A nurse-led health coaching intervention for stroke survivors and their family caregivers in hospital to home transition care in Chongqing, China: a study protocol for a randomized controlled trial

Stroke contributed to 5.9 million deaths and 102 million severe adult disabilities globally in 2010 [1]. Up to 70% of stroke deaths and 78% of stroke associated disability-adjusted life-years (DALYs) lost occur in low- and middle-income countries (LMICs) including China [1]. In China, health loss is mainly caused by stroke, and the morbidity and mortality rates of stroke show an increase over the past 20 years [2]. It is estimated that there are two million new-onset stroke survivors each year in China, making this the second highest incidence of stroke in the world [3]. Of stroke survivors, 75% lose the ability to work, 40% have severe disability and 25%–33% suffer a second-time stroke [4]. Hospital to home transition is viewed as the most challenging period of time for stroke survivors and their family caregivers to adapt self-care at home while engaging in rehabilitation to gain full potential of functional ability and social integration [3, 5, 6]. However, transition care services are largely underdeveloped in most LMICs including China [7, 8]. About 80% of stroke survivors have to discharge to home for later physical and functional rehabilitation due to deficient rehabilitation centers and nursing homes in China [9‐11]. Family caregivers play a crucial role in assisting stroke survivors in self-care and rehabilitation during hospital to home transition [12, 13]. However, they usually received little preparation for their caregivers’ role. It is reported that a lack of support for caregivers is associated with physical and psychological stress, caregiving burden and a low level of quality of life [13‐16]. Transition care interventions therefore need to consider support for caregivers. This study addresses a gap in research by implementing and evaluating an evidence-based health coaching intervention for stroke survivors and their family caregivers in hospital to home transition in Chongqing, China.

Maladaptation of stroke survivors to self-care at home after hospital discharge is associated with complications, adverse events, high readmission rates to hospital, delayed recovery, psychological and emotional stress, social isolation and a low level of quality of life [5, 6]. Therefore, hospital to home transition care for this patient population has become a priority care area to optimize care outcomes and relieve burdens on the healthcare system [17]. Health coaching is an effective strategy to enhance transition care for stroke survivors and their caregivers. In this study, we adapt the definition of health coaching by Wolever and colleagues described as “a patient-centered approach wherein patients at least partially determine their goals, use self-discovery or active learning processes together with content education to work toward their goals, and self-monitor behaviors to increase accountability, all within the context of an interpersonal relationship with a coach” [18]. Although considerable evidence supports the effectiveness of health coaching on quality of life and activities of daily living in other chronic diseases [19‐23], findings from the mentioned studies indicate that the effect on stroke survivor’s health outcomes varies.

The aim of this study is to determine the effectiveness of nurse-led health coaching for stroke survivors and primary caregivers in hospital to home transition care in Chongqing, China. We hypothesis that stroke survivors in the health coaching intervention group will demonstrate better health outcomes at 12 weeks from the baseline compared to the usual care group.

Self-efficacy theory, a component of social cognitive theory developed by Bandura, focuses on the interrelationships among four concepts that determine a person’s self-efficacy: (1) self-efficacy expectations, (2) behavior, (3) outcome expectations and (4) outcome [44]. Self-efficacy is activated by goal setting through which a person is motivated to take actions (or change behaviors) to achieve their goal. Motivation includes intrinsic motivation (or self-motivation) and extrinsic motivation (being motivated by others, for example, a health coach or a role model). We have adapted self-efficacy theory to health coaching as illustrated in Fig. 3. In our study, stroke survivors and their caregivers will engage in individualized stroke education facilitated by a health coach prior to discharge. This education will equip them with knowledge about health consequences during the hospital to home care transition. A health coach will also work with them to set realistic goals for transition care (activate self-efficacy) and motivate them to achieve their goals (motivated by others). Transitional care goals will be individualized and include aspects of (1) self-care skills, (2) the functional recovery plan (provided by the patient’s medical specialist), (3) medication adherence, (4) maintaining a safe home environment, and (5) prevention of secondary stroke, complications and adverse events.

Health coaching is informed by self-efficacy theory which is widely applied to behavior changes for improved self-management of chronic conditions [44]. Together, the definition and the theory base of health coaching suggest that health coaching interventions should incorporate behavior change techniques to engage participants in the processes of behavior change [45] (Additional file 3). The CALO-RE taxonomy developed by Michie et al. [46], which standardizes behavior change techniques to improve self-efficacy in chronic disease management, is applied to health coaching interventions [45]. The CALO-RE taxonomy targets two areas of behavioral change: (i) barriers to behavior change (or behavior variables), for example, behavioral change goal-setting and motivation to engage in change processes; and (ii) barriers to achieving health outcomes (or outcome variables) including physical and psychosocial well-being outcomes [44, 46].

This study supports the health initiative in China focusing on the prevention and management of stroke. The National Health and Wellness Committee launched this initiative in 2009 and strengthened the stroke comprehensive prevention program in 2016 [47, 48]. These health initiatives aim to reduce the burden on patients, family members, medical resources and society. However, hospital to home transition care was not a focus. Gaps in supporting self-care, rehabilitation, prevention of secondary stroke and reducing caregiver burden still exist in the healthcare system of China compared to high-income countries [48]. It is anticipated that findings from this intervention study will provide research evidence to inform policy initiatives in the care of stroke survivors in hospital to home transition.

It has been argued that the relationship between the health coach and the program participant is crucial to ensure positive health outcomes [18, 49, 50]. Core competencies to help health coaches build support are (1) facilitating participant-centered health coaching activities; (2) helping participants to identify their own goals for change; (3) enabling participant self-discovery of processes to improve self-management; (4) understanding how to help participants be accountable to themselves and self-monitor; (5) knowing how to help participants adapt to the processes of behavior change; and (6) demonstrating interpersonal skills to integrate content information into the change process [18]. We have considered these competencies and embedded them into the workshop training for intervention nurses. Role plays during the training for intervention nurses will also provide opportunities to solve problems in building relationships with participants.

Goal setting in health coaching needs to be individualized, and the goal needs to be achievable for participants [51]. In hospital to home transition care, stroke survivors may experience changes on a weekly basis. Therefore, timely adjustment of transition care goals is imperative. Weekly telephone support, bi-weekly assessments and needs-based phone contact in the post discharge follow-up will enable intervention nurses to work with participants to adjust their care goals when needed.

Physical exercise training for stroke survivors is critical to enable them to optimize poststroke recovery, functional ability and well-being [52, 53]. Moreover, physical exercise typically demands the integration of strength, dosage and duration of repetitive practice according to the patient’s conditions [54]. Although an individualized physical functional recovery and exercise plan will be provided by the medical specialist, in this study intervention nurses will play a key role in motivating stroke survivors to adhere to the plan and encouraging them to provide feedback to their medical specialists to alter the plan when needed.

Fidelity of implementation is an important factor in the intervention’s effectiveness [55]. There is little consensus about key factors affecting intervention fidelity. However, the domains of fidelity, such as study design, training and intervention delivery, have been considered and will be addressed through the following strategies [56]. First, the researchers in this study have adapted the health coaching definition, self-efficacy theory and CALO-RE taxonomy that standardizes health coaching intervention design and behavior change techniques [45, 46]. Second, the training of intervention nurses to standardize health coaching interventions will improve adherence to the intervention protocol. Third, intervention nurses will encourage stroke survivors to record self-care in their health coaching diary to self-monitor processes to achieve set goals. In addition, open-ended questions will be provided at the end of the trial to analyze factors that may affect intervention fidelity.

The protocol has some limitations. First, although all outcomes will be recorded by an independent researcher to minimize the risk of bias, participant dyads and health coaches cannot be blinded due to the nature of the intervention. Second, successful behavior modification is a sustainable long-term process. However, the duration of the intervention and follow-up in this study are 12 and 24 weeks respectively. Therefore, the long-term effectiveness of health coaching in stroke rehabilitation needs to be further explored. In addition, future studies need to consider the measures of cardiovascular events as part of study outcomes when it is appropriate.

T#he Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12619000321145, registered on 1st March 2019.