Enhancing communication skills for telehealth: development and implementation of a Teach-Back intervention for a national maternal and child health helpline in Australia

The inability of patients to correctly recall information from a healthcare consultation is a well-known problem with significant consequences for treatment adherence. It is estimated that 40–80% of information is forgotten immediately or misremembered [1]. For example, while parents are typically able to remember their child’s diagnosis, their memory for a treatment protocol and actions to take remains poor [2]. These problems may be more pronounced for telephone consultations, given that up to 55% of the impact in a face to face consultation can be attributed to visual and non-verbal communication [3], and there is evidence that callers frequently misunderstand health information given by phone [4]. Telehealth consultations involve more frequent patient requests for information to be repeated [5]; however, people with low health literacy are typically less inclined to ask questions and may not indicate if they do not understand [6‐8]. People experiencing acute stress or anxiety may also suffer temporary cognitive impairments that limit their ability to process information [1, 9, 10]. Telephone-based healthcare is expanding and can improve access, convenience and cost savings for both health care providers and clients [11, 12]; however, it also carries risks [13], and issues of patient safety in telehealth are largely unexplored [14]. The value of a telephone health service is questionable if callers immediately forget or misinterpret the information or instructions they have been given.

There is agreement that telehealth providers require high-level communication skills to compensate for lack of visual cues [13, 15]. There is currently no consensus on what their learning outcomes should be [16, 17], guidance on training methods is lacking [18, 19], and opportunities for further training remain limited [20]. One communication technique that has been recommended for consumer telephone consultations [3, 4] is Teach-Back, also known as the “interactive communication loop”. A key feature of Teach-Back is that the onus of ensuring information has been correctly understood rests with the health professional. Teach-Back requires information providers to invite consumers into the conversation, by asking individuals to explain back using their own words the information or action plans discussed. The healthcare provider can then add, clarify, or correct information as required. Teach-Back has been used effectively to improve accuracy of telephone communication between professionals [21] and to support child health outcomes in paediatric settings by improving parents’ comprehension of information [22]. It is regarded as an important patient safety practice [23], is widely recommended as a universal precautions approach in healthcare settings [24‐29] and was recently ranked as the number one health literacy practice by experts [30]. We are not aware of previous efforts to train and evaluate the impact of Teach-Back in a consumer telehealth setting.

Previous research with healthcare providers has identified four key barriers to delivering Teach-Back: perceived time constraints [24, 31‐34], quantity and complexity of information discussed [35], discomfort with phrasing [34, 36] (including consumer-reported discomfort [37]), and divided attention (of parents) [34, 35]. Enablers to the use of Teach-Back include a supportive work environment and practitioner self-reflection [38]. Critical self-reflection is an essential component of self-regulated learning. It is regularly recommended for nursing clinical skill development [39‐41] and has been used in a number of nursing contexts (see [42] for a recent review) to bridge the gap between theory and practice [39]. Engaging nurses to purposively reflect on their practice while developing new communication skills may both acknowledge their professional competence [43] and encourage them to “test” the efficacy of the new techniques.

This paper describes the development and implementation of a theory-informed ‘Teach-Back skills’ program delivered to nurses operating a national maternal and child health telephone helpline. It is part of a larger study evaluating the effectiveness of Teach-Back for telehealth. We have previously reported nurse experiences using different Teach-Back phrases and with different kinds of calls at the helpline [44]; in this paper we report their experiences learning to use Teach-Back.

Our findings indicate that our theory-informed intervention combining ongoing deliberate self-reflection with a single 2-h workshop was largely successful for experienced maternal and child health nurses to develop confidence and skills to use Teach-Back in a telephone helpline for the first time. Nurses perceived they were more effective at ensuring comprehension when using Teach-Back, which may have been enhanced by their deliberative focus on clear explanation and caller understanding with the self-reflection surveys. Nurses reported that the training workshop and self-reflection surveys were helpful for developing Teach-Back skills, and were unanimous in wanting more opportunities to learn from peers on how to use Teach-Back in a range of situations relevant to their specific work environment. This was particularly true for nurses who struggled to use Teach-Back in a way that sounded natural to them. Nurses who reported success with finding their “voice” generally focused on one or two phrases they were comfortable with.

Although the usual target of reflective practice is clinical judgment, this study provides qualitative evidence that a simple online program encouraging self-reflection has value for enhancing communication skill development. This is aligned with current thinking on moving away from a “training mindset” in communication skills development and focusing instead on building on learners’ pre-existing knowledge and skills through “reflection, experiential work, and self-directed learning” [43]. We are not aware of any other studies prompting real-time self-assessments for communication skills training or telenursing (although a variation of this technique has previously been used in undergraduate statistics teaching [49]). Most nurses had not engaged in this kind of deliberate self-reflection for their role in delivering telephone advice to consumers, or reflection on what went well. Communication skills training for medical professionals has elsewhere been shown to increase communication self-efficacy [50]. Reflecting only on negative experiences can promote loss of confidence [39], but reflecting on positive experiences may balance this. In this study nurses reported benefits from reflecting on what they did well. The surveys were considered annoying as well as useful, so any future implementation will need to find an appropriate balance. The focus groups were another opportunity for reflection, and nurses appeared to enjoy learning from and with each other, which may have helped consolidate learning.

The organisational context was an important factor in changing behaviour, including implementation momentum from key stakeholders. To reduce time pressure on nurses the management team temporarily relaxed guidelines and consequences for call duration (although nurses still found this a challenge as reported elsewhere [44]). External reinforcement, such as feedback by colleagues or supervisors was not built into this training, and nurses relied on self-reflections and reactions from their clients to monitor their success using Teach-Back. This is consistent with a paradigm of nurse education that harnesses reflective practice to equip learners to develop their own expertise [51].

With the increased use of telehealth services it is critical to continue to develop strategies to improve the safety and quality of telephone health advice and embed them into routine clinical governance [52]. In this study, telehealth nurses were able to build the Teach-Back method into their practice, following a theory-informed intervention consisting of a brief training workshop combined with ongoing self-reflection. This intervention may also be adapted for other advanced communication skills and in other telehealth settings.