HL is recognized as a social determinant of health based on its impact on health outcomes. Nurses play a vital role in the promotion of HL, HL practices enable nurses to offer understandable health information to all people and contribute to health equity. Nurses, as educators, are obligated to evaluate the patients’ health literacy and find strategies to improve patients’ health literacy. Furthermore, nurses' health literacy knowledge is essential to the quality of health education. Nurses’ lack of health literacy knowledge can lead to reduced effectiveness of health education, blocked public access to health information, a further expansion of the gap in HL among the population, and finally detriment to health-related outcomes. Recent studies show that in the United States, the knowledge of health literacy for nursing students and practicing nurses is obviously insufficient, and their experience in health literacy activities is very limited [15].
Our study supported the previous findings in the United States as we found that RNs in China had low HL knowledge level, especially regarding basic HL facts, which had the lowest correct answer rate. 50.9% nurses had never heard of HL and 86.1% never attended HL training. Macabasco-O'Connell A’s study also revealed that nursing professionals’ knowledge of HL and their understanding on the role HL plays on patient health outcomes is limited [16]. Nevertheless, some studies reported better circumstance, for example, Knight et al. found that RNs in Georgia had some HL knowledge. Three of the six basic facts on health literacy items were answered correctly by the majority of participants but three were also answered incorrectly by the majority of participants [17]. Low HL knowledge level may be caused by various factors. Our study was able to find that HL education background may have relationship with health literacy knowledge level. Ozen found that the HL of almost one-third of nursing students was limited, likely due to a lack of HL courses related in their 4-year curriculum [18]. In China, some universities set up mandatory or optional health education and health promotion courses in undergraduate program. In fact, HL education is also very scarce in continuing education program in hospitals. That explained why there was no significant difference in HL knowledge among nurses in different levels of hospitals in our study. Above findings suggested that HL education was essential for nursing group.
Our findings indicate that nurse manager, nurse educator and nurses with higher professional titleNational career ladder for nurses: level 1-5) have a higher level of HL knowledge level, possibly because they have more willingness to receive HL knowledge and learning resources. Nurses from different departments also showed gaps in HL knowledge. HL training for nurses in Health examination centers and Outpatient department needs to be strengthened. However, there was no statistical significance in whether or not they had attended HL training. It indicates that the effectiveness of HL education is not enough, which may be the problem of educational methods, educational content, or teaching ability of teachers. Kaper et al. reported that HL communication training for HCPs enhanced their knowledge and skills to improve patients’ autonomy in decision-making and strengthened their intention to employ HL-related communication [19]. Nurse educators and leaders could use the HL Tapestry conceptual model in education and practice to describe and define HL across the continuum of care [20]. Thus, well-designed and comprehensive HL education programs integrated into the nurse curriculum in universities and continuous training in hospitals are urgently needed. At the same time, it can choose senior title’s nurses and nurse managers as teachers, and further improve their knowledge of HL. Develop individualized training programs to meet the training needs of nurses in different departments.
Regarding HL-associated practices, most nurses lacked the ability to evaluate a patient’s level of HL with a HL screening tool. This is closely related to the lack of popularization of HL screening tools, such as the Test of Functional Health Literacy in Adults (TOFHLA) and Rapid Estimate of Adult Literacy in Medicine (REALM), in clinical applications. Currently, there are no rapid HL screening tools in clinical practice in China. Due to inadequate awareness of the popularization of HL, resulting in limited HL, less than half of nurses evaluate a patient's reading level and the cultural appropriateness of materials when providing health-related information. Most nurses assess patients' HL empirically. 27% of nurses never or rarely ask whether a patient has difficulty reading medical information or completing medical forms. A total of 60% of respondents stated they use their “gut feeling” to assess the patient’s HL often or always [16]. Therefore, future studies should focus not only on the development of HL screening tools but also on the applicability of such tools in clinical settings. When selecting health education pathways, nurses can choose written materials, videotapes or computer software. A total of 47.5% of nurses always or frequently use the teach-back method to assess the effect of health education. Though nurses conduct these practices in everyday patient interactions, there is still room for improvement. As Loan et al. noted, the use of the HL Universal Precautions Toolkit (AHRQ) may be beneficial for all health care providers across a variety of settings, as it promotes clear verbal and written communication to support optimal outcomes in health care [20]. Therefore, nurses should adopt effective communication techniques, such as using simple language, using teach-back methods, writing or printing out instruction materials or drawing pictures, when conducting health education [21]. Our study found that the higher the level of nurses' HL knowledge, in practice, nurses do better in using written materials. But nurses who never using computer software to provide healthcare information and never using teach-back to examine the effect of health education have higher HL scores. Nurses need to use more modern and effective educational tools and methods to educate patients with HL knowledge, not only with written materials
There are certain limitations of this study that need to be discussed. First, selection bias cannot be excluded, as only 768 nurses in hospitals in Zhejiang Province of China were recruited. Therefore, the samples are not representative of the whole nation. Second, during the adaptation of the instrument, no pilot tests were conducted, which may reduce the reliability and validity of the questionnaire, but the Cronbach's alpha and KMO values still indicate that the adapted version has good reliability and validity.