“Like a dialogue”: Teach-back in the emergency department

Abstract

Objective

Teach-back may improve communication, but has not been well studied in the emergency setting. The goal of this study was to characterize perceptions of teach-back in the emergency department (ED) by health literacy.

Methods

We conducted an in-depth interview study the ED discharge process teach-back techniques in two tertiary care centers (adult and pediatric), using asthma as a model system for health communication. Participants were screened for health literacy, and purposive sampling was used to balance the sample between literacy groups. Interviews were conducted until thematic saturation was reached for each literacy group at each site; audiotaped, transcribed, coded, and analyzed using a modified grounded theory approach.

Results

Fifty-one interviews were completed (31 parents; 20 patients). Across all groups, participants felt that teach-back would help them confirm learning, avoid forgetting key information, and improve doctor-patient communication. Participants with limited health literacy raised concerns about teach-back being condescending, but suggested techniques for introducing the technique to avoid this perception.

Conclusion

Most participants were supportive of teach-back techniques, but many were concerned about perceived judgment from providers.

Practice Implications

Future investigations should focus on feasibility and efficacy of teach-back in the ED and using participant generated wording to introduce teach-back

1. Introduction

Existing emergency department (ED) communication and discharge practices leave patients at risk of poor comprehension¹, which often goes unrecognized.² Less than a quarter of interactions involve confirming comprehension,³ and patients are rarely encouraged to ask questions.⁴ Previous research has suggested that patients want information that defines complex terms, clarifies uncertainty and provides a logical flow of information,⁵ but the ideal method for ED teaching remains to be defined.⁶

“Teach-back” or “read-back-teach-back,” part of the Health Literacy Universal Precautions Toolkit, is a method by which patient understanding is confirmed by explaining the information back to the provider.⁷ If recall and comprehension are not demonstrated, the provider can clarify and modify the explanation, and reassess.⁸ This iterative approach allows for attention to factors such as “literacy, anxiety, culture, distracting symptoms…that can influence a patient’s understanding.”⁹

Limited health literacy is associated with decreased frequency of correct teach-back,¹⁰ and patients with limited health literacy may require more iterations of teaching. Furthermore, health literacy or education may be associated with acceptability of teach-back techniques, with one study finding that patients with higher educational levels were more likely to describe such methods as problematic.¹¹ Understanding the effects of teach-back on individuals with varying health literacy is of key importance as limited health literacy is common, and associated with increase costs to the healthcare system.¹² Asthma was chosen as the model system for investigating ED discharge communication because it is common in both adult and pediatric patients, with standard clinical pathways and information to be communicated at the time of discharge. Limited health literacy is associated with worse asthma outcome measures in both adults¹³ and children,¹⁴ demonstrating the importance of improving asthma care for patients with limited health literacy. The goal of this study was to examine the acceptability of teach-back to patients and parents in the emergency department and examine how perceptions of teach back techniques varied by health literacy.

2. Methods

Recruitment was conducted in two urban tertiary care EDs: one adult and one pediatric. The adult center sees approximately 1000 patients with asthma per year, and the pediatric center sees approximately 7000 patients with asthma per year. Adult ED patients were eligible for inclusion if they were undergoing asthma treatment with plan for discharge home and had no significant medical comorbidities. Parents of patients age ≤11 were recruited in the pediatric ED. Parents were eligible for inclusion if they spoke English and had a child who was being treated for asthma in the ED with planned discharge home. Parents of children with complex healthcare needs, such as mechanical ventilator support, cystic fibrosis or active oncology treatment (see¹⁵ for examples) were excluded from the sample, as they are often less likely to be discharged home and have very different experiences of learning in the healthcare system. Eligible individuals underwent a verbal consent process to reduce literacy-related barriers to study participation. Nominal gift cards were offered as incentives for participation. The protocol was approved by the Institutional Review Board (protocol 13-010112).

Semi-structured, in-depth interviews were conducted in person during the ED visit. The interview guide asked specific questions about the acceptability of teach back techniques (Table 1). After providing verbal informed consent, participants completed a brief demographic survey and an assessment of health literacy. Parents completed the Parental Health Literacy Activities Test (PHLAT),¹⁶ which covers domains of literacy and numeracy particularly relevant for the care of young children. Adult patients completed the Newest Vital Sign.¹⁷ Literacy score was used to define adequate and inadequate (limited) health literacy, based on comparisons to previously published values for the literacy assessments.^16–18 As we expected the experiences and needs to differ based on health literacy, we used purposive sampling to enroll approximately equal numbers of participants in each literacy group. Parents and patients were recruited until thematic saturation was reached for each group (Patient adequate and limited health literacy; parental adequate and limited health literacy). Thematic saturation is the point at which interviews are no longer revealing new information about the primary topic of interest, and marks the point at which a qualitative study, designed to elicit the range of experience and opinions is complete.¹⁹ Thematic saturation was identified by concurrent analysis and team consensus.

Table 1.

Teach-back questions

Introduction	There are many different ways to learn. One way would be to have parents repeat back what they have learned to the doctor or nurse before they leave.
Core questions	How would you feel about that? How do you think other parents would feel about that?
Additional prompts	Some of what we are learning about how to teach families comes from the airline industry. Pilots are taught to repeat back what they have been told to confirm their understanding. For example, if air traffic says ‘clouds ahead’ the pilot would respond ‘understand, clouds ahead.’ This method can be used with teaching parents, and having the parents then repeat back or teach back what they have learned to make sure that they understand

Interviews were completed by a research staff who underwent a comprehensive training program in qualitative interviewing and analysis. All interviews were recorded and professionally transcribed. Interviews were observed by the principal investigator (MSK) until the quality was consistent, and then interview recordings and transcripts were reviewed by investigators with expertise in qualitative methods (MSK, KVR, CM) for quality improvement and to identify areas for further exploration. An initial coding guide was developed based on the interview guide, and was refined with input of the entire team. Each transcript was coded by two trained independent coders. Coding disagreements were resolved by team consensus meetings. Themes were identified by reviewing relevant sections of transcripts, and were discussed by the entire study team. Coding and theme development was ongoing throughout the study process, with changes made to the coding tree and interview guide as themes emerged.

3. Results

Fifty-one interviews were completed. Of the 31 parents interviewed, 15 (48%) were limited literacy, 26 (85%) were African-American and 25 (81%) had public insurance. Of the 20 adult patients interviewed, 12 (60%) had limited literacy; 17 (85%) were African American; 6 (30%) completed college; 16 (80%) had public/no insurance.

Benefit of teach-back techniques

Across both literacy groups and across both the adult patient and pediatric parent populations, participants felt that teach-back would help them confirm learning and avoid forgetting key information: “because sometimes some people are talking to you and you’re listening, but you’re watching other things go on, but – and to know that you just heard what the person just said and if they can repeat it back to you, then you know they got it. Plus also you saying it yourself kind of puts it in your memory, like you have to take care of step one first and then so forth and so forth.” (Pediatric parent, adequate literacy). An adult patient commented on the importance of teach-back for those with reading difficulty: “It probably would make things a lot more better, easier for people…I mean, what if somebody couldn’t read? You’re giving them a paper and they can’t read nothing. You’re not even breaking down and say, well, this is for this… They just give you a piece of paper and I guess you rock with it and take it to the pharmacy and let the pharmacy deal with it, I guess.” (Adult patient, limited literacy) Many parents, and some adult patients, talked about teach back as an opportunity to prove to the providers that they were paying attention “That would- that’s okay because then if I repeated back everything that I learned or heard today, that’ll make them know if I was paying attention or that would help the doctor be sure that I will be able to handle my child once I leave the emergency department. (Pediatric parent, adequate literacy)” One adult patient described teach-back as an opportunity for true doctor-patient communication “it’s best to sit there, talk with each other, so the doctor going to explain to you how you feel and you’re going to agree or don’t agree… Yeah, like a dialogue and getting connected with each other, doctor-patient.”(Adult patient, adequate literacy)

Concerns about teach-back

A sizable minority of participants raised significant concerns about teach-back strategies. In the adult ED, patients with adequate literacy reported that teach-back would be a waste of time, saying: “because I don't have time to be repeating back what I already understand. You tell me I’m going to do it.”(Adult patient, adequate literacy) In the pediatric ED, parents from both literacy groups reported feeling that teach-back was unnecessary “I fully understood what you were saying and I feel like there is no need for me to repeat back what you said to me, because if I didn't get it, then I would have questioned to you or told you that I didn't understand. (Pediatric parent, limited literacy).

Although concerns about teach back being offensive or condescending were raised by participants in all groups, the predominance of concerns were raised in the limited health literacy group. These concerns intersected with comments on race and class, specifically regarding perceived provider profiling and bias: “They would probably think that the doctor’s trying to say they’re dumb, or stupid, they don’t know anything. … a patient is gonna take it as disrespect. Especially a patient that really don’t know how to read. … Well, sometimes a doctor might ask you. Well, what did that say? And they’ll probably go, what you think, I’m not gonna sign? You trying to say I’m stupid? I ain’t stupid. … That person gon’ think, oh, well, you might think I’m stupid or I’m dumb because I’m this race, or I’m that race, and you’re a higher rank than that what I am. And I’m the patient. And you’re a physician. Most people do think like that.” (Adult patient, limited literacy)

Participants also raised concerns about feeling judged and nervous to report a lack of understanding to their provider “I would feel nervous, because I would feel like I'm telling the doctor, you know, what I think, and I know how they feel about that. Some doctors are like this lady's crazy. But no, I don't think it would be a waste of time at all. (Pediatric parent, limited literacy). In both the pediatric and adult ED populations, a number of participants reported that while they themselves would be fine with teach-back, other patients or parents would not be: “I mean, everybody may not want to do that, you know, because some people, to be honest, they don't listen. … But just be prepared to get some attitude…you know, I heard what you said, now leave me alone. (Pediatric parent, limited literacy).

Participant suggestions for introducing teach-back

Many parents of pediatric patients suggested possible wording for introducing teach back techniques to improve acceptance. There were fewer suggestions from the adult patients. Both adequate and limited literacy parents suggested encouraging parents not to take offense: “I guess it all just depends on the approach that you say it to them. Once you teach them everything, then you're going to be like okay. Well, now start over saying don't take offense, but I want to make sure that you're going to be as great as a caretaker as we have been here, so tell me now how much of the Flovent are you supposed to give them, which ones are you supposed to give them, just so I know you have a great understanding, because a lot of times parents won't ask questions or we don't think of questions until we go home. (Pediatric parent, adequate literacy) Parents also suggested being explicit about the reasons for verifying comprehension, and suggested language for providers to use: “It’s not that I don’t think you understand, I just want you to be able to put it in simpler terms that you will understand. Teach me back. Maybe I misunderstood something I said. Maybe I didn’t say something correctly. (Pediatric parent, adequate literacy) Please see table 2 for further supporting quotes.

Table 2.

Selected quotes

Theme	Setting	Adequate literacy	Limited Literacy
Confirmation of learning and avoid forgetting; prove attention	Adult	I mean, to me, I don’t have a problem with it because you can say you understand and then get out there, you really don’t…And maybe the doctor got to re-word it around or show examples or anything, just so the person understands. To repeat that information you know that your patient is actually listening, they got the information that you wanted to – the point that you was trying to make. So that is a good idea. I can maybe not repeat back exactly, but repeat it back in my own words to let the doctor know that I understood what they’re trying to tell me.	One doctor caught me off-guard because I basically wasn’t paying him no mind. I was really focusing on getting up out the hospital. And he like – excuse me. He asked me. He was like, you understand what I’m saying? I’m like, yeah. I do. And he was like, tell me what I said. And I really couldn’t explain, tell him anything that he said to me. Because I wasn’t really paying attention. I was really focusing on hurry up. Signing them discharge papers, so I can hurry up and get home and lay down. So, now, I know to listen.
	Pediatric	I think that would be pretty good, to make sure, because it's like ensuring that you learned it, that you're not just going okay, okay, okay, and walk out the door and forget immediately. Well, if they ask me to recite everything back, that means I got it and I know what to do. That's what I like about that. Even though it may not help because, like I said, once you leave out of them doors, it's so much stuff going on that you might forget all of it. By the time you get home, you never know what you've got to go through.	That way you know they understand. I need to know that you understand what I’m saying. So yeah, repeat it.
Concerns about distraction and time	Adult	When you're sick you're actually in the panic mode and you're all you're thinking about is I want to be better. I don't want to die type of stuff…it's the feeling where you cannot breathe and you feel like you'd like to take your last breath, then you in a panic mode and your memory is pretty – probably you're probably not focusing on that. So it probably won't work for everyone…but I think it would be useful.
	Pediatric	So sitting down verbatim while I repeat what you said. To me, that'd just be a waste of time because we already went through that once if you've done it thoroughly. If my son is sick or you know maybe I just wanted to get out of there and I knew I was getting written information, I don’t know if I necessarily would want to sit there and repeat or school the doctor back into what he said…. It may be like a time crunch or maybe – I don’t think I like being put in a situation where I feel like I have to repeat what someone else said. Maybe if it was worded differently or maybe if they said something to the effect like do you understand? …Do you have any questions and then kind of open the line for conversation. But I don’t think I would like Ms. [Last Name] everything I just told you about his asthma I need you to tell me back.	You don’t know what type of time the parents is on when they come so you- they might not want to listen and want to be taught in all the- I mean me personally, I would because I’m probably younger, but older people, they don’t be having the time for that.
Concerns about provider profiling and bias	Adult		What you mean do I understand? Of course I understand what you saying. I’m not dumb. That’s the first thing they gonna say soon as you ask. Do you understand what I’m saying? They gon’ come off on the high horse. I don’t know if you experienced it or not, but I’m telling the truth. That’s how they gon’ come off at you. No. Because then you're making that person feel like a child…Nobody wants to feel belittled, underneath a doctor or a nurse‥I don't think nobody wants to do that. But I would definitely be on –I understand, the instructions and what the doctor was telling me and I know how to read and write, so I would be fine with that.
	Pediatric	I think that may be a little annoying, because they may feel like what you think, I'm stupid? So I don't know if that would be a good approach. Just asking them like you sure you understand it, if you give them paperwork, then they should know. But I would be a little annoyed, because you are, or you may have been up all night with your kid and you may be tired or anything, and then if they say, repeat back to me what I said, like I may feel like, what? So I don't think that would be a good idea.	If your speaking down to a person, or you talking to them like they don’t know no better, they can take offense. But if you’re speaking in a tone where your teaching and your really being therapeutic with it, then I don’t see that the issue…But like I said, some parents just are who they are and you can’t get past that. But if your speaking in a tone and you’re like it’s therapeutic and it’s teaching and you’re just letting them know, I need you to just show me back what I’m showing you so that I know that you are doing it right to make sure he’s getting his best possible care, I won’t take any offense. But if you’re talking down to me or you talking to me in this nasty side of your voice, like look, you know you have to do this and do that, like I don’t know any better or I don’t understand what you’re saying, then that could be taken offensively. How would it go? Because it makes me seem like I'm dumb if, can you repeat me back? Like I feel kind of offended a little bit… I would feel a little like you look like I don’t – it looks like I don’t understand, and I look like that type of person I guess…Maybe if they come a different way about it, like not just asking me, can you relay what I just told you… I'm like excuse me. I'm not gonna repeat this to you, because of course I'm not gonna remember
Concern about admitting lack of understanding	Adult	So by them asking, okay, what did I say, and me being a doctor, if you can’t repeat it back, I’m gonna tell you again anyway because me being a doctor, okay, she didn’t understand or he didn’t understand, I’m gonna explain it to them different so they can, because you get some people that’s ashamed to say, okay, I really don’t understand. It’s their pride.
	Pediatric	I don’t think that’s a good idea, one, because everybody is not able to explain. I’m learning that more as I’m getting older that everybody is not good at explaining something that they were just told, even if they understand it. So, maybe demonstrate, that could be a option, but some people can’t – they know exactly what you said, but it’s like you just – you was saying what it’s like they just can’t get it out. So, for people that’s not really verbal, it’s not going to work for them, and then now they’re not going to want to do it and now it’s like they’re pushing them up against the wall.	So when the doctor asks me again before I leave, it’s like a test that I –I mean that’s probably not the really the best thing to do. I don’t think that’s a good idea, because you can’t put nobody on the spot like that
Suggestions for introducing teach back	Pediatric	I guess it all just depends on the approach that you say it to them. Once you teach them everything, then you're going to be like okay. Well, now start over saying don't take offense, but I want to make sure that you're going to be as great as a caretaker as we have been here, so tell me now how much of the Flovent are you supposed to give them, which ones are you supposed to give them, just so I know you have a great understanding, because a lot of times parents won't ask questions or we don't think of questions until we go home. I wouldn't take it as the doctor or whoever is telling me the discharge instructions. I wouldn't take it as them talking down to me. It would be more so like okay, I want to make sure you understand this, because this is about your child, this is about helping your child to get better. I wouldn't take offense to it, because it’s that not how I'm perceiving it to come down to me. So I would be okay with it. It’s not that I don’t think you understand, I just want you to be able to put it in simpler terms that you will understand. Teach me back. Maybe I misunderstood something I said. Maybe I didn’t say something correctly.	I’m not putting you down. I just want to make sure that you’re understanding what I’m saying or like, okay, what if you didn’t know your child has asthma and I’m trying to tell you your child have asthma and you’re telling me no, no, no. It doesn’t run in the family. It doesn’t have to run in the family to get it. So repeating what I’m saying, yeah. Because like I said, some of the medicine that he gets, because you say it, doesn’t mean I say it. So I need to know if I hear it, I can understand it, ya, ya that’s what they said. But I might not pronounce it but I can hear it and say oh yeah that’s what they said or hear and stuff like that. I could see if y’all asked them something like, do you remember the form of care that we talked about doing for your child while they're at home. I could see if y’all said something like that, but don’t’ ask nobody to repeat back the whole conversation that y’all had You might do get frustrated but if they explain to you, like okay, we need you to – it’s our policy to review or go over and make sure that you understand because it might not be emergency or you can understand what to look for or you know what’s going on, so when you come back the next time, or when you go to the doctor, you can explain what happened.

4. Discussion and conclusion

4.1 Discussion

In our study, adult patients and parents of patients with asthma were broadly supportive of teach-back techniques for the ED discharge process, but raised significant concerns about the timing and bias that might be experienced by patients or parents.

The opportunity to clarify and customize information in response to misunderstanding may be why teach-back techniques are associated with improved outcomes for patients with diabetes.⁸ Careful verbal instruction can compensate for limited health literacy in the teaching of patients with asthma,²⁰ suggesting that appropriate educational techniques may help to reduce literacy-related disparities in care. Finally, some have suggested that high quality physician-patient conversation at the time of discharge may help improve physician satisfaction.²¹

Teach-back has been studied in the informed consent literature^22,23, where it has been shown to increase recall.²⁴ Teach-back has been estimated to add an estimated additional 5 minutes is required to the informed consent process.²⁴ A randomized controlled trial of teach-back for surgical consent found that the process took an average of 2.6 minutes longer and was associated with increased comphrension.²⁵ Furthermore, longer time spent teaching was associated with improved ability to answer questions, but not with decreased readmission rates in one heart failure study.²⁶ Although some have suggested that assessment of understanding should be part of the ED discharge process,²⁷ such strategies have not become part of the routine practice. This may be because the average ED discharge process has been estimated to last approximately 76 seconds.²⁸ Future studies will need to investigate the true time demands of teach-back as compared to the potential morbidity of leaving the ED with incomplete comprehension.

Many participants, particularly those with limited health literacy, felt that teach-back techniques could easily be seen as condescending and judgmental, and reinforcing existing power differentials between patients and providers. Of those, several felt that this would occur only if teach-back was introduced inappropriately, and provided suggestions on wording and ideas to introduce teach-back that would be less likely to be seen as offensive. These included recognizing the potential for teach-back to be seen as insulting and explicitly addressing that concern in the introduction, explaining that often people forget information after leaving the ED, and focusing on the potential for the provider to have explained something incorrectly as the justification for teach-back.

Limitations

This study was conducted in two tertiary care academic centers, potentially limiting generalizability to community EDs or other discharge settings such as day surgery or inpatient care. Asthma was used as a model system for understanding ED discharge teaching. Although few of the teach-back responses specifically referenced asthma, the interviews were conducted in the setting of an ED visit for asthma and patients and parents presenting for other conditions may have different perspectives on teach-back techniques. Finally, as with all qualitative work, these findings should be taken to be hypothesis generating and further work is needed to test teach-back in the ED for efficacy and acceptability.

4.2 Conclusions

Parents and patients in the ED with asthma broadly approved of teach-back techniques used at ED discharge to assist with remembering information and confirm understanding. Participants raised concerns around perceived judgment from providers and power dynamics, but also provided a number of strategies for introducing teach back to avoid giving offense or appearing condescending.

4.2 Practice implications

Teach-back was broadly acceptable to this population of parents and patients. And deserves further study as an ED intervention. Future research should focus on parentand patient-derived introductions to teach back strategies and exploring the efficacy and acceptability of teach-back interventions in the ED.

Highlights.

• Participants were broadly supportive of teach-back strategies.

• Teach-back was though to confirm learning and help avoid forgetting key information.

• Limited-literacy participants were concerned about perceived provider judgment.

• Participants suggested methods for introducing teach-back to avoid perceived bias.