Assessment of an educational intervention on nurses ... - Heart & Lung

Heart & Lung 43 (2014) 204e212

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Assessment of an educational intervention on nurses’ knowledge and retention of heart failure self-care principles and the Teach Back method Tara Mahramus, MSN, RN, CNS, CCNS, CCRN a, *, Daleen Aragon Penoyer, PhD, RN, CCRP, FCCM b, Sarah Frewin, MSN, RN, CCNS, CNS, PCCN c, Lyne Chamberlain, MSN, CNS, CCRN-CMC, CCNS d, Debra Wilson, RN e, Mary Lou Sole, PhD, RN, CCNS, FCCM, FAAN f a

1414 Kuhl Ave., MP 107, Orlando, FL 32806, USA Orlando Health Center for Nursing Research, 1404 Kuhl Ave., MP 161, Orlando, FL 32806, USA c 1414 Kuhl Ave., MP 102, Orlando, FL 32806, USA d Department of Nursing, Seminole State College, 850 State Road 434, Altamonte Springs, FL 32714, USA e Visiting Nurse Association, Orlando Health, 102 W. Pineloch St., Suite 23, Orlando, FL 32806, USA f University of Central Florida College of Nursing, 12201 Research Parkway #300, Orlando, FL 32826, USA b

a r t i c l e i n f o

a b s t r a c t

Article history: Received 14 May 2013 Received in revised form 14 November 2013 Accepted 22 November 2013 Available online 20 February 2014

Background: Nurses must have optimum knowledge of heart failure self-care principles to adequately prepare patients for self-care at home. However, study findings demonstrate that nurses have knowledge deficits in self-care concepts for heart failure. Methods: A quasi-experimental, repeated measures design was used to assess nurses’ knowledge of heart failure self-care before, immediately after, and 3-months following an educational intervention, which also included the Teach Back method. Follow-up reinforcement was provided after the educational intervention. Results: One hundred fifty nurses participated in the study. Significant differences were found between pre-test (65.1%) and post-test (80.6%) scores (p < 0.001). Teach Back proficiency was achieved by 98.3%. Only 61 participants completed the 3-month assessment of knowledge. In this group, mean knowledge scores increased significantly across all three measurements (p < 0.001): 66.5% (pre-test); 82.1% (posttest); 89.5% (follow up post-test). Conclusions: Participation in a comprehensive educational program resulted in increased nurses’ knowledge of heart failure self-care principles and the knowledge was sustained and increased over time. Ó 2014 Elsevier Inc. All rights reserved.

Keywords: Heart failure Self-care Patient education Teach Back Nurse

Introduction Heart failure (HF) is the leading discharge diagnosis for Medicare recipients and the most frequent cause of readmission to the hospital.1 Approximately 50% of patients hospitalized for HF will be readmitted for exacerbation of HF within 6 months and is associated with increased mortality.2 Thus, efforts to reduce readmissions in HF patients are needed. Common causes of preventable readmissions of

Abbreviations: HF, heart failure; SC, self-care; TB, Teach Back. * Corresponding author. Tel.: þ1 321 843 3993. E-mail address: [email protected] (T. Mahramus). 0147-9563/$ e see front matter Ó 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2013.11.012

HF patients are related to inadequate knowledge at discharge, inadequate follow-up with a health care provider, and nonadherence with the treatment plan. These factors can contribute to exacerbation of HF symptoms and lead to readmission.3e6 Heart failure is a chronic disease process that often progresses and deteriorates over time, even when guideline-recommended therapies are employed.1 Patients with chronic HF require ongoing disease management, including symptom control, medication and dietary adjustments, and lifestyle changes.2 Patients with HF often experience exacerbation of their symptoms, which may lead to readmission to the hospital for treatment. Thus, using a variety of methods to support the patient in their disease management is often needed.

T. Mahramus et al. / Heart & Lung 43 (2014) 204e212

For over 30 years self-care (SC) has been a strategy used to promote active patient engagement in their care in partnership with health care providers for disease management.7e9 In SC, the patient learns specific assessment and treatment strategies to manage their usual care following a prescribed regimen and parameters for when to notify their health care providers. Building on the original theory of SC by Orem, Riegel and Dickson developed a situation-specific theory for HF SC.8 Self-care activities for HF include adhering to a treatment plan, monitoring and recognizing symptoms, taking appropriate actions to manage symptoms, and evaluating the effectiveness of their actions.10 Self-care is an approach supported by the American Heart Association (AHA) to reduce readmission rates and mortality in patients with HF.11 The situation-specific theory of HF SC was used as a theoretical framework as a foundation for concepts in this study.8 For patients to actively participate in SC, they must understand their disease process and treatment plan. Comprehensive patient education on disease management through diet and lifestyle modifications, medication administration, weight monitoring, and signs and symptoms of worsening condition are important concepts needed to be engaged in the SC process for HF. Nurses are often responsible to prepare patients with HF the knowledge required to appropriately manage their disease after discharge. In order to provide this type of comprehensive discharge education, nurses must have optimum knowledge of HF SC.12 In 2002, Albert et al reported significant gaps on HF SC, using a tool that had been developed to measure nurse knowledge on SC for HF in that study.12 Since Albert’s original study, findings from other studies further documented knowledge deficits about HF SC principles by nurses who care for patients with HF.13e19 Knowledge deficits identified across these studies were similar, including signs and symptoms associated with hypoperfusion (dizziness, confusion), evaluation of fluid status (weight, edema) and blood pressure, dietary and medication restrictions and management, symptom management at home, and parameters for when to notify health care providers.12e19 For patients to have a thorough understanding about SC for HF, nurses must adequately convey these concepts during patient education. Studies on interventions to improve nurse knowledge of HF SC principles are limited. In a study by Fowler, advanced practice nurses (CNSs and nurse practitioners) partnered with health care workers from various disciplines to provide education on various HF topics and the Teach Back (TB) method to community health nurses over a one year period.17 A variety of methods were used to deliver the education, including class presentations and health fairs, with reinforcement of content using electronic messages.17 In another study, a clinical nurse specialist student investigator provided an educational intervention on HF to cardiac nurses. Participants in that study were asked to rate their knowledge of HF on a 0e10 point scale as well as complete a knowledge assessment tool.18 In both of these studies, nurses’ knowledge of HF SC principles was measured before and after the educational intervention. Results from both studies showed that test scores after the interventions increased, but with insignificant differences.17,18 Nurses who have a better understanding of SC for HF may provide more effective SC patient education.12 Therefore, strategies to improve nurse knowledge about SC for HF are needed. One component of patient education is to evaluate understanding of content delivered.20,21 One strategy to assess the patient’s understanding following education is through a process known as “Teach Back.”20 Teach Back is a method to assess learners’ understanding by asking them to state back in their own words what they heard or understood after education is provided. A key purpose of using TB is to assess the effectiveness of the educator’s ability to convey concepts to the learner. The Joint Commission,

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Institute for Healthcare Improvement (IHI), and the Agency for Healthcare Research and Quality (AHRQ) promote TB as a “best practice” to enhance patient knowledge and improve transitions from acute care settings to the home environment21e23 To facilitate these transitions of care, the IHI recommends efforts to improve education and support for self-management as potential means to reduce avoidable readmissions. Further, the IHI supports the use of TB as a strategy to close gaps in understanding of concepts provided during education between health care providers and patients to assess their ability to perform SC.23 The AHRQ promotes the use of TB as a top patient safety practice in asking patients to recall information they have been told as a means to improve assessment of patient understanding during education.22 The TB method assesses knowledge during patient education and allows for immediate remediation and clarification of concepts if inaccurate. Using this approach may better inform the nurse what the patient actually understands, with an opportunity to immediately clarify any misunderstandings. The TB method has been used for HF education; however, published reports of outcome studies are limited.17,24,25 Fowler described the use of TB for HF SC education; however, she did not describe the content presented nor an assessment of the nurses’ ability to apply TB during patient education.17 The study aim was to evaluate the effect of a comprehensive educational intervention on nurse knowledge on HF SC principles, including the use of TB for patient education for HF, and to evaluate the sustainability of knowledge gained over time. A secondary aim of the study was to assess nurses’ perception of the educational intervention.

Methods Design A quasi-experimental, repeated measures design was used to answer the research questions. Testing was conducted prior to the educational intervention (pre-test), immediately after (post-test), and 3 months later (follow-up post-test). The study was approved by the nursing research council, and the Institutional Review Board (IRB) with a waiver of written informed consent. The investigators included three clinical nurse specialists (CNS) and one home health clinical manager who have expertise in the care of patients with HF and had conducted a previous study of nurses’ knowledge of HF SC principles.16

Setting and sample The study was conducted in 2011 in a large tertiary hospital system in the Southeastern United States. A convenience sample of 250 registered nurses (RN) who regularly care for patients with HF were recruited to participate in the study. The sample was recruited from four adult inpatient units in three hospitals and the home health department.

Power analysis A power analysis to detect differences in mean total scores on the Nurses’ Knowledge of Heart Failure Education Principles (NKHFEP) test among three measurement periods was computed. With a small effect size of 0.10, alpha 0.05, power of 0.80, and correlation of 0.60 among repeated measures; a sample size of 132 participants was calculated.

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Study intervention

Table 2 Sample characteristics.

The intervention was a comprehensive educational program designed by the study investigators and based upon current literature on HF SC principles. The program included a variety of approaches to reinforce content, including a three and a half hour lecture/discussion on HF SC principles (diet, medications, signs and symptoms of worsening condition, fluids or weight, and exercise), and the use of the TB method. The investigators chose to incorporate education on the TB method to provide a strategy for participants to enhance assessment of patient understanding of SC for HF. The investigators offered the same educational program eight times at three sites within a two month period. Table 1 summarizes the content of the educational intervention. Although participation in the study was optional, unit managers from the study units required that all nurses attend one of the scheduled programs as a learning activity for teaching patients with HF. Variables and measures The researchers used two measures to assess nurses’ knowledge of SC for HF. The Nurses’ Knowledge of Heart Failure Education Principles (NKHFEP) instrument, a 20-item true-false test, was used

Table 1 Classroom content for heart failure self-care principles. Content section

Items reviewed

Importance of self-care (SC) principles

Evidence behind SC Disease progression and mortality risk of heart failure Regulatory issues and requirements Costsereadmissions, care costs Review of the five HF education principles How health literacy may influence learning Teach Back demonstration by investigators Limit sodium to 1500 mg/day Read food labels Discuss food with hidden sodium Avoid potassium salt substitutes Effects of sodium on heart failure Teach Back demonstration by investigators When to perform daily weights and comparison to dry weight e 2 lb/day or 5 lb/week e Call provider Daily monitoring for edema Low sodium diet promotes fluid balance Fluid restrictions and how to measure fluids Teach Back demonstration by investigators Indications and side effects of: - Beta Blockers - Angiotensin converter enzyme inhibitors - Angiotensin receptor blocking Agents - Aldosterone antagonists - Diuretics Avoid non-steroidal anti-inflammatory drugs (NSAIDS) Teach Back demonstration by investigators Perform daily exercises Promote smoking cessation Limit alcohol intake Stress management options Maintain provider appointments Teach Back demonstration by investigators Weight gain of 2 lbs in a day or 5 lbs in a week Increasing edema Increased shortness of breath, or need to use additional use of pillows at night or need to sleep in a chair Increased fatigue and tiredness Lightheaded or dizziness that does not resolve quickly Teach Back demonstration by investigators Nurse demonstration and competency

Teach Back technique

Diet

Fluids and weight

Medications

Exercise and other activities

Signs and symptoms

Teach Back practice and check off

Characteristics

Original sample (n ¼ 150) n (%)

Work Setting: Acute Care Heart Failure Unit-Tertiary Care Hospital Acute Progressive Care Unit-Community Hospital 1 Acute Progressive Care Unit-Community Hospital 2 Home Health No response Certified Yes Type of certification: Progressive Critical Care Nurse (PCCN) Critical Care Registered Nurse (CCRN) Medical-Surgical Nursing Gerontology

Years of nursing experience Years of experience on current unit

3-month follow-up cohort (n ¼ 61) n (%)

19 (12.7)

9 (14.8)

31 (20.7)

10 (16.4)

57 (38.0)

25 (41.0)

33 (22.0) 10 (6.7)

17 (27.9) 0 (0.0)

40 (28.8)

20 (32.8)

23 2 5 11

13 0 1 6

(56.1) (4.9) (12.2) (26.8)

(65.0) (0.0) (5.0) (30.0)

m (SD)

m (SD)

13.6 (12.2) 4.6 (5.3)

14.2 (12.5) 5.14 (5.5)

to measure knowledge of HF SC principles.12 The questions in the NKHFEP are categorized into five principles: medications, diet, exercise, fluid and weight management, and signs and symptoms of worsening condition. The authors who developed this instrument tested it for face and content validity using HF experts and then pilot-tested for test-retest reliability among nurses who were knowledgeable about HF. Psychometric data were not reported by the authors. Due to multiple themes with five subscales, internal consistency reliability was not assessed by the investigators.12 When the current study was conceptualized, the NKHFEP was the only tool available to measure nurse knowledge of HF SC principles and provided a means of comparison between studies.13e16 The investigators held discussions with the tool author (Albert), and deemed it appropriate to use despite limited published data related to its psychometric properties. After the current study had begun, Hart et al reported higher psychometric properties of an adapted version of the NKHFEP using a Likert-type scale for responses.15 However, since Hart et al were assessing agreement with the statements rather than knowledge, the investigators believed that further testing of the adapted version of the NKHEFP was needed. Therefore, the investigators chose the original format of the NKHFEP to evaluate knowledge. The second measure of nurse knowledge was to assess competency in using the TB method. The investigators developed a competency tool to rate the nurses’ ability to correctly use the TB

Table 3 Test scores across measurement periods.

Mean test scores: Pre-test score Post-test score Three month follow-up score Median test scores: Pre-test score Post-test score Three month follow-up score a

p < 0.001.

Original sample (n ¼ 150)

3-month follow-up cohort (n ¼ 61)

m (SD)

m (SD)

65.1 (13) 80.6 (9.7)a

66.5 (12.9) 82.1 (9.9)a 89.5 (7.5)a

65.0 80.0

70.0 80.0 90.0


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Table 4 Educational intervention evaluations (n ¼ 60). Evaluation questions

Mean score (SD)

Median

Generally agree

The education program I attended 3 months ago, increased my knowledge of the 5 HF self-care principles that I need to teach patients I understand how to use the Teach Back method to teach and assess patient’s knowledge of the 5 HF self-care principles I am better prepared to teach HF patients self-care strategies I use the Teach Back on a consistent basis when I educate my patients on the 5 HF self-care principles I educate all or the majority of my HF patients on the 5 self-care principles I feel the education program has changed the way I educate my HF patients The Teach Back method is not practical when educating a patient about HF self-care principles I would recommend the educational program in the future for nurses who care for HF patients

4.37 (0.69)

4.00

96.7%

3.3%

4.35 (0.71)

4.00

95.0%

5.0%

4.27 (0.73) 4.05 (0.77)

4.00 4.00

91.7% 96.7%

8.3% 3.3%

4.18 (0.77) 4.19 (0.73) 2.49 (1.22)

4.00 4.00 2.00

90.0% 89.8% 23.7%

10.0% 10.2% 76.3%

4.30 (0.74)

4.00

91.7%

8.3%

method when teaching SC principles for HF. Prior to the study, a member of the investigative team developed five patient education scenarios on HF SC principles, depicting appropriate or inappropriate TB technique. While simultaneously observing enactment of the five case scenarios, the investigators rated the TB demonstrations independently to assess inter-rater reliability. Observers on the research team established a 90% inter-rater reliability using this approach. The raters reviewed all results to reconcile differences in assessment prior to the study and gained consensus on use of the competency assessment tool for the study. The final competency assessment tool contained three questions that the nurse was required to address to achieve a passing score: did the nurse 1) teach an SC principle 2) demonstrate appropriate use of the TB method, and 3) communicate that TB is a tool to assess patient understanding of education. Competency was achieved if the nurse performed all three questions correctly. Lastly, the investigators developed an evaluation tool to assess the nurses’ perceptions of the effectiveness of the educational intervention and the feasibility of using the TB method. This tool included eight questions using a Likert-type scale ranging from strongly disagree (1) to strongly agree (5) (Table 4). The evaluation was to be administered at the 3-month follow-up phase of the study. Study procedures At the beginning of the educational intervention, the investigators provided information about the study and invited all nurses attending the class the opportunity to participate. Those who consented to participate in the study were asked to create a unique study identification code (ID) to ensure anonymity. Prior to the educational intervention, all participants completed the NKHFEP and completed a demographic form. Demographic data collected included work unit, years of experience in nursing and on the study unit, and certification. Two of the study investigators (SF and LC) conducted each class and provided the same educational content. After completion of this content, the investigators demonstrated patient education scenarios through role-play with each SC HF principle using the TB method. Following the educational program and TB demonstration, all participants were asked to complete the NKHFEP post-test. Once everyone completed the test, the investigators reviewed the correct answers with the entire group and provided rationale for all of the test questions to reinforce content. After completing the post-test, participants were given time to practice using TB with each other while the investigators monitored and provided feedback on their performance. Participants randomly chose one of four case scenarios to role-play HF SC

Generally disagree or neutral

education, followed by demonstrating the use of TB to assess understanding. The investigators observed and critiqued their performance using the competency assessment tool (Appendix 1). If the investigators deemed that the participant did not demonstrate competency, they provided immediate remediation and reinforcement of TB. The participant was then given the opportunity to re-demonstrate the skill. In those cases, the investigator made a notation on the competency tool to indicate if remediation was required. If the participant failed to demonstrate competency after remediation, a failing score was noted on the data collection form. After completion of the TB competency skill the investigators gave all participants, regardless if they correctly demonstrated TB a laminated handout with the five HF SC principles and examples of how to use TB to reinforce and enhance retention of concepts (Appendix 2). In the three months following the educational sessions, the investigators provided ongoing reinforcement of the educational content. The investigators sent messages to all nurses on the study units via inter-hospital email every two weeks containing a onepage summary of one of the five HF SC principles and an example of how to incorporate TB (see Appendix 3 for an example). The investigative team reinforced the same information during staff meetings or “team huddles” on the study units on the weeks between each of the electronic messages. The study investigators used the information written in each of the emails to guide the discussions with the staff. Three months after completion of the eight educational programs, the investigators sent a message through inter-hospital email to all nurses on the study units, giving them an opportunity to participate in a follow-up assessment of their knowledge on HF SC principles. The message included a hyperlink to a secured website that directed the participants to an online version of the NKHFEP instrument that was open for a one month period. The investigators used this approach to protect the identity of the participants in the original cohort and believed that the use of an online version would promote more willingness to take the followup post-test rather than taking additional time to take the test in a proctored setting. The investigators sent reminders weekly during this period in an attempt to maximize participation in this phase of the study. Participants were instructed to enter their unique study ID to gain access to the instruments and were asked to affirm that they were taking the test without study aids or help from others. Those who completed the online instruments were also asked to complete the evaluation tool assessing the program and usefulness of TB when providing patient education. Instructions on the evaluation form encouraged participants to be honest with their assessment of the program (Table 4). Fig. 1 summarizes procedures in the study.

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Fig. 1. Study procedures and assessments.

Data analysis IBM SPSS (version 18.0) was used for statistical analyses. Descriptive statistics were used to obtain the summary measures for all data including a description of the sample characteristics. Categorical variables were statistically represented in frequency distributions, percentage distributions, and graphical illustrations. Since the sample size between the immediate post-test and 3-month follow-up differed, data were analyzed using paired t-tests to evaluate differences between pre- and post-test scores, and Repeated Measures ANOVA tests to compare scores across the three test periods (pre-education, post-education, and three months post education). The Friedman test was used to assess repeated measures categorical data (e.g., passing score of 85%). Multivariate analysis of variance (MANOVA) was used to determine differences in total correct scores by demographic characteristics, such as work setting and certification status, at the different time intervals. Post hoc analyses were used to detect significant differences across time. Differences in ability to use the TB method were compared by demographic characteristics via cross-tabs/chi-square analysis. The secondary aim of the study to assess the effectiveness of the educational program and usefulness of TB for patient education was summarized using descriptive statistics. An ‘a priori’ significance level of 85% based on norms for established at the hospital system. Of the original sample of 150 nurses, 6.0% passed the pre-test and 41.3% passed the post-test (p < 0.001). Of the 61 participants in the follow-up cohort, 6.6% achieved a passing score on the pre-test, 45.9% passed the immediate post-test, and 88.5% passed the follow up post-test at three month period (p < 0.001). Participant use of the Teach-Back method for HF SC patient education

Results

After initial return demonstration of the TB method, 43.1% of participants required remediation. Following remediation, nearly all participants (98.3%) demonstrated competency in TB method.

Sample characteristics

Evaluations on the educational intervention

A total of 250 nurses attended one of the eight identical educational classes offered at the three hospitals within the health care system. Of those attendees, 150 registered nurses (60%) consented to participate and completed the pre-test and post-test following the class. Most of the nurses worked in acute care hospital settings (n ¼ 88; 62.8%) on cardiac progressive care units, and had an average of 13.6 years of nursing experience, with 4.6 years working at the study unit. Forty nurses (28.8%) held specialty certification, with 56.1% certified in progressive care (PCCN). Only 61 participants (41%) completed the 3-month follow-up test in the study. The demographic characteristics of this cohort were similar to the larger initial group (p > 0.05). The participants worked in a variety of acute care and home care settings, with 41% from one of the community hospital’s progressive care unit (PCU). The mean years of nursing experience was 14.2 years, and mean years working on the current unit was 5.1 years. One third (32.8%) of these participants were certified; of those, 65% certified with a PCCN. Demographic characteristics for the immediate post-test were not significantly different between those who completed or declined participation at the 3-month follow-up. Table 2 summarizes demographic characteristics.

Sixty of the 61 participants completed the program evaluation at the 3-month time period; their responses were overwhelmingly positive. Ninety-seven percent of participants indicated that the educational intervention increased their knowledge of HF SC, and 90% reported that they regularly educate their HF patients on the five SC principles. While 96.7% of participants reported that they used TB during HF education on a consistent basis, only 76.3% indicated that TB was practical to use for this purpose (Table 4).

Mean knowledge scores Mean pre-test score (n ¼ 150) was 65.1% and post-test score was 80.6%, demonstrating a statistically significant improvement

Discussion We found that nurses had significant knowledge deficits about SM for HF related to signs and symptoms of HF exacerbations, fluid and blood pressure assessments, dietary and medication restrictions, and symptom management at home and when to contact their health care provider prior to participation in the educational intervention. This finding is consistent with a previous study at the same institution (mean score of 71%) and other study findings reported in the literature using the same knowledge instrument.12e19 Scores on the post-test improved significantly immediately following the educational intervention and were sustained and increased after three months of reinforcement education. Additionally, a substantial increase in percentage of scores in the passing range (85%) was realized at both the post-test and three month follow-up measurements. This may indicate that an intervention of this structure and delivery, with continued reinforcement, is


effective in improving nurses’ knowledge of HF SC principles. Alternatively, this may indicate that the participants gained more familiarity with the test over time. In the study by Fowler, of the original 61 participants, only 15 (25%) completed the post-test measure, an insufficient sample size to draw any conclusions about the impact of the intervention.17 In the current study, 61 (41%) RNs from a variety of work settings completed the follow-up post-test three months after the educational intervention. In contrast to the study by Fowler, our sample size was sufficiently adequate to detect differences in scores after the educational intervention, compared to pre-test and immediate post-test measures. Although the attrition at the 3-month period was high and did not achieve the original sample size estimate of 132 participants, the effect size was large (0.67), and the final sample size of the follow-up cohort (n ¼ 61) was adequate to assess the effects of the intervention. The comprehensive nature of our intervention, along with focused reinforcement, is a likely explanation for the increase in scores across time. While a significant portion of the educational intervention and assessment was focused on using the TB method for educating patients on HF SC, many nurses required remediation and reinforcement of TB content. Much of the remediation was on the appropriate words to use when soliciting feedback using TB. Teach Back requires users to position themselves in a non-shaming demeanor when asking the learners to “teach back” or “state back” what they heard. For TB to be effective, the educators should put the emphasis of their questions on their teaching ability when conveying messages rather than testing the learner’s knowledge. During practice sessions using TB, the investigators had to re-direct class participants on the appropriate way to perform TB. Nurses used sentences like, “do you understand” and “did you hear what I said?” When performing TB correctly, one should state, “in order to make sure I did a good job at teaching you, can you tell me what you heard me say,” or “so that I can make sure you heard me correctly, can you repeat back what you heard?” This takes the emphasis off the (patient) learner and places it on the educator. While it may seem simple, the art of using TB correctly often requires practice. In a study by White nurses provided education on HF to patients prior to discharge.24,25 The nurses telephoned patients within 7 days of their discharge to assess patient knowledge on the same four questions asked while hospitalized. Patients in that study were able to answer three of the four questions correctly 84% of time while hospitalized and 77% of the time during follow up period.24,25 Fowler stated that education on TB was included in an HF fair but did not describe the content taught or how the learner’s ability to use TB was assessed. That study did not report statistical values from measures analyzing the use of TB.17 Our study is one of the first to report statistical results on the use of a comprehensive educational intervention utilizing the TB method provided to direct care nurses. The study had several limitations. The study was conducted in one hospital system with a small sample size, thus findings may not be generalizable across other settings. Participants comprised a convenience sample of nurses willing to participate out of a larger class cohort, thus those who elected to be in the study may have felt more comfortable with their knowledge about patient education for HF. Another limitation of the study is the possibility that increased test scores by participants may reflect more of a familiarity with the test questions rather than an enhanced knowledge about HF SC content. Increased test score results at the 3-month follow-up period in the current study may be attributed to testing for the third time using the same instrument. Additionally, some nurses on the study units had participated in a previous study by the same investigators to assess nurses’ knowledge of HF SC, possibly influencing their familiarity with the test.16 The

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investigators had no way of knowing who those participants were, given that anonymity was preserved in both studies, and investigators did not ask about participation in the previous study. However, the overall pre-test scores in the current study were low, so the real influence on their recall is likely minimal. Administration of an online test for the third and final assessment of nurse knowledge of HF SC may have contributed to the small sample size in this cohort of participants through self-selection. In future studies it may be advantageous to provide a proctored test for all participants to increase enrollment. Only 41% of the original cohort of participants volunteered to participate in the 3-month follow-up testing. It is possible that these participants were more motivated to participate in the study or felt more confident in their knowledge of the content. However, no differences were found in post-test scores and demographic characteristics between the participants in the follow-up assessment and those in the original sample of 150 nurses; therefore, the investigators believe this group may be representative of the larger group. The researchers could not determine the effect of the reinforcement strategies used over the three month period on participants’ scores since it was impossible to know which participants took part in reading the emails or team huddles. Finally, the followup assessment was performed online as opposed to a proctored classroom setting in the first two assessments. Even though the instructions called for participants to complete the test independently, and without references, it was possible that some participants may have discussed the test with others and/or used study material to complete it.

Summary and conclusions Findings from this study showed that a comprehensive educational program for nurses on HF SC principles and TB, along with regular reinforcement after the program, resulted in improved measures on nurses’ knowledge and retention over time. However, given the small sample size and that the study was conducted in a single hospital system, findings may not be generalizable across all settings. Future studies with larger sample sizes and increased number of study sites are warranted to add to the body of knowledge about this concept. Studies are limited with regards to interventions to improve nurse knowledge of HF SC principles, thus replication of studies like the current study may enhance understanding on the most effective strategies for this type of education. Research to assess the effect of nurses who have specialized knowledge and skills providing enhanced patient education on HF SC on patient outcomes, such as measures of their knowledge, adherence to SC practices, and readmission rates, is needed. Finally, other studies are needed to determine if using TB to reinforce HF SC concepts improves patient knowledge and adherence to treatment regimens.

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T. Mahramus et al. / Heart & Lung 43 (2014) 204e212 older patients with heart failure: a systematic review and meta-analysis of published reports 2004. Eur Heart J. 2004;25(18):1570e1595. Phillips CO, Wright SM, Kern DE, Singa RM, Shepperd S, Rubin HR. Comprehensive discharge planning with post discharge support for older patients with congestive heart failure: a meta-analysis. J Am Med Assoc. 2004;291(11): 1358e1367. Annema C, Luttik ML, Jaarsma T. Reasons for readmission in heart failure: perspectives of patients, caregivers, cardiologists, and heart failure nurses. Heart Lung. 2009;38(5):427e434. Becker G, Gates RJ, Newsom E. Self-care among chronically ill African Americans: culture, health disparities, and health insurance status. Am J Public Health. 2004;94(12):2066e2073. Riegel B, Dickson VV. A situation-specific theory of heart failure self-care. J Cardiovasc Nurs. 2008;23(3):190e196. Lipshitz R, Klein G, Orasanu J, Salas E. Taking stock of naturalistic decision making. J Behav Decis Mak. 2001;14:331e352. Riegel B, Moser DK, Anker SD, et al. State of the science: promoting self-care in persons with heart failure: a scientific statement from the American Heart Association. Circulation. 2009;120(12):1141e1163. McAlister FA, Stewart S, Ferrua S, McMurray J. Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials. J Am Coll Cardiol. 2004;44:810e819. Albert NM, Collier S, Sumodi V, et al. Nurses’ knowledge of heart failure education principles. Heart Lung. 2002;31(2):102e112. Washburn SC, Hornberger CA, Klutman A, Skinner L. Nurses’ knowledge of heart failure education topics as reported in a small midwestern community hospital. J Cardiovasc Nurs. 2005;20(3):215e220. Willette EW, Surrells D, Davis LL, Bush CT. Nurses’ knowledge of heart failure self-management. Prog Cardiovasc Nurs. 2007;22(4):190e195. Hart PL, Spiva L, Kimble LP. Nurses’ knowledge of heart failure education principles survey: a psychometric study. J Clin Nurs. 2011;20(21/22):3020e3028.

16. Mahramus T, Penoyer D, Sole ML, Wilson D, Chamberlain L, Warrington W. Clinical nurse specialist assessment of nurses’ knowledge of heart failure. Clin Nurse Spec. 2013;27(4):198e204. 17. Fowler S. Improving community health nurses’ knowledge of heart failure education principles. Home Healthc Nurse. 2012;30(2). 18. Phillips C. A Program Evaluation of an Educational Intervention to Improve nurses’ Knowledge of Heart Failure. Poster Presented at: National Association Clinical Nurse Specialist (NACNS); 2011:153. 19. Delaney C, Apostolidis B, Lachapelle L, Fortinsky R. Home care nurses’ knowledge of evidence-based education topics for management of heart failure. Heart Lung. 2011;40(4):285e292. 20. Always Use Teach-Back! Iowa Healthcare System. http://www.teachbacktraining. com/; Accessed 08.08.13. 21. The Joint Commission. What Did the Doctor Say? Improving Health Literacy to Protect Patient Safety. Transforming Care at the Bedside. How-to-guide: Creating an Ideal Transition Home for Patients With Heart Failure. Institute for healthcare improvement, http://www.jointcommission.org/assets/1/18/ improving_health_literacy.pdf; 2007. Accessed 08.08.13. 22. National Quality Forum. Safe Practices for Better Healthcare, 2010 Update. A Consensus Report, http://www.qualityforum.org/Publications/2010/04/ Safe_Practices_for_Better_Healthcare_%E2%80%93_2010_Update.aspx; 2010. Accessed 08.08.13. 23. Institute for Healthcare Improvement. How-to Guide: Creating an Ideal Transition Home. http://ah.cms-plus.com/files/IHI_How_to_Guide_Creating_an_Ideal_ Transition_Home.pdf; Accessed 24.10.13. 24. White M, Garber R, Carroll M, Brinker E, Howie-Esquivel J. Is “Teach Back” associated with knowledge retention and hospital readmission in hospitalized heart failure patients? J Cardiovasc Nurs. 2013;28(2):137e146. 25. Esquivel J, White M, Carroll M, Brinker E. Teach-Back is an effective strategy for educating older heart failure patients. Circulation. 2011;124(suppl 1) [abstract 10786].


Appendix 1. Patient case scenarios for competency assessment of heart failure self-care and use of teach back Scenario Mr. Jones is a 68 year old retired white male who lives alone. He is being discharged after 5 days in the hospital for an exacerbation of heart failure. He was complaining of shortness of breath and needing to sleep in a lounge chair prior to admission. Mr. Jones takes Coreg 6.25 mg po bid, Lasix 40 mg po daily, Potassium 20 mEq po daily, and Lisinopril 20 mg po daily. He has a scale at home. You are reviewing the discharge medication list with Mr. Jones. Education assignment choices: medication, signs and symptoms, fluid and weight management, diet, activity and exercise.

Appendix 2. Heart failure handout with SC principles and Teach Back examples

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Appendix 3. Example of one email message sent to study participants over three months following the educational intervention for reinforcement