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Coaching for Health
What the module is about
This module is written for healthcare professionals about how to coach people in
addressing health related goals in clinical settings. It covers the reasons why the topic is
of importance and the evidence base for this way of working. It gives some examples of the
skills and techniques that can be used and exercises for you to practise.
By the end of the module you should have become more aware of the value of coaching people for
health, learned more about different models and thought about opportunities to use some of the
techniques. You will also have an opportunity to apply the learning from the module to your own
practice through carrying out activities and reflecting on these. You may want to use the questions
in this module as a focus for discussion in a self-directed learning group.
Coaching for Health is a huge area. The aim of this module is to introduce you to some of the key
ideas. It is not intended to be a comprehensive overview of the topic. If you want to delve further
there is a suggested reading list in the appendix. You may also want to go on a course so that you
can practise applying some of the techniques and obtain focused feedback from colleagues and
trainers, as well as having an opportunity to reflect on your experiences in coaching people. We
aim to keep the module growing, so please email [email protected] with feedback,
relevant articles and helpful resources that you have come across, as well as personal experiences
and coaching stories that have inspired you.
Before you start
Before you start the module we recommend that you spend a few minutes thinking about the
following points and noting down some of your thoughts. If you are registered on the site, you can
do this in the ‘reflections area'. Click on the ‘my area' link at the top of the page to access your
personal pages. Please note that you must be logged in to do this. Please also note that you will
need to contribute to the ‘reflections area' during the course of the module in order to complete and
print out your certificate.
Thinking points

• Have you had any training in coaching or mentoring and if so, what are some of the key points that you remember? • What experiences of coaching for health have you had? What went well and what difficulties did you have? • What are your reasons for choosing to study this module? Definitions
Health coaching
There are a number of different ways of defining health coaching. Here are a few suggestions: • Unlocking a person's potential for learning how to maximise their own health. • Helping people gain the knowledge, skills, tools and confidence to become active participants in their care so that they can reach their self-identified health goals (Bennett and Bodenheimer 2010). • The practice of health education and health promotion within a coaching context, to enhance the well-being of individuals and to facilitate the achievement of their health-related goals (Palmer et al 2003). • A behavioural intervention that facilitates participants in establishing and attaining health promoting goals in order to change lifestyle-related behaviours, with the intent of reducing health risks, improving self-management of chronic conditions and increasing health-related quality of life (Van Ryn and Heaney 1997). Working in partnership
One of the standard coaching principles is that the coach and client work together in a partnership of equals (Rogers 2008). In coaching for health we need to think carefully about the power dynamics that may affect the relationship and which may be more apparent than in other, non-clinical, coaching situations. What ideas do you have about the power issues that may be present when healthcare professionals coach people? When can these differences be useful and when might they get in the way? Background and context
The challenge for healthcare professionals: the size of the problem
According to the World Health Organisation (WHO 2005) by 2020 three quarters of all deaths will
be from chronic diseases. Apart from any other concerns, people with these conditions will use a
disproportionate amount of healthcare budgets.
In England there are about 15 million people with long-term medical conditions (Department of
Health 2011). In a report for The Health Foundation de Silva (2011) states that "already the 30% of
the population with long term conditions accounts for 70% of NHS spending."
Smoking, alcohol consumption, unhealthy diet and lack of physical exercise are responsible for
80% of worldwide coronary heart disease and strokes worldwide, and in the UK smoking is the
single risk factor which accounts for 25 000 deaths (Knapton et al 2011).What are the main
conditions that you see in your own clinical practice?

Why health professionals need to change their approach
"Doing things to people instead of with them can be profoundly disempowering. It encourages
patients to believe that professionals have all the answers and that they themselves lack relevant
knowledge and skills, and hence have no legitimate role to play in decisions about their healthcare.
Paternalism breeds dependency, encourages passivity and undermines people's capacity to look
after themselves. It may appear benign, comfortable and reassuring, but it is a hazard to health."
(Coulter 2011 p.2)
It is reported that average adherence rates for prescribed medication are about 50% and for
lifestyle changes they are below 10% (Bennett and Bodenheimer 2010).
What is your response to these figures?
A report from Diabetes UK (2011) underlines how people with diabetes can reduce their risks of
developing life-threatening complications by ensuring that they receive all the care they require and
by self-managing their condition through blood glucose monitoring, eating sensibly, taking
medication appropriately, leading a healthy lifestyle and attending all their healthcare
Although people with long-term conditions generally feel comfortable taking responsibility for their
own health, some people may be surprised to be asked for their opinions or what their health-
related goals are in a medical consultation. This may mean that they are not ready to respond on
the first occasion. However, they may think about the questions after leaving the consultation so
that they are prepared for a different kind of consultation next time.
There are a number of ways in which we need to change and engage in dialogue with our people.
"Instead of treating patients as passive recipients of care, they must be viewed as partners in the
business of healing, players in the promotion of health, managers of healthcare resources, and
experts on their own circumstances, needs, preferences and capabilities." (Coulter 2011 p.1)
Recognising people's own ability to look after themselves and using their identified strengths and
resources can allow clinicians to stop moralising, criticising and pathologising and to concentrate
instead on negotiating, tailoring and supporting individuals more appropriately (Greenop 2010).
Supporting a person's ability to care for themself has the potential to have a major impact on the
way that health services are used and it is important to be aware of how the evidence for coaching
people for health fits into this.
What's the evidence?
Coaching for health is a relatively new topic of research and there is a developing evidence base for determining the best strategies to support behaviour change. The studies are of variable quality and this module only refers to some of the more recent and more reliable sources and overviews. The Health Foundation report (de Silva 2011) outlines a large number of studies with some conflicting evidence, depending on what outcome measures are used e.g. costs, self-efficacy, feelings of control, use of medication, blood test results etc. The review of evidence for self-management suggests that a focus on behaviour change and interventions that promote self-efficacy can have a positive impact on health and are more effective than the passive provision of information. These interventions include face-to-face and telephone coaching. "Evidence shows that it is possible to significantly increase people's knowledge and understanding of their condition, but information alone has little impact on symptoms or behaviours. Studies of the impact of self-management support on health behaviour and health status have produced mixed results, with different outcomes for different conditions." (Coulter 2011 p.187) An article in the British Medical Journal (Richards 2011) states that ".there is good evidence, from a wide range of community based studies in low and middle income countries, that engaging patients and supporting them to play an active role in managing their disease holds promise in all countries." A large study in the USA indicated that motivational interviewing-based health coaching is an effective management intervention in outcome measures of chronic disease, including personal efficacy, lifestyle change and perceived health status (Linden et al 2010). Wolever et al (2010) report a small randomised trial of telephone health coaching in the USA for people with type 2 diabetes which showed benefits in terms of reduced HbA1C levels, self-reported adherence to treatment, exercise frequency, reduced stress and perceived health status. They used a technique described as integrative health coaching (Wolever 2011) which includes approaches from human development, humanistic psychology, positive psychology, motivational interviewing, organizational psychology, leadership development and solution-focused therapy. In contrast to promoting self care of individuals with long-term conditions, South et al (2010) looked at a community-based approach for the general population to reflect on their health. They identified that while self care is feasible and relevant to different stakeholder groups, there is a need to respond differently to participants in different settings. The Commonwealth Fund published an interesting case study (Klein 2010) which describes how a health insurer in Minnesota, USA invited people with risk factors to participate in a free telephone-based health coaching programme with goals chosen by the individuals themselves. The study looked at impact on inpatient use, emergency department visits, cholesterol levels, body mass index and self-reported improvement. It reported beneficial effects in those who engaged with a health coach compared with similar members who did not choose to take up the coaching programme. Including the cost of training the coaches, the programme was cost neutral to the company. Rubak et al (2005) carried out a review of more than seventy studies which demonstrated that motivational interviewing was more effective than traditional advice-giving in stimulating improved health behaviours and that people were more likely to comply with setting their own goals for change rather than with the healthcare professional's agenda. Grant (2003) carried out a small, exploratory study which showed that solution-focused, cognitive-behavioural life coaching has promise as an effective approach to goal attainment and that over-engagement in self reflection may not be helpful. In other words, coaches should focus on a results-oriented solution-focussed process rather than on something more introspective. An 8 week study of peer coaching for people with diabetes who needed to change their behaviour suggested that this was a viable low-cost intervention but it did not look at long term outcomes (Hunt Joseph et al 2001). Indeed it is complicated to work out the cost-effectiveness of health coaching as it depends on what outcome measures are used. If you would like to find out more about health coaching studies and the efficacy of coaching people for health you may want to refer to: Making changes to health-related behaviours
What kinds of health behaviour do you think may be amenable for coaching?
Notice your interactions with people over a week at work. What kinds of health-related behaviour do you see that might be amenable to coaching? Try making a list. Some possible areas are: Adhering to prescribed medication, monitoring tests, attending appointments Stopping or reducing the use of: drugs, alcohol, smoking Following a more healthy diet, or a diet necessary for a medical condition e.g. coeliac disease Taking an appropriate amount of exercise Managing weight, stress, anger Attending to dental hygiene Making changes
It will not be a surprise to learn that people have to be committed and want to change their behaviour in order for them to be effective in doing so. Think about a time when you made a change to your own health behaviour. What motivated you to make the change? What resources did you need? Who else helped or hindered you and how? What were the first green shoots that showed you were on the path to success? How did you sustain the change? What does a health coach do?

As we have seen from the evidence above, people with chronic conditions such as coronary heart
disease (CHD) often need more than just health education to become knowledgeable about their
disease or disorder in order to take a proactive approach (Palmer 2004). We may know that we
ought to make a change but personal experience probably bears out how hard it can be to achieve
this. Bandura (1977) has written about the relationship between cognition and behavioural change.
Part of the coach's role is to help people address psychological and other barriers to change
through the use of an appropriate level of challenge. Later in this module we look at some of the
blocks that you may come across and how to approach these issues. An important skill in working
as a health coach is to get the right level of challenge for the individual concerned. You will see
that coaching people for health therefore involves offering education, motivation and support.
What qualities are needed in coaching people for health?
Here are some of the skills needed. You may be able to think of others. Which of these do you
think that you already do well enough and which you do think you need to develop further?
• Having an ability to support people, combined with challenging them at a level that is individually appropriate • Taking a questioning approach • Summarising • Reflecting • Using clinical expertise to inform • Believing in the patient's resourcefulness • Allowing the patient to set the agenda Healthcare professionals can offer the following support for people (Coulter 2011 p.87): • Give information and education about health and choice of any treatment or management • Offer education about symptoms and how these can be modified • Give training in technical tasks when appropriate e.g. blood glucose monitoring, measuring peak flow, adjusting medication • Challenge unhelpful beliefs about causes of illness and what can or cannot be done to • Help people manage the emotional impact of health concerns • Offer support for behaviour change We will explore some of these further in the module. Who can carry out health coaching?
The GMC document Good Medical Practice (2011) states that among the duties of a doctor registered with the General Medical Council you must: "Support people in caring for themselves to improve and maintain their health." It therefore seems appropriate that doctors (and other healthcare professionals) understand some of the principles and skills of health coaching. Although not all health coaching projects use clinicians (Gaughan and McMahon 2007), healthcare professionals are in a unique position, as they have the knowledge to provide information to people which can be combined with a coaching approach. Medical assistants have been used in primary care settings in Germany (Gensidchen et al 2009)
as coaches for people with depression; and an innovative model is described by Chen et al (2010)
where a dyad of clinician and medical assistant or health worker, trained as health coaches,
collaborate to support people to manage their own conditions within a primary care setting in the
USA. The health coaches help people build the information, skills and confidence needed to reach
their own health goals. They also provide emotional support and the practical assistance needed
by many people living with chronic illnesses.
Pharmacists are also increasingly acknowledged as a valuable resource to support self-
management (Lee et al 2006).
Do you think that health coaches need to be clinicians?
How does clinical training help in coaching people and what might be the drawbacks?
How can coaches give information without disempowering people?

Where can health coaching take place?
In addition to face to face consultations and meetings, health coaching can be carried out by
telephone. Evidence of the effectiveness of telephone coaching is limited but there are a number of
studies that show some beneficial effects (e.g. Jelinek et al 2009, Inglis et al 2010, Wennberg et al
2010). Health coaching can also be carried out using Skype or other internet links. Coaching in
groups in community settings has a long history of success e.g. for weight management.
What qualities are needed in a patient for them to achieve success?

• Motivation • Willingness to make a personal change • Confidence/feeling that they are capable of making a change/finding solutions • Being prepared to take personal responsibility for making the change • Suitable external factors How do these fit with your own experience? Are there other qualities that you would include? The ways that you can help people in activating some of these qualities are explored further later in the module. Andy is a 45 year old journalist who has come for a review of his type 2 diabetes. He is not currently on any medication but his diabetes has not been well controlled on diet and he has a BMI of 27. His blood pressure has been mildly elevated on the last few occasions he has seen you. He has agreed to have ambulatory blood pressure monitoring as he is interested in seeing how his blood pressure might fluctuate over the working day. However, he tells you that if his blood pressure is high he will not want to take medication because it makes him think of himself as a patient rather than as a normal person. He currently drinks about 6 units of alcohol 3 or 4 times a week. He says that he is not prepared to stop drinking alcohol as going out to the local wine bar is part of his professional networking and it is also a great stress reliever. He managed to stop smoking a few years ago when he and his wife gave up together when their children were born. However he attributes his weight gain to stopping smoking as well as to his wife's excellent cooking. When you ask him about exercise he raises his eyebrows and laughs. Assuming that you are not feeling rushed and that you have dealt with any other issues that Andy brought up, how might you introduce the idea of health coaching? Andy agrees that he cannot allow his health to deteriorate further and accepts your offer of seeing him again for coaching. What goals do you think he might have? Who else in your professional network could help Andy achieve his goals?

Coaching models
A number of coaching models can be adapted to the particular focus of health coaching. You may choose to use a model with which you are already familiar or use a blend of different models and skills. Some models are outlined below linked to ways of coaching for health. Whichever model you use it is helpful to begin by establishing a working contract. Contracting
These are some of the questions that you may want to ask: • Are we going to work together? • How will we work together? • What will we need to work together? • What will success look like for you? Thinking about change
Here are the main areas to cover: • What is the health issue? • How important is this for you? • Who is it an issue for? • What have you tried so far? • What support is available to you? • What do you ideally want? • What is a realistic goal? • What are the disadvantages of change versus the advantages of change in health • How confident do you feel about achieving the change? Action planning

• What strategies will help achieve the desired goal? • Which of these best fits the individual person? • What is the plan? Break it down into small steps. What is the timeframe for each step? What kind of record/self-monitoring system will the person keep? • What factors will help and what might get in the way? • How can you strengthen the helpful aspects and reduce the impact of factors that might prevent success? Maintaining change
What kinds of problems do you think may arise in maintaining change? What are the kinds of
reasons that Andy might come with?
How might you help work with the person about the following? • Loss of motivation • Lack of visible improvement • Lack of social support • Lapse back to unwanted unhealthy behaviour Think about what you might do in these situations and jot down some ideas. We suggest some strategies on the next page.
Here are some ways to help in these situations: • Loss of motivation
Suggest follow-up meetings. Help the person to build in some rewards that are personally meaningful to them. Help them visualise their goal(s). • Lack of visible improvement
Discuss realistic expectations and time-frames. Arrange appropriate monitoring e.g. blood tests. • Lack of social support
Coach the person about possible involvement of others. Help them identify local networks. • Lapse back to unwanted unhealthy behaviour
Revisit goal setting with the person. Normalise the occurrence of lapses. Coach them about their preferred future. Coaching Frameworks

Here are the frameworks of some coaching models that you may know. Can you see how the themes and questions above fit into the framework? IGROW model (Whitmore 2002)
What is the health issue? What do you want to change? What is happening now? options/obstacles What could you do differently?/What might get in the way? How committed are you? Action points (SMART) Egan skilled helper model (Egan 2002)
What is the health issue? What are the possible solutions/which of these fit for you? How can you make the changes you want? 5 As model (Glasgow et al 2006)
This is a collaborative evidence-based model of behaviour change that has been used in smoking cessation research in the USA. The model can also be used for other conditions and health behaviours for example in prescribing exercise in primary care (Khan et al 2011) 1. Assess – knowledge, behaviours and confidence 2. Advise – using up to date, evidence-based clinical information 3. Agree – goals and plan for self management 4. Assist – anticipate and plan how to overcome barriers (see below) 5. Arrange – other resources that may be of help Some add a 6th stage – assess again Three pillars of health coaching (Hibbard et al 2010)
Pillar 1 - Patient Activation The Patient Activation Measure is a tool designed by Judith Hibbard that assesses a patient's knowledge, skill and confidence in managing their health so that interventions can be appropriately tailored to their needs. Pillar 2 – Motivational Interviewing Motivational interviewing (e.g. Prochaska and DiClemente 1992) is an approach to behaviour change especially where there is ambivalence. An editorial by Knapton and colleagues (2011) quotes how there has been insufficient focus on understanding how to motivate the necessary behaviour change of individuals with, or at high risk of, coronary heart disease. Pillar 3 – Positive Psychology Positive psychology (e.g. Seligman and Csikszentmihaly 2000) is about looking at what works for people to improve their sense of happiness. Driver (2011) links positive emotions with health and a sense of wellbeing. He describes six core themes of positive psychology that are relevant to coaching: 5. relationships 6. personal growth.
Decision making
Here is a grid that you may find useful in health coaching.
Talk through the questions in the four boxes and write in the person's responses. What stands out for the person when they look at the completed grid? MAKE SOME CHANGES What's working for you What are the potential benefits of change? What's the downside of What's the downside of what you are doing now? changing things? (Adapted from McDowell 2011) Top 10 useful questions: (Rollnick 2010)
1. What changes would you most like to talk about? 2. What have you noticed about.? 3. How important is it for you to change.? 4. How confident do you feel about changing.? 5. How do you see the benefits of .? 6. How do you see the drawbacks of.? 7. What will make the most sense to you? 8. How might things be different if you.? 9. In what way.? 10. Where does that leave you now? Use of scaling questions
Scaling questions can be used to check motivation. How important is this issue for you? How confident are you that you can do something about this? You may find it helpful to use a visual scale as well as asking the question. You need to be clear about the range of the scale e.g. 10 is very important and 1 is minimally important. If someone ranks an issue as a low number it can help to boost their motivation by asking why they didn't rank it even lower: What makes it a 3 rather than a 1? Be prepared that the ranking questions may highlight that the person is not ready for change and that health coaching is therefore inappropriate at the moment. You may also want to ask another other key coaching question: How much energy have you got for making this change? When do you find scaling questions helpful in your practice? How do people respond to being asked scaling questions? What do you do when you ask a scaling question and the person seems confused or unable to

Offering information in coaching style
(Rogers 2011)
There are many occasions as a clinician when you have to give people information. The more important it is that some behaviour change happens as a result of the information, the more important it is to give it in coaching style. Just telling and advising has a low chance of success. There are several tactics that help: • Asking permission - This creates a collaborative climate. It is the equivalent of giving a
polite knock on someone's door before entering. ‘I've got some information to give you about. But first I'd like to check with you. Will it be best if I just outline the main points first, or would you like to hear the detail This has immediate impact on the discussion that follows. Being asked permission lowers resistance: it is courteous, it makes it more likely that the information will be heard. • Emphasizing freedom to disagree - This may feel counter-intuitive, but by inviting
disagreement you are merely acknowledging what is inevitable anyway – that people have their own views and that these may not coincide with yours. "I'm aware you may not agree with this." "I guess you'll have your own views on this and I'd like to hear them, even though I'm afraid that x or y can't be changed at this stage." • Offering choices wherever possible - Encouraging the other person to consider what
these might be is yet another way of emphasizing autonomy. So your actual aim in the conversation might be to help the person make an informed choice. "It seems to me that you have several choices here. You could explore the option of a or you could do b. Which of those seems to make most sense to you at the • Using the rhythm of draw out – provide information – draw out. Instead of starting from
your own agenda (I need to give this person information and on my terms) you start from theirs. So you might say: What do you already know about this? Which aspect would it be most useful for us to concentrate on? This way you elicit from the other person what their interests and concerns are, answering these as your priority rather than being preoccupied with what you need to tell them. Essentially you are providing information but then immediately encouraging the other person to voice their own interpretation using phrases like: What's your immediate response to this? How does that seem to you? What are your feelings about this? What further information would you like to have? • Offering stories about how other people have dealt with similar issues. This is a
better way of offering helpful ideas than advice-giving. By giving several anecdotes you will be suggesting that there is more than one way of solving a problem, it also gives people hope and all of this enables you to stay neutral. Follow it with, ‘All of that worked for those people, but how does it strike you?' These approaches are based on compelling evidence that taking a collaborative approach hugely increases the likelihood of behavioural change, whereas approaches based on telling, even where the teller is an acknowledged expert, have been shown to be largely ineffective.
Barriers to change and overcoming them
We are all familiar with the difficulties associated with changing unhealthy behaviour. As you can appreciate these barriers are often mixtures of behavioural, emotional, situational, cognitive, interpersonal and physiological factors. Olson (1992) has suggested three categories of psychological barriers: 1. Those that prevent the admission of the problem a. Trivialisation or denial conceptualisations 2. Those that interfere with initial attempts to change behaviour a. Lack of knowledge c. Dysfunctional 3. Those that make long-term change difficult a. Cognitive and motivational drift b. Lack of perceived improvement c. Lack of social support What techniques can healthcare professionals use to help people in overcoming some of these barriers? Firstly it can help if we understand the person's perceptions and health beliefs. Then we can offer education, motivation and support. Interestingly, Olson (1992) quotes evidence that giving anecdotal descriptions of personal experiences is more effective in promoting behaviour change than abstract population information. Knox (2011) writes "I find that the hardest thing in medicine isn't making the right diagnosis or knowing what treatment to recommend; the hardest thing is getting patients to agree that my treatment is right for them." He uses techniques from transactional analysis to change his style of communication with different people to help with adherence. Knox refers to five main driver diagnoses that he makes and how he responds to each to engage people' own problem solving capabilities: diagnosis Response "Do the best you can." "Well done for staying active even when it hurts." "What is it you want from treatment?" "Slow down, there is enough time." "Tell me what you think." Helping to overcome unhelpful thinking
Helping the person to reframe into a more helpful approach is described by Palmer (2004): Coachee/client: Yesterday I binged. I've totally blown my diet. I may as well give up now! This is an example of all-or-nothing thinking. The coach asks a question to help the person reframe their thinking. Coach: Just because you have eaten excessively on one day, how does it logically follow that you have totally blown your diet for good, unless you continue to binge every day? Together they come up with a more helpful approach for the person: Just because today I ate too much food, it does not mean that I have totally blown my diet. Tomorrow I can continue my diet as usual.
Look back at Andy's story. He decides that it seems to make sense for him to try to reduce his
drinking. What are the push and pull factors he might identify in an exercise with his coach? Try
setting them out in a force field analysis (adapted from Connor and Pokora 2007):
The helpful factors that I
The unhelpful factors that I
need to use more or I need
need to minimise
I want to reduce my drinking to strengthen
Factors related to self
Factors related to others
Factors related to life
Factors related to work
Here is an example of how Andy might respond: The issue that you want to
What will help you?
What might hinder you?
(these factors need to be (these factors need to be I want to reduce my drinking Tell my colleagues that my I enjoy going out with my doctor has advised me not to colleagues and drinking Personal factors
Choose non-alcoholic drinks I associate drinking with – find one that I enjoy routine after-work relaxation Remember that I don't want I'm not sure that I'm to have to take medication to convinced of the benefits of control my diabetes drinking less – some evidence suggests that Reducing might be more moderate alcohol intake is feasible than stopping better than none completely but stopping completely might be easier My wife wants me to lose People think you're a wimp if weight and control my The effect of other people
It's hard to refuse when One of my friends managed someone puts a drink in your to stop drinking alcohol after he was stopped for drink-driving Find other ways to reduce Alcohol makes me feel stress – investigate package Life factors
Drinking is an important part Go to bed earlier – no late of my networking There is an expectation that we go out for a drink after Work factors
It's the culture to buy a round of drinks. How to start coaching people for health

Without trying to change your practice, just notice any consultations or meetings with people in the
next week where the idea of coaching for health might fit.
You may find it helpful to use a force field analysis to review the factors that are influencing your ability to carry out coaching people for health. As you can see it is the same table that you might use with people in helping them think about the changes they want to make. THE ISSUE:
The helpful factors that I
The unhelpful factors that I
need to use more or I need
need to minimise
Using health coaching with to strengthen
Factors related to self
Factors related to others
Factors related to life
Factors related to work
To get started, try carrying out a small piece of work on coaching for health when you feel that a good opportunity arises. What worked well? What can you try doing differently next time? What skills have you identified that you need to work on? Are there other changes that you need to make that would make the coaching more effective? You might want to keep some brief reflective notes on your experiences. The problem of time
What aspects of coaching for health do you think will take the most time? What ideas do you have for how you can address these? Having a number of short consultations over a long period of time can be a fantastic opportunity for multiple brief coaching interventions and we should not underestimate the value of working in this way. A recent study by Amabile and Kramer (Stratton 2011) talks about "the progress principle" and suggests that small incremental gains are more energising than the occasional major achievement. Try working with people on making steps with small, achievable goals in a series of action plans. You are probably familiar with the idea of action plans being SMART: Referring back to Andy's story or to a person that you are currently coaching for health, can you suggest a series of action plans based on some of the goals you identified earlier? Coaching stories
Here is a story from one of the London Deanery mentors: Mrs. W. is a delightful 80 year old woman who sees me dutifully every month for blood pressure monitoring. Every consultation has followed the same pattern: her readings are a bit high; I give health education on the benefits of lowering her blood pressure; she responds about the side effects she has experienced with the various antihypertensives we've tried; we hope that this new one will not cause any unwanted side effects and she leaves with a green prescription. On this occasion though, the consultation goes differently. Mrs. W. returns informing me that she had stopped amlodipine after a week because she "just didn't feel right" on it. This is a pattern for her. This time I decide to try a different line of questioning using some health coaching techniques and ask her to rate on a scale of 1-10 how important controlling her blood pressure is to her. After a pause she replies "Well, zero doctor, but I know it is important to you and I like coming so." By using a different approach Mrs. W.'s own opinion is finally revealed. We discuss the risks of not taking antihypertensives; a potential stroke sooner in life or a heart attack. Despite this Mrs. W. says that she is in her eighties, has had a great life, and would rather not take them due to side effects. I believe she has capacity to make this decision, and we agree to stop them. I feel QOF points slipping away but reflect that the savings in the pharmacy budget will in all likelihood make up for this when looking at the bigger picture. We arrange a review in a month to see how things are going. She leaves without a green piece of paper whilst I have a better understanding of her real opinion. (Rollinson 2011 unpublished) You may like to read the inspirational story of how David Festenstein (2010) used self-coaching and neurolinguistic programming skills on himself to gain nearly complete recovery from a stroke which paralysed him in 1998. Here is the link: In this module we have looked at some definitions of health coaching and the growing body of evidence for the effectiveness of coaching people for health and self-care. We have outlined some techniques and tools that you may want to use with people and to help you overcome some common barriers to change. We have suggested exercises for you to try and thinking points for you to reflect on in relation to your own practice. You may want to book onto a course in coaching for health so that you can have personal coaching in developing your skills. Author information
This module was written by Helen Halpern who is a GP and medical educator and a member of the London Deanery coaching and mentoring team. Thanks to Rebecca Viney and Sue Morrison for their help and feedback and to Jenny Rogers for her contribution of the section on Giving Information in Coaching Style. References
Amabile T. and Kramer S., 2011, The Progress Principle: Using Small Wins to Ignite Joy, Engagement and Creativity at Work, Harvard Business Review Press, Boston, Mass. Bandura A., 1977, Self Efficacy : Toward a Unifying Theory of Behavioural Change, Psychological Review, 84:191-215 Bennett H., Coleman E., Parry C., Bodenheimer T. and Chen E., 2010, Health Coaching for Patients, Family Practice Management, 17, (5): 24-29 Chen E., Thom D., Hessler D., Phengrasamy L., Hammer H., Saba G. and Bodenheimer T., 2010, Using the Teamlet Model to Improve Chronic Care in an Academic Primary Care Practice, Journal of General Internal Medicine, 25, (4): 610-614 Connor M. and Pakora J., 2007, Coaching and Mentoring at Work, McGraw Hill, Open University Press, Berkshire and New York pp.160-161 Coulter A., 2011, Engaging Patients in Healthcare, Open University Press, McGraw-Hill Education, Maidenhead and New York de Silva D., 2011, Helping People Help Themselves: a Review of the Evidence Considering Whether it is Worthwhile to Support Self-management, The Health Foundation, London Department of Health, 2011, Driver M., 2011, Coaching Positively: Lessons for Coaching from Positive Psychology, Open University Press, McGraw Hill, Berks. and New York Egan G., 2002, The Skilled Helper, 7th edition, Belmont, CA: Thomson Brooks/Cole Festenstein D., 2010, A Stroke of Luck, Speakeasy, 16-17 and also see: GMC, 2011,, accessed 20.9.2011 Gaughan M. and McMahon S., 2007, Gensidchen J., von Korff M., Peltz M, Muth C., Beyer M., Güthlin C., Torge M, Petersen J., Rosemann T., König J. and Gerlach F., 2009, Case Management for Depression by Health Care Assistants in Small Primary Care Practices: a Cluster Randomized Trial, Annals of Internal Medicine, 151, (6): 369-378 Glasgow R., Emont S. and Miller D., 2006, Assessing Delivery of the Five "As" for Patient-centred Counseling, Health Promotion International, 21 (3): 245-55 Grant A., 2003, The Impact of Life Coaching on Goal Attainment, Metacognition and Mental Health, Social Behavior and Personality, 31 (3): 253-264 Greenop D., 2010, Self-care and Cystic Fibrosis: a Review of Research with Adults, Health and Social Care in the Community, 18 (6): 653-661 Hibbard J., Lawson K., Moore M. and Wolever R., 2010, Three Pillars of Health Coaching: Patient Activation, Motivational Interviewing and Positive Psychology, Healthcare Intelligence Network, Manasquan NJ Hunt Joseph D., Griffin M., Hall R. and Doherty Sullivan E., 2001, Peer Coaching: an Intervention for Individuals Struggling with Diabetes, Diabetes Educator, 27: 703-710 Inglis S.C., Clark R.A., McAlister F.A., Ball J., Lewinter C., Cullington D., Stewart S. and Cleland J.G., 2010, Structured Telephone Support or Telemonitoring Programmes for Patients with Chronic Heart Failure, Cochrane Database of Systematic Review, no. 8: CD007228 Ipsos/Mori, April 2009 Jelinek M., Vale M. J., Liew D., Grigg L., Dart A., Hare D.L. and Best J.D., 2009, The COACH Program Produces Sustained Improvements in Cardiovascular Risk Factors and Adherence to Recommended Medications – Two Years Follow Up, Heart, Lung and Circulation, 18 (6): 388-92 Khan K., Weller R. and Blair S., 2011, Prescribing Exercise in Primary Care: Ten Practical Steps on How to do it, British Medical Journal, 343: d4141, DOI: 10.1136/bmj.d4141 Klein S., 2010, Case Study: Health Plan-Led Coaching Program Leads to Improved Outcome and Cost Savings, Quality Matters, The Commonwealth Fund Knapton M., Lewin R. and Doherty P., 2011, Long-term Cardiovascular Conditions: the Role of Primary Care, British Journal of General Practice, 659-660 Knox G., 2011, Contracting for Treatment, BMJ Careers, DOI: 10.1136/bmj.d459 Lee J., Grace K. and Taylor A., 2006, Effect of a Pharmacy Care Program on Medication Adherence and Persistence, Blood Pressure and Low-density Lipoprotein Cholesterol: a Randomized Controlled Trial, JAMA, 296 (21): 2563-2571 Linden A., Butterworth S. and Prochaska J., 2010, Motivational Interviewing-based Health Coaching as a Chronic Care Intervention, Journal of Evaluation in Clinical Practice, 16: 166-174 Olson J., 1992, Psychological Barriers to Behavior Change, Canadian Family Physician, 38: 309-319 Palmer S., Tubbs I. and Whybrow A., 2003, Health Coaching to Facilitate the Promotion of Healthy Behaviour and Achievement of Health-related Goals, International Journal of Health Promotion and Education, 41, (3): 91-93 Palmer S., 2004, Health Coaching: a Developing Field within Health Education, Health Education Journal, 63 (2): 189-191 Prochaska J. and DiClemente C., 1992, Stages of Change in the Modification of Problem Behaviours, Program Behaviour Modification, 28: 183-218 Richards T., 2011, Enlist the Patient's Help, British Medical Journal, 343:d5827 Rogers J., 2011, unpublished Rogers J., 2008, Coaching Skills: A handbook, 2nd edition, Open University Press, McGraw Hill Education, Berkshire, p.8 Rollnick S., Butler C., Kinnersley P., Gregory J., and Mash B., 2010, Motivational Interviewing, British Medical Journal, 340: 1242-45 BMJ2010;340:c1900 DOI: 10.1136/bmj.c1900 Rubak S., Sandboek A., Lauritzen T. and Christensen B., 2005, Motivational Interviewing: a Systematic Review and Meta-analysis, British Journal of General Practice, 55, 513: 305-312 Seligman M. and Csikszentmihaly M., 2000, Positive Psychology: an Introduction, American Psychologist, 55 (1) 5-12 DOI: 10.1037/0003-066X.55.1.5 South J., Darby F. and Bagnall A., 2010, Implementing a Community-based Self Care Training Initiative: a Process Evaluation, Health and Social Care in the Community, 18 (6): 662-670 Stratton P., 2011, Research Update: How to be Happy, Context, 117: 46-47 Van Ryn M., and Heaney C., 1997, Developing Effective Relationships in Health Education and Practice, Health Education Behavior, 24: 683-702 Wennberg D.E., Marr A., Lang L., O'Malley S. and Bennett G., 2010, A Randomized Trial of a Telephone Care-management Strategy, The New England Journal of Medicine, 363 (13): 1245-55 Whitmore J., 2002, Coaching for Performance: GROWing People, Performance and Purpose, 3rd edition, London, Nicholas Brealey WHO 2005 Preventing Chronic Diseases: a Vital Investment. Geneva: WHO Wolever R., Dreusicke M., Fikkan J., Hawkins T., Yeung S., Wakefield J., Duda L., Flowers P., Cook C. and Skinner E., 2010, Integrative Health Coaching for Patients With Type 2 Diabetes: A Randomized Clinical Trial, The Diabetes Educator, 36, (4): 629-639 Wolever R., Caldwell K., Wakefield J., Little K., Gresko J., Shaw A., Duda L., Kosey J. and Gaudet T., 2011, Integrative Health Coaching: An Organizational Case Study, Explore, 7, (1): 30-3 Also see further reading and resources on the website LEARNING ACTIVITIES Select one or more of the activities below to develop your skills in coaching patients for health. If you are registered on the site, you can write up your reflections in the ‘reflections area'. Click on the ‘my area' link at the top of the page to access your personal pages. Please note you must be logged in to do this. Activity 1. Reviewing your work Keep a log of when you have coached patients for health. Note what worked well and what you found difficult. You could try filling the force field diagram to reflect more on the factors affecting you and to consider how you could address some of these. Activity 2. Getting some feedback Ask a colleague and/or patients to give you some honest and constructive feedback on your approach, your questioning techniques and how you might improve your skills. Activity 3. Your own development and training needs Identify some of your own learning needs from the above activities. You could look at some of the references and suggested reading from the module and go on an interactive course on coaching patients for health to get some personal coaching on your skills.



Annual Report 2006 Mipharm at a glance Total assets (€/000) Net fixed assets (€/000) Cash Flow (€/000) Free Cash Flow (€/000) MIPHARM® S.p.A. 20141 Milan – Italy Phone (39) 02 53548.1 Fax (39) 02 53548.010 e-mail: [email protected] Annual Report 2006 Mipharm at a glance

Jennifer Guldin Gardasil Injury Timeline/Diary August 29, 2008: My only child, Gracyn, was born. Sept.-Oct. 2008: Left knee surgery Sept.-Oct. 2009: Right knee surgery February 10, 2010: Appt. with PCP; diarrhea; hurts to cough; sore throat; cough; congestion and chest pains from coughing; began February 8 (2 days ago); taking OTC Cold Medicine; abdominal pain; cramping; denies nausea and vomiting; swallowing is painful; bilateral ear pain when swallowing; postnasal drip frequently; bilateral facial pain; chest pain WITH DEEP BREATH; shortness of breath worse with exertion, relieved with rest; headache; chest congestion; loss of appetite; no weakness; fatigue; headache; no tingling or numbness; no seizures; no insomnia; no memory loss; no dizziness; no gait abnormality; no tremor; no syncope; no myalgias; hoarseness. Treated for upper respiratory infection and diarrhea; prescribed Omnicef, Hycodan syrup, magic mouthwash, Continue Antivert 25 mg (NEVER TAKEN); injection Depo-Medrol; 1 ml of methyl prednisone 80mg/ml IM to right glut; Stop tamiflu capsule, zyrtec D (NOT TAKING), Veramyst spray (NOT TAKING), Demerol HCI (NOT TAKING), Phenergan (NOT TAKING), stool softener (NOT TAKING).