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BeyondthePrescriptionImprovingPatientOutcomesThroughLifestyleCoachingLillyTryon,DNP,FNP-BC

Whyischangesohard?

©LillyTryon2018 BeyondtheRx:ImprovingOutcomesThroughLifestyleCoaching 3

(http://hagarthehorrible.com/comics/december-2-2004/)

Objectives

• Exploretheoriesforunderstandingbehaviorchangethroughthelensofmypatients.

• Reviewevidenceforalifestylecoachingapproach.


3IngredientsforChange

HealthBehavior

Changeand/orAdherence

Iact

Information(What)Iknow

Motivation(Why)Iwant

Strategy(How)Ican

(Martin,Haskard-Zolnierek,&DiMatteo,2010)©LillyTryon2018 BeyondtheRx:ImprovingOutcomesThroughLifestyleCoaching 5

Lydia’sStory


Whenthedoctortoldmethatmykidneys

werefailing,ithitme--Iamgoingtodie.Ilefttheofficeintears.

Thatafternoon,IgotaphonecallabouttheJumpstartProgram.Iknewthiswasananswertoprayer.

Valerie Dufour

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HealthBeliefModel


(Rosenstock,1974)

Sandy’sStory

Iknewinmyheartthatanimalmeatandwhitebreadwas

makingmybloodsugarssobad,butinAmericait’seasierandmoreacceptedtojustdotheeasything.Ineededhelpto

learnhowtomakegoodtastinghealthyfoods.Iwasscared

becauseIwondered,howamIgoingtodothis?


Self-Efficacy&TheSocialCognitiveModel


(Bandura,2001)

Self-Efficacy:Believingoneself

capableofsuccessfully

performingabehaviororachievingagoal

Dave’sStory


TranstheoreticalModel

(Prochaska&DiClemente,1983)

PreContemplation“I can’t” or “I won’t”

Not thinking about changing current behavior

Termination“Healthy Lifestyle Change”New behavior integrated into lifestyle habits. Successfully

managing high-risk situations.


Lorraine’sStoryNomatterwhatItried,Icouldn’tseemtogetahandleonexercise…Onethingthathelpedimmenselyistojournalmyconversationswith

GodasImovedthroughthechangeprocess.Itgavemeasafeplacetovent,helpedmethinkthroughmygoals,slowedmedownwhenIwasrunningand

needtowalk,andgavemevisibleevidenceofmyprogress

intheprocess.©LillyTryon2018 BeyondtheRx:ImprovingOutcomesThroughLifestyleCoaching 12

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DisconnectedValuesInterventionModel

“Istherea”disconnect”betweenyourvaluesandyour

actions?Isthisdisconnectacceptable?”

(Anshel,2016)©LillyTryon2018 BeyondtheRx:ImprovingOutcomesThroughLifestyleCoaching 13

Paula’sStory


Thethinkingthatchangedformeinordertoloseweight,wasthatIhadtofacethemainemotion

thatIhadtriedtoavoidfor50years.

IrealizedthatIwaschasinganexcuseforselfcomfortthatwasself-destructive—and

nolongerevenneededinmylife.

IheardGodsaying"youdon'tneedtocopewithfoodanymore.Thatweightdoesnotbelongtoyou.LetMetakecareofyou."

ImmunitytoChange“theinabilitytoclosethegapbetweenwhatwegenuinelyorevenpassionatelywant,andwhatweareactuallyabletodo”


(Kegan&Lahey,2009)

Visiblecommitment Doing/notdoinginstead

Hiddencompetingcommitments

Bigassumptions

Iamcommittedtolosingweight.

Icomfortmyselfwithfood.

BIGFEAR:Beingalone,unloved,uncaredfor.

I amcommittedtonurturingandcomfortingmyself.

Iassumethatthereisnoonetotakecareofme.

Footongas …………………………… andonbrake

Linda’sStoryIammissingthestructure…

IneedhelptogettothepointwhereIcantakeoffthetrainingwheels…Makingprogressforwardisnotaseasywithoutasupportsystem.I'mnotfeelingsecureinmyfood

sobriety,sotospeak.The21dayswaslikeenteringfoodrehab.NowitfeelslikeIamanaddicttryingtostayclean.


HealthActionProcessApproach


(Schwarzer,2008)

OtherChangeTheories

• Self-determinationTheory

• Pender’sHealthPromotionModel

• TheoryofReasonedAction/TheoryofPlannedBehavior

• RelapsePreventionModel

• Lewin’s ChangeTheory

• Andmanymore….


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SpiritualDimensiontoChange

• “CananEthiopianchangehisskinoraleoparditsspots?Neithercanyoudogoodwhoareaccustomedtodoingevil.”Jeremiah13:23,NIV

• “Iwanttodowhatisright,butIcan’t. Iwanttodowhatisgood,butIdon’t.Idon’twanttodowhatiswrong,butIdoitanyway....Oh,whatamiserablepersonIam!Whowillfreemefromthislifethatisdominatedbysinanddeath?ThankGod!TheanswerisinJesusChristourLord.”Romans7:18,19,24,25,NLT

• “Hisdivinepowerhasgivenuseverythingweneedforagodlylife...”2Peter1:3,NIV


USPSTFRecommendations

• Reviewed74studies• Healthmarkersimprovedwith"intensivebehavioralcounseling"aboutdietorexerciseforoverweightindividualswithriskfactorsforheartdisease.

• Noevidencethatofferingadviceorgivinginformationishelpful.

• Bestinterventionsarefrequentandindividualized


(LeFevre etal.,2014)

WhatisCoaching?

Coachingis“agoal-oriented,client-centeredpartnershipthatishealth-focusedandoccursthroughaprocessofclientenlightenmentandempowerment.”


(Olsen,2014)

CoachingComplementsHealthEducation

HealthEducation• Informationregardingevidenceforhealthfulpractices

• Problem-focused• Prescribessolutionsbasedonguidelines

• Short-term

LifestyleCoaching• Supportivepartnershiptohelpindividualapplynewlearning

• Focusedonpersonalresponsibilityandgrowth

• Individualizedplan• Long-termsupport


CoachingScience


CoachingPublications


(Moore,2010)

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CoachingResearchStudies

• Impactsonhealthoutcomesmixed.• Thereisevidenceinthemedicalliteraturethatcoachingaloneiseffectiveatimprovingclinicaloutcomes:

• Cardiovasculardisease• Diabetes• Asthma• Cancerpain• Weightloss• ADHD• Co-morbidmentalandphysicalconditions


(Moore,2010;NHSEvidenceCentre,2014)

CoachingOutcomes:Psychosocial

• Increasedpatientengagement andincreasedhealth-relatedself-efficacy (Galantino etal.,2009;Lindenetal,2010)

• Increasedmotivation andself-confidencetochangehealthbehaviors(NHSEvidenceCentre,2014)

• Improveddepressivesymptoms,loweredperceivedstress (Saccoetal.,2009;Wolever etal.,2010)

• Greatervitalityandimprovedmentalhealth (Thomasetal.,2009)


CoachingOutcomes:HealthBehaviors

• 59%of32RCTsreviewedreportedthathealthcoachingcansupportpeopletoadopthealthybehaviors andlifestylechoices.(NHSEvidenceCentre,2014)

• Smokingcessationcoachingprogramledtohighquitrate(72.7%)andsmokefreeratesat6mo (76.9%)and12mo (63.2%).(Sforzo etal.,2014)


CoachingOutcomes:Diabetes

• 34diabeticsself-selectedtocontrol,class,orcoaching

• Six2-hourgroupcoachingsessionsover2months• Asignificantdifferencewasfoundbetweengroupsforweight changeoverthecourseofthestudy,evenaftercontrollingformultiplevariables.

• 75%ofcoachinggroupindicatedmakingpositivelifestylechangesasaresultoftheirexperience.


(Tryon,2014)

CoachingOutcomes:Physical

• 6systematicreviews,60randomizedtrialsand43otherstudiesexaminedtheimpactofhealthcoachingonhealthoutcomes.33%ofreviews,37%oftrialsand84%ofotherstudiesfoundabenefit.(NHSEvidenceCentre,2014)

• Improves totalcholesterol,BMI,FBS,A1c,riskofsubsequentcoronaryevents.(Allenetal.,2011;Appeletal.,2011;Edelmanetal.,2006;Kumanyikaetal.,2012;Leahey &Wing,2013;Rimmer etal.,2009;Saccoetal.,2004;Valeetal.,2003;Whittemore etal.,2004;Wolever etal.,2010).


CoachingResearchConclusions


1. Coachingcanbeaneffectivemodeoffacilitatingchange.

2. Coachingimprovespsychologicalresourcesthatpredicthigherperformance,capacitytochange,andmentalhealth.

3. Coachingincreasesgoalattainment.4. Healthcoachingmayneedtobepartofawider

programsupportingeducationandbehaviorchange.

(Moore,2010)

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CoachingOutcomes:ClientPerspectives

• “CoachingencouragedmetoconsiderwhereIwantedtobeandhowIcouldgetthere.Itenabledmetotakebackcontrol”– Formerclientofahealthcoach(NHSEvidenceCenter,2014)

• “Ihadtriedverysincerelytoexercise,eatright,etc.before,butneversucceededformorethanafewmonths. Coachinghasmadeahugedifferenceandhasimpactednotjustmyweight,buttherestofmyhealth,andevenmore,ithasbeenacatalystformyspiritualgrowth.”–Formerclient


BiblicalEvidenceforCoaching

“Beloved,Ipraythatallmaygowell withyouandthatyoumaybeingoodhealth,asitgoeswell withyoursoul.”(3John2,ESV)

Greekwordtranslatedasprosperiseuodoo• eu =good,well• hodos =road,progress,journey

"tohelpontheroad,succeedinreaching”


TravelAgentvs.TourGuide


Coachingisanapproachthatallowsustotravelwithothersonthewellnessjourney.

God’s Relational Approach

“TheSaviormingledwithmenasOnewhodesiredtheirgood.HeshowedHissympathyforthem,ministeredtotheirneeds,andwontheirconfidence.ThenHebadethem,‘FollowMe.’”

EllenWhite,TheMinistryofHealing,p.143


Conclusion


OR

Howwillyouapplythisinformationinyourpractice?

References• Anshel,M.H.(2016).Intervention strategies for changing health behavior. NewYork:Routledge

• Appel,L.J.,Clark,J.M.,Yeh,H.C.,Wang,N.Y.,Coughlin,J.W.,Daumit,G.,…Brancati,F.L.(2011).Comparativeeffectivenessofweight-lossinterventionsinclinicalpractice.NewEnglandJournalofMedicine,365(21),1959–1968.

• Bandura,A.(2001).Socialcognitivetheory:Anagentiveperspective. AnnualReviewofPsychology,52,1-26.

• Edelman,D.,Oddone,E.Z.,Liebowitz,R.S.,Yancy,W.S.,Olsen,M.K.,Jeffreys,A.S.,…Gaudet,T.(2006).Amultidimensionalintegrativemedicineinterventiontoimprovecardiovascularrisk.JournalofGeneralInternalMedicine,21(7),728–734.doi:10.1111/j.1525–1497.2006.00495.x

• Galantino,M.L.,Schmid,P.,Milos,A.,Leonard,S.,Botis,S.,Dagan,C.,…Mao,J.(2009).Longitudinalbenefitsofwellnesscoachinginterventionsforcancersurvivors.InternationalJournalofInterdisciplinarySocialSciences,4(10),41–58.

• Kegan,R.,&Lahey,L.L.(2009).Immunitytochange:Howtoovercomeitandunlockthepotentialinyourselfandyourorganization.Boston:HarvardBusinessPress.

• Kumanyika,S.K.,Fassbender,J.E.,Sarwer,D.B.,Phipps,E.,Allison,K.C.,Localio,R.,…Wadden,T.A.(2012).One-yearresultsoftheThinkHealth!studyofweightmanagementinprimarycarepractices.Obesity,20(6),1249–1257.doi:10.1038/oby.2011.329


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References• Leahey,T.M.,&Wing,R.R.(2013).Arandomizedcontrolledpilotstudytestingthreetypesof

healthcoachesforobesitytreatment:Professional,peer,andmentor.Obesity,21(5),928–934.doi:http://dx.doi.org/10.1038/oby.2012.179

• LeFevre,M.L.,&U.S.PreventiveServicesTaskForce.(2014).Behavioralcounselingtopromoteahealthfuldietandphysicalactivityforcardiovasculardiseasepreventioninadultswithcardiovascularriskfactors:U.S.PreventiveServicesTaskForceRecommendationStatement. AnnalsofInternalMedicine,161(8),587-593.doi:10.7326/M14-1796

• Linden,A.,Butterworth,S.W.,&Prochaska,J.O.(2010).Motivationalinterviewing-basedhealthcoachingasachroniccareintervention.JournalofEvaluationinClinicalPractice,16(1),166–174.

• Martin,L.R.,Haskard-Zolnierek,K.B.,&DiMatteo,M.R.(2010).Healthbehaviorchangeandtreatmentadherence:Evidence-basedguidelinesforimprovinghealthcare. NewYork,NY:OxfordUniversityPress,Inc.

• Moore,M.(2010).Theevidenceforcoaching:Lessonslearned&futuredirections.PowerPointPresentation.

• Moore,M.,&Tschannen-Moran,B. (2010).Coachingpsychologymanual. Baltimore,MD:Lippincott,Williams&Wilkins.


References• NationalHealthService[NHS]EvidenceCentre(2014).Doeshealthcoachingwork?Summaryof

keythemesfromarapidreviewofempiricalevidence.EastofEngland:TheEvidenceCenterforHealthEducationEastofEngland(HEEoE).Retrievedfromhttps://bit.ly/1i27mjT

• Olsen,J.M.(2014).Healthcoaching:Aconceptanalysis.NursingForum, 49(1),18-29.

• Prochaska,J.O.,&DiClemente,C.C.(1983).Statesandprocessesofself-changeofsmoking:Towardanintegrativemodelofchange.JournalofConsultingandClinicalPsychology,51(3),390-395.

• Rimmer,J.H.,Rauworth,A.,Wang,E.,Heckerling,P.S.,&Gerber,B.S.(2009).ArandomizedcontrolledtrialtoincreasephysicalactivityandreduceobesityinapredominantlyAfricanAmericangroupofwomenwithmobilitydisabilitiesandsevereobesity.PreventiveMedicine,48(5),473–479.

• Rosenstock,I.(1974).HistoricalOriginsoftheHealthBeliefModel. HealthEducationMonographs. Vol.2No.4.

• Sacco,W.P.,Morrison,A.D.,&Malone,J.I.(2004).Abrief,regular,proactivetelephone‘coaching’interventionfordiabetesrationale,description,andpreliminaryresults.JournalofDiabetesanditsComplications,18(2),113–118.


References• Schwarzer,R.(2008).Modelinghealthbehaviorchange:Howtopredictandmodifytheadoption

andmaintenanceofhealthbehaviors.AppliedPsychology:AnInternationalReview,57(1),1–29.

• Sforzo,G.A.,Kaye,M,.Ayers,G.D.,Talbert,B.,&Hill,M.(2014).Effectivetobaccocessationviahealthcoaching:Aninstitutionalcasereport.GlobalAdvancesinHealthandMedicine3(5),37-44.

• Thomas,M.L.,Elliott,J.E.,&Rao,S.M.(2012).Arandomized,clinicaltrialofeducationormotivational-interviewing-basedcoachingcomparedtousualcaretoimprovecancerpainmanagement.OncologyNursingForum,39(1),39–49.

• Tryon,L.(2014).TheeffectofagrouplifestylecoachingmodelonHgA1c,weight,&psychosocialconstructsinlow-incomepatientswithtype2diabetes.(Unpublisheddoctoraldissertation).SouthernAdventistUniversity,Collegedale,TN.

• Vale,M.J.,Jelinek,M.V.,Best,J.D.,Dart,A.M.,Grigg,L.E.,Hare,D.L.,…McNeil,J.J.(2003).HealthcoachingpatientsOnAchievingCardiovascularHealth(COACH):Amulticenterrandomizedtrialinpatientswithcoronaryheartdisease.ArchivesofInternalMedicine,163(22),2775–2783.

• White,E.G.(1905).Theministryofhealing.Washington,D.C.:ReviewandHeraldPublishing.


References• Whittemore,R.,Melkus,G.D.,Sullivan,A.,&Grey,M.(2004).Anurse-coachinginterventionfor

womenwithtype2diabetes.DiabetesEducator,30(5),795–804.

• Wolever,R.Q.,Dreusicke,M.,Fikkan,J.,Hawkins,T.V.,Yeung,S.,Wakefield,J.,…Skinner,E.(2010).Integrativehealthcoachingforpatientswithtype2diabetes:Arandomizedclinicaltrial.TheDiabetesEducator,36(4),629–639.doi:10.1177/0145721710371523

• Wolever,R.Q.,Moore,M.A.,&Jordan,M.(2016).Coachinginhealthcare.InT.Bachkirova,G.Spence,&D.Drake(Eds.),TheSAGEhandbookofcoaching(521-543).ThousandOaks,CA:SAGEPublications.

• Wolever,R.Q.,Simmons,L.A.,Sforzo,G.,Dill,D.,Kaye,M.,Bechard,E.M.,...Yang,N.(2013). Asystematicreviewoftheliteratureonhealthandwellnesscoachingthrough2012:Definingandoperationalizingakeybehavioralinterventioninhealthcare. GlobalAdvancesinHealthandMedicine,2(4),38-57.doi:10.7453/gahmj.2013.042


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