Clinical Coaching:Clinical Coaching:An Approach to Motivating Clinical

Practice Change in Home Care

Adele W. Pike RN, EdD

Motivating clinical practice change among home care clinicians has many Motivating clinical practice change among home care clinicians has many challenges given the autonomy of their roles and the multiple (and often challenges given the autonomy of their roles and the multiple (and often competing)demands for their time and attention.competing)demands for their time and attention.

In 2007, Adele Pike was selected as a Geriatric Practice Change Fellow (In 2007, Adele Pike was selected as a Geriatric Practice Change Fellow (www.practicechangefellows.org) Her change project was to create a model for ) Her change project was to create a model for motivating evidence-based practice change among home care clinicians and then motivating evidence-based practice change among home care clinicians and then to use that model to improve core geriatric competency.to use that model to improve core geriatric competency.

The critical objective of this project was to increase the knowledge, skill and The critical objective of this project was to increase the knowledge, skill and confidence of front line managers in motivating clinical practice change.confidence of front line managers in motivating clinical practice change.

Clinical Coaching was identified as the tool front line managers identified as Clinical Coaching was identified as the tool front line managers identified as holding the greatest promise for motivating practice change among clinicians.holding the greatest promise for motivating practice change among clinicians.

Background:Background:New Trends, New Ideas and Better Practices in Geriatric Home CareNew Trends, New Ideas and Better Practices in Geriatric Home Care

Consensus on What is Consensus on What is “Clinical Practice”“Clinical Practice”

Clinical Practice is the hands on care that Clinical Practice is the hands on care that clinicians provide at the bedside, the chair-clinicians provide at the bedside, the chair-side, or the home-side. It includes patient side, or the home-side. It includes patient and family assessment, critical thinking and family assessment, critical thinking about the assessment and ensuing creation about the assessment and ensuing creation of a plan of care. Additionally, clinical of a plan of care. Additionally, clinical practice is the actual “hands on” application practice is the actual “hands on” application of interventions, and evaluation of the of interventions, and evaluation of the patient’s family’s response to interventionspatient’s family’s response to interventions..

 

Clinical CoachingClinical CoachingClinical coaching is a purposeful, planned, regularly Clinical coaching is a purposeful, planned, regularly occurring meeting between clinician(s) and manager for occurring meeting between clinician(s) and manager for the purpose of envisioning, planning and improving the purpose of envisioning, planning and improving patient care in accordance with evidence based practice. patient care in accordance with evidence based practice. One to one coaching meetings are goal driven with a clear One to one coaching meetings are goal driven with a clear articulation of the purpose, the expected outcomes, and articulation of the purpose, the expected outcomes, and the agenda for each encounter. Coaching in this context the agenda for each encounter. Coaching in this context can be conceived of as a “thinking partnership” between can be conceived of as a “thinking partnership” between manager and clinician, and must be grounded in mutual manager and clinician, and must be grounded in mutual trust and respect. Managers use skills such as active trust and respect. Managers use skills such as active listening, asking thought provoking questions, providing listening, asking thought provoking questions, providing feedback, reinforcement of practice strengths, reframing feedback, reinforcement of practice strengths, reframing of clinical situations, and transforming ideas into action of clinical situations, and transforming ideas into action steps to help clinicians integrate changes into their clinical steps to help clinicians integrate changes into their clinical practices. Managers use a formalized process to follow up practices. Managers use a formalized process to follow up on these action steps.on these action steps.  

                              

What’s the Goal?What’s the Goal?

To facilitate ongoing development of the clinician in the context of practice and to

enhance the delivery of care.

-Hines-Martin, V. and Robinson, K. (2006).

Supervision as Professional Development for Psychiatric Mental Health Nurses.

Clinical Nurse Specialist. 20(6), 293-297

Styles of Clinical SupervisionStyles of Clinical Supervision

≈Prescriptive≈Informative≈Confronting≈Supportive≈Catalytic

Clinical Coaching Skill SetClinical Coaching Skill Set

•Managing Meetings•Prepping for coaching sessions•Differentiating when a clinician will benefit from coaching and when a clinician needs a corrective action plan•Formulating Socratic Questions•Active Listening•Giving Feedback•Timely and consistent follow up

Steps in Clinical CoachingSteps in Clinical Coaching

1.1. The Invitation to Clinical CoachingThe Invitation to Clinical Coaching

2.2. Selecting the LocationSelecting the Location

3.3. Planning the LogisticsPlanning the Logistics

4.4. Plan for the SessionPlan for the Session

5.5. Running the sessionRunning the session

6.6. Plan for follow upPlan for follow up

7.7. The Follow UpThe Follow Up

The Invitation to Clinical CoachingThe Invitation to Clinical Coaching

Inviting clinicians into a coaching relationship takes thought and planning. Clinicians’

defenses and suspicions can go up quickly and coaching can readily be perceived as a

disciplinary tool.

Selecting the LocationSelecting the Location

In the office?Out of the office?At the curbside?

Planning the LogisticsPlanning the Logistics

Time to Meet Prevent Interruptions

Avoid Distractions Seating Arrangement

Planning for the SessionPlanning for the Session

When preparing for a coaching session, ask yourself, “What do I really want to be

the outcome?” and use that as your compass.

Running the sessionRunning the session

The two riskiest times in a coaching session tend to be at the beginning and at

the end.

-Patterson, K., Grenny, J., McMillan, \R., and Switzler, A. (2002)

Crucial Conversations.

McGraw-Hill

Center for Creative Leadership’sCenter for Creative Leadership’s

Framework for Coaching:Framework for Coaching:

A- AssessA- AssessC- ChallengeC- Challenge

S- SupportS- Supportwww.ccl.orgwww.ccl.org

Coaching Element What’s Involved? Skills that can help

ASSESS(allow 10 minutes)

Identifying what you see as an area for practice improvement

Discovering the clinician’s perspective about what you have identified

Assessing clinician’s motivation to improve this area of practice; to grow and/or change his or her practice

What are the clinician’s strengths and interests and areas for growth

What would the clinician consider improvement or success in this area of practice

Socratic QuestioningActive Listening

CHALLENGE(allow 20 minutes)

Engage the clinician in dialogue, problem solving about a particular patient situation, and/or envisioning about how care could be even better than it is now

You want to create a bit of a disequilibrium for the clinician between current practice and what practice could be

You want to challenge the clinician – or better yet- get him or her to challenge him/herself to growth his or her practice around this issue

Socratic QuestioningActive Listening

SUPPORT(allow 10 minutes)

Support a plan for practice growth, but not a plan to “do for “ the clinician

End the session by getting the clinician to identify learning needs and then help in finding resources to meet those needs

Help by managing or problem solving barriers to the clinician addressing learning needs

Recognize wins and set backs Acknowledge small gains and improvements Celebrate success

Written action or follow up plans

Regularly planned follow up meetings

Regular and spontaneous feedback

Center for Creative Leadership’s Coaching Framework Applied to Clinical Coaching in Home Care

Socratic QuestioningSocratic Questioning

Thinking is driven by questions, not by answers

What’s a “Good Question”?What’s a “Good Question”?

•One that causes clinicians to reflect on their practice

• One that probes the decisions clinicians have made in a particular patient situation

• One that encourages clinicians to think about how care could be different

• One that causes clinicians to question the assumptions on which they base clinical judgments

• One that engages clinicians in discovering their own answers to clinical problems

Sample Socratic QuestionsSample Socratic Questions What is your experience with this clinical problem?

How do you manage this problem when it occurs with a patient in your care?

Describe how patients have responded when you have managed the problem this way?

What other ways are there of managing this problem?

What is another perspective you could consider?

What is another approach to care you could try?

What would superb care of this patient look like? What would be the outcomes of this care?

What do you think about the outcomes your patients achieve?

Planning for Follow UpPlanning for Follow Up

The two riskiest times in a coaching session tend to be at the beginning and at the end.

-Patterson, K., Grenny, J., McMillan, \R., and Switzler, A. (2002)

Crucial Conversations.

McGraw-Hill

The Follow UpThe Follow Up

LLeaving following up to chance eaving following up to chance reduces clinical coaching to a nice reduces clinical coaching to a nice

chat!chat!

Practice and ReflectionPractice and Reflection“It takes a lot of practice to adopt a coaching

approach to practice improvement and to stop wrestling with clinicians and start partnering with

them”-Diane Garrow

Patient Service ManagerVisiting Nurse Association of Boston

Opportunities for Opportunities for Practice and ReflectionPractice and Reflection

•Every other week “Coaching for the Coaches” Rounds

•Role Plays and Video Case studies

•Small, rapid cycles of change: try something new and out of the box and see what happens

•Using clinical coaching with joint visit: Discovering of the power of Curbside Coaching