Constance M. SavagePerspectives in Ambulatory Care

Executive Coaching: Professional Self-Care for NursingLeaders

investing in your pro-fessional development andrealizing a 53% increase in

ity. Maybe you would rather see a39% increase in the retention rateof your managers. Or perhaps youwould simply like to see a 61%jump in your own job satisfaction?

Constance M. Savage According to 100 executives (most-ly from Fortune 1000 companies),

they achieved these changes through executive coach-ing (Manchester Inc., 2001). Whether driven by cost sav-ings, the exclusivity of having one's own personalcoach, or even the awareness that classroom trainingmay not always be the most effective modality for adultlearners who happen to be captains of industry, the ben-efits of executive coaching are clear. Coaching, a valu-able and efficient way to promote professional and per-sonal development, has found its niche in the businessworld. Will the same hold true in health care?

You might be thinking it's a long way from aFortune 1000 company to the intricately choreographedchaos of an ambulatory care clinic in a health care facil-ity or the steady stream of crises being fielded daily bynursing executives. When you consider nursing execu-tives' widened span of control coupled with the real-lifeconsequence of life and death decisions, executivecoaching should be right at home in the health careindustry.

Why Executive Coaching for Nursing Leaders?Nursing professionals are part of a special breed.

For the majority, their chosen work isn't just a job; it'smore of a vocation -a calling -in the truest sense ofthe word. And while they work shoulder-to-shoulderwith physicians and other allied health care profession-als, the realities nursing professionals share with theseother health care professionals can be worlds apart.Leaders from corporate America who manage daily

operations can begin to understand a portion of thepressure that nursing leaders feel every day. But themajority of leaders in business or health care, for thatmatter, don't feel the weight of decisions, practices, poli-cies, and systems that affect the life and death of otherhuman beings as do nursing leaders.

A graduate school professor once said, "The prima-ry function of people who work in health care is to man-age anxiety -their own as well as that of patients andtheir families." Isabel Menzies, in her seminal researchon nurses and development of social defense mecha-nisms to manage anxiety (Menzies, 1975), explored theevolution of this tacit and often unconscious dynamicamong nurses. From their initial classroom training,through their clinicals and into their professional prac-tice, nurses, like other health care professionals, wrestlewith managing the anxiety inherent in the life and deathnature of health care organizations. Add to this theseemingly never-ending increases in environmentalstresses for nurses -staffing shortages, higher acuity,increasing demands for improved service and ever-pre-sent cost containment -and the result is a workingenvironment that tests the limits of even the most high-ly skilled, most well-adjusted individual. Then imaginethe responsibility for leadership and oversight of thisworkforce and one begins to appreciate the magnitudeof the task facing nursing executives. The self-sufficien-cy so ingrained in the nursing culture begs to be tem-pered through resources such as executive coaching.

Prescription for Failure

If, through their training, nurses absorb the messageto be self-sufficient, the message only gets stronger as itis continually reinforced throughout their careers.Because self-sufficiency is rewarded by our society andorganizational cultures, recognizing it becomes prob-lematic. In the name of getting the job done, self-care issacrificed to preserve self-sufficiency. Consider onebusy nursing executive who casually mentions episod-ic heart palpitations that she should "probably getchecked out one day." Or the director of ambulatorycare who, after a meeting with her fellow non-nursingexecutives, comments that she can't quite figure outhow she always ends up leaving with more work thanher executive counterparts.

Add to these scenarios the high turnover of newlyhired nurses, impending retirements of scores of sea-soned nurses, and broadened spans of control. Mix inthe aftermath of doing more with less coupled withshrinking reimbursements and, to paraphrase an oldchestnut, nursing leadership begins to look like rear-ranging deck chairs on the iltanic. Nursing leaders canpersist in this seeming endgame or they can fight the

CONSTANCE M. SAVAGE, PhD, is Owner of Condia Enterprises,a Consulting Firm that Provides Professional Services in the Areasof Organizational and Leadership Development, ExecutiveCoaching, Educational Programs, Life Strategies, and RetirementPlanning. You can reach her bye-mail at cmsavage@mind-spring. com or by phone at (440) 930-5702.

NOTE: This column is written by members of the AmericanAcademy of Ambulatory Care Nursing and edited by REBECCALINN PYLE, MS, RN, Medical Office Administrator, KaiserPermanente, Denver, CO. For more information about the organi-zation, contact: AAACN, East Holly Avenue, Box 56, Pitman, NJ08071-0056; (856)256-2300; (800) AMB-NURS; FAX (856) 589-7463; E-mail: aaacn@ajj.com; Web Site: http://AAACN.inurse.com

inclination towards self-sufficiency and reach out forsupport as executives in other industries have learnedto do.

Coaching Corporate AmericaCoaching, long associated with sports, has moved

from the locker room to the board room. Evolving overthe years with a variety of labels, executive coaching hasbeen an integral, albeit transparent part of the corporatelandscape. Since the 1990s executive coaching hassolidified its image and focus, gaining a greater accep-tance in corporate America for a variety of reasons. Nolonger carrying the onus of remedial or corrective inter-vention, coaching is now accurately viewed as a tailoredapproach to professional development that helps influ-ence the bottom line.

Heartily embraced by corporate America for a vari-ety of reasons, coaching provides benefits that otherchange and growth modalities do not offer. Prinlarily,the content of coaching sessions is tailored to the spe-cific developmental needs of the executive. Simply put,this means that what the executive needs in terms ofprofessional growth and development, the executivegets. Because coaching aims at specific targets, itincreases the likelihood for success in a way that class-room training and education cannot match. A coachhones in on not only a particular issue an executivewants to focus on (the what), but also calibrates the ses-sion to the "how" it will play, given that particular exec-utive's skills, competencies, and experience.

When we think of a waltz, we tend to think ofstringed instruments with lush and resonant "voices"and not the low, vibrating tones of a tuba. Similarly, the1812 Overture conjures up the sound of a full-bodied,booming orchestra and not the high-pitched, wispysound of a piccolo. In both cases the instrument has animpact on the overall musical score. The same is true inleadership. Who an executive is and how she/he leadsare linked. When different leaders "play" the musicalscore of leadership, the results vary. So while there areleadership best practices (akin to the musical scores),effective leadership is influenced by the instrument andhow the music is played. For instance, some leadersmay be bold, gregarious risk takers. Others may be quiet"servant leaders" (Greenleaf, 1973). Both can be effec-tive, create unique organizational cultures, and inspireothers to achieve great things. But to expect a reservedleader to effectively glad-hand at a reception or ask aself-assured executive to be laid back and just blend inat the team meeting is unrealistic. Coaching helps exec-utives discover what works best for them, thus maxi-mizing their positive impact as a leader. In that respect,executive coaching is the equivalent of caring for andtuning one's leadership "instrument." When a leaderrecognizes the profound impact her leadership has onothers, then caring for one's leadership instrument -oneself -becomes an imperative for leaders who wishto create a long-lasting, positive leadership legacy.

What Coaching Is -and Isn'tExecutive coaching is, in essence, an organizational

intervention focused at the individual level. When anexecutive employs a coach, the coaching addresses spe-cific issues or concerns. These may range from assessingthe benefits and liabilities of a particular course ofaction to improving leadership effectiveness to identify-ing in-house bench strength as part of succession plan-ning. The common thread in all these situations is a feltneed arising from an organizational issue or concern.This is the defining characteristic of coaching and dis-tinguishes it from a therapeutic relationship.

Distinguishing the differences between executivecoaching and therapy is important for an executive con-sidering working with a coach. Some coaches comefrom the ranks of occupational and organizational psy-chiatry or industrial psychology where the educationand training may be more from a therapeutic model.Other coaches come from different disciplines such asorganizational behavior, management, business, or com-munications and combine the expertise of their givenfield of study with a solid knowledge of psychologicaldynamics. No matter the coach's professional trainingand background, one thing is clear: the primary focus ofcoaching is always linked to a business issue. Whetheraimed at leadership development, strategic planning,business analysis, or effective negotiations, executivecoaching addresses business issues that affect individu-als in their organizational roles. Executive coaching isnot a substitute for personal counseling. Knowing thisdistinction could make the difference between an actionthat is career enhancing or career ending.

Professional Self-Care for Nursing LeadersThe leadership challenges in today's health care

organizations are enormous and tax the personal andprofessional resources of its leaders daily. Today morethan ever, nursing leaders must proactively attend totheir own professional development if they are to pro-vide the kind of leadership that will inspire others to fol-low and succeed. Often the response to the pressures ofleadership is to stop the action, take a break, and pam-per oneself. And while a spa day or manicure or send-ing flowers to yourself may allow you to feel refreshed,re-entry is jolting and quickly obliterates the sense ofwell-being that had all too briefly been recaptured.Thus, nursing leaders may find themselves returning toany number of recurring scenarios. Some engage inunsuccessful battles to convince fellow non-nursingexecutives that onsite day care isn't a luxury but anecessity to ease the burden on already stressed nurses.Others face the challenge of enlightening a medicaldirector who fails to see the systems issues affecting caredelivery in the ambulatory care department and alwaysconcludes that it's a nursing problem.

However, imagine an alternative course of actionaimed at the root causes of the stress and pressure.

ow and accompanies the client to meetings, whileobserving interactions, presentations, and the like toprovide the client with feedback about her/his leader-ship behavior, its impact on others, and alternativebehaviors that might produce better outcomes.

Feedback is an essential component of effectivecoaching. So often leaders get caught up in doing theirjobs that they lose sight of whether or not what they aredoing is effective. Since it is difficult to be circumspectin a turbulent environment, so it is understandablethat leaders don't stop and take stock of their actions.Even those leaders who make the time to solicit feed-back often get caught in the predicament of having todecode the feedback they receive. They know that boththeir status and role as a leader often causes directreport feedback to be either cautious or soft peddled.Successful coaching avoids this Catch-22 by offeringobjective 360 degree feedback as a starting point fordiscussion and determining a developmental focus.The anonymous and confidential feedback from boss-es, peers, and direct reports gathered through validand reliable feedback instruments is the hallmark of asolid 360 degree feedback process.

Subsequent coaching sessions might be face-to-face, via phone, or even through e-mail. You wouldexpect to see ongoing dialogue between the coach andthe client, addressing the issues and concerns identi-fied by the client. At times the content may focus onreal-life work situations that the client determines arecritical for success. In other instances, the coachingsession may address a longer-term developmentalneed such as negotiating skills or strategic thinking.Yet other sessions might address emergent issuesrequiring objective analysis before action is taken.Coaching contracts usually span a 6-month to i-yearperiod, although different arrangements can be devel-oped to meet specific client needs.

Regardless of the content, coaching clients place ahigh value on the fact that coaching can focus onbehavior change in the privacy of their office wheremissteps won't raise eyebrows and rehearsing newbehaviors can be done in a psychologically safe andsupportive environment. You might see a clientrehearsing the opening of a particularly sensitive dis-cussion. Or witness a client mapping out a strategy tocreate buy-in for a controversial plan. In another situa-tion you might observe a role play between the clientand the coach with the coach giving feedback on theclient's tone, body language, or even choice of words.The coach might model different behaviors and ask theclient for a return demonstration. You might hearlaughter and groans. You might see smiles of satisfac-tion or furrowed brows communicating resistance ordisagreement. Above all, you would see incrementalprofessional growth and development grounded inreal-life organizational issues and everyday leadershipchallenges.

Envision a kind of professional self-care that helps yoube better prepared to effectively handle issues on a dailybasis. Learn how to strategize more effectively or perfectyour negotiating skills. Be more persuasive and sell anidea or analyze alternative staffing plans. As a nursingleader, give yourself the option of on-demand profes-sional support. Take some time to reflect on the leader-ship demands faced in your current role. Where do youfeel most in command of situations? When do younotice butterflies in your stomach? What sort of situa-tions or issues do you dread? As you laundry list youranswers, you are beginning to develop an agenda foryour first coaching session.

Coaching sessions provide you with on-demand oras-needed support that conforms to your schedule. Inaddition, coaching frees you from having to sift through(and sit through) a lot of information and material thatcomes with conventional workshops, seminars, or train-ing programs. In exchange, you will need to be preparedto work with direct feedback about your leadership andbe willing to ante up and change your behavior.Coaching may be one of the few professional develop-ment options in which your willingness and ability to"walk the talk" is immediately apparent.

As one executive coach put it, "Professionals havecoaches. Amateurs do not" (Agno, 2001). Deciding toengage an executive coach is a commitment of your dol-lars, your time, and your word that you want to and willchange. While this might feel daunting, consider thatcoaching can provide you with both the support andchallenge so that you in turn can give your direct reportsthe kind of leadership they need to be successful.

Coaching: Behind Closed DoorsDuring an initial executive coaching session, you

would probably see the client and consultant meeting inthe client's office. The consultant might provide anoverview of the consulting process or discuss groundrules for the coaching relationship. Of foremost impor-tance in any coaching relationship is confidentiality.Other ground rules might include: frequency and dura-tion of sessions, scheduling and canceling sessions, aswell as expectations regarding the completion of anypost-session assignments or exercises.

The coach would also ask a series of open-endedquestions to assist in identifying the client's priorities.Coaching sessions usually focus on the client's leader-ship or relational skills. And while the client's personalstyle influences both these areas, coaching is not one-on-one counseling or therapy. Personal issues oftenarise during coaching sessions, but should be relevant tothe leadership issue at hand.

The coaching session is shaped by the client'sagenda and guided by the coach's expertise, observa-tions, and feedback. The coach might have the clientcomplete a leadership assessment that might incorpo-rate 360 degree feedback or shadowing. There is muchto be gained when the coach acts as the client's shad-

The Right Coach for YouSelecting a coach with whom you can work effec-

tively is critical if you want results. Coaches come fromdiverse fields of study and disciplines -organizationaldevelopment, industrial psychology, psychology, man-agement consulting, and business. Coaches also bring dif-ferent levels of education, experience, and qualificationsto the table. Some coaches will have doctorates, othersmight be masters prepared. Still others may have a bach-elor's degree, certification in coaching, or no collegedegree but years of front-line management and leadershipexperience. There are many Web sites that promotecoaching services as part of a range of consulting servicesoffered through their companies. Because there is no sin-gle standard by which to select a coach, the followingideas may help you navigate the selection process.

Use referrals. Network with trusted colleagues (bothin and outside of nursing) and inquire about their experi-ence with coaches. Ask specific questions about theirworking relationships with their coaches -what theyliked and didn't like, what worked and didn't work. Apositive referral from a colleague with whom you sharevalues, work styles, etc. will probably be a good match foryou as well. Be alert, however, to referrals from colleagueswhose leadership styles or values are very different fromyours. H after a phone conversation or face-to-face meet-ing with a prospective coach you determine that it's not agood fit, don't lose heart. Use their referral as a spring-board to other coaching contacts.

D-uise the infonnation highway. Use search enginesto visit Web sites of companies that offer coaching ser-vices. Familiarize yourself with the various types ofcoaching available. Check out the qualifications of thecoaches on-line, if available. Typically, the more yearsspent coaching, the higher the likelihood that the exper-tise you require will be there. E-mail prospective coachesto obtain names and telephone numbers of client refer-ences. You can also use Web sites to get an idea of howfees and coaching arrangements vary. But be aware thatyou may be comparing apples and oranges. Typicallylarger firms offer set coaching "packages" (X number ofsessions for Y dollars over a specified time). Smaller firmsor sole practitioners may offer you more choices and flex-ibility.

Screen prospective coaches. Before you commit to aworking relationship, pre-screen prospective coachesthrough telephone or face-to-face interviews. As withany good interviewing technique, ask the same ques-tions of all prospects and be sure to include open-endedquestions since they will provide you with the richestinformation. Seek coaches who bring to the table a goodworking knowledge of your business or the ability toquickly come up to speed. Also, look for coaches whoare well-versed in appreciating organizational politics.Finally, investigate coaches who are grounded in asound understanding of psychological dynamics. Thecombination of these three elements -business knowl-edge, organizational politics, and psychological dynam-

ics are baseline competencies for an effective coach(Levinson, 1996).

Assess the assessments. Many coaches will useassessments as part of the initial coaching process toidentify baseline data. If the coach you are consideringuses assessment tools, ask about the reliability andvalidity of the instruments. Be aware that some instru-ments look slick but lack solid psychometrics andresearch to back them. Also, be aware that only licensedpsychologists can administer and interpret most psy-chological tests, including personality tests and intelli-gence tests.

Broaden your search. Don't assume that out-of-town talent means out-of-sight fees. While coaches andconsultants often charge for their travel expenses and/ortravel time, you may still be able to work with the coachof your choice if you look at creative alternatives. If youfind an out-of-town coach you like, consider the optionof team coaching and maximize the coach's on-site time,gaining more value for the travel dollars you expend. Ifyour budget is stretched and team coaching isn't in theplan, consider creating a coaching consortium. Networkwith fellow nursing executives and propose a regionalcoaching consortium -a collection of professionalsfrom other organizations who will work with one par-ticular coach. In this way the travel costs can be divid-ed among the consortium members. Remember thatonce you have built initial rapport, effective coachingcan take place via phone or e-mail.

Listen to your inner voice. All things being relative-ly equal among your final choices for coach -creden-tials, experience, expertise -you'll know you've foundyour coach if you can answer "yes" to these questions:.Do I feel comfortable enough to let my hair down

with this person?.Do I feel certain that this coach will maintain confi-

dentiality?.Does this coach possess the necessary expertise to

provide appropriate support to me through thechange process?

.Does this coach understand organizational politicswell enough to effectively counsel me?

.Does this coach possess the skills to push back andchallenge me in ways that I can hear and accept thefeedback?

Coaching for OthersDetermining likely candidates for executive coach-

ing within the nursing profession is not without itsquestions. Do coaching candidates need to have titlessuch as vice-president, director, or executive managerafter their names? In today's ambulatory care environ-ment, a nurse manager is involved in levels of decisionmaking that would rival those of an executive in aFortune 1000 company. The same could be said of bed-side nurses on a busy medical-surgical unit. So in addi-tion to those with an executive title after their names,who else in the nursing population might be considered

worked for a nurse manager who had a significantimpact on me. She was the kind of leader that couldbring the best out of people. You could be at the end ofyour shift with your coat on ready to head out the doorand if she stopped and asked you to please lend a handfor a few minutes because of one reason or another, evenif you were dog tired, you would gladly hang up yourcoat and pitch right in."

When I asked the participant what it was about thatparticular nurse manager that evoked such dedication,she replied, "She was a professional. She was alwayslooking for ways to improve what she was doing. Shetook her job seriously. We saw her asking for help whenshe needed it and she wasn't embarrassed to say if shedidn't know something because she could always findsomeone who could teach her. It made me feel that if myboss didn't know everything, then it was OK if I didn'tknow everything too. But one thing was for sure. If youtold her you didn't know something, you knew thatshe'd say 'Okay for today, but I expect you to get a han-dle on it by tomorrow.' And you knew that she wouldhelp you get the help you needed to succeed."

Clearly the leadership legacy of that nurse managerpromoted professional growth and inquiry. Your leader-ship legacy is uniquely your own. Your leadership lega-cy begins with your vision of the ideal. To uncover thatideal is simple. Take a few moments to time travel intothe future and imagine that you are at your retirementparty. Imagine that your staff is bringing in a huge cake.Your staff had the cake decorated and there is a specialinscription on it. This inscription captures the essenceof the impact your leadership has had on your staff.They thought long and hard to come up with just theright wording. You come closer to the cake and you readthe words. What do they say?

That's the beginning of the vision of your leadershiplegacy.1fanslating that vision into action is the next step-a step made easier with the support of your ownexecutive coach. $

REFERENCESAgno, J. (2001). [On-lineJ. Available: www.coachthee.comGreenleaf, R.K. (1973). The servant as a leader. Peterborough, NH:

Windy Row Press.Levinson, H. (1996). Executive coaching. Journal of Consulting

and Clinical Psychology Journal: Practice and Research.48(2), 115-123.

Manchester, Inc. (2000J. Executive coaching yields return on invest-ment of almost six times its cost, says study [On-lineJ.Available: http://www.manchesterUS.com

Menzies, I. (1975). A case study in the functioning of social sys-tems as defense against anxiety. In A. Coleman & W. HaroldBexton (Eds.), Group relations reader (pp. 281-312).Sausalito, CA: GREX.

likely candidates for executive coaching?If you are a nursing executive, you might want to

consider how to retain your best managers. Researchshows that those who receive coaching consider it aperk. Savvy nursing leaders know that building man-agerial and leadership bench strength is a matter of sur-vival. They consider executive coaching a way to pro-vide one-on-one attention to members of their leader-ship teams. Consider executive coaching as a retentiontool. Coaching's three-fold benefits aid in retaining lead-ership talent, building leadership know-how, anddeveloping future leaders.

Team coaching is a variation on this theme. Teamcoaching focuses on two goals: improving executiveteam effectiveness and enhancing both the leadershipand "followership" of the members. Unlike convention-al team building or team development, team coaching isevent or situation driven and grounded in real-life, real-time issues facing executive teams. Because there is aclearly defined goal in team coaching, you realize threebenefits. First, the organizational issue requiring atten-tion is addressed head on. Second, the team learns towork more effectively by working on an actual issueinstead of a simulated exercise. Third, individual teammembers receive direct feedback and gain insight intohow they help or hinder the team's operation.

The other advantage of using a coach for your pro-fessional development is intergenerational coaching. illessence, as you experience the coaching relationshipyou receive the direct benefit of one-on-one issue-focused coaching as well as the indirect benefit of learn-ing how and when to coach your own staff. Over time,as you begin to coach your own staff, your staff will belearning to effectively coach those individuals whoreport to them. This is not to say that once you workwith a coach you are prepared to become a professionalcoach yourself, but the experience of coaching doesraise awareness about how and when you can andshould intervene as a leader.

Create Your Leadership Legacy

Most often leaders assume their roles and quicklyimmerse themselves in the job with little thought to theimpact that their leadership will have on others. ill thepush of daily work, purposefully carving out time tocreate a leadership legacy often falls to the bottom of thelist. The truth is, however, that high impact, positiveleadership rarely, if ever, happens by default. ill thesetimes of incredible change within health care, thosewho serve others deserve the best leadership.

One way to be the best leader is to clarify your lead-ership legacy. The notion of a leadership legacy came tome many years ago when I was leading a workshop formanagers at a local health care organization. We werediscussing effective and ineffective leadership as a wayto help managers recognize their impact on their workgroups. One participant recalled a scenario that sheshared with the group. She commented, "Years ago I

Reprinted from Nursing Economic$, 2001, Volume 19, Number 4, pp.178-182. Reprinted with permission of the publisher, JannettiPublications, Inc., East Holly Avenue Box 56, Pitman, NJ 08071-0056; Phone (856)256-2300; FAX (856)589-7463. (For a sample ofthe journal, please contact the publisher).