 item

    inventory.

    Table 1. Comparison of Pre-Test and Post-Test Health Literacy Scores

    Mean T df P

    Pre-Test (N = 103) 6.5 -15.48 102 .000

    Post-Test (N =...

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