The Journal of Continuing Education in Nursing

Original Article 

Using the Teach-Back Method in Patient Education to Improve Patient Satisfaction

Andrea M. Centrella-Nigro, DNP, RN, CNE; Catherine Alexander, MSN, RN-BC

Abstract

Background:

This quasi-experimental research study used two similar nursing units to test the effects of teach back on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

Method:

A pretest–posttest design tested 24 nurses' knowledge, attitudes, and beliefs about teach back. Education specialists provided a 1-hour teaching session on teach back to all nurses in the intervention unit.

Results:

A significant improvement in knowledge scores in the pretest–posttest was found using paired t tests (p = .002). Qualitative analysis of nurses' comments demonstrated strong support for teach back in the post-test. The HCAHPS scores were not significantly improved in the intervention unit when compared with the control unit.

Conclusion:

More research needs to be conducted to determine the effectiveness of teach back on HCAHPS scores.

J Contin Educ Nurs. 2017;48(1):47–52.

Abstract

Background:

This quasi-experimental research study used two similar nursing units to test the effects of teach back on Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores.

Method:

A pretest–posttest design tested 24 nurses' knowledge, attitudes, and beliefs about teach back. Education specialists provided a 1-hour teaching session on teach back to all nurses in the intervention unit.

Results:

A significant improvement in knowledge scores in the pretest–posttest was found using paired t tests (p = .002). Qualitative analysis of nurses' comments demonstrated strong support for teach back in the post-test. The HCAHPS scores were not significantly improved in the intervention unit when compared with the control unit.

Conclusion:

More research needs to be conducted to determine the effectiveness of teach back on HCAHPS scores.

J Contin Educ Nurs. 2017;48(1):47–52.

Teach back is an educational technique that involves patients or primary learners in the teaching process and asks patients to restate information as it has been taught to them (Agency for Healthcare Research and Quality, 2015). Nurses and other professionals engaged in health teaching can use teach back as a tool to evaluate the patient's understanding of the material that is taught. The National Quality Forum (2010) has recommended using teach-back methodology as one of its 34 endorsed methods of safe practice for health care professionals. Much of the information that is taught in health care settings is complicated, and it has been estimated that up to 80% of the material is not able to be immediately recalled after a teaching session. In addition, up to 50% of the retained information is incorrect (Kessels, 2003).

Literature Review

Teach back has been shown to be an effective method of patient teaching. Patients with heart failure can recall discharge information better when the teach-back method is used (White, Garbez, Carroll, Brinker & Howie-Esquivel, 2013). Patients with heart failure were taught discharge information using the teach-back method. Recall of information was evaluated during hospitalization and 7 days after discharge. Although teach back was recommended for patient education, the researchers were not able to demonstrate a significant decrease in 30-day readmission rates with these same patients with heart failure. However, Peter et al. (2015) demonstrated significant improvement in heart failure readmissions using the teach-back method in their discharge process. A 12% reduction in heart failure readmissions was demonstrated with the patients who received teach back as an educational strategy. In a recent study of patients with heart failure, using the teach-back method reduced 30-day heart failure readmission rates from 18% to 13% (Haney & Shepherd, 2014).

In a systematic review of nine studies, Dantic (2014) found that the technique of teach back in the education of patients with chronic obstructive pulmonary disease resulted in a significant proportion of the correct use of inhalers. Dantic concluded that more research is needed to demonstrate the long-term effects of teach back in patients with chronic obstructive pulmonary disease.

Using teach back as a discharge teaching methodology for total joint patients demonstrated a decrease in 30-day readmissions by 36% (Green, Dearmon, & Taggart, 2015). A quality-initiated telephone follow-up intervention with total joint patients evaluated the effectiveness of discharge teaching with total joint patients. Discharge teaching used teach back to reinforce important aspects of discharge teaching. The authors of the project reaffirmed the importance of using teach-back in discharge teaching (Darcy, Murphy & DeSanto-Madeya, 2014).

Nurses retained more information of heart failure self-care when educators used the teach-back method of instruction (Mahramus, Penoyer, Frewin, Chamberlain, & Sole, 2014). One hundred fifty nurses participated in the study. An objective test on their knowledge of self-care measures for heart failure was used to measure the differences in retained knowledge. Nurses were administered a pretest prior to the educational intervention, immediately postintervention, and at a 3-month follow up. A significant difference in pre- and posttest scores (i.e., immediately and at the 3-month follow up) was demonstrated (p < .001) using the teach-back method.

In a pilot educational program for nurses to improve their patient teaching strategies, Fidyk, Ventura, and Green (2014) concluded that formally educating nurses in the technique of teach back results in the improved knowledge retention of nurses and increased use of taught material. However, they also recommended that more research is needed to evaluate the use of teach back on patient outcomes and satisfaction.

In another systematic review of 21 studies examining the effectiveness of the use of teach back in patient education, Dinh, Bonner, Clark, Ramsbotham, and Hines (2016) concludeed that although some evidence exists for positive patient outcomes, such as decreased readmissions, improved retained knowledge, and adherence of health measures in chronic illness, more controlled trials with more patients are needed (Dinh et al., 2016).

Although these cited studies have demonstrated improvement in the knowledge retention of health care-related information, there remains a gap in the literature regarding the effects of using this approach in raising patient satisfaction scores as measured by Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores in the areas of patient education. Do patients perceive that nurses are always communicating and teaching them the information they need about new medications and overall health care needs?

Theoretical Framework

This research study was based on Orem's (2001) self-care deficit theory. According to Orem (2001), nurses helped patients to provide self-care. For patients to achieve self-care, much education is needed. Teach-back methodology supported self-care, promoted better retention, and allowed the educator to evaluate the patients' understanding and retention of material.

Design

This research study took place in a 361-bed community Magnet-designated hospital in northern New Jersey. A quasi-experimental design was used for this study. Two similar medical units were chosen: one as the intervention group and one as the control. These two units were chosen because they have a similar acuity level, admission and discharge rates, and staffing ratios. The intervention unit has a large percentage of patients with a neurological disease in comparison to the control unit, which has a predominance of genito-urinary and infectious diseases. A quasi-experimental design was chosen over a randomized controlled trial because it is neither practical nor feasible to randomize patients to one of the two units and follow them. The study received approval from the medical center's institutional review board.

Sample

The intervention group consisted of all the permanently assigned nurses on a designated nursing unit (n = 24). The 1-hour teaching intervention was presented as an educational requirement for the intervention unit, and each nurse was paid for the extra hour and awarded one contact hour. The control group consisted of the permanently assigned nurses on another similar medical unit (n = 30). The nurses on this unit were blinded to the intervention in which the experimental unit nurses participated. Nurses on the control unit continued to apply the standard of care to their patients using their usual method of teaching patients and families.

Instruments

The pre- and posttest consists of three multiple choice, three true-or-false, and three open-ended, short-answer questions about their knowledge, attitudes, and beliefs of the teach-back method. One example of a multiple choice question is:

  • Which of the following statements is not conducive to evaluating teaching effectiveness?

    • Can you explain back to me what you understand about this medication?
    • Please tell me how you will care for your mother when you get home.
    • Do you have any questions regarding the medications?
    • What information will you tell your spouse about what you learned today?

The open-ended questions addressed the current use of teach back in their nursing practice, as well as their perceptions of the technique and whether the technique should be a mandatory part of a nurse's practice. One example of the three open-ended questions is “What are your thoughts about the technique of teach back? State any positive or negative comments.”

Content validity of the pre- and posttest was established by several expert nurse educators. It was estimated that the 9-item test took 5 to 7 minutes to complete. Cronbach's alpha for the three multiple choice and three true-or-false questions on the test was .231.

Procedure

Those in the intervention group signed consent and took the pretest. Immediately following the pretest administration, a teaching session on the educational technique of teach back was held. Six different teaching sessions were held in November and December 2014 over a 4-week period, to accommodate all the direct care nurses on various shifts, and was conducted by the same educator to ensure greater consistency. This 1-hour teaching session used various modalities, including lecture, role-play, discussion, and videos. Each nurse participant took the same test 1 month after the teach-back technique was introduced. This lapse in the time period was planned to capture any changes in perceptions by the nurses, as well as determine an increase in their knowledge of teach back. The tests were coded using the nurses' employee identification numbers to allow for anonymity. Because the education documentation in the patient record did not include the use of teach back, nurses on the intervention unit were instructed to document specifically about using the technique of teach back in their patient education sessions. The nurse educator in the intervention group where the intervention was located monitored the documentation through regular audits of charts throughout 2015.

After the teaching intervention was implemented by the nurse educator to all permanently and regularly scheduled nursing staff on the intervention unit, 12 months of HCAHPS data (January to December 2015) were collected from both the intervention and control group units. This data were compared to the previous 6 months of HCAHPS scores (July to December 2014). Because all the nurses on the intervention unit did not complete the teaching intervention until the middle of December 2014, the time period for preintervention encompassed December 2014. Nurses from both units were not given information about the analysis of these scores to prevent biasing the results. Specifically, seven scores from HCAHPS which were applicable to discharge teaching topics were collected and analyzed (Table 1).


HCAHPS Questions Related to Patient Education and Discharge

Table 1:

HCAHPS Questions Related to Patient Education and Discharge

Data Analysis

Quantitative analysis was conducted for the multiple choice answers on the pre- and posttest. Paired t tests were used to analyze the difference in the pretest and posttest teach-back scores using SPSS version 18 software (Table 2). Independent t tests were used to test the difference between the intervention and control groups for significant differences in the preintervention HCAHPS scores (July to December 2014) and postintervention time periods (January to December 2015). Qualitative thematic analysis was conducted on the open-ended questions.


Pre- and Posttest Means and Paired Samples t Test

Table 2:

Pre- and Posttest Means and Paired Samples t Test

Results

A significant improvement in the pretest–post-test knowledge scores was found using paired t tests (p = .002) (Table 2). For seven HCAHPS statements related to patient teaching, only one demonstrated significant improvement in the intervention group during one quarter (i.e., 3 months) after teach back was initiated (p = .025). This question was “Tell you what new medicine was for.” A positive trend was noted in the intervention group scores; however, some positive scores were also noted in the control group (Table 3).


Results of Hospital Consumer Assessment of Healthcare Providers and Systems Scores (Intervention Unit and Control Unit) on Independent t Tests

Table 3:

Results of Hospital Consumer Assessment of Healthcare Providers and Systems Scores (Intervention Unit and Control Unit) on Independent t Tests

Qualitative analysis of nurses' comments demonstrated strong support for teach back in the posttest. The common theme among the 24 nurse respondents was one of Support for the Use of Teach Back in Nursing Practice. Nurses gave some specific examples when teach back was used in their practice, including psychomotor skills such as the correct use of inhalers, self-administration of insulin, and cognitive learning specifically when coping with follow-up care after discharge. An increased use of teach back and positive support for using the teaching technique were expressed more in the posttest than the pretest. This finding was expected, as the majority of nurses had expressed that they had little knowledge of the teach-back technique prior to the teaching intervention. Nurses supported having teach back as a mandatory part of their practice, but with the caveat of needing more time allotted in their busy schedules to conduct patient and family teaching. In an answer to the open-ended question “Do you think the use of teach back should be mandatory and consistently applied to patient education? Why or why not?” one nurse stated, “realistically, time would be a big factor, though it is very useful.” This brings into question how much education is being provided to patients based on their many needs and the time constraints of direct care nurses.

Limitations

There are acknowledged limitations to this study. The relatively small number of nurse participants in the intervention group (n = 24) and the use of two nursing units from one hospital limits its generalizability. Other factors may have affected HCAHPS scores in both nursing units, such as staffing patterns, acuity levels, and levels of the health literacy of patients, among others. These factors were not accounted for in this study. Because the nurses on the control unit were not given the same pre- and posttests as the intervention unit, their knowledge level of teach back during the study is not known. Perhaps nurses on the control unit were not only knowledgeable of teach back, but also using the technique in their patient and family education. In addition, the developed instrument had low reliability as measured by Cronbach's alpha; however, this may be due to the low number of measured test items.

Discussion

This study did not definitely demonstrate a significant improvement in the seven HCAHPS scores addressing patient education. The hypothesis that the use of the technique of teach back in one nursing unit would result in improved scores compared with a nursing unit that did not use the technique was not demonstrated. A positive trending of scores in the intervention and control groups was seen, but these were not consistent and not significant. Many factors affect the nurse–patient relationship and thus affect the evaluation that takes place via the process of obtaining information for HCAHPS. The score is based on always responses of the queried discharged patients. If the response is usually, sometimes or never, these answers are not considered in the recorded score. Perhaps when comparing the two studied nursing units, there would be an improvement in the percentage of patients discharged from the intervention group reporting usually versus none. However, that was not evaluated in this study.

Conclusions

The t score (p = .025) shows a significant improvement in the question “Tell you what new medicine was for” for the intervention unit's HCAHPS scores. There was a positive trend in some of the other scores related to discharge teaching, although they were not statistically significant. The qualitative responses of the nurses in the intervention group demonstrated support for the use of teach back as an evaluation of taught material. Although nurses recognized the value of using teach back in their patient education, a perceived lack of time emerged as a theme from the open-ended statements. Patient and family education can be accomplished in a variety of ways, such as written materials, videos embedded into the intranet system that patients can access, or the one-to-one explanations provided by members of the health care team that includes nurses. More research needs to be conducted to measure the outcomes of nurses' knowledge and the use of teach back in patient education. Patient and family education continues to challenge nurses in health care settings, and teach back is one technique that may improve outcomes such as patient satisfaction.

References

  • Agency for Healthcare Research and Quality. (2015). Use the teach-back method: Tool #5. Retrieved from http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool5.html
  • Dantic, D.E. (2014). A critical review of the effectiveness of ‘teach-back’ technique in teaching COPD patients self-management using respiratory inhalers. Health Education Journal, 73, 41–50. doi:10.1177/0017896912469575 [CrossRef]
  • Darcy, A.M., Murphy, G.A. & DeSanto-Madeya, S. (2014). Evaluation of discharge telephone calls following total joint replacement surgery. Orthopaedic Nursing, 33, 188–195. doi:10.1097/NOR.0000000000000062 [CrossRef]
  • Dinh, H.T., Bonner, A., Clark, R., Ramsbotham, J. & Hines, S. (2016). The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: A systematic review. JBI Database of Systematic Reviews & Implementation Reports, 14, 210–247. doi:10.11124/jbisrir-2016-2296 [CrossRef]
  • Fidyk, L., Ventura, K. & Green, K. (2014). Teaching nurses how to teach: Strategies to enhance the quality of patient education. Journal for Nurses in Professional Development, 30, 248–253. doi:10.1097/NND.0000000000000074 [CrossRef]
  • Green, U.R., Dearmon, V. & Taggart, H. (2015). Improving transition of care for veterans after total joint replacement. Orthopaedic Nursing, 34, 79–86. doi:10.1097/NOR.0000000000000124 [CrossRef]
  • Haney, M. & Shepherd, J. (2014). Can teach-back reduce hospital readmissions?American Nurse Today, 9(3), 50–51.
  • Kessels, R.P. (2003). Patients' memory for medical information. Social Medicine, 96, 219–222. doi:10.1258/jrsm.96.5.219 [CrossRef]
  • Mahramus, T., Penoyer, D.A., Frewin, S., Chamberlain, L. & Sole, M.L. (2014). Assessment of an educational intervention on nurses' knowledge and retention of heart failure self-care principles and the teach back method. Heart & Lung, 43, 204–212. doi:10.1016/j.hrtlng.2013.11.012 [CrossRef]
  • National Quality Forum. (2010). Safe practices for better health-care: 2010 update. Retrieved from https://www.qualityforum.org/Publications/2010/04/Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx
  • Orem, D. (2001). Nursing: Concepts of practice. St. Louis, MO: Mosby.
  • Peter, D., Robinson, P., Jordan, M., Lawrence, S., Casey, K.J. & Salas-Lopez, D. (2015). Reducing readmissions using teach-back: Enhancing patient and family education. Journal of Nursing Administration, 45, 35–42. doi:10.1097/NNA.0000000000000155 [CrossRef]
  • White, M., Garbez, R., Carroll, M., Brinker, E. & Howie-Esquivel, J. (2013). Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients?Journal of Cardiovascular Nursing, 28, 137–146. doi:10.1097/JCN.0b013e31824987bd [CrossRef]

HCAHPS Questions Related to Patient Education and Discharge

Question
Nurses explain in the way you understand.
Information regarding symptoms/problems to look for.
Good understanding managing health.
Tell you what new medicine was for.
Understood purpose of taking medications.
Staff described medicine side effect.
Discharge information.

Pre- and Posttest Means and Paired Samples t Test

VariablePretest Mean/SDPosttest Mean/SDMean Differencet valuep value
Knowledge of teach back4.71/1.195.62/0.590.91−3.516.002*
Practice of teach back1.90/0.3011.71/0.4630.1901.706.104
Mandatory teach back1.90/0.3011.90/0.3010.0000.0001.0

Results of Hospital Consumer Assessment of Healthcare Providers and Systems Scores (Intervention Unit and Control Unit) on Independent t Tests

HCAHPS Question/Time LineRespondents Reporting AlwaysRespondents Reporting Always


Intervention Unit (No.)t ScoreControl Unit (No.)t Score
Nurses explain in the way you understandt(157) = 0.11, p = .913t(219) = 0.524, p = .601
  July to December 201472.3% (59)63.8% (90)
  January to December 201573.1% (100)67.2% (131)
Information regarding symptoms/problems to look fort(135) = 0.362, p = .718t(195) = 0.739, p = .461
  July to December 201489% (51)81.2% (76)
  January to December 201586.9% (86)85.2% (121)
Good understanding managing healtht(124) = 0.334, p = .739t(205) = 1.752, p = .081
  July to December 201445% (54)38.1% (82)
  January to December 201548% (72)50.5 % (125)
Tell you what new medicine was fort(90) = 2.287, p = .025**t(121) = 0.085, p = .932
  July to December 201453.2% (21)58.8% (41)
  January to December 201578.5% (71)59.6% (82)
Understood purpose of taking medicationst(179) = 0.025, p = .980t(202) = 1.872, p = .063
  July to December 201455% (53)44.6% (80)
  January to December 201555.2% (128)58% (124)
Staff described medicine side effectt(73) = 0.024, p = .981t(95) = 0.338, p = .736
  July to December 201443.7% (21)41.1% (40)
  January to December 201543.4% (54)37.7% (57)
Discharge informationt(119) = 0.512, p = .610t(189) = 0.453, p = .651
  July to December 201482.5% (53)77.3% (84)
  January to December 201585.9% (68)80% (107)
Authors

Dr. Centrella-Nigro is Assistant Professor, School of Theoretical and Applied Science, Ramapo College of New Jersey, Mahwah, and EBP/Research Specialist; and Ms. Alexander is Education Specialist, Department of Professional Practice, Holy Name Medical Center, Teaneck, New Jersey.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Andrea M. Centrella-Nigro, DNP, RN, CNE, Assistant Professor, School of Theoretical and Applied Science, Ramapo College of New Jersey, and EBP/Research Specialist, Department of Professional Practice, Holy Name Medical Center, 718 Teaneck Road, Teaneck, NJ 07666; e-mail: centrella-nigro@holyname.org.

Received: May 25, 2016
Accepted: September 27, 2016

10.3928/00220124-20170110-10

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