Background on Coaching

The CalNOC PFQ Project began its coaching intervention by approaching each hospital in a systematic, somewhat standardized, yet highly individualized way. From the outset we acknowledged and recognized the following:

“Whatever strategies or practices may be used, they must be implemented, and implementation requires adaptation of a strategy or practice within the local context of a school [hospital]. Contexts vary greatly from one [setting] to another; they also change within the same [setting] over time. Furthermore, implementation follows a nonlinear path—a path that does not lend itself to be sufficiently captured in any one “model” for improvement. Therein lays the challenge. Implementation is a nonlinear process that is highly context-specific; therefore, it requires the authentic participation of those who know the context best.” ¹¹

In preparation for launching the coaching intervention, the investigative team confronted key questions at the heart of the coaching role effectiveness, which included:

• How is authentic participation best supported and guided?
• How can implementation of new practices be supported?
• What are the key obstacles to successful adaptation and implementation?
• How can these obstacles be avoided or effectively addressed?
• Finally, and perhaps most importantly to the project’s aims, in the midst of such a nonlinear process of improvement, how can an organization make steady and even accelerated progress and improve outcomes?

In the field of education, scholars and school-change experts have found that practitioners tend to engage in deep, sustained, technical, and normative change when they are in a relationship with a knowledgeable guide or coach. We began our coaching intervention in anticipation that the experience gleaned from education would be relevant to our efforts in health care. Furthermore, we posited that the explicit role of the coach working in collaboration with a designated hospital staff person, literally linking clinicians in that setting with the project team, was consistent with and operationalizing Havelock’s Linkage Model, our conceptual perspective.¹³

What Is the Role of a Coach in the Context of Change?

In the field of education, coaching is effective, not only for facilitating changes in practice, but also for building individual and organizational capacity for continuous improvement. The commitment and capacity (i.e., knowledge, skills, habits) required to change practice are effectively supported by a coach. Likewise, the commitment and capacity (i.e., processes, systems, norms) required for an organization (e.g., team, unit, floor, hospital) to change are greatly enhanced through coaching support. What, then, is the role of the coach in the context of change?

In both education and nursing, coaches can help organizations navigate effectively through the complex process of change by addressing key elements of the change process, including, but not limited to:

• Obtaining buy-in for change efforts, including data collection and analysis that help identify goals and priorities.
• Ensuring systematic and detailed planning.
• Accessing support and ongoing professional development.
• Adapting new practices in the local context.
• Evaluating goals and the implementation process to inform next steps, paying particular attention to indicators of positive fall prevention efforts.
• Cycling back continuously to each element, maintaining thoughtful focus on each discrete element and the interconnectedness among the various elements.¹¹

This is not a sequential list of steps that the coach facilitates; rather, they are touchpoints that coaches can address as they build the capacity of the organization to engage in continuous learning and improvement. With the expertise and objectivity of an “outside” consultant—but with an understanding of the site’s culture, history, and vision characteristic of an “inside” leader and advocate—coaches are well-positioned as “insider/outsiders” to help the organization address tensions that, in many change processes, can erode or derail the change process. For example, coaches help sites (1) maintain focus and be adaptable and responsive, (2) achieve clarity and tolerate confusion, (3) understand reality and imagine other possibilities, and (4) think systemically andact specifically.¹¹

While coaches may at times provide instruction or training (e.g., in data analysis, goal setting, evaluation/measurement), they do not direct or instruct their sites as consultants might. Instead, coaches bring more of a mentoring, or guiding, presence by:^{11, 14, 15}

• Asking questions, e.g., “How might you…?” “What evidence do you have that…?”
• Brokering resources and relationships, e.g., “I know of a site that worked with that evaluation software last year. Let me put you in touch with them directly to see if they could guide you in implementing it at your site.”
• Developing the commitment and capacity of a core leadership team within the site, e.g., linkers and linker teams.
• Observing, listening, inquiring, and reflecting upon local processes in the context of larger efforts aimed specifically at improving the overall quality of patient care and reducing patient falls.
• Optimally, posing thought-provoking comments and questions that bring out the positive qualities in site personnel and organizations and ultimately deepening or accelerating the change process.

Conceptual Perspectives Guiding Project Methods

As noted above, the CalNOC PFQ Project coaching intervention was grounded in Havelock’s principles of reciprocal communication¹³ and guided by Rogers’ concepts of organizational, work unit, and individual innovation adoption and diffusion processes.¹⁶

Havelock’s Linkage Model posits reciprocal and interdependent relationships between the knowledge generation subsystem and the knowledge user subsystem, with human “linkers” playing a key role in transmitting new knowledge and in enabling feedback.¹³ The model assumes that knowledge diffusion and utilization are fundamentally acts of communication between resource systems producing new knowledge and systems that apply and use knowledge to attain societal goals (e.g., health care). Human “linkers” literally connect the resource and user systems, facilitating communication and feedback, thus making collaboration to accomplish the transfer and use of research possible. Our project highlighted communication by envisioning the project team as a “source of knowledge,” with individual coaches as representatives, by identifying “linkers” for each hospital site and by providing hospital “users” with assistance in accessing/synthesizing research-based evidence to support specific fall-reduction efforts.

Although Havelock’s linkage concept is invaluable in explaining reciprocal relationships between knowledge producers and knowledge users in health care practice, Rogers’ theorizing relates to how practice change (i.e., innovation) diffuses or spreads. Rogers¹⁶ posits stages in the processes that make up individual and organizational adoption of innovations.

At the organizational level, the organizational innovation process comprises five stages:¹⁶ (1) agenda setting, (2) matching, (3) redefining/restructuring, (4) clarifying, and (5) routing. Affirming the organization’s commitment to change emerges from agenda setting efforts and launches the next steps to refine the match between the organization’s need and the target innovation. At the heart of innovation adoption is a concurrent process of sequential decisionmaking that culminates in a commitment to implementation of the change.

This five-stage process is the “Innovation-Decision Process”¹⁶ and includes the following phases: (1) knowledge acquisition, (2) persuasion, (3) decision, (4) implementation, and (5) confirmation. The challenge of interventions geared toward translating research into practice arises from the tough reality of moving through the phases of innovation decisionmaking within and between organizational, work unit, and individual levels.

Guided by Rogers’ conceptualizations of these processes that culminate in successful diffusion of innovations, we aligned our coaches’ approach with phases of the innovation decision processes. The content and tactics of coaching intervention were intentionally contingent on the needs of the organization and the medical-surgical patient care units working through the processes of fall-related innovation implementation unique to each setting.

Design and Implementation of the Coaching Intervention

In our project, the coaching intervention was designed principally as a telephone-based contact between one coach and the linker(s) assigned to the project, about 30 to 60 minutes in length at 3 to 6 week intervals, with the option for one or more site visits or multi-site conference calls. Coaches’ actions included:

• Monitoring: Activity focused on tracking the status of target milestones; includes listening, assessing progress, eliciting feedback, and guiding discussion to clarify.
• Providing information: Knowledge is exchanged.
• Providing support: Mutual sharing; includes active listening, being a sounding board, and validating and highlighting common experiences across sites; also, anticipatory guidance.
• Identifying action/prescription: Identification of activities to be done; includes planning assistance; clarifying next steps; identifying stakeholders; interpreting/reframing organizational responses, challenges, and barriers; and articulating mutually agreed upon tasks.
• Providing referral: The process of connecting linkers/hospitals, who have needs with someone or something with the knowledge; includes connecting people to people and people to information (e.g., publications, Web sites).
• Identifying resources: Assistance in the form of individuals, information, and energy; identification of resources needed for “next steps” in advancing the improvement plan.

Recruiting Coaches – Characteristics of the Coaching Team

Prior to initiating coaching contact with linkers in hospital sites, the project team developed a role description for a project coach that clarified availability (hours/month; number of site visits/month), explicated principles of honesty and boundary setting, highlighted the importance of being able to deal with ambiguity, and outlined some of the content and skill areas that were desirable. The coaching team included six registered nurses with specialized knowledge and skills related to research utilization, evidence-based practice, nursing services administration, and fall prevention strategies. Three coaches were doctorally prepared, and three were masters prepared, including a gerontology clinical nurse specialist. Coaches brought a wealth of insight, expertise, and a strong commitment to their role, which was considered key to the authenticity of their relationship with hospital linkers. Eligible hospitals (N = 33) were distributed among coaches to address site mix (small, large, community, academic) and to cluster sites geographically. The coaching team remained stable throughout the project, with the exception of one coach, a doctoral student, who ended his role with the project after completing his doctorate. His three hospitals were reassigned to other members of the coaching team.

Coaching Role Clarification

At the beginning of the intervention phase of the project, coaches met several times with the seasoned coach facilitator—an educator—to discuss the coaching role. In order to differentiate the coaching role from more familiar consulting and mentoring roles, the following key points were stressed:

• The length of a coach’s relationship is usually longer than that of a consultant.
• The scope of a coach’s work is customized to a specific hospital culture and focuses on specific targeted areas of priority work. The coach always moves between the specific and the systemic, keeping the big picture in mind. In contrast, consultants tend to focus on the big picture or targeted areas of work, without the back-and-forth thinking.
• Coaches leverage site expertise to actualize improvement, whereas consulting often presumes that the consultant has the expertise to achieve the desired improvements.
• Coaches are interested in building site capacity to: (1) accelerate change/improvement (e.g., sites should reduce falls more significantly and more quickly than if the coach had not been involved) and (2) sustain improvements that continue after the coach is gone (i.e., coaches should try to work themselves out of a job). Building capacity may include the “brokering” of services, such as connecting sites with resources (e.g., people, literature, data). Compared with coaches, consultants may focus more on (1) than on (2).
• Coaches understand that context mediates the change/improvement process. In light of this, coaches do not come with a predetermined approach to the work. Rather, they bring project goals and objectives along with a repertoire of process skills, content knowledge, and relationships from which to draw to support, challenge, and guide the site’s efforts to reduce falls. In comparison, consultants might bring a more specific “model” that might not take into account the unique context of the hospital.
• Mentors usually reside within the same organization as the person being mentored. On the other hand, coaches more often than not are external to the organization. However, there can be internal coaches. The approach each coach takes differs in relation to the person being coached. Individuals engaged in coaching or mentoring relationships understand the unique support and assistance that each provides.

The coach facilitator was engaged as a “coach” to the coaching team throughout the project, regularly participating in team conference calls.

The Linker Role

Linkers for each hospital were designated by the hospital’s chief nurse officer (CNO). The nurse executives were asked to select nurses with specific characteristics when designating linkers. Preferred qualifications included an advanced practice role with at least a baccalaureate degree and multiple years of clinical experience. Additional linker characteristics suggested to CNOs included:

• Interest in fall prevention and reducing fall-related injuries.
• “Systems savvy,” i.e., experience and knowledge with making things happen within a nursing service organization.
• Credibility with staff and leadership.
• Support on immediate unit or work area.
• Ability to champion a cause and motivate others in championing a cause.
• Experience with making changes that lead to improvements, with evidence-based practice, or with implementing research-based changes.
• Familiarity with stakeholders for a fall prevention program.
• Ability to develop relationships among multidisciplinary stakeholders.
• Ability to develop, modify, and implement a plan among different stakeholders.

While our project team was able to guide hospitals in selecting certain types of linkers, we ultimately did not determine their selection. All but one linker were nurses. While most hospitals selected a single linker, about one-third of the hospitals chose to use a linker team with two or more staff.

Phase 1: Pre-Engagement – 60 Days

The target objectives were refined by the coaching team. Prerequisite “enabling aims” were made for each target outcome objective, providing direction for coach actions. To provide a common language to describe coaching actions, a worksheet served as a documentation/communication tool that captured the “content” of each coaching interaction. The content was framed in the target objectives, highlighting coach actions.

Phase 2: Site Entry and Planning – 120 Days

During the orientation period, coaches focused on building rapport with linkers and establishing a plan for ongoing telephone-based collaboration. In each contact, coaches informally assessed site capacity for evidence-based practice and fall prevention/assessment experience and practice. Coaches also established preliminary agreement with linkers related to their ongoing relationships, clarifying the relevance and appropriateness of target outcomes and the way this project fit into the site’s strategic priorities. Based on self-assessment and review of detailed CalNOC falls data from each hospital, site-specific plans for improvement were developed by linkers and their teams with the support of the coach.

Phase 3: Doing the Work of Performance Improvement and Change – 24 Months

For most of the project, coaches worked with hospital sites to achieve site-specific performance improvement objectives. Guided by the focused plan for falls-related change, preliminary communication planning was refined and expanded to focus on the following:

• How the linker communicated with unit staff.
• How the linker, coach, and staff communicated with site leadership.
• How coaches and CalNOC leadership communicated with CNOs for participating hospitals.

All communications aimed at optimizing the work of the CalNOC Partners for Quality Project. The number of telephone calls and visits varied according to different coach assignments (e.g., one coach carried half of the sites), site needs, and linker availability. No interactions involved actual observation of practice.

As sites developed and implemented their plans for change and performance improvement, coaches worked with linkers to clarify outcome measures with the site and to identify resources necessary to attain goals and address emerging barriers to progress.

An ongoing focus for coaches and linkers was to develop site-team capacity to fully use site-specific CalNOC data as a source of evidence for identifying priorities for change and for evaluating progress. Throughout this phase, coaches sought to understand site priorities (goals/strategic plans) and pressures (external/internal) to help align this project within the context of overall organizational priorities. Ultimately, this maximized the strategic value of the work.

At the same time, coaches were doing some of their own role-development work with CalNOC. This included the following activities:

• Advocating for site resource needs (e.g., various query reports using CalNOC data).
• Experiencing professional development: “Coaching the coach.”
• Receiving feedback from CalNOC’s evaluation of and reflections on coaching.
• Developing and using consistent documentation methods for site experience.

Phase 4: Phasing Out – 6 to 9 Months

During the final phase of the coaching intervention, coaches initiated anticipatory plans for ending the coaching contacts and assessing the impact of the project. During this phase, coaches and linkers considered the site’s capacity to maintain data collection and analysis (i.e., making sense of the data and using it to inform practice). This involved activities such as tying reduced falls to job evaluations (accountability tied to outcomes) or linking data collection and analysis to dissemination and use with nurses on site, which in turn was tied to a reduction in patient falls. Coaches worked with sites to complete self-assessment surveys and to plan subsequent steps in sustaining the work and the changes achieved. Linkers and their CNOs were formally thanked for their commitment and contributions to the project. Preliminary outcomes were shared in formal and informal conferences/meetings.

Tracing the Content and Activities of Coaches in Action

Throughout the coaching intervention, the content of site contacts—principally telephone contacts—was captured using Coaching Intervention Documentation Worksheets. Selected site visits did not differ substantively from telephone contacts and typically were used to “kick off” work or inspire teams by engaging them in face-to-face contact with the coach. Notes from the Documentation Worksheets enabled coaches to record content foci and key actions (described elsewhere in this paper) emerging from contacts with sites. In addition, “field notes” of conversations related to fall prevention efforts, issues, challenges, and concerns were recorded. These recordings helped coaches anticipate the foci and plan for next contacts.

Descriptive analysis of the Coaching Documentation Worksheets for year 1 reveals that all topics were discussed across multiple contacts. Listed below are the topics and percent of times each was documented:

Challenges Faced by Coaches

Coaches faced a number of challenges to the effectiveness and impact of the intervention. First, challenges arising from the linker role included turnover, inability to focus on falls due to competing demands, perceived lack of support from organizations, lack of time, and difficulty sustaining contact with coaches. These challenges across sites and coaches resulted in difficulty establishing and sustaining “traction” in advancing project outcomes.

Another challenge was related to the capacity of the hospital and project linkers to access and use their CalNOC fall-related data. In particular, linkers had trouble extracting from these data setting-specific implications for strategic performance improvement. Although assigned to spearhead the work in their setting, many linkers were initially unable to read and interpret these data because they lacked experience with spreadsheets and dashboards.

Organizational capacity for transformational change varied widely but was also a theme across sites as CNOs faced shifting priorities. Turnover of executive leadership influenced the pace and intensity of change as priorities became realigned with expectations of new leaders.

An interesting challenge arose when the coaching team explored linkers’ knowledge related to new literature on the impact of medication-focused interventions on falls reduction. The vast majority of linkers were unaware of this literature. To address this problem, the CalNOC coaching team developed a fact sheet that synthesized relevant findings and provided linkers with a tool (including references) to launch discussions within sites.

Impact of the Coaching Intervention on Policies, Procedures, Practices, and Outcomes

The coaching intervention lasted for just under 3 years. A short formative survey was sent to CNOs midway through the project to be completed by CNOs with linker input. Responses to three open-ended questions were received from 28 organizations (85 percent response rate). The findings suggested work in progress that may have ultimately led to many of the actual practice changes that were documented a year later on the final self-assessment evaluation.

Heightened awareness of falls as a universal problem in hospitals was reported as a common consequence of the coaching intervention. Participants reported a high degree of satisfaction with the coaching process, attributing the highest value to the interpersonal contacts.

Hospital pre- and post-intervention self-assessments suggested minor and major changes in policies and practices across sites. The percentage of hospitals that evaluated fall prevention equipment increased from 55 percent to 89 percent. An increase (from 29 percent to 79 percent) was also reported in the percentage of hospitals that used systematic post-fall analysis as part of the fall incident followup. There were also increases in the number of hospitals that reported fall rates monthly or more often (from 3 percent to 39 percent) or quarterly (from 18 percent to 57 percent). While almost all hospitals had a fall prevention protocol in place at the beginning of the project (94 percent), elements of fall prevention policies or protocols changed over the time of the intervention (Table 2) to reveal more evidence-based strategies.

Table 2

Impact of the coaching intervention on fall prevention protocols.

Similarly, hospital responses to a fall incident became more systematic, incorporating more elements that would truly assist in fall prevention efforts (Table 3). At the final assessment, linkers were asked to evaluate several elements of the project (Table 4).

Table 3

Impact of the coaching intervention on hospital response to a fall incident.

Table 4

Linker-rated usefulness of CalNOC PFQ interventions at final self-evaluation.

In general, evaluations were positive about the coaching intervention and its impact on fall-related performance improvement efforts (Table 5). The lowest ratings were for elements without a personal component (e.g., CalNOC data). Analysis of pre- to post-intervention fall incidence and injuries did not reveal significant differences, despite reported process and practice changes.

Table 5

Impact of the PFQ project on fall prevention efforts.