EXECUTIVE COACHING TO THE DEVELOPMENT OF COMPETENCES OF NURSE LEADERS

Objective: to analyze the development of individual skills of leading nurses in peer coaching sessions. Method: qualitative, descriptive and analytical study, carried out in a university hospital in Northern Brazil. Eight nurse managers of care and technical units participated. Data were collected during and after peer coaching sessions, through non-participant observation, documents and interviews. Subsequently, they were gathered and analyzed using the content analysis technique. Result: 25 sessions were held. From the current state, a desired state and the related competence or skill were chosen. They were elected: conflict resolution, supervision, organization, administrative process, delegation, leadership, teamwork, decision making, communication and permanent education. Competences were assessed with absent, partial or integral development. Conclusion: the results suggest that, regardless of whether objective and subjective data can classify the development of competences, the awakening of consciousness, the conduct of accountability and the process of reflection of the experience are individual and, consequently, organizational advances. It is emphasized that the development of skills and the implementation of changes are possible with coaching. The process changed the nurses' perception, motivated and was positive, even in an adverse scenario.


INTRODUCTION
In the management of people in health organizations, different conceptions and policies can be adopted, from the traditional ones, focused on recruitment, selection and training, to the modern ones, focused on competences, development and performance promotion. Regardless of this, professional updating is a growing demand, with a view to improving the care provided, in a context of gradual reduction of budgetary allocations, stressful environments, loosening of bonds and perceived loss of rights. 1 Coaching, although not necessarily new, in health it appears to be innovative, capable of contributing to personal, professional and organizational development.
Coaching is a process of identifying the current state and establishing a desired state. It involves at least two people: the coachee, individual or organizational representative who determines the object of the coaching agreement, receives support and seeks to develop; and the coach, a trained professional, who helps the first one to move from the current state to the desired state, carrying out actions in the present oriented to the future. 2 Coaching processes can be directed to life (life coaching), organizational (business or internal and organizational coaching) or professional (executive coaching) issues. The purpose of business coaching is to organize, promote growth, including defining the mission, vision, values and objectives. Executive coaching takes the organizational scope into consideration, but focuses on leaders or managers, on improving individual skills. 3,4 Communication, interpersonal relationships, teamwork and leadership are examples of competencies presented as desired states. 5 Organizations that manage by competencies can particularly benefit from coaching processes, either adopting it internally or relying on an external coach. 3 Business coaching helps in the establishment of organizational skills, while executive coaching promotes the development of individual skills. 6 Together, organizational and individual competencies are articulated in people management policies that map, develop and promote performance.
The development of individual skills through coaching has relevance for the health area in general and for Nursing in particular, since acting at the operational level at the strategic level, the nurse is by nature a manager of personnel. Coaching, as a promoter of the development of leadership competence, 7 directly associated with patient results, has been the subject of research that suggests its effectiveness. It is noteworthy that it boosts the potential of professionals and promotes transformation in the organizational culture and can also promote improvement in the relationships between leaders and followers, allowing significant advances in achieving goals. 3,8,9 Internationally, Nursing has contributed to expand the knowledge about coaching for the development of skills, [10][11][12] however Brazilian studies are still scarce and not directly related to this cut. 8,13,14 The need to deepen knowledge about the relevance for the development of the skills of nurses is a reality. 3,15 The emphasis on people management and the contingencies of health organizations demand increasingly competent leaders, which challenges even professionals with years of experience in a leadership position. 16 Thus, the question is: does coaching promote the development of skills of nurse leaders in a university hospital? Is it possible to promote the development of skills among peers? The purpose of this article was to analyze the development of individual skills of nurse leaders in peer coaching sessions. A four-session process was envisaged. In the first, the results of the QUAPEEL-QUEPTAEL 8 tests were returned and expansion was promoted. The coachee spoke freely about her perception of work and challenges; from the report, the funneling induced by questions from the coach to define the objective began, a competence to be developed. They were managerial skills described in the list: supervision, leadership, administrative process, permanent education, interpersonal relationships, decision making, teamwork and communication.

METHOD
Thus, from its current state, the coachee defined, with assistance, the desired state; competence or knowledge, skill and attitude that she wished to develop, in order to be able to follow progress and points of improvement in sessions. Therefore, they usually started with feedbacks of activities, goals and actions proposed in previous sessions. At the end of each session, the date and time of the next one were agreed.
The second author, initially, was an observer, recorded objective and subjective notes in a field diary and then conducted the interviews from October to November 2017. The interviews were recorded with the aid of a recorder, with an average duration of 40 minutes, also in the reserved room. The documents served as a subsidy for the interviews, as it sought to validate events, objective phrases and subjective aspects perceived in the peer coaching sessions.
For data analysis, Bardin's content analysis technique was used. 19 The pre-analysis consisted of: a) the organization of the collected material; b) choice of documents that would be submitted for analysis; c) preparation of documents; d) interpretation and typing of field diary records, selecting objective and subjective aspects to validate in the interviews; e) attentive listening and transcription of the interviews; f) validation of the interviews and post-validation adjustments.
The assessment of the material consisted of an exhaustive reading of the digitalization of the field diary and validation of the interviews. In the first assessment, 44 codes were created. In the second, these codes were described one by one and those referring to similar contents were grouped, generating 37 codes. In the third, the codes were organized into four categories: a) organizational context; b) perceptions about coaching; c) competencies, goals and actions worked on in the coaching process; d) assessment of the development of skills based on coaching.
In this article, only category c is addressed -"competencies, goals and actions worked on in the coaching process". The codes that make up this category are goals related to the development of skills, actions related to the development of skills and perception of the development of skills after the coaching process. In order to preserve the anonymity of the coachees, they will be called "nurse" followed by natural numbers (1,2,3,4,5,6,7,8). and is responsible for the planning, organization, direction, coordination, execution and evaluation of the Nursing service. 17 As a result of contracting with EBSERH, the hospital was in transition from a managerial model, being therefore intentionally chosen as the research, teaching and extension scenario of the first author, within the scope of the research projects "Nursing management: new approaches to training and work in public universities and university hospitals ", approved by the Ethics and Research Committee under Opinion Report Nr. 2, 165,945; and extension "Introduction of strategic tools to the management of Nursing personnel in university hospitals". Both supported by the service.
The transition in management highlights the implementation of people management based on competences, previously not developed in the hospital. Thus, in defining the sample, nurses in leadership positions were purposely highlighted as participants in the study and could be multipliers in this new moment. The construction of a list of nurses' individual skills and their development through coaching were investigated in parallel, the focus of this article.
Eight nurse managers of care and technical units participated based on the inclusion criteria: a) being a nurse; b) being in a leadership role; c) having participated in the activities of building the nurses' individual skills list; d) having a coaching leadership profile, according to the scores of the Nurse Self-Perception Questionnaire in Leadership Exercise questionnaires (Questionário de Autopercepção do Enfermeiro no Exercício da Liderança, QUAPEEL) and Nursing Technician and Assistant Perception Questionnaire in Leadership Exercise (Questionário de Percepção do Técnico e Auxiliar de Enfermagem no Exercício da Liderança, QUEPTAELL). 8 It was an exclusion criterion to have a temporary contract with the institution. Figure 1 below summarizes the coachees identification process.
Data collection comprised three sources, collected progressively: a) non-participant observation of peer coaching sessions; b) documents (frequency of sessions and accompanying document with skills, goals and actions worked); c) interview. Peer coaching is a method of professional development carried out among peers, to improve or produce skills, 18 chosen for the study due to the first author being a nurse, coach and having teaching activities on the spot. Thus, she was a peer coach for nurses/coachees.
The sessions were individual, weekly or biweekly, according to the availability of the coach and coachees, from June to September 2017. They took place in a hospital room reserved for this purpose, with an average duration of one hour. The conduction of the sessions was not rigid but structured. Table 1 shows an overview of the current and desired states in relation to the competencies worked on, as recorded in the accompanying documents. Then, the codes of goals and articulated actions and perceptions about the development of competencies through peer coaching sessions. It is worth mentioning that 38 sessions were scheduled, 25 of which were held and 13 canceled due to absences from the coachees. There were situations in which the interval between one session and the other was one month.
In the first session, the current state was identified, and the desired state was established, articulating actions based on the competence that would be developed. Considering the desired state and having established the conflict resolution competence as necessary to develop, nurse 1 agreed on the following actions: (1) build the proposal for a course for October with the theme of coaching and humanization; (2)

(1) survey and identification of problems, perceptions with the nurses of each team; (2) approaching each clinic team in their work shift to identify problems and discuss service improvements; and (3) establishing partnerships
with the multiprofessional residency to approach the teams regarding the humanization of assistance and teamwork (Nurse 5: follow-up form for peer coaching sessions -19: 12).
Nurse 6, to improve decision-making competence, planned the following actions: Based on the definitions of the current and desired states, elected competences, actions, frequency in sessions and nurses' perception of the development of competences, development was classified as absent, partial and integral.
As for the absent development, nurse 1 assessed that she did not develop the conflict resolution competency. There was low frequency in the sessions, in which of the five Most coachees remained during the process with the desired state established in the first session. Nurse 2 chose the organization skill and the supervision competence, with a view to later assuming the role of manager, as she was an interim manager. However, as the sessions took place, taking on a management position was no longer in her perspective. In this context, it continued to work on the organizational skill: The administrative process competence was shared by nurses 3 and 4, each with specific actions for their desired contexts and states: (1) identify process failures; (2) giving feedback from the analyzes to the assistance teams on adjustments to be made; (3) collect return and adjust individual situations on time; (4) carry out two rounds of conversation a week to problematize, exemplify process correction (Nurse 3: follow-up form for peer coaching sessions -17: 8).
(1) describe the problems of each sector; (2)  It focused on individual gains (nurses 2 and 6), with difficulties in noticing how they could be multipliers of this new moment. This scenario may have affected the individual variable of motivation and commitment (nurses 1 and 7), with damage to the perception about the skills development of some nurses.
As for the individual variables, the mindset (view that is adopted about oneself and its development) 20 can be of two types: fixed and growth. The fixed expresses the belief that the qualities or competencies are unchanging; that of growth, that it is possible to cultivate characteristics or competences or to develop from commitment.
In general, the coachees showed a growth mindset by taking responsibility for conducting the actions they proposed. It is observed in the description of these actions the importance of their own conduct to resolve them, or at least promote their resolution. However, the commitment between the coachees was different, as evidenced by the differences between the frequencies of the sessions and the eventual failure to carry out the actions. This can be justified by the perception of some coachees about instability in organizational variables.
Therefore, three aspects are emphasized. The first is the scenario of an organization in transition, out of alignment and without common strategies between people and units. The second is that of some coachees molded, bonded and absorbed by this unfavorable scenario. The third is the awareness of other coachees, the choice to try to act and take responsibility, regardless of the circumstances. Among other words, the coaching process allowed nurses to choose: to attribute their development to the organization or to become aware of their own progress.
It can be mentioned that the nurse sometimes has difficulties in really recognizing the nature and purpose of her work. In view of this, beliefs can enhance or limit their professional development. 9,11 The process provided nurses with a moment of immersion, awareness and assumption of responsibility, basic pillars of coaching in change processes. 3 This movement is opposite to the dynamics usual practice of Nursing work methods, it is also opposed to common human development strategies in organizations, based on training.
Nursing work is commonly characterized by the articulation of care, management, educational, investigative and political processes, which makes it intrinsically complex. 15,16 As a professional category, it presents the organization with concepts and positions about its contribution to institutionalized care, negotiated in the daily life of its relations with other categories, within the scope of practice and structure, expanding or reducing the scope of action. The results of these negotiations are evident in the location of the service in the hierarchy, in the Nursing organization chart, in the mission, vision, values, expressed in manuals and regulations, which serve as a guideline It should be emphasized that although nurse 7 highlighted the evolution in communication competence, she was only present in one peer coaching session, missing all the others scheduled and making it impossible to monitor the activities.

DISCUSSION
To assess the results of coaching processes, it is necessary to condition them, simultaneously, to the analysis of organizational variables, such as assistance model, management model, organizational design, people management policy, organizational culture, and the support they are for the process; in addition to individual variables, such as mindset, awareness, commitment and motivation of the coachees. 4,9,11,20 The combination of these variables will allow the adequate conclusion of the expected return.
At the site of the study in question, although the assistance and management models were present, the new organizational design was not clear to everyone. Health organizations, in order to achieve their goals, need the synergy of multiple professional categories, 15, 16 a challenge in times of transition from the management model; in these situation[ns, the objectives, positions, roles and competences are not clear and a mixture of policies and processes, old and new, is observed. It is evident that the coaching tool brings clarity of roles to those involved. 11 Changes in policies and processes provide opportunities for the improvement of professionals. By replacing systems, newly structured health organizations can evolve and improve results. 21 In this context, however, the transition from university management to EBSERH caused the indecision of positions and roles. In view of this, many units were without chiefs, and between new and old assignments the nurses accumulated both. In this overload scenario, uncertainties about the Nursing management work made it difficult for the coachees to find out where they should go with the sessions.
It is expected that the definition of the competencies to be worked on is in partnership with the organization, by immediate leadership or people management. 15 In this way, business and executive coaching processes are connected, which increases the chances of results. In this study, a list of competencies (means of support and alignment for the service) was discussed with the manager based on organizational competencies, but this did not spread from the Nursing division to the units, so that it reached the coachees with due importance.
In this circumstance, individual skills were chosen by coachees based on particular beliefs and understandings about what was necessary for the organization (nurses 3, 4, 5 and 8), by habit or custom, with little dimension of the impact that the development of those skills could generate in the service.
for their performance, with the leaders being responsible for directing and controlling the results.
In addition, a paradigm of transferring a model based on strict Nursing management to a care management model must be considered. Thus, the constant development of nurses is essential for quality. 10 For this, coaching proved to be favorable and develops key skills such as setting goals, time management, communication 23 supervision and organization of a set of skills (conflict resolution, administrative process, delegation, leadership, team work, decision making and continuing education). It should not be considered a universal solution though. 3

CONCLUSION
To maximize the reach of the desired states, it was initially assumed that performance coaching was configured as the best alternative to favor Nursing work, as it would improve important skills in a context of transition and new organizational moment. This consideration was partially translated into more productivity at work, according to the coachees. However, coaching for development was the main aspect for raising awareness and behavioral changes, extrapolating to issues of life.
The results suggest that, regardless of whether objective and subjective data prove the development of competences, classifying them as absent, partial or integral, the awakening of consciousness, the conduct of accountability and the process of reflection of the experience are individual advances and, consequently, organizational.
It is emphasized that the development of skills and the implementation of changes are possible with coaching. The process changed the nurses' perception, motivated and was positive, even in an adverse scenario.
For further research, it is recommended that coaching should be applied at other levels of the organization.