Exploring the potential of telephone health and wellness coaching intervention for supporting behaviour change in adults with diabetes

Abstract

The purpose of this article is to outline the development of a telephone-based health and wellness coaching intervention for people with type 2 diabetes. A specifically modified health and wellness coaching intervention underpinned by the transtheoretical model of behaviour change, motivational interviewing and appreciative enquiry was delivered by telephone to 10 people with type 2 diabetes over 3 months. The coaching showed high acceptability, low cost and effectiveness in increasing patient autonomy and self-efficacy. Coaching training may be useful to healthcare workers, and coaching interventions for people with type 2 diabetes may be effective and warrant further exploration in a large clinical trial.

Full text

394 Journal of Diabetes Nursing Volume 19 No 10 2015
Article
Exploring the potential of telephone health and
wellness coaching intervention for supporting
behaviour change in adults with diabetes
Helen McGloin, Fiona Timmins, Vivien Coates, Jennifer Boore
Citation: McGloin H, Timmins F,
Coates V, Boore J (2015) Exploring
the potential of telephone health
and wellness coaching intervention
for supporting behaviour change
in adults with diabetes. Journal of
Diabetes Nursing 19: 394– 400
Article points
1. An evidence-based health
and wellness coaching
intervention is described.
2. The intervention was highly
acceptable to people
with type 2 diabetes.
3. Coaching training should
be offered to healthcare
professionals and further
evaluation of the impact
on client health behaviour
should be undertaken.
Key words
- Health behaviour
- Health and wellness coaching
Authors
Helen McGloin is Lecturer in
Nursing at St Angela’s College,
Sligo, Republic of Ireland; Fiona
Timmins is Associate Professor of
Nursing at Trinity College Dublin;
Vivien Coates is Professor of
Nursing at University of Ulster and
Assistant Director of Nursing at
Western Health and Social Care
Trust (Joint Appointment); Jennifer
Boore is Emeritus Professor of
Nursing at University of Ulster.
The purpose of this article is to outline the development of a telephone-based health and
wellness coaching intervention for people with type 2 diabetes. A specifically modified
health and wellness coaching intervention underpinned by the transtheoretical model
of behaviour change, motivational interviewing and appreciative enquiry was delivered
by telephone to 10 people with type 2 diabetes over 3 months. The coaching showed
high acceptability, low cost and effectiveness in increasing patient autonomy and
self-efficacy. Coaching training may be useful to healthcare workers, and coaching
interventions for people with type 2 diabetes may be effective and warrant further
exploration in a large clinical trial.
Traditional methods of support for behaviour
change among people with lifestyle-related
illnesses have relied heavily on education
and persuasion, and typically work only in the
short term (Hayes et al, 2008). This suggests
a need for a conceptual shift in providing
educational support. Coaching is a possible
mechanism to incorporate all the suggested aspects
required to support people to become active
participants in self-management (Lindner et al,
2003).
As there have been recent calls in the literature
to develop coaching within a behaviour change
framework to facilitate enhanced support of
people with type 2 diabetes in the primary care
setting (Hayes et al, 2008), this article outlines the
development of a wellness coaching educational
intervention to support behaviour change for these
people.
Wellness coaching: Theoretical
underpinnings
Wellness coaching draws on a number of theories,
including motivational interviewing (Miller
and Rollnick, 2002), the transtheoretical model
of behaviour change (Prochaska, 2005) and
appreciative inquiry (Cooperrider and Whitney,
2005). The aim is to help individuals develop
their vision for wellness and to clarify areas for
improvement or development. Coaching is defined
by Moore et al (2015) as:
“A close relationship and partnership with a coach,
providing the structure, accountability, expertise
and inspiration to enable an individual to learn,
grow and develop beyond what s/he can do alone.”
A one-to-one personal approach that can be
easily facilitated by phone is used. Clients choose
the behaviour they want to change and verbalise
the required changes. In the first session, a wellness
vision is developed. A wellness vision coaching tool
is summarised in Table 1.
Using this tool as a prompt to elicit information,
vision and goals for the client, goals are set to
achieve the desired changes. Issues discussed and
individual goals are recorded in a “coaching log”
after the session (Figure 1).
Sessions occur weekly, and weekly goals are
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Exploring the potential of telephone health and wellness coaching intervention for supporting behaviour change
Journal of Diabetes Nursing Volume 19 No 10 2015 395
discussed and set. At each coaching session
the previous week’s goals are reviewed and the
strengths that led to success are highlighted. These
are also documented (Figure 2). Clients then
choose the area they want to work on that week
and once again they are coached on that issue.
Obstacles and strategies to overcome these are also
identified and discussed.
Motivational interviewing
Motivational interviewing is an important skill
for this intervention. Principles that underpin this
are expressing empathy, developing discrepancy,
rolling with resistance and supporting self-eff icacy.
These principles can be explained as follows.
Ambivalence towards behaviour change or
feeling stuck is expected in consultations (Miller
and Rollnick, 2002). The development of
discrepancy is a key goal in which ambivalence
is addressed and the practitioner aims to increase
the importance of change to the person. This is
achieved through selective ref lections that focus
the client on the discrepancy between behaviour
and personal values. The practitioner elicits
the reasons to change from the individual, and
if resistance is expressed it is a cue to change
Valu e Explain the value of creating a wellness vision: A vision is a compelling statement of who you are and what health-promoting,
life-giving behaviours you want to do consistently.
What’s working
now
Ask about strengths and current successes: What are you currently doing to support your health and well-being? What
elements of your life do you feel best about? In what way did you contribute to making those true and/or possible?
Strengths Collaborate to identify the client strengths: What are your success stories? What gives you pride? What qualities do you most
appreciate about yourself?
Thrive Identify ways a client can thrive: What makes you thrive? When are you most alive?
Important Ask what is most important to the client right now: Given all that is going well, what are you wishing? What elements of your
health and well-being do you want to improve?
Motivation Discover the client’s motivators: What are the benefits of making changes now? What is the driving force behind the desire to
change now? What do you treasure most about potential change?
Visualise Support the client in visualising his or her vision, and describe it in detail: What are the most important elements in your vision?
Tell me what your vision looks like. Paint me a picture. What would you look and feel like at your ideal level of wellness? What
kind of person do you want to be when it comes to your health and well-being?
Past successes Discover previous positive experiences with elements of the vision: What have been your best experiences to date with the
key elements of your vision – times when you felt alive and fully engaged? Tell one or two stories in detail.
Strengths to
realise vision
Identify the strengths and values that could be used to reach the vision: Without being modest, what do you value most about
your life? What values does your wellness vision support? What strengths can you draw on to help you close that gap and
realise your vision? How can the lessons from your successes in life carry over to your current situation?
Major challenges
hurting confidence
Identify obstacles to boosting confidence: What challenges do you anticipate having to deal with on the way to reaching your
vision? (Talk through multiple possibilities and express empathy.) What concerns you most?
Strategies Explore the strategies and structures (people, resources, systems, and environments) needed to navigate challenges and ensure
success: On what people, resources, systems, and environments can you draw to help you realize your vision and meet your
challenges? What strategies may be effective in helping you realise your vision and meet your challenges? (Brainstorm and
clarify multiple possibilities before focusing.)
Recap Reflect and summarise what you have heard the client saying about his or her vision. Collaborate on a first draft statement that
captures the vision in a way that is meaningful and compelling for them.
Commit Ask the client to state and commit to the vision.
Table 1. Protocol for designing a wellness vision. Adapted from Moore et al (2015), page 131.
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396 Journal of Diabetes Nursing Volume 19 No 10 2015
direction or “roll with the resistance.” Miller and
Rollnick (2002) point out that many people who
seek support are already aware of this discrepancy
between what they want to happen and what
is happening but that they are also ambivalent
or stuck. Motivational interviewing is directed
towards helping people to become unstuck, so that
they can move towards the desired behaviour.
Confidence in the ability to change is termed
self-efficacy and is central to motivation to change
(Bandura, 1994). Development of self-efficacy
is related to the individual’s previous successes.
Failure undermines self-efficacy. However, if
only easy successes are experienced then the
person comes to expect fast results and is easily
discouraged. Overcoming obstacles through
perseverance builds a more resilient sense of
efficacy.
Empathy is a stance taken by the coach and is
underpinned by acceptance. Acceptance involves
accepting and understanding the client’s position
without judgement, and respectfully and actively
listening to the client’s perspective without
endorsing it or agreeing with it (Miller and
Rollnick, 2002).
The motivational interviewing coaching tool used
in this wellness coaching is outlined in Table 2 .
The transtheoretical model of behaviour
change
This model provides a framework for identifying
each individual’s stage in relation to the chosen
health behaviour (Prochaska, 2005; Moore
et al, 2015). It proposes that people progress
through five stages when changing behaviour:
precontemplation, contemplation, preparation,
action and maintenance.
Appreciative inquiry
Appreciative inquiry is defined as the “cooperative,
co-evolutionary search for the best in people,
their organisations and the world around
them” (Cooperrider and Whitney, 2005). It
originated from organisational change research
in which, instead of problem solving, the team
was encouraged to look at strengths, skills and
competencies. It holds that change is more
effective if it occurs as a continuation of those
strengths and competencies (Cooperrider and
Srivastva, 1987). Unconditionally positive
questioning is used to bring out the best in
people. Appreciative inquiry allows people to rise
above and move beyond the conditions of their
present problems (Stake, 2005). Existing alongside
the problems are hopes, dreams and joy, and
Figure 2. Weekly coaching log. From Wellcoaches Core Coach Training Program. Reprinted
with permission from Wellcoaches Corporation, 2015.
Figure 2. Weekly coaching log.
This week’s goals: Week 1
Date goals set:
Section
(Fitness, Nutrition, Stress, Weight, Health, Other)
:
Goal:
Comments:
Priority:
Completed %:
Section (Fitness, Nutrition, Stress, Weight, Health, Other):
Goal:
Comments:
Priority:
Completed %:
Figure 1. Coaching log for the rst session. From Wellcoaches Core Coach Training Program.
Reprinted with permission from Wellcoaches Corporation, 2015.
Figure 1. Coaching log.
Client name:
Coach name:
Session schedule
Session 1:
Session 2:
Session 3:
Wellness vision
My wellness vision is …
My motivators are …
My obstacles are …
My strategies to overcome my obstacles are …
Three-month goals
Month started:
Section
(Fitness, Nutrition, Stress, Weight, Health, Other)
:
Goal:
Comments:
Priority:
Completed %:
Section
(Fitness, Nutrition, Stress, Weight, Health, Other)
:
Goal:
Comments:
Priority:
Completed %:
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Journal of Diabetes Nursing Volume 19 No 10 2015 397
appreciative inquiry allows people to create a new
identity in relation to these. This enables them to
rise above problems by acknowledging strengths
and imagining possibilities (Moore et al, 2015).
All of these principles are observed in coaching,
through the use of conversation to construct a new
reality. Instead of asking what went wrong, the
coach asks “what’s the best thing that happened in
the past week?” and, rather than focusing on the
problem, draws on past successes by asking “could
you describe a time when you had a very healthy
lifestyle?” Coaching the clients to consider their
strengths opens up new possibilities and focuses on
previous successes. See Tabl e 3 for an outline of the
technique.
Integration of the underpinning theories
These theories are integrated into the delivery of
the coaching intervention. The transtheoretical
model is used to identify the stages of change for
each behaviour chosen by the client. Principles
of motivational interviewing are observed
throughout. Motivational interviewing techniques
are then used to help resolve barriers and obstacles.
Appreciative inquiry is used as necessary to
transform a negative stance or as an alternative to
help shift stuck behaviour.
Implementing the model of coaching
intervention
Becoming a coach
Before coaching, training is required. A certified
training programme is provided in the US by
Wellcoaches Corporation. This certification
is endorsed by the American College of Sports
Medicine. Training entails 18 weeks of online
instruction, including learning about the
transtheoretical model, motivational interviewing
and appreciative inquiry. There are online
examinations and practical skills assessment.
Training occurs via live teleclasses via Skype to
incorporate the skills training. In addition, peer
Clarify and
summarise issue
Please drill down to the issue you would like to explore in the next 10–15 minutes. Summarise and clarify so that we’re clear and
focused on what we’re working on.
Revisit vision
and goals
Describe your vision, values, and goals as they relate to this issue.
Decisional
balance
Pros: Explore reasons (benefits) to making the change and how they serve your vision. Which one is the most important and
energising? What will your life be like if you change?
Cons: Describe reasons (benefits) to stay the same. Describe the challenges to change. What will your life be like if you don’t
change?
Which has more weight – the pros or cons?
Discrepancy Sounds as though the pros and cons are well-balanced. What does it feel like to live with this ambivalence? What would it be like
to tip the balance toward the change? Away from the change?
Importance Rate the importance of making the change now on a scale of 1–10. Why is it x and not a lower number? What would make it
more important?
First steps What do you want to do about this? What’s your first step?
Confidence Rate your confidence on successfully making this change on a scale of 1–10, with 10 being the most confident and 1 being the
least. Why is it not lower than x? What would it take to increase your confidence? What strengths can you use to be successful?
Summarise and
confirm
Summarise the situation and next steps.
Ready and
committed
Are you ready to commit to moving forward?
Table 2. Motivational interviewing coaching moment tool. From Wellcoaches Core Coach Training Program. Reprinted with
permission from Wellcoaches Corporation, 2015.
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398 Journal of Diabetes Nursing Volume 19 No 10 2015
groups meet weekly via conference call rooms
to practise the key skills. This is useful as it
role-models the implementation of client coaching
via the telephone.
In this study, Helen McGloin trained as a coach
as part of a PhD study and implemented the
coaching with clients with diabetes.
Piloting the intervention
A telephone coaching intervention was piloted
using an instrumental case study approach
(Whitney and Trosten-Bloom, 2010). While
rigorous empirical methods are favoured for
testing interventions, there is a school of thought
that favours the subjective view (Flyvbjerg, 2006).
This can be particularly useful for the early
development of new innovations.
Clients were recruited by the DSNs and
coaching was offered free of charge. Following
consent, 10 people with type 2 diabetes were
coached by telephone on a weekly basis for 4 weeks
and fortnightly for 8 weeks, up to a period of
3 months. Further description of the methodology
may be found elsewhere (McGloin et al, 2015).
The first phone call was 60 –90 minutes long and
weekly phone calls thereafter were 30–45 minutes
long. The coaching relationship developed through
five phases, as outlined below.
Phase one
In phase one, a client assessment form was
completed (Figure 1). This served as a baseline
assessment for the areas of weight, exercise, health
status, stress and mental health.
Phase two
In this phase, participants were facilitated to
develop a wellness vision. They also identified
specific 3-month behavioural goals and obstacles
that may have prevented them from achieving
these. Strengths and strategies that they wished to
use to overcome the obstacles were also explored.
The technique of reflective listening was used to
address ambivalence and to respond to resistance.
The core skills that underpin motivational
interviewing – open questioning, aff irmations
and reflective listening, and summarising – were
utilised throughout all coaching conversations.
Reflective listening took a number of formats.
These included simple reflection, amplified
reflection and double-sided reflection. Simple
reflection paraphrases what the client said, whereas
“Q uote.”
Clarify and
summarise issue
Please drill down to the issue you would like to explore in the next 10–15 minutes. Summarise and clarify so that we’re
clear and focused on what we’re working on.
Discover best
experience
When were you doing your best in relation to this issue? Describe the circumstances. What factors enabled you to be at
your best? What strengths were you using? What values did you have at the time to support this best experience?
Describe dream,
vision or three wishes
What is this situation calling you to become? What does your dream or vision for this situation look like? Or what three
wishes would you ask a genie to grant you? What values do your dream, vision or three wishes reflect?
Energy How would it feel to realise your dream, vision or wishes? What is most exciting and energising about your dream vision
or wishes? What stories, metaphors, images or symbols can you use to bring more life to your dream?
Strengths What core strengths support you in your journey to your dream/vision/wishes?
Design What next steps do you want to take to bring your dream, vision or wishes alive? If you were your best self now, what would
you do next? What can you do to build confidence?
Destiny How can you keep the fire burning – stay on track to reach your dreams, make your dreams your destiny?
Summarise and
confirm
Summarise the situation and next steps.
Ready and committed Are you ready to commit to moving forward?
Table 3. Appreciative inquiry obstacle coaching tool. From Wellcoaches Core Coach Training Program. Reprinted with
permission from Wellcoaches Corporation, 2015.
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Journal of Diabetes Nursing Volume 19 No 10 2015 399
amplified ref lection is an exaggerated version
of the clients’ words that tends to elicit the other
side of ambivalence (Miller and Rollnick, 2002).
Double-sided reflection gives both sides of the
clients’ ambivalence if they have already given the
other side; for example, “you want to measure your
blood sugar but you are afraid of the result”. In
addition, the underpinning principles of expressing
empathy, rolling with resistance and taking a
non-judgemental stance were observed throughout
all conversations. This phase ended with the
setting of 3-month SMART (specific, measurable,
action-based, realistic and timely) goals.
Phase three
In phase three the coach helped the clients move
forward in the attainment of goals through weekly
SMART goal setting. The clients were coached
in identifying strategies to overcome barriers and
to increase self-eff icacy. Self-eff icacy was scored
for each goal to assess the clients’ confidence in
achieving the goal for that week. Open questioning
and reflective listening was used to explore
ambivalence and to examine discrepancy between
participants’ wishes and actual behaviour (Miller
and Rollnick, 2002). Affirmations and appreciative
inquiry were used to recognise past achievements
and build confidence. Strategies for achieving
change were discussed with the client at this point
(Prochaska, 2005).
Phase four
Phase four was the longest phase of the coaching
relationship, in which specific weekly goals were
set and reviewed the following week. At each
session the clients chose the sequence of review
and awarded a percentage achievement score to
each goal. Successes were focused on, and the
strengths and strategies that led to success were
highlighted. The technique of focusing on the
positive outcomes is underpinned by appreciative
inquiry and is a powerful method of increasing
self-efficacy (Orem et al, 2005).
Obstacles that prevented goal achievement were
also discussed, and ambivalence and challenges
were explored using reflective listening. In this
phase the coach helped the client to come up with
new strategies for managing challenges based on
the processes of change in the transtheoretical
model. Rewarding oneself, substituting alternatives
for the problem behaviour, helping relationships
and controlling situations and other cues for
the behaviour are all processes used by people
in the action and maintenance stages of change.
Connecting and talking with like-minded people
to support the change was used by participants
across all stages. However, all processes of change
were used, as in each conversation participants
could be in many stages of change for different
health behaviours (Prochaska, 2005).
Once the previous week’s goals were reviewed,
the participants picked the goal they wanted to
focus on, which was usually the goal that was the
biggest challenge for them. Using the principles
outlined, the goal was discussed and strategies
for goal achievement were put forward. Obstacles
and strengths were discussed and a score on a
scale of 1–10 was attributed by the participants.
Depending on the score, the participants were
asked what would make it higher or why was it
a nine, for example, and not a three. In this way,
they visualised the obstacles and facilitators for the
coming week.
Following each conversation, the goals and goal
review were written up and posted or emailed to
the participants, along with any resources they
needed which were identified in the call.
Phase five
The final stage of the coaching relationship
involved the evaluation of the coach, adherence
to the programme and general satisfaction of the
participants with the process.
Findings
Choice emerged as a core requirement for
successful coaching. The right to choose the
specific behaviour and change strategies emerged
as an important core concept in the coaching
intervention. Participants chose to change the
behaviour that was most important to them.
Stages of change were used by the coach to
guide the intervention. Enrolling in a coaching
intervention had the effect of moving people
along the stages prior to the first coaching call,
showing the recognised effect of commitment. All
processes of change were apparent in the coaching
conversations.
The five phases of the
wellness coaching
intervention
1. Client assessment.
2. Development of a wellness
vision and setting of
3-month SMART (specic,
measurable, action-based,
realistic, timely) goals.
3. Setting of weekly SMART goals.
4. Weekly review of goal
achievement and setting
of new goals.
5. Evaluation of the programme
and the coach.
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400 Journal of Diabetes Nursing Volume 19 No 10 2015
Ambivalence to change was common
throughout all stages of the intervention, showing
that it is a normal aspect of human behaviour
change and arises in response to internal conflict
and changes in the person’s social context. The
most common method used to resolve ambivalence
in this intervention was the use of ref lection and
an emphasis on choice. Motivational interviewing
thus proved useful in this context.
The use of appreciative inquiry underpinned the
coaching conversations, and this technique, based
largely on the positivist principle, had the power to
shift conversations. The distinction in appreciative
inquiry is that the technique is used to trigger
the person to look at the problem from a positive
angle and assumes that everybody has some level
of competence from past experience. Increases in
self-efficacy and confidence were observed. The
elements of the coaching relationship that clients
found helpful were encouragement, no judgement,
empathy, choice and listening.
Conclusion
It appears that coaching may cause a shift in role
identity through the nature of the relationship
between the coach and client. People with
diabetes find self-care difficult (Keers et al,
2006); however, with this approach the client’s
perception of the level of medical authority can
shift, with responsibility and power going to
the individual. The coach’s non-judgemental
stance and empowerment of the client may
have assisted participants to move towards
increasing responsibility and power in relation
to health. Telephone coaching emerges as a
cost-effective method of assisting with behaviour
change for people with type 2 diabetes. It fosters
independence and shifts responsibility from
the medical authority to the client. In order to
develop this intervention further, however, large
randomised controlled trials will be necessary to
establish efficacy. n
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“Telephone coaching
emerges as a
cost-effective method of
assisting with behaviour
change for people
with type 2 diabetes. It
fosters independence
and shifts responsibility
from the medical
authority to the client.”
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