Nursing students use of teach-back to improve patients' knowledge and satisfaction: A quality improvement project

Nursing students use of teach-back to improve patients' knowledge and satisfaction: A quality improvement project

Journal of Professional Nursing xxx (xxxx) xxx–xxx Contents lists available at ScienceDirect Journal of Professional Nursing journal homepage: www.e...

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Journal of Professional Nursing xxx (xxxx) xxx–xxx

Contents lists available at ScienceDirect

Journal of Professional Nursing journal homepage: www.elsevier.com/locate/jpnu

Nursing students use of teach-back to improve patients' knowledge and satisfaction: A quality improvement project ⁎

Debra Nicklesa, , Mary Dolanskyb, Jane Marekb, Kathleen Burkec a

Ramapo College of New Jersey, Nursing Programs, Mahwah, NJ, United States of America Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, OH, United States of America c Ramapo College of New Jersey, Mahwah, NJ, United States of America b

A R T I C LE I N FO

A B S T R A C T

Keywords: Students, nursing Teach-back Patient satisfaction Patient knowledge HCAHPS

Background: Nurses provide education on medications to hospitalized patients and this intervention is measured by patient's satisfaction on the Hospital Consumer Assessment of Healthcare Providers and Systems Survey [HCAHPS] (Center for Medicare & Medicaid Services[CMS], 2008). Purpose: Nursing students implement the teach-back method in a quality improvement project to improve patients' knowledge of medications and satisfaction on the HCAHPS survey. Specific aim 1: increase nursing students use of teach-back from the current state of 0% to 80% of their patient encounters; Specific aim 2: ensure that 80% of the patients approached can state the name, purpose and side effects of their current medications; Specific aim 3: have 80% of the patients satisfied with their medication teaching. Methods: The Model for Improvement framework from the Institute for Healthcare Improvement was used (Ogrinc et al., 2012). Process and outcome measures and Plan-Do-Study-Act cycles were analyzed. Results: Senior nursing students used teach back on 82.9%% of their patient encounters. Of the N = 55 patients who received the intervention, 58.2% could state the name and purpose, and 50.9% knew the side effects of their medications. HCAHPS survey responses did not achieve the benchmarks of 77.2% and 52.3% for “always” responses for medication education questions. However, patient satisfaction was measured at 96.4% with the One Minute Evaluation (Appendix A) by nursing students following the intervention. Conclusion: Integrating QI into the clinical environment is a method to not only increase patient outcomes but also exposes students to the methods of QI. Although the intervention did not meet the benchmark for patient satisfaction in “Communication about Medicines” category as measured by HCAHPS survey results, the teachback method was an effective evidence-based tool for improving patient knowledge of medications.

Background Since its inception, health care facilities acknowledge the HCAHPS survey (CMS, 2008) results as an indicator for patient satisfaction and quality patient care. Improved patient satisfaction and the communication process between patients and nurses is a result of nursing interventions (Wolosin, Ayala, & Fulton, 2012). The hospital Value-Based Purchasing program through the Centers for Medicare and Medicaid Services [CMS] (2015) incentivizes health care facilities to achieve the highest quality of care and patient satisfaction to receive a higher level of reimbursement. Reimbursement for services based on patient satisfaction with hospital care is determined through the analysis of HCAHPS survey results (CMS, 2015). The HCAHPS survey consists of several questions to evaluate the patient's view of his/her recent hospital experience and encompasses several categories, including ⁎

knowledge about medications (CMS, 2008). A goal of health care institutions is to improve the method of delivery for educating patients, family members and/or caregivers about medications to improve the quality of patient care, patient satisfaction scores, and to increase reimbursement to hospitals. Patient education includes providing information regarding the patient's medications during hospitalization and prior to hospital discharge. The Joint Commission National Patient Safety Goals (Joint Commission, 2016) endorses medication education with patients and family members as an element of medication safety. In an inpatient hospital setting, medication education that is begun prior to discharge, especially in the elderly population, will improve a patient's understanding of medications (Kimball et al., 2010). Medication instruction is often limited to a review of medications at discharge due to a lack of available time, patient workload, and lack of knowledge about the

Corresponding author at: Ramapo College of New Jersey, Nursing Programs/TAS, 505 Ramapo Valley Road, Mahwah, NJ 07430, United States of America. E-mail address: [email protected] (D. Nickles).

https://doi.org/10.1016/j.profnurs.2019.08.005 Received 17 January 2019; Received in revised form 31 July 2019; Accepted 13 August 2019 8755-7223/ © 2019 Elsevier Inc. All rights reserved.

Please cite this article as: Debra Nickles, et al., Journal of Professional Nursing, https://doi.org/10.1016/j.profnurs.2019.08.005

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Project model

patient's learning capability (Albrecht et al., 2014; Mooney, 1987). The teach-back method is an evidence-based technique for educating patients by verifying a patient's understanding of healthcare information by asking the patient, family member or caregiver to repeat the information provided in the recipient's own words (Agency for Health Care Research and Quality, 2016; Kornburger, Gibson, Sadowski, Maletta, & Klingbeil, 2013; Tamura-Lis, 2013). Teach-back improves a patient's understanding of health information, level of trust, and patient satisfaction (Schillinger et al., 2003; Tamura-Lis, 2013). Any healthcare member can utilize this learning method for any situation requiring patient education (Tamura-Lis, 2013). Nursing students are active participants in patient care within healthcare facilities. Establishing a nursing student and patient relationship builds the foundation for effective patient teaching. Patient teaching is an objective that students are expected to meet during clinical experiences. The American Association of Colleges of Nursing [AACN] (2008) identifies the anticipated outcomes of students graduating from a baccalaureate program of nursing to include patient teaching and patient involvement in care as competencies.

The top row of the Project Model (Fig. 1) illustrates the Model for Improvement that connects process changes (nursing implementation of an evidence-based intervention) with patient outcomes (satisfaction and increased knowledge). The second row of Fig. 1 shows the variables in the project model, consisting of the teach-back method for medication education, and its relationship with patient satisfaction and patient knowledge. The teach-back method is evidence-based and has been found to improve patient satisfaction and patient knowledge of medications (Dantic, 2014; Griffey et al., 2015; Negarandeh, Mahmoodi, Noktehdan, Heshmat, & Shakibazadeh, 2013; Tamura-Lis, 2013). The third row of Fig. 1 illustrates the process measures, including a “Teachback Observation Tool” (AHRQ, 2015) to evaluate the student's knowledge of the teach-back method; and the Nursing Student Perception of Teach-back Effectiveness Survey (D) for students to evaluate the effectiveness of the teach-back technique. The third row also illustrates the outcome measures including, the (1) One Minute Evaluation (Appendix A) for the patient and/or caregiver to rate the usefulness and satisfaction of the teaching session; (2) the HCAHPS survey10 “always” responses to questions pertaining to medication education to evaluate patient satisfaction; and (3) patient knowledge measured by the Patient Knowledge Tool (B). The details of the tools developed to measure the variables are displayed in Appendices A, B, C and D.

Problem description A non-profit healthcare facility in New Jersey identified several hospital units with HCAHPS survey results pertaining to medication education below the benchmark, which affected the funding received by the hospital. A 37-bed medical geriatric unit was identified as one of the lowest scoring in “always” responses to medication education in the HCAHPS survey. The HCAHPS survey benchmark for “Always” responses to questions pertaining to medication education purpose was 77.2% and for communication about side effects of medications was 52.3%. An academic-clinical team was established to carry out a quality improvement project that included students. Evidence exists indicating that nursing students' involvement has a positive influence on patient care (Austria, Baraki, & Doig, 2013; Marks & Koren, 2011). The lead faculty member had students on the patient care unit and created a fishbone diagram using information obtained from direct observation of the medication education process and from the nurse's feedback. A fishbone diagram is a tool that can be used to illustrate cause and effect. The “head” of the fishbone diagram displays the problem and the “spine” shows catgories, such as policies, procedures, and people (Ogrinc et al., 2012). The process of creating the fishbone diagram helped to identify elements in each category that may have contributed to the problem of an ineffective medication education process. The purpose of the QI project was to have nursing students implement the teach-back method on all identified patients during the time of medication administration to improve patient knowledge of medications and patient satisfaction in the “Always” responses in the HCAHPS survey (CMS, 2008).

Design The quality improvement project used the Model for Improvement and the Plan-Do-Study-Act (PDSA) method to improve medication education (Ogrinc et al., 2012). Setting and participants The proposed project took place over three months on a 37-bed medical geriatric unit within a 700-bed non-profit, health care facility in northern New Jersey. The most common diagnoses for patients admitted to this medical geriatric unit included sepsis, urinary tract infection, pneumonia, congestive heart failure, chronic obstructive pulmonary disease, and failure to thrive. The range of number of medications prescribed for each patient upon discharge from this unit varied from five to twelve. The average length of stay for patients was three to five days. The geriatric unit has accommodated nursing students for their clinical practicum experiences in the past. During the implementation of the quality improvement project, nursing students from baccalaureate and associate degree nursing programs were on the unit four days each week. However, only two groups of nursing students from one baccalaureate nursing program agreed to participate in the quality improvement project. The Project Coordinator sought the assistance of the nursing students' clinical faculty for identifying patients for medication education, obtaining patient's Medication Administration Record (MAR), and drug information resources. The QI project targeted patients who (a) anticipated discharge to home; (b) had current and/or new medications prescribed; (c) were awake, alert and oriented to time, place and person, or had a caregiver present. The exclusion criteria for the project included patients who (a) anticipated discharge to a long-term care or rehabilitation facility; (b) had dementia or an altered mental status and did not have a caregiver present; (c) anticipated discharge to a home outside of the United States.

Specific aims The specific aims of this QI project were to: (1) increase nursing students use of teach-back with their patient encounters on the designated medical-geriatric unit from the current state of 0% to 80%; (2) ensure that 80% of the patients who receive the teach-back intervention can state the name, purpose and side effects of their current medications as measured by the Patient Knowledge Tool (B); (3) have 80% of the patients satisfied with their medication teaching as measured by the One Minute Evaluation (Appendix A); and the HCAHPS survey (CMS, 2008) “Always” response to questions pertaining to medication education will be at or above the benchmark of 77.2% for staff explanation of purpose of new medications and 52.3% for communication of possible side effects of new medications.

Protection of human subjects The QI study was deemed expedited review through the hospital's institutional and affiliated academic medical center's review board. No personal information or identifiers of the participating patients or 2

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Fig. 1. Teach-back Project Model.

students intended to teach eligible patient(s) the purpose and side effects of their current and new medications using the evidence-based teach-back method. The intervention took place on the designated days of the junior-level and senior-level designated clinical days. The juniorlevel nursing students requested to conduct the medication education in pairs, whereas senior-level nursing students conducted the medication education individually. Students initially evaluated patients pre-intervention knowledge of medications and utilized the patient's Medication Administration Record, drug information resources, and Using Teachback for Medication Education handout (Appendix C) to deliver medication education for deficient knowledge of medications. If the student found that the patient was unable to teach-back medication purpose or side effects, the nursing student explained the information again and repeated the teach-back education intervention. If a patient's primary language was not English, the student would seek the assistance of a translator or the translator phone for providing medication education. Following the teaching session, the patient and/or caregiver that received the teaching intervention completed the One Minute Evaluation (Appendix A) and was provided the drug information resources in English or in Spanish translation. Immediately afterwards, students' completed the Patient Knowledge Tool (Appendix B) and informed the primary nurse of the outcome of the medication education. At the conclusion of each week, students self-evaluated the teach-back method by completing the Nursing Student Perception of Teach-back Effectiveness Survey (Appendix D).

nursing students were recorded. There was no anticipated risk to the subjects or nursing students included in this project. Intervention training The faculty member served as the Project Coordinator and facilitated the training session one week prior to the implementation date. The training session was conducted with two clinical faculty members of one group of ten junior-level nursing students, and one group of ten senior-level nursing students. The primary resource for the student training was “Using the Teach Back Toolkit” developed by the Agency for Healthcare Research and Quality [AHRQ], including “The 10 Elements of Competence for Using Teach-back Effectively”, the “Interactive Teach-back Learning Module”, and the “Teach-back Observation Tool” (2015). Training commenced for the nursing students with an instructive session. The project coordinator reviewed the document, “The 10 Elements of Competence for Using Teach-back Effectively” (AHRQ, 2015), and answered questions regarding information provided about teach-back and elements of “Using Teachback Effectively”. Next the students and clinical faculty viewed the “Interactive Teach-back Learning Module” (AHRQ, 2015). Lastly students partnered to simulate a patient encounter by role-playing as the nurse and the patient, and practiced the teach-back method using the tools for the intervention. The Project Coordinator created the Using Teach-back for Medication Education handout (Appendix C) as a reference for scripting and guidelines while interacting with the patients during the intervention. The students' clinical faculty also received training in the process of teach-back, and information regarding the medication education intervention during the training session. Evaluation began at the end of the training session and was threaded through the teach-back process. The Project Coordinator utilized the “Teach-back Observation Tool” (AHRQ, 2015) to evaluate the nursing student's learning of the teach-back method. Nursing students evaluated patients' pre and post intervention learning with the Patient Knowledge Tool (Appendix B) and self-evaluated the teach-back method every week by completing the Nursing Student Perception of Teach-back Effectiveness Survey (Appendix D).

Process measures Prior to implementing the intervention, students were trained and evaluated using the “Teach-back Observation Tool” (AHRQ, 2015). The tool was used to evaluate the nursing students' knowledge of the use of the teach-back method for medication education. The tool consists of 11 questions that the Project Coordinator responded with a “Yes = 1, No or N/A = 0” to evaluate the nursing students' knowledge of the teachback method. The 11 questions are summed for a total score ranging from 0 to 11. During the implementation of the teach-back intervention, nursing students evaluated the intervention weekly using the Nursing Student Perception of Teach-back Effectiveness Survey (Appendix D). The survey consisted of four questions on the use of teach-back for medication education using a Likert-type scale response of Strongly Disagree = 0, Disagree = 1, Undecided = 2, Agree = 3, and Strongly Agree = 4. This tool was used to measure the number of patients per

Intervention process In collaboration with the units' clinical faculty and nursing leadership, patients were identified for the purpose of the medication education intervention. During the time of medication administration, 3

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(20%) of the 37 non-english speaking patients. The nursing students met resistance from the telephone translators due to the amount of content and “repetitiveness” of the teach-back method. A third PDSA cycle began as students changed the delivery of medication education to the purpose and side effects of a medication, evaluated understanding, and then proceeded to the next medication. However, the process was time-consuming and a fourth PDSA developed. Medication education was translated in-person by three spanish speaking student nurses for 7 (12.7%) patients. In doing so, the patient and student nurse translator found the information to be less repetitive and the process to be more efficient which resulted in a slight improvement in patient knowledge of the purpose and side effects of medications.

week who received the intervention and this number was compared with the number of patients identified as eligible for the intervention. Both tools provided data for specific aim 1. Outcome measures Patient satisfaction, was measured by the One Minute Evaluation (Appendix A) and was completed by the patient and/or caregiver upon completion of the medication education. The usefulness and satisfaction with the teaching session was rated on a scale of 1 to 10, from not very useful or not very satisfied (rating = 1) to very useful or very satisfied (rating = 10), and provided an opportunity for comments about the teaching session. Another measure of satisfaction was the “Always” response to questions in the “Communication about Medicines” category in the HCAHPS survey (CMS, 2008) for the hospital unit. Responses to survey questions were coded as 0 = Never, 1 = Sometimes, 2 = Usually, and 3 = Always. The HCAHPS survey was obtained six months prior to implementation of the project and monthly during implementation of the project. Patient knowledge, was measured by the Patient Knowledge Tool (Appendix B). Immediately after completing medication education with each patient, nursing students answered questions to evaluate the patient's knowledge of medications before and after the medication education intervention. Four questions evaluated the patient's knowledge of medications before and after the intervention. Responses to all four questions were coded as 0 = none, 1 = some of the medications, and 2 = all of the medications.

Results The participants (N = 55) consisted of both male and female patients, with a mean age of 65 (SD = 1.9). Most participating patients spoke English, but 32% spoke Spanish. Junior-level nursing students provided medication education to 26 patients and senior-level nursing students provided medication education to 29 patients (N = 55). A majority of the medication education was provided to patients (87.3%) without a family member/caregiver present. Five (9.1%) teaching sessions were conducted with the patient's family member/caregiver. Two (3.6%) teaching sessions included both the family member/caregiver and the patient. The number of current medications taught by nursing students to each patient varied (M = 5.07, SD = 2.50). Data analyzed from the Teach-back Observation Tool (AHRQ, 2015) demonstrated nursing student competence (M = 9.7, SD = 1.7) with 80% of nursing students confident with medication education using the teach-back method. Data analyzed from The Nursing Student Perception of Teach-back Effectiveness Survey (Appendix D) revealed that 55% found the teach-back method easy to use; 65% found that their patients had to repeat the information more than once to demonstrate understanding of their medications; and 45% found that the teach-back method enabled their patients to understand the purpose and side effects of their medications. Specific aim 1 was to increase nursing students use of teach-back with their patient encounters on the designated medical-geriatric unit from the current state of 0% to 80%. The junior level nursing students were unable to achieve specific aim 1. The junior nursing students provided medication education to 26 out of 43 eligible patients (60.5%). The senior nursing students achieved specific aim 1 by educating 29 out of 35 eligible patients (82.9%). Of the 78 total eligible patients identified for medication education, 55 (70.5%) patients received medication education by junior and senior level nursing students. Specific aim 2 was to ensure that 80% of the patients who receive the teach-back intervention can state the name, purpose and side effects of their current medications as measured by the Patient Knowledge Tool (Appendix B). Nursing students used the teach-back method and witnessed improvement from 16.4% to 58.2% of patients who knew the purpose of all of their medications; and an improvement from 1.8% to 50.9% of patients who knew the side effects of all of their medications after nursing students used the teach-back method. The patients who did not know the name and purpose of their medications decreased from 27.3% to 9.1%. Also, 67.3% of patients who did not know the side effects of their medications decreased to 9.1% after nursing students used the teach-back method. Overall, the patients' knowledge of the name, purpose, and side effects of their medications improved after nursing students used the teach-back method for medication education. Specific aim 3 was to have 80% of the patients satisfied with their medication teaching as measured by the One Minute Evaluation (Appendix A); and the HCAHPS survery “Always” response to questions pertaining to medication education will be at or above the benchmark. The patient satisfaction that were reported by patients on the One Minute Evaluation (Appendix A) had a Mean of 9.1 (SD = 1.7)

Balancing measure A balancing measure is when one considers if any negative changes have taken place other than the intended area for improvement (Ogrinc et al., 2012). In this quality improvement project, the balancing measure utilized to identify any negative results was for the unit's leadership (charge) nurses to obtain information from any patient complaints received during the implementation of the project. The units' leadership nurses would document the date, number of patient complaints, and comments received by patients. Data analysis The data from the two process and three outcome measures was analyzed in the “Study” phase of the PDSA Method (Ogrinc et al., 2012) each week of the project. After an analysis of the results, modifications to the medication education intervention took place in the “Act” phase and another PDSA cycle ensued. Data for each measure was entered into a Statistical Package for the Social Sciences [SPSS file] using the coding as previously described. A numerical value was assigned to responses for questions on all tools and surveys. Descriptive statistics were used to describe the data obtained in the project, including the improvement in “Always” responses in the HCAHPS survey (CMS, 2008), patient satisfaction with the teaching session, patient knowledge of medications, and the teach-back method. PDSA cycles Several PDSA cycles ensued. During the first week of implementation, the first PDSA cycle addressed the problem of identifying patients. The process to obtain the patient's medication administration record (MAR), and drug information resources were inefficient. By the second week names of eligible patients were provided and the Project Coordinator was allowed access to the drug information resources which reduced the time spent during the initial steps of implementation. A second PDSA cycle was implemented to address the language barrier of the patient population on the designated unit. The process of teach-back had to be adapted by adding a translator telephone for 11 4

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used the teach-back method for medication education. Results from the project are consistent with earlier studies supporting teach-back as an effective method of improving patients' knowledge (Dantic, 2014; Negarandeh et al., 2013; Peter et al., 2015; Schillinger et al., 2003). Patient knowledge was assessed immediately following the teaching session. No data was collected as to which day of the patient's hospital stay teaching was performed. Patients' knowledge of medication was not re-evaluated at a later date to evaluate long-term retention of information. The nursing students' inability to achieve the second aim can be attributed to difficulty with managing patients' language barrier. Language has been identified as one of the barriers that can prevent patient education (Beagley, 2011). Use of the translator phone presented several challenges to the nursing students when trying to use the teach-back method to provide medication information to patients. Nurses avoid using the teach-back method if they need the assistance of an interpreter during discharge instructions, including instructions about medications (Kornburger et al., 2013). Several (12.7%) of the nursing students participating in the project were able to translate in Spanish. When available, bilingual nursing students were utilized to translate the medication information instead of using the interpreter phone. Overall, a change in the teach-back process by using bilingual nursing students resulted in positive outcomes as noted by nursing students' anecdotal comments on the Nursing Student Perception of Teach-back Effectiveness Survey (Appendix D). With use of the translator phone, the effectiveness of teach-back can be enhanced by providing the patient with written materials in their preferred language during the training session; using plain language; and chunking information (AHRQ, 2015). The third specific aim was to have 80% of patients satisfied with their medication teaching as measured by the One Minute Evaluation (Appendix A) and the HCAHPS Survey (CMS, 2008) “always” responses to questions pertaining to medication education will be at or above the benchmark of each quarter. Results of the One Minute Evaluation (Appendix A) yielded that 96.4% of all participants were highly satisfied with the teach-back method used for their medication teaching (M = 9.1, SD = 1.7). Scores were reported on a scale of 1 (not satisfied) out of 10 (very satisfied). All scores reported by patients were greater than a 5 indicating that 100% of the patients were satisfied with the use of the teach-back method. Patients' comments about the teach-back method included, “I actually didn't know about anything they gave me so this was very helpful”; “thought it was very helpful and was explained well”; and “found the information very useful”. The results are consistent with the literature confirming that the teach-back method contributes to patient satisfaction (Caplin & Saunders, 2015; Tamura-Lis, 2013). No previous studies demonstrated the link between a nursing student driven teach-back intervention which affected patient satisfaction. The implementation of a short feedback survey facilitates students' awareness of the connection between what they do and patient outcomes, thus facilitating learning centered on quality. The third specific aim also addressed the HCAHPS Survey “Always” responses to questions pertaining to medication education. The results reported for the fourth quarter when the project was implemented on the unit at 75% and 50% did not exceed the benchmark for that quarter. The reported HCAHPS results align with the findings in a previous study by Jha, Orav, Zheng, and Epstein (2008) that reported a low percentage of “Always” responses in the category of “Communication about Medications” is not unusual, attributing the low scores to ineffective communication during the discharge process. Unfortunately, the results of this project do not reflect the results of a recent study in which pharmacy students taught patients about their medications and resulted in improved HCAHPS survey results (Soric, Glowczewski, & Lerman, 2016). There are several possibilities as to why the project did not improve patient satisfaction scores as indicated on the HCAHPS survey. One

indicating that all patients were satisfied. Patients' comments about the teach-back method included, “I actually didn't know about anything they gave me so this was very helpful” and “found the information very useful.” HCAHPS survey results were received for each quarter prior to the intervention. Survey respondents reporting “always” to the first question, “Staff explained the purpose of new medications” included 68.4%, 72.2%, and 81.8% pre-intervention. With a benchmark of 77.2%, post-intervention for the fourth quarter was 75.0%. The second question, “Communication of possible side effects of new medications”, survery respondents reported “always” in the pre-intervention quarters at 47.4%, 50.0%, and 66.7%. With a benchmark of 52.3%, survey respondents reported “always” post-intervention at 50.0%. Patient satisfaction reported on the HCAHPS survey results did not meet the benchmark for the quarter during the intervention. Discussion The purpose of this project was for nursing students to participate in a quality improvement project and implement and evaluate the teachback method to improve patient knowledge of medications and patient satisfaction, and experience QI in the clinical setting. The first specific aim was to: (1) increase nursing students' use of teach-back from the current state of 0% to 80% of their patient encounters on the medical geriatric unit. At the conclusion of the eight-week project, senior students were able to educate 83% of eligible patients, while the junior students provided medication education to 60.5% of eligible patients. The difference in the junior students' inability to not meet the benchmark can be attributed to lack of clinical experience and knowledge. At the time of implementation of the project, most of the junior level nursing students were in their first semester of clinical experience and did not have pharmacology. As a result, most of the nursing programs with students on the designated unit for clinical experience declined their students' participation in the quality improvement project. The lack of pharmacology knowledge was not a barrier to teaching since the drug information sheets were in plain language enabling junior level nursing students to teach patients about their medications without difficulty. The junior-level students visited patients in pairs to enhance their confidence in teaching. By doing so, the junior level students took more time with each patient and were unable to provide medication education to as many patients as the senior level nursing students. The senior level nursing students were able to provide medication education using the teach-back method for 82.9% (29/35) patients and achieve specific aim 1. The junior level nursing students provided medication education to 60.5% (26/43) and did not achieve specific aim 1. Overall, 80% of the nursing students strongly agreed that they felt confident using the teach-back method to educate their patients. Most nursing students (85%) strongly agreed or 30% agreed (15% undecided) that the teach-back method was easy to use in educating patients about their medications. Results of the project reflect previous findings that the teach-back method is a simple, effective, evidencebased teaching strategy that can be used by any member of the healthcare team (Kornburger et al., 2013; Tamura-Lis, 2013). The second specific aim of this quality improvement project was to ensure that 80% of the patients approached could state the name, purpose, and side effects of their current medications as measured by the Patient Knowledge Tool (Appendix B). As illustrated in Table 1, after nursing students used the teach-back method there was an improvement from 16.4% to 58.2% of patients who knew the purpose of all of their medications; and an improvement from 1.8% to 50.9% of patients who knew the side effects of all of their medications. The patients who did not know the name and purpose of their medications decreased from 27.3% to 9.1%. Also, 67.3% of patients who did not know the side effects of their medications decreased to 9.1% after nursing students used the teach-back method. Although the second specific aim was not met, the patients' knowledge of the name, purpose, and side effects of their medications improved after nursing students 5

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Table 1 Patients' knowledge of the name, purpose and side effects of their current medications before and after nursing students' use of the teach-back method. Total number of patients educated (N = 55)

Before nursing students used teach-back N (%)

After nursing students used teach-back N (%)

Patients Patients Patients Patients Patients Patients

15 (27.3%) 31 (56.4%) 9 (16.4%) 37 (67.3%) 17 (30.9%) 1 (1.8%)

5 (9.1%) 18 (32.7%) 32 (58.2%) 5 (9.1%) 22 (40.0%) 28 (50.9%)

who who who who who who

knew knew knew knew knew knew

none of the names and purposes of their medications some of the names and purposes of their medication all of the names and purposes of their medications none of the side effects of their medications some of the side effects of their medications all of the side effects of their medications

participation of nursing students during other afternoon, evening and weekend hours limited the number of eligible patients identified for the project. Another limitation of the project is that long-term retention of medication information taught to patients using the teach-back method was not evaluated. Since patient knowledge was evaluated by the nursing students immediately following the teaching session, the project did not investigate whether patient's retained the knowledge. A future PDSA cycle could include a secondary evaluation of patient knowledge before discharge and additional teachback sessions, if indicated.

reason was that the nursing students only intervened with 55 patients. The low participation by nursing students was due to two clinical units declining participation in the project. This reduced the number of patients who received the intervention. The patient's disposition at discharge is a contributing factor to the project's outcomes as there were many patients who were identified as ineligible for the project and did not receive medication education by nursing students. A third reason could be that the HCAHPS question about medications focuses on the purpose and side effects of “new” medications. Nursing students provided medication education for current medications prescribed for the patient at the time of the teaching session. Health care providers might have been prescribed additional medications at the time of discharge. Also, the issues encountered by nursing students using the interpreter phone during teaching sessions could have negatively affected patient satisfaction with medication education as reflected by the HCAHPS survey results. A recommendation for hospitals to achieve the HCAHPS benchmark would be to include the participation of all nursing students to use teach-back during medication administration. Clinical partnerships between healthcare facilities and academic institutions enable nursing students to experience various learning opportunities. The teach-back method is an evidence-based intervention for improving patient care and nursing advocates the use of evidence-based interventions. A future PDSA could implement a change requiring nursing students to use teach-back during medication administration. In doing so, the nursing student benefits by understanding the role of the nurse, time management and communication skills, and patient teaching skills. Healthcare institutions benefit by improving patient satisfaction and patient outcomes. Overall, the results of the project support the implementation of an evidence-based intervention of the teach-back method delivered by nursing students to both teach quality improvement in the clinical setting and to improve patient outcomes. A consideration for a future PDSA would be to implement a campaign to ensure the involvement of family or caregivers during medication education during the patient's hospitalization. As previous research noted, involving the patient's family members or caregivers in the patient's education about medications had a positive effect on the patient's medication compliance after discharge and readmission rate (Cargill, 1992; Foust, Naylor, Bixby, & Ratcliffe, 2012; Kerzman, Baron-Epel, & Toren, 2004). In the current quality improvement project, there were no patient complaints. This was an important balancing measure to include to ensure that the care delivered by the nursing students was professional and supervised for accuracy by the Project Coordinator or clinical faculty. Results align with a previous study that found nursing students positively affect patient satisfaction (Oskay, Gungor, & Basgol, 2015). One limitation of the project was not having the full participation of each group of nursing students assigned to the designated unit. Two nursing programs declined participation as a result of the students' lack of pharmacology knowledge, inexperience with patient encounters, and their inability to administer medications.This lack of participation led to the reduced sample size. The low sample size was also affected by the project being implemented only during the hours of clinical experience for the two participating groups of nursing students. Not having

Conclusion Nursing students' implementation of an evidence-based teach-back intervention using quality improvement methods contributed to the students' experience of QI and improved patient outcomes. The patients' knowledge of the purpose and side effects of their medications improved from the use of the teach-back method by the nursing students, as evidenced by the results of the Patient Knowledge Tool (Appendix B). Positive anecdotal responses on the One Minute Evaluation (Appendix A) demonstrated patient satisfaction with the teach-back method for medication education, even though the HCAHPS results did not reflect patients' responses on the evaluation. Nursing students felt confident in their use of the teach-back method, but did struggle with language barriers. The positive outcomes of the project suggest the importance of not only having nursing students use the teach-back method during medication education, but also the importance of engaging students in the QI process to increase student QI competence as suggested by the Quality and Safety Education for Nurses [QSEN] competencies (2014). Supplementary data to this article can be found online at https:// doi.org/10.1016/j.profnurs.2019.08.005. Declaration of competing interest None. References Agency for Health Care Research and Quality (2016). Use the teach-back method: Tool #5. Retrieved September 2, 2016 from https://www.ahrq.gov/professionals/qualitypatient-safety/qualityresources/tools/literacy-toolkit/healthlittoolkit2.html. Albrecht, J. S., Gruber-Baldini, A. L., Hishon, J. M., Brown, C. H., Goldberg, R., Rosenberg, J. H., ... Furuno, J. P. (2014). Hospital discharge instructions: Comprehension and compliance among older adults. Journal of General Internal Medicine, 29(11), 1491–1498. https://doi.org/10.1007/s11606-014-2956-0. American Association of Colleges of Nursing (2008). The essentials of baccalaureate education for professional nursing practice. Retrieved from http://www.aacn.nche. edu/educator-resources/BaccEssentials08.pdf. Austria, M. J., Baraki, K., & Doig, A. K. (2013). Collaborative learning using nursing student dyads in the clinical setting. International Journal of Nursing Education Scholarship, 10(1), 1–8. https://doi.org/10.1515/ijnes.2012-0026. Beagley, L. (2011). Educating patients: Understanding barriers, learning styles, and teaching techniques. Journal of Perianesthesia Nursing, 26(5), 331–337. Caplin, M., & Saunders, T. (2015). Utilizing teach-back to reinforce patient education. Orthopedic Nursing, 34(6), 365–368. https://doi.org/10.1097/NOR. 0000000000000197. Cargill, J. M. (1992). Medication compliance in elderly people: Influencing variables and

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