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T

he Hispanic population is projected to nearly

triple to 132.8 million, by 2050, when nearly1 in 3 US residents would be Hispanic. The Black

and Asian populations are projected to increase to

15% and 9.2%, respectively, of the total population

by 2050.2 All remaining racial groups are projected

to rise, as are the number of people who identify

themselves as being multiracial. The nation’s changing

sociocultural composition has implications for virtually

every aspect of American life, especially public health

and the delivery of health care.3

In addition to a more ethnically and racially diverse

population, an increase in the US population aged 65 years or

older is also projected as a result of the aging of the babyboomers and an increase in life expectancy.2 In fact, more

persons were age 65 years and over in 2010 than in any pre-

vious census. And the US Bureau of the Census 2010 projects

that by 2050, 19 million, or 4.6%, of the population will be

age 85 and older compared to 3.1 million, or 1.3%. of the

population in 1990.4 Within the coming decades, 1 in 5

Americans will be eligible for Social Security and Medicare,

contrasting with 1 in 8 Americans today.5

Persons with limited English proficiency (LEP) are

unable to communicate effectively in English because their

primary language is not English and they do not have fluency

in the English language.6

Consistent with the growth of the

US foreign-born population, the number of LEP individuals

in the United States grew by 80% from 1990 to 2010, withSpanish-speaking LEP individuals accounting for 66% of the

total United States LEP population in 2010, followed by

Chinese and Vietnamese, with 6% and 3%, respectively.7

Sixty-three percent of hospitals treat LEP patients daily or

weekly, 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 both

accessible and offered in a manner that is linguistically and

culturally understandable for all.9

The “graying of America” combined with the rapid

growth of a more ethnically and racially diverse population

with 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 beenexperiencing a demographictransformation 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


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challenges for nursing leaders as well as all healthcare profes-

sionals and organizations. Recognition of the fundamental

differences among people from various nationalities, ethnici-

ties and cultures, and the effect on health beliefs is important

for all members of the healthcare community.10

In an effort to adequately serve these changing demo-

graphics, the delivery of healthcare must focus on providing

all persons with the “capacity to obtain, communicate,process, and understand basic health information and services

needed to make appropriate health decisions.”11 Research has

documented that certain patient populations experience

poorer health outcomes and decreased patient safety and

quality of care as a result of race, ethnicity, language, disability,

and sexual orientation.12 Cultural and linguistic differences

among 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 speakers

of English and elderly adults.13 Therefore, in order to provide

safe, quality healthcare to diverse communities, it is critical

that components of health literacy be incorporated through-

out the entire continuum of prevention, wellness, and illness.

HEALTH LITERACY AND THE AFFORDABLE CARE

ACT

The Affordable Care Act (ACA) was landmark legislation

designed to provide millions of Americans with increased

healthcare coverage. Although the ACA was not designed to

be health literacy legislation, it does have implications for

health literacy. The ACA defined health literacy as “the

degree to which an individual has the capacity to obtain,

communicate, process, and understand health information

and services in order to make appropriate health decisions.”14

The indirect provisions for health literacy exist within the

domains of equity, coverage expansion, workforce, patient

information, public health, and wellness and quality improve-

ment.15 Although the ACA provides insurance for millions of

Americans, 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 disproportionately

affects nonwhite racial and ethnic groups, the elderly, individ-

uals with lower socioeconomic status and education, people

with physical and mental disabilities, those with LEP, and

non-native speakers of English.18 Individuals with low healthliteracy will have significant challenges understanding what

coverage they may be eligible for, making informed choices

about the best options for themselves and families, and com-

pleting the enrollment process.15(p2) The success of reforming

healthcare cannot be achieved if the populations we serve are

not health literate. In addition, a focus on health literacy

efforts of healthcare professionals and the health system is also

needed to help achieve the success of the ACA.

MAGNITUDE OF THE ISSUE

Low health literacy is a crosscutting priority that will impact

everyone at some point throughout their life-long continuum

of health and illness. In 2003, national data reported that

nearly 9 of 10 US adults were below the proficient level in

health literacy, and over 75 million US adults combined had

basic or below basic health literacy.17 In 2013, the First Look

results from the most recent adult literacy assessment, the

Program for the International Assessment of Adult

Competencies (PIAAC) reported that US adults ages 16 to

65 years were below the international average score in theLiteracy Domain and Problem-Solving in Technology-Rich

Environments Domain and scored third to last in the

Numeracy Domain.19 Although the PIAAC did not have a

specific health literacy domain, low literacy and numeracy

skills have a direct relationship upon an individual’s health

literacy skills. The First Look report provides important

initial results, although the complex relationship between the

data and all variables remains to be fully explored.

Early definitions of health literacy primarily focused on

the ability of an individual to apply basic numeracy and

reading skills to a concept that was health related with the

sole responsibility for enhancing health literacy skills on the

individual. Fortunately, there has been a shift towards the

understanding that health literacy is about the relationship

between the skills of persons receiving care or treatment and

the professionals or systems that are providing the care and

treatment. Health literacy skills are dynamic and can

improve or diminish depending upon the context, changes

in individual skills and experiences or changes in the health

care system. Research indicates that persons with low health

literacy have less knowledge about disease management, less

use of preventive services, and higher hospitalization rates,20

incur higher health care costs,21 have an increased risk of

mortality,22 and report poorer health status than persons with

adequate literacy skills.18

Health literacy continues to be an evolving concept that

has more recently been viewed as priority that crosses all

boundaries in the delivery of safe, quality healthcare. In fact,

health literacy has been referred to as the “currency” for

improving the quality of US health, healthcare, and health

outcomes.23 Nurse leaders must spearhead the change that is

necessary for the implementation of health literacy strategies

into nursing practice with the ultimate goal of advancing

health for all.

LEADING CHANGE TO OPTIMIZE HEALTH

With more than 3 million members of the nursing profession,there is the potential to implement cross-cutting changes in

the healthcare system.24 Nurses are employed across many

areas of healthcare and public health, are true patient advo-

cates, and are uniquely positioned to create a cultural change

in healthcare that will shift the focus to optimizing health and

wellness. They have a vital role in the promotion of health

literacy, thereby assisting our communities to align with the

overarching goal of the National Prevention Strategy, to

“increase the number of American’s who are healthy at every

stage of life.”25(p7) Nurses have an opportunity to rise to the

challenge and provide leadership that prioritizes primary and

preventive care, focuses on healthcare that is patient-centered

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and delivered in the community setting as often as possible,

and ensures that all care across the continuum is seamlessly

coordinated across health conditions, settings, and

providers.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 implement

key health literacy strategies to foster a culture that enhances

effective communication, which is culturally and linguisticallyrespectful of each patient.

NURSE LEADER STRATEGIES

Nurse leaders must set the vision and culture of the nursing

workforce so that they are prepared to meet the increasing

demands on the healthcare system and the patients and fami-

lies they care for. After all, nurses are perfectly positioned to

help bridge the health literacy gap between patients and

providers. Nurse leaders can enhance the culture of the

organization by integrating health literacy into all patient

safety and quality measures. Performing a baseline organiza-

tional assessment to ensure alignment with effective, patient-

centered communication is an important first step. This

should incorporate a review of all nursing policies and prac-

tices as well as an assessment of the nursing culture. For

example, nurse leaders can implement patient education

policies that advocate for the use of plain language and teach-

back when educating all patients.

Ensuring compliance with regulatory standards for health

literacy, patient education, and language and communication

access services will assist in identifying best practices, as well

as opportunities for improvement. Benchmarking of metrics

can assist in targeting communication interventions to patient

safety and reducing readmission rates. A nursing dashboard

that aligns health literacy as an essential component will assistin monitor ing progress and sustainability of initiatives. These

data 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 efforts

necessitates 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 in

providing the foundational framework and offers suggestions

of examples that would help meet each attribute.

Enhancing nurses’ knowledge and awareness of health

literacy for patients and the healthcare system continues to be

a 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 health

literacy, less than half had formal health literacy training, and

56% 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 or

informally as lunch and learns, interdisciplinary rounds, or

through activities of collaborative care councils. Once the

baseline education is completed, set an expectation under

which 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 implemented

across the entire organization, such as always asking a patient

the preferred language they wish to discuss healthcare and

speak to patients in plain language. Using plain language

purposefully is one of the most important ways clinicians can

reduce 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?” rather than “Do you have any questions?” Ensuring that the nursing

workforce engages in lifelong learning is key to gain the

competencies needed to meet the current and future health

needs of populations.24(p13)

Engaging community members and encouraging their

participation 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 local

culture and are effective in addressing the health issues that

are of greatest importance.25 It is important to include a

diverse group of community members, including those that

have limited English proficiency and adult learners whenever

possible. Community partnership and ongoing relationships

with key community members can assist in establishing trust.

Ensuring that community education and prevention efforts

consider language, culture, age, preferred communication

channels, 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 needs

of the entire community without a feeling of stigma and

shame. Building these relationships can assist with influenc-

ing the health of the community. After all, many of the

strongest predictors of health and well-being fall outside of

the healthcare setting.25

Allocating fiscal and human resources towards health liter-

acy initiatives can be challenging in the current healthcare

arena. Because health literacy is a cross-cutting priority and

truly 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 one

department or discipline assumes ownership. Therefore, build-

ing collaborative partnerships within the organizational set-

ting and across clinical service lines will have the greatest

impact and will allow for sustainability. One example is to

collaborate with the finance department to achieve

economies by aligning health literacy strategies with 30-dayreadmission rates. Partnering with your quality colleagues can

assist in aligning health literacy strategies that impact upon

patient safety and patient satisfaction scores. Another exam-

ple of a health literacy collaborative initiative could be with

the food and nutrition department, because health literacy

incorporates 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 low

health literacy. A consistent awareness and knowledge base

will enhance the ability of the team to work together in

search for collaborative solutions to enhance health literacy

across the organization.

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Health literacy is an essential component within the fabric

of an organization that will lead to innovative practices that

truly meet the needs of the population served. Nurse leaders

that focus on health literacy as an essential component of care

will provide a fundamental shift to patient-centered care that

will enhance patient safety, patient satisfaction, and ultimately,

patient outcomes. NL

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Terri Ann Parnell, DNP, RN, is principal and founder of HealthLiteracy Partners in Garden City, New York. She can be reached at [email protected].

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
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Nusring Leadership Strategi