Nurse Educator
Vol. 41, No. 2, pp. 93-97
Nurse Educator
A Systematic Review of the Literature on Health
Literacy in Nursing Education
Voncella McCleary-Jones, PhD, RN, BC, CNE
Health literacy has an impact on patient health outcomes and should be included in prelicensure nursing curricula to prepare
the next generation of nurses to provide care for patients with limited health literacy. Nursing curricula should go beyond
inclusion of patient teaching strategies. This article provides a systematic review of the current literature related to health
literacy in nursing education and identifies implications for nursing curricula.
Keywords: health literacy; nursing curriculum; nursing education; systematic review
H
ealth literacy has been found to be a stronger predic-
tor of health status than socioeconomic status, age,
and ethnic background.1 Health literacy is defined as
the degree to which individuals have the capacity to obtain,
process, and understand basic information and services needed
to make appropriate decisions regarding their health.2 It is
estimated that about half of American adults have difficulty
understanding and using health information, resulting in a
higher rate of hospitalization and use of emergency services
among patients with limited health literacy. 2 Nearly 9 of
10 adults have difficulty using the everyday health informa-
tion that is routinely available in health care facilities, retail
outlets, media, and communities.3
Low literacy is associated with difficulty understanding
written or verbal health care advice, adverse health outcomes,
and negative effects on the health of individuals.4 An indi-
viduals ability to function in the health care environment
can be affected by low literacy, as well as patient-provider
communication, and can lead to substandard health care.4
Individuals with limited health literacy skills are more likely
not to seek important preventive measures, such as mammo-
grams, Papanicolaou smears, and flu shots, and enter the
health care system when they are sicker, compared with those
with adequate health literacy skills.5 Those with limited health
literacy are more likely to have chronic conditions and are
less able to effectively manage them. Studies have found that
Author Affiliation: Associate Professor, College of Nursing, University
of Oklahoma Health Sciences Center.
The author declares no conflicts of interest.
Correspondence: Dr McCleary-Jones, College of Nursing, University of
Oklahoma Health Sciences Center, 1100 N Stonewall Ave, Oklahoma City,
OK 73117 (voncella-mccleary-jones@ouhsc.edu).
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journals Web site (www.nurseeducatoronline.com).
Accepted for publication: June 13, 2015
Published ahead of print: July 30, 2015
DOI: 10.1097/NNE.0000000000000204
Nurse Educator
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
Copyright * 2016 Wolters Kluwer Health, Inc. All rights reserved.
patients with conditions such as high blood pressure, diabe-
tes, asthma, or HIV/AIDS who also have limited health literacy
skills have less knowledge of their illness and its management.5
Low literacy is more prevalent in people with fewer
years of education, those of certain racial or ethnic groups,
the elderly, and individuals with lower cognitive ability.4 In
addition, individuals with low health literacy are at increased
risk of health disparities.6 Many health care professionals are
unaware which of their patients have limited health literacy
or how to intervene appropriately.7 Furthermore, patients
with low health literacy may report a sense of shame about
their skill level and may hide their reading or vocabulary dif-
ficulties to maintain their sense of dignity.5
Health literacy should be included in nursing curricula
to adequately prepare students to provide care in the clinical
setting.8 Although most curricula include information on the
patient teaching process, they do not specifically address health
literacy.9 The significant impact of limited health literacy on
patient outcomes makes health literacy a critical topic area to
be addressed in nursing education. This article reports on a
systematic review of the current literature related to health
literacy in nursing education programs.
Search of the Literature
Methods and Search Parameters
The aim of the systematic review was to review the litera-
ture that identified health literacy in nursing education.
The electronic databases reviewed for the systematic review
of the literature included CINAHL Complete, MEDLINE
(OVID), Health Source: Nursing/Academic Edition, Google
Scholar, and Digital Dissertations and Theses through Pro-
Quest. The selected databases included studies found in
nursing journals, state nurses association publications, full-
text articles, and dissertations. Search parameters included
the years 2000 to 2014, providing a focused search of current
literature. Search terms included health literacy and nurs-
ing education.
Volume 41 & Number 2 & March/April 2016 93
Sources
CINAHL Complete, MEDLINE (OVID), Google Scholar, and
Health Source: Nursing/Academic Education produced
61 references when the MeSH terms health literacy and
nursing education were used. The database Dissertation
and Theses through ProQuest produced 26 292 results using
these 2 search terms, which required additional search terms
and limitations to be added to the search criteria. The ProQuest
database returned 39 results when the following search terms
and limits were applied: and undergraduate, and curricu- of nursing, medicine, and health literacy. Participants were
lum, and nursing PRE/1 education NOT nursing adminis-
tration NOT health care. After further review of abstracts, no
dissertations were included from the ProQuest search. One
pertinent dissertation was included from the Google Scholar
search results.
Analysis and Evaluation
Inclusion and Exclusion Criteria
Inclusion criteria for the literature review consisted of studies
that examined health literacy, targeted undergraduate nursing
education, and were written in the English language. Exclu-
sion criteria included studies focused on health literacy in grad-
uate nursing education and those targeting practicing nurses.
Sample Description
The results of the search yielded 100 references related to
health literacy and nursing education. Twelve results were
duplicates and were removed, leaving 88 articles. Based on
the exclusion criteria, 78 references were eliminated. A final
yield of 10 studies was included in this systematic review of
the literature (see Table, Supplemental Digital Content 1,
http://links.lww.com/NE/A238). Each of the selected studies
identified an aspect of health literacy in nursing education.
Results
The areas of focus in this review of the literature on health
literacy in nursing education included health literacy knowl-
edge, experiences of students in caring for patients with
limited health literacy, and inclusion of health literacy con-
tent in nursing curricula. These focus areas were further cat-
egorized into 3 themes: learned knowledge and skills, learner
perceptions, and curricular content. Learners perceptions
included sensitivity to health literacy, self-confidence in pro-
moting patients health literacy, respecting different languages,
empathy, and sensitivity to patients life contexts.
Learned Knowledge and Skills
Five studies focused on the health literacy knowledge of
nursing students.7,8,10-12 Sample sizes ranged from 53 to
391 participants, and several different instruments were used
to measure health literacy knowledge among the partici-
pants. Validity data were variable among the instruments used
for data collection. Two of the studies had a pretest-posttest
design,7,11 and 3 used a cross-sectional design.8,10,12
Sand-Jecklin et al7 reported a significant increase in stu-
dent knowledge about health literacy after a brief 20-minute
educational session for beginning baccalaureate nursing stu-
dents. Educational content covered the problem of low health
literacy, identifying it using behavioral cues of patients, Chews
3 screening questions, and interventions for interacting with
94 Volume 41 & Number 2 & March/April 2016
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
and teaching patients with health literacy issues. The session
included a case study of a patient with limited health literacy.
No data were provided on the number of items on the survey
instrument or any information about its development.
Jukkala et al8 used an instrument with 8 multiple-choice
questions to examine students and health care providers
knowledge about the impact of limited health literacy on pa-
tients and the health system. Content validity was established
through examination of the instrument by experts in the fields
most knowledgeable about the relationship between level
of education and low health literacy and least knowledge-
able about the prevalence of limited health literacy in the
United States. While the total sample size was 230, only
40 participants were students, and 15 participants did not
supply information describing their background. Findings
should be interpreted in the context of an inability to identify
the total number of nursing students who participated. The
authors concluded that inability to recognize and intervene
for patients with limited health literacy will have an effect on
nurses ability to successfully fulfill 1 of their most vital roles
educating patients on self-care.8
Cormier10 used the 44-item Health Literacy Knowledge
and Experience Survey (HL-KES) to assess the health literacy
knowledge and experiences of senior-level baccalaureate
nursing students enrolled at state universities in Louisiana.
Participants identified low socioeconomic groups as high
risk of low health literacy skills and were strongly aware of
the consequences associated with low health literacy skills;
however, knowledge gaps existed in identification of the
older adult as a high-risk group, health literacy screening,
and guidelines for written health care information.
In another study, McCleary-Jones11 used a 5-item tool to
assess students knowledge of health literacy. Students took
a pretest, and posttest after completing an asynchronous on-
line educational module. A significant increase in the posttest
mean scores was noted among beginning baccalaureate nurs-
ing students. Content validity for the tool was established via
use of a test blueprint to ensure test questions correlated to
the objectives and content presented, and the Cronbachs !
statistic was .173. The finding of increased knowledge among
students after the educational intervention was similar to the
findings of Sand-Jecklin et al.7
Torres and Nichols12 used the HL-KES to survey associate
degree nursing students and found participants had some
knowledge about health literacy, but additional instruction
could be beneficial. These findings were similar to those
reported by Cormier.10 The authors recommend introducing
health literacy in the first class for incoming students, incor-
porating the Newest Vital Sign health literacy assessment
tool into clinical assignments, and exposing students to more
health literacy content throughout the curriculum via a series
of workshops that address the needs of patients with limited
health literacy.
Learner Perceptions
Four studies focused on the experiences of nursing stu-
dents in caring for patients with limited health literacy.13-16
Sample sizes ranged from 8 to 146 participants, and different
qualitative research methods were used to elicit the experi-
ences of the students; 1 study used a mixed-methods approach.
Nurse Educator
 Scheckel et al13 elicited the experiences of 8 baccalau-
reate students in providing patient education via unstruc-
tured interviews, which were analyzed using hermeneutics.
A central theme of addressing health literacy emerged as a
primary practice of students learning and providing patient
education. There were 3 subthemes: (a) respecting languages:
learning persistence, recognizing barriers to health literacy
such as using terms like CPR (cardiopulmonary resuscita-
tion), and the meaning of persisting with teaching until the
patient can demonstrate understanding; (b) helping patients
understand: learning to teach, to facilitate patients under-
standing of health information via observing nurses teach
effectively with simple instructions and ineffective approaches
they knew would not result in patients comprehension of
health information; and (c) promoting engagement: learning
sensitivity, recognizing that nurses attention or inattention
to patients readiness to learn can disengage them from learn-
ing and understanding health information. These findings
emphasize the importance of providing health literacy con-
tent within the nursing curriculum to support the ability of
nurses to address the education needs of patients with limited
health literacy.
Using qualitative content analysis, Shieh et al14 analyzed
narratives written by undergraduate nursing students relat-
ing to experiences in caring for patients with low health lit-
eracy. Three themes were uncovered: (a) sensing low health
literacy by behavioral cues, (b) promoting health literacy
with multiple strategies, and (c) closing the health informa-
tion loop. The researchers found students were able to iden-
tify behavioral cues suggestive of low health literacy and
provide solutions to increase the patients health literacy.
However, students did not use standardized tools to assess
the patients literacy or knowledge of specific diseases, did
not assess readability of patient education materials, and did
not provide patient empowerment interventions to encour-
age active information seeking and participation in self-care.
These findings suggest that even when some health literacy
content is included in curricula, additional information is
needed to adequately prepare nursing students to provide
effective care to patients with low health literacy.
Weekes and Wyatt15 used a mixed-methods approach
to examine students understanding of limited health literacy
from a patients perspective. Beginning nursing students were
given a 3-item quiz with questions written using medical
terminology at an advanced level. The students were to use
the information to complete a series of activities including
identifying nursing priorities for the patient. The students
were then instructed to view a module with information about
health literacy and submit a reflection paper on what they felt
was the purpose of the quiz, their experience of taking a quiz
filled with unfamiliar medical jargon, and how this experience
would affect their nursing practice.
In the postexperience debriefing, most student reflec-
tions indicated they understood the purpose of the quiz was
for them to experience how patients with inadequate and
marginal health literacy feel. Nearly all of the participants
stated they could now empathize with patients who struggle
with health literacy, and the experience would have an im-
pact on their communication with patients throughout their
nursing career.15 Weekes and Wyatt15 concluded that intro-
duction of health literacy content early and repeated through-
Nurse Educator
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
out the nursing program is essential to preparing nursing
students to apply health literacy concepts in their professional
practice. Experiencing the struggles of patients with limited
health literacy may assist students to understand the impor-
tance of its assessment in nursing practice.
Zanchetta et al16 used three 1-time individual interviews
and 3 focus groups to analyze students performance and self-
assessment of their roles in promoting health literacy. Two
major themes that emerged from thematic analysis were stu-
dents awareness of challenges to becoming effective health
educators and their sensitivity to health literacy. The researchers
found that students performed best as health promoters in
supportive teaching hospitals. Performance was hindered by
clinical settings unsupportive of health education, with an
absence of role models, and with insufficient theoretical prep-
aration for health teaching.
The researchers reported that in multicultural health
care settings students sensitivity to clients diversity reinforced
the interconnection between health literacy and other social
determinants of health. Students recommended that more
socially inclusive and experiential learning initiatives related
to health teaching be included to address education gaps
between the classroom and practice.16 Each of these studies13-16
highlights the importance of inclusion of health literacy con-
tent in the didactic and clinical preparation of nursing students.
Curricular Content
Dunn17 used a cross-sectional design to survey nurse edu-
cators in Floridas higher-education institutions regarding
awareness and application of health literacy in their cur-
ricula. Eleven of 22 institutions participated in the Florida
Nurses Association Health Literacy Committee Survey. The
author identified a common theme among the responding
institutions: health literacy was integrated throughout the
curricula but was not transparent. For instance, some schools
reported health literacy awareness was accomplished through
class discussion and stressed with patient education. Another
school stated health literacy was introduced in theory and
applied in clinical practice, whereas another institution inte-
grated health literacy through health assessment and health
promotion for vulnerable groups in their baccalaureate program.
Critique of Methods
Limited health literacy can have significant impact on health
outcomes and is a critical topic area that should be addressed
in nursing education. The studies in this review included
health literacy as a variable for consideration in the knowl-
edge level of nursing students, assessment of learning ex-
periences, and inclusion in nursing curricula. All articles
reported original research, and a variety of instruments and
research methods were used to obtain student data. Health
literacy measurements were clearly reported in all of the ar-
ticles, and the research methods appeared to be sound.
It is clear based on the articles included in this review
that while health literacy has received much attention in the
health care arena, inclusion of health literacy content in nurs-
ing curricula has not been widely addressed in the literature.
Initiatives to standardize health literacy content and experi-
ences in nursing curricula can enhance nursing students ability
to provide care to patients who experience limited health liter-
acy and may contribute to improved patient health outcomes.
Volume 41 & Number 2 & March/April 2016 95
Implications for Nursing Education
Based on this literature review, areas to be addressed in
nursing programs include integrating health literacy content
in both didactic and clinical courses and continuing edu-
cation to update faculty knowledge about health literacy.
The Table provides specific recommendations for curricular
changes. These strategies will equip students with knowl-
edge, skills, and attitudes to interact effectively with patients
experiencing limited health literacy and modify patient teach-
ing strategies and materials for this patient population.
In the absence of accreditation guidelines for health
literacy content and experiences, each faculty will need to
examine its curricula to determine the best placement for
Table. Recommended Health Literacy Content in
Nursing Curricula
Contenta
Identification of patients with limited health literacy
Common signs that indicate low health literacy
Tools used to measure health literacy
Methods to enhance communication with individuals with low literacy
Methods for verification of patient understanding of health care
information taught
Evaluation of patient teaching materials for health literacy level
Best practices for simplifying written material
Use of pictures in patient education
Adverse medication events and limited health literacy
Plain Language resources
Ask Me 3 communication
Psychosocial issues for patients with limited health literacy
Impact of limited health literacy on patient outcomes, health system, and costs
Teaching Strategies
Watch videos depicting the impact of limited health literacy on patient
health outcomes and on patient interactions with health care providers
Universal precautions strategy: approach all patients with assumption
they are at risk of not understanding their health conditions or how to
deal with them, then confirm and ensure patients understanding
(http://www.nchealthliteracy.org/toolkit/introduction.pdf)
Complete evaluations of patient education materials for health literacy
level prior to use in patient teaching
Evaluate patient education materials available at local health care
agencies for appropriateness for patients
Practice completing health literacy assessments on volunteers, eg, students,
family members, friends
Include health literacy assessment as a requirement for every clinical encounter
Role play teaching patients with limited health literacy and teach-back
techniques in various case presentations, such as acute care, mental
health, gerontology, pediatrics, others
Develop teaching plans appropriate for patients with limited health literacy
Conduct a brown bag assessment of prescribed medications with all
assigned patients
Identify local literacy resources in the community, such as adult
education programs and literacy leagues
Practice revising health care materials using Plain Language guidelines
(http://www.plainlanguage.gov/resources/index.cfm)
Conduct simulations and debriefings for scenarios related to health
literacy, eg, patient education, communication, patient safety
a
Integrate health literacy content throughout curriculum
96 Volume 41 & Number 2 & March/April 2016
Copyright 2016 Wolters Kluwer Health, Inc. All rights reserved.
health literacy content and experiences. A health literacy
champion among the nursing faculty can be a positive in-
fluence on efforts to include this content and strategies in the
curricula. Currently, health literacy is not included in accred-
itation standards; however, it is noted as sample content in
the American Association of Colleges of Nursing Essentials
of Masters Education in Nursing VIII Clinical Prevention and
Population Health, IX Masters-Level Nursing Practice,18 and
also included in Essential IX Baccalaureate Generalist Nurs-
ing Practice as a consideration in providing appropriate patient
teaching.19
Conclusion
The available studies revealed that inclusion of health lit-
eracy content and experiences in nursing curricula enhances
nursing students awareness, knowledge, and skills regard-
ing health literacy and provision of care to patients with lim-
ited health literacy. The systematic review of the literature also
revealed limited and inconsistent health literacy content in
nursing curricula.
Nurses provide teaching and information to patients in a
variety of health care settings. It is important that nursing
curricula include information on health literacy to enhance
the awareness of future nurses of the impact that limited
health literacy can have on patient outcomes, and strategies
that can be implemented in providing care to patients with
limited health literacy.
References
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fact sheet. Health literacy and health outcomes. Available at
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factsliteracy.htm. Accessed May 24, 2015.
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standing health disparities. J Gen Intern Med. 2007;21(8):862-866.
7. Sand-Jecklin K, Murray B, Summers B, Watson J. Educating
nursing students about health literacy: from the classroom to the
patient bedside. Online J Issues Nurs. 2010;15(3):1.
8. Jukkala A, Deupree J, Graham S. Knowledge of limited health
literacy at an academic health center. J Contin Educ Nurs. 2009;
40(7):298-302.
9. Cornett S. Assessing and addressing health literacy. Online J
Issues Nurs. 2009;14(3):1.
10. Cormier C. Health Literacy: The Knowledge and Experiences
of Senior Level Baccalaureate Nursing Students [dissertation].
New Orleans, LA: Louisiana State University; 2006.
11. McCleary-Jones V. Assessing nursing students knowledge of
health literacy. Nurse Educ. 2012;37(5):214-217.
Nurse Educator
12. Torres R, Nichols J. Health literacy knowledge and experiences
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dents in caring for patients with behaviors suggestive of low health
literacy: a qualitative analysis. J Nurs Educ Pract. 2013;3(2):75-85.
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18. American Association of Colleges of Nursing (AACN). The Es-
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Teaching Psychomotor Skills in Nursing

Are students in your nursing program competent in performing psychomotor skills? It may be that we are not providing
sufficient practice for students to develop their competency. In learning a motor skill, students first need to understand the skill
and how to perform it accurately. To gain proficiency, they have to practice it and receive feedback to correct any errors.
With practice, students learn to do it more quickly. Movements become more consistent.1 Further practice enables them to
perform the skill without thinking through each step. If students do not use or practice a skill after their initial instruction in the
laboratory, it is unlikely they will retain it particularly as time goes on. We need to integrate practice of essential psychomotor
skills in simulations, clinical practice, and laboratory experiences throughout the curriculum. This will help students retain their
skills and become more competent in performing them. Consider using dyad practice in which students alternate between
observing and physically practicing the skill. When students observe their partner performing the skill, they gain insight into
aspects of the skill that are difficult to notice when doing it themselves.2 Dyad practice can improve performance and retention,
and it is efficient (2 students at a time).

Submitted by: Marilyn H. Oermann, PhD, RN, ANEF, FAAN, Editor-in-Chief, marilyn.oermann@duke.edu.

References
1. Schmidt RA, Lee TD. Motor Control and Learning: A Behavioral Emphasis. 4th ed. Champaign, IL: Human Kinetics; 2005.
2. Granados C, Wulf G. Enhancing motor learning through dyad practice: contributions of observation and dialogue. Res
Q Exerc Sport. 2007;78(3):197-203.

DOI: 10.1097/NNE.0000000000000245

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