LITHUNIAN UNIVERSITY of HEALTH SCIENCES Department of Emergency Medicine
FINAL MASTER THESIS
COMMUNICATION SKILLS TRAINING PROGRAMS FOR HELPING
MEDICAL PERSONNEL TO IMPROVE PATIENTS’ SATISFACTION
IN THE EMERGENCY DEPARTMENT.
Medicine Faculty. Author: Felipe Alberto Lucas Mayorga. Supervisor: Arturas Kačiulis. Kaunas, Lithuania, 2019.
TABLE OF CONTENTS
SUMMARY 3 ACKNOWLEDGMENTS 4 CONFLICT OF INTEREST 5 TERMS 6 INTRODUCTION 7AIM AND OBJECTIVES 9
LITERATURE REVIEW 10
THE IMPORTANCE OF MEDICAL COMMUNICATION.CAN IT HAVE A REAL IMPACT? 10 COMMUNICATION BETWEEN PATIENTS AND HEALTHCARE PROFESSIONALS.ARE WE DOING IT RIGHT? 11 HOW DOES THE PROFESSIONAL COMMUNICATION SKILLS IMPACTS PATIENT SATISFACTION? 12 WHY IT’S IMPORTANT TO CONSTANTLY IMPROVE YOUR COMMUNICATION SKILLS? 13
METHODOLOGY AND METHODS 15
RESULTS 17
DISCUSSION OF THE RESULTS 22
THE RELATION BETWEEN PATIENTS’ SATISFACTION AND COMMUNICATION SKILLS 22
PATIENT SATISFACTION IN THE EMERGENCY SERVICE 22
COMMUNICATION SKILLS IN THE EMERGENCY SERVICE. 23
CONCLUSION 26
PRACTICAL RECOMMENDATIONS 27
SUMMARY
Author’s name and surname: Felipe Alberto Lucas Mayorga
Research title: “Communication skills training programs for helping medical personnel to
improve patients’ satisfaction in the emergency department.”
Aim: This Final Master thesis will review communication skills training programs for helping
medical personnel to improve patient satisfaction in the emergency department.
Objectives:
1. Investigate communication skills training programs in the emergency department.
2. Investigate patients‟ satisfaction in the emergency department.
3. Study what correlation exists between the terms Health Communication, Patient Satisfaction, Emergency Service, Hospital and Teach-Back Communication.
4. Review scientific information to determinate the best strategy and methods to improve patients‟ satisfaction using communication skills training programs in the emergency department.
Material and methods: A literature review in the data bases MEDLINE, EMBASE, Cochrane
was surveyed. The keywords used were the following: health communication, communication skills, patient satisfaction, emergency service, teach back. All databases were screened in December, 2018.
Results and discussion: For a total of 4,516 studies available for selection for data retrieval
after removing duplicates, disregarding irrelevant studies by reading title and abstract, 16 studies where left, 10 of which assessed patients‟ satisfaction and communication skills, 2 of them assessed patients‟ satisfaction in the emergency department and 4 studies assessed emergency service and communication skills.
Conclusions: Teach-Back method is found to be the most studied communication skill tool
and with the biggest evidence-based. Teach-Back method should be a „„universal precaution‟‟ and utilized with every patient regardless of demographic details. Further investigation is needed to test teach-back in the emergency service for efficacy and implementation.
Practical recommendations: Patients prefer a teach-back collaborative approach so we
encourage physicians who currently ask patients providing safe and understandable discharge instructions to patients and families.
ACKNOWLEDGMENTS
I would first like to thank my thesis supervisor Kačiulis. The door to Kačiulis office was always open whenever I ran into a trouble spot or had a question about my research or writing. He consistently allowed this paper to be my own work, but steered me in the right the direction whenever he thought I needed it.
The author is grateful to the University of Health Sciences (LSMU), Kauno Klinikos for providing the data and all the needed material, This accomplishment would not have been possible without it.
I would also like to thank the experts who were involved in the validation survey for this research project. Without their passionate participation and input, the validation survey could not have been successfully conducted.
Finally, I must express my very profound gratitude to my partner, for providing me with unfailing support and continuous encouragement throughout my study and through the process of researching and writing this thesis. Thank you.
Author
CONFLICT OF INTEREST
TERMS
I present briefly the meaning of the most relevant words to approach these study taken by consensus of the PubMED MeSH terms data base.
Health Communication: The transfer of information from experts in the medical and public
health fields to patients and the public. The study and use of communication strategies to inform and influence individual and community decisions that enhance health.
Patient Satisfaction: The degree to which the individual regards the health care service or
product or the manner in which it is delivered by the provider as useful, effective, or beneficial.
Emergency Service, Hospital: Hospital department responsible for the administration and
provision of immediate medical or surgical care to the emergency patient.
Teach-Back Communication: Providing the patient, family or others information, and then
allowing them to take an action or restate the information in their own words. The clinician prefaces communications with a statement framed to show the clinician has the burden of effective communication rather than the patient.
INTRODUCTION
This review discusses the relation of the Health Communication, Patients‟ Satisfaction, Emergency Service, Hospital and Teach-Back Communication in order to determinate the best strategy and methods to improve patient satisfaction using communication skills training programs in the emergency department.
The emergency department is a service in of need of special communication skills due to its own nature and factors like a high workload, caring for multiple patients at once, lack of time and time as a limited resource. Communication is critical in the emergency department because there is no follow up and all the information must be clear before the discharging process. To be effective, the medic should be sure that the patient understood the diagnosis, how to manage the disease and medications before the discharge because “Patients‟ dissatisfaction with discharge instructions has been cited as one important factors for patient noncompliance with medications after emergency department discharge.” [1].
The ability to communicate properly with the patient is another field to reach excellence as a professional; in fact communication is one the largest source of preventable medical error during acute clinical care. This can be a good starting point and an example in were the communication programs can improve the service by acting as a tool not just to increase the quality of the service by decreasing the possible hospital readmissions objectively, but also to increase the satisfaction as a subjective perspective of the patient were we can generate good impressions while we are checking that the patient has understood everything all in one.
Communication skills are not always innate, cannot always be intuited and may not be ameliorated by more experience. Fortunately, communication training for medical practitioners has been associated with increased confidence, and improved patients‟ satisfaction, anxiety, depression and post-traumatic stress disorder [2-5].
Satisfaction is known to be subjective and to understand it as a variable, we should consider the emotional aspect related to a medical action since satisfaction is not only dependent of the quality of the service because the patients‟ perception of the service is going to
determinate the level of satisfaction together with the expectations of the patient which relies in socio-economic factors.
Understanding all dimensions and factors related to patients‟ satisfaction is important in order to improve the quality of healthcare. Olivierand Fournier & Mickexpressed satisfaction as the subjective comparison between expectations and perceptions of the service performance [6], [7].
Of course a good service is an essential start point to be able to generate this good satisfaction level, but what we are going to try is to find out in this study how a good communication level affects the subjective perception and which one is the best method to do so.
AIM AND OBJECTIVES
The Aim of this Final Master thesis will review communication skills training programs for helping medical personnel to improve patient satisfaction in the emergency department.
Objectives are:
1. Investigate communication skills training programs in the emergency department.
2. Investigate patients‟ satisfaction in the emergency department.
3. Study what correlation exists between the terms Health Communication, Patient Satisfaction, Emergency Service, Hospital and Teach-Back Communication.
4. Review scientific information to determinate the best strategy and methods to improve patients‟ satisfaction using communication skills training programs in the emergency department.
LITERATURE REVIEW
The importance of medical communication. Can it have a real impact?
Health communication is usually left aside in the formation of professionals, especially for those hospitals with overloaded services, which try to treat the most number of patients in the best possible way. That, may produce a gap in the service and furthermore, it can generate the opposite effect which is if the patient misunderstand the indications or they weren‟t even given but just the treatment, so the patients have to come back to the service with the same or even worse problems, resulting in a aggravated workload issue.
The patient have a higher risk of poor comprehension and miscommunication in the Emergency department [8]. Health professionals often do not recognize this problem [9]. They rarely confirm the comprehension, less than a quarter of interactions involve feed-back of the understanding of the patient [10], and patients don´t use to feel confident enough to ask about their health problems [11]. Previous research has suggested that patients want information that defines complex terms, clarifies uncertainty and provides a logical flow of information [12]. There is not a gold standard method for ED teaching, so it remains to be defined [13].
There is a high cost for inadequate understanding of medical information for the patient, the physician, and society as a whole. For patients, misunderstanding can lead to a lack of adherence to treatment recommendations with concomitant adverse health outcomes, as well as decreased satisfaction with the clinician and the medical encounter. Physicians who fail to check for patient understanding of medical information may increase their risk of malpractice claims. Finally, the society as a whole absorbs an estimated $73 billion annually because of misunderstood medical information [14].
As we can see, there is a huge preventable socioeconomic problem that not just affect the patients‟ satisfaction but also the whole health system and so the society. This is reflected as not just the leak of valuable resources but the patients‟ satisfaction and trust, and also losing time which is essential to provide an effective treatment.
Given the evidence of the impact of the communication on the health system mentioned previously the assessment of understanding should be part, also, of the emergency department discharging process.
Communication between patients and healthcare professionals. Are we doing it right?
It is common for the professionals the feeling of doing a good job even when a patient didn‟t understand the indications properly, without the doctors‟ acknowledgement. This can be seen in a study documented by the findings of Campion et al in a large study about communication skills of physicians, over 10,000 videotapes submitted by 2,094 physicians and found that 44.9% of these physicians failed to confirm understanding in 1 of 5 videotapes. Furthermore, 99.7% failed to confirm understanding consistently across all 5 tapes they submitted. Applicants themselves selected these 5 tapes as their “best” work [14]. Even more in a study of audiotaped patients encounters with primary care physicians showed that patients understanding was assessed only 2% of the time [14].
In 2012 K. Engel et al in a cohort study of 159 adult English within 24 to 36 hours of emergency service discharge showed that patient knowledge deficits were demonstrated by the majority of patients in home care instructions (80%) and return instructions (79%), medications (22%), and diagnosis (14%). The authors concluded that patients demonstrate knowledge deficits which raise significant concerns for adherence and outcomes [15].
So patients typically misunderstand or fail to recall accurately half or more of medical information given to them!
In 2013 T. Alberti et al conducted a review utilizing the following databases: CINAHL, Health Reference Center Academic, Medline, Cochrane, and Ovid. And after assessing 21 relevant studies, they concluded that clinicians seldom clarify patients‟ comprehension in practice [16].
This is especially an issue when we know that in another study of patients‟ retention of information given during consent for mammoplasty found that patients were able to recollect on average 3 of 12 pieces of the information given them, or only 25% [14]. This gap, between the information given and the information understood with lack of the confirmation of the understanding and the false perception of good job done, is a worrisome combination for the
Focusing in this study´s objective, the emergency department, it has special characteristics because of the need of a fast attention (patient and relatives use to be more nervous and tend to understand less information); also the lack of the follow up by the emergency department due its own nature, makes more difficult the patient-professional communication.
In 2018 H Sheikh et al conducted a multicentered study with live observations of physicians providing discharge instructions in the emergency service to 100 patients and found that patients had poor understanding of discharge instructions, ranging from 24.0% having poor understanding of their follow-up plan to 64.0% for return to emergency instructions. And almost half (42%) of patients did not receive complete discharge instructions [18].
Concerning about the dimension of this issue, in more specific and vulnerable patients as are children, we found similar results about the lack of communication. In 2018 Glick AF et al also conducted a literature review CINAHL, PubMed/Medline and Embase about Parental Management of Discharge Instructions with 48 of them being in the emergency service and concluded that parents frequently make errors related to knowledge and execution of inpatient and emergency department discharge instructions. The authors highlighted that medication dosing errors are common with almost half parents making errors in dosing liquid medications [17].
How does the professional communication skills impacts patient satisfaction?
Satisfaction is a complex concept to study because it is the degree to which the individual regards the health care service or product or the manner in which it is delivered by the provider as useful, effective, or beneficial. It is considered to be a multidimensional construct. But also subjective and because of this factors is a very difficult variable to measure.
Understanding the multiple dimensions and variables related to patients‟ satisfaction is crucial if we want to promote the quality of healthcare [6].
Communication is decisive in the emergency department because the lack of time, and because there is no follow up so the patient must understand all the important information related to his disease before the discharging process, and the health professionals should know if that information was clear before the discharge. “Patients‟ dissatisfaction with discharge instructions has been cited as one important factors for patient noncompliance with medications after emergency department discharge.” [1].
Perhaps, this is why there is not a consensus about a reference instrument (gold standard) for patients‟ satisfaction measurement in healthcare. However, the main dimensions of many instruments utilized are patient-professional interactions, physical environment and internal management processes [19].
All in all it is important to mention that the teach-back method is the one with more proved evidence but in the counterpart we find the increased of the consult time and the increase of the health system cost because the need of inversion in specialized formation in communication.
It is also relevant to highlight the need to better understand the role of patient experience and satisfaction as a measure of quality of care.
Why it’s important to constantly improve your communication skills?
Because patients typically misunderstand or fail to recall accurately half or more of medical information given to them [20].
In another study, patients were asked immediately after discharge from the emergency department about diagnosis and treatment recommendations; although 79% of patients gave the correct diagnosis, correct treatment information was given by only 49% of patients.
A study of audiotaped patient encounters with primary care physicians showed that patient understanding was assessed only 2% of the time [21].
A study of 20 general practices in England reported that misunderstandings associated with actual or potential adverse outcomes occurred in 80% of consultations [10].
As we saw before Patient teaching is an fundamental part of the plan of care in the emergency department for improving patient outcomes. Health professionals should be a skilled educator in order to improve patient results and satisfaction. The most studied method to train health communication skills is the Teach-back method.
Besides the Teach-back method is a valuable strategy that can improve the safety and quality of health care and supports the National Action Plan to Improve Health Literacy. There is significant evidence that staff do not routinely use teach-back while communicating with patients and families [22].
Teach-back, is an effective health literacy tool that allows for immediate confirmation of patient understanding, thus, improving compliance and reducing hospital readmissions. Teach-back is an effective tool in engaging the patient and family in the learning process, leading to increased knowledge and retention of information learned during educational sessions [23].
Teach-back is an essential component of the discharge and follow-upprocess.
The teach-back method had a positive association on retention of discharge instructions in the ED regardless of age and education [23], [24].
METHODOLOGY AND METHODS
A systematic review in the data bases MEDLINE, EMBASE, Cochrane was surveyed. The keywords used were the following: medical communication, communication skills, programs and trainings for communication skills, patient satisfaction, emergency service. All databases were screened in December, 2018. No age, gender, profession, literacy, patients or family relationship, economical status nor others socio-demographic variables were applied. No limitations were set for languages. Both published and unpublished reviews were examined if applicable. Duplicate publications were excluded.
It is important to mention that these terms where the most optimal search for this study purpose. Using for example “emergency” instead of “emergency service, hospital” leads to a whole new variety of possibilities irrelevant for us, such as “pre-hospital emergency” or “leukemia emergency red flags”
I present briefly the meaning of the most relevant words to approach these study taken by consensus of the PubMED MeSH terms data base.
Health Communication: The transfer of information from experts in the medical and public health fields to patients and the public. The study and use of communication strategies to inform and influence individual and community decisions that enhance health.
Patient Satisfaction: The degree to which the individual regards the health care service or product or the manner in which it is delivered by the provider as useful, effective, or beneficial.
Emergency Service, Hospital: Hospital department responsible for the administration and provision of immediate medical or surgical care to the emergency patient.
Teach-Back Communication: Providing the patient, family or others information, and then allowing them to take an action or restate the information in their own words. The clinician prefaces communications with a statement framed to show the clinician has the burden of effective communication rather than the patient.
Selection criteria:
1. Inclusion criteria: Only studies published in English, Spanish, French and Portuguese; (b) studies published between 2009 and 2019; (c) studies which described information for at least two of the relevant mesh terms.
2. Exclusion criteria: Studies that were focused on medics which follow up regularly the same patients like family physicians and other specialties in which communication can extremely different from the emergency department settings could bias the result on patient satisfaction related to skill communication.
RESULTS
After testing several words and improving MeSH terms, the search strategy was:
("Patient Satisfaction"[Mesh]) AND "Health Impact Assessment"[Mesh] with a total of 5 studies
("Patient Satisfaction" [Mesh] AND emergency service, hospital) with a total of 1564 studies
("emergency service, hospital"[Mesh]) AND "health communication"[Mesh] with a total of 10 studies
Teach back with a total of 2706
("teach back " [Mesh] AND ("emergency service " [Mesh], hospital) with a total of 88
("teach back " [Mesh] AND ("patient satisfaction " [Mesh], hospital) with a total of 143
For a total of 4,516 studies available for selection for data retrieval. After applying selection criteria only where chosen those as relevant for the objectives of this study so that data extraction and evaluation of quality were made afterwards.
After adding together these number of studies, 4516 where found, 4052 by removing
duplicates, disregardings irrelevant studies by reading title and abstract, 16 studies where left 10 of which assessed patient satisfaction and communication skills, 2 of them assessed patient satisfaction in the emergency department (it is to say that discarded studies referred to patient satisfaction in emergency department associated with procedures for example myocardial infarction revascularization), and 4 studies assessed emergency service and communication skills (teach back). (figure1)
4516 studies
Revoming duplicates
4052 Studies
Non relevant for this study’s objectives after reading title or abstract AND applying inclusion and exclusion criteria.
16 Studies full text for assessment
9 full text for assessment for patient satisfaction, and communication skills (teach back)
5 studies full text for assessment for emergency service and
communication skills (teach back) 2 studies full text for assessment for patient satisfaction, and emergency service
Out of the 16 studies. 2 studies in our review were systematic reviews and 2 clinical trials, which accounted for the highest evidence level. The other 12 were in a lower level of scientific research. (tab 1)
Table 1. Results. Reviewed studies
Reviewed studies
Category Authors Year Title and publication site Type Emergency service and communicat ion skills (teach back) Sheikh H, Brezar A, Dzwonek A, Yau L, Calder LA.
2018 Patient understanding of discharge instructions in the emergency department: do different patients need different approaches? Int J Emerg Med. Clinical study non randomized Patient satisfaction, and communicat ion skills (teach back) Klingbeil C, Gibson C.
2018 The Teach Back Project: A System-wide Evidence Based Practice Implementation. J Pediatr Nurs. Before and after descriptive study (implementa tion program) Patient satisfaction, and communicat ion skills (teach back) Glick AF, Farkas JS, Nicholson J, et al. 2017 Parental Management of Discharge Instructions: A Systematic Review. Pediatrics.
Systematic Review Patient satisfaction, and communicat ion skills (teach back) Batbaatar E, Dorjdagva J, Luvsannyam A, Savino MM, Amenta P. 2017 Satisfaction measurement
instruments for healthcare service users: a systematic review.
Perspect Public Health.
Systematic review Emergency service and Slater BA, Huang Y,
2017 The Impact of Teach-Back Method on Retention of Key Domains of
Before and after
communicat ion skills (teach back)
Dalawari P. Emergency Department Discharge Instructions. J Emerg Med.
descriptive study Emergency service and communicat ion skills (teach back) Samuels-Kalow M, Hardy E, Rhodes K, Mollen C
2016. . “Like a dialogue”: Teach-back in the emergency department. Patient Educ Couns. Clinical study non randomized Patient satisfaction, and emergency service Ríos-Risquez MI, García-Izquierdo M.
2016 Patient satisfaction, stress and burnout in nursing personnel in emergency departments: A cross-sectional study. Int J Nurs Stud.
cross-sectional study Patient satisfaction, and communicat ion skills (teach back) Caplin M, Saunders T.
2015 Utilizing Teach-Back to Reinforce Patient Education. Orthop Nurs.
literature review Emergency service and communicat ion skills (teach back) Alberti TL, Nannini A. 2013 Patient comprehension of discharge instructions from the emergency department: A
literature review. J Am Acad Nurse Pract. literature review Emergency service and communicat ion skills (teach back) Engel KG, Buckley BA, Forth VE, et al. 2012 Patient understanding of
emergency department discharge instructions: Where are knowledge deficits greatest? Acad Emerg Med. Prospective cohort Patient satisfaction, and communicat Danielle McCarthy, Katherine Waite, Laura
2012 What Did the Doctor Say? Health Literacy and Recall of Medical Instructions. Med Care.
Clinical study multivariabl e
(teach back) Kirsten G Engel, David W Baker MSW. Patient satisfaction, and communicat ion skills (teach back) Kemp EC, Floyd MR, McCord-Duncan E, Lang F.
2008 Patients Prefer the Method of “Tell Back- Collaborative Inquiry” to Assess Understanding of Medical Information. J Am Board Fam Med.
Non randomized clinical study Patient satisfaction, and communicat ion skills (teach back) Schillinger D, Piette J, Grumbach K, et al.
2003 Closing the Loop. Arch Intern Med. Non
randomized clinical study Patient satisfaction, and emergency service Tejedor, M., Pérez, J.J., Tejedor, A.
2013 Satisfacer al paciente. . . también en urgencias y emergencias. Rev. Emerg. 25, 161–162.
Non
randomized clinical study
DISCUSSION OF THE RESULTS
These studies give us an approach to the health communication and its benefits but also mean there is a lack of information, bringing us the opportunity to better understand how to teach health professionals to improve the patient-professional communication and the implications in long term to choose the best methods.
With this new research will give more evidence to promote health communication in order to give better results for both, hospital and patients.
The relation between patients’ satisfaction and communication skills
10 studies were found. Only qualitative test were used to assess patients satisfaction all of these studies.
We found out that satisfaction as a construct is not just complex and multidimensional but also it is a very difficult variable to study empirically.
However, there is not a clear pattern of what the essential dimensions (factors) that must be included in a satisfaction measurement are but some dimensions are essential for this construct: Quality of Health Care; Patient-Centered Care; Patient Satisfaction;
Psychometrics [13].
About which measurement instrument should be used to assess the patient satisfaction in one systematic review were considered 34 different instruments, with the The COSMIN score for methodological quality showed that most of them scored a good or fair average and
concluded that there is not a gold standard instrument for patient satisfaction assessment [13].
Patient satisfaction in the emergency service
2 studies were included. Of the excluded studies retrieved, the whole majority had objectives of measuring a particular intervention or specific situation within the emergency
about patients satisfaction of a chirurgical act in the emergency service would bias our own objective as a third element is present in them.
Even nowadays, in the information era, there is a lot of wrong, unclear, or misleading health information. So the patients expect and trust the health professionals to give proper
information, remarking the importance of the health communication skills of the professionals. This is especially important for the mental limited, low literacy patients or elderly patients.
Inadequate physician counseling has been previously implicated as a source of
misunderstanding, which may be caused by time limitations, lack of skill, or distractions in the clinical environment [14].
Some have suggested that high quality physician-patient conversation at the time of discharge may help improve physician satisfaction [15].
Communication skills in the emergency service.
4 studies were included. Excluded studies were, the vast majority, the result of isolated words mismatches.
After reading the content we found that the most studied communication skill tool and with the biggest evidence-based is Teach-back. Other communication skills programs include audiovisuals.
So it is known from previous studies that Teach-back is an evidence-based strategy identified as a cornerstone intervention for improving communication during healthcare encounters. the use of teach back with patients and families improves understanding of discharge
instructions and supporting self-management. There is significant evidence that staff do not routinely use teach-back while communicating with patients and families [16]
We can considerate that the teach-back a gold standard method at least as a first approach in order to avoid miscommunication since it can be used regardless educational level, race, age, gender, and ethnicity.
Teach-back consists of four stages: explaining, assessing, clarifying, and understanding (DeWalt et al., 2010). In the first stage, you begin your patient education by explaining the information that the patient needs to know. In stage 2, you assess your patient‟s
understanding of the teaching session using teach-back. The third stage provides you with the opportunity to clarify any concepts your patient did not understand. You may need to repeat stages 2 and 3 until the patient is ready to move to stage 4, the stage of
understanding [17].
There are 2 main types of teach-back inquiry to check the patient understanding, Teach- Back-Collaborative inquiry was specifically formulated to be patient-centered, with elements such as addressing patients‟ feelings and the sharing of power and responsibility. In a Shame-free environment. Tell Back-Directive was de- signed to be physician-centered , as suggested by Weiss. it was formulated using a conventional paternalistic approach in which authority and control lie with the physician [17].
Over all, Teach-Back inquiry helps the patient to remember the important medical information but In the studies, patients use to prefer the Teach-Back-Collaborative over the others inquiry types because the shame free environment and the lack of potential embarrassment.
Tell Back- Collaborative inquiry may be that it serves to create the “shame-free” environment recommended by Weiss [8]
The main problem these methods face is the increased cost for the formation, and a
increased time required for the health consult. That is why some might be concerned about the increased time required for Tell Back in an actual clinical situation but this would be more than offset by the time needed to manage complications resulting from a misunderstanding [8].
Effective communication is a cornerstone in preparation for discharge, prevention of errors and prevention of chronic health conditions overall. Emergency service providers are responsible for providing safe and understandable discharge instructions to patients and families.
Fig 2. The interactive communication loop; Teach-back, in clinical patients education. Taken from Schillinger D. et al. “Closing the loop” 2003
Research studies and quality improvement initiatives suggest that teach-back is an effective tool in engaging the patient and family in the learning process, leading to increased
knowledge and retention of information learned during educational sessions. Teach-back has also been shown to play a major role in reducing readmissions and improving patient
satisfaction and building trust [17].
Teach-back method should be a „„universal precaution‟‟ and utilized with every patient regardless of demographic details such as age, race, education level, and income.1
There are subtypes of teach back being applied as a training program like Samuels-Kalow reports in 2016. Specifically in the emergency department this is the first study that has used teach-back method in the emergency service to gauge patient understanding and retention of discharge instructions by assessing knowledge after the visit. Their results suggest that the teach-back method has a positive association on short-term retention of discharge
CONCLUSION
There is a scientific correlation between the terms, health communication, Patient Satisfaction, Emergency Service and Teach-Bach.
Patient Satisfaction in the Emergency Department is strongly dependent on communication skills of the health professionals, and this communication can be promoted by communication programs; Teach-Back method is found to be the most studied communication skill tool and with the biggest evidence-based. Teach-back method should be a „„universal precaution‟‟ and utilized with every patient regardless of demographic details.
Further investigation is needed to test teach-back in the emergency service for efficacy and implementation.
PRACTICAL RECOMMENDATIONS
Patients prefer to restate their understanding of medical information, a finding that should reassure physicians who might otherwise fear putting patients “on the spot”. Additionally, patients prefer a collaborative approach. We encourage physicians who currently ask patients, “Do you have any questions?” or “Do you understand?”, to ask instead that patients restate what they understand using their own words [15].
Emergency department providers are responsible for providing safe and understandable discharge instructions to patients and families.
REFERENCES
[1] Thomas EJ, Burstin HR, O‟Neil AC, Orav EJ, Brennan TA. Patient noncompliance with
medical advice after the emergency department visit. Ann Emerg Med 1996;27:49–55.
[2] Cyna AM, Andrew MI, Tan SM, Smith AF, editors. Handbook of Communication in
Anaesthesia & Critical Care: A Practical Guide to Exploring the Art. New York: Oxford University Press; 2011. [Google Scholar]
[3] Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for
relatives of patients dying in the ICU. N Engl J Med. 2007;356:469–78. [PubMed] [Google Scholar]
[4] Curtis JR, White DB. Practical guidance for evidence-based ICU family conferences.
Chest. 2008;134:835–43. [PubMed]
[5] Shaw DJ, Davidson JE, Smilde RI, Sondoozi T, Agan D. Multidisciplinary team training to
enhance family communication in the ICU. Crit Care Med. 2014;42:265–71. [PubMed]
[6] Oliver RL. A cognitive model of the antecedents and consequences of satisfaction
decision. J Mark Res 1980; 44:460-7.
[7] Fournier S, Mick DG. Rediscovering satisfaction. JMark 1999; 63:5-23.
[8] Musso MW, Perret JN, Sanders T, et al. Patients' Comprehension of Their Emergency
[Google Scholar]
[9] Engel KG, Heisler M, Smith DM, Robinson CH, Forman JH, Ubel PA. Patient
comprehension of emergency department care and instructions: are patients aware of when they do not understand? Ann Emerg Med. 2009;53:454–461. e15. [PubMed] [Google Scholar]
[10] Vashi A, Rhodes KV. „„Sign right here and you‟re good to go‟‟: a content analysis of
audiotaped emergency department discharge instructions. Ann Emerg Med 2011;57:315– 3221.
[11] McCarthy DM, Ellison EP, Venkatesh AK, et al. Emergency Department Team
Communication with the Patient: The Patient's Perspective. J Emerg Med. 2012 [PubMed]
[12] Buckley BA, McCarthy DM, Forth VE, et al. Patient Input into the Development and
Enhancement of ED Discharge Instructions: A Focus Group Study. J Emerg Nurs. 2012 [PubMed]
[13] Samuels-Kalow M, Hardy E, Rhodes K, Mollen C. “Like a dialogue”: Teach-back in the
emergency department. Patient Educ Couns. 2016;99(4):549-554. doi:10.1016/j.pec.2015.10.030
Back- Collaborative Inquiry” to Assess Understanding of Medical Information. J Am Board Fam Med. 2008;21(1):24-30.
[15] Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department
discharge instructions: Where are knowledge deficits greatest? Acad Emerg Med. 2012;19(9):1035-1044.
[16] Alberti TL, Nannini A. Patient comprehension of discharge instructions from the
emergency department: A literature review. J Am Acad Nurse Pract. 2013;25(4):186-194.
[17] Glick AF, Farkas JS, Nicholson J, et al. Parental Management of Discharge Instructions:
A Systematic Review. Pediatrics. 2017;140(2):e20164165. doi:10.1542/peds.2016-4165
[18] Sheikh H, Brezar A, Dzwonek A, Yau L, Calder LA. Patient understanding of discharge
instructions in the emergency department: do different patients need different approaches? Int J Emerg Med. 2018;11(1).
[19] Liu K, Squires A, You L-M. Translating Patient Satisfaction into Chinese: A Pilot Study of
a Systematic Translation Method for Health Services Research Survey Instruments. J Adv Nurs. 2012;67(5):1012-1021. doi:10.1111/j.1365-2648.2010.05569.x.Translating
[20] Danielle McCarthy, Katherine Waite, Laura M Curtis, Kirsten G Engel, David W Baker
MSW. What Did the Doctor Say? Health Literacy and Recall of Medical Instructions. Med Care. 2012;50(4):277-282.
[21] Samuels-Kalow M, Hardy E, Rhodes K, Mollen C. “Like a dialogue”: Teach-back in the
emergency department. Patient Educ Couns. 2016;99(4):549-554. doi:10.1016/j.pec.2015.10.030
[22] Klingbeil C, Gibson C. The Teach Back Project: A System-wide Evidence Based
Practice Implementation. J Pediatr Nurs. 2018;42:81-85. doi:10.1016/j.pedn.2018.06.002
[23] Caplin M, Saunders T. Utilizing Teach-Back to Reinforce Patient Education. Orthop
Nurs. 2015;34(6):365-368.
[24] Slater BA, Huang Y, Dalawari P. The Impact of Teach-Back Method on Retention of Key
Domains of Emergency Department Discharge Instructions. J Emerg Med. 2017;53(5):e59-e65.
[25] Engel KG, Buckley BA, Forth VE, et al. Patient understanding of emergency department
discharge instructions: where are the knowledge deficits greatest? Acad Emerg Med 2012;19:E1035–44
[26] Zavala S, Shaffer C. Do patients understand discharge instructions? J Emerg Nurs
2011;37:138–40.
with knowledge retention and hospital readmission in hospitalized heart failure patients? J Cardiovasc Nurs 2013;28:137–46.
[28] Lin MJ, Tirosh AG, Landry A. Examining patient comprehension of emergency
department discharge instructions: who says they under- stand when they do not? Intern Emerg Med 2015;10:993–1002.
[29] Samuels-Kalow M, Hardy E, Rhodes K, Mollen C. teach-back in the emergency
department. Patient Educ Couns 2016;99:549–54.
[30] Samuels-Kalow ME, Stack AM, Porter SC. Effective discharge communication in the
emergency department. Ann Emerg Med 2012;60:152–9.
[31] Biese K, Lamantia M, Shofer F, et al. A randomized trial exploring the effect of a
telephone call follow-up on care plan compliance among older adults discharged home from the emergency depart- ment. Acad Emerg Med 2014;21:188–95.
[32] James TD, Smith PC, Brice JH. Self-reported discharge instruction adherence among
different racial groups seen in the emergency department. J Natl Med Assoc 2010;102:931– 6.
[33] Showalter JW, Rafferty CM, Swallow NA, Dasilva KO, Chuang CH. Effect of
standardized electronic discharge instructions on post- discharge hospital utilization. J Gen Intern Med 2011;26:718–23.
[34] Caplin M, Saunders T. Utilizing teach-back to reinforce patient ed-ucation: a
step-by-step approach. Orthop Nurs 2015;34:365–8.
[35] Tejedor, M., Pe´ rez, J.J., Tejedor, A., 2013. Satisfacer al paciente tambien en
