Mrs. Arnow loved her morning coffee cake. But her diabetes did not. My colleague, Kathleen Olsen, a registered nurse and clinical nurse specialist for Visiting Nurse Service of New York, made a deal with her patient: "Let's try no cake for two weeks," Kathleen told her. "And I'll give you your cake on Sundays."
So, after six days without cake, Mrs. Arnow indulged on Sunday. She noticed she didn't feel as well as she had all week. By the second Sunday, she had her cake with a sinking feeling, knowing that it would make her feel bad. By the third Sunday, Kathleen reports, Mrs. Arnow decided -- of her own volition -- to forgo the cake.
This is "health coaching" in action, a shift in approach from more prescriptive nursing and towards supporting patients in identifying and achieving their own goals. "You can tell patients from now till Sunday what to do," says Kathleen. "But coaching is about finding a way to effectuate change. I begin by asking, 'What do you want me to do for you?' That way, you get buy-in from the start."
Americans are living longer, and those with chronic debilitating conditions are increasingly opting to age in place. For seniors to remain independent and safe in their own homes, they must be active participants in their wellbeing for as long as possible, whether they are cared for by nurses and home health aides or family caregivers. This is the goal of health coaching -- with the ultimate goal of keeping patients out of the hospital.
Kathleen, who is clinical director of our long-term care program in Manhattan, recently piloted a coaching program with nurses who care for elderly patients living at home and managing multiple chronic conditions.[1] Preliminary results show that those who received "health coaching" were twice as likely to stay out of the hospital as those in the control group.
If you are caring for an aging parent or spouse, or even looking in on a friend who is managing a chronic condition, here are some steps you can take to bring the coaching approach to caregiving:
- Assess the loved one's level of understanding about his or her condition. Begin with a simple, "Tell me about your condition?"
Education and Problem-Solving
Nurse Phyllis Downer brings the coaching approach to her patient Sister Catherine, an elderly Franciscan nun who lives in a Harlem convent and suffers from edema, diabetes and severe hearing loss. The sister is as stubborn as she is big-hearted, walking the corridors of the convent and the streets of her neighborhood offering help when she can and a kind word. When Phyllis first began visiting, Sister Catherine's blood-sugar levels were consistently in the danger range, 300 to 500, and she was slow to acknowledge her diabetes. "Every machine we tried, something was wrong with the machine," Phyllis says with a smile. "Finally we got one that worked."
Once the sister saw the evidence of her diabetes with her own eyes and began to believe it, Phyllis embarked on a course of education that is essential to successful coaching, She printed out and posted on the wall of the convent a color-coded chart: Blood sugar numbers in the green zone were good, yellow indicated moderately high, and alarm-red meant out of control. Phyllis explained, "Sister, when you're in the red, here's what happens. Your eyes go, your feet go, your kidneys go." Next time the sister's numbers inched toward red, Phyllis enlisted her help: "I said, 'Sister, we've got to do something. What are we going to do?'"
That "we" is key. It means partnership, and it invited the sister to divulge some predawn snacking when she was awake doing laundry and puttering around the convent at 4 a.m. Phyllis tacked on the wall of the laundry room an appropriate snack list -- bread, cheese, a small apple -- and began the give-and-take that underlies coaching. "Let's do it for a week," Phyllis said of the list. "Tell me how you feel. If it doesn't work, I'll keep my mouth shut."
Fast forward several months, and Sister Catherine's sugars are consistently in the normal range with the occasional spikes when she goes off course. But now, she knows when she's off course and she increasingly knows what she needs to do to get herself back on track. The other day, her sugar level was high because she had neglected to take her insulin the night before. After telling her nurse the story, Sister Catherine quickly added, "I've got to get someone around here to remind me to take my insulin."
"Now she's problem-solving herself!" Phyllis exulted.
This dovetails with Kathleen's coaching approach to medication management. For patients on multiple medications -- which means just about anyone with a chronic condition -- she and her nurses enlist the patient's help to come up with a system of reminders, be it a telephonic reminder, a light or beep going off on the medication box or having a family member remind the patient. "Whatever the patient thinks would work best for them, given the ins and outs of their daily life, that's what we'll try," says Kathleen.
Goal-Setting
As spring comes to upper Manhattan, Sister Catherine's goal is to control her edema and diabetes enough to stroll the neighborhood, watching, greeting and helping people as she has done for years. She is particularly excited about having joined the gym in the park across the street. She raises an arm and flexes her bicep. "She wants me to get muscles," the sister says of Phyllis, and they share a laugh.
Phyllis is as excited about the possibilities as Sister Catherine is. "I'm so curious about what she'll bring back from the gym, because I'll follow her lead," Phyllis says. "Remember, I'm not trying to achieve my goal. With my patients, it's their goal I want us to achieve. Nobody likes to go it alone."
Phyllis often gives Sister Catherine a high five for a job well done, which brings a smile to the sister's face. Yes, Phyllis allows, the high five is a distinctly "coaching approach." But it also harks back to good old-fashioned nursing. "I use whatever I need to use for each patient," she says. "Sometimes it requires more touch. The high five is a form of touch, and the sister relates to it."
What motivational or other "coaching" tools do you use in caring for a loved one? Share your tips on what works -- and what doesn't.
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References:
[1] Olsen, Kathleen, et. al. "Clinical Coaching in a Patient-Centered Long-Term Home Care Model." Presentation for Hunter Graduate School of Nursing. 2011.