Can coaching paramedics help them reflect on their wellbeing and confidence and be empowered within their profession? Gabby Barody, Oxford Brookes University, Oxford, UK. Contact: [email protected]
Abstract There has been a significant increase in the number of paramedic practitioners leaving the profession, in relation to the increased anxiety and stress associated with the evolving, diverse role, and increased workload. The ambulance services are struggling nationally to recruit the numbers of staff required to support the current healthcare demands. This qualitative study was set up, to ascertain whether delivering a short course of coaching sessions, over a two-month period to a group of practitioners, could make a difference to the general wellbeing and satisfaction of the paramedic professional. Findings revealed themes, including confidence building, enabling expression, professional and personal improvements, recognition of patterns of thought and behaviour, and a reduction of stress Key words: Coaching, paramedic, stress, workload, job satisfaction, confidence.
Introduction There are many challenges currently facing. the paramedic profession. At present, there is a shortage of paramedic practitioners nationally, which has been well documented, especially within the London Ambulance Service (London Health Board 2014). There is also evidence that attrition rates within the services are extremely high, resulting in many paramedic practitioners exiting their frontline roles relatively early within their career. The shortfall for most of the ambulance services is between 400 and 700 practitioners. According to Richard Webber from the College of Paramedics, there is a shortage of between 2400 and 3000 nationally. Jayne McCubbin (BBC 2015) reported that the shortages nationally range from 16% to 37% and are attributed to low morale and absenteeism. There has been a continuum of high attrition rates relating to care workers (Brannon et al., 2007). Comments from practitioners themselves relate this situation to the high pressure cases that they are experiencing shift to shift now becoming the norm, which is unsustainable. Some services have been recruiting people from Poland and Australia (South Central and London) to try and fill some of the vacancies. Amongst the other reasons attributed to this are burnout, fatigue, lack of motivation, reduced work-life balance, increased cost of living and uncertainties relating to the current economic state and changing healthcare care demands. There is evidence available to suggest that changes associated with demand and workload have already raised concerns regarding the overall reduction in staff morale and commitment to an organisation (Caykoylu et al., 2011 and Borril and West, 2002). The uniqueness of this research was linked to the fact that it was not possible to carry out a case study looking at the effects of coaching on the paramedic profession, as there was little if no evidence of this in practice. It was therefore important to take action and set up and deliver a coaching package, and more importantly to assess the impact of such a programme. The research centred on a combination of action research and a case study approach to be called an action case study. The main International Journal of Evidence Based Coaching and Mentoring Special Issue No. 10, June 2016 Page 147 The current issue and full text archive of this journal is available at: http://ijebcm.brookes.ac.uk
focus was on the coaching itself and the impact, rather than the traditional cycles of change associated with action research. This article will concentrate on the background and context to the study, some of the objectives, the literature supporting the research, the methodology, the findings and finally a discussion, conclusion and recommendations for future practice. Some of the objectives of this research are listed below: • • • •
To improve confidence in the ability to perform the role To reduce the personal stress experienced in relation to the high pressure environment To empower and enable practitioners to create their own career pathway To alter the “intent to leave” outlook if it exists at the time of coaching thus benefiting the ambulance service
Literature Review I was hoping to find some literature relevant to paramedic practice. The search was disappointing initially as there was very little if anything to be reviewed. I decided to search more broadly to incorporate the healthcare sector, medium to large scale organisations and the public sector in general. This extended out to include teachers, social workers, local authority workers and indeed employees who work in medium to large scale organisations with “stressful “workloads. I wanted to see what supporting and development structures were available to such employees including coaching. The reason for choosing to look at the paramedic profession as a case study, is that as I currently teach (with an academic and mentoring accountability) paramedic students studying towards foundation degree/registration status, and I could see from my experience that there was a difference in the developmental opportunities being provided for this group of practitioners, as opposed to for example, the nursing and medical profession. I could see that there was a gap with regard to the support and development for the paramedic profession. The National Health Service (NHS) laid out recommendations to invest in staff wellbeing after finding that over 60% of healthcare has suffered the physical and psychological effects of working in such stressful environments (Department of Health, 2009). Work related stress develops when a person is unable to cope with the demands being placed on them. This can lead to illness related to both physical and mental health and is a significant catalyst associated with increasing sickness absence, critical incidents and a high turnover of staff (Health & Safety Executive (HSE), 2014). Research has shown that one of the major causes of work related stress, is the impact of managers and their ability to manage staff and stress in the work place (HSE, 2009). The working group that reported the highest rates of work-related stress, depression or anxiety were the health and social care, teaching and educational professionals. (HSE, 2014). There are standards that should be met by employers to support employees to work through issues relating to stress and to find solutions collectively There is evidence to suggest that adopting a supportive, professional and trusting approach to employees can reduce the incidence of stress. Employees can seek out occupational health support to assist with reducing the negative effects of the stressors, or if possible reduce the incidents of the stressors themselves, which in itself is more difficult in reality (Ivancevich et al., 1990). Counselling can be considered, especially if there are external, personal factors adding to the situation. Counselling is a very important intervention that can be sought independently or a referral can be made by the employer; There has been a significant increase the number of employees within the ambulance service suffering from mental health disorders (Kirby, 2015). Could couching be utilised as an interim or strategy, before counselling would be suggested or required? There is evidence to suggest that coaching could be used, as a way of reducing stress in the workplace. Wales (2003) and Ascentia (2005) reported a reduction in stress after staff received coaching intervention International Journal of Evidence Based Coaching and Mentoring Special Issue No. 10, June 2016 Page 148 The current issue and full text archive of this journal is available at: http://ijebcm.brookes.ac.uk
There is also further research to suggest that stress can be reduced through coaching methods, even when stress was not the main objective of the intervention (Green et al., 2006, Grant, 2003). The coaching approaches involved in the aforementioned research, focused on cognitive, phenomenological and life coaching within a group setting. Coaching has also been offered to telephone operators within a financial organisation resulting in however reduced anxiety and depression indices. There have been many discussions relating to stress in the work place, especially during a period of role transition in medium to large scale organisations within the public sector. Coaching initiatives have been successfully used to address and support employees with issues relating to stress, general well-being, career development and job satisfaction (Sinclair 2008). These initiatives however, have been utilised successfully for staff at senior and executive level within the health service. To my surprise, this has not expanded to include the frontline, patient facing staff. Therefore, a coaching initiative might be able to deliver independently, or support and complement the structures and processes already in place for this group of employees. Further, there is evidence from the nursing profession to suggest that that commitment from an organisation is pivotal to staff motivation, development and overall job satisfaction (Saari & Judge, 2004). Whilst the aforementioned relates to the nursing profession, this can easily be applied to the paramedic profession who have similar roles. Managers and or executives can also make a positive difference to confidence, self- esteem and job satisfaction by utilising supportive and developmental initiatives (HSE, 2015). Creating a coaching culture can also influence self esteem and job satisfaction (Hoyle, 2011). The previous study relates to team leaders working for Merseyrail in Liverpool. External coaches were employed to facilitate teamwork and performance, and internal coaches were used to address job satisfaction. Employees across the region, now utilise a virtual forum to recreate the coaching culture. The results were very positive in within this organisation, in terms of improving employee confidence, development and performance. Team development and communication has also been an initiative used within the healthcare setting, particularly within the nursing profession (Cox et al., 2014; Woodhead, 2011; Sommers et al., 2000). Cognitive development coaching has also been utilised successfully yielding more confidence, within the nursing profession. The practitioner within this forum, is encouraged to adopt a flexible thinking approach to problem solving, avoiding rigid words such as, “should” or “must be” (Neenan & Palmer 2012:18). Coaching initiatives have been utilised within the ambulance service and for paramedics but on a small scale (Orsan, 2011). This study was conducted in Ontario Canada, where a coaching initiative was introduced within the orientation programmes. Evaluations indicated increased morale and career development. There is also evidence that clinical supervision, mentorship and other supportive initiatives have been effective in supporting and developing medical and nursing staff Methodology It was important to choose the most appropriate and relevant methodology for this research study (Morgan, 2007). I chose to combine an action research (Bryman, 2012), approach as there was no data to use with reference to paramedic coaching with a case study, that is to say, the paramedic profession. This action case study was unconventional and unique, as it incorporated some of the attributes for both methods. I did not actively address the cycles associated with action research as that really was not my aim. I did however, reflect upon my coaching ability and style throughout and after each coaching session. This constituted an element of “reflection in action” (Yanow & Tsoukas, 2009). The philosophy within the research was based on constructivism, as my belief around this research was that individuals construct their own perspectives and experiences (Lincoln & Guba, 2000). I was interested in finding out if this group of practitioners could benefit from coaching following a constructivist approach. International Journal of Evidence Based Coaching and Mentoring Special Issue No. 10, June 2016 Page 149 The current issue and full text archive of this journal is available at: http://ijebcm.brookes.ac.uk
A pilot coaching programme, incorporating four coaching sessions was delivered over two months. This was offered to paramedic practitioners on a voluntary basis. I was the researcher and the coach for all six participants. Once the sessions had completed (the action part of the study), then a semi -structured questionnaire (Crabtree & Miller, 1999), was used to interview the participants to assess if the coaching had made a difference and in what way. I wanted the questionnaire to evoke open and authentic responses (Harding, 2013). I used my own coaching model and approach (Figure 1), which was exciting, particularly as coaching is not my full time role at present. The participants ranged in ages from 22 years to 55 years of age. They also worked for one of two ambulance service trusts. The experience of the practitioners within the ambulance service, ranged from 8 months to over 15 years.
Figure 1: Coaching Model (as used in the study) Data Analysis Notes were taken during and following each coaching session in a professional manor. The interviews were transcribed with consent from the participants. Thematic analysis was used to identify the groupings of responses from the participants following the coaching sessions and the interviews. There were also specific questions used to address issues such as stress and also the actual experience of being coached. Findings Five out of the six participants completed their coaching sessions and interviews. There was a strong correlation between trust and the coaching being effective: I trusted you so I did not think you were high risk. This made a difference in opening up as I never knew that I could be that authentic with you. International Journal of Evidence Based Coaching and Mentoring Special Issue No. 10, June 2016 Page 150 The current issue and full text archive of this journal is available at: http://ijebcm.brookes.ac.uk
I trusted you and I was interested. I trusted that something would come out of this even if there was no change in my circumstances. Themes arose from the coaching sessions and following analysis of the interviews. All the participants involved in the study had either no or a very limited concept of what coaching was initially, but were intrigued to find out what was going to occur. Words such as “excitement”, “fascinated”, and “just what I needed” were used to describe their feelings before the sessions commenced. Reduction of stress All the participants expressed feeling less stressed in their work place. The range went from a slight improvement to a noticeable a “tangible” reduction. Not only was this apparent within the workplace but also in relation to personal and family issues (for some). The subject of stress itself was a discussion that emerged out of the sessions. It appeared that the participants associated the reduction in stress to be a by product of the coaching itself. I felt like I honestly do not procrastinate as much and that has reduced my experience of stress at work - I am not so worried about the things I have put off, including work issues. I have a sense of calmness. Yes, I have noticed a difference. It is difficult to assess the level pre and post the coaching but I generally do not think or dwell on things as much as I used to. For the first time in my life I had high blood pressure following a stressful period of my life - and now after the sessions I no longer have this condition or the need for medication. I feel more in control. The quote above illustrated what can be achieved by reducing stress levels, including no longer needing medication for hypertension Being able to articulate and express issues of importance The importance of being able to express and articulate an issue, emotions or experiences became a theme amongst the participants. During the coaching sessions, the participants often requested myself as the coach, to rephrase or explain anything in order to be clear and to be understood. Once the participants felt “listened to” or heard then their experience of themselves and their issues appeared to transform. I found it difficult in articulating why some things bothered me or why there was a discrepancy in how I felt about myself and what an ideal version would be - It worked though as I just trusted that something would be revealed. The difficulty was getting started and expressing and speaking my mind - I now feel more comfortable in doing this and feel helped and transformed. It was important to me to remain open, altruistic and empowering for the participants. I wanted them to feel valued and respected. Having confidence at work and being able to take the next career step Some of the participants reported feeling more grounded, satisfied and secure in their work place and or role: -
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I was trying to get ahead with work even though I had only just qualified. This way of being was very tiring. I can now just enjoy my position in the moment and realising that things were OK as they were and that was really good, more relaxing. I am able to set boundaries at work and ask for what I need. I have noticed that I have been more productive and effective within my work role and that compromise does not mean being resentful or giving up. The reason for the above improvements in outlook appeared to be the development of empowerment and the renewed ability to contribute in a more productive manner within the work place. This new experience of empowerment appeared to emerge following close examination and reflection of what was important to them right now and career wise. One participant realised that actually taking risks, in terms of going for an advanced clinical role was the thing that was missing from him being fulfilled at work. He realised that he was “playing it safe!” which was why he was unfulfilled. I am confident that the decision to take on a new role is right for me as I realise it was the new challenge is fulfilling and that was missing for me ...That is who I am, a risk taker Discussion and Conclusion It would appear that a short programme of coaching (four one-hour sessions) proved worthwhile to the participants, and appeared to have made a difference in some of the areas and issues that were important to them. From the coaching sessions and my diary notes, I noticed a difference in how the participants were behaving. They appeared to be more open and authentic about their issues associated with work, as the sessions moved forward. The feedback appeared to suggest that the coaching intervention did contribute to a reduction in stress associated within the working environment. (Theeboom et al., 2013). Coaching could be used to explore stress as an alternative to counselling. This is offered to support individuals suffering from stress but is sometimes tend not taken up, for fear of the perceived stigma (Gyllensten et al., 2005). The coaching model that I had used appeared to work with the participants, who were able to articulate both their professional and personal issues that they wanted to address. Those that completed the sessions, stated that the coaching had been successful and that they had noticed differences in their approach to and perception of their role and developmental opportunities. All the participants reported improvements in both their professional and personal lives. and viewed themselves as people that could overcome their barriers. This was certainly apparent by their increase in self efficacy, self-esteem and relaxed demeanour. Once their patterns of thoughts and behaviours were identified in certain areas, this generally allowed them to examine their triggers, and how to alter or mitigate against the frequently associated disempowering emotions and feelings I was also interested in whether the coaching had influenced any of the practitioners’ intentions to leave the profession, given the current shortage within the NHS. I am not sure that this could be proven, but the participants all were empowered within their roles and appeared to be more secure and grounded in their current work. The more experienced practitioners were looking to diversify their roles within the profession. One actually applied to re-join as a part time frontline ambulance paramedic following the coaching sessions. It would be useful to expand the coaching to more practitioners to see if it made any significant statistical difference to recruitment and retention of staff, which as already suggested has been an ongoing concern within the ambulance services (Chapman et al., 2009). All the participants suggested that coaching would have been useful post registration and at certain points following registration.
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It is useful to reflect that this small-scale study was carried out with six participants. As much as the data is enriched by qualitative data, it would be interesting to see if coaching could be used to address similar issues to a larger group of practitioners. Another limitation is that I was the coach and also the researcher, therefore was open to being subjective to a natural unconscious bias, in favour of coaching. It is also worth stating that although the outcomes were generally very positive, there was no guarantee that these would be sustainable over time. This is also an area for further research. Recommendations for further research The research revealed some key findings as already discussed. The pilot study was set up to with the intention of performing further research (if the findings were positive), with paramedic practitioners and possibly the ambulance service in general. Listed below are some recommendations for engagement, discussion and further research to support the paramedic profession: • It would be beneficial to perform a follow up interview with the participants, to see if the benefits they received from the coaching sessions were still present and or active. • It would be appropriate to widen the study, to include more participants and other ambulance services • It would be appropriate to present the findings to the ambulance services and the college of paramedics. The purpose would be to feedback and discussion and the relevance of establishing a coaching culture and to introduce a coaching programme at proposed career intervals post registration (for example at 2-3 years, 5 years and 10 years).
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Gabby Barody is a senior lectuer currently working with the BSc Paramedic and the MSc Nursing programmes at Oxford Brookes University. She is from a critical care nursing background, and works as a triage practitioner within primary care. Her interest in mentoring and coaching has developed over the last eight years, and is very much focused on the development of students and staff, from a professional and personal perspective.
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