Coaching Leadership in the context of the Mobile Emergency Care Service

3 Universidade de São Paulo, Escola de Enfermagem de Ribeirão Preto, Programa de Pós-Graduação em Enfermagem Fundamental, Ribeirão Preto, SP, Brazil. ABSTRACT Objective: To analyze the Coaching Leadership exercised by nursing coordinators in the Mobile Emergency Care Service units, in the coordinators and nursing technicians’ perception, in addition to its correlation with three sociodemographic variables. Method: Descriptive and analytical study carried out on nursing coordinators and nursing technicians from the pre-hospital care units, using the Coaching Leadership questionnaires and the Spearman correlation test to analyze the results. Results: 11 nursing coordinators and 155 nursing technicians participated in the study. The Coaching Leadership exercise was observed in the perception of two professional categories: “giving and receiving feedback”, which was the domain with the highest average for the coordinators (21.45; SD=2.84); and “communication” (20.43; SD=5.57) for technicians. Furthermore, in the coordinators’ self-perception of the Coaching Leadership, there was an indirect correlation between the domains “giving and receiving feedback” (Spearman -0.720; p-value 0.012) and “total scale score” (Spearman -0.652 and p-value 0.029) with regard to “training time”. Conclusion: The research results indicate significant contributions to nursing practices and denote this competence impact on the pre-hospital care nursing staff, in the work environment, and in the care provided to the patient.


INTRODUCTION
The changes arising from the labor market in the health field, increasingly competitive and characterized by the adoption of new management models, require from the professionals the training to take on different tasks and exercise some skills. Giving this scenario, it is essential for nurses to use leadership, in order to promote nursing actions aimed at the quality of care and, therefore, patient safety (1) .
It is through and from the use of leadership that nurses guide their work process and lead their team to reach common goals (2)(3) . In addition, the nurse's leadership promotes the quality of nursing care to the extent that it inspires and motivates the team to accept innovative and transformative practices (4) . Therefore, it is important for nurses that this competence is based on theoretical references or on models, especially those that are more contemporary, in order to impact the results related to the nursing team (job satisfaction and empowerment) and patients (patient safety) (1,5) .
Thus, new leadership models and theories have been adopted by health organizations, more specifically by nursing teams, among which the Coaching Leadership stands out (6) . Such a leadership model allows leaders to strive to support the team in obtaining results, while boosting talent, developing other skills and stimulating potential (7) . Thus, conceptually, this leadership model is based on the coaching process, through which the coach (leader) directly accompanies and influences the team to achieve the goals, concomitantly with the development of skills, knowledge, and the followers' attitudes (2,(5)(6)(7) .
Hence, in view of the countless contexts in which nurses can exercise leadership, it is important to highlight the urgency and emergency, as these environments need quick responses from professionals and assertive decision-making. Since it is a competence, that is, a set of knowledge, skills, and attitudes (2) necessary for the nurses' practice in the context of the emergency, these professionals must remain up to date and consider skills of communication, negotiation, autonomy, creativity, and appreciation of team members for their effective mobilization (3) .
Corroborating this analysis, an integrative review conducted in 2014 points out that from the dynamism of work in urgent care, leadership becomes a basic competence, from which the teamwork synchrony, quality service, minimization of medical and nursing errors is obtained, providing better results for the patient. In this same research, the value of the nurse's leadership in the context of the Mobile Emergency Care Service (SAMU -Serviço de Atendimento Móvel de Urgência) is emphasized, since this competence allows the professional to promote both direct care to the patient and the local and team management. Thus, integrating group members for safe and quality care (4) .
It should be noted that the studies already produced in nursing, about leadership in the context of urgency and emergency, focused on the hospital scenario. Therefore, this research is justified by analyzing the Coaching Leadership model in nursing in a not explored context: mobile pre-hospital care. It is expected that the results of the work will foster discussion spaces among managers, nursing coordinators, and professionals from SAMU units, regarding the leadership conditioning factors for the development of nursing in this context (1,(4)(5) . For this purpose, it was decided that the research should be based on new contemporary leadership models, such as Coaching Leadership (1) . Based on the context described and this new leadership model, the present study aimed to analyze the Coaching Leadership exercised by the nursing coordinators in the units of the Mobile Emergency Care Service, in the coordinators and nursing technicians' perception, in addition to its correlation to three sociodemographic variables; in order to answer the following questions: "What is the nursing coordinators' perception about their practice of Coaching Leadership and the nursing technicians' perception about the practice of this leadership, exercised by SAMU nursing coordinators?"; and "Is there a correlation between the dimensions of Coaching Leadership and the quantitative sociodemographic variables: age, training time, and time in the unit?"

Study deSign
Descriptive and analytical study.

PoPulation
The study sought to analyze the Coaching Leadership practiced by nursing coordinators, both in the coordinators' self-perception and in that of nursing technicians, from eleven units of SAMU in the state of Goiás, and its correlation with quantitative sociodemographic variables: age, training time and time in the unit.
The total population comprises 221 workers, of which 210 were nursing technicians and eleven were nursing coordinators who worked in eleven of the twelve headquarters units of the SAMU macro-regions. It is noteworthy that one of the headquarters units, of the macro-regions covered by SAMU, did not allow the research to be carried out. In addition, the other professionals working in these organizations (nurses from the advanced support units, physicians, radio operators, administrative staff ) did not correspond to the population to be analyzed.

Selection criteria
This is an intentional sample and not probabilistic, as it was expected that all professionals in the categories under analysis would participate in the research. Thus, for the selection of individuals participating in the research, coordinators and nursing technicians who were working during the data collection period and who consented to participate in the research were included, through signing the Informed Consent Form (ICF).

data collection
One used an instrument to characterize the subjects and sociodemographic data and, for the data obtained regarding the Coaching Leadership, part of the following instruments was adopted: Nurse Self-Perception Questionnaire in the Exercise of Leadership (QUAPEEL), for the nursing coordinators which, in this study, presented a Cronbach's Alpha of 0.9376; and the Nursing Technician/Assistant Perception Questionnaire in Leadership Exercise (QUEPTAEEL) to analyze the perception of the Coaching Leadership by nursing technicians (7) , with a Cronbach's Alpha of 0.9664.
These two questionnaires include 20 items subdivided into four domains corresponding to the Coaching Leadership: "communication" -the process of interpreting and sharing messages sent and received, in order to establish the interaction between leaders and followers (items 1 to 5); "giving and receiving feedback" -related to the exchange of information about the performance of leaders and followers (items 6 to 10); "giving power and exerting influence" -denotes that the leader, in a natural and spontaneous way, is able to decentralize his activities, giving the followers the power to make decisions (items 11 to 15); and "supporting the team to achieve organizational results" -represents the support of the leader towards their team, in an articulated manner among individual expectations with organizational goals and objectives (items 16 to 20). Arranged on a Likert scale, each question presents answer items ranging from "never" to "always". The score of the general instrument ranges from 0 to 100, with values closer to 0 corresponding to the lower perception of the Coaching Leadership practice and 100 to the greater perception of that practice. It is important to mention that the two questionnaires have the same four dimensions, however with the questions directed to the target population; and they were elaborated and validated in Brazil, with Cronbach's alpha values of the self-perception instrument of 0.911 and 0.932 of the nursing technicians/assistants perception (7) .
One of the researchers, on dates and times previously scheduled, was responsible for delivering and applying the questionnaires to the subjects who consented to participate in the research. The collection took place between the months of April and August 2017.

data analySiS and management
The data collected were double typed in spreadsheets and, subsequently, the descriptive statistics and correlation analyzes of the variables were performed, using, for this purpose, the statistical software SAS® 9.3 (Statistical Analysis System).
The exploratory data evaluation was performed using measures of central position and dispersion so that the qualitative variables were described by means of absolute and relative frequencies and the quantitative ones demonstrated by means, medians, standard deviations, minimum values, and maximum values. To analyze the association between the Coaching Leadership domains and sociodemographic variables (age, training time, and service time at the unit) one used Spearman's non-parametric statistical test and, for all statistical tests performed, the level of significance of 5% (α = 0.05) was adopted.

RESULTS
From a population of 221 individual, at the end of data collection, a percentage of 75.11% (n=166) of research participants was obtained: eleven nursing coordinators and 155 technicians. In the SAMU units from the state of Goiás, it was found that both coordinators and nursing technicians were predominantly: female (n=103; 62.05%) and had State employment bond (n=100; 60,24%).
The majority of nursing coordinators (n=10; 90.91%) were specialized and worked eight hours a day (n=10; 90.91%). In addition, they presented the following means: 38 years old (SD=7.09), 10.45 years of training since graduation date (SD=3.7), and 4.73 years of employment in the unit (SD=2.8).
On the other hand, in relation to nursing technicians: less than half had a complementary course to their training (n=68; 43.87%); the largest portion fulfilled a 12-hour scale, with 60 hours of rest (n=114; 73.55%) and; had a mean of 39.87 years of age (SD=8.17), 13.33 years since vocational training (SD=6.2) and 6.55 years of experience in their respective units (SD=3.63).
Tables 1 and 2 correspond to the distribution of the coordinators measures scores' self-perception and the nursing technicians' perception, respectively, about the practice of Coaching Leadership exercised by SAMU's nursing coordinators.   Tables 1 and 2 show that, both in the nursing coordinators' self-perception and in the technical level professionals' perception, the nursing coordinators exercise of the Coaching Leadership was perceived, as in the evaluations of the two categories of professionals, the means of the two scales are closer to 100 than zero (80.91 and 70.97).
It should be noted that in the coordinators' self-perception of the Coaching Leadership practice, the dimension "giving and receiving feedback" had the highest mean and highest score among the interviewed subjects, followed by the "communication" domain (Table 1). On the other hand, in the nursing technicians' perception, there was an inversion in the order of the two dimensions with the highest means: the "communication" domain, in both the maximum score value was 25 (Table 2).
Another highlight of these two tables is that the perception of the Coaching Leadership practice was better evaluated in the self-perception of the coordinators than of the nursing technicians, a fact denoted by the means of the total scales scores. In sequence, Tables 3 and 4 show Spearman' s correlation coefficients and p-value between the dimensions of the Coaching Leadership practice, both in the nursing coordinators' self-perception and in the SAMU nursing technicians' perception, with quantitative sociodemographic variables: age, training time, and service time at the unit. The values of Spearman' s coefficients are presented in the first line, while the p-values of this test are found in the second.
From Table 3, a statistically significant indirect correlation was observed between the domain "giving and receiving feedback" and "training time", which demonstrates that the shorter the training time, the greater the nursing coordinator's self-perception about the practice of giving and receiving performance information. There was also an inverse relationship between the "total scale score" of the Coaching Leadership and the variable "training time", thus denoting that the shorter the training time, the greater the nursing coordinator's self-perception of their Coaching Leadership practice.
In Table 4, according to the nursing technicians' perception, there was no statistically relevant correlation between the four domains of the Coaching Leadership practice, with the three sociodemographic variables analyzed.

DISCUSSION
The result of this study identified, through the total scores of the QUAPEEL and QUEPTAEEL questionnaires, the exercise of the Coaching Leadership model perceived by the two categories of actors involved in the research, that is, coordinators and nursing technicians. The leadership must base the nurses' practice in order to influence the team to provide nursing care that meets the expectations of patients and families (4) .
Thus, the self-perception of nursing coordinators, regarding the practice of Coaching Leadership, was high, that is, closer to the maximum score of the questionnaire. The dimension "giving and receiving feedback" presented a higher mean and score among the interviewed subjects, similar to the studies (5,7) that used the same instruments for data collection, however in the hospital context. For nursing technicians, this domain comprised the second-highest mean, totaling 17.72. Similarly, a survey carried out in 2011 (6) showed that 30.6% of respondent nurses chose the alternative "giving and receiving feedback" as essential for the nurse -coach. Similar to the work developed in the countryside of São Paulo state, in which 21.4% of the nurses questioned highlighted the dimension "I ask for feedback on how my attitudes affect the performance of others" as important in the practice of their leadership (8) .
In this regard, it is pertinent to consider that daily challenges are presented to leading nurses in their work practice, such as the difficulty in giving and receiving feedback, the insecurity, and the lack of empathy peculiar to superficial relationships. Therefore, in order to overcome such barriers, it is necessary the leading nurse's effort and commitment to developing their leadership capacity through study, promoting moments of feedback with the group, and reflections on their practices (9) . For that matter, it is necessary to value opportunities to clarify and receive feedback, especially with regard to goals and personal and other individuals' expectations (10) , considering that the inability regarding this fundamental competence can compromise the work process and the leadership of nurse coordinators (11) .
The feedback comprises a unique skill for the leader coach, because as the employees of an organization strive to achieve the goals, later they need to know how they are developing their actions, in order to identify successes and points that can be improved. The reverse is also fundamental, since the leader can benefit from the feedback of their collaborators and, based on information from his coachees, analyze the effectiveness of the leadership and, if necessary, review the procedures and processes used (12) .
In addition to this, it is possible to infer that the nurses' perception, about creating opportunities to give and receive feedback in the practice of leadership, is an essential skill for the exercise of Coaching Leadership. Therefore, it appears that feedback allows the leader to expand and improve his self-perception, in addition to contributing to the learning of all those involved (7) .
The "communication" domain obtained the highest mean regarding the other dimensions of the Coaching Leadership practice, in the nursing technicians' perception, and represented the second-highest mean among nurses, with maximum score values of 25 and 24, respectively. Corroborating these findings, it is worth mentioning the result of the study, through which nursing technicians and assistants identified this competence as a weakness to be overcome, with regard to the leadership exercised by nurses (13) .
In line with the above, the study identified that some obstacles are overcome, depending on the strategies used to improve communication, which, in turn, must be clear, sincere, and responsible. Still, the authors of the same work pointed out that the nurse-leaders manage conflicts in the team, through communicative competence (14) .
Given this perspective, it is worth emphasizing that communication is the main component of leadership since it can influence the behavior and performance of the followers in reaching the established goals (15) . In addition, the relevance of communication is highlighted as a work tool in the managerial exercise of nurses, considering that this professional plays an articulating and intercessory role in professional activities related to the care of human beings -both in the context of the organization of health work, as of nursing -thus, being a fundamental competence in the Coaching Leadership model (16) . In this context, interpersonal communication, when open and guided by dialogue with the nursing team, as described in democratic leadership styles (17) , becomes a fundamental element in leadership, as it helps in the development of teamwork (8) .
Findings from an article on nursing leadership in the context of urgency and emergency identified that nurses need to stimulate communication processes, as well as make assertive decisions (18) . In accordance with this finding, the research developed at SAMU in the countryside of São Paulo state, through which 20 nursing assistants interviewed pointed out the difficulty of communication with professionals who occupy leadership positions (general and nursing coordinator), mainly regarding accessibility, due to the fact these professionals are not present in the unit during all shifts (19) .
Although the mean scores in the categories "empowering and exerting influence" and "supporting the team to achieve results" were the lowest -both in the nursing coordinators' self-perception and in the nursing technicians' perspective -these are aspects that should be analyzed in the nurses' exercise of Coaching Leadership.
"Giving power and exerting influence" includes faces of the power interaction that the leader exercises over their followers. Accordingly, it is pertinent to say that this Coaching Leadership domain comprises the empowerment of the followers and, as such, this process corresponds to the meaning of empowering, developing, enabling and/or decentralizing power (20) . When the use of power occurs in a natural, spontaneous, and shared way, there is recognition of the bond and respect between leaders and followers (6) . In addition, the aforementioned empowerment occurs from the moment the leader shares their vision, stimulating learning and creativity, thus allowing the followers to have space to demonstrate the best of themselves and their talents (20) . The followers empower themselves and strengthen their relationship with the leader coach from the moment that they share power and provide more responsibility and autonomy for the follower (21) . Additionally, the work on the coaching process points out that the results obtained in organizations must be based on mutual commitment, based on the division of responsibilities by the leader coach (22) .
In this perspective, it is worth mentioning that the domain "enable others to act", related to the five transformational leadership practices present at work (8) , presented the highest mean and median in comparison to the other four practices: "prepare the path", "inspire a shared vision", "challenge the process" and "encourage the heart". Based on this result, it is concluded that training others to act enables individuals to collaborate, through trust and encouragement, to a vision focused on the future, as well as enabling people's empowerment through self-determination and skills development (21) . Given this, the empowerment of nurses and their staff, therefore, is essential for nursing practice, and organizations should invest in this process (23) , in order to ensure a safer work environment and with better results for the nursing team (24) .
Meta-analysis data showed that there is an increasing number of studies in which empowered leaders influenced the results obtained through their followers, both in individual and organizational perspectives (25) . Similarly, the results of an integrative review highlighted that this empowerment intermediated the relationship between leadership and job satisfaction of nursing professionals (1) . In the co-management model, giving and exerting influence are characteristics of the work organization aimed at nursing professionals, as well as other areas that are involved in most decision-making (26) .
With regard to the category "support to the team to achieve results", it is important to emphasize that in the coaching process, the coach must be able to minimize the barriers related to the development and the creation of a supportive atmosphere in their team, in a way to stimulate the best performance of the members of that group. To this end, it is crucial that the leader: offer the help and assistance needed when requested; encourage people with enthusiasm and; recognize the value of each contribution of the individuals that make up the team (21) .
Such aspects, regarding the supportive environment, were evidenced in a study in which 40.5% of the interviewed nurses stated that they showed support and recognition to the team members for their contributions (8) . Another study pointed out that team support is like a fortitude of leadership, and it must happen through the exchange of experiences, unity, cooperation, and partnerships, leading to joint construction and maturing in the work team quality (27) . Finally, a research carried out with the nursing team pointed out that the "supportive environment" was identified as a weakness in the leadership exercised by nurses, from the nursing technicians and assistants' perspective (13) .
In this context, it is pertinent to emphasize that to improve the team's effectiveness, performance, and the overall excellence of the organization, it is necessary to promote the support of the team and invest in leadership based on coaching (28) . Another important result is that, in the perception of the Coaching Leadership practice, it was better evaluated in the coordinators' self-perception than in that of the nursing technicians, a fact observed from the means of the total scale score. From this perspective, it is worth highlighting works (5,13) through which higher means were observed in nurses' self-perception when compared to the perception of an observer, such as technicians. According to one of the studies, this happens because nurses are more aware of their influence on their collaborators (5) . The other research points to the importance of communication as an element that the followers have a greater dimension of this competence practice (13) .
When observing the correlations between the practice of Coaching Leadership and the sociodemographic variables under analysis, there is a similarity to the findings of the research developed with the instrument Leadership Inventory Practice. This study evidenced the negative correlation between one of the leadership practices "encourage the heart" (showing appreciation and using strategies to motivate the followers positively) and the variable "time working in assistance", as well as a negative relationship between the same practice and the variable "time of employment bond". Thus, according to the aforementioned study, the longer the assistance time and also the longer the employment bond, the less the practice of "encourage the heart" by nurses (8) . For the technicians' perception, present in Table  4, the sociodemographic factors analyzed did not correlate with the Coaching Leadership domains.
The participation of all SAMU units' nursing technicians was not possible due to the shift change of some of these professionals, a fact that represented a limitation to the present study. In view of the results, the relevance of leadership for the nursing team was demonstrated, especially for those working in the context of SAMU. In addition, the present research contributes so that the nurse in the coordination position can analyze their leadership practice. Based on the dimensions of Coaching Leadership, this professional should look at the aspects of this competence that need to be improved.
Thus, it is worth recalling that leadership makes it possible to promote a positive and favorable work environment for professional practices (1,4) . It also influences directly and indirectly the results of nursing care (5) .

CONCLUSION
The present study, carried out in the SAMU units in the state of Goias, showed that the coordinators of these units exercise the practice of Coaching Leadership, both in the self-perception of the coordinators and in the perception of SAMU nursing technicians, although the mean value of the "Total scale score" for this last category of professionals is lower compared to the coordinators' self-perception. In addition, the data indicate a statistically significant indirect correlation between the "Giving and receiving feedback" domain and training time.
Finally, bearing in mind the domains present in the Coaching Leadership framework adopted in the research, it appears that the nurse-leader, when adopting effective communication, providing moments to give and receive feedback, promotes the empowerment of professionals, through sharing power and supporting the team to achieve the objectives.