Let's face it. The way we, as a healthcare system in general, have been communicating with our patients for the past several decades hasn't worked well. Patients just don't seem to do what we tell them to do or want them to do. Everyone is frustrated. Something has to change.
Not Patient Centered
Our current system is not really patient centered. It is one that is driven by healthcare accrediting agencies such as the Joint Commission, the Commission on Accreditation of Rehabilitation Facilities or the Accreditation Association for Ambulatory Health Care. Providers with 10- to 15-minute appointments for each patient must cram all the preventive criteria and other mandated indices for accreditation into the visit, as well as the actual reason for the visit. That leaves little time for active listening, joint discussion, resolution of healthcare issues and goal setting. The other major distraction is the use of the electronic health record, which limits face-to-face contact between provider and patient. Traditional approaches to patient care recognize the healthcare provider as the expert, giving facts and do's and don'ts to achieve optimal health and wellness. It has become more like a parent-child relationship.
Nurse practitioners and physician assistants have been trained in the traditional medical and nursing models and have generally bought into this type of patient-provider interaction. How can they use what they already know to change how healthcare is delivered?
One evolving method, health coaching, is to shift toward a partnership model in which "clients" (the term preferred in this approach because "patient" suggests someone not on an equal level with the provider) are responsible for their healthcare and help direct their healthcare. The provider is responsible for using special techniques, personal experience, expertise and encouragement to assist the client in meeting healthcare goals. It is not about giving advice; it is about helping the client remove obstacles that prevent his or her goal from being achieved. It is performed in an atmosphere in which providers give full attention to the client.
Health coaching is not new. It actually began in the 1990s, with psychologists who were treating people addicted to alcohol. They determined that motivational interviewing, the approach used in health coaching, is more cost effective and timely than other strategies in reaching desired results. A survey conducted in 20061 identified the following successful attributes for health coaches:
The type of communication used in health coaching is much more person-centered than current practice. The interpersonal relationship between the provider and the client influences the quality of the care provided, and the ultimate goal is to support the client's overall health and well-being. The shift is giving control to the client.
Setting the Stage
Prochaska's stages of change theory2 presents six well-defined stages:
Precontemplation: People in this stage have no intention of changing their ways and often deny that they have a problem.
Contemplation: People in this stage realize that there is a problem and begin to think about possible solutions.
Preparation: People in this stage are planning to take action on the problem identified.
Action: This stage is absorbed and intentional, with specific behaviors being modified.
Maintenance: People in this stage continue to maintain the changes made in the action phase. A strong commitment is needed so that healthy habits continue and relapses do not occur.
Termination: This stage represents the ultimate goal, and the behavior no longer represents a risk or temptation to backslide.
The health coach assesses which stage the client is in and assists him or her in progressing to the next stage.3 Each stage does not inevitably lead to the next; it is possible to become stagnant in one stage. By understanding the stages and the mental complexity that accompanies each one, the NP or PA can help effect change. It is important to realize that this is the client's responsibility overall. Record-keeping should include documentation of progress toward goals or barriers to progress, either real or perceived.3
Once a health issue has been identified and discussed, goals should be set. Effective health coaches need to have the ability to understand the use of conventional medical treatments as well as alternative or integrative options to effectively guide the client toward a more healthy state. There are six criteria for goal setting: The goal should be specific, measurable, agreed upon, realistic and time sensitive, and the roles of the provider and the client must be spelled out.4
The downside to health coaching in our current system is that it is time intensive. Health coaching can't be done in a 7- to 11-minute time block! A comprehensive assessment that encompasses mind, body and spirit with a well-defined and validated wellness assessment tool (such as the Wheel of Life tool at http://www.wholeperson.com/) lays the foundation and begins the journey for the client. This initial reflection of the client's current state of being helps to prioritize and shape goals. Many coaches allow 1 to 2 hours for this initial intake. Follow-up sessions are derived by goals set and plans implemented. Telephone appointments may also be used and can be just as effective as face-to-face meetings.3
Incorporating health coaching into an existing practice can have the positive effect of achieving better understanding of the person who is being cared for and what may be underlying causes of an acute or chronic problem. Obviously, there is a need for a medical team that is well versed in acute illnesses as well as chronic conditions. Clients do not have expertise in these matters. However, the client should receive explanation of all options for treatment so that he or she can make an informed decision in partnership with the provider. This can be done in less time intensive appointments.
Support for the client's goals may require involvement of other specialties, such as nutritionists, physical therapists and mental health professionals. The client may have ideas about where to find these support systems or may need suggested referrals from the health coach.3
Methods to measure and track the progress of goal setting and to identify outcomes are necessary. When will clients know that they have succeeded? Making the shift to the health coaching model can result in improved quality of care, increased satisfaction with healthcare, and improved health outcomes.5,6 Isn't that what we all want?
Healthcare practitioners who are interested in becoming health coaches can find many programs across the country. These programs are mostly geared to the nonprofessional student. One program, Health Coaching Made Easy for Healthcare Providers is provided through the National Society of Health Coaches. More information can be obtained at www.nshcoa.com.
1. MacPherson C, Mulvihill M. Defining Best Practices in Health Coaching. http://www.ceridian.com/www/content/9998/15514/15571/15582/15669/defining_best_practices.pdf
2. Prochaska JO, et al. Changing for Good: A Revolutionary Six-Step Regiment for Overcoming Bad Habits and Moving Your Life Positively Foward. New York, N.Y.: Harper Press; 1994.
3. Arloski M. Wellness Coaching for Lasting Lifestyle Change. Duluth, MN: Whole Person Associates; 2007.
4. Drucker P. The Practice of Management. New York, N.Y.; Harper Collins: 1993.
5. Luck S. Wellness Coaching in Integrative Health Care: A Holistic Nursing Perspective. http://www.integrativepractitioner.com/article.aspx?id=17056
6. Morgan S, et al. A concept analysis of person-centered care. J Holist Nurs. 2012;30(1):1:6-15.
Rosemary King is an adult nurse practitioner who provides health coaching and hypnotherapy at her business, Focused Wellness Solutions (www.FocusedWellnessSolutions.com), in Green Valley, AZ.