54 International Coaching Psychology Review Vol. 8 No.

1 March 2013
The British Psychological Society ISSN: 1750-2764
Paper
Developing a healthcare leadership
coaching model using action research and
systems approaches a case study:
Implementing an executive coaching
programme to support nurse managers in
achieving organisational objectives
in Malta
Ho Law & Reggie Aquilina
Objectives: This study aims to show how a leadership coaching programme for Nurse Ward Managers may
be implemented in a general hospital with the following objectives:
clarify the Nurse Ward Managers idealised leadership attributes (ILA);
identify any perceived gaps in leadership skills;
develop and provide a comprehensive coaching programme; and
identify the impact of the programme.
Design: An Action Research (AR) was adopted to involve the participants in a collaborative partnership
and influence both the implementation process and outcome of the programme. It incorporated two iterative
Plan-Act-Reflect cycles.
Methods: The sample consisted of 12 randomly chosen Nurse Ward Managers. The coaching methods used
in the Action stages include a range of eclectic coaching psychology approaches. The analytical tools used
in the Reflective stages included thematic analyses and a systems approach. The impact of the programme
was identified using Law et al.s (2007) Universal Integrative Framework.
Results: 27 idealised leadership attributes were identified. Both group and individual coaching sessions
were found to be effective in helping the participants identify areas of development and goals. The impact
of the coaching programme included enhanced self-awareness, feelings of support, ability to take decisions
and keep to time frames and achievement of organisational and personal goals.
Conclusions: The structured coaching programmes had a substantive impact on developing Nurse Ward
Managers leadership skills, providing them with an on-going support, and helping them achieve both
personal and organisational goals.
Keywords: Action research; coaching psychology; coaching programme; leadership coaching; executive
coaching; healthcare; learning; nursing; Universal Integrative Framework; systems approach.
U
NDER THE current global economic
condition, organisations are increas-
ingly expecting employees to do more
with the same, or less, resources (Ohman,
2000). Organisations are constantly chal-
lenged by the ever increasing demands of
rising costs, continuous change, increased
patient acuity, multiple professional hierar-
chies and staff shortages (Contino, 2004;
McAlearney, 2006; Storey, 2010). This entails
leaders to engage and inspire employees to
achieve peak performance using transforma-
tional and ethical forms of leadership
(Alban-Metcalfe & Mead, 2010; Alimo-
Metcalfe & Alban-Metcalfe, 2005). The need
to develop such leadership styles is experi-
enced even more acutely within the health-
care sector than other sectors. There is a
growing awareness that the traditional hier-
archical and bureaucratic organisational
model is incompatible with the new
complexities of the healthcare system
(McAlearney, 2006) and this is leading to the
decentralisation of healthcare management
with more leadership responsibilities placed
on the Nurse Ward Managers (Casida, 2007).
However, there is evidence that Nurse Ward
Managers are frequently ill-prepared in
assuming leadership roles and do not receive
the support they need (Mathena, 2002;
Grindel, 2003). Thus, developing leadership
capacity at the mid-management level has
become an urgent item on the change
agenda in the healthcare system.
Nevertheless, the effectiveness of formal
leadership training programmes is an issue
with little empirical evidence to demonstrate
improved performance (Ford & Weissbein,
2008; Kirwan & Birchall, 2006). Leadership
Training seminars may create a moderate
buzz of enthusiasm for a short period but
they rarely lead to sustained behavioural
change (Dearborn, 2002). This may be due
to the short duration of such seminars, lack
of post-training support to implement
changes and lack of regular reinforcement
through on-going practice (Clarke, 2002).
On the other hand, Executive and Leader-
ship coaching has been identified as a
powerful vehicle to develop leadership
within the organisational context (Law, et al,
2007) and has been linked to several positive
outcomes including enhanced transforma-
tional leadership skills (Abrell et al., 2011);
goal self-concordance and attainment
(Burke & Linley, 2007; Grant, 2006; Law et
al., 2007); self-awareness, accountability and
just-in-time learning (Turner, 2006) and
productivity and ROI increases (McGovern
et al., 2001; Olivero, Bane & Kopelman,
1997). Leadership coaching can capitalise
on the energy and enthusiasm that is gener-
ated during formal training sessions (Finn,
2007) since it is not a one-time event, but a
strategic process that adds incremental value
both to those being coached and to the
bottom line of the organisation (Goldsmith
& Lyons, 2006). It also promotes the appli-
cation of knowledge within the reality of the
work settings through feedback and on-
going customised support; thus making
learning immediately applicable (Hernez-
Broome & Hughes, 2004; Oberstein, 2010).
In the healthcare setting there is still a
dearth of research studies related to nurse
coaching. However, the few studies available
have also shown positive outcomes with a
leadership coaching intervention. A study by
Kushnir, Ehrenfeld and Shalish (2008)
found that compared with the control group
nurses who participated in a coaching
project improved in training motivation, self-
efficacy and behavioural transfer of several
skills. These results were in contrast with the
decline in most outcomes of the control
group. Another study by Johnson, Sonson
and Golden (2010) found that coaching
helped to improve individual and organisa-
tional performance and job satisfaction.
Rivers et al. (2011) found that a coaching
programme for 30 Nurse Ward Managers
helped with setting goals, making realistic
plans, accountability, and setting priorities.
Further research and case studies on imple-
mentation of leadership coaching in the
healthcare setting are, therefore, welcome.
This paper provides such a case study
with an aim to show how a leadership
International Coaching Psychology Review Vol. 8 No. 1 March 2013 55
Developing a healthcare leadership coaching model using action research and systems approaches
coaching programme may be implemented
for Nurse Ward Managers in a general
hospital. More specifically, the key objectives
of this study were to:
Clarify the Nurse Ward Managers
idealised leadership attributes (ILA).
Identify any perceived gaps in leadership
skills.
Identify an ideal model to implement a
comprehensive coaching programme.
Identify the impact of the programme.
Methodology
Action Research (AR) was chosen as a
methodology approach since it focuses on
generating evidence through research so as
to find solutions to practical problems or
issues of pressing concern with the aim of
helping practitioners improve the quality of
their practice (Craig, 2009; Elliott, 1991;
Reason & Bradbury, 2006). With its focus on
generating collaborative solutions to prac-
tical problems it empowers practitioners to
engage themselves within the research
process (Meyer, 2000). It consists of a collab-
orative spiral of reflective cycles, or itera-
tions, that include identifying a problem,
designing inquiry-based questions, planning
a change, acting and introducing the
change, observing and reflecting on the
process and re-planning again (Craig, 2009;
Kemmis & McTaggart, 2005). Thus it is an
ideal approach for facilitating the process of
introducing a coaching programme into the
organisation (the primary aim of this
research). It is also in line with the principles
of coaching as a learning process (Law et al.,
2007), a reflective practice (reflection in
action, Schn, 1983, 1991), and a collabora-
tive partnership to improve personal and
professional performance (Kilburg, 1996).
The AR approach adopted for this study .
Design
The researchers designed to incorporate the
AR process in two cycles, (iterations or
phases). Each cycle maps on to Kolbs (1984)
learning cycle, that is, integrating planning,
action, and reflection stages with the aim of
addressing the research objectives (see
Figure 1).
The detailed methods and procedures
for implementation are described next; the
outcome of the reflection forms part of the
results and discussions.
The inclusion criterion is that partici-
pants were the Nurse Ward Manager in the
hospital. For practical purpose, the stratified
random sampling approach that was based
on the random choice of two Nurse Ward
Managers out of seven from each of the six
departments ensured that that the final
sample of 12 Nurse Ward Managers reflected
an unbiased representative sample of the
whole hospital and all departments. The
exclusion criteria are seemly those who have
not been randomly selected. There were no
matching criteria for the sample, as this was
an action research, not a quasi-experimental
design.
Methods
A mixed range of research methods were
used. A stratified random sampling tech-
nique (Polit & Hungler, 1999; Burns &
Grove, 1993) was used to identify the partic-
ipants. Thematic and systems analyses were
applied in the reflective process (evaluation
and conceptualisation) to identify the rele-
vant themes and develop a conceptual
model for leadership coaching. Finally, Law
et al.s (2007) Universal Integrative Frame-
work (UIF) was used to evaluate the impact
of the coaching programme.
The coaching programme consisted of
four one-to-one coaching sessions. While the
basic coaching process followed the GROW
model (Whitmore, 2002), a range of eclectic
coaching psychology methods were
embedded according to the individual
coachees need. This included cognitive
behavioural coaching (Palmer & Szymanska,
2007) and solution-focused (Green, Oades &
Grant, 2006). These aimed to help the
participants to focus on identifying and
achieving self-congruent goals within speci-
fied time-frames. In general, the coaching
approaches were underpinned by the philo-
56 International Coaching Psychology Review Vol. 8 No. 1 March 2013
Ho Law & Reggie Aquilina
sophy of Positive Psychology (Seligman,
2002) and integrated transpersonal and
narrative collaborative practice the third
generation coaching practice advocated by
Stelter and Law (2010) to support reflective
exploration of personal meaning and aspira-
tions. These would address the individuals
psychological, cultural and spiritual needs
and identify core values as guiding markers
for decisions in their private and profes-
sional lives (Law, Lancaster & DiGiovanni,
2010; Law, 2007; Stelter & Law, 2010).
Research area and participants
This study was conducted at Mater Dei
Hospital which is the largest acute hospital
in Malta. A stratified random sampling of
12 Nurse Ward Managers was carried out to
extract the study sample from the total target
population of 42 Nurse Ward Managers of
the hospital. Participation in this study was
on a voluntary basis and there was no pres-
sure on the Nurse Ward Managers to partici-
pate. The age group of the participants was
between 32 and 46 years and all the Nurse
Ward Managers drawn up through the strati-
fied random sampling willingly accepted to
participate in the study. Seven of the partici-
pants were female and five participants were
male.
Reflexivity validity and rigour
Kock (2007) states that action research has
three validity threats to contend with,
namely: Subjectivity threats, due to personal
bias of the researcher; Contingency threats
due to the broadness and complexity of data
generated; and Control threats due to the
lack of full control over the environment.
As an antidote to counter these threats
Kock (2007, p.103) suggests action
researchers to conduct multiple iterations of
the AR cycle and collect cumulative data to
strengthen the findings. It is also suggested
International Coaching Psychology Review Vol. 8 No. 1 March 2013 57
Developing a healthcare leadership coaching model using action research and systems approaches
Figure 1: Action research learning cycle (adopted from Law et al., 2007).
that findings are validated by participants
throughout the study (Meyer, 2000). In
conducting this research, the researchers
were fully aware of their own subjectivity and
how this might have an impact upon the
research process and the participants
responses. In line with the qualitative
research philosophy, participants were
regarded as co-researchers who equally
contributed to the knowledge production.
Ethical considerations
The Research proposal for this study was
approved jointly by the University of East
London, the CEO of Mater Dei Hospital and
the Director of Nursing. A covering letter
explaining the issues of confidentiality,
anonymity and the aims of the action
research was given to the participants and
informed consent was obtained in line with
ethical principles (Polit & Hungler, 1999;
Bowling, 2002).
Procedures
As previously stated, the AR process incorpo-
rated two cycles.
Cycle 1:
Planning Phase
A meeting was held with the Director of
Nursing to discuss the Agenda for the Focus
Groups and coaching sessions. It was agreed
that the main organisational objective for this
study would be to help Nurse Ward Managers
become more aware of their Leadership
attributes. During this planning phase the
stratified random selection of participants
was carried out and an Action plan and the
date for the first focus group was decided.
The Idealised Leadership Attributes (ILA)
Exercise consisting of a list of Leadership
Attributes was developed and piloted.
Action Phase
The first Focus Group was carried out using
a Nominal Group Facilitation Technique.
Following this two coaching sessions with
each individual participant were carried out
and these sessions were followed by a Valida-
tion Group meeting to decide the way
forward for the second iterative cycle process
and to validate the emergent themes from
the first Focus Group.
The reflective outcomes from this first
cycle are presented in the Results section.
Cycle 2:
Planning Phase
The reflection on the experience of the first
Cycle led to the development of a Coaching
Log template to structure better the next set
of individual coaching sessions with the
participants. The ILA exercise was revised
and simplified and a plan for a second round
of coaching sessions was drawn up. A date
was also agreed for the second Focus Group.
Action Phase
The second round of coaching sessions were
conducted with the participants and the
final Focus group was carried out as a way of
concluding the second cycle.
The results of the two cycles will now be
presented.
Results
The First Iteration
Findings of the first Focus Group
The first iteration of the study was initiated
through a Focus Group with the aim of
piloting the ILA Exercise and identifying the
Leadership values and attributes that the
participants identified as the most important
and impactful in effective leadership. The
following themes and attributes emerged
from thematic analysis of the discussion tran-
scripts:
Intrinsic values Intrinsic values such as
honesty, loyalty, fairness, empathy and trust-
worthiness emerged as a central component
of idealised leadership. These were viewed as
blending within each other to provide an
ethical foundation that could be expressed
in any life situation.
Vision Having a vision that is congruent
with ones behaviour was also emphasised.
58 International Coaching Psychology Review Vol. 8 No. 1 March 2013
Ho Law & Reggie Aquilina
It was stated that although Nurse Ward
Managers were not directly involved in
creating the Organisational vision they still
needed to create their own mini vision.
Visibility Visibility and presence of the
Nurse Ward Manager in the clinical area
helped to integrate the leaders with
followers, create a sense of teamwork and
provide an opportunity to role model good
values. It also helped the leader remain
connected and in control, know the team
better and delegate and supervise more
effectively.
Assertiveness Assertiveness was viewed as a
means of expressing ones certainty, commit-
ment and conviction about doing what is
right in a persistent way without being
aggressive. It gave a sense of empowerment,
control and pride as well as the ability to
realise the vision through role modelling
and educating others.
The experience of the first iterative cycle
suggests the need of integrating the GROW
model (Whitmore, 2002) within the
coaching sessions to increase the focus on
goal attainment. The ILA pilot exercise also
shows the need to make the tool more
compact.
The Second Iteration
Findings of the second Focus Group
From the findings of the second focus
group, we can provide possible answers to
our research questions as follows:
1. What are the idealised leadership attrib-
utes of Nurse Ward Managers?
In total, 27 Idealised Leadership Attributes
have been identified from the focus group
discussion and the thematic analyses. These
are summarised in Table 1.
It is important to emphasise that the list
in Table 1 does not reflect the complex inter-
actions of the attributes. Consequently, a
visual representation was drawn up to inte-
grate the chosen attributes and provide a
depiction of their interrelationships. For
example, values related to Authenticity,
Direction and Caring emerged as a central
component while dominant, competitive and
manipulative approaches were rejected as
being incongruent with these values. Visual
representation was found to be useful as a
framework to develop a 360 feedback tool.
This visual representation was further devel-
oped using a General System Approach
(GSA,) during the Reflection stage (concep-
tion phase in the learning cycle) to handle
the complexity of organisational interactions
and relationships. This is congruent with the
recent discussions and current debates on
using systems approach for coaching and
action research (Ulrich, 1996; Cavanagh,
2006; Eidelson, 1997; Cavanagh & Lane,
2012; Shams & Law, 2012). A conceptual
model was mapped out in a Systems Rela-
tionship Diagram (SRD) (Figure 2). This
shows the potential positive effect on the
behaviour of the healthcare team, patient
care and the subsequent output (patient
satisfaction) as a positive feedback loop. The
system of interest that emerged from the
modelling exercise is named as a healthcare
Leadership System (HLS).
2. Do Nurse Ward Managers identify deficits
in their leadership attributes or skills?
The Nurse Ward Managers stated that the
process of going through the ILA and Values
Clarification Exercises helped them to iden-
tify both their strengths and areas of devel-
opment. The one-to-one coaching further
fine-tuned the process and specific develop-
ment areas were identified. However, there
was also consensus on the need of doing a
360 feedback as part of the self-awareness
process. The ILA exercise increased partici-
pants knowledge about different leadership
attributes and served as a self-assessment
exercise to increase their insights about
personal strengths and areas of develop-
ment. This self-awareness was further devel-
oped through the Values Clarification
Exercise and one-to-one coaching. Although
the ILA, Values clarification exercises and
International Coaching Psychology Review Vol. 8 No. 1 March 2013 59
Developing a healthcare leadership coaching model using action research and systems approaches
60 International Coaching Psychology Review Vol. 8 No. 1 March 2013
Ho Law & Reggie Aquilina
Table 1: Idealised Leadership Attributes of Nurse Ward Managers.
Idealised Characteristics
leadership
attributes
(themes)
Authenticity honesty, integrity, fairness, equality, transparency, respect, self-awareness,
trustworthiness, loyalty, ethical behaviour, role modelling, openness to criticism,
acknowledging mistakes.
Responsibility accountability, reliability, dependability, dedication, fidelity, constancy, consistency,
commitment, self-discipline.
Collaboration teamwork, communication, co-operation, partnership, solidarity, support, conflict
management, consensus building.
Caring empathy, concern, compassion, dignity, kindness, generosity, nurturance, helpfulness,
consideration, understanding.
Excellence high quality, competence, skills, high standards, aptitude, professionalism,
effectiveness, evidence-based practice.
Safety security, protection, well-being, risk containment
Empowerment involvement, power sharing, delegation, broad-mindedness, freedom,
self-determination, autonomy, non-blame culture
Influence authority, power, decisiveness, assertiveness, command, control, confidence.
Growth development, coaching, learning, guidance, counsel, mentoring, supporting,
challenging, knowledge-sharing.
Vision clarity, strategy, purposefulness, direction, future minded, pro-activity, initiative
Visibility support, presence, instruction, supervision, accessibility, role modelling
Contribution serving others, making a difference, leaving a legacy, altruism, generosity,
selflessness, abundance mentality
Patience serenity, flexibility, tolerance, endurance, temperance
Inspiration passion, optimism, encouragement, engagement, charisma, motivation, energising,
confidence, stimulation, humour
Determination resolve, certainty, fortitude, hardiness, resilience, persistence, perseverance,
steadfastness.
Courage daring, boldness, challenge, risk-taking, audaciousness, non-conformity.
Orderliness tidiness, neatness, structure, efficiency, organisation
Appreciation praising, thanking, gratitude, acknowledging, rewarding, gratefulness, cherishing
Creativity originality, inventiveness, innovativeness, imagination, ingenuity, resourcefulness.
Humility serving others, modesty, humbleness, gentleness, reserve.
Diligence duty, industry, accountability, conscientiousness, self-discipline.
Pragmatism practicality, realism, sensibleness, factuality, expediency, feasibility, convenience
Prudence carefulness, cautiousness, non-risk decisions, discretion.
Reputation status, esteem, standing, popularity, admiration, recognition.
Ambition achievement, results, success, accomplishment, being the best, competition,
superiority, pride, winning, drive, triumph, territorialism.
Meticulousness precision, accuracy, perfection, exactness, thoroughness.
Conformity stability, constancy, compliance, observance, conventionality.
one-to-one coaching provided awareness
and insights about personal strengths and
areas of development, a 360 feedback was
requested to provide participants with a
genuine and complete picture of their lead-
ership strengths and weaknesses.
3. What form of development or coaching
do Nurse Ward Managers need to improve
their leadership skills?
From the focused group discussion, it was
identified that a coaching service providing
an integrated approach of formal training
programs, group coaching and individual
one-to-one coaching sessions was required.
These are further elaborated on below.
Formal Training Programmes: It was stated that
there is still a place for traditional leadership
training sessions were the basic theoretical
and practical elements of leadership could
be covered. It was also suggested that Nurse
Ward Managers could be provided with a
formal and basic coaching skills training
programme to help them hone their
coaching skills.
Individual Coaching: It was suggested that
one-to-one coaching sessions should form an
integral part of any effective leadership
programme. These sessions should be based
on self-awareness, personal core values, iden-
tification of leadership strengths, areas of
development, organisational and personal
goals including homework and reminders. It
was also stated that a coaching service should
be available according to needs and that
booster sessions should continue as
required.
Group Coaching: It was identified that group
coaching could serve as a healthy forum for
sharing ideas and group goals. 360 feedback
based on the Idealised Leadership Attributes
was also suggested as a way of developing
self-awareness.
International Coaching Psychology Review Vol. 8 No. 1 March 2013 61
Developing a healthcare leadership coaching model using action research and systems approaches
Figure 2: A Healthcare Leadership System (HLS); note: the leadership coaching system is
still outside the system, which is to be implemented. The hand drawn line represents the
HLS system boundary and emphases the fact that it is a human system.
4. What is the impact of Executive Coaching
on Nurse Ward Managers at a personal and
professional level?
The perceptions of Nurse Ward Managers
related to the impact of the four coaching
sessions they received included enhanced
self-awareness, clarifying personal strengths
and areas of development, and enhanced
social and professional skills. Although indi-
vidualised coaching was limited to four
sessions, participants verbalised a number of
tangible organisational and personal
achievements. The organisational goals
achieved included changes in the Medica-
tion distribution systems, enhanced interdis-
ciplinary documentation and development
of training programmes and standard oper-
ating procedures. The other benefits elicited
by the participants in relation to the effects
of this coaching programme could be organ-
ised according to the structure of the
Universal Integrative Framework (Law,
Ireland & Hussain, 2007) as follows.
Personal Competence
Enhancing self-awareness about intrinsic
core values, beliefs and behaviour.
Understanding own behaviour and
associated beliefs, rules, musts and
shoulds.
Identifying personal strengths and areas
of development.
Using personal strengths as leverage to
enhance expertise.
Providing a structured way of identifying
and achieving personal and professional
goals.
Creating accountability to achieve goals
and keep to time-frames.
Utilising and adopting insights into new
situations.
Eliciting out of the box thinking and
exploration of new solutions from
different perspectives in a flexible way.
Increasing resilience in challenging time.
Providing a positive outlook for each
situation.
Supporting and encouraging authen-
ticity and mindfulness.
Providing a healthy and safe environ-
ment to discuss concerns, feel reassured
and understood whilst reducing feelings
of isolation or helplessness.
Receiving total attention and personal
time from your coach without any hidden
agenda.
Social Competence
Developing communication skills.
Managing anger when communicating
with others.
Conflict management techniques to
handle different situations.
Learning to appreciate and praise others.
Delegating more to others.
Role modelling values and taking
congruent decision and actions.
Becoming honestly open to criticism and
feedback from others.
Cultural and Organisational Competence
Building a sense of cultural bonding to
enhance collective consciousness
through group coaching.
Developing new ways to enhance team-
work, for example, more efficient
documentation systems.
Championing empowerment of staff by
listening more, using effective questions
and giving people space and time to talk
and be involved in decision-making.
Supporting and integrating those who
may seem ineffective to cope with their
responsibilities or situations.
Professional Competence
Development of Nurse Ward Managers
Coaching skills to introduce one-to-one
coaching for staff.
Developing CPD training programmes
for nurses.
Introducing changes and standard
operating procedures that lead to
enhanced safety for staff and patients.
Helping new Nurse Ward Managers to go
through transition process to reduce fear.
62 International Coaching Psychology Review Vol. 8 No. 1 March 2013
Ho Law & Reggie Aquilina
Discussion
Idealised Leadership Attributes
On reflection, the researchers conclude that
the participants themselves effectively co-
developed the emerging idealised health-
care Leadership System in relation to how
they desire to be as leaders. Using GSA/SRD,
the researchers have developed a conceptual
model to represent such system (Figure 3).
The emergence of Authenticity as a funda-
mental ideal component within this SRD
provides further evidence to the claim that
Authentic leadership represents an overar-
ching component that beneficially encom-
passes other forms of effective leadership
(Avolio et al., 2004; Avolio & Gardner, 2005).
The main attributes in Figure 3 shows an
alignment towards an authentic-transforma-
tional leadership style (Bass, 1985; Nichols,
2008) with aspects of Servant leadership
(Greenleaf, 2003) and Spiritual leadership
(Fry, 2003). These leadership styles revolve
around the values-based, ethical leadership
compass focusing on authenticity and
integrity of the leader (Poff, 2010).
The findings of this study are also in line
with the findings of several other nursing
studies. Stanley (2006 a,b,c,) found that
nurses preferred a congruent leadership
style aligned to actions based on authentic
and ethical core values. Other studies
pointed out the importance of enduring
relationships, presence and visibility, caring
about the teams well-being, loyalty, trust,
respect, flexibility, shared vision, self-disci-
pline, commitment to principles, and
empowerment of others rather than
personal prestige (Cummings, Hayduk &
Estabrooks, 2005; Johansson, Sandahl &
Andershed, 2011; Kleinman, 2004; Manley,
2000; Shirey, 2006; Stanley, 2008). These
were all referred to in this study and form an
integral component of the HLS. The fact
that the participants also rejected manipula-
tive, competitive and dominant styles of lead-
ership also reflects the findings of a study by
Hendel et al. (2006). Although the desirable
attributes of managers have been well-docu-
mented in the literature, the finding added
value by confirming that similar leadership
International Coaching Psychology Review Vol. 8 No. 1 March 2013 63
Developing a healthcare leadership coaching model using action research and systems approaches
Figure 3: A Healthcare Leadership Coaching Model (HLCM).
attributes are required for nursing managers
and thus it has implications on the knowl-
edge transfer in terms of applying leadership
to the nursing sector. Also the study high-
lighted the different priority of the leader-
ship attributes in nursing in comparison with
other sectors (e.g. care and ethics).
Thus, through the application of a GSA,
the complexity and interaction of the partic-
ipants idealised leadership attributes was
mapped out. The SRD provided a means of
explaining the pattern of relationship and
interaction of these values with system
elements and how these adapt in novel ways,
interact and provide feedback to the system
to impact on ongoing behaviour and change
(Cavanagh, 2006).
Identifying strengths and areas of development
The ILA and Values Clarification Exercises
served as a prompt for the participants to
identify both their strengths and areas of
development, thus developing a benchmark
against which to measure their performance
and leadership style. However, it was also
acknowledged that self-reported scoring was
limited in providing a complete picture and
360 feedback was requested. This method
has been confirmed by research to be effec-
tive in promoting awareness about personal
skills and deficiencies (Hagdberg, 1996;
Shipper & Dillard, 2000; Lord & Emrich,
2001, Law et al., 2007). Kleinman (2004)
also identified a discrepancy between Nurse
Ward Managers perceptions of their leader-
ship styles and staff perception of their
leaders, thus indicating the importance of
having unbiased feedback from others.
Accordingly, it was agreed that the next
phase of the coaching programme would
include a 360 feedback exercise.
Leadership Development Programmes
The results of this study further confirms the
importance of an integrative approach
towards leadership development (Carey,
Philippon & Cummings, 2011; Clarke, 2002;
Dearborn, 2002; Horner; 2002; Reno, 2005;
Tobias, 1996, Law et al., 2007), which is not
only limited to conventional training
programmes, but also to post-training
support. The participants stressed the impor-
tance of using a combined approach that
includes formal training programmes
supported by one-to-one and group
coaching.
The systems mapping exercise in Figure 2
shows how coaching matches onto the need
of leadership. We call the model in Figure 3
a healthcare Leadership Coaching Model
(HLCM) which may represent a blueprint
for leadership coaching programmes. This is
congruent with the good coaching practice
as exemplified by Law, Lancaster and Di
Giovanni (2010). A further systems model-
ling shows how leadership coaching may be
embedded within the healthcare system as
an integral part leading to an organisational
development process (Figure 4).
Impact of Coaching
The impact identified in this study also
relates to the coaching outcomes reported in
the literature reflection, insights, increased
self-awareness, and the importance of
continuous one-to-one attention, expansion
of thinking and personal accountability
(Grant, 2006; Horton-Deutsch, Young &
Nelson, 2011; Passmore, 2010; Turner,
2006). Other benefits mentioned in this
study include: goal self-concordance and
commitment, values alignment, and
increased resilience (Burke & Linley, 2007;
Grant, Curtayne & Burton, 2009); enhanced
planning and accountability (Rivers, Pesata,
Beasley & Dietrich, 2011); non-judgemental
support (Du Toit, 2006; Byrne, 2007); well-
being (Green, Oades, & Grant, 2006; Pass-
more, 2010); adoption of a coaching
leadership style as a result of being coached
(Gegner, 1997); solving own problems, iden-
tifying development needs and improving
work-life balance (Jarvis, 2004); develop-
ment of authentic behaviour (Drenthen,
2010); and resistance to social pressures that
challenge ones ethical values (Avolio &
Gardner, 2005).
64 International Coaching Psychology Review Vol. 8 No. 1 March 2013
Ho Law & Reggie Aquilina
The Values clarification exercise using
picture cards to evoke critical reflection
provided a number of important insights to
the participants about their attitudes, beliefs
and values, thus providing transformational
learning (Mezirow, 1991). The participants
also felt challenged to stretch and commit
themselves to timeframes to achieve their
identified goals and homework given. This
movement out of ones comfort zone is
referred to by Stacey (2000) as a place where
the tensions between chaos and stability,
described as the edge of chaos, elicits
creativity and innovation. On the other hand,
the therapeutic environment of group
coaching referred to in this study seems to be
in line with Wengers theory of communities
of practice (COP), which are groups of
people who share a common concern or
passion for something they do and interact
regularly to learn how to do it better (Lave &
Wenger, 1998). It also provides a way to iden-
tify and address system wide issues (Crethar,
Phillips & Brown, 2011; Edmondstone, 2011).
Limitations of the study
Like most qualitative methods, lack of gener-
alisation is a limitation. However, the AR
process may be replicated as a standard of
good practice. Since AR is dynamic it is diffi-
cult to control all stages of the study,
however, the support and commitment
shown by the participants ensured a positive
outcome and no derailing issues emerged
during the research process. To address facil-
itator and social desirability bias all
perceived measures were taken by the
researchers by limiting their personal input
to asking questions, reflecting back and
summarising.
International Coaching Psychology Review Vol. 8 No. 1 March 2013 65
Developing a healthcare leadership coaching model using action research and systems approaches
Figure 4: A Healthcare Leadership Development System (HLDS) which shows leadership
coaching is embedded as part of the HLDS. The hand drawn line represents the HLDS
system boundary and emphases the fact that it is a human system.
Research implications
Future research may include replication
studies to identify any variances in leader-
ship attributes, preference of leadership
development programmes and impact of
coaching on Nurse Ward Managers (or
different management level) in different
hospitals (or organisation) and countries.
The impact of a comprehensive coaching
programme as discussed in this research
study, that includes formal, one-to-one and
group coaching can be further explored.
Such studies can further inform healthcare
organisations on the benefits of adopting
such coaching programmes as an integral
part of their healthcare leadership develop-
ment programmes. Research can also shed
light on the impact of coaching programmes
on the outcomes of patients and the effect
on accountable, effective and efficient use of
scarce resources of society.
An exploration of the effect of intro-
ducing values clarification exercises for
healthcare students can also be researched
since there seems to be a gap in this area.
This research may be further informed by
exploring present value system of student
nurses and newly-graduated nurses.
In line with good practice of action
research, in addition to the publication of
this paper in an appropriate professional
journal, the researchers have also presented
the findings of this study at the 3rd Interna-
tional Orthopaedic Nursing Conference as
part of wider dissemination of knowledge
(Aquilina & Law, 2012, in press).
Conclusion
The constant changes and decentralisation of
management in healthcare has put more
responsibility on the Nurse Ward Managers
(Casida, 2007). Thus, an organisational
commitment towards appropriate on-going
training to support these key frontline leaders
is required to sustain the healthcare system
and provide quality care to patients (Care &
Udod, 2003; Mathena, 2002; Kowalski,
Bradley & Pappas, 2006; Smith & Sandstrom,
1999; Wessel Krejci & Malin, 1997).
This study has identified a list of idealised
leadership attributes as established by the
participants of the study and developed a
healthcare leadership model that centres
around authentic-transformational and
servant leadership styles. It has also indicated
the importance of using an integrative,
eclectic framework of coaching psychology
approaches coupled with the formal
training, group and one-to-one coaching
sessions as a recommended format for the
development of the Ward Leaders skills.
The researchers hope that this study has
contributed to the growing evidence on the
effectiveness of coaching as a mode of
support, self-awareness, empowerment, self-
concordant goal setting and impact on the
professional and personal levels. It has
confirmed that as little as four coaching
sessions can be effective in providing
tangible benefits and goal achievement
(Burke & Linley, 2007; Grant, Curtayne &
Burton, 2009).
In addition, this study recommends the
integration of leadership coaching in a
healthcare system to develop the future
leaders. As suggested by Walumbwa et al.
(2008), such an eclectic leadership
programme may be effective in building a
coaching culture so as to develop leaders
and promote authentic, ethical, and trans-
formational leadership that can lead to posi-
tive impacts and high levels of performance.
While the hospital in Malta is funded by the
government, the value added intervention
may enable further funding from the
government. Embedding coaching culture
within the existing infrastructure would
require very little additional resources.
Moreover, the transferability of the model
may be applied across cultures to the areas
where healthcare systems have not suffered
from the same financial constraints as those
experienced in the UK. Finally, this study has
also resonated with the importance of
adopting an ethical leadership as a coaching
model; as Law (2010, p.97) described:
66 International Coaching Psychology Review Vol. 8 No. 1 March 2013
Ho Law & Reggie Aquilina
If a leader is to move people, he or she must
move them with their hearts and minds so as to
instill the team with a sense of great purpose,
a mission that they are compelled to achieve.
They and their leader share the same goal.
To do that, the shared vision has to be
grounded in an ethical principle.
Acknowledgements
The authors are very grateful to the
reviewers for their helpful comments. The
revised paper has taken their suggestions on
board which hopefully would enable
improved readability and facilitate further
knowledge transfer.
The Authors
Ho Law
Chartered & Registered Psychologist,
PhD CPsychol CSci CMgr MISCP(Accred)
AFBPsS; FCMI; FHEA
Chartered Psychologist, Chartered Scientist,
Chartered Manager,
Registered Psychologist, Registered Applied
Psychology Practice Supervisor (APPS);
Senior Lecturer, School of Psychology,
University of East London, UK.
Reggie Aquilina
Dip. Adult Training & Development (U.M.),
BSc Nursing Studies (U.M.),
MSc Coaching Student (UEL),
Practice Development Nurse,
Mater Dei Hospital,
Malta.
Correspondence
Ho Law
University of East London,
Stratford Campus,
Water Lane,
London E15 4LZ, UK.
Email: law2@uel.ac.uk
Skype username: hochunglaw
Reggie Aquilina
Practice Development Team Office,
Yellow Foyer, Ground Floor,
San Gwann,
Mater Dei Hospital,
Malta.
Email: reggie.aquilina@gmail.com
International Coaching Psychology Review Vol. 8 No. 1 March 2013 67
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