Training participants were 16 female maternal and child health nurses, including the team leader who oversaw operations. Focus group (n = 8) and interview (n = 5) participants were 13 nurses (including the team leader) aged 37–61 years (mean 55.1) who had been registered as nurses for 13–41 years (mean 29.5 years) and working in maternal and child health for between 7 months and 33 years (mean 14.2 years). Two had worked on a helpline previously. Number of shifts nurses worked per week ranged from 1 (3–4 h) to full-time (team leader); training groups were balanced by average hours worked per week. Two nurses who attended training declined to be interviewed, saying they had not had much opportunity to use Teach-Back due to rostering and leave. One was on leave and could not be contacted.
All nurses made an effort to engage with the online surveys. Responses were inconsistent however, ranging from 14 to 608 call reflections per nurse as captured in the online survey (0 to 265 reflections following Teach-Back training) and 1 to 20 end-of-shift reflections per nurse. This reflected differences not only in hours worked during the study period but also in interpretation of and engagement with the self-reflection activities. We examined distributions of the quantitative data from the self-reflection surveys (Additional file 1) to identify how frequently nurses reported using Teach-Back (following training). Most nurses (n = 10) most commonly responded that they used Teach-Back “fully”; for two others the mode was “yes-somewhat or partially”. This suggests that overall nurses made considerable effort to use Teach-Back strategies. Two nurses most frequently responded that they did not use Teach-Back because they felt it was “inappropriate” for that call.
We explored nurse experiences learning the new skills, what worked, and what could be improved for learning to use Teach-Back (Additional file 2). We identified three key themes in the data: learning to use Teach-Back, using self-reflection for skill development; and suggestions for future. In the nurse quotes reported below, we denote data from focus groups and interviews “N”, and comments from the self-reflection surveys “SR”.
Changing practice: Learning to use teach-back
Confirming a lack of prior knowledge of Teach-Back, all but one nurse reported she had not learned or used Teach-Back previously.
“It was all teach, not teach-back”. (N5).
Prior to the Teach-Back workshop nurses’ self-reflections described using communication techniques such as active listening, confirming understanding, and asking for clarification; but some noted they were not always sure if clients understood or will follow through. Following training, nurses reported asking callers what they will do following the call, and indicated they found added value from Teach-Back techniques.
“Clients showed me that they understood my instructions. It helps me feel more confident that the information I am conveying is coming across accurately.” (SR).
Several nurses reported speaking to a client who was unable to Teach-Back the information. Nurses commented both on the perceived impact on the client “I think she felt embarrassed and felt like she had been put on the spot” (SR), and expressed interest or surprise that their message had not been received “oh my goodness she could not recall one word I said!” (SR).
A few nurses reported they were comfortable using Teach-Back within one or two shifts, but many struggled to find wording that sounded or felt natural to them, or felt that they were imposing Teach-Back on callers. One nurse reported feeling overwhelmed by numerous possible Teach-Back strategies, saying this interfered with her ability to focus on the call and implement Teach-Back. One technique reported to be effective was to read through the list of suggested phrases, identify a couple that sounded “like me”, and restrict Teach-Back to those phrases.
“Well try not to get too bogged down in how to go about it, find something that's natural and easy that will just sort of roll off the tongue. It's going to take time, isn't it …” (N2).
Nurses commented that they enjoyed the approach to training and this was a factor in them embracing it. They made frequent reference to the training video because it highlighted the contextual factors of the unseen caller that may interfere with information transfer. The majority thought the social environment of face to face sessions were important for introducing a new skill such as Teach-Back. One nurse commented that the training had too much theory and not enough role playing. Nurses frequently mentioned that they enjoyed the practical application of skill during role play, because “nurses are such practical people”. (N3).
“Yeah, two times was good I think…and the fact that we swapped partners as well, so you didn't just do it with the same person, that seemed to work well.…”(N6).
Comfort with using Teach-Back did not appear to be related to prior experience or the overall number of shifts worked. In the self-reflections nurses commented they were “getting better” or “more comfortable” with using the techniques over time, indicating practice may help overcome some of these barriers. When Teach-Back was not considered appropriate nurses indicated this was because of a distressed child that needed attention, because the caller taught back spontaneously, or the call was a transfer to another service. At the end of the shift some nurses reflected they did not use Teach-Back as often as they thought they “should”.
Self-reflection to support skill development
One nurse described the self-reflection that is part of nurse training:
“We are taught to do self-reflection as nurses.. [if].. there was some issue you need to unpack it yourself or improve what actually happened in that call...” (N9).
In focus groups and interviews nurses commented that the self-reflection surveys were helpful initially but became boring and repetitive after a while. Despite this, many nurses commented that this was the first time they had truly reflected on their own calls. One nurse reported she enjoyed the opportunity to reflect on “good” calls, and others described the self-reflections as therapeutic by helping remove any worries about how clients were going to manage the situation or what they would do after hanging up.
“And it produces closure to the day, to the shift, [so you don’t] go home worrying that somebody’s going to do something at three o’clock in the morning… ”(N3).
Some mentioned it was difficult to keep up with self-reflections when multiple calls were coming through in rapid succession. The multiple tasks sometimes resulted in them forgetting to use Teach-Back, self-reflect, and/or recruit the caller for follow-up. Some nurses commented that they tended to self-reflect instinctively, but others mentioned it was helpful to have this focus and think about their own satisfaction with the call.
“I think the reflecting was good to start with, I don’t know that we need to do it anymore, but I wonder if you need to revisit it…...every couple of months or twice a year or once a year.”(N6).
Nurses mentioned that visual reminders such as posters or a field in their computer system that they need to check each time would be helpful to maintain Teach-Back practice. Several mentioned it would be helpful to have a follow-up session with the trainers to monitor progress and to learn from their colleagues. Some thought Teach-Back could be incorporated into their performance management and professional development, or could be part of the initial training they underwent when starting work at the helpline. A few thought training could be conducted via video or podcast but found added value with the group face to face interaction. All nurses commented that learning from colleagues and listening to real examples was very helpful for learning how to apply new communication techniques in different contexts.
“I find just the listening [to other nurses] works really well….because I think you just learn to do it on the run.” (N2).
Although there was widespread agreement that they learned the most from each other, nurses noted opportunities to do this were limited because they were rarely together in the same room. Some suggested that the team leader, who routinely reviews calls for quality audits, could identify call recordings in which Teach-Back was used very well (or very poorly) for training purposes; others thought there may be also value in listening to recordings of their own calls:
“Even the times where I thought, I didn't say that correctly, they gave me the responses that I expected and I thought obviously I must have sounded better than what I thought. So if you can reflect on that and listen to yourself, that's a good teaching tool.” (N1).
Integration with theoretical domains framework
In Table 1 we presented the barriers and enablers to using Teach-Back identified in the literature, and strategies to manage them informed by the revised Theoretical Domains Framework (TDF). Here we discuss the nurse data with reference to the TDF (domains denoted “x)” corresponding to numbering in ). With respect to nurse behaviour change, the primary objectives in this study were to increase nurses’ 1) knowledge, 2) skills, and 4) beliefs about capability to use Teach-Back in telephone consultations. In order to embed Teach-Back into professional practice it primarily targeted 14) behavioural regulation (self-monitoring), 3) professional role and identity, and 6) beliefs about consequences. The option to count self-reflection activities towards continuing professional development accreditation also acted as a reward, i.e. 7) reinforcement.
Feedback from nurses suggests the program was largely successful in developing 1) knowledge and 6) beliefs about consequences of Teach-Back; however, nurses reported varying levels of 2) skill, 13) comfort and 4) beliefs about capabilities for using Teach-Back. The wide range of Teach-Back phrases offered as a resource for nurses negatively impacted 10) attention and memory processes for some, a difficulty that may have been compounded by the additional requirement to complete self-reflection surveys. Explicit instructions to focus on only one or two Teach-Back phrases may overcome this. Future implementation may add salient 11) environmental cues such as visual reminders in the workplace like posters or a “did you use Teach-Back” checkbox in the customer relationship management (CRM) software. Future iterations should also facilitate opportunity to learn from colleagues for both 2) skills and 12) social influences. This might include formal training with colleagues by telephone, for example telephone role-play scenarios - although the social impact of a telephone conversation is likely different from a group session.