HEALTH CARE, like other industries, is faced with operating in a rapidly changing, dynamic, and competitive market. A top challenge facing organizations is their ability to effectively develop leaders to lead in an increasingly volatile, uncertain, complex, and ambiguous environment. A leader's ability to create a climate within the context of the organizational culture that influences individuals and teams is foundational to the performance and outcomes that organizations achieve, as they strive to improve quality, safety, and experience. Leaders who unleash the power of individuals and teams demonstrate the ability to collaborate across boundaries and solve problems in more agile and innovative ways. Organizations with effective leaders have been shown to outperform their peers.1–4
Trust and psychological safety are foundational elements of the climate a leader should create, as they foster and influence individuals and teams engaged in learning from failures, in speaking up, and in achieving the desired outcomes.5–8 Leaders also play a role as agents of change in creating an environment where learning can occur.1,9,10 Coaching as a leadership competency, when based on a foundation of trust, has been shown to advance employee engagement and professional career-enhancing behaviors.11,12 Coupling coaching with other leadership development opportunities, while increasing personal responsibility for learning, increases satisfaction and supports and enables the adoption of new behaviors.13,14 The climate and culture where leaders and other employees work influence both the individual and the teams overall.6,7,9,15,16 In an observation-based study, Tucker and Edmondson8 found that working through problems or creating workarounds, rather than speaking up about process problems, was reported by 70% of nurses interviewed, resulting in the problems never being addressed. Twelve percent of Veterans Health Administration workers surveyed reported that they would never report an error.8 Curry et al1 found that the risk-standardized mortality rate had a significant improvement for the hospitals who had a change in their culture after the implementation of their Leaders Saves Lives intervention, compared with the hospitals who did not experience a significant culture change.
The coach mindset framework can be used to enhance the capabilities of leaders in a variety of roles. The intent is to positively impact climate, influence culture, and subsequently enable psychologically safe settings, for the leaders, individuals, and teams. This article describes a conceptual framework, a key concept, mediating antecedents, and consequences that result when leaders adopt a coach-based mindset. This work can be used in future research and applied as a part of implementation and adoption-related activities.
Culture, climate, beliefs, and learning
The coach mindset is based on a conceptual framework (see Figure 1) that adapts, combines, and extends classic models from Edgar Schein on culture and Amy Edmondson on psychological safety and teaming. It is intended to illustrate the dynamic interplay between the culture, climate, leadership beliefs, and behaviors and the expected consequences for employees, teams, and patients.
Schein17,18 suggested that culture develops as an organization collectively solves problems together and is intended to stabilize and reduce organizational anxiety during times of stress. Culture also is embedded in the habits of how an organization operates, and these habits are adopted by new members who join the organization and who operate as members of teams. Whereas culture represents the norms and habits, climate is an individual's interpretation of the culture and equates to how one lives out those norms and how they represent the values of the organization. The climate is the evidence by which the culture is made manifest. In Edmondson's19 model, the role of the leader is to create the environment, which then fosters a team's beliefs. Beliefs dictate the types of learning behaviors (eg, fear or psychological safety) that are incorporated into the day-to-day work and drive the performance of the team and the value delivered to the patient. Edmondson's20 second model on teaming (eg, speaking up, collaboration, experimentation, and reflection) shows that leaders who create climates of psychological safety influence the culture and subsequently allow teams to learn while executing the work, instead of learning after completing the work. The adapted and extended framework encapsulates the leader and team within the organizational culture and climate and directly affects the value and outcomes delivered to the patient.
Coach mindset concept and definition
The earliest use of the concept of coach is derived from a Hungarian word associated with a carriage or conveyance that transported people from place to place. Later the concept was applied to athletics, education, and subsequently business.21 The literature showed that a variation in definitions and application of what coaching means within an organization exists and is not commonly applied.22
Adoption of a coach mindset can only be accomplished when the leader has a common understanding of what having a coach mindset means. For the purposes of this work, the definition of a coach mindset has been derived through identifying key attributes and is defined as: The implicit and habitual use of a mental paradigm that reflects how you think, believe, and act every day with others, and enables a leader (coach) to connect and partner with individuals (client) and teams as they learn together and pursue the client-focused personal and/or workplace results-oriented goals.
The concept of a coach mindset and the attributes, antecedents, and consequences that helped formulate the definition above is described in Figure 2 and aligns with the conceptual framework described in Figure 1.
The literature shows that coaching includes a composition of attributes, beliefs, behaviors, and attitudes held by the individual designated as the coach.23,24 Snyder25 demonstrated that mindsets are made up of a set of patterns, or paradigms, that allow more rapid processing of information and making judgments, and the lens individuals use to view the world is central to the application of unique mindsets as part of that process.
Antecedents and consequences
The antecedents that are associated with a coach mindset are reflected in the culture, organization, leadership experience, and employee or caregiver capabilities. A leader who focuses on enabling the antecedents will ultimately reap the benefits or consequences of what it means to adopt a coach mindset.
A culture that values the natural talents and abilities of the employees and believes that each individual is able to contribute and solve problems on their own or as a member of a team sets the leader/coach up for success.21 Focusing on the abilities and strengths of individuals and teams enables a leader to create a safe space for each person to grow and progress, learn from mistakes, and improve their own professional skills and abilities while helping the team to achieve better results together. Doing this routinely and incorporating a new mindset is more challenging than it might first appear. Leaders who begin to lead with a coach mindset and create the climate will find that pausing and staying curious first rather than relying on hierarchy to solve the problem does not come naturally and can be learned with daily practice. Listening intently and asking meaningful questions is the first step and will make coaching others a positive experience for all involved. This is how leaders demonstrate living the values. Allowing others to try first instead of jumping in to ensure success will ultimately result in better and more innovative solutions to the problems at hand. It also creates the space to view errors or safety lapses as opportunities to learn rather than labeling the person or the situation as a failure. A leader's investment in professional development, role clarity, and appreciation of the resourceful and creative employee signal the application of a coach mindset.21
For example, the approach a leader takes to evaluate the performance of an employee is largely influenced by the assumptions and mindsets that are applied when making judgments.26 Hierarchical attributes (employee-supervisor/physician, individual status, or job title) also influence voice or a willingness to speak up when reporting problems and errors.6,7,16 The relationships formed between the leader with the coach mindset and the employee will determine the employee's ability to recognize growth opportunities, feel safe enough to take risks, and to freely express their ideas and opinions.
Ortega et al9 showed the relationship between leadership, defined as change-oriented leadership, and both learning behavior and psychological safety. Psychological safety showed a significant relationship or mediating effect between change leadership and learning, or a difference from 0.56 to 0.37. Singer et al10 analyzed 76 articles that showed, when focusing on improvements in quality and safety, there was a relationship between leadership and learning and the presence of a supportive environment. Subfindings categorized as part of the review included concepts around learning from failure, that organizational culture positively impacts variability in performance, and that coaching by leaders influences learning. Huang and Hsieh12 showed that there was a significant relationship between coaching and in-role behavior and professional career behaviors. They also demonstrated that psychological empowerment fully mediates coaching and the relationship to in-role behavior and professional career behaviors.
Changing workforce dynamics continue to evolve. Younger generations of nurses enter the workforce and expect leaders to lead in new ways. Millennial nurses expect to be coached and have help to focus on professional growth opportunities.27 Coaching focuses on maximizing the potential of the individual, in addition to achieving personal goals. Nurses, nurse managers, nurse executives, and all leadership roles can accelerate outcomes and strategies and personally benefit by working in an environment where a coach mindset is embedded in the behaviors exhibited by all leaders and in the day-to-day work.
Leadership development approaches that have proven effective include a focus on ensuring that leaders acquire the right capabilities and mindsets needed to lead. The adoption of new mindsets needs to have an intentional approach included in leadership development strategies.2,28 Using coaching when interacting with others will require that leaders clearly understand and learn what it means to lead with a coach mindset. It is equally important to demonstrate the behaviors associated with applying a coach mindset to interactions with individuals and teams. Studies that assess and evaluate the effectiveness of using coaching as a strategy at all levels of leadership are worthy projects. In addition, documenting changes in retention, engagement, employee and manager satisfaction, and ultimately patient outcomes can all be used to justify expenses incurred in leadership education focused on adoption of a coach mindset and the associated behaviors.
Coupling coaching with other leadership development opportunities, while increasing personal responsibility for learning, increases satisfaction and supports and enables the adoption of new behaviors.13 Organizations that are able, through leadership interventions, to impact both the culture and the adoption of best practices should foster demonstrable results that outperform organizations that fail in efforts to improve psychological safety and learning behaviors.
1. Curry LA, Brault MA, Linnander EL, et al. Influencing organisational culture to improve hospital performance in care of patients with acute myocardial infarction: a mixed-methods intervention study. BMJ Qual Saf. 2018;27(3):207–217. doi:10.1136/bmjqs-2017-006989.
2. Development Dimensions International. Global leadership forecast 2018: 25 research insights to fuel your people strategy. https://www.ddiworld.com/glf2018
. Accessed November 1, 2019.
3. McChrystal S, Collins T, Silverman D, Fussell C. Team of Teams: New Rules of Engagement for a Complex World. New York, NY: Portfolio/Penguin; 2015.
4. Till A, Dutta N, McKimm J. Vertical leadership in highly complex and unpredictable health systems. Br J Hosp Med (Lond). 2016;77(8):471–475. doi:10.12968/hmed.2016.77.8.471.
5. Carey W, Philippon DJ, Cummings GG. Coaching models for leadership development: an integrative review. J Leadersh Stud. 2011;5(1):51–69. doi:10.1002/jls.20204.
6. Derickson R, Fishman J, Osatuke K, Teclaw R, Ramsel D. Psychological safety and error reporting within Veterans Health Administration hospitals. J Patient Saf. 2015;11(1):60–66. doi:10.1097/PTS.0000000000000082.
7. Schwappach D, Richard A. Speak up-related climate and its association with healthcare workers' speaking up and withholding voice behaviours: a cross-sectional survey in Switzerland. BMJ Qual Saf. 2018;27(10):827–835. doi:10.1136/bmjqs-2017-007388.
8. Tucker AL, Edmondson AC. Why hospitals don't learn from failures: organizational and psychological dynamics that inhibit system change. Calif Manage Rev. 2003;45(2):55–72. doi:10.2307/41166165.
9. Ortega A, Van den Bossche P, Sánchez-Manzanares M, Rico R, Gil F. The influence of change-oriented leadership and psychological safety on team learning in healthcare teams. J Bus Psychol. 2014;29(2):311–321. doi:10.1007/s10869-013-9315-8.
10. Singer SJ, Benzer JK, Hamdan SU. Improving health care quality and safety: the role of collective learning. J Healthc Leadersh. 2015;7:91–107. doi:10.2147/JHL.S70115.
11. Hamlin RG, Ellinger AD, Beattie RS. Coaching at the heart of managerial effectiveness: a cross-cultural study of managerial behaviours. Hum Resource Dev Int. 2006;9(3):305–331. doi:10.1080/13678860600893524.
12. Huang J, Hsieh H. Supervisors as good coaches: influences of coaching on employees' in-role behaviors and proactive career behaviors. Int J Hum Resour Man. 2015;26(1):42–58. doi:10.1080/09585192.2014.940993.
13. Cable S, Graham E. “Leading better care”: an evaluation of an accelerated coaching intervention for clinical nursing leadership development. J Nurs Manag. 2018;26(5):605–612. doi:10.1111/jonm.12590.
14. Wilson W, Lawton-Smith C. Spot-coaching: a new approach to coaching for organisations operating in the VUCA environment. Int Coaching Psychol Rev. 2016;11(1):24–38.
15. Nelson K, Boudrias J, Brunet L, et al. Authentic leadership and psychological well-being at work of nurses: the mediating role of work climate at the individual level of analysis. Burnout Res. 2014;1(2):90–101. doi:10.1016/j.burn.2014.08.001.
16. Tucker AL, Edmondson AC, Spear S. When problem solving prevents organizational learning. J Organ Change Manage. 2002;15(2):122–137. doi:10.1108/09534810210423008.
17. Schein EH. Coming to a new awareness of organizational culture. Sloan Manag Rev. 1984;25(2):3–16.
18. Schein EH. The role of the founder in creating organizational culture. Organ Dyn. 1983;12(1):13–28. doi:10.1016/0090-2616(83)90023-2.
19. Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–383. doi:10.2307/2666999.
20. Edmondson A. Teaming. Hoboken, NJ: John Wiley and Sons; 2012.
21. Ross A. Perspectives on the definition of coaching. In: English S, Sabatine JM, Brownell P, eds. Professional Coaching Principles and Practice. New York, NY: Springer Publishing Company; 2019:3–8.
22. Gormley H, van Nieuwerburgh C. Developing coaching cultures: a review of the literature. Coach Int J Theory Res Pract. 2014;7(2):90–101. doi:10.1080/17521882.2014.915863.
23. Huang JT, Hsieh HH. Supervisors as good coaches: influences of coaching on employees' in-role behaviors and proactive career behaviors. Int J Hum Resour Man. 2015;26(1):42–58. doi:10.1080/09585192.2014.940993.
24. Smith HA. Manager as coach characteristics for dealing with team challenge. J Work App Manag. 2019;11:165–173. doi:10.1108/JWAM-06-2019-0022.
25. Snyder AW. Breaking mindset. Mind Lang. 1998;13(1):1–10. doi: 10.1111/1468-0017.00061.
26. Heslin PA, Keating LA. In learning mode? The role of mindsets in derailing and enabling experiential leadership development. Leadersh Q. 2017;28(3):367–384. doi:10.1016/j.leaqua.2016.10.010.
27. Sherman RO. Leading a multigenerational nursing workforce: issues, challenges and strategies. Online J Issues Nurs. 2006;11(2):3.
28. Kennedy F, Carroll B, Francoeur J. Mindset not skill set: evaluating in new paradigms of leadership development. Adv Dev Hum Resour. 2013;15(1):10–26. doi:10.1177/1523422312466835.