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Traditional Patient Teaching is Out.. Health Coaching is IN!

Nurses Article   (1,525 Views 22 Comments 764 Words)
by MHuffman MHuffman (New Member) New Member

9 Likes; 1 Article; 122 Visitors; 3 Posts

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Do you know of someone who has struggled to say on a special diet, who has difficulty making exercise part of a weekly routine, or one who doesn’t quit smoking even though the risk of lung cancer related to tobacco is widely known?  OR maybe you have had difficulty changing an unhealthy behavior in your life only to fall short time after time.  Changing behavior isn’t easy, even when you know it’s better for you. Why is this? This brief article explains this interesting phenomenon and how nurses can make a difference!

Traditional Patient Teaching is Out.. Health Coaching is IN!

Research at Oregon Health and Science University in the U.S. revealed the most common reasons why people don’t change behavior. 

  • Their values don’t support it.
  • They don’t think it’s important.
  • They don’t think they can.
  • They haven’t worked through their ambivalence.
  • They aren’t ready for it.
  • They don’t have a good plan.
  • They don’t have adequate social support.

Notice that “lack of knowledge” isn’t on this list. A few years ago, the motivation for me personally to change my exercise level and dietary habits to address my high cholesterol had more to do with the personal implications for my life than my knowledge about my condition or its potentially detrimental effects. After all, I’m a cardiovascular clinical nurse specialist. I enjoyed eating and didn’t want to give up the foods I love. Regular exercise only dropped my total cholesterol by nine points and barely budged my HDL/LDL. I was disappointed and torn between the two choices. Such is the difficulty with health behavior change.  

The traditional approach to health teaching directs information “at” the patient/client, expecting compliance. In essence, a healthcare provider’s goal is to have the patient/client do the things we determine they need to do; most often as the result of the diagnosis, condition, or prescribed treatment plan.  Our expectation is that if we impart this knowledge to the patient/client and family, they will and should comply. Generally, this “knowledge-only” based approach has little concern for how this affects the social context of the patient/client’s life. 

Dr. William Miller, originator of Motivational Interviewing, suggests that people have difficulty with changing behavior, not because they don’t understand its downside, but because they have conflicting feelings about it. Consider these examples: “I would exercise, but I’m just too tired when I get home”.  “I know that I should eat more fruits and vegetables, but I don’t have time to cook.”  “I had my new prescription filled, but the more I thought about taking it, the more concerns I had. So, I haven’t started it.”

Dr. Miller goes to say that it’s the “but” in the middle that maintains the patient’s status quo or ambivalence about the change. As healthcare providers, we can “tell” individuals what to do and “teach” them how to do. However, guiding them to explore their ambivalence about their condition or situation is the key to tapping into their own motivation to do something about it.

Evidence-based Health Coaching (EBHC) is not counseling, but skilled conversation that engages individuals to discuss their health and health conditions within the social context of their lives, to identify their own values, beliefs, and concerns that support or hinder lifestyle change needed to improve health, wellness or recovery. EBHC replaces the traditional “Do as I tell you” model of healthcare with guidance that taps into the patient/client’s own personal motivation to change.

In health coaching, the clinician’s role changes dramatically. We become the patient’s partner and guide to achieve what the patient wants to achieve while integrating health teaching along the way.

It takes both the healthcare provider’s expertise in medicine and health to guide the patient/client safely to achieve health-related goals when chronic conditions and health risk(s) are present and the patient/client’s expertise about their own life to jointly established a 50/50 partnership in health achieving goals far beyond what can be achieved alone.

Note this example of traditional health teaching versus evidence-based health coaching in two patient/client scenarios:


Patient/Client: “I don’t think I can lose weight, but my doctor says I have too."
Traditional Provider: "He’s right! Your blood pressure can lead to stroke.”
Nurse Health Coach Response: (with empathy) “What are your thoughts about losing weight?”

-------------
Patient/Client: "I want to start exercising, but I get home so late after work. I’m just too tired.” 
Traditional Response“Everybody needs exercise. Maybe a different time of day?"
Nurse Health Response: “It’s hard to be in the mood for exercise when you're tired. What do you think might work for you?” 

While the traditional method is well-intentioned, it misses the opportunity to engage in a conversation with the patient/client about what they think will work for them.

Meet the patient/client where they are!  

Addressing the concern as the patient conveys it is only the beginning of a series of conversations that use scientific strategies to guide the patient/client to talk about the change(s) he/she wants to make and to help them move safely and knowledgeably toward it!

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Melinda Huffman, BSN, MSN, CCNS, CHC is a Co-Founder of The National Society of Health Coaches, best-selling author, writer and nationally known speaker in the areas of evidence-based health coaching for clinicians, chronic condition management and wellness in the workplace. www.nshcoa.com

9 Likes; 1 Article; 122 Visitors; 3 Posts

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kat7464 has 5+ years experience and works as a Hospice Nurse.

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Oh, brother! More touchy-feely crap. Most patients are not interested in changing their lifestyle no matter how you address it. And do not ever tell me a patient cannot afford to eat healthy. This is pure BS. They are willing to spend $$ on Coke, fast food, and the many processed foods found in their kitchen, but WILL NOT cook beans, eggs, rice, etc., all cheap meals, for their health. I am tired of coddling patients; they are grown adults who (mostly) make their own decisions. They should be taught on the consequences of their bad choices, not the touchy-feely crap to make them feel okay. Meet them where they are but don't be afraid to call a spade a spade.

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Have to laugh at the new term "Health Coach".....and I see someone wants nurses to pay money to be called one.  Let's be clear....if you want to be a good nurse you should also be a good educator no matter what approach you take. 

Bottom line all the labels in the world won't help a patient be able to tell you what diabetes is.  Most will tell you everything but the simple answer.  Diabetes is when the body has trouble using glucose/sugar.  Ask them...see if I'm right.

Most are so confused with all the stuff we tell them.  It is overload, and they just tune you out.  Medication information is so complex it goes in the trash unread.  We educate at a level greater than a patient's understanding.  And most of all, we fail to listen to what they need and want to know.  If you don't listen, how can you get them to engage and retain?

Ask your heart patients if they understand circulation - Draw them a picture and have them explain it to their spouse.

Ask your COPD patients if they know what respiratory system looks like - Tell them it is like an upside down tree.

Ask your patients if they know what the lymph system is - Tell them it is the sewer system for the body.  They all understand sore throats and the bump on their necks. 

Ask your patients with swollen feet to tell you how much salt is in a food they eat, then teach them how to read the label.  Get out a spoon and show them how much salt they are eating - visual explanation.

Nurses are teachers, it is part of what we do.  But if you are talking without listening and engaging, are you getting anywhere?  It is the quality of the teacher, not the label, title, or initials behind your name that shows your skill and effectiveness. 

We need fewer certifications and more quality in our nursing. 

Edited by SeasonedOne

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Daisy4RN has 20 years experience.

460 Likes; 1 Follower; 5,583 Visitors; 752 Posts

Thank you for the article. It reminds us all that it is very important to meet the pt where they are at and go from there. Some pts will be easily taught and OK with that, and others may need more nuance (coaching). 

I had my new prescription filled, but the more I thought about taking it, the more concerns I had. So, I haven’t started it.”

This exact scenario happened to me as a patient. I was diagnosed with an chronic autoimmune illness and prescribed medication for it. I was at the MD office and he basically said you have this illness, now take this medication, see ya in 3 months. I got the Rx filled, went home and thought about it for 2 weeks and went back to the MD and asked him, Are you sure about the diagnosis, what about this med with the (potential) bad SE etc etc.. He tells me, yes, I am sure and you need to take this, start now and see ya in 3 months. 

Needless to say I was not inspired by those encounters. I don't know if he always acted like that or did so bc he knew I was a nurse, but in that moment I was a patient first. 

 

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Katillac has 18 years experience as a RN.

166 Likes; 6,936 Visitors; 321 Posts

Where's the disclosure, Ms. Huffman? Yes, you co-founded the National Society of Health Coaches, but you are also a principal in the Miller and Huffman Outcome Architects which markets, among other things, the $600 course to prepare for the test you designed. Not surprising then that you extol the virtues of health coaching. This piece is little more than an advertisement.

Moderators, why is this allowed?

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Emergent has 25 years experience and works as a Emergency Room RN.

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12 hours ago, kat7464 said:

Oh, brother! More touchy-feely crap. Most patients are not interested in changing their lifestyle no matter how you address it. And do not ever tell me a patient cannot afford to eat healthy. This is pure BS. They are willing to spend $$ on Coke, fast food, and the many processed foods found in their kitchen, but WILL NOT cook beans, eggs, rice, etc., all cheap meals, for their health. I am tired of coddling patients; they are grown adults who (mostly) make their own decisions. They should be taught on the consequences of their bad choices, not the touchy-feely crap to make them feel okay. Meet them where they are but don't be afraid to call a spade a spade.

Amen and amen. 

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138 Likes; 546 Visitors; 202 Posts

I don't see any difference between the examples listed in the OP vs. "traditional" patient teaching.  Asking open ended questions was taught to us in 1st semester of nursing school as part of "therapeutic communication".  

I don't think becoming a "health coach" behooves us.  As nurses we already have the clout and skills to provide education to our clients wherever we work (although we don't always have enough time, but that is another discussion altogether).  

This post reminds me of a recent article on allnurses that discussed the scope of RNs in relation to nutrition teaching, and I think these "health coaches" need to be mindful of stepping into the realm of the RD. 

Edited by Golden_RN

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1,094 Likes; 7 Followers; 21,235 Visitors; 2,679 Posts

I am in favor of these kinds of interactions. They are basically the therapeutic communication techniques we were all taught, or, at least, this style of communication is consistent with what we have already been taught. They go along with traditional information-sharing (not in place of), since a great many people do not have factual information in addition to not having decided (or, become motivated) to change something.

In addition to it being therapeutic, these open/reflective communication styles are both more respectful and more realistic. Another plus is the acknowledgment that lifestyle changes have to come from within. I find it interesting to hear a little more of patients' stories and generally find it more fulfilling than interactions where there isn't much of a connection.

Only drawbacks: 1) It takes time.....time....to interact with patients in these ways. 2) In the end, it is another method of leading the horse to water. If it is more successful at enabling the horse to decide to take a drink, that's wonderful as long as there is always the acknowledgment that no other individual can be made ultimately responsible to see to it that the horse actually voluntarily takes the drink.

With regard to some of the commentary - this article seems to be promoting a communication style, not a course that people must take. Since I already am a health coach (and so are many of you, if you choose to be), it's all good.

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Davey Do has 35 years experience and works as a Behavioral Health RN.

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I'm interested in becoming a Health Coach for patients diagnosed with an axis II Borderline Personality Disorder.

No I'm not.

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Davey Do has 35 years experience and works as a Behavioral Health RN.

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This could be an applicable example:

Psychotic Patient/Client: “I see Gila monsters climbing up the wall."
Traditional Psych Provider: "Let's give you a PRN anti-psychotic.”
Psych Nurse Health Coach Response: (with empathy) “Hey- as long as they're climbing up the wall and not your leg, let 'em ride!”

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1,094 Likes; 7 Followers; 21,235 Visitors; 2,679 Posts

8 minutes ago, Davey Do said:

I'm interested in becoming a Health Coach for patients diagnosed with an axis II Borderline Personality Disorder.

No I'm not.

Being that you are seriously the best nurse ever and I can tell just by looking at your cartoons that you're not rude and mean like every single other nurse at your place, you would probably have great success with that endeavor.

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Katillac has 18 years experience as a RN.

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11 minutes ago, JKL33 said:

Only drawbacks: 1) It takes time.....time....to interact with patients in these ways. 2) In the end, it is another method of leading the horse to water. If it is more successful at enabling the horse to decide to take a drink, that's wonderful as long as there is always the acknowledgment that no other individual can be made ultimately responsible to see to it that the horse actually voluntarily takes the drink.

With regard to some of the commentary - this article seems to be promoting a communication style, not a course that people must take. Since I already am a health coach (and so are many of you, if you choose to be), it's all good.

I see what you're saying. I think I'm overly sensitive to somebody saying essentially, "That teaching you're doing? Substandard. You need to use this new strategy that takes at least twice as long." It feels like all the other "new and exciting initiatives" that get thrown at us on a regular basis with no extra time to do them. Great ideas, many of them, but just more stuff I'd love to do but never have time for. So I get defensive. My bad, something I need to work on. I get to decide what I can accomplish on a given day, and I can't do it all.  Doesn't make me a bad person, or a bad nurse. I gotta remember that!

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