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Strategies for improving the quality of verbal patient and family education:
a review of the literature and creation of the EDUCATE model
Cara Marcus
*
Director of Library Services, Brigham and Women’s Faulkner Hospital, Boston, MA, USA
(Received 14 November 2013; accepted 28 February 2014)
Objective: Patient and family education includes print, audio-visual methods, demonstration, and
verbal instruction. Our objective was to study verbal instruction as a component of patient and
family education and make recommendations for best practices for healthcare providers who
use this method. Methods: We conducted a literature review of articles from 1990 to 2014
about verbal education and collaborated on departmental presentations to determine best
practices. A survey was sent to all nursing staff to determine perceptions of verbal education
and barriers to learning. Results: Through our work, we were able to identify verbal education
models, best practices, and needs. We then constructed the EDUCATE model of verbal
education, which built upon our findings. Conclusion: Verbal education of patients and family
members requires a multidisciplinary approach that takes into account learning styles, literacy,
and culture to apply clear communication and methods for the assessment of learning.
Providers need the skills, time, and training to effectively perform patient and family verbal
education every time they care for patients. Further research needs to be performed on how to
test, document, and quantify patients’ comprehension and retention of verbal instructions.
Keywords: patient education; communication; interpersonal relations; health literacy;
communication barriers; health education; teach-back
1. Introduction
The need for patient education is widely recognized in the medical community (Behar-Horenstein
et al., 2005 ). Well-educated patients are better able to understand and manage their own health and
medical care throughout their lives. Patient–provider communication is a key element of patient
education and is often used in conjunc tion with other teaching practices. Communication is effec-
tive when patients receive accurate, timely, complete, and unambiguous messages from providers
in ways that enab le them to participate responsibly in their care. Patient understanding of infor-
mation communicated by healthcare providers can lead to enhanced patient satisfaction, better
compliance with treatment instructions, improved outcome s, and decreased treatment times
and costs (Behar-Horenstein et al., 2005; The Joint Commission, 2010). Patient education is
also a requirement for accreditation of healthcare facilities.
In a study of adult patients and visitors enrolled at four Boston-area emergency departments
(N = 1010), 24% of participants listed speaking with an expert as their preferred educational
modality. That metric was even higher for various demographic groups: 32% of Hispanic respon-
dents and those with less than a high school education preferred verbal education (Kit Delgado,
© 2014 The Author(s). Published by Taylor & Francis
*Email: cmarcus@partners.org
This is an open-access article distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/
licenses/by/3.0/, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited. The moral rights of the named author(s) have been asserted.
Health Psychology & Behavioural Medicine, 2014
Vol. 2, No. 1, 482–495, http://dx.doi.org/10.1080/21642850.2014.900450
Ginde, Pallin, & Camargo, 2010). Effective verbal patient education has been s hown to improve
the patient’s ability to care for him or herself post-discharge, thus reducing morbidity and
mortality. Patient education has also resulted in improvements in the patients’ hospitalization
experiences, including lessening of pain and anxiety (Montin, Johansson, Kettunen, Katajisto,
& Leino-Kilpi, 2010). If improved communication results in better self-care, future medical inter-
ventions may be needed less frequently (Kripalani & Weiss, 2006).
Not all patient education is successful. In reality, communication is often partially understood,
misunderstood, or misinterpreted. Even with the best of intentions, patient education that fails to
educate can lead to adverse events or poor outcomes. The Joint Commission studied patient–pro-
vider communication as the root cause of sentinel events and found that poor oral communication
caused 10% of these events (The Joint Commission, 2010).
The Brigham and Women’s Faulkner Hospital (BW FH) Patient/Family Education Committee
set out to explore literature on verbal education and barriers to effective education. Our goal was to
share our own internal methodologies and develop a new model of verbal education that included
recommendations for best practices for healthcare institutions and providers. While verbal edu-
cation should be just one part of an integrated, multimodal patient education session, it is vital
that it be delivered in a fashion that augments the patient’s learning, comprehension, and retention.
2. Methods
BWFH is a 150-bed non-profit, community teaching hospital located in Jamaica Plain, Massachusetts.
The BWFH Patient/Family Education Committee develops and implements standardized, easily
accessible patient education processes and resources in accordance with regulatory requirements.
The multidisciplinary committee includes members from nursing, medicine, administration, allied
health, nutrition, physical therapy, pharmacy, social work, library services, and the patient population.
In 2010, the committee prioritized initiatives through a brainstorming session, multi-voting
process, criteria grid, and impact matrix. Our brainstorming session identified the following pro-
jects that our committee saw as priorities at the time:
.
Brochure inventory
.
Cultural competency
.
Educational TV
.
Identification of learning styles
.
Literacy
.
New employee orientation
.
Online resources
.
Patient education packets
.
Patient/Family Resource Center
.
Rounding
.
Verbal education
Subcommittees were set up within the committee to present the three priority projects selected at
the first meeting (inventory, educational TV, and verbal education). The verbal education subcom-
mittee consisted of a physician, a nurse, and a dietitian. The three projects were assessed through
an impact matrix for their feasibility, cost not to fix (this includes monetary and public health
costs), and impact on the problem.
Verbal education became our initial priority project as the committee discussed that this method
was used in every patient–provider encounter and often was used in conjunction with additional
forms of education, such as written material. We would address the following focus areas: (1)
Health Psychology and Behavioral Medicine 483
identifying the learner, (2) assessment of comprehension, (3) continuous education, and (4) docu-
mentation of education. We planned to develop guidelines and staff training in these areas.
The committee conducted a literature review of articles from 1990 to present utilizing the fol-
lowing databases: EBSCO CINAHL, GALE InfoTrac Health Reference Center Academic, MD
Consult, OVID Journals Database, ProQuest Nursing and Allied Health, and PubMed. Search
terms included verbal education, oral education, patient education AND communication,
patient education AND oral, patient education AND verbal, physician–patient communication,
and nurse–patient communication. We included articles that addressed one or more of the four
focus areas identified by the committee. Committee members were asked to volunteer to read
one or more articles and report their findings to the group. In addition to the literature review,
committee members presented their own approaches to delivery of verbal education within
their disciplines (Table 2). The summary of our own approaches was also used to help us formu-
late a model of best practices. We also conducted an online survey of the nursing staff on patient
education practices, which helped determine needs surrounding verbal instruction.
3. Review
3.1. Effectiveness of verbal education
The literature review identi fied studies involving verbal education of various demographic groups
(children, the elderly, those with hearing impairment, etc.) In addition, studies were conducted
surrounding education of patients undergoing treatment for various conditions (cancer, cardiol-
ogy, orthopedics, etc.).
Posma, van Weert, Jansen, and Bensing (2009 ) studied 38 patients and found that they wanted
to receive concrete information about their disease and treatment, such as diagnosis, prognosis,
treatment side-effects, possible complications, and other practical information. This study
found that older patients benefited from a question list prepared to discuss subjects during
patient education sessions.
Johnson and Sandford (2005) conducted a systematic Cochrane review that compared written
with verbal information to verbal information only in a study of parents of children with health
problems. In the two trials selected by the study, findings indicated that parents were more knowl-
edgeable and satisfied with the combination of written and verbal information than verbal edu-
cation alone. The combination of the information improved parents’ scores significantly in
terms of knowledge of medications and how to recognize signs of improvement and concern.
In a study of 61 patients (Behar-Horenstein et al., 2005), cardiac patients provided more specific
information to their providers about their conditions than general medical patients, resulting in
better patient –provider communication. Overall, the patients reported that they received most of
their information from verbal interactions they had with doctors and nurses. The majority of the
verbal education was perceived by the patients as effective. Nearly three-fourths of the patients
(n = 45) stated that they were satisfied with the information they received and the methods hospital
staff used to teach them. Only 5% of patients claimed that they received little or no information on
signs and symptoms, and only 5% of patients seemed uninformed about their medications.
In a prospective, blinded, randomized, controlled study of 605 patients (Liu et al., 2014), only 9%
of patients showed non-compliance with instructions after receiving telephone-based re-education on
the day before colonoscopy versus 32.6% of patients who did not receive the verbal re-education.
None of the articles we reviewed developed an approach to quantitatively measure the effec-
tiveness of verbal education; studies have focused on qualitative perceptions of its effectiveness
and/or patient satisfaction with education received. Research still needs to be performed on how
to test, document, and quantify patients’ comprehension and retention of verbal instructions
before and after various provider interventions.
484 C. Marcus
3.2. Identifying the learner
Patient education is a Joint Commission requirement for hospital accreditation. The hospital pro-
vides patient education and training based on each patient’s needs and abilities (PC.02.03.01).
The hospital performs a learning needs assessment for each patient, which includes the patient’s
cultural and religious beliefs, emotional barriers, desire and motivation to learn, physical or cog-
nitive limitations, and barriers to communication (EP 1). The hospital respects the patient’s right
to receive information in a manner he or she understands (RI.01.01.03) (The Joint Commission ,
2012).
To offer the highest quality verbal education, a healthcare provider must understand the
patient’s background, reading level, and how he or she learns best. Different people have different
abilities to learn, and providers need to understand what distinct learning preferences and needs
the patient may have (Anonymous, 2000; Montin et al., 2010; Posma et al., 2009). After the pro-
vider understands the patient’s optimal method of learning, he or she can adjust the teaching and
training strategy to incorporate many techniques, including demonstrations, diagrams, reinforce-
ment, review, teach-back, support, etc. (Anonymous, 2000).
Cultural, cognitive, and physical differences require different educational approaches (Goody &
Drago, 2009). For example, Lieu et al. (2007) recommended that providers communicating with deaf
patients should make eye contact, may need to write to communicate, but never assume that there is
an exact translation of medical terms into sign language. In another study focusing on hearing-
impaired patients, Tye-Murray (1992) empathized that it helps if the provider anticipates hearing
loss and the patient may be able to prepare for communication by reading or writing words that
he or she wants to know about. For patients whose preferred learning style is not verbal communi-
cation, Behar-Horenstein et al. (2005) recommended that providers broaden the use of alternative
instructional aids and methods of delivery that utilize auditory, visual, and kinesthetic modalities.
Pictures on paper or a screen may serve as simple visual aids to supplement verbal education.
Differences in communication and learning may stem from a variety of factors, including age,
gender, ethnicity, or level of education. Elderkin-Thompson and Waitzkin (1999) compared
research on communication by men and women as both providers and patients. This study ident-
ified a great many differences in communication styles among genders, such as providers com-
municating more with female patients by giving them more time and using easier terminology.
The authors also found that women generally use discussion to clarify explanations, while men
often present problems and expect to resolve them. The research also focused on socioeconomic
groups; for example, providers usually give more emotional support to poorer patients.
Articles in our review identified roadblocks to education, particularly low literacy
(Anonymous, 2000; Owen, 2005). Anyone, even highly literate people, may not be healthcare
literate. Providers need to assess patients for their level of literacy prior to providing education.
An assessment may include interviews with patient or family members, communication with
members of the medical team, or observations of patients (Behar-Horenstein et al., 2005). Provi-
ders may be able to assess poor literacy in verbal interactions if the patient asks questions about
what has already been explained, asks irrelevant questions, or provides unusual or irrelevant
answers to questions (Remshardt, 2011). Another method to identify patients ’ learning styles is
asking what help is needed with understanding medical information (Posma et al., 2009).
3.3. Patient–provider communication
When patient education is delivered verbally as part of a multimodal patient education program,
the provider assumes the role of the teacher and the patient that of the learner. Richard and Lussier
(2007) found that provider–patient discussions have often been regarded as interactive in nature.
Health Psychology and Behavioral Medicine 485
However, this study found that resulting dialogue mainly consisted of separate monologues, with
insufficient real exchange in understanding of the other participant’s perspective. The authors
described how physicians often adopted the “Information Provider” role in discussions involving
medications, and patients the “Listener” role, often significantly limiting their active input. When
patients did have some prior knowledge of medications related to their care, discussions with their
providers tended to be more interactive, resulting in improved outcomes. Further research is
needed to determine what ideal provider and patient communication roles should be. While
this may prove elusive, various art icles have focused on wa ys providers can improve communi-
cation. For example, Skorpen and Malterud (1997) described communication based on mutual
trust.
Talen, Grampp, Tucker, and Schultz (2008) addressed what providers needed from patients to
have positive verbal interactions. The patient should have knowledge of his or her medical history
and prescriptions and have an attitude that is focused on the treatment plan and the need for
follow-up care. Education can be improved by providing supportive staff to help patients and pre-
paring worksheets with questions for the patient to ask in advance. Talen et al. stressed that
patients can be trained to communicate more effectively with their providers, thus improving
their ability to have a conversation that results in better understanding.
3.4. Comprehension and retention
Patient education is ineffective if the patient fails to understand what is being taught. However,
patients may not even be aware that they do not understand what is being taught to them. In a
study of two teaching hospitals (Engel et al., 2009), the majority of patients with comprehension
deficits failed to perceive that they had any deficiencies. Only about 20% of patients in this study
reported comprehension difficulties, but about 78% of the patients demonstrated a comprehen-
sion deficiency in at least one domain of their visit. Many patients had poor comprehension of
multiple aspects of their emergency department care and discharge instructions in this study.
Another study by Margolis (2004) found that patients retained about 50% of information by
health care providers, and about half of that was remembered correctly.
The ability to comprehend and retain information may decline as patients and family members
age; Posma et al. (2009) studied 38 patients and found that older people had more difficulties pro-
cessing and remembering information than younger ones. Barriers to information retention may
also include anxiety, denial, memory deficits, pain, stress, or unfamiliarity (Anonymous, 2000;
Margolis, 2004). Talen et al. (2008) found that higher satisfaction with patient–provider com-
munication correlated to the patient’s ability to remember his or her provider’s recommendations
and comply with the instructions. These factors are some of many that may affect the individual’s
ability to process and comprehend verbal education.
3.5. A multidisciplinary approach
Patient and family education should exist throughout the continuu m of care. A team of healthcare
providers should teach the patient and loved ones about disease management, medications, post-
discharge management, and advice on when and how to seek medical attention following
hospitalization.
Nurses play a critical role in the education of patients. In a study of more than 400 orthopedic
operations, pati ents who preoperatively visited their nurse reported receipt of more knowledge
about their condition than other patients (Montin et al., 2010). A hospital instituted an effective
verbal education program where chemotherapy information was provided by oncology nurses
during a consultation lasting approximately one hour. A booklet was often used to supplement
486 C. Marcus
the verbal consultations. The consultation usually took place two weeks to one day before the first
treatment started (Posma et al., 2009 ). Vreeland, Rea, and Montgomery (2011) conducted an evi-
dence-based review of the literature on heart failure and discharge education. They recommended
that the optimal patient education would be a structured, one-on-one session with a specialized
registered nurse and repetition of the information by the staff during care.
Physicians provide verbal education during every communication encounter. Richard and
Lussier (2007) conducted a descriptive study of medication-related exchanges during
1492 consultations between patients and general practitioners. The authors identified physicians’
clinical expertise as technical knowledge that patients do not generally share to any great extent
and suggested that physicians can build on patients’ own knowledge and experience to increase
dialogue.
Many other providers and practitioners play a crucial part in patient education and counseling,
including social workers, rehabilitation therapists, home healthcare workers, educators, patient
advocates, librarians, etc. Each provider should work individually and collaboratively. Case man-
agers can become facilitators for recognizing gaps in patient education and putting an appropriate
plan in place given the patient’s needs (Owen, 2005). Behar-Horenstein et al. (2005) surveyed
patients about their education and found that about 12% received information from dietitians
or pharmacists, with slightly less reporting receiving information from physical therapists or
transplant coordinators. Cant and Aroni (2008) stressed that dietitians needed to display a high
level of communication competence because the purpose of their communication had the edu-
cation of a patient as a goal. A hospital developed a scripted patient education tool so that research
pharmacists could conduct 45 minute one-on-one patient education sessions (N = 528). Following
the patient education sessions, patients were given the opportunity to ask questions or voice con-
cerns. Medication adherence increased to 94.4%, compared to 89.9% in the pre-intervention
group (P < .0001) (Piazza et al., 2012).
Kruzik (2009) described a team-based initiative that offered a free preoperative program to
surgical patients and allowed patients a chance to meet team members, ask questions, and get
immediate feedback. This approach led to more positive educational experiences.
The literature als o discussed the patient’s role in the communication process. Avitzur (2011),
medical advisor to the Consumer’s Union, identified steps that patients could take to improve
communication with their doctor, such as not providing superfl uous information and using
clear, descriptive language to describe the patient’s main problem.
4. Models of verbal education
Three verbal education models were identified in our literature review. These models addressed
aspects of knowledge, communication competencies, educational methodologies, and communi-
cation assessment (Table 1).
Table 1. Models of verbal education identified in the literature review.
1. Six dimensions
of knowledge 2. Four main communication competencies 3. Suite of tools
Biophysiological Interpersonal communication Health information needs
Functional Nonverbal communication Health information behaviors
Experiential Professional values
Ethical Counseling skill
Social
Financial
Health Psychology and Behavioral Medicine 487
Model 1 (Montin et al., 2010) followed a sample of 123 total joint arthroplasty patients and
found that perceived knowledge was highest in the area of biophysiological and functional.
Model 2 (Cant & Aroni, 2008) demonstrated that no single skill set operated alone; all were required
to be applied in concert to enable effective communication with patients. In their model, they devel-
oped specific performance indicators surrounding each competency, such as “Introducing myself to
my clients is important” as a component of the professional values competency. The Consumer
Health Education Institute (CHEDI) at the University of Virginia developed a model system to
create a suite of tools to assist practitioners (1) assess patients’ and consumers’ personal character-
istics and preferences for health information, (2) segment patients and consumers into groups that
minimize differences within groups and maximizes differences between groups, and (3) match
groups to the health information that most directly meets their needs and preferences (Cohn
et al., 2006). CHEDI identified segments of patients, such as those with low literacy, and then devel-
oped requirements for health education for those segments, such as avoiding medical jargon.
Table 2 is a summary of presentations given by various departments and services at our insti-
tution on their own best practices in verbal education.
Based on our literature review and presentations of best practices, the committee developed a
process-based model that leads the educator through five stages of verbal education to reach
teaching and education goals: the EDUCATE model (Table 3).
5. Results
In our online survey of nursing staff (n = 46), 81% of the respondents felt that their experience and
knowledge were shared verbally as part of the patient and family educ ation process. The survey
asked the strengths of patient education at the hospital, the responses (n = 31) included “nurses”,
“experienced multidisciplinary staff”, “knowledge base”, “experienced staff”, “the nursing staff”,
“nursing staff’s expertise”, and “the experience of nurses”.
The survey also identified barriers to verbal education (n = 30) that echoed our findings in the
literature review:
.
Nurses need more time to listen to and teach patients and families.
.
Not all patients are alike.
.
Patients’ needs are not always known until they are on the unit.
.
The timing of education needs to be right.
.
When new issues arise, there needs to be a process so the nurse can teach that issue.
.
There needs to be communication between surgeons and the family on what to expect after
surgery.
.
Teaching needs to begin in physician’soffice at the preoperative visit.
.
Caring for a patient alone can be difficult.
.
There needs to be a method to follow-up on whether patients really understood what they
were taught.
6. Discussion
While many articles in our literature review have focused on issues surrounding patient education
handouts, classes, video, and online information, we found less research addressing one-on-one
verbal education of patients. Verbal education is usually not, and should not, be delivered alone as
the only method of patient education. The articles our committee reviewed echoed common
themes addressing difficulties encountered in providing and measuring this type of education.
While some articles studied specific populations and provided practice recommendations for
488 C. Marcus
Table 2. Summary of presentations on success strategies used in practice.
Home healthcare Library services Nutrition
E Give patients information in small increments, so that
the patient can build on each block of information
D Teach the patient problem solving skills
Try to motivate the patient to gain information, skills,
and confidence so that they can make informed
decisions about their health
U Consumer health library staff can play a role in patient education
through the “reference interview” to find out the patient’s
information needs and learning abilities in order to provide
them with resources that they can learn from and share with
their providers
C Professional tools like “conversation maps” may be helpful in
aiding communication
A Address the patient’s current living situation, barriers the
patient may be facing in complying with instructions
and the patient’s motivation and level of confidence
Rehabilitation Social work Surgery
E Patients are instructed how to perform exercises and
each time they come, the exercise is reviewed and
changes are demonstrated
A nurse discusses the surgery with the patient at least one week
before. It is also recommended that there should be verbal
education early on by the patient’s physician. Patients are asked
to call in the day before surgery to review the information
Face-to-face is the best way to communicate because a provider
can assess if the patient really understands
D Try to get an understanding of the patient – how they connect with
family, what support systems are in place, and how their
environment impacts their care
Try to assess if the person is taking in the information presented to
them and what stressors are in the way. If they are anxious, try
to find out what the source of the anxiety is
Try to get the person engaged in conversation and find topics that
the patient feels comfortable talking about
Try to establish a relationship with the patient
U
C Patients have the opportunity to ask many questions and
are given expectations throughout treatment
A Visual tools usually supplement verbal education
Notes: (E) Enhance comprehension and retention; (D) deliver patient-centered education; (U) understand the learner; (C) communicate clearly and effectively; (A) address health literacy
and cultural competence.
Health Psychology and Behavioral Medicine 489
Table 3. EDUCATE model for verbal education.
EDUCATE
Enhance comprehension
and retention
Deliver patient-centered
education Understand the learner
Communicate clearly and
effectively
Address health literacy and
cultural competence
Teaching and
education goals
Use a question list so that
patients can ask
questions and providers
can answer them
(Posma et al., 2009)
Talk to – NOT AT –
people (Anonymous,
2008; Behar-
Horenstein et al.,
2005)
Find out what the patient
already knows before
providing information;
ask, “What do you
already know about high
blood pressure?”
(Kripalani & Weiss,
2006)
New communication skills
require practice to use
them effectively and
structured skill
development exercises
may be helpful for
providers. (Kripalani &
Weiss, 2006)
Ask patients, “Do you need
help understanding
health information?”
(The Joint Commission,
2010)
Adequate
preparation
for teaching
and learning
Repeat the most important
information (Margolis,
2004) and increase the
frequency of the
message exposure
through several
repetitions (Ronco,
Iona, Fabbro, Bulfone,
& Palese, 2012;
Takemura et al., 2011)
Practice empathetic skills
especially when the
view of the patient is
different from that of
the provider (Cant &
Aroni, 2008; Posma
et al., 2009; Skorpen &
Malterud, 1997)
Be aware of nonverbal
messages when
delivering verbal
communication,
including gestures, body
language, and dress
(Cant & Aroni, 2008)
Present the most important
information first
(Margolis, 2004).
Emphasize one to three
key points (Kripalani &
W
eiss, 2006). Focus on
one issue at a time
(Avitzur, 2011). Present
the information in
logical blocks
(Remshardt, 2011). Use
concrete instructions
(Margolis, 2004)
Supplement verbal
education with simple
written and visual
materials (Anonymous,
2008; Behar-Horenstein
et al., 2005; Margolis,
2004); however, the
materials should be used
for reinforcement and not
to replace verbal
instruction or direct
interaction (Anonymous,
2000)
Good teaching
methods
Ask patients to repeat
information in their own
words (Engel et al.,
2009)
Ask patients about their
life experiences and
use to teach (Montin
et al., 2010). Use
metaphors comparing
the patient’s care to
their life situation
(Anonymous, 2008;
Behar-Horenstein
et al., 2005)
Determine the patient’s
barriers to health literacy
(Paasche-Orlow, 2011).
Assessing the ability to
learn may include
interview or observation
(Behar-Horenstein et al.,
2005)
Use easy to understand
language (Kripalani &
Weiss, 2006; Margolis,
2004; Posma et al.,
2009)
Use an interpreter if a
patient requires one due
to language or disability
(Dreger, 2001; Lieu et al.,
2007). Avoid using
technical terminology or
medical jargon (The Joint
Commission, 2010)
Overcoming
barriers to
learning
490 C. Marcus
Provide information in
several different ways to
make sure the patient
understands (Skorpen &
Malterud, 1997).
Audiotapes of patient
consultations can be
effective for patient
recall of verbal
education (Friedman,
Cosby, Boyko, Hatton-
Bauer, & Turnbull,
2011)
Pay attention to the
patient’s worries and
fears and try to dispel
them (Posma et al.,
2009)
On many occasions family
members also need to be
educated (e.g. pain
management) (Behar-
Horenstein et al., 2005)
Patients must be given an
opportunity to ask
questions prior to
discharge. Give them
time to speak
(Anonymous, 2008;
Behar-Horenstein et al.,
2005)
A scripted tool may help
providers verbalize
clearer and more
understandable patient
education (Piazza et al.,
2012)
Teaching as an
interactive
process
Use the teach-back method
(Anonymous, 2008;
Kripalani & Weiss,
2006; The Joint
Commission, 2010)
Ask patients to state their
goals of medical care
to begin a discussion
(Paasche-Orlow, 2011)
Realize that patients may
not even be aware that
they do not understand
what is being
communicated to them
(Engel et al., 2009)
Audiotapes of patient
consultations can be
effective for patient
recall of verbal
education (Friedman
et al., 2011)
Do not just ask the patient,
“Do you understand?”.
Regardless of their
ability to understand,
many patients may still
answer “Yes ” (The Joint
Commission, 2010)
Assessment of
learning
Note: The last column of the EDUCATE model stands for T and E, Teaching and Education goals, which outlines principles of the model as they relate to the model’s individual
components.
Health Psychology and Behavioral Medicine 491
verbal education to those groups, we found a lack of literature on the ideal verbal education
encounter. Measurement of effective verbal education focused mainly on obtaining qualitative
patient satisfaction feedback with the instructions received.
The best practices we identified suggest goals providers should strive for when educating
patients verbally. Providers should be empathetic and pay attention to patients’ fears. Practices
like using concrete instructions may be considered common sense, but may be difficult to
achieve unless one focuses on doing s o. Effective patient education practices need to be
learned and reinforced by staff educators in order to become part of the everyday provider care
environment. There is a well-known marketing adage called “The Rule of Seven”, which
states that someone needs to see or hear your marketing message at least seven times before
they take action and buy from you (Hammer & Stanton, 1995).
In their study, Richard and Lussier (2007) concluded that there is no “ideal” patient education
conversation. Medical terminology itself is a huge challenge; many of the words that describe
medical conditions and treatments are long and multisyllabic and there are no short synonyms.
Even seemingly “normal ” words, like “diet” may be interpreted differently (e.g. all the calories
a person consumes, an organized effort to lose weight, etc.) (Paasche-Orlow, 2011). However,
providers can make a dedicated effort to avoid lingo, which may be so ingrained in speech
that this will require concentration and willpower.
Two of the more challenging aspects of verbal education are finding out what the patient needs
to know (understand the learner) and, after the education has been completed, determini ng if the
patient understood it (enhance comprehension and retention). Providers should conduct health lit-
eracy assessments. Certain patients are extremely knowledgeable about their conditions and the
consultation can build upon that. An assessment is also a way to find out if there are going to be
literacy, disability, or cultural issues. The same education will obviously not apply to every
patient. Teach-back tools, such as the Ask-Me-3 program, are recommended for assessing
whether the education has been effective. Teach-back includes asking questions to assess what
the patient has learned from their education, offering feedback to focus on aspects not understood,
and then reevaluating with additional questions to determine if the patient has learned the infor-
mation (Paasche-Orlow, 2011).
However, even if the patient appears to understand the teaching during a verbal consultation,
this does not assure the ability for self-care when the patient goes home. Patients must be able to
manage and commit to their own healthcare for the education to be effective (Committee on
Patient Safety and Quality Improvement, Committee on Health Care for Underserved Women,
American College of Obstetricians and Gynecologists, & Committee Opinion Number 585,
2014). Throughout the patient’s medical care, there will be numerous providers teaching the
patient, all with different approaches and areas of expertise. Patients need time to understand
and absorb the messages their doctors, nurses, and other caregivers provide.
Education also does not necessarily lead to behavioral change. Questions for further research
include how one should relate learning to behavioral compliance, and what educators’ long-term
roles should be in the spectrum of health and wellness.
The ongoing challenge to healthcare organizations is training the frontline staff responsible for
educating patients. Programs like the American Medical Association’s Health Literacy Train-the-
Trainer Program teaches health care professionals how to conduct health literacy programs, which
may in turn improve provider education and communication (Maniaci, Heckman, & Dawson, 2008).
7. Conclusion
What verbal patient and family education depends upon is the approach and content of patient –
provider communication. Our research indicates that there are many complex parameters that
492 C. Marcus
influence this communication, such as the patient’s learning style, literacy level, culture, environ-
ment, etc. By incorporating our simple EDUCATE model into staff education and professional
practice, healthcare providers can help guide verbal education to be more patient and family cen-
tered. It will be a modification to the providers’ current communication styles to incorporate the
model’s teaching and learning goals into their everyday conversations.
Not all areas of the tool need to be used in all encounters. The EDUCATE model is structured
so that providers can apply modules applicable to the individual teaching situation. In its entirety,
the model addresses the commonly encountered impediments and obstacles we have identified, as
well as provides specific recommendations for modification.
To raise awareness of our findings and educate the hospital staff about our committee’s
project, we sponsored a presentation on verbal education at a meeting of department heads of
our organization and published an article in the hospital newslette r Faulkner Nurse (Marcus,
2011). We also piloted a modified Ask-Me-3 handout and poster in our Rehabilitation Department
to raise awareness of this type of tool. Ask-Me-3 is a tool developed by the National Patient Safety
Foundation that asks three questions: (1) What is my main problem? (2) What do I need to do?,
and (3) Why is it important for m e to do this? (National Patient Safety Foundation, 2013 ). After
educating patients, providers “teach-back” by asking patients the same questions to test if the
learning occurred.
The next steps for our committee are to develop methods of determining whether provider
education is comprehended by patients and their families. While our Ask-Me-3 pilot wa s well
received by patients, we realized that we would need a way to document receipt of patient edu-
cation and change brought about by teach-back tools. We are investigating ways to best document
patient education encounters, which will enhance patient care and outcomes beyond the initial
encounter and throughout the spectrum of the patient’s healthcare continuum.
Acknowledgments
The author thanks the members of the Brigham and Women’s Faulkner Hospital Patient/Family Education
Committee who worked on this project for their time, presentations, literature and manuscript review, and
thoughtful recommendations: Christi Barney, Lisa Cole, Noreen Connolly (Committee Co-Chair),
Maureen Fischer, Jean Flanagan Jay (Ask-Me-3 pilot), Kimberlee Frasso, Ellen Fusfeld, Georgette
Hurrell (developer of nurse survey), Kerstin Palm (Ask-Me-3 pilot), Kitty Rafferty, Peggy Tomasini,
Shannon Vukosa, and John Wright. Christi Barney and Noreen Connolly’s thorough review and suggestions
for this article were greatly appreciated.
The author gratefully acknowledges contributions and assistance from the following individuals and
departments: BWFH Information Systems, Rebecca Blair, Kathy Duckett (presenter at department head
meeting), Carolyn Geoghegan, Sally Gore, Paula Knotts, Megan McAlpine, Pat McCarthy, Bruce Mattus,
Kenneth Pariser, Billie Starks, Drew Sanita, Kelly Schoppee, Kathryn Shaughnessy, and Kieron Tumbleton.
References
Anonymous. (2000). Giving patients the tools is first step, ensuring they understand is the next. Patient
Education Management, 7 (10), 109–112, 120.
Anonymous. (2008). Create a standard for communication despite patient’s level of health literacy. Patient
Education Management, 15(4), 37.
Avitzur, O. (2011). How to make your doctor listen. Consumer Reports, 76(7), 13.
Behar-Horenstein, L. S., Guin, P., Gamble, K., Hurlock, G., Leclear, E., Philipose, M., … Weldon, J. (2005).
Improving patient care through patient–family education programs. Hospital Topics, 83(1), 21–27.
Cant, R. P., & Aroni, R. A. (2008). Exploring dietitians’ verbal and nonverbal communication skills for
effective dietitian–patient communication. Journal of Human Nutrition and Dietetics, 21(5), 502–511.
Cohn, W. F., Pannone, A., Schubart, J., Lyman, J., Kinzie, M., Broshek, D. K., … Garsona, A. T. (2006).
Iailored educational approaches for consumer health (TEACH): A model system for addressing
Health Psychology and Behavioral Medicine 493
health communication. Annual Symposium Proceedings 2006, p. 894. Washington, DC: AMIA.
Retreieved June 18, 2013, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1839357/
Committee on Patient Safety and Quality Improvement, Committee on Health Care for Underserved Women,
American College of Obstetricians and Gynecologists, & Committee Opinion Number 585. (2014).
Health literacy. Obstetrics & Gynecology, 123(2), 380–383.
Dreger, V. (2001). Communication: An important assessment and teaching tool. Insight, 26(2), 57–60.
Elderkin-Thompson, V., & Waitzkin, H. (1999). Differences in clinical communication by gender. Journal of
General Internal Medicine, 14(2), 112–121.
Engel, K. G., Heisler, M., Smith, D. M., Robinson, C. H., Forman, J. H., & Ubel, P. A. (2009). Patient com-
prehension of emergency department care and instructions: Are patients aware of when they do not
understand? Annals of Emergency Medicine, 53(4), 454–461.
Friedman, A. J., Cosby, R., Boyko, S., Hatton-Bauer, J., & Turnbull, G. (2011). Effective teaching strategies
and methods of delivery for patient education: A systematic review and practice guideline recommen-
dations. Journal of Cancer Education, 26(1), 12–21.
Goody, C. M., & Drago, L. (2009). Using cultural competence constructs to understand food practices and
provide diabetes care and education. Diabetes Spectrum, 22(1), 43–48.
Hammer, M., & Stanton, S. A. (1995). The reengineering revolution. New York: Harper-Collins.
Johnson, A., & Sandford, J. (2005). Written and verbal information versus verbal information only for
patients being discharged from acute hospital settings to home: Systematic review. Journal of Health
Education Research, 20(4), 423–429. Retrieved June 18, 2013, from http://her.oxfordjournals.org/
content/20/4/423.long
The Joint Commission. (2010). Advancing effective communication, cultural competence, and patient- and
family-centered care: A roadmap for hospitals. Oakbrook Terrace, IL: Author. Retrieved June 18, 2013,
from http://www.jointcommission.org/assets/1/6/aroadmapforhospitalsfinalversion727.pdf
The Joint Commission. (2012). The Joint Commission E-Edition. Retrieved March 18, 2014, from https://e-
dition.jcrinc.com.
Kit Delgado, M., Ginde, A. A., Pallin, D. J., & Camargo, C. A. Jr. (2010). Multicenter study of preferences
for health education in the emergency department population. Academic Emergency Medicine, 17(6),
652–658.
Kripalani, S., & Weiss, B. D. (2006). Teaching about health literacy and clear communication. Journal of
General Internal Medicine, 21(8), 888–890. Retrieved June 18, 2013, from http://www.ncbi.nlm.nih.
gov/pmc/articles/PMC1831575/
Kruzik, N. (2009). Benefits of preoperative education for adult elective surgery patients.
AORN Journal, 90
(3),
381–387.
Lieu, C. C., Sadler, G. S., Fullerton, J. T., & Stohlmann, P. D. (2007). Communication strategies for nurses
interacting with deaf patients. Medsurg Nursing, 16 (4), 239–245.
Liu, X., Luo, H., Zhang, L., Leung, F. W., Liu, Z., Wang, X., … Guo, X. (2014). Telephone-based re-edu-
cation on the day before colonoscopy improves the quality of bowel preparation and polyp detection
rate: A prospective, colonoscopist-blinded, randomised, controlled study. Gut, 63(1), 125–130.
Maniaci, M. J., Heckman, M. G., & Dawson, N. L. (2008). Functional health literacy and understanding of
medications at discharge. Mayo Clinic Proceedings, 83(5), 554–558.
Marcus, C. (2011, Summer). Patient and Family Education Committee provides recommendations for verbal
education. Faulkner Nurse,p.11.
Margolis, R. H. (2004). Boosting memory with information counseling: Helping patients understand the
nature of disorders and how to manage them. The ASHA Leader, 9(14), 10–13. Retrieved June 18,
2013, from http://www.asha.org/Publications/leader/2004/040803/f040803b.htm
Montin, L., Johansson, K., Kettunen, J., Katajisto, J., & Leino-Kilpi, H. (2010). Total joint arthroplasty
patient perception of received knowledge of care. Orthopaedic Nursing, 29(4), 246–253.
National Patient Safety Foundation. (2013). Ask Me 3. Retrieved February 2, 2013, from http://www.npsf.
org/for-healthcare-professionals/programs/ask-me-3
Owen, M. (2005). Take lead in filling your patients’ perception gap; low health literacy affects many people.
Patient Education Management, 12(11), 126–127.
Paasche-Orlow, M. (2011). Caring for patients with limited health literacy: A 76-year-old man with multiple
medical problems. Journal of the American Medical Association, 306(10), 1122–1129.
Piazza, G., Nguyen, T. N., Morrison, R., Cios, D., Hohlfelder, B., Fanikos, J., … Goldhaber, S. Z. (2012).
Patient education program for venous thromboembolism prevention in hospitalized patients. American
Journal of Medicine, 125(3), 258–264.
494 C. Marcus
Posma, E. R., van Weert, J. C. M., Jansen, J., & Bensing, J. M. (2009). Older cancer patients’ information
and support needs surrounding treatment: An evaluation through the eyes of patients, relatives and pro-
fessionals. BMC Nursing, 8, 1. Retrieved June 18, 2013, from http://www.biomedcentral.com/1472–
6955/8/1
Remshardt, M. A. (2011). The impact of patient literacy on healthcare practices. Nursing Management, 42
(11), 24–29.
Richard, C., & Lussier, M. T. (2007). Measuring patient and physician participation in exchanges on medi-
cations: Dialogue ratio, preponderance of initiative, and dialogical roles. Patient Education and
Counseling, 65(3), 329–341.
Ronco, M., Iona, L., Fabbro, C., Bulfone, G., & Palese, A. (2012). Patient education outcomes in surgery:
A systematic review from 2004 to 2010. International Journal of Evidence Based Healthcare, 10(4),
309–323.
Skorpen, J. B., & Malterud, K. (1997). What did the doctor say – What did the patient hear? Operational
knowledge in clinical communication. Family Practice, 14(5), 382–386. Retrieved June 18, 2013,
from http://fampra.oxfordjournals.org/content/14/5/382.long
Takemura, M., Mitsui, K., Itotani, R., Ishitoko, M., Suzuki, S., Matsumoto, M., … Fukui, M. (2011).
Relationships between repeated instruction on inhalation therapy, medication adherence, and health
status in chronic obstructive pulmonary disease. International Journal of Chronic Obstructive
Pulmonary Disease, 6,97–104. Retrieved June 18, 2013, from http://www.ncbi.nlm.nih.gov/pmc/
articles/PMC3048085/
Talen, M. R., Grampp, K., Tucker, A., & Schultz, J. (2008). What physicians want from their patients:
Identifying what makes good patient communication. Families, Systems & Health, 26(1), 58–67.
Tye-Murray, N. (1992). Preparing for communication interactions: The value of anticipatory strategies for
adults with hearing impairment. Journal of Speech and Hearing Research, 35(2), 430–435.
Vreeland, D. G., Rea, R. E., & Montgomery, L. L. (2011). A review of the literature on heart failure and
discharge education. Critical Care Nursing Quarterly, 34(3), 235–245.
Health Psychology and Behavioral Medicine 495
