Applying the teach-back tool - Medical Observer

A medical consultation is a situation that is potentially ripe for crossed wires and confusion. The woman in your office may be struggling to get their head around new information about their health and any associated terminology. There may be questions not asked, or answers not heard, understood or remembered.

However, there is a proven communication tool that can help safeguard both patients and healthcare professionals from misinformation and missed information during a consultation – and it can take as little as one minute to use. This tool is called teach-back. Teach-back, quite simply, involves asking a patient to explain, in her own words, what the healthcare provider has just told them. Healthcare professionals provide the majority of health information to people, yet effective communication in healthcare between clinicians and patients remains a challenge.

Research shows that up to 80% of healthcare information is forgotten immediately, and 78% of patients discharged from the ED did not understand the information given to them. Crucially, most of these 78% did not realise they had not understood. The way in which healthcare providers communicate health information affects adherence and health outcomes.

Although the aim of the healthcare system is to reduce health inequities, the universal approach (or one-size-fits-all model) has, at times, widened the gap. In Australia, vulnerable and disadvantaged populations carry a greater burden of chronic disease, including higher rates of mortality, morbidity and unplanned hospital readmissions. The importance of clear, two-way communication between patient and healthcare provider is crucial. Patients must be able to understand, remember and act on that information.

About teach-back

Teach-back is used widely in the US but is just starting to be used in Australia. It can be tailored to a patient's health literacy ability and socio-economic status. A 2016 systematic review of teach-back use in chronic disease found that, overall the tool was associated with improved knowledge, skills and self-care abilities in patients. The teach-back tool has five steps:

1. Use simple terms to explain and demonstrate.

   • Minimise medical or other jargon by avoiding acronyms and clarifying the meaning of words.
   • Be specific and concrete, not abstract. Avoid words with multiple meanings, such as dressing, needle-stick, negative, diet or stool.
   • Use short statements – keep to three main health messages.

2. Check understanding.

   • Get the person to demonstrate their understanding by asking them to explain what you have just told them in their own words. In this way, the person becomes the teacher for a brief time.
   • Frame the question in a way that isn't patronising or feels like a test. Ask questions, such as, 'Could you tell me what you've understood from our meeting today?' Or be more specific, such as, 'I want to make sure I was clear about the side effects of taking this medicine. Can you just explain back to me the side effects you need to watch out for?'

3. Identify and address any misunderstanding.

   • Actively listen to what the person is 'teaching-back' to you to check whether they understand your meaning. Provide feedback, focusing on what is not understood, such as, 'I haven't been clear in
     regard to the part about … What I meant was that...I might have confused you a little…'
   • When re-explaining, don't just repeat word-for-word what you said the first time. Try different wording or a different approach, such as doing a simple drawing or using a model.
   • It might be helpful to assess the client's preferred learning style.

4. Repeat steps 2-3 until misunderstandings are clarified.

   • Once you have re-explained the information, ask the person to repeat back to you in their own words again. Then provide feedback, identifying and addressing any misunderstandings.
   • Teach-back is not a one-size-fits-all approach. You will need to be flexible. Some people will need you to use teachback just once, while others will require a much gentler, tailored approach.
   • Repeat the process of re-checking and re-clarifying up to three times. If you have taken learning styles into account and teach-back doesn't seem to be working, consider the following:
     • you may be trying to teach too much at once. Try delivering your information in bite-sized chunks, then check the patient's understanding after each one ('chunk and check')
     • other factors may be affecting the exchange, such as cultural expectations, language barriers, embarrassment or the client's emotional or cognitive state
     • another health worker or family member may need to do the teaching.

5. Close the loop.

   • To finalise the teach-back process, ask the person to repeat everything back to you again, in their own words.
   • Ask them to tell you from the beginning. This helps people to remember everything in sequence.
   • If they demonstrate understanding at this stage, provide positive feedback.

Practice points

• Teach-back is an evidence-based health literacy intervention that improves patient-provider communication and health outcomes.
• It is intended to improve efficiency during the consultation and has been shown to take no more time than a normal consultation.
• Teach-back is a way of checking the patient's understanding of the health information conveyed in their own words and, if needed, offers the chance to re-explain and check again.

In summary, think about what the patient really needs to know. Do not assume baseline understanding of the health topic. Given that most people only remember about three things at any one time, try to focus on the three most important points and ask the patient to teach-back just on those; don't ask the patient to teach-back everything. This will keep the time required to complete the teach-back process to a minimum.

About the author

Dr Alison Beauchamp was recently awarded an NHMRC Medical Research Future Fund TRIP fellowship to evaluate the use of teach-back in Australian healthcare settings.

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