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A Proposed ‘Health Literate Care Model’ Would Constitute A Systems Approach To Improving Patients’ Engagement In Care

Levels of Evidence
Levels of Evidence


This article is part of the Nursing Research Challenge. Thanks to a colleague championing health literacy in my workplace for sharing this article with me!

The Article: Koh, H. K., Brach, C., Harris, L.M., & Parchman, M.L. (2013). A proposed ‘Health Literate Care Model’ would constitute a systems approach to improving patients’ engagement in care. Health Affairs, 32(2): 357-367.

Big Idea: Health literacy is people’s’ ability to obtain and understand basic health information. Numerous studies indicate a large portion of Americans have low health literacy skills, which is not linked with formal education status or other socioeconomic variables; yet, health literacy remains one of the key drivers for positive patient outcomes, and it is seldom addressed via a systems perspective. This article discusses the authors’ Health Literate Care Model and how it should be and could be infused into healthcare organizations’ values and processes via “health literacy universal precautions” to improve patient empowerment, care, and health outcomes.

Survey Says!: This article is not research. It is, however, a valuable part of the levels of evidence as it is expert opinion based on other levels of health literacy evidence.

Quotable: “Patient engagement in health care has been termed the “blockbuster drug of the century,” with the potential to transform the practice of medicine. As noted in the Affordable Care Act, however, engaging patients in their own health care fundamentally relies on health literacy—that is, their ability to obtain, process, communicate, and understand basic health information and services. Unfortunately, relatively few people are proficient in understanding and acting on available health information to fully engage in their own care [references]” (p. 357).

“In too many clinical encounters, patients fundamentally do not understand the medical information presented to them [reference] and therefore cannot act in an informed fashion. In fact, the only national health literacy survey conducted to date shows that just 12 percent of Americans are proficient in completing tasks considered essential to successfully navigating the health system and acting on health information [reference]” (p. 358).

“Health literacy experts have begun to advocate health literacy universal precautions [reference]. Initially, the concept of universal precautions applied to across-the-board preparations instituted by health care organizations to prevent the transmission of blood-borne diseases among patients…Adopting health literacy universal precautions acknowledges that the complexity of the health care system challenges virtually everyone” (p. 358).

So What?: The authors discuss several innovative strategies for organizations to become “health-literate organizations,” incorporating a systems approach to health literacy. The concept of health literacy universal precautions is a novel but “simple” one that many organizations or even individual teams or units could implement. In addition, the authors also give several health literacy resources, such as the Health Literacy Universal Precautions Toolkit, to help organizations in this effort. You should definitely read this article, and if you’re a patient, you should absolutely pass it forward to your providers for them to share with their senior leaders.

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Do Patients “Like” Good Care?: Measuring Hospital Quality Via Facebook

The Article: Timian, A., Rupcic, S., Kachnowski, S., & Luisi, P. (2013). Do patients “like” good care?: Measuring hospital quality via Facebook. American Journal of Medical Quality. Advance online publication. doi:10.1177/1062860612474839

Big Idea: This first-of-its-kind exploratory study uses multivariate regressions, adjusting for numerous factors, to research the correlations between a cluster sample of 82 New York hospitals’ Facebook page “Likes,” patient satisfaction, patient recommendations, and 30-day mortality rates.

Survey Says!: 40 of the 82 hospitals had a Facebook page to qualify for the research. Study authors found there was, indeed, a significant negative relationship between hospital Facebook “Likes” and 30-day mortality rates. In addition, there was a significant positive relationship between “Likes” and patients’ recommendations of the hospital via the HHS Hospital Compare website.

Quotable: “In a recent study, 94% of respondents who gather health care information from social media use Facebook specifically [reference]” (p. 1).

“This research speaks to Facebook’s potential as a monitoring and evaluation tool that provides continuous data collection and allows researchers to gauge attitudes without costly and time-consuming surveys” (p. 2).

“Contrary to the hypothesis, teaching hospitals were found to be negatively associated with Facebook ‘Likes'” (p. 4).

“If one takes the existence of a Facebook page as a sign of hospitals’ public relations savvy, this suggests that patient recommendation is not simply a reflection of hospital quality but also is responsive to hospital public relations management. This finding supports the idea that patient recommendation is affected by variables outside of the model used and is an interesting topic for further research” (p. 6-7).

So What?: The researchers admit these findings may be “intuitive,” but are important to verify Facebook’s potential value to monitor patient satisfaction and quality care. This article is fascinating, and the authors do a good job of pointing out study limitations and opportunities for future research. Perhaps you should share it with your hospital’s communications/marketing department?

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Predictors of Survival in Patients with Non-Small Cell Lung Cancer [Article A Week]

The Article: Luo, J., Chen, Y., Narsavage, G. L., and Ducatman, A. (2012). Predictors of survival in patients with non-small cell lung cancer. Oncology Nursing Forum, 39(6): 609-616.

Big Idea: Lung cancer remains the leading cause of cancer deaths both in the U.S. and worldwide. Non-small cell lung cancer (NSCLC) makes up 80%-85% of lung cancers. Patients typically present with advanced stages, and the median survival time is 4 to 15 months. Chemotherapy slightly increases five-year survival rates. The authors retrospectively studied several factors of 110 rural-Appalachian hospitalized NSCLC patients’ charts to determine one-year overall survival outcomes.

Survey Says!: The researchers found several significant predictive factors of NSCLC one-year survival including: low BMI, elevated neutrophil counts, elevated platelet counts, and advanced cancer stage.

Quotable: “The current study confirmed that cancer staging and low BMI are powerful predictive factors of survival” (p. 613).

“As with elevated neutrophil counts, elevated platelets also may have inflammatory significance; whether inflammation relates directly to prognosis or is merely associated warrants further exploration” (p. 614).

“The study findings were limited to investigating short-term (one year) lung cancer survival rather than long-term survival outcomes. However, in predicting short-term lung cancer survival, the study results demonstrated significant clinical prognostic factors that could be meaningful in clinical trial research with survival outcomes, clinical care, and related areas for treatment” (p. 614).

So What?: This article is fascinating to me. I learned a lot about already extensively-studied predictors of NCSLC survival as well as about the Charlson Comorbidity Index, or CCI, a validated comorbidity tool that helps weigh the impact of comorbidities on mortality.

NSCLC is a common cancer diagnosis with a relatively poor prognosis. It’s important for oncology professionals to understand predictors of survival – common parameters – in order to create early interventions impacting those predictors.

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How Leadership Behaviors Impact Critical Care Nurse Job Satisfaction

Screen Shot 2013-02-21 at 9.52.01 PM The Article: Moneke, N. & Umeh, O. (2013). How leadership behaviors impact critical care nurse job satisfaction. Nursing Management, 44(1): 53-55.

The Big Idea: Nurses’ job satisfaction is correlated with many organizational, financial, and patient health outcomes. The authors of this article discuss analysis of 112 surveys completed by critical care nurses within a New York nonprofit healthcare organization. The surveys inquired of job satisfaction in light of five perceived leadership behaviors: enabling others to act, encouraging the heart, inspiring a shared vision, challenging the process, and modeling the way.

Survey Says!: The researchers discovered critical care nurse satisfaction is significantly and positively correlated with four of the five leadership behaviors – model the way, inspire a shared vision, challenge the process, and enable others to act. Interestingly, “encouraging the heart” was not correlated with critical care nurse job satisfaction.

Quotable: “And organizational empowerment [is] found to be directly associated with job satisfaction, particularly in areas where nurses feel they can impact policy [reference]…Studies suggest that leader behaviors can affect the work climate, which in turn affects financial results [reference]” (p. 53).

“Exemplary leaders model the way by making explicit that there are no gaps between ‘what they say they do and their explanations for their actions’ and ‘what they actually do and the real reasons for their actions [reference]'” (p. 54).

So What?: For the most part, people leave organizations because of their leaders and managers. Leadership, leadership, leadership; it makes a difference. Organizations need to invest in their managers, and develop them as authentic leaders. It’s a retention strategy for both the managers and the frontline team members. Current leaders and managers should take note of these behaviors and develop them personally to impact their teams and their careers. High-performing teams don’t just happen, and when they do happen, people tend to look for the leader who created them. Be that leader.


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From Toyota to the Bedside: Nurses Can Lead the Lean Way in Health Care Reform

Screen Shot 2013-02-16 at 4.33.05 PMThe Article: Johnson, J.E., Mastro, K.A., & Smith, A.L. (2012). From Toyota to the bedside: Nurses can lead the lean way in health care reform. Nursing Administration Quarterly, 36(3), 234-42.

Big Idea: The Toyota Production System of the 1960’s produced a new quality and efficiency method called Lean, which focuses on standardization and reducing waste. With healthcare systems required to “do more with less,” Lean initiatives are appropriate options. Nurses can help lead the way with Lean ideas and programs. The authors discuss the overall concept of Lean, how it can impact health care, two case studies of how nurse-led Lean initiatives are changing care within the operating room and the emergency department, and lessons learned from the Lean change processes.

Survey Says!: The two nurse-led initiatives streamlined supply/inventory processes, improved OR turnaround time, reduced overtime, aligned staffing with demand, and reduced ED length-of-stay by 47 minutes. All of these efforts led to increased revenue.

Quotable: “Since 2005, Lean has been used tactically for discrete, departmental problems in hospitals [ref]. Lean techniques have been used to increase the performance of hospital administration, specialty clinics in dermatology and gastroenterology, health plans and medical practices [ref]; heart and vascular centers [ref]; oncology clinics [ref]; radiology [ref]; emergency departments [refs]; and entire hospital systems [ref]. Increasingly, Lean has been used as a system-wide operating framework within health care systems that have emerged as early adopters of Lean as a major innovation in health care” (p. 235).

“As Senge [ref] suggested more than 20 years ago, the systems perspective is badly needed in a world overwhelmed by rapid technologic change, changing demographics, shifting borders, and increasing complexity” (p. 238).

“Leading a complex Lean transformation of a large hospital department is a natural role for nurses, who have experience leading multi-disciplinary teams, are trained in assessment, and are system thinkers. Nurses also bring added advantages to the role of Lean leader – an uncompromising commitment to patient care and the natural ability to view hospital systems through the lens of the patient” (p. 238).

So What?: With the Affordable Care Act fully implemented in 2019, it is essential for hospitals to work at maximum efficiency. Lean initiatives can help streamline care and processes, and nurses are ideal Lean leaders. If you are interested in systems, processes, quality improvement, or improving your healthcare organization’s bottom line, you should definitely read this article and engage your nurses and other healthcare leadership.

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Ethical Reasoning and Online Social Media

The Article: Englund, H., Chappy, S., & Jambunathan, J. (2012). Ethical reasoning and online social media. Nurse Educator, 37(6): 242-247.

Big Idea: While nurses and nursing students frequently utilize social media, little research has been done to understand nursing students’ own understanding of the ANA’s Principles for Social Networking or their accountability for their social media posts and how they relate to the ANA Code of Ethics. After experiencing an increase in students’ unprofessional use of social media, researchers at the University of Wisconsin Oshkosh surveyed their first semester and last semester undergraduate nursing students using a 21-item survey corresponding to the nine provisions within the Code of Ethics.

Survey Says!: 124 nursing students completed the surveys. Mean ages of the two semester groups were young – 22.4 and 24.4 years of age. The convenience sample was predominantly female, and the two groups – first semester and last semester students – had significant differences in their understanding of ethical decisions to not post certain information. Be sure to view the original article for the specifics of all the tests.

Quotable: “The increasing use of social media sites by nursing students has opened a ‘‘Pandora’s box’’ of issues related to ethicality and nursing professionalism in a cyber world” (p. 243).

“Although the CON [College of Nursing] has a policy in place, unfortunately, results of this study indicated that 27.5% of the sophomore 2 students and 30.4% of the senior 2 students were either unaware or unsure if the CON had such a policy. Clearly, more effective methods are needed to ensure that students are aware of the CON’s social media policy” (p. 247).

So What?: The stories of nurses and nursing students (and other healthcare professionals/students) misusing social media are everywhere. This study indicates nursing students have varying levels of understanding of ethical boundaries while using social media and that it is a learned skill. Perhaps nursing schools and programs should more heavily focus on this skill early in the curriculum to circumvent future issues.

This study could be easily replicable in any nursing school in the world. In fact, the authors encourage others to use their tool to further validate the survey. Every nurse should reach out to his alma mater to make it aware of this study and the tool as it just might shed some light on this highly unstudied yet incredibly needed area of research.

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Estimates of the Annual Direct Medical Costs of the Prevention and Treatment of Disease Associated with HPV in the U.S.

The Article: Chesson, H.W., Ekwueme, D.U., Watson, M., Lowy, D.R., Markowitza, L.E. (2012). Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States. Vaccine,

Big Idea: Human papillomavirus, or HPV, infection is linked to numerous diseases, both benign and malignant. Cancers linked with various HPV strains include cervical, vaginal, penile, anal, and certain head and neck cancers. Two HPV vaccines are currently available within the U.S. and could potentially reduce the incidence of the benign and malignant HPV-related diseases. The study authors updated the direct medical costs of HPV-associated diseases to stress the overall health and economic benefits of HPV vaccination.

Survey Says!: After all the computing, the researchers reported the direct cost of HPV-related diseases in the U.S. is $8 billion, most of which is attributed to the burden of cervical cancer.

Quotable: “Cervical cancer screening and follow-up together account for about $6.5 billion of the $8 billion total, or a little over 80% of the total estimated costs. This observation is consistent with findings from numerous studies that the cost-effectiveness of HPV vaccination could be enhanced greatly if vaccination is combined with reductions in routine cervical cancer screening costs through a delayed age of onset of screening or less frequent screening, or both [references]. Further, vaccination can help to reduce the follow-up costs of cervical cancer screening, such as costs associated with cervical intraepithelial neoplasia (p. 3).

So What?: $8 billion is quite a number. This is only direct costs, and does not include indirect costs such as loss of work, etc. for those living with HPV-related illnesses. It is clear the economic burden of HPV-related cancers is high. This article is helpful as leverage to increase HPV vaccination. I found that I was lacking comparison, though, to help me think through the study. What is the economic burden of other cancers? Preventable cancers? Virus-linked cancers? With the current cost of HPV vaccination and FDA vaccination guidelines/recommendations, what is the estimated financial impact on the estimated annual direct medical costs if vaccination increased? Overall, this is an interesting and useful article, and it left me wanting and wondering more.




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Teaching the Literacy of Professionalism: When Clinical Skills Are Not Enough

The Article: Smith, Y. & Caplin, M. (2012). Teaching the literacy of professionalism: When clinical skills are not enough. Nurse Educator, 37(3): 121-125.

Big Idea: Writing, presenting, and speaking are professional nursing skills that are expected but rarely taught intentionally. Many nurses incorrectly think professional presentations, posters, and articles are reserved for nurses with advanced degrees. Smith and Caplin, recognizing this knowledge gap and ongoing false assumption, utilized the term “professional literacy” to explain the phenomenon. In order to increase RN-BSN nursing students’ professional literacy, they developed a three-credit-hour, online, elective course incorporating the Community of Inquiry framework, which focuses on cognitive presence, social presence, and teaching presence. The course covered five objectives encompassing numerous professional nursing skills.

Survey Says!: All of the nurses who enrolled in the elective course completed the requirements for completion. They studied articles each week, developed presentations, prepared mock articles for journal submission, and encouraged one another along the way, providing open and constructive criticism. The authors, who were also the course teachers, received excellent student evaluations, which recommended the course as a required course rather than an elective. Authors were also surprised by the far reach of the course as participants openly shared the coursework and knowledge gained to their colleagues both informally and formally.

Quotable: “Interesting career accomplishments, unique clinical scenarios, and valuable project contributions are common among nurses and are worth sharing with colleagues. But when asked how often they speak or write about their work, nurses identify barriers such as feeling inadequate, lacking knowledge on how to present, and failing to recognize the value of contributions [reference]” (p. 121).

So What?: I agree many nurses lack professional literacy to present and write their great work to others; this honor and expectation is not solely for advanced practice nurses. Others interested in beginning a similar program either within their school or health care facility should review this article as it contains objectives and a framework for the entire course. Professional literacy is an important skill all nurses should possess.

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The Impact of Nursing Characteristics and the Work Environment on Perceptions of Communication

Article: Tschannen, D. and Lee, E. (2012) The impact of nursing characteristics and the work environment on perceptions of communication. Nursing Research and Practice, E-pub February 22, 2012, 1-7. Retrieved from

Big Idea: Communication within health care is a major concern. Poor communication can lead to fatal errors. A stressful work environment may lead to break down of communication; the values of the work environment (i.e. respect, trust, etc.) likely impact communication, as well. In this cross-sectional, descriptive study, researchers analyzed 135 nurses’ individual nursing characteristics (i.e. experience, education, etc.) in relation to their self-reported perceptions of communication. The frontline nurses, both RNs and LPNs, were from four medical-surgical units at two hospitals.

Survey Says!: After many statistical tests, environmental values such as trust and respect, specific nursing unit, higher levels of nursing education, and more years of experience correlated with nurses’ increased perception of open communication among other nurses and physicians. Both the RN and the LPN groups agreed communication among nurses was more open than communication between nurses and physicians.

Quotable: “For the past three years, miscommunication has been identified as one of the most frequently identified root causes of sentinel events reported to The Joint Commission, with 82% of the sentinel events in 2010 identifying communication as the primary root cause [reference]” (p. 1).

“Understanding the environment (e.g., presence or absence of trust, respect, status equity, and time availability) is a foundational step that must occur before implementing any strategies aimed at improving communication. A failure to understand the environment may in part explain why no one strategy has been shown to consistently improve nurse-physician communication [reference]” (p. 6).

So What?: Not only does this article provide a method to measure nurses’ perceptions of open communication among units and hospitals, but it also gives practical solutions and ideas to improve open communication among the RN-LPN dyad as well as the nurse-physician dyad.

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Family Homelessness Viewed Through the Lens of Health and Human Rights

Article: Lee, R. (2012). Family homelessness viewed through the lens of health and human rights. Advances in Nursing Science, 35(2): E47-E59.

The Big Idea: This ethnographic study focuses on the viewpoints of health, human rights, and dignity as perceived by 12 Appalachian mothers, raising children in an urban family homeless shelter.

Survey Says!: Three themes emerged through this study: “enduring threatening lifeways before coming to the shelter…struggling to earn the respect of self and others…[and] remaining emotionally and spiritually strong while facing challenges of shelter living and an uncertain future” (p. E55-E56).

Quotable: “More than 600 000 American families, including some 1.5 million children, will experience homelessness in any given year [reference]. During the period from 2007 to 2009, there was a 30% increase in the numbers of families who were homeless [reference]. These numbers do not include the additional families precariously housed and living in doubled-up situations or in substandard housing.” (p. E47).

“According to the National Low Income Housing Coalition’s 2011 figures, the average minimum wage worker in most states would have to work 102 hours each week to be able to afford a 2-bedroom apartment at the fair market housing rate [reference]. The fact that many individuals and families experiencing homelessness actually do work was confirmed by the US Conference of Mayors [reference], who found that between 15% and 25% of the urban homeless population are in fact employed (p. E48).

“Article 25 of this declaration [Universal Declaration of Human Rights, 1948] speaks to human rights at their most basic level: ‘Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control’ (Article 25, 1)” (p. E50).

So What?: This article has a wealth of information within it. I found myself wanting to quote the entire article. It discusses the health impact homelessness has on women and children. Homelessness is an extremely stressful situation for mothers and their children. Everyone deserves the right to dignity in health care; nurses can play a major role in culturally competent and empathetic care.