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Health literacy concepts in nursing education.


The impact of low health literacy on the health care system is astronomical. The ability to learn, retain, and apply health information is greatly affected by health literacy and thus greatly affects patient outcomes. The responsibility of patient education is mostly shouldered by nurses and yet nursing is the discipline that is most lacking in knowledge and awareness about health literacy. Providing nursing students with the necessary tools to assess patient health literacy and to assess their own patient teaching is a vital component of patient education. Nursing curricula is the place to start.

KEYWORDS Health Literacy--Nursing Education--Patient Education


Health literacy is a multidimensional concept strongly influenced by culture and linguistics that involves more than just health and literacy. It also includes the skills needed to understand and communicate health information to best maneuver through the health care system (Berkman, Davis, & McCormack, 2010). A link establishing the impact of culture and language on health literacy levels and the connection to health outcomes was demonstrated in a causal model by Paasche-Orlow and Wolf (2007).

The US Department of Health and Human Services points out that only 12 percent of adults in the United States have proficient health literacy skills needed to manage their health and prevent disease (2010). The degree to which one is able to manage one's own health care has huge implications for the future health of the individual and members of the individual's family. Mismanagement can lead to increased and exacerbated illness, increased hospitalization, and increased recidivism.

As the largest provider of patient health teaching, nursing has historically been the discipline largely charged with that responsibility. Therefore, as it is important to include the best teaching methods for improved patient outcomes to nursing students, preparation in how to best address the problem of health literacy should be included in nursing curricula. New nurses should be taught awareness of health literacy and given the tools to address it. What innovations can be included in nursing education to prepare nursing students to deal with this monumental problem?


The problems surrounding low health literacy are paramount because they affect a major portion of the population in the United States. The vast extent of the health literacy problem is a central theme in most of the general health care literature. Low health literacy has a financial effect on the entire population, either through increased insurance costs or unnecessary tax dollars being spent. With low health literacy affecting the health care of millions and costing billions (or perhaps trillions) of dollars, it is imperative that action be taken to help alleviate this national problem.

Baur's (2011) commentary on the US Health and Human Service's National Action Plan to Improve Health Literacy emphasizes that health literacy priorities need to be incorporated into nursing curricula. The action plan draws attention to the need for health literacy topics to be included in all health care professional education, but especially in nursing education. This leaves us with the question: What action can nurses, as health educators, take to make a difference in dealing with this problem, and at what point in the nursing education continuum should action be taken?

It has only been in very recent years that studies have introduced the notion that health care providers should share some responsibility for providing patient information in a manner in which it can be more easily understood and acted upon (Sorensen et al., 2012). Consideration of linguistic and cultural competence strategies is found to improve communication and health care quality in diverse societies (Andrulis & Brach, 2007). A landmark study funded by the Institute of Medicine, Health Literacy: A Prescription to End Confusion, acknowledged that health care professionals need to be educated about health literacy beginning in their professional schools (2004).

In a multidisciplinary study by Jukkala, Deupree, and Graham (2009) examining health care providers' health literacy knowledge base, nursing was found to have the highest reported rate of no prior health literacy knowledge. This is especially noteworthy since "nurses comprise the largest segment of the healthcare work force and are charged with patient education" (p. 301). This finding suggests that an entry point to help correct the problem may begin with addressing gaps in nursing education. Scheckel, Emery, and Nosek (2010) acknowledge that "there is a need for teachers to design instructional strategies that deepen students' extant knowledge and skills in health literacy prior to graduation from nursing programs" (p. 794).


The Quality and Safety Education for Nurses program of teaching strategies (QSEN, 2012) incorporates health literacy assessment as a patient-centered care learning competency. In providing instruction on patient education, it is important for nursing faculty to emphasize to the new "teacher" the need to be aware of potential low health literacy in certain vulnerable populations in this diverse society. The Health Literacy Universal Precautions Toolkit was developed by the Agency for Healthcare Research and Quality (AHRQ, 2013) in an effort to provide tools to assist health care providers in removing health literacy barriers. Nursing faculty can introduce such tools to nursing students for use in their new roles as patient educators.

Additional well-established, valid, and reliable tools are available for health professionals to utilize when assessing the health literacy levels of patients. These tools can help nurses determine a baseline of the patient's understanding of health-related matters. According to Weiss et al. (2005), commonly used tools to assess health literacy levels include the Test for Functional Health Literacy (TOFHLA), the Rapid Estimate of Adult Literacy in Medicine (REALM), and Newest Vital Sign (NVS). The TOFHLA measures reading comprehension as well as numerical ability but takes 18 to 22 minutes to administer. The REALM is a pronunciation and word recognition tool that can be administered quickly. The NVS also measures numeracy, which is an important skill when patients need to calculate medications.

These tools should be introduced to students prior to graduation so that they can become familiar with how best and when to use them in clinical settings. Students should also practice how to modify patient education to accommodate the individual patient's understanding. This skill should also extend to evaluating patient education materials for appropriate health literacy level.

Another area of concern is assessment of what the patient has understood of the information that has been provided. Techniques have been developed such as the 'Teach Back Method" to identify exactly what the patient is able to take away from the information or education session (AHRQ, 2013). Asking a patient "How will you explain this information to your family when you get home?" or "What are the important points of what we discussed today?" will help the nurse establish how well the information has been presented for that patient.


Research evidence shows that nursing is a discipline that needs information, cultural competence, and skills to handle patients presenting with low health literacy. The evidence also indicates that nurses are a population that tends to be unaware of the indicators, prevalence, and assessment tools needed to help circumvent the problem. Early in their education, nursing students should be presented with means to obtain the skills and tools they need to provide their patients (and their future patients) with culturally and linguistically appropriate education. It is vitally important that information about health literacy be included in nursing curricula so that future nurses can have a strong influence on their patients' future health.


Agency for Healthcare Research and Quality (AHRQ). (2013). Health literacy universal precautions toolkit. Retrieved from toolkit/index.html

Andrulis, D. P., & Brach, C. (2007). Integrating literacy, culture, and language to improve health care quality for diverse populations. American Journal of Health Behavior, 37, S122-S133.

Baur, C. (2011). Calling the nation to act: Implementing the national action plan to improve health literacy. Nursing Outbok, 59(2), 63-69. doi:10.1016/j.outlook. 2010.12.003

Berkman, N. D., Davis, T. C., & McCormack, L. (2010). Health literacy: What is it? Journal of Health Communication, 75(Suppl 2), 9-19, doi:10.1080/10810730. 2010.499985

Institute of Medicine. (2004). Health literacy: A prescriptbn to end confusbn. Retrieved from

Jukkala, A., Deupree, J. P., & Graham, S. (2009). knowledge of limited health literacy at an academic health center. Journal of Continuing Educatbn in Nursing, 40(7), 298-302.

Paasche-Orlow, M. K., & Wolf, M. S. (2007). The causal pathways linking health literacy to health outcomes. American Journal of Health Behavior,

31, S19-S26.

Quality and Safety Education for Nurses. (2012). Teaching strategies. Retrieved from

Scheckel, M., Emery, N., &Nosek, C. (2010). Addressing health literacy: The experiences of undergraduate nursing students. Journal of Clinical Nursing, 19, 794-802. doi:10.1111/j. 1365-2702.2009.02991 .x

Sorensen, K., Van den Broucke, S., Fullam, J., Doyle, G., Pelikan, J., Slonska, Z., & Brand, H. (HLS-EU) Consortium Health Literacy (2012). Health literacy and public health: A systematic review and integration of definitions and models. BioMed Central Public Health, 72(1), 80-92. doi:10.1186/1471-2458-12-80

US Department of Health and Human Services. (2010). Quick guide to health literacy. Retrieved from

Weiss, B. D., Mays, M. Z., Martz, W., Castro, K. M., Dewalt, D. A., Pignone, M., ... Hale, F. (2005). Quick assessment of literacy in primary care: The newest vital sign. Annals of Family Medicine, 3(6), 514-522. doi:10.1370/afm.405

Deborah K. Kennard, MSN, RN, is an assistant professor, Kean University School of Nursing, Union, New Jersey. For more information, write to

doi: 10.5480/14-1350
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Title Annotation:Innovation Center
Author:Kennard, Deborah K.
Publication:Nursing Education Perspectives
Article Type:Report
Date:Mar 1, 2016
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