Executive Summary
Health literacy is a precursor to health and achievement of a culture of health (
Barton et al, 2017
). Patient empowerment, engagement, activation, and maximized health outcomes will not be achieved unless assurance of health literacy is applied universally for every patient, every time, in every health care encounter, and across all environments of care. Organizations such as the Agency for Healthcare Research and Quality (AHRQ) and the Institute for Healthcare Improvement (IHI) endorse the use of available resources such as the Health Literacy Universal Precaution Toolkit (Brega et al, 2015
). Health literacy universal precautions are suggested steps that can be implemented by health care systems and practices when they assume that everyone may have difficulty understanding health information and accessing health services. The toolkit is a resource that provides evidence-based guidance to primary care practices with the overarching goals of reducing the complexity of health care, increasing patient understanding of health information, and providing support for all patients regardless of their health literacy level (Brega et al, 2015
). Despite these endorsements, health literacy is not well understood by clinicians, rarely approached as a health care system issue, and is not universally executed across health care domains. Strategies and initiatives must be implemented to prepare nurses and other health care providers to embrace the importance of health literacy and to use available resources to enhance health literacy skills. In health-care systems and community health care settings, leaders must provide resources that enable all health-care providers to minimize the gap between patient skills and abilities and the demands and complexities of health care systems.Background
In the United States, 88% of adults have health literacy limitations, and 77 million Americans—more than one third of U.S. adults—struggle with routine self- and family-care management tasks, such as following discharge instructions, complying with directions for taking prescribed medications, and adhering to pediatric immunization schedules (
Kutner et al, 2006
). Individuals with low health literacy are more likely to experience poor health status (DeWalt et al, 2004
).Health literacy is recognized as a social determinate of health based on its impact on health outcomes. The link between health inequality and low health literacy is also well established, and both are prevalent among the elderly, the poor, ethnic minorities, and in populations with chronic health conditions (
Logan et al, 2015
).Beginning definitions of health literacy focused on an individual's risk, as in the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (
Institute of Medicine, 2004
). The health literacy definition evolved toward a public health focus of promotion and empowerment that allow people to have greater control over their health and to determine an individual's motivation and ability to access, understand, and use information to promote and maintain good health (Nutbeam, 2008
).Financial ramifications of low health literacy have added a cost emphasis to the health literacy imperative. According to the American Medical Association (AMA) Foundation, the average annual health care cost for individuals with low health literacy is more than four times higher than for similar individuals with high health literacy ($13,000 as compared with $3,000) (
Weiss, 2007
). Although definitions and foci have evolved over time, the nursing potential to enhance low health literacy is unchanged. Nurses have formidable direct and indirect influences on health literacy as we are often at the first point of care and are leaders in organizational and public health transformation. Nurses have a vital role in the promotion of health literacy, are employed across many areas of health care and public health, and are uniquely positioned to create the cultural change required to shift the focus from sickness to optimizing health and wellness (Parnell, 2014
).The dialogue about antecedents to and consequences of low health literacy is ubiquitous; calls for its status as a universal precaution exist (
DeWalt et al, 2010
). Agencies and organizations such as the Agency for Healthcare Research and Quality (AHRQ) (Anonymous, 2017
), the Centers for Disease Control and Prevention, 2017
, the - Centers for Disease Control and Prevention
Health literacy.
https://www.cdc.gov/healthliteracy/
Date: 2017
Health Resources and Services Administration, 2017
, the Health Research and Educational Trust, 2015
, the American Hospital Association's Hospital in Pursuit of Excellence platform (American Hospital Association (AMA), 2017
), and the AMA Foundation (Weiss, 2007
) provide health literacy-specific policy recommendations, resources, tools, and training. A PubMed search of published works using the terms “health literacy” and “nursing” retrieves more than 1,700 articles. With so much emphasis on health literacy, it is disheartening to note that there is no policy promoting health literacy as a nursing imperative. Additionally, the teach-back method commonly used by nurses is effective, not just for improving patients' understanding but also for improving outcomes (Schillinger et al, 2003
). However, evidence associating the use of other nursing tools with diminished impact of low health literacy is lacking.Health literacy is a precursor to health and achievement of the Robert Wood Johnson Foundation's vision for a culture of health (
Barton et al, 2017
). Patient engagement is well recognized as a cornerstone of successful health care reform (Pelletier, Stichler, 2013
, Pelletier, Stitchler, 2014
), and health literacy is fundamental to engaging patients in their own health (Koh et al, 2013
). Patient engagement is also a critical aspect of success for accountable care organizations and a vital component of patient-centered medical homes.The Academy's Position
The endorsement of health literacy policies, strategies, and initiatives aligns with the Academy's vision—to transform health policy and practice through nursing knowledge and leadership. Health literacy is also congruent with the Academy's strategic goal 1—to influence the development and implementation of policy that improves the health of populations and achieves health equity, and part two of this strategic goal, to advance evidence-based policies that support patient and family engagement in health care and care decisions (
American Academy of Nursing, 2017
).The complex concept of health literacy acknowledges the need for assessing and addressing health literacy for every patient, every time, and in every health-care encounter; and ensuring patients know what they must do after all health care encounters to self-manage their health. Additionally, there is a need for research and evidence-based findings concerning the relationships among nursing interventions to mitigate untoward consequences of low health literacy and patient safety, as well as patient and system outcomes. The timing is right for a call to action to increase nurses' knowledge, attitudes, behaviors, practice resources, and system capabilities to lessen the health literacy-related burden on patients and costs for health care. Implementation of a nursing-specific health literacy policy will result in patient empowerment, engagement, and activation; increased health care equity; and improved patient, population, organization, and system outcomes (
Parnell, 2015
, Pelletier, Stichler, 2013
, Pelletier, Stitchler, 2014
).Recommendations
The overarching goal of this policy statement is to influence policy in three domains—practice, systems of care, and partnerships—to minimize the gap between patient skills and abilities and the demands and complexities of health care systems.
Practice
Health literacy is fundamental to the success of every patient and health care professional interaction (
U.S. Department of Health and Human Services, 2010
). In fact, patient safety cannot be assured without mitigating the negative effects of low health literacy and ineffective communication on patient care (The Joint Commission, 2007
). A nursing focus on health literacy as an essential component of all patient care will enhance the provision of person-centered care, patient safety (Parnell, 2015
), and patient, population, and system outcomes.Recommendation: Partner with nursing and other health care organizations to accomplish any and all of the following health literacy practice goals:
- •Urge the global use of a health literacy universal precautions approach and advocate for assuming all patients are at risk for not understanding health information (DeWalt et al, 2010,Koh et al, 2013).
- •Integrate patient-centered nursing practice elements that maximize patient engagement and health literacy into interprofessional practice models.
- •Assimilate patient-specific health literacy nursing diagnoses, nursing interventions, and patient predischarge self-management capabilities as components of the electronic medical record.
- •Promote shame-free environments where health literacy can flourish (Brach et al, 2012,Rudd, Anderson, 2006).
- •Use plain language and the teach-back method in all patient communications (Baker et al, 2011).
Health Care Systems
Health literacy is a priority area for patient safety and quality improvement in the U.S. health care system (
Nielsen-Bohlman et al, 2004
, U.S. Department of Health and Human Services, 2010
, U.S. Department of Health and Human Services, 2017
). Health literate care organizations are those that implement strategies universally and make it easier for all patients to navigate, understand, and use health information and services so they can take care of their health (Brach et al, 2012
).Recommendation: Collaborate with the IHI, AHRQ, the AMA Foundation, American Hospital Association, the American Organization of Nurse Executives (AONE), and other organizations to
- •promote organizational use of existing resources such as the Health Literacy Universal Precautions Toolkit (Brega et al, 2015), Building Health Literate Organizations: A Guidebook to Achieving Organizational Change (Abrams et al, 2014), Ten Attributes of Health Literate Health Care Organizations (Brach et al, 2012), and The Health Literacy Environment of Hospitals and Health Centers (Rudd, Anderson, 2006);
- •increase the use of health communication strategies, health information technology, and measures of patient postencounter self-management competency to monitor and improve health care quality and population health outcomes, and to achieve health equity (U.S. Department of Health and Human Services, 2017);
- •develop goals, accountability, and financial incentives for professionals in all health care settings to use evidence-based models and guidelines that improve health literacy and enhance patient engagement and empowerment;
- •build a business case for recruiting and retaining a diverse workforce with health literacy expertise (Brach et al, 2012); and
- •encourage and engage community partners to participate in the development and evaluation of health literacy initiatives (Brach et al, 2012).
Partnerships
Partnerships to promote health across specialties, professions, and sectors, are effective, because of alliances formed around values and common goals.
Recommendation: Develop and implement policies that promote health literacy to ensure consistency and sustainability.
- •Collaborate with nursing and other health care organizations to integrate nursing models of care for health literacy into Quality and Safety Education for Nurses (QSEN), Nursing Alliance for Quality Care, and other national health care initiatives to improve quality and patient safety.
- •Encourage nurse educators and leaders to use the Health Literacy Tapestry conceptual model (Parnell, 2015) in education and practice to describe and define health literacy across the continuum of care.
- •Urge The Joint Commission to evaluate successful incorporation of a health literacy universal precautions approach as a required component for attaining Joint Commission accreditation (Brach et al, 2012,Koh et al, 2013,Parnell, 2014).
- •Advocate for funding to evaluate nursing and other health literacy programs in education, practice, and systems of care.
- •Urge the American Nurses Credentialing Center to requiring evidence of health literacy initiatives and sustained achievements as a component of Magnet recognition.
Acknowledgments
This policy brief represents the work of the Health Literacy Task Force of the Quality Health Care Expert Panel of the American Academy of Nursing. The authors acknowledge the assistance provided by the members of the Quality Health Care Expert Panel, American Academy of Nursing Board Liaison Patricia Hinton Walker, PhD, RN, FAAN, PCC, and American Academy of Nursing Policy Manager and Staff Liaison, Matthew Williams, JD, MA.
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Article Info
Publication History
Published online: November 27, 2017
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© 2017 Elsevier Inc. All rights reserved.
