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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 = 103) 8.4

Data from 94 patients hospitalized on one of the medical-surgical units at the university hospital

were obtained through care plan review. Students had collected health literacy assessment data,which was a component of the patient assessment database, through interviewing a patient who

was assigned to them during the clinical rotation. The health literacy patient assessment sheet

was removed from the remainder of the assessment database--no identifying patient informationremained in the data sheet containing the health literacy assessment questions. Data were codedand entered into SPSS version 17 for analysis. There were no more than three missing data

points in any of the analyses, and cases with missing data were excluded on a test by test basis.

Mean patient age was 54 years and median education level was that of a high school graduate.

Race/ethnicity data was not available from the care plan source, but no students identifiedlanguage as a barrier for any patients. Three of the 94 patients were identified as having potential

minor, short-term-memory problems.

Patient responses to the question about patient confidence in filling out medical forms indicated

that 43% were somewhat confident, a little confident, or not at all confident, meeting Chewscriteria for health literacy risk. Similarly, 38% of patients reported sometimes, often or alwaysneeding help reading hospital materials, and 38% reported sometimes, often, or always having

problems learning about their health condition due to trouble understanding written material,meeting Chews criteria for limited health literacy levels (See Table 2).

Table 2. Frequency of Categorical Responses to Chews Screening Questions


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Item Response Response Response Response Response

Confidence infilling out medical

forms

N = 92

Extremelyconfident

n = 20

(22%)

Quiteconfident

n = 32

(35%)

Somewhatconfident

n = 17

(18%)

A littleconfident

n = 12

(13%)

Not at allconfident

n = 11

(12%)

How often needhelp reading

hospital materials

N = 91

Never

n = 29

(32%)

Occasionally

n = 27

(30%)

Sometimes

n = 8

(9%)

Often

n =13

(14%)

Always

n = 14

(15%)

How often problems learning

about healthcondition

N = 92

Never

n = 34

(37%)

Occasionally

n = 24

(26%)

Sometimes

n = 18

(20%)

Often

n = 10

(11%)

Always

n = 6

(7%)

Note: Responses to the right of the bold column line indicate a limitation in health literacy.

After collapsing age into two categories--under 60 years (n = 51), and 60 years and older (n =

41)--we compared patient responses to the health literacy questions by age, using the Mann-Whitney statistic. No age determination was available for two of the 94 patients. Results

indicated that older patients were significantly less confident in filling out medical forms (Z = -3.9, p = .000), and reported more often needing help in reading hospital materials (Z = -3.1, p =

.002) (See Table 3).

Table 3. Comparison of Age and Health Literacy Responses

N Mean

Rank

Sum of

Ranks

Test Statistics

Confidence filling out medical forms

< 60 yrs old

60 yrs and >

49

41

54.92

34.24

2691.00

1404.00

Mann-Whitney U 543.00

Wilcoxon W 1404.00

Z -3.86

Sig (2-ailed) .000How often need help readinghospital materials

< 60 yrs old

60 yrs and >

48

41

52.48

36.24

2519.00

1486.00


Wilcoxon W 1486.00

Z -3.06

Sig (2-tailed) .002


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How often have problems learningabout health condition

< 60 yrs old

60 yrs and >

49

41

50.18

39.90

2459.00

1636.00


Wilcoxon W 1636.00

Z -1.93

Sig (2-ailed) .000

Comparisons of patient education level with responses to the health literacy questions via

Kruskal-Wallis analysis indicated significantly different responses according to education level.In general, as reported education levels increased, the confidence in filling out medical forms

increased 2

(df 6) = 28.1, p = .000, and patients reported less often needing help reading hospitalmaterials;

2(df 6) =19.0, p = .004see Table 4. In addition, as education levels increased,

patients reported less often having problems learning about their health condition because oftrouble understanding written information; 2 (df = 6) = 24.2, p = .000. However, as evident in

the mean rank data presented in Table 4, there were two instances in which the mean ranks

decreased somewhat as education level increasedan unexpected finding. Mean ranks for allthree literacy questions were slightly lower for patients reporting middle school education asopposed to elementary education. However, only one patient in the study sample reported an

elementary school educationthus the findings may not be noteworthy. In addition, mean ranksfor patients reporting college graduation were slightly lower than for those reporting some

college for all three of the health literacy questions.

Table 4. Comparison of Education Level and Health Literacy Responses

>N >Mean

Rank

>Test Statistics

Confidence filling out medical forms

Education Elementary

Middle school

Some H. S.

H. S. grad

Some college

College grad

Graduate degree

Total

>

>1

>6

>8

>46

>18

>12

>1

92

>

>17.50

>16.08

>24.94

>44.27

>64.53

>57.00

>82.50

>

>Chi-Square 28.14

>df 6

>Sig. .000


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How often need help reading hospitalmaterial


Middle school

Some H. S.

H. S. grad

Some college

College grad

Graduate degree

Total

>

>1

>6

>8

>46

>18

>11

>1

91

>

>21.00

>18.25

>42.94

>41.88

>62.03

>53.82

>77.00

>

> Chi-Square 18.96

> df 6

> Sig. .004

How often have problems learning abouthealth condition


Middle school

Some H. S.

H. S. grad

Some college

College grad

Graduate degree

Total

>

>1

>6

>8

>46

>18

>12

>1

92

>

>25.50

>12.50

>30.75

>46.02

>64.22

>48.58

>75.50

>

> Chi-Square 24.19

> df 6

> Sig. .000

Patients more frequently identified directing their questions to an RN as opposed to their

physician. Patient narrative responses to the questions asking what they did when they hadtrouble understanding either written or verbal health information were categorized according totheme and tallied. In reviewing the data it was noted that patients typically responded with only

one answer or behavior, and sometimes provided general answers to the questions, such as askquestions or ask someone. Students had not been given instructions to prompt patients for

specific behavioral responses or additional behaviors, if only one answer was given.


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Patient responses to the question asking what they did if they were having trouble understandingwritten information are listed in Table 5. The most frequent patient response was to ask a family

member, followed by an RN or MD. Patients more frequently identified directing their questionsto an RN as opposed to their physician. Five patients reported not usually having any trouble

understanding written health information. Although only a few patients identified responses of

trying to understand the material themselves, or trusting the MD and signing a form, theseresponses are quite concerning in terms of potential contributions to an adverse patient outcome.

Table 5. Identified Compensatory Behaviors for Lack of Understanding of Written

Information (N = 94)

Ask family member n = 34 (36%)

Ask MD or RN n = 14 (15%)

Ask for explanation (not specified who to ask) n = 12 (13%)

Ask RN n = 11 (12%)

Ask MD n = 7 (7%)

Usually dont have any difficulties understanding n = 6 (6%)Try again to understand/do on own n = 5 (5%)

No response/missing n = 3 (3%)

Trust MD/just sign forms n = 2 (2%)

The most common specific patient response to lack of understanding of...health information was

to ask a family member... [they, however] may have no better understanding...

than the patient... Patient responses to the item asking what they do if they dont understandverbal instructions were, most commonly, to ask questions, although patients often didnt

identify to whom they would direct the questions. When patients did specifically state whomthey would ask questions of, family members were identified more frequently than the RN or

physician (See Table 6). Six of 94 patients identified that they would just let it go or donothinga response that could contribute to continued lack of understanding and adverse patient

health outcomes. Three patients indicated not having any difficulty understanding verbal healthinformation.

Table 6. Identified Compensatory Behaviors for Lack of Understanding of Verbal

Instructions (N = 94)

Ask questionsno specific person identified n = 44 (47%)

Ask family member n = 19 (20%)

Ask RN n = 8 (9%)

Do nothing/let it go n = 6 (6%)

Research it myself n = 6 (6%)

Ask MD or RN n = 4 (4%)

Usually dont have any difficulties understanding n = 3 (3%)

No response/missing n = 3 (3%)

Ask MD n = 1 (1%)


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...health literacy... should be threaded throughout the entire nursing curriculum... even a shorteducation intervention can impact student knowledge...Our final step in data review and analysis

was to look at student responses to the health literacy assessment data that they had collected.Students identified appropriate interventions in response to identified patient health literacy

limitations, including making sure the patient understands the health information, using

teach-back to assess patient understanding, explaining the information in simple terms, usingalternative teaching forms and videos, assuring that patient family members are present duringteaching, presenting information in small pieces, and using simple terms and explanations.

The interventions students identified in response to the assessment data reflected appropriateapplication of health literacy principles.

Discussion and Implications

Nursing graduates must be astute in identifying patients who lack understanding of health

information and who may be using detrimental behaviors to compensate for a lack ofunderstanding. This section will discuss why these study findings should raise concern among

nurses and all healthcare professionals regarding the adequacy of patient comprehension of thehealth-related teaching they are given. Study limitations will be addressed. Future directions will

be identified.

Discussion

In this exploratory study, the significant increase in nursing student knowledge scores after

presentation of health literacy education content in the classroom setting indicates that even ashort education intervention can impact student knowledge of critical health literacy issues.

However, whether students continue to retain and use the knowledge gained in this briefeducation session is not known. Just as with other critical nursing education content, health

literacy is a topic that should be threaded throughout the entire nursing curriculum and stressedin each clinical rotation. New nursing graduates need to be able to: (a) identify patients at risk for

not being able to understand and act on health information, (b) communicate health informationand instructions in a way that promotes patient understanding, and (c) check for patient

understanding (DeSilets & Dickerson, 2009; Speros, 2009).

Another...concern was that some patients would try again to understand...and not askquestions, just let the issue go...[t]he likelihood for adverse health outcomes could be

significantly increased by patient compensatory behaviors. The incidence of low health literacyamong this convenience sample of hospitalized medical-surgical patients is consistent with

national norms (Kutner et al., 2006) and findings of other researchers (Katz et al., 2007). Thefinding that older patients and those reporting lower education levels are at higher risk for low

health literacy is also consistent with the literature (Kutner et al., 2006; Rudd, 2007; Speros,2009).

Patient compensatory behaviors for lack of understanding of health information have not beenreported in the literature as frequently, but some behaviors identified in this study are quite

concerning. The most common specific patient response to lack of understanding of both writtenand verbally conveyed health information was to ask a family member. The concern with this


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response is that family members may have no better understanding of the health information thanthe patient, and may cause the patient to become even more confused about what he/she was

told. Thus, the patient would continue to lack an understanding of vital information. Anotherissue of concern was that some patients would try again to understand printed material or

instructions independently and not ask questions, just let the issue go (meaning do nothing

about their lack of understanding), or trust the physician and sign any requested forms regardlessof understanding. These compensatory behaviors might result in adverse outcomes, includingpatients consenting to procedures that they have no understanding of, going home from a clinic

without filling a needed prescription, taking medications incorrectly, or not performing necessaryself-care activities. The likelihood for adverse health outcomes could be significantly increased

by these patient compensatory behaviors.

Study Limitations

This study was a retrospective data analysisa quasi-experimental design. Use of a controlgroup in implementation of the student education intervention would have strengthened the

design. In addition, the patient population represented a convenience sample of patients,specifically those patients that the students selected for completion of the formal assessment and

care planning clinical assignment. Although the proportion of patients with lower health literacylevels was comparable to those reported by other authors, these findings cannot be widely

generalized. In addition, when patients responded in broad terms to student questions askingwhat they did when they didnt understand health information or instructions, students had not

been instructed to request that the patient identify specifically of whom he/she would ask thequestions. Regarding patients responding in general terms that they would ask questions about

the information they didnt understand, it was not possible to determine whether their behaviorswould most likely lead to clarification of information, or potentially result in continued lack of

understanding. It would be beneficial in future patient assessments to ask specifically whompatients would consult to clarify the health information they were given.

Implications

Incorporation of simple and effective health literacy questions into all patient assessmentdatabases would help to identify patients for whom health literacy is an issue. Results of this

study have significant implications for nursing practice and nursing education, as well as forguiding future research. Given the significance of low health literacy in the US, all nursing

education programs should be incorporating health literacy content throughout theirundergraduate and graduate curricula. Nursing graduates must be astute in identifying patients

who lack understanding of health information and who may be using detrimental behaviors tocompensate for a lack of understanding. They must also be able to adapt patient education

interventions to assure patient understanding of vital health information. Practicing nurses mustbe competent in these same areas. Perhaps completion of a continuing education program about

health literacy should be required for re-licensure of RNs. Outcome measures for such aneducation program would need to be identified and monitored, including both measurement of

patient understanding of health information presented by nurses who had completed healthliteracy education, and also patient health outcomes.


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Incorporation of simple and effective health literacy questions into all patient assessmentdatabases would help to identify patients for whom health literacy is an issue. Development and

implementation of appropriate interventions to assure patient understanding may significantlyreduce negative health outcomes. Research is needed to identify the most effective interventions

to assure patient understanding of important health information, and to document the impact of

these interventions on patient treatment adherence and health outcomes. Nurses, who are thefront-line providers of patient education and information, are encouraged to take the lead indemonstrating the value of health literacy assessment and the need for appropriate education

interventions to improve patient health outcomes.