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CONTINUING PROFESSIONAL DEVELOPMENT

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Using coaching interventions to develop clinical skills

NS500 Price A (2009) Using coaching interventions to develop clinical skills. Nursing Standard. 23, 44, 48-55. Date of acceptance: November 7 2008.

Summary
This article contributes to the development of senior nurse coaching interventions to help colleagues develop their clinical skills. It introduces a practice skill analysis framework as a recommended tool and examines the challenges that can arise in its use.

Author
Adrienne Price is head of midwifery, Frimley Park Hospital, Surrey. Email: altanprice@aol.com

Keywords
Clinical skills and competences; Coaching and interventions; Procedural knowledge These keywords are based on the subject headings from the British Nursing Index. This article has been subject to double-blind review. For author and research article guidelines visit the Nursing Standard home page at nursingstandard.rcnpublishing.co.uk. For related articles visit our online archive and search using the keywords.

The context for this work will vary. Sometimes the nurse will ask for assistance from a respected senior colleague. Sometimes the work takes place within a supervisory or mentorship framework. In other circumstances, skill development work may be remedial, where a line manager has suggested that the practitioner and a senior colleague might work collaboratively to correct a skill. The aim of this article is to assist the reader to use simple coaching principles while working with colleagues who are reviewing and improving a chosen clinical skill. After reading this article you should be able to: Identify the general principles of coaching. Explore your own potential to assist others using a coaching approach. Summarise how a review of reasoning and behaviour can support skill development. Use a framework for skill analysis to help focus coaching discussions.

Aims and intended learning outcomes

Clinical skills have never been more highly prized. Health care requires skilful practitioners who are able to translate ideas into action. Many of the competences that practitioners are required to demonstrate are stated in terms of clinical skills. Much of the skill development work done to date has concentrated on pre-registration learners. Further work remains to be done with established practitioners, some of whom have been supporting patients for many years (Wright 2006). It is here, in the area of professional update, that an opportunity exists to combine coaching with an approach to skill analysis to help colleagues to realise their potential. 48 july 8 :: vol 23 no 44 :: 2009

Introduction
In this article, clinical skills refers to all the measures used to ensure that knowledge and expertise are brought together in the service of patients (Table 1). Some clinical skills are highly technical, for example interpreting an electrocardiogram trace, some require dexterity, such as manipulating an endoscope, others are more interpersonal in nature, for example providing patient education (Baillie 2005, OSullivan et al 2008). Typically, clinical skills require the practitioner to adapt what is said or done to specific contexts, perhaps to individualise care or to help minimise risk. Clinical skills change NURSING STANDARD

TABLE 1 Examples of clinical skills

Clinical skill Helping patients to manage their anxiety. Declarative components (that which we can assert) Triggers that typically provoke anxiety in a given context. Ways in which patients demonstrate anxiety. Ways in which patients cope with anxiety. Urinary catheterisation. The normal anatomy and physiology of the genito-urinary tract. Indications of urinary obstruction and/or rupture of the urethra. Normal points of pressure associated with urinary catheterisation (for example, advancing the catheter beyond the prostate gland). Merits of different catheter materials, designs and sizes (dependent on the patient and purpose of catheterisation). Procedural components (that which we know how to do) Ascertaining the origins of anxiety. Reviewing the nature of a threat and its significance. Revisiting coping resources and strategies to reduce anxiety. Establishing rapport and maintaining a private and comfortable environment. Obtaining informed consent. Locating the correct orifice for catheter insertion. Managing catheter insertion and monitoring discomfort. Advancing the catheter safely. Establishing that the catheter has been inserted correctly.

according to context and need the practitioner becomes adept at adjusting his or her practice to support patients (Higgs and Jones 2000). However, it is relatively difficult for colleagues to talk effectively about such skills, not only because clinical skills are complex (Sullivan et al 2008), but also because practitioners need a better understanding of the process by which skills might be examined, evaluated and developed. Practitioners are understandably cautious about talking about their skills, often because these have been closely associated with judgements about competence. The skills that a professional uses are part of what sets the individual apart from other healthcare workers (Thompson and Dowding 2001). Opening a discussion about clinical skills requires trust between the practitioner and the coach. Colleagues might not welcome an instructional approach to skills development, preferring instead a shared examination of that which is problematic and that which the practitioner intends to improve. For example, Jemma is a nurse who works in cancer care who regularly supports anxious patients. She notes that giving patients information about their tumour and treatment plan does not necessarily reduce anxiety levels. To help Jemma to develop skills designed to reduce patient anxiety it will be important to assist her in ascertaining what is already being done and what might be done differently. Simply instructing Jemma on specific NURSING STANDARD

techniques will not necessarily assist her to make changes in her practice.

Time out 1
Reflect on whether you think talking about clinical skills can be difficult. For example, do you think that it might expose feelings of inadequacy where a skill seems poorly mastered? What in your experience has helped colleagues to discuss their clinical skills in a constructive manner?

Principles of coaching
Sullivan et al (2008) observed that even expert clinicians can experience problems analysing the decisions that they take when completing healthcare procedures. The more practitioners become accustomed to skills in use, the more automated they can become and the less such individuals are able to develop them. Expert practitioners need to form an account of what is done and how it is done. Only by doing this can they share their expertise with others and remain alert to new possibilities. It is the how to procedural knowledge that for many colleagues can be problematic. In the case of Jemma, it might not be what she says about cancer and its treatment, but the way in which she gives the information that determines whether patient anxiety is reduced. july 8 :: vol 23 no 44 :: 2009 49

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Coaching is one means of developing procedural knowledge the ways in which practitioners use their experience, knowledge and ability to address clinical needs. Coaches function as inquisitive companions who assist individuals to explore what they know and how they think and act. While historically many coaches have operated external to an organisation, hired by an employer, Frisch (2001) identified increasing scope for in-house coaches to play a part in developing best practice. He described coaching as a one-to-one relationship of trust aimed at fostering learning and professional growth. Such relationships TABLE 2 Characteristics of an effective in-house coach
Characteristic Develops a trusting relationship with the practitioner, focused on professional growth and development. Conversant with a model of coaching and ready to execute it flexibly and dependably. Notes

often provide the impetus for professional breakthroughs significant changes in practice, achieved through increased personal insight. To operate successfully, Frisch (2001) suggested that coaches should: Coach only those for whom they do not have line management responsibility. Establish clear parameters for the work to be done in collaboration with the practitioner. Start with an opening assessment of the skill and agree with the individual in what ways it will change. Table 2 summarises some characteristics of an effective in-house coach.

Points for reflection Do you develop an easy rapport with other practitioners? Do they describe you as empathetic? Are you ready to discuss what you have seen the practitioner do, and to explore with him or her the reasoning that underpinned his or her decisions and actions? Are you used to asking tactful, but sometimes probing questions? Are you comfortable reflecting in this way? If you tend to be rigid about practice, coaching may be difficult for you.

Trust is critical. Coaching is not an opportunity to score points or demean the work of others.

There are different frameworks for coaching and some require specialist training. In this article, a simple cognitive-behavioural approach is explored.

Can explain observed behaviour to the practitioner in an accessible, useful and sensitive way.

The coach needs to sum up what has been learnt through observation and discussion. The reflections are tactfully presented to the practitioner. Constructive curiosity is important.

Interested in how others think and act and committed to helping them improve.

Do you think that experience affords learning opportunities? Are you ready to change your views and attitudes as a result of what may be learnt through coaching? Are you able to view issues from different perspectives, and discover fresh ways to proceed?

Optimistic and creative, with experience of the skill in question.

Familiarity with the chosen skill is important. Asking new questions about the skill should start from a position of insight. Knowing when to refer a problem or when to recommend other sources of assistance is important if coaching is to be constructive. Nursing practice is inherently about managing risk and respecting the needs of others.

Organised listeners who understand their own expertise limitations.

Are you known as someone who knows and respects your limitations?

Can balance a concern for the individual with recognition of the needs of practice.
(Adapted from Frisch 2001)

Are you clear about boundaries, and what is ethical and professional?

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Time out 2
Study Table 2 to discover the extent to which you think that you have the characteristics of a successful coach. To ensure that you are being objective, discuss your observations with a colleague to obtain a second opinion. While you are likely to be more accomplished in some areas than others, you should remain confident in most if you are to assist others as a coach. Coaching has been used as part of nursing care. For example, Hayes et al (2008) discussed the use of coaching to help patients diagnosed with diabetes mellitus, and Fahey et al (2008) explored the use of coaching to modify patient attitudes towards effective cancer pain management. Both of these TABLE 3 The eight-step coaching intervention
Steps Greeting Demonstrate interest by listening to nurses experiences. Ascertain which skill will be the focus of discussion. Current issue Establish what attitude or concern the practitioner has associated with the skill. Problem Help the individual to describe and consider the nature and extent of the problem and why the skill seems unsatisfactory. Problem impact Examine why change is necessary. What are the consequences of using a less than successful skill in practice?

papers show that coaching is especially well placed to help others as they work with the attitudes, beliefs, decisions and experience of practitioners. The coaching approach has the potential to assist others to explore sensitively why they act as they do and how perceiving matters in different ways can improve practice. If we return to the work of Jemma once more, we might discover, for instance, that a discussion develops around the premise that more information promotes better care, and examine what the patient needs to digest before he or she can use it to allay anxiety. Jemma may believe that, because she feels reassured by having all the facts, patients prefer this approach too.

Exploring reasoning and behaviour

Successful coaching requires both a process and a tool to facilitate skill analysis. Authors describe

Notes Establishing early rapport is important, especially if the nurse has been directed to you for assistance.

Acknowledging feelings and attitudes at the outset is necessary as these affect how individuals use skills. The practitioner needs to develop an initial diagnosis of what could be better about the chosen skill. Do not forget to acknowledge what is done well. One impetus for change is personal satisfaction with practice. This is reinforced when we can identify other benefits as well, such as opportunities for promotion or greater recognition by colleagues within a multidisciplinary team. It is important to start modestly, describing two or three goals to be achieved in three or four weeks. Goals can be revised and added to. Strategies may vary. In this article, a skill analysis framework and discussion of practice episodes are used. It is important to indicate tasks for the individual to continue working on. These can then be discussed at the next meeting. Typically, tasks involve thinking about particular aspects of a skill in use. Each coaching discussion needs to end with a summary, but there should also be one at the end of the coaching relationship.

Short-term goals Work with the practitioner to identify what might be achieved. Strategies Identify strategies that can assist the individual to revisit the skill and make selective adjustments. Tasks Select tasks that the practitioner can report back on.

Summary Summarise what has been agreed and learned.

(Adapted from Fahey et al 2008)

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the coaching process in different ways. In medicine, for example, Sullivan et al (2008) discussed the process in terms of cognitive task analysis. Colleagues are engaged in an examination of ways of thinking and its relationship to treatment tasks. Fahey et al (2008) thought of the coaching process as a series of eight steps (Table 3).

Time out 3
Consider whether you have ever used the series of steps described in Table 3 as part of supervisory or mentoring work with others. If you used steps such as these what were the benefits of working in this way? If you worked in a less structured fashion, were there any limitations or benefits to that approach? In working through the coaching steps of Table 3, it is important to consider the nature of conversations shared with the practitioner. The focus is on what the practitioner does and how the individual thinks about what he or she does. Ducharme (2004) described a cognitive-behavioural approach to coaching that has particular appeal in this regard. It is based on a series of assumptions about the work conducted with the practitioner, including the assumptions that: How we think about our experience of the skill in use can affect how we practise that skill. Through tactful and thoughtful discussion we can access, monitor and alter our thinking. Changes in the way we think can produce sustainable changes in the way we practise. Dobson and Dozois (2001) observed that cognitive-behavioural approaches can be used in different ways to: Help individuals to cope with their situation. Help people to restructure how they think about the world. Solve problems that have presented. The first two uses of cognitive-behavioural work are associated with therapy and will not be the focus of work recommended here. This article examines how practitioners relate reasoning to action as a means to develop more skilled practice. Referring back to the case scenario involving Jemma, coaching work is directed at helping her 52 july 8 :: vol 23 no 44 :: 2009

discover new ways to use information to allay patient anxiety. It is not designed to help her investigate deep-seated feelings regarding her adequacy as a practitioner. In coaching colleagues on a chosen skill, the coach provides a series of valuable services to the practitioner (Kampa and White 2002). First, the coach provides feedback on what he or she has seen and heard. Commentary needs to be measured, identifying what has worked and what has been problematic. Second, the coach helps the practitioner to direct discussions about his or her thinking and behaviour to the organisational and professional context of practice. The coach may therefore invite the individual to consider the fit between a chosen way of giving care and what seems required by the context. Third, the coach helps the practitioner to identify the changes made as a result of the work done together. Coaching is successful to the extent that the practitioner can see how reasoning and behaviour have changed. In the case of Jemma, that might include exploring and questioning past assumptions about information, knowledge and anxiety.

Time out 4
Look back at how you responded to Time out 2 and update your assessment of your readiness to coach colleagues on skill development. Now answer the following questions: Do you support the assumptions that underpin cognitive-behavioural approaches to coaching? Are you ready to explore with a colleague what he or she did and why it was done in a particular way? Being willing to discuss how and why something was done is important if skills are to be analysed sympathetically and if the practitioner is to be assisted to change his or her practice.

Using a skill analysis framework

One effective way to discuss a clinical skill is to use a skill analysis framework. This framework has been described in association with different contexts (Price 2007, 2008, Catterson and Price 2008). The skill analysis framework used in this article is based on the work of Gobet (2005), who analysed skills used in other areas of life, including the practice of chess grand masters. While chess masters and healthcare practitioners might not appear to have much in common, both are required to use skills strategically, to address developing situations and to secure key objectives. Both, for example, manage risk. NURSING STANDARD

Gobet (2005) explained that the key premise of skill analysis work is that individuals develop templates in their mind that they use to determine how best to proceed. Some of these templates are regularly used, but rarely questioned. Some of the templates used by each of us remain tacit that is, we do not understand how we are using them. When we start to examine the individual components of a skill, we identify that which could be improved. This was true for Jemma, as she confronted her assumptions about the use of information and the reduction of patient anxiety. Jemma came to appreciate that patients needed to be ready to receive information and that skilful practice involved judging when a patient felt ready to learn more.

Time out 5
Consider with colleagues whether you have ever been aware that you are using mental templates to direct the way in which you deliver care. Were there moments when you became aware that the template no longer seemed appropriate for what you needed to achieve? The skill analysis undertaken should be based on a first description of the skill as currently used. This will form a contrast to the future skill and can be written as part of the current issue stage of coaching (Table 3). One or two paragraphs should suffice, but this should include reflections on both what is done and how the practitioner thinks about what to do next. The individual is then ready to work on the four components of skill described by Price (2007, 2008) (Figure 1): Declarative. Procedural. If this, then that thinking. Available knowledge. These are attended to only after the practitioner has written a description of the skill as known and used, as part of the current issue stage of coaching. The purpose of the description is to provide a contrast to how the practitioner thinks about and uses the skill later on. The description does not have to be structured in a particular way, but should include remarks about action and reasoning, and typically extends to two or three paragraphs in length. After this, the skill analysis framework can be used to inform the examination of the problem and problem impact as described in Table 3. It can guide the way in which short-term goals are described and the NURSING STANDARD

tasks that the coach sets the practitioner as part of work designed to investigate or develop the skill. Practitioners sometimes find it difficult to know what they can confidently assert about a skill, especially when they are newly qualified. In the case scenario, Jemma was hesitant about what she could assert regarding the value of information as a means of reducing anxiety, in part because she was aware that her assumptions might not be shared by others. She suggested that information is key to managing anxiety and also that the information has to be accurate and reliable. The coach agreed with both points. It was time to start thinking too about whether Jemma could make other assertions about the volume and nature of information to be shared in support of anxiety management. Turning to the procedural component of a skill is sometimes easier for practitioners. Individuals feel more confident about discussing what they do and how they do it. However, the procedural component of a skill is not limited to recounting all that is done and why, but to determine in what order it is done and to what purpose. In the case of Jemma, this might relate to the incremental provision of information designed to allay anxieties about illness, treatment or care. Jemma needs to consider if there is an optimal amount of information to share at any one point. Is there, for example, any point in conveying information about rare complications, if it is clear that the patient wishes to concentrate on that which routinely happens? It is helpful for the coach to watch the practitioner at work at this stage. Instead of judging the performance seen, the coach simply notes the sequence of work done, that which was said and that which was conveyed by other means of communication, such as touch. Afterwards, the coaching FIGURE 1 A skill analysis framework
Declarative component That which we can assert Procedural component That which we know how to do Skill deconstruction Discovering the template we use (Gobet 2005) If this, then that thinking How we fit the skill to the circumstance Available knowledge Research evidence and practice experience. How do we apply this?

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conversation focuses on the way in which work was arranged. The coach works with the practitioner to develop a picture of the template that he or she uses to arrange care.

support the skill in use. Coaching at this stage might involve tasking the practitioner to do some extra reading. The discussion is designed to ascertain how much knowledge is available, where it comes from and whether it is in a form that can readily be used. In some instances, the discussion may reveal a paucity of knowledge, or that the practitioner applies such information selectively and infrequently.

Time out 6
Despite developing a good rapport with staff, practitioners may still express concern about having you watch them use a skill in practice. If this is the case, you might consider inviting them to watch you use the skill first. The purpose of such an invitation is not to establish your expertise; it is to demonstrate the thoughtful reflections on how you proceed. Acknowledge the doubts that you felt and the queries that you had to confront as you assisted the patient. Ask a colleague to watch you use a skill in practice and then discuss the experience. What emerges from the discussion of procedure is a review of if this, then that thinking. If this, then that thinking attends to the decision-making process and highlights how a practitioner adjusts a skill so that it works properly with a given need. As practitioners, we think on our feet. Coaching can help practitioners discover the thinking shortcuts they sometimes use. In the case scenario, Jemma observed: Sometimes the patient suddenly says, no, dont tell me any more, Id really rather not know! I realise now that I rarely accepted that. I would wait a while until the patient seemed calmer and then ask the registrar to give them the information. As the coach discusses the if this, then that thinking with the practitioner, he or she may discover that there are many choices that could be made. This is sometimes why colleagues feel so stressed at work they know that they have to confront difficult decisions again and again. The purpose of the coaching discussion here is not to catalogue every last possible option, but to look for traits or habits that the coach and the practitioner can review together. For example, the review enabled Jemma to re-examine her thoughts about the responsibilities involved in information giving. Sometimes a skilful nurse was better suited to help the patient more by deliberating with them about what they needed or wanted to know at a given moment. As part of the skill analysis, it is important to discuss what might be termed the available knowledge pool. It is also vital to consider what research evidence or good practice seems to 54 july 8 :: vol 23 no 44 :: 2009

Motivating skill development

At this point, the skill analysis framework has been used to help the practitioner appreciate how he or she thinks about the skill, to establish what the individual does, to identify the decisions made and to identify what knowledge is available to underpin the skill. For someone such as Jemma, deconstructing the skill may have proven uncomfortable. She may have concluded that much of her approach to work was misguided and perhaps even arrogant. It is necessary therefore to move on, helping the practitioner to reconstruct the skill in a new way so that it meets his or her aspirations.

Time out 7
How do you think you might assist a practitioner to work towards skill improvement? Consider the importance of goals and a clear description of how the skill will work in the future? Use experiences of successful work with colleagues to inform the notes that you make. Three things are important during the final stages of the coaching relationship. The first is to write down a vision for how the skill will be used in the future and to contrast this with the description of the skill as it has been used. The advantage of doing this is not only that the practitioner sets out his or her ideas for improvement, but that the individual realises how much his or her thinking has changed. In the case of Jemma, this work went relatively smoothly and she summarised her vision in a few short sentences: Less can be more, selective is better than lots and I am going to spend more time listening to how patients make sense of their predicament, before I share information. Coaching at this stage should be upbeat and positive, celebrating the new insights that the practitioner has developed and encouraging the individual to identify why his or her new skill will fit better with healthcare requirements. It is also important to establish how others will know that the skill has changed. What will NURSING STANDARD

be evident to others in relation to what the practitioner does and how he or she communicates? A number of possible indicators could be considered in the case of Jemma and her plans. These could include: Patients expressing how supportive and sensitive Jemmas care seemed. Colleagues noting that Jemma approaches the subject of anxiety in a different way with patients. Jemma reflecting that she feels more in control of the urge to overwhelm the patient with information. The third aspect to consider is that the skill can only be reconstructed afresh if the practitioner understands how he or she managed the transformation. Understanding how to repeat the skill transformation process is valuable for the future. It is helpful to set the practitioner one last task, which is to describe the change in skill to others. This work can be handled in a variety of ways. At the most intimate and private level, it remains a final conversation between the practitioner and the coach. Where the practitioner has gained confidence, it can be translated into a skill analysis presentation at a team meeting or as part of a clinical seminar. Skill analysis of this sort may be suitable for

publication in a professional journal or as a conference or study day presentation.

Conclusion
There is considerable merit in using coaching as an approach to help colleagues develop their clinical skills. While coaching has historically been used in management, a simple form of coaching is amenable to use within the clinical area and fits with much of the supervisory or mentoring work that is carried out. It is suited to use with more experienced practitioners because it involves a collegiate investigation of challenges and focuses on skill enhancement as much as practice competency. Coaching needs a process, an underpinning theory and at least one tool to guide the work done with colleagues. The use of an eight-step process (Fahey et al 2008), a cognitive-behavioural approach (Ducharme 2004) and a skill analysis framework (Price 2007, 2008) have been recommended NS

Time out 8
Now that you have completed the article you might like to write a practice profile. Guidelines to help you are on page 60.

References
Baillie L (Ed) (2005) Developing Practical Nursing Skills. Second edition. Hodder-Arnold, London. Catterson M, Price B (2008) Managing conflict in the care of older people. Nursing Older People. 20, 6, 25-31. Dobson KS, Dozois DJA (2001) Historical and philosophical bases of the cognitive-behavioural therapies. In Dobson KS (Ed) Handbook of Cognitive-Behavioural Therapies. Second edition. Guilford Press, New York NY, 3-39. Ducharme MJ (2004) The cognitive-behavioural approach to executive coaching. Consulting Psychology Journal: Practice and Research. 56, 4, 214-224. Fahey KF, Rao SM, Douglas MK, Thomas ML, Elliott JE, Miaskowski C (2008) Nurse coaching to explore and modify patient attitudinal barriers interfering with effective cancer pain management. Oncology Nursing Forum. 35, 2, 233-240. Frisch MH (2001) The emerging role of the internal coach. Consulting Psychology Journal: Practice and Research. 53, 4, 240-250. Gobet F (2005) Chunking models of expertise: implications for education. Applied Cognitive Psychology. 19, 2, 183-204. Hayes E, McCahon C, Panahi MR, Hamre T, Pohlman K (2008) Alliance not compliance: coaching strategies to improve type 2 diabetes outcomes. Journal of the American Academy of Nurse Practitioners. 20, 3, 155-162. Higgs J, Jones MA (2000) Clinical Reasoning in the Health Professions. Second edition. Butterworth-Heinemann, London. Kampa S, White RP (2002) The effectiveness of executive coaching: what we know and what we still need to know. In Lowman RL (Ed) The California School of Organizational Studies Handbook of Organizational Consulting Psychology: A Comprehensive Guide to Theory, Skills, and Techniques. Jossey-Bass, San Francisco, CA. 139-158. OSullivan P, Chao S, Russell M, Levine S, Fabiny A (2008) Development and implementation of an objective structured clinical examination to provide formative feedback on communication and interpersonal skills in geriatric training. Journal of American Geriatrics Society. 56, 9, 1730-1735. Price B (2007) Developing Skills for Practice: Course K823 study guide. The Open University, Milton Keynes. Price B (2008) Enhancing skills to develop practice. Nursing Standard. 22, 25, 49-55. Sullivan ME, Ortega A, Wasserberg N, Kaufman H, Nyquist J, Clark R (2008) Assessing the teaching of procedural skills: can cognitive task analysis add to our traditional teaching methods? American Journal of Surgery. 195, 1, 20-23. Thompson C, Dowding D (2001) Clinical Decision Making and Judgement in Nursing. Churchill Livingstone, Edinburgh. Wright J (2006) Crisis and opportunity: coaching older workers in the workplace. Work. 26, 1, 93-96.

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