Health literacy: An essential element of health care professionalism and resilience

1. Introduction

Health care professionalism remains at the forefront of discussions related to sustaining the delivery of person-centered, high quality care to patients. In addition, thought leaders in the field are now suggesting the benefits of health care professionalism include combating burnout and improving resilience of health care professionals as they navigate the U.S. health care environment. This report focuses on the health care delivery challenges in the U.S. The authors also aim to initiate a dialogue about similar issues in other countries with similar or different health care delivery systems.

This is a challenging time for U.S. health care managers and executives as they navigate a complex and dynamic health care environment. Health care organizations continue to face many external factors brought about by rapidly changing political, financial, demographic, and technological influences. These factors may include threats of increased mergers, additional public reporting, changes in the insurance industry, impact of social determinants of health upon outcomes, data security, declining reimbursement, consolidation of physician practices, and a consumer driven culture.

In addition, many internal aspects influence health care managers, professionals and the organizations they lead as they strive to provide the ultimate goals of safe, cost effective, quality health care and services for increasingly diverse patient populations. Being able to successfully manage these innumerable challenges requires a partnership between effective leadership and productive clinicians [1].

Unfortunately, health care leaders often partner with clinicians who experience stress and burnout. Burnout is often used to describe a state of fatigue and frustration brought about by a commitment to a way of life, or relationship that has not produced an expected reward [2]. In fact, U.S. physician satisfaction regarding work-life balance has been reported at extremely low levels and burnout among them has been reported at 50 percent or more [3].

However, burnout is not limited to physicians as all members of the health care workforce can experience its impact. Although research regarding burnout among other health care providers and staff is preliminary, the stress of working in the health care industry is far reaching and burnout is a widespread concern impacting the healthcare professions [4,5].

The success of a health care organization also is dependent upon how stressful events are addressed on both a personal and team-based level. Morrow et al propose “focusing on overall improvement of the environment for all staff to optimize wellness and resiliency” to ultimately decrease burnout [[4], p.293;6]. Meanwhile, resilience is the internal ability of a system to adapt its functioning before, during, or after changes and disturbances so it can sustain operational efficiency after major disasters, or even in times of extreme stress [6].

The importance of competency in professionalism and ethics extends beyond the traditional healthcare provider-patient relationship. To provide an environment in which healthcare providers are supported in their goals of providing high-quality care in a professional environment, healthcare managers and professionals must become competent in the realms of professionalism and ethics. This report: defines health care management professionalism and its subcomponents; operationalizes the healthcare management professionalism competency; presents a case study; and concludes with a potential to incorporate health literacy tools which can combat burnout and increase resilience for health care professionals.

2. Health care management professionalism definition

To facilitate competency attainment in professionalism and ethics in healthcare management and administration education, an examination of the healthcare management professionalism definition and the components included in this important definition are necessary. The literature and discussions focused on the crucial components of health management professionalism and ethics regularly overlook the importance of health literacy. The authors suggest it is essential to recognize the incorporation of health literacy as a vital component of the healthcare management professionalism competency definition.

Importantly, an understanding of health literacy and its impact upon health care organizations can serve as a tool for all healthcare administrators to better understand the healthcare environment in which they practice as well as the necessary elements needed to provide safe, equitable care for all. In turn, the authors suggest health literacy should be included as an achievable and measurable sub-competency in support of the critical goal of promoting competence in healthcare management professionalism. With a sound, inclusive healthcare professionalism competency definition in place, educators in the field will be well-positioned to operationalize the agreed upon health literacy sub-competencies by developing sound assessment methods and attainment measures to ensure and promote improved competence in healthcare management professionalism.

3. Health care management professionalism competency

In general, healthcare managers and professionals often believe they are sufficiently “competent” in the area of health management professionalism and ethics. Historically, such an assessment has been made of individuals without robust quantitative data to support the ascribed position. Although the definition of healthcare management professionalism and ethics remains amorphous, a definition is becoming more enunciated as part of the healthcare management field’s movement toward competency-based education and assessment.

The movement toward competency-based education has facilitated an opportunity within the healthcare management education field to delve into the definitions of critical competencies. One of the most critical competencies identified for healthcare managers has been and remains the competency of “professionalism and ethics”. The latter competency seems to have a legitimate place in an effort to promote the delivery of high-quality patient care – as care delivered in a professional and ethical manner is likely to result in improved practice and resulting patient satisfaction. Simultaneously, professional and ethical behavior builds recognition of healthcare management as a distinct “profession”. The benefits of educating healthcare professionals to gain competence in professionalism and ethics suggests parallel benefits, such as improved outcomes for patients and simultaneous improvement in professional well-being, which deters burnout.

Yet, one challenge to facilitate competency attainment within this realm is the lack of an agreed upon definition of healthcare management professionalism and ethics. Without an agreed upon definition, it is difficult to determine what should be assessed and the appropriateness of an assessment.

More promisingly, the Commission on Accreditation of Healthcare Management Education (CAHME) provides a resource for guidance. Currently, CAHME addresses competency attainment related to professionalism and ethics using a number of non-systematic approaches. While flexibility is one benefit of CAHME’s accreditation process, additional standardization within the professionalism and ethics domains would serve the profession well. Without an agreed upon definition or set of minimum standards for professionalism and ethics, it is difficult to uniformly assess competency attainment in this critical area. The authors suggest a standardized definition or guideline should be an essential starting point in an effort to meaningfully contribute to the attainment of professionalism and ethics competencies.

Still, facilitating the competency attainment of professional and ethical healthcare managers remains an ongoing challenge for healthcare management educators. As noted above, the growing acceptance of competency-based education has allowed the transformation of focus to grow from purely an assessment of substantive knowledge and skills to recognition of the importance of behavioral development in the area of professionalism and ethics. However, the way in which educators implement this complicated competency remains unsettled.

A recent study by Meacham, Thompson, and Hall found healthcare management programs address issues of professionalism in diverse ways including the development of courses, dedicated effort to preparing résumés and cover letters, seminars, and practice-based internships [7]. Similarly, topics related to ethics and ethical decision making have been integrated into healthcare management programs primarily through the use of case studies and practicums. The prior research is scarce about competency-based education that targets the development of professionalism in healthcare management. The preponderance of the prior literature on professionalism describes current applications of professional development, competency model development, and the importance of competency attainment for graduate students [8–10].

To provide more clarity on this issue, CAHME added to this competency development discussion in 2013 with then-new accreditation standards [11]. CAHME’s standards placed a new emphasis on the attainment of competencies among master’s-level students and focused on developing four domains: (a) III.A.3 a program curriculum to develop students’ competencies in communications and interpersonal effectiveness; (b) III.A.4 a program curriculum to develop students’ competencies in critical thinking, analysis, and problem solving; (c) III.A.5 a program curriculum to develop students’ competencies in management and leadership; and (d) III.A.6 a program curriculum to develop students’ competencies in professionalism and ethics [11].

To assess desired competencies, programs seeking CAHME accreditation complete a Self-Study document consisting of a series of questions about the program, which is reviewed during the accreditation process. To engage in this review, graduate programs initially requested further guidance on definitions of terms such as “professionalism and ethics” to ensure they were measuring students appropriately. Their inquiries suggested the definition of healthcare management professionalism and ethics was not necessarily straightforward.

To assist in moving educators’ ability to assess competencies forward, CAHME eventually provided guidance to define III.A.6. (professionalism and ethics) to include the domains of “Accountability”, “Acting with Integrity”, “Achievement Orientation”, “Ethical-Decision Making”, “Professionalism”, “Lifelong Learning”, and “Self-Confidence”. The definition of each of these terms can be informed by the literature as well as related healthcare management education guidance documents.

Nevertheless, the aforementioned organizations as well as experts in the field have not overtly recognized the importance of incorporating “health literacy” into the definition of health management professionalism and ethics. As a result, the following discussion outlines how health literacy fosters provider competency and how health literacy constructively impacts evolving definitions and assessment methods related to healthcare management professionalism and ethics.

The authors suggest that incorporating health literacy as an essential element of health care management competencies will assist health care managers and leaders in the ability to have meaningful interactions with patients, health care professionals, and all health care staff. When health care organizations are committed to being health literate, everyone benefits from clear communication that is easy to understand [12].

Fortunately, Brach et al. identify ten attributes of a health literate health care organization, which strives to help people navigate, understand, and use information and services to take better care of their health [12]. Brach et al.’s first attribute is a leadership focus to make health literacy integral to a health care organization’s mission, structure, and operations [12]. Brach et al.’s suggestions to meet the latter attribute are not prescriptive and are adaptable for diverse health care organizations. Their specific suggestions include: making clear and effective communication a priority across all departments, levels and channels; fostering a culture that values patient/consumer perspectives and two-way interactions; provide incentives for health literacy improvement; and allocating fiscal and human resources needed to meet the organizational health literacy goals [12].

Assuming it is best to inculcate these ideas early in a health care manager’s career, recent efforts have attempted to integrate health literacy within the education of sub-competencies expected of healthcare management students. The next section describes the implementation of an ongoing initiative in a university in the Northeastern U.S.

4. Case study

A foundational introduction of health literacy was provided within the Stony Brook University, Master of Health Administration introductory course in Professionalism and Ethics through assigned readings and reflections. This effort was supplemented by an incorporation of health literacy knowledge into subsequent healthcare management professionalism case study assignments accompanied by robust classroom discussions.

In the summer between their first and second year course work, Stony Brook graduate students participated in two health management practicum and seminar courses. The practicum placements provided practical, real-world management and administrative experience.

The goals of these courses were for students to demonstrate an understanding of the application of their theoretical and conceptual knowledge to realistic and unique management challenges. In addition, Stony Brook students were encouraged to assess how health organizational cultures and structures can be redesigned to respectfully accommodate diverse populations. A focus on clear communication in health care organizations was discussed, as well as how miscommunication can negatively affect patient care and outcomes. Some assigned readings about health care management and health literacy formed the foundation for reflection, discussion and analyses of student experiences during faculty led seminars and synchronous learning.

Several examples of inculcating sub-competencies during this coursework included effective patient communication as well as how body language, facial expression and tone of voice impacted the content being communicated. During discussions to enhance interpersonal understanding, a sub-competency was incorporated to better appreciate cultural, ethnic and social preferences. The latter sub-competency also included actively using diversity and multicultural approaches to create a welcoming environment within a health care organization. Within the sub-competency of strategic orientation, the ten attributes of a health literate health care organization were included in an effort to further expose and educate the students about the integral role health literacy plays in developing the mission, culture, structure and outcomes of health care organizations [12].

Student achievement in these interwoven health literacy sub-competencies were evaluated. The assessments included hypothetical-reflective writing assignments where Stony Brook students (asked to assume the role of a future health care management professional) responded to questions about ethical and professional challenges. Other assessments included interactive group discussions and faculty led synchronous discussions. In addition, health literacy sub-competencies were evaluated from interactive discussion board posts coupled with reflective writing assignments based on each student’s “real-world” practicum field experience.

In turn, the case study suggests a health literacy focus within the curriculum enhanced pedagogical efforts to facilitate meaningful competency development within a health management professionalism curriculum. For instance, a class focus on the benefits of clear communication to enhance patient care triggered discussion and student learning relevant to the domains of “accountability” and “acting with integrity”, as outlined in the CAHME standards related to professionalism [11]. A discussion of health management professionalism through the lens of health literacy also enabled students to appreciate the importance of clear communication and how the implementation of latter skills boosted provider-to-patient “accountability”. An improved student understanding of the meaning of clear patient communication additionally suggested how providers can “act with integrity” within routine patient care.

Overall, the Stony Brook case study suggests the field of health literacy creates opportunities for similar, meaningful student learning opportunities as they evolve from beginner, to intermediate, to advanced levels of competency attainment. There are constructive lessons learned by the integration of health literacy sub-competencies into the overall healthcare management professional competencies. Similarly, the case study suggests healthcare management students absorb the concepts of healthcare professionalism at a more diverse, deeper level when health literacy is incorporated into competency learning and assessment. The breadth of health literacy examples infused in the health management curriculum provides an asset by which students can carry tangible tools away from their learning experiences. Moreover, the inclusion of health literacy enables students to become upstanding healthcare professionals with foundational organizational tools, and strategies that can assist with combating burnout and promote resilience.

In the future, to assist with the program’s sustainability, the assigned readings, reflective writing assignments, group sessions, faculty–led synchronous discussions and case study assignments will be incorporated annually. This ensures Stony Brook healthcare management students have the opportunity to learn about health literacy as a critical dimension of healthcare professionalism.

5. Conclusion

Bringing health literacy to the forefront in healthcare management education shines new light on the health literacy and healthcare management fields. This Stony Brook case study suggests the fields are integral components of each another and serve as a model to revise competency development among healthcare management professional educators.

The overall importance to develop healthcare management professionals with high levels of professionalism competence remains an undisputed goal in the U.S. The employment of U.S. medical and health care services managers is projected to grow by 20 percent from 2016 to 2026 [13]. Concurrently, a demographic transformation will continue to evolve in terms of health care administrators, provides, and patients. As the latter occurs, health care management professionals with an understanding of the importance of health literacy will be better prepared to align health care services to meet the needs of the U.S’. increasingly diverse patient population [14].

Health care leadership is “the ability to effectively and ethically influence others for the benefit of individual patients and populations” and should focus on enhancing clinical outcomes, while also improving clinician well-being by promoting workplace engagement and decreased burnout [15]. Incorporating health literacy into the healthcare management professionalism competency provides a novel opportunity to not only enhance healthcare professionals’ health literacy knowledge and competence, but it also contains the potential to incorporate tools to combat burnout and increase resilience for health care professionals.

This report suggests while health literacy research and practice are missing from discussions about medical ethics and professionalism, their integration creates a rising tide that lifts all boats. The issues raised within this report provide research and leadership opportunities for the fields of medicine, nursing, public health, as well as health literacy students and other health care professionals. The authors hope this report contributes to an ongoing discussion about health literacy, medical ethics, and provider professionalism in the U.S. and other nations.