03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside

Educating Nursing Students about

Health Literacy: From the Classroom
to the Patient Bedside

Kari Sand-Jecklin, EdD, MSN, RN, AHN-BC

Billie Murray, MSN, FNP-BC
Barbara 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 the
authors 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 impact
of this brief, health literacy education session. The analysis and results of this assessment indicated
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. Patient initiative in asking
for assistance in understanding health-related information was limited. Discussion and implications
of these findings for nursing education and nursing practice are provided.

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: The Online Journal of Issues in Nursing
Vol. 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

Todays healthcare environment is rapidly changing and becoming

increasingly complex. For patients who must navigate this complex system,
make informed healthcare decisions, and care for acute or chronic health It is imperative
conditions at home, the complexity of healthcare terminology, devices, and that...providers recognize
instructions can be overwhelming. If, in addition to this complexity, when patients are
patients have limited health literacy, managing their healthcare becomes struggling to understand
even more difficult. Although low health literacy levels have been health-related instructions,
associated with poorer patient health outcomes, many healthcare identify patients usual
professionals are unaware of which of their patients have health literacy means of compensating for
limitations; and often they do not know how to intervene appropriately with health literacy limitations,
these patients (Rogers, Wallace, & Weiss, 2006; Singleton, 2009). It is and intervene
imperative that we as healthcare providers recognize when patients are appropriately...
struggling to understand health-related instructions, identify patients usual
means of compensating for health literacy limitations, and intervene
appropriately to assure patients understanding of their health conditions
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 skilled in communicating with patients having low
health literacy levels.

In this article we will discuss the significance of inadequate health literacy and ways to identify and intervene with
patients who have limited health literacy. We will describe how we incorporated 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 clinical setting. 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 compensate for
their lack of understanding of health-related information.

Significance of the Health Literacy Problem

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles-Pr 1/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside

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 healthcare information and instructions. This
includes activities such as taking prescribed medications appropriately,
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 prescribed diet, 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% of adults 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 Black and Hispanic) and immigrant populations (Kutner et al.,
2006; Rudd, 2007; Singleton, 2009). United State citizens covered by Medicare and Medicaid insurance, and those
without insurance also 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 the complexity of healthcare
terminology and procedures (Cornett, 2009; IOM, 2004a).

Limited health literacy has been identified as having a significant impact

on patient health. Patients with lower health literacy levels experience
higher rates of hospitalization and emergency room use. They have Patients with lower health
overall poorer physical function, less knowledge about managing their literacy levels experience
chronic health conditions, and less participation in the healthcare higher rates of hospitalization
decision-making process. They also use fewer preventive care services and emergency room use.
(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 is costly, both
in terms of poorer health and the financial burden on the healthcare
system. It is estimated 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

Although healthcare providers often think that they are able to identify patients with limited health 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 to list and
describe the purpose of prescribed medications, limited questioning of the healthcare provider, 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 patients health 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 Vital Sign (TNVS) (Baker et al., 2007; Cutilli, 2005; Lehna & McNeil,
2008; Peterson, Dwyer, Mulvaney, Dietrich, & Rothman, 2007; Reeves, 2008; Rogers et al., 2006). However, all
these tests 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 they are 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, however, another approach to identifying patients with health

literacy limitations--one that is more efficient to administer and may
There is...[an] another elicit fewer negative feelings among patients. Chew has developed three
approach to identifying specific screening questions that have been shown to identify patients
patients with health literacy with low levels of health literacy (Chew, Bradley, & Boyko, 2004). These
limitations--one that is more questions, using a five-point Likert scale, ask patients: How confident
efficient to administer and are you in filling out medical forms by yourself? (response options
may elicit fewer negative range from Not at all Confident to Very Confident); How often do you
feelings among patients. have someone help you read hospital materials (responses range from
Always to Never); and How often 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 and
REALM tests, finding strong correlations between test scores. In a semi-structured interview with clinic patients
from an urban, underserved family medicine residency clinic, participants indicated that Chew and colleagues
questions were generally acceptable, particularly if asked in the privacy of the examination room (Farrell,
Chandran, & Gramling, 2008). All respondents felt that health literacy screening was worthwhile.

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles-Pr 2/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside
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 of understanding. In some cases, patient compensatory
behaviors (described below) may contribute to the failure to understand important health information. Without this
assessment data, it is difficult for health professionals to either support patients in using compensatory behaviors
that will promote understanding or suggest behaviors that would better help patients understand vital health
information.

Incorporating Health Literacy Content into Nursing Education Programs

Many nurses and other healthcare professionals have not been adequately trained in identifying and 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 taken place (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 issues when 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 review of 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 this knowledge 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 patients use 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 112 students (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, and only 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-test was 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 the instruction 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 health literacy, identifying via behavioral cues those patients who may have health literacy
issues, Chews three screening questions, and essential interventions in interacting with and teaching patients 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, students completed 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 to complete while caring for a
hospitalized patient. This added content included Chews three screening questions and questions asking patients
what they do when they have difficulty understanding 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 be valuable. At that point an application was
made to the West Virginia University Institutional Review 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 the brief 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

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles-Pr 3/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside

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 information remained in the data sheet containing the health literacy assessment
questions. Data were coded and 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 identified language 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 Chews criteria for health literacy risk.
Similarly, 38% of patients reported sometimes, often or always needing 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

Item Response Response Response Response Response

Confidence Extremely Quite Somewhat A little Not at all

in filling out confident confident confident confident confident
medical
forms n = 20 n = 32 n = 17 n = 12 n = 11

N = 92 (22%) (35%) (18%) (13%) (12%)

How often Never Occasionally Sometimes Often Always

need help
reading n = 29 n = 27 n=8 n =13 n = 14
hospital
(32%) (30%) (9%) (14%) (15%)
materials

N = 91

How often Never Occasionally Sometimes Often Always

problems
learning n = 34 n = 24 n = 18 n = 10 n=6
about health
(37%) (26%) (20%) (11%) (7%)
condition

N = 92

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 Sum of Test Statistics

Rank Ranks

Confidence filling out 49 54.92 2691.00 Mann-Whitney U 543.00

medical forms
41 34.24 1404.00 Wilcoxon W 1404.00
< 60 yrs old
Z -3.86
60 yrs and >
Sig (2-ailed) .000

How often need help 48 52.48 2519.00 Mann-Whitney U 625.00

reading hospital
materials 41 36.24 1486.00 Wilcoxon W 1486.00

< 60 yrs old Z

-3.06
60 yrs and >

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles-Pr 4/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside
Sig (2-tailed) .002

How often have 49 50.18 2459.00 Mann-Whitney U 775.00

problems learning about
health condition 41 39.90 1636.00 Wilcoxon W 1636.00

< 60 yrs old Z

-1.93
60 yrs and >
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 hospital materials; 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 of trouble 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 all three literacy questions were slightly lower
for patients reporting middle school education as opposed 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 ranks for 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 >Test Statistics

Rank

Confidence filling out medical > > >

forms
>17.50 >Chi-Square 28.14
Education Elementary >1
>16.08 >df 6
Middle school >6
>24.94 >Sig. .000
Some H. S. >8
>44.27
H. S. grad >46
>64.53
Some college >18
>57.00
College grad >12
>82.50
Graduate degree >1

Total 92

How often need help reading > > >

hospital material
>1 >21.00
Education Elementary > Chi-Square 18.96
>6 >18.25
Middle school
>8 >42.94 > df 6
Some H. S.
>46 >41.88 > Sig. .004
H. S. grad
>18 >62.03
Some college
>11 >53.82
College grad
>1 >77.00
Graduate degree

Total 91

How often have problems > > >

learning about health condition

Education Elementary >1 >25.50 > Chi-Square 24.19

Middle school >6 >12.50 > df 6
Some H. S. >8 >30.75
> Sig. .000
H. S. grad >46 >46.02

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles-Pr 5/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside
Some college >18 >64.22

College grad >12 >48.58

Graduate degree >1 >75.50

Total 92

Patient narrative responses to the questions asking what they did when they
had trouble understanding either written or verbal health information were
categorized according to theme and tallied. In reviewing the data it was Patients more frequently
noted that patients typically responded with only one answer or behavior, identified directing their
and sometimes provided general answers to the questions, such as ask questions to an RN as
questions or ask someone. Students had not been given instructions to opposed to their
prompt patients for specific behavioral responses or additional behaviors, if physician.
only one answer was given.

Patient responses to the question asking what they did if they were having trouble understanding written
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 questions to 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, these responses 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%)

Patient responses to the item asking what they do if they dont

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...
understand verbal instructions were, most commonly, to ask questions,
although patients often didnt identify to whom they would direct the
questions. When patients did specifically state whom they 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 do nothinga response that could contribute to
continued lack of understanding and adverse patient health outcomes.
Three patients indicated not having any difficulty understanding verbal
health information.

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%)

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles-Pr 6/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside

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 n = 3 (3%)

understanding

No response/missing n = 3 (3%)

Ask MD n = 1 (1%)

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 ...health literacy... should be
patient health literacy limitations, including making sure the patient threaded throughout the
understands the health information, using teach-back to assess patient entire nursing curriculum...
understanding, explaining the information in simple terms, using even a short education
alternative teaching forms and videos, assuring that patient family intervention can impact
members are present during teaching, presenting information in small student knowledge...
pieces, and using simple terms and explanations. The interventions
students identified in response to the assessment data reflected
appropriate application of health literacy principles.

Discussion and Implications

This section will discuss why these study findings should raise concern
among nurses and all healthcare professionals regarding the adequacy of
Nursing graduates must be patient comprehension of the health-related teaching they are given. Study
astute in identifying limitations will be addressed. Future directions will be identified.
patients who lack
understanding of health
information and who may
be using detrimental
behaviors to compensate
for a lack of
understanding.

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 a short education intervention can impact
student knowledge of critical health literacy issues. However, whether students continue to retain and use the
knowledge gained in this brief education 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 stressed in
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 information and instructions in a way that
promotes patient understanding, and (c) check for patient understanding (DeSilets & Dickerson, 2009; Speros,
2009).

The incidence of low health literacy among 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., Another...concern was that
2007). The finding that older patients and those reporting lower some patients would try
education levels are at higher risk for low health literacy is also again to understand...and
consistent with the literature (Kutner et al., 2006; Rudd, 2007; Speros, not ask questions, just let the
2009). issue go...[t]he likelihood
for adverse health outcomes
could be significantly
increased by patient
compensatory behaviors.

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles-Pr 7/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside

Patient compensatory behaviors for lack of understanding of health information have not been reported 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 written and verbally conveyed health information was to
ask a family member. The concern with this response is that family members may have no better understanding of
the health information than the 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. Another issue 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 regardless of understanding. These compensatory behaviors might result
in adverse outcomes, including patients 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 necessary self-
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 control group 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 literacy levels 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 asking what 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 the questions. 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 behaviors would 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 whom
patients would consult to clarify the health information they were given.

Implications

Results of this study have significant implications for nursing practice and
nursing education, as well as for guiding future research. Given the
Incorporation of simple and significance of low health literacy in the US, all nursing education programs
effective health literacy should be incorporating health literacy content throughout their
questions into all patient undergraduate and graduate curricula. Nursing graduates must be astute
assessment databases in identifying patients who lack understanding of health information and
would help to identify who may be using detrimental behaviors to compensate for a lack of
patients for whom health understanding. They must also be able to adapt patient education
literacy is an issue. interventions to assure patient understanding of vital health information.
Practicing nurses must be 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 an
education program would need to be identified and monitored, including
both measurement of patient understanding of health information
presented by nurses who had completed health literacy education, and also patient health outcomes.

Incorporation of simple and effective health literacy questions into all patient assessment databases would help to
identify patients for whom health literacy is an issue. Development and implementation of appropriate
interventions to assure patient understanding may significantly reduce 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 the front-line providers of patient education and information, are encouraged to take
the lead in demonstrating the value of health literacy assessment and the need for appropriate education
interventions to improve patient health outcomes.

Author

Kari Sand-Jecklin, EdD, MSN, RN, AHN-BC

E-mail:ksandjecklin@hsc.wvu.edu

Dr. Sand-Jecklin is an Associate Professor of nursing at West Virginia University (WVU). Her scholarly interests
include teaching/learning strategies, health literacy, and holistic/complementary nursing care. She has conducted
research studies in the areas of health literacy and nursing education. Dr. Sand-Jecklin has received the WVU
Outstanding Teacher Award for her work in the field of education.

Billie Murray, MSN, FNP-BC

E-mail: bmurray@hsc.wvu.edu

Ms. Murray is a Lecturer and Clinical Instructor in nursing at West Virginia University. Her research interests
include health literacy and patient self-medication management. She has received the WVU School of Nursing
Innovative Teaching Award for utilizing simulation as an education strategy.

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles-Pr 8/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside
Barbara Summers, MSN, RN
E-mail: bsummers@hsc.wvu.edu

Ms. Summers is a Lecturer and Clinical Instructor at West Virginia University School of Nursing. She teaches an
introductory freshman nursing course and a sophomore clinical course. Barbara has 36 years of clinical experience
in adult critical care. Her scholarly interests include team-based learning and simulation.

Joanne Watson MSN, RN

E-mail: jewatson@hsc.wvu.edu

Ms. Watson is a Senior Lecturer and Clinical Instructor at West Virginia University School of Nursing. She
coordinates the sophomore-level theory and clinical courses. Ms. Watson has 20 years of experience in Critical
Care/Emergency Nursing; she has taught nursing for 16 years. Her scholarly interests include clinical education
and evidence-based practice.

References

Baker, D. W., Gazmararian, J. A., Williams, M. V., Scott, T., Parker, R. M., Green, D., et al. (2002). Functional
health literacy and the risk of hospital admission among Medicare managed care enrollees. American Journal of
Public Health, 92(8), 1278-1283.

Baker, D. W., Wolf, M. S., Feinglass, J., Thompson, J. A., Gazmararian, J. A., & Huang, J. (2007). Health literacy
and mortality among elderly persons. Archives of Internal Medicine, 167(14), 1503-1509.

Chew, L. D., Bradley, K. A., & Boyko, E. J. (2004). Brief Questions to identify patients with inadequate health
literacy. Family Medicine, 36(8), 588-594.

Chew, L. D., Griffin, J. M., Partin, M. R., Noorbaloochi, S., Grill, J. P., Snyder, A., et al. (2008). Validation of
screening questions for limited health literacy in a large VA outpatient population. Journal of General Internal
Medicine, 23(5), 561-566.

Cornett, S. (Sept 30, 2009). Assessing and addressing health literacy. [Electronic Version]. OJIN: The Online
Journal of Issues in Nursing, 14, 12. Retrieved November 4, 2009 from
www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol142009/No
3Sept09/Assessing-Health-Literacy-.aspx.

Cutilli, C. (2005). Do your patients understand? Determining your patients health literacy skills. Orthopaedic
Nursing 24(5), 372-377.

DeSilets, L. D., & Dickerson, P. S. (2009). Filling gaps in knowledge: educating nurses to provide appropriate
patient materials. The Journal of Continuing Education in Nursing 40(4), 148-149.

Dewalt, D. A., Berkman, N. D., Sheridan, S., Lohr, K. N., & Pignone, M. P. (2004). Literacy and health outcomes: a
systematic review of the literature. Journal of General Internal Medicine, 19(12), 1228-1239.

DeWalt, D. A., Boone, R. S., & Pignone, M. P. (2007). Literacy and its relationship with self-efficacy, trust, and
participation in medical decision making. American Journal of Health Behavior, 31 Suppl 1, S27-35.

Farrell, T. W., Chandran, R., & Gramling, R. (2008). Understanding the role of shame in the clinical assessment of
health literacy. Family Medicine, 4(4), 235-236.

Fernandez, L., & Schillinger, D. (2009). Literacy and Patient Care.

Hess, J., & Whelan, J. (2009). Making health literacy real: adult literacy and medical students teach each other.
Journal of the Medical Library Association, 97(3), 221-224.

Institute of Medicine. (2004a). Health Literacy: A Prescription to end Confusion, Report Brief.

Institute of Medicine. (2004b). Health literacy: A prescription to end confusion. Washington DC: Institute of
Medicine, Board on Neuroscience and Behavioral Health, Committee on Health literacy.

Joint Commission on Accreditation of Healthcare Organizations. (2005). Comprehensive accreditation manual for
hospitals: the official handbook: Standards, rationales, elements of performance, scoring. . Oakbrook Terrace, Il.:
Joint Commission Resources.

Katz, M. G., Jacobson, T. A., Veledar, E., & Kripalani, S. (2007). Patient literacy and question-asking behavior
during the medical encounter: a mixed-methods analysis. Journal of General Internal Medicine, 22(6), 782-786.

Kutner, M., E., G., Jin, Y., & C., P. (2006). The health literacy of America's Adults: Results from the 2003 National
Assessment of Adult Literacy (No. NCES 2006-483). Washington, DC: U.S. Department of Education: National
Center for Education Statistics.

Lehna, C., & McNeil, J. (2008). Mixed-methods exploration of parents' health information understanding. Clinical
Nursing Research, 17(2), 133-144.

Lorenzen, B., Melby, C., & Earles, B. (2008). Using principles of health literacy to enhance the informed consent
process. AORN Journal, 88(1), 23-29.

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles-Pr 9/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside
Paasche-Orlow, M. K., & Wolf, M. S. (2008). Evidence does not support clinical screening of literacy. J Gen Intern
Med, 23(1), 100-102.

Parker, R. M., & Gazmararian, J. A. (2003). Health literacy: essential for health communication. Journal of Health
Communication, 8, 1116-1118.

Peterson, N. B., Dwyer, K. A., Mulvaney, S. A., Dietrich, M. S., & Rothman, R. L. (2007). The influence of health
literacy on colorectal cancer screening knowledge, beliefs and behavior. Journal of the National Medical
Association, 99(10), 1105-1112.

Reeves, K. (2008). Health literacy: the newest vital sign. MEDSURG Nursing, 17(5), 288, 296.

Rogers, E. S., Wallace, L. S., & Weiss, B. D. (2006). Misperceptions of medical understanding in low-literacy
patients: implications for cancer prevention. Cancer Control, 13(3), 225-229.

Rudd, R. E. (2007). Health literacy skills of U.S. adults. American Journal of Health Behaviors, 31 Suppl 1, S8-18.

Singleton, K. (Sept. 30, 2009). Understanding cultural and linguistic barriers to health literacy. OJIN: The Online
Journal of Issues in Nursing, 14(3, manuscript 4.), 11.

Speros, C. (Sept. 30, 2009). More than words: promoting health literacy in older adults. OJIN: The Online Journal
of Issues in Nursing, 14(3, manuscript 5.), 10.

US Department of Health and Human Services. (2000). Healthy People 2010. Washington DC: US Government
Printing Office.

Vernon, J. A., Trujillo, A., Rosenbaum, S., & DeBuono, B. (2007). Low health literacy: Implications for national
health policy. [Electronic Version], 12. Retrieved November 20, 2009 from
www.clearhealthcommunication.com/pdf/Low-Health-Literacy_Implications-for-National-Health-Policy.pdf.

Wallace, L. S., Cassada, D. C., Rogers, E. S., Freeman, M. B., Grandas, O. H., Stevens, S. L., et al. (2007). Can
screening items identify surgery patients at risk of limited health literacy? Journal of Surgical Research, 140(2),
208-213.

Wallace, L. S., Rogers, E. S., Roskos, S. E., Holiday, D. B., & Weiss, B. D. (2006). Brief report: screening items to
identify patients with limited health literacy skills. Journal of General Internal Medicine, 21(8), 874-877.

2010 OJIN: The Online Journal of Issues in Nursing

Article published July 23, 2010

Related Articles
Assessing and Addressing Health Literacy
Sandy Cornett, PhD, RN (September 30, 2009)

Validation of the English and Spanish Mammography Beliefs and Attitudes Questionnaire
Gloria Lopez-McKee, PhD, RN; Julia Bader, PhD (March 21, 2011)

Development of the Mammography Beliefs and Attitudes Questionnaire for Low-Health-Literacy

Mexican-American Women
Gloria Lopez-McKee, PhD, RN (November 24, 2010)

Enhancing Written Communications to Address Health Literacy

Gloria Mayer, EdD, RN, FAAN; Michael Villaire, MSLM (September 30, 2009)

Promoting Health Literacy Through Storytelling

Vivian Day, BSHCA, MHA, RN (September 30, 2009)

More than Words: Promoting Health Literacy in Older Adults

Carolyn I. Speros, DNSc, APRN, ANP/FNP-BC (September 30, 2009)

Health Literacy: Challenges and Strategies

Nichole Egbert, PhD; Kevin M. Nanna, MSN, RN, BC-NE (September 30, 2009)

Understanding Cultural and Linguistic Barriers to Health Literacy

Kate Singleton, MSW; Elizabeth M. S. Krause, AB, SM (September 30, 2009)

Electronic Personal Health Records That Promote Self-Management in Chronic Illness

Beverly Mitchell, BScN, MSN, RN; Deborah L. Begoray, PhD (July 20, 2010)

Follow Us on:

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles- 10/11
03/11/2017 Educating Nursing Students about Health Literacy: From the Classroom to the Patient Bedside

2017 The American Nurses Association, Inc. All Rights Reserved

American Nurses Association - 8515 Georgia Avenue - Suite 400 - Silver Spring, MD 20910
ISSN: 1091-3734 | 1-800-274-4ANA | Copyright Policy | Privacy Statement

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol152010/No3-Sept-2010/Articles- 11/11