Transcript Main title here Peggy Troy, MSN, RN, President and CEO

Cori Gibson, MSN, RN, CNL
Carol Klingbeil, MS, RN, CPNP-PC
Laurie Newton, DNP, RN, CPNP
Disclosure Statement
• There are no relevant financial
relationships related to this
presentation.
• There is no sponsorship/commercial
support of this presentation.
• The content being presented will be
fair, well-balanced and evidencebased.
Learning Objectives
• Identify disciplines that can benefit from
learning health literacy teaching
strategies.
• Describe a brief educational intervention
that was effective at improving
knowledge and use of health literacy
focused communication strategies.
• Evaluate evidence of both initial
improvement and subsequent
sustainability over time after a brief
educational intervention.
Background and
Significance
• Health Literacy
– “The degree to which individuals have the
capacity to obtain, process, and understand
basic health information and services
needed to make appropriate health
decisions.”*
– Low health literacy is associated with poor
health outcomes.
• Higher rates of hospitalization & ED use
• Prolonged recovery time from illnesses
• Illness complications
*Healthy People 2010
Background and
Significance
• Many patients/families leave medical
encounters with a poor understanding
of their illness and treatment plan.
• Several studies back this:
– 40-80% of information provided by
practitioners was forgotten immediately
after visit.
– Only about 50% of information given by
health care providers was retained.
Background and
Significance
• This becomes even more complicated
in pediatrics.
– Healthcare workers are responsible for
addressing both the parents’ and
children's literacy skills.
– Growing evidence that health status and
access to care in children may be linked
to the parent’s level of health literacy.
Background and
Significance
• As health care providers, we often
expect patients to ask us questions if
they don’t understand…
– This is not always the case.
• Too often we use closed ended
questions.
– “Do you have any questions?”
– “Do you understand?”
Background and
Significance
• Strategies to help improve
communication with patients:
– Slow down
– Use plain language
– Show or draw pictures
– Limit information
– Use the “teach-back” technique
Background &
Significance
• Teach-back
– Asking the parent and/or child to repeat
back what they understood in their own
words, and clarify information as needed
– Process is highlighted by Joint Commission
and National Quality Forum as one of its
30 practices for improving patient safety
Why is Teach-Back so
Powerful?
10
Emily’s Story
Juan’s Story
Purpose
• To examine the impact of a brief
educational intervention for
multidisciplinary staff on health literacy
and the use of teach-back
Evidence Based Practice
Fellowship Project
The “Teach-Back” Project
Sample and Setting
• Over 300 healthcare team members
– Nurses (acute care, emergency room,
surgical)
– Dieticians
– Respiratory care practitioners
– Occupational and Physical therapists
• Children’s Hospital of Wisconsin and
Children’s Hospital of Wisconsin Surgicenter
Methods
Descriptive pre/post test design
• Pre-survey (Survey Monkey®)
– Self evaluation of prior knowledge on
health literacy and teach-back
Methods
• Educational intervention
– 30 minute instructor led sessions
• Goals:
– Raise awareness of prevalence and impact of low
health literacy
– Educate on use of key strategies to improve
communication and safety
– Encourage staff to incorporate use of teach-back
into everyday practice
Methods
• Post survey (Survey Monkey®)
– 2 months after session
• One year sustainability(follow-up)
survey (Survey Monkey®)
– Nurses (subset of inpatient units)
– Dieticians, respiratory care practitioners,
and therapists
Results
Do you know what the term “healthy literacy” means?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Yes
Not Sure
Pre-Survey N=318
Post-Survey N=239
No
Results
Do you routinely check for patient and family
understanding of your teaching?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Always
Sometimes
Pre-Survey
Post-Survey
Never
Follow-Up
Results
How do you ask patients and families to assess their
understanding? Check all that apply.
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Do you have any questions?
Do you understand?
Pre-Survey
Post-Survey
Follow-Up
Other
Results
Are you familiar with the teach-back process?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Yes
Not Sure
Pre-Survey
Post-Survey
No
Results
Do you currently use teach-back in your practice?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Always
Sometimes
Pre-Survey
Post-Survey
Never
Follow-Up Survey
Results
Do you think that teach-back helps patients and families
better understand your teaching?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Yes
No
Post-Survey
Follow-Up Survey
Results
Since learning about health literacy and teach-back, have
there been any times when you were able to clarify info
or correct misunderstandings using the teach-back
process?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Yes
No
Post-Survey
Follow-Up Survey
Results
When using teach-back with families, approximately how
often do you clarify or correct misunderstandings?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
<25% of the time
25-49% of the time
Post-Survey
50-75% of the time
Follow-Up Survey
>75% of the time
Results
• Question: When do you feel it’s
necessary/important to use teachback?
– When I don’t think they understand
– With medications and treatments
– With signs and symptoms to call for
Results:
Clarifying Information
Nurses
Non-nurses
2 months
• Medications (64%)
• Diets (20%)
• Signs and symptoms to
call back about (20%)
• Skills such as central line
care and CPR (18%)
Treatments:
• Exercises (PT/OT)
• Mixing formula
• Feedings (Dieticians)
• Respiratory treatments
and medications (RTs)
1 year
• Medications
Treatment focused:
• Trach care
• Asthma care
• Equipment teaching
• Exercises
• Feeding and formula
mixing
How often clarifications
were needed about care
were surprising to staff.
Clarifications needed from
instructions from health
care teams were surprising
to nurses.
Quotes
• Asthma albuterol inhaler, mom was using it every 4 hours
& prn instead of q 4 hours prn. She was doing this for 3
years!!!
• Family of a toddler with a head injury told the Dr. that
they understood when to call and follow-up. I asked
what they were told and what they knew, many
questions surfaced and many things were not
understood.
• I am often surprised at how many times the reiteration is
wrong, so we go through it again.
• I have been able to catch many misunderstandings
about when you give home meds using teach back.
Results: Barriers
2 months
Nurses
Non-nurses
•
•
•
•
Time (44%)
Parent anxious (33%)
Language (17%)
Disinterested parent
(16%)
Staffing
Staff uncomfortable
Learning capacity of
parent
Lack of availability of
learner
• Time
• Stressed or
disinterested families
• Night shift or pharmacy
impact on med
availability
• Child is sleeping or just
was fed
Time
Language
Feeling awkward
Remembering to use it
• Time
• Language
•
•
•
•
1 year
•
•
•
•
Quotes
• Feels cumbersome, takes time and I feel like I’m
quizzing them.
• Parents are in a huge rush to leave and just want to
get out of here. So they kind of listen but kind of
don’t.
• A lot have chronically ill children and maybe feel as
though they already are competent in caring for
them. They get defensive when you try to review it
with them.
• Still feeling awkward.
• Need to remember to use.
Results: Other Comments
Nurses and non-nurses
2 months •
•
•
•
•
•
•
1 year
Good openers are helpful and scripting helpful
Hearing good catches are important
Helpful intervention
Universal tool to assess health literacy on admission is needed
Improved medication print out with family friendly language
Staffing adjustments especially in areas with rapid turnover
Recognition of the problem and that many families are
overwhelmed with information
• Comments made at this point were positive over all at the strength
of the intervention.
• Several said they needed more time to feel comfortable with teachback.
• Still wanted assessment tool for reading and health literacy.
Quotes
• I have become aware of how complicated the
words are that I am using when teaching that are
unneeded.
• I think it made me realize that many people say
they understand and do not.
• Helpful intervention.
• I believe it’s the only way to teach families.
• Simple powerful tool.
• Are we teaching this to residents?
Conclusions
•
•
•
•
•
•
•
•
Teach-back is evidence based.
Use open ended questions.
Start early with teaching.
Scripting is supportive and appreciated.
Coaching is needed over time.
Time must be given and teaching prioritized.
Language barriers need to be addressed.
Discharge safety needs to be an
organizational priority.
Sharing Time
• What stories do you have to share?
• What improvements can be made in
your practice given what you learned
today?
What Questions Do
You Have?
Resources
• Always Use Teach-back! Toolkit available
at: http://www.teachbacktraining.org/
• AHRQ Health Literacy Universal Precautions Toolkit available at:
http://www.ahrq.gov/professionals/quality-patientsafety/quality-resources/tools/literacy-toolkit/index.html
• Plain Language Thesaurus for Health Communications
available at:
https://depts.washington.edu/respcare/public/info/Plain_Lang
uage_Thesaurus_for_Health_Communications.pdf
• Ask Me 3 for Clear Health Communication from the National
Patient Safety Foundation available at:
http://www.npsf.org/?page=askme3
• Health Literacy Missouri – resources available at:
http://www.healthliteracymissouri.org/
• Center for Disease Control health literacy resources available
at: www.cdc.gov/healthliteracy/
References
•
•
•
•
•
•
•
•
Attwood, C.A. (2008). Health literacy…Do your patients really understand?
American Academy of Ambulatory Care Nurses: Viewpoint, 3-5.
Betz, C.L., Meeske, K., Ruccione, K., Smith, K., & Chang, N. (2008). Health literacy: A
pediatric nursing concern. Pediatric Nursing, 34(3), 231-239.
Kemp, E.C., Floyd, M.R., McCord-Duncan, E., & Lang, F. (2008). Patients prefer the
method of “tell back-collaborative inquiry” to assess understanding of medical
information. Journal of the American Board of Family Medicine, 21(1), 24-30.
Levetown, M. (2008). Communicating with children and families: From everyday
interactions to skill in conveying distressing information. Pediatrics, 121(5), e14411460.
Nair, E.L. & Cienkowski, K.M. (2010). The impact of health literacy on patient
understanding of counseling and education materials. International Journal of
Audiology, 49, 71-75.
National Quality Forum. (n.d.). Improving patient safety through informed consent
for patents with limited health literacy. Retrieved from www.qualityforum.org.
Scotten, M. (2015). Parental health literacy and its impact on patient care.
Primary Care Clinical Office Practice, 42, 1-16.
Squellati, R. (2010). Health literacy: Understanding basic health information.
Creative Nursing, 16(3), 110-114).