Health Literacy: Essential for a Culture of Health

Amy J. Barton, PhD, RN, FAAN; Patricia E. Allen, EdD, RN, CNE, ANEF, FAAN; Diane K. Boyle,
PhD, RN, FAAN; Lori A. Loan, PhD, RN, FAAN; Jaynelle F. Stichler, DNSc, RN, NEA-BC, FACHE,
FAAN; and Terri Ann Parnell, DNP, MA, RN, FAAN

tunity to make choices that lead to the healthiest lives

abstract possible.
l Business, government, individuals, and organizations

Background: A culture of health requires a com- work together to build healthy communities and lifestyles.
mitment from all—individuals, families, communities, l No one is excluded.

organizations, and municipalities—to value health l Everyone has access to affordable, quality health care

and make decisions reflective of a healthy society. At because it is essential to maintain, or reclaim, health.
the individual level, health literacy is a necessary pre- l Health care is efficient and equitable.

cursor to assist individuals in achieving a higher level l The economy is less burdened by excessive and unwar-

of health. ranted health care spending.

Method: One method for ensuring that staff mem- l Keeping everyone as healthy as possible guides public

bers are routinely assessing and promoting health lit- and private decision making.
eracy is using competencies and practices previously l Americans understand that we are all in this together.

identified for all health professions. A culture of health requires all individuals, families,
Results: Cross-walking these competencies with the communities organizations, professionals and cities to
Health Literacy Tapestry model can be extremely help-
ful in framing assessment, action steps, and outcomes
for nurses. Dr. Barton is Professor, Daniel & Janet Mordecai Rural Health Nurs-
ing Endowed Chair, and Associate Dean for Clinical and Community Af-
Conclusion: Professional development nurse lead-
fairs, University of Colorado, College of Nursing, Aurora, Colorado; Dr.
ers have the challenge of ensuring that nurses are Allen is Professor and University Distinguished Faculty, Texas Tech Univer-
addressing patient health literacy as a fundamental sity Health Sciences Center School of Nursing, Lubbock, Texas; Dr. Boyle
nursing activity in every nursing–patient–family inter- is Wyoming Excellence Chair in Nursing and Professor, Fay W. Whitney
action. Assuming health literacy deficits as a “universal School of Nursing, University of Wyoming, Laramie, Wyoming; Dr. Loan
is Associate Professor, Family, Community, & Health Systems, University of
approach” to care is one method of ensuring health
Alabama School of Nursing, Birmingham, Alabama; Dr. Stichler is Profes-
literacy needs are routinely addressed by staff. sor Emerita, San Diego State University and Professional Development &
J Contin Educ Nurs. 2018;49(2):73-78. Research Consultant, Sharp Memorial & Sharp Mary Birch Hospital for
Women & Newborns, San Diego, California; and Dr. Parnell is Clinical
Associate Professor, School of Health Technology and Management, Stony

T
Brook University, Southampton, New York, and also Principal and Found-
he vision for a culture of health (Robert Wood er, Health Literacy Partners, LLC, New York, New York.
Johnson Foundation, 2017, para. 1) is based on The authors have disclosed no potential conflicts of interest, financial
10 principles: or otherwise.
l Good health flourishes across geographic, demograph- Address correspondence to Patricia E. Allen, EdD, RN, CNE, ANEF,
ic, and social sectors. FAAN, Professor and University Distinguished Faculty, Texas Tech Univer-
l Attaining the best health possible is valued by our en-
sity Health Sciences Center School of Nursing, 3601 4th Street, Lubbock,
TX 79430; e-mail: [email protected].
tire society. Received: May 23, 2017; Accepted: October 25, 2017
l Individuals and families have the means and the oppor-
doi:10.3928/00220124-20180116-06

The Journal of Continuing Education in Nursing · Vol 49, No 2, 2018 73

make decisions promoting a healthy society. At the indi- terminology, the anxiety or confusion of the moment, or
vidual level, health literacy (i.e., the degree to which in- the complexity of the issue at hand. The National Acad-
dividuals have the capacity to obtain, communicate, pro- emies of Sciences, Engineering and Medicine, Health and
cess, and understand basic health information and services Medicine Division (2016) noted even those with strong
so they may make appropriate health decisions [Centers health literacy can struggle with recall of information pre-
for Disease Control and Prevention, 2013]) is a necessary sented verbally, as there are two parts in understanding the
precursor to assist individuals in achieving a higher level complexity of health literacy. The first is communication
of health. Collaborating with a commitment to health lit- (written and verbal), and the second is numeracy (num-
eracy will assist in eliminating barriers and improving ac- bers, graphics, and diagrams) (Palumbo, 2016).
cess to understandable and actionable health information Nurses can engage in health literacy practices and com-
so everyone can achieve better health (U.S. Department of petencies, which are patient-centered standards designed
Health and Human Services, 2010). to minimize the negative outcomes of low or limited
Several federal reports have proclaimed the impor- health literacy and improve health-related outcomes (Bar-
tance of health literacy from a public health or population rett, Puryear, & Westpheling, 2008). In a recent Delphi
health perspective (Agency for Healthcare Research and study, Coleman, Hudson, and Maine (2013) achieved
Quality, 2017; The National Academies of Sciences, Engi- consensus on 24 knowledge competencies, 27 skill com-
neering, and Medicine, 2015; U.S. Department of Health petencies, 11 attitude competencies, and 32 practice
and Human Services, 2010). However, few have provided competencies in health literacy that all health care profes-
strong guidance for nurses within the acute care environ- sionals should achieve. The practices range from eliciting
ment. Therefore, we must look at emerging research on a full range of the patient’s concerns at the onset of the
health literacy and identify key nursing competencies and visit to negotiating a mutual agenda at the first interac-
essential practices to promote health literacy among hos- tion, speaking slowly and clearly using plain language or
pitalized patients. an interpreter as needed, to routinely referring the patient
Survey findings from the past 10 years show the U.S. to resources to enhance his or her literacy (Coleman et al.,
health care system has not prioritized health literacy as an 2013). However, dissemination of these competencies to
essential component of health care delivery. More than staff nurses has been inconsistent.
one third of adults in the United States still demonstrate
low health literacy; for example, 77 million people have A CONCEPTUAL MODEL OF HEALTH LITERACY
difficulty following directions on a prescription (Centers The health literacy tapestry model provides the struc-
for Disease Control and Prevention, 2013; U.S. Depart- ture for organizing potential nursing practices and compe-
ment of Health and Human Services, 2010). Health lit- tencies to support health literacy (Parnell, 2015). Parnell,
eracy is foundational for individuals’ ability to assume re- Stichler, & Barton (2017) described the health literacy
sponsibility for their health care, as well as the health of tapestry using a holistic nursing approach that fosters a
their family and community. Low health literacy leads to partnership that affects individuals, nurses, and the health
a continuum of poor outcomes, including “poorer ability care system and is illustrated by interwoven threads (an-
to demonstrate taking medications properly and interpret tecedents) and fibers (domains). The three basic domains
medication labels and health messages and, among elderly of health literacy are oral communication, written com-
persons, poorer overall health status and higher mortal- munication, and environmental communication, which
ity” (Berkman, Sheridan, Donahue, Halperin, & Crotty, comprises access to care and navigation within the health
2011, p. 7). By contrast, patients and families engaged in care delivery system. These domains are centered on the
their care have improved health outcomes (Carman et al., existence of misconceptions and unconscious bias that
2014; Pelletier & Stichler, 2013). may influence provider–patient interactions from both
perspectives. The threads of the model consist of con-
EXPLORING WHO IS AT RISK textual factors that may influence an individual’s level of
Previous researchers have identified “at-risk popula- health literacy and include the media and marketplace,
tions” for limited health literacy to include older adults, health knowledge and experience, demographics, overall
minorities, and individuals with cognitive decline, low health status, community support, and cultural, spiritual
education levels, low socioeconomic status, and limited and social influences.
English proficiency (Kobayashi, Wardle, Wolf, & von To make the model “actionable” for nurses in health
Wagner, 2015). However, health literacy does cross all age care settings, the Table provides a cross-walk of health lit-
groups and ethnicities, and, at times, even those who may eracy practice competencies identified by Coleman et al.
typically have high literacy are challenged with medical (2013) within the health literacy domains of oral com-

74 Copyright © SLACK Incorporated

munication, written communication, and environmen- motion, we again revisit the challenge of ensuring health
tal communication. Competencies for oral and written literacy. Therefore, nurses and other care providers need
communication include use of clear and simple language enhanced knowledge and skills in implementing health
and eliminating the use of jargon. Use of the teach back literacy strategies to meet the diverse needs of all patients
method is essential so that patients demonstrate what they and to support improved patient outcomes. The following
have been taught. Competencies concerning environmen- link highlights the skills needed for all health professionals
tal communication include navigation within a hospital or via a brief tutorial and quiz for the health team members:
clinic, instructions for follow-up, and links to community https://www.cdc.gov/healthliteracy/training/page669.
resources. html (Centers for Disease Control and Prevention, 2013).
The central competency is the use of a universal pre- In exploring the complex concept of health literacy, we
cautions approach to health literacy. The Agency for acknowledge the need for integration of health literacy
Healthcare Research and Quality (2017) identified the knowledge and competency skills into nursing education
term health literacy universal precautions in the creation curricula. In addition, continuing professional develop-
of a health literacy “universal precautions toolkit.” Even ment is essential to employ evidence-based findings given
though use of the term, universal precautions, may gener- the relationship of health literacy to patient safety and
ate confusion in its association with blood and body fluids outcomes, patient-centered care, engagement, and the
precautions, the notion that everyone may have difficulty movement to a culture of health.
understanding health information and accessing health For nurses, health literacy is not addressed adequately
care services is important for nurses to embrace. The prac- by checking a box on the health record after asking the
tice of health literacy universal precautions is as important patient and family how best they learn. Health literacy is
for nurses to embrace as good hand washing practices. an old concept in nursing and health care, but it is also a
The Health Literacy Tapestry model recently has been complex issue as the United States continues to experience
expanded to include the concepts of patient empower- a demographic transformation and a health care system
ment, engagement, and activation (Parnell et al., 2017). that is uncertain and shifting to a value-based payment
“Empowerment relates to providing patients with access model. The result is a new sense of urgency for nurses to
to information, education, support, and skills that facili- promote health literacy. Therefore, nurses need to learn ac-
tates their role as partners with providers in decisions and tionable practices to change clinical practice and enhance
actions in their own care” (Pelletier & Stichler, 2013, p. patient outcomes. We recommend health literacy be con-
52). Once patients are empowered, they are more likely to sidered in every type of patient education to enhance the
be engaged in their health journey and part of the decision patient’s ability to access, understand, and engage in self-
making process. Health literacy enhances engagement at management of their care. The mantra of “every patient,
all levels and provides a level of activation for patients to every time” should apply to health literacy practices.
successfully manage their health. The lower section of the Do your clinical nurses and other providers routinely
Table lists the health literacy practice competencies that assess patients’ health literacy and use standardized nurs-
map to the concepts of patient engagement, empower- ing behaviors to promote health literacy and evaluate pa-
ment, and activation. The competencies listed facilitate tient outcomes? One method to ensure all clinical nurses
a collaborative approach to teaching and initial efforts at are routinely using a universal precautions approach and
shared understanding. promoting health literacy strategies is using competen-
cies and practices previously identified by Coleman et al.
ROLE OF PROFESSIONAL DEVELOPMENT IN (2013) for all health professions. Further, cross-walking
ENSURING THE HEALTH LITERACY COMPETENCY these competencies with the health literacy tapestry model
OF CARE PROVIDERS (Parnell, 2015) can be extremely helpful in framing assess-
The National Academies of Sciences, Engineering and ment, action steps, and outcomes for your clinical nurses
Medicine, Health and Medicine Division (2016) noted as they assume responsibility for implementing health lit-
that health literacy is not only about patients’ abilities eracy strategies.
to make decisions during episodic or chronic care but
also about health and fitness, nutrition, prevention, and PRACTICES AND COMPETENCIES FOR THE
other behaviors and decisions influencing optimal health PROMOTION OF HEALTH LITERACY
and well-being. To build a culture of health care enhanc- As key members of the health care team, nurses play a
ing patients, families, and communities’ health literacy is major role in boosting health literacy to move beyond the
a challenge for all members of the health care team. As current “cycle of crisis care” system to the triple aim of
we move to a health care system focused on health pro- improving the patient experience of care (including qual-

The Journal of Continuing Education in Nursing · Vol 49, No 2, 2018 75

 TABLE

CROSS-WALK OF HEALTH LITERACY PRACTICE COMPETENCIES WITHIN TAPESTRY MODEL DOMAINS

Tapestry Domain Health Literacy Practice Competency
Oral communication Routinely recommends the use of professional medial interpreter services for patients whose preferred language
is other than English
Consistently speaks slowly and clearly with patients
Routinely uses verbal and non-verbal listening techniques
Consistently avoids using medical jargon in oral communication with patients, and defines unavoidable jargon
in lay terms
Routinely conveys numeric information, such as risk, using low numeracy approaches
Consistently uses health literacy universal precautions approach to oral communication with patients
Routinely uses short action-oriented statements, focused on answering patient’s questions, “What do I need to
do?”
Routinely documents in the medical record that a teach back, or closed communication loop technique has
been used to check the patient’s level of understanding at the end of the encounter
Written communication Routinely puts information into context by using subject headings in written communication with patients
Consistently follows principles of easy to read formatting when writing for patients, including the use of short
sentences and paragraphs, and the use of bulleted lists rather than denser blocks of text, when appropriate
Routinely writes in English at approximately the fifth to sixth grade reading level
Consistently writes or rewrites (i.e., translates) unambiguous medication instructions when called for during
regular duties
Routinely encourages and facilitates patients to carry an updated list of their medications with them
Consistently uses a health literacy universal precautions approach to written communication with patients
Consistently avoids using medical jargon in written communication with patients, and defines unavoidable
jargon in lay terms
Consistently locates and uses literacy-appropriate patient education materials, when needed and available, to
reinforce oral communication, and reviews such materials with patients, underlining or highlighting key infor-
mation
Environmental Routinely anticipates and addresses navigational barriers within health care systems and share responsibility with
communication patients for understanding and navigating systems and processes; attempts to make systems and processes as
transparent as possible
Consistently treats the diagnosis of limited health literacy as “protected health information” requiring specific
“release of information” for disclosure
Routinely refers patients to appropriate community resources for enhancing literacy or health literacy skills (e.g.,
adult basic literacy education) within the context of the therapeutic relationship
Routinely arranges for timely follow-up when communication errors are anticipated

ity and satisfaction), improving the health of populations, teaching by incorporating the teach-back method are all
and reducing the per capita cost of health care (Koh et al., health literacy principles that support patient centered-
2012, p. 434). Nurses are employed across many areas of ness. An awareness of what affects a patient’s level of health
health care, public health, and community organizations literacy and the corresponding related nursing actions is
and are uniquely positioned to create a cultural change in foundational to providing safe, equitable health care.
health care that will shift the focus to optimizing health Using these recommended practices in everyday pa-
and well-being (Parnell, 2014). Nurses must consider a tient interactions is only addressing one side of the health
patient-centered approach by respectfully asking patients, literacy challenge. Just as resources are needed to support
“What questions do you have?” rather than “Do you have patients in becoming health literate, the organization
any questions?” Asking patients about their preferred lan- also must address health literacy. Organizations can start
guage to discuss health care, always speaking in plain lan- by considering the competencies within environmental
guage, and ascertaining whether they were clear in their communication and recognizing the challenges faced by

76 Copyright © SLACK Incorporated

 TABLE (cont’d)

CROSS-WALK OF HEALTH LITERACY PRACTICE COMPETENCIES WITHIN TAPESTRY MODEL DOMAINS

Tapestry Domain Health Literacy Practice Competency
Engagement, empow- Consistently elicits the full list of patient concerns at the outset of encounters
erment, and activation
Consistently negotiates a mutual agenda with patient at the outset of encounters
When preparing to educate patients, routinely asks about patients’ preferred learning style in a nonshaming
manner
Routinely elicits patients’ prior understanding of their health issues in a non-shaming manner
Routinely emphasizes one to three “need to know” or “need to do” concepts during a given patient encounter
Routinely makes instructions interactive, such that patients engage the information, to facilitate retention and
recall
Routinely assesses adherence to treatment recommendations, and root causes for nonadherence, nonjudgmen-
tally, before recommending changes to treatment plans
Consistently elicits questions from patients through a “patient-centered” approach (e.g., “What questions do
you have?” rather than “Do you have any questions?”
Routinely ensures that patients understand at minimum: (a) what their main problem is, (b) what is recom-
mended that they do about it, and (c) why this is important
Routinely uses a teach-back or “show me” technique to check for understanding and correct misunderstandings
in a variety of health care settings, including during the informed consent process
Adapted from Coleman, Hudson, & Maine (2013).

patients with low health literacy within their walls (Pa- Berkman, N.D., Sheridan, S.L., Donahue, K.E., Halpern, D.J., & Crot-
ty, K. (2011). Low health literacy and health outcomes: An updated
lumbo, 2016). systematic review. Annals of Internal Medicine, 155, 97-107.
Carman, K.L., Dardess, P., Maurer, M.E., Workman, T., Ganachari, D.,
RECOMMENDATIONS AND CONCLUSION & Pathak-Sen, E. (2014). A roadmap for patient and family engagement
Professional development nurse leaders have the re- in healthcare practice and research. Palo Alto, CA: Gordon and Betty
sponsibility of ensuring clinical nurses are implement- Moore Foundation. Retrieved from http://patientfamilyengagement.
org
ing a health literacy universal precautions approach as Centers for Disease Control and Prevention. (2013). Health literacy for
a foundational nursing activity in every nurse–patient– public health professionals. Retrieved from https://www.train.org/
family interaction. Advocating this universal approach cdctrain/course/1057675/
to health care delivery is one method to ensure that all Coleman, C.A., Hudson, S., & Maine, L.L. (2013). Health literacy prac-
clinical nurses and other care providers use clear effec- tices and educational competencies for health professionals: A consen-
sus study. Journal of Health Communication, 18, 82-102.
tive communication with all patients, regardless of their Kobayashi, L.C., Wardle, J., Wolf, M.S., & von Wagner, C. (2015).
perceived health literacy skills (National Action Plan; Cognitive function and health literacy decline in a cohort of aging
U.S. Department of Health and Human Services, 2010) English adults. Journal of General Internal Medicine, 30, 958-964.
In addition, recommending that clinical nurses use the doi:10.1007/s11606-015-3206-9.
health literacy tapestry model cross walked with the Koh, H.K,. Berwick, D.M., Clancy, C. M., Baur, C., Brach, C., Har-
riss. L. M., & Zerhusen, E. G. (2012). New federal policy initiatives
competencies and practices identified by Coleman et al. to boost health literacy can help the nation move beyond the cycle
(2013) in the Table will provide nurses with a model to of costly “Crisis Care.” Health Affairs, 31, 434-443. doi:10:1377/
follow when providing patient- and family-centered care. hlthaff.2011.1169
The National Academies of Sciences, Engineering, and Medicine. (2015).
REFERENCES Health literacy: Past, present, and future: Workshop summary. Washing-
Agency for Healthcare Research and Quality. (2017). AHRQ health ton, DC: The National Academies Press.
literacy universal precautions toolkit. Rockville, MD: Author. Re- The National Academies of Sciences, Engineering and Medicine, Health
trieved from http://www.ahrq.gov/professionals/quality-patient- and Medicine Division. (2016). Relevance of health literacy to precision
safety/quality-resources/tools/literacy-toolkit/index.html medicine. Workshop in brief. Retrieved from http://nationalacademies.
Barrett, S.E., Puryear, J.S., & Westpheling, K. (2008). Health literacy org/hmd/activities/publichealth/healthliteracy/Relevance-of-Health-
practices in primary care settings. Examples from the field. Washington, Literacy-to-Precision-Medicine-SWIB.aspx
DC: The Commonwealth Fund. Palumbo, R. (2016). Designing health-literate health care organization:
A literature review. Health Services Research Management, 29, 79-87.

The Journal of Continuing Education in Nursing · Vol 49, No 2, 2018 77

Parnell, T.A. (2014). Nursing leadership strategies, health literacy, and tunity for nursing. Nursing Outlook, 61, 51-54.
patient outcomes. Nurse Leader, 12(6), 49-52. Robert Wood Johnson Foundation. (2017). How we got here. Retrieved from
Parnell, T.A. (2015). Health literacy in nursing: Providing person-centered https://www.cultureofhealth.org/en/about/how-we-got-here.html#ten-
care. New York, NY: Springer. underlying-principles
Parnell, T.A., Stichler, J., & Barton, A.J. (2017). Leading health literacy U.S. Department of Health and Human Services, Office of Disease Pre-
initiatives to optimize patient outcomes. Manuscript submitted for pub- vention and Health Promotion. (2010). National action plan to im-
lication. prove health literacy. Washington, DC: Author.
Pelletier, L.R., & Stichler, J.F. (2013). Action brief: Patient engagement
and activation: A health reform imperative and improvement oppor-

78 Copyright © SLACK Incorporated

Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.