Good Steps to Safety: Guidelines for Communication and Health Literacy

By Cristina Vaz de Almeida and Celia Belim, PhD

Health literacy is “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Healthy People, 2010).

To improve this access, but above all foster the processing and understanding that allow smarter and safer decisions, it is also necessary to have patients’ perspectives on their desires, their knowledge, their adherence to medication and treatments, and their self-efficacy.

According to Kennedy et al. (2017), to improve our own practices, we need to gain patients’ perspectives on navigating healthcare services, interacting with medical providers and staff, understanding health information, and self-care.

Partnership between professionals and patients to maintain communication and health literacy can improve healthcare safety. However, involving and committing patients to their health requires professionals to possess broad skills.

Patient safety is enhanced by:

  • Good health communication (IOM, 2001)
  • Previous scripts for use in consultations (Hulsman, 2009)
  • Positive relational interactions that stress patient-centered decisions
  • Symmetry, mutuality, and equality
  • Trust, openness, involvement, investment, and commitment (Ledingham & Bruning, 1998; Mechanic & Meyer, 2000)


As a result of 10 focus groups (n = 60) and a qualitative approach, following mixed method principles (Bryman, 2012), five in-depth interviews were conducted with health literacy specialists to evaluate literacy issues in patient health, the importance of communication, and the knowledge and safety benefits of patient participation in healthcare. In this article, we will evaluate the interviews in depth.

The interviews, each lasting about an hour, were done with health professionals who took intensive and postgraduate health literacy courses in Portugal at the University Institute of Applied Psychology ( Interview participants included a public health doctor (male), a clinical trial specialist (female), a psychologist (female), a nurse (female), and an intensive care coordinating physician (female).

According to Steber (2017), advantages of in-depth interviews include establishing rapport with participants to make them feel more comfortable, and the ability to monitor changes in tone and word choice to gain understanding and generate more insightful responses—especially regarding sensitive topics. The in-depth interview allows us to collect high-quality data because it requires a concentration on everything the person transmits, obtaining a clear view of the themes under analysis. The in-depth interviews were all conducted face to face, thus obtaining an expressive dynamic regarding nonverbal language, which was also recorded.

Discussion and outcomes

Patient safety: The holistic view

There are some medical domains, such as surgery, where errors lead to observable consequences that need to be addressed immediately (Ericsson, 2008).

One interview subject was the intensive care coordinating physician at a large hospital on the outskirts of Lisbon that serves a population with low economic and educational resources, including many migrants and elderly people, where health literacy is limited (Espanha & Ávila, 2016). She stressed the importance of taking a “global approach, where you see the patient as a whole.”

The subject explained that, currently, organized medicine does not allow for a holistic view of the patient (at the hospital level). She gave the example: “The elderly person comes to a hospital and goes to an orthopedics service because he has suffered a fall, but then he has a heart problem and has to go to the cardiology service, and if he has breathing problems, he also has to [go to the] pulmonology service.” Patients with complex pathologies end up needing intervention from many discrete specialties. “These specialties turn out to be very technical,” she said. “There is therefore a ‘big bag’ that goes into internal medicine, and I think there should be more and more in the hospital a global and holistic patient approach, and this also contributes to patient safety.”

The public health practitioner, another interview participant, was also of the opinion that the cross-referencing of information between primary care and hospitals is not always optimal, and the patient is penalized for this lack of information transfer. The Institute of Medicine confirms (IOM, 2001) that hospitals and physician groups generally operate independently of one another, without the benefit of complete information on the patient’s condition or medical history, services provided in other settings, or medications prescribed by other providers.

The importance of guidelines to patient safety

The performance of health professionals is often conditioned. To better understand the patient, the professional must employ a set of behaviors and specific communicative skills (Dance, 1970; Hulsman, 2009) as a clear language (Pina, 2003), and maintain an assertive and positive attitude (Belim & Vaz de Almeida, 2018) during the consultation and interaction (Rawlins, 2007).

In a procedural approach, Hulsman (2009) states that health communication is regulated by goals and constraints, with diverse sequences and interactions, and should be aided by cognitive guidelines for the selection of choices and responses. Hulsman notes that health professionals must prepare prior to an interaction with a patient, and states that the various constraints during professional-patient interaction are behavioral regulators.

Improvement in clinicians’ performance does not automatically follow from extensive experience, general education, or knowledge related to their domain; other ingredients are needed, according to Ericsson (2008). Thus, significant improvements in the performance of health professionals include developing a task with a well-defined goal, being motivated to improve, receiving feedback, and having ample opportunities for repetition and gradual improvement of their care.

Corroborating with Hulsman (2009) and Fishbein (1995), we find that behavioral intention is important, but it is also necessary to evaluate the context in which professional-patient communication occurs. Therefore, means (facilitating communication) must be arranged to obtain a cognitive response (Littlejohn, 1982). The initial impulse for this health behavior begins with the intention to act, as observed in the studies of Fishbein and Ajzen (2005).

Given the contextual factors where communication occurs, patient variables such as gender, age, level of education, ethnicity, and familiarity with healthcare inform the goals and problems to be addressed in the communicative process (Hulsman, 2009).

Among the factors that influence behavior, we find a mosaic of internal and external factors: knowledge, skills, physical condition, self-esteem, interpersonal environment, time available, complexity of tasks, and stress (Hulsman, 2009).

Wiemann (1977) points out that a competent communicator is aware of the “sacred quality of the meetings,” helping to establish and maintain participants’ personal and social identity. This communicator has the ability to help others “save face”—for example, helping a person maintain his or her identity in the presence of a threat.

Proper communication is based on a two-way process (Teixeira, 2004), and on coding and decoding of both actors (Hall, 1980; Schramm, 1955); it implies a good identification of the relevant objectives (Hulsman, 2009). Personal communication is how one person persuades another to engage in a specific behavior, which is one way behaviors spread (Smith & Carpenter, 2017).

But to engage, inform, and motivate others requires some specialized skills. The Organisation for Economic Co-operation and Development (OECD) defines competence as the ability to meet the complex demands of today’s world by utilizing and mobilizing psychosocial resources (including skills and attitudes) in a specific context. Therefore, competence is more than just knowledge and skills, such as the ability to communicate effectively, which is a skill that can draw on language knowledge, digital practical skills, and attitudes toward those with whom a person interacts (OECD, 2005). However, key competencies are not determined by arbitrary decisions about which personal qualities and cognitive skills are desirable, but rather by careful consideration of psychosocial prerequisites for a successful life and society (OECD, 2005), thus being an important factor in how individuals help shape the world, not just deal with the world. From this, it can be inferred that human behavior without basic skills can be erratic and aimless, impeding people from making the right decisions about their health (Sorensen et al., 2012). Health professionals, in their relationship with patients, should have these social prerequisites (OECD, 2005) in the development of their behaviors, which will allow them to positively shepherd the therapeutic relationship.

The intensive care coordinating physician we interviewed reinforced the urgent need for skill development in health professionals, especially in the area of ​​communication; she stressed that basic coursework does not stimulate or integrate this essential area. “Communication training should start early,” she said. “Sometimes I see colleagues talking to patients and family and just use one or two words and people don’t understand anything. People do not understand simple things. For example, if I tell a family that their relative’s situation is ‘stable’ (a patient in intensive care) … most people don’t understand what that means and think the person is all ready to recover. But we have to make the effort to make them understand.”

But therapeutic communication skills are neither innate nor automatic (Włoszczak-Szubzda & Jarosz, 2013), being acquired and refined through education and practice. Behavioral skills are also usually consciously acquired through practice, becoming automated and therefore not dependent on monitoring and control (Hulsman, 2007), so individuals can have hundreds of organized and interpretive scripts that are automatically activated when needed. Hulsman reinforces that the existence of scripts, as prior knowledge, reduces cognitive effort in the performance of complex tasks. Because health professionals have prior knowledge and preparation of health communication models, which are available at all times and at different stages of consultation, they will be able to find better solutions to issues raised by patients and help patients access healthcare in a more effective and motivated way.

All health professionals who participated in the in-depth interview agreed that patients are more satisfied and more committed when professionals give more information, show support and affection, and facilitate participation. But professionals do not always follow this path, often due to the stress they are under (Ammentorp, Sabroe, Kofoed, & Mainz, 2007) and being faced with multiple decisions and time constraints (Hulsman, 2007). The health professionals interviewed also agreed that the verbal and nonverbal components of the dyadic conversational encounter have enormous influence during a consultation (Wiemann, 1977).


In the professional-patient interaction, the use of previous intervention guidelines in the domains of therapeutic relationship building and communication with patients (Hulsman, 2009) seems to be a learning pathway for better handling the challenges that arise during these interactions.

When healthcare professionals have this set of previously learned scripts accessible, they enrich their communication with flexible and reliable response alternatives. Because these responses have been tested before, they allow for less stressful solutions to be found, subsequently meeting consultation goals and patient needs.

In a competent communicative practice (Hulsman, 2007; Weimann, 1977), the health professional—based on previous preparation of a set of communicative skills that include assertiveness, clarity, and positivity in behaviors, attitudes, and verbalizations (Almeida, 2016; Belim & Vaz de Almeida, 2017)—can encourage patients to adopt healthy behaviors and recommendations (Koh, 2010), contributing to the problem solving process (Kim & Grunig, 2011).

Cristina Vaz de Almeida is director of the Post Graduate Course on Health Literacy at ISPA in Portugal; she is also a PhD student in communication science and health literacy at ISCSP. Celia Belim is a professor at ISCSP.


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For Further Reading

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