Methods: In the non-randomized Phase 1, student nurses, nurse practitioners, and nurses were trained in an 8-week hybrid online and in-person course on Spanish language health coaching. Content focused on disease understanding and management including motivational interviewing, culturally congruent exemplars and strategies. Student health coaches were evaluated using standard course evaluation and competencies. In Phase 2, a randomized design was utilized to compare the effects of health coaching to usual care on A1C, depression, and anxiety in limited English proficiency Latinx patients with T2D and A1C 7 or higher.
Results:
Phase 1, focused on the health coaches, followed standard educational evaluation metrics such as exams, quizzes, and interpersonal communication competencies with the student nurses. This also included an evaluation of competency using standardized patients. The course was evaluated very highly overall with a mean of 4.78 (SD=.23) on a 5 point Likert-type assessment. The students were positive in their comments noting, “Great interviewing techniques were discussed”; “Friendly instructors helped to be able to make mistakes and still learn”; and the “use of Standardized Patients before actual patients really helped to boost confidence and helped us anticipate what kind of issues we will encounter.” Comments for improvement focused on including “more medical terminology in Spanish” and suggesting “More expansive inclusion of other health issues and age groups.” Virtually all of the student nurses, nurse practitioners, and licensed nurses noted that they were not prepared for the amount of time that was necessary to master the course work and to conduct their coaching.
Additionally, we conducted qualitative evaluations of the experiential components in Honduras and Nogales, AZ. The participants were very positive in their evaluation of the experiential components. One participant wrote, “My experience in Honduras was wonderful. I was very nervous at first, but with each patient I got more confident about my Spanish and knowing what to say” and from a student in Nogales, “I was sad about the poverty I saw all around me, but so encouraged by being able to help and the positive feedback I got from my patients.”
Phase 2, focused on the Latinx participants receiving the health coaching, included satisfaction with the coaching (M= 4.0 (SD=.6) on 5-point Likert-type scale) and meaningful health metrics such as significant differences for the intervention group in A1C from baseline to time 2 and to time 3.
Challenges:
Scientist are taught how to design and conduct research studies. What is not often taught in our PhD programs is how one, at times, must be nimble and creative while maintaining appropriate rigor in analyzing the effects of a study. While we had designed a comprehensive evaluation and statistical analysis in the current study, we were faced with both anticipated and unanticipated challenges.
In Phase 1, changes of the NP curriculum at both schools where we delivered the health coaching training as an elective course left no room to accommodate an additional course, even in the summer months. Thus, there was a very small response rate of 19% and, of those enrolled, there was 32%student dropout, and, finally, of those who completed the course, there was additional dropout of 36% because HCs were unable to complete the complete coaching regimen with Latinx participants. In response to this we recruited licensed nurses and/or NPs already in practice to deliver the coaching, offering the option of obtaining continuing education credits for those who were not enrolled in a nursing program. Particularly effective was the recruitment through the National Hispanic Nurses Association and area community health clinics.
In Phase 2, while anticipated, we needed to cope with Latinx participant attrition due to both HC’s and patient’s competing life demands. This had an impact on intervention fidelity, and will be factored into the statistical analysis of the larger RCT.
Conclusions: Planning for potential challenges and alternate solutions is imperative especially in studies where populations are underserved or where circumstances, such as curricular or program changes, may be out of one’s control. Careful attention to relevant metrics based on the research question/s being asked can add rigor and meaning to findings even when sample size decreases or intervention fidelity is negatively impacted.