Ioanna Iordanou and Rachel Hawley explore the landscape and ethical implications of coaching patients in the UK as a client group
The arrival of the Coronavirus (Covid-19) has prompted the launch of a number of initiatives offering pro-bono coaching to health service professionals, including for example, volunteer wellbeing coaches to support NHS staff (see news, page 7).
However, coaching was already permeating the healthcare sector, including with patients as clients. What are the backdrop and ethical implications of coaching this client group?
Coaching patients is growing in a variety of settings, shapes and forms, as it permeates the wider UK healthcare sector. Offered traditionally, to health leaders, healthcare professionals (such as doctors, nurses, and other allied clinicians), and less often to other support staff (such as healthcare assistants and porters), coaching can be formal or, most frequently, informal, embedded in traditional learning and development interventions, such as leadership development, clinical supervision, personal development planning and reviews, and mentoring (see, for instance, Williamson, 2009; Woodhead, 2009).
Moreover, for staff it has been used in developmental and performance related contexts, offered on a one-to-one basis or in teams. There are growing examples of coaching for cultivating collaborative leadership in healthcare, for staff and patient leaders. One of the authors (Rachel Hawley), for example, is currently leading the development of a Patient Leader Mentor programme (developing patent leaders as coaches for senior NHS leaders) and a Patient Leader Coach programme (peer coaching) on behalf of the NHS Leadership Academy, and recently co-delivered with David Clutterbuck a Coaching for Collaborative Leadership masterclass on behalf of NHS Yorkshire and the Humber Leadership Academy for staff (https://bit.ly/3aMmEEA).
Some staff might be recipients of coaching, while expected to incorporate coaching tools and techniques in their formal interactions with colleagues and subordinate staff, acting as peer coaches or even as manager-as-coach (Ellinger et al, 2014). Increasingly, however, over the past few years, the clinician-coach has had a new remit or responsibility, that of coaching patients (Hawley, 2015). The idea of “making every conversation count” (Hawley 2012; 2015) is a philosophy that underpins this article. We’re committed to the view that through open and creative dialogue, coaching patients can open new opportunities for achieving improved health and wellbeing (Iordanou, Hawley & Iordanou 2017).
Coaching patients has emerged as an important type of coaching in healthcare contexts (Hawley, 2015; Iordanou, Hawley, and Iordanou, 2017; Moore and Jackson, 2018). A variety of terms are used to describe this concept, such as ‘health coaching’, ‘wellness coaching’, or ‘self-management coaching’ (Hawley, 2015: 117). Coaching patients is broadly defined as an approach for “helping people gain the knowledge, skills, tools and confidence to become active participants in their own care so that they can reach their self-identified health goals” (Bennett et al, 2010: 24). In practice, it involves clinicians (and other professional groups within the UK’s National Health Service (NHS) using coaching skills in everyday conversations to empower patients. Coaching patients can help people in a range of ways, such as supporting them to take ownership of the management of long-term conditions (eg, diabetes), and to navigate lifestyle and behaviour change, as well as enhancing recovery, health and wellbeing more widely.
Enabling conversations that encourage patients, carer and citizens more widely, to be active participation as partners in healthcare is an outcome of UK health policy, which has increasingly emphasised public engagement as a lever for quality improvement. It marks a shift, away from ‘doing to’ people to ‘doing with’ people, changing relationships (Coulter, Roberts & Dixon, 2013; Hibbard & Gilburt 2014). It also reflects the changing emphasis from ‘illness’ to ‘wellness’, by supporting lifestyle and behaviour change for improving public health and wellbeing. Such changes, for instance, involve the promotion of physical exercise and smoking cessation (American College of Preventive Medicine, 2009).
Our emphasis is therefore on embracing coaching conversations as a way for building collaborative relationships between staff and the public, beyond the individual patient-clinician relationship to the wider conversations across the healthcare system, shaping quality of care and experience.
Ethical implications of coaching patients
One of the principal ethical issues facing healthcare professionals who are encouraged to use coaching skills and approaches in their leadership and conversations with patients, is of knowledge and, by extension, power.
Conversations in healthcare are shaped in a variety of ways, ranging from the traditional, direct instruction of the expert clinician (‘doing to’), to a more facilitative approach of the coach (‘doing with’) people. The former entails offering direct advice, with a focus on solutions, which can engender intimidation, fear, and dependency, especially due to an imbalance of power. The more facilitative approach of coaching patients plays a vital role in building collaborative relationships in healthcare; in this kind of approach patients’ lived-experience and health-professional experience are valued in equal measure. But due to the novelty of the latter approach, its wider application is more sluggish, as lack of expert knowledge on behalf of the patient plays an important role.
The nature of health policy increasingly emphasises public engagement is widely recognised as a lever for quality improvement; changing relationships. As a consequence of this shift, the concept of patient leadership emerges as an important approach for leaders working with the public, building on earlier debates for understanding the characteristics that make patient as well as professional leadership effective (McNally et al, 2015). The King’s Fund began exploring the concept of patient leadership in 2013, seeking to disrupt the ‘them and us’ relationship dynamic in the health and care system (Searle 2016).
The move away from traditional approaches in healthcare (that focus on rescuing patients by identifying problems and offering solutions) to facilitative coaching approaches (that are more non-directive in nature), entails further ethical considerations for health professionals (eg, clinical relationships and wider leadership conversations across the healthcare system more widely). This is because adapting to such an approach necessitates a fundamental shift from ‘a directive paradigm (telling patients what to do)’ to ‘a collaborative paradigm (asking patients what changes they are willing to make’; Bodenheimer et al, 2002, cited in Bennett et al. 2010: 25).
In essence, then, there is an incongruity – even clash – between the expert approach of the clinician as authority and the facilitative approach of the coach as the partner (Moore & Jackson, 2018). Accordingly, a major ethical issue for the clinician/coach is to balance, even prioritise, coaching conversations over traditional approaches of offering direct instructions to patients on how to manage their condition.
The differences between traditional approaches and facilitative coaching conversations need to be reconciled if coaching is to be effective and ethically grounded. In practice, this reconciliation is not always easy; context is key. Indeed, although supporting people in lifestyle and behaviour change or self-management of long-term conditions calls for the more collaborative coaching conversations, there are more urgent or acute situations in healthcare that may call for the expert, authoritative approach.
What seems compelling, according to developing research, is that due to its collaborative and empowering nature, coaching patients can improve patient experience and outcomes (Iordanou et al, 2017). Furthermore, coaching patients can reduce healthcare costs in contexts such as the managing long-term conditions and improving public health and wellbeing (Wolever et al, 2013).
Aside from the crucial issue of whether the clinician, or health leaders more widely, is the expert or facilitator in healthcare, there are some ethical issues that healthcare professionals engaging in coaching patients face (Iordanou et al., 2017):
- Capacity building and training: Clinicians who are increasingly asked to employ coaching approaches in their interactions with patients are not always adequately trained to do so. As such, the transition from the traditional and direct medical model towards a more facilitative coaching approach poses a challenge that needs serious consideration.
- Competing perceptions of the professional role: Healthcare professionals must be clear about the approach they’re expected to pursue with patients, in order to delineate the boundary between offering directives and enabling the self-management of the patient’s condition and health. The patient’s condition will play an important role here.
- Managing expectations: Following from the above, clinicians acting as coaches should clearly communicate to patients the way they will be working with them. This is particularly important for patients who expect to be told what to do in order to manage their condition and health.
These factors illuminate some of the ethical implications relevant to the emergence of coaching patients in UK healthcare. The paradigm shift away from traditional approaches of ‘doing to’ patients, towards more collaborative approaches of ‘doing with’ patients is gradual. As a result, more equal partnerships between professionals and the public are now considered crucial to improving our health services. Coaching approaches encourage patient experience and clinical experience in equal measure. Ultimately, ethical coaching for patients, and in healthcare more widely, entails understanding the impact of coaching on the whole system, not only directly on patients and clinicians/leaders. While further empirical research on this subject is needed, opening up to the benefits, opportunities, as well as risks of this approach will enable more informed decisions and actions, both on the part of healthcare professionals and patients.
To conclude, the current context of healthcare, and challenges illuminated by navigating Covid-19 and its impact on staff and patient wellbeing, the role for coaching patients seems to be widening, not only in clinical relationships but in the context of quality improvement and leadership in health and care more widely. Against this backdrop it is important to consider the ethical implications of coaching patients.
- Dr Ioanna Iordanou is a reader in human resource management (coaching and mentoring) at Oxford Brookes Business School, co-author of Values and Ethics in Coaching (Sage, 2017), and co-editor of The Practitioner’s Handbook of Team Coaching (Routledge, 2019)
- Rachel Hawley is a leadership associate (patient and citizen leadership) at the NHS Leadership Academy and Yorkshire and the Humber Leadership Academy. She is also the co-author of Values and Ethics in Coaching (Sage, 2017)
References
- American College of Preventive Medicine, Lifestyle Medicine – Evidence Review, Washington, DC: ACPM, 2009
- H Bennett, E Coleman, C Parry, T Bodenheimer and E Chen, ‘Health coaching for patients with chronic illness. Does your practice “give patients a fish” or “teach patients to fish”?’, in Family Practice Management, 17(5), 24-9, 2010
- A Coulter, S Roberts and A Dixon, Delivering Better Services for People with Long-term Conditions: Building the House of Care, London: The King’s Fund, 2013
- R Hawley, ‘Coaching patients’, in C van Nieuwerburgh (ed), Coaching in Professional Contexts (pp115-130). London: SAGE, 2015
- J Hibbard and H Gilburt, Supporting People to Manage their Health: An introduction to Patient Activation, London: Kings Fund, 2014
- I Iordanou, R Hawley and C Iordanou, Values and Ethics in Coaching, London: SAGE, 2017
- D McNally et al, ‘Patient leadership: Taking patient experience to the next level?’, in Patient Experience Journal, 2(2), article 3, 2015
- M Moore and E Jackson, ‘Health and wellness coaching’, in E Cox, T Bachkirova, and D Clutterbuck (eds), The Complete Handbook of Coaching, 3rd edn (pp345-62), London: SAGE, 2018
- B Seale, Patients as Partners: Building Collaborative Relationships among Professionals, Patients, Carers and Communities, London: The King’s Fund, 2016
- C Williamson, ‘Using life coaching techniques to enhance leadership skills in nursing’, in Nursing Times, 105(8), 20-23, 2009
- R Q Wolever, L A Simmons, G A Sforzo, D Dill, M Kaye, E M Bechard, M E Southard, M Kennedy, J Vosloo and N Yang, ‘A Systematic review of the literature on health and wellness coaching: Defining a key behavioural intervention in healthcare’, in Global Advances in Health & Medicine, 2(4), 35-53, 2013
- V Woodhead, ‘How does coaching help to support team working? A case study in the NHS’, in International Journal of Evidenced Based Coaching and Mentoring, S5, 102-119, 2011