Heart & Lung 43 (2014) 204e212

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Heart & Lung

journal homepage: www.heartandlung.org

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
b
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

a r t i c l e i n f o a b s t r a c t

Article history: Background: Nurses must have optimum knowledge of heart failure self-care principles to adequately
Received 14 May 2013 prepare patients for self-care at home. However, study ndings demonstrate that nurses have knowledge
Received in revised form decits in self-care concepts for heart failure.
14 November 2013
Methods: A quasi-experimental, repeated measures design was used to assess nurses knowledge of heart
Accepted 22 November 2013
failure self-care before, immediately after, and 3-months following an educational intervention, which
Available online 20 February 2014
also included the Teach Back method. Follow-up reinforcement was provided after the educational
intervention.
Keywords:
Heart failure
Results: One hundred fty nurses participated in the study. Signicant differences were found between
Self-care pre-test (65.1%) and post-test (80.6%) scores (p < 0.001). Teach Back prociency was achieved by 98.3%.
Patient education Only 61 participants completed the 3-month assessment of knowledge. In this group, mean knowledge
Teach Back scores increased signicantly across all three measurements (p < 0.001): 66.5% (pre-test); 82.1% (post-
Nurse test); 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.
2014 Elsevier Inc. All rights reserved.

Introduction HF patients are related to inadequate knowledge at discharge,

Heart failure (HF) is the leading discharge diagnosis for Medicare
recipients and the most frequent cause of readmission to the hos-
pital.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.: 1 321 843 3993.
E-mail address: Tara.Mahramus@orlandohealth.com (T. Mahramus).
inadequate follow-up with a health care provider, and non-
adherence 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, medi-
cation 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 man-
agement is often needed.

0147-9563/$ e see front matter 2014 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.hrtlng.2013.11.012
 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 specic assessment and treatment strategies to
manage their usual care following a prescribed regimen and pa-
rameters for when to notify their health care providers. Building on
the original theory of SC by Orem, Riegel and Dickson developed a
situation-specic 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-specic 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
modications, medication administration, weight monitoring, and
signs and symptoms of worsening condition are important con-
cepts 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 signicant gaps on HF SC, using a tool that had been
developed to measure nurse knowledge on SC for HF in that
study.12 Since Alberts original study, ndings from other studies
further documented knowledge decits about HF SC principles by
nurses who care for patients with HF.13e19 Knowledge decits
identied across these studies were similar, including signs and
symptoms associated with hypoperfusion (dizziness, confusion),
evaluation of uid status (weight, edema) and blood pressure, di-
etary 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 pro-
vided an educational intervention on HF to cardiac nurses. Partic-
ipants 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 prin-
ciples was measured before and after the educational intervention.
Results from both studies showed that test scores after the in-
terventions increased, but with insignicant 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 under-
standing of content delivered.20,21 One strategy to assess the pa-
tients 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 educators
ability to convey concepts to the learner. The Joint Commission,
205
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 in-
formation 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 clarication 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.
206 T. Mahramus et al. / Heart & Lung 43 (2014) 204e212

Study intervention Table 2

Sample characteristics.

The intervention was a comprehensive educational program Characteristics Original 3-month

designed by the study investigators and based upon current liter- sample (n 150) follow-up
ature on HF SC principles. The program included a variety of ap- n (%) cohort (n 61)
n (%)
proaches to reinforce content, including a three and a half hour
Work Setting:
lecture/discussion on HF SC principles (diet, medications, signs and
Acute Care Heart Failure 19 (12.7) 9 (14.8)
symptoms of worsening condition, uids or weight, and exercise), Unit-Tertiary Care Hospital
and the use of the TB method. The investigators chose to incorpo- Acute Progressive Care 31 (20.7) 10 (16.4)
rate education on the TB method to provide a strategy for partici- Unit-Community Hospital 1
pants to enhance assessment of patient understanding of SC for HF. Acute Progressive Care 57 (38.0) 25 (41.0)
Unit-Community Hospital 2
The investigators offered the same educational program eight times Home Health 33 (22.0) 17 (27.9)
at three sites within a two month period. Table 1 summarizes the No response 10 (6.7) 0 (0.0)
content of the educational intervention. Although participation in Certied
the study was optional, unit managers from the study units Yes 40 (28.8) 20 (32.8)
Type of certication:
required that all nurses attend one of the scheduled programs as a
Progressive Critical Care Nurse (PCCN) 23 (56.1) 13 (65.0)
learning activity for teaching patients with HF. Critical Care Registered Nurse (CCRN) 2 (4.9) 0 (0.0)
Medical-Surgical Nursing 5 (12.2) 1 (5.0)
Gerontology 11 (26.8) 6 (30.0)
Variables and measures
m (SD) m (SD)

The researchers used two measures to assess nurses knowledge Years of nursing experience 13.6 (12.2) 14.2 (12.5)
Years of experience on current unit 4.6 (5.3) 5.14 (5.5)
of SC for HF. The Nurses Knowledge of Heart Failure Education
Principles (NKHFEP) instrument, a 20-item true-false test, was used

to measure knowledge of HF SC principles.12 The questions in the

Table 1
NKHFEP are categorized into ve principles: medications, diet,
Classroom content for heart failure self-care principles.
exercise, uid and weight management, and signs and symptoms of
Content section Items reviewed worsening condition. The authors who developed this instrument
Importance of Evidence behind SC tested it for face and content validity using HF experts and then
self-care Disease progression and mortality risk of heart failure pilot-tested for test-retest reliability among nurses who were
(SC) principles Regulatory issues and requirements
Costsereadmissions, care costs
knowledgeable about HF. Psychometric data were not reported by
Teach Back technique Review of the ve HF education principles the authors. Due to multiple themes with ve subscales, internal
How health literacy may inuence learning consistency reliability was not assessed by the investigators.12
Teach Back demonstration by investigators When the current study was conceptualized, the NKHFEP was the
Diet Limit sodium to 1500 mg/day
only tool available to measure nurse knowledge of HF SC principles
Read food labels
Discuss food with hidden sodium and provided a means of comparison between studies.13e16 The
Avoid potassium salt substitutes investigators held discussions with the tool author (Albert), and
Effects of sodium on heart failure deemed it appropriate to use despite limited published data related
Teach Back demonstration by investigators to its psychometric properties. After the current study had begun,
Fluids and weight When to perform daily weights and comparison to
dry weight e 2 lb/day or 5 lb/week e Call provider
Hart et al reported higher psychometric properties of an adapted
Daily monitoring for edema Low sodium diet version of the NKHFEP using a Likert-type scale for responses.15
promotes uid balance However, since Hart et al were assessing agreement with the
Fluid restrictions and how to measure uids statements rather than knowledge, the investigators believed that
Teach Back demonstration by investigators
further testing of the adapted version of the NKHEFP was needed.
Medications Indications and side effects of:
- Beta Blockers Therefore, the investigators chose the original format of the
- Angiotensin converter enzyme inhibitors NKHFEP to evaluate knowledge.
- Angiotensin receptor blocking Agents The second measure of nurse knowledge was to assess compe-
- Aldosterone antagonists tency in using the TB method. The investigators developed a
- Diuretics
Avoid non-steroidal anti-inammatory
competency tool to rate the nurses ability to correctly use the TB
drugs (NSAIDS)
Teach Back demonstration by investigators
Exercise and other Perform daily exercises Table 3
activities Promote smoking cessation Test scores across measurement periods.
Limit alcohol intake Original sample 3-month
Stress management options (n 150) follow-up cohort
Maintain provider appointments (n 61)
Teach Back demonstration by investigators
Signs and symptoms Weight gain of 2 lbs in a day or 5 lbs in a week m (SD) m (SD)
Increasing edema Mean test scores:
Increased shortness of breath, or need to use Pre-test score 65.1 (13) 66.5 (12.9)
additional use of pillows at night or need to sleep Post-test score 80.6 (9.7)a 82.1 (9.9)a
in a chair Three month follow-up score 89.5 (7.5)a
Increased fatigue and tiredness Median test scores:
Lightheaded or dizziness that does not resolve quickly Pre-test score 65.0 70.0
Teach Back demonstration by investigators Post-test score 80.0 80.0
Teach Back practice Nurse demonstration and competency Three month follow-up score 90.0
and check off
a
p < 0.001.
 T. Mahramus et al. / Heart & Lung 43 (2014) 204e212
Table 4
Educational intervention evaluations (n 60).
Evaluation questions
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 patients 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
method when teaching SC principles for HF. Prior to the study, a
member of the investigative team developed ve patient education
scenarios on HF SC principles, depicting appropriate or inappro-
priate TB technique. While simultaneously observing enactment of
the ve case scenarios, the investigators rated the TB demonstra-
tions 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 nal 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 in-
vestigators 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 identication 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 certication. 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 moni-
tored and provided feedback on their performance. Participants
randomly chose one of four case scenarios to role-play HF SC
207
Mean score (SD) Median Generally agree Generally disagree
or neutral
4.37 (0.69) 4.00 96.7% 3.3%
4.35 (0.71) 4.00 95.0% 5.0%
4.27 (0.73) 4.00 91.7% 8.3%
4.05 (0.77) 4.00 96.7% 3.3%
4.18 (0.77) 4.00 90.0% 10.0%
4.19 (0.73) 4.00 89.8% 10.2%
2.49 (1.22) 2.00 23.7% 76.3%
4.30 (0.74) 4.00 91.7% 8.3%
education, followed by demonstrating the use of TB to assess un-
derstanding. The investigators observed and critiqued their per-
formance using the competency assessment tool (Appendix 1). If
the investigators deemed that the participant did not demonstrate
competency, they provided immediate remediation and rein-
forcement 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 ve 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 in-
vestigators 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 one-
page summary of one of the ve 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 be-
tween 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 pro-
grams, the investigators sent a message through inter-hospital
email to all nurses on the study units, giving them an opportu-
nity 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 follow-
up 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 afrm 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 eval-
uation form encouraged participants to be honest with their
assessment of the program (Table 4). Fig. 1 summarizes procedures
in the study.
208 T. Mahramus et al. / Heart & Lung 43 (2014) 204e212
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. Cate-
gorical variables were statistically represented in frequency distri-
butions, 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 eval-
uate differences between pre- and post-test scores, and Repeated
Measures ANOVA tests to compare scores across the three test pe-
riods (pre-education, post-education, and three months post edu-
cation). 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 certication status, at the different time intervals. Post hoc an-
alyses were used to detect signicant differences across time. Dif-
ferences 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 signicance
level of <0.05 was considered statistically signicant for all analyses.
Results
Sample characteristics
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%) con-
sented to participate and completed the pre-test and post-test
following the class. Most of the nurses worked in acute care hos-
pital settings (n 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 cer-
tication, with 56.1% certied 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 hospitals 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 certied; of those, 65% certied with a
PCCN. Demographic characteristics for the immediate post-test
were not signicantly different between those who completed or
declined participation at the 3-month follow-up. Table 2 summa-
rizes demographic characteristics.
Mean knowledge scores
Mean pre-test score (n 150) was 65.1% and post-test score was
80.6%, demonstrating a statistically signicant improvement
(p < 0.001). Mean scores across each of the three measurement
periods improved signicantly, including the follow-up cohort,
ranging from a mean of 66.5% at the pre-test to 89.5% at the 3-
month follow-up period (p < 0.001). Post-hoc pairwise compari-
sons found signicant differences among all measurement periods
(p < 0.001). Similar trends were noted in median test scores, which
increased from 70% to 90%. No differences in scores noted across
time by characteristics of work unit (p 0.176) or certication
(p 0.671). Table 3 summarizes test score results.
Participant pass scores
The passing score for testing was set at >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 imme-
diate 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
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.
Evaluations on the educational intervention
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
ve 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).
Discussion
We found that nurses had signicant knowledge decits about
SM for HF related to signs and symptoms of HF exacerbations, uid
and blood pressure assessments, dietary and medication re-
strictions, and symptom management at home and when to contact
their health care provider prior to participation in the educational
intervention. This nding is consistent with a previous study at the
same institution (mean score of 71%) and other study ndings re-
ported in the literature using the same knowledge instrument.12e19
Scores on the post-test improved signicantly immediately
following the educational intervention and were sustained and
increased after three months of reinforcement education. Addi-
tionally, 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
 T. Mahramus et al. / Heart & Lung 43 (2014) 204e212
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 insufcient 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 educa-
tional intervention. In contrast to the study by Fowler, our sample
size was sufciently 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 nal
sample size of the follow-up cohort (n 61) was adequate to assess
the effects of the intervention. The comprehensive nature of our
intervention, along with focused reinforcement, is a likely expla-
nation for the increase in scores across time.
While a signicant 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 rein-
forcement 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 learners 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 learners 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
rst 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 ndings 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 reect more of a famil-
iarity 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 inuencing their familiarity with the test.16 The
209
investigators had no way of knowing who those participants were,
given that anonymity was preserved in both studies, and in-
vestigators did not ask about participation in the previous study.
However, the overall pre-test scores in the current study were low,
so the real inuence on their recall is likely minimal. Administra-
tion of an online test for the third and nal 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 condent 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 assess-
ment 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 rein-
forcement strategies used over the three month period on partici-
pants scores since it was impossible to know which participants
took part in reading the emails or team huddles. Finally, the follow-
up assessment was performed online as opposed to a proctored
classroom setting in the rst two assessments. Even though the
instructions called for participants to complete the test indepen-
dently, and without references, it was possible that some partici-
pants 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 educa-
tional 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, ndings 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 knowl-
edge 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 effec-
tive 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 out-
comes, 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 211

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 symp-
toms, uid and weight management, diet, activity and exercise.

Appendix 2. Heart failure handout with SC principles and

Teach Back examples
212 T. Mahramus et al. / Heart & Lung 43 (2014) 204e212

Appendix 3. Example of one email message sent to study

participants over three months following the educational
intervention for reinforcement