Health Literacy, Nursing Curricula, Teach-Back



  1. Feinberg, Iris
  2. Hendry, Terri
  3. Tighe, Elizabeth
  4. Ogrodnick, Michelle
  5. Czarnonycz, Catherine


Abstract: For nurses to communicate effectively, they must understand how patients obtain, understand, and use health information to make health decisions, that is, their health literacy (HL) level. A gap in teaching HL communication skills exists in nursing curricula. This study explored nursing students' knowledge and beliefs about HL communication before and after an HL training. Analysis revealed a significant increase in knowledge after training (Mpre = 9.00, Mpost = 9.89), t(36) = 3.75, p < .001. Participants (84.6 percent) used teach-back technique with simulated patients and identified additional training as an aid to skill building.


Article Content

Communication between nurses and patients is impacted by information overload, medical jargon, anxiety, and how patients understand disease, risk, and self-management (Wittenberg et al., 2018). Individuals at all health literacy (HL) levels can have difficulty understanding health information. Moreover, 88 percent of adults in the United States have less than adequate HL, which can lead to delays in preventive services, missed office visits, unmanaged acute conditions, and exacerbation of chronic conditions (Institute of Medicine, 2004). The nurse's role in educating patients is paramount to patients' understanding of medication and discharge instructions and self-care. Nurses should use HL communication techniques as a universal precaution in educating all patients (Liang & Brach, 2017).


HL communication can be taught through systematic and intentional training. Knowledge of HL skills is an expected outcome for graduates of baccalaureate nursing programs (American Association of Colleges of Nursing, 2008), yet there remains a gap in standard nursing curricula, with HL exposure more often happening in continuing education courses, during clinical rotations, or on the job (Mosley & Taylor, 2017). Teach-back (TB), an HL communication technique that asks a patient to state what has been learned from the nurse, has been found to be effective both during patient education and for patient outcomes (Almkuist, 2017). To inform future curriculum development, the purpose of this study was to determine if nursing students' knowledge and beliefs about health literate communication changed after a one-hour HL/TB skills training intervention with a simulated patient (SP). Three research questions were asked: 1) Are there differences in knowledge and beliefs about health literate communication before and after a one-hour HL/TB skills training? 2) What was the frequency of TB use by students in the simulation? 3) What are perceived barriers and facilitators to the use of TB?



After the university's institutional review board approved this study, undergraduate nursing students (n = 56) at a large Southeastern university provided consent. Students completed knowledge and beliefs surveys prior to the HL/TB skills intervention. SPs were used and provided consent. Students also completed a demographic survey and the knowledge/beliefs survey following the intervention and simulation center experience.


The survey consisted of 11 multiple-choice knowledge questions based on the one-hour skills training and 11 Likert-style beliefs questions. The skills training was delivered during a regularly scheduled class. Training content included how HL impacts health outcomes, how to develop clear communication styles with all patients, and how to use TB to ensure patients understand their care plan. Students watched a reminder video one week before the simulation. SPs were trained using a TB skills video. SPs indicated on a scorecard whether the student used TB; students completed a semistructured interview to discuss barriers/facilitators to the use of TB.


Mean score differences were examined using a paired-samples t-test to determine changes between pre- and post-knowledge responses. Internal consistency estimate for the knowledge measure was unobtainable because some of the items had no variance; as each question came directly from the HL training, the survey had adequate face validity.



Pre- and post-knowledge responses were moderately correlated (r = .584), indicating test-retest reliability. For the belief questions, a nonparametric Wilcoxon signed-ranks test was used to measure median differences between pre- and post-belief responses. The beliefs survey exhibited a Cronbach's alpha coefficient of .82 at pretest (n = 39) and .87 at posttest (n = 37); pre- and post-belief responses were moderately correlated (r = .509).


To answer the first research question, pre- and postresponses to the knowledge/belief survey questions were compared. For the knowledge questions, a paired-samples t-test revealed a statistically significant increase in knowledge scores after the intervention (Mpre = 9.00, Mpost = 9.89), t(36) = 3.75, p < .001, with a moderate effect size, d = 0.616. For the beliefs questions, the Wilcoxon signed-ranks test was used; there was no statistically significant median difference score before and after the intervention, Z = 1.15, p = .250.


To answer the second research question, the percentage of students who used TB after skills training was examined; 84.6 percent of students (n = 33) used TB. In response to the third question, barriers were nervousness about being in the simulation center and delivery of the TB questions. The key facilitator was to ensure patient understanding. Students felt that additional hands-on training and periodic reminders throughout the semester would help with TB skill building.



Patient education is a primary responsibility of registered nurses and influences both patient safety and outcomes of care; effective education necessitates communication relative to each patient's HL level. TB is an evidence-based technique to validate patient comprehension of education. Students' knowledge and beliefs of HL/TB were assessed before and after an intentional instruction session designed to fill a gap in classroom content. Our results show that the session was effective for knowledge improvement, but no significant difference was found regarding beliefs. Nurses are more task-oriented at this stage (Benner, 1984), so it is not surprising that they demonstrated knowledge and use of TB more readily than belief changes.


A function of the SP is to provide feedback regarding performance (Lewis et al., 2017). SP feedback indicated that 84.6 percent of the participants used TB to provide discharge teaching, indicating that our deliberate TB teaching approach was effective for a majority of learners. Mastery of HL/TB techniques can be facilitated in the classroom with purposeful instruction.


Students experience performance anxiety during simulation for many reasons (Shearer, 2016); their feedback regarding barriers support these findings, as nervousness and fear of performance were identified. Students also recognized that a patient's understanding of instructions is key to successful nurse-patient interactions. Responses from students support that deliberate integration of TB would be beneficial for course content.


Results of the study indicate that inclusion of HL/TB intentional classroom instruction and simulation experiences may be effective if incorporated into curricula. Student knowledge increased after skills training, and many students were able to use TB with an SP; both are necessary to provide patient-centered HL education. Because patient education is a priority in all nursing curricula, inclusion of HL/TB would be beneficial in specific courses where students learn to provide patient education.


The convenience sample and small number of participants are one limitation to this study. A second limitation is lack of generalizability because this study was done with representation from one university and a single nursing program. Finally, this was the students' first experience with SPs and simulation, which may have impacted their use of TB.



Communication techniques are part of most nursing courses, and patient education is stressed as a critical part of patient care. The US Agency for Healthcare Research and Quality recognizes and promotes using TB to ensure safe patient care (2017). Our study indicates that deliberate classroom instruction about HL/TB, along with a simulation experience, may promote development of TB skills. Given that nursing students gain experience and higher level comprehension as they progress in their program, patient-centered HL/TB content could be included in all clinical courses to help build skills as more sophisticated levels of patient interaction occur. Use of simulation to evaluate students' mastery of TB may help prepare students for transition into practice.




Agency for Healthcare Research and Quality. (2017). Teach-back: Intervention.[Context Link]


Almkuist K. (2017). Using Teach-Back method to prevent 30-day readmissions in patients with heart failure: A systematic review. Medsurg Nursing, 26(5), 309-351. [Context Link]


American Association of Colleges of Nursing. (2008). The essentials of baccalaureate nursing education for professional nursing practice.[Context Link]


Benner P. (1984). From novice to expert: Excellence and power in clinical nursing practice. Addison-Wesley. [Context Link]


Institute of Medicine. (2004). Health literacy: A prescription to end confusion. National Academies Press. [Context Link]


Lewis K. L., Bohnert C. A., Gammon W. L., Holzer H., Lyman L., Smith C., Thompson T. M., Wallace A., Gliva-McConvey G. (2017). The Association of Standardized Patient Educators (ASPE) standards of best practice (SOBP). Advances in Simulation, 2, 10. [Context Link]


Liang L., Brach C. (2017). Health literacy universal precautions are still a distant dream: Analysis of U.S. data on health literate practices. Health Literacy Research and Practice, 1(4), e216-e230. [Context Link]


Mosley C. M., Taylor B. J. (2017). Integration of health literacy content into nursing curriculum utilizing the health literacy expanded model. Teaching and Learning in Nursing, 12(2), 109-116. [Context Link]


Shearer J. (2016). Anxiety, nursing students, and simulation: State of the science. Journal of Nursing Education, 55(10), 551-554. [Context Link]


Wittenberg E., Ferrell B., Kanter E., Buller H. (2018). Health literacy: Exploring nursing challenges to providing support and understanding. Clinical Journal of Oncology Nursing, 22(1), 53-61. [Context Link]