Applying Health and Wellness Coaching to O&P
March 2018 Issue
Each year hundreds of prospective students with diverse educational backgrounds apply to O&P master's programs around the country. Roughly 20 percent of applicants have an undergraduate background in engineering, and more than 50 percent have a background in health or movement sciences. The relatively large size of the latter group may be due to the scarcity of undergraduate degree programs in O&P, which leads undergraduates to choose a degree that reflects their general interest in healthcare. Regardless of why they selected this type of undergraduate program, one result is that many individuals enter the profession with an educational background that gives them important perspectives on health and wellness. Patients who require O&P care often have chronic health conditions. These conditions can be directly related to lifestyle choices and specific health-related behaviors. Additionally, a patient's comfort, safety, and function while using an O&P device may be significantly impacted by an ongoing pattern of unhealthy choices and habits. As an example, poorly managed diabetes can result in amputation, and can also directly affect a patient's ability to function optimally with a prosthesis. Practitioners spend significant amounts of time providing education and instructions to patients on proper wear and care of their device, but a patient who struggles to adhere to medication or therapy protocols likely also struggles with sock management, wear and care guidelines, and maintaining an appropriate follow-up schedule. Improper use and wear patterns can increase the need for follow-up visits, adjustments, and re-education, which require a significant investment of practitioner time and other resources. Greater effectiveness in influencing patients to develop and maintain health-promoting habits may result in improved adherence to recommendations, fewer complications, and more effective use of clinical time. This article explores literature related to health and wellness coaching (HWC) and suggests ways that principles within this discipline can be applied to O&P practice.
What Is Health & Wellness Coaching?
Despite a dramatic increase in the number of peer-reviewed articles on the subject in the past decade, there is no universally recognized definition of HWC.1 Citing the lack of agreement on what constitutes coaching, the role of a coach, and the training required, a group of researchers set out to establish a consensus definition of HWC. They performed a systematic review of peer-reviewed medical literature to answer the question, "How are interventions described as health or wellness coaching defined and operationalized?"1 This type of research is an important step in establishing evidence-based HWC practice, identifying skills required of coaches, and determining the efficacy of HWC interventions. In their review, the researchers focused on the type of article, descriptions of the coaching process, and the coaches' characteristics. The review included 284 articles, 185 of which "were empirical studies wherein data were systematically collected." Other articles included descriptions of proposed research protocols, reports of existing HWC practices, or conceptual articles with no data presented. This broad range of articles was considered because conceptual articles can influence the literature and practice even if no data is collected. They found that the articles described HWC "as a process that is fully or partially patient-centered…included patient-determined goals…incorporated self-discovery and active learning processes…encouraged accountability for behaviors, and provided some type of education to patients along with using coaching processes…." (see sidebar above.)1 In the articles reviewed, professionally trained coaches were most commonly nurses and mental health providers. A variety of behavior-change skills were a part of the formal training, and included "communication skills specifically for developing rapport, expressing empathy, and/or providing emotional support…. [T]he use of powerful questions, assertiveness training, negotiation skills, providing feedback, and various types of reflections including those that emphasize possibilities, underline the positive side of an issue, or highlight the gap between where a patient wants to be and where he or she is now."1 Interestingly, "…42 percent of articles that documented the content of the coaches' training specifically referred to training in…motivational interviewing (MI)."1
Does It Work?
In 2014, a group of Finnish researchers performed a systematic review of the effects of HWC on adult patients with chronic diseases. Thirteen studies published between 2009 and 2013 were included in their review, and 11 of those studies were randomized control trials (RCTs). They reported on the physiological, behavioral, and social outcomes in the subjects and concluded that the results "were very encouraging. They indicate that health coaching has positive effects…."2 A systematic review performed by Hill et al. in 2015 comprised 16 RCTs related to HWC. The authors reported that "94 percent of studies reported a positive intervention effect on at least one outcome variable, with overall study quality deemed fair. Hence, we could deduce that health coaching shows promise as a technique for eliciting positive behavioral or outcome change, at least for certain outcomes…."3 Because of diversity in the interventions' approaches, lack of intervention detail, and diversity of outcomes measured, they caution that "…we are not confident in making conclusions from the literature as available in its current form." Despite these concerns, they report, "The current state of the health coaching literature does suggest that it is an effective strategy for promoting healthy behavior change…."3 A "Compendium of the Health and Wellness Coaching Literature," published in 2017 by Sforzo et al., reported on the effectiveness of HWC for a broad range of health conditions. The compendium is a collection of 219 articles including 150 data-based articles, almost half of which were RTCs. Diabetes and obesity were the focus of more than 60 percent of the articles. Another 26 percent of the articles addressed the management of cholesterol, heart disease, and hypertension. There is good evidence that HWC is a valuable intervention for the conditions reported on in those studies. The authors report that the articles on diabetes "present an overwhelmingly positive group of outcomes for the effects of HWC," and those related to obesity "found a significant positive impact of coaching on weight reduction."4 It is likely that the strategies used to facilitate healthy decision making and lifestyle change in the management of the chronic conditions addressed within the scope of these systematic reviews can be applied to O&P care. This potential can be demonstrated by describing the importance of patient self-management and the distinction between patient education and coaching.
The Importance of Self-management
According to Reiger, et al., "…programs of health and coaching are…based on the assumption that the way clinical teams interact with patients makes a signiﬁcant difference to patients' health outcomes."5 Too often, patient education is part of a care delivery system that places patients in passive roles regarding their own health and wellness. Coaching recognizes that the ultimate responsibility for healthy choices and habits rests with patients. Rather than simply instructing patients, it is important that practitioners support patients in self-managing their own care. "Self-management is deﬁned as ‘engaging in activities that protect and promote health, monitoring and managing symptoms and signs of illness, managing impact of illness on functioning, emotions and interpersonal relationships, and adhering to treatment regimens.'"5 For O&P patients, effective self-management requires adherence to a recommended break-in period, maintaining a proper wear schedule, managing sock ply, and determining when to initiate a follow-up appointment, to name just a few examples. "In contrast to the more traditional role of ‘expert' whereby the healthcare professional engages primarily in informing, directing, and making choices on behalf of the patient, the healthcare professional in the role of a health coach collaborates in joint goal setting, problem solving, and following up on the patients' choices."5 Practitioners can more effectively support self-management by listening to patients, focusing on their concerns, and using strategies to coach a patient toward greater self-efficacy (their belief in their own ability to change) than is possible by simply repeating instructions about wear and care.
Education Versus Coaching
To manage chronic health conditions, patients must adhere to a treatment plan and make health-promoting lifestyle changes.5 The same is true of O&P patients who want to maintain or improve their health, function, and mobility. Most practitioners recognize that it is their professional responsibility to educate patients and use a variety of methods to deliver important content related to the device and overall treatment plan. However, this "transfer of knowledge about a condition and treatments, has been shown to be a necessary but not sufﬁcient component to sustainable behavior change."5 Providing knowledge is inadequate, in part, because lack of knowledge is often not the primary barrier to making healthy choices: "…[T]here are other cognitive factors in addition to knowledge that influence individuals' ability to modify healthy behavior."3 According to Wolever, et al., "There is evidence that behavior change and learning occur most reliably when there is a helping relationship that (1) acknowledges the individual, (2) is collaborative, and (3) encourages active learning…. [H]ealth and wellness coaching conceptualizes patients as lifelong learners whose individual personal values and innate internal resources can be cultivated in the context of a supportive relationship to guide them toward their own desired vision of health."1 When interacting with patients during the normal course of a clinical encounter, practitioners may default to instructing them on what they should do, without an awareness of the patients' desires and readiness to act on those instructions. Patients may acknowledge that the expert is correct, without any real commitment to alter their behavior. In addition to expertise in the knowledge content of our profession, practitioners must become proficient in a set of interpersonal skills "to integrate the content information into the patient's change process rather than dictating it."1
Clinicians and Coaches
Are O&P practitioners qualified to coach patients? According to Wolever et al., "there is an emerging consensus in the literature that coaching be provided by health professionals…who…have specific training in coaching processes and not only expertise in the knowledge base of their profession."1 It is worth noting that the most positive outcomes reported in Kivela's systematic review "were found in studies in which coaches were trained psychologists."2 Lack of appropriate training leaves traditionally trained practitioners "vulnerable to using approaches that are expert driven, authoritarian, and advice-giving as opposed to taking stances that are supported by the latest research in behavior change models…."1 These researchers go on to conclude that specific training and credentialing will be required to provide the type of coaching described in their consensus definition. The National Commission on Orthotic and Prosthetic Education's requirement that O&P schools teach behavioral science skills and strategies ensures that those entering the profession have been exposed to these principles. Related efforts from the American Academy of Orthotists and Prosthetists include a recently formed Behavioral Sciences Society and a One-Day Certificate Program in Behavioral Sciences. The exposure to broader and more holistic perspectives on health and wellness encountered in the undergraduate programs of a large segment of O&P students may influence them to integrate that perspective into their interactions with patients. As the next generation of practitioners leaves our educational institutions and begins to practice, they can harness their training in a more robust view of health and wellness and use the skills learned in their undergraduate and graduate programs to raise the level of clinical practice.
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has more than 20 years of experience treating a wide variety of patients.
1. Wolever, R. Q., L. A. Simmons, G. A. Sforzo, D. Dill, M. Kaye, E. M. Bechard, and M. E, Southard, et al. 2013. A systematic review of the literature on health and wellness coaching: Defining a key behavioral intervention in healthcare. Global Advances in Health and Medicine 2(4):38-57.
2. Kivelä, K., S. Elo, H. Kyngäs, and M. Kääriäinen. 2014. The effects of health coaching on adult patients with chronic diseases: A systematic review. Patient Education and Counseling 97(2):147-57.
3. Hill, B., B. Richardson, and H. Skouteris. 2015. Do we know how to design effective health coaching interventions: A systematic review of the state of the literature. American Journal of Health Promotion 29(5):e158-68.
4. Sforzo, G. A., M. P. Kaye, I. Todorova, S. Harenberg, K. Costello, and L. Cobus-Kuo, et al. 2017. Compendium of the Health and Wellness Coaching Literature. American Journal of Lifestyle Medicine May 19:1559827617708562.
5. Wong-Rieger, D., and F. P. Rieger. 2013. Health coaching in diabetes: Empowering patients to self-manage. Canadian Journal of Diabetes 37 (1):41-4.