As nurse educators in both the academic and/or clinical settings, we must provide our students with tools that support evidence-based practice to assist them in meeting the demands of their expanding role and responsibilities within the healthcare environment. Research suggests that ineffective communication and low health literacy levels have resulted in poor patient outcomes evidenced by increased readmission rates and rising costs. (Insert citation) The purpose of this paper is to support the development of an educational activity that identifies factors associated with health illiteracy and promotes the evidence-based teaching strategy, “teach-back”. My capstone projects describes the components of health literacy, low health literacy warning signs, communication basics, and includes role play exercises utilizing the teach-back methodology to senior level students in a baccalaureate nursing program.
Central to Dorothea Orem’s Self-Care Deficit Nursing Theory is the assumption that individual’s should be self-reliant and responsible for their own care as well as others in their family who need care (Insert citation). She further asserts that an individual’s understanding of their potential health problems is essential to support self-care behaviors. When applying her theory in the context of low levels of health literacy, it is clear that nursing must develop methods that improve communication and understanding with each patient-nurse interaction for optimal outcomes to be achieved.
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The Institute of Medicine defines health literacy as the “degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” (Neilsen-Bohlman, Panzer & Kindig, 2004, p. 32). With Orem’s self-care concept as a backdrop for my research, I found many articles correlating low health literacy levels with ineffective management of self-care treatment regimens. According to Boyd and Stacey (2016), “Patients with limited health literacy are at greater risk of poor health outcomes, including poorer knowledge, less preventative service use, increased hospitalization, reduced chronic disease management, poorer health status and chronic disease control, and greater mortality” (p. 356) Additional studies also identified that failed care transitions result from poorly understood discharge instruction and recommend a jargon-free, slowed-down verbal communication technique integrating the evidence-based strategy of teach-back, formerly called “closing the loop” (Cloonan, Wood & Riley, 2013; RED PROJECT(Insert citation).
There are two settings for my practicum project. The Program of All-Inclusive Care for the Elderly (PACE) healthcare facility called Beacon of Light in New Jersey and the simulation lab at Georgian Court College. At Beacon of Light, patients receive both secondary and specialty medical care along with rehabilitative therapies. The facility also serves as a day health center. The Beacon of Light has recently undergone a change in ownership and management . While services have remained the same, there appears to be some decline in the number of members attending the day health center and recreation activities. At the Georgian Court Simulation Lab, instructional time may be reserved and students can participate in experiential learning activities in a safe, controlled, hospital room-like setting. My target audience is comprised of two communities health student nurse groups totally 19 students. By participating in my integrated health literacy teach-back practicum program, students will develop the knowledge, skills and attitudes necessary for communication about health-related issues.
My project will be implemented between November 1, 2018 and March 15, 2019. The program will consist of three phases. During the initial phase, a didactic educational activity featuring a Power Point presentation addressing health literacy issues ( and teach-back (with an embedded video link demonstrating teach-back methodology) will be conducted for each community nursing student group. The initial phase will also include a return demonstration of the teach-back methodology. Students will engage in role-playing activities using scenarios; they will be observed and evaluated using an evidence-based checklist. Students will pair-up and non-performers will be observers providing feedback based on the checklist criteria.
Role-play allows learners to participate in the dramatizations of real situations involving human interaction with the goal of increasing understanding. It is often used for learning objectives in the affective domain offering insight on attitudes and values. Bradshaw and Lowenstein (2012) support the use of role-play exercises for enhancing communications and interviewing skills. Role-playing is comprised of three stages: briefing, running and debriefing.
Its best managed with small groups where all students are actively engaged with one or more actors playing a role or an observer in the audience. It’s a creative strategy that encourages students to improvise and behave like the person they are pretending might act.
Phase two will continue with informal observations based on checklist criteria with feedback for one month after initial education. These practice sessions may take place at Beacon of Light with visiting patients, when possible, or during student-initiated practice groups at the skills lab. At the end of one month, all students that attended the initial education will participate in a skills validation session for competency in the teach-back method. There will be no coaching during final evaluation and students must complete all checklist requirements. While the ideal for demonstrating competency would include reality-practice and final evaluation on actual patients, inconsistent patient attendance and willingness to participate create a barrier for this endeavor.
Phase three includes timely submission of the Conviction and Confidence Scale Survey. This scale is to be completed at the time of the initial education, one month after training (practice/validation period); and then three months later. Students will be working on their capstone project and participating in a senior internship requiring a full day clinical with an assigned nurse. This experience will provide them with consistent patient interaction to apply what they have learned, utilize the teach-back method in practice and provide reality-based feedback on the three-month survey.
The project will not require any financial resources. I will be providing the handouts and portable audio-visual equipment; there is also audio-visual support available at the College. Human resources will include time to research and develop the didactic presentation and create scenarios, along with post-conference time allocated by my preceptor for providing feedback and evaluation. Potential barriers to success of this project include low student engagement, competing academic priorities, and non-compliance in submitting survey evaluations at the. three-month interval.
Ascribing worth or value to a methodology, such as teach-back, requires a high degree of commitment and a strong preference to behave consistently. For the effective domain evaluation is performed over a period of time or intervals to determine a consistent pattern of behavior in response to a belief, value or attitude. The outcomes will be measured using pre-and-post surveys utilizing a Conviction and Confidence Scale before the education is provided; and at one-month and three-month intervals following the didactic educational activity and skills validation competency assessment on teach-back. This practicum project anticipates the following outcomes:
- 100% of the students will attend the didactic educational activity on health-literacy and teach-back.
- 100% of the students that attended the teach-back educational activity will meet the threshold for competency by achieving 100% on the performance criteria listed on the observation scale.
- Using the AHRQ Confidence and Conviction Scale administered prior to conducting the educational activity, again at one-month, and three-months later, survey results will reflect a positive trend of increased use of teach-back in practice . exhibiting by increased confidence and commitment.
Nurses are the largest providers of health-related patient information. Providing students with experiential programs that enhance communication skills will improve their knowledge, attitudes and skills regarding health literacy The benefits to nursing programs may be seen in producing baccalaureate prepared nurses for licensing exams and level prepared nurses : For prospective employers of newly licensed practitioners, staff that value and utilize teach-back can positively impact on re-admission rates, , medication compliance and patient outcomes. .
Project Relationship to the MSN Program Outcomes
The successful implementation of my practicum project should result in the achievement of the following program outcomes:
1. Demonstrates the use of scholarly inquiry to evaluate current knowledge from nursing theory, nursing science and related disciplines to inform and/or initiate change in nursing practice.
2. Applies ethical decision making to nursing practice.
3. Demonstrates the use of leadership strategies that advance the design, implementation and evaluation of nursing practice.
Integrates advances in technology into healthcare.
- Agency for Healthcare Research and Quality (AHRQ). (2013). Health literacy universal precautions toolkit. Retrieved from www.ahrq.gov/professionals/qualitypatient-safety/quality-resources/tools/literacy-toolkit/index.html.
- Billings, D. M., & Halstead, J. A. (2012). Teaching in nursing: A guide to faculty (4th ed.). St. Louis, MO: Elsevier.
- Boland, L., & Stacey, D. (2016). Health literacy in practice and research. Canadian Oncology Nursing Journal, 26(4), 359–364. Retrieved from Ebscohost
- Bradshaw, M. J., & Lowenstein, A. J. (2014). Innovative teaching strategies nursing and related health professions (6th ed.). Burlington, MA: Jones & Bartlett Learning, LLC Hubbard,
- Fidyk, L., Ventura, K., & Green, K. (2014). Teaching Nurses How to Teach. Journal for Nurses in Professional Development, 30(5), 248–253.
- Lambert, V., & Keogh, D. (2014). Health literacy and its importance for effective communication. Part 1. Nursing Children & Young People, 26(3), 31–37. doi:2122/10.7748/ncyp2014.04.26.3.31.e387
- Lambert, V., & Keogh, D. (2014). Health literacy and its importance for effective communication. Part 2. Nursing Children & Young People, 26(4), 32–36. doi:2122/10.7748/ncyp2014.05.26.4.32.e387
- Neilsen-Bohlman, L., Panzer, A. M., & Kindig, D. A. (2004). Health literacy: A prescription to end confusion. Washington DC: National Academies Press. Retrieved from Ebscohost
Reducing theiry day admisssion
JONA: Journal of Nursing Administration
July/August 2013, Volume :43 Number 7/8 , page 382 – 387 [Free
Conviction and Confidence Scale
Fill this out before you start using teach-back, and 1 and 3 months later.
Name: Check one: Before – Date:
1 month - Date:
3 months – Date:
- On a scale from 1 to 10, how convinced are you that it is important to use teach-back (ask patients to explain key information back in their own words)?
Not at all important Very Important
- On a scale from 1 to 10, how confident are you in your ability to use teach-back (ask patients to explain key information back in their own words)?
Not at all confident Very Confident
- How often do you ask patients to explain back, in their own words, what they need to know or do to take care of themselves?
I have been doing this for 6 months or more.
I have been doing this for less than 6 months.
I do not do it now, but plan to do this in the next month.
I do not do it now, but plan to do this in the next 2 to 6 months.
I do not do it now and do not plan to do this.
- Check all the elements of effective teach-back you have used more than half the time in the past work week.
Use a caring tone of voice and attitude.
Display comfortable body language, make eye contact, and sit down.
Use plain language.
Ask the patient to explain, in their own words, what they were told.
Use non-shaming, open-ended questions.
Avoid asking questions that can be answered with a yes or no.
Take responsibility for making sure you were clear.
Explain and check again if the patient is unable to teach back.
Use reader-friendly print materials to support learning.
Document use of and patient’s response to teach-back.
Include family members/caregivers if they were present.
Care Team Member: Date: Observer:
_D id t_h_e c_a_r_e t_e_a_m mem_be_r_…
Use a caring tone of voice and attitude?
Display comfortable body language, make eye contact, and sit down?
Use plain language?
Ask the patient to explain in their own words what they were told to do about:
Signs and symptoms they should call the doctor for?
Critical self-care activities?
Use non-shaming, open-ended questions?
Avoid asking questions that can be answered with a yes or no?
Take responsibility for making sure they were clear?
Explain and check again if the patient is unable to use teach-back?
Use reader-friendly print materials to support learning?
Document use of and patient’s response to teach-back?
Include family members/caregivers if they were present?
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