Keywords

1 Introduction

Health literacy is presented as a critical determinant of health and sustainable development in the future. Sustainability in health services requires autonomous and health-literate people who are able to assess, analyse, and comprehend health information in order to make decisions about their health (WHO 2017). There are great expectations in regard to increasing the level of the population’s health literacy (Ministry of Health and Care Services 2019). These expectations place new demands on health professionals. Health professionals’ communication, pedagogical competence, and professional knowledge are significant for supervision which is intended to increase health literacy (Ministry of Health and Care Services 2019).

A change in the roles and relationships between patient and health professionals have been described. The role of the patient has evolved from being a passive recipient of medical care to an active, empowered, and informed co-producer of health (WHO 2013a; Nylenna 2020). Increased patient participation through patient education, rehabilitation, supervision, and support has been emphasised as important for improving health literacy and shared decision-making. This change is in line with the underlying thinking of sustainable development. Health literacy empowers and drives equity in sustainable health development. Health-literate people have knowledge and skills to make the healthiest choices and decisions for themselves (WHO 2017). Supervision is based on the patient’s preferences and experiences and facilitates a patient-centred approach. It is a strategy for strengthening health literacy and ensuring equal health services. Supervision may promote equitable quality education and facilitate lifelong learning in good health and well-being (SDG 3,4). An underlying thought in supervision is to stimulate the person’s own thinking (Lauvås and Handal 2014). Continuous critical thinking linked to lifestyle choices is vital in developing good health and well-being.

Within public health, the role of the public health nurse has changed from acting as an expert to involving the parents as active participants at child health clinics (Dahl et al. 2014). Many problems cannot solely be solved by biomedical knowledge. This recognition served as the precursor to both health promotion strategies and the 1986 Ottawa Charter (WHO 1986; Dahl et al. 2014). Public health nursing is concerned with striking a balance between the role of experts and safeguarding service user involvement (Dahl 2016). One of the goals of supervision is to empower the service user so that they can make well-informed decisions for themselves and their families for good health and well-being (SDG 3).

Supervision is a tool which can be used for improving health literacy and creating health literate–friendly organisations. Examples from health-promoting, preventive, and therapeutic health services will be used to illustrate supervision in different contexts.

2 Supervision

Pedagogues, namely Gunnar Handal and Per Lauvås, have developed a pedagogical strategy, the action and reflection model, for vocational supervision that has been used in recent decades in professional educations and collegial supervision (Handal and Lauvås 1983, 1999; Lauvås et al. 2004; Lauvås and Handal 2014). This supervision strategy has been experienced as valuable in peer supervision in Higher Education (de Lange and Lauvås 2018).

We argue that the strategy is transferable to healthcare contexts to increase individual and organisational health literacy. The aim of the supervision strategy is that the person becomes aware of the knowledge, experience, and values on which the professional activity is based on rather than conveying the “right knowledge” (Bårdsgjerde et al. 2023). The action and reflection model is based on the person’s own experiences and helps to draw connections between values and theoretical knowledge about thinking and acting in a specific situation (Lauvås and Handal 2014; Lauvås et al. 2016). It intends to make the person aware of own knowledge, experiences, and values, and Lauvås and Handal (2014) state that becoming aware of one’s own knowledge increases the possibilities for change and development (Lauvås and Handal 2014).

An underlying thought in the action and reflection model is to empower the person to develop their knowledge base and stimulate critical thinking. Health literacy is a complex phenomenon related to the competencies of accessing, understanding, appraising, and applying health information in the domains of healthcare, disease prevention, and health promotion (Sørensen et al. 2012). Critical thinking is vital in this process, and we consider the action and reflection model to be valuable for strengthening health literacy. Health supervision presupposes that health professionals can use different forms of knowledge and pedagogical tools in their efforts to strengthen service users’ critical thinking.

3 Pedagogical Tools

We will present tools from the action and reflection model (Lauvås and Handal 2014; Lauvås et al. 2016) that we consider to be valuable in supervision within a healthcare context (in Table 5.1). Based on practical challenges, the strategy stimulates the person to think about the underpinning assumptions of their practice. Transferred to a healthcare context, this may mean that the supervision strategy can help strengthen the service user’s knowledge of their health challenges, as well as the consequences of various choices (Bårdsgjerde et al. 2023).

Table 5.1 Pedagogical tools
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4 Individual Supervision

Individual supervision is a common form of knowledge sharing between patients and health professionals (Ministry of Health and Care Services 2019). Stressful life events, for example, being diagnosed with a chronic disease, can make individuals receptive to developing their knowledge and skills, often referred to as “teachable moments”(Rowlands et al. 2019). Research has shown that after a heart attack, the patient may be highly motivated to make lifestyle changes (Bårdsgjerde et al. 2019).

4.1 Relationships in Health Supervision

In health supervision, there often is an asymmetrical relationship, where health professionals possess expert knowledge. It will be important that health professionals base their work on the patient’s understanding of the problem. Health professionals may learn from listening to patients’ experiences (Bårdsgjerde et al. 2023). A study described patients’ experience of breathlessness in COPD exacerbation, which is a dramatic situation and patients may experience the use of coercion during acute treatment (Kvangarsnes et al. 2013b). Loss of trust may be a consequence, and coping in acute situations is a relevant topic for supervision (Kvangarsnes et al. 2013a).

Health professionals should neither seek to instruct nor moralise, and health information must be adapted to the service user’s circumstances and preferences. Many patients experience shame in their role as a patient, and this can be an obstacle to a positive learning process (Gulbrandsen 2006). The patient’s feeling of shame is often underestimated, and health professionals should be aware of this phenomenon when working towards building health literacy.

In cases of supervision over time, it may be appropriate to ask the patient in advance to formulate what they wish to discuss. Listening to the patient’s experience of the situation may give the patient’s voice significance. By asking the patient open-ended questions, the patient may develop a better understanding of how they cope with the various challenges related to the situation (Bårdsgjerde et al. 2023).

4.2 Frame Factors and Structures

Time and access to health professionals are important in supervision. It might be useful if health professionals communicate the time available in each situation to the service user. This allows the service user to prioritise what is important to discuss. Many issues are complex, and it may be appropriate to have multiple consultations. Health professionals and service users should draw up a plan for the issues that need to be discussed (Bårdsgjerde et al. 2023). Research has emphasised time and continuity as important in follow-up of patients after a heart attack (Bårdsgjerde et al. 2022). Similar findings have been found in the palliative care setting. Continuity is important for patients and their next of kin so that they know who they should contact when the patient’s condition worsens (Tarberg et al. 2022).

The importance of architecture and physical frames for consultation (Martinsen 2006) has been highlighted. In many institutions, patients do not have access to single rooms, and there is also a lack of rooms for private conversation. This makes it challenging to maintain confidentiality (Bårdsgjerde et al. 2023). A study found that the lack of facilities for private conversations hindered dialogue between physicians and patients in cardiac care (Bårdsgjerde et al. 2022). Rooms for consultations are often designed to fulfil several functions. An example is the doctor’s office, which is planned for examinations, reporting, and supervision. This may make the patient feel that diagnostics take precedence, and that there is little room for personal conversations (Bårdsgjerde et al. 2023). Questions have been raised about what time, architecture, and knowledge do to the tone of space (Martinsen 2006; Kvangarsnes 2007). Standardised forms and checklists increasingly characterise consultations between healthcare professionals and patients. This may lead to less space for patients’ stories and communication of their preferences. There is a risk that patients become an object rather than a participant in the process (Martinsen 2005). Health-literate patients mean active and engaged patients with confidence in their coping with the disease, decisions about lifestyle choices, and use of health services.

Increased standardisation in programmes and procedures has been found to challenge the use of professional judgement at child health centres (Dahl and Clancy 2015). Strategies to promote health are often designed to reach population groups, such as primary and secondary school classes (Dahl and Clancy 2015; Orkan 2019). Dahl and Clancy (2015) found that standardised education programmes implemented in school classes often revealed individual needs. Sometimes, public health nurses succeeded in applying standardised protocols to solve these individual needs: However, standardisation often hindered flexibility and the ability to make the correct clinical judgements.

4.3 Progression and Various Perspectives

Progression over time in supervision is important (Lauvås and Handal 2014; Lauvås et al. 2016). Health professionals should not proceed too quickly when providing advice. A common expectation is that the patient will present a problem, and the health professional will provide a solution (Bårdsgjerde et al. 2023). Shared decision-making is an example of how health professionals and patients can make joint decisions. Makoul and Clayman (2006) identified important elements of shared decision-making in encounters between physicians and patients. These elements have inspired the development of a tool for shared decision-making between patients and health professionals (Kienlin et al. 2020). The tool follows a structure: explaining the problem, presenting options and discuss pros and cons, identifying the patient values, preferences and discuss patient self-efficacy, health professionals provide their knowledge/recommendation, check and clarify understanding and make or defer decisions, and arrange further follow-up (Makoul and Clayman 2006). The process often takes place over time, and plans should be made.

In complex cases, follow-up consultations focusing on various perspective may be valuable. A common challenge in families with young children is problems with sleeping, and this may present challenges for the parents’ professional life, social activity, and family life. The parents often need supervision over time to cope with the situation. The issues can be perceived as complex and unmanageable and needs to be explored from different perspectives. Relevant perspectives can be the child’s, the sibling’s, the parents’, and the family’s views. Clarifying the problem from different perspectives can help support parents in discovering new coping strategies (Bårdsgjerde et al. 2023).

4.4 Communication and Metacommunication

At the end of a supervision session, a summary of the conversation and decisions made should be carried out. Health professionals should ensure that the patient has understood the information provided and give the patient the opportunity to ask questions (Bårdsgjerde et al. 2023). One method for improving communication between patients and health professionals is called the “teach-back technique”. The patient is asked to recall in their own words what the health professional has told them. The technique is often used to secure a common understanding between the patient and the health professionals (Talevski et al. 2020).

Health-literate organisations aim to make it easy for patients to navigate, understand, and use information and services to take care of their health (Brach et al. 2012; Brega et al. 2019). Written information prepared by health professionals is criticised for having a professional and bureaucratic language that is difficult for service users to understand (WHO 2013b; Hem and Nylenna 2021). Creating health literate–friendly organisations is one of the strategies to increase health literacy in populations globally. The Shanghai Declaration (WHO 2017) stated that health literacy was one of three pillars required to achieve SDG 3 ensuring healthy lives and promoting well-being for all people at all ages.

5 Supervision Among Colleagues

5.1 Exercise in Peer Group Supervision

In this section, we describe an exercise for peer group supervision among colleagues. The exercise has been applied in Higher Education (Lauvås et al. 2004, 2016; de Lange and Lauvås 2018; Kirkevold and De Lange 2023). We believe that this exercise is a valuable strategy to strengthen individual and organisational health literacy. Peer group supervision will be significant, for example, to analyse the degree to which organisations enable individuals to find, understand, and use information and services to inform health decisions and actions for themselves and others (Centers for Disease Control and Prevention (CDC) 2020). This is an important task for all health services. Organisational health literacy is complex, and highlighting various perspectives might be valuable. Examples of perspectives that might be relevant are the service user’s e-health literacy, access to equipment, standardised equipment, cooperation between different levels in health services, legislation, clinical guidelines, and access to individual supervision.

Progression and structure are experienced as important in the exercise (de Lange and Lauvås 2018). The exercise provides practice in asking open-ended questions, which invite reflection and insight into the knowledge, experiences, and values underpinning their actions (Bårdsgjerde et al. 2023).

The exercise is suitable in professional communities with five to ten participants. The exercise is based on a specific problem as experienced by the professional. It should not be a general problem but rooted in a real situation related to strengthening organisational health literacy. This exercise consists of seven phases, as shown in Table 5.2. It takes approximately 90 minutes to complete, depending on the number of participants and the complexity of the chosen problem. The exercise has a leader who has a governing role. Lauvås et al. (2016) and de Lange and Lauvås (2018) recommend that the various phases must be followed as a procedure.

Table 5.2 The seven phases
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5.2 Follow-Up: Reflections on Health Literacy and Sustainability

  • What learning outcomes were experienced by the person receiving supervision?

  • How did the participants experience the tight structure in the exercise?

  • How did the participants experience the use of open-ended questions?

  • What pedagogical tools (practical theory, progression and structure, various perspectives, communication, and metacommunication) were applied?

  • What learning outcomes did the participants experience?

  • What can be transferred to individual or organisational supervision to strengthen health literacy and sustainability?

  • How can supervision improve health literacy and sustainability?

It is important to be able to reflect on the experiences of the exercise to become aware of the importance of progression in supervision. By participating in the exercise, the participants will gain insight into and learn the value of using the various pedagogical tools in supervision and interaction with colleagues. This knowledge may be valuable and can be transferred to strengthen health literacy at an individual and organisational level.

6 Conclusion and Implications for Practice

We have presented experiences and theoretical perspectives about supervision to strengthen health literacy at both the individual and organisational levels. Health-literate people and organisations are important for sustainable health services and in achieving SDG 3 Good health and well-being. One of the goals of supervision is to make individuals and organisations aware of conditions for strengthening health literacy so that people can make good choices in order to achieve good health and well-being. There is a need for supervision at the individual and organisational levels to build health literacy and sustainable development. Supervision is a tool for healthcare professionals to empower individuals and organisations for lifelong learning. The requirements for health literacy will continue to change and require people to be able to adapt to new challenges in terms of climate and environment, economy, and social conditions.

We argue that there is a need to focus on supervision strategies to enhance individual and organisational health literacy in the future. Supervision can contribute to sustainable health services aiming to achieve good health and well-being through lifelong learning. Supervision for good health and well-being should be emphasised in curricula globally. Students in higher education within health care should be trained in supervision to strengthen health literacy at the individual and organisational levels.