Integration of Health Literacy Content Into Nursing Curriculum Utilizing the Health Literacy Expanded Model

Teaching and Learning in Nursing xxx (2017) xxx–xxx

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Teaching and Learning in Nursing journal homepage: www.jtln.org

Integration of Health Literacy Content Into Nursing Curriculum Utilizing the Health Literacy Expanded Model 1, 2 Carolyn M. Mosley, DNP, APN ⁎,3, Barbara J. Taylor, DNP, RN-BC, APN-BC, CNE Rowan College at Gloucester County, 08080

a r t i c l e

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Available online xxxx Keywords: Health literacy expanded model Low health literacy Nursing curriculum

a b s t r a c t Nurses must have the ability to adapt care for patients with low health literacy, making health literacy education of nursing students essential. This article presents a health literacy content curriculum integration project in an associate degree nursing curriculum. A health literacy learning needs assessment survey constructed from the health literacy expanded model and identified gaps in health literacy content. The survey results, current best practice, and the health literacy expanded model provided a framework for the health literacy curriculum integration plan. © 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

Introduction Nurses play a key role in educating patients about critical health care information such as medication administration and discharge instructions. The Institute of Medicine identified health literacy as a necessary concept to be incorporated into prelicensure nursing curricula (American Association of Colleges of Nursing, 2008; NielsenBohlman, Panzer, and Kindig, 2004). Additional mandates from Healthy People 2020 and The Joint Commission support teaching nurses about health literacy (Smith & Zsohar, 2011). However, there are no current examples of a systematic plan for integration of health literacy content and patient teaching strategies for low health literacy in an associate degree nursing curriculum. Health literacy is defined as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Ratzan & Parker, 2000, p. 23). This capacity allows patients to make an informed decision about their health care concerns and facilitate their understanding of obtaining optimal health outcomes. In the present day, patients have a greater responsibility managing

1 Acknowledge of Financial Support: This quality improvement project did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 2 Presentation information: Presented poster at The National Organization for Associate Degree Nursing (N-OADN) OADN Convention “OADN: Gateway to Nursing Excellence” November 14-16, 2014 National Conference. Presented at the New Jersey State Nursing Association and Institute For Nursing NJ State Convention in Atlantic City, New Jersey, October 15, 2015. ⁎ Corresponding author. Tel.: +1 609 929 7397. E-mail address: [email protected] (C.M. Mosley). 3 Present/Permanent address: Rowan College at Gloucester County, Nursing and Allied Health Department 1400 Tanyard Road, Sewell, NJ 08080, USA. Tel.: +1,856,415 2185.

their own health care needs and are expected to navigate a more difficult and complex health care system (Cornett, 2010; Parker & Gazmararian, 2003). The Institute of Medicine reported that over 90 million adults in the United States lacked the skills to utilize health care information (Nielsen-Bohlman et al., 2004). Low health literacy can produce problems for patients on a daily basis, ranging from misinterpreting warnings on prescription labels to being unable to recall recently prescribed medications, even when the patient was given printed materials (Kutner, Greenberg, Jin, & Paulsen, 2006). Additional problems associated with low health literacy are an increased risk for hospital readmission and included misunderstanding of follow-up and discharge instructions, misinterpretation of blood glucose values leading to dosing errors, and decreased ability of disease self-management (Baker, Parker, Williams, & Clark, 1998; Berkman et al., 2004; Lindquist et al., 2011; Schillinger et al., 2002). The effect of low health literacy on patient outcomes makes inclusion of health literacy content important to include in nursing education. Nursing schools have the responsibility of implementing curricula that include content to facilitate student learning on how to effectively communicate and teach patients with low health literacy. The purpose of this article is to outline curriculum content and evidenced-based patient teaching strategies for low health literacy using the health literacy expanded model as a framework.

Background A prelicensure nursing literature search was conducted utilizing multiple databases and following key terms: low health literacy, teaching health literacy, health literacy assessment, health outcomes, patient safety, nursing curriculum, prelicensure nursing students, and

http://dx.doi.org/10.1016/j.teln.2016.12.005 1557-3087/© 2016 Organization for Associate Degree Nursing. Published by Elsevier Inc. All rights reserved.

Please cite this article as: Mosley, C.M., & Taylor, B.J., Integration of Health Literacy Content Into Nursing Curriculum Utilizing the Health Literacy Expanded Model, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2016.12.005

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C.M. Mosley, B.J. Taylor / Teaching and Learning in Nursing xxx (2017) xxx–xxx

nursing faculty. The review of this literature substantiated the need for health literacy content to be included into nursing curricula. In addition, the national nursing licensure board, nursing educational accrediting agencies, and national quality and safety initiatives for nursing education were examined for implications of health literacy curriculum integration. The associate degree nursing program is accredited by the Accreditation Commission for Education in Nursing and currently incorporates the National League of Nursing competencies within the nursing curriculum. Also integrated into the curriculum are the prelicensure nursing competencies designed by Quality and Safety Education for Nursing (QSEN). Nurse educators utilize these competencies as a guide for curriculum design. The health literacy expanded model and the student learning activities are aligned with these competencies. The participating associate nursing degree program is part of the Nursing and Allied Health Department of a 2-year community college in the northeast. Enrollment in the nursing program during the time of the survey was 150 students and 15 nursing faculty including fulltime and adjunct faculty. Students are admitted yearly in the fall and complete four semesters in nursing, which include a total of eight nursing courses and nine co-requisites. An assessment of the required textbooks and course syllabi from the associate degree nursing program revealed an absence of the health literacy content in its curriculum. Despite the lack of health literacy content in the nursing curriculum, the investigators recognized that students may have learned or been exposed to health literacy content in their various clinical rotations. In addition, nursing faculty may have taught health literacy content independent of the course syllabi. Therefore, a health literacy curriculum learning needs assessment of the graduated nursing students and faculty would be valuable in providing recommendations for health literacy content. The health literacy expanded model was chosen to provide structure for the learning needs assessment survey and integration of health literacy student learning objectives and activities. The learning activities were chosen from current best practice patient-teaching strategies for low health literacy from regulatory, medical, federal, and nonprofit organizations advocating for the improvement of patient safety and quality of care (See Appendix A).

Conceptual Framework: The Health Literacy Expanded Model The health literacy expanded model developed by Zarcadoolas, Pleasant, and Greer (2006) has proven to be effective in understanding health literacy and its application in patient education, communication, and health promotion. This public health model includes four key domains: fundamental, scientific, civic, and cultural literacy (see Fig. 1). These domains involve a group of skills that develop over time and assist the patient in understanding health information. This expanded definition of health literacy, along with the Institute of Medicine's definition of health literacy, provides the foundation for teaching nursing students what health literacy entails and its effect upon patient care. When students are teaching patients and providing health information, each of the four domains of the health literacy expanded model should be considered.

Fundamental Literacy Fundamental literacy (reading, writing, speaking, and numeracy) is the predominant domain which influences daily life and has an impact upon the ability to interpret health information and patient education materials. The understanding of the fundamental literacy domain is a core component in the integration of health literacy content in the associate degree nursing program.

Scientific Literacy The scientific literacy domain requires an individual to have some comprehension of the physical and natural sciences. The understanding of the occurrence of scientific uncertainty and the rapid changes in technology are additional factors that influence patient learning success and decision making (Zarcadoolas et al., 2006). The health literacy expanded model describes the health-literate person as having acquired skills to make simple to complex health care decisions and requiring abilities in addition to reading, writing, speaking, and numeracy. Low scientific literacy can lead to the patients' misinterpretation of disease process with the potential to decrease their ability of selfdisease management. The understanding of basic science is necessary for the management for all health issues, although some medical conditions require a more advanced level of scientific literacy. For example, patients with diabetes need to understand many scientific concepts such as the function of the pancreas, regulation of insulin, and other factors that influence blood glucose levels (Zarcadoolas et al., 2006). Civic Literacy Civic literacy addresses the individual's capacity to make decisions regarding public health concerns. These personal decisions involve evaluation of the quality of the health care information being provided through various civic, governmental, and media sources (Zarcadoolas et al., 2006). Population health issues such as Ebola, possible flu pandemic, and outbreaks of the Zika virus are complicated and require community and governmental level responses. Interpretation of these public health messages has an impact upon personal actions and broader public health implications. As communicators of health information, nursing students need to guide patients in determining the reliability of the health messages from diverse media sources, including the Internet (Zarcadoolas et al., 2006). Cultural Literacy Cultural literacy as described in the health literacy expanded model refers to the mutual understanding of how the health care provider's professional culture and the patient's culture influences communication (Zarcadoolas et al., 2006). Students need to recognize and understand a patient's cultural background in order to effectively communicate. Methods Samples and Setting The method for this quality improvement project was a descriptive on-line survey design. All 15 faculty members and 53 graduated nursing students were invited to participate in the study. Eligibility for faculty included full-time status and adjunct faculty at the associate degree nursing program. Eligibility for nursing students included those who have completed and graduated from the investigated nursing school, May 2013. Alumni before 2013 of the investigated nursing program were excluded. Completion of the survey data was compiled from the e-mail responses to direct the recommended student learning objectives and teaching strategies for the health literacy content inclusion. The project was approved by the college's institutional review committee. Investigational review board notice of approval was given as exempt status for this study.

Please cite this article as: Mosley, C.M., & Taylor, B.J., Integration of Health Literacy Content Into Nursing Curriculum Utilizing the Health Literacy Expanded Model, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2016.12.005

C.M. Mosley, B.J. Taylor / Teaching and Learning in Nursing xxx (2017) xxx–xxx

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Fundamental Literacy Reading, Writing, Speaking, and Numeracy

Cultural Literacy Mutual Understanding

Health-literate Individual

Scientific Literacy Scientific Concepts, Technology, Uncertainty

Civic Literacy Media literacy, Civic & Govt. Systems, and Personal choices

Fig. 1. Health Literacy Expanded Model adapted from: Zarcadoolas et al. (2006).

Instrumentation

Results Data Analysis

The presence of the health literacy content was the attribute measured in the curriculum needs assessment survey. Student learning objectives were designed to reflect the four domains of the health literacy expanded model, and the survey questions were aligned with these objectives. The 13-item survey instrument was piloted for understanding of intended content and readability using academic colleagues. These individuals were chosen for their expertise in the areas of nursing education and curriculum development and health literacy training for pharmacists. These colleagues included five expert nursing faculty with credentials of doctor of philosophy and masters of science in nursing and one doctor of pharmacy. The first survey question was mandatory for the participant to identify themselves as either a graduate student or faculty member. Participants selected answers for the following 11 close-ended questions using a 5-point Likert scale format. The final survey question was open ended to elicit comments and opinions concerning what was the most important information that participants would like students to be taught about health literacy. The qualitative data obtained from this open-ended survey question added depth and attention to detail regarding the development of health literacy content in the nursing curriculum.

The quantitative data were calculated using frequency distribution (the number of occurrences of each response) for each question and the subsequent five categories using a Likert format. This frequency distribution was calculated into a percentage. A qualitative question in the student and faculty survey was included in order to discover ideas not anticipated in regard to health literacy content. The one open-ended survey question asked participants to describe what was most important for students to be taught about health literacy. This study does not meet the criteria for qualitative research, but several qualitative analysis techniques were utilized when reviewing the 35 comments received in response to this question.

Data Collection Participants were composed of 15 nursing faculty and 53 graduated nursing students, who received an e-mail invitation to access an on-line survey over a 4-week period. The survey was completed anonymously, with no personal identifiers or demographics. Informed consent to participate in the study was acknowledged in the introduction of the survey.

Findings Of the 68 participants surveyed, the response rate was 81% or 55 responses. Upon further breakdown of participant response rate, 75% of the graduated students and 100% of the nursing faculty responded to the e-mail invitation. The 50 completed responses were calculated as frequencies within the 5-point Likert format, which was compressed and classified into yes, no and not-sure groups as shown in Appendix B. The categories of “Not at all” and “Sometimes” were combined and represent the “No” group. The categories of “Most of the time” and “Always” were combined to represent the “Yes” group. The Likert category labeled “Not sure” was considered neutral. The “Not sure” category allowed the participant to neither agree nor disagree; therefore, they were not forced to express an opinion that they did not actually hold. In analyzing the health literacy survey responses, positive findings and gaps in the nursing curriculum were determined by creating benchmarks to focus on a problem area and aid in quality management. The

Please cite this article as: Mosley, C.M., & Taylor, B.J., Integration of Health Literacy Content Into Nursing Curriculum Utilizing the Health Literacy Expanded Model, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2016.12.005

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C.M. Mosley, B.J. Taylor / Teaching and Learning in Nursing xxx (2017) xxx–xxx

health literacy survey benchmarks provided a baseline to measure improvement of the integration of health literacy content into the nursing curriculum. A benchmark of 60% frequency rate among the “yes” group demonstrated that the health literacy content was taught in the nursing curriculum at least four or more times consistently. Based on the collected responses, 4 of the 11 survey questions had a positive finding, and 7 of the 11 survey questions were identified as gaps or areas less frequently taught in the nursing curriculum (see Appendices B and C). The themes that emerged from the one open-ended survey question were health literacy assessment, communication, patient teaching, and health literacy knowledge. These themes closely resemble the content being asked in the 11 close-ended questions and can correlate to the health literacy expanded model. Participants affirmed that students should be taught health literacy assessment tools and expressed the importance of communication and relaying information to patients in clear basic language. Discussion The purpose of the survey was to complete a learning needs assessment to identify the presence of health literacy content in an associate degree nursing curriculum. The survey revealed that health literacy content had been introduced into the curriculum, and multiple gaps of health literacy content instruction were also identified. Reinforcement of the content already taught and the gaps were both included in the health literacy student learning objectives and learning activities that are being integrated into the curriculum. The faculty agreed upon the integration of health literacy learning activities, and the plan was initiated with the freshman class, fall semester of 2015. Integration of Health Literacy Content Few nursing schools incorporate health literacy as a curriculum standard that includes teaching students the relationship between health literacy and health outcomes, developing assessment skills, and collaborating in the design of interventions for teaching patients with low health literacy (Owens & Walden, 2007; Smith & Zsohar, 2011; Speros, 2005). This evidence supports the inclusion of health literacy content and the recommended student learning activities. These activities incorporate diverse learning styles while encouraging active learning and cooperation among students. Various teachings strategies include simulation, clinical assignments, and case-based learning. The student learning objectives are aligned to the health literacy expanded model and are included in the lesson plans according to the expected level of difficulty of each of the eight nursing courses (see Appendix D). Fundamental Literacy Student Learning Activities When teaching students about health literacy, nurse educators should instill the importance of this content and the vital role it plays in daily professional nursing practice (Smith & Zsohar, 2011). Professional identity, a National League of Nursing Associate Degree Nursing competency, encourages students to implement one's role as a nurse that reflect various professional attributes (National League of Nursing, 2010). Demonstration of professional identity within the fundamental domain includes students who are committed to evidence-based practice by making nursing judgments that integrate effective communication and teaching strategies that are sensitive to patients with low health literacy. The nursing literature identified that many students lacked awareness of appropriate teaching strategies for patients with low health literacy (Scheckel, Emery, & Nosek, 2009; Zanchetta et al., 2012). Some examples of communication techniques that are beneficial when teaching patients with low health literacy include the use of nonmedical language and visual guides (Weiss, 2007). These communication

techniques are taught in the first nursing course through a classroom exercise which reinforces the use of plain language. The screening for health literacy has been identified as an area in which students are unfamiliar. Determining a patient's health literacy level is considered a “vital sign” to assess during each patient encounter, and nurses' knowledge and skills are pivotal to this process (Dennison-Himmelfarb & Hughes, 2011). The importance of health literacy assessment is supported by Heinrich (2012) who suggested that assessment of health literacy should be considered the sixth vital sign. Beginning nursing courses which focus on assessment skills should include the identification of patients with low health literacy (Owens & Walden, 2007). The evidence for strengthening students' abilities to demonstrate effective strategies when caring for patients with low health literacy include utilizing a reliable and valid assessment tool such as the Newest Vital Sign (NVS) for identifying patients with low health literacy (Cornett, 2010; Shah, West, Bremmeyer, & Savoy-Moore, 2010). Because of free access, ease of use, and short administration timeframe (three minutes), the NVS was included in the integration of health literacy content in the nursing curriculum (Shah et al., 2010; Van Geest, Welch, & Weiner, 2010). Students practice the administration of the NVS through role play in the fundamental laboratory setting and progress to administering the NVS to patients in the clinical setting. This learning activity meets the QSEN competency of patient-centered care and is recommended by the QSEN institute, a nursing faculty resource offering modules containing teaching strategies that incorporate the six competencies (Dudas, 2011). It is recommended that health care providers be taught to identify clues or red flags that indicate that a patient may have low health literacy, and nurses can look for indicators such as difficulty following discharge instructions or statements made by patients such as, “I forgot my glasses” or “I'll read this when I get home” (Weiss, 2007, p. 17). When utilization of the NVS tool is not feasible, awareness of these clues are taught to nursing students. A health literacy learning activity includes viewing the American Medical Association YouTube vignettes of persons with low health literacy (Cornett, 2010). These vignettes show examples of these red flags and also reveal how low health literacy impacts patients. Patients' noncompliance with a medication regime is a red flag that may indicate low health literacy. The identification of clues and red flags for inclusion as a student learning objective in the health literacy content is strongly supported by the evidence in the literature. In a health literacy simulation learning activity, the students utilize the techniques that lend to effective instruction and the development of a trusting relationship with patients. These techniques involve developing a shame-free environment in a private setting, displaying an attitude of helpfulness, using simple plain language, speaking slowly, conveying the most important points, limiting content for each teaching session, and utilizing visual aids, short sentences, and teachback methods (DeWalt et al., 2010). The Agency for Health-Care Research and Quality Universal Precautions Toolkit emphasizes the evaluation of written patient education materials for readability as an important step in making health information less complex (Weiss, 2007). One of the readability formulas recommended is the Simplified Measure of Gobbledygook (SMOG), which is a grading system analyzing the number of sentences and number of words with three or more syllables followed by the application of a mathematical calculation to decipher the reading level of the material (McLaughlin, 1969). The process for writing educational materials in simple language is outlined by various resources and includes the following principles: develop materials at a fifth grade reading level or lower, introduce no more than two to three key ideas, and emphasize benefits of desired behavior (Doak, Doak, & Root, 1996). The health literacy learning activity requires students to review health care forms currently used in the clinical agencies. After evaluation of these forms utilizing SMOG, students revise health materials in plain language as a clinical assignment (Smith & Zsohar, 2011).

Please cite this article as: Mosley, C.M., & Taylor, B.J., Integration of Health Literacy Content Into Nursing Curriculum Utilizing the Health Literacy Expanded Model, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2016.12.005

C.M. Mosley, B.J. Taylor / Teaching and Learning in Nursing xxx (2017) xxx–xxx

The National League of Nursing Associate Degree Nursing competency, spirit of inquiry, inspires students to offer new insights into quality improvement for health care and can also be associated with the fundamental literacy domain. Students display the spirit of inquiry by challenging the status quo and identifying quality initiatives in health care delivery systems (National League of Nursing, 2010). Students can contribute in quality improvement by reviewing patient educational materials for readability and ensuring availability of an interpreter when needed (Smith & Zsohar, 2011). Providing understandable written patient educational materials has the potential to improve patient self-management and health outcomes. Scientific Literacy Student Learning Activities Diabetic patients who have difficulty identifying symptoms of hypoglycemia are an example of inadequate scientific literacy. The lack of scientific literacy as a skill may cause diabetic patients to misinterpret blood glucose values and decrease their ability of self-disease management (Schillinger et al., 2002; Zarcadoolas et al., 2006). The health literacy learning objective requires the nursing student to identify the core concept of scientific literacy as a necessary skill of the health-literate person. This objective is met through discussion of a patient education health topic during which students decide what scientific knowledge the patient must know, comprehend, and act upon regarding this health information. In addition, students will discuss the following question: What assumptions about the patient's scientific literacy are made by the developers of the health information? (Zarcadoolas et al., 2006). National programs continue to focus on improving patient and health care professional dialog with the possibility of enhancing patient understanding of science involved in the disease. The National Patient Safety Foundation's ASK-Me-3© program created a shared responsibility for clear communication by encouraging patients to ask their health providers the following three essential questions in every health care interaction: (a) What is my main problem? (b) What do I need to do? (c) Why is it important for me to do this? (National Patient, n.d.). These three questions can help simplify scientific information and assist in the patients' comprehension of health messages. Likewise, nursing students should provide a consistent approach by encouraging their patients to ask questions and understand the answers. The AskMe-3© program was found to be useful for patients as a framework for speaking to health care providers (Mika, Wood, Weiss, & Treviño, 2007). This framework reflects the QSEN competency of patientcentered care and the students' understanding that patients need to be informed in order to be a full partner in the decision making. Improving interpersonal communication with patients involves creating a shame-free environment and encouraging questions (Weiss, 2007). The ASK-Me-3 © program urges the patient to ask three questions in order improve or reinforce knowledge of scientific health care messages. In the clinical setting, students will teach each patient the ASK-ME-3 © program. In a reflective journal assignment, the students report how this learning activity will influence their future nursing practice. The patients' responses to this program are also addressed in the journal. When nursing students investigate the scientific concepts that are included in health teaching and question the assumptions that patients have knowledge of this science, they demonstrate the National League for Nursing Associate Degree Nursing competencies of spirit of inquiry and human flourishing. Civic Literacy Student Learning Activities The learning activities for the civic literacy domains have been recommended but not yet initiated. A classroom case study discussion is a health literacy learning activity that will identify civic literacy as a necessary skill for the health-literate person. Within these case studies, the

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patients' perception on civic, governmental systems, and their personal choices will be discussed. An additional learning activity will include students discussing a health topic in the media. This activity will involve role play where students teach patients that governmental health care agencies, such as the Centers for Disease Control and Prevention or the National Institutes of Health, are accurate and trustworthy sources of health information. More importantly, students will reinforce that patients need to understand about the relationship between their actions and broader public health concerns (Zarcadoolas et al., 2006). The National League for Nursing competency of human flourishing and the QSEN patient-centered care competency can be demonstrated when students assess the patient's understanding of how and where to obtain quality health care information. Students meet these competencies by recognizing the significance of civic literacy and the impact it has upon a patient's decision-making process and ability to advocate for oneself and others. Cultural Literacy Student Learning Activities The utilization of language concordant clinicians and mandatory professional interpreters is an initiative to reduce communication barriers and supports the learning activity of teaching nursing students how to care for a patient who requires an interpreter (Yip, 2012). Professional interpreters have an impact upon quality of health care for low English proficiency patients by decreasing communication inaccuracies and increasing patients' understanding, which improves health outcomes and reduces health disparities (Karliner, Jacobs, Chen, & Mutha, 2007). Recommended through Institute of Medicine teaching strategies and The Joint Commission, introducing nursing students to the experience of using an interpreter facilitates communication with their patients with low English proficiency (Finkelman & Kenner, 2009). During a simulation experience, students will be given the opportunity to communicate with a patient through an interpreter. The Joint Commission's recommendation to restrict health care workers or family members to act as interpreters is introduced in the first semester and will be reinforced during this planned learning activity. The National League of Nursing competency, human flourishing, is met when students have an increased awareness of patient preferences and the patients' cultural perspective of health in comparison to health providers' viewpoint in the treatments or instructions given to patients. Conclusion The rise of high-risk groups, such as older adults and individuals with limited English proficiency, and the campaign to reduce hospital readmission highlight the importance of nursing students' understanding of the impact of health literacy upon patient care (Center for Disease Control, 2009; Kutner et al., 2006). The health literacy expanded model provides an outline for student learning activities highlighting teaching strategies for patients with low health literacy. This model offers a comprehensive definition of the health-literate individual beyond fundamental literacy and correlates to QSEN and the National League for Nursing Associate Degree of Nursing competencies. The National League for Nursing competency, human flourishing, is reflected in the overall health literacy integration plan. Students who meet the human flourishing competency demonstrate an understanding of the potential problems of patients with low health literacy and encourage human flourishing by advocating and promoting integrity for this vulnerable group. Support has been documented for introducing health literacy content early in curriculum to prepare students with hands-on learning through scenarios focused on assessment and effective communication (Sand-Jecklin, Murray, Summers, & Watson, 2010). The health literacy curriculum

Please cite this article as: Mosley, C.M., & Taylor, B.J., Integration of Health Literacy Content Into Nursing Curriculum Utilizing the Health Literacy Expanded Model, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2016.12.005

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integration plan begins in the first semester and provides students with active learning opportunities in each nursing course. Nurse educators have a role in preparing students to instruct patients at the bedside. This student preparation should include health literacy knowledge, skills, and attitudes. The health literacy curriculum integration plan is an ongoing process, and student learning activities will be revised based upon ongoing literature review and current best practice. Future research in nursing education is needed to explore the impact of inclusion of health literacy content into nursing curricula and how it relates to positive patient-centered outcomes.

(continued) Domains of Health literacy health literacy student learning expanded model objectives

Survey questions • Effective communication requires both the nurse's ability to understand aspects of a patient's individual culture and the patient's ability to understand aspects of health care professional culture.

Appendix A. Health Literacy Expanded Model Domains Aligned to Student Learning Objectives and Survey Questions

Health literacy Domains of student learning health literacy expanded model objectives Fundamental literacy • • • •

Reading Writing Speaking Numeracy

Scientific literacy • Scientific concepts • Technology • Scientific uncertainty

Civic literacy • Media literacy • Civic and government systems • Personal choices Cultural literacy

• Identify clues or red flags indicating that a patient has low health literacy. • Utilize a health literacy assessment tool such as the NVS to identify a patient with low health literacy. • Demonstrate effective strategies for teaching all patients including individuals identified with low health literacy. • Discriminate between high-level and low-level reading materials utilizing the simplified measure of SMOG. • Demonstrate the understanding of the National Safety Foundation ASK-Me-3© program • Identify the core concept of scientific literacy as a necessary skill for a healthliterate person • Discuss the core concept of civic literacy as a necessary skill for a healthliterate person in classroom and clinical settings

• Apply the use of health literacy quality • Mutual initiatives in clinical understanding settings (includes culture sensitivity and diversity training)

Survey questions • How often in the nursing school's curriculum was the health literacy concept included as a required course objective? • Noncompliance with a medication regimen is a common patient sign that indicates low health literacy. • Patients with low health literacy may misunderstand discharge instructions. • Using an assessment tool to evaluate a patient's health literacy level is valuable. • The use of nonmedical language is an effective teaching strategy for patients. • The SMOG should be utilized to evaluate reading levels of patient education materials provided by clinical agencies. • The ASK-ME-3© program should be utilized when caring for patients. • Diabetic patients with low health literacy may have a problem identifying the symptoms of hypoglycemia.

• A case study which utilized health literacy interventions is a requirement in the classroom or clinical setting.

• How often in the nursing school curriculum (include all nursing courses) were students provided the experience of teaching a patient who required an interpreter?

Appendix B. Positive Findings of Health Literacy Content Identified in the Nursing Curriculum

Question

Q 3. Patients with low health literacy may misunderstand discharge instructions. Q4. Using an assessment tool to evaluate a patient's health literacy level is valuable. Q6. The use of nonmedical language is an effective teaching strategy for patients. Q10. Effective communication requires both the nurse's ability to understand aspects of a patient's individual culture and the patient's ability to understand aspects of health care professional culture.

Response categories No

Not sure

Yes

34%

2%

64%

21%

17%

62%

10%

4%

86%

8%

4%

88%

Note. The “No” grouping includes Likert categories: “Not at all”, “Sometimes” (one to three times), and “Not Sure.” The “Yes” grouping includes Likert categories: “Most of the time” (four to six times) and “Always” (seven or more times).

Appendix C. Gaps of Health Literacy Content Identified in the Nursing Curriculum

Question

Response categories No

Not sure

Yes

Q2. Noncompliance with a medication regimen is a common patient sign that indicates low health literacy. Q5. Diabetic patients with low health literacy may have a problem identifying the symptoms of hypoglycemia. Q7. The ASK-ME-3© program should be utilized when caring for your patients. Q8. The SMOG should be utilized to evaluate reading levels of patient education materials provided by clinical agencies. Q9. A case study which utilized health literacy interventions as a requirement in the classroom or clinical setting. Q11. How often in your nursing school's curriculum (include all nursing courses) were student provided the experience of teaching a patient who required an interpreter? Q12. How often in your nursing school's curriculum was the health literacy concept included as a required course objective?

42%

10%

48%

40%

12%

48%

46%

42%

12%

50%

32%

18%

55%

8%

37%

76%

14%

10%

46%

24%

30%

Note. The “No” grouping includes Likert categories: “Not at all,” “Sometimes (one to three times), and “Not sure.” The Yes grouping includes Likert categories: “Most of the time” (four to six times) and “Always” (seven or more times).

Please cite this article as: Mosley, C.M., & Taylor, B.J., Integration of Health Literacy Content Into Nursing Curriculum Utilizing the Health Literacy Expanded Model, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2016.12.005

C.M. Mosley, B.J. Taylor / Teaching and Learning in Nursing xxx (2017) xxx–xxx

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Appendix D. Domains of Health Literacy Model, Student Learning Objectives, and Activities

Domains of Health Literacy expanded model

Health Literacy student learning objectives Upon completion of the associate degree nursing program the student will:

Learning activities

Fundamental literacy

• Identify clues or red flags indicating that a patient has low health literacy (S1, Fall, 2015)

• (S1) Review Health Literacy Facts SheetsShow American Medical Association YouTube vignettes of persons with low health literacy and have discussion related how low health literacy impacts patients (Cornett, 2010). Plain language classroom exercise.

• • • •

Reading Writing Speaking Numeracy

•

•

•

Scientific literacy • Scientific concepts • Technology • Scientific uncertainty

Civic literacy

•

•

•

• Media literacy • Civic and government systems • Personal choices Cultural literacy • Mutual understanding

•

• (S1 L) Have students construct a script explaining the purpose of the NVS. Students will than role play with each other in administering the NVS. • (S2, S3, S4, and TP) Have students administer NVS to a patient in the Utilize a health literacy assessment tool such as clinical setting. Have students reflect this experience in their the NVS to identify patient with low health clinical journals (Dudas, 2011). literacy (S1, Fall, 2015) • (S3) Utilizing a simulation Demonstrate effective strategies for teaching all Have students teach about medication or a procedure to a patients including individuals identified with patient utilizing the following strategies: low health literacy (S2, Spring, 2016) ➢ Use of nonmedical language ➢ Speak slowly ➢ Limit the amount of teaching in one session ➢ Use of simplified educational reading materials ➢ Use of visual aids ➢ Use of the “teach back” technique, confirm that patients understand by asking them to repeat back your instructions (DeWalt et al., 2010) • (S2 L) Review currently used health care forms in clinical agencies. Discriminate between high-level and low-level Create educational health materials in plain language reading materials utilizing the SMOG (Doak et al., 1996; Smith & Zsohar, 2011). (S2 L, Spring, 2016) • (S3, S4, and TP) Students will teach each patient the ASK-ME-3© program. Demonstrate the understanding of the National In a reflective journal assignment, the student reports how this learning Safety Foundation ASK-Me-3 © program (S3, Fall, 2016) activity influences their future nursing practice. The patients' response to the program is also journaled. Identify the core content of scientific literacy as a • (T) Assign students a particular health topic in regard to patient education. Discuss the following questions: What science must a patient know to necessary skill for a health-literate person comprehend and decide to act on a specific health message? What (T, Fall, 2017) assumptions about the patient's scientific literacy are made by the developers of the health messages? (Zarcadoolas et al., 2006) • (S2, S3, S4) Utilize simulation/classroom case studies discussions. Discuss the core content of civic literacy as • (T) Assign students a health topic currently in the media. Discuss the areas of a necessary skill for a health-literate person civic literacy that is needed by the patient in order to: judge the source and in classroom and clinical setting quality of the information, know where and how to access the information (S4 & TP, Spring 2017) needed, know how to advocate for one's self and others, and understand the relationship between one's actions and the larger social group (Zarcadoolas et al., 2006). Apply the use of health literacy quality initiatives • (S4) Simulation patient-centered care: health teaching and working with an interpreter. Student should speak directly to the patient not the in the clinical setting (includes culture sensitivity, interrupter or telephone.Understand policy of agencies such as do diversity training; S4, Spring, 2017) not use health care worker or family as an interpreter (Finkelman & Kenner, 2009).

Key: S1-Semester 1, S1 L- Semester 1 Lab, S2- Semester 2, S2 L-Smester 2 Lab, S3-Semester 3, T-Trends in Nursing, S4-Semester 4 and TP-Transition in Practice. Date integrated: Semester and Year.

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Please cite this article as: Mosley, C.M., & Taylor, B.J., Integration of Health Literacy Content Into Nursing Curriculum Utilizing the Health Literacy Expanded Model, Teaching and Learning in Nursing (2017), http://dx.doi.org/10.1016/j.teln.2016.12.005