The nursing profession remains at the forefront of healthcare delivery as the world continues its attempt to bring the COVID-19 pandemic under control. A pandemic which to date has led to the death of almost 4 million people worldwide (World Health Organization (WHO), 2021) and continues to affect the most vulnerable in society, especially those with a disability (Dickinson et al, 2020).
This, however, is the tip of the iceberg when counting lives lost as a result of the many non-communicable diseases that have developed in recent decades. As little as a 100 years ago, the leading causes of death, especially for young people, occurred as a result of infections; typically, polio, diptheria, tetanus, pertussis, rubella, mumps and tuberculosis, but as a result of medical advances, immunisation and improved measures such as nutrition, hygiene and healthcare, these have virtually been eliminated in the UK (Office for National Statistics (ONS), 2017). However, with such advances came a new problem: longevity. And an increasing susceptibility to poor health, especially for older people (WHO, n.d.). With Christensen et al (2009) emphasising the widespread concern that ‘exceptional longevity has grim results’ for both individuals and societies as a whole.
However, despite the continued emphasis on longevity being linked to poor health, a paradox exists. For, as Seals and Melov (2014) argue, increasing demographics and current attitudes [associated with aging] are generating an unprecedented demand for ‘optimal longevity’; ie living longer but with increased healthspan.
Causes of death
According to the WHO (2020), causes of death can be grouped into three categories: communicable, noncommunicable and injury, with non-communicable disease accounting for 74% of deaths globally in 2019 (Figure 1).
This dire situation has become a global challenge and has been incorporated into the United Nations 17 Sustainable Development Goals; specifically Goal 3, [Good Health and Wellbeing], with the ambitious target of reducing premature mortality caused by non-communicable disease by one-third by 2030 (UN, 2015).
Encouragingly, the UK government has, in recent years, recognised the catastrophic impact of non-communicable disease and has sought to improve the health of the nation, with a number of key policies being introduced. The Five Year Forward View published in 2014 (NHS, 2014) sought to create a new strategy for service delivery, and through this, the NHS Long Term Plan (NHS, 2019a) emerged: a plan based on the experiences of patients and staff and designed to meet healthcare needs of the future.
This plan emphasised the importance of personalised care, and established the document - Universal Personalised Care Implementing the Comprehensive Model (NHS, 2019b), through which a delivery plan and a new service model – ‘social prescribing’ – emerged.
Essentially, ‘a social prescription’ is used to support those with multiple health conditions; those who have mental health and complex social needs; and those who are lonely or isolated. The latter being a significant problem in the current health crisis (Hwang et al, 2020).
Health coaching
Health coaching is considered an essential element and a driving force in the delivery of personalised care and the envisaged success of the NHS Long Term Plan (NHS, 2019a) with a number of policy frameworks (NHS, 2020; NHS England and NHS Improvement, 2020) driving the significant roll out of this care intervention.
Table 1. Leading causes of non-communicable disease
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Used increasingly in the clinical area, health coaching is a developing field of practice that encourages patients to adopt healthy lifestyle behaviours that can avert the impact of chronic disease (Sforzo et al, 2019), the purpose of which is to empower patients to self-manage their long-term health conditions (Shah et al, 2019), through the creating of partnerships and the use of motivational interviewing (Perlman and Abu Dabrh, 2020). Motivational interviewing is extensively explored in the work of Miller and Rollnick (2012).
In order to do this successfully, however, requires a paradigmatic shift, for as Rogers and Maini (2016) argue, health coaching emphasises the importance of the patient being the expert in their own lives, rather than affirming the paternalistic viewpoint that ‘clinicians know best’, instilled in us all ‘from an early age’. This emphasis continues to place the patient in the subordinate position that ‘clinicians know best’ rather than in an equal partnership (Rogers and Maini, 2016).
Such a shift requires much more than simply putting an end to the paternalistic stance. Demographic change resulting from wars; global economic pressures; and increased migration have given rise to acutely diverse populations, with resulting language barriers having a negative impact on a patient's ability to access effective care (Rogers and Maini, 2016).
Furthermore, the social, economic, environmental and biological factors – essentially the wider determinants of health that continue to exist – have been extensively explored in the literature, with Marmot et al (2020) highlighting the devastating impact of poverty in the UK.
Inextricably linked is the phenomenon of health literacy, defined by the WHO (1998) as:
‘The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health.’
Health literacy
According to Raynor (2012), there are three key aspects of health literacy:
- The ability of people to read and understand information
- The ability of people to engage with the healthcare process
- The need for healthcare systems to eradicate ‘unnecessary complexity and barriers to patient understanding and involvement’.
Limited health literacy is frequently linked with smoking, poor dietary habits and exercise levels. Disproportionally linked to certain demographic groups including the elderly, ethnic minorities, recent immigrants, the homeless and those who have low literacy skills, limited health literacy is associated with increased risk of morbidity and premature death in older adults (Public Health England (PHE) and UCL, 2015).
Health literacy therefore contributes to health inequalities, because the population groups most at risk of low health literacy are also known to have the poorest health outcomes (PHE and UCL, 2015).
Various interventions including the avoidance of jargon, simplifying of information, encouraging patient questions and the use of a process known as Chunk and Check, (providing small digestible pieces of information) can all help to support health literacy, with Chunk and Check being used alongside tools such as Teach-Back to assist in promoting understanding (The Health Literacy Place, 2021). Teach-back – a method used to encourage patients to explain what they understand from the information given – can help identify misunderstandings and encourage further explanation until the patient fully comprehends what they need to know (Talevski, 2020). This is supported by Yen and Leasure (2019) whose systematic review highlighted the use of the Teach-Back method as being effective in reinforcing or confirming patient education.
Health literacy, however, is only one barrier that limits the capacity of patients to benefit from health coaching. Others include (Newman and McDowell, 2016):
- Competing priorities
- Increased workloads
- Short-term thinking
- Change fatigue
- Increasing expectations.
Health coaching, with its emphasis on shared decision making and the setting of realistic and attainable goals (Ghorob et al, 2013), has the potential to negate some of these barriers, while improving the chances of good clinical outcomes, realistic behaviour change and long-term personal health management.
To be successful, however, requires the health coach to act with the intention of building strong and effective working relationships; the aim of which is to create an equal partnership – one which ultimately supports growth and actualisation of the patient's full potential (Iliffe-Wood, 2014). This is supported by Reed (2021) who argues for the importance of establishing a collaborative approach to the coaching process, by asking the right questions, through which patients are able to find their own solutions to improving their own health problems.
When undertaken effectively, argues Boyatzis et al (2019), coaching can help people articulate their personal vision and encourage behaviour change that will move them closer towards the realisation of their goals.
Furthermore, demonstrating unconditional positive regard [by the health coach], a concept developed by Rogers (1951), is fundamental in developing trusting, dynamic and progressive relationships through which the patient is able to speak openly and confidently without the sense of being judged.
Coaching models
Coaching models are used extensively in coaching and are useful adjuncts in supporting others to achieve their goals. One such example of a model is that of the GROW model (Whitmore, 2017) (Table 2). Used extensively in coaching circles, this model can help create structure, help set realistic goals and plan the way forward, with the patient having complete control over the way in which they manage their goals.
Table 2. GROW coaching model
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Coaching narrative
An important element of coaching practice, therefore, is the ability of the coach to encourage people to tell their stories, a process through which they are able to ‘give meaning to events, which ultimately affects their behaviours’ (MacMillan, 2015).
Storytelling is considered a natural form of communication (Langer, 2016), and for the patient can often create deeper meaning (Price, 2011). Using one's own narrative as a catalyst for change, argues Drake (2018), is a progressive approach, through which people can make a shift ‘in their identities and perspectives’ which in turn can help ‘resolve their issues at a number of levels’.
Conclusion
Health coaching is taking its rightful place in service delivery as an alternative to telling patients how to manage their health, reinforcing the message that the old ways of physician or health professional ‘knows best’ is at best outdated, and at its worst, limits the potential of patients to take responsibility for their own health and wellbeing.
Behaviours such as demonstrating respect and unconditional positive regard (Rogers, 1951); asking powerful questions (Rogers and Maini, 2016); listening with the intent to understand rather than to reply (Covey, 1989); and supporting the patient to manage their health conditions (Deeny et al, 2018) are all essential skills of the health coach.
Although, we are still in the early phase of evaluating the impact of health coaching, it is conceivable that in the future it will be possible to determine an associated reduction in healthcare costs (Edward et al, 2018), essentially freeing up resources that are desperately needed elsewhere.
KEY POINTS
- Non-communicable disease accounts for 74% of deaths globally
- Health coaching is considered an essential element and a driving force in the delivery of personalised care
- Health coaching is a developing field of practice that encourages patients to adopt healthy lifestyle behaviours that can avert the impact of chronic disease and empower patients to self-manage their long-term health conditions
- Coaching models are used extensively in coaching and are useful adjuncts in supporting others to achieve their goals
CPD reflective practice
- What is meant by the paternalistic stance of current practice? Do you recognise this in your own practice?
- How can low health literacy affect health outcomes? How can health coaching improve health literacy?
- How could coaching models like the GROW model help support your patients to achieve their goals?