Bárbara Souza Rocha
Denize Bouttelet
Munari
Bruna Mendes de Sousa
Maria Lúcia Leal
Luana Cássia Miranda
Ribeiro
I Enfermeira. Doutora em
Enfermagem. Docente da Faculdade de Enfermagem da Universidade Federal de
Goiás, (FEN/UFG). Goiânia, Goiás. Brasil; E-mail: barbarasrocha@gmail.com;
ORCID ID: https://orcid.org/0000-0001-6059-8399
II Enfermeira. Doutora em
Enfermagem. Docente Aposentada da Faculdade de Enfermagem da Universidade
Federal de Goiás, (FEN/UFG). Goiânia, Goiás. Brasil.
E-mail:
boutteletmunari@gmail.com; ORCID ID: https://orcid.org/0000-0002-2225-770X
III Graduanda em Enfermagem
pela Universidade Federal de Goiás, (FEN/UFG). Goiânia, Goiás. Brasil. E-mail:
bmds.enfermagem@gmail.com; ORCID ID: https://orcid.org/0000-0003-3793-2031
IV Psicóloga. Mestre em
Psicologia Social pela Pontifícia Universidade Católica de Goiás. Goiânia,
Goiás. Brasil. E-mail: lucia.sobrap@gmail.com ORCID ID:
https://orcid.org/0000-0001-8003-9172
V Enfermeira. Doutora em
Enfermagem. Docente da Faculdade de Enfermagem da Universidade Federal de
Goiás, (FEN/UFG). Goiânia, Goiás. Brasil. E-mail: luaufg@yahoo.com.br ORCID ID:
https://orcid.org/0000-0002-4254-2030
*Artigo oriundo da tese de doutorado
intitulada: DESENVOLVIMENTO DE LIDERANÇA PARA ENFERMEIROS DA SAÚDE DA FAMÍLIA
COM O USO DA ESTRATÉGIA COACHING EM GRUPO defendida no Programa de
Pós-Graduação em Enfermagem da Faculdade de Enfermagem da Universidade Federal
de Goiás, em 02 de Dezembro de 2014
Abstract: Objective: To describe the use of
coaching tools in the leadership development process of nurses working in
Primary Health Care (PHC). Method: A descriptive study with a
qualitative approach of the action-research type. Data from the application of
the Wheel of Life and the E.S.P.E.R.T.A Goal tools for nine nurses were
organized in the WebQDA software and analyzed by content categorization. Results:
The participants experienced three main actions: self-knowledge, goal setting
and consolidation of changes. The changes happened in delegation of
responsibilities, emotional balance, conflict management, and communication. Final
considerations: the tools favored the identification of advantages,
limitations and directed the process of change in attitude and behavior by
setting goals. The study presented an innovative characteristic, combining
experimentation and objectification, leading nurses to incorporate changes in
daily work and PHC leadership.
Keywords: Primary Care Nursing;
Leadership; Organizational Innovation
Resumo: Objetivo: descrever o uso
de ferramentas do coaching no processo de desenvolvimento da liderança
de enfermeiros que atuam na Atenção Primária à Saúde (APS). Método: estudo
descritivo, de abordagem qualitativa, do tipo pesquisa-ação, em que os dados da
aplicação das ferramentas Roda da Vida e Meta E.S.P.E.R.T.A para nove
enfermeiros foram organizados no software WebQDA e analisados por
categorização de conteúdo. Resultados: os participantes vivenciaram três ações
principais: autoconhecimento, estabelecimento de metas e consolidação de
mudanças. As mudanças aconteceram ao delegar responsabilidades, no equilíbrio
emocional, ao lidar com conflitos e na comunicação. Considerações finais:
as ferramentas favoreceram a identificação de potencialidades e limitações e
direcionaram o processo de mudança atitudinal e comportamental pelo
estabelecimento de metas. O estudo apresentou característica inovadora, unindo
experimentação e objetivação, levando os enfermeiros à incorporação de mudanças
no cotidiano do trabalho e na liderança da APS.
Descritores:
Enfermagem de Atenção Primária; Liderança; Inovação Organizacional
Resumen: Objetivo: describir el uso
de herramientas de coaching en proceso desenvolvimiento de lideranza de
enfermeros que actuan en Atención Primaria a la Salud (APS). Método: estúdio
descriptivo, abordaje cualitativa, tipo investigación-acción, en datos de
aplicación herramientas Rueda de
Vida y Meta E.S.P.E.R.T.A, nueve enfermeros fueron organizados
en software
WebQDA y analizados por categorias de contenido. Resultados: los participantes
vivenciaron tres acciones principales: autoconocimiento, establecimiento de
metas y consolidación de cambios. Los cambios pasaron a delegar
responsabilidades, en equilíbrio emocional, lidar con conflictos y en la
comunicación. Consideraciones
finales:
las herramientas favorecen en identificación de potencialidad, limitaciones y
direccionan el processo de cambios actitudinales de comportamiento por
establecimiento de metas. El estúdio presento característica inovadora, uniendo
experimentación y objetivación, llevando los enfermeros a la incorporación de
cambios en su cotidiano de trabajo y lideranza de APS.
Descriptores: Enfermería de
Atención Primaria, Liderazgo, Innovación Organizacional
Introduction
Nurses have been
taking leadership roles throughout the health care chain. Their responsibilities
range from the care process to strategic decision making in the executive
environment of organizations.1-2
In Primary Health
Care (PHC), nurses are a reference in the articulation of management and care
actions, as they plan, execute, monitor and evaluate the actions of the team
and of the professionals under their supervision.3-4 For this
reason, leadership development processes are important for nurses,5 especially
in PHC, where these professionals need management skills to ensure the continuity
of the Family Health Strategy4 (FHS) and strengthen the PHC
principles.4,6-7
These competences enable nurses to work
proactively within the health system, with greater involvement in political
dialogue and in decision-making processes for the planning, development and
evaluation of services and policies”.7:5 Leadership training for
nurses should be part of institutional initiatives and public health policies,
with a goal that goes beyond the individual need to improve in this area.2-5
Studies,5,8 have demonstrated
the importance of leadership development programs. Among the methodological
strategies of these programs, coaching has been identified as a potent strategy
to develop the ability to lead and to produce important changes in the behavior
of high-performing leaders.9-10 Coaching is a process that leads to
self-knowledge and goal setting through a deep analysis of the individual,
provoking reflection on perspectives, mindsets, beliefs and approaches, which
can lead to more sustainable behavior and favor self-leadership capability. In
short, coaching is a process that leads the individual from a current state to
the desired state.11-12
The impact of coaching tools on the
development of management skills and on the training of new nurse managers is demonstrated
in nursing literature.2,9-10,12-16 However, most studies are
restricted to the training of nurses in the hospital2,10,12-15 or in
the teaching field.16
A search conducted in national and
international databases did not identify the use of coaching in PHC or for the
development of nursing leadership in this context. Studies,15 highlight
the lack of nursing research using coaching tools, which points to an important
gap. Therefore, how can coaching tools assist in the development of leadership among
nurses working in PHC?
Based on this justification, this study
aims to describe the use of coaching tools in the leadership development
process of nurses working in PHC.
This research is an innovative
contribution as it shows the potential of coaching in producing changes in
nurses’ performance and its strategic importance in the training of PHC nurses.
Method
This
is a descriptive study with a qualitative approach, based on action research (AR),
which is a type of intervention/research that requires a collaborative and
emancipatory relationship between the researcher and the participant, aiming to
promote changes that can improve the practice.17 The choice of the
methodology was based on its adequacy to the research proposal, which includes
a leadership development (LD) program for nurses.
The
LD program (table 1) lasted seven months, in which seven group meetings were
held, with an average duration of six hours each, totaling 42 hours of
intervention. The meetings occurred every twenty days, on Wednesdays, always in
the same room. In addition, the nurses had an individual counseling session
lasting four hours. Six months after the end of the program, a focus group for
evaluation was conducted.
|
No. of the
meeting
|
Theme
|
No. of
participants
|
Objective
|
Month of the
meeting
|
|
1st
|
Diagnosis
and work contract with the group.
|
21
|
Identify
the current situation of nurses in leadership;
Draw
up a contract with the group;
Sign CF
|
Jun./2012
|
|
2nd
|
Assembling the
group
|
19
|
Experience
the assembling of the group towards self-knowledge;
Elaborate
the “Wheel of Life”.
|
Aug./2012
|
|
3rd
|
Communication
and Feedeback.
|
15
|
Diagnose
communication in the group, in life and at work;
Understand
the theory of feedback.
|
Sept./2012
|
|
4th
|
Role
of nurses in leadership
|
12
|
Define
the roles of nurses in leadership
|
Oct./2012
|
|
5th
|
Leadership.
|
12
|
Understand
the in-depth concept of leadership.
|
Nov./2012
|
|
6th
|
Planning and
change.
|
15
|
Create
strategic planning – tree method;
Define the
individual goal.
|
Nov./2012
|
|
Individual
counseling
|
E.S.P.E.R.T.A.
Goal
|
17
|
Review
the goal and define steps toward change.
|
Dec./2012
|
|
7th
|
Needs and Coach
Leader.
|
16
|
Identify
needs for change and understand the role of the coach leader.
|
Dec./2012
|
Table
1: Presentation of the LD program,
Goiânia, 2014
This
LD program was based on coaching11, as we believe this method can
enhance changes in nurses’ performance in the context of PHC. Coaching is
predominantly a one-on-one process, but it can be developed with groups when a
group of individuals, along with their current issues, gathers together to work
with a facilitator, aiming to develop group plans to solve the difficulties
pointed out.11
For
the development of the research, the recommendations of the Consolidated
Criteria for Reporting Qualitative Research (COREQ) were followed.18
The study was conducted by the main researcher, who has basic training in group
dynamics and is an internationally certified coach.11 In
addition, the study had a team consisting of an observer, who also had basic
training in group dynamics, and two organizational psychologists from the
Brazilian Institute of Psychoanalysis, Group Dynamics and Psychodrama
(SOBRAP/GOIÁS). The study was supervised by the advisor. All these
professionals were trained in coaching.11
The investigation was carried out at the Municipal Health
Department (MHD) of a capital in the Midwest region of Brazil, with Family
Health (FH) nurses. There was an initial mobilization meeting, in which
the details and conditions for participation in the DL program were presented and
its association with the research was clarified. Nurses should have a degree in
Nursing, minimum of one year working in FH, effective employment bond with the MHD,
interest and willingness to participate and should agree with the methodology adopted.
Twenty-four
nurses were invited to participate in the study. At the first meeting, 21
attended. All the 24 nurses were invited again for the second meeting, and 19
attended. From then on, those nurses who did not participate in any meeting
were excluded from the study. The number of participants per meeting is
described in Table 1 above.
At the first
meeting of the LD program, after clarifying the research, those who were
interested to participate were asked to sign the Informed Consent Form (CF). In
addition, the rules for coexistence and participation were established together.
Data was
collected from February 2012 to June 2013, when the DL program (seven meetings
and one individual counseling) and the focus group for evaluation occurred. The
latter made it possible to identify the changes resulting from this process. The
data were extracted from the records in the coaching tools used and through
audio recording of the group discussions. The coaching tools used for this
study were the Wheel of Life and the E.S.P.E.R.T.A. Goal11
The Wheel of Life
(WoL) was created in the 1960s and is attributed to Paul J. Meyer. It is a
simple self-knowledge tool and it is basically a circle divided into areas of
life that are considered important to success. In this study, the original WoL was
adapted and was applied at the second meeting with the group. Each participant
completed the WoL considering a scale from zero to 100% of satisfaction in
relation to the 12 areas previously defined by the researchers, which were
related to aspects of personal and/or professional life. The central question
to be answered in the WoL was: “How did I get here?”.
The parts of the
wheel referred to 1. Time management; 2. Ability to give and receive feedback;
3. Management ability; 4. Communication (knowing how to listen and how to
express); 5. Balance of personal life; 6. Emotional intelligence; 7. Conflict
management; 8. Leadership; 9. Interpersonal relationship; 10. Health and good
shape; 11 and 12. Optional areas (leisure, ability to deal with pressure,
professional development, personal organization, finances and spirituality). The
participants could choose from these options.
The E.S.P.E.R.T.A
Goal (EG) was applied in the sixth meeting, when the group began the process of
establishing individual goals to improve the exercise of leadership. It was
reviewed in an individual session and/or when requested by the participant,
even if not on previously scheduled hours. The EG form enables the definition
of goals when the participant fills its components in the initials of the word
"esperta" (smart), which correspond, respectively to: específica
(specific); sistêmica (systemic); passos (steps);
evidências (evidence); recursos (resources); tesão
(excitement); alternativas/adversidades (alternatives/adversities).
The participants established their goals of changes based on the question: “Looking
at my wheel of life, what do I want to change?”.
The software WebQDA was used for storing
and organizing the data of the coaching tools. Content analysis was used for
the analysis and interpretation of the results.19 The process of
categorization of data in the system occurred by “collection”, and the
analogical and progressive classification of the data generated the categories19.
This study respected all the ethical
precepts of research involving human beings and was approved by the Research
Ethics Committee of the Hospital das Clínicas/UFG under protocol 171/2011, with
a deadline extension authorized by the same ethics committee on December 3rd
2015, in compliance with the legislation in force in Resolution 466/2012. In
order to preserve the identity of the participants, their records are presented
by the letter “E” followed by numbers (from one to nine).
Results
The
results presented in the study refer to nine participants of the LD program who
completed the two tools used. Of these, six were district supervisors and three
were nurses of the local team.
The
first category, called Self-knowledge, refers to nurses’ situational
diagnosis in relation to the exercise of leadership in FH, according to the
Wheel of Life records.
Subsequently,
goal setting was emphasized through the E.S.P.E.R.T.A Goal, which showed the
process of creation of goals for changes to be achieved in the LD program.
Finally, the category Consolidation of changes presents a general
evaluation of the process experienced by nurses, reinforcing the changes and
presenting the effects of the LD program.
Self-knowledge
In the
elaboration of their individual WoL, nurses demonstrated that in some areas
their satisfaction was below 50%, such as in emotional intelligence, time
management, ability to deal with pressure, and the ability to give and receive
feedback. These data are highlighted since they directly influenced the
creation of the goals that mobilized nurses in the change process. Graph 1
shows the percentage of nurses who rated less than 50% satisfaction on certain
areas.
Chart 1 - Distribution of areas
that received satisfaction scores below 50% (GOIÂNIA, 2014).
Goal setting
The use of the
Wheel of Life made nurses aware of their weakest areas. This guided the
identification of priority aspects that needed further attention and
development. From then on, the process of prioritizing the changes desired by
nurses began and the use of the EG facilitated the organization of thoughts.
Table 2 illustrates the goals set by nurses and the description of each of
their components.
|
ASPECTS IDENTIFIED
|
CHANGES
OCCURRED
|
|
Ability to give and receive feedback
|
[...] with the wheel of life,
I improved my ability to give and receive feedback, and this was very good
for me [...]. (E8)
|
|
Time
management
|
In my wheel, under time
management, I chose 30%; I believe that I have improved, I can manage my time
better. (E7)
|
|
Ability to deal with pressure
|
Looking here at the Wheel of
Life, I chose the ability to deal with pressure; it has improved today
because in pressure situations I can do a little of what I wrote in the
ESPERTA goal. (E5)
|
|
Communication
|
In communication, I am learning
to listen more, and I am also learning to express myself. I used to have
outbursts; I'm learning to control myself because sometimes I'm actually
right, but with the outburst I lose my argument. Knowing how to speak at the
right time, how to shut up at the right time, I'm learning, it’s a process. (E7)
|
|
Leadership
|
In the role of leadership, the
course was very good. We learned that, for leadership, it is important to
plan, to learn to delegate, to respect other people’s pace. However, this is
not easy, because I am very impetuous, I can not wait, I just go there and I
want to do it without waiting, but I am controlling this. (E7)
|
Table 3 - Description of the aspects
identified as weaknesses and changes occurred (GOIÂNIA, 2014)
To illustrate some results of the consolidation of the changes
that occurred, nurses analyzed, through the EG, the desired states and those
achieved six months after the intervention. This process allowed recognizing
and describing the steps taken, increasing the ability of nurses to incorporate
their desired changes. Table 4 illustrates the process of some nurses.
|
DESIRED STATE
|
REACHED STATE
|
|
Delegate
responsibilities and provide orientations
|
The most important change was learning how to
delegate, which was difficult for me; it helped me a lot. (E6)
|
|
Be emotionally
balanced.
|
I believe I come from a process of emotional
maturation because, before, I was an extremely impetuous person. (E3)
|
|
Deal with
conflicts.
|
Today, I can have more peace of mind, which was
difficult for me before, now I can wait before doing. (E8)
|
|
Learn to
communicate.
|
I learned a lot about how to talk, how to talk to
different people, because we talk to different people with different styles,
and how to wait for other people's pace. (E4)
|
Table 4 – Description of the desired
state and the reached state (GOIÂNIA, 2014)
Discussion
The use of coaching tools allowed nurses
to perceive their difficulties to exercise leadership in the context of PHC. Their
weaknesses were revealed and paths to exercise and consolidate changes were
pointed out, aiming to improve their leadership skills.
The WoL enabled nurses to identify low
levels of satisfaction in some areas related to leadership. Thus, they were
called to develop self-knowledge, which triggered the process of change, made
possible by gaining awareness of aspects that required change. Studies2,14,16
have shown the importance of self-knowledge for the improvement of leadership
skills. A study2 showed that nurses considered that improvement of
self-knowledge was a relevant additional benefit of the coaching process.
The results of the research point out to
the importance of providing opportunities to help nurses recognize their
management skills and their limitations. Self-knowledge is a favorable path for
this, as it helps professionals to improve their individual and organizational
performance. The improvement of these skills makes nurses more empowered to
perform their duties and committed to strengthening and implementing important
reforms in PHC.3-4,20
In
short, self-knowledge is the first individual step towards change.21
The use of tools that favor this process can help nurses to developing their
leadership, as they allow people to reflect about themselves, their own needs,
and their own worldview, values and beliefs. Thus, they deepen learning and help
incorporating new skills and capabilities.2,9,12
By analyzing the goals set by nurses, we
found points of convergence in relation to the needs for improvement. Among the
aspects pointed out, the organization of time, with prioritization of tasks and
planning is highlighted. There was also a common need to improve communication,
specifically with regard to giving and receiving feedback and managing
conflicts. Emotional intelligence and dealing with stress were also pointed as
priority goals. These aspects reveal the need for the development of leadership
improvement programs, as these are the basis and starting point for good
leadership.7-9
When nurses were invited to elaborate the
EG, already more aware of their limitations on leadership, they set their goals
aiming to achieve personal improvement and to strengthen relationships within
work teams. Thus, the importance of improving the
perception of the work context and of interpersonal relationships and the need for
permanent self-knowledge and recognition of the other within the team became
clear. These aspects were also recognized as essential for the
improvement of leadership and have been pointed out by nurses in coaching
processes in other investigations.2,12,14,16 A study13 also
pointed out that coaching contributes to the development of leadership among
nurses in collaborative practices. This result shows the potential of the use
of this tool for nurses working in PHC.
Nurses do not always feel prepared when they
are asked to experience a coaching process.2 However, the
recognition and awareness of advantages and weaknesses inspired this
professional in the search for new knowledge, which strengthens the process of
change. Moreover, it becomes more clear when they define the evidence on how
changes will be perceived. Nurses hope that other team members will validate
them in this process, and that the working climate will be changed for better.
These results
indicate how the leadership of nurses in the context of PHC can be valued when
these professionals have a better and more assertive performance. Leadership is
committed and grounded in management knowledge, as indicated by studies conducted
in this perspective.3-4, 20, 22-23
Regarding the
data on changes pointed out by nurses six months after the LD program, it can
be observed that the use of coaching tools enabled the identification of needs
and demands, guided the change through defined steps and produced significant
effects with positive results.
Looking
at the state achieved and the state desired by the nurses, it can be seen that
the tools used during the LD program led to improvements in satisfaction in the
areas indicated in the WoL as development priorities, especially ability to
give and receive feedback, time management and communication. The main changes
pointed out by nurses are related to learning to delegate, emotional maturity,
tranquility in relationships and knowing how to wait for the other people’s
pace.
In
PHC, it is essential that nurses exercise a participative leadership that
includes the entire team. Studies highlight the difficulties of professionals
in this role.24-25 In this sense, the results pointed out by the nurses
who participated in the study show how the coaching tools (WoL and EG) were
essential to exercise their delegation skills, to feel calmer in the role of
leader, and to have more mature relationships.
The
process of change is seen by nurses as necessary for the perception of new
meanings and adoption of new habits. Thus, becoming aware of themselves as
subjects of actions, both at work and in personal life, was one of the
important gains from this experience.
Final considerations
The model created
in this LD program was unique and innovative, as it articulated different
coaching tools, combining experimentation and objectification and leading
nurses to effective transformation with the incorporation of changes in their
daily work and in their leadership in PHC. Considering the results achieved in
this LD program, it is possible that it will be reproduced and used not only to
train nurses in PHC, but also in other areas, at different levels of management.
The combined use of the WoL and EG tools
favored the process of change, helping the subject to identify needs and make
the decision to change by directing their reflection-action towards the desired
state. Thus, the importance of the development of new intervention studies is
emphasized, that is, new studies should use coaching tools to promote changes
not only in leadership, but in other aspects of nursing.
For Nursing, the importance of using
innovative strategies in the development of leadership among nurses in PHC is
evident. In addition, new studies that can support the implementation of this
type of tool in the organizational context are also important.
Study limitations
include the lack of research that specifically describes the use of these
specific tools. Likewise, there is the fact that not all nurses completed the
tools, even though they systematically participated in the DL program. This is
actually a calculated risk when using action research. In addition,
participants commit in their own way to advance as they can in the change
process.
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Autor correspondente
E-mail: barbarasrocha@gmail.com
Endereço: Rua 1040 n.285 apt.502
Setor Pedro Ludovico
CEP: 74.823-250
Contribuições
de Autoria
1 – Bárbara Souza
Rocha
Concepção e
planejamento do projeto de pesquisa, obtenção, análise e interpretação dos dados, redação e revisão
crítica.
2 – Denize
Bouttelet Munari
Concepção e planejamento do projeto de pesquisa,
obtenção, análise e interpretação dos
dados, redação e revisão crítica.
3 – Bruna
Mendes de Sousa
Análise e interpretação
dos dados, redação.
3 – Maria
Lúcia Leal
Concepção e planejamento do projeto de pesquisa,
obtenção, redação e revisão crítica.
4 –
Luana Cássia Miranda Ribeiro
Redação e revisão
crítica
Como citar este
artigo
Rocha BS, Munari
DB, Sousa BM, Leal ML, Ribeiro LCM. Ferramentas do coaching no
desenvolvimento da liderança da enfermagem na atenção primária à saúde. Rev.
Enferm. UFSM. 2019 [Acesso em: Anos Mês Dia];vol e46: P1-P20.
DOI:https://doi.org/10.5902/2179769234762