Significance and Originality

Diabetes self-management can be increasingly difficult for young people and it is important to provide appropriate programs targeting each patient. Life coaching has been suggested for young adults with type 1 diabetes aimed at enhancing personal empowerment. However, only a few studies have addressed the potential effect of life coaching on health and what facilitates a positive outcome of life coaching, and what could be possible barriers. Therefore, this study provides important new knowledge on how to care for young adults living with type 1 diabetes.

Highlights

• Talking about troubling life issues empowers patients to manage their diabetes.
• The relationship between the patient and the coach influence the coaching process.
• Coaching and communication methods must be adjusted to meet patient preferences.

Introduction

Type 1 diabetes mellitus (T1D) is a chronic disease that often begins in childhood or adolescence [1]. Its successful treatment depends on appropriate choices regarding insulin dosage, food intake, physical activity etc.; choices to be made by the patient many times every day. Despite new insulin analogues and increased use of insulin pumps and glucose sensors, maintaining good glycaemic control remains challenging, especially during adolescence and early adulthood [2].

There is solid evidence that strict diabetes control at a younger age results in a significantly better prognosis for T1D [3]. Therefore, it is important to offer the best possible treatment and care for younger patients. Diabetes distress describes depression-like symptoms specific to the burden of its management, and intervention studies have suggested a positive effect of specially designed programs [4]. However, most young people with diabetes do not suffer from mental diseases caused by their diabetes; rather, their emotional, social, and developmental challenges are related to their transitional life stage [5].

Consequently, diabetes self-management can be increasingly difficult in this age group [6], and it is important to provide appropriate programs targeting each patient. Life coaching has been suggested for young adults with T1D as a supplement to standard diabetes treatment aimed at enhancing well-being and personal empowerment [7]. There are many different coaching methodologies [8], but coaching is generally used to enhance personal development and improve quality of life. Bachkirova et al. defined coaching as a human development process that involves structured, focused interactions and the use of appropriate strategies, tools, and techniques to promote desirable and sustainable changes to benefit the client and potentially other stakeholders [9].

Life coaching is a process of helping people identify and achieve their goals. It has been proven to increase personal insight and sense of self and reinforce changed behaviours [10,11]. Life coaching is a collaborative relationship between the coach and the patient that focuses on the person’s whole life and wellness rather than on the associated pathology [12]. Patients can raise whatever issues they want to address, which means that topics are self-identified and self-prioritized. Moreover, the patients themselves choose the actions and the results they want to achieve [12]. The outcomes of life coaching include cognitive, emotional, and behavioral changes that facilitate improvements in quality of life and well-being [10,13].

Only a few studies have addressed the potential effect of life coaching on health and well-being [14]. Life coaching has been suggested as a method to improve diabetes outcomes, one’s sense of well-being, and personal empowerment [7,15]. However, we know little about what facilitates a positive outcome of life coaching and what could be possible barriers.

Aim

To explore the experience of life coaching in young adults with T1D and poor glycaemic control and discuss the usability of the method.

Design and Methods

For this qualitative study, data were collected through semi-structured interviews and focus group interviews applying the interview methods described by Steiner Kvale (16). The interview data were analysed using meaning condensation [16,17].

Participants and Inclusion

This interview study was part of a larger intervention study including young adults with poorly controlled T1D defined as HbA1c of ≥ 8 % (64 mmol/mol) during a period of at least 12 months (hereafter referred to as patients). The patients were randomized to receive coaching sessions as a supplement to their usual care and treatment or a control group receiving extra telephone contact with their diabetes specialist nurse as a supplement.

The patients included in the present study were part of the intervention group that received coaching sessions. They were chosen to represent patients with different levels of participation in the coaching sessions. Informed consent was obtained from all participants.

Twelve patients were interviewed but due to technical problems, only 11 interviews remained for analysis (five men, six women; aged 20-28 years). In interview studies, the number of participants tends to be approximately 12 as this provides a sufficient base as data material which is generally more important than the number of participants [19]. The three coaches were subsequently invited to participate in a focus group interview.

Coaching Intervention

In addition to the usual hospital visits, the included patients were allocated 12 coaching sessions of 1-1.5 hours each over 18 months. Each patient was assigned a personal coach. The coaching sessions were held during face-to-face meetings or via telephone. Most patients met with the coach at the hospital or in the patients´ homes. A few went for a “walk and talk” and a couple of sessions were performed by phone or Skype.

The coaching aimed to give patients the opportunity to reflect on their lives in terms of their resources and wishes for the future. The coaching intervention began with a “kick-off” day of small groups for all included patients to inform and prepare them for the coaching sessions.

The three participating life coaches were not part of the diabetes team and had non-specialist knowledge of diabetes. If asked about specific advice related to the patient’s diabetes care they referred to the diabetes specialist nurse. The coaches were all certified master coaches from the International Coach Federation using an integrative dynamic and identity-oriented approach [18].

Data Collection

To explore the patients’ experiences with life coaching, we conducted individual interviews with patients and focus group interviews with the life coaches. The focus group interview contributed to knowledge and reflections about the coaching processes. This study was conducted at Lillebaelt Hospital, Hospital of Southwest Jutland, and Regional Hospital in Horsens from February 2015 to December 2017. A semi-structured interview guide with open-ended questions was used to perform the individual and focus group interviews. The interviews were audio-recorded and transcribed verbatim before being deleted.

Data Analysis

Data were analyzed by applying Kvale’s interpretations of Giorgi’s meaning condensation [16,17]. This method implied that the meaning expressed by the participants through the interviews was given a shorter formulation, long statements were summarised, and the meaning expressed in the interviews was formulated in a few words. This process followed the five following steps:

1. Reading through the interview transcripts to become familiar with the data and understand the participants’ experiences;
2. Coding data by searching through the interview transcripts and identifying meaning units;
3. Restatement of the dominating meaning units to ensure that the statements from the participants were as simple as possible and preserved the essence of meaning;
4. Reviewing the identified themes against the study aim; and
5. Develop a descriptive statement by synthesizing the main themes into a descriptive whole.

Consideration of Validity

To ensure transparency, as an important part of validating the qualitative research, a detailed description of the different methodological steps is provided in the Methods section, including the five phases of the analysis [19]. Furthermore, the study findings were evaluated and reflected through validation discussions with the study co-authors to ensure coherence between the interviews and the interpretations [19].

Ethics

The patients received written and oral information about the project and were informed that their participation was voluntary and that they could withdraw consent at any time without any consequences for their treatment. This study was approved by the Danish Data Protection Agency through the Region of Southern Denmark (approval no. 18/11185) and by the Regional Scientific Ethical Committee for Southern Denmark (project ID: S 20140067 GSF).

Results

A total of 12 interviews were conducted: 11 with patients and one as a focus group interview with the life coaches. The findings were divided into four themes: 1) Talking about life to cope with diabetes; 2) Successful coaching processes; 3) Unsuccessful coaching processes; and 4) Coachable or uncoachable.

Theme 1: Talking About Life to Cope with the Disease

Several patients underlined the pleasantness of simply having someone listening to them without questioning. In addition, one of the patients stated, ‘It is mostly talking about this and that, everyday life, what happened yesterday, what happens tomorrow. This was mostly what had an impact on me’ (ID67). Eventually, some endorsed the coaches’ ability to praise the patients’ efforts and accomplishments during the process. The patients chose the topic of conversation. There were two main subject categories: diabetes and patients’ lives in general. As one of the patients put it, ‘We've talked a lot about life, actually’ (ID75). The latter covered everyday life issues, such as job, family, friends, and school, but also more existential matters, including the past, the future, childhood, heartache, and death.

Five of the patients thought of it as positive or even an advantage that the coaches did not have any knowledge about diabetes, while a few felt it was of no importance. However, two patients reported that it was a disadvantage (‘Like having a Danish-teacher teaching maths’ [ID35]). Patients who saw a lack of knowledge as an asset felt that the coaches were unprejudiced and non-judgmental, which ensured a more neutral and listening coach. Moreover, having to explain about diabetes to the coach also gave one patient new insights: ‘Then I had to explain a little about it [diabetes]. And sometimes when you're explaining something, it makes you think: “Well yes, that's the way it is” as if a light was suddenly turned on’ (ID51).

Interestingly, several patients discovered that problems and challenges in their lives affected their routines of measuring blood glucose levels and taking insulin. However, having a chance to talk about these troubling issues and finding tools and methods to handle problematic life concerns empowered them to take responsibility and action regarding measuring their blood glucose levels and taking insulin.

Theme 2: Successful Coaching Processes

Eight of the eleven patients described having a positive coaching experience. They attended between eight and twelve coaching sessions each, and one asked for extra sessions in addition to those scheduled.

The patients who had a successful coaching process described the experience as very positive, surprising, and refreshing, although one stated that, in the beginning, it felt very different and weird. They described the coaching sessions as cosy and very much as a dialogue. Some felt it was enjoyable to work with themselves and dive into their own life situation. One patient even stated that she felt it was like changing to a different person through coaching.

For some patients, attending the sessions felt like being in a free space and they considered the coach a sparring partner, project manager, ‘adult friend’, and support teacher. Several stressed the advantages of an objective external person who saw things from an outsider’s perspective, a person with whom they could talk openly without being judged or contradicted. This generated trust and made them open up to the coach, as one of the patients illustrated by saying: ‘(…) I was thinking, well, then she had reached something where no one has been able to reach before’ (ID73). Furthermore, a few expressed that it was very positive that things being said in the sessions were kept confidential, not passed on to colleagues or members of the diabetes team, and not documented in their medical records. Moreover, the patients experienced the coaches had time, were listening, ‘pushed’ them forward, gave them self-confidence, opened up new possibilities, showed them new pathways, and helped them take responsibility for their own situations.

The patients found the coaching methods both intriguing and very useful. Some went from primarily negative to positive thinking, while others felt it was beneficial to work with their own strengths and weaknesses. A few specifically sought methods and tools for creating structures in their lives and felt that they had been satisfactorily fulfilled. Some emphasized the importance of the coaches’ questions for stimulating self-reflection.

The outcomes of a successful coaching process can be divided into diabetes-related outcomes and personal outcomes although they are closely connected.

In terms of diabetes-related outcomes, some of the patients revealed that, before being coached, they either ignored measuring their blood glucose or only managed it a few times a day. After being coached, they regularly measured their blood glucose levels, which positively affected the blood glucose levels, either stabilising them or even making them decrease for the better. One patient experienced a sudden improvement in the morning glucose levels, but whether this could be attributed to the coaching process was unknown, as she had also changed insulin within the same period of time.

The patients focused more on their diabetes than they had before; they felt they had become more confident about the disease. Some only had to consult their diabetes doctor once a year, and one even stated that the coach had saved his life. One of the patients said that diabetes used to be a dark shadow and still had a negative connotation, but that she recently felt in control of it. This finding corresponds to that of another patient who by the coaching had become aware that he was responsible for the disease himself; previously, he had left this responsibility to his diabetes doctor and nurse.

Focusing on more personal outcomes, the patients stated the following important outcomes of the coaching process: having more confidence, getting better grades in school, feeling more freedom in daily life, being more conscious about the future, becoming attentive to bad excuses, taking action instead of postponing, feeling more in control of everything, wanting to have children, setting goals, becoming responsible, feeling that life was no longer without meaning, experiencing that the future looked different and better, changing from negative to positive thinking, and being conscious of their own strengths and weaknesses. Furthermore, one of the patients stopped smoking, another said, ‘It made me change a lot as a person, I think’ (ID60), and yet another added, ‘I feel it has given me so much. I would not have been without it’ (ID73).

Theme 3: Unsuccessful Coaching Processes

Three patients did not experience a successful process; one attended only one session before withdrawing, one attended four sessions, and the last completed all 12 sessions hoping she would eventually benefit. All three stated that they did not have good personal chemistry with the coach, and that this was unrelated to the age and gender of the coach. They found it difficult to understand the coaching methods, particularly the way the questions were asked, as one patient said: ‘Well, it was too weird. Everything else than what I had imagined’ (ID35). They felt that it was a waste of time for themselves and the coaches. One patient suggested that it might have worked out with a different coach, while another recommended giving the patients more information on coaching methods beforehand, in particular about the more creative and abstract approaches.

From the very first moment, the three patients with unsuccessful processes felt that the coaching methods were strange and far from their own way of thinking. For instance, being asked to identify oneself with animals, balloons, or nuts, or finding colors that represented their emotions was too creative and abstract for them. In addition, the patients described that the exercises they had to perform at home were odd. The outcomes for these patients were very limited, although the patient who completed all 12 sessions experienced improved blood glucose levels; however, whether this could be attributed to the coaching process is unknown.

Coachable or Uncoachable[TG1] 

The definition of successful versus unsuccessful coaching was discussed in the focus group with the coaches, and as one coach explained: ‘The success is not getting them through. The success is when they experience: Wow, now I got what I came for’. This suggests that even though some patients decided to withdraw from the project without attending all 12 sessions, they may still be defined as having had a successful process, whereas others who completed the entire project may be defined as unsuccessful if the outcome did not meet their expectations. The coaches unanimously stated that a successful coaching process is entirely person-dependent as specified below.

Characteristics of patients who experienced successful coaching

The characteristics of the patients who experienced a successful coaching process were also characterised as ‘coachable’ by the coaches and described as: resourceful, willing, and open-minded with an ability to reflect and having the courage to work with themselves. One coach indicated features such as being intelligent and having a certain intellect, while another coach contradicted her somewhat by saying that it was not necessarily a matter of intelligence but instead a matter of being socialised into being responsible, wanting to develop, and being able to set goals.

The patients stated that they first and foremost required an open mind to attend a coaching process along with the willingness to talk, engage in the process, and work with themselves. It required a desire to enter the coaching process and be able to see its aims. Others believed that the ability to self-reflect and have a certain degree of self-understanding and talent for abstraction was needed. A few mentioned personal chemistry between the coach and the patient as prerequisites for a successful coaching process.

Characteristics of those who experienced unsuccessful coaching

The coaches described that the patients with an unsuccessful coaching process had different conditions in life that made them ‘uncoachable’. Some of these patients came from socially burdened backgrounds (e.g. alcohol/drug abuse and parental failure), some lacked maturity and were unable to be self-reflective, and others cancelled or simply did not show up for appointments. A dominant issue was denial and blocking when it came to diabetes. The patients were characterised by not recognising the seriousness of the disease, which was a new experience for the coaches and very different from the clients they normally worked with.

Discussion and Conclusion

Discussion

Our findings indicated that, when patients were offered life coaching sessions, they often chose to talk about important and sometimes troubling life issues. Interestingly, not addressing diabetes directly had a significant impact on the patients’ management of their condition, especially regarding good routines in measuring their blood glucose and taking their insulin.

Other studies exploring the implications of life coaching confirmed that life in general can have a decisive influence on how patients manage their disease [7,20]. Having the opportunity to talk about existential issues and meaningful resources when experiencing illness is a powerful way to support patient well-being [21]. Furthermore, research suggests that patients’ engagement in their own health and disease can be positively influenced by coaching [7].

Nevertheless, an important question raised by the present study is what it takes to be coached and whether life coaching is suitable for all patients. Those with unsuccessful coaching experiences were characterised as uncoachable by the coaches; however, the question is whether everyone has the potential to be coachable. Regarding the literature about the term ‘uncoachable’, the grey literature shows that the term is used by coaches (Google search) and is mostly associated with the skills of the person being coached rather than those of the coach; however, research in the field is lacking. Some of the key effective ‘mechanisms’ of coaching [7] are: 1) letting the young adult set the agenda; 2) using visualisation, 3) giving a voice to the patient’s inner thoughts and feelings; 4) using role models; and 5) encouraging positive thinking. Moreover, being coachable demands motivation and willingness to open up and engage in relationships with the coaches [7,22]. Based on the results of our study, it might be advantageous to explore patients’ self-reflection abilities. Taking the patient’s perspective as a foundation for communication can increase their ability for self-reflection, motivate more changes, and reduce resistance to the coaching process [20,22]. This approach to patient communication is in accordance with patient-centred communication as described by Epstein [23]. Patient-centered communication acknowledges individual patient preferences, needs, and values and ensures that clinical decisions are guided by patient preferences [23]. However, coaching differs from patient-centred communication with a broader view of empowering patients to make positive life changes, with less focus on the disease and clinical decisions [7]. Coaching can contribute to patient communication through a more person-centred approach, which is a wider concept than the patient-centred approach; as it is not restricted to the role of the patient but sees the patient as a whole person with a disease. It concerns both the patient and the provider and enables reflection [24].

As the results illustrate, the impact of coaching is diverse and quite comprehensive for some patients. Those who experienced a successful coaching process had completely different experiences than those who experienced unsuccessful coaching processes. The former were by the coaches characterized as resourceful, willing and open-minded with an ability to reflect. This was very similar to the patients’ experiences, stating that it first and foremost required an open mind to attend a coaching process, willingness to engage in the process, and ability to work with oneself. The dissimilarities between patients who experienced a successful coaching process and those who did not, concur with other research literature on coaching methods describing that a prerequisite for coaching is that the person being coached should request coaching, or at least agree to be coached [25].

Some of the patients mentioned personal chemistry between the coach and the patient as a requirement for a successful coaching process. In this study, we decided that patients could not switch coaches. However, the results may indicate that this would have been an advantage. This is also in accordance with the self-determent theory, which states that, given our nature as social and cultural creatures, our motivational process is influenced by the relationship with the coaches and their approach [22]. Furthermore, a person-centred approach focused on the relationship between healthcare professionals and their patients [24].

Patients experiencing unsuccessful coaching processes mostly described the sessions and coaching methods as not making any sense to them and being difficult to comprehend. Approaches applied in coaching sessions, ex. various visualization methods, are very different from other encounters the patients are faced with in the healthcare system and might, for some patients, demand coaching methods that are adjusted to their ability for self-reflection. We found that if the patients do not feel capable of self-reflection and feel it is a completely different world (other language, strange examples, etc.), then there is a great risk that they are less motivated and may even resist the intervention.

From the coaches’ perspective, patients who reported unsuccessful coaching processes were characterised as immature, unable to self-reflect, and not serious about their disease. Moreover, the coaches stated that successful coaching processes were associated with a focus on the disease and goal-setting. However, the literature on coaching methods underpins that a successful coaching process is more likely if the focus is less on setting goals and more on the person’s whole life and what makes sense to them [11,26]. Hence, these statements from the coaches related to the patients´ experiences indicate that the coaching processes could have benefitted from adjusting the coaching methods more to the individual patients [27,28].

Conclusion

This study presents new knowledge about young adults’ experiences receiving coaching sessions and shows that life coaching can provide patients with new insigths and tools to manage life with diabetes. Accordingly, we suggest that no one is uncoachable. With coaching approaches tailored to individual patients and coaches capable of establishing a confident and trusting relationship, all young people with diabetes may benefit from being coached.

Practice Implications

It is important to adjust the coaching methods and communication to the patients’ preferences and their ability to self-reflect to facilitate a successful coaching experience; therefore, we suggest that future research focus more on methods that are adjusted to reflect patient individuality. Moreover, it may positively influence patient involvement and person-centred healthcare if current communication training incorporates knowledge and learning based on self-reflective practice to a greater extent.

Strengths and Limitations

A limitation of this study is that the data from the patients that experienced an unsuccessful coaching process is based on three patients, only. The results might have been different if an equal number of patients with successful or unsuccessful processes were interviewed. A strength is that both patients and coaches were interviewed, which contributed to a more nuanced view of the term successful coaching.

Consent to Participate

The patients received written and oral information about the project and were informed that their participation was voluntary and that they could withdraw consent at any time without any consequences for their treatment.

Acknowledgments

We thank the patients and the life coaches for participating in our study. This study was funded by the Region of Southern Denmark (11/21462) and Lillebaelt Hospital (28.10.2016). None of the funding sources were involved in the research.

Ethics Approval

This study was approved by the Danish Data Protection Agency through the Region of Southern Denmark (approval no. 18/11185) and by the Regional Scientific Ethical Committee for Southern Denmark (project ID: S 20140067 GSF).

Availability of Data and Material

Data is not available due to the anonymity of the participants

Author Contribution

Trine A. Gregersen: Conceptualization; Formal analysis; Methodology; Roles/Writing - original draft.

Jane Thomsen: Conceptualization; Data curation; Funding acquisition; Investigation; Methodology; Project administration; Writing - review & editing.

Karin Yde Waidtløw: Formal analysis, Writing - review & editing.

Claus Bogh Juhl: Writing - review & editing.

Jette Ammentorp: Conceptualization, Funding acquisition, Supervision, Writing - review & editing.

Poul-Erik Kofoed: Conceptualization; Funding acquisition; Methodology; Supervision; Writing - review & editing.

Connie Timmermann: Methodology; Formal analysis; Roles/Writing - original draft; Writing - review & editing.

Funding

This study was funded by the Region of Southern Denmark (11/21462) and Lillebaelt Hospital (28.10.2016). None of the funding sources were involved in the research.

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