James Banks, a 65-year-old white male, is newly diagnosed with type 2 diabetes. At 210 lbs, he has a history of hypertension and hyperlipidemia. At his doctor’s appointment today, nurse Ann Rogers plans to provide patient teaching on how to manage diabetes at home. She has prepared teaching materials, including the brochures “Facts about diabetes” and “How to manage diabetes at home.” She also plans to show videos that cover basic information about diabetes management, such as how to use the blood glucose meter.
After Ann explains the information and shows Mr. Banks the videos, she asks,” Do you have any questions about diabetes management?” He replies, “I have a lot of questions, but I don’t know where to begin. You’ve overwhelmed me with all that information!”
Most nurses have been in this situation. Providing patient and family education is an important nursing role and a core competency of nursing practice. Successful education can improve health outcomes, reduce hospital readmissions, decrease healthcare costs, and improve patient and family satisfaction.
But how can you prevent your patient from feeling overwhelmed after a teaching session? And how do you determine how well he or she comprehends and recalls the information you’ve just taught?
Closing the loop
Patient education can take place in any healthcare setting. But finding the best way to provide it and evaluating the results of your teaching can pose a challenge. How well patients comprehend and recall the information they’re taught helps predicts their adherence to management.
For effective teaching and assessment of patient’s comprehension and recall, you must use a patient-centered communication approach. That’s where the teach-back method comes in. Also called “closing the loop” or the “show me” method, teach-back confirms the patient understands the information the care provider has imparted. It closes the communication gap between clinician and patient while enhancing the patient’s knowledge. During a teach-back session, after you teach a concept, you confirm the patient’s understanding by asking him or her to explain the concept back to you accurately. (See the box below.)
Teach-back: Interactive communication loop in patient education
Arch Intern Med. 2003 Jan 13;153(1):83-90. © 2003 American Medical Association. All rights reserved.
Here’s how teach-back works: After you provide teaching, ask the patient to explain the material you’ve just covered. Based on the response, you can determine how much and how well the patient comprehends and recalls what you’ve taught. If the patient’s has trouble explaining or recalling the material, you’ll need to repeat, clarify, or modify it—and then reassess the patient’s understanding and recall. You might need to repeat this cycle several times.
Teach-back has been used to assess patients’ understanding of important points covered in informed consent and Health Insurance Portability and Accountability Act documentation. It also has proven effective in assessing patient understanding during prostate and breast cancer screening and in improving low-income mothers’ understanding of childhood immunization.
A self-management tool
By enhancing patients’ knowledge, teach-back increases their adherence to disease management and makes them more accountable for their own health. Especially for patients with chronic diseases, enhancing self-management skills is an essential part of health care. To manage their health effectively, they must understand their health condition, its signs and symptoms, rationales for treatments, medication side effects, and when to seek help from healthcare professionals. Effective self-management increases patients’ confidence in health management—especially in performing specific tasks, such as monitoring symptoms, watching their diet, adjusting medications based on specific criteria, incorporating exercise into the daily routine, and knowing when to seek medical advice.
Patients with chronic diseases who live at home need to learn how to manage the disease independently over the long term. Teach-back puts the patient, not the care provider, in the primary disease-management role. The benefits of self-management for patients with heart failure, arthritis, and diabetes have been studied widely.
Teaching a complex topic
Traditional teaching methods can fall short when it comes to assessing the patient’s learning and understanding. A study of 100 patients’ understanding of medications at discharge found about 15% were unaware that a new medication had been prescribed, and only half understood specific information about their medications, including dosages, dosing schedule, and purpose. With teach-back, you can ensure patients understand their conditions and are able to manage their conditions at home.
For example, with a diabetes patient like Mr. Banks, you’ll probably need to introduce or reinforce multiple concepts during one teaching session. Teach-back can help you avoid overwhelming the patient with information. Each time you teach the patient a new concept or reinforce one you’ve already taught, use teach-back to assess what the patient has learned.
To manage his diabetes at home, Mr. Banks needs to understand what type 2 diabetes is and what causes it; how to check his blood glucose at home with a meter, and how to schedule his blood sugar checks. If he takes insulin to manage his blood glucose level, he also needs to learn how to calculate the insulin dosage based on his blood glucose level and how to self-administer insulin. He needs to know what glucose levels are too high and too low, how to manage a high or low glucose level at home, and when to consult his healthcare provider. As described in the case study, Mr. Banks has other health issues as well, including hypertension, high cholesterol levels, and obesity. So teaching sessions should include how to recognize and modify his risk factors for those conditions.
Breaking information into multiple teaching sessions
Especially given the amount of new information involved in diabetes teaching, using multiple teach-back sessions may be best. During the first session, the nurse introduces what diabetes is and what its major causes are. At the end of this session, she states, “I’ve talked about diabetes with my patients many times. I always like to make sure I’ve explained everything clearly. Could you please explain back to me in your own words what diabetes is and what are its major causes?”
In the second session, the nurse connects Mr. Banks’s other risk factors (high blood pressure, high cholesterol, and obesity) with diabetes to help him understand the importance of adjusting his lifestyle. Then she addresses these risk factors using the teach-back technique. Next, she asks him to repeat back the information she has given by describing how to adjust his diet to reduce sodium and fat content, how to get more exercise, and how to lose weight to improve his diabetes control and health outcomes.
The third teaching session focuses on medication management. The nurse uses teach-back to assess Mr. Bank’s learning process by asking him to repeat the information he’s heard in his own words. This enhances his learning by helping him understand his condition and how to control his blood sugar with medications.
When using the teach-back method, follow the recommendations in the box below.
Make a difference
With the increasing incidence of chronic disease, patient self-management has become more important. Incorporating the teach-back method into your daily practice can improve your patients’ knowledge and self-management skills.
During the teach-back process, patients transition from having their diseases managed by healthcare providers to managing it themselves. When you use teach-back, you reinforce what patients already know and teach them what they don’t know. Repeating this process as part of the interactive communication loop increases patients’ self-care capacity, boosts their confidence in managing their condition, and allows them to self-manage it successfully. To promote patient self-management of disease, actively involve your patients in the learning process by using teach-back.
Benjamin Franklin said, “Tell me and I forget. Teach me and I remember. Involve me and I learn.”
Albert SM, Musa D, Kwoh K, Silverman M. Defining optimal self-management in osteoarthritis: racial differences in a population-based sample. Cross-Cult Gerontol. 2008 Dec;23(4):349-60.
Agency for Healthcare Research and Quality. U.S. Department of Health and Human Services. Health Literacy Universal Precautions Toolkit. AHRQ Publication No. 10-0046-EF; April 2010.
Audulv A, Asplund K, Norbergh KG. Who’s in charge? The role of responsibility attribution in self-management among people with chronic illness. Patient Educ Couns, 2010 Oct;81(1):94-100.
Bourbeau J. The role of collaborative self-management in pulmonary rehabilitation. Semin Respir Crit Care Med, 2009 Dec;30(6):700-7.
Ditewig JB, Blok H, Havers J, van Veenendaal H. Effectiveness of self-management interventions on mortality, hospital readmissions, chronic heart failure hospitalization rate and quality of life in patients with chronic heart failure: a systematic review. Patient Educ Couns. 2010 Mar;78(3):297-315.
Farrell MH, Kuruvilla P, Eskra KL, et al. A method to quantify and compare clinicians’ assessments of patient understanding during counseling of standardized patients. Patient Educ Couns. 2009 Oct;77(1):128-35.
Jack BW, Chetty VK, Anthony D, et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med. 2009 Feb;150(3):178-87.
Kluzer B, Hermanns N, Reinecker H, et al. Effects of self-management training in Type 2 diabetes: a randomized, prospective trial. Diabet Med. 2007 Apr;24(4):415-23.
Kripalani S, Bengtzen R, Henderson LE, et al. Clinical research in low-literacy populations: using teach-back to assess comprehension of informed consent and privacy information. IRB. 2008 Mar-Apr;30(2):13-9.
Maniaci MJ, Heckman MG, Dawson NL. Functional health literacy and understanding of medications at discharge. Mayo Clin Proc. 2008 May;83(5):554-8.
North Carolina Program on Health Literacy. The Teach-Back Method. www.nchealthliteracy.org/toolkit/tool5.pdf . Accessed March 8, 2011.
Schillinger D, Piette J, Grumbach K, et al Closing the loop: physician communication with diabetic patients who have low health literacy. Arch Intern Med. 2003 Jan;163(1):83-90.
Tung YC, Chang GM. Patient satisfaction with and recommendation of a primary care provider: associations of perceived quality and patient education. Int J Qual Health Care. 2009 Jun;21(3):206-13.
Wilson FL, Baker LM, Nordstrom CK, et al. Using the teach-back and Orem’s Self-care Deficit Nursing theory to increase childhood immunization communication among low-income mothers. Issues Compr Pediatr Nurs. 2008 Jan-Mar;31(1):7-22.