Developing Effective Health Coaches: Experience Gained in a Clinical Trial of a Health Coach Intervention

Abstract

Objective:

to identify the characteristics of an effective health coach and describe how these characteristics can be developed.

Methods:

A qualitative descriptive design was used to obtain insights from a convenience, homogenous sample of health coaches, social workers, and research staff members collaborating as members of a team providing a health coaching telehealth intervention for lay caregivers. Individual interviews were analyzed using thematic analysis.

Results:

The 11 study participants interviewed were predominately married (75%), female (92%) and Caucasian (83%). Ages ranged from 27–66 with an average age of 42 years. The sample was highly educated, with five having attained a terminal degree (PhD or DNP). The participants described three themes of characteristics that contributed to the success of health coaches: personal characteristics, professional characteristics, and program characteristics.

Conclusions

These characteristics expand what is known about attributes that contribute to successful health coaching. Most can be trained or used in developing programs and interventions.

Practice implications:

Our findings suggest that many of the core skills of an effective health coach can be developed through individual training, program design, and peer support. Innate personal characteristics such as trustworthiness, integrity, and compassion are hard to influence but can be identified in the hiring process.

1. Introduction

Health coaching is a client-centered approach to engaging users in setting personal goals to achieve positive health behavior changes that lead to improvements in self-care [1]. Health coaches actively work with people to assist them in developing healthy behaviors such as adequate physical activity, a healthy diet, and weight loss [2,3]. Health coaches who successfully complete a standardized course of study, pass an exam, and hold an active license in the healthcare field (e.g., registered nurse; licensed professional clinical counselor etc.) are eligible for certification by the National Society of Health Coaches (NSHC) in the United States (US) [4]. Certified Health Coaches (CHCs) must recertify every 5 years by re-taking the exam and a skills assessment [4]. The NSHC’s position is that CHCs should “have the clinical education and training to safely guide clients with acute or chronic conditions” coupled with evidence-based coaching training focused on facilitating behavioral chance and client engagement [5].

Health coaching has grown increasingly popular in recent years as the benefits of this approach have been established in chronically ill patient populations (e.g., type 2 diabetes, rheumatoid arthritis, and heart failure) [2,6,7]. Health coaching is also an effective intervention to assist caregivers develop self-efficacy, promote self-care, and reduce stress [8].Despite the effectiveness of this intervention, there is little evidence on what characteristics make a health coach effective or how to develop an effective health coach. Thus, the aims of this study were to 1) explore what characteristics make an effective health coach and 2) describe how health coaches and the social workers and research staff members working in support of health coaches believe these characteristics can best be developed.

1.1. Health Coaching for Caregivers

In the US, approximately 44 million lay caregivers provide unpaid care through emotional or practical support (e.g., mobility assistance, checking medications) to friends or family members unable to care for themselves [10]. The caregiving role often results in major life upheaval, requiring caregivers to reframe their identity, learn new skills, and develop expertise while coping with feelings of helplessness [9,10]. Caregivers often experience mental, physical, and emotional distress while performing their duties and experience a decrease in quality of life [10,11]. These stressors have been exacerbated by the global pandemic and the resulting quarantine measures, which have increased social isolation, making it difficult to access healthcare and services for themselves and their loved ones [10].

Investigators have acknowledged the necessity of providing caregivers with support to reduce patient hospital stays and caregiver burnout [10,13]. Health coaching is highly adaptable to a telehealth platform. Doing so has decreased hospital usage and improved quality of life for caregivers [8]. However, delivering a telehealth coaching intervention requires that health coaches be autonomous and highly skilled.

Previous research on the desirable characteristics of health coaches suggests that clients want trustworthy health coaches who treat them with respect [2]. Health coaches perceived as knowledgeable, having strong communication skills, and able to express empathy are most likely to be considered as respectful and trustworthy [2,14]. Little is published about how to develop these characteristics in health coaches, so we conducted this study to address this gap in the literature.

2. Methods

2.1. Design

A qualitative descriptive design was used to obtain insights from health coaches, social workers, and research staff members collaborating as members of a team providing a telehealth coaching intervention for caregivers. This method was selected because it is well-suited for studies in areas with little previously developed theory and those seeking to describe a specific phenomenon [15,16].

2.2. Setting and Participants

A convenience sample was recruited from individuals involved in an ongoing randomized clinical trial (RCT) of caregivers of adults with heart failure being conducted at a large academic medical center in an urban environment in the northeastern US [17]. The social workers and research staff members lived in the vicinity and worked on the study in-person before the pandemic. But the intervention tested in the RCT was virtual, so the health coaches providing the intervention were able to telework from multiple locations across the USA. We hired health coaches living on the East Coast, West Coast, and in the Midwest. All health coaches involved in this study had previous professional experience and formal training in health coaching. All were certified or eligible for certification. After they were hired for the study, they were given additional training on the intervention to be administered. During this training they had walk-throughs of the medical facility, formal introductions to the medical staff (e.g., physicians, nurses) providing direct patient care, training on the hardware and software to be used for the intervention, and didactic classes on the health conditions of the patients that the caregivers were supporting.

The study reported was approved by the university Institutional Review Board. Inclusion criteria for study participants included participation as a health coach, a social worker, or a research staff member working in the implementation of the RCT. Exclusion criteria were individuals who had no interaction with the health coaches or the caregiver recipients of health coaching, or no role in assessing the fidelity of the intervention provided by the health coaches.

The health coaches, social workers, and research staff members working in the RCT (hereafter referred to as ‘study participants’) were invited to participate if they were involved with delivering the intervention, overseeing intervention fidelity, or working directly with recipients of the intervention (Table 1). All eligible participants were notified of the study during a routine team meeting where they had the opportunity to ask questions. They were then contacted by email and provided with a detailed description of the purpose of the study and procedures to be followed. Those interested in participating contacted the primary author to schedule the interview and provided written consent to having the interview digitally recorded. Interviews were stopped when data saturation was achieved. This variety of participants helped to ensure diverse perspectives. Interviews took place between October 2020 and October 2021.

Table 1.

Titles, Roles, and Rationales for Inclusion of Study Participants

Job Title	Job Description	Rationale for Inclusion
Health Coaches	Experienced health coaches given additional training for a specialized intervention for the caregivers of adults with heart failure. The health coaches conducted 10 telehealth sessions with the caregivers to complete the intervention.	Health coaches possess the lived experience to describe what they feel has contributed to their professional development and success.
Social Workers	Licensed professionals who typically assist caregivers to access and obtain resources (e.g., transportation, appointment coordination, additional health education). Health Coaches collaborated with social workers to address the support needs of caregivers that were identified during telehealth sessions.	Social workers were identified by all health coach participants as being critical to health coach success. This initial finding was unexpected. The recruitment strategy was adapted to collect input from social workers to enrich data collection and enhance triangulation. Social workers were able to report on direct feedback they had received from caregivers about their experiences with the health coaches and intervention. The inclusion of social workers provided greater clarity on the initial findings from the health coach participants as to what made an effective health coach.
Research Staff Members	Various personnel who performed various tasks in support of intervention such as: fidelity assessments and audits; trainers who instructed health coaches on specific health conditions (e.g., heart failure) and the telehealth intervention; personnel who had direct involvement with caregivers during data collection).	Research Staff Members were included to provide operational insight on how effective and successful the health coaches were based on assessment metrics gathered for intervention. Two Research Staff members were trained as social workers but working as Research Staff Members. For the purposes of this study, they were categorized as Research Staff Members.

2.3. Data Collection

Study participants were interviewed individually by the primary author. All interviews were conducted in English and lasted 12 to 47 minutes with an average of 31 minutes per interview. An online platform was used to digitally record audio and video input, which was automatically uploaded to a secure server. The Rev Recorder v4.9 for iPhone app was used to record a backup of the audio data. A semi-structured interview guide (Appendix A), developed by CC, FB, and BR was used to explore the key questions: 1) What are the characteristics that you think make an effective health coach? and 2) How do you feel these characteristics can be best developed? Possible probe questions were prepared and included in the interview guide with the goal of eliciting feedback about the practice of health coaching, health coach training, and program support for health coaches. Additional questions were tailored to capture data relevant to the various roles (health coach; social worker; research staff member). Participant responses captured data on their views regarding health coach success and development not limited to the RCT in which they were participating.

2.4. Coding and Data Analysis

The audio data were transcribed verbatim by a HIPAA-compliant transcription company specializing in qualitative interview transcription. Transcripts were compared line-by-line against audio and video files for accuracy and then the audio and video files were destroyed. Pseudonyms were used during interviews and while reviewing transcripts to protect the identities of the study participants and people they mentioned (e.g., caregivers, patients, and other research staff members associated with the RCT) during the interview. The qualitative software program NVivo 12 [18] was used to store and manage data.

A codebook was developed by conducting a line-by-line reading of the first few transcripts to isolate key ideas. These key ideas became codes. A definition of each code and decision rules for its use were included in the codebook (see Figure 1), which was finalized by CC and BR. Thematic analysis was used for the analysis in conjunction with an inductive approach. Thematic analysis was selected for its unique strengths in studying phenomena without an existing framework and for its soundness as a method for identifying, analyzing, and reporting patterns found in qualitative data [19]. One author (CC) read the transcripts in their entirety and conducted line-by-line coding based on the codebook. Another investigator (KS) used these codes to independently code themes from the transcripts. The two investigators involved in coding (CC & KS) then met to discuss their results and resolve discrepancies using the negotiated consensus approach [20, 21]. The final coding agreement was 100%. The final coding results were reviewed and discussed with the senior author, BR.

Figure 1.

Data Analysis

3. Results

The 11 study participants, all employed as members of the ongoing RCT were interviewed. Most were married (75%), female (92%), and Caucasian (83%). The 11 study participants included 3 health coaches, 2 social workers, and 6 research staff members. Two of the research staff members were trained as social workers so they offered both perspectives. Ages ranged from 27–66 with an average age of 42 years. The sample was highly educated, with five having attained a terminal degree (PhD or DNP) (see Table 2). Participants described three criteria that they perceived contributed to the success of health coaches: personal characteristics, professional characteristics, and program characteristics (see Table 3).

Table 2.

Participant Demographic Characteristics (N=11)

Sex
Male	1
Female	10
Age Range
20–39	5
40–59	5
>60	1
Race/Ethnicity
White	8
Black	2
Hispanic	1
Highest Level of Education
Bachelor’s Degree	3
Master’s Degree	3
Terminal Degree (e.g., PhD, DNP)	5

Table 3.

Key Themes Identified in Interviews with Study Participants

Key Theme	Definition	Exemplar Quote
Personal Characteristics Contribute to Success as a Health Coach	Innate personal core and essential characteristics of a health coach such as trustworthiness, integrity, compassion, and empathy	“An effective health coach has to be able to communicate and establish a rapport with the person that they’re—and a trusting relationship with the person that they’re working with. That trusting relationship doesn’t have to develop right away, but it needs to build over time. I think that is grounding.” – Research Staff Member
Professional Characteristics Contribute to Success as a Health Coach	Professional characteristics amenable to training such as active listening, rapport building, and adaptability	“I think what I learned in coaching was if you just take that time to be quiet and not only appreciate silence but also actively listen to the other person, that’s actually when the magic happens. That’s where you find someone else’s motivation, someone else’s value, someone else’s deep thoughts because you gave them the space to express it. Or if everyone’s silent and you’re comfortable with silence, it gives you the space to truly take a step back and understand your thoughts. It doesn’t always have to be uncomfortable. I feel that that’s something that can be learned if I just practice.” – Health Coach
Program Characteristics Contribute to Health Coach Success	Intensive training enhanced understanding of the health coaches about the healthcare system, the resources (e.g., social workers) available to them, and the technology to be used.	“The program has the built-in process that if there’s some unanticipated issues that come up, that we have a framework to handle and manage it.”– Research Staff Member “The social worker will help the family… If somebody needs respite care ‘cause they’re caring for somebody or they need a ramp built for their home or there’s food insecurity, tax help.” – Social worker

3.1. Personal Characteristics Contribute to Success as a Health Coach

Trustworthiness and integrity were considered innate personal core and essential characteristics of a health coach. The rationale was that if a client could not trust their health coach, then they would not have faith in the intervention nor would they be comfortable being honest about their experiences. Other personal characteristics that participants thought to be innate were compassion and empathy. Participants defined empathy as a “behavior or action” as opposed to a passive emotion or perspective on an issue. These attributes were considered important not only because they enhanced care of the caregivers but because they made it easier to master the characteristics that could be improved through training.

“I think folks can try to practice empathy, but…it’s also just in…your perspective and the way that you process information that someone is giving you, and that’s a really hard thing to teach in a training.”

– Health Coach

3.2. Professional Characteristics Contribute to Success as a Health Coach

The health coach participants identified professional characteristics that were amenable to training, such as active listening and giving clients the time to talk through and process their thoughts and emotions. Active listening was defined as a foundational technique used by health coaches to engage clients in the intervention. The ability to be a good active listener was described as the most important characteristic predicting success.

“The [health coach’s] goal is helping the caregiver define what their goal is and then to be focused on their own self-care and management of their stress…somebody who can be an active listener and …able to be supportive and engaging and help to pull from that person and help them to reflect back on what they’re saying can be very effective in this role.”

– Research Staff Member

Being an active listener also involved remaining present in the moment and nonjudgmental, which allows the client to “feel safe to share” while matching tempo and energy. The opposite of these characteristics was being too directive, “giving too many commands and not allowing the [client] to respond” by asking too many questions, asking too quickly, and using close-ended questions. Notably, participants believed that these habits could be unlearned if the coach is empathetic and trustworthy.

“You don’t contradict them or challenge somebody… You wouldn’t use criticism or any aspects of …control [in] the relationship. You’re really letting that person guide the relationship. Not everybody can do that. I think it’s a skill that everybody can learn, but not everybody learns that skill.”

– Research Staff Member

Professional characteristics did not directly contribute to the delivery of the intervention, although these characteristics were described by participants as contributing to the overall success of a health coach. The ability to transfer and apply prior experience was considered a highly desirable characteristic of the health coaches. When asked about prior experience, one health coach stated:

“…the toolkit…[and] also what I have learned [previously] as a coach…it’s transferrable… I can do it in any setting with any person.”

The health coaches stated that previously acquired knowledge and the ability to transfer this knowledge to a health coaching role allowed them to have a deeper and more holistic understanding of how the illness impacted the caregivers. This understanding was not limited to prior knowledge of illness pathophysiology but did include prior clinical experiences as a nurse and as a health coach for ill individuals. Those health coaches with a background in nursing felt that they had a more complete understanding of the inpatient and outpatient settings and what interventions and outcomes could be expected.

“…some form of education or direct service where you’re interacting a lot with diverse people from different backgrounds and supporting them in some way…”

One health coach participant noted that prior experience helped to build skill in establishing rapport. Having a well-developed rapport building skill was more important than previously acquired clinical knowledge of a specific patient or caregiver population.

Comfort with autonomy and the ability to adapt were also described by participants as critical professional characteristics. One health coach stated that these skills were important because health coaching is “so client-centered and not everyone’s the same”. Participants felt that these characteristics facilitated delivery of the intervention to caregivers who were already managing several stressors. All the health coaches addressed the importance of flexible scheduling as an example of adaptability. Adjusting to the caregivers’ schedules was “important to make them feel valued and special”. The health coaches interviewed thought that being able to change a scheduled meeting to a better time for a client not only helped to “facilitate their life balance” but conveyed respect and helped to build trust. They also considered the ability to set healthy boundaries with the caregivers while maintaining rapport to be another important aspect of autonomy and adaptability. This was described as knowing what personal information not to divulge to caregivers, when not to push too aggressively for personal information from them, and the ability to guide sessions and “reign it in a little bit” so that caregivers did not ruminate for extended periods on unhelpful topics.

3.3. Program Characteristics Contribute to Health Coach Success

An unexpected finding that emerged was how important participants believed that program characteristics were in contributing to the success of the health coaches. Although the health coaches were all experienced in coaching and telehealth, the “two days of intensive training regarding the population […] standard policies, [and] procedures…” contributed in important ways to their success. This training was conducted in-person prior to COVID-19 at the medical center where caregivers were enrolled, to orient them to the site and staff. They learned specifics of the illness trajectory and toured the facilities. The health coaches observed where caregivers would be recruited including the clinic and hospital floors where patients were admitted. The health coaches said this experience enhanced their understanding of the system, helped them to “engage in the understanding of the caregiver’s perspective”, and familiarized them with the resources available for the caregivers. The heath coaches unanimously voiced their appreciation of the two-day training session, calling it “really special”, “extremely helpful”, and saying “Frankly, I wish we’d do it again. I wish it would be yearly”.

“Going over all the session content, the 10 sessions that we would be completing with the caregivers, was extremely helpful. They went through it very thoroughly and helped explain and expand upon what was behind all of it, the reasoning behind all of it and the reasoning for the sequential order of it… they brought in individuals to help educate us a little further on those topics, which was extremely beneficial.”

– Health Coach

The role of the health coach was to promote self-care and their interactions with caregivers were limited to those specified in the treatment manual. Thus, when other issues arose, they would strategize with the caregivers to identify known resources, counting on the social workers to connect them with the resources needed. They believed that the intervention would be ineffective if caregivers lacked the resources to care for themselves and their patient, to meet their basic needs like transportation, shelter, or respite care.

“The social worker’s essential ‘cause a lot of the issues that come up, it’s the social worker that will help the family… If somebody needs respite care ‘cause they’re caring for somebody or they need a ramp built for their home or there’s food insecurity, tax help…”

– Social worker

Social worker participants described providing support that focused on “troubleshooting and timing and educating” clients about the resources available, which permitted the health coaches to concentrate on providing the intervention as it was designed. The health coach participants felt that the social workers acted as a “bridge” to healthcare professionals when coordinating care between different environments.

“It usually does come down to the social worker …I’ve had a lot of my [caregivers] that went somewhere else…where they’re so far away from [the original location of treatment], or they’re rural…and it’s really difficult to get services [without social worker involvement].”

– Health Coach

The health coaches described the importance of the solid theoretical foundation of the program, which provided everyone with the same point of reference and expectations (e.g., motivational interviewing). Fidelity assessment was designed to provide standardized feedback to health coaches and a way to audit how well they were delivering the intervention. Technical support was important to assist with troubleshooting telehealth technology issues.

“Initially, the main challenge was related to the tablets…every [formal] meeting time or session included just troubleshooting the tablet… a point of frustration for the caregiver as well.”

– Health Coach

The health coaches identified their peer-to-peer health coach support sessions outside of the formal study meetings as instrumental to their success. They felt that in-person training allowed them to build rapport with one another, so their informal meetings were used to seek informed, empathetic support when they needed it; to share their experiences and expertise with one another while collaboratively problem solving; and to roleplay to further refine their delivery of the intervention. One health coach stated, “I think we all help fill in gaps for each other or tips or insights of things that have worked for ourselves and how we can apply it”.

“When you present something, how would you state—this is what I want to get to, but how would you state that question or how would you get to that goal for this patient or help them get to their goal? It seems more like roleplay, I guess.”

– Health Coach describing peer conversations

4. Discussion and Conclusion

4.1. Discussion

The purpose of this study was to explore what characteristics make an effective health coach and describe how health coaches, social workers, and research staff members working in support of health coaches believe these characteristics can best be developed. We interviewed members of a team engaged in delivering a health coaching intervention for caregivers. The participants described three themes of characteristics that contributed to the success of health coaches: personal, professional, and program characteristics. These characteristics expand what is known about attributes that lead to successful health coaching and can be trained or used in developing programs and interventions.There were no apparent differences among the study participants in perceptions of what made a health coach effective or how to develop these characteristics.

Because caregivers often develop a nuanced and extensive knowledge base regarding the illness impacting their loved one, it is important that they believe that their health coach is knowledgeable and experienced when it comes to the intervention, the skills they are teaching, and the disease process being addressed – bad or ill-informed advice and information was seenas a negative. This result replicates earlier findings [2,14], as participants identified the need for successful health coaches to have strong communication skills and to be perceived as trustworthy and empathic.

The health coaches identified characteristics that could be trained and those that were innate. Based on prior studies, we anticipated that innate personal characteristics would be the major factor associated with the effectiveness of health coaches, but study participants did not perceive personal characteristics to be too important. Instead, they stated that training was critical to develop the characteristics that maximized the effectiveness of the health coaches. For example, motivational interviewing has been linked to successful health coaching in programs that effectively increased knowledge and improved well-being of clients [14]. We found that health coaches praised their two-day training period. This result supports the findings of prior investigators who recommended a minimum of two days of training to ensure that health coaches understand the intervention and practice newly acquired skills to build confidence [22]. Our health coaches also found value in using their personal relationship with each other to try out coaching approaches and roleplay scenarios to increase comfort and confidence in providing the intervention.

The design of the health coaching program has previously been cited as contributing to program success; successful programs allow professional autonomy so that health coaches can alter schedules to best meet the needs of clients [20]. The caregivers wanted health coaches to have flexible scheduling options that are responsive to time restrictions, availability, and communication needs [2]. Caregivers already struggle with multiple demands on their time, trying to balance patient support and self-care [11]. Our study participants validated this finding by repeatedly identifying the ability to accommodate flexible scheduling as an optimal way to build health coach-caregiver rapport and ensure satisfaction with the intervention.

The importance of support from social workers for the health coaches is a new finding. The symbiotic role of these two groups and how the social worker augments support from the health coaches is one that requires further study. The necessity of technical support for health coaches and their clients is another area requiring more research, especially as remote options become more available and widely used. The perception of the participants in this study emphasizing the value of health coaching interventions for caregivers echoes that of other studies where caregivers described health coaching as positive and helpful [14].

Limitations of this study include the small sample size and focus on staff in a single program. Future studies should include care recipients to obtain their direct reflections on what characteristics they feel make a health coach effective in that role and what design considerations programs should use to increase the success of health coaching interventions.

4.2. Conclusion

Participants identified three characteristics that they believed contributed to the success of health coaches: personal, professional, and program characteristics. Personal characteristics were described as innate personal attributes or skills that the health coaches came with (e.g., trustworthiness). Professional characteristics could be developed through training (e.g., active listening). Participants felt that these characteristics enabled health coaches to successfully engage and interact with the caregivers. These characteristics drew from the health coaches’ experiences and allowed them to address the caregivers’ concerns and deliver the intervention effectively. Program characteristics were those that participants attributed to the program in which their health coaching was offered. That is, these characteristics were not attributed directly to the health coaches themselves but were identified as critical for ensuring that health coaches could be successful in delivering the health coaching intervention.

4.3. Practical Implications

Health coaching is an approach growing in popularity. Yet, little has been written about how to develop effective health coaches. Our findings suggest that the core skills of an effective health coach can be developed through individual training, program design, and peer support. Personal characteristics cannot be trained but can be identified during the hiring process.

HIGHLIGHTS.

• Professional characteristics such as active listening, rapport building, and adaptability can be trained

• Personal characteristics such as trustworthiness, integrity, compassion, and empathy can be identified in the hiring process

• Program characteristics such as training are essential supports that cannot be bypassed