Coaching effective for return-to-work and wellness; takes time to build into culture

'Natural bridge' from disability to ability, OH managers say

Health coaching and the "stages of behavior change" have become accepted wisdom in the preventive medicine and wellness arenas, but occupational health managers, with pharmaceutical giant GlaxoSmithKline, have found health coaching an invaluable tool for getting injured or ill employees back to work.

"We see this as a natural bridge for people coming back from disability to ability status," says Joanne Ebert, MBA, MS, CRRN, CCM, clinical manager for GSK in Philadelphia. "Many times, companies have a robust history of managing programs of this kind, but many times there's no bridge from disability to ability, so there is a higher preponderance of them going back out or not being as productive as they could be."

A health coach or health advocate promotes healthy living and lifestyle changes by providing support and guidance to facilitate employees through the stages of behavior change, or Prochaska stages (precontemplative, contemplative, preparation, action, and maintenance). Coaching is designed to help employees integrate and maintain improvements in personal health and work behaviors into the work environment and prevent further injury-related problems, and is most often used with programs targeting wellness goals such as smoking cessation, blood pressure and diabetes management, weight loss and diet, and exercise.

But Ebert points out that health coaching is just as valuable when the goal is getting back to wellness, not just staying well.

Motivate employee to take charge of health

"Health coaching promotes the employee taking control of their health, and that's important because when someone is disabled, they feel removed from their social framework," Ebert says. "When you use health coaching, especially when the person has a chronic illness, it helps give them that trajectory to get back. They can talk about their plan to stay well, and the nurse makes sure they are seeing their provider, talks with them about how things are going, if they are following their plan, so they can continue being on their wellness track."

When that approach is in place, Ebert continues, "what we have is a formal process where the employee is central to the process. It is more coaching and less prescribing, because we know that prescriptive services don't work, and the occupational health nurse can be extremely effective in successful coaching."

The key to successful coaching is developing skill in motivational interviewing, says Ebert, is a patient-centered method of interviewing that enhances the patient's internal motivation to change. The nurse doesn't motivate, but instead helps the patient realize and foster his or her own desire and motivation.

According to Bruce A. Berger, PhD, RPh, a professor at the Harrison School of Pharmacy at Auburn University in Auburn, AL, motivational interviewing relies on five principles or skills to assess and create motivation, represented by the mnemonic READS:

  • Roll with resistance: Ignore antagonistic comments by the patient, and focus on the underlying issues behind them;
  • Express empathy;
  • Avoid arguments;
  • Develop discrepancy: Encourage the patient to describe pros and cons about the changes; recognizing that the dissonance between the two fosters motivation, Berger writes;
  • Support self-efficacy: It is important that the patient have a strong belief in his or her ability to change.

Diane D. Mackie, BSN, MHM, COHN-S/CM, of GSK's medical affairs division in Research Triangle, NC, says motivational interviewing and health coaching, unlike more prescriptive measures, work equally well when the nurse is face to face with the client and when the coaching is done remotely.

"Fifty percent of our patient population is remote, and health coaching can be applied to them with equal effectiveness," says Mackie. "And it works in all areas of the health model — primary, secondary, tertiary. It's how to keep healthy people healthy, keep them out of the revolving door."

Moving to a health coaching model for case management is an ongoing process, Mackie and Ebert say, one that they are tweaking even after having worked together on it for years.

"It takes time to really start embracing this — not like a switch you turn off and on," Ebert explains. "You need to build into your culture, and that takes time. Some employers are extremely skeptical of it, and for some employees, it has to repeat three or 4 times before it resonates. You have to be resilient, because it's a long process."

"It really is difficult when you're coming from the mentality of check-listing," Mackie adds. "Health coaching requires more openness, more willingness to see what can be done differently to get the results you want to see."

But nurses have the basic tools already, she adds.

"What you need is really strong communications skills, strong listening skills. Employees' ability to stay on track and take care of themselves may need some nudging, but they have to make it happen," she says. "Nurses know inherently how to do this — that's why people go into nursing, to assist people in their wellness.

"There's no right or wrong answers, and that, itself, can be daunting to people because you can't put it in a binder. There's listening, and you listen and go with it. People make their own choices, and you have to remember you're there as their coach."


Diane D. Mackie, BSN, MHM, COHN-S/CM, GlaxoSmithKline Medical Affairs Commercial Operations, PO Box 13398, B.4101, Five Moore Drive, Research Triangle Park, NC 27709-8535.

Joanne Ebert, MBA, MS, CRRN, CCM, Clinical Manager, GlaxoSmithKline, One Franklin Plaza, Box 7929, Philadelphia, PA 19101-7929

Berger BA. Assessing and interviewing patients for meaningful behavioral change: Part 2. Case Manager 2004;15:58-62.