Registed Nurses' Association of Ontario

Knowledge and skills in health coaching to support self-management in patients with diabetes

Elena Cacchione
Toronto Western Hospital, University Health Network

The RNAO Advanced Clinical Practice Fellowship (ACPF) occurred at the Toronto Western Hospital Family Health Team. It is primary care setting rostered to 13, 000 patients in the West End of Toronto. It is a diverse population covering a wide variety of ethnic and cultural backgrounds.

The RNAO ACPF, has been a wonderful experience for me professionally and personally. I have thoroughly enjoyed this unique opportunity. Health coaching to me has new meaning. The notion of health coaching when I started seemed unclear. What made it special? What was all the “hype” about?What made it different from the status quoof seeing the patient and providing education with what we the clinician (nurse) felt they needed to do or needed to know? Well, re-learning a new style which incorporates coaching with the use of motivational interviewing, was harder than I thought. Over the period of my fellowship I became more fascinated with the approach health coaching had to offer. A deep desire within me was burning. I wanted to learn how to help people make better choices and live happier and healthier lives. This fellowship gave me the opportunity to explore and embark on a journey of what motivates people to change. I wanted to develop my skills and knowledge with the best possible tools and strategies to help people change in order for my patients to succeed. My focus was primarily working on patients with a chronic disease specifically diabetes and smoking. I did not remain inclusive to this group while working at the FHT. I found the principles of health coaching can be applied to any challenge or health concern regardless of illness. By working with patients with a chronic disease I came to realize how complex and challenging it may be for them. I have learned that health coaching is an approach. A way of engaging, and having a focused conversation. Over the time of my fellowship I have come to realize how aligned it was with the Toronto Western Hospital patient philosophy “Partners in Care Service Standards” The two are synonymous in their meaning.Both see the patient perspective and most importantly provides a service of excellence.

My overall goal to gain knowledge and skill in health coaching and motivational interviewing to support self-management in diabetes was supported by my mentors and the clinical experiences I had through my fellowship. Prior to my fellowship I was allowed to attend a Health Coaching Workshop offered at the Toronto Western Hospital facilitated by Mary Wheeler and Michelle Cooper as a late career initiative. It introduced me to the principles and key concepts of health coaching. It gave me the foundation to work on developing the necessary skills and knowledge to coach my patients along their health journey.
My first objective was to learn as much as possible about health coaching in the literature dating back the last few years. After completing my research and summarizing my findings it allowed me to see the clear evidence that health coaching works. In the United States, due to its private health care utilizes more of the health coaching role versus Canada’s health care system. In this country, the role still needs to be further developed and standards of practice continue to be developed. Their does exists some roadblocks particularly funding for the health coaching role to succeed. For now, I see the role at FHT’s as an essential role for very complicated and ill patients.

I was able to connect to a Health Coach in S.C.O.P.E. Winnie Wong who works for UHN. This particular coach acted as a mentor and provided encouragement for me to “ look outside the box” . To not be afraid to be creative and explore different approaches other then what I was comfortable using. The approach of looking at situations or problems as an area of growth versus roadblocks. Her feedback on my client’s encounters have been invaluable. As a professional she made me see the wonderful potential that nurses can offer to very complicated patients. Acting as a health coach, provided them support and motivation to assist them along their journey to health.

Having the opportunity to do a site visit to Bridgepoint Rehabilitation Centre has been a unique experience. It provided me the autonomy to explore and learn about a Health Coaching Pilot program implemented at the facility. My summary of the visit was discussed with my primary mentor and the nursing group. Strengths and barriers of the model were discussed. This experience made me realize the importance of having a universal charting tool for all clinicians involved to be accessible for the patients’ electronic record. Unfortunately, not having a tool made it difficult for the clinicians at Bridgepoint to communicate goals, and their action plan to each other. This particular insight made me identify this as a possible barrier to the success of providing health coaching at our FHT.

Through the duration of the fellowship I was able to modify and work on developing a tool I used for health coaching. In my search in the literature I didn’t find one that contained all the pieces I was looking for. I wanted a tool that allowed any clinician to use. Our team is still in the developing stage to build an existing one. My experience, and the tools I have developed will assist with the final tool for health coaching. We want to have a tool that will capture all the nursing activities and the patient’s goals, including other clinicians work. At the present time, I am working with other team members in the formulation of a health coaching tool.

Over the course of the fellowship I enhanced my knowledge on strategies to support self-management in chronic diseases. A needs assessment was completed at the beginning of the fellowship to determine the interest and knowledge gaps in health coaching and self-management. It was found that the group had a keen interest but lacked awareness of the best practice guidelines for self-management strategies. The nursing group and I attended the webinar series provided by RNAO “Back to Basics” This gave all of us a wonderful opportunity to review, and understand the best practice guidelines, and quality improvement to name a few for chronic disease management. Dedicated time was protected for all the nurses to attend this webinar and coverage was provided to ensure the unit was running properly. Our Manager Teri Arany has had an active and supportive role in identifying the need to develop and expand our nursing skills to reflect best practices in chronic disease management. Near the end of the fellowship I provided tips or “pearls of wisdom” via e-mails which included relevant articles, video clips of motivational interviewing. It allowed me to share the insights gained in this fellowship to the nursing group. My desire is to continue to share my learnings and knowledge with the nursing group on an on-going basis. I foresee new development in this approach in not just our FHT but others as well. To ensure access to the information a shared drive in our computer system has been activated and can be used by all staff.

During my fellowship I attended an in-depth Motivational Interviewing course offered by CAMH. It was on-line course over 6 weeks. It allowed me to achieve my goal, which was to gain knowledge in motivational interviewing in order to enhance my health coaching skills. It was the most rewarding experience for me because it gave me the tools, and strategies to help people change. It was a necessary approach for me since I needed the skills and an approach for engaging my clients. The four processes in motivational interviewing provided me with a framework to build. I am still a novice in the area of MI, but I feel more confident now than before. After completing the course, I felt more confident in my skills of health coaching. I would ask informally for feedback from my health coaching sessions. My patients would tell me how it has been so helpful to have someone support them and motivate them to stay with their goals. The feedback received from my patients has made me feel more satisfied with my role as a nurse. Seeing my patients change and making healthier lifestyle choices has made me feel more confident that health coaching works.

For the next three months I will continue to build and enhance my skills in health coaching. My role as a clinic nurse has now shifted into one that provides support for patients living with chronic disease. This role will assist me to maintain my knowledge and skills. My active participation in our Diabetes Program has enabled me to share my learnings on health coaching with other clinicians. The development of a tool for health coaching is still being formulated for our Diabetic Program. Monthly meetings are planned to assist with this process. Presently, a community of practice with Michelle Cooper one of the health coach facilitator’s has enabled the nurses to communicate and sustain our health coaching interests and skills. My Manager Teri Aranyhas been very supportive in the field of Chronic Disease Self-Management. She has been providing protected time and adequate staffing in order to maintain our competencies in chronic disease management. After completing my fellowship, I now feel confident and knowledgeable to now take on a role as a coach mentor. This additional role will be vital in maintaining and sustaining health coaching as a competency at our FHT. As more and more nurses feel comfortable in the skill of coaching. Myself, and other clinicians on our team will provide support and assistance in providing the necessary skills to enhance and improve coaching skills.

Health coaching is an approach that does require an understanding of a multitude of unique dynamics in the patient and nurse relationship. I feel I am still a novice in this field. But I am excited about my journey to continue to learn more about this purposeful, and client centered approach.

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