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Keywords:

  • coaching;
  • collaboratives;
  • facilitation;
  • health care quality improvement;
  • interprofessional teams;
  • leadership

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

Aim

To investigate health care improvement team coaching activities from the perspectives of coachees, coaches and unit leaders in two national improvement collaboratives.

Background

Despite numerous methods to improve health care, inconsistencies in success have been attributed to factors that include unengaged staff, absence of supportive improvement resources and organisational inertia.

Methods

Mixed methods sequential exploratory study design, including quantitative and qualitative data from interprofessional improvement teams who received team coaching. The coachees (n = 382), coaches (n = 9) and leaders (n = 30) completed three different data collection tools identifying coaching actions perceived to support improvement activities.

Results

Coachees, coaches and unit leaders in both collaboratives reported generally positive perceptions about team coaching. Four categories of coaching actions were perceived to support improvement work: context, relationships, helping and technical support.

Conclusions

All participants agreed that regardless of who the coach is, emphasis should include the four categories of team coaching actions.

Implications for nursing management

Leaders should reflect on their efforts to support improvement teams and consider the four categories of team coaching actions. A structured team coaching model that offers needed encouragement to keep the team energized, seems to support health care improvement.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

Despite a variety of health care improvement programmes, inconsistencies between desired and actual improvements exist (Berwick 2003a,b, Spear 2005, Varkey et al. 2007, Landrigan et al. 2010, Chassin & Loeb 2011). The inconsistencies in successful health care improvement have been attributed to many factors, including a lack of organisational infrastructure, leadership, context and cultural insights, supportive resources and unengaged front-line staff (Greenhalgh et al. 2005, Bate et al. 2008, Scott 2009). Therefore, exploration of these factors to increase the success of improvements is necessary. Better understanding of supportive resources, specifically team coaching from different perspectives, may provide one missing link in successful improvement.

The improvement collaborative (Øvretveit et al. 2002, Ayers et al. 2005, Nembhard 2009) modelled on the Institute for Healthcare Improvement Breakthrough Series (BTS) approach was first described by Kilo (1998). The BTS is grounded in Kolb's (1984) experiential learning theory, and emphasizes the central role that experience plays in the learning process by alternating learning sessions with workplace practice. Both randomized trials and quasi-experimental intervention studies of collaboratives with pre- and post-measures show inconsistent improvement results (Cretin et al. 2004, Landon et al. 2004, Dellinger et al. 2005, Homer et al. 2005, Howard et al. 2007, Lindenauer 2008, Schouten et al. 2008, Øvretveit 2011). Methodological problems might explain the differences in collaborative results and may not get to the root cause of reinforcement of basic improvement skills and knowledge within the context of the workplace (Nembhard 2009).

Many health care improvement collaboratives consistently report on collaborative models and processes, but report less frequently on the period between the learning sessions when teams meet the challenges of providing patient care while simultaneously improving care (Øvretveit et al. 2002, Øvretveit 2003). Improvement teams are often faced with on-the-job crises and organisational inertia that diminish their ability to achieve their goals (Schonlau et al. 2005, Hohenhaus 2009).

Improving knowledge and skills are important, but do not achieve sustainable change alone. Brandrud et al. (2011) identified three factors contributing to success in continual improvement in health care: (1) continuous and reliable information, (2) engagement of everybody in all phases and (3) an infrastructure based on this knowledge including coaching, which contributes to a culture of improvement.

Coaching front-line teams has occurred in a variety of fields, including education, business, industry, sports and organisational development. Measured results have included improved productivity, morale and team dynamics (Brumwell et al. 2006, Elliott 2006, Anderson et al. 2008, Grant et al. 2010). However, most coaching programmes are directed at coaching individuals such as executives, new nursing graduates and surgeons (Byrne 2007, Gawande 2011, Johnson et al. 2011, Hu et al. 2012). Individual mastery may result in one's own individual development, but the delivery and improvement of care and services requires interprofessional teams (Edmondson 2003, Batalden & Davidoff 2007, Nelson et al. 2009).

Since 1987, several randomized controlled trials (RCTs), non-RCTs, pre- and post-studies, and case studies in Europe and North America have tried to understand the role of facilitators and ‘helpers’ (i.e. a role ranging from completion of specific tasks such as setting up rooms and recording meeting minutes to guiding improvement activities) and their influence on health care improvement (Harvey et al. 2002, Thor et al. 2004, Hogg et al. 2005, Jaen et al. 2010). Frequently, the facilitator role that supports practitioners to make improvements is not clearly described.

Team coaching may represent an opportunity to address resources to support interprofessional health care teams work productively in their own context between structured improvement learning sessions. Team coaching includes direct interactions with a team with the intention of helping members make coordinated and task-appropriate use of their collective resources to accomplish the team's work (Hackman & Wageman 2005). The impact of team coaching in health care improvement has not been evaluated from the perspectives of the interprofessional team, coaches or leaders in order to learn what was most supportive of their improvement activities.

Aim

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

The aim of this study was to investigate health care improvement team coaching activities from the perspectives of coachees, coaches and unit leaders in two national improvement collaboratives.

Methods

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

Research design

A mixed methods design with three phases of data collection was used (Ivankova et al. 2006, Creswell & Plano 2007, Östlund et al. 2011). Each phase represented one perspective on coaching and occurred from 2005 to 2009 (Figure 1). The combination of quantitative and qualitative methods enabled a robust analysis of coaching phenomena using three different data sets. The multistaged, mixed method, sequential exploratory design gave priority to qualitative data. The three data collection and analysis phases in the design were connected between phases and integrated during the final interpretation phase of the study, resulting in categories of coaching actions (Tashakkori & Teddlie 2003, Ivankova et al. 2006). Ethical approval (#22131) was granted by the Committee for the Protection of Human Subjects at Dartmouth College (2012). Participation was voluntary, confidential and based on informed verbal consent.

image

Figure 1. Mixed methods three-phase sequential exploratory study design for coaching perspectives. CF, Cystic Fibrosis Foundation Centres; ICN, Vermont Oxford Network Intensive Care Nurseries.

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Improvement in collaborative intervention

Interprofessional teams in two separate collaboratives, The Cystic Fibrosis Foundation (CF) centers and the Vermont Oxford Network Intensive Care Nurseries (ICN), received coaching before, during and between learning sessions from 2005 to 2008. The collaboratives were grounded in the Dartmouth Microsystem Improvement Curriculum (Nelson et al. 2009, pp. 199–432). The ICN coaches received coaching training from The Dartmouth Institute coaching programme; an adapted version of this training was conducted during the CF collaboration (The Dartmouth Institute 2012). Both collaborative's national leaders assigned coaches to clinical teams with consideration of physical location and time zones.

The collaboratives consisted of two face-to-face learning sessions per year to learn and practice improvement skills, to share progress, to learn from colleagues and to achieve collaborative goals. Telephone and face-to-face coaching were included in the collaboratives to help the teams develop their improvement capabilities. Phone interactions included monthly collaborative conference call learning sessions and regular team telephone coaching, which decreased over time from weekly to monthly. Task book reminders and ‘to do lists’ of required activities were completed between learning sessions. E-mail communication, between coaches and teams was frequently used. The ICN collaboration included three site visits by coaches; there were no CF site visits.

Sample for the study

The study included coachees (members of interprofessional health care teams and patient or family members), coaches and unit leaders from two improvement collaboratives from different contexts in overlapping time-periods. The CF collaborative's goal focused on improving nutrition and pulmonary care for children with cystic fibrosis. The ICN collaborative's goal focused on improving care for premature infants. Characteristics of the two collaboratives are presented in the Supporting Information, Appendix S1. Leaders representing either CF centers or ICN teams applied to participate in the improvement collaboratives. All accepted CF and ICN teams and assigned coaches were included in this study.

The CF improvement collaborative consisted of three 1-year collaboratives with a total of 49 different CF teams and 31 different novice-to-intermediate coaches over the 3 years. Each team was assigned ‘paired’ coaches, a novice and experienced coach, to provide flexible coverage of the team. The coaches were selected from within the CF community, had no previous improvement coaching experience and ranged in their participation in the three CF learning collaboratives from 1 to 3 years. The ICN collaborative consisted of one 2-year improvement collaborative with 12 ICN teams and eight coaches from outside the ICN community. Four highly experienced health care improvement coaches were paired with four novice coaches and were assigned two to four ICN sites.

Instrument and data collection

Data collection consisted of three phases: an Internet survey, focus groups and semi-structured interviews (Figure 1).

Coachee internet survey

The aim of the first phase was to describe the ‘coachee’ perceptions about coaching experiences in the collaborative. An Internet survey (SurveyMonkey) consisted of 15 questions with a five-point Likert-type scale (strongly agree = 4, agree = 3, disagree = 2, strongly disagree = 1 and cannot answer = 0) and eight open-ended questions. The Internet survey was chosen for respondent convenience and could produce a higher completion rate than a paper survey (Truell et al. 2002). The questions were based on extensive field experience and survey research methods literature for developing valid and reliable questions. The survey was pretested with a small sample of respondents (Rea & Parker 2005, Fowler 2009). The coachee survey was completed at the end of each of the three 1-year CF collaboratives after the final face-to-face learning session and on three occasions during the 2-year ICN collaborative.

The Internet survey link was distributed to one contact person for each CF and ICN team, who then distributed the link to team members. The survey was completed anonymously by 198 of 240 CF coachees and 184 of 288 ICN coachees. The only identifier was at the organisation level.

Coach focus groups

The aim of phase two was to describe coach perceptions about team coaching. Qualitative data were obtained from the coaches: one focus group for CF and one for ICN. The focus group moderator guide was based on the Internet survey findings and aimed to deepen understanding and increase knowledge of team coaching from the coaches' perspective.

An independent moderator led the 90-minute discussion using the same semi-structured moderator guide for both groups (Krueger 1998, Krueger & Casey 2000). The focus groups were conducted virtually and recorded using Adobe Connect video conferencing and an external digital recorder. The two focus groups included web cameras to allow participants to see each other during the discussion. All recordings were transcribed, and validated by the first author (MMG) through review of digital recordings.

Leader telephone interviews

The aim of phase three was to describe leader perceptions about coaching. The data collection consisted of 60-minute, semi-structured, recorded telephone interviews of paired leaders (physician and nurse). Unit leaders for teams whose coaches participated in the focus groups were identified and invited to participate in a telephone interview about the team coaching experience. The telephone interview, conducted by first author (MMG), was selected as the data collection method given the wide geographic distribution of the leaders. This method was convenient and allowed probing questions to gain better understanding about the leaders' perspectives of the team coaching experience (Maxwell 2005). The interview guide emerged from the themes of the coachee surveys and coach focus groups. The recordings were transcribed and then validated by the first author (MMG) through review of digital recordings and notes from the calls.

Analysis

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

Quantitative data analysis

The quantitative analysis of the coachee surveys was reported for each item at the descriptive level, and differences between the two groups, CF and ICN, were analysed using Fisher's exact test on ordered categorical data. As calculation of means and standard deviations is not recommended on ordered categorical data, non-parametric analysis was selected. Fisher's exact test is recommended for use with small samples (Motulsky 2010). The data analysis process was reviewed and guided by the fourth author (MN) using SAS 9.2 software (SAS Institute, Inc., Cary, NC, USA). A P-value ≤ 0.05 was considered statistically significant. A sensitivity analysis to determine the influence of non-respondents to the survey showed no difference in results from the high ceiling effect found in the survey responses.

Qualitative data analysis

The open-ended survey questions, focus group and leader interview transcripts were analysed using manifest qualitative content analysis (Neuendorf 2002, Krippendorff 2003, Graneheim & Lundman 2004). The first author (MMG) read each of the three phases of qualitative data several times to gain insights and identify patterns from the respondents' comments. Member checking occurred through sharing these insights with the focus groups and interview participants (Tashakkori & Teddlie 2003). The first impression was that several patterns in the qualitative data mirrored the content of the survey that provided the initial categories for a deductive content analysis. Re-reading of the qualitative data resulted in inductive data coding within the original categories. nvivo8 software (QSR International Pty LTD 2012, Doncaster, Victoria, Australia) was used to organise and analyse the qualitative data. Meaning units were identified in the text from the survey's open-ended responses, focus groups and telephone interviews. The meaning units generated 88 codes, which were scrutinized and compared in order to collapse similar codes into 15 subcategories (Graneheim & Lundman 2004). The subcategories were compared with each other and synthesized into four categories. During the coding process, the fifth author (GA) reviewed the codes and categories to mitigate single-source bias. The two authors (GA and MMG) discussed the analysis to identify agreement and explore disagreement in the coding, resulting in some reformulation of codes and categories. Finally, the comments related to each category and subcategories were quantified across the three perspectives.

Results

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

All three perspectives in both collaboratives reported generally positive perceptions of team coaching. Four categories – context, relationship, helping and technical support – and 15 subcategories of coaching actions emerged, as illustrated in the tree diagram in Figure 2. The most frequently mentioned coaching action from all three perspectives in both collaboratives was in the category of helping and, specifically, encouragement. The CF collaborative reported more positive perceptions compared to the ICN collaborative.

image

Figure 2. Coaching actions perceived by coachees, coaches and leaders to support improvement.

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Phase one: the coachees

Coachee survey quantitative and qualitative results

The quantitative results of the survey showed significant differences between the coachee groups on nearly half of the survey items (Table 1). The CF coachee results had a higher percentage of ‘strongly agree’ responses, indicating more satisfaction with coaching than the ICN coachees. The differences between the two groups were in the categories of relationship, helping and technical support.

Table 1. Comparison of Cystic Fibrosis Foundation Centers (CF) and the Vermont Oxford Network Intensive Care Nurseries (ICN) coachee survey results on reported coaching behaviours and actions presented in categories identified in the content analysis (n = 382)
Coachee Internet Survey Statements, categories and itemsCF (n = 198),% strongly agree (median)ICN (n = 184),% strongly agree (median)Fisher's exact test, P-value
  1. * 0.05

1. Context
a. Our coach has been effective in learning about and responding to local conditions and issues that are particularly significant at our site43450.94
2. Relationship
a. Our coach developed a positive working relationship with our team63480.01*
b. Our coach participated in conference calls with our team66550.05*
c. We had the right amount of telephone interaction with our coach53430.13
d. We had the right amount of e-mail interaction with our coach49370.03*
e. Our coach is easily accessible52460.36
f. Our coach has been timely in responding to our requests58510.28
3. Helping
a. Our coach was effective in facilitating our exercises during the learning sessions5629< 0.001*
b. Our coach was able to help us out when we got ‘stuck’5632< 0.001*
c. Our coach offered valuable encouragement68550.003*
d. Our coach has been effective in clarifying tasks47420.38
e. Our coach kept us on track with an eye toward the goals and completion of tasks53500.06
f. Our coach provided support and guidance to help us become an effective team5732< 0.001*
g. Our coach has been effective in encouraging the development of the self-learning and self-leading capacities of our team46470.87
4. Technical support
a. Our coach provided needed materials, resources and advice56420.02*

The qualitative analysis of the coachees' open-ended comments further elaborated the quantitative results with additional subcategories emerging: site visits, expectations and feedback. Both coachee groups most often reported perceptions in the category of helping. The subcategory of encouragement was the most frequently cited action and technical support the least cited (Table 2). The CF coachees' next most frequently emphasized category was relationships followed by context. The ICN coachees' second most frequent category was context followed by relationship. Table 2 (columns 4 and 6) shows that negative comments from ICN coachees ranged from 3% to 27% across the four categories compared with negative CF coachees' comments, which ranged from 0 to 16%.

Table 2. Frequency and percentage of coded comments by category and subcategory by Cystic Fibrosis Foundation Centers (CF)/Vermont Oxford Network Intensive Care Nurseries (ICN) coachees, CF/ICN coaches and CF/ICN leaders
CategorySubcategoryCoachees' CommentsCoaches' CommentsLeaders' Comments
CF, n = 478 n (%)Of which negative in category n (%)ICN, n = 444 n (%)Of which negative in category n (%)CF, n = 140 n (%)Of which negative in category n (%)ICN, n = 248 n (%)Of which negative in category n (%)CF, n = 326 n (%)Of which negative in category n (%)ICN, n = 731 n (%)Of which negative in category n (%)
ContextTotal number of comments56 (12)9 (16)117 (26)4 (3)26 (19)070 (28)2 (3)32 (10)6 (19)205 (28)7 (3)
Leader conflict22255
Local context3343632239223149
Site visit23581142983512
RelationshipTotal number of comments75 (16)5 (7)83 (19)21 (25)29 (21)066 (27)10 (15)74 (22)5 (7)137 (19)16 (12)
Communication611529414636443
Expectations5412921302184498
Interpersonal skills91934222201445
HelpingTotal number of comments298 (62)1 (0)193 (43)17 (9)51 (36)091 (37)2 (2)157 (48)0278 (38)2 (1)
Encouragement12853213184667
Clarifying14327616116231
Feedback3812455143048
Enable29283714111431
On track32160372025
Intensity14200910540
Teach432008122932
Technical SupportTotal number of comments49 (10)2 (4)48 (11)13 (27)34 (24)021 (8)063 (19)0111 (15)6 (5)
Improvement, measurement and meeting skills26117106831484
Resources1162242632
To do/task books121253696312

The CF coachees reported that they wished their coaches had visited their center to gain insights into the context. This contributed to 16% of the negative context comments. The ICN coachees wanted clarification on expectations and roles as noted in the quoted examples in Appendix S2. They did not always welcome coaching feedback and frequently disliked the technical tools and collaborative processes.

Phase two: the coaches

Coach focus groups

Overall, the CF and ICN coaches concurred with the coachee comments. The category of helping (including encouragement) was emphasized most in both coach groups. The CF coaches had more comments related to technical support than the ICN coaches (Table 2). The ICN coaches commented more frequently about relationships and context. There were no negative comments by the CF coaches whereas the ICN coaches made negative comments about context, relationship and helping. The largest percentage of negative ICN coach comments was in relationships (15%), including challenging relationships with some unit leadership as illustrated in the comment examples in Appendix S2.

New categories specific to the coaches emerged from the focus groups: coaching development, support and networking. The coaches in both collaboratives discussed the importance of a coaching network to share stories and struggles, to offer support and learn about coaching. Illustrative comments about support and networking include:

‘I appreciate the input of my colleagues. Maybe coaches ought to have a systematic way of discussing and offering ideas.’ (CF Coach)

‘I remember a lot of interaction among our coaching group. We would discuss what is going well, what is not going well and get feedback from each other. I know we talked a fair amount about our coaching experiences with a regular monthly coach call and emails in between.’ (ICN Coach)

Phase three: the leaders

Leader telephone interviews

The interviews reinforced previous knowledge identified in the coachee survey and coach focus groups. Again, the category of helping (specifically encouragement) was the most emphasized category in both leader groups. Nineteen per cent of the negative comments made by CF leaders were about desired site visits concurring with the coachee analysis (Table 2). The CF leaders offered mostly positive comments whereas the ICN leaders had more negative comments related to the relationship with the coaches (see Appendix S2). The CF and ICN leader interviews introduced new categories of sustaining improvement gains and benefits of coaching, including leaders learning about improvement and leadership skills:

‘Coaches should follow up every 6 months for a year to give us incentives – they should always check back.’ (CF Leader)

‘I learned that I should be quiet more often. [Having] patience was one behaviour that they [the coaches] modelled. [I learned] more listening and not imparting your own personal ideas before the group can come up with it on their own and have the opportunity to.’ (CF Leader)

‘Getting work done as the team, not just by me. I am more confident as a leader through the past year with the coaching.’(ICN Leader)

‘We run meetings differently and the QI [quality improvement] process is much clearer to me.’(CF Leader)

‘Having a coach and a sense of not wanting to let someone down over a 2-year period got you into a habit of doing QI. You can wean yourself from a coach when improvement becomes part of your daily routine.’ (ICN Leader)

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

The main finding in this study was that team coaching was perceived to positively support the improvement process from the perspectives of coachees, coaches and leaders in both collaboratives. Improvement can be defined as a process or an outcome (Batalden & Davidoff 2007, Berwick 2008). This study focused on team coaching, supporting the process of improvement and did not measure specific, predetermined outcomes.

There were differing degrees of perceived team coaching success between the two collaboratives from all three perspectives. Four categories of team coaching actions that supported health care improvement emerged. The actions included exploring the context where the team provides care and services, building relationships and communication processes with the improvement team and leaders, offering helping actions to support making improvements and reinforcing the process by offering technical support. The survey showed that the CF coachees were more satisfied with coaching than the ICN coachees, a finding that was further explained by the descriptive statements.

One explanation for the differences may be found in the characteristics of the CF and ICN collaboratives. The CF teams were ‘novice’ improvers whereas the ICN members had years of experience of improvement and could be considered ‘proficient’ improvers. However, the coaching actions were the same in both collaboratives. A ‘one size fits all’ approach to coaching without consideration of the unique skills, context and culture may be unproductive (Jones & Spooner 2006). Benner (2004) outlines the continuum of novice to expert and reports that the novice stage requires clear rules and guidelines for execution. The CF coachees, coaches and leaders were novices in improvement and needed clarity and guidance provided by the curriculum. The ICN coachees, coaches and leaders were more experienced improvers and found some coaching fundamentals, such as effective meeting skills and the improvement curriculum, disruptive to their usual improvement methods.

Interestingly, an anomaly emerged in the analysis of ‘internal’ to the community coaching compared with ‘external’ to the community coaching. The ICN coaches, who were ‘external’ to the ICN community, had years of experience of coaching interprofessional teams in the process of making improvements in various health care settings, yet some coachees and leaders made negative comments in some categories. Knights and Poppleton (2008) discussed the advantages and disadvantages of internal versus external coaching. Advantages of internal coaching include the knowledge of the specialty, culture, history, people, systems and organisation that may expedite trust and confidence. These advantages were clearly experienced by the CF coaches who were ‘within’ the larger national CF community and ‘external’ to the individual CF centers. They brought knowledge and experience of CF care while at the same time needed to learn about the unique local settings. External coaching may offer a ‘fresh’ view of the context, broader and varied coaching experiences and a wider range of ideas. The ICN coaching results verify the disadvantage of external coaching in not having intimate knowledge of the local context, culture, history and organisation (Frisch 2001). Both types of coaching require effort to understand the unique settings of interprofessional teams.

Knowledge of the local context of improvement was further reinforced and articulated by the three groups as important to coaching. Healthcare improvement leaders have strongly suggested that local context should be taken into account (Donabedian 1988, Batalden & Davidoff 2007, Bate et al. 2008, Berwick 2008, Nelson et al. 2009). Attempts to ‘install’ or ‘insert’ evidence-based practice or best-known practices frequently fail because of a lack of insights about the context and the need to reinvent, tailor or modify the innovation to fit local conditions (Berwick 2003b, Batalden & Davidoff 2007, Walshe 2007).

Relationships between coaches and the coachees and leaders were different in the two collaboratives. The CF coaches had a more positive relationship with the coachees and leaders than the ICN coaches. However, the ICN leaders reported relationship improvements during the coach site visits where the coachees, coaches and leaders spent time together. Creating honest and open conversation is essential to calibrate the relationship and prevent a positional hierarchy. Schein (2009) deliberately creates a space for the coachees and the coach to explore the ‘ignorance about the internal world of each other’. Creating this shared space or ‘cultural island’ to learn about and help each other to practice improvement, supports learning that may have started in a formal setting.

Helping (specifically encouragement) was the most frequently cited supportive coaching action in both collaboratives from all three perspectives. For a coach to provide help, it was essential that there was a degree of understanding to know what help to offer. Trust is needed for the coachee or leader to engage in honest dialogue to reveal what is needed and then accept the help that is offered (Schein 2009). Other helping actions included clarifying the tasks and improvement processes, reframing situations and offering guidance and constructive feedback to keep the team on track. The ICN coachees and leaders expressed concerns that not enough of the coaching feedback was positive, which may have related to the coaches' desire to challenge the experienced improvers to higher levels of performance (Vermont Oxford Network 2005, Jacob et al. 2011).

Technical support was the least identified action by the ICN coachees, coaches and leaders. The CF coaches and leaders commented frequently about benefiting from tools and resources to support their nascent improvement activities. The ICN coachees' negative comments were related to the same topic, but they tended to dislike new tools and processes that required them to learn new improvement methods.

The gap between formal improvement knowledge and application in the workplace might become smaller with intentional efforts to study the local context and identify support needed such as team coaching. Documented models and recommendations about ‘training transfer’ into a challenging workplace do not consistently consider the regular support those engaged in the adaptation of knowledge may need (Brinkerhoff & Montesino 1995, Facteau et al. 1995, Burke 1997). The PARiHS framework (Rycroft-Malone 2004) consists of three elements (evidence, context and facilitation) to help address the issue of knowledge transfer and translation that might inform improvement efforts. A number of authors (Kitson et al. 1998, Harvey et al. 2002, Rycroft-Malone et al. 2002, Rycroft-Malone 2004) have identified the need for research to clarify the interventions and effectiveness of the facilitation.

The coaches expressed interest in learning and networking with other coaches to advance their own expertise. Social networks have been identified by many groups to support common goals and interests. House (1981) described four broad categories of social network supportive behaviours that could contribute to coach development: emotional support, appraisal support, informational support and instrumental support.

Leadership development emerged as an unexpected outcome of team coaching. Leaders described learning about health care improvement, meeting skills, measurement techniques and ways to ‘manage up’ in the organisation (e.g. providing improvement updates and information to leaders at higher levels in the organisation to raise awareness). These findings reinforce the recommendation that for health care improvement to become part of the daily work of providing care and improving care, health care leaders should be able to offer support and guidance to the staff they supervise (Batalden & Davidoff 2007).

Our study highlights what matters to those who are being coached. Over 80% of the comments offered by coachees, coaches and leaders focused on the personal experiences of learning about and trying to make improvements in health care. Building relationships, being respected, having positive interpersonal communications and receiving help (encouragement) were reported to make a difference to those engaged in health care improvement. The technical know-how that is often the primary focus in health-care improvement strategies was the least perceived need of front-line teams. Bate et al. (2008) support this finding in their research on how health systems organise for quality. They found that successful enterprises see quality not as a method, technique, discipline or skill, but as a human and organisational accomplishment.

Stober and Grant (2006) call for more coaching practice that is linked with existing, applicable bodies of knowledge and science to enhance coaching credibility. An evidence-based team-coaching model built from previous knowledge, combined with current research findings, may provide a practical path towards supporting health care improvement in the workplace. The inclusion of the three perspectives in a team coaching model may result in more consistent and sustainable improvements.

Limitations

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

The study had several limitations. First, the focus group data collection method was selected for the coaches to explore their shared coaching experiences through dynamic interactive discussion (Morgan 1997, Stewart & Williams 2005, Stewart et al. 2007). However, the planned in-person focus groups were cancelled to avoid unintentional spread of the 2009 H1N1 influenza virus. The rescheduled focus groups used web technology and web cams (Adobe Connect) and were smaller as a result of rescheduling (CF n = 4, ICN n = 5) (McLafferty 2004). Carey and Smith (1994) suggest that smaller groups result in more interaction and greater ease of managing group dynamics. The participating coaches were representative of the two coaching groups with regard to years of coaching experience. The novel use of a web camera during the focus groups enhanced communication because the moderator and focus group members could observe facial expressions. Focus group literature cites many examples of virtual focus groups, but not with web cameras (Kenney 2005, Stewart & Williams 2005). Using web cameras presents an opportunity for further research to understand benefits, potential risks and pitfalls of using this technology.

Second, there is a risk of bias in this study related to the first author's (MMG) role in the planning and execution of the collaborative initiatives: MMG partnered with CF and ICN leaders to develop the improvement curriculum and coaching programmes, and was a coach for three of the ICNs. The use of an external moderator for the coach focus groups was an attempt to mitigate bias. MMG facilitated the leader telephone interviews and this might have reduced participant candour and increased participant reluctance to offer negative opinions.

Third, there are difficulties in drawing meaningful and accurate conclusions. Threats to validity in a study often include using the same individuals, the same sample for qualitative and quantitative phases and not using an instrument with established validity and reliability (Bazeley 2004). The mixed methods study design included different individuals and different samples sizes in the three-phase design to generate multiple different perspectives. Triangulation of findings was used across groups to converge on coaching actions that tended to be viewed as helpful or not helpful. Discussions amongst the authors helped to verify the first author's (MMG) analysis and may increase the credibility of the findings (Graneheim & Lundman 2004). With respect to the coachee survey, although it has been used with hundreds of individuals in many health care settings (beyond those in this study) to provide reports on coaching actions, the survey has not undergone formal testing to establish its reliability and validity.

Fourth, there is the problem of generalizability. The generalizability of the findings may be limited because of the study's focus on just two specific improvement topics (improving care in CF centers and ICNs), each with varied histories of collaborative improvement work done in the USA.

Fifth, there were no pre-collaborative and post-collaborative improvement outcome measurements to demonstrate if coaching, within the context of the collaborative, was associated with the desired improvements.

Conclusions

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

Research literature has documented the inconsistent outcomes of improvement collaboratives to achieve desired improvements in health care. Introducing a structured team coaching model to support interprofessional teams to learn and practice improvement processes and methods at the front line of care may provide help in achieving desired improvements. Leaders can benefit from team coaching by participating with the teams and learning improvement science along with new ways to lead teams. Coachees, coaches and leaders agreed that regardless of who the coach is, emphasis should be on the local context, building relationships, offering help in the daily work of providing and improving care, and providing technical help as needed.

Implications for nursing management

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

Leaders should reflect on their own actions to support improvement teams and consider the four categories of beneficial team coaching actions. They might seek opportunities to learn about improvement science and explore leadership styles that promote interprofessional team participation in improvement. When planning strategies for health care improvements, it is important to consider developing coaches who understand the importance of meeting interprofessional teams ‘where they are’ and building helping relationships. Using a structured team coaching model that offers needed encouragement to keep the team energized appears to support health care improvement.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

The authors gratefully acknowledge the Cystic Fibrosis Foundation and Vermont Oxford Network for providing the study context of the Learning and Leadership improvement collaboratives and the ‘Your Ideal NICU’ improvement collaborative. Special acknowledgement is expressed to all the interprofessional teams, coaches and unit leaders in the improvement collaboratives who generously participated and shared their unique perspectives of team coaching. We also thank Jönköping University School of Health Sciences, Jönköping Academy for Improvement of Health and Welfare, Jönköping County Council, Qulturum and Futurum and the Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, NH, USA, for funding for this study.

Sources of funding

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

The authors received funding from Jönköping University, School of Health Sciences, and Jönköping County Council; Qulturum and Futurum, Jönköping, Sweden. The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH, USA.

Ethical approval

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information

Ethical approval (#22131) was granted by the Committee for the Protection of Human Subjects at Dartmouth College (Trustees of Dartmouth College 2012).

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  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information
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Supporting Information

  1. Top of page
  2. Abstract
  3. Background
  4. Aim
  5. Methods
  6. Analysis
  7. Results
  8. Discussion
  9. Limitations
  10. Conclusions
  11. Implications for nursing management
  12. Acknowledgements
  13. Sources of funding
  14. Ethical approval
  15. References
  16. Supporting Information
FilenameFormatSizeDescription
jonm12068-sup-0001-Appendixs1-s2.docWord document70K

Appendix S1. Characteristics of coachees, coaches and paired leaders by collaborative type (Word document).

Appendix S2. Cystic Fibrosis Foundation Centres (CF) and Vermont Oxford Network Intensive Care Nurseries (ICN) comment examples by category, coachee, coaches and leader roles (Word document).

Please note: Wiley Blackwell is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.