Over the past three decades health literacy has emerged as a prominent field of research due to the many challenges and complexities of health care. Health care, like most professions, has a language of its own, and the differences between its vocabulary and that of everyday conversation can make it difficult for patients to understand their diagnosis and follow instructions.

Alabama, along with many other states have taken measures to improve health literacy using a grass roots approach through advocacy and research opportunities.  The Centers of Disease Control and Prevention has a section dedicated to health literacy and the Alabama Health Literacy Initiative is recognized as one of the 25 states that have an official health literacy organization dedicating resources to educating the public so they will have a better understanding of how to navigate the healthcare system.

Health literacy has been one of the goals of the Alabama Health Action Coalition (AL-HAC) since 2017. Housed in the UAB School of Nursing and supported with a research grant from the Alabama Public Health Department, Joy Deupree, PhD, RN, FAAN and co-lead of the AL-HAC is the lead investigator on the grant to study health literacy in Alabama.

There are many factors that contribute to the challenges of health literacy, “the vocabulary of health care may be the primary issue, but there are other considerations that can get between you and a clear understanding of the meaning you are trying to communicate,” Deupree said. “English is a second language for more patients these days, and important nuances can be lost in the translation. Likewise, declining vision, hearing and cognition may cause communication difficulties with the escalating aging population. Poor reading skills, dyslexia, other learning disabilities, limited education, and low cognitive function can interfere with understanding and make following instructions for medication difficult.”

To raise awareness of health literacy, Healthy People 2030 linked health literacy to health equity. One of the initiative’s overarching goals demonstrates this focus: “Eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all.”

Nurses are responsible for most discharge teaching and patient education, and they spend more time with patients and families than most other healthcare professionals.  Time constraints limit nurses from always having the amount of time to properly educate a patient or their caregivers prior to discharge or during an office visit and once they return home, the challenges then become more challenging.

The advocacy and research nurses and other healthcare professionals are conducting to study health literacy in an effort to improve patient understanding are an important part of efforts to improve our healthcare system. For more information on how you can get involved in advocacy efforts for health literacy in your state and include it as part of you Action Coalition’s goals, contact Dr. Joy Deupree at deupreej@uab.edu.  

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List of major accomplishments

Resources Produced by AL-HAC

Resources developed to inform the articulation of ADN students and nurses into and graduation from BSN and higher nursing degree programs:

• Fact Sheets Show Nursing Workforce Advancements in the State (2017)
• MSN Comparison Profile (2017)
  • This table showed a brief comparison of the Master of Science in Nursing programs at all accredited, non-profit nursing institutions with a physical campus in Alabama.
• Terminal Nursing Degree Comparison Profile (2017)
  • This table showed a brief comparison of the Doctor of Nursing Practice (DNP), Doctor of Philosophy in Nursing (PhD), and Doctorate of Education (EdD) in Nursing degrees at all accredited, non-profit nursing institutions with a physical campus in Alabama. All information was obtained from the individual schools’ website.
• Nursing Career Mapping Template (2017)
  • This template was created to provide students with a basic overview of nursing qualifications and degrees and the associated career path in Alabama.

Funding Resource Guide for Alabama Program Comparisons

This comprehensive guide was created to identify and facilitate the development of additional financial resources to support nursing education in Alabama. 

To create the most complete financial resource guide possible, the components were vetted through several AL-HAC stakeholders that work with colleges of nursing and are familiar the resources available to students at all levels of education. AL-HAC Chairperson for the Alabama 80×20 Taskforce, put out a call out for assistance to the Alabama 80×20 Taskforce, which has 43 members from schools of nursing varied across the state and in different program types (both 2 year ad 4 year institutions) with the expertise to provide resources. AL-HAC also collaborated with the president of the Alabama Council of Administrators of Professional Nursing Education Programs (ACAPNEP) and AL-HAC member, to identify new funding and scholarship support. A call for assistance to ACAPNEP whose membership includes all Community Colleges with Nursing Programs was advertised. Feedback from each group was used to add to AL-HAC’s resource guide information.

AL-HAC collected the contact information on every nursing program with a campus in Alabama’s financial aid office in an effort to guide students to seek out additional information at the nursing program they select that might assist identifying additional resources throughout a student’s BSN education. Website links were also added to maintain accuracy of the information and ease students’ ability to find further information.

Baseline Metrics Report (2012-2014)

Prior to AL-HAC’s Baseline Metrics report published in May 2015, nursing workforce data had not been interpreted or made publicly available since Alabama’s Center for Nursing Excellence closed in 2009. The Alabama Board of Nursing (ABN) partnered with AL-HAC by supplying raw, de-identified data from the 2012 and 2014 RN license renewal survey and the 2013 LPN license renewal survey. 

AL-HAC also used this information to track progression towards Alabama achieving 80% of RN nurses with a BSN or higher degree by the year 2020. AL-HAC was able to create the below chart to demonstrate Alabama’s progress towards this goal: The Baseline Metrics Report also highlighted the successes of Alabama such as a large percent increase (35.7%) in the number of RNs who were DNP prepared from 2012 to 2014.

The ABN databases were used to establish baseline demographics for RNs as reported in 2012 (n=58,263) and 2014 (n=66,662) and LPNs in 2013 (n= 16,488). Variables for the data collected included gender, race, ethnicity, age, Alabama county of residence, currently enrolled in a mobility program, highest degree earned, highest level of education, employment status in nursing, and primary place of work. The reported descriptive statistics were limited to the data as provided by the ABN where the data were not coded for data mining; there were gaps in responses; data were missing or unknown for some variables, such as for race in the 2013 LPN database; and, variables were not consistent from year to year, which hindered the ability to trend data.

As a result of this project, the presented baseline demographics established for RNs and LPNs in Alabama provided a starting point from which to compare future workforce planning demonstrated the absence of robust workforce data. AL-HAC presented the gaps in nursing workforce data to the Board Executive Director and made presentations surrounding the Baseline Metric Report and the facts that Alabama lacked the evidence to influence policy; enhance diversity; forecast the nursing workforce supply and demand, including nursing education program planning; or identify nursing shortage areas versus overly saturated areas within the state. 

Following this report, AL-HAC and ABN collaborated enhance the data collection on the nursing workforce. The ABN fulfilled AL-HAC’s recommendation with the implementation of the National Council of State Boards of Nursing and Nursing Workforce Center’s National RN Minimum Dataset (MDS) beginning with the 2015 LPN license renewal survey to utilize the standardized national tool, identify trends, and align Alabama with other states to compare progression in the future.

These new questions, altered to be applicable to LPNs, became voluntary part of the license renewal process. The RN MDS will also be implemented in the 2016 RN license renewal survey. AL-HAC and the ABN jointly published a one page Frequently Asked Questions sheet to LPNs in fall 2015 to provide information on the new section of the LPN licensing survey which consists of the MDS questions to nurses and provide contact information for further questions.

The following reports were created by AL-HAC from the raw, de-identified data supplied from LPN and RN license renewal surveys:

• 2013 LPN Workforce Snapshot
• 2014 RN Workforce Snapshot
• 2015 LPN Workforce Snapshot
• 2015 LPN Workforce Report
• 2016 RN Workforce Report

Nursing Student Faculty Diversity Report
Prior to this report, Alabama currently lacked a comprehensive survey that spanned all accredited, non-profit nursing institutions in the state that collects the information0necessary to establish a baseline and track the progress of increasing diversity in schools of nursing. The Nursing Student and Faculty Survey filled a data gap in Alabama on the diversity of Alabama’s nursing students and faculty.

AL-HAC vetted the survey tool with deans of Baccalaureate and higher nursing programs through the State of Alabama Association of Colleges of Nursing (SAACN). AL-HAC also vetted the survey through the Advancing Education Taskforce which represents deans, directors, and faculty of 2 and 4 year nursing programs in Alabama. The AL-HAC survey team gathered input from these groups and implemented feedback from the schools of nursing in an effort to optimize the survey’s response rate. 

After extensive vetting, AL-HAC sent the Nursing Student and Faculty surveys out in November 2017 to all accredited, nonprofit nursing programs with a physical campus in Alabama. The AL-HAC survey team gathered input from these groups and implemented their feedback in an effort to optimize the survey’s response rate. The survey was then circulated electronically and the report was published and presented throughout the following year.

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Rita Jablonski, PhD, CRNP, FAAN, has developed strategies to help people with dementia care for their mouths and teeth. Photo courtesy of the University of Alabama at Birmingham.

The care of older adults with dementia has come a long way since 1982. That’s when Rita Jablonski, PhD, CRNP, FAAN, professor and director of research and scholarly development at the University of Alabama at Birmingham School of Nursing, began studying nursing. “We were told in nursing school back then to reorient people who have dementia. That made the behaviors worse,” Jablonski says, and nurses bore the brunt of patients’ frustrations, sometimes physically.

Jablonski has been around people with dementia since taking her first job after high school as a nurse’s aide at St. Joseph Manor outside Philadelphia. She worked the 3–11 p.m. shift and was assigned to do mouth care. At the time, very few people retained all their teeth into older adulthood, she says. Dentures were the norm.

Jablonski vividly recalls trying to remove the dentures of a 98-year-old woman in her care. “She had dementia, and she could fight,” Jablonski says. “She would literally pummel me.” When Jablonski sought advice from the RN in charge, she was told to hold the woman’s nose so she would open her mouth. Jablonski wasn’t having it, but another solution soon presented itself. “When I did bed checks two hours later, she was snoring with her mouth open. I was able to remove her dentures, and I thought, ‘Ah, this is a strategy.’”

In choosing to focus on mouth care, Rita Jablonski, PhD, CRNP, FAAN, joined a small but growing sorority of nurses who champion the integration of oral health into overall health care. Photo Courtesy of the University of Alabama at Birmingham.

Several decades have passed since that seminal experience, but it continues to inform Jablonski’s work as a nurse and her focus on research that’s relevant to both clinicians and caregivers. In choosing to make mouth care a central focus of her work on dementia, Jablonski joined the small but growing sorority of nurses who have focused their careers on championing the integration of oral health into overall health care. This influential group has made impressive strides—in research, education, and practice. Yet as the population of older adults with dementia steadily grows, the supply of nurses who are prepared to help maintain their oral hygiene is not keeping pace, and systemic barriers to providing such care remain firmly entrenched.

Jablonski notes that federally mandated staffing ratios for skilled nursing facilities were set in 1987, when nursing homes housed a mix of people, many of whom were relatively independent. Today, healthier older adults reside at home or in assisted living facilities, she says, so nursing homes “have a frailer, older, and in many cases medically complex population, and a nursing assistant taking care of 10 people who all require 100 percent care.” Under these circumstances, she says, mouth care is the easiest thing to skip, especially if patients resist that care. This reality is unfortunate—not only for the oral and overall health of patients, but also for their caregivers. In Jablonski’s experience, “many disruptive behaviors in long-term-care facilities are generated by oral health problems.”

The lack of an oral health benefit in Medicare further exacerbates the problem. In 2018, an AARP survey of older adults found that 38 percent of respondents had not seen a dentist or dental hygienist in the previous year, and almost half did not receive care or delayed care for an oral health condition. Respondents cited lack of insurance and cost as the primary impediments to dental visits.

That may change as advocacy for an effort known on social media as TeethinMedicare gains ground. Three bills (S.22, H.R.2951, and S.1423) aimed at creating a dental benefit in Medicare have been introduced in Congress, and in 2020, the Office of the Surgeon General will be releasing an oral health report that could catalyze action on this legislation. In the meantime, oral health champions in the nursing community are pushing ahead. Their priorities include clinical research to further the case for routinely attending to the oral health needs of older adults, and developing techniques that can assist caregivers in accomplishing this goal.

Today, Jablonski is  engaged in a three-year project, “Brushing Away Infections,” funded by the Centers for Medicare and Medicaid Services. She and her collaborators are training caregivers in seven Birmingham, Ala., nursing homes to provide mouth care and minimize care-resistant behaviors in older adults with cognitive impairments. Eventually, Jablonski would like to see caregivers apply these same techniques to other activities, such as bathing and dressing.

Toward the end of her tenure at St. Joseph’s, as she was about to complete her nursing degree, Jablonski had an experience that still guides her to this day. At 2 a.m., she heard a woman struggling to get out of bed, saying she needed to catch a train to go to work. Jablonski responded as she had been taught in nursing school.

“‘Miss Smith, it’s 1985. You are at St. Joseph Manor, and you are safe. Please go back to sleep.’ I’m standing there arguing with this 80-year-old woman with dementia, and as I’m making her more and more agitated, in walks another nurse’s aide. She gently held the woman’s hand and said, ‘The train isn’t here. It’s the middle of the night. Go back to sleep, and I’ll wake you up in time to catch the train, so you won’t be late for work.’ She entered the woman’s reality. The woman said, ‘Thank you,’ rolled over, and went back to sleep.”

Nurse Rita Jablonski has developed videos and other teaching tools to help caregivers identify and overcome care-resistant behaviors.Photo courtesy of the University of Alabama at Birmingham.

Jablonski fears that today’s nursing students are still not being prepared to deliver the type of compassionate care she witnessed that night or to attend to patients’ oral health needs. In 2011, she reviewed the most popular nursing fundamentals textbooks to see how much content was devoted to oral health. The answer was just one half of one percent. Much of it was outdated or erroneous, she says, and only one textbook contained anything about cognitively impaired older adults or care-resistant behavior. She believes nursing education will also need to change before the oral health of adults with dementia receives the attention it deserves.

Resources on Providing Mouth Care to People with Dementia

Oral Hygiene and Care-resistant Behaviors: Making a Difference

A 30-minute video explaining how nurses can recognize care-resistant behavior in persons with dementia and intervene to provide evidence-based mouth care.

Managing Dementia in Acute and Long-term Care Settings

A 34-minute video with tips on managing dementia-related behaviors in acute and long-term care settings.

Make Dementia Your B*tch!

Rita Jablonski’s blog with guidance on “turning a devastating disease into a positive journey!”

Research

Links to Rita Jablonski’s published papers on oral health and the care of people with dementia.

Nursing Contributions to Oral Health Integration

Tooth decay is preventable, yet it is the most prevalent chronic disease in the United States. Dental disease also contributes to systemic conditions such as diabetes and heart disease. Meanwhile, many people neglect their dental health because they lack insurance coverage and the cost of dental care places prevention and treatment out of reach.

To remedy this situation, a vanguard of health professionals has called for the integration of oral health and comprehensive health services. Nurse practitioners like Rita Jablonski have led the way in developing resources to inform educators and clinicians and help them integrate oral health in curricula and practice. To learn more, explore the resources below.

Oral Health Nursing Education and Practice (OHNEP)

This initiative, based at the New York University College of Nursing, provides a gateway to a wide array of resources, both for educators who want to prepare nursing students to play a role in preventing dental disease, and for clinicians who want to improve the quality of their patients’ oral health.

Oral Health

This special issue of Nursing Research and Practice features articles on the diverse ways nurses are promoting oral health integration.

Innovations in Oral Health Toolkit

This online resource, housed at Northeastern University’s Bouvé College of Health Sciences, offers guidance on integrating oral health content into health professions programs and courses.

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Left: Kathleen Ladner at her graduation from Barry University, in Miami, where she received her Bachelor of Science in Nursing. Right: Ladner in 2017.

Nursing Journeys is a profile series featuring Action Coalition leaders discussing their career paths and reflecting on the lessons they’ve learned.

Kathleen Ladner, PhD, RN, FACHE, a retired chief nursing officer and U.S. Navy captain in Nurse Corps, is co-leader of the Alabama Action Coalition. She is an adjunct associate professor of nursing at the University of Alabama in Birmingham School of Nursing in the Nursing Health Systems Administration program. On active duty from 1968-1973, she served in all nursing leadership capacities, including charge nurse, head nurse, and nurse director. In 1974, she was reactivated in the Naval Reserve; her management positions included administrative officer, executive officer, and commanding officer of a reserve hospital unit and fleet hospital units.

Why did you decide to become a nurse?

I had a desire to care for sick people. My focus early on was working with active duty military personnel and their dependents. I suspect my passion to work with the military population was due to the fact my father was a disabled veteran from the Korean War.

Describe the journey you took to get from that decision to where you are today.

Ladner in her Navy Dress blues.

My journey began with the single professional goal: to be the best military nurse to my patients. My desire to work in the military and the need to secure funding for a baccalaureate nursing education led me to apply for a scholarship with the Navy Nurse Corps Nurse Candidate Program. I was fortunate to be selected in my junior year and the rest is history. I have served in the U.S. Navy Nurse Corps for 25 years, a combination of active and reserve duty.

Throughout my career, I have been fortunate to serve in distinctive roles while continuing my military duties. I was faculty in three university-based nursing programs while having joint appointments in nursing service. Next, I was approached to consider becoming a senior leader in a hospital. Thus, for 18 years, I was the vice president of nursing and chief nursing officer at four complex acute care facilities in the South.

Since retiring as a health care executive and from the Navy, I have focused on giving back to my profession and community.

What impact did the Institute of Medicine’s Future of Nursing report have on you?

I found this report informative and inspiring. This report provides a roadmap of what our profession needs to do to transform. Its recommendations show how to maximize the levels of nurse providers in a manner that reflects “out-of-the-box thinking” to improve upon our delivery of care—delivery to all people, in diverse settings, to improve health and continue to provide efficient, cost-effective and quality care to everyone in the U.S. and the world.

How have you been involved with the Campaign for Action?

As president of the Alabama Organization of Nurse Executives (AlaONE), I worked with several leaders in nursing academia and practice, business, and medicine to apply to the Robert Wood Johnson Foundation to become the state’s Action Coalition. RWJF did select our application in February 2012. I am privileged to be one of the nurse co-leaders of the Alabama Health Action Coalition to further the work of the Institute of Medicine’s Future of Nursing initiative.

Of all you have accomplished, what are you most proud of?

I have had a rich, unplanned journey with outstanding opportunities and experiences. Honestly, it is difficult to single out one accomplishment. I believe one of the threads of my success is my ability to establish credible and successful relationships with every level of nurses, physicians, academic administrators, health care executives, business leaders, and military leaders to succeed in whatever endeavor before me and community.

What is the most important action that nurses can take to lead the way to improve health and health care in America?

First, nurses need to collaborate more among themselves.

Second, nurses need to acknowledge that leadership characteristics are present in each of us but there are varying levels that are unique to everyone.

Third, as a profession we need to mentor individuals to become visible outside their profession such as suggesting they take leadership roles in their community, serve on boards, and consider running for public office at all levels to improve health for all.

Last, I believe that membership in our professional organizations and others will help nursing achieve these points mentioned above.

What advice do you have for the next generation?

Get involved and be part of the solution. What an influential profession we should be for the 21st century, with its challenges and opportunities for nursing and health care. We should be active, not passive, partners in developing the best health care solutions.

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RN to BSN Mobility

LPN to RN 

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