HealthNurses understand that teaching patients with complex medical problems can be challenging in the hospital setting. Tools can help make teaching more effective. I was part of a team at a large academic medical center that developed a teach-back tool and corresponding RN resource to address the educational needs of adult patients receiving liver, kidney, pancreas, heart, and lung transplants. We have found the tool and resource effective in addressing these patients’ educational needs. This article describes our project.
The teach-back tool
The project work group consisted of three RNs and a nurse manager. The first step was to determine what patients need to learn in the hospital. Organ transplant patients are closely followed across the continuum, so we asked transplant RNs in both the hospital and clinic setting to identify via email what information was needed before patient discharge from the hospital. Based on that feedback, we developed a teach-back tool. The tool, used to assess patients’ and caregivers’ understanding of the information, consists of a list of questions that nurses initial and date as the patient demonstrates understanding. (See Post solid organ transplant teach-back tool.)
The tool is displayed prominently in each patient’s hospital room. The teach-back tool serves multiple purposes. Patients and caregivers are understandably overwhelmed after organ transplantation. The teach-back tool offers them reassurance they are learning what they need to.
Research shows that patients are frustrated when they are taught the same information over and over. The teach-back tool allows nurses to see at a glance what the patient already understands. The RN’s goal is to teach a little each shift, but at times that is not possible. The teach-back tool helps nurses see when a more concentrated “catch up” session is needed.
The RN resource tool
We used our organization’s educational materials and input from hospital and clinic RNs to develop an RN resource tool as a supplement to the teach-back tool and to encourage consistency in education efforts. The resource tool consists of expected answers to the teach-back tool questions. (See RN resource for post solid organ transplant teach-back tool.)
A printed copy of the resource is placed with the patients’ medical record for reference, and it’s available on the patient care unit’s webpage. The resource is used by hospital RNs to maintain consistency in the answers expected from patients/caregivers.
Costs and implementation
The patient care units’ practice committees reviewed the tool and RN resource before we finalized them. The information was presented by project group RNs to staff RNs at regularly scheduled unit-based staff meetings.
The primary cost associated with developing the tool and RN resource was the approximate 16-hour time investment.
We used pre- and post-implementation questionnaires with patients, hospital RNs, and clinic RNs to determine the project outcomes.
Patients completed the questionnaire at their first clinic visit after hospital discharge. We found that patients understood most key information even before the teach-back project was implemented, but a notable exception was their understanding of trough level. Transplant patients must understand trough level because at least one of their immunosuppressive medications is dosed based on that level. Patients must time their lab work appropriately to obtain an accurate trough level. Before implementing the tool and resource, fewer than half of patients agreed or strongly agreed that they understood what a trough level is. This improved to 90% after implementation.
Hospital RNs also responded that patients understood most of the needed information even before project implementation. Again, the exception was trough level. The number of RNs who agreed or strongly agreed that patients understood what a trough level was went from 60% before implementation to 80% after.
Clinic RNs may be the best judge of whether patients have learned what they needed to in the hospital. Only 15% of clinic RNs agreed or strongly agreed that patients understood trough level when they left the hospital. After project implementation, this improved to more than 63%. Clinic RNs also noted improvement in whether patients understood how to contact their healthcare team (from 77% to 100%).
Although we sought input from the start of the project, we didn’t receive as many responses as we would have liked. In person conversations probably would have been more effective.
We also learned that not all RNs retained the information from the education programs, so use of the teach-back tool was variable. We provided reinforcement of the education as part of another program and displayed the teach-back tool more prominently. These efforts improved compliance.
Many patient populations could benefit from RNs developing similar teach-back tools and resources, including those with left ventricular assist devices, heart failure, and many others. It’s important to first determine the information that is crucial for patients to know before they are discharged from the hospital, and then develop a list of questions that addresses those patient needs. Make it clear to patients that the questions being asked are to assess how effective the teaching has been, not to “test” them. Create a resource for RNs to maintain consistency of education.
Frank-Bader M, Beltran K, Dojidko D. Improving transplant discharge education using a structured teaching approach. Prog Transplant. 2011;21(4):332-9.
Somes J. Health literacy in the ED: Is beer a clear liquid. nursing.advanceweb.com/Archives/Article-Archives/Healthcare-Literacy-in-the-ED-Is-Beer-a-Clear-Liquid.aspx. October 11, 2010.
Note: For more information about teach-back, access a teach-back toolkit and teach-back learning module at teachbacktraining.org/
Brenda Kochevar is a staff nurse on an organ transplant patient care unit within the department of nursing at Mayo Clinic in Rochester, Minnesota. The author would like to acknowledge the other members of this quality improvement team: Tera Gross, DNP, RN, NE-BC; Stephanie Mann, BSN, RN; and Kevin Praska, BSN, RN, CCTC.