The delivery of a telephone coaching programme to people with type 2 diabetes by practice nurses in Victoria, Australia: a qualitative evaluation

Authors

  • Christine Walker PhD,

  • John Furler PhD, MBBS,

  • Irene Blackberry PhD, MBBS,

  • James Dunbar MD,

  • Doris Young MD,

  • James Best MD


John Furler John 200 Berkeley St, Carlton, Melbourne, Victoria 3053, Australia
Telephone: +61 3 8344 4747
E-mail: j.furler@unimelb.edu.au

Abstract

walker c, furler j, blackberry i, dunbar j, young d & best j (2011) Journal of Nursing and Healthcare of Chronic Illness 3, 419–426
The delivery of a telephone coaching programme to people with type 2 diabetes by practice nurses in Victoria, Australia: a qualitative evaluation

Aim.  To evaluate telephone coaching undertaken by practice nurses in a randomised controlled trial of self-management support for people with type 2 diabetes.

Background.  Qualitative evaluation of the processes that take place in randomised controlled trials has the advantage of providing information on those variables that contribute to the success or failure of the randomised controlled trial. This additional information can be used to improve or modify chronic disease management programme designs.

Methods.  Grounded theory was used to analyse transcriptions of telephone coaching sessions between practice nurses and patient participants in the randomised controlled trial.

Findings.  Analysis of transcriptions found that patient participants had complex multiple medical conditions to manage, as well as maintaining their daily lives. Two approaches to working with this complexity by practice nurses emerged. We characterised one as ‘treat to target’ and the other as ‘personalised care’. While each approach shapes identities available to patients within the relationship with the practice nurse, the impact or effectiveness of these approaches on outcomes has yet to be reported.

Conclusions.  Telephone coaching takes place in complex social contexts as well as complex medical conditions. People with type 2 diabetes must manage their diabetes care and their care of other conditions within their social contexts. This means a constant negotiation of priorities.

Relevance to clinical practice.  Awareness of how health professional support for patients’ self-management becomes a relationship and element of the negotiated identity of patients is important in adapting clinical guideline-based protocols to achieving targets in the management of chronic illness.

Introduction

People with chronic illnesses must manage their conditions on a daily basis. Lay-led self-management programmes such as the UK Expert Patients Program (Department of Health 2001, Lee et al. 2006) and the US Stanford chronic disease self-management programme (Lorig et al. 2001, Bodenheimer et al. 2002) have been developed to assist people to maintain daily regimes that will lead to optimal health outcomes. Much of the research on self-management of diabetes indicates that people who have better knowledge about their condition and who take an active role in management are likely to achieve better health outcomes (Heisler et al. 2005). Self-management requires translating knowledge into practice. Education for self-management is a focus of the United States and British guidelines for diabetes, as well as the Diabetes Australia Guideline Development Consortium (Colagiuri et al. 2009). The optimal role for health professionals in supporting patient self-management remains open to debate (Furler et al. 2008), although there is an emerging consensus that integrating self-management support with patients’ usual care from a trusted general practitioner or primary care professional is important (Kennedy et al. 2007).

This is the context in which we initiated the PEACH (Patient Engagement and Coaching for Health) project, a clustered randomised controlled trial (RCT) of structured telephone coaching for people with type 2 diabetes. This study aimed to test the effectiveness of telephone-based self-management support provided by practice nurses (PNs) to patients with poorly controlled diabetes. PNs are the most rapidly growing section of the primary care workforce in Australia and are subject to substantial Government investment (Commonwealth Department of Health and Aged Care 2010). Our study aimed to contribute to the evidence base for the role of PNs. Our intervention was based on a successful RCT of hospital-based telephone coaching for patients postacute cardiac event (Vale et al. 2005). That coaching intervention explicitly involved a focus on achieving the targets for lifestyle risk factors as well as disease monitoring and medication adherence and intensification in supporting patients to achieve the biochemical targets as recommended by best practice guidelines. The PEACH trial involved translating that intervention to the primary care setting for patients with type 2 diabetes. In this study, General Practices employing PNs were recruited and randomly allocated to the control or intervention group. PNs in the intervention group were trained over two days to deliver telephone coaching sessions to individuals. The training was a didactic delivery and provided the PNs with pragmatic information on nutrition, exercise, medication adherence and optimal risk factor testing protocols and target levels with which to engage their patients. The aim of PN coaching calls was to motivate patients to make lifestyle changes and adhere to medication regimes as well as empower them to negotiate with their GP to intensify their treatment and monitoring to achieve biochemical targets. All PNs received the same training and were expected to coach their patients according to the protocol, thus providing an internal methodological consistency to the study. Eight coaching calls were scheduled with each participating patient over 18 months.

Randomised controlled trials are increasingly applied to complex social settings where it is impossible to create a controlled environment as in a scientific experiment, with every variable accounted for. This is especially true in multisite RCTs where the intervention is potentially modified as it becomes more distant from the research centre (Hawe et al. 2004, Oakley et al. 2006). Exploring variation in the implementation of an intervention necessarily precedes any analysis of ‘success’ or ‘failure’ (Hawe et al. 2004). For this reason, it was decided to undertake a process evaluation. A process evaluation looks beyond ‘measuring an intervention mechanistically’ (Oakley et al. 2006:789) to explore how the intervention was implemented in its naturalistic setting and what otherwise unrecognised variables have contributed to its success or failure. This paper presents some results from a process evaluation of the PEACH study.

Methods

The full process evaluation consisted of pretrial focus groups (Furler et al. 2008), observation of PN training which the intervention PNs undertook to become telephone coaches, field notes made by research team staff during support visits and calls to PNs, recordings of a sample of coaching calls, interviews with a sample of patients, PNs and GPs from participating practices and focus groups at the end of the study. The data reported here only relate to fourteen coaching sessions conducted by six different PNs. PNs in the intervention arm of the PEACH study were randomly selected and asked to record a coaching session they undertook with one of their patients participating in the PEACH study. Recording of the interviews used audio recording equipment adjacent to a speaker phone. The recordings were then transcribed by a research assistant. Random sampling of both patients and PNs and transcriptions were undertaken by research assistants not involved in the process evaluation to preserve the anonymity of all participants in the process evaluation, to maintain the integrity of the RCT and ensure lack of bias in the process evaluation itself.

Using a grounded theory approach (Charmaz 2006), the contents of the transcriptions were analysed thematically by author initials independently. This began with close reading of the transcripts, coding or labelling sections of dialogue that appeared meaningful to the participants. Author initials met and discussed the coding, reread the transcripts, individually categorised their codes into themes and met to reach consensus on the themes. This approach identified that the social context in which diabetes was experienced was an important variable in telephone coaching. We present data on the unique social context in which telephone coaching was delivered; where that context influenced the participants’ responses to the coaching calls and how this social context impacted on the PNs role in coaching people to achieve better diabetes control.

Results

Overview

Self-management of type 2 diabetes has been identified as a complex task, which requires significant organisational skills and energy from the person with diabetes as well as others (Thorne 1993, DiMatteo 2004, Anderson 2007, Macdonald et al. 2008).

Consistent with this, the data generated from the evaluation of interviews demonstrated that patients participating in the research were expected to have a high level of knowledge and competency. Coaching calls followed a semi-standardised protocol where questions were asked about medication, blood test results, nutrition and exercise, and patients were advised on how they could make improvements. Where participants demonstrated a deviation from or a failure to meet targets the PN provided information and support to assist them to do so. However, the evaluation identified that these tasks related to managing type 2 diabetes took place in conjunction with other quite specific daily needs and life events.

  • 1‘I couldn’t do my weights this week’: the unique social context in which participants managed their diabetes.

For some of the patient participants, managing their diabetes was part of living with and managing a number of conditions. Patient participants reported taking medications for diabetes as well as hypertension, high cholesterol, cancer, pain control, sleeplessness, depression, anxiety, epilepsy and cardiac problems. Of the twelve patient participants in the recorded coaching sessions, most were taking at least four medications, one was on three different medications and one was on nine different medications. Those on higher numbers of medications were more confused about the names of the medications, their dosages and which medication related to which condition.

The number of conditions complicated people’s daily lives, both in terms of undertaking daily living activities and in terms of undertaking diabetes-specific activities. People who had painful conditions or had had recent surgery for cancers or heart conditions reported that it was difficult to complete tasks such as cooking a meal, doing the shopping or doing gardening. One female patient who was treated for cancer of the kidney just prior to the interview had not been able to care for her grandchildren, an activity she enjoyed. Surgery and recent hospitalisations or having the ‘common cold’ meant that diabetes-specific activities such as exercising and eating well were compromised, often taking a lower priority to simply accomplishing basic tasks to survive the day. For example, a female with mobility problems took several hours to prepare a meal, while the patient with cancer of the kidney was no longer walking the 3.5 km to the shops because there was a steep hill involved. One man was walking but not using his usual weights because of a shoulder injury. A hospitalisation might also result in missed appointments for blood tests and general practice visits including visiting the PN to discuss diabetes regimes. Social activities also impeded diabetes-specific activities. Visits to relatives and friends might mean relaxing some of the restrictions on diet or alcohol intake.

  • 2The impact of social context on the PNs’ roles in coaching to achieve better diabetes control.

The analysis of the coaching calls demonstrated that they were made and experienced within this complex social milieu. Training and the coaching call protocol relate only to diabetes and associated risk factors. However, the recorded calls demonstrated that participants experienced the care and self-management of diabetes within the context of their overall lives and other conditions, with participants frequently explaining the circumstances influencing their approach to their diabetes on a weekly or daily basis. At the same time, the coaching calls introduced a relationship between the PN and the participant into this social complexity. How the relationship developed was partly determined by the perceptions of both the PN and participant of the role the calls played in their lives. Some PNs recognised the social context in which people experienced their diabetes and its care, while others chose to concentrate exclusively on coaching to improve diabetes control.

  • 3‘Alright my love, how is the diabetes going?’: Relationships between the PN and participants.

Two distinct relationships emerged from the data and maybe characterised as ‘Treating to Target’ (T2T) and ‘Personalised Care’ (PC). In T2T, the PN was primarily concerned that the patient reached the disease targets set by the study protocol as effective control of type 2 diabetes and its associated risk factors. PNs who ‘treated to target’ concentrated on achieving the set targets regardless of the patient participants’ circumstances or their verbalised needs. In PC, the PN was aware of and responsive to the mitigating factors in the person’s life that made it difficult for the person to achieve an ideal target including his/her health, emotions and family situation.

Characteristics of T2T approach:

In this approach, the PN undertook to coach the participant on the blood glucose, cholesterol and blood pressure level targets they needed to achieve with little or no divergence from the protocol. The manner of delivery was generally impersonal, though not unkind. When the participant offered additional information about him/herself, it was generally ignored or if the participant was persistent then it was responded to very briefly, usually followed by a request to return to the coaching protocol.

Treating to target is a means of making participants aware of the targets they must reach and assisting patients to achieve and maintain the behaviours that will achieve them. The focus is on practical advice on ways to achieve the targets and not on other issues unrelated to their diabetes risk factors. While a participant’s achievements might be acknowledged, they are acknowledged in the context of meeting the target, rather than a personal achievement, with meaning for their identity and wider life.

PN: Now your blood pressure-what was your last reading?

Part: 133 over 82.

PN: That is pretty good-we just aim not to go any higher-so less than 130 over 80 is really good but I think that is really good. Now what is your weight at the moment?

Sometimes acknowledgement even came in a negative form, highlighting how far short of the target the person still remains.

PN: do you remember the result (of your HbA1C blood test)?

Part: yes it was 8.

PN: OK. Do you know what is normal for that?

Part: They are going for 5.5 or 6 but when it is 8 it is no good.

PN: That is right, it should be 6.5. That is normal. You need to aim to bring it down.

The wider contexts of the person’s life are often ignored or acknowledged only fleetingly.

PN: OK, try (to walk) everyday instead of every two or three days, try to do 15 minutes twice a day.

Part: Alright, I will try to do it.

PN: OK how much activity do you do around the house?

Part: Oh in the house I can make a cup of coffee, I can cook a little bit but if I have to cook dinner I have to start at 12 o’clock because I am so slow. I have pins and needles in my hands, I have no strength. It is very bad for me, this life; my life- it is really horrible.

PN: So putting on weight is not good.

Characteristics of the PC approach:

Practice nurses who had a personalised care approach engaged with the research participant on a personal basis. There was acknowledgement of past conversations between them and that they are in a relationship. Coach calls may diverge from the protocol to discuss the participant’s health more broadly, talk of grandchildren or the weather:

PN: Alright, my love, how is the diabetes going?

Part: Oh yes, reasonable.

PN: We did your 12 monthly cycle of care a few weeks ago didn’t we?

Part: We did, yes.

PN: Can you remember what your HbA1c was at that time?

Part: 7.1

PN: That is right! What was it previously?

Part: 7.7

PN: Right! So you are doing alright with that, aren’t you? Considering all that you have been through (death of relative; diagnosis of cancer).

While targets are acknowledged as an ideal to strive for, reasons for not achieving them are acknowledged by the PN:

PN: You wanted to lose some weight-is that right?

Part: Yeah-well I would like to; it is a bit hard…the dietician said I should because it would protect my remaining kidney but it’s a bit hard…

PN: And it is a very hard thing to do just after you have been through an operation.

Encouragement and acknowledgement of even small achievements are a feature of this approach.

PN: It looks like the last time I spoke with you (your weight) was 79.4. Now it is 77.6.

Part: Actually I have had to tighten my belt an extra notch so I must be losing a little bit of weight.

PN: Fantastic!

There is room to share jokes and to share experiences.

Part: I see the eye doctor…he wants to see me every 12 months…apparently I am developing cataracts.

PN: I think if you have the start of cataracts it is better to keep a good eye on them (Both laugh). Sorry!

Part: I haven’t been (to the gym) for a week now. I have been feeling a bit yuck (with a sore throat and fatigue).

PN: Oh! Hasn’t everybody? My God, the daughters are the same and my husband has no motivation whatever...I think it’s probably these viruses that sort of…

  • 4‘You’ve got to get some enjoyment out of life’: Participants’ approaches to their own targets

The analysis demonstrated that these approaches are not limited to the PNs. One interview identified that a carer (spouse) had adopted a T2T approach. She was monitoring her husband’s diet and exercise very carefully so he maintained the target levels. However, at the point in his life when the interview took place, she was reluctant to demand more of him as he had recently had heart surgery. Another interview demonstrated that a participant himself had adopted this approach and was working towards achieving each of the levels. He expressed high levels of satisfaction with the personal control he experienced.

Surprisingly, only one participant challenged a T2T PN, pointing out the targets were unrealistic in his circumstances and removed any enjoyment from his life. This participant considered that a regular glass of whisky was reasonable and said he would continue this habit. The T2T PN chose to ignore this challenge and pursued the point that little alcohol and alcohol-free days were necessary parts of any diabetes control strategy. In general, however, we found little indication that participants objected to the T2T approach or saw it as somehow ‘draconian’. While T2T overlooked mitigating factors, it was not necessarily delivered in an aggressive manner.

The interviews between PNs who practised PC and their participants showed an easygoing relationship where the participant could express her/his needs and request advice. However, there was no indication that this led to greater motivation. The target levels patients were achieving did not seem to be dependent on the approaches. Participants reported making improvements regardless of the PN’s approach and despite mitigating factors. No participants expressed antipathy towards any PNs, with all of them making the point they appreciated the PNs level of interest on their health.

Discussion

The evaluation identified that the unique social context in which this intervention takes place impacts on the abilities of people with diabetes to meet targets. The content of the interviews provides information on how people with diabetes negotiate the tensions related to diabetes management within a constantly changing social context. Some of the changes a person might have negotiated related to changing health status and involved more medications or hospital admissions or periods of reduced activity. This might include prioritising care of another condition over diabetes care. At times, social activities such as seeing grandchildren, family demands or attending a celebration might take priority over health care regimes. When ill health meant reduced activity, it was evident that thought went into priorities about quality of life. In some instances, negotiating these changes and fitting in diet, exercise, appointments and tests for diabetes was a daily exercise. Self-care support from PNs was received within this context and became absorbed into the broader negotiation process.

The negotiation of the tensions of this social context was evident when participants explained why they had not been able to meet all the self-care targets since the last coaching call. Similarly, such activities as having a regular evening drink or forfeiting self-care activities in favour of social ones demonstrate that the coaching calls became absorbed into the broader context to be negotiated over time. This evaluation then suggests that the power of the intervention of coaching calls to produce changes had many other issues to compete with.

Sociological studies of chronic illness offer some further insight into the reasons that people with diabetes might negotiate their support from coaching calls within the broader social contexts of their lives. Being ‘normal’ is important (Parsons 1951, Bury 1982, Townsend et al. 2006). Bury (1982) argues that the value of ‘normality’ is only recognised when it is thrown into relief by life disruptions such as chronic illness. Townsend et al. (2006) argue that while people with chronic illnesses try to manage their condition, the priority is always given to behaviours that typify having a normal life. Paterson (2001, 2003) presents illness as an ongoing changing process where people negotiate their illness and the world around them. At times, people may see themselves as well and at other times as ill. Paterson emphasises that these changes are related to the unique experiences of each person.

Activities such as having a regular evening drink of whisky or socialising instead of exercising carry great symbolic value of being ‘normal’. They may be undertaken both in terms of being an achievement (‘I am well enough to have a social life’) and with full acknowledgement of the tension this creates in their lives (‘I will pay for this neglect of my health regime in the future’). Equally for some people in the study, working to achieve targets of weight and blood glucose levels was also powerfully symbolic of being ‘normal’. Charmaz (1983) argues that many people who are disabled by an illness do not question that the world is set up for the healthy and able-bodied but simply use that as their yardstick and judge themselves by it. The coaching calls were incorporated into each participant’s individual negotiation between health demands and having a normal life.

The process evaluation identified that coaching styles used by the PNs in this intervention were broadly different. We have characterised this difference as T2T and the PC coaching styles. It is unlikely that the results of the RCT would have identified this potentially important variable.

We cannot conclude from this evaluation whether the different styles of coaching produced different outcomes because the evaluators were not able to identify participants each PN worked with to compare to coaching styles. Additionally, there was little to suggest from the content of the interviews that participants recognised or objected to the approach the PN adopted with them. None of the participants expressed hostility to a too familiar approach or a too distant approach.

One explanation that might shed some light on why the participants did not react to the coaching styles is provided by Shortus (unpublished thesis). Shortus (unpublished thesis) explored how general practitioner involved people with chronic illness in their own care. He argues that patients have the objective of engaging with health professionals to receive ‘appropriate care’. They bring certain needs to the consultation, and they judge whether those needs are being addressed. In this sense, participants in the PEACH study may have accepted that the coaching calls would address their needs only where they related to diabetes rather than their broader social, health and emotional needs when they agreed to participate. This may be one of the reasons that participants in the PEACH project did not appear to find the model of delivery of the coaching problematic.

Shortus’ explanation suggests that the social exchange between the research participants and PNs has a level of complexity beyond coaching styles, including expectations of both the participants and the PNs of one another, their understanding of one another’s needs, social contexts and the role of coaching. Receiving appropriate care provides an illustration of this level of complexity.

‘Appropriate care’ is a complex notion and may mean very different things to individuals. Feeling acknowledged by health care providers may be a base on which to establish common ground, rather than an all-encompassing element of the health professional–patient relationship as Shortus argues (unpublished thesis, 264):

Providers do not necessarily need to solicit the patients’ concerns, so long as the care they offer appropriately addresses them. Nor do providers need to agree with the patients’ view of their problems and priorities, or accommodate all of the patient’s concerns in their recommendations. Patients will accept their providers’ agenda when it differs from their own, or accept the providers’ recommendations when they are at odds with the patients’ expectations, so long as patients feel that their concerns have been acknowledged and addressed satisfactorily.

‘Appropriateness’ here is limited to the ‘type’ of relationship established between a patient and health professional. For some patients being treated to target may be accepted as an appropriate relationship to have with a health professional. The reason that it is maintained is because outside of this relationship the patient works to mediate the complex relationship of diabetes, its treatment, other medical conditions and other aspects of life, through a process of continuous self-negotiation of changing priorities and compromises. At some points in a person’s life, other health conditions or social activities take priority and compromises are made with regard to levels of exercise and diet. At the same time, the commitment to the relationship to achieve ‘appropriate’ care remains intact though it may be ‘put on hold’. In this manner, people with diabetes maintain as much of their old lifestyle as possible or negotiate a newer changed lifestyle with themselves and their families.

What we describe here can be understood as part of maintaining and negotiating ontological security or being ‘normal’. Lifestyle and its maintenance have been described as providing ‘a cluster of habits and orientations’, which give a sense of identity and ontological security in an uncertain world (Giddens 1991), uncertainty that in this case has been created by having diabetes. Charmaz (1983) recognised the threat chronic illnesses posed to people’s ontological security. Being independent, responsible and hard working are all functions that give meaning to contemporary lives. When chronic illnesses threaten functioning at this level, people lose the social roles that define them and their lives. Their primary aim is to return to the security of the ‘normal’, even if this is at some cost to their health. Townsend et al. (2006) further developed this theme in their research on Scottish people with multiple morbidities where they found managing symptoms was an important facet as people were attempting to continue their ‘normal’ lives. In fact, leading a normal life was sometimes prioritised above caring for the illnesses, and people had to negotiate the tensions this caused them.

Limitations

The process evaluation draws on a small sample of calls and participants from a much larger study and as such is not necessarily representative of the overall participant sample. We are not able to say whether the different coaching styles had an influence on disease or psychosocial outcomes as measured in the full study because we are not able to identify the PNs in relationship to the participants.

Conclusions

This process evaluation unearthed important qualitative data relating to the way coaching calls took place between patient participants and nurses. The analysis of interview transcripts demonstrated that coaching calls were in effect social exchanges between PN and patient participants and these took place within the participants’ social context, which included the continual negotiation of health and illness and other aspects of social life. This social context included the relationship with health professionals, in this case PNs.

This social context includes valuing ‘being normal’ in this case, working, managing family and relationships as well as being responsible and independent. Patients must constantly self-negotiate and self-mediate between the demands placed on them by their health and the need to remain valued members of society in their own eyes. Our study shows how health professionals vary in the connection they make with this complex mediation when supporting patients’ self-management. We identified two broadly different styles of coaching adopted by PNs, which we termed ‘treat to target’ and ‘personalised care’, following Shortus’ work. While the effect of this on outcomes is unclear as yet, it was not an aspect of the coaching that could be identified from the quantitative data collected as part of the larger study. Having been identified, it now becomes possible to include this variable in analysis of outcomes. It may help elucidate how critical counselling styles and social and emotional support are in supporting self-management in the context of patients’ lives. DiMatteo (2004) argues that while the relationship between social support and health is known to impact on health outcomes, its mechanisms are not fully understood. She argues that a research agenda to understand the relationship better would assist in designing programmes.

Implications for clinical practice

Randomised controlled trials of interventions tend to ignore the social context in which those interventions take place. Indeed, the design of RCTs favours isolating interventions from these variables. However, in practice, this does not work and health professionals are part of the broader social context of an individual’s life. Our study suggests that much of the evidence accruing from RCTS provides little assistance to those PNs who must deal with both the multi-morbidity and complexity of a person’s life.

We argue that it is important that health professionals recognise that their relationship with the patient is part of each patient’s unique social context and part of a continually negotiated process, over which the person has ultimate control. Following DiMatteo (2004), we argue that health professionals should be assisted in this endeavour with research to better understand the mechanisms of social context in the way people manage their health. In turn, these research results would contribute to creating effective health professional interventions in the design of all self-management support programmes. From our evaluation, we suggest that one specific area that would benefit from a better understanding of the relationship between social context and self-management support is training programmes for PNs in effective self-management support.

Ancillary