From business to caring: the conceptualisation of holistic coaching for cancer patients

Abstract

Coaching in healthcare is a growing topic within research and practise but there has been little exploration of its theoretical underpinnings for cancer patients. This review covers current health coaching research, illness identity, and communication processes to highlight how coaching holistically (placing emphasis on values and narrative over behavioural models) is appropriate for cancer patients facing uncertainty and changes in their life. A conceptual framework for Holistic Coaching in Cancer and a set of coaching values are provided as a theoretical underpinning for coaching this population. Future research directions are also discussed.

Keywords

coaching cancer identity review well-being

Introduction

Coaching is a one‐on‐one learning or change process between a hired coach and an individual through systematic interpersonal interactions and behavioural techniques (Grant, 2014; Sperry, 2008). It has been predominantly applied in organisational and management settings. The research and practice of coaching are mainly influenced by theoretical domains, such as adult learning (Cox, 2015), managerial studies (Lawrence, 2017) and psychology (Grant, 2017), due to their broad application. These include business and management (Passmore & Fillery-Travis, 2011) and healthcare settings (Olsen, 2010). This paper primarily focuses on healthcare coaching, given there are gaps concerning the theoretical underpinnings for coaching as a therapeutic support for individuals facing and managing cancer. This scoping review highlights how coaching can support cancer patients as they manage the unique challenges and transitions arising from cancer as an illness.

Health coaching has been defined in multiple ways. An early definition by Palmer and his colleagues (2003) suggested that health coaching is “the practice of health education and health promotion within a coaching context, to enhance the wellbeing of individuals and to facilitate the achievement of their health-related goals” (Palmer et al., 2003 p. 92). In addition, Olsen’s conceptual analysis (2014) emphasised a client-centred partnership, which seeks to empower and enlighten the client on a behavioural change journey to achieve health and wellness goals (Table 1 in Appendix). Moreover, Wolever et al. (2016) and Jordan et al. (2015) explored key skills and attributes of coaches working in health coaching domains, such as a client centred approach, value led, and empowerment.

With the considerable expansion of coaching in the healthcare setting, contemporary research evidence (e.g., Singh et al., 2022) has found that coaching approaches improve patients with chronic illness behaviours, including Chronic Heart Disease (Kivelä et al., 2014), Chronic Obstructive Pulmonary disease (Long et al., 2019), and Diabetes (Lin et al., 2021). However, the application of coaching to support cancer patients is less explored and underrepresented in health coaching research (Sforzo et al., 2019).

Cancer has a substantial impact on modern populations with an estimated four million people expected to be living with or beyond cancer by 2030 (Maddams et al., 2012). Supporting these patients is a critical objective of health organisations such as the National Health Service (NHS) in the UK. The NHS has detailed person-centred care as a priority (NHS Long Term Plan, 2019) and promotes interventions for supporting cancer patients regarding their self-management, health improvements and learning priorities for recovery, coping and skills development (NHS Cancer Forward View, 2014). Chronic illnesses such as cancer, can have a profound impact on an individual’s life. This can include a loss of sense of self and meaning (Martin, 2016; Murray, 2000), heightened anxiety and psychological distress (Montgomery & McCrone, 2010), and work and employment issues (Paul et al., 2016). Coaching can be viewed as a holistic care approach that explores an individual’s underpinning values, motivations and strengths to facilitate positive behavioural and attitude changes (Lai & Palmer, 2019; Passmore & Fillery-Travis, 2011; Whitmore, 1992). In line with this, within cancer care, coaching could be used to support cancer patients’ emotional responses, understanding and awareness, when living with and beyond cancer.

This paper, therefore, proposes the concept and value of health coaching within cancer care settings. To achieve this, existing literature regarding health coaching and support for cancer patients is scrutinised to explain how coaching can work holistically and facilitate patients’ illness identity transitions, and their ability to stay present and/or forward-looking. A conceptual framework is outlined as a preliminary guideline for the future of coaching research and practice within this particular healthcare context.

The scoping review process

A scoping review was undertaken to capture and integrate relevant literature for a better understanding of health coaching and cancer support. Only research and papers published since 2010 were included. This is because of a rapid rise in publications, which saw 150 to 200 between 2003-2010 and a similar amount within the next two years between 2010-2012 (Wolever et al., 2013). After the initial review, a set of iterative searches took place to expand the collected knowledge on illness identity, communication interaction with identity, and living with cancer. Participant groups from the reviewed papers were adult populations (over 18 years old). The scope of the review was on cancer patients as coaching clients only, to explore the role of coaching as a transitional experience when living with cancer. While the focus of this review is patients themselves, it is noted that coaching has been used to support their caregivers and loved ones in a few publications (e.g., Smith et al., 2022). However, the coaching approaches used in these papers drew upon an ‘instructional style’. When reviewing cancer focused papers, participants had a range of cancer diagnoses (e.g. prostate and breast), as illustrated by Barakat and colleagues' (2018) review which demonstrated improved quality of life in cancer patients. The coaching research reviewed predominantly used healthcare professionals, such as nurses, to facilitate the coaching following some training (Butterworth et al., 2007; Dermody, 2021).

This review explored gaps in current health coaching knowledge and central theories which define coaching in healthcare settings. It was primarily constructed through examining 16 meta-analyses or systematic reviews. The primary gap was identified as a lack of clarity around the role, approach, and theoretical underpinning of coaches working within healthcare settings (Hill et al., 2015). In addition, cancer patients were an underrepresented coached group in contemporary literature. The majority of health coaching research has explored illnesses that traditionally engage with more overtly defined goals, such as heart disease and diabetes. With these gaps identified, the review moved on to exploring the lived experiences of cancer patients and the transitional period they face at this time.

Coaching as a discipline can provide a space to explore self and values (Stelter, 2014), and has been suggested as an important topic for future direction within coaching research and practice (Diller, 2021a: 2021b). As such, transitions through cancer were explored to see how coaching might support cancer patients as they renegotiate self, identity, and life. Questions can be raised about current and future desires, as well as how to manage life while going through treatment, treatment effects, and impacts on relationships (Currin-McCulloch et al., 2021; Park et al., 2009). Thus, the impact of cancer on people's lives was explored in conjunction with how illness and identity are linked. When connected, these factors highlight the potential of coaching as a holistic intervention support. For example, the two-way communicative process in coaching (e.g., coach and client relationship) allows space for the renegotiation of self by allowing for client self-discovery, un-picking of meaning and understanding, and implementation of new skills to create change. All of which are central to the client's new sense of self.

Findings

1. Health coaching makes positive impacts on patients’ life and behavioural change

Coaching has been developed to support clients who are patients with health and wellness-related goals or growth transitions. At its foundation, health coaching follows some of the core themes of executive or business coaching. In this respect, coaching relationships are characterised by a one-to-one relationship; seek to raise awareness; improve performance; and enact client behavioural change (Passmore & Fillery-Travis, 2011). Scholars have suggested four core pillars to define health coaching (Lawson, 2013), whereby a person-centred relationship that fosters trust between coach and client helps raise awareness, increases client accountability, links behaviour and purpose (e.g., values), and works toward a meaningful goal.

Sforzo et al. (2019) set out a compendium for health coaching, detailing the implementation of coaching to support health performance as a core outcome when researching health coaching interventions. This is a mirror for Grant’s (2017) conceptualisation of coaching shifts within managerial coaching. This is, for example, where coaching starts with a directed goal for the client, moves to self-discovery and a client-directed goal, and then to more narrative and exploratory coaching. This focus on health coaching research has identified improvements in health performance (Ammentorp et al., 2013; Singh et al., 2019), such as showing coaching effectiveness on patient medication adherence, illness perceptions, and psychosocial measures (Hill et al., 2015). Multiple meta-analyses of health coaching interventions also demonstrate a positive influence of coaching on patient outcomes (Dejonghea et al., 2017: Kivelä et al., 2014: Pirbaglou et al., 2018). Beyond health performance, coaching has been found to increase quality of life, self-control and self-efficacy, and reduce stress (Carmona-Terés et al., 2017). Sullivan et al., (2019) found coaching to decrease anxiety levels and foster self-management among patients with Type-2 Diabetes. Wang et al. (2018) explored the experiential learning of patients with Chronic Obstructive Pulmonary Disease. Patients noted they gained insights about themselves and their illness, which allowed them to take action and enact positive changes in their lives. The evidence for coaching in healthcare settings has shown how coaching has been utilised as a support intervention for patient health and wellness.

2. A mixed picture of existing research evidence in health coaching

However, the picture is not clear-cut, as evidence for the effect of coaching within healthcare is mixed (Wolever et al., 2013; Oliveira et al., 2017). This reflects methodological issues, evaluation strategies, and lack of clarity of coaching approaches utilised. For example, Blackberry et al. (2013) disclosed that the health outcomes of the coaching group were similar to those of the non-coached group when compared with usual care for patients with type 2 diabetes. They demonstrated that coaching is no more effective than regular primary care. Long et al. (2019) highlighted little long-term effects of coaching for patients with Chronic Obstructive Pulmonary disease. A potential factor in these mixed findings is the lack of clarity concerning the coach's role, behaviours, and theoretical underpinnings (Holden et al., 2014). There is also confusion around the processes, strategies, and behaviours of coaches in health coaching, as well as the role of the coach as a guide, and/or facilitator, and/or educator (Butterworth et al., 2007; Wolever & Eisenberg, 2011). Dejonghea et al. (2017) highlighted that there are varied theoretical concepts underpinning health coaching interventions, whereby each study's intervention is governed by a different theory/approach, or none at all. As such, there is a need to explore the fundamental underpinning of coaching within healthcare settings, and in terms of cancer care, provide a framework for coaches to work safely and effectively with these patients.

To address these gaps, a comprehensive framework that brings together and addresses the specific challenges of living with an illness and coaching in these healthcare settings is needed.

3. Practice of cancer care coaching is ahead of research

Given that there are around 385,000 new cancer diagnoses each year (2017-2019), and this is expected to increase by 2/ between 2023-2025 (Cancer Research UK, 2023), it is not surprising that many cancer charities offer psychological support services to their patients. Some like the Fountain Centre (FC) based in the Royal Surrey Hospital in the UK, provides a coaching service as part of their psychological support interventions. The coaching they deliver offers features relevant for individuals who experience transitions due to cancer, as well as anxieties, uncertainties, and emotions that can arise from a cancer diagnosis (Jackson & Parsons, 2016).

Whilst practitioners’ expertise (for example at the Fountain Centre), has set up a tone for coaching cancer patients, there is still a need to conduct a critical and rigorous empirical study for the development of evidence-based coaching in this setting (Briner et al., 2009). In order to address this and establish a theoretical underpinning for coaching cancer patients, an exploration of how coaching interacts with identity, communication and cancer, is needed.

4. The theoretical interactions between coaching and cancer patients’ identity transition

Coaching has been viewed as a way to support transitions. In line with this, the coaching profession has moved toward a more narrative and explorative process to help clients explore what is important to them, why this is important, and how clients align their values with actions and goals (Grant, 2017; Stelter, 2014). Coaching in a narrative (e.g., non-directive, values and learning focussed manner), is critical to those facing transitional periods such as new managers learning to move into a new work role and identity (Yip et al., 2020). During the transition, new leaders are attempting to renegotiate their identity at work and can face increased levels of uncertainty and anxiety (Nicholson & Carrol, 2013). For new leaders, coaching provides an explorative space to examine identity anxieties and uncertainties (e.g., loss of old and fear of new identities). In such situations, the coach creates a space for the emotions, values, and meaning in the client’s narrative to be explored and discovered (Sbarra & Hazan, 2008; Stelter, 2014). Interventions which explore narrative and communication, like coaching, allow for the discoveries, re-negotiation, and re-ordering (Townsend et al., 2006) of identities through narrative exploration of language, values, and norms. This in turn informs the client's behavioural responses. Similarly, following a chronic illness diagnosis, patients often experience an identity transition as they comprehend the personal (e.g. personal knowledge or experiences) and social meanings (e.g. cultural understandings) of the illness, its impact on present life and lifestyle, and its impact on future desires and aspirations (Asbring, 2001).

For such transitions, it’s important to consider the timescale of coaching for clinical populations. Existing literature lacks evidence regarding the best timing for patients to enter coaching, such as at diagnosis, during treatment, or after treatment. Reviews have shown coaching across different timescales. Nevertheless, there has been research exploring coaching as a support for patients with advanced cancer and end of life discussions (Rodenbach et al., 2017). Therefore, coaching in a holistic manner could be appropriate across the patient's journey, especially when managing the changes in their life or facing the end of life. Cancer is often a life-shattering event, that brings personal changes in identity due to loss of the previous self (Hannum et al., 2016; Hannum & Rubinstein, 2016). For example, a person who strongly identifies with their work for their value will struggle if they have to take time off for cancer treatment. As such, there can be a need for re-negotiation of existing identities and the new illness identity (Leventhal, et al., 1999). The explorative space provided by coaching can enable cancer patients to examine their values, meaning, and identities while moving through cancer. Thus, coaching in a healthcare setting needs to consider the broader influence of illness on the individual, as identity and illness directly impact the psychological and physical functioning of patients (Oris et al., 2016; 2018).

The next section discusses the review’s findings on the links between illness and identity, to highlight the influence of identity on a patient’s functioning and providing a context for coaching with cancer patients.

5. Chronic illness has significant impacts on patients’ identity

Fundamentally, identities are the norms, values, meanings, and attitudes which make up a person's sense of themselves, their perceptions of others, and the world around them (Erikson,1968; Tajfel & Turner, 1979, 2004; Ybema, 2020). Identities help people understand what to do, what they value, and how to behave in situations which are not static, but are fluid self-perceptions rooted in the past (what was once true of oneself), the present (what is true of oneself now) or the future (desire to become, obliged to become, or fear to become). Commonly, the flexibility and malleability of identity is shaped by a person exerting effort into constructing their own identities (Sveningsson & Alvesson, 2003). Individuals seek out, engage with, and perform activities which form, repair, and strengthen the norms and values associated with their identity, to create a coherent sense of self. However, not all identities are driven by personal values or future desires. Identities may be ascribed or collide with existing ones (Leventhal et al., 1999), such as a new leader being promoted in quick succession. In this way, the individual personal experiences of interacting with others and the social cultural understanding, are used as a reference for this new situation (Ybema, 2020). When faced with a cancer diagnosis, patients have a pre-existing language of cancer, which is commonly associated with language of loss, bereavement and grief, for the patient and their family (Madsen et al., 2023). This language is created through the common perceptions of the illness as cultural knowledge of what is healthy and what is unhealthy (Haslam et al., 2009). As such, when faced with a cancer diagnosis, patients incorporate the common language about the illness and form connections between the language and their expectations of the illness as they manage this.

The incorporation of a chronic illness like cancer, is noted as being undertaken in an adaptive or maladaptive manner (Oris et al., 2016; 2018). Maladaptive incorporations of illness are those which are undertaken detrimentally, either via the patient being engulfed by or rejecting, the illness. For instance, a patient who has rejected their illness excludes the illness from their sense of self, as it is seen as a threat or unacceptable part of the self (Luyckx et al.2015). A patient may ignore, divert thinking about, and/or conceal their illness (Tilden et al., 2005). Illness concealment is a cognitively tasking operation requiring significant effort to hide symptoms, treatment sessions, and maintain a non-illness self-image (Sedlovskaya et al. 2013). Furthermore, the effort to conceal illness-related identities erodes one's sense of belonging and social engagement (Lattanner & Richman, 2017). Alternatively, a patient with an engulfment illness identity is overwhelmed by the illness as it encroaches on all aspects of life, creating a negation of other aspects of the self (Morea et al., 2008). This singular focus overwhelms individuals, positively linking to increased depressive and anxiety symptoms (Oris et al., 2018). Both engulfment and rejection of one’s illness are maladaptive incorporations of illness. Patients with these identities can often experience increased depression, comorbidity risk, and decreased hope (Ai et al., 2010), and also be negatively influenced by their physical and psychological functioning (Oris et al., 2018; Van Bulk et al., 2018). The renegotiation space afforded in coaching may create an environment for the exploration of self and illness, potentially supporting these patients’ transitions and management associated with cancer.

Comparatively, when illness identity has been incorporated in a coherent and positive manner, the patient is adaptive and is characterised by acceptance or enrichment (Oris et al., 2016). An acceptance illness identity reflects successful incorporation of illness into the patient’s sense of self, without becoming overbearing, and the illness is balanced with existing identities (Helgeson et al., 2006). Acceptance of illness has been linked to positive functioning (e.g., quality of life, physical, and psychological), as an illness is not in conflict with other aspects of the patient's sense of self (Luyckx et al., 2015; 2018). Furthermore, illness may lead to the enrichment of the self (Oris et al., 2016), as patients make positive adjustments in their lives (Mols et al., 2005). In line with this, between 60-90/ of cancer patients have indicated positive changes post-diagnosis (Sawyer et al., 2010). In this respect, the negative consequences of a life-changing event, such as a chronic illness, are seen to be alleviated through positive psychological changes in life direction, interpersonal relationships, and sense of self (Hauken et al., 2019), as well as the development of new skills (Senol-Durak, 2014; Tedeschi & Calhoun, 2004). When illness is incorporated adaptively, patients have a more cohesive identity which can lead to positive physical and psychological functioning, and/or patient enrichment and post-traumatic growth. The coaching space offers patients the time to explore their narratives, values and emotions, which may help to develop acceptance and enriched illness identities.

This section has highlighted how illness and identity are connected and influence patient outcomes. The following section discusses how coaching can support the transitions and adaptive incorporation of illness into a cancer patient's sense of self.

6. The importance of communication and identity in coaching

A central mechanism underpinning illness identity and coaching is communication. Communication and language are critical to identity as a two-way reciprocal process: (1) an individual's ability to share their identities, values, and emotions; and (2) an individual’s ability to understand the identities, values and emotions of others during interactions (Hecht & Choi, 2012). Communication allows for the exploration of identity performance. This is a key component in identity formation, maintenance and change (Jung & Hetch, 2004), through sharing and comprehending communication signals to derive an understanding of ourselves and others. The communication we use is filled with meaning and understanding (Giles & Ogay, 2007). For instance, cancer is commonly associated with the “Big C”, a euphemism for cancer which is filled with meanings of uncertainty, loss, and negative change (Appleton & Flynn, 2014). The term is used to lessen the emotional toll of the disease (Lanceley & Clark, 2013). Similarly in coaching, communication is at the forefront of the coach-client relationship, as the coach engages the client to share their narrative, self-discovery, self-evaluation, search for awareness and set actions (Stelter, 2014). More importantly, coaching provides the arena for the client's language to be unpicked, explored and analysed, to help raise their understanding and awareness (Rees & Manea, 2016). As such, more narrative and experiential styles of coaching (Stelter, 2014) provide an inspection of language and meaning which directly influences the formation, repair, and maintenance of identity.

The unpicking of language is established in therapeutic studies through the conceptualisation of Acceptance and Commitment Therapy – ACT (Hayes, 2004). In a therapeutic context, ACT has been utilised to help individuals expand their psychological flexibility by becoming more emotionally open, aware of self-talk, adaptive with thoughts and feelings to healthier psychological functioning, and aligned to a sense of self, values, and identities (Hayes, 2004; 2015). By unpicking the connections between language and meaning, a client can become more aware of their thoughts and emotions surrounding the language and learnt associations (Hayes, 2015). For example, a newly diagnosed cancer patient may have a learned association that the cancer is related to a horrible experience with the illness, expectations of immense physical strain, and the resulting need to leave employment. In healthcare, the unpicking of language and accepting the connections rather than modifying them (Hayes, 2015), has been shown to increase psychological flexibility - a predictor of positive changes in quality of life (Feros et al.2011). As such, the coaching process of unpicking language through the coaching conversation mirrors the cognitive process presented in ACT. Indeed, acceptance of the meaning is a parallel for the acceptance of illness identity and identity cohesion. The unpicking is not to reform the language, but to develop awareness and understanding of the connection in order to develop acceptance and compassion for the client's self. In this way, coaching cancer patients with an emphasis on the narrative and experiential values of coaching may be directly unpicking language associations and supporting illness identity incorporation, as the patient becomes more accepting of the illness concerning their sense of self.

The conceptual framework for Holistic Coaching in Cancer

This section collates the information currently reviewed and provides a new conceptual framework, defined as Holistic Coaching in Cancer. This builds on the work of Jackson and Parsons (2016), who initially explored the type of coaching service delivered at the Fountain Centre.

The Holistic Coaching in Cancer framework outlines how coaching can unpick language and meaning to support a patient's transformational learning. As shown in Figure 1, the coach and patient enter coaching by facilitating patients to disclose their anxieties, uncertainties, emotions, values, and norms.

Through two-way communication, the Holistic Coaching process offers patients a space to explore, self-discover, and renegotiate their sense of self following the disruption caused by living with or beyond cancer. Meanwhile, the patient is able to create a learning loop outside of coaching conversations by testing out and adjusting their new concepts of self in the real world, and reviewing their learning with the coach in the following session. The coaching dyad could agree on their timeline to exit coaching when the patient is confident with their new sense of self.

Figure 1
Overview of the Holistic Coaching in Cancer Framework

Table 2 outlines each of the stages within the conceptual framework for Holistic Coaching in Cancer.

Table 2
Overview of the Holistic Coaching in cancer Conceptual Framework

Stages of Holistic Coaching in Cancer Description

Entering Coaching The coach facilitates a therapeutic space for patients to disclose their anxieties, uncertainties, emotions, values, and norms.

During Coaching Session Share - Externalisation of Identity. The coach empowers patient self-discovery through an empathic, compassionate, and client-centred holistic coaching conversation with patients about their lives. The coach allows the client to share their present thoughts, emotions, uncertainties, and anxieties

Explore - Identity Work. The coach uses tools, techniques, questions, and language exploration to unpick the patient’s language through exploring meaning and understanding. The focus is on the narrative in the present to raise patients’ present awareness of where they are now and where they want to be in their future.

Change - Identity Modification. The coach unpicks the patient's language and meaning through clarifying questions and exploration of what is being said, how it’s being said, and why it's being said. The client's new awareness and clarity creates a sense of cohesion between the present situation and what is important to the client and their future desires and learning opportunities.

Implement Internalising New Identity. The coach and patient develop strategies to embed the new learning and values into the patient's life. The actions are then taken back into the next coaching session for monitoring and feedback.

Outside of Coaching Session Testing the New Identity. The implementation of the new aspect learnt through the coaching conversation and strategies are tested in the patient's outside world, and then feedback is collected and taken back into the next coaching session or for self-management and self-reflection after finishing the coaching relationship.

Leaving Coaching The patient has explored their values and identities and developed new learning about who they are and how they want to be, which has adjusted their sense of identity and self.

Unlike traditional coaching models, this conceptual framework highlights the values of a holistic and emotionally connected coaching process. By working in a holistic way, coaches can support patients’ renegotiation of their sense of self and learning about themselves. To underpin the conceptual framework for identity change in therapeutic coaching, a set of underpinning values is critical, and these are listed in Table 3.

Table 3
Holistic Coaching in Cancer Underpinning Values

Aspects Values

The Holistic Coaching Process
A non-directive process that is rooted in narrative exploration and experiential coaching.

Undertaken in an environment which creates trust, safety, and empathy, designed to be a space for the client to share their narrative.

The focus is on the client's shared narrative, allowing the client to share their present focused uncertainties, anxieties, vulnerabilities, emotions, and understandings of their reality.

The focus of the coaching process is transitional learning rather than the completion of a goal (unless the client works in that way).

Holistic Coaches in Cancer
Value the client's learning and cares for their transitions during a period of change and discomfort.

Has the ability, values, and comfort to work in a space which is characterised by the client's present anxieties, uncertainty, values, and emotions.

Has acknowledged the challenges facing cancer patients and has engaged in learning about cancer's impact, living with cancer, and cancer awareness.

Has awareness of themselves as a coach to be able to regulate and manage their emotions and thoughts during sessions.

Is committed to and values their own development and safety by active engagement with supervision.

Cancer Patients as Coaching Clients
A sense of present anxiety and uncertainty about living with or beyond cancer.

A sense of psychological functioning, e.g., not a heightened sense of distress or negative functioning. The patient is not wanting to delve into their past traumas or negative thoughts or wanting advice/support for managing a mental health diagnosis.

A sense that there is something missing or lacking in their current life and the gap in identity or sense of self. For example, wanting to reengage with hobbies or work.

A sense that they need support to manage their illness, e.g., becoming more confident in attending medical appointments.

Review limitations, future directions, and conclusion

Whereas this review offers a glimpse of existing publications in health-related coaching and chronical illness patients’ identity transformation, it is restricted to the exploration of narratives in contemporary literature instead of the examination of research evidence. This is due to limited empirical studies in relevant areas. Hence, this Holistic Coaching in Cancer framework is grounded in theoretical interactions of extant literature discussions. However, it is recognised that relevant and rigorous empirical studies are needed to establish an evidence-based foundation.

Indeed, this paper has expanded on existing coaching to help form a conceptual framework for coaching cancer patients. By moving toward a Holistic Coaching in Cancer framework, coaches may support transitional learning when patients are managing and living with or beyond cancer. In developing this conceptual framework, large gaps were identified in the theoretical underpinning for coaching in healthcare, coaching for cancer patients, and coaching interaction with identity transitions. As a theoretical foundation, the Holistic Coaching in Cancer framework can help coaches and healthcare organisations implement coaching as a support intervention for cancer patients. The main purpose for the conceptual framework is for it to be used to inform coaching interventions and move coaching in healthcare to a more narrative and experiential process, that moves beyond health goal interventions. Additionally, this paper serves as a call for more research into the holistic forms of coaching within clinical populations, and to further develop the process of evidence-based coaching within healthcare. From a coach’s perspective, there is a need to further explore the approaches and behaviours of coaches working holistically with cancer patients as coaching clients. From a client perspective, exploring the experiences of cancer patients who have attended holistic coaching as a support intervention, would illuminate the impact of coaching on patients' transitions in self and the management of their illness.

Future research should focus on qualitative explorations to better understand the ways in which coaches work holistically and capture patient transitional learning and identity shifts. Potentially, this could involve exploring the approaches and behaviours of coaches working holistically with cancer patients, to define the role and competencies of Holistic Coaching in Cancer. Research that garners in-depth accounts of patients' experiences of the coaching process as a form of support when living with or beyond cancer, could explore potential transitions, new learnings, and psychological changes that can occur through a Holistic Coaching in Cancer approach.

Footnotes

Appendix

Table 1
Summary of Health Coaching as a Concept, adapted from Olsen (2014)

Initiating Factors for coaching Themes of the coaching process Outcomes from coaching

Client with a health-related problem, e.g., increasing physical activity to combat obesity. The goal is health and wellness focussed and the coaching is orientated around the goals. Achievement of health and wellness goals

Client wanting to enhance their health and wellbeing, e.g., management of stress/improving mood The coaching is client-centred and a partnership. Health-related behavioural change,

A coach with the desire and training to support in a health and wellness setting. An adaptable intervention centred on the client's needs, e.g., not a stagnant process. Improvements in physical and mental health outcomes.

An empowering and enlightening process, e.g., education, transformational learning, self-awareness, and self-understanding,

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Stages of Holistic Coaching in Cancer	Description
Entering Coaching	The coach facilitates a therapeutic space for patients to disclose their anxieties, uncertainties, emotions, values, and norms.
During Coaching Session	Share - Externalisation of Identity. The coach empowers patient self-discovery through an empathic, compassionate, and client-centred holistic coaching conversation with patients about their lives. The coach allows the client to share their present thoughts, emotions, uncertainties, and anxieties
	Explore - Identity Work. The coach uses tools, techniques, questions, and language exploration to unpick the patient’s language through exploring meaning and understanding. The focus is on the narrative in the present to raise patients’ present awareness of where they are now and where they want to be in their future.
	Change - Identity Modification. The coach unpicks the patient's language and meaning through clarifying questions and exploration of what is being said, how it’s being said, and why it's being said. The client's new awareness and clarity creates a sense of cohesion between the present situation and what is important to the client and their future desires and learning opportunities.
	Implement Internalising New Identity. The coach and patient develop strategies to embed the new learning and values into the patient's life. The actions are then taken back into the next coaching session for monitoring and feedback.
Outside of Coaching Session	Testing the New Identity. The implementation of the new aspect learnt through the coaching conversation and strategies are tested in the patient's outside world, and then feedback is collected and taken back into the next coaching session or for self-management and self-reflection after finishing the coaching relationship.
Leaving Coaching	The patient has explored their values and identities and developed new learning about who they are and how they want to be, which has adjusted their sense of identity and self.

Aspects	Values
The Holistic Coaching Process	A non-directive process that is rooted in narrative exploration and experiential coaching. Undertaken in an environment which creates trust, safety, and empathy, designed to be a space for the client to share their narrative. The focus is on the client's shared narrative, allowing the client to share their present focused uncertainties, anxieties, vulnerabilities, emotions, and understandings of their reality. The focus of the coaching process is transitional learning rather than the completion of a goal (unless the client works in that way).
Holistic Coaches in Cancer	Value the client's learning and cares for their transitions during a period of change and discomfort. Has the ability, values, and comfort to work in a space which is characterised by the client's present anxieties, uncertainty, values, and emotions. Has acknowledged the challenges facing cancer patients and has engaged in learning about cancer's impact, living with cancer, and cancer awareness. Has awareness of themselves as a coach to be able to regulate and manage their emotions and thoughts during sessions. Is committed to and values their own development and safety by active engagement with supervision.
Cancer Patients as Coaching Clients	A sense of present anxiety and uncertainty about living with or beyond cancer. A sense of psychological functioning, e.g., not a heightened sense of distress or negative functioning. The patient is not wanting to delve into their past traumas or negative thoughts or wanting advice/support for managing a mental health diagnosis. A sense that there is something missing or lacking in their current life and the gap in identity or sense of self. For example, wanting to reengage with hobbies or work. A sense that they need support to manage their illness, e.g., becoming more confident in attending medical appointments.

Initiating Factors for coaching	Themes of the coaching process	Outcomes from coaching
Client with a health-related problem, e.g., increasing physical activity to combat obesity.	The goal is health and wellness focussed and the coaching is orientated around the goals.	Achievement of health and wellness goals
Client wanting to enhance their health and wellbeing, e.g., management of stress/improving mood	The coaching is client-centred and a partnership.	Health-related behavioural change,
A coach with the desire and training to support in a health and wellness setting.	An adaptable intervention centred on the client's needs, e.g., not a stagnant process.	Improvements in physical and mental health outcomes.
	An empowering and enlightening process, e.g., education, transformational learning, self-awareness, and self-understanding,