Healthcare Literacy and the Decision Making Process

Updated | Published
by Nurse SMS Nurse SMS, MSN, RN (Guide)

Specializes in Critical Care; Cardiac; Professional Development. Has 11 years experience.

Healthcare literacy remains one of the most dynamic and challenging aspects of gaining patient engagement. Increased patient involvement has been shown in studies to decrease inpatient stays, cost of treatment, and increase a patient’s well-being and confidence in their medical care. While this is a growing area of concentration, particularly in the population health setting, it remains a challenging endeavor to put into practice.

What's the best route in educating our patients?

Healthcare Literacy and the Decision Making Process

Why Literacy Matters?

Healthcare literacy goes far beyond the ability of a patient to read or write. In fact, patients who have advanced degrees in other areas often are found to have low healthcare literacy!

When a patient is able to understand the key points of information and assimilate those concepts into their own perceptions of themselves and their health, they are better able to choose treatment options that match their own values, lifestyle and preferences. This, in turn, fosters greater trust in the medical system as a whole and can dramatically improve a patient’s sense of satisfaction with the care received. A reduction in the number of inpatient stays, length of hospitalizations and overall healthcare costs have been linked to patient education provided utilizing best practices for addressing potential healthcare literacy issues.


Like most issues in medicine and nursing care, the issue of healthcare literacy can be fraught with challenges. These include:

English as a second language (in countries with English as a primary language

Nonnative English speakers, regardless of fluency, tend to revert to their native language when stressed. Often the subtleties of options and cultural differences in practice and verbiage fail to cross over.

Socioeconomic challenges

Those individuals who do not read or write well or who suffer from poverty are more likely to have greater needs from a healthcare literacy perspective. Often the patient’s healthcare problems cannot be successfully addressed until needs lower on Maslow’s hierarchy are taken care of.

Access to and ability to use technology

Computerized charting and apps that permit patients access to their own medical records are not useful for those who lack access to the Internet or who are uncomfortable using it.

Numeracy skills

Added to these issues are variations in patient numeracy skills. The interpretation of graphs and statistics can be confusing. Utilizing that information and applying it to self is noted to be ineffective in a healthcare literacy challenged population.


Finally, bias remains a heavy player in the realm of Internet information sharing. Web-based sources tend to market particular treatments or specific treatment centers, offering information more as an advertisement than true patient education. Particularly for health care systems and specialty pages, risk is often downplayed and benefits emphasized. This can be understandably misleading to a patient seeking information.

Best Practices

As nurses, our goals should align with known best practices. The extra time it takes to educate a patient adequately can be immensely fulfilling, both for the patient and for your own nursing practice. Here are some tips on best practices for educating patients with low healthcare literacy.

  1. TIP #1 First, patients need assistance in identifying and communicating their core values, their tolerance for risk, and their own goals for their health and standard of living. Content shared with them should be varied and accessible, consisting of more than written handouts. In fact, most patients relate to never reading handouts that are provided. Many patients, however, report a greater understanding and satisfaction with teaching when utilizing modalities such as videos or interactive modules.
  2. TIP #2 Plain Language remains best practice, with elimination of terms greater than two syllables whenever possible and complete eradication of medical jargon from any written text. Keep content to 10 words or less per sentence and three to four sentences per paragraph.
  3. TIP #3 Watch for and utilize the “golden moment”. This is defined as a time when a patient asks you a question about their care. Their questioning indicates a readiness in the brain to take on new information. Expound upon your answer and provide a bit more information beyond what the patient directly asked for.
  4. TIP #4 And, lastly, be sure to utilize teach back. Teach Back remains the most reliable way to assess your patient’s understanding of the information that has been provided. As you provide patient education, give the patient time to rest and ponder, then circle back to approach the topic again, perhaps from a different direction or using a different mode.


Healthcare literacy remains one of the greatest barriers to addressing recurring medical issues, particularly those which are chronic and ongoing. Diabetes, COPD, CHF, and renal failure remain repetitive causes of patient readmission; this subject has been better addressed at home with adequate patient teaching and at-home involvement by social service agencies. The increase in well days, patient satisfaction, and a decrease in healthcare spending make this a win/win situation for medical providers, our healthcare systems, and the patients themselves. I have attached some links for your perusal as you contemplate current patient education practices where you work.

FACT: An increased focus on healthcare literacy benefits everyone.


Centers for Disease Control and Prevention (CDC): Health Literacy

Centers for Medicare & Medicaid Services+: Toolkit for Making Written Material Clear and Effective

Nurse SMS specializes in Critical Care; Cardiac; Professional Development. "You did what you knew how to do; when you knew better, you did better". - Maya Angelou

2 Articles   6,837 Posts

Share this post

Link to post
Share on other sites

3 Comment(s)

simba and mufasa

Has 18 years experience. 5 Articles; 59 Posts

Very important and overlooked topic. I work in CVICU and it is astounding how illiterate people are when it comes to health. Many people have cell phones, laptops etc and Google anything they want, instead people are interested in other things other than health. Small simple sessions are helpful. We should also not forget that patients will not retain a lot especially in hospital or in pain. The patients portal is handy to those who understand but useless to some because of the medical jargon used. Language is a major use, my hospital prints education and discharge instructions in any language thus helpful.

Thank you

simba and mufasa


CommunityRNBSN, BSN, RN

Specializes in Community health. Has 4 years experience. 774 Posts

Does anyone have suggestions for how to initiate Teach Back? Particularly with a patient who is passive and not very verbal. I say “Did you understand what I said about your blood pressure medicine?” And they say “Yes.” But it feels confrontational to directly ASK them to explain it back to me.

Nurse SMS, MSN, RN

Specializes in Critical Care; Cardiac; Professional Development. Has 11 years experience. 2 Articles; 6,837 Posts

On 8/6/2020 at 12:38 PM, CommunityRNBSN said:

Does anyone have suggestions for how to initiate Teach Back? Particularly with a patient who is passive and not very verbal. I say “Did you understand what I said about your blood pressure medicine?” And they say “Yes.” But it feels confrontational to directly ASK them to explain it back to me.

You can explain the process of teach-back to them, then ask them to teach you as if they were teaching someone else how to do it. Most patients react to this very positively!

"Did you understand what I said about your blood pressure medicine?"


"Great! Okay, so now let's switch roles. I am the patient and you are the nurse. Can you tell me how to take this medicine?"



Specializes in med-surg. Has 6 years experience. 58 Posts

I am curious about the increased usage of telehealth and health literacy, in addition to patients having access to their health information through HC portals. I think that we need to incorporate teaching about using these resources. Many patients will come in with smartphones. We can show them how to download the app and use it to review their information, explain how it operates, and how to communicate through email in the portal with their care team. As far as telehealth, I recognize that this is not always accessible for patients but I would imagine that it is for the majority. The concern I would have for those in a lower economic bracket would be that they have data caps on their cell phone use. Hospitals and clinics do their best to help the patient set up the visit prior to using it on a computer through WiFi, but for rural patients, this can be difficult because of their internet connectivity issues and for urban patients, I would be concerned about their overall access to WiFi. Great article. The technological aspect of this has been something that I have been thinking about for a long time. How can nurses improve this accessibility to improve health care literacy? Possibly offering suggestions to utilize the library WiFi for accessing their patient portal, or, if there are quiet personal rooms in their library, they could possibly try that for telehealth. I think about patients being able to review test results and not understanding the meaning or reason. I think this would be a good educational point about how they can communicate with their healthcare team about these types of issues. Possibly, something the bedside nurse can educate them on before they are discharged. In my opinion, it is an excellent resource though it comes with barriers and a learning curve. I think we have the opportunity to help with this.