Chester County Medicine Fall 2019 - 12

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Using Teach-Back
BY MARY POWELL, PHD, CRNP

Not too long ago I was caring for a gentleman in his
early seventies who had angina. I taught him about using
nitroglycerin and he understood he was to use one nitro
pill every five minutes for his chest pain and if he didn't
get relief, he should go the Emergency Department. I did
a good job teaching him or so I thought. This gentleman
was also the caregiver for his 5-year-old grand-daughter.
One day she came home from school and said "Grandpa,
my chest hurts" (she had fallen off the monkey bars during
recess that day)-you guessed it-he did exactly what I
told him and gave her the nitro every 5 minutes for 'chest
pain'. Of course it didn't help and together they showed up
in the ED.
What went wrong? Perhaps a simple inter-active technique
to improve communication where clinicians ask patients to say
back in their own words the information they have just heard-
teach-back-may have prevented this medical error. Teach-back
is one of the tools in the Health Literacy Toolkit developed by
AHRQ. Health literacy is best understood as the ability to find,
process, and understand health care information so you can
make appropriate health care decisions. Health literacy has been
identified as a national priority to improve the nation's health
along with improving self-management and clinical coordination.
We all benefit from receiving clear, easy to understand
information and that is particularly true regarding health care
education. Doctor or nurse speak is truly a foreign language for
most of our patients. How we teach patients and their families can
have a significant impact on quality care and patient safety-as in
the case of the grandfather and his granddaughter. We likely don't
have to ponder for very long to remember stories from our own
practices that were near misses, some perhaps with tragic endings,
all stemming from miscommunication.
One promising, evidence based method for providing patient
education is the Teach-Back Method, also called "closing the loop"
or "show me." This method, endorsed by AHRQ and the National
Quality Forum, helps clinicians confirm the message patients hear
is the intended message and that the clinician and patient have
come to a shared meaning regarding the subject at hand. Research
shows that patients remember and understand less than half of
what clinicians explain to them. Patients may try to hide their
lack of understanding of health information due to fear of being
embarrassed, misunderstood or disrespected. Teach-back helps to
support that health education messages have been delivered and
received as expected, in a fashion that is both understandable and
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usable for patients/families-to evaluate whether true learning
of required medical information has occurred. This brief article
expands a) on the evidence for teach-back, b) the process of teachback, and c) how to use teach-back appropriately so as to protect
patient dignity by keeping the onus for clarity on the clinician
rather than shaming the patient for not understanding. Pros and
cons of teach-back are also outlined.
Evidence for Teach-Back
A systematic review of 12 studies suggests that chronic illness
outcomes in adults may be improved statistically and/or clinically
with the use of teach-back. Specifically, increased adherence to
diet, exercise, and foot care among patients with diabetes as well
as improved adherence to daily weights among patients with heart
failure was noted in two studies. Five studies found a reduction
in readmission rates and hospitalization among those with heart
failure after teach-back, but these data were not always statistically
significant. Overall, the review showed improved outcomes in
disease specific knowledge, adherence, and self-efficacy and use
of an inhaler among COPD patients. There was also a positive
trend in improved self-management and reduced readmission
rates, but this was not always consistent or statistically significant.
One study conducted during pediatric primary care encounters
found that teach-back was associated with more patient-centered
communication and parent engagement. Finally, teach-back is one
of 11 top safety practices based on strength of evidence according
to AHRQ.

Process of Teach-Back
Teach-back is used to ensure patients understand health
information and the risk-and-benefit tradeoffs associated
with treatments, procedures, and tests. It is an evidence based
approach where a clinician-and optimally, the entire health care
team-asks a patient/family member to repeat back instructions
in their own words, providing the opportunity to check for
misunderstanding and shared meaning. To use our initial example,
shared meaning of chest pain as heart pain may have averted the
unfortunate use of nitroglycerin for musculoskeletal pain in a child
(as well as only using the medicine for whom it was prescribed).
Patient education delivered in any one clinical visit should be
limited to three key points whenever possible. Information is best
delivered in "chunks" of three key points followed by a clinician
checking in with the patient to verify understanding-known as
"chunk and check." The clinician should always keep the onus for

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Chester County Medicine Fall 2019

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