Coaching is a relatively new application to promote the development of leadership skills in health care and nursing. It is defined as supporting another person in achieving specific performance goals by providing guidance and ongoing support. It differs from mentoring, a more familiar term in that its focus is on specific aims rather than general professional development (Wolever, Moore, & Jordan, 2016; Baker, Lefebvre, & Sevin, 2017; Funari, Feider, & Schoneboom, 2015). Coaching may be the start of, or a part of, a mentoring relationship that develops over time and can continue beyond accomplishment of a specific goal (Fielden, Davidson, & Sutherland, 2009). Despite recommendations from the Institute of Medicine's Future of Nursing: Leading Change, Advancing Health (2010), which outlined strategies that would enhance and enable nurses to lead health care transformation, evidence in the literature is limited on coaching to promote nursing leadership development (Doerksen, 2010). Mentoring efforts are reported primarily in academic and emerging professional programs and reports on coaching currently available suffer from weak methodologies and lack consistent, measurable, or generalizable outcomes. Clearly, studies that evaluate the impact of coaching on the leadership abilities of advanced practice nurses (APNs) are warranted. The purpose of this report is to describe the current literature related to coaching among APNs and the results of the coaching experiences from APN Fellows who participated in coaching circles during their national nurse leadership program.
The Duke–Johnson & Johnson Nurse Leadership program was developed to provide APNs with the opportunity to gain the knowledge and skills to lead the development, implementation, and evaluation of a transformational project that focuses on improving health outcomes for underserved populations (Duke–Johnson & Johnson Nurse Leadership Program, 2017). Selected participants are chosen annually through a rigorous application process that includes the APNs' written explanation of leadership and project goals and personal interviews conducted by a designated selection committee. The year-long Fellowship, underwritten by grant funding and academic support from the University (Fellows pay only travel expenses), offers bimonthly synchronous and asynchronous learning modules, in-person retreats throughout the year, and deliverable project assignments, including the culmination presentation of their project. The overarching goals of the program include participant achievement of leadership competencies, enhanced communication techniques, and management skills not typically offered in traditional graduate nursing education (e.g., financial budgeting, fiscal forecasting, and planning), which promote the participants' ability to lead transformational changes and health care system improvements within their communities or organizations.
Another significant component of the program is mentoring and support of each Fellow through the use of “coaching circles”: groups of two to three Fellows who work with an assigned coach on at least a monthly basis as the Fellowship unfolds. Coaches are assigned to circles on the basis of their expertise and clinical specialty, as well as their geographic location, aiming to closely match interests and clinical expertise while also ensuring time zone–specific ease in scheduling circle meetings. The coaches are each experienced nurse leaders (not always a nurse practitioner [NP]) charged with supporting and guiding the Fellows in successful completion of their transformational health projects (a specific goal). The coaches preview outlined projects prior to meeting their coaching circle Fellows in person at the first retreat, then continue to closely mentor each of the Fellows' projects. Coaches offer suggestions, strategies, and guidance to address issues that emerge through monthly hour-long virtual coaching circle meetings and during midyear and final retreats, where coaching circles meet in person. Coaches also offer mentoring support through e-mail and telephone contact to their circle of Fellows and provide availability for one-to-one consultation and troubleshooting. The video conferencing and e-mail communication is facilitated via the university learning platform and the program administrative team.
Fellows complete evaluations of their coaching circle experiences following each of the in-person retreats and at year end, and are invited to offer a value statement of their circle experience. All coaches in the program receive orientation to their role and responsibilities from the program director prior to participating as a coach, and all participate in peer learning and quality improvement efforts annually, which includes discussion of successful coaching techniques, the value of the experience in promoting APNs in leadership roles, and a standardized year-end evaluation of their experience as a coach. The coaches are offered and encouraged to access all learning activities in which Fellows participate throughout the year via the learning platform and during retreat sessions.
Evidence on the use of coaching specifically among APNs is limited. Various mentions of coaching and mentoring techniques are present in the relevant literature; however, much of it comes from outside the United States and is limited in numbers of participants and evaluation strategies. Many nursing leadership programs have used mentoring, rather than coaching programs, from within the nursing profession or relied on executive coaches from outside of nursing who aim to establish and promote leadership skills. Only two reports that included NPs were identified from Australia (Leggat, Balding, & Schiftan, 2015) and the United Kingdom (Fielden et al., 2009), which range in time of participation from 6 months to 18 months. Legatt et al. (2015) described a formal program to assist NP candidates in developing competence in clinical leadership. While this program is labeled as a mentoring program, the methods described included coaching and active learning. Participant goals were specific with short term aims, aligning more with coaching than mentoring. In the study from the United Kingdom, two groups were compared, with one group of NPs receiving mentoring and the other group receiving coaching. The focus of the mentored group was long-term career development, whereas the coached group's focus was short-term specific development related to skill and or performance. A more commonly reported phenomenon is executive coaching of nurses in or aspiring to leadership roles (Karsten, 2010; McNally & Lukens, 2006; McNamara et al., 2014; Ponte, Gross, Galante, & Glazer, 2006).
The quality of the evidence is low due to methodological issues. The case study (Karsten, 2010) and program evaluations (McNamara et al., 2014; McNally & Lukens, 2006; Ponte et al., 2006) provide descriptive information only. A quasi-experimental design provided some comparisons on certain self-perceived leadership abilities (Leggat et al., 2015). Only one study used a controlled trial design to compare the outcomes of two small groups (Fielden et al., 2009). The number of NP participants in the reported literature ranges from unreported (Karsten, 2010) to 64 participants (McNally & Lukens, 2006).
Evaluation tools are also inconsistent in reports to date; half of the reports developed their own evaluation surveys without prior psychometric testing, two used the Leadership Practices Inventory (Leggat et al., 2015; McNally & Lukens, 2006), and one used the Leadership Circle Profile (Karsten, 2010). Some additional evaluation information was collected via open-ended responses (Leggat et al., 2015; McNamara et al., 2014), interviews (Fielden et al., 2009; McNamara et al., 2014; Ponte et al., 2006), and focus groups (McNamara et al., 2014) with qualitative analysis applied.
Most of these reports reveal the use of coaches external to the organization (Fielden et al., 2009; Karsten, 2010; Leggat et al., 2015; Ponte et al., 2006), although two used external and internal coaches (McNamara et al., 2014; McNally & Lukens, 2006). All reported using external coaches in different ways. One provided an individual coach for each nurse executive to assist with developing action plans based on each individual's leadership circle profile (Karsten, 2010). Ponte et al. (2006) qualitatively evaluated and described the relationship experience of four coach–client pairs from four different health-related settings. In the program for NPs in Australia, senior nurses in executive roles outside the clients' own organization were used (Leggat et al., 2015), and similarly in the United Kingdom, coaches were external to the immediate organization but within the same Health Trust (Fielden et al., 2009).
The fit or match between coaches and clients was discussed by five of the six reports. Attention to pairings was determined to be important to success. Important aspects of pairing were paying attention to special background knowledge or experience seniority and professional background (Fielden et al., 2009; McNalley & Lukens, 2006), education (e.g., graduate education) (Karsten, 2010), learning styles (Leggat et al., 2015), gender, culture, and age (Karsten, 2010). Keeping coaching appointments (McNalley & Lukens, 2006; Ponte et al., 2006), as well as being available for just-in-time access (Karsten, 2010; Ponte et al., 2006) built trust in the relationship. Engagement by both coach and client, completing homework or other assigned tasks, and being involved in discussions and responsiveness (Fielden et al., 2009; Karsten, 2010; McNalley & Lukens, 2006) were essential to the success of the coach–client relationship.
A serial cross-sectional survey design was used. Four cohorts of leadership Fellows from 2013–2014 to 2016–2017 were invited to complete standardized program surveys upon completion of the program. Survey questions were derived from standardized program evaluation tools used by the partnering organization to evaluate program objectives and satisfaction. All responses used a Likert scale (1 = strongly disagree; 2 = disagree; 3 = undecided; 4 = agree; 5 = strongly agree), and some survey questions provided the opportunity for participant narrative response as well. Data were collected annually and evaluated for themes, areas of strength, and opportunities for program improvement. Survey questions that were omitted in various evaluation years and number of respondents are noted in parentheses below. University institutional review board approval was obtained prior to implementation of the leadership program.
Eighty-three (96%) of 86 Fellows participated in the survey. All participants were APNs with graduate degrees who worked primarily with underserved communities in rural or urban settings. The participants were diverse in gender and ethnicity: 7% were male, 73% were White, 14% were African American, and 13% self-identified in other racial/ethnic categories. Fifty-nine percent of the APNs practiced in urban areas, whereas 15% practiced in rural areas. Ninety-two (90%) were NPs and 10% were certified nurse midwives. Geographic location included Fellows from 23 states, the majority living in North Carolina, Ohio, Massachusetts, Indiana, Florida, and California.
Coaching Circle Size and Schedule
When asked about having three to four Fellows in each coaching circle as the right size for optimal group dynamics, the mean response was 4.5 (first 3 years only, N = 57). Most Fellows thought the size was optimal, although several thought it was too small and that they would have appreciated more input from others—for example, “I would have benefited from more cohorts' input, experiences, and support.” Fellows also agreed that interactions with other Fellows during coaching circle meetings were beneficial to the process of developing and managing their project, with a mean score of 4.3, as exemplified by this comment: “I found the other Fellows to be excellent in terms of support and encouragement.” Participation of all coaching circle members with thoughtful sharing of time among all was critical; one Fellow commented “We had one Fellow that was rarely present, and another that was frequently late,” and another wanted more time to discuss their project. Another member wrote, “Our coaching circle was short and limited in terms of opportunity to share. The leader rushed through each cohort's project and was very task orientated, leaving little time for sharing.”
Monthly coaching circle meetings during the year-long program was rated sufficient to help support Fellows throughout the process of developing and managing the project (M = 4.33). Despite the agreement, many comments highlighted difficulties with scheduling and attendance by both Fellows and coaches. One Fellow's statement echoed others, stating “Many of our meetings were cancelled [or] rescheduled to the point I got lost in when they were taking place. We did not end up having monthly meeting, and I could have used more support and feedback.”
Conversely, the aspect they least appreciated about the coaching circle experience included only two themes: difficulty with scheduling across time zones, and lack of commitment to circle meetings from Fellows and occasionally coaches. One Fellow stated, “We experienced uncertainty if the coaching circle would meet or not meet. There were times when it was cancelled the same morning, but I was not aware of the change in plans.”
Fellows suggested a desire for more time to be together and engage in discussion outside of the project goal, particularly when face to face. Comments reflected:
It would be helpful to have more time together with the coaches at the retreat, particularly earlier on in the program. Also, ideally, it would be nice if coaches had a more proactive role in leadership development, not just on the project.
Value of Coaching Circles
When asked about what they most appreciate about the coaching circle experience, the themes of support, encouragement, receiving expert advice and feedback, and accountability emerged. Additional themes related to the connections, networking, and friendships were also noted. Examples of Fellows' responses included, “Opportunity to receive feedback from other Fellows (and provide feedback/suggestions to the other Fellows) enhanced the feedback from the coach/staff (i.e., mutually beneficial)—it provided a variety of perspectives” and “Sharing ideas and giving each other feedback on how to tackle difficulties or to look at other options, I think I appreciated walking through this with my colleagues and hearing about their challenges and opportunities. I learned from that, and really felt a connection with them as we all tried to evoke change.”
Fellows agreed that the coaching circle meetings both onsite and distance based to be a productive use of time for guidance through the process of developing and managing the project, with a mean score of 4.1. Again, when explanations for the score were offered, they addressed similar concerns as above, including scheduling, time together (especially at the onsite retreats), and how coaching circles were conducted. The following quotation exemplifies these concerns:
I think we all remained a bit uncertain as to what we were going to accomplish with the circle time. Most of the time was spent catching up on the project status of the members. We did conference calls, but I almost feel that the information could have been conveyed via a message board just as efficiently. I think a little more formal preparation going into the calls with what the goal of the call is might have helped the productivity.
Coaching Availability and Match. Fellows also agreed that their coach made himself or herself available on average at least once per month to check on the Fellow's progress (mean score = 4.2). Lack of responsiveness and scheduling issues were frequently mentioned in the comments. However, Fellows more strongly agreed (mean score = 4.4) that coaches did make themselves available for contact outside of the circle meeting (via telephone and e-mail) for additional guidance on the project or other program-related matters.
A good match between the coach and Fellows was important to the Fellows, with a mean score of 4.2. Fellows commented that it was important for the coach to have at least enough experience or similar enough background to appreciate and understand the situation the Fellow was in. An example statement was, “She was lovely, and I enjoyed getting to know her, but I had a lot of trouble getting her to understand what I was doing with my project.”
The main function of the coaches was to provide useful guidance, feedback, and encouragement throughout the process of developing, implementing, and evaluating the transformational project. The Fellows generally agreed they received this coaching (mean score = 4.2). Comments commonly addressed the desire for more constructive criticism of the Fellow's efforts, as these Fellows stated “My coach provided me with encouragement. I feel less like I was provided feedback and guidance” and “She was always very positive and didn't have much feedback about changing my reports/project paperwork. I wished that she would have been more critical because I know that there was always room to improve.”
Coaching Skills and Attributes. Fellows were offered the opportunity to provide their opinions on what skills and attributes make a “good coach.” Thematic analysis of responses again, highlighting the desire for constructive criticism. In addition, good listening skills, assistance with problem solving, and anticipating potential problems were identified as strengths of a good coach. One Fellow wrote that a good coach “helps with all aspects of project from conception to evaluation in terms of providing guidance, anticipating possible hurdles and help with problem solving.” Another wrote that a good coach should “Help identify resources. Act as resource of leadership issues that are not related specifically to the project but aide in leadership growth.” Another stated that a good coach “listens, points in directions of new resources, pulls out the strengths and weaknesses of your project to help you see more clearly, keeps you focused on your overall goals.” This Fellow thought a good coach should have the “ability to quickly understand role and scope of the coaching circle members as well as their institutions. [Be] supportive and constructive. [Be] available outside of circle meetings to discuss issues as they arise. Has a solid understanding of the program and its requirements.”
Given the limited reports of coaching as a tool to promote nurse leadership among advanced practice nurses, this report offers insight to strategies of coaching that would be useful in a variety of health care settings to promote the advancement of nurse leaders. Four years of data from APNs who participated in small-group coaching circles highlights key findings that are valuable for implementation: Coaching circle size should be small (two to four members); consistent, shared communication among all members is critical for engagement; strategies that promote a good fit among coaches and participants are important to ensure shared values and establishment of short-term goals. Coaches who are excellent listeners, proactive in troubleshooting, and demonstrate mutual respect for the group members are ideal for the role. Members who participate in coaching circles can be cultivated to become coaches themselves through their shared experience in leadership training as circle participants. These themes are evident in this and the other modest number of reports and should be the focus of future evaluation of leadership programs. Our experience supports this theme given that three former Fellows have emerged as effective small group coaches in the program following their program completion.
The overall experience of the APN Fellows in the Duke–Johnson & Johnson Nurse Leadership program is similar to those in the review of the literature, with a lack of clear communication about expectations as the most common reason for less than positive experiences. Participating in coaching enabled the nurses to clarify and examine their personal leadership development needs (Ponte et al., 2006). Similar to all previous reports, coaches were external to the participants' organization. Advantages of having coaches outside of the participants' organization included the ability of coaches to provide objective general advice and innovative ideas. Each Fellow is also a peer coach and brings additional perspectives from outside. In particular, with coaches and Fellows from diverse geographic areas and organizations across the United States, participants are exposed to new perspectives and ways of thinking. Fellows thought a coach should be able to take the time to understand the role and organizational context in which they were working, and Thompson, Wolf, and Sabatine (2012) found the inability to make the effort to do this was a disadvantage of outside coaches. Therefore, fit between coaches and Fellows was a priority in this program as in others, and this could make the difference in whether or not the experience was satisfactory for the participant (Fielden et al., 2009; Leggat et al., 2015; McNally & Lukens, 2006). In particular, the coaches' availability when the APN Fellow needed him or her was critical to the participants' perception of coaching effectiveness (Karsten, 2010; Ponte et al., 2006).
A difference in this program compared with others described in the literature was the long-term nature of this evaluation. All others described only one cohort or occurrence of a program, whereas this report includes four cohorts and years of data. The number of participants is also the largest reported, at 86 compared with 64 (McNally & Lukens, 2006), which strengthens the results. Prior reports of leadership programs for APNs focused more on improving specific skills to improve participants' management of clinical practice or leadership skills (Fielden et al., 2009; Leggat et al., 2015). In contrast, the Fellows in the Duke–Johnson & Johnson Nurse Leadership program use their new skills and education along with the support of their coaches and peers in the coaching circle to work towards a similar goal of developing, implementing, and evaluating an individual transformational project within 12 months.
With attention to making a good fit between coaches and Fellows, clear expectations, and communication, the coaching circle can be a unique active learning process. It provides the forum for participants to share experiences of practice and leadership problems and find possible solutions to them through group processes. With the coach as a role model, participants can develop as peer coaches as well. The skills and knowledge needed for leadership development in APNs may not be much different than for other nurses, but the purpose is not purely to advance to or further a career as a manager or administrator but to truly lead in place. If that place is direct patient care, education, or practice change, the health care system and patients will be the winners.
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