Background
Recently, as patients are being recognized as active consumers of medical services, their right to know has evolved, medical information has become popular, and medical service utilization has increased. In line with this, the paradigm of medical services has shifted from expert-to patient-centered [
1,
2]. This also affects nursing care practice, and modern nursing care emphasizes on providing holistic patient-centered care that recognizes patients as individuals with personal needs [
3]. Patient-centered care, also known as person-centered nursing or individualized nursing care, refers to providing routine nursing care, such as medication nursing according to a doctor’s prescriptions, assisting in health-related decision-making, and providing individualized care while considering the individual characteristics and needs of patients [
4,
5].
Patient-centered care refers to respecting patients and focusing on their physical, psychological, social, and spiritual needs [
6]. From a patient’s perspective, it has positive effects such as improved physical and mental functions and autonomy, which may result in shortening the length of hospital stay, reducing readmission and emergency room visits, and reducing mortality [
7‐
9]. From the nurses’ perspective, patient-centered care can contribute to improving the continuity and quality of nursing care through nurses’ job satisfaction and organizational commitment [
8,
10,
11]. Nurses’ competencies that affect patient-centered care include empathy, self-leadership, communication skills, nursing professionalism, prioritization, and management [
12‐
15]. Since the American Medical Association defined patient-centered care, tools for its measurement, involving various elements, have been developed [
16], and intervention studies have also been reported [
17]. Since most health-related information contains technical content and difficult medical terms, patients may have difficulty communicating with medical professionals and acquiring health information. Therefore, to provide patient-centered care, communication between patients, their families, and healthcare providers with a focus on patients’ values, preferences, and needs is essential, and effective communication should be achieved in a way that patients can understand [
13].
Health literacy refers to the ability to understand and acquire basic information and services for health-related decision making. Since it is related to all clinical situations, nurses should identify it in patients and be aware of its effects on patient outcomes [
18]. Patients’ low health literacy can lead to negative consequences, such as lack of health-related knowledge, inadequate management of chronic diseases, poor medication adherence, increased emergency room visits, and increased hospitalization and mortality [
19‐
21]. Failure to consider patients’ health literacy in communicating with them can have a profound impact on their ability to access and comply with healthcare services. If patients cannot understand medical instructions, it is difficult to expect them to take medications or practice healthy behaviors. However, because most healthcare workers lack the knowledge, skills, and attitude to effectively provide health information and health services to patients and their caregivers with low health literacy, that is, health literacy competencies, its training is emphasized [
22]. It has been reported that only a few healthcare professionals use formal assessment tools to determine their patients’ health literacy, and the remaining majority use informal methods, such as their assumption or intuition, to roughly assess patients’ health literacy on the basis of patients’ education level [
23]. Nurses are responsible for understanding various health information, such as management of patients’ hospital stay, medications and health education, and daily life and exercise after discharge, and they play an important role in promoting patients’ health literacy [
24]. Therefore, nurses’ health literacy competencies in communicating with patients and providing patient education are professional nursing practice standards and the main competencies that nurses should have.
Nurses’ health literacy competencies can be the cornerstone of patient-centered care. This is because their failure to accurately assess patients’ health literacy may result in one-sided communication and limited effectiveness of patient education [
25]. Therefore, many organizations recommend a ‘universal precaution’ approach [
26,
27]. Enhancing health literacy is not a patient’s personal issue; thus, a comprehensive approach from the perspectives of health care providers and organizations should be made to form partnerships with patients and provide patient-centered care. Recently, medical curricula dealing with patients’ and physicians’ health literacy competencies in the medical science field are being actively provided, but such efforts in the nursing science field are insufficient. According to a study analyzing the educational goals of 60 nursing education institutions in South Korea, health literacy competencies were not included in nursing students’ expected abilities [
28]. To develop curricula for improving nurses’ health literacy competencies, studies should determine health literacy competencies expected from nurses and identify priority factors to be conducted in advance as groundwork [
18,
22].
Studies on health literacy in nursing science have, so far, mainly focused on specific patient groups and disease states, and nursing professionals’ educational preparations for health literacy competencies, the effects of health literacy competencies on nurses’ roles, and patient outcomes have not been evaluated [
23,
29]. Some studies have reported significant differences between health literacy competency-related knowledge, skills, and practice among nurses [
23,
30,
31]. Considering that nurses are responsible for direct patient care and delivery of medical services, it is necessary to determine their understanding and perception of health literacy competencies and to provide empirical evidence for their effects on patient-centered care. Therefore, this study aims to identify the association between health literacy competency levels and patient-centered care among nurses, present evidence for enhancing nursing care practice, and provide basic data for the composition of education programs on health literacy competencies.
It also aims to investigate the effects of health literacy competencies on patient-centered care among nurses and to understand the association between them.
Discussion
This study attempted to investigate health literacy competencies and patient-centered care levels, and to determine the association between health literacy competencies and patient-centered care among nurses. The following interpretations were made based on the results of this study.
Of the 180 participants in this study, 46.7% had experience dealing with health literacy in nursing education courses or clinical situations, which was lower than the 80.0% found in a study involving nurses in the US [
23], and higher than the 38.9% found in a study involving nurses in Iran [
31]. Most studies on health literacy in South Korea have focused on patients’ health literacy, but not on medical professionals’ health literacy competencies. There is also a lack of programs on health literacy competencies in nursing education. These findings suggest that nurses may have difficulty understanding the reality of patients’ health literacy competencies and related problems.
The scores for health literacy knowledge, skills, and attitude, which are the subdomains of health literacy competencies, were 3.15, 3.08, and 3.39 (out of 4 points), respectively, indicating that the scores for knowledge and attitude were higher compared to the score for skills. With regard to knowledge, the score for the item: ‘I know the red flag behaviors suggesting that a patient lacks the ability to understand health information’ was the lowest with 2.72 points, and the mean score for the item: ‘I am aware of the difference between reading ability and reading comprehension ability, and the reason why general reading skills do not guarantee a patient’s understanding’ was low with 2.83 points.
With regard to attitude, the mean score for the item ‘universal precautions’ approach for all patients is required because it is difficult to distinguish persons at the risk of communication errors through simple observations, and the ordinary patient-caregiver interactions’ was low with (3.18 points. As found in previous studies [
30,
35] reporting that most medical professionals tend to overestimate patients’ health literacy, nurses who participated in this study may also have overestimated patients’ health literacy when communicating with them. In fact, since individual patients’ knowledge about medical terms and information needs may be inaccurately identified and their health literacy overestimated, there is a possibility that communication might be conducted in a way that patients cannot understand well. According to a study analyzing the educational goals of 60 nursing education institutions in South Korea, health literacy competencies were not included in nursing students’ expected abilities [
28]. There is a need to establish educational goals related to nurses’ health literacy competencies in universities and medical institutions to compose a curriculum or provide additional educational programs in clinical practice. With regard to skills, the score for the item: ‘I can find out individual patients’ prior understanding level of health problems without making them feel ashamed’ was the lowest at 2.81 points. Hospitals generally provide patients with test guidance and handouts such as patient education materials in a textural format [
36]. Efforts are required to identify patients’ cultural and social characteristics and understanding levels, and to provide appropriate education. The scores for the items: “I can accurately and effectively communicate verbally in patients’ preferred language using medical interpretation services’ and ‘I can provide resources for patients with disabilities’ were low at 3.01 points and 2.83 points, respectively. It has been reported that the biggest problems with medical services felt by foreigners in South Korea were a lack of medical services that took into account their cultural characteristics and communication difficulties [
37], and that individuals with hearing and speech impairments had reduced medical service utilization and decreased satisfaction due to communication difficulties [
38]. It is necessary to improve interpretation services so that patients and healthcare workers can use them 24 hours a day, and to provide proactive support to address the low health literacy of vulnerable social groups including disabled people.
In terms of the subdomain of patient-centered care, the score for clinical situation was the highest at 3.61 (out of 5 points), the score for decisional control was 3.52 (out of 5 points), and the score for personal life situation was the lowest at 3.20 (out of 5 points). These results are similar to the results of a study measuring patient-centered care in nurses using the same tool [
14] and are consistent with the results of a study conducted in seven countries, including the US and Finland, in which the score for the clinical situation subdomain was the highest [
39]. Most nurses prioritize identifying patients’ disease state when providing nursing care and perceive that it is important to identify patients’ needs in clinical situations and reflecting them in nursing care [
40]. As the recent trend of medical services has changed from disease- to patient-centered, patient-centered communication has been emphasized as a factor that positively affects patient health outcomes [
41]. However, for its active application, as in the US and European countries, sufficient communication training should be provided to nursing students, considering patients’ health literacy levels and clinical situations in nursing education curriculums at nursing colleges. The score for the subdomain personal life situation, which is supposed to reflect in nursing care by asking questions about individual patients’ hospitalization experience and daily life habits, was the lowest. For patient-centered care, it is important to provide patients with individualized nursing care in consideration of their personal life situations. However, in actual clinical settings, nurses only collect personalized data through a nursing information survey immediately after a patient’s hospitalization, and it is difficult to additionally assess the patient’s preferences and needs and to reflect them in nursing care due to the heavy workload. Although patient-centered care, which perceives patients as individuals with diverse and individual needs, is being established as a major paradigm [
3], it can be said that under the current medical system, it is difficult to provide because of the lack of the required nursing workforce [
42]. In order to consider patients’ personal aspects, it is necessary to improve nurses’ perceptions and attitudes, policies, and institutional efforts at the level of hospitals, and the government needs to relocate the nursing workforce and adjust the number of patients per nurse to reduce nurses’ workload and burden.
The results of this study showed significant differences in patient-centered care according to religion, education level, total clinical experience, and prior health literacy knowledge among the general characteristics of the participants, which differ from the results of previous studies indicating that there was a significant difference according to age and working department [
14,
43]. Therefore, repetitive studies involving different participants and clinical situations are required to investigate the general characteristics of patient-centered care.
Health literacy competencies and their subdomains: knowledge, skills, and attitudes, all had a positive association with patient-centered care. The skills subdomain had the highest association with patient-centered care (
r = .58), followed by knowledge (
r = .35) and attitude (
r = .30). Medical professionals should have different types of health literacy skills and the related practical principles. Therefore, studies are needed to prioritize the subdomains of health literacy competencies by identifying their subdomain [
26] that have the greatest potential impact on patient outcomes and evaluating their relative values. Based on participants’ self-assessments in this study, the score for health literacy skills was relatively lower compared to the score for knowledge or attitude. Empirical teaching methods can be suggested to practice specific strategic approaches for communicating with patients with low health literacy competencies, such as changing technical terms into easier terms, drawing pictures, and checking patients’ understanding level using the teach-back technique [
44,
45].
When multiple regression analysis was performed to identify the major factors affecting patient-centered care, the results revealed that higher health literacy competencies were positively associated with higher patient-centered care, its explanatory power was 36%. This finding supports the results of a study indicating that nurses’ health literacy knowledge, skills, and attitudes will be the basis of patient-centered care [
46]. Inconsistent with the principles of universal precautions for health literacy, it was reported that it is an important process for realizing patient-centered care for nurses to identify individual patients’ health literacy and use differentiated communication strategies for patients with low health literacy [
47]. Although the importance of patient-centered care is being emphasized in South Korea, interest and efforts in nurses’ health literacy competencies are lacking. To achieve patient-centered care, additional research is required to develop standards and practice guidelines for health literacy competencies for nurses to use tools to accurately identify patients’ health literacy or to communicate effectively according to its level reflecting the cultural context of South Korea; for example, Chinese characters are often used in medical terms. This study is significant in that it identified nurses’ health literacy competencies and determined their association with patient-centered care. In addition, the results of this study will be a basis for developing health literacy curricula to enhance health literacy competencies in nursing students and clinical nurses in the current local situation where health literacy practice is not consistently applied and guidelines for its content and structure are not established. It will also be a basis for improving the quality of nursing in providing patient-centered care.
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