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Introduction of Clinical Coach to the Care Delivery Model in LTC

Mary Boudart & Tamara GhermanMary Boudart & Tamara GhermanMarch, 2007March, 2007

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ObjectivesObjectives

To clarify clinical coaching: definition, model, role dimension, process, variables, effectiveness

To examine how coaching applies to health care professionals in LTC

To discuss implementation of clinical coaching role and the outcome evaluation

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Literature ReviewLiterature Review

Little information specifically on Clinical Little information specifically on Clinical Coaching as compared to coaching, Coaching as compared to coaching, mentoring and mentoring and preceptoringpreceptoring..Clinical Coach helping new graduates to Clinical Coach helping new graduates to make the transition to professional make the transition to professional registered nurse role (registered nurse role (HekkersHekkers, V. 2005), V. 2005)Coaching and Mentoring new graduates Coaching and Mentoring new graduates into into perinatalperinatal nursing practice (nursing practice (HomHom, E. M., , E. M., 2003)2003)

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Literature ReviewLiterature ReviewCoaching behavior of nurses helping clients Coaching behavior of nurses helping clients enhance self care, self management and enhance self care, self management and adjusting to cancer (Lewis, F. & adjusting to cancer (Lewis, F. & ZahlisZahlis, E., 1997), E., 1997)Clinical Nurse Specialist use of coaching as a Clinical Nurse Specialist use of coaching as a strategy for enhancing evidencestrategy for enhancing evidence--based nursing based nursing practice (Ervin, N., 2005).practice (Ervin, N., 2005).Experiential learning of clinical skills by Experiential learning of clinical skills by beginning nursing students: beginning nursing students: ““coachingcoaching”” project project by fourthby fourth--year interns (year interns (AviranAviran, M., , M., OphirOphir, R., , R., RavivRaviv, D. & , D. & ShiloahShiloah, M., 1998). , M., 1998).

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What is Coaching?What is Coaching?

A relationship between 2 peopleA relationship between 2 peopleA conversation model (process) with 5 stepsA conversation model (process) with 5 steps

1.1. Establish the focus (problem, agenda, goal)Establish the focus (problem, agenda, goal)2.2. Discover possibilities (set of questions)Discover possibilities (set of questions)3.3. Plan of action (focus on outcomes, set targets)Plan of action (focus on outcomes, set targets)4.4. Remove barriers (uncover possibilities, resources)Remove barriers (uncover possibilities, resources)5.5. Recap (what has been learned, gain commitment)Recap (what has been learned, gain commitment)

WWWW.CCUI.COMWW.CCUI.COM

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What is Clinical Coaching?What is Clinical Coaching?Coaching dyad: 2 people with mutually agreed goals Coaching dyad: 2 people with mutually agreed goals

Clinical Coachskilled and experienced nurse, a trusted counselor

powerful, knowledgeable and willing to share knowledge

Staff nurseless skilled and experienced nurse

willing to assume responsibility for own growth and development

Yonder, L. (1990)

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A Model of Coaching in NursingA Model of Coaching in NursingClinical coachClinical coach--staff nurse dyadstaff nurse dyad

Relationship (psychosocial): rRelationship (psychosocial): role modeling, counseling, empathyFunctions (instrumental): sFunctions (instrumental): sponsorship, visibility, coaching protection, challenging assignments

Organizational contextOrganizational contextIncreased job satisfaction, retention, professionalismIncreased job satisfaction, retention, professionalismcost effective way to develop staff, to pass on skills and experience, to retain motivated staff, to increase professionalism Yoder, L., 1990

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Clinical Coach Clinical Coach -- 3 dimensions3 dimensions1. Interpersonal relationship-occurs between clinical coach

(an experienced and trusted nurse) and the staff nurse

2. Structural role phenomenon-emphasizes role development of a staff nurse through role clarification, role rehearsal, and role modeling. Instrumental in career progression

3. Organizational phenomenon-integral part of a corporate community needed to ensure success and organizational continuity and stability; mechanism of introducing employees to the culture and operations of the organization Yonder, L., 1990

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Coaching vs. Mentoring (1)Coaching vs. Mentoring (1)CoachingCoaching

Instrumental function Instrumental function Professional developmentProfessional developmentTeaching/Training/CounselingTeaching/Training/Counseling

Focus on specific Focus on specific behavioursbehaviours, skills, attitudes, skills, attitudesUse handsUse hands--on approach to:on approach to:increase job knowledge & skills increase job knowledge & skills increase performance & competencyincrease performance & competencystrengthen work relationshipsstrengthen work relationships

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Coaching vs. Mentoring (2)Coaching vs. Mentoring (2)MentoringMentoring (Mentor(Mentor--ProtProtééggéé) exists over a long period ) exists over a long period

of timeof timeEvaluatesEvaluates

assess developmental needs, assess developmental needs, plan & implement activitiesplan & implement activitiesassess progress, give feedbackassess progress, give feedback

StimulatesStimulatesencourage, motivate, listen, encourage, motivate, listen, ask questions, counsel, coachask questions, counsel, coach

FacilitatesFacilitatesidentify resources, open doorsidentify resources, open doors

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Related ConceptsRelated ConceptsPreceptorship: a time-bound relationship with a competent peer to assists the social and professional integration of a nurse in a new role

Mentoring: relationship of longer duration, process to further career development and advancement; marked by substantial commitment from both parties using formal and informal forms of influence

Sponsorship: pragmatic function of finding one’s fit within an organization

Role modeling: identification with a person through internalizing another’s standards and qualities

Peer strategizing

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Coaching Outcomes Coaching Outcomes Evaluation: Essential for long-term commitment

Qualitative (testimonials) and Quantitative

At micro-level: Clinical coach and staff nurse (testimonials)

At mezzo-level: Value to the organization Organizational outcomes: performanceStaff retention Organizational knowledge transferCost-effectiveness Cost-benefit analysis Yoder, L., 1990

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Organizational Need for ChangeOrganizational Need for Change

New strategic planning implementation New strategic planning implementation 20032003--2005 (clarification of Vision, Mission)2005 (clarification of Vision, Mission)Need to Reconnect to Baycrest Values: Need to Reconnect to Baycrest Values: Compassion, Advocacy, Respect, and Compassion, Advocacy, Respect, and Excellence (C.A.R.E.)Excellence (C.A.R.E.)Operational needs to save money by Operational needs to save money by replacing the RNs with replacing the RNs with RPNsRPNsNeed to expand the role of Need to expand the role of RPNsRPNs to full to full scope of practicescope of practice

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Why has Clinical Coaching been Why has Clinical Coaching been added to staffing model at added to staffing model at

BaycrestBaycrestTo reinforce the Mission, Vision and Philosophy of BaycrestTo focus on rapid nursing staff career and professional development to meet standard expectations by acquisition of new skills, behaviors, attitudes and by empowering staffTo improve Quality of resident care: reducing falls, abuse and other incidents, improving client and family satisfaction with care (as per surveys)

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Why Coaching?Why Coaching?Popular methods of staff development and training

Effective method of building capacity in an organization through knowledge and skill transfer

Effective method to share best practices and lessons learned

Increase staff retention in organization

Method to increase individual and organizational performance

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Who is Clinical Coach ?Who is Clinical Coach ?

Clinical Practice Leader Clinical Practice Leader Role ModelRole ModelChange Agent Change Agent Excellent communicator: has selfExcellent communicator: has self--awareness, is an awareness, is an excellent listener, nonexcellent listener, non--judgmental, empatheticjudgmental, empatheticWorks with: individual staff and/or groups of staff, clients, asWorks with: individual staff and/or groups of staff, clients, aswell as other disciplines and the manager well as other disciplines and the manager Clinically focused and skilled, promotes best practice and Clinically focused and skilled, promotes best practice and understands operationsunderstands operationsProvides staff with Provides staff with ““justjust--inin--timetime”” teaching and with ongoing teaching and with ongoing teaching of clinical skills and problemteaching of clinical skills and problem--solving skills solving skills

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Clinical Coach Skill Inventory (1)Clinical Coach Skill Inventory (1)

MOHLTC Legislation andMOHLTC Legislation and StandardsStandardsAtypical Presentation of Illness in the ElderlyAtypical Presentation of Illness in the ElderlyBest Practice Guidelines for care of geriatric Best Practice Guidelines for care of geriatric population population Dementia/Delirium/DepressionDementia/Delirium/DepressionProtocols: e.g. Head Injury Routine, postProtocols: e.g. Head Injury Routine, post--fallfallfollow up follow up Wound Care Protocol and othersWound Care Protocol and others

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Clinical Coach Skill Inventory (2)Clinical Coach Skill Inventory (2)Expert in documentation Expert in documentation Gentle Persuasive CareGentle Persuasive CareDementia Care Dementia Care ––P.I.E.C.E.S, trainedP.I.E.C.E.S, trainedMotivation PrinciplesMotivation PrinciplesAdult Learning PrinciplesAdult Learning PrinciplesTeaching/Learning and Coaching styleTeaching/Learning and Coaching styleSelf Assessment ToolsSelf Assessment ToolsCompetency in performance appraisal and Competency in performance appraisal and developing learning plans developing learning plans

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What does a Clinical Coach do?What does a Clinical Coach do?Works with the staff, clients and leadership teamWorks with the staff, clients and leadership teamFunctions as a clinically focused and skilled Functions as a clinically focused and skilled professionalprofessionalPromotes best practicePromotes best practiceUnderstands and appreciates operational needsUnderstands and appreciates operational needsProvides staff with Provides staff with ““justjust--inin--timetime”” and ongoing and ongoing teaching of clinical and problemteaching of clinical and problem--solving skillssolving skillsEnsure continuity of care and sustainability of Ensure continuity of care and sustainability of programmingprogramming

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What else does a Clinical Coach do?What else does a Clinical Coach do?

Identifies system problems, barriers and challengesIdentifies system problems, barriers and challengesAssists with staff performance reviews and remedial Assists with staff performance reviews and remedial planningplanningWorks flexible hours to provide 24/7 coverageWorks flexible hours to provide 24/7 coverageProvides leadership visibility on off hoursProvides leadership visibility on off hoursAssists staff in responding to residentsAssists staff in responding to residents’’ needsneedsAssists in locating resources and navigating through Assists in locating resources and navigating through the systemthe systemContributes to quality and risk managementContributes to quality and risk management

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What else does the CC do?What else does the CC do?

Lead and participate in various task forces Lead and participate in various task forces and committees e.g. Wandering client task and committees e.g. Wandering client task force, Skin integrity task forceforce, Skin integrity task forceProvide staff orientationProvide staff orientation--both general and both general and on the uniton the unitAssist the staff with use of Electronic Assist the staff with use of Electronic Healthcare Record (EHR) and Healthcare Record (EHR) and documentationdocumentation

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What does a CC NOT do?What does a CC NOT do?Does not do staffingDoes not do staffingDoes not replace a nursing staff if illDoes not replace a nursing staff if ill

Will respond to residentWill respond to resident’’s needs by s needs by providing care providing care ””withwith”” the staff but not the staff but not ““forfor””the staffthe staff

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Desired Outcomes (1)Desired Outcomes (1)

For the Staff Nurse focus on personal and professional

development widening horizonsunderstanding own strengths & limitationsviews feedback objectivelyrealistic career choicesprofessional advancement

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Desired Outcomes (2)Desired Outcomes (2)For the Clinical Coach

opportunity to practice and share experience and skillsto see staff nurse grow and developopportunity for professional contact with different individuals and viewsincrease work satisfactiongenerativity

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Implementation RoadblocksImplementation Roadblocks

Role clarity vs. role confusionRole clarity vs. role confusionPersonal characteristics of the Clinical Personal characteristics of the Clinical Coach and the level of expertiseCoach and the level of expertiseClient perception of the Clinical Coach roleClient perception of the Clinical Coach roleStaff understanding of the Clinical coach Staff understanding of the Clinical coach rolerole

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Clinical CoachClinical Coach--Role EvaluationRole Evaluation

Clinical Coach kept diary of activities and Clinical Coach kept diary of activities and interactions for one weekinteractions for one weekClinical Coach provided feedback on the Clinical Coach provided feedback on the role as describedrole as describedSurveys distributed to all staff to explore Surveys distributed to all staff to explore their perceptions and goals for the roletheir perceptions and goals for the roleFocus group sessions held for all staff Focus group sessions held for all staff

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How Staff Know Clinical Coach is How Staff Know Clinical Coach is Working Working (51 Respondents)(51 Respondents)

02468

1012141618

ClinicalCoach isAlwaysVisible

Inquire WhenClinicalCoachMakes

Rounds

Unsure Scheduleor Notice

Board

Freq

uenc

y

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Issues/Concerns For Which Clinical Issues/Concerns For Which Clinical Coach Has Been InvolvedCoach Has Been Involved (26 Respondents)(26 Respondents)

0

2

4

6

8

10

To Call

Physici

anWound

Care

Emergen

cy Situ

ation

Assist

ance

with

Family

Confl

ict

Assist

ance

with

Paper

workTea

ching

Conce

rns R

egard

ing O

ther Staf

f

To Acc

ess a

n Ass

ignment L

oad N/A

Various I

ssues

with

Res

ident

Freq

uenc

y

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Issue ( CC Log)Issue ( CC Log)

0

20

40

60

80

100

Family

Practic

e

Administrativ

eOther

Clinica

l

Type of Issue

Freq

uenc

y

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Primary Person Involved ( CC Log)Primary Person Involved ( CC Log)

05

101520253035404550

Family RN

NoneResidentManager

PSW

Other

RPNFr

eque

ncy

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Location of Activities ( CC Log)Location of Activities ( CC Log)

01020304050607080

3E 4W A2 A3 A4 A5 A6 A7

Floor

Freq

uenc

y

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Satisfaction with the Role of Satisfaction with the Role of Clinical Coach (58 Respondents)Clinical Coach (58 Respondents)

0

3

6

9

12

15

SomewhatSaitsfied

N/A Depends onthe Clinical

Coach

Unsure ofTheir Role

No Yes

Freq

uenc

y

PSW/HCARN/RPN

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CC Satisfaction ( CC Log)CC Satisfaction ( CC Log)

0

20

40

60

80

100

120

Other

Unsatis

factory

Ongoing Follow-up

Satisfacto

ry

Freq

uenc

y

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Next Steps (1)Next Steps (1)

Ongoing evaluation of the role and Ongoing evaluation of the role and satisfaction levelssatisfaction levelsContinued role clarification for both staff Continued role clarification for both staff and the Clinical Coachesand the Clinical CoachesContinue to empower the staff while Continue to empower the staff while maximizing the availability of CC to staff maximizing the availability of CC to staff Celebrate the successesCelebrate the successes

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Next Steps (2)Next Steps (2)Nursing Leadership retreat to clarify roles Nursing Leadership retreat to clarify roles of Manager and Coachof Manager and CoachIdentify natural coaching styles: Identify natural coaching styles:

1.1. directingdirecting2.2. presenting presenting 3.3. mediating mediating 4.4. strategizing strategizing

When to use which of the 4 stylesWhen to use which of the 4 styleswww.ccui.comwww.ccui.com

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References (1)References (1)AviramAviram, M., et. all. (1998). Experiential learning of , M., et. all. (1998). Experiential learning of

clinical skills by beginning nursingclinical skills by beginning nursingstudents: students: ““CoachingCoaching”” project by fourth year project by fourth year student student internsinterns.. Journal of Nursing Education, 37Journal of Nursing Education, 37(5),(5), 228228--231.231.

Ervin, N. E. (2005). Clinical Coaching: A strategy Ervin, N. E. (2005). Clinical Coaching: A strategy for enhancing evidencefor enhancing evidence--based nursingbased nursing practice. practice. Clinical Nurse Specialist, 19, (6),Clinical Nurse Specialist, 19, (6), 296296--301.301.

HekkersHekkers, V. (2005). Clinical coaches: Making a difference , V. (2005). Clinical coaches: Making a difference for new nurses. for new nurses. NursingmattersNursingmatters, , 16 (12),16 (12), 1010--11.11.

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References (2)References (2)HomHom, E. M. (2003). Coaching and mentoring new , E. M. (2003). Coaching and mentoring new

graduates entering graduates entering perinatalperinatal nursing practice. nursing practice. Journal Journal of of PerinatalPerinatal Nursing, 17 (1),Nursing, 17 (1), 3535--49.49.

Lewis, C. K. (1996). The clinical nurse specialistLewis, C. K. (1996). The clinical nurse specialist’’s role s role as coach in a clinical practiceas coach in a clinical practice development model. development model. Journal of Vascular Nursing, 14 (2)Journal of Vascular Nursing, 14 (2), 48, 48--52.52.

Lewis, F.M. & Lewis, F.M. & ZahlisZahlis, E.H. (1997). The nurse as coach:, E.H. (1997). The nurse as coach:A conceptual framework for clinical practice. A conceptual framework for clinical practice.

OncologyOncologyNursing Forum, 24 (10),Nursing Forum, 24 (10), 16951695--1702.1702.

Yonder, L. (1990). MentoringYonder, L. (1990). Mentoring--a concept analysis.a concept analysis.Nursing Administration Quarterly,Nursing Administration Quarterly, 15(1),15(1), 99--19.19.