The case for nurse coaching

What do the following situations have in common?

  • A nursing home resident with high blood pressure refuses to take his medication.
  • The daughter of an assisted living resident reports that her mother isn’t eating properly because she “hates” the food being served in the dining room.
  • One of your most skilled nurses demonstrates one critical flaw—frequent tardiness.

The connection is that no lasting solution to such challenging situations can be achieved without the cooperation of the individual involved. Let’s look at a proven method for gaining the necessary cooperation.

In recent years, a new approach has been added to the kit bag of thousands of nurses and scores of nurse supervisors across the country. Called nurse coaching, this relatively new discipline is intended to assist a nurse in the fulfillment of his or her primary responsibilities.

As defined by Susan Misiorski, national director of coaching and consulting for Bronx, NY-based PHI, an organization that provides consulting services to both the home and residential care industries, coaching focuses on building “a relationship-centered approach to supporting the growth and development of others.”

Rather than “telling someone what to do,” the nurse coach seeks to awaken an individual’s sense of self-awareness and self-management. In other words, Misiorski suggests, the idea is to get the person to acknowledge the problem and buy into a viable course of corrective action.

AT THE CORE

Misiorski says core coaching skills needed to attain this goal include:

  • Active listening: Use of good body language, paraphrasing and asking open, curious questions
  • Self-awareness: Regarding strengths, personal styles, judgments/assumptions and blocks to listening
  • Self-management: The ability to maintain control in emotionally charged situations and the ability to manage judgments and listening blocks in order to maintain focus on the other person
  • Feedback: The ability to offer all feedback (both positive and constructive) while being clear and direct and using language free of blame and judgment

“Nurse coaches walk with clients through a discovery process,” suggests Barbara Dossey, co-director of the International Nurse Coach Association. Dossey, who has a long string of credentialed initials following her name, including PhD and RN, says the goal of nurse coaching is to help clients tap into their own creativity, become more resilient and reduce anxiety and the fear of frustration. “Using our core competencies, we try to connect with patients’ strengths, help them recognize what they want to learn, and encourage them in what they want to do with their lives,” Dossey explains. She adds, “Coaching is an ideal model to help understand patients’ desires, constraints and barriers, and then use the knowledge to develop an ongoing plan of care.”

To the uninitiated it might seem that nurse coaching is nothing more than advising and counseling patients—something that nurses have been doing for centuries, if not millennia. Dossey disagrees, noting, “While many nurses have naturally used coaching skills to support their patients over the years, the practice of nurse coaching is just beginning to emerge as a distinct role, with specialized training and broader recognition.”

It now even has its own accreditation efforts, including the Integrative Nurse Coach Certificate Program, the PHI certificate of completion, and, since this past January. a professional certification as a coach that can be earned through the American Holistic Nurses Credentialing Corporation. In addition, the American Nurses Association (ANA) has published a book on the subject entitled The Art and Science of Nurse Coaching: The Provider’s Guide to Coaching Scope and Competencies.

WHAT COACHING IS NOT

Gail Donner, RN, PhD, and Mary M. Wheeler, RN, MEd, PCC, the authors of Coaching in Nursing: An Introduction, make a distinction between coaching and advising, counseling or mentoring. They say that unlike these other techniques, coaching is time-limited and focused on conversations in which the client often takes the lead.

In their book, they state, “[T]he coach acts like a midwife: supporting, encouraging and helping the client through the experience while acknowledging the client as the expert and the person ‘making it happen.’”

A NEED TO COMMUNICATE

At its most elemental level, coaching is about communicating. In practice, here is an example of how it works and what it may do for an LTC environment:

Mrs. Jones, a resident, wants to sleep late every day and have a light breakfast of tea and toast. Her daughter insists that the staff get her mother up by 8 a.m. for a full breakfast including bacon, eggs, toast and juice. The nurse coach doesn’t tell anyone what to do—not staff, mother or daughter. Instead, she listens intently and assesses the situation. Asking open-ended questions that cannot be answered with a yes or no, she urges each party to express needs, desires and feelings. She offers all an opportunity to suggest ways to modify their position. She encourages each to consider the perspective of the others and gives them a chance to come to a mutually agreed-on solution. Once this option has been implemented, the nurse coach continues to check back to make sure everyone is satisfied with the arrangement.

“For coaching like this to be effective, the communication skills must be embedded deeply throughout the organization,” says Misiorski. “One or two coaches cannot have consistent meaningful impact 24 hours a day with the number of residents and employees that need support.”

Ideally, all staff members would undergo specialized training, but where that is not possible, selected staff members should be sufficiently well taught to be able to return home and train their colleagues and support staff.

WHAT TO EXPECT

When it goes right, coaching can produce impressive results. Orchard Cove in Canton, Mass., is a continuing care retirement community (CCRC) with 227 independent living apartments, 28 “assistance in living” units for residents who require help with daily activities and a 45-bed skilled nursing floor.

Founded in 1993 as a member of Boston-based Hebrew SeniorLife, Orchard Cove has 250 employees—including 36 certified nursing assistants (CNAs). Human resources director Jim Quinn credits the PHI coaching approach with facilitating a friendlier working environment, greater empowerment for CNAs and culture change that has improved the quality of care.

Meanwhile, Executive Director Paul Hollings asserts, “If you can’t measure it, you can’t prove you’re making a difference.” Committed to tracking outcomes, he readily points with pride to the following improvements:

  • Reduction in pressure ulcers.The percentage of high-risk residents reported with pressure ulcers fell below the national average in 2008, trended downward for the next two years and reached zero between March and July 2010.
  • Reduction in urinary tract infections. Residents reported with a urinary tract infection showed a downward trend, reaching zero in July 2010.
  • Reduction in falls.Between June 2008 and July 2010, prevalence of falls decreased from more than 25 percent to around 7.5 percent.
  • Other improvements in resident care. Additional positive outcomes for Orchard Cove’s skilled nursing residents include:
  1. The percentage of residents who were receiving nine or more medications declined from 61 percent in 2008 to 40 percent in July 2010, well under the national average of 70 percent.
  2. The percentage of residents becoming more anxious or depressed decreased from nearly 20 percent to just over 10 percent over the same time span.
  3. No residents were reported as needing more help performing their activities of daily living in July 2010, compared with 45 percent who needed increased help in September 2008.

Today, Dossey reports that nurse coaching is no longer a novelty but a well-respected technique that is finding favor in all sorts of settings. “Nurse coaches are working as public health nurses, community healthcare providers and parish nurses, as well as in the full range of ambulatory care,” she says.“Some hold positions in governmental regulatory agencies. And many are caring for the full array of patients in oncology,cardiology, pediatrics, acute-care settings, primary care,home care, hospice, hospitals,clinics and, of course, long-term care and rehabilitation centers.”

WHEN COACHES NEED COACHING

In addition to its usefulness in dealing with patients, residents and family members, nurse coaching has proven value in strengthening employee performance and loyalty.

At the Edgewood Centre, a 156-bed, family-owned, for-profit business in Portsmouth, N.H., turnover rates for licensed nursing assistants (LNAs) declined substantially—from 52 percent to 37 percent—during three years that the Centre participated in the Northern New England LEADS (Leadership, Education, and Advocacy for Direct-care and Support) Institute. An initiative of the PHI training and consulting organization, the LEADS Institute aims at building a core of strong leaders among direct care staff, supervisors and administrators.

Edgewood also reported a “substantial decline” in callouts (which occur when employees call with less than 24 hours notice that they will not come to work that day). This suggests that its LNAs were more satisfied with their jobs as a result of the changes implemented during the 2005–2008 period.

Edgewood’s Administrator Tricia Cummings says, “Our philosophy is that when supervisors can develop a deeper relationship with an employee—and empower an employee to solve his or her own problems—nine times out of 10, the employee actually has a better answer than the supervisor. There’s more ownership around the issue, whether it is related to a resident or to the employee’s personal job performance. And the hope would be that this person would be more committed to the job and to the organization, and stay.”

Hope P. Miller, RN, BSN, MS, vice president of care services, leads a staff of nearly 600 nurses, LPNs and CNAs at the Isabella Geriatric Center in northern Manhattan. With a client load that includes a 705-bed nursing facility, 90 slots for adult day healthcare, 80 independent units, a Child Care Department, 500-plus Long-Term Home Health Care (Lombardi) Program patients, Licensed Home Care Services (Isabella Visiting Care Inc.), a Benefit Enrollment Center and The Upper Manhattan Partnership for Senior Independence, which offers free case management in consortium with other senior service organizations, everyone is under enormous pressure.

Miller says Isabella is in the process of switching from the “telling” approach to management that most nurses learned in school to one that uses the more collaborative coaching style. So far, she says, the results have been good. For example, Miller says, the nursing supervisor who has to assign or re-assign staff after the shift has been scheduled has started to use coaching techniques, as opposed to issuing a directive. She reports that this ensures a more positive response from the staff and sets the tone for an easier transition when working with residents. When staff is given an explanation of the circumstances and/or an acknowledgement of their feelings about having to cover another assignment, they are far more likely to react well than if they were merely ordered to do it, Miller explains.

Alan Richman is a freelance writer based in New Jersey.

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