Cognitive Coaching: a leadership essential?
Margie Sills-Maerov, MBA, with contributions from John Clarke, MEd
The roles that physicians play in the health care system — as leaders, mentors, providers, and colleagues — require not only the technical skills taught in medical school, but also the adaptive skills of communicating and engaging and fostering others’ thinking in a psychologically safe way. Adaptive leadership requires that leaders help guide others through problem-solving, rather than providing the answer. As part of continuing professional development, health care improvement facilitators and administrative leaders in Alberta were trained in the skills of adaptive leadership using a model called Cognitive Coaching. Participants noted a qualitative shift in the culture of teams toward greater collaboration and better quality of conversation. Lessons from the health care experience to date and from the education sector indicate a benefit to physicians from building this intention and skill base.
Physicians play many roles: mentor, partner in health, skilled clinician, colleague, and leader. As a result, they must be attuned to both the complex and complicated aspects of health care. Complicated environments require technical skills. Complex environments require adaptive skills. Complicated issues require a high degree of expertise in protocols, formulas, and knowledge. Goals are clear, and outcomes — the results of imaging or a simple surgical procedure — can be managed. Complex issues fail with rigid protocols, outcomes are uncertain, and resolution will vary from person to person; an example is helping a patient manage their blood sugar level.1 Complex issues require the ability to surface and “upend longstanding traditions and deeply held beliefs,”2 using the skills of listening, inquiring, and responding, and helping a person shift from where they are to where they want to be. A leader must be able to “guide others through problem solving, rather than dictating a solution.”3 Top
CanMEDS recognizes this need for physicians to possess both technical and adaptive skills, not only as medical expert, but also as communicator, collaborator, and leader. However, medical training is focused on the role of the medical expert and reinforced in hierarchical expert-driven structures in practice.1,4 As a result, the default leadership role is that of a technical leader using a “teaching” or “expert” approach to engagement, which does not tackle the complex issues fully.5 In contrast, adaptive leadership means that leaders are not necessarily responsible for having the answers, but rather for finding the answers in others with whom they work and fostering the most supportive interactions possible.1
Adaptive leadership skills are difficult to attain, and it has been suggested that there is a need to purposefully and systematically support the development of such skills in a manner replicating the rigours of the medical expert.6 To help build awareness of these skills, the Canadian Society of Physician Leaders (CSPL) has adopted LEADS in a Caring Environment as a guiding framework for physician leaders in addition to the CanMEDS framework. Frameworks help guide but not implement skill development and growth, and, in Canada, the health care system does not always support the ongoing training of the physicians who are needed to be leaders in the system.7 Thus, the system is perfectly designed to get the results it gets.
Why are adaptive skills important? At the most basic functional level, our brains are wired to detect a threat. The amygdala can be triggered by any hint of a threat — stress, fear, aggression.8 This was needed when we were hunters and gatherers, but is less functional in today’s world. Managing a threat can be countered by keeping the more rational prefrontal cortex engaged, and appealing to the cortex is at the heart of “psychological safety.” Thanks to Paul Gilbert’s research9 and advances in Compassion Focused Therapy, we also know that mirror neurons in the frontal lobe play a role in how we “feel safe.” Looking at attachment theory and neurology, Gilbert noted that activation of the areas of the brain that promoted “the social safeness system” was linked to non-verbal behaviour, tone, and touch, which indicated caring. Activation of those areas promoted the ability to explore and learn with a greater sense of confidence. The mirror neurons help us understand others through the “feelings” we get from others and are the link between sciences and humanities.10 In addition, when we feel connected to others, oxytocin and serotonin are released and contribute to creating long-lasting psychological safety in a working environment.11 Top
We know that adaptive skills are important, and we know why they impact others positively. However, what specific behaviours and mindsets are needed in leaders to support change and for others to thrive in an adaptive manner? Three years ago, I did some research on this question. Coaching in general seemed to be a common theme, but in many models, “executive leadership” focused or was entrenched in expensive for-profit models of training. A colleague pointed me in the direction of Cognitive Coaching (a service marked body of work).12
This coaching model is a skill development program that has been used for 35 years in education. It is designed to facilitate conversations that invite others to share, explore, and deepen their own thinking in a safe environment. It focuses on creating a learning environment versus embedding external coaching practices — it is about culture change. The premise behind it challenged some of my own thinking on change management. Rather than targeting behaviour, the intention is to support the thinking that preceded any behaviour. It ticked many of the boxes I needed: it came from an entity focused on improvement in education; it was rooted in skill development not just a framework; it was theoretically sound, well researched, and studied for over 35 years; it was not a “rote” set of tools; and it was quite cost-effective as it emerged out of another “cash-strapped” human services delivery sector — education. In considering the “teaching” aspect of health care, it also made intuitive sense. Good teachers foster a sense of curiosity, make you feel that you can figure things out, help refine your thinking, and likely make you think and reflect on your thinking years later. In many ways, good leaders have similar traits.
As part of continuing professional development, a number of health service agencies in Alberta pooled resources to fund training for improvement professionals and change leaders in the province and test the effectiveness of Cognitive Coaching. We tested the training with two cohorts of 40 improvement professionals and health care leaders. We were quite hesitant at first, as the training required eight six-hour days over the course of eight months or so. However, once we all completed the first two days, we quickly realized why it would take eight days: it consisted of skill building, not teaching. It was about learning, testing, practising, and internalizing. The way it was structured allowed for thinking to be shifted, and then behaviour followed. Top
We completed qualitative and quantitative evaluations of the participants, looking at self-efficacy, skill acquisition, and application and practicality in the health care environment. Participants experienced a shift in how they looked at their role: they found that they used the skills in high-stress or conflictual situations with success, and it changed the way team members interacted and worked with each other. They had a greater sense of being effective in helping others with change. Instead of having to have the answers about a change, they were instead getting the answers out of the teams that they were supporting and had a greater impact. They moved away from being “problem solvers” to acting as coaches who enhanced the thinking of others and grew teams and collaborative partnerships (M. Sills-Maerov, unpublished action research, 2015–2018).
The learning design of the course broke down key components and built skills over time in ways that allowed changes in thought and behaviour. At its base, the coaching training taught a core pattern of “pausing, paraphrasing and posing questions,” that
- Supported mirror neuron function in paced conversations and non-verbal alignment to match the thinking of the person being coached, resulting in a high degree of rapport
- Reduced the level of perceived threat by using artful ways to paraphrase, indicating deep listening and understanding
- Fostered new patterns of thinking with thought-provoking questions
The course focused on how to apply that core pattern based on the needs of the individual. It helped shape the flow of a conversation based on the type of issue: to reflect on something that went well or did not, to plan something coming up, or to resolve a problem. Through their coaching skills, the facilitators were able to help the coachees identify, name, and articulate their issue(s) and then strategically reorient them to a more resourceful state through the questions asked. This method can be used both formally and informally. A structured conversation could be held or the skills applied in everyday situations.
We also learned that coaching is not always the answer. At times a leader needs to be an expert, or an evaluator, or a collaborator.11 However, in coaching, it is the purposeful application of skills designed to help others build their capacity as self-directed individuals that sets it apart from other models. The premise is that the greater the cognitive resourcefulness of a team, the better its members can adapt and change within a changing landscape. Fostering the development of autonomous, self-directed learners on our teams means they recognize their actions and the impact of those actions within the larger system — a key function of a leader in the LEADS framework.
Although coaching has not been fully studied in health care or with physicians, it has been well researched in education, and a number of lessons may apply to physicians in their practice. For example, Joyce and Showers13 seminal work in 1980 affected how professional development was delivered and shed light on how to increase teachers’ ability to put new ideas and approaches into practice in the classroom. Simple professional development outside the context of work resulted in about 20% uptake of new practices. When individuals received professional development and coaching, implementation increased to 80–90%.13 In what ways might coaching change the impact of continuing medical education or best practice guidelines?
The results of research specific to Cognitive Coaching have been collected over the past 35 years. Some of the themes may also be applicable to physicians and translate well into health care.14 Top
Finding 1: Teachers and mentors who were coached or received specific Cognitive Coaching training were better able to improve the performance of their students and teacher mentees.
This appeared to be linked to several areas: the ability to more thoughtfully reflect on their own learning, a greater emphasis on the needs of others, their ability to ask questions to stimulate thinking of others, as well as a fundamental shift away from “creating clones” in thinking to fostering the development of others and focusing on their success. Those who were coached consistently demonstrated improvements in their ability to reflect and learn and become critical thinkers.15-19
Questions for health care: Like teachers, physicians are in the business of human services. Physicians support co-designed health care with patients, in particular for chronic condition management. Adaptive leadership skills supported by training in coaching might improve those interactions, as in the case of teachers and students. As physicians are also teachers to residents and students, their ability to support learning might be aided by coaching. Competence by design, as set out by the Royal College of Physicians and Surgeons of Canada,20 is already focusing on the role of the preceptor as coach. How might the skills developed through Cognitive Coaching affect these interactions? Top
Finding 2: Culture in the classroom with students and between teachers improved.
Teachers who had been teaching for years found that using Cognitive Coaching resulted in a “calmer” classroom with fewer (problematic) student behaviours. They found the culture of the classes to be “more friendly” and open, which affected student achievement. The skills can be used both formally in structured conversations and informally in everyday interactions, thus the impact on culture.21,22
Questions for health care: Like teachers, physicians are often put in the role of being an “expert” and part of a hierarchy, both formal and informal. Their interactions with colleagues, professions, and patients are all affected by people’s sense of safety and connectedness and can be enhanced with greater skills and abilities in conversations. If coaching promotes a “social safeness system” resulting in a shift in the culture, what might be some of the impacts on health care? Could it decrease the level of burnout seen in health care providers? How might physicians, as key leaders in the health care system, have an impact by leading with adaptive skills versus technical skills, when appropriate?
Finding 3: Teachers who were coached had a greater degree of self-reflection supporting their own professional development.
The studies highlighted the impact of an increased emotional intelligence rating of teachers by others and a greater awareness of their own metacognition. Teachers who were coached were better able to reflect on their own practice in a more balanced way and became more flexible and adaptable in their teaching style. Administrators also noted that teachers who received coaching training had an increased desire to grow and learn professionally. Some of the flexibility was attributed to a greater use of both sides of the brain, engaging both the analytic and intuitive functions.23-26
Questions for health care: Emotional intelligence is the ability of people to recognize, discern, label, and manage their own emotions and the emotions of others. This is quite similar to the Leads self domain in the LEADS framework. Given the finding above, how might Cognitive Coaching skills increase the ability of a provider be more self-aware, manage self, develop self, and demonstrate character? As medicine moves to a competency-based learning model, in what ways might the skills of coaching affect the mentor–mentee relationship? How might they affect a mentor’s own self-reflection? Top
Finding 4: Coaching is a practical leadership tool to foster a positive culture.
Alberta-based education studies looked at the impact of Cognitive Coaching on leadership development.27 Before training, the sense of efficacy as tested with a validated educational tool showed that newly appointed school principals were markedly lower in efficacy compared with more experienced principals. After two years of collegial support through coaching and mentorship from the experienced principals, the level of efficacy between the two was equal. Adopting Cognitive Coaching as a tool and a way of interacting among principals resulted in improvements in school climates in terms of professionalism, leadership, engagement, and academic results. Other studies demonstrated more positive attitudes as a result of a greater sense of trust, community, collaboration, and networking. Teachers and leaders felt less isolated and, as a result, a greater ability to have a positive impact in the workplace. Over time, any concerns about the extra time needed for coaching fell away.
Questions for health care: Learning adaptive leadership skills is not easy. However, if physician leaders purposefully focused on building adaptive leadership skills, as proposed by Schwartz and Pogge,6 how might they affect mindsets and long-term change? What skills could foster Developing coalitions (mobilize knowledge) and Systems transformation (critical thinking, support innovation, and orchestrate change) as defined in LEADS?
Adaptive leadership is a necessary skill in health care, as underlined by CanMEDS and LEADS. Adaptive leadership skills are not taught, nor reinforced in health care structures. The adaptive skills needed to guide teams through problem solving are aligned with those educators need to develop self-resourced children and learning environments, and they hold potential in health care. As an example, the faculty of medicine and dentistry at the University of Alberta will be offering Cognitive Coaching as part of continuing medical education starting in 2020. We hope to learn more about the impact of training providers purposefully in the “soft skills” of leadership. As in any skill building exercise, incorporating the skills into a person’s approach takes time, reflection, and personal growth. If we want physicians to be the leaders we expect them to be, we need to afford them that opportunity. Top
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Margie Sills-Maerov, BScOT, MBA, CHE, is a passionate change leader with 25 years of experience at clinical, management, and policy levels. She is the education program officer at the Department of Lifelong Learning at the University of Alberta Faculty of Medicine and Dentistry, and senior director at Thought Architects, an organization committed to helping physicians in their clinics with their Human Resource Management, Improvement Initiatives and Leadership and Coaching skills. You can view her ongoing thoughts about physician leadership on her blog at https://www.thoughtarchitects.ca/blog.
John Clarke, BA (Arts), BEd, MEd, is a training associate for Thinking Collaborative (www.thinkingcollaborative.com) and an authorized presenter of Cognitive Coaching seminars. John works with corporate and health care organizations, and school districts in the areas of leadership development, change management, communication skills and the creation and sustainability of effective professional communities.
Margie Sills-Maerov is in the process of becoming a Cognitive Coaching trainer and supports training at the University of Alberta and with Thought Architects.
This article has been peer reviewed.