Strategies and approaches for evaluating patient learning
The Teach-Back Method
The teach-back method is widely recognised as one of the most effective ways to assess patient learning. Instead of simply asking, “Do you understand?”, which can result in yes/no answers that do not assess actual comprehension, the teach-back method encourages patients to explain key information in their own words.
Let’s look at some examples in practice.
- “Just so I can be sure I explained this clearly, can you tell me what you are going to do when you get home?”
- “We covered a lot today about your back pain. Let’s go over the key points. Can you tell me the three things you are planning to do to manage your symptoms?”
Why the teach-back approach is so effective
- It encourages active recall rather than passive agreement.
- It identifies misconceptions early, so they can be corrected before they become ingrained.
- It reinforces learning by prompting the patient to process and summarise the information, often in a different way than it was initially delivered.
Assessing problem-solving with hypothetical scenarios
This approach allows us to see whether the patient can apply the information or skills learned during education, rather than simply repeating information. By asking patients how they would handle realistic situations related to their condition, you can assess their ability to apply knowledge in a practical context.
- “If your pain flares up while you’re at work, what strategies would you use to manage it?”
- “Let’s say you’re getting ready for a long car ride. What are some things you would do to prevent stiffness and discomfort?”
- “When your grandchild asks to be picked up, can you show me how you will do that?”
Why it works:
- Tests real-world application of knowledge.
- Encourages problem-solving and critical thinking.
- Highlights gaps in understanding, allowing for targeted follow-up education.
Patient demonstration of skills
If your patient education includes physical tasks (e.g., exercises, using assistive devices, ergonomic adjustments), observing the patient perform the skill is a highly effective evaluation method.
- “Can you show me how you would perform this exercise at home?”
- “Let’s go through how you’ll set up your workstation to help with your neck pain, can you walk me through it?”
Why it works:
- Identifies errors in execution that can be corrected.
- Ensures patients feel confident performing skills on their own in their own context.
- Reinforces correct technique and adherence.
Evaluating behavioural changes over time
Our education may be focused on changes in behaviour, such as increased physical activity, better symptom management, or improved adherence to a treatment plan. Checking in on these changes over time helps determine whether the education was effective.
- “Since our last session, how have you been applying what we discussed?”
- “Have you noticed any changes since using the strategies we talked about?”
- “What’s working well for you, and what’s been more challenging?”
Why it works:
- Reinforces continued learning and adaptation.
- Allows us to provide further guidance or motivation.
- Encourages self-reflection, which can improve adherence.
Using questionnaires or other measures to evaluate patient education
Other evaluation strategies can be used to provide a more comprehensive picture of the outcomes of our patient education.
Why consider using questionnaires?
Self-report measures like questionnaires can provide reliable and objective measures of patient knowledge, confidence, and engagement, or other outcomes of patient education. They are particularly valuable when used at the start and end of an education program, across multiple sessions, or as part of program evaluation or discharge planning. Having objective measures are helpful for showing change over time and can be particularly helpful when communicating to the patient, other health professionals and funding providers.
The Patient Activation Measure (PAM-13)
The Patient Activation Measure (PAM) is a validated tool (Hibbard et al, 2005) that can be used in physiotherapy settings to assess the knowledge, skills and confidence that our patients have towards managing their health. It is designed to measure how engaged and proactive a patient is in self-care and decision-making.
Research indicates that higher PAM scores are associated with better adherence to physiotherapy and improved functional outcomes. For instance, a study found that higher PAM scores correlates with greater participation and engagement in postoperative physiotherapy following surgery (Skolasky et al, 2008).
Let’s look at some example PAM-13 questions: (Patients rate their agreement on a 4-point scale: Strongly Disagree – Disagree – Agree – Strongly Agree)
I know what treatments are available for my health problems.
I am confident I can figure out solutions when new problems arise with my health.
I am confident that I can follow through on medical treatments I may need to do at home.
Why consider using the PAM-13?
- It can help identify how ready a patient is to take an active role in their care.
- It allows us to tailor education and support based on a patient’s activation level.
- It can track improvements in self-management behaviours over time.
The Health Education Impact Questionnaire (heiQ)
The Health Education Impact Questionnaire (heiQ) (Osborne et al., 2007) is a tool that assesses the effectiveness of patient education programs by evaluating changes in self-management skills, health literacy, and emotional well-being for individuals with chronic conditions. The tool evaluates eight key dimensions, all considered critical in the overall outcomes of patient education for those with chronic conditions. These are:
- Positive and Active Engagement in Life
- Health Directed Behaviour
- Skill and Technique Acquisition
- Constructive Attitudes and Approaches
- Self-Monitoring and Insight
- Health Service Navigation
- Social Integration and Support
- Emotional Wellbeing
Why consider using the heiQ?
- It evaluates the broader impact of patient education, including emotional well-being.
- It captures whether patients feel more capable and empowered after education.
- It can be used to assess specific education interventions (for example, pain management programs).
The Brief Illness Perception Questionnaire (BIPQ)
The BIPQ (Broadbent et al, 2006) measures how patients perceive and understand their health condition. It is particularly useful for assessing misconceptions or negative beliefs that may affect self-management.
Example BIPQ items: (Patients rate each question on a 0–10 scale, with higher scores indicating stronger agreement with the perception.)
How much does your condition affect your daily life? (0 = No effect, 10 = Severe effect)
How well do you feel you understand your condition? (0 = No understanding, 10 = Full understanding)
How much control do you feel you have over your condition? (0 = No control, 10 = Full control)
How concerned are you about your condition? (0 = Not at all, 10 = Extremely concerned)
Why use the BIPQ?
- It helps identify negative illness beliefs that may shape our patient education by identifying misunderstandings early in the education process.
- It can be used to measure changes in patient perceptions before and after education.
The Self-Efficacy for Managing Chronic Disease Scale (SEMCD)
The SEMCD (Stellefson et al, 2012; Ritter & Lorig, 2014) measures a patient’s confidence in managing their symptoms, emotions, and treatment plan. It is particularly useful for assessing long-term self-management skills if this has been a focus of our patient education.
Example SEMCD items: (Patients rate their confidence on a 1–10 scale, where 1 = Not at all confident, and 10 = Completely confident.)
How confident are you that you can keep the physical discomfort or pain of your disease from interfering with the things you want to do?
How confident are you that you can keep the emotional distress caused by your disease from interfering with the things you want to do?
How confident are you that you can do things other than just taking medication to reduce how your illness affects your everyday life?
Why use the SEMCD?
- It assesses the patient’s ability to self-manage rather than just their knowledge.
- It can be used to track confidence changes over time following patient education.
- It highlights areas where further support or education may be needed.
Condition-specific self-report tools
For some conditions, we have access to specific questionnaires that can provide more targeted insights into the effectiveness of our patient education for particular conditions. For example,
The Oswestry Disability Index (ODI) – Evaluates functional limitations due to back pain.
The Knee Injury and Osteoarthritis Outcome Score (KOOS) – Assesses pain, function, and quality of life for knee osteoarthritis.
The Tampa Scale for Kinesiophobia (TSK) – Measures fear of movement and avoidance behaviors, which are key barriers to recovery.
Why use condition-specific tools?
- They can provide a deeper understanding of how education affects daily function.
- They allow us to track physical and psychological progress.
- They can help evaluate the effectiveness of our condition-specific education.
Integrating self-report measures into physiotherapy practice
Self-report measures can be integrated into routine physiotherapy consultations in a number of ways. This might include:
At the start of a session – to assess baseline knowledge, confidence, or engagement.
At the end of a session – to check comprehension, identify concerns, or reinforce learning.
Between sessions – through follow-up surveys or patient journals to track progress over time.
At discharge – to evaluate long-term improvements in confidence and self-management.
Avoiding common pitfalls in patient education evaluation
Looking now at the range of ways we have learned about how to evaluate our patient education, let’s look at some common issues we need to be aware of:
Pitfall 1: Asking “Do you understand?”
Patients may say “yes” even if they are confused or misinterpret the information.
Better alternative: Ask them to explain or demonstrate their understanding.
Pitfall 2: Making the teach-back method awkward
Asking “can you repeat back to me what you’ve learned” is awkward, puts the patient on the spot and does not really assess understanding.
Better alternative: Frame the teach-back method as a way to check your own explanation: For example “I realise I’ve covered a lot today. Just so I can make sure I explained things clearly, can you tell me what your understanding is now about what’s happening with your knee?”
Pitfall 3: Leaving evaluation too late
If we leave evaluation too late, we fail to provide opportunities to correct misunderstandings as they arise.
Better alternative: Evaluate patient learning as you go, so that you can be up to date with the patient’s understanding.
Pitfall 4: Not individualising the evaluation process
Different patients learn in different ways, some may need verbal repetition, others may need hands-on practice.
Better alternative: Use a mix of evaluation methods (teach-back, demonstration, problem-solving).
Conclusion
Evaluating the effectiveness of patient education is just as important as delivering it. Without proper evaluation, there is no way to confirm whether patients truly understand and can apply what they have learned. We have a range of ways of evaluating patient learning, including:
- Using the teach-back method to check understanding.
- Applying hypothetical scenarios to test problem-solving skills.
- Observing patient demonstrations of skills we have taught.
- Checking for behaviour changes over time to assess long-term impact.
- Using self-report measures.
By integrating ongoing evaluation into physiotherapy practice, we can ensure that patient education leads to meaningful improvements in health outcomes.
