Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development

G Model COLEGN-380; No. of Pages 8

ARTICLE IN PRESS Collegian xxx (2016) xxx–xxx

Contents lists available at ScienceDirect

Collegian journal homepage: www.elsevier.com/locate/coll

Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development Annette Faithfull-Byrne a , Lorraine Thompson a,∗ , Keppel W. Schafer a , Michelle Elks a , Jenny Jaspers a , Anthony Welch b , Moira Williamson b , Wendy Cross c , Cheryle Moss c a

Sunshine Coast Hospital & Health Service, PO Box 547, Nambour, Queensland, Australia School of Nursing and Midwifery, Noosa Campus, Central Queensland University, Queensland, Australia c School of Nursing and Midwifery, Faculty of Medicine, Nursing and Health Sciences, Monash University Clayton Campus, Victoria 3800, Australia b

a r t i c l e

i n f o

Article history: Received 8 April 2014 Received in revised form 2 June 2016 Accepted 7 June 2016 Available online xxx Keywords: Clinical coach Workplace learning Nursing and midwifery staff development Education Clinical

a b s t r a c t Contemporary demands for workplace learning and development in real time have guided one health service to create a new role, that of the clinical coach. Clinical coaches provide point of care educational interventions to achieve clinical skill and practice development for nurses and midwives and to stimulate a culture of learning and development within the organisation. Clinical coaches use coaching processes and mantras, facilitation skills, practice development principles, adult learning strategies, supported practice and clinical assessment tools to achieve these goals within a person-centred philosophy. Specific point of care accountabilities of the coaches related to staff development include supporting clinical induction requirements, supporting preceptor and learner practices, supporting evidence-based clinical development, ensuring that mandatory training requirements are met, and coaching for the maintenance of safe and competent practice. The clinical coach role has evolved throughout the health service over a number of years. Organisational data reveal the acceptability of the coaching role in the organisation along with successful outcomes. Based on this case experience, it is recommended that other health services consider clinical coaching as a relevant mechanism for advancing point of care workplace integrated learning and development. © 2016 Australian College of Nursing Ltd. Published by Elsevier Ltd.

1. Introduction The innovative use of coaches in clinical settings can make a difference to how nurses and midwives engage in workplace learning and development. This paper reports on the progress of a clinical coach role that has been developed and implemented across a health service in Queensland, Australia. Specifically, this new education role is an innovative response designed to advance the learning of clinical teams at the point of care. Using concepts of coaching, which originated from sport, clinical coaches have been used as a vehicle for supporting staff to progress their learning journeys. The focus of coaching is on both the personal and professional development of the clinical team,

∗ Corresponding author. Tel.: +61 7 5470 5273; fax: +61 7 5470 6571. E-mail addresses: [email protected] (A. Faithfull-Byrne), [email protected] (L. Thompson), [email protected] (K.W. Schafer), [email protected] (M. Elks), [email protected] (J. Jaspers), [email protected] (A. Welch), [email protected] (M. Williamson), [email protected] (W. Cross), [email protected] (C. Moss).

with the overall goal of improved patient care. Fostering productive and positive relationships within clinical teams, working with person-centredness, and using concepts of practice development are all ways in which clinical coaches help teams to achieve their clinical development goals. In this paper, the authors identify the theoretical and conceptual background to model of coaching that has been developed. They share the context in which the innovative role was developed, and explain the conceptual model of coaching that is used across the health service. 1.1. Theoretical and conceptual background In Australia, there has been significant investment in education of health professionals at the bedside where the focus of learning has been on the needs of individual learners (Maxwell, Black, & Baillie, 2015; Santos, 2012). Clinical educators teaching in these clinical settings serve post-registration professionals and undergraduate students (Conway & Elwin, 2007; Govranos & Newton, 2014; Maxwell et al., 2015; McKenna & Newton, 2008). Internationally, clinical nurse educators have been associated with quality and

http://dx.doi.org/10.1016/j.colegn.2016.06.001 1322-7696/© 2016 Australian College of Nursing Ltd. Published by Elsevier Ltd.

Please cite this article in press as: Faithfull-Byrne, A., et al. Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development. Collegian (2016), http://dx.doi.org/10.1016/j.colegn.2016.06.001

G Model COLEGN-380; No. of Pages 8

ARTICLE IN PRESS A. Faithfull-Byrne et al. / Collegian xxx (2016) xxx–xxx

2

safety advancement in health services (Bargagliotti & Lancaster, 2007; Cronenwett et al., 2007; Day & Smith, 2007; Sherwood & Drenkard, 2007; Singer, Benzer, & Hamdan, 2015). Clinical educators work with professional development frameworks and strategies to promote and achieve a highly skilled professional workforce that can function in specific clinical environments and achieve wider functionality within the health services context (Considine & Hood, 2000; Gaberson, Shellenbarger, & Oermann, 2015; Kelly & Simpson, 2001). They promote nurses and midwives performance and work attitudes (Gaskell & Beaton, 2015; Johnson, Hong, Groth, & Parker, 2011) assess and monitor clinical learning environments (Chan, 2001, 2002; Faithfull-Byrne, 2011b; Santos, 2012), and assist achievement of health service modernisation (Page, 2002; Thorpe, Moorhouse, & Antonello, 2009). Attention has been paid to assisting registered nurses and midwives in their transition from clinical roles to education work (Duffy, 2013; Grassley & Lambe, 2015; Weidman, 2013). Over the past decade the roles of nurse educators have needed to evolve and expand. In particular, educators are now highly involved in strategic and team development in response to organisational and industry changes, and quality management requirements (Adelman-Mullally et al., 2013; Haines & Coad, 2001; Sayers & DiGiacomo, 2010). Clinical point of care is when clinicians deliver healthcare products and services to patients at the time of care (Ebell, 1999). While the term point of care is commonly associated with clinical documentation and information technology needs at the bedside, in this paper we use the term in the context of providing educational services to patients and health professionals at the time of care. National and international reports on the requirements for the nursing and midwifery clinical workforce identify the need for new point of care educational strategies and for the technological training and development of the registered health professional workforce (Curran, Sheets, Kirkpatrick, & Bauldoff, 2007; Health Workforce Australia, 2011; Werrett, Helm, & Carnwell, 2001). In addition, there is greater demand for bedside training and support of unregulated health care workers (Duffield et al., 2014; Health Workforce Australia, 2013a, 2013b). Modern health professionals require professional development plans, the need to achieve set hours of continuing education, and assume responsibility as adults for their ongoing learning and skill development (Clinical Education & Training Queensland, 2011; Eraut, 2000). These activities generate the need for new models of learning and development to be implemented within clinical contexts at the point of care (McCormack & Slater, 2006). Point of care learning concerns time and place of learning interventions, is orientated to clinical situations and occurs as the need arises within the circumstances of care. Point of care learning is about learning in real time, compared to classroom learning and other forms of education that often involve preparatory work, reflective and retrospective actions. Prioritisation of point of care learning is a crucial impetus behind the development of the role and function of the clinical coach in nursing and midwifery services.

1.2. Contextual background In response to contemporary needs for point of care education the Sunshine Coast Hospital and Health Service (SCHHS) has innovated a clinical coach role in nursing and midwifery education services (Faithfull-Byrne, 2011a, 2011b, 2015). Precipitating forces within SCHHS determined that the organisation provide quality and safe clinical practices, and ensure these by responding to the learning needs of nurses and midwives. The organisation identified the need for clinical coaches, and this generated clarity regarding the intentions and purpose of the role that would be needed for organisational functionality.

2. The need for clinical coaches: precipitating forces Analysis of nursing and midwifery education roles in the SCHHS revealed several important issues. Nurses and midwives in clinical educator roles experienced significant competing priorities for their time. Their roles in leading workplace clinical education had expanded massively. While maintaining staff development responsibilities, clinical educators were also heavily enmeshed in service development. Joint participation in strategic organisational and change management activities, leadership and practice development projects were essential in their clinical worksites. Clinical educators’ time was at a premium and many reported that time spent educating at the bedside was being compromised. Similar challenges were reported in nursing and midwifery education throughout Australia over an extended period of time (Haines & Coad, 2001; Heath, 2002; Ministerial Taskforce on Clinical Education and Training, 2007; National Nursing & Nursing Education Taskforce, 2006; Sayers & DiGiacomo, 2010). Compounding this situation, clinical educators were relatively isolated as the organisational structure meant that they worked independently of each other in specific areas and facilities. Group fragmentation was exacerbated by the educators’ experiences of multiple reporting lines and differing service models. In addition, the overall demand for point of care learning and clinical educator interventions in clinical areas meant that there were insufficient people and resources available to attend to all the required and expected work. Due to diffused workplace structures, varying degrees of financial commitment to education, and geographical challenges there was inconsistent staffing and utilisation of the clinical education team. A review recommended an alternative structure and intervention for clinical education at the bedside or point of care. The vision for the clinical coach framework was produced. In addition to the need to develop a new role to support clinical educators, there was also a need to support the transition of clinical nurses to educational positions. The vision for clinical coaches who would work in partnership with clinical educators throughout the organisation, carried possibilities for ‘point of care’ education focused work, enhanced functionality of educational teams, and skill transitions for nurses and midwives who were wanting to provide ‘on the ground’ education. The analysis provided opportunities for the SCHHS to examine the model of point of care education and the contemporary educational philosophy to be implemented, to achieve a modern and adult professional nursing and midwifery workforce. It was recognised that clinical coaches using practice development methodologies, facilitation skills and person-centred approaches to learning and development could complement clinical educators. This was seen as a vehicle to shift the clinical environments towards attaining an organisational culture of learning. 3. The clinical coach framework: a new model of education The intent, educational strategies and some of the theoretical bases that embedded the clinical coach model at the SCHHS are identified below (Faithfull-Byrne, 2011b). 3.1. The clinical coach conceptual model The clinical coach role was designed to provide a new real time, in-situ model of education to support clinical staff in their workplaces and to achieve advancement in practice and organisational learning cultures (Faithfull-Byrne, Thompson, Cross, & Moss, 2015). The clinical coach role was designed to complement and provide additional infrastructure to clinical educators by ensuring that clin-

Please cite this article in press as: Faithfull-Byrne, A., et al. Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development. Collegian (2016), http://dx.doi.org/10.1016/j.colegn.2016.06.001

G Model COLEGN-380; No. of Pages 8

ARTICLE IN PRESS A. Faithfull-Byrne et al. / Collegian xxx (2016) xxx–xxx

3

Fig. 1. Clinical Coach Intent, Skills and Outcomes: Conceptual Representation.

ical education occurred at the point-of-care, within the clinical context in real time. Identification of the context and the purpose of coaching, enabled conceptualisation of teaching-learning processes that needed to be embedded within coaching practices. This resulted in the development of a clinical coach framework; the teaching learning processes are identified in Fig. 1. These include: coaching processes and mantras, facilitation skills, practice development principles, adult learning strategies, person-centredness, coaching accountabilities, clinical assessment tools and framework, and a supported practice framework. It was envisaged that the clinical coach framework would provide an improved clinical and organisational learning climate, specific clinical coaching outcomes, better-quality patient care, enhanced team development across the services with clinical educators, and learning trajectories for registered nurses clinical facilitation and learning skills for the organisation. In the context of the SCHHS the Clinical Coach Framework evolved from an eclectic mix of general coaching philosophies (sport, life and health coaching), professional practice development and clinical learning philosophies and practices (nursing and midwifery), and specific role responsibilities derived from performance needs within the health service. 3.2. Definition of coaching Clinical coaches work at the point of care, coaching and supporting nurses and midwives in their delivery of high quality services. They provide individual and group learning facilitation for health professionals and students who work alongside them, in their clinical area by using a coaching philosophy and a person-centred approach to guide their interactions. These practices are informed by definitions derived from various sources. The International Coach Federation (Federation, 2008) defines coaching as “a thought-provoking and creative process that inspires [individuals]. . . to maximise their personal and professional potential” (p.1). Similarly, Spence and Grant (2007) view coaching as “a collaborative relationship formed between a coach and the coachee for the purposes of attaining personal development outcomes which are valued by the coachee” (p.186). Lyle (2002) described coaching as residing in a humanistic philosophy and

being a “person-centred ideology that emphasises the empowerment of the individual towards achieving personal goals within a facilitative interpersonal relationship” (p.174). 3.3. General philosophy of coaching The general philosophy of clinical coaching was widely influenced by the work of leaders and coaches as diverse as Australian National Rugby League coach Wayne Bennett and spiritual leader His Holiness the Dalai Lama, both of whom advocate compassion for their teams/people and use relationships as the vehicle for change and personal improvement (Bennett & Crawley, 2002; Dalai Lama & Cutler, 2005). The life and work of Australian track and field coach Paul Faithfull, also inspired the vision and philosophical directions of the Clinical Coach model. His compassionate and collaborative coaching style drove a culture of person-centeredness and high performance within his athletic teams (Gardiner, 2005, January 14th; ““Toowoomba athlete remembered as a pioneer”,” 2005, January 12th). Coaches require and use emotional intelligence, particularly the elements of personal and social competence (Bennie & O’Connor, 2010). For instance, Côté and Gilbert (2009) writing about sports coaching define coaching effectiveness and expertise as “the consistent application of integrated professional, interpersonal, and intrapersonal knowledge to improve athletes knowledge competence, confidence, and character in specific coaching contexts” (p. 316). These elements are developed through self-awareness, self-regulation, social awareness and relationship management (Kunnanatt, 2008). Coaches need to be aware of their own strengths and areas to work on, as well as being open to feedback. The ‘use of self’ as a tool and the ability to reframe their thinking are key tools. Coaches often promote the development of these skills in others. Coaching is guided by adult learning, lifelong learning, and psychological principles. Aspects of cognitive behavioural theory, solution focussed theory, and humanism/person-centredness underpin many coaching strategies (Moore & Tschannen-Moran, 2010; Spence & Grant, 2007; Starr, 2011; Whitmore, 2010). The coaching philosophies that interested our organisation for application by health professionals are also generally consistent with adult learning theories such as those proffered by Eraut (2000), Foley (2004), Lave and Wenger (1991), Rogers and Horrocks (2010),

Please cite this article in press as: Faithfull-Byrne, A., et al. Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development. Collegian (2016), http://dx.doi.org/10.1016/j.colegn.2016.06.001

G Model COLEGN-380; No. of Pages 8

ARTICLE IN PRESS A. Faithfull-Byrne et al. / Collegian xxx (2016) xxx–xxx

4

Rogers, Lyon, and Tausch (2014), and Wenger (1998). Contemporary needs for life-long learning (Clinical Education and Training Queensland, 2011; Duff, 2013; Gopee, 2005), ongoing self and professional development (Katsikitis et al., 2013) and ongoing performance improvement (Tovey, Uren, & Sheldon, 2010) also influence coaching practices. The intentions of coaching vary considerably. However, the principles of active listening, working collaboratively, setting goals, maintaining motivation, monitoring progress towards goals, asking potent questions and promoting self-awareness are all important coaching skills. These are commonly applied when assisting individuals in overcoming obstacles and to reach their personal and professional goals. Coaching is less about teaching techniques and more about learning. As Whitmore (2010) identifies it is about “unlocking a person’s potential to maximise their own performance. It is helping them to learn rather than teaching them” (p.10). The philosophies of person-centeredness and coaching are applied and experienced as the ‘espirit de corps’ of the role. Karsten et al. (2010) while discussing coaching for nursing managers in the frontline (executive coaching) identify key aspects that we believe relate to the remit and outcomes of clinical coaches. Karsten et al. (2010) report that coaching can provide coachees with the necessary tools to excel in their jobs, enhance their effectiveness in their roles and result in increased feelings of competence and confidence, and generate better retention of staff and better team outcomes. Kellett (1999) who researched sports coaches in Australia found that coaches offered leadership by promoting and supporting their coachees. Coaches’ practices generally assisted coachees to realise their leadership potential, by providing a supportive learning culture and environment, by using methods of personal and professional empowerment, by being skilful in communication, and by planning workable guidelines for performance. 3.4. Nursing and midwifery coaching strategies Clinical educators have traditionally used health professional training models and frameworks. Some of these include clinical competence assessment, problem solving, critical thinking, technical skilling and risk management (Gaberson et al., 2015). Facilitative frameworks in nursing and midwifery have proliferated over the past decade; these include positive psychology approaches, collaborative partnerships, practice development, culture work, and evidence based practice. Within the SCHHS other clinically specific development strategies to professional coaching were added. These encompassed strategies of facilitation (Karsten, Baggot, Brown, & Cahill, 2010; Rogers et al., 2014), practice development (McCormack, Manley, & Titchen, 2013), team mantras (Moore & Tschannen-Moran, 2010; Starr, 2011), a clinical assessment framework (Robb, Fleming, & Dietert, 2002; Watson, Stimpson, Topping, & Porock, 2002; Wilkinson, 2013), and a supported practice framework (Chan, 2002; Nursing and Midwifery Board of Australia, 2008, 2010). 3.5. Facilitative learning The theory of facilitative learning (Karsten et al., 2010; Rogers et al., 2014) is used as a simple guide for the facilitative processes and relationships that are intentioned by the clinical coaches. Rogers postulated that learning occurs when educators act in a facilitative manner through fostering situations in which learners feel comfortable, are able to consider new ideas, and are not threatened by other factors. For Rogers, when using a facilitative process ‘teachers’ are more able to listen and prioritise the learner’s learning than their own teaching constructs, and they use genuine rapport to generate constructive insight between themselves and their learners. In principle, using Rogerian humanistic processes

Fig. 2. Example of Coaching Mantras.

in health services, learners are assisted to take responsibility for their own learning, have input into the learning through their own insights and experiences and use self-evaluation while focusing on the factors that contribute to solving important problems or achieving significant results. 3.6. Concepts and principles of practice development Internationally used concepts and principles of practice development (McCormack et al., 2013) are adopted as processes by the clinical coaches. These comprise person-centred facilitation and systematic processes for examining and advancing practice and workplace cultures. Coaches and clinical teams work towards identification of values and the examination of current practices at a local unit level. This provides a foundation to explore practice and workplace cultures, to challenge rituals, routines and assumptions, and to facilitate new ways of working that are values and evidence based. Grounded in the principles of practice development coaches and teams seek to enlighten, empower and liberate others towards local action within their clinical units. 3.7. Coaching mantras Coaches do not place themselves as the expert who has come to “teach” people. Although coaches do provide information about subjects, their role is to partner with the individual on their learning journey, empowering staff in their learning and development. To assist clinical coaches and teams, the techniques of using coaching mantras were adopted (Fig. 2). For example, some mantras taught and used by the teams and the clinical coaches are ‘be the guide on the side not the sage on the stage’ (Morrison, 2014, p. 1; Saulnier, 2008), ‘do with, not for’, and the proverb “give a man a fish and he eats for a day, teach him to fish and he can feed his village for life” (a proverb attributed to Lao Tzu). The use of these mantras has resulted in individual coaches being more engaged in a team approach to clinical practice development, similar to how a team’s mantras are used to unite players. Each of these examples place the coach in a motivating and adjunctive position, rather than a central place. 3.8. Clinical assessment tools and framework Clinical Assessment Tools (CATs) are widely used in nursing and midwifery education (Rebeiro, Jack, Scully, & Wilson, 2013; Tollefson, 2012; Wilkinson, 2013) for pre-performance preparatory teaching, in-situ or real time clinical skill performance assessment, and for reflective post-performance critical analysis. CATs are also used for self-assessment and peer review. The clinical coaches work a range of CATs in coaching processes, and encourage others to use them for workforce and individual development (Rainbow, Thompson, Mullamphy, Faithfull-Byrne, & Cross, 2015).

Please cite this article in press as: Faithfull-Byrne, A., et al. Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development. Collegian (2016), http://dx.doi.org/10.1016/j.colegn.2016.06.001

G Model COLEGN-380; No. of Pages 8

ARTICLE IN PRESS A. Faithfull-Byrne et al. / Collegian xxx (2016) xxx–xxx

Apart from using published CATs (Rebeiro et al., 2013; Tollefson, 2012), the SCHHS produces evidenced based, criterion based CATs related to required skills and task performance by nursing and midwifery staff in specific clinical areas (Rainbow et al., 2015). Required performance and skills may be identified through organisationwide CATs or site/program specific CATs. For instance CATs for the Emergency Department, often need to be different to those in a general medical inpatient unit and these in turn may be different to those used in a community or outreach service setting. The clinical coach with site/program specific responsibilities and skills is well placed to assist the staff working in specialised areas achieve and maintain relevant and agreed clinical competencies and to achieve safe and quality care. 3.9. Supported practice framework The supported practice framework (Faithfull-Byrne, 2011a) used by the clinical coaches involves a range of learning and performance development strategies. Many of the standards and processes are drawn from professional regulation, industry standards and organisational requirements (Australian Commission on Safety and Quality in Health Care, 2010; Nursing and Midwifery Board of Australia, 2008, 2010; Robb et al., 2002). All standards and expectations are transparent in the clinical environment, and there are team and workplace expectations within the culture of work that all staff achieve and perform at levels appropriate to their role and appointment. The supported practice framework is implemented when there is concern about an individual’s competence or performance or if his/her practice needs to be improved. Clinical coaches and others use this structured and supportive approach in the clinical setting to achieve valid assessment of performance where competence and safety standards have been questioned. Across numerous clinical situations health professionals may at times find their standards (knowledge, skills attitudes) and performance challenged. This is particularly true when new evidence is identified and practice change needs to occur. In addition, some staff may be at risk of performing a skill marginally or incompletely, or need to improve their technical capacity to deliver care at the expected professional and workplace standard. Health professionals in this situation are supported and provided with opportunities for performance and competency appraisal with the objective of performance improvement. Using a collaborative action cycle, staff members set goals then practice and perform with feedback and coaching. This targeted intervention is designed to achieve agreed performance standards and criteria. There are natural justice processes embedded in the cycle, and an array of assessment tools are used to achieve fair and reliable assessment of performance, based on guidelines for performance improvement. 3.10. Specific clinical coaching responsibilities Just as in sport coaching (Lyle, 2002), life coaching (Starr, 2011), leadership coaching (Whitmore, 2010) there are multiple coaching foci and outcomes to be achieved. The SCHHS has created specific clinical coaching responsibilities and outcomes that must be achieved by the coaches. Areas of accountability are directly related to the specific responsibilities of the clinical coach, are aligned to the overall development of a learning organisation culture and to the philosophy of coaching. Specific coaching interventions and accountabilities ensure that each workplace/clinical program achieves clinical induction goals, learner and preceptor goals and activities, clinical development strategies and goals, mandatory training requirements and safe professional practice. These practical and philosophical processes form the basis for realising the desired development in workplace learning through

5

the clinical coach model. Further work could be undertaken to explore other aspects of coaching work and to consider whether these should be further incorporated into the coaching model. Additionally, similar to other innovative role developments in health services, the conceptual and operational framing for the clinical coach role is somewhat intuitive and relies on tacit fuzzy logic (Jensen & Lopes, 2011).

4. Clinical coaches: implementation and outcomes Importantly within the SCHHS clinical coaches have specific staff development responsibilities (Table 1). These include responsibilities for workplace learning related to supporting clinical induction requirements and preceptor and learner practices, enabling evidence based clinical development, ensuring that mandatory training requirements are met, and coaching for the maintenance of safe practice. Clinical skill development is achieved within the milieu of person centeredness. The focus is on both the personal and professional development of individuals and the clinical team. The ultimate aim is improved patient care. The team approach to skills and knowledge acquisition and refinement is centred on the philosophy of in-situ educational delivery. The humanistic educational philosophy also affirms the importance of clinical coaches who foster a culture of openness, transparency and collegiality. The clinical coaching model supports measurable outcomes to be reported across all clinical units in the organisation. Outcomes are measured using the above five key areas of accountability and the ten indicators, which are reported biannually (Table 1). The new model of clinical education has been adopted across three of the hospitals within the health service. In 2014, 35 Clinical Coaches held positions in 30 clinical areas. Utilising the ratio of one coach to fifty staff, the framework has been successfully implemented across a range of practice settings including midwifery, emergency, medical, surgical, renal, aged care, palliative care, intensive care, peri-operative, cancer care, special care nursery and paediatrics. Adopting the model of education service delivery required executive support. Directors of Nursing and Midwifery Services within the SCHHS have endorsed the model, thereby enabling it to be implemented across the entire health service. Executive support coupled with a robust and clearly articulated service delivery model was the critical success factor for effective clinician engagement. Over the seven years that the clinical coach role has been in place, the SCHHS has concentrated on developing clinical coaches and achieving role readiness, ‘norming’ clinical coaches in workplace culture, and building achievements in relation to specific clinical performance indicators. Internal audit data assists the organisation in monitoring the progress and outcomes of the clinical coach project to improve point of care workplace learning and development. From the inception of the Clinical Coach role there has been a demonstrated increase in organisational training compliance and clinical skill advancement. Some of the greatest rewards of the approach, however, are found within the immeasurable aspects of individual personal and professional development. The culture of person centeredness has resulted in a more compassionate, collaborative and collegial environment that embraces positive educational experiences at the point of care. Services have noted major improvements in all point of care education and staff report greater satisfaction whether receiving clinical support or through coaching itself and enacting the clinical coach role. Service reports indicate quality gains in the five key areas of accountability across services. For example, each year since the introduction of clinical coaches, the whole service shows improvement trends in the percentage of staff trained as preceptors

Please cite this article in press as: Faithfull-Byrne, A., et al. Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development. Collegian (2016), http://dx.doi.org/10.1016/j.colegn.2016.06.001

G Model

ARTICLE IN PRESS

COLEGN-380; No. of Pages 8

A. Faithfull-Byrne et al. / Collegian xxx (2016) xxx–xxx

6

Table 1 The Clinical Coach Framework: Accountabilities and Measurable Outcomes. Nursing and Midwifery Clinical Coaches Five Specific Clinical Accountabilities

Recommended/Example Strategies to Achieve these Outcomes

Ten Measurable Outcomes/Indicators

A) Clinical Induction

Establish unit demographics (staff and patient) Ensure unit induction process is current Support Performance Appraisal & Development (PAD) process Facilitate staff to become preceptors

Induction reviewed Improved (%) PAD rate for current year c/f previous 12mths

B) Preceptor / Learner Support

Support preceptors to induct/support learners

C) Clinical Development

D) Mandatory Training E) Safe Practice

advanced planning of roster preceptor allocation on roster access to learning resources Implement clinical education/in-service plan Identify core clinical competencies & evidence based practices that staff prioritise for team & workplace development Access educational resources Management of unit based training data Support portfolio holders to implement mandatory training plans Identify education resources and strategies required Support portfolio holders with education resources for quality activities/education on audit results/in-service Report on coach FTE (funded) and actual coach time (utilised)

(2008 – 46%, 2013 – 57%), mandatory training compliance (2008 – 84%, 2013 – 96%), and in performance appraisal and development (2008 – 64%, 2013 – 81%). Importantly, clinical educators report partnerships with clinical coaches and consider that their roles are now more effective and strategic and their practices are safer and more supported. Example quotes from evaluations reveal several of these points (Table 2). These quotes also reflect the clinical coach interventions in respect of their clinical accountabilities. Not only has the introduction of clinical coaches resulted in improved learning climates; it has also assisted the development of a clinical education career pathway for aspiring registered nurses and midwives. Clinically based nurses and midwives who wish to advance their skills in facilitating clinical development now have opportunities to learn these within the clinical coach role. Clinical coaches who, after a period of time, decide to move onto other roles, are able to continue to apply these skills in other clinical and professional leadership roles, or advance to the level of clinical nurse educator. Some clinical coaches have already been provided with structured succession planning and successfully progressed to clinical educator roles. A matrix of communication and reporting lines has been developed. This assists the service model for clinical education by providing clear reporting and communication channels across the service groups. This enables education measurement across whole of service. There is accountability for point of care educational delivery and associated indicators, which is delivered by a diverse team of coaches and educators spanning the organisation but who are united in a governance model.

% of staff trained and utilised in preceptorship; % of learners taking up learning opportunities Results of annual staff satisfaction survey about how the coach role is working in the context

Workplace clinical education plan collaboratively negotiated, reviewed & updated annually Core clinical competencies and evidence based practice targets identified & learning development strategised

% of staff completing mandatory training Portfolio holders identified/supported Audit results/action plans included in in-service education Clinical coach FTE & FTE utilised in coach role

itation and practice development principles, and an array of adult learning methods to achieve professional workforce development and enable a learning culture as an in-situ intervention. Service and clinical quality outcomes in the health service demonstrate continual improvement and organisational data also reveal satisfaction with the role and with the interventions and support provided by clinical coaches. Based on this case experience we recommend to other health services to trial similar approaches and coaching models. Already several health care organisations in Australia have indicated some interest in adopting the clinical coach point of care model. There is a need to replicate and test the coaching model generated by the SCHHS. Further evaluation of the role and research into the impacts of the clinical coach framework and the clinical coach role are continually being undertaken. Moreover, further theoretical analysis of the application of coaching principles in nursing and midwifery clinical contexts is needed. Numerous theoretical and practical questions arise from the SCHHS experience. For example, understanding more about the interplay between the context in which the change is occurring and the mechanisms by which the change is facilitated in relation to the outcomes achieved by specific interventions is needed. The SCHHS employed an intuitive type of fuzzy logic in bringing together coaching, facilitation, practice development, adult learning and mantras in combination with specific staff development responsibilities to achieve functional and deliverable service outcomes from the role implementation. These assumptions require further analysis and testing.

5. Implications and discussion 6. Conclusion This paper has revealed the responses of one health service in Queensland for meeting the increasing need for point of care workplace learning and development to ensure competent, safe and quality care. A new and complementary role to the traditional clinical educator, that of the clinical coach has been developed and implemented across the health service and has achieved advancements in the quality and culture of nursing and midwifery care delivery. The role activities of the clinical coach were developed after needs analysis of the contemporary nursing and midwifery workforce and review of the shifting scope of clinical educator roles. Clinical coaches utilise contemporary coaching philosophies, facil-

There is potential for clinical coach roles to be adopted in health services to improve point of care personal and professional development. Clinical coaches, using a combination of person-centred practice development approaches, within a coaching genre of education and facilitation have genuine potential to improve care and professional development in Australian health care contexts. More evaluation and longitudinal research of the clinical coach role is needed. Based on the achievements thus far in one health service, similar considerations and implementation of the role in other Australian health care contexts is recommended.

Please cite this article in press as: Faithfull-Byrne, A., et al. Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development. Collegian (2016), http://dx.doi.org/10.1016/j.colegn.2016.06.001

G Model COLEGN-380; No. of Pages 8

ARTICLE IN PRESS A. Faithfull-Byrne et al. / Collegian xxx (2016) xxx–xxx

7

Table 2 Qualitative Examples of Staff Perceptions Related to Clinical Coaches. Areas

Staff Perceptions Related to Clinical Coaches (Quotations)

Clinical learning strategies and goals

“It is great having a clinical coach in the unit so regularly – I appreciate being able to identify learning goals and areas to improve my practice.” “The clinical coach has an encouraging attitude, keen to meet me at my skill level and to support me to achieve my best.” “The clinical coach is open to discussions and questions, she provides great feedback and discusses ways of improving.” “The clinical coach aids self-confidence and learning.” “I feel personally that the clinical coach makes me feel comfortable in my workplace.” “Having the support of the clinical coach as a neutral reference person alleviates stress and anxiety for all staff – especially new members.” “The clinical coach role is very important, staff require a supportive colleague to assist development in aspects of the job. All types of issues arise on the job and the clinical coach provides a role that ensures decrease in the level of anxiety.” “Our current coach is fantastic to work with. The clinical coach role itself has a positive effect on staff morale and this is a great support network for staff”. “I love the opportunity for practical support and skill development, especially having opportunities to work alongside the coach.” “Being a new employee, having a coach on the unit has been fantastic, it is an excellent service”. “The clinical coach is a pivotal role within this ward as the support received for all staff junior or senior is readily available.” “The clinical coaches of this ward are brilliant – they create clinical support, the provide leadership with the floor staff at all levels”. “The clinical coach role is vital to our ward. As a member of staff I feel more confident having a clinical coach on the ward if I need to ask any questions about my practice.” “The clinical coach needs to have solid clinical skills and a variety of work experiences to draw on.” “It is very important that the clinical coaches have a communication style that encourages dialogue when staff request support.” “It is very important that clinical coaches have good people skills to build up staff and to encourage them”. “Clinical coaches enhance ward safety! To have the clinical coach input available for input with clinical procedures, a resource for queries re patient care, and to aid in preceptor roles, I have found the clinical coach invaluable”. “The clinical coach role is vital to the unit, in constantly improving its’ outcomes.” “The clinical coach has made practice in our unit more accountable, this has a flow on effect with motivation, achievement of mandatory training, and in helping us to progress our portfolios”. “The clinical coach provides support, leadership and encouragement in meeting learning needs, this has a flow on effect as patients receive up to date and expert clinicians.” “Having a clinical coach on the floor helps to maintain a common, unified and up to date standard with regard to protocols and patient care.” “The clinical coach also keeps us up to task with mandatory training and education – a vital link on our ward. No more floundering.” “For the clinical coach to effect positive and effective improvements requires appropriate support from the unit particularly in allocation of staff and the nurse/patient ratio.”

Stress reducing and confidence building

Working alongside

Skill needs and strengths of the coach

Assisting unit standards, developments and outcomes

(Ethical Approval: HREC/14/QRBW/416: The clinical coach framework – de-identified quotations used)

References Adelman-Mullally, T., Mulder, C. K., McCarter-Spalding, D. E., Hagler, D. A., Gaberson, K. B., Hanner, M. B., et al. (2013). The clinical nurse educator as leader. Nurse Education in Practice, 13(1), 29–34. Australian Commission on Safety and Quality in Health Care. (2010). Australian safety and quality framework for health care. Canberra, Australia: Australian Commission on Safety and Quality. Bargagliotti, L. A., & Lancaster, J. (2007). Quality and safety education in nursing: more than new wine in old skins. Nursing Outlook, 55(3), 156–158. Bennett, W., & Crawley, S. (2002). Don’t die with the music in you. Sydney, Australia: ABC Books. Bennie, A., & O’Connor, D. (2010). Coaching philosophies: perceptions from professional cricket, rugby league and rugby union players and coaches in Australia. International Journal of Sports Science & Coaching, 5(2), 309–320. Côté, J., & Gilbert, W. (2009). An integrative definition of coaching effectiveness and expertise. International Journal of Sports Science & Coaching, 4(3), 307–323. Chan, D. (2001). Development of an innovative tool to assess hospital learning environments. Nurse Education Today, 21(8), 624–631. Chan, D. (2002). Development of the Clinical Learning Environment Inventory: using the theoretical framework of learning environment studies to assess nursing students’ perceptions of the hospital as a learning environment. Journal of Nursing Education, 41(2), 69–75. Clinical Education and Training Queensland. (2011). Building blocks of lifelong learning: a framework for nurses and midwives in queensland. Queensland Health: Brisbane, Queensland. Considine, J., & Hood, K. (2000). A study of the effects of the appointment of a clinical nurse educator in one Victorian emergency department. Accident & Emergency Nursing, 8(2), 71–78. Conway, J., & Elwin, C. (2007). Mistaken, misshapen and mythical images of nurse education: creating a shared identity for clinical nurse educator practice. Nurse Education in Practice, 7(3), 187–194. Cronenwett, L., Sherwood, G., Barnsteiner, J., Disch, J., Johnson, J., Mitchell, P., et al. (2007). Quality and safety education for nurses. Nursing Outlook, 55, 122–131. Curran, C., Sheets, D., Kirkpatrick, B., & Bauldoff, G. S. (2007). Virtual patients support point-of-care nursing education. Nursing Management, 38(12), 27–33. Dalai Lama, H. H., & Cutler, H. (2005). The art of happiness at work. New York, USA: Riverhead Books.

Day, L., & Smith, E. L. (2007). Integrating quality and safety content into clinical teaching in the acute care setting. Nursing Outlook, 55(3), 138–143. Duff, B. (2013). Creating a culture of safety by coaching clinicians to competence. Nurse Education Today, 33(10), 1108–1111. Duffield, C. M., Twigg, D. E., Pugh, J. D., Evans, G., Dimitrelis, S., & Roche, M. A. (2014). The use of unregulated staff: time for regulation? Policy, Politics & Nursing Practice, 15(1/2), 42–48. Duffy, R. (2013). Nurse to educator? Academic roles and the formation of personal academic identities. Nurse Education Today, 33, 620–624. Ebell, M. (1999). Information at the point of care: answering clinical questions. The Journal of the American Board of Family Practice, 12(3), 225–235. Eraut, M. (2000). Non-formal learning and tacit knowledge in professional work. British Journal of Educational Psychology, 70(1), 113–136. Faithfull-Byrne, A. (2011a). Supported practice assessment framework. Sunshine Coast Health Service District: Queensland Health. Faithfull-Byrne, A. (2011b). Toward a Culture of Learning. A Narrative report on the development of a positive clinical learning environment. Sunshine Coast Health Service District: Queensland Health. Faithfull-Byrne, A. (2015). Service profile. practice development, nursing, midwifery and allied health. 2015–2017. Nambour, SCHHS: Queensland Health. Faithfull-Byrne, A., Thompson, L., Cross, W., & Moss, C. (2015). Innovating point of care education: the clinical coach. Australian Nursing and Midwifery Journal, 23(1), 36. Federation, I. C. (2008). ICF code of ethics. , from. http://www.coachfederation.org/ about/landing.cfm?ItemNumber=854&navItemNumber=634 Foley, G. (2004). Introduction: the state of adult education and learning. In G. Foley (Ed.), Dimensions of Adult Learning. Adult education and training in a global era (pp. 3–18). Berkshire, England: McGraw-Hill Education (UK). Gaberson, K. B., Shellenbarger, T., & Oermann, M. H. (2015). Clinical teaching strategies in nursing. New York, USA: Springer Publishing Company. Gardiner, P. (2005). Champion coach always brought the very best. the sunshine coast daily (January 14th).. Retrieved from. http://www.sunshinecoastdaily.com.au/ news/scd-champion-coach-always-brought-out-the-very-bes/324741/ Gaskell, L., & Beaton, S. (2015). Developing clinical competency: experiences and perceptions of Advanced Midwifery Practitioners in training. Nurse Education in Practice, 15(4), 265–270. Gopee, N. (2005). Professional development. Facilitating the implementation of lifelong learning in nursing. British Journal of Nursing, 14(14), 761–767.

Please cite this article in press as: Faithfull-Byrne, A., et al. Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development. Collegian (2016), http://dx.doi.org/10.1016/j.colegn.2016.06.001

G Model COLEGN-380; No. of Pages 8 8

ARTICLE IN PRESS A. Faithfull-Byrne et al. / Collegian xxx (2016) xxx–xxx

Govranos, M., & Newton, J. M. (2014). Exploring ward nurses’ perceptions of continuing education in clinical settings. Nurse Education Today, 34(4), 655–660. Grassley, J. S., & Lambe, A. (2015). Easing the transition from clinician to nurse educator: an integrative literature review. Journal of Nursing Education, 54(7), 361–366. Haines, S., & Coad, S. (2001). Supporting ward staff in acute care areas: expanding the service.clinical nurse educator. Intensive & Critical Care Nursing, 17(2), 105–109. Health Workforce Australia. (2011). National health workforce innovation and reform. strategic framework for action 2011–2015. Adelaide, South Australia: Health Workforce Australia. Health Workforce Australia. (2013a). Health workforce Australia annual report 2012–13. Retrieved from. https://www.hwa.gov.au/sites/default/files/HWAAnnual-Report-2012-13 LR 0. pdf Health Workforce Australia. (2013b). Nurses in focus. Adelaide, South Australia: Health Workforce Australia. Heath, P. (2002). National review of nursing education 2002: our duty of care.. Retrieved from. http://www.voced.edu.au/content/ngv%3A16709 Jensen, R., & Lopes, M. H. (2011). Nursing and fuzzy logic: an integrative review. Revista Latino-Americana De Enfermagem (RLAE), 19(1), 195–202. Johnson, A., Hong, H., Groth, M., & Parker, S. K. (2011). Learning and development: promoting nurses’ performance and work attitudes. Journal of Advanced Nursing, 67(3), 609–620. Karsten, M. A., Baggot, D., Brown, A., & Cahill, M. (2010). Professional coaching as an effective strategy to retaining frontline managers. Journal of Nursing Administration, 40(3), 140–144. Katsikitis, M., McAllister, M., Sharman, R., Raith, L., Faithfull-Byrne, A., & Priaulx, R. (2013). Continuing professional development in nursing in Australia: current awareness, practice and future directions. Contemporary Nurse: A Journal for the Australian Nursing Profession, 45(1), 33–45. Kellett, P. (1999). Organisational leadership: lessons from professional coaches. Sport Management Review, 2(2), 150–171. Kelly, D., & Simpson, S. (2001). Methodological issues in nursing research. Action research in action: reflections on a project to introduce clinical practice facilitators to an acute hospital setting. Journal of Advanced Nursing, 33(5), 652–659. Kunnanatt, J. T. (2008). Emotional intelligence: theory and description: a competency model for interpersonal effectiveness. The Career Development International, 13(7), 614–629. Lave, J., & Wenger, E. (1991). Situated learning: legitimate peripheral participation. Cambridge, UK: Cambridge University Press. Lyle, J. (2002). Sports coaching concepts: a framework for coaches’ behaviour. London: Routledge. Maxwell, E., Black, S., & Baillie, L. (2015). The role of the practice educator in supporting nursing and midwifery students’ clinical practice learning: an appreciative inquiry. Journal of Nursing Education & Practice, 5(1), 35–45. McCormack, B., & Slater, P. (2006). An evaluation of the role of the clinical education facilitator. Journal of Clinical Nursing, 15(2), 135–144. McCormack, B., Manley, K., & Titchen, A. (2013). Practice development in nursing and healthcare (2nd ed.). Chichester, West Sussex: John Wiley & Sons. McKenna, L., & Newton, J. M. (2008). After the graduate year: a phenomenological exploration of how new nurses develop their knowledge and skill over the first 18 months following graduation. Australian Journal of Advanced Nursing, 25(4), 9–15. Ministerial Taskforce on Clinical Education Training. (2007). Final report. Queensland Ministerial Taskforce on Clinical Education and Training. Moore, M., & Tschannen-Moran, B. (2010). Coaching psychology manual. Philadelphia, USA: Wolters Kluwer Health/Lippincott, Williams & Wilkins. Morrison, C. (2014). From ‘Sage on the stage’to ‘Guide on the side’: a good start. International Journal for the Scholarship of Teaching and Learning, 8(1), 4. National Nursing and Nursing Education Taskforce. (2006). National nursing and nursing education taskforce (N3ET) final report.. Retrieved from. http://www. nnnet.gov.au/downloads/n3et final report.pdf Nursing and Midwifery Board of Australia. (2008). Code of professional conduct for midwives. , from. http://www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Professional-standards.aspx

Nursing and Midwifery Board of Australia. (2010). A nurses guide to professional boundaries. , from. http://www.nursingmidwiferyboard.gov.au/CodesGuidelines-Statements/Professional-standards.aspx Page, S. (2002). The role of practice development in modernising the NHS. Nursing Times, 98(11), 34–36. Rainbow, D., Thompson, L., Mullamphy, L., Faithfull-Byrne, A., & Cross, W. (2015). Situating clinical assessment tools within workplace learning. Australian Nursing and Midwifery Journal, 23(1), 37. Rebeiro, G., Jack, L., Scully, N., & Wilson, D. (2013). Fundamentals of nursing: clinical skills workbook (2nd ed.). Chatswood, NSW: Elsevier Australia. Robb, Y., Fleming, V., & Dietert, C. (2002). Measurement of clinical performance of nurses: a literature review. Nurse Education Today, 22(4), 293–300. Rogers, A., & Horrocks, N. (2010). Teaching adults (4th ed.). Berkshire, UK: Open University Press. Rogers, C., Lyon, H. C., & Tausch, R. (2014). On becoming an effective teacher: person-centered teaching, psychology, philosophy, and dialogues with Carl R. Rogers and Harold Lyon. New York, USA: Routledge. Santos, M. C. (2012). Nurses’ barriers to learning: an integrative review. Journal for Nurses in Staff Development, 28(4), 182–185. Saulnier, B. M. (2008). From sage on the stage to guide on the side revisited:(un) covering the content in the learner-centered information systems course. Information Systems Education Journal, 7, 3–10. Sayers, J. M., & DiGiacomo, M. (2010). The nurse educator role in Australian hospitals: implications for health policy. Collegian, 17(2), 77–84. Sherwood, G., & Drenkard, K. (2007). Quality and safety curricula in nursing education: matching practice realities. Nursing Outlook, 55(3), 151–155. Singer, S. J., Benzer, J. K., & Hamdan, S. U. (2015). Improving health care quality and safety: the role of collective learning. Journal of Healthcare Leadership, 7(1), 91–107. Spence, G. B., & Grant, A. M. (2007). Professional and peer life coaching and the enhancement of goal striving and well-being: an exploratory study. The Journal of Positive Psychology, 2(3), 185–194. Starr, J. (2011). The coaching manual: the definitive guide to the process, principles and skills of personal coaching (3rd ed.). Pearson Education. Thorpe, G., Moorhouse, P., & Antonello, C. (2009). Clinical coaching in forensic psychiatry: an innovative program to recruit and retain nurses. Journal of Psychosocial Nursing & Mental Health Services, 47(5), 43–47. Tollefson, J. (2012). Clinical psychomotor skills: assessment skills for nurses PDF. South Melbourne: Cengage Learning Australia. Toowoomba athlete remembered as a pioneer. (2005, January 12th). The Chronicle. Retrieved from http://www.thechronicle.com.au/news/apntoowoomba-athlete-remembered-a/1221/. Tovey, M. D., Uren, M.-A. L., & Sheldon, N. E. (2010). Managing performance improvement. Frenchs Forrest, NSW: Pearson Higher Education AU. Watson, R., Stimpson, A., Topping, A., & Porock, D. (2002). Clinical competence assessment in nursing: a systematic review of the literature. Journal of Advanced Nursing, 39(5), 421–431. Weidman, N. A. (2013). The lived experience of the transition of the clinical nurse expert to the novice nurse educator. Teaching & Learning in Nursing, 8(3), 102–109. Wenger, E. (1998). Communities of practice: learning, meaning, and identity. Cambridge, UK: Cambridge University Press. Werrett, J. A., Helm, R. H., & Carnwell, R. (2001). The primary and secondary care interface: the educational needs of nursing staff for the provision of seamless care. Journal of Advanced Nursing, 34(5), 629–638. Whitmore, J. (2010). Coaching for performance: growing human potential and purpose: the principles and practice of coaching and leadership. London, UK: Nicholas Brealey Publishing. Wilkinson, C. A. (2013). Competency assessment tools for registered nurses: an integrative review. Journal of Continuing Education in Nursing, 44(1), 31–37.

Please cite this article in press as: Faithfull-Byrne, A., et al. Clinical coaches in nursing and midwifery practice: Facilitating point of care workplace learning and development. Collegian (2016), http://dx.doi.org/10.1016/j.colegn.2016.06.001