The Hispanic population is projected to nearlytriple to 132.8 million, by 2050, when nearly

1 in 3 US residents would be Hispanic. The Blackand Asian populations are projected to increase to15% and 9.2%, respectively, of the total populationby 2050.2 All remaining racial groups are projectedto rise, as are the number of people who identifythemselves as being multiracial. The nation’s changingsociocultural composition has implications for virtuallyevery aspect of American life, especially public healthand the delivery of health care.3

In addition to a more ethnically and racially diversepopulation, an increase in the US population aged 65 years orolder is also projected as a result of the aging of the babyboomers and an increase in life expectancy.2 In fact, morepersons were age 65 years and over in 2010 than in any pre-vious census. And the US Bureau of the Census 2010 projectsthat by 2050, 19 million, or 4.6%, of the population will beage 85 and older compared to 3.1 million, or 1.3%. of thepopulation in 1990.4 Within the coming decades, 1 in 5Americans will be eligible for Social Security and Medicare,contrasting with 1 in 8 Americans today.5

Persons with limited English proficiency (LEP) areunable to communicate effectively in English because theirprimary language is not English and they do not have fluencyin the English language.6 Consistent with the growth of the

US foreign-born population, the number of LEP individualsin the United States grew by 80% from 1990 to 2010, withSpanish-speaking LEP individuals accounting for 66% of thetotal United States LEP population in 2010, followed byChinese and Vietnamese, with 6% and 3%, respectively.7

Sixty-three percent of hospitals treat LEP patients daily orweekly, and more than 15 languages are frequently encoun-tered by at least 20% of hospitals.8 This has vital implications,because healthcare and health information must be bothaccessible and offered in a manner that is linguistically andculturally understandable for all.9

The “graying of America” combined with the rapidgrowth of a more ethnically and racially diverse populationwith limited English proficiency present increasingly complex

Nursing Leadership Strategies,Health Literacy, and Patient

Outcomes

www.nurseleader.com Nurse Leader 49

T he United States has been

experiencing a demographic

transformation which began decades ago

and is continuing to accelerate and dra-

matically change our landscape. Minority

groups are the fastest growing demo-

graphic, currently accounting for one-

third of the U.S. population1 and the US

is projected to become a majority-minor-

ity nation for the first time in 2043.

Terri Ann Parnell, DNP, RN

challenges for nursing leaders as well as all healthcare profes-sionals and organizations. Recognition of the fundamentaldifferences among people from various nationalities, ethnici-ties and cultures, and the effect on health beliefs is importantfor all members of the healthcare community.10

In an effort to adequately serve these changing demo-graphics, the delivery of healthcare must focus on providingall persons with the “capacity to obtain, communicate,process, and understand basic health information and servicesneeded to make appropriate health decisions.”11 Research hasdocumented that certain patient populations experiencepoorer health outcomes and decreased patient safety andquality of care as a result of race, ethnicity, language, disability,and sexual orientation.12 Cultural and linguistic differencesamong patients directly impact their health literacy levels,which, in turn, is a contributing factor to an increased preva-lence of health disparities among racial and ethnic minorities,immigrants, low-income individuals, and non-native speakersof English and elderly adults.13 Therefore, in order to providesafe, quality healthcare to diverse communities, it is criticalthat components of health literacy be incorporated through-out the entire continuum of prevention, wellness, and illness.

HEALTH LITERACY AND THE AFFORDABLE CAREACTThe Affordable Care Act (ACA) was landmark legislationdesigned to provide millions of Americans with increasedhealthcare coverage. Although the ACA was not designed tobe health literacy legislation, it does have implications forhealth literacy. The ACA defined health literacy as “thedegree to which an individual has the capacity to obtain,communicate, process, and understand health informationand services in order to make appropriate health decisions.”14

The indirect provisions for health literacy exist within thedomains of equity, coverage expansion, workforce, patientinformation, public health, and wellness and quality improve-ment.15 Although the ACA provides insurance for millions ofAmericans, millions will still lack coverage in 2019.16

National data suggest that only 12% of adults have profi-cient health literacy.17 Although low health literacy is preva-lent across all demographic groups, it disproportionatelyaffects nonwhite racial and ethnic groups, the elderly, individ-uals with lower socioeconomic status and education, peoplewith physical and mental disabilities, those with LEP, andnon-native speakers of English.18 Individuals with low healthliteracy will have significant challenges understanding whatcoverage they may be eligible for, making informed choicesabout the best options for themselves and families, and com-pleting the enrollment process.15(p2) The success of reforminghealthcare cannot be achieved if the populations we serve arenot health literate. In addition, a focus on health literacyefforts of healthcare professionals and the health system is alsoneeded to help achieve the success of the ACA.

MAGNITUDE OF THE ISSUELow health literacy is a crosscutting priority that will impacteveryone at some point throughout their life-long continuum

of health and illness. In 2003, national data reported thatnearly 9 of 10 US adults were below the proficient level inhealth literacy, and over 75 million US adults combined hadbasic or below basic health literacy.17 In 2013, the First Lookresults from the most recent adult literacy assessment, theProgram for the International Assessment of AdultCompetencies (PIAAC) reported that US adults ages 16 to65 years were below the international average score in theLiteracy Domain and Problem-Solving in Technology-RichEnvironments Domain and scored third to last in theNumeracy Domain.19 Although the PIAAC did not have aspecific health literacy domain, low literacy and numeracyskills have a direct relationship upon an individual’s healthliteracy skills. The First Look report provides importantinitial results, although the complex relationship between thedata and all variables remains to be fully explored.

Early definitions of health literacy primarily focused onthe ability of an individual to apply basic numeracy andreading skills to a concept that was health related with thesole responsibility for enhancing health literacy skills on theindividual. Fortunately, there has been a shift towards theunderstanding that health literacy is about the relationshipbetween the skills of persons receiving care or treatment andthe professionals or systems that are providing the care andtreatment. Health literacy skills are dynamic and canimprove or diminish depending upon the context, changesin individual skills and experiences or changes in the healthcare system. Research indicates that persons with low healthliteracy have less knowledge about disease management, lessuse of preventive services, and higher hospitalization rates,20

incur higher health care costs,21 have an increased risk ofmortality,22 and report poorer health status than persons withadequate literacy skills.18

Health literacy continues to be an evolving concept thathas more recently been viewed as priority that crosses allboundaries in the delivery of safe, quality healthcare. In fact,health literacy has been referred to as the “currency” forimproving the quality of US health, healthcare, and healthoutcomes.23 Nurse leaders must spearhead the change that isnecessary for the implementation of health literacy strategiesinto nursing practice with the ultimate goal of advancinghealth for all.

LEADING CHANGE TO OPTIMIZE HEALTHWith more than 3 million members of the nursing profession,there is the potential to implement cross-cutting changes inthe healthcare system.24 Nurses are employed across manyareas of healthcare and public health, are true patient advo-cates, and are uniquely positioned to create a cultural changein healthcare that will shift the focus to optimizing health andwellness. They have a vital role in the promotion of healthliteracy, thereby assisting our communities to align with theoverarching goal of the National Prevention Strategy, to“increase the number of American’s who are healthy at everystage of life.”25(p7) Nurses have an opportunity to rise to thechallenge and provide leadership that prioritizes primary andpreventive care, focuses on healthcare that is patient-centered

December 201450 Nurse Leader

and delivered in the community setting as often as possible,and ensures that all care across the continuum is seamlesslycoordinated across health conditions, settings, andproviders.24(p50) It is key to keep health literacy as a vital com-ponent when caring for patients of any age, culture, educa-tion, or socioeconomic status.26 Nurse leaders can implementkey health literacy strategies to foster a culture that enhanceseffective communication, which is culturally and linguisticallyrespectful of each patient.

NURSE LEADER STRATEGIESNurse leaders must set the vision and culture of the nursingworkforce so that they are prepared to meet the increasingdemands on the healthcare system and the patients and fami-lies they care for. After all, nurses are perfectly positioned tohelp bridge the health literacy gap between patients andproviders. Nurse leaders can enhance the culture of theorganization by integrating health literacy into all patientsafety and quality measures. Performing a baseline organiza-tional assessment to ensure alignment with effective, patient-centered communication is an important first step. Thisshould incorporate a review of all nursing policies and prac-tices as well as an assessment of the nursing culture. Forexample, nurse leaders can implement patient educationpolicies that advocate for the use of plain language and teach-back when educating all patients.

Ensuring compliance with regulatory standards for healthliteracy, patient education, and language and communicationaccess services will assist in identifying best practices, as wellas opportunities for improvement. Benchmarking of metricscan assist in targeting communication interventions to patientsafety and reducing readmission rates. A nursing dashboardthat aligns health literacy as an essential component will assistin monitoring progress and sustainability of initiatives. Thesedata can be of assistance when modifying services or pro-grams to meet the changing needs of a diverse patient popu-lation. Enhancing health literacy organizational effortsnecessitates changes in both nursing and organizational prac-tices. “Attributes of a Health Literate Organization,”27 pub-lished by the Institute of Medicine, can be of assistance inproviding the foundational framework and offers suggestionsof examples that would help meet each attribute.

Enhancing nurses’ knowledge and awareness of healthliteracy for patients and the healthcare system continues to bea challenge.28 Preparing the nursing workforce to be healthliterate can be an immense, but rewarding, action step.Research has reported that 80% of nurses had heard of healthliteracy, less than half had formal health literacy training, and56% viewed health literacy as a low priority.29

Health literacy education metrics and timelines for ongo-ing training could be incorporated formally in annual man-dated topics, nursing grand rounds and competencies orinformally as lunch and learns, interdisciplinary rounds, orthrough activities of collaborative care councils. Once thebaseline education is completed, set an expectation underwhich all nurses utilize a “universal precautions approach,”and do not assume the health literacy level of any patient.

Several health literacy tenets can be consistently implementedacross the entire organization, such as always asking a patientthe preferred language they wish to discuss healthcare andspeak to patients in plain language. Using plain languagepurposefully is one of the most important ways clinicians canreduce health disparities related to low health literacy.30

Encourage the use of teach-back to ascertain understanding,and ask the patient “What questions do you have?” ratherthan “Do you have any questions?” Ensuring that the nursingworkforce engages in lifelong learning is key to gain thecompetencies needed to meet the current and future healthneeds of populations.24(p13)

Engaging community members and encouraging theirparticipation in health services project design, user testing,and evaluation is a rewarding experience for all involved.Participation of community leaders, members, and organiza-tions helps ensure that programs and policies align with localculture and are effective in addressing the health issues thatare of greatest importance.25 It is important to include adiverse group of community members, including those thathave limited English proficiency and adult learners wheneverpossible. Community partnership and ongoing relationshipswith key community members can assist in establishing trust.Ensuring that community education and prevention effortsconsider language, culture, age, preferred communicationchannels, and health literacy skills will help to increase peo-ple’s use of information, as well as adoption of health behav-iors.25 These considerations can assist with meeting the needsof the entire community without a feeling of stigma andshame. Building these relationships can assist with influenc-ing the health of the community. After all, many of thestrongest predictors of health and well-being fall outside ofthe healthcare setting.25

Allocating fiscal and human resources towards health liter-acy initiatives can be challenging in the current healthcarearena. Because health literacy is a cross-cutting priority andtruly impacts upon every department or service in a health-care organization, it “belongs to everyone.” When responsi-bilities are vague, the challenge often is that no onedepartment or discipline assumes ownership. Therefore, build-ing collaborative partnerships within the organizational set-ting and across clinical service lines will have the greatestimpact and will allow for sustainability. One example is tocollaborate with the finance department to achieveeconomies by aligning health literacy strategies with 30-dayreadmission rates. Partnering with your quality colleagues canassist in aligning health literacy strategies that impact uponpatient safety and patient satisfaction scores. Another exam-ple of a health literacy collaborative initiative could be withthe food and nutrition department, because health literacyincorporates patient and family cultural and religious prefer-ences. Nurse leaders have a vital role in educating all mem-bers of the administrative team about the implications of lowhealth literacy. A consistent awareness and knowledge basewill enhance the ability of the team to work together insearch for collaborative solutions to enhance health literacyacross the organization.

www.nurseleader.com Nurse Leader 51

Health literacy is an essential component within the fabricof an organization that will lead to innovative practices thattruly meet the needs of the population served. Nurse leadersthat focus on health literacy as an essential component of carewill provide a fundamental shift to patient-centered care thatwill enhance patient safety, patient satisfaction, and ultimately,patient outcomes. NL

References 1. Betancourt, JR, Renfrew MR, Green AR, Lopez L, Wasserman M. Improving

Patient Safety Systems for Patients With Limited English Proficiency: AGuide for Hospitals. AHRQ Publication No. 12-0041. Rockville, MD: Agencyfor Healthcare Research and Quality; 2012.

2. US Census Bureau. An Older and More Diverse Nation by Mid-Century.2008. http://www.census.gov/newsroom/releases/archives/population/cb12-243.html. Accessed October 14, 2014.

3. National Cancer Institute, National Institutes of Health. America’sDemographic and Cultural Transformation: Implications for Cancer.President’s Cancer Panel. Rockville, MD: US Department of Health andHuman Services; 2011.

4. Werner CA. (2011). The Older Population: 2010. 2010 Census Briefs.November 2011. http://www.census.gov/prod/cen2010/briefs/c2010br-09.pdf. Accessed June 28, 2014.

5. Moody HR, Sasser JR. Aging: Concepts and Controversies. 7th ed. ThousandOaks, CA: Pine Forge Press; 2012.

6. US Department of Health and Human Services, Office of Civil Rights. LimitedEnglish Proficiency. 2001. http://www.hhs.gov/ocr/civilrights/resources/specialtopics/lep/. Accessed June 28, 2014.

7. Pandya C, Batalova J, McHugh M. Limited English Proficient Individuals inthe United States: Number, Share, Growth, and Linguistic Diversity.Washington, DC: Migration Policy Institute; 2011.

8. US Department of Health and Human Services, OPHS Office of MinorityHealth. National Standards for Culturally and Linguistically AppropriateServices in Health and Health Care: A Blueprint for Advancing andSustaining CLAS Policy and Practice. Rockville, MD: US Department ofHealth and Human Services; 2013.

9. The Joint Commission. What Did the Doctor Say? Improving Health Literacyto Protect Patient Safety. Oak Brook, IL: The Joint Commission; 2007.

10. National Center for Cultural Competence. National Center for CulturalCompetence. 2010. http://nccc.georgetown.edu/. Accessed July 5, 2014.

11. Somers SA, Mahadevan R. Health Literacy Implications of the AffordableCare Act. Washington D.C.: Center for Health Care Strategies; 2010.

12. The Joint Commission. Advancing Effective Communication, CulturalCompetence, and Patient- and Family-Centered Care: A Roadmap forHospitals. Oakbrook Terrace, IL: The Joint Commission; 2010.

13. Benjamin RM. Surgeon general’s perspective for improving health by improv-ing health literacy. Public Health Rep. 2010;125:784-788.

14. Patient Protection and Affordable Care Act, Public Law 148, 111thCongress, 2nd session. March 23, 2010.

15. Institute of Medicine. Health Literacy Implications for Health Care Reform:A Workshop Summary. Washington, DC: National Academies Press; 2011.

16. Congressional Budget Office. Cost Estimates for the 111th Congress: H.R.4872, Reconciliation Act of 2010 (Final Health Care Legislation). 2010.http://www.cbo.gov/publication/21351. Accessed June 30, 2014.

17. National Center for Education Statistics. Institute of Education Sciences.2003 National Assessment of Adult Literacy (NAAL). 2003.http://nces.ed.gov/naal/. Accessed June 27, 2014.

18. Nielsen-Bohlman L, Panzer A, Hamlin B, Kindig DA, eds. Health Literacy:A Prescription to End Confusion. Washington, DC: National Academies Press;2004.

19. National Center for Education Statistics. US Department of Education.Organization for Economic Cooperation and Development (OECD). Programfor the International Assessment of Adult Competencies 2012: First Look.Alexandria, VA: US Department of Education; 2012.

20. Baker DW, Gazmararian JA, Williams MV. Functional health literacy and therisk of hospital admission among Medicare managed care enrollees. Am JPublic Health. 2002;92:1278-1283.

21. Howard DH, Gazmararian JA, Parker RM. The impact of low health literacyon the medical cost of Medicare managed care enrollees. Am J Med.2005;118:371-377.

22. Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J.Health literacy and mortality among elderly persons. Arch Intern Med.2007;167: 503-1509.

23. Paasche-Olow MK, Parker RM, Gazmararian JA, Nielsen-Bohlman LT, RuddRR. The prevalence of low health literacy. J Gen Intern Med. 2005;20:175-194.

24. Institute of Medicine. The Future of Nursing: Leading Change, AdvancingHealth. Washington, DC: National Academies Press; 2011.

25. National Prevention Council. National Prevention Strategy. Washington, DC:US Department of Health and Human Services, Office of the SurgeonGeneral; 2011.

26. Berkman ND, DeWalt DA, Pignone MP, et al. Literacy and Health Outcomes.Evidence Report/Technology Assessment No. 87. AHRQ Publication No. 04-E007-2. Rockville, MD: Agency for Healthcare Research and Quality; 2004.

27. Brach C, Dreyer B, Schyve P, et al. Attributes of a Health LiterateOrganization. January 2012. http://www.iom.edu/global/perspectives/2012/attributes.aspx. Accessed June 29, 2014.

28. Jukkala A, Deupree JP, Graham S. Knowledge of limited health literacy at anacademic health center. J Contin Educ Nurs. 2009;40:298-302.

29. Macabasco-O'Connell A, Fry-Bowers EK. (). Knowledge and perceptions ofhealth literacy among nursing professionals. J Health Commun.2011;16(Suppl 3):295-307.

30. Sudore RL, Schillinger D. Interventions to improve care for patients withlimited health literacy. J Clin Outcomes Manage 2009;16:20-29.

Terri Ann Parnell, DNP, RN, is principal and founder of HealthLiteracy Partners in Garden City, New York. She can be reached atTparnell@healthliteracypartners.com.

1541-4612/2014/ $ See front matterCopyright 2014 by Elsevier Inc.All rights reserved.http://dx.doi.org/10.1016/j.mnl.2014.09.005

December 201452 Nurse Leader