NR 602 Week 8 Practice Reflection Example

Practice Reflection: A Parent Who Nodded Through the Milk Advice and Then Asked Whether to Give More Whole Milk, and the Teach-Back That Replaced My Explanations

Student Name

College of Nursing, Chamberlain University

NR 602: Primary Care of the Childbearing and Childrearing Family Practicum

Instructor Name

Month Day, Year

Practice Reflection: A Parent Who Nodded Through the Milk Advice and Then Asked Whether to Give More Whole Milk, and the Teach-Back That Replaced My Explanations

The Position I Started From

I came into this practicum believing that if I explained something clearly, families understood it. I am a careful explainer. In my first weeks I measured a visit's success by whether I had covered everything on the guidance list.

One Exchange, in Detail

At M.O.'s 15-month visit, I explained to the parent that M.O.'s weight had fallen across two percentile lines, that the likely cause was too much milk and that M.O. should have no more than two or three cups of milk a day. I explained iron deficiency, showed the growth chart and wrote down the plan. The parent nodded throughout and said, "Okay, that makes sense."

At the door, the parent turned and asked: "So whole milk is good for the iron, right? Should I switch to the whole milk instead of the two percent at daycare and give more of it?"

Nothing I had said had landed. The parent had heard "milk" and "iron" in the same breath and concluded that milk supplied iron. My preceptor sat back down with the parent and asked, "Can you tell me how many cups of milk M.O. will drink tomorrow, and when?" The parent said, "As much as M.O. wants, I guess, because it's healthy." We started again.

What I Misread

I took nodding for understanding. I did not ask a single question that required the parent to say the plan back. I had also loaded the explanation with too much: percentiles, iron, milk and the growth chart in one stretch, in clinical language, with a hungry and tired toddler on the parent's lap.

I also assumed that the parent and I shared a picture of milk. For the parent, milk was the healthiest thing a toddler could drink, something grandparents and advertisements had confirmed for years. My advice to limit it collided with that picture, and the parent resolved the collision by hearing what fit.

What Changed

The second explanation, led by my preceptor, was different in three ways. It was shorter: one change, "two to three cups a day, in a cup, with meals." It used the parent's words: "bottles" and "cups," not ounces and percentiles. And it ended with the parent saying the plan back: "Three cups, at breakfast, lunch and dinner, no bottle at night." The parent then asked a real question, about what to do when M.O. cried for the bottle at bedtime, which we answered.

Teach-back, in which the family restates the plan as they understood it, has been shown in a systematic review to improve understanding and adherence in health education (Ha Dinh et al., 2016). I had read about it. I had not done it, because I thought my explanations were clear enough not to need it.

Why the Second Explanation Worked

I have thought about why the preceptor's version worked when mine did not. Mine was accurate and complete. The preceptor's was short and practical, and it gave the parent something to do rather than something to understand. "Two to three cups, with meals" is an action. "Milk displaces iron-rich foods" is an idea, and the parent had a stronger idea about milk already.

What I Now Do

I give one main change per visit where possible, in the family's words. I end with a teach-back question that cannot be answered with yes: not "Does that make sense?" but "What will you do differently tomorrow?" When the answer is wrong, I treat it as information about my explanation, not about the parent.

Did It Work for M.O.?

At the 4-week follow-up, the parent reported three cups a day and no bedtime bottle. M.O.'s weight had risen from 9.6 kg to 9.8 kg and hemoglobin from 10.1 to 10.9 g/dL. Then the ear infection at 17 months cost 0.4 kg. The guidance was understood and followed; the illness was not something guidance could prevent. Milk at this age displaces iron-rich food (Baker & Greer, 2010), and the recovery fits that explanation.

What Is Still Unresolved

I am also unsure how teach-back works when a family speaks another language through an interpreter, since a correct answer may reflect the interpreter's skill as much as the family's understanding.

Teach-back takes time, and I have not yet worked out how to fit it into a 15-minute well child visit with three or four topics. My preceptor's answer is fewer topics. I worry about what gets left out. The Bright Futures guidance for each visit covers many priorities (Hagan et al., 2017), and choosing which to leave for later still feels uncomfortable.

A Commitment Narrow Enough to Check

For the rest of the practicum, I will end every well child visit with one teach-back question about the single most important change, and I will record in my practicum log whether the answer was correct the first time. After four weeks I will count how many first answers were wrong. If it is more than one in four, my explanations, not the families, are what need work.

References

Baker, R. D., Greer, F. R., & Committee on Nutrition. (2010). Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics, 126(5), 1040-1050. https://doi.org/10.1542/peds.2010-2576

Ha Dinh, T. T., Bonner, A., Clark, R., Ramsbotham, J., & Hines, S. (2016). The effectiveness of the teach-back method on adherence and self-management in health education for people with chronic disease: A systematic review. JBI Database of Systematic Reviews and Implementation Reports, 14(1), 210-247. https://doi.org/10.11124/jbisrir-2016-2296

Hagan, J. F., Shaw, J. S., & Duncan, P. M. (Eds.). (2017). Bright Futures: Guidelines for health supervision of infants, children, and adolescents (4th ed.). American Academy of Pediatrics.