Teach back and performance improvement
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The document summarizes the development and evaluation of a training program to improve nurse-patient communication skills at Vanderbilt University Medical Center. It describes conducting a needs assessment that found opportunities to better educate patients. A class was designed using experiential learning theory, with a presentation, practice simulations, and commitment to use "teach back" technique. Evaluations assessed satisfaction, learning, demonstration of skills, and observations of teach back use, finding greater use by nurses who completed the training.
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Teach back and performance improvement
- 2. Presentation Outline I. Needs assessment II. Content development III. Class design IV. Evaluation V. Workplace behavior change and performance improvement
- 3. Needs Assessment Call to action – Leadership at Vanderbilt pushing for more patient and family engagement and improved readmission rates Leadership initiated a Patient and Advisory Council - formed and delivered success in providing the patient perspective on the patient experience and improving processes and patient interactions. Leadership began asking clinicians to improve patient education process to improve patient engagement in their own healthcare and readmission rates. GAP analysis: Observations for teach back during patient education events -nurses targeted as a group who has multiple opportunities for patient education throughout hospital stay. Nurse residents are new nurses entering Vanderbilt system. Attend year long program of teaching and learning to become competent. Entry point training key for forming expectations. Targeted for pilot intervention. Observations of all nurses all levels as a whole in December (in this sample) was 35 out of 134 or 26%. This proportion is lower than the population proportion reported in the literature of 39% to a statistically significant degree.
- 4. Improving patient-nurse communication at VUMC Goal: Nurses will use “teach back” to ensure understanding when educating patients every patient every time.
- 5. Theoretical Basis for Question, Intervention and Evaluation theory - We learn by doing and reflecting on Experiential learning the doing. Social-Cognitive learning theory – We learn new behaviors through models and the consequences of doing the modeled behavior. Internal processes, the rewards given and perceived self-efficacy influence the learning outcomes. Communication skills are best learned in the setting, situational and require role modeling, practice with feedback to be acquired. Volunteer patients and learners attempt to come to shared understanding and potential for social consequences improves. Commitment to use teach-back is key to internal motivation.
- 6. Content and Instructional Design Development Constraints – financial and people resources EBP – publications Sunil Kripalani. Demonstrated that non-actors can portray patients during patient education simulation. Thus providing a precedence. Organizations – Institute for Patient and Family Centered care – Recognizes the importance of the patent perspective in improving clinician performance and involvement in local improvement improves care. Agency for Healthcare Research and Quality – the proven patient education strategies used during patient education sessions. Subject Matter Expert - Lynn Webb, (expert in health professionalpatient communication) – task analysis, checklist validation
- 7. Class Design Presentation of content. The Hook. Brief explanation (goal of less that 20 minutes) of patient education principles including an example: AMA video demonstrating the identified gap between patients and clinicians when communicating and teaching. Power point of the principles of teach back including a video of skill demonstrated. Opportunity to practice with feedback An opportunity to practice educating “patients” who are volunteers from the Patient and Family Advisory Council Feedback received from “patients” and trained coaches. Commitment to use teach back when educating patients. Self Evaluation and Tracking Log to continue the deliberate practice in the clinical setting.
- 8. Evaluation Level 1 – Participation (compulsory) Level 2 – Learner satisfaction (post class evals) Level 3 – Learning, Declarative and Procedural Knowledge (self report of knowledge gain) Level 4 – Competence (Demonstration in class) Level 5 – Performance (Patient Teaching Observations) Level 6 – Patient Health (we will measure readmission rates) Level 7 – Community Health (we may measure key outcomes, such as life expectancy rates)
- 9. Level 2 & 3 – Satisfaction, learning I never realized how challenging discharge information can be to effectively communicate and elicit patient understanding. I will take it much more seriously now. Teach-back was helpful, but will take time to practice fully. The simulation was very nerve racking but effective in helping us communicate with patients and learning how to effectively teach. I was really absorbed with the content that I forgot to be empathetic. I liked how outside sources/previous patients were brought in to give us a different perspective on our communication skills. This was such a helpful topic and simulation. It's nice to hear feedback about communication skills that were done well and need improvement. The discharge education was confusing at first. Maybe make a little more organized. Otherwise it was a great experience and practice. The patient-nurse simulation was a great way to learn It would be more of a benefit to have more time with the simulated patients. I enjoyed the interaction. Thank you to the people who volunteered their time! Role-play was useful So intimidating, but so informative!
- 10. Level 2 & 3 – Satisfaction, learning The role play was very helpful. The video clips were really effective, especially the AMA clip. PowerPoint was a bit disorganized. I enjoyed getting to practice! Really helped I really liked the presentation - easy to follow. Great examples provided and the activity with the "patient" was very helpful & encouraged creative thinking & exposed areas for improvement. Very effective presentation! Presentation presented information in an effective and interactive manner. Great lecture! A bit too long, too many examples of simple topics. Great video from AMA! Good topic and information. Really liked the education group breakout, very helpful! I liked the use of videos during the presentation. I love that the lecture was varied: lecture, videos, demonstration, Q&A, and practice/application. She was very interactive with us and gave good examples. The video clips and demonstration was helpful.
- 11. Level 4 Observations The Null Hypothesis : The Proportion of nurse residents in cohort July 2012 Winter TB using teach back during observations of patient education sessions is equal to the Proportion of nurse residents in cohort Feb 2013 Spring TB using teach back during observations of patient education sessions. The Alternative Hypothesis: The Proportion of nurse residents in cohort July 2012 Winter TB using teach back during observations of patient education sessions is NOT equal to the Proportion of nurse residents in cohort Feb 2013 Spring TB using teach back during observations of patient education sessions.
- 12. Teach-Back Use Winter/Spring Cohort 60 50 40 30 No Yes 20 10 0 Winter Spring
- 13. Teach-Back Use RN Levels 60 50 40 30 No Yes 20 10 0 RN1 RN2 3 4
- 15. Teach-Back Use Teaching Type 40 35 30 25 20 No Yes 15 10 5 0 1 2 3 4 5 6 (blank)
- 16. Conclusions More nurses who were trained used teach back than existing staff nurses. More nurse residents who signed commitment and used self eval and tracking log used teach back with real patients. The experience of simulated patients with patient advisory council members improved the attitudes and seemed to affect the value statements made during post class evaluations. This serves as a proxy for Affective learning domain. The class with commitment and self eval and tracking log seemed to improve use of teach back with patients.
Editor's Notes
- The number of nurses using teach-back in this sample was 35 out of 134 or 26%. This proportion is lower than the population proportion reported in the literature of 39% to a statistically significant degree. Using a simple z test for proportions we get the following results:Using the formula z=p hat- population proportion/standard deviation of p hatThe standard deviation was calculated as .042Z= .26-.39/.042 = -3.85; the probability of getting a z score of that size when the population proportion is 39% is .001. This indicates that this is an unusual result and differs from the population proportion to a statistically significant amount.
- The key elements necessary in lecturing on teach back generally holds to:explaining why clinical area specific learners should learn about educating patient and caregivers (all of us should be using the same term to describe patient's family/support person) What is in it for the learners? A story of a teach back fail or win specific to learner clinical specialty is helpful(Inpatient hospital nurses use it for hospitalised patient safety education, admission, discharge and teachable moments throughout hospital stay) (Clinic nurses use it with medication teaching and home care instructions) (Chemo nurses use it with chemo and biotherapy medications, side effects, illness and report of adverse reactions and symptoms)The Patient and Family Promise help clinicians to connect to Vanderbilt mission, credo and purpose.the AMA video is a very compelling video that drives home the need (ensuring audio-visual capability in classroom is important) https://www.youtube.com/watch?v=BgTuD7l7LG8 statistics that support teach back and and those related to the problem in the clinical area in which learners practiceintroducing the concept of closed loop communication as a way to verify understandingAnalogies of drive thru example are effective for teaching conceptAlso nurses use read back for confirming verbal orders is effective analogyExplaining "getting a teach back for verification is a clinican responsibility, just like getting the right order is for ordering a hamburger or getting a verbal order"Explaining elements of teach back:setting the tone and sitting down to talk to patient and caregivers, AIDETassessing the patient and caregivers health literacyplain simple languageclear communicationslow and pacedchunk and check for understanding. Ensuring not too much information is delivered at oncecreating and setting a tone for the patient and caregiver to ask questions. Inviting questions by using the question: What questions do you have? Do not ask "Do you have any questions?"asking the teach back question in a non-shaming manner. Do not quiz patients.Examples of non-shaming teach-back questions are importantputting the responsibility on the clinician, not on the patient and caregiverRole model of teach back is a keyA bad example is fun to debrief and prompt for what didnt go well. https://www.youtube.com/watch?v=MCoIDdFvEu0 A good exampleA nurse to patient example done by Judy Johnson and Linda Dial: https://www.youtube.com/watch?v=tSHEJ0HQ0hU&list=PLD46489676755CD49&index=8 A physician/nurse discharge good example exist on Vanderbilt Website: Good Hospital Discharge Counseling (requires media player) http://medicineandpublichealth.vanderbilt.edu/center.php?userid=1815073&id=12314246&home=1 Live lectures may include facilitators role play in front of group3. A practice experience in which constructive feedback is given is important:The patient education content used during the experience must be relevant and easy. Provide patient education materials specific to learner level and specialty level. I've attached a booklet used before as an example.In unit based inservices, I've asked the nurses to teach fall prevention or hospital safety without materials. They know this like the back of their hand.Role play between learners is a fair method to use during practice time. Ensure that trained coaches observe, facilitate and provide feedback. Do not expect learners to provide effective feedback to each other in isolation.Train the trainer is key for ensuring observations and feedback are effective.Service Excellence Coaches and Chemo Simulation Facilitators are trained in observing and giving feedback. Recommend train the trainer to grow this pool of resources for future classes. Recommended experienced master trainers for trainer the trainer sessions: Lynn Webb, Mary Scheib, Linda Dial, Judy Johnson, Sunil KripalaniBe sure to review with facilitators the expected feedback technique of allowing learners to self reflect on what they did first, positives, then opportunities for improvement, providing individualized feedback and not lecturing during debrief and feedback time. Learners should be talking more than facilitator during debrief time. Feedback should be specific and re-emphasize key elements of teach back. A checklist for observation is helpful for learner and coach.For large classes, in which a practice experience occurs live, larger number of separate spaces and coaches are needed. (space to accomodate this is key- i.e. room dividers or separate spaces for small groups to divide to)a max class size of 30 has been successful in Ballroom. 47 were done in Light Hall 411 A - D.Volunteers for role as patient for simulated teach back exercise are recruited for class up to 2 months in advance. This takes time to manage which includes managing up, emails and personal phone calls to volunteers. Thank you notes to volunteers are very appropriate. Notices are sent to Andy Peterson, Director of volunteer services and Terrell Smith, Director of Patient and Family Centered Care. They recruit from Volunteer Pool and Patient Adisory Council. Response to these volunteer calls are fairly reliable.Volunteers should be briefed on expectations over the phone or by email prior to day of event. Their time should be valued and respected. They should arrive and go right to work as "patients".
- Winter cohort July 2012, 33 leaners surveyed and 98% said very effective.
- Spring Cohort Feb 2013, 45 learners surveyed, 93% said teaching was very effective.
- Hypothesis looks at the different cohorts in this sample. The July 2012 winter cohort received a class with simulation experience. The Feb 2013 spring cohort received a class with simulation plus "homework" in the form of a self -evaluation and tracking log, plus they were asked to sign a promise that they would use TB. This is in essence comparing the effects of the different levels of the intervention; the class with simulation versus the class with additional activities.The analysis used to test this hypothesis is the Chi Square test of independence. Using XLSTAT, the null is stated as the rows and columns are independent and the alternative is the rows and columns are dependent.If the variables are independent, that would be interpreted that there is no evidence that the level of the intervention – whether simulation alone or simulation with additional training – has any impact on whether teach- back was used or not. If the scores turn out to be dependent that implies that there is evidence from this sample that the level of the intervention does influence whether teach-back was used.As can be seen in the tables below the cohorts – and therefore whether the nurse had simulation alone or simulation with additional training- are dependent. Since the p =.004, one should reject the null hypothesis and accept the alternative. Therefore this provides evidence that the type of training you received has an influence on whether teach-back is used.Test Results Hypothesis 2 Test of independence between the rows and the columns (Chi-square): Chi-square (Observed value) 8.108 Chi-square (Critical value) 3.841 DF 1 p-value 0.004 alpha 0.05 Test interpretation: H0: The rows and the columns of the table are independent. Ha: There is a link between the rows and the columns of the table. As the computed p-value is lower than the significance level alpha=0.05, one should reject the null hypothesis H0, and accept the alternative hypothesis Ha. The risk to reject the null hypothesis H0 while it is true is lower than 0.44%. Test of independence between the rows and the columns (Chi-square with Yates' continuity correction): Chi-square (Observed value) 7.026 Chi-square (Critical value) 3.841 DF 1 p-value 0.008 alpha 0.05 Test interpretation: H0: The rows and the columns of the table are independent. Ha: There is a link between the rows and the columns of the table. As the computed p-value is lower than the significance level alpha=0.05, one should reject the null hypothesis H0, and accept the alternative hypothesis Ha. The risk to reject the null hypothesis H0 while it is true is lower than 0.80%.