Nursing coaching leadership and its influence on job satisfaction and patient safety

1 Universidade Estadual de Campinas, Hospital de Clínicas, Campinas, SP, Brazil. 2 Universidade Estadual de Campinas, Faculdade de Enfermagem, Campinas, SP, Brazil. 3 Universidade Federal de São Paulo, Escola Paulista de Enfermagem, São Paulo, SP, Brazil. ABSTRACT Objective: To compare the nursing technicians’ perception with the nurses’ self-perception of the exercise of nurses’ coaching leadership and to check the influence of this leadership model on the safety climate and on the team’s satisfaction. Method: This is a correlational study, carried out with 85 nurses and 85 nursing technicians, using the Questionnaire on the Nurse’s Self-Perception of Leadership Exercise, the Questionnaire on Nursing Technicians’ and Assistants’ Perception of Leadership Exercise, and the subscales Safety climate and Satisfaction at Work. The relations among the professionals’ responses were assessed using the Mann Whitney test and Spearman’s coefficient. Results: Nurses achieved higher means in the four dimensions of coaching Leadership, and in three, the differences were significant (p < 0.05). The dimensions of Coaching Leadership obtained positive and significant correlations with the subscales Safety Climate and Satisfaction, the majority being of moderate magnitude. Conclusion: Nurses’ self-perception regarding the exercise of leadership was more positive than the technicians’ assessment. The more the nurse exercises the dimensions of Coaching Leadership, the better the team’s safety climate and satisfaction.


INTRODUCTION
The concept of leadership is multidimensional and complex. Among the various attempts to elucidate the term, authors point out that leadership is the "ability to influence a group of people to achieve goals and objectives" (1) .
The exercise of nursing leadership influences the organization of health care work and materializes in the interaction of the nursing team with the multidisciplinary team, focusing on assistance to the individual and his/her family.
In this regard, the National Curriculum Guidelines determine that leadership, considered a central competence, shall be developed since the undergraduate course (2) , because, besides providing greater resolution to the managerial work process, it allows nurses to perform the role of team articulator and motivator (3)(4) more effectively.
Nurses shall assume a posture that conveys confidence, and shall direct the work relationships considering that leading is not only delegating tasks, but also seeking a work environment that favors their team members' professional and personal development (5) .
In this context, researchers have demonstrated a relationship between contemporary leadership models and better results regarding patient safety and workers' satisfaction, factors that can contribute to quality of care improvement (6)(7) . Among these leadership models, literature has mentioned transactional leadership (8) , transformational leadership (9) , authentic leadership (10) , and coaching leadership, with the latter being guided by a process of promoting and stimulating learning, with practical guidance to achieve goals related to technical and personal development (11)(12) . The Coaching Leadership model stands out in the business sector and has been gaining ground in the health care area, both in the private and public spheres, as it aims to improve the work teams' performance (13)(14) . This leadership model is seen as an important strategy and as a driver for the development of competences, as well as a stimulus for the followers' self-knowledge, thus becoming an accelerator of results. Therefore, "Coaching Leadership is considered a new direction for organizations in the health sector and innovative among Brazilian nurses. It is appropriate and necessary to study it in our reality" (15) .
The coaching process dimensions include Communication, Providing and receiving feedback, Empowering and exerting influence, and Providing support to the team to obtain joint results. These are aspects that are reflected on the competencies required for the exercise of the nurse leader (16) .
In the nursing area, coaching leadership studies bring an innovative methodology proposing a correlational assessment of the perception of leadership among leaders and followers (3,13,15) . Results show that the exercise of this leadership model brings significant improvements to increase productivity, and even the willingness of the team to cooperate (5) , job satisfaction (3) , continuous interaction between nurses and nursing technicians, and the search for professional and personal development (13) .
In a general panorama, nursing coaching leadership has studies both in primary care and in hospital care, being the second with a significantly larger number of publications. In most studies, it is approached based on the principle that it is a tool used in the development of leadership competence for nurse leaders (3,15) , as well as that it assesses the impact of this leadership model on the nursing team, relating it to job satisfaction (3) and professional development (13) .
As the nurse's task as a leader is not a simple action, since it involves the complex management of the work team in favor of a more effective assistance to the patient, one can conclude that the study of this competence is increasingly necessary, to map how this leadership has occurred in the institutions' clinical practice, and its reflexes on patient safety and on job satisfaction, as authors claim that the exercise of leadership can influence these results (3) .
Taking the importance of leadership into account as an essential competence for nurses, there is an urgent need to understand how nurses self-assess the leadership they exercise in practice and how nursing technicians perceive this leadership exercised by nurses, and to understand the influence of this variable on job satisfaction and on the team's perception of the safety climate.
In view of these considerations, the questions that guided the present research arose: "What is the nurse's self-perception regarding his/her practice as a coaching leader?", "What is the perception of nursing technicians regarding the coaching leadership exercised by nurses?" and "Does Coaching Leadership influence job satisfaction and the safety climate?".
The answers to these questions will allow improving the knowledge about this leadership model, with regard to improving quality of care and job satisfaction. In addition, they will be able to subsidize nursing management, tailoring the development of this competence based on the results found. Thus, the objectives of this study were to compare the nursing technicians' perception with the nurses' selfperception of the exercise of their coaching leadership and to check the influence of this leadership model on the safety climate and on the team's satisfaction.

Design of stuDy
This is a cross-sectional, quantitative, descriptive, and correlational study.

scenario
The research was carried out in a teaching hospital, located in the city of Campinas, SP, Brazil, which provides assistance at tertiary level, serving highly complex patients and providing 405 beds. The hospital's mission is the training and qualification of human resources and the production of scientific knowledge. The nursing team consists of 329 nurses and 1,060 nursing technicians. In the institution's organizational chart, the director of the nursing department responds directly to the hospital's superintendence. Then, lower in the hierarchy, there are the directors of areas, who get support from the supervisors, who are directly responsible for nurses, and these, for the nursing technicians. The inclusion criteria were being nurses and nursing technicians working directly in the assistance and having at least three months of experience. This time was considered as it is the one adopted as the minimum period necessary for a professional to become a permanent employee after being hired in most Brazilian hospitals. Therefore, it is believed that, during this period, the professional has already got adapted to the environment and knows the processes and the team with which he/she works better. Professionals who were absent during the data collection period, whether due to vacation or sick leave, and those who left blank answers in any of the instruments were excluded.

sample Definition
The sample size was calculated based on 80% power, a significance level of 5%, an estimate for the correlation coefficient equal to 0.30, and a correlation coefficient equal to 0.00 as a null hypothesis. The calculation resulted in a minimum sample of 168 professionals (84 nurses and 84 nursing technicians). Nurses were randomized using Microsoft Excel for Windows® spreadsheets, which included the names of all professionals.

Data collection
Collection was carried out in the period between October and December 2019, in a single step and after randomization. The researchers went to meet the nurses in their own work places and shifts. Following the explanation of the objectives of the study, those who agreed to participate signed the Free and Informed Consent Form. At this time, the schedule of the nursing technicians on duty that day was requested to the nurse.
This way, the technicians present were also randomized through a website, accessed by smartphone. Those who agreed to participate received explanations on the objectives of the study and, this way, a paired sample was constituted.
To assess Coaching Leadership, the Questionnaire on the Nurse's Self-Perception of Leadership Exercise (QUAPEEL) was used, directed to the nurse, and the Questionnaire on Nursing Technicians' and Assistants' Perception of Leadership Exercise (QUEPTAEEL), directed to nursing technicians. Both were built and validated for use in Brazil (16) .
The instruments QUAPEEL and QUEPTAELL are subdivided into three parts. For the present study, only two parts were used: social and professional characterization of the sample, as well as 20 items distributed in four dimensions: Communication, consisting of five items (1 to 5); Providing and receiving feedback, consisting of six items (6 to 11); Empowering and exerting influence, consisting of four items (12 to 15), and Supporting the team to achieve organizational results, consisting of five items (16 to 20) (16) .
With regard to the instruments reliability, Cronbach's alpha coefficients obtained for QUAPEEL and QUEPTAEEL were 0.67 and 0.84, respectively, for the dimension Communication; 0.71 and 0.81 for Providing and receiving feedback; 0.74 and 0.89 for Empowering and exerting influence; and 0.79 and 0.85, for Supporting the team to achieve organizational results.
These items are evaluated using a Likert scale, with six points, where the value one point represents "never -I don't notice the statement" and the value five points represents "always -I notice the statement every time"; that is, the higher the score obtained, the greater the perception of the described behavior in daily practice. In the scale of responses, the participant also has the option of "does not apply". The scores for the subscales are obtained by averaging the sum of the professionals' responses (16) .
With regard to Job Satisfaction and Safety Climate, data were obtained using the Safety Climate and Job Satisfaction subscales, from the Safety Attitudes Questionnaire (SAQ), both validated for use in Brazil. The Safety Climate subscale (α = 0.67) considers the perception of professionals with regard to organizational commitment, for patient safety, consisting of seven items. The work satisfaction subscale (α = 0.77) reflects the positive view of the professional in relation to his/her work environment, consisting of five items, of which one item is reverse (17) . These subscales were applied to nursing technicians to check whether the perception of these professionals about the leadership exercised by the nurse (real leadership) was related to safety climate and job satisfaction.
The answer to each question is assessed using a Likert scale with five options, being A -strongly disagree (0 points), B -partially disagree (25 points), C -neutral (50 points), D -partially agree (75 points), E -totally agree (100 points) and X -does not apply (item should be excluded from the mean calculation). The instrument's final score ranges from zero to 100 points, with 0 being the worst assessment and 100 being the best. Scores above 75 indicate the perception of a safe climate for the patient and job satisfaction. To perform the score calculation, it is necessary to recodify the reverse items and, after this, to calculate the mean of the sum of responses from participants in each domain (17) .

Data analysis anD treatment
The data obtained were tabulated in Microsoft Excel for Windows® spreadsheets, in which the absolute and relative frequencies of the categorical variables and the measurements of the position of the continuous variables (mean and standard deviation) were calculated. Professionals leaving blank questions (missing data), in any of the instruments, were excluded from the data analysis.
For comparisons between groups, regarding the instruments scores, Mann-Whitney tests were applied. Correlations were assessed using Spearman's correlation coefficient, whose values between 0.1 and 0.29 are considered to be of low magnitude; from 0.30 to 0.49, of moderate magnitude; and those greater than or equal to 0.50, of strong magnitude (18) . The level of significance adopted was 5%. The statistical software Statistical Analysis Software® (SAS) version 9.4 was used in all analyses.

RESULTS
A total of 170 nursing professionals were invited to participate in the research, 85 nurses and 85 nursing technicians. Among the participants, some did not fill in the fields related to age and time in the function and in the unit. Table 1 shows the data that allows getting to know a more detailed profile of the participants.
The correlation between the SAQ dimensions of Safety Climate and Satisfaction at work and the technicians' perception of the exercise of leadership by nurses is shown in Table 3. Table 2 shows the assessment of the nurses' selfperception regarding the exercise of their leadership, the assessment of the technicians' perception regarding the leadership exercised by the nurse, as well as the comparison between these assessments considering the pairing of nurses and technicians. It is possible to notice, in this table, that in the dimensions Communication, Providing and receiving feedback, Empowering and exerting influence, eight participants were excluded from the analysis. In the dimension Supporting the team to achieve organizational results, 11 participants were excluded due to missing.  In the Table 3, it is possible to observe significant, positive and moderate correlations between Safety climate and Providing and receiving feedback (r = 0.39; p = 0.0002); Empowering and exerting influence (r = 0.47; p < 0.0001), and Supporting the team to achieve organizational results (r = 0.37; p = 0.0009). Positive and moderate magnitude correlations were also presented between Job satisfaction and Empowering and exercising influence (r = 0.39; p = 0.0003), Supporting the team to achieve organizational results (r = 0.31; p = 0.0052).

DISCUSSION
The latest report by the all-party parliamentary group on global health, Triple Impact of Nursing, demonstrated that nursing needs qualified leaders who encourage their teams to work their full potential (19) .
On the grounds of this, the coaching tool stands out as an important model of qualified leadership, contributing to the development of both clinical practice and people management. As a result, the assessment of the dimensions of the coaching process is increasingly necessary for the innovative direction of health organizations (3,(12)(13) .
In this study, the comparison of nurses' and nursing technicians' perceptions as for the exercise of coaching leadership allowed observing that nurses had a better perception of their own performance of leadership than the technicians about the leadership exercised by the nurse, in all dimensions; and in three of them (Providing and receiving feedback, Empowering and exerting influence, and Supporting the team to achieve organizational results), this difference was significant.
Researchers found results similar to those of the present study, in which nurses' self-assessment reached higher means in the dimensions Providing and receiving feedback, Empowering and exercising influence, and Supporting the team to achieve organizational results, when compared to the perception of nursing technicians and assistants (13) . This fact reinforces that the technicians evaluated that they are not receiving periodic monitoring of their performance, or noticing influence on the development of their skills and support in solving difficulties, differently from the way nurses assessed their own performance of leadership (16,20) .
Studies have shown a positive relationship between feedback and increase in the safety culture in the health care environment, improvement in the quality of care, development of the professionals' technical skills, reduction of the followers' emotional exhaustion, and less likelihood of professionals leaving their jobs. Therefore, feedback is an important dimension that can contribute to positive results for patients, professionals, and institutions; thus, it shall be valued and effectively implemented (21)(22) .
Regarding the dimension Empowering and exerting influence, the results of this study showed that nurses need to review their perception regarding power sharing. Empowering and receiving influence is related to the followers' participation in the management and to the sharing of responsibilities to achieve more favorable results (16) . The nurse's performance becomes more significant for the team when the decisions are taken together (13) , because in this way, the followers feel more valued and, consequently, more satisfied and motivated for the work development (23) .
Regarding the dimension Supporting the team to achieve organizational results, as reported by other authors (13) , it could be noticed that nurses still need to improve their ability to encourage and support teams, aiming at reaching goals for an open and trustful relationship to be established in the workplace.
Regarding Communication, it is noteworthy that this dimension was the one obtaining the highest means among professionals, with no significant differences between groups being evidenced. This result is positive, as effective communication contributes to reducing stress, promoting the team's well-being, and improving workers' quality of life (3) , as well as improving patient safety (24) .
Another important aspect of this research was the assessment of the relationship between the perception of nursing technicians about the leadership exercised by nurses and the perception of Safety climate. It could be noticed that the more aspects of the coaching dimensions are exercised and, thus, perceived by nursing technicians, the better is also the safety climate permeating patient care.
Other studies have evaluated the influence of different leadership models on the safety climate (25)(26) and revealed that the leadership exercised by nurses is essential to provide high quality care to the patient (7,23,27) and to ensure favorable organizational results (7) .
When relating the perception of the technicians regarding the leadership exercised by the nurse and the variable Job satisfaction, it was also observed that the more the nurse implements the dimensions of coaching leadership, the more the professionals will be satisfied with their jobs. Corroborating these findings, it was found that other researchers also found that inspiration, motivation (3,13) , mutual trust, continuous interaction between leaders and followers, and the search for professional and personal development are essential for the professionals' satisfaction (3) .
Another study revealed that the leadership model can influence the strengthening of the workplace, which, in its turn, increases the nurses' job satisfaction and decreases the frequency of adverse outcomes for patients (28) .
Scholars point out that when the nurse maintains a closer relationship with the team, supporting it to achieve organizational results, valuing effective communication, providing feedback and exercising a positive influence, better results are achieved (29)(30) .
The nurses in the present study were not trained for coaching leadership. Considering that this model allows professional development, it is recommended that the theme be addressed since the undergraduate course, as nursing, a dynamic and challenging profession, requires leaders to involve and inspire their followers.
In the current health environment, identifying and developing leaders is one of the greatest challenges faced by managers, because, to achieve better results, the nursing needs increasingly qualified professionals. Therefore, this study can be considered an important means to stimulate the practice of coaching Leadership. Furthermore, the study provides information that can help institutions to realize that qualified leadership based on effective communication, feedback, influence and support is a tool of critical importance in the search for job satisfaction and the quality of care provided to the patient.
As a limitation of the study, it is highlighted that the analysis of the comparison of the perceptions of the nursing team took place in one setting, therefore, characterizing the perceptions of a specific population. In addition, when considering the exclusion criteria, the total number of participants ended up not reaching the sample size calculated initially. Therefore, further studies on the theme are required to enhance knowledge, as well as the nurses' awareness of their leadership practice.

CONCLUSION
The nurses' self-perception regarding the exercise of their leadership was more positive than the technicians' assessment of the exercise of leadership by the nurse, especially in the dimensions Providing and receiving feedback, Empowering and exerting influence, and Supporting the team to reach the organizational results. The more the nurse exercises the dimensions of Coaching Leadership and, consequently, this is perceived by the team, the better the safety climate and the team's job satisfaction.