136 Chapter 6 Our findings support previous literature reporting satisfaction with teach-back by patients and proxies [23,46]. Although satisfaction was already high in both study groups and the between-group differences were small, participants seemed more satisfied with the discharge conversation after receiving teach- back; the vast majority described teach-back as a self-evident and useful tool to help confirm learning and to avoid forgetting key information. This finding contradicts concerns by both patients and professionals that teach-back might be perceived as a patronizing or condescending way of determining if information is understood [46,47]. Contrary to previous studies questioning the feasibility of teach-back in the ED setting [48,49], our study did not show an extension of discharge time as a result of teach-back. Interestingly, discharge conversations with teach-back were generally shorter than ‘standard’ discharge conversations. This suggests that teach-back may contribute to more efficient care in a setting where professionals often need to work under time constraints. Our study had several limitations. First, we conducted a pre–post design without randomisation. Although causation cannot be determined in this type of study design [50], there were no major policy changes in the delivery of care or other healthcare quality improvement initiatives in the ED during our study period that could have confounded the findings. Also, the created time plots and histograms illustrate that retention of discharge instructions was not already changing in the desired direction prior to the implementation of teach-back and suggest that found effects were most likely related to the use of teach-back rather than a general ongoing trend over time. Second, the study was performed in a single ED site. The findings may, therefore, not be generalisable to other sites. Third, the relatively small sample of older participants limits the precision of the associations on knowledge retention and self-management. Although this was a limiting factor, we deliberately chose to use the available research time and capacity to ensure provider compliance with teach-back, perform a reliable pre–post analysis of outcomes and provide an accurate determination of knowledge retention of discharge instructions provided at ED discharge. Fourth, data were collected by two investigators who were not blinded to the phase of the study. This may have introduced interinvestigator variation and bias in the collection of interview data and in the assessment of knowledge retention. However, we tried to control for these aspects by using a standardised interview protocol and scoring system. In addition, interrater agreement of knowledge retention was tested and the tests showed acceptable kappa scores. Fifth, participants may have been aware of a change in the discharge process. Self-reported findings on satisfaction and self-management may have been biased by the Hawthorne effect. Sixth, some selection bias may have occurred because of patient unavailability at the time of the phone
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