Using the Teach-Back Method in Patient Education to Improve HCAHPS Scores

Saturday, 21 April 2018: 2:45 PM

Andrea Marie Centrella-Nigro, DNP, RN
Professional Practice, Holy Name Medical Center, Teaneck, NJ, USA

Teach-back is an educational technique which involves patients and /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 [AHRQ], 2015). National Quality Forum (NQF) has recommended using teach-back methodology as one of its 34 endorsed methods of safe practice for healthcare professionals (NQF, 2010). Much information that is taught in healthcare settings is complicated and it has been estimated that up to 80% of material is not able to be recalled immediately after a teaching session.

Teach-back has been shown to be an effective method of patient teaching. Patients with heart failure (HF) can recall discharge information better when the teach-back method is utilized (White, Garbez, Carroll, Brinker & Howie-Esquivel, 2013). Peter et al. (2015) demonstrated significant improvement in HF readmissions utilizing the teach-back method of teaching in their discharge process. In a recent study of HF patients, utilizing the teach-back method reduced 30 day HF readmission rates from 18% - 13% (Haney & Shephard, 2014). In a systematic review of nine studies, Dantic (2014) found that the technique of teach-back in the education of COPD patients resulted in a significant proportion of correct use of inhalers. 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).

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

Although these cited studies have demonstrated improvement in retention of knowledge of health care related information, there remains a gap in the literature regarding the effect 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 regarding


A quasi-experimental design was utilized for this study. Two similar medical units were chosen; one as the intervention group and one as the control. These two units were chosen as they have a similar acuity level, admission and discharge rates and staffing ratios.


The intervention group consisted of all the permanently assigned nurses on a designated nursing unit (N=24). The one 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.


The pre-posttest consists of 6 multiple choice questions (3 multiple choice and 3 true-false) and 3 opened ended, short answers regarding their knowledge attitudes and beliefs of the teach-back method.

The open-ended questions addressed the current use of teach-back in their nursing practice as well as their perceptions of the technique and if the technique should be a mandatory part of a nurse’s practice. One example of the 3 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-posttest was established by several expert nurse educators. It was estimated that the 9 item test took 5-7 minutes to complete.


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 late November and December 2014 over a four week period to accommodate all the direct care nurses on various shifts and was done by the same educator to ensure greater consistency. This one hour teaching session used various modalities including lecture, role play, discussion and videos. Each nurse participant took the same test one month after the teach-back technique was introduced. This lapse in time period was planned to capture any changes in perceptions by nurses as well as to determine an increase in their knowledge of “teach-back”. The tests were coded using the nurse’s employee ID number to allow for anonymity. Since 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 regarding using the technique of teach-back in their patient education sessions. The nurse educator on 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, regularly scheduled nursing staff on the intervention unit, 12 months

of HCAHPS data (January 2015- December 2015) were collected from both the intervention and control group units. This data was compared to the previous 6 months of HCAHPS scores (July 2014- December 2014). Nurses from both units were not given information about the analysis of these scores so as to prevent biasing the results. Specifically, seven scores from HCAHPS were collected and analyzed which were applicable to discharge teaching topics.

Data Analysis

Quantitative analysis was done for multiple choice answers on the pre and posttest. Paired t-tests were used to analyze the difference in scores in the pretests and posttests of “Teach-Back” using SPSS version 18. Independent t-tests were used to test a difference between the intervention and control groups for significant differences in HCAHPS scores for the pre-intervention (July-December 2014) and post intervention time periods (January-December 2015). Qualitative thematic analysis was done on the open-ended questions.

A significant improvement in the knowledge scores in the pretest-posttest was found using paired t-tests (p=.002). For seven HCAHPS statements related to patient teaching , only one demonstrated significant improvement in the intervention group during one quarter (three months) after teach-back was initiated p=.025. This question was “Tell you what new medicine was for. A positive trending of scores was noted in the intervention group however, some positive scores were also noted in the control group.

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 his/her practice which included psychomotor skills such as the correct use of inhalers and self-administration of insulin and cognitive learning specifically dealing 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 post test when compared with the pretest. This finding was expected as a majority of nurses had expressed that they had very 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 in which to do patient and family teaching. In 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”. The question arises regarding how much education is being provided to patients based on the many needs of patients and time constraints of direct care nurses.


The t-score (p=.025) shows there is a significant improvement on the question, ‘Tell you what new medicine was for’ on HCAHPS scores for the intervention unit. There was a positive trending in some of the other scores related to discharge teaching although 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, the 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 through written materials, videos embedded into the intranet system that patients can access in addition to the one to one explanations provided by members of the healthcare team including nurses. More research needs to be done 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 healthcare settings and teach-back is one technique that may improve outcomes, particularly patient satisfaction.

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