NO NURSE wants to hear that a patient who was just discharged from the hospital is being readmitted due to complications or a medication error. Several studies have shown that when patients don't fully understand discharge instructions, the risk of complications, medication errors, and hospital readmissions increases.1
Educating patients about self-care is a nursing responsibility. The teach-back method, also known as closing the loop, is an effective method to use in patient education related to self-care. It's been recognized by the National Quality Forum as the preferred method for validating understanding.2 This article explains how we used teach-back to improve patient outcomes and reduce readmissions at our facility.
The teach-back method is used in patient education to confirm that the patient or family member understands education they've received.3 Patient and family understanding is confirmed when they explain to the educator, in their own words, what was taught.
The teach-back method has great potential for improving patient understanding and reducing hospital readmissions, such as for heart disease.3 At our institution, 600 cardiac catheterization procedures are done annually. With these patients, lack of adherence to the prescribed medication regimen can lead to serious complications and impact long-term outcomes.
A newly placed coronary artery stent can become occluded very quickly. No matter what type of stent is used, whether drug-eluting or bare metal, antiplatelet therapy is prescribed to prevent stent thrombosis. As nurses on a step-down cardiac unit, we stress the importance of all medications, particularly the antiplatelet agents, to all patients. So imagine our concern and disappointment when, within 48 hours after discharge, two patients were readmitted with chest pain and stent thrombosis.
Mr. J returned through the ED with chest pain and ECG changes suggesting ongoing myocardial ischemia. He went directly to the cardiac catheterization lab, where the stent placed 3 days earlier was found to be completely occluded. When Mr. J was asked about his adherence to his discharge medications, he readily admitted, “I just didn't get around to going to the pharmacy yet.”
Another patient, Mr. S, was transferred to our hospital from another facility with an acute ST-elevation myocardial infarction. Postcardiac catheterization, he'd also been placed on antiplatelet therapy and discharged to home with prescriptions and printed handouts about his medications. Yet his cardiac catheterization on readmission showed stent thrombosis.
In both cases, the patients knew the purpose of the medication but didn't understand its importance or the consequences of missing a dose.
As the clinical educators for our cardiac division, we recognized that nurses weren't using the teach-back method when educating patients about their medications. To establish a baseline understanding of the effectiveness of current patient-education practices, we completed an assessment of 30 patients who'd undergone cardiac catheterizations. In our role as clinical educators, we met individually with each of these patients. Our goal was to evaluate patient teaching from the patient's perspective. We developed a standardized assessment tool that asked patients specifically if they understood the indications, timing, and adverse reactions for their procedure-specific medications.
In this group of patients, we found that 12 of 30 understood their medications upon discharge (40%). Four of 30 patients (13.3%) were readmitted within 30 days. Of these four, three hadn't demonstrated full understanding of medications at discharge.
Steps to improve practice
We developed an educational program for all clinical nurses in the cardiac step-down unit. It included role playing and emphasized the value of the teach-back method. As follow-up, we performed one-on-one observations with the clinical nurses to not only ensure adherence but also to give support and provide feedback. Our nurses needed to understand the value of their role as patient educators.
Real-life stories of our own patients showed the importance of validating our patients' understanding of their medications. If we'd used this technique and truly assessed whether our patients understood the consequences of nonadherence to antiplatelet therapy, could we have prevented these patients' second procedures? We decided that, although many factors could influence patients' adherence to their medication regimens, providing education and assessing understanding were ways in which we could make a difference!
We as educators wanted to determine the impact of this program on our patients and to hear patients' perspectives. After nurses' education was completed, it was expected that they would begin to incorporate teach-back into their daily practice. We followed up with another 30 patients and used the same assessment tool used before implementation of the teach-back intervention to evaluate the patients' understanding of their medications.
In our one-on-one conversations, we found that patients appreciated the opportunity to ask questions, discuss concerns, and clarify misconceptions before discharge. This group of patients had improved results, with 25 of 30 patients (83.3%) understanding their medications. After we implemented the teach-back method, only 2 of the 30 patients were readmitted within 30 days (6.7%). Our study looked at only the number of readmissions; it didn't investigate the specific reasons for the readmissions.
The nurses' original concerns all related to the extra time they believed using the teach-back method would add to their already-busy workload. In reality, most nurses found this method was easy to incorporate into their daily routine. An evaluation of nurses' use of teach-back following the education of nursing staff and subsequent implementation of teach-back on the unit revealed that nurses were using this method 77% of the time. (See What do nurses think?)
While this was a pilot study with a small number of participants, the promising results indicate that using the teach-back method is a valid component of safe, quality nursing care. We recognize that sustaining this type of an initiative can be challenging. Our plan is to continue to engage our nurses in this practice through education and regularly reviewing patient satisfaction results that focus on the patients' understanding of medications. To further evaluate patients' understanding, future studies may include follow-up discussions with patients by phone or in person. When patients have to be readmitted, we want to be sure it's not because they didn't understand their medications at discharge.
What do nurses think?
Here's some feedback from the nurses about using the teach-back method:
- “It's part of our daily practice now.”
- “Every time I give a medication, I make it part of my routine.”
- “Sometimes I think a patient understands a medication, but when I ask the patient to tell me about it, I realize this just isn't the case. It gives me a chance to go back and really make sure the patient understands.”
1. Kornburger C, Gibson C, Sadowski S, Maletta K, Klingbeil C. Using “teach-back” to promote a safe transition from hospital to home: an evidence-based approach to improving the discharge process. J Pediatr Nurs
2. White M, Garbez R, Carroll M, Brinker E, Howie-Esquivel J. Is “teach-back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients. J Cardiovasc Nurs
3. Peter D, Robinson P, Jordan M, Lawrence S, Casey K, Salas-Lopez D. Reducing readmissions using teach-back: enhancing patient and family education. J Nurs Adm