Nurse managers (NMs) confront multiple challenges in today’s healthcare environment. Nurse managers, defined as middle managers charged with 24-hour fiscal, quality, and human resource responsibilities for at least 1 nursing unit, must attend to both management and leadership duties. Because of wide-reaching responsibilities, the NM role can be 1 of the most challenging in the healthcare organization.1 Nurse managers must lead change, establish work-life balance, manage resource concerns, handle relational conflicts, and meet benchmarks.2 Role demands can result in role stress and burnout.3 As healthcare systems and challenges evolve, these demands will continue to expand and require enhanced NM skill levels.4
Nurse managers have been identified as crucial to the success of healthcare organizations, influencing nurse satisfaction and retention, profitability, and organizational culture.5,6 As the key interface between patients, nursing staff, and medical staff, NMs also impact patient outcomes. Investing in the development of NMs is critical to achieving high-performing teams and organizational goals.1 Despite their vital contributions, thoughtful recruitment, orientation, and professional development of NMs are often lacking.7-9 Staff nurses with demonstrated clinical competence, but without equal leadership competence, are frequently promoted to the NM role.9 Learning the role often occurs through a trial by fire approach.8 Strategies must be designed to support and develop NMs if they are to remain satisfied in the role and the role is to have sustainability.7
Professional coaching is a strategy that can be useful in supporting and developing NMs. Professional coaching is defined as “partnering with clients in a thought-provoking and creative process that inspires clients to maximize their personal and professional potential.”10 Professional coaching has been cited as effective in leadership development at multiple levels within organizations,11 but less has been written about the use of a professional coach with the NM role and other middle management positions. The purpose of this article is to present findings from a descriptive, qualitative investigation that examined the perceptions of professional coaches regarding their experiences coaching NMs. Understanding these experiences highlights how coaches can be supportive of NMs and promote their development and how nurse executives may find this level of support useful in developing this key role.
Professional coaching has been well established as an effective leadership development strategy in a variety of organizations at multiple levels.11 Coaching services have supported providers in the healthcare arena, including physicians12 and nurse executives.13 Nurse executives have identified coaching as a critical component to their success and professional development.13 Coaching services have rarely been reported at the NM level.1,14
Rather than serving as a remedial process for underperformers, coaching is used by employees for expanded purposes.15 Coaching can help individuals enhance their outlook on work-life balance, while improving their leadership effectiveness and skills. Coaching can help to identify opportunities for further development and have a significant positive impact on performance, well-being, coping, work attitudes, and goal-directed self-regulation,16 while also furthering the goals of the employing agency.17
Much of the existing literature on coaching for healthcare leaders focuses on evaluative reports of coaching programs. Postprogram evaluations are positive and suggest that coaching is a valuable component to building leadership skills and supports new leaders in building relationships between themselves and colleagues.18 Coaching programs have also helped leaders develop new ways of thinking about leadership and become more committed to their career.17 Increased engagement, retention, and feelings of satisfaction and empowerment for nurse leaders have resulted.1
Few empirical studies have been conducted examining the impact of coaching for NMs.15 One small pilot study reported that 92% of NMs agreed or strongly agreed that coaching enhanced their level of job satisfaction, 75% agreed or strongly agreed that coaching promoted improved relationships with direct reports, and 66% agreed or strongly agreed that coaching promoted a stronger relationship with their direct supervisor.14 Another study found that NMs gained increased resilience, confidence, and better coping mechanisms after coaching. This fostered improvement in team management and cohesion and promoted better quality of care.15
No studies were identified that focused on professional coaches’ perceptions of NMs and the NM role. This study addresses this literature gap and focuses on 4 areas, including: 1) why coaches made the decision to coach NMs, 2) how coaches believed the experiences of NMs differed from that of other leaders, 3) why NMs sought coaching, and 4) what coaches believed was their most valuable contribution when working with NMs.
Design, Participants, and Data Collection
Semistructured researcher-participant interviews were used to generate data for this descriptive, qualitative study. Professional coaches who coached NMs were sought as participants. An e-mail that described the study was sent to 11 professional coaches practicing in healthcare organizations across the United States. All 11 coaches agreed to participate. Participants ranged in age from 39 to 75 years (mean [SD], 57.36 [10.156] years). One was male (9%). Ten (91%) held master’s degrees and 1 (9%) held a doctoral degree. The number of years participants practiced coaching ranged from 1 to 26 years (mean [SD], 7.23 [7.03] years). Eight (73%) participants’ coaching practice included a variety of healthcare practitioners, whereas 3 (27%) focused entirely on NMs. Nine (82%) were certified through nationally recognized certification programs and 2 (18%) were in the process of completing certification.
Institutional review board approval was obtained from Xavier University. E-mails were sent to potential participants and a date and time for the researcher-participant interviews were determined. Before each interview, written consent was obtained. Ten interviews were conducted via telephone and 1 was conducted face-to-face. Interview questions, developed by the researchers, were designed to assist participants to share their experiences coaching NMs. Interviews lasted approximately 1 hour. Each interview was audio recorded for transcription. Each transcription was verified for accuracy by both researchers.
A conventional content analysis was used to analyze the transcripts, allowing categories and names for categories to emerge from the data.19 Both researchers independently read each transcript and captured the data that pertained to the coaches’ perceptions of NMs and the NM role. Main ideas were identified and labeled without interpretation by highlighting key words and phrases. Working together, the researchers clustered similar ideas and moved them to higher levels of abstraction through interpretation. From the clustered groups, representative categories emerged. The researchers tracked the number of participants represented in each category and determined frequency counts. Scholars have suggested that using a content analysis approach can yield data that can be analyzed both quantitatively and qualitatively and have noted that a higher frequency may indicate a greater level of significance.20
Rigor for the study was enhanced when both researchers independently analyzed the data, discussed the data, and came to agreement regarding the analysis. When divergent viewpoints arose, before coming to a consensus, researchers returned to the data to ensure that the findings were grounded in the data. Throughout the study, an audit trail was maintained.
Study findings revealed coaches’ perceptions regarding NMs, the NM role, and how coaches can be supportive in the development of NMs. Categories emerged as participants discussed why they chose to coach NMs, why NMs sought coaching, how the experiences of NMs differed from that of other leaders, and what coaches believed was their most valuable contribution. Emergent categories accompanied by the number of participants and the percentage represented in each category are presented.
Why Coach NMs
Three categories emerged from participants’ descriptions regarding why they decided to coach NMs, including (1 a desire to provide needed services (n = 11, 100%), (2 a recognition of the indispensability of NMs and the role (n = 8, 73%), and (3 an appreciation for NMs (n = 8, 73%). One participant’s comments were echoed by many regarding the NMs’ “real need” for coaching services and the belief that coaching could “make a significant [positive] impact” in NMs’ lives. Participants suggested that coaching provided NMs an additional “support system” and “cleared the way for NMs to do a great job.” Participants also decided to coach NMs because they recognized the indispensability of NMs and their role. One participant spoke of NMs as an “integral part” in determining the overall “success” of healthcare organizations. Another commented, “The rubber meets the road with those frontline managers. They need to be right there and catch things in the moment.”
A deep appreciation for NMs and the role was evident. One participant commented, “I keep coming back to something related to NMs’ strength…They do their job with courage, grace, and quiet modulation…They have a level of commitment that other professionals do not have.” Another participant echoed, “NMs are incredible people. They have an enormous capacity for caring and empathy…technical skills may have gotten them where they are going, but it’s the emotional intelligence skills that really help them succeed.” Another added, “To see that level of commitment and concern and altruism, very Florence Nightingale.”
Why Managers Seek Coaching
Two categories emerged when participants spoke about why NMs sought coaching, including: 1) professional role development (n = 11, 100%) and 2) handling conflicts (n = 10, 91%). Help with role development was evident in this statement: “they just want to figure out who they are as leaders.” Participants helped NMs understand how “to have work life balance,” “to be less critical of themselves,” and to develop “professional presence” and “leadership courage.”
Managers also sought help with conflicts, both with staff and higher-level leaders. One participant told of how NMs use coaching time to “run over difficult conversations,” noting that “often they are inexperienced in dealing with difficult employees.” Another commented, “Sometimes they’re intimidated by the strong nurses on their staff.” Conflicts with leadership can also bring managers to coaches. One participant stated, “Sometimes, NMs have issues with their directors…they don’t seem to be able to relate, to connect.”
Participants were questioned about what they believed made the experiences of NMs different from that of higher-level leaders. Because 3 participants solely coached NMs, they were unable to make a comparison; therefore, the following findings are based on 8 participants’ comments. Three categories emerged: 1) overwhelming stress (n = 5, 63%), 2) expansive span of control (n = 4, 50%), and 3) minimal support (n = 4; 50%).
Overwhelming stress was apparent in the descriptions shared. One participant clearly articulated, NMs “experience a higher level of stress than other leaders,” and another echoed, “NMs are overwhelmed, stressed out.” This overwhelming stress stemmed from several sources, including managing from the middle. One commented, “Middle managers probably have the most difficult job…they have to manage up to their managers and also have to lead other people. They’re in this sandwich role and that can be tougher than being an executive.” Participants also believed that NMs experienced stress because they recognized that their actions could impact human life. One expressed, “There are such safety and quality issues, that ‘I’ve got a lot of balls to juggle and if a ball falls down it could mean somebody’s life.’ Whereas other leaders, the ball might fall and they get in trouble, but it likely won’t result in a death…the magnitude…the risk is higher. It’s high stress.”
Nurse managers’ excessive span of control emerged as a notable difference from other leaders. One stated, “Their span of control is not doable. In other industries you wouldn’t find this.” Another commented, “They’ve got way too many people that they have to manage…their hands may be fuller than any other position in our organization.”
The category minimal support also emerged. One participant’s statement pointed to the lack of resources, “When we talk about other management roles, NMs really do have less resources, less training…it’s a whole different set of skills that they have never really had the opportunity to develop.” Another echoed, “I think the NM has less resources and less training than CNOs.”
Most Valuable Contribution
When participants were questioned regarding their most valuable coaching contribution, 2 categories emerged: (1 fostering NM self-efficacy and self-awareness (n = 10, 91%) and (2 providing a multi-level positive impact (n = 10, 91%). Participants spoke about managers coming to know themselves and finding inner strength. One commented, “we help nurses generate a leadership sense about themselves, to know who they are, what they are, where they thrive, and where they need to grow.” Another stated that coaching helped managers to “discover that leadership comes from within.” Yet others similarly noted that coaching helped managers “access their own power,” “really get comfortable in leader boots,” and eventually, learn to “coach themselves.”
Participants’ descriptions were threaded with examples of how coaching yielded a multilevel, positive impact, effecting not only NMs but also the nursing staff, patients, and organization. One stated, “Success starts at the top, and the more successful, the more engaged, the more effective the leader, the better the process, the happier the employees, the more trusting and nurturing the culture.” Another echoed, “NMs are more effective and their units work better (when coached). Staff is happier. Retention is better…and their patients do better.” One spoke directly to metrics, noting, “patient satisfaction is increased. Our scores have gone up in areas where we provided coaching. Our employee engagement scores have also gone up.” The positive impact of coaching was summarized in this comment, “we have seen that as we equip managers with the skills to manage…they’re able to improve the satisfaction of their staff…it’s not all related to our coaching work…but I know that we are a piece of that…definitely a return on investment.”
Several findings merit discussion as they highlight how professional coaches may be helpful in promoting growth, development, and support for NMs. The findings that 100% of coaches reported being sought out by NMs for help with role development and 91% reported being sought out for help with relational conflicts are not surprising considering previously reported literature.8,9,21 Staff nurses are often not prepared for advancement to the NM role because clinical and leadership competence vary.9 Nurse managers often learn their role through a trial by fire approach and some report struggle for years.8 Nurse managers commonly confront relational conflicts and describe being uncomfortable addressing such issues.21 Findings suggest that coaches can assist novice managers to gain an understanding of the role, the leadership qualities needed, and ways to develop those qualities. Expert NMs can be coached to further develop their leadership capabilities. Coaches can also guide NMs when conflicts arise by using role-playing to practice difficult conversations and assist NMs to gain insight regarding managing different types of staff.
Most coaches believed that their most valuable contribution was enhancing NMs’ self-efficacy and self-awareness. Coaches told of how they helped NMs gain a sense of who they were as individuals and their capabilities. Coaches spoke about how, over time, NMs gained an ability to “coach themselves” and “solve their own problems.” Understanding one’s inner self is a crucial component to becoming a successful leader. Others have similarly noted that self-efficacy and self-awareness can be enhanced in NMs through coaching15 and that self-efficacy is an important attribute of NMs, changing how they think, behave, feel, and motivate themselves.22
Some of the most troubling findings emerged when coaches were asked to share their perceptions of how the role of NMs differed from higher-level administrative roles, having coached both. The most concerning finding is the level and depth of challenges faced by NMs. Coaches believed that NMs experienced more overwhelming stress (63%), a broader span of control (50%), and less support, training, and resources (50%) than other leaders do. Stress for NMs came from being caught in the middle compounded by their awareness that human life could be impacted by their decisions. Coaches noted that administrators at higher levels do not commonly report this combination of stressors. Whereas other leaders may have many competing priorities, if something falls through for the NM, “it could mean somebody’s life.” Although challenges inherent in the NM role have been noted in the literature such as 24/7 accountability, staff satisfaction pressures, and quick deadlines,3 this life and death stress has not been readily reported. Findings suggest that NMs confront an added level of stress not faced by other administrators.
This study suggests that coaching can help NMs achieve competence. Nurse manager competencies,23 derived from the Nurse Manager Learning Domain Framework,24 provide important benchmarks for NMs. This framework delineates 3 domains of learning. Our findings suggest that coaching can be especially useful in guiding NMs to accomplish competencies within domains 2 and 3. Competencies in domain 2 focus on managing relationships and address emotional IQ, self-awareness, and conflict management. Competencies in domain 3 focus on assessing self and developing action plans for personal growth. In this study, 73% of the coaches acknowledged a deep appreciation for NMs. Such healthy respect provides an excellent foundation for the flourishing of coach-NM relationships. Providing NMs opportunities for coaching can be an excellent starting point to provide NMs the support and guidance needed to grow and develop in the role.
Nurse managers play a crucial role in the healthcare system. The challenges confronted by NMs are wide-ranging. Unfortunately, these leaders can often be inadequately prepared and developed in the role. Strategies, including coaching, must be used to meet this need. Findings from this study suggest that professional coaching can prove beneficial for supporting, developing, and sustaining NMs for the future.
The authors acknowledge the Sigma Theta Tau Omicron Chapter for financial support of this project.
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