Although health care costs are rising to unsustainable levels, health outcomes remain disappointing in the United States. Multiple endeavors are under way to examine how to improve health outcomes and create greater value (Josiah Macy Jr. Foundation, 2014; Smith, Saunders, Stuckhardt, & McGinnis, 2012). Recommendations from these and other studies have concluded that there is the need for a cultural shift in health professions' education and clinical practice, including both what and how health professions students are taught.
Redesign of primary care settings is occurring due to rising concerns for improving health and lowering the cost of care (Arend, Tsang-Quin, Levine, & Thomas, 2012). As a result, nurses are playing new roles in coordinating care through managing caseloads of clients with complex health needs. It is predicted that there will be increased accountability and responsibility for nurses in the areas of transitional care and care coordination (Robert Wood Johnson Foundation, 2015). It is predicted that an increasing amount of health care will occur in ambulatory care settings (Bureau of Labor Statistics, U.S. Department of Labor, 2015). Care coordinators and health coaches are being employed in growing numbers in health care systems. RNs assume many of these roles, but some suggest that nurses are not being fully prepared to provide care coordination (George & Shocksnider, 2014).
A growing body of evidence suggests that proper care coordination reduces hospital readmissions and improves health outcomes (Carter et al., 2015; Coburn, Marcantonio, Lazansky, Keller, & Davis, 2012). Effective care coordination captures a shift from illness-based to community health-based and refocuses on patient centeredness (Fortier et al., 2015). One study found that the most effective care coordination interventions are focused on providing holistic, relationship-based care (Vanderboom, Thackeray, & Rhudy, 2015). Among other things, this shift in focus involves clients earlier by using behavioral-based questions to explore what clients perceive as their needs and thus offering a base for the coordination process (Zlateva et al., 2015). General strategies for care coordination can include but are not limited to collaborating with other disciplines, setting goals and tracking measurable outcomes, using evidence-based practice, accessing key resources, and using teaching and coaching interventions focused on client behavior (Dossey & Kegan, 2013; Haas & Swan, 2014).
Coaching is one skill that has been used as part of care coordination to assist clients in achieving desired health outcomes (Haas, Swan, & Haynes, 2013). The role of the nurse as coach recently has been adopted by the American Nurses Association (Hess et al., 2013) and the International Council of Nurses and Sigma Theta Tau International (Donner & Wheeler, 2009). Publications from these organizations clearly differentiate between coaching, mentoring, and counseling, and identify the benefits of contractual agreements between nurse coach and client as a commitment for goal attainment. Donner and Wheeler (2009) further regard coaching as a key competency for nursing leaders, managers, educators, researchers, and practitioners. The Johnson & Johnson HealthMedia® CARE® for Your Health program, which addresses management of chronic conditions with the use of digital health coaching, has significantly reduced medical utilization costs (Schwartz et al., 2010).
The focus of coaching may include, but is not limited to, client improvement of self-awareness, skill development, behavior change, and personal growth. It is critical for a successful coaching interaction that the nurse, regardless of practice setting, be focused on client desires and capabilities while simultaneously being attuned to the potential need to shift from nurse as expert to nurse as coach based on client needs. “The nurse coach spends time with the client in discovery and only moves into the nurse expert role, when indicated, to assist the client” (Hess et al., 2013, p. 19). The nurse coach works with the client to address the client's capacity and motivation to overcome perceived deficits followed by facilitating the client's selection of activities. This process respects client choice and supports the process of change that leads to behavior change and improved outcomes.
This article describes how one BSN program revised curriculum by partnering with community agencies and health care systems to redesign a nursing education program to prepare nurses for emerging community-based roles in the health care system.
The project began with support from local Partners in Nursing grant (Robert Wood Johnson Foundation and Northwest Health Foundation). The goal of the project was twofold: (a) Increase nursing student clinical site opportunities and (b) increase the skill set needed to provide services for the gaps of care within a health service continuum of care for selected underserved populations. Following consultation with the Research Committee of the clinical partner organization, 31 potential participants were identified; these individuals were employed as nurse coaches, health navigators, and care coordinators in hospital or clinic settings. Participants were identified because of their unique new roles in working with clients outside of the acute care settings to improve health outcomes. Because the project was viewed as a curriculum improvement effort for the university, the Research Committee did not recommend a formal review, but the committee did require that participants sign informed consent documents prior to interview or focus group participation. Signed, informed consent was obtained from all participants.
Twenty-four participants attended one of two focus group sessions lasting approximately 90 minutes each. Written consent was obtained from all participants before the focus groups began and the recording device was turned on. In addition to identifying community gaps of care, the purpose of the focus groups was to identify skills, processes, and curriculum components needed to prepare RNs to work with clients across the continuum of care. Focus groups were tape-recorded, and the audiotapes were transcribed and categorized into themes and subthemes using the constant comparison technique as described by Glaser and Strauss (1967). The following questions were developed to guide the focus group discussions:
- What is the starting point for your involvement with a given client?
- What skills and knowledge did you need to obtain to be effective in your role?
- Where and how did you obtain this knowledge and skill?
- What knowledge and skills did you need to learn for this role that you did not learn in your nursing education?
- Through your role, what have you discovered about gaps in community services?
- What difference does this work make to patient care and health outcomes?
- What are the strengths and limitations of your role as it currently exists?
- How could nursing students participate in clinical experiences to gain an understanding of these new roles?
Three themes emerged from the data analysis of the structured focus groups, and several subthemes were identified within each theme.
- Theme 1: Be Case Focused, Not Place Focused. Subthemes that emerged were: (a) track progress and outcomes, (b) think about clients outside the hospital, (c) look for barriers to health goals, and (d) think case management and discharge planning all of the time.
- Theme 2: Focus on Behavioral Change. Subthemes that emerged were: (a) include motivational interviewing and coaching, (b) let clients, not the nurse, set the goals and the pace, and (c) teach what clients need in simple language.
- Theme 3: Broaden Clinical Experiences. Subthemes that emerged were: (a) increase exposure to the whole experience of health care across all settings, (b) job shadow primary care providers, coaches, health navigators, and care coordinators, (c) practice coaching and behavior modification in clinical settings, and (d) learn about resources and obstacles, both in acute and community settings.
The following statement from one participant resonated with the rest of the group and gave overarching meaning to all of the categories: “If I had this knowledge and skill [care coordination and coaching] when I worked at the bedside, my approach would have been so different, and I would have had a bigger impact on my patients' health.”
From this analysis, the three overarching themes were used to guide curriculum design. First, the program focus would be case-based not place-based nursing. Second, the skill set of coaching would be woven into the curriculum. Third, varied community experiences would be incorporated throughout the BSN curriculum. The case-based focus refers to individual client focus and client-driven health goal development regardless of setting. The knowledge about and skill of health coaching would be introduced early in the curriculum and practiced throughout all clinical experiences. Community health concepts would be threaded throughout the curriculum. A seminal course entitled, “Caring, Coaching, and Educating Across Settings,” was created in semester two of the traditional BSN program. The same course was created for the RN-to-BSN completion program to be introduced as the first course in that curriculum.
The curriculum design included two semesters of student experiences in community settings. Several representatives from community health and social service agencies were invited to a meeting to discuss possible clinical placement sites for students to engage in working with underserved populations. As a result, several clinical placement sites were identified, including county jail work release facilities, homeless shelters, after-school programs, faith-based mission outreaches, and parish nurse programs. Students were paired with clients for a period of 8 weeks, worked with clients using health coaching and education strategies to work toward improved health goals selected by the individual clients, and coordinated care with other disciplines and resources as needed.
Faculty members required additional education to prepare for the new curriculum, especially those who were supervising students in their clinical practice experiences. One faculty member who was certified as a coach was instrumental in designing the Caring, Coaching, and Educating Across Settings course; this faculty member served as a consultant regarding coaching for the overall curriculum design. Classroom and clinical faculty collaborated to ensure that course content and clinical experiences were parallel for concept and skill development.
Preliminary feedback from course evaluations, clinical evaluations, and small surveys indicate that students valued the opportunity to work with clients in diverse community settings to improve health outcomes. Community agencies and clinical partners expressed enthusiasm about the students gaining new perspectives for care, as well as the skill set of coaching. A more structured study is needed to measure the outcomes of this curriculum change.
Educating faculty members and students about new perspectives for care and importance of new skill sets has been challenging and has required frequent reinforcement. It was difficult to find textbooks that were well-suited to support the content related to coaching and outcomes management as skills that differed from client teaching. Key articles from the literature were used, in part, to support content on coaching skill as well as aspects of care coordination. Reinforcement of content on assessment, motivational interviewing, coaching frameworks, and outcome tracking occurred in both classroom and laboratory sessions.
Care coordination is an evolving RN role and is part of the Health Care Home initiative (Arend et al., 2012). Competencies and strategies for care coordination and managing transitions recently have been created by a task force of the American Academy of Ambulatory Care Nursing and may prove useful to guide curriculum development and teaching strategies in the future (Fortier et al., 2015).
Coaching has become an important skill for nurses working to improve health outcomes in health care systems, and this skill should become a part of the nursing curriculum. Although little has been published in nursing literature regarding coaching as part of an undergraduate curriculum, theoretical evidence of its premise has been published. Hess et al. (2013) referenced Benner's use of the term “nurse coach” as relevant for a patient-nurse partnership based on social support theory as well as Orem's foundation of client-based decisions about their own self-care being instrumental in the process of change. An integrative review that analyzed strength-based health coaching indicated there were significant improvements in health behaviors using patient-centered strategies (Olsen & Nesbitt, 2010). These theoretical premises and findings are consistent with focus group results indicating that success is case based, with clients setting both the goals and the pace of the coaching process in collaboration with their nurse coach. Tasks of guidance and joint decision making evolve through this and capture a sense of holism and self-care that focuses on behavior changes desired by clients.
Expanding clinical experiences to increase student exposure to various client populations, as well as to diverse nursing roles and settings, is both worthwhile and challenging. The varied settings offered students clinical diversity outside of the traditional acute settings. Students were able to practice both teaching and coaching skills based on assessment, initiate care coordination for additional resources, and collaborate with colleagues such as parole officers, social workers, vocational educators, dieticians, community health nurses, and physicians. Clinical evaluation feedback indicated students felt anxious and intimidated at first, and then became more confident in their roles as the experience progressed.
Care coordination and coaching are important concepts and require different skills than what have been traditionally taught in most nursing curricula. There is a growing body of literature supporting care coordination as an important role for RNs. Although some theoretical guidelines have been established related to care coordination and coaching, more study is needed to determine when and how this content is best introduced to pre-licensure nursing students. In addition, collaboration between faculty and practicing nurse care coordinators and coaches can assist in discovering real-world experiences for students.
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