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Call for action: Nurses must play a critical role to enhance health literacy

Published:November 27, 2017DOI:https://doi.org/10.1016/j.outlook.2017.11.003

      Executive Summary

      Health literacy is a precursor to health and achievement of a culture of health (
      • Barton A.J.
      • Allen P.E.
      • Boyle D.K.
      • Loan L.A.
      • Stichler J.F.
      • Parnell T.A.
      Health literacy: Essential for a culture of health.
      ). 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 A.G.
      • Barnard J.
      • Mabachi N.M.
      • Weiss B.D.
      • DeWalt D.A.
      • Brach C.
      • West D.R.
      Health literacy universal precautions toolkit.
      ). 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 A.G.
      • Barnard J.
      • Mabachi N.M.
      • Weiss B.D.
      • DeWalt D.A.
      • Brach C.
      • West D.R.
      Health literacy universal precautions toolkit.
      ). 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 M.
      • Greenberg E.
      • Jin Y.
      • Paulsen C.
      The health literacy of America's adults: Results from the 2003 National Assessment of Adult Literacy.
      ). Individuals with low health literacy are more likely to experience poor health status (
      • DeWalt D.A.
      • Berkman N.D.
      • Sheridan S.
      • Lohr K.N.
      • Pignone M.
      Literacy and health outcomes: A systematic review of the literature.
      ).
      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 R.A.
      • Wong W.F.
      • Villaire M.
      • Daus G.
      • Parnell T.A.
      • Willis E.
      • Paasche-Orlow M.K.
      Health literacy: A necessary element for achieving health equity.
      ).
      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
      Health literacy: A prescription to end confusion.
      ). 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 D.
      The evolving concept of health literacy.
      ).
      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 B.D.
      Health literacy and patient safety: Help patients understand. Manual for clinicians.
      ). 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 T.A.
      Nursing leadership strategies, health literacy, and patient outcomes.
      ).
      The dialogue about antecedents to and consequences of low health literacy is ubiquitous; calls for its status as a universal precaution exist (
      • DeWalt D.A.
      • Callahan L.F.
      • Hawk V.H.
      • Broucksou K.A.
      • Hink A.
      • Rudd R.
      • Brach C.
      Health literacy universal precautions toolkit.
      ). Agencies and organizations such as the Agency for Healthcare Research and Quality (AHRQ) (
      • Anonymous
      AHRQ health literacy universal precautions toolkit.
      ), the
      • Centers for Disease Control and Prevention
      Health literacy.
      , the , the , the American Hospital Association's Hospital in Pursuit of Excellence platform (
      • American Hospital Association (AMA)
      Hospitals in Pursuit of Excellence Platform (HOPE).
      ), and the AMA Foundation (
      • Weiss B.D.
      Health literacy and patient safety: Help patients understand. Manual for clinicians.
      ) 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 D.
      • Piette J.
      • Grumbach K.
      • Wang F.
      • Wilson C.
      • Daher C.
      • Bindman A.B.
      Closing the loop: Physician communication with diabetic patients who have low health literacy.
      ). 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 A.J.
      • Allen P.E.
      • Boyle D.K.
      • Loan L.A.
      • Stichler J.F.
      • Parnell T.A.
      Health literacy: Essential for a culture of health.
      ). Patient engagement is well recognized as a cornerstone of successful health care reform (
      • Pelletier L.R.
      • Stichler J.F.
      Action brief: Patient engagement and activation: A health reform imperative and improvement opportunity for nursing.
      ,
      • Pelletier L.R.
      • Stitchler J.F.
      Patient-centered care and engagement: Nurse leaders imperative for health reform.
      ), and health literacy is fundamental to engaging patients in their own health (
      • Koh H.K.
      • Brach C.
      • Harris L.M.
      • Parchman M.L.
      A proposed health literate care model would constitute a systems approach to improving a systems approach to improving patient's engagement in care.
      ). 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 ().
      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 T.A.
      Health literacy in nursing: Providing person-centered care.
      ,
      • Pelletier L.R.
      • Stichler J.F.
      Action brief: Patient engagement and activation: A health reform imperative and improvement opportunity for nursing.
      ,
      • Pelletier L.R.
      • Stitchler J.F.
      Patient-centered care and engagement: Nurse leaders imperative for health reform.
      ).

      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
      National action plan to improve health literacy.
      ). 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
      “What did the doctor say?:” Improving health literacy to protect patient safety.
      ). 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 T.A.
      Health literacy in nursing: Providing person-centered care.
      ), 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:

      Health Care Systems

      Health literacy is a priority area for patient safety and quality improvement in the U.S. health care system (
      ,
      • U.S. Department of Health and Human Services
      National action plan to improve health literacy.
      ,
      • U.S. Department of Health and Human Services
      Healthy People 2020 topics & objectives: Health communication and health information technology.
      ). 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 C.
      • Keller D.
      • Hernandez L.M.
      • Baur C.
      • Parker R.
      • Dreyer B.
      • Schillinger D.
      Ten attributes of health literate health care organizations.
      ).
      Recommendation: Collaborate with the IHI, AHRQ, the AMA Foundation, American Hospital Association, the American Organization of Nurse Executives (AONE), and other organizations to

      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 T.A.
        Health literacy in nursing: Providing person-centered care.
        ) 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 C.
        • Keller D.
        • Hernandez L.M.
        • Baur C.
        • Parker R.
        • Dreyer B.
        • Schillinger D.
        Ten attributes of health literate health care organizations.
        ,
        • Koh H.K.
        • Brach C.
        • Harris L.M.
        • Parchman M.L.
        A proposed health literate care model would constitute a systems approach to improving a systems approach to improving patient's engagement in care.
        ,
        • Parnell T.A.
        Nursing leadership strategies, health literacy, and patient outcomes.
        ).
      • 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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