by Susan Luck
As health and wellness coaches, nurses are the trusted professionals emerging as pioneers on the vast frontier of our nation’s health care reform. Nurses possess the essential tools to create health coaching programs that embrace our nation’s renewed focus on wellness and patient-centered care.
Health and wellness education has historically been an integral element of nursing practice. Nurses are the crucial interface between health care services and the lives and health of the people who are served by them. It is time to build upon nursing’s skills and knowledge and use these skills within health promotion strategies.
According to the National Centers for Disease Control and Prevention, more than 133 million adults, or nearly half of all adults in America, are living with at least one chronic disease such as obesity, diabetes, or cardiovascular disease.1 The cost of managing their care is estimated at an astounding $270 billion a year. Growing evidence demonstrates these diseases can largely be reduced or prevented through education and behavioral changes.
The Call for Health Coaches
In 2009, the Samueli Institute crafted a document promoting a Wellness Initiative for the Nation (WIN). In collaboration with leaders in the fields of health policy, health promotion, and integrative health care practices, the authors suggested several important ways to help move America toward a more productive self-caring society with a greatly expanded wellness and prevention infrastructure.
WIN proposes training thousands of full-time, community- based “health and wellness” coaches to work on chronic disease prevention through comprehensive lifestyle and integrative health care approaches. This corps of health coaches will march into unknown territory with a mission to transform health care and the health of our nation.
In the Sep/Oct 2009 issue of Alternative Therapies in Health and Medicine, Karen Lawson, MD, director of the Health Coaching Professional Certificate Program at the University of Minnesota’s Center for Spirituality and Healing, suggested that coaching at its core is first and foremost about helping individuals effectively make changes in their beliefs and behaviors to achieve increased health and well-being.4 The foundations of health coaching include creating a safe space and a caring, relationship-centered practice. Inherent in this process are deep listening and authentic communication skills to promote self-awareness, perceptive reflections, and self-efficacy, facilitating the health and healing journey of the individual.
The Role of Nursing In a Wellness Model
It is an important time for the nursing profession to expand its visibility in our nation’s emerging wellness model. Nurses must actively partner with physicians and other health care providers to promote the value of an integrative model of health, resiliency, and well-being.
The nursing profession is centered around caring for the whole person. The American Holistic Nurses Association’s (AHNA) 2007 Holistic Nursing: Scope and Standards of Practice, published in partnership with the American Nurses Association (ANA), defines holistic nurses as “facilitators of healing: consultants, collaborators, educators and guides.”
A cornerstone of holistic nursing practice is helping individuals find meaning in their experience, listening deeply, and creating a therapeutic, collaborative, and caring environment to explore the dimensions of self.
Mary Jo Kreitzer, PhD, RN, FAAN, founder and director of the Center for Spirituality and Healing at the University of Minnesota explained in a recent interview, “the concept of coaching is very consistent with the idea of encouraging and empowering individuals to take charge of their health.”
Nurse coaching is not a new practice. More than 30 years ago, Betty Neuman, RN, PhD, FAAN, and Dorothea Orem, RN, BSN, MSN, two prominent nurse scholars, described an intervention to assist patients with self-care and development of desired goals. Newman viewed a person as a complete system who is constantly seeking to maintain balance and harmony between his or her internal and external environments. To help the person attain this goal, Newman created a nursing assessment tool that focuses on patient-identified challenges. Dorothea Orem’s Self Care Model of Nursing Practice views the relationship of nurse and patient as interactive, with the promotion of health, well-being, and self-care based on an individual’s capabilities. Patricia Benner, RN, PhD, FAAN, also defined the patient/nurse partnership as a joint decision-making process maximizing a person’s innate wisdom.
Sarah Hughes takes a slightly different, albeit complementary, approach. She believes it’s important to integrate mentoring and counseling skills into the nurse coach model. In the article, “Promoting Independence: The Nurse as Coach,” Hughes describes nursing processes in disease management. She looks at the goals of patient care from dependence to independence. Using the skills of questioning and a deep listening process, Hughes describes the nurse coach’s ability to guide and support clients/patients by exploring how they want to take control of their health, including strategies for disease management and treatment. These techniques promote openness, trust, and increased awareness within the context of a collaborative relationship.
Susan Schenk, RN, MN, APN-BC, and Kay Hartley, RN, BSN, in their article, “Nurse Coach: Healthcare Resource for this Millennium,” say, “the nurse coach role can be defined as an expanded professional interaction based on mutual respect of the knowledge and skills that both nurse and client bring to the situation.” In this model, clients identify their goals for their health. The nurse coach engages the individual in a process of questions and finding answers to the problems revealed, which in turn increases one’s self-efficacy. The concept of self-efficacy, stages of change, and motivational enhancement are integrated into the nurse coaching or partnering role.
Using this model, Albert Bandura described self-efficacy as an important dimension to the practice of nurse coaching: “The nurse serves as a partner in the relationship guiding the individ- ual’s perception of his/her ability to manage different aspects of personal health and function and provides an integrative framework to sustain behavioral and lifestyle changes.” Lewis and Zahlis, also used Bandura’s self-efficacy framework to explore clinical applications for nurse coaching with clients experiencing cancer, as an example. They define nurse coaching as a “professional counseling model for nurses that derives from the client’s frame of reference; the nurse an active listener who uses increasingly specific questions to engage the individual in the process of identifying problems and in the process, assists the individual in finding answers to those questions.” Patients are often better able to identify their needs than the health care professionals from whom they seek care.
Recently, the International Council of Nurses partnered with Sigma Theta Tau International in releasing Coaching in Nursing. The document emphasizes nursing leadership’s role in creating coaching standards and establishing a relationship between health and wellness coaching and nursing. A national nursing task force, established through the American Holistic Nurses Association and representing national credentialing organizations and nurse coach leaders, is actively developing core curricula and standards of practice leading to a national nurse coach certification, which includes foundational concepts and core competencies for the nurse coach.
According to the New York State Nurse Practice Act, coaching is woven into nursing process and builds on the excellent knowledge and skills that are the foundation of the nursing profession. Language relevant to coaching in New York state education law says, “The practice of the profession of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential health problems through such services as casefinding, health teaching, health counseling, and provision of care supportive to or restorative of life and well- being.” each state has its own Nurse Practice Act that governs nursing practice legally and ethically and sets the standards of practice. Coaching language is in the standards of practice in most states.
Professional Coaching Programs
There is a growing interest in and a concern for standards of practice for health coaches. Several professional coaching pro- grams have been created, including those at the University of Minnesota’s Center for Spirituality and Healing, Duke University, and the California Institute for Integral Studies.
Dr Lawson has indicated that the majority of the participants attending the University of Minnesota’s Center for Spirituality and Healing program are nurses. She said, “It is a natural evolution of where nurses want to go. Nurses are called to a coaching model, and it seems that nurses who have been working in the field for 35 years are reconnecting to their intention of why they went into nursing.”
One of the challenges Dr Lawson sees in all health care providers, including nurses, when integrating the coaching process into their professional work is that they often ask, “How do I slip out of my educator role and into the coach role?” As health care providers, she says, “We are used to giving advice, fixing, and res- cuing.” She emphasizes that there is a “deprogramming process” that occurs as we develop coaching competencies and engage in an authentic coaching relationship. She describes different levels of interaction within professional coaching that are not linear and often include coaching process work; skills and tools such as imagery, biofeedback, and energy work; and the educator role for providing strategies and information for long term health.
Nurse Coach Perspectives
Barbara Dossey, PhD, RN, AHN-BC, FAAN, author, Nightingale scholar, and well-established holistic nurse coach, strongly believes holistic nursing and self-care practices, along with the integration of a healthy lifestyle, are just as important for the nurse as the patient: “Our life’s challenge is to understand how to handle the double-edged sword of capacity—our ability to give and contribute to society and also to find ways to care for and coach ourselves so we do not burn out. When we understand this, we can be a coach for clients at a deeper level.”
Darlene Hess, PhD, RN, holistic nurse coach and nurse educator, suggests stepping back from the expert role nurse coaches know how to elicit and build upon the inner resources of clients to enhance health outcomes: “Learning coaching skills has enhanced my professional practice in ways undreamed of. It is so rewarding to work with nursing faculty in ways that allow me to role model coaching skills that they in turn can utilize with students.”
Dr Hess anticipates a next step to include coaching skills in educational programs for nurses. The American Association of Colleges of Nursing lists interprofessional communication and collaboration for improving patient health outcomes as one of the “essentials” of baccalaureate education for professional nursing practice: “I foresee coaching skills being added as an essential requirement for nurses to have. When that occurs, nursing pro- gram across the country will be adding coaching skills training to their curricula.”
Linda Bark, PhD, RN, master certified coach of As One Coach Training Institute, explains that as a nurse coach it is important to mix coaching, asking powerful questions, and consulting. In a recent conversation, Dr Bark described a new client, a 48-year- old man who was recently diagnosed with diabetes. He was having trouble managing his diabetes. The endocrinologist claimed the client was noncompliant. The client claimed he was simply overwhelmed with information. As his coach, Dr Bark spent much of their time together clarifying goals and the best ways for him to see and celebrate his successes.
California Institute of Integral Studies offers a certificate in wellness coaching as part of the master’s degree in integrative health studies for diverse health care professionals. Meg Jordan, PhD, RN, department chair and professor of integrative health studies, believes a coaching alliance is first and foremost a means for recognizing the resourcefulness within clients and allowing them the space and support to go within and come up with their hopes, intentions, ideas, willingness, and plans about moving for- ward on their goals. “It’s definitely not about ‘fixing people,’” Dr Jordan says. “Nurse coaches work with a variety of tools in this supportive alliance with the client. Most of all, they adopt a new way of being with people, and secondly, they must role model a ‘coaching orientation’ in their own lives. Being a coach—in the pure, original sense of the profession’s genesis—changes one from the inside out.”
Looking To The Future
There is no question that nursing is poised to take on a leading role in health care reform. With more than three million nurses in America, nursing has the capacity to provide wellness coaching where it is needed; in every sector of society. The new focus on wellness and disease management will require the guidance of a profession that has always adapted to change. As the American Nursing Association states, nurses are “dynamic and continually evolving in response to the shift- ing needs, demands, and resources of society.” The emphasis on health and wellness will undoubtedly change nursing practice a solid scientific foundation of coaching based on evidence-based outcomes research will further define the art and science of nursing within coaching.
Coaching presents nurses with exciting and creative opportunities to be leaders with their professional colleagues in trans- forming health care. Perhaps more empowering is the knowledge that health and wellness education may be the greatest gift to future generations and nursing’s most enduring legacy.
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- New York State education. Office of the Professions. Education Law. Article 139, nursing. Available at: http://www.op.nysed.gov/prof/nurse/article139.htm. Accessed July 15, 2010.