The Art and Science of Behavior Change in Nurse Coaching

It was the summer of 2011 when I first decided that I needed to pursue wellness coaching to sustain my path in the field of environmental and occupational health nursing- although I had no idea the role of “holistic nurse coach” even existed. That summer I completed my Masters in Community and Public Health Nursing with a capstone project in New Orleans, leading a public health coalition focused on addressing the health impacts of the British Petroleum Oil Spill in the Gulf Coast. It was the largest manmade disaster in history: 4.2 million barrels of crude oil leaked, and 1.8 million gallons of chemical dispersants were applied to assist in cleanup. These products- Corexit 9500 and Corexit 9527- were banned in several countries including Britain, and not until one year after the spill and a legal settlement did the EPA publicly disclose the chemicals in these dispersants: the 57 ingredients collectively pose health hazards to every organ system in the human body, and 13 of the chemicals pose harm to aquatic organisms and acute toxicity to fish. Over 150,000 cleanup workers and millions more living along the Gulf Coast were exposed (Toxipedia, 2011).

Talk about a significant reality check! Even though I grew up in Louisiana, this experience left me with a fresh perspective on how cultural norms and behavioral habits truly are the building blocks of population health. I returned to Seattle contemplating questions that never aroused during nursing school or in clinical settings: “How do we empower patients to seek health care in the face of new or unknown toxic exposures- and within a system not yet focused on prioritizing disease prevention?”; “How do collective cultural norms and attitudes toward health care systems impact the health of a population?”; and the often elusive question we all face as nurses, “How do I continue to do this work while maintaining my own emotional and physical well being?”

This urge toward emphasizing the link between environment and health has been further reinforced over the past two years while I’ve had the privilege of Co-Chairing the Health Care Without Harm Nurses Work Group (NWG). This group of environmental health nurse leaders was the first to raise red flags about the health hazards hospitals create in the process of providing care.  The NWG has addressed nurses’ exposure to hazardous chemical agents in the hospital such as glutaraldehyde, chemotherapy and antineoplastic drugs, and anesthetic gases. They have been monumental in shifting legislation and practices that impact population health: reducing the use of nontherapeutic antibiotics in animal agriculture, eliminating mercury containing devices from hospitals, and addressing the clinician’s role in mitigating climate change to promote population health.

It has been over two years since my epiphany in New Orleans that I must integrate wellness promotion as a means of disease prevention into nursing practice. As fate would have it, what I was seeking as seeking me. As I began a wellness coach training with a Seattle based company called Vera Whole Health last fall, I was contacted by Susan Luck, RN, BS, MA, HNC, CCN, HWNC-BC, a fellow NWG member and founder of the International Nurse Coach Association (INCA). This scope of nursing practice being formalized by INCA is the missing link I’d been seeking in New Orleans: a vehicle for nurses integrate their professional skill set and expertise into a personal patient/client centered relationship focused on a holistic understanding what health means to them.

I am elated to be joining INCA for their Integrative Nurse Coach training at Harmony Hill near my home in Seattle this spring. In preparation for this wonderful program, I continue contemplating the nurse coach trajectory that began for me five months ago. The topics I have considered most are behavior change and how community affects health.

According to a recent report by the World Health Organization, global cancer rates are expected to rise by over 70% in the next two decades. About half of these projected increases will be due to preventable disease related to smoking, increased alcohol consumption, obesity, and sedentary lifestyles. Changing someone’s lifestyle and unhealthy habits…is less about will power and therapeutic compliance than it is about understanding the neuroscience of behavior change and truly exploring the humanity of each patient so we can support healing and wellness-something unique to each person. Our rapidly changing health care system does not currently function from this paradigm. Luckily, nurse coaches are critically positioned to lead this cultural shift toward patient-centered care.

As we continue to learn about the science of behavior change, we now understand that changing habits require much more than will power. No matter how well intentioned our goals may be, it is the “tribal” nature of human beings that we also need accountability from one another to successfully sustain personal behavior change. Nurses understand this better than most; we could not manage the emotional, physical, and mental stressors of being a nurse without support from one another and the satisfaction of being able to help our patients heal and grow. This is the primary role of the nurse coach with the patient client- to provide professional accountability and guide the evidence-based process for their clients’ goals to be successfully met.

This relationship-centered bond is not exclusive to nursing, but integral to all humans. Jodi Gold and Carole Kammen describe this universal urge in Sacred Tribal Values:

Tribe is not the creation of an association of like minds but an exploration of our diversity and the universal bonds that exist beyond that diversity. Slowly, through this process of acknowledging our need for tribe, we get our humanity back. We begin to see how we are all parts in the circle of life. We heal the sense of separation and alienation that has created our longing. We remember that we are connected to everything that exists, the eternal flow of past, present, and future.” (Gold and Kammen, 2011).

In addition to having human accountability supporting positive growth, the process of writing and regularly reviewing personal goals has shown to significantly increase success rates. Virginia Tech professor emeritus David Kohl has lectured and hosted workshops on finance, business management, and entrepreneurship. He’s published four books and over 1,200 articles on the topic. Dr. Kohl anecdotally states that 80 percent of Americans do not set regular goals. Approximately sixteen percent set goals, but only mentally. Fewer than four percent of Americans actually write their goals, and less than one percent both write and review their goals on a regular basis. Kohl states that the less than one percent who write and regularly review their goals earn nine times more over the course of their lives than those who do not set goals.

Although this article is about nurse coaching and the science of behavior change rather than earning power, Kohl’s argument supports the notion that willpower in and of itself is not adequate to sustain lasting behavior change. Our technologically savvy fast-paced lives are vulnerable to information overload on a daily basis. The bundle of nerves known as the basil ganglia in the forebrain responds to multiple stimuli responsible for behavior modulation and regulation. It has the remarkable capacity to “chunk” repeated action sequences to create automatic behavioral habits. This neuroplasticity of the basil ganglia ultimately allows our brains to preserve effort while automatic behaviors take place. Unfortunately, the brain does not recognize a habit as either good or bad; once the habit loop has been established, the basil ganglia tends to fire automatically in response to the learned cue and in anticipation of the desired reward.

“How much of our daily behavior stems from these automatically learned habit loops?”, you may be wondering. A Duke study in 2005 suggests that approximately 45 percent of the actions humans take each day are learned habits rather than conscious decisions (Wood, Tam, and Guerrero, 2005).

So how do we as holistic nurse coaches support self-care and behavior change for clients through accountability, goal setting, and visualization of desired outcomes? The uniqueness of the nurse coach role is that it integrates these skills by combining the art and science of professional nursing practice with the foundational tenets of behavior change psychology.

The art of nurse coaching is relationship-centered: first the relationship with self-awareness and self-care are prioritized, and secondly, the relationship with the patient client is established in a context that is free of judgment and focused on collaborative learning. Prior to engaging with a client/patient, the nurse coach understands that he or she must be aware of his or her own energy and affect. By modeling wellness and learning to be fully present with the patient, the nurse coach ultimately builds a trusting relationship with their client, making space for generative growth to take place.

Secondly, the art of nurse coaching necessitates an ability to assess patients through an integrative framework: considering the bio, psycho, social, spiritual, cultural, and environmental factors affecting the patient’s health (Schaub, Luck, and Dossey, 2012). In  order to be effective in the art of nurse coaching, the nurse must also be free of his or her own agenda for the patient’s wellness, delineating classical clinical education (i.e. differential diagnosis) from the art of nurse coaching. Rather than the nurse’s “expert medical hat” serving as the compass to create a care plan, the patient becomes the primary architect, designing a wellness plan utilizing their innate wisdom as a roadmap.

The science of nurse coaching requires professional medical training and expertise to guide clients in their wellness path. We share health-specific information as well as resources to assist patients in navigating the health care system. We ask powerful questions that guide clients to create S.M.A.R.T. goals for themselves. When clients are challenged to visualize success for themselves, we encourage them to embrace the fact that success is more about progress than it is perfection.

As part of my training with Vera Whole Health, we were each assigned to our own Wellness Coach to collaboratively learn about the coaching process. The highly trained Vera staff offered this to each of us, and I benefitted from 12 weeks of sessions with Jamie Hall, our instructor. This experience was phenomenal. Although I consider myself very motivated as a “goal setter”, the process of checking in with Jamie and really exploring the motivation and habit loops involved in my wellness goals (reducing coffee intake and regulating sleep hygiene) allowed me to live my way into better health. Having to articulately write these goals and why I wanted to achieve them (increased emotional/physical health) prepared me mentally to break down what was an unconscious cue-routine-reward habit loop in my brain into individual components that I could consciously examine. Once the loop was understood both piece by piece and as a system, I could identify where my routine could be altered to change my behavior. Wow! This seemed like a simple concept from the onset, but it was beautiful to understand the complexity of unraveling a habit ten years in the making and enlightening to find peace with the fact that it wasn’t my weak willpower preventing sustained progress. It was that I had not specifically defined and reviewed the change I wanted to make, believed in my capacity to make it, and had someone hold me accountable to succeed.

I find it entertaining yet no coincidence that two of my randomly assigned “practice clients” for Vera’s Wellness Coach training have backgrounds similar to my own: they also work in the health care industry and have taken on jobs where they often find themselves working independently. Although our sessions never involve my sharing this personal epiphany, it is mind-boggling how much wisdom I also glean by mindfully listening- helping these clients define their own wellness vision and untangle hidden saboteurs to their success. Profound change has taken place, but not because I have administered medications or given a prescriptive diet to my clients. Change is taking place merely by my holding a mirror for them to see and believe in the best version of themselves and by walking with them along the path of self-discovery.

A wise friend recently shared this observation on coaching and culture: “Change is a recipe and a living organism in itself. There are so many factors that are needed to culminate in positive change, but this includes much more than just the coach and the client; it’s also the space between them and the environments they share with others that make change possible.” Generative moments of change with clients are given roots when we as coaches are also able and willing to “go there” ourselves- to sit with them in pregnant silence and be open to vulnerability ourselves. Nurses understand all too well that humans are relational beings. Therefore we also appreciate that sustainable change and the ability to model wellness as nurses is only possible when we as a tribe hold one another accountable and support one another as healers.

Energy is contagious; it can be an agent for disease or an agent for healing. As nurse coaches, we must be conscious of the energy we put out into the world. Be sensitive to the energy that is in your space on a regular basis and how it inspires or expires you. My energy in writing this article at this moment is gratitude- that role of the nurse coaching allows us to truly connect with the humanity that drew us to nursing in the first place. In our efforts to model healing, let us appreciate the wise words of Florence Nightingale: “No amount of medical knowledge will lessen the accountability for nurses to do what nurses do, that is, manage the environment to promote life processes.” (Nightingale, 1859). And last but not least, let us not forget to celebrate our success!

 

 

Resources

Gold, J., & Kammen, C. (2011). Sacred Tribal Values. Retrieved online from

http://www.soulfulliving.com/sacred_tribal_values.htm

Nightingale, F. (1859). Notes on Nursing, What it is, and What it is not. Retrieved online

from http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html

Schaub, B. G., Luck, S., & Dossey, B. (2012). Integrative Nurse Coaching for Health and

Wellness. Alternative and Complementary Therapies. 18, 1:14-20. Doi:

1089/act.2012.18110

Wood, W., Tam, L., & Guerrero, W. (2005). Changing circumstances, disrupting habits.

Journal of Personality and Social Psychology, 88, 918-933.

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3 Responses

  1. Hi Mary,
    A wonderful article and the reminder that we must be mindful in all we do.
    As nurses across the globe we have the ability to join forces towards a connected and unified global system of respect and care for all that live and for all of nature.

    In New Zealand at the moment, big oil companies are wanting to drill off our shores and have been given consents
    by the present government. A land in the ring of fire and earthquake prone,
    many New Zealanders are appalled
    and protests continue.
    We have the ability as nurses to impact positive change if we work globally together with humble respect and care for others and this most precious planet.
    I look forward to meeting you,
    To your new Integrative Nurse coach
    role, travel well,
    Anah :))

  2. Hi Mary, excellent article and work you are doing! I am happy to be a graduate from INCA, the 2nd cohort. I am an environmentalist as well as a nurse educator, teaching holistic and psychiatric nursing courses to undergraduate nurses. My education continues, as I am enrolled at Capital University here in Ohio, and amd developing my philosophy and theory of Self Care Is Health Care. As I share what I am finding in my own research with my students and colleagues, I recognize how much there is to do, and how far we have come as a profession. Coaching is the next right step. Congrats on putting the environment on the top of the pile, right under your own self care! We say more with our role modeling than our words. For the earth, Judy Fasone

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