Guidance and Coaching

Patient Engagement

There are many reasons why people are becoming more engaged in their health care: the ease of information access through the Internet, the shifting of costs of care to consumers, the heightened awareness of healthy behaviors leading to longer health spans, and an aging population with chronic illness insisting on living with the highest degree of independence and functionality possible. Patient experience surveys focus on how patients feel about the care they receive, and for acute care institutions, payment add-ons or decrements depend on those patient experience results. Hibbard and Greene (2013) have shown that patients activated to engage in their care have better outcomes and lower costs.

Guiding and coaching patients requires patient activation and empowerment by placing the responsibility of the pursuit of health where it rightly belongs—with the patient. Information technology has advanced to support the activation and empowerment of patients by giving them critical health information. The Patient Protection and Affordable Care Act of 2010 in the United States provided the structures and requirements to make data about quality of care publicly available and enhanced patient-centered care through client-centered medical homes and healthcare financing models that empower patients. Health systems are continuing to design care that engages patients in their treatment, develops their abilities to manage their health and lowers their modifiable risks, helps them express concerns and preferences regarding treatment, empowers them to ask questions about treatment options, and builds strategic patient–provider partnerships through shared decision making (Chen et al., 2016). Recognizing patients as the source of control for their health requires building confidence, trust, and partnerships with patients rather than having healthcare providers simply tell patients what they need to do.

Burden of Chronic Illness

The current biomedical model of care does not work for lifestyle-related diseases. In the United States, 6 in 19 people have one chronic disease and 4 in 10 have two or more chronic illnesses (Centers for Disease Control [CDC], 2020). Heart disease, cancer, respiratory illness, and diabetes account for 71% of deaths worldwide (World Health Organization [WHO], 2020a). These diseases are costly and are the lead driver of healthcare costs that are amenable to prevention. These diseases are caused by four behaviors: tobacco, inactivity, poor nutrition, and excessive alcohol use (CDC, 2020). Helping patients change these behaviors will greatly decrease untold suffering, early mortality, and disability.

A startling statistic that represents opportunity for behavior change is the number of people who are obese tripled between 1975 and 2016, with over 340 million children and adolescents aged 5 to 19 overweight or obese in 2016 (WHO, 2020b). Of great concern is the 2019 estimate that 38.2 million children under the age of 5 were overweight or obese (WHO, 2020b). Overweight and obesity are generally preventable and present an impending disaster for worldwide health, for society, and for the global macroeconomy.

Chronic disease in the United States is estimated to cost $3.7 trillion a year, including direct and indirect costs, with a gross domestic product (GDP) of $21 trillion. This accounts for almost 20% of the US GDP (O’Neill-Hayes & Gillian, 2020). It is estimated that global GDP could increase 8% by 2040 if chronic illness were reduced through innovation and prevention of illness (Remes et al. 2020). Chronic illnesses cause billions of dollars in losses of national income and push millions of people below the poverty line each year. In the United States alone, chronic diseases attributable to lifestyle factors are responsible for 7 of 10 deaths each year, and they account for an estimated 90% of our nation’s healthcare costs, which in 2019 was $3.8 trillion (before the COVID-19 pandemic; Centers for Medicare & Medicaid Services, 2020). In addition, the increasing burden of preventable chronic diseases globally has made very clear the vulnerability of those with a chronic condition to COVID-19 and other acute health emergencies that have arisen (Institute for Health Metrics and Evaluation, 2020).

As every APRN knows, lifestyle factors and behaviors can be modified to lessen the risk of chronic illness. People can reduce their chances of getting a chronic disease or improve their health and quality of life if they already have a chronic disease by making healthy choices. Liu et al. (2016) found that only 6.3% of US adults engaged in all five key health behaviors that can reduce their risk of chronic diseases: (1) avoiding alcohol consumption or only drinking in moderation, (2) exercising regularly, (3) getting enough sleep, (4) maintaining a healthy body weight, and (5) not smoking. These findings, based on nearly 400,000 adults aged 21 and older, showed that 1% failed to engage in any of the five health behaviors; 24% engaged in four, 35% engaged in three, and 24% engaged in two. As APRNs use their expertise to sharply focus on patients’ lifestyles, their value in the healthcare marketplace will be more fully realized.

Guidance

Guidance is a broad term that means the provision of help, instruction, or assistance, and there are several forms of guidance. The distinguishing feature of guidance compared with coaching is that guidance requires the provision of advice or education, whereas coaching is an inquiry, an excavation of answers from a person. To guide is to advise, or show the way to others, so guidance can be considered the act of providing expert counsel by leading, directing, or advising. To guide also means to assist a person to travel through or reach a destination in an unfamiliar area. Guidance is best used in situations when a person has a perceived knowledge deficit in an area for which expert APRN knowledge can fill the void. When providing guidance, the APRN is serving as a knowledge source for the patient. Guidance can include laying out, simplifying, or integrating the options for a patient to make a healthcare decision. It is imperative that the APRN determine the patient’s level of knowledge before launching into guidance. Asking patients what they know about their condition is an important skill to respectfully build on what they know and make APRN guidance more powerful and effective. What follows are some common forms of guidance.

Coaching

Coaching is a broad umbrella term that encompasses different approaches, philosophies, techniques, and disciplines. Coaching is defined by the International Coaching Federation (ICF, 2020) as “partnering with clients in a thought-provoking and creative process that inspires them to maximize their personal and professional potential.” For APRNs this definition also extends to a health potential. The ICF (2020) identified four main domains of a coach’s responsibility which could apply to APRN practice:

1. 1. Engages in foundational work that is based on ethical principles and a coaching mindset that is flexible, open, curious, and client centered.
2. 2. Cocreates a relationship that is based on agreement about the relationship, plans, goals, and client accountability and creates trust and safety and maintains presence with the client.
3. 3. Communicates effectively using deep listening and evokes client awareness.
4. 4. Cultivates learning and growth.

The ICF definition and components of coaching provide significant leeway in the development of different philosophic approaches to coaching. Although there are common principles, there are different philosophies and schools of thought in the coaching sphere. One example is motivational coaching, based on a focused approach to explore and ignite motivation for change and address ambivalence. Another is integrative coaching, developed at Duke University to help patients make changes to lead healthier lives (Duke Integrative Health, 2020). Integrative coaching is intended to address the gap between medical recommendations and the patient’s success in implementing the recommendations. Each of these approaches has commonalities, including working toward change that is defined by the patient. In addition, there are different foci of coaching, such as health and wellness, executive, life transition, end of life, and attention deficit/hyperactivity coaching, to name a few. A meta-analysis on coaching by Sonesh et al. (2015) found wide-ranging impacts of coaching, including that coaching is an effective way to change patient behaviors and improve leadership skills, job performance, and skill development. Specific findings concluded that coaching:

• ■ Improves personal and work attitudes, including self-efficacy, commitment to the organization, and reducing stress.
• ■ Elicits a strong bond, which in turn facilitates joint goal setting and may be the mechanism through which goals are reached.

In addition, systematic reviews related to the more prevalent chronic conditions such as weight loss, type 2 diabetes, chronic obstructive lung disease, and cardiac risk factor reduction found health coaching reduces hospitalization and improves healthy behaviors (An & Song, 2020; Perez-Cueto, 2019; Long et al., 2019; Pirbaglou et al., 2018).

Coaching is based on a relationship in which the individual identifies their goals. It is founded on the recognition that the person seeking coaching is mentally healthy and has internal resources to deploy toward attaining their goals. The role of the coach is to work with that person in accomplishing those goals. The coach helps individuals clarify, define, reflect, and move forward. Coaching can be thought of as leading change from behind as well as walking with the patient (McLean, 2019). This concept clearly puts the individual in charge while the coach fully engages with the patient. A coaching partnership can last from a “spot” coaching session of one time to interactions over several years.

There is considerable discussion within coaching as to how much advice-giving should be offered. Because coaching is considered a partnership with a coach asking powerful questions, the APRN must trust that the person has their own answers that are true and right for them. However, working with patients to make change is different in that providers have specific health-related information that patients need and want. Providing that information is providing guidance within a coaching context. Combining coaching with guidance is essential to a complete provider–patient relationship. Table 7.1 differentiates guidance and coaching. It is important to note that coaching is neither counseling nor mentoring. The American Counseling Association defines counseling as “a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals” (Kaplan et al., 2014, p. 368). Counseling can be a very long-term relationship focused on helping individuals address their problems. Counseling is generally focused on psychological, social, or performance issues. The key distinction is that counseling is intended to “fix” a problem through gaining insight and advice from the counselor. Counseling as a technique operates from a problem-based approach as well as building on a person’s strengths. Psychiatric mental health nurse practitioners use all three modalities: counseling, coaching, and guidance.

Nightingale’s Environmental Theory

Florence Nightingale’s Notes on Nursing: What It Is and What It Is Not (1860) makes a strong link between a person’s environment and their health. Working with a person to manage their environment is the fundamental role of nursing, and as we experience a chronic illness epidemic in modern times, this observation still holds true. In fact, Nightingale built the foundation of nursing as a distinct profession on her observation that external factors associated with patients’ surroundings greatly affect their lives, their development, and their biologic and physiologic processes (Nightingale, 1860). This seminal conceptual thinking lies at the heart of modern APRN guidance and coaching.

Middle Range Theory of Integrative Nurse Coaching

A theoretical framework for nurse coaching has been developed by Dossey et al. (2015). They defined an integrative nurse coaching framework as “a distinct nursing role that places clients/patients at the center and assists them in establishing health goals, creating change in lifestyle behaviors for health promotion and disease management, and implementing integrative modalities as appropriate” (Dossey et al., 2015, p. 29). The authors identified five components of this model: “(1) Self-development (Self-reflection, Self-assessment, Self-evaluation, and Self-care); (2) Integral Perspectives and Change; (3) Integrative Lifestyle Health and Well-being; (4) Awareness and Choice; and (5) Listening with HEART (Healing, Energy, Awareness, Resiliency, and Transformation)” (Dossey et al., 2015, p. 29). Based on this theoretical framework, the ANA published a guide to nurse coaching competencies (Dossey et al., 2013). This model is patient directed, with the coach facilitating learning and decision making.

Transtheoretical Model

The transtheoretical model is an integration of several hundred psychotherapy and behavior change theories; hence the term trans (Prochaska et al., 2002). Using smokers as research subjects, Prochaska et al. (2002) learned that behavior change unfolds through a series of sequenced stages of change, which were not delineated in any of the existing multitude of theories. The transtheoretical model has been used successfully in many maladaptive lifestyle behaviors such as alcohol and substance abuse, eating disorders, anxiety/panic disorders, obesity, sedentary lifestyles, high-risk sexual behavior, and nonadherent medication use. This model is highly relevant to the APRN, who can tailor the intervention to the patient’s specific stage of change to maximize the likelihood that the patient will proceed through a needed change process. Providing specific knowledge about disease trajectories or prevention strategies and advice is overused and often counterproductive when it comes to motivating patients toward sustained lifestyle change. A thorough discussion on readiness for change and application of this theory is provided later in this chapter in Determining Patients Readiness for Change.

Watson’s Model of Caring

The theoretical framework for Watson’s model of caring is based on loving kindness. Her work has focused on the science of caring and moving from carative to caratas (“love”); that is, the process of relating to others in an authentically present way, going beyond the ego (Watson, 2020). The APRN would go beyond self-interest and ego to fully and spiritually integrate body, mind, and spirit. This model provides a strong feelings-based approach to coaching, recognizing the openness of spirit to another person as essential in a therapeutic relationship. Honoring and respecting the patient’s values, history, beliefs, autonomy, goals, and being are foundational in this model. It also requires self-reflection for the APRN to reach deep love and respect in a relationship. This includes, for example, being present to and supportive of the expression of positive and negative feelings, the creative use of self and using all ways of knowing, and assisting with basic needs with intentional caring consciousness (Watson, 2020). Ways of knowing are how knowledge comes to us and can include, for example, our experiences, senses, logic and reason, language, emotions, and imagination.

Positive Psychology

Positive psychology is the scientific study of the strengths that enable people to thrive. The field is founded on the belief that people want to lead meaningful and fulfilling lives, to cultivate what is best within themselves, and to enhance their experiences of love, work, and play (Positive Psychology Center, 2021). There are many notable positive psychologists, including Carl Rogers, Alfred Adler, Abraham Maslow, and Martin Seligman (2011) who built on their work and found five dimensions that lead to a flourishing life or a high degree of well-being. The five dimensions (PERMA) are as follows: Positive emotions are emotions that feel good. People who are flourishing feel positive emotions in a 3:1 ratio to negative emotions. These are not positive or optimistic thoughts; they are deeper full-body feelings of connection to others, to meaningful work or the feeling one gets with important accomplishments. Engagement, also known as flow is the state of being completely absorbed in an activity. It is the sweet spot between stress and boredom. People in this state are entirely absorbed in what they are doing and lose track of time while doing it. If a person is angry, anxious or depressed they are completely barred from this state. When people engage in these kinds of activities regularly they are able to withstand the hardships of life more effectively. Relationships are strong in people who are flourishing because other people matter and very little in life is positive that is solitary. People who are flourishing tend to have strong and positive relationships of many kinds from acquaintances all the way up to intimacy. Meaning and purpose is evident in those who flourish because what they do and what they engage in matters to them. They also feel that they belong to something that is larger than themselves. People who are flourishing have a strong sense of achievement that they’ve been practicing a craft, hobby or their work for years and have achieved some level of mastery in what they do (Seligman, 2011).These dimensions can be cultivated to build one’s capacity to flourish. The five dimensions of positive psychology are directly applicable to the APRN interacting with a wide range of people. In looking at the dimension of positive emotions as an example, Fredrickson (2001, 2020) significantly contributed to our understanding of how positive emotions can broaden a person’s momentary thought–action choices, which builds their enduring personal resources. This “broadening and building” suggests that the capacity to experience positive emotions may be a fundamental human strength central to human well-being. The APRN can facilitate a person’s positive psychology, especially in a guidance and coaching interaction, by promoting any or all of the five dimensions of well-being.

Growth Mindset

Dweck (2017), in her study of mindset and its impact on achievement, found that there are two types of belief systems. One is a growth mindset in which the individual believes they can learn and practice and achieve success. In addition, there is the belief that people with a growth mindset have a high degree of resilience. People with a fixed mindset believe they are endowed with talents that are fixed; they focus on documenting and defending their talent rather than developing skills. People with fixed mindsets delink talent from effort, acting on the belief that talent is a fixed, immutable entity. Fostering a growth mindset in the clinical space can create motivation and productivity, leading to improved outcomes. Guiding patients to shift from a hunger for approval (fixed mindset) to a passion for learning (growth mindset) by the tiniest degree can have a profound impact on nearly every aspect of life (Dweck, 2017).

Self-Determination Theory

Ryan and Deci (2006) provided a framework for the understanding of human motivation and conditions that either promote or thwart it. The theory purports that there are two forms of motivation, intrinsic and extrinsic, and that all humans are motivated both by rewards (outside of ourselves) and by our interests, curiosity, and abiding values (inside). This framework offers three conditions that are associated with the level of a person’s motivation for engagement (Fig. 7.1). These three psychological needs have a robust impact on wellness (Ryan & Deci, 2006).

This framework is directly applicable to the APRN guidance and coaching competency because the APRN can promote the environment that supports competence, autonomy, and human relatedness (Exemplar 7.2). When these three needs are satisfied, enhanced self-motivation and health follow; when thwarted, motivation and well-being are diminished. Placing high value on positive regard, warmth, and giving patients as much psychological freedom as possible will lead to more engaged patients and better health outcomes (Ryan & Deci, 2000).

Transitions in Health and Illness

Guidance and coaching assists patients with a variety of life experiences in order to reduce healthcare costs and increase quality of care (Naylor et al., 2011). Early work by Schumacher and Meleis (1994) remains relevant to the APRN guidance and coaching competency and contemporary interventions, often delivered by APRNs, designed to ensure smooth transitions for patients as they move across settings (e.g., Aging and Disability Resource Centers, 2011; Coleman & Berenson, 2004; Coleman & Boult, 2003).

Schumacher and Meleis (1994) defined the term transition as a passage from one life phase, condition, or status to another: “Transition refers to both the process and outcome of complex person-environment interactions. It may involve more than one person and is embedded in the context and the situation” (Chick & Meleis, 1986, pp. 239–240).

Transitions have been characterized according to type, conditions, and universal properties. Schumacher and Meleis (1994) proposed four types of transitions: developmental, health and illness, situational, and organizational. Developmental transitions are those that reflect life cycle transitions, such as adolescence, parenthood, and aging. Health and illness transitions require not only adapting to an illness but more broadly reducing risk factors to prevent illness, changing unhealthy lifestyle behaviors, and numerous other clinical phenomena. Situational transitions are most likely to include changes in educational, work, and family roles. These can also result from changes in intangible or tangible structures or resources (e.g., loss of a relationship or financial reversals; Schumacher & Meleis, 1994). Organizational transitions are those that occur in the environment: within agencies, between agencies, or in society. They reflect changes in structures and resources at a system level.

Developmental, health and illness, and situational transitions are the most likely to lead to clinical encounters requiring guidance and coaching. Successful outcomes of guidance and coaching related to transitions include subjective well-being, role mastery, and well-being of relationships, all components of quality of life (Schumacher & Meleis, 1994).

This description of transitions as a focus for APRNs underscores the need for and the importance of incorporating guidance and coaching into the APRN–patient therapeutic partnerships.

Presence

How well honed is your ability to be present? Thich Nhat Hah (2015), a Buddhist philosopher, said, “The most precious gift we can give others is our presence.” In a guiding or coaching relationship, presence is not only a gift but a prerequisite to being a full partner. The ICF defines coaching presence as the “ability to be fully conscious and create [a] spontaneous relationship with the client, employing a style that is open, flexible and confident” (ICF, 2016). This definition uses the words “fully conscious”; others may use the words “fully aware” or “mindful.” Some people equate the words “mindful” and “presence.” A definition of mindfulness noted by Kabat-Zinn (2017, para. 2) is “mindfulness means to purposefully pay attention in the present moment with a sense of acceptance and nonjudgment.” The commonality of both definitions is paying attention and being fully conscious. Presence requires mindfulness and mindfulness requires presence.

There are two common pitfalls to being present that relate to APRNs: external distractions/interruptions and the well-honed ability to anticipate what the patient needs. We are often physically present, but our minds tend to jump from one thought to another. When we are with a patient, we may be thinking about the patient we just saw, our frustration with one of our colleagues, or getting our child to basketball practice. When we take the time to be aware of what we think during a patient visit, we may be astounded by how many thoughts unrelated to the patient enter our mind.

In addition to the challenges of our work environment, we have deeply rooted ways of thinking as nurses and APRNs to anticipate patient problems. (See Chapter 6 for a discussion on thinking errors in practice.) We have been taught that we need to have answers for problems so we can fix a problem and thereby fix a patient. We think ahead of what we hear from the patient. Once we start anticipating, we have stopped being present. We need to slow our thinking and follow what the patient is saying. This is a fundamental challenge to the APRN: the art of coaching is to develop the ability to set aside distractions—including jumping ahead in problem solving, which often leads to misdiagnosis and care that is not patient-centered—and engage fully in the moment with the patient.

Presence can be enhanced through practice with the following tools:

• ■ Review patient information before seeing the patient, not when you are initially with the patient.
• ■ Situate yourself at eye level when possible, to maximize eye contact.
• ■ Recognize the patient’s feelings—without this recognition, trust will be limited.
• ■ If looking at or entering data into a device, invite the patient to look at the data with you.
• ■ Use the STOP method that was developed by Jon Kabat-Zinn (2020, para. 3) to refocus and be present:
• ■ S: Stop. Stop what you are doing and pause momentarily.
• ■ T: Take a breath. Take a deep breath or several. Deep breathing can anchor you to the present moment.
• ■ O: Observe. Notice what is happening both outside and inside of yourself. Where has your mind gone? What do you feel? What are you doing?
• ■ P: Proceed. Continue doing what you were doing or, using the information gained during this check-in, change course.

Rachel Naomi Remen (1996) is a pioneer of relationship-centered care and noted, “The most basic and powerful way to connect with another person is to listen. Just listen. Perhaps the most important thing we give to each other is our attention” (p. 143). Listening is a foundational skill to both guidance and coaching and in any relationship. Listening is the process of understanding others and establishing trust in the relationship. Trust is the foundation of the APRN–patient therapeutic relationship. We can only understand a person’s level of health literacy if we listen deeply.

There are several different taxonomies of listening. A useful classification described by Whitworth and colleagues (2007) includes three levels of listening (Fig. 7.2). The level 1 listener is tuned out, either ignoring the person talking or pretending to listen. This level is also referred to as internal listening, where the listening is all about the listener. Level 2 listening is selective, with the listener sometimes focusing but at times being distracted by his own inner dialogue. Level 2 listening has a sharper focus on the other person than level 1. In level 3, the APRN becomes a mirror in which the information is reflected back. This listening is collaborative, empathic, and clarifying. The APRN is unattached to their agenda and own interests. Level 3 is empathic listening, representing the highest level, in which the listener gives time and attention to listening and gives their full self. Empathic listening is not only hearing what is said but also understanding the words, emotions, and meaning. It is considered “deep” listening or listening with the heart. Deep listening is hearing what is not said and includes tone of voice and nonverbal expressions. It is a global form of listening, in which one is using all of the senses to listen, noticing gestures, the action, inaction, and interaction. It requires the APRN to be very open and softly focused without an agenda or judgment of any kind. Level 3 listening is often described as a force field with invisible radio waves in which only the skilled listener can receive the information, often unobservable to the untrained listener (Whitworth et al., 2007). Guiding and coaching require level 3 listening in order to fully engage with the patient’s baseline knowledge, goals, actions, and emotions. Suggestions for levels 2 and 3 listening are the following:

• ■ Stop talking!
• ■ Relax for a minute prior to engaging with a patient by deep breathing, visualizing a pleasant memory that triggers relaxation.
• ■ Review the health record prior to beginning a dialogue.
• ■ Remove distractions and potential interruptions and clear your head of intruding thoughts.
• ■ Listen for the tone of the conversation as well as the words.
• ■ Acknowledge what is said by reflecting and probing further.
• ■ Ask powerful questions (Table 7.2).

Literature reflecting the benefits of deep listening includes patient satisfaction with care, enhanced patient engagement in care planning, and improved health outcomes (Wentlandt et al., 2016). Listening is the most critical skill for APRNs, as discussed in Chapter 6. There is no guidance or coaching without deep listening.

Nonjudgmental (Suspending Judgment)

Being completely accepting toward another person, without reservations, is a concept developed by the psychologist Carl Rogers. He proposed that each individual has vast resources to marshal for self-understanding and self-directed behavior, but an interpersonal climate of positive regard was necessary to facilitate this (C. Rogers, 1961). It is about accepting a person as they are without judgment and is the basis for patient-centered therapy.

Being judgmental means that we are unusually harsh or critical in disapproving, blaming, or finding fault in others. Often judgmentalism is steeped in our biases and closed-mindedness. When we hold negative opinions of others, it distorts our perceptions of other people and of ourselves. By judging others, we garner distorted feelings of power or righteousness over others. Being judgmental is associated with poor self-worth and self-esteem. Currently, more attention is being paid to implicit (unconscious) bias as a contributing factor in health disparities in the United States. One definition of implicit bias is “attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner” (Kirwan Institute, 2015). Everyone has implicit biases, and they are based not only on race, ethnicity, or religion but also on manner of dress, weight, gender, political views, religious practices, and other issues. And they may be based on how we perceive the behavior of a patient as a patient. Is the patient deferential? Are they personable? Are they a complainer?

A patient must feel physically and psychologically safe from being judged in order to fully engage in a relationship. We often take for granted that people seek health care and trust APRNs to do the best for them simply because we are credentialed healthcare providers. However, they often feel that they must “please us” rather than being honest about their concerns. Pleasing a provider is deeply rooted in patient behavior. Patients want their APRN to like them, so they may be afraid that the APRN will be angry or judgmental of them if they are challenging or have not adhered to a treatment plan, so they may tell APRNs what they think we want to hear. We often give subtle messages of greater acceptance when patients are “compliant” and of nonacceptance if they are not.

Suspending judgment does not mean we have to like every patient. Mearns (1994) noted that liking someone is based on shared values and complementary needs and is therefore conditional. However, it is especially important to be nonjudgmental for all patients and particularly for those we find most frustrating. Being nonjudgmental includes setting boundaries by creating clarity of expectations in the relationship. The concept of boundary awareness in coaching is founded on the initial work of Kerr and Bowen (1988) on self-differentiation within the context of family. In an APRN coaching relationship, there is a fine line between boundaries that are too tight and those that are too loose, and it can be a significant challenge to maintain a balance. To be more aware of boundaries, pay attention to situations in which you feel stressed. Reflect on the sources of stress and how you are establishing boundaries. Another exercise in clarifying boundaries is to be aware of feelings of resentment, discomfort, and/or guilt (Gionta & Guerra, 2015). If you experience these feelings within a patient relationship, it is time to focus on setting or resetting boundaries. Examples of boundaries include not tolerating hurtful behaviors (if the patient has the capacity to manage their behavior) or being treated disrespectfully as an APRN. APRNs need to establish their own set of boundaries and clarify and maintain them with their patients, families, and healthcare team.

There is an important difference between judgment and discernment. Discernment is differentiating between what is appropriate or inappropriate and is a conscious act. Judgmentalism is holding strong, often unconscious negative opinions of others involving little knowledge and fast thinking. If we are judging, it is nearly impossible to be truly helpful. TOME is a tool to practice being nonjudgmental:

• ■ Notice Triggers. Notice what triggers judgments and why. Understanding the triggers will enhance awareness of making judgments about patients.
• ■ Observe like a reporter. Look at your patients in as neutral a manner as possible. Look at them without placing your value set on them and explore their values and the meaning of health and/or illness to them.
• ■ Meditate. Meditation is a way of being aware of thoughts and questioning their origins and impact on patients.
• ■ Extend empathy. Every patient wants to be understood and have their APRN understand their situation and how they feel about their health or illness. Conveying empathy through acknowledging the patient’s feelings helps patients move through the change cycle.

Carl Rogers built on Maslow’s hierarchy of needs by adding that in order for a person to “grow,” they need acceptance, genuineness, and empathy. Rogers believed that each person can achieve their deepest desires in life and achieve self-actualization but that empathy helps foster that growth, just as a seed needs soil and water. His greatest contribution was likely in his study of accurate empathy and its role in the growth of humans. He described empathy as an underappreciated way of being and posited that accurate empathy is “being one with the patient in the here and now, being highly sensitive to their experience and their world” (C. Rogers, 1961, p. 34). He stressed that listening is not a passive endeavor, because active listening can bring about changes in people’s attitudes toward themselves. People who experience accurate empathy and are listened to in this way become more emotionally mature, more open, and less defensive (C. Rogers, 1961). There is increasing recognition and evidence that provider–patient relationships, the quality of their communications, and accurate empathy influence quality, safety, and health outcomes (Price et al., 2014).

Trzeciak et al. (2019) suggested in their book Compassionomics that empathy precedes compassion, that first you need to have empathy—the feeling of truly understanding another person—and then compassion, the action that results from empathy. In working with patients to create change, empathy and compassion are essential. Although empathy is woven into basic nursing, as we get pressed for time with interruptions, technology intrusions, and demands of patients, exhibiting empathy requires constant vigilance.

Although we accept empathy as an emotional state, there is growing understanding of the neurophysiology of empathy. Research beginning in the mid-1990s has identified neural networks of mirror neurons that may explain the capacity for empathy (Rizzolatti & Craighero, 2004). Mirror neurons are activated by both the action of an individual and the observation of a similar action performed by another (Lamm & Majdandzic, 2015; Preston & de Waal, 2002). It appears that mirror neural pathways extend to multiple structures in the brain based on the stimuli producing the effect. A possible explanation for empathy is that when we are listening to and looking at a patient, our mirror neurons are activated as if we are experiencing what the patient is doing or experiencing. With ongoing research into mirror neurons, there is great promise to better understand the neural activation that forms and supports relationships and how feelings are experienced. To expand empathy and compassion:

• ■ Audio-record a visit with a patient and reflect on the content of the visit.
• ■ Practice reflecting back to the patient your understanding of the feelings the patient may be experiencing. Be present and listen.
• ■ Acknowledge the emotional content of what the patient is saying.
• ■ Ask the patient how you can help them.

• ■ Take a deep breath before responding. This will be calming and provide a moment to recognize the situation.
• ■ Never meet a feeling with a fact. Acknowledge the patient’s feelings. This all-important step deescalates highly charged encounters. Until intense emotions are acknowledged, there is little that will be accomplished in a patient visit. For example, if a patient comes into an exam room angrily saying that they were treated rudely by the receptionist, the APN must first recognize and notice that they are upset. By validating the patient’s feelings first, the conversation can move to a constructive dialogue.
• ■ Ask questions to understand the patient’s emotional landscape. Asking about how they are doing or feeling makes the well-being of the patient the priority (within a realistic boundary).
• ■ Maintain a respectful stance with the patient while working through the conflict.
• ■ Make sure they feel heard and understood. Provide a summary of the conflict and agreements to the patient before the patient leaves.

• ■ Create a safe environment.
• ■ Recognize and respect patient preferences. Ask questions such as:
  • ■ What is most important to you at this moment?
  • ■ What are your life goals?
  • ■ What do you value most?
• ■ Convey your understanding of the patient’s concerns.
• ■ Set goals that are patient driven.
• ■ Create a plan that is the result of shared decision-making.

Patient Readiness

In order to be coached, the patient must be functionally able, creative, and resourceful. Therefore most people in the general population are appropriate to receive/participate in coaching. If an APRN is considering using coaching, patients must first be deemed well enough to imagine a better future for themselves. Consequently, coaching will not be productive with people who cannot envision a different future. Explicitly, those who are severely mentally ill, psychotic, manic, severely depressed, suicidal, inebriated, obtunded, demented, or high or who are in a severe emotional state such as acute grief or trauma are not appropriate to engage in a coaching partnership. People with mental illness or in an acute intense emotional state are best engaged with empathy and guidance. A simple way to determine whether a person is coachable is to ask the individual to describe their life in the future, if everything went as well as it possibly could for them. If the person cannot articulate an answer, the APRN should not enter into a coaching dialogue but instead work with them to be able to envision a future healthier life.

After rapport has been established and some degree of empathy expressed, the APRN must determine the person’s readiness for change. The person’s stage of change in any given self-defeating lifestyle must be documented in the health record for the entire healthcare team to use and build on, measure progress, and guide interventions. Staging people is a necessary first step to any coaching encounter because it drives skilled conversations. Taking the time to assess where the person is in the change process and their willingness to be coached on any issue sets the stage for a deeper, more meaningful, and more effective encounter.

Agenda Setting

Agenda setting, and the broader coaching methodology, requires handing over control and the choice of topic to the patient. The APRN elicits the agenda (the topic the patient wants to discuss) from the patient and the APRN and patient work together to address the patient’s agenda. Guidance can be useful in this stage by providing factual information that the patient can use in creating their agenda. For example, the APRN may say, “You have a lot of things going on with you and we have 15 minutes together today. What would be most useful for you to have accomplished with our time together?” Allow for silence, because this is a powerful question in and of itself. The patient may struggle with that question, and the APRN may need to ask more probing questions; however, the agenda must be specific, measurable, and within the patient’s control. Agendas cannot be centered around feelings or the actions of others. Acceptable agendas could include, “I need a plan for managing sugar cravings” or “I want to be able to manage the colostomy myself,” and unacceptable agendas are “I want to feel better” or “I want my wife to have more concern about my pain.” Eliciting and clarifying the agenda is a necessary and important step in the coaching process. If no agenda is determined by the patient, then no coaching can occur (Kimsey-House et al., 2011).

Focusing on the patient’s agenda is a sharp departure from what is typically provided by APRNs in the form of patient education because the encounter is entirely directed toward what the patient wants. The decisions each person makes, no matter how small, lead them toward (or away from) a life that is healthier. Thus at some level, the patient agenda is wrapped in the person’s fundamental values and truth.

Awareness Raising

Awareness raising requires challenging the patient’s mindset and assumptions about an issue with which they are struggling. It requires skillful inquiry in which the APRN adopts a highly curious approach to understand what and how the patient thinks about an issue. Awareness is raised by asking powerful questions (Table 7.2) that have likely never been asked of the patient and require deep reflection. This phase of coaching generally is the most time consuming. It can also be useful to incorporate guidance in the form of providing the patient information about their health concerns or interests as well as information about their health status. As the APRN builds coaching skills, it can be helpful to have five powerful questions that are used regularly to begin an inquiry. During the awareness phase, the APRN is using deep listening skills, watching for nonverbal messages. The APRN may become aware of the moment in which the patient has a major insight or makes new connections. The APRN can identify when awareness has been raised because there may be more silence and the patient will begin to identify changes they want to make.

Actions and Goal Setting

The APRN asks the patient what they want to do and when they want to do it. Goals flow directly from the awareness raised, which arouses emotions, and the patient has a higher degree of self-efficacy in pursuing the goal(s). If the patient seems stuck on developing a solution, the APRN can set up a brainstorming exercise in which the patient and APRN take turns coming up with a list of ideas/solutions. The key competency in brainstorming is to not allow the patient to judge the ideas until they are all laid out. Once the goals or actions are determined, the APRN must determine self-efficacy (the belief a person has in themselves to complete a task). The APRN asks, “On a scale of 1 to 10, how successful are you likely to be in doing this (10 = success)?” If the chosen number is less than 7, the goal must be modified. That is, the goal must be made less ambitious so that the patient has a self-efficacy score of at least a 7 in order for the patient to be positioned for success. Guidance may be useful here to help the patient define manageable goals and actions by providing information related to specific goals such as realistic lab measures for cholesterol or specific products available for smoking cessation.

Success breeds success, so as any adult embarks on a change process, it is important to have early successes. During this phase of the coaching, the APRN is letting the patient talk. The APRN may need to ask clarifying questions to make the patient’s goal more specific. If the APRN has a sense the patient could do more, they can challenge the patient. This skill is only used during the goal-setting phase and when the APRN thinks the patient could do more. For example, if the patient commits to ambulating down the hall once a day, the APRN can challenge them to do so three times a day. The patient will respond to the challenge in one of three ways: (1) agree to it, (2) reject it, or (3) modify it. It is crucial that the APRN accepts fully however the patient responds and challenges the patient no further.

Accountability

The final step in the coaching method is determined by the APRN asking, “How do you want to hold yourself accountable?” Ideally, it is best for the patient to rely on their own resources to achieve accountability, such as relatives, coworkers, or apps. The APRN could offer themselves as a way to hold a patient accountable, but it must not present any burden to the APRN. Accountability could be in the form of an email, text, or follow-up visit. It is important in this phase to have the patient outline a plan if the goals are not being met; this may include developing “when–then” strategies such as “When a week goes by and I haven’t done what I said I would, I will reschedule with you” (J. Rogers, 2016).

Ask Questions

Perhaps the most important single change an APRN can do to move toward a coaching and guiding mindset is pause when you are going to tell a patient to do something. Do a self-check about whether it is an opportunity for coaching and ask a question instead. For example, replace “I see you are short of breath and that you need to take your diuretic every day” with “I see you are short of breath, and maybe uncomfortable. How can I best be helpful to you today?” In order to more fully engage patients in their self-care, asking questions places the patient in the driver’s seat, where they belong. It creates a psychological spaciousness for patients to feel and claim a sense of agency over their own care.

Ask Permission

Although nursing is a wonderful blend of science, technology, and caring, nurses have a strong drive to make people better, whatever the specific situation. APRNs have embraced the idea of holistic health care and are empathic with patients, but there continues to be an attitude that providers know what is best for patients. Integrating coaching into practice requires a culture shift and a change in personal philosophy and approach to caring for patients. To effectively integrate coaching into personal beliefs as well as the practice culture, there are many small actions that can support more effective APRN encounters. This can be difficult as the APRN is a clinical expert and knows the population so well, making it hard to resist telling others what and how to do things.

A crucial first step is asking permission from each person prior to initiating a coaching conversation. Asking permission, such as “Is it okay for me to explore this with you further?” is a way of respecting boundaries. Asking permission also demonstrates to the person that they have a choice and power in the relationship (Kimsey-House et al., 2011). If the patient decides against coaching, the APRN should move to providing guidance.

Build on Strengths

There is increasing recognition that building on patient strengths is a way for patients to gain confidence in their ability to change. The tendency in the past has been to focus on what is broken or not working or what an individual does not do well. This has supported the idea that the health issues a patient has are the result of not doing something or not doing something correctly, and that gap needs to be addressed. Rather than fixing what is broken, building on strengths can make the broken parts desiccate and shrink. For example, if a person has a great appreciation for excellence in their profession, that inherent skill can be applied to a weight loss journey by raising the quality of food they are ingesting or using love of learning to experiment with different strategies to manage their stress. An interprofessional summit was convened to identify that a major change that must occur in care delivery is to build on patient strengths to assist patients to achieve their goals (Swartwout et al., 2016).

The recent focus on building strengths is based on seminal research by Peterson and Seligman (2004), who demonstrated the benefit of assessing and using people’s strengths in making and sustaining change in a person’s life. There are years of research showing the benefits of building on strengths (VIA Institute on Character, 2016). The Classification of Strengths is an important tool that has been used in a growing body of evidence since the mid-1990s (Peterson & Park, 2009). This classification has six “virtues”: wisdom and knowledge, courage, humanity, justice, temperance, and transcendence. In addition, there are 24 characteristics within the overall classification (Table 7.5). Although the research has not been specific to health care, there are clearly applications to health promotion by assessing and then building on patients’ strengths for a healthier future.

Building on strengths has become an approach broadly used in health coaching. Confidence gained from building on strengths helps individuals not only to deploy those strengths toward achieving their goals but to also work on areas to be developed. Often people do not recognize their strengths, and the initial work of the APRN is to help the patient identify their strengths. There are strengths assessments available online that have strong validity profiles. One example is the VIA Survey of Character Strengths, which can be found at http://www.viacharacter.org/www/Character-Strengths-Survey. If there is no formal values in action (VIA) assessment, the APRN can help the patient recognize their strengths to build on by asking:

• ■ “Tell me about a challenge that you feel you successfully managed.”
• ■ “What would your friends and family say were the best parts about you?”
• ■ “What strengths helped you be successful?”
• ■ “How would you describe your strengths to create the change you want to make?”

Having patients consider small changes may produce bigger and more lasting results. According to Seligman (2011), humans are more likely to achieve their goals if they have early success. A person trying to lose a few pounds may believe that a strict diet is mandatory, requiring considerable changes, such as how food is purchased and prepared, who does the preparation, limiting food intake, and changing social patterns to adhere to the diet. However, as a coach, you can work with your patient to make a small change, such as taking a walk to add exercise or decreasing the amount of liquid low-nutrient calories. Small changes are part of a larger process of change. Patients can be coached to do one intervention, and once that is integrated into their lives, additional small changes can be added. These small changes can add up to major lifestyle changes.

Although small changes can have a big impact and are a useful start for lifestyle change, there may be patients who need to decide on a big change in their lives, such as having bariatric surgery to achieve weight loss or leaving a toxic relationship.

Be Curious

Perhaps one of the most useful coaching tools is to be curious (Sherman, 2019). Curiosity provides the foundation for asking great questions. Patients nearly always give clues as to what is on their minds but may not be direct. One should follow up with questions such as “I wonder what … means to you?” or “I am curious about what you just said that. …” These very simple questions based on curiosity often net a rich conversation and help bring out issues that are important to patients. In a time-constrained environment, APRNs may feel inhibited from opening any doors to topics that they may not be able to pursue with patients. However, not opening the door deprives patients of opening up about what is really important to them, and opportunities to positively impact their life are missed.

Challenge

Are you comfortable challenging a patient? The APRN coach must be willing to challenge a patient in order to help move the patient forward. While it is important to maintain a good working relationship, wanting to be liked may interfere with the effectiveness of challenging a patient’s view or with interpretation of situations, beliefs, or values. Patients often get “stuck,” and respectfully challenging them to think differently or see themselves or their situation differently can get them “unstuck” (Moore & Tschannen-Moran, 2010). Challenging patients is a way of deepening awareness and forwarding action by making a request or suspending a belief. For example, a challenge might be, “Could I challenge you to 30 days with no sugar?” or “What would it be like to approach this situation without any fear or anxiety, instead cultivating calm confidence?” One useful way of maintaining an effective APRN therapeutic relationship while challenging the patient is to inquire about feedback. Ask the patient if the conversation was useful, what part was most helpful, and what created discomfort. When challenging, make sure patients know that you are fully with them on their journey and that the point of the journey is to create change.

Get to the Feelings

Change happens when people understand and incorporate the need for change at an emotional level. Although knowledge of data is helpful, it is usually only a starting point, because the knowledge alone usually does not create transformative change. In coaching patients, it is important to get to the emotional meaning of their issues (Stober & Grant, 2006). Naming emotional feelings is a driver for motivation to change. Exploring feelings related to change links mindfulness and contemplation to taking action.

Getting to the feelings requires awareness of the APRN’s comfort level with range of feelings for both yourself and the patient, including anxiety, fear, sadness, and anger, in order to give patients the opportunity to talk about their feelings. If a patient senses your discomfort with anxiety, they will not talk about it. Transformational change for patients occurs at the emotional level, and the APRN coach will only be able to support this by recognizing and accepting their own feelings in order to accept those of the patient. A patient with newly diagnosed breast cancer or who is having unexpected triplets will have a range of feelings, and if the APRN is not comfortable with the patient’s feelings, the patient will feel inhibited to share those feelings.

A universal response to change—even change we believe we should make—is resistance. We create reasons for or exceptions to why we cannot change, such as, “It’s too hard,” “I don’t really like/need/want to do this,” or “I’ve tried before and failed.” A major reason for resistance to change is simply fear—fear of not being successful, fear of what other people may think, and many other types of fears. As an APRN, having a trusting relationship with your patients can help them name and understand their fears and other feelings about change.

Getting to the feelings has boundaries. This does not mean getting to feelings that relate to psychopathology or feelings related to issues that require counseling. Naming/identifying feelings should not be focused on the past, such as on past relationships with family members, but on the present and future. It is about getting to the feelings related to the present circumstances creating the need for change, the change process itself, and the potential outcome. The following statements can be used to get to feelings:

• ■ “Tell me about how you feel when you think about (or talk about). …”
• ■ “Knowing how you feel about … is important to me.”

To get a better understanding of one’s own feelings when interacting with a patient, use root cause analysis. Create some mental space (between patients) and keep asking yourself why you were experiencing your feelings. This can take you to a deep level toward understanding your feelings. It is also useful to pay attention to triggers. When you note a particular feeling while guiding or coaching, reflect on what might have contributed to that feeling. Being aware of your physical (somatic) responses to different emotional situations will help you make adjustments in being effective with your patients. Somatic sensations will let you know when you are getting into uncomfortable emotional territory. Some people may feel a physical tenseness, while others may clench their teeth or cross their arms. Whatever the reaction may be, it is important to be aware of the somatic feeling in order to make adjustments, such as taking deep breaths or mentally calming yourself for effective APRN guidance and coaching. A technique that may be useful to enhance somatic awareness is using Silsbee’s (2018) “body scan” approach. Starting with the feet and, moving up your body, scan for physical responses to a situation. This can be done quickly—in a few seconds.