CERT Researcher Engages Nurses To Address Low Health Literacy
by Shelley Norden Barnes
Extensive research shows that people who have low health literacy have poorer health outcomes and higher medical costs. Carolyn Dickens, a nurse practitioner at the University of Illinois-Chicago and a member of the Northwestern University CERT, is challenging nurses to help reverse this trend. To do so, she believes, they need to understand how prevalent health illiteracy is and how it affects the overall wellness of many patients. Her goal is to raise awareness of low health literacy and show how nurses can address the problem with clear and simple communication strategies.
Low Health Literacy: A Pervasive Problem
Health literacy is multifaceted and includes a patient’s ability to navigate the health care system, to understand oral and written instructions, to read and interpret print materials, and to communicate concerns to a health care provider. According to health literacy experts, the ability of patients to understand their illness and what they can do to control it is critical for patients to maintain their health.
A 2003 study by the U.S. Department of Education found that 43 percent of participating adults have basic or below-basic health literacy.1 Many people can be anxious during medical encounters, and even highly literate patients may be overwhelmed by the complexities of the health care system. This is especially true of those populations that the U.S. Department of Education identified as most vulnerable: patients over age 65, racial or ethnic minorities, and patients whose incomes are at or below the U.S. poverty level.
Although there are documented ways to actually measure health literacy, the literature recommends that clinicians avoid these measures because of the shame and embarrassment patients may feel when they realize they are being tested on their literacy level.
In her experience with heart failure patients, Dickens has found that some try to mask their limited knowledge or understanding of their condition when she asks them questions. "Some of them might simply be embarrassed by their lack of understanding," she says. "I don’t think they are consciously trying to deceive me about their health literacy level but rather feel they need to somehow figure out the situation for themselves when they get home." Usually, patients are not able to do so.
Rallying Nurse Educators
Dickens and her colleague Mariann Piano recently published a review in the American Journal of Nursing that examines health literacy prevalence, definitions, and strategies nurses can use to assess and improve health literacy among their patients.2 Through this article, Dickens hopes to bring the issue of low health literacy to the forefront by helping nurses understand their unique role in addressing it and motivating them to take action.
"This article has struck a chord with people all over the country. Pharmacists and physicians have published literature on the topic, but the nursing perspective has been missing," says Dickens. "Nurses provide education on medications every single day, but there’s not a lot of literature related specifically to health literacy and nursing. So, there is a huge opportunity for nurses to get involved."
Dickens knows how difficult it can be to give instructions that patients will understand and remember, especially when it comes to prescription medications. "When patients with heart failure leave the hospital, we give them reams of paper explaining how they should take care of themselves. One of the most important documents is the list of medicines they need to take," she says. "They leave the hospital with their new prescriptions and their instructions, and a week later the only thing to remind them of what they were told are the labels on their prescription bottles."
Dickens continues, "Patients with heart failure also have to weigh themselves every morning and know what symptoms to look for that may indicate their condition is getting worse or that they need immediate care. Nurses play a major role in educating them. It’s our job to help patients understand what they need to do to stay healthy and out of the hospital."
While there are communications strategies that have been shown to improve health literacy, nurses often find these strategies difficult to implement. It takes a conscious effort to engage a patient and confirm what he or she understands. "You’re never supposed to ask them, 'Do you understand?,' which is what we’ve been trained to say," Dickens notes. "A patient usually replies 'Yes, I understand,' and then you find out that he or she did not."
Even for nurses who understand the impact of low health literacy, recognizing it in their own patients is a challenge. In another study,3 Dickens and her colleagues found that nurses often overestimate their patients’ health literacy levels. For this reason, Dickens believes it is important to raise awareness of the pervasiveness of low health literacy in certain patient groups among staff nurses who are directly involved in patient care. The rule of thumb she advocates is to treat every patient as if he or she has low health literacy.
Helping To Improve Health Literacy
In 2010, the Agency for Healthcare Research and Quality published a health literacy toolkit4 addressing ways in which health care organizations can tackle the problem of low health literacy. Topping the list was a directive to involve a committed leadership team, an idea that Dickens fully endorses.
"At our hospital, we are required to take annual competencies to keep up licensures and for accreditation. My push is to have the Northwestern CERT develop a 1-hour health literacy learning module that nurses will have to complete annually," she says. With low health literacy being a problem across the country, Dickens thinks that the responsibility lies with health care employers and professional nursing associations to provide continuing education courses related to health literacy.
Nurses in many community hospitals are often in charge of patient education materials because of their role as educators. Dickens recommends that they join together to produce materials that address low health literacy and improve patient comprehension. Doing so could not only impact individual patients in their institutions but also the health care system at large.
In addition to revamping written materials, Dickens stresses the importance of training nurses to use proven verbal methods to communicate with patients. One method is to ask patients what questions they have, rather than asking if they understand a set of instructions. Dickens also recommends using a communication tool—the teach-back method—in which the nurse asks the patient, "Can you repeat what I just told you?" This method has been shown to be useful in uncovering misunderstandings and in improving retention of information.
"A lot of research shows that using proven health literacy tools and educating patients correctly doesn’t take much more time than nurses are already spending," Dickens explains. Clearly, using new communication tools will not add an extra burden.
For more information on the health literacy research program at the Northwestern CERT, including a new study evaluating patient involvement in medication reconciliation, see the related article published by the National Patient Safety Foundation in its online journal Patient Safety InSight.5
The Centers for Education and Research on Therapeutics (CERTs) are a nationwide network of six research centers and a coordinating center that receive core financial support from the Agency for Healthcare Research and Quality. The CERTs conduct research and provide education that will advance the optimal use of drugs, medical devices, and biological products; increase awareness of the benefits and risks of therapeutics; and improve quality while cutting the costs of health care.
- Kutner M, Greenberg E, Jin Y, et al; National Center for Education Statistics. The Health Literacy of America’s Adults: Results From the 2003 National Assessment of Adult Literacy. NCES Publication No. 2006-83. Washington, DC: U.S. Department of Education; September 2006. Available at http://nces.ed.gov/pubs2006/2006483.pdf.
- Dickens C, Piano MR. Health literacy and nursing: an update. Am J Nurs. 2013 Jun;113(6):52-7. PMID: 23702767.
- Dickens C, Lambert BL, Cromwell T, et al. Nurse overestimation of patients’ health literacy. J Health Commun. 2013;18 Suppl 1:62-9. PMID: 24093346.
- Agency for Healthcare Research and Quality. Health Literacy Universal Precautions Toolkit. http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html. Accessed November 5, 2013.