A mixed methods pilot study of an internal coaching program within an academic emergency department

Abstract

Background

Over 60% of emergency medicine physicians experience burnout. Professional coaching of physicians may reduce emotional exhaustion and burnout, while improving quality of life and resilience; however, few studies have specifically investigated coaching’s impact on job satisfaction and burnout of emergency physicians. This study assesses the effects of a novel coaching program, which utilized internal professional coaches, on burnout and job satisfaction among emergency physicians in an academic emergency department.

Methods

In January 2022, an internal coaching program commenced for upper-level residents, fellows, and new faculty physicians. Participants engaged in individual coaching sessions, and group coaching sessions (n = 4) were offered to the entire department on a variety of topics (e.g., Leadership, Bedside Teaching). Quantitative data were collected to measure baseline and follow-up burnout and job satisfaction scores via the 2-Question Summative Score of Maslach Burnout Inventory [MBI] and Global Job Satisfaction [GJS] scales, respectively. Qualitative data gathered through surveys were inductively coded, leading to the identification of experiential themes.

Results

Thirty-two participants enrolled in individual coaching. Eighty-nine individual coaching sessions were delivered, totaling 69.34 h. Participants received a median of 2 (range:1–6) sessions. Department-wide baseline and follow-up survey response rates were 33.7% and 32.7%, respectively. Among all respondents, burnout symptoms did not change significantly (MBI: t(55) = 2.00, p = 0.15), but job satisfaction declined significantly, with mean GJS scores decreasing from 3.73 (SD = 0.70, 95% CI: 3.49–3.98) to 3.15 (SD = 0.91, 95% CI: 2.82–3.47). When analyzed by coaching participation, no significant differences were found in MBI (t(12) = 2.18, p = 0.71) or GJS (t(10) = 2.23, p = 0.75) scores between participants and non-participants. Thematic analysis highlighted benefits and challenges of the internal coaching program. Identified themes reinforced coaching best practices (e.g., solutions-focused sessions), provided context for future efforts (e.g., maintaining diverse perspectives), and highlighted advantages and disadvantages of internal coaches (e.g., familiarity versus privacy).

Conclusion

Our pilot study did not demonstrate a reduction in burnout or an increase in job satisfaction. However, internal coaching offers valuable opportunities for academic emergency departments, including unique benefits and challenges. Future research should explore system-level impacts on burnout and job satisfaction during coaching program implementation as well as cost-effectiveness.

Introduction

Coaching has been leveraged in many fields to improve personal and professional growth. Using individual or group coaching formats, participants are guided to utilize their own skills and knowledge to develop solutions to existing challenges. Medicine has become increasingly interested in the application of coaching to the development of physicians [1,2,3], in particular addressing wellness [4]. Physician wellness is critical for retention, self-care, and team morale, as well as patient safety and quality of care. This is particularly salient given recent data suggesting that one-third of academic physicians are considering leaving their institution within two years [5].

Physician wellness is influenced by both burnout and job satisfaction, which are inversely related [6]. Burnout is recognized by the International Classification of Diseases (ICD-11) as an occupational syndrome, distinct from a medical condition or lack of individual resilience [7]. It is often preceded by moral injury, a form of distress experienced when systemic barriers hinder physicians from delivering optimal patient care [8, 9]. Emergency medicine (EM) physicians experience burnout at rates exceeding 60%, and frontline providers, including EM physicians, report the highest levels of burnout [10, 11].

Although burnout stems primarily from systemic factors, evidence suggests that professional coaching can reduce symptoms of burnout and improve job satisfaction. Specifically, coaching interventions have been shown to reduce emotional exhaustion and burnout, while enhancing resilience and quality of life among primary care physicians [12]. A recent novel approach utilizing a virtual coaching format for women physicians demonstrated significant improvement in rates of burnout, professional fulfillment, and self-valuation [13]. Coaching programs for physicians have typically used external professional coaches [12, 14] or internal peer coaching within hospitals [15, 16] to reduce burnout and improve well-being. A recent randomized trial showed that three months of internal peer coaching significantly reduced burnout and increased professional fulfillment [16]. Internal coaching, an organization-supported model where a trained colleague coaches a peer for personal or professional growth [17], offers potential advantages over external coaching: stronger relationships, deeper organizational knowledge, greater accessibility, and lower cost. However, it also presents challenges, including perceived lower credibility and concerns about confidentiality and neutrality [17, 18].

The purpose of this pilot study was to assess the effect of a novel coaching program, utilizing internal, professionally trained coaches for both individual and group coaching on burnout and job satisfaction among academic EM physicians, including residents, fellows, and clinical faculty.

Methods

Program description

Between October 2020 and March 2021, 7 EM department members (6 faculty physicians and 1 faculty administrator) completed training and certification as professional coaches. Training included didactics on foundational concepts of professional coaching and required practical coaching experience and feedback. Training and certification were provided by Transformation Edge Coaching & Consulting (Raleigh, NC) under the approval of the International Coaching Federation (Lexington, KY). Throughout the program, supervision meetings were held between the external consulting coaches and internal coaches to debrief coaching sessions and develop plans for program improvement. The cost of training and certifying coaches, implementing the program, and ongoing professional supervision through the first year was approximately $125,000 USD. In addition, each faculty coach was provided salary support of approximately 6.6% of full-time equivalent. The program was promoted through departmental emails and in-person presentations delivered by the lead coach during residency conferences and faculty meetings.

Coaches were trained using the well-known GROW coaching framework: Grow, Reality, Options, Will [19]. Under this model, coaches guided conversations through example core questions such as: “What are your goals? What is the current reality? What are your options? and What will you do?” By incorporating goal setting, asking powerful questions, and practicing active listening, coaches aimed to help participants clarify their own insights and achieve meaningful breakthroughs.

Coaching session format

Individual coaching sessions were available to all senior residents, fellows, and junior clinical faculty. Efforts were made to increase engagement among junior faculty, including those within 2 years of initial employment or who were transitioning to leadership roles. Participants were given the option to select their coach; otherwise, coaches were matched with participants based on the lead coach’s assessment of the best fit, with the understanding that either party could request a change to achieve better alignment. Coaching meetings were scheduled based on the preferences of both the coach and the participant, typically initiated by an email prompt from the coach. Individual sessions were completed one-on-one, either in person, virtually, or by phone. We offered 4 initial sessions plus follow-up sessions at 9- and 12-months. Four group coaching sessions, available to the entire department, were conducted over 12 months on the following topics: Leadership, Niche Development, Bedside Teaching, and Burnout/Moral Injury. These topics were selected by consensus of the trained coaches due to their saliency and growth in academic emergency medicine. Participation in individual and group coaching activities was voluntary. The program was structured to maintain confidentiality with content being protected from department leadership.

Survey development

A composite survey was developed for this study to characterize the EM physician population (e.g., demographics, prior coaching experience) based on prior validated instruments assessing burnout [20] and job satisfaction [21]. Demographic characteristics and prior experience with coaching activities were assessed using closed-ended questions. Burnout was measured using the two-question summative score of the Maslach Burnout Inventory – Human Services Survey (MBI). With a sum ranging from 0 to 12, total MBI scores > 3 met criteria for burnout [20]. Job satisfaction was measured using the five-question Global Job Satisfaction (GJS) subscale of the Physician Worklife Survey [21]. Responses to each of the 5 questions appearing in GJS were averaged for each respondent. The range of possible averaged scores was 1 to 5. The follow-up survey contained additional closed- and open-ended questions to assess participant engagement in and experience with the coaching program. An additional survey was developed to assess the participant experience after each group coaching session.

Survey distribution

The composite baseline survey link was sent via department email on January 17 th, 2022, and contained 24 closed-ended questions; responses were collected between January and March 2022. The composite follow-up survey link was sent via department email on April 19 th, 2023, and contained 38 items, including several skip-logic questions dependent on coaching program participation; responses were collected between April and July 2023 (Fig. 1).

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The group coaching session survey contained 1 Likert scale question assessing perceived benefit to professional development and 5 open-ended questions assessing opinions regarding the content and utility of the session. Each session’s participants received the same set of questions after each group coaching session.

All surveys were distributed through Qualtrics XM (Provo, UT) by a non-clinical research team member with no involvement in the design or implementation of the coaching program. We obtained informed consent from all survey respondents and obtained appropriate licensure to utilize aspects of the MBI (Copyright ©1981 Christina Maslach & Susan E. Jackson).

Participants

Respondents were eligible to participate in the baseline and follow-up survey if they were clinical faculty, fellows, or residents in the department during any part of the coaching program implementation. Participants were included in the baseline survey even if they did not intend to partake in any coaching activities. Similarly, participants who did not partake in the baseline survey or any coaching activities were included in the follow-up survey. Exclusion criteria included EM faculty without clinical responsibilities (e.g., research faculty), staff, students, and direct participation in this publication.

Clinical faculty, fellows, and residents not involved in this publication's development were eligible to participate in any group coaching survey for sessions they attended. The exclusion criteria were applied.

Data analysis

Quantitative baseline, follow-up, and group session survey data were analyzed using descriptive and inferential statistics as appropriate in Excel version 2310 (Microsoft Corporation, Redmond, WA). Before review by the coaching leadership team, personally identifiable data were removed from survey responses by a non-clinical research team member who was not involved in the coaching program design or delivery.

Qualitative follow-up and group session survey data were analyzed using thematic analysis. A six-step approach was taken to inductively identify themes as described by Kiger & Varpio [15, 22]: 1. Data familiarization through in-depth review; 2. Development of initial codes across responses; 3. Searching data for themes; 4. Reviewing themes; 5. Applying definitions to themes; and 6. Final reporting of themes. Two team members independently reviewed qualitative survey responses to develop initial codes. The team members again independently reviewed the data to identify potential themes. Codes and themes were then cross-compared, and a final set of themes was developed and defined. Final themes and their associated data were reviewed by all 4 team members to ensure consensus in data interpretation.

Ethics

This research was approved by the department’s overseeing Institutional Review Board.

Results

Baseline survey

At the time of baseline survey initiation, there were 92 eligible members within the department. Thirty-one eligible individuals completed the survey (response rate [RR] = 33.7%). Most respondents were faculty (61.3%, n = 19), identified as White non-Hispanic (83.9%, n = 26), and identified as male (67.7%, n = 21) (Table 1). Of the 31 baseline survey respondents, 12 respondents (5 faculty, 7 residents/fellows) received individual coaching, and 7 respondents (5 faculty, 2 residents/fellows) received group coaching.

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Mean (standard deviation [SD], 95% Confidence Interval [95%CI]) MBI at baseline was 5.67 (SD = 1.92, 95%CI = 4.58–6.76) for residents and fellows, 5.58 (SD = 1.92, 95%CI = 4.71–6.44) for faculty, and 5.61 (SD = 1.89, 95%CI = 4.95–6.28) for the pooled sample (Table 2). Mean GJS at baseline was 3.73 (SD = 0.61, 95%CI = 3.39–4.08) for residents and fellows, 3.60 (SD = 0.77, 95%CI = 3.26–3.94) for faculty, and 3.73 (SD = 0.70, 95%CI = 3.49–3.98) for the pooled sample.

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Follow-up survey

At the time of the follow-up survey invitation, there were 92 eligible members within the department. Thirty eligible individuals completed the survey (RR = 32.7%). Most respondents were faculty (76.7%, n = 23) and White non-Hispanic (80.0%, n = 24). A majority identified as male (67.7%, n = 14) (Table 1). Of the 30 follow-up survey respondents, 11 (7 faculty, 4 residents/fellows) received individual coaching and 7 (7 faculty, 0 resident/fellows) received group coaching.

Mean MBI was 7.14 (SD = 3.67, 95% CI = 4.42–9.86) for residents and fellows, 6.22 (SD = 1.95, 95%CI = 5.42–7.02) for faculty, and 6.43 (SD = 2.42, 95%CI = 5.57–7.3) for the entire sample (Table 2). Mean GJS was 2.94 (SD = 1.11, 95%CI = 2.12–3.76) for residents and fellows, 3.21 (SD = 0.86, 95%CI = 2.86–3.56) for faculty, and 3.15 (SD = 0.91, 95%CI = 2.82–3.47) for the entire sample.

Change in burnout and job satisfaction

Physicians’ baseline and follow-up MBI and GJS scores were compared. Prior to performing analysis, the distributions of baseline and follow-up responses were assessed using quantile–quantile (QQ) plots; all QQ plots indicated data followed normal distributions. Given the normal distributions of MBI and GJS scores, two sample t-tests were used. Between the pre- and post-survey, there was no significant change in MBI (t(55) = 2.00, p = 0.15), but there was a significant change in GJS (t(55) = 2.00; p = 0.019) with a decline in mean GJS between pre- and post-coaching timeframes (3.73, SD = 0.70, 95%CI = 3.49–3.98 and 3.15, SD = 0.91, 95%CI = 2.82–3.47, respectively) across the department (Table 2).

Fifteen respondents completed both the baseline and follow-up surveys; this included 11 faculty, of whom 5 participated in the coaching program, and 4 residents/fellows, of whom 2 participated in the coaching program. Further analyses were performed for only this group of 15 respondents who completed both surveys. Comparing change in baseline and follow-up scores, there were no significant differences in either MBI (t(12) = 2.18, p = 0.71) or GJS (t(10) = 2.23, p = 0.75) between participants and non-participants (Table 3).

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Individual and group coaching sessions

Thirty-two participants enrolled in individual coaching. Eighty-nine individual coaching sessions were delivered, totaling 69.34 h. Participants received a median of 2 (range:1–6) sessions and a mean of 2.16 h of individual coaching.

Group coaching participant numbers ranged in size and follow-up survey RR. There was an average of 4 participants in each group session. Most participants attended 1 group session each, while 2 participants attended 2 sessions (Fig. 1). The participation numbers and survey RRs for each group session were as follows: Bedside Teaching (n = 4; RR = 100%), Niche Development (n = 3; RR = 0%), Leadership (n = 4; RR = 50%), and Burnout/Moral Injury (n = 5; RR = 20%).

Qualitative analysis

Qualitative analysis of survey responses yielded four themes (Table 4). These themes are described below.

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Personalization as benefit

Personalization in the context of coaching takes many forms. This coaching program was unique because it offered both individual and group sessions and allowed participants to choose how and how often they received coaching. This format benefited respondents, who found the variety offered distinct opportunities. For example, some participants enjoyed the comradery and team-based aspect of group coaching, while others appreciated individual coaching sessions to work on specific, personal challenges and solutions. In the words of one respondent, coaching “helped me focus on the things I need to work on in order to make work more satisfying.”

Diverse experiences as benefit

A frequently noted benefit of group coaching was sharing experiences among participants, which provided validation and normalization of challenges faced by EM physicians. However, respondents suggested that these benefits extended even further. Hearing others share methods for overcoming personal and professional challenges allowed participants to broaden their knowledge of solutions to similar personal obstacles. Overall, representation from a variety of career stages was beneficial to provide a diversity of experience.

Structured sessions

Respondents highlighted several key features of coaching as particular benefits. Participants preferred sessions which focused on the given topic, delivered as coach-guided conversations, and provided reference materials and visuals. Participants desired coaches to effectively manage time to achieve these aims. One criticism of group coaching sessions was the tendency to devolve into “complaining” rather than solutions-based work. Participants found value in coaches who could effectively refocus the group on problem solving. Finally, participants found sessions beneficial when tangible resources were provided or visual aids were utilized. These included simple practices such as documenting discussions on a whiteboard during group coaching or providing a summary email after a session.

Mixed effects of internalization

The final theme focused on the consequences of utilizing internal coaches. Some respondents were concerned by decreased objectivity and confidentiality, while others were concerned with internal hierarchy when more senior faculty provided coaching. These are valid concerns, given that professional coaches are intended to serve as neutral facilitators of an individual’s growth. Simultaneously, some participants found comfort in working with coaches familiar to them and who were respected within the department.

Discussion

During implementation of the coaching program, there was no significant change in our resident/fellow or attending physician symptoms of burnout, as measured by the two-question MBI. As defined, a score greater than 3 on the two-question MBI correlates with symptoms of burnout [20]. Although there was no change in our measure of burnout at baseline and follow-up, a median of 6 suggests that our EM physicians are experiencing ongoing symptoms of burnout.

Between the initial and follow-up surveys, there was a significant decline in job satisfaction at the department level, as measured using the five-question GJS subscale. However, when evaluating the change in job satisfaction among the coaching program participants and non-participants, there was no significant difference between these groups. These results suggest a potential decline in job satisfaction among the EM physician population within the department but do not imply an association between coaching program participation and decline in job satisfaction. Because coaching was delivered on a rolling basis, participants received coaching at varying times relative to survey completion (between 2–18 months, Fig. 1). This reflects the pragmatic nature of the program and was designed to accommodate physicians'busy and unpredictable schedules. However, prior research has shown that the impact of coaching may decline after six months [12] so our findings may reflect a known loss of benefit over time.

Additionally, department stressors likely contributed to burnout and job dissatisfaction. Given these findings, we reviewed both local and national challenges during our study period. Our department faced numerous operational changes, including newly assigned responsibilities such as a provider-in-triage model, care for long-stay patients, and increased behavioral health patient clearances. Like many EDs across the United States, we also experienced a return to pre-COVID patient volumes and a significant boarding crisis, prompting frequent operational changes [23]. Staffing shortages, COVID-related absences, and critical medication shortages further strained the system, mirroring national trends [24].

Coaching, in isolation, is not likely to influence sustained, overall symptoms of burnout or resilience [10]. Recent literature demonstrates that increased workloads, adverse events, and ED boarding/crowding decrease job and career satisfaction in EM physicians [25]. Results of our study suggest similar challenges, which may have contributed to our participants’ decreased job satisfaction. Moreover, the results illustrated in Table 2 suggest that this holds true for both faculty and residents, with perhaps an increased burden in the resident population. Known factors which contribute to career satisfaction originate primarily at the system level, with fewer factors originating at the individual level [25]. Reducing stress on providers by addressing system-level challenges (e.g., electronic health record documentation, staffing shortages, EM patient boarding) may be helpful [26]. Creating institutional provider wellness metrics, improving work conditions, supporting career development, and prioritizing provider self-care are all recommendations to prevent provider burnout [9]. Trends in department job satisfaction should be further monitored over time and within the context of system-wide changes. As recommended by the National Academies of Sciences, a coordinated effort across all levels of the health care system is needed to mitigate, and ideally eliminate, burnout among physicians [27].

While our quantitative analysis suggests limited effect from the coaching program regarding changes in burnout and job satisfaction, our qualitative analysis indicates several individual-level benefits that may not be seen in aggregate at the department level. The Personalization as Benefit theme confirmed that EM physicians find value in self-selecting their coaching engagement, as individuals hold unique communication and learning preferences. For example, individual coaching provides an environment in which conversation can focus exclusively on the participant, as opposed to the team-based approach of group coaching. However, connecting colleagues with diverse experiences via group coaching also provided growth opportunities, as indicated in the Diverse Experiences as Benefit theme. However, respondents also desired the presence of individuals at similar career stages in group coaching, presumably because of the validation, normalization, and comradery described by participants. These data indicate the distinct benefit of including individuals across the career spectrum in group coaching to promote both personal growth and validation of experience.

Professional coach training emphasizes that sessions must remain focused on a specific topic or goal and work toward solutions to challenges. Notably, survey respondents also highlighted this methodology and supported the coaching process under the Structured Sessions theme. Participants recognized when coaches used methods to improve their experience, including effective facilitation and sharing of reference materials. Although coaching participants highlighted many of the benefits of individual and group coaching activities, the Cost of Internalization theme added important nuance to the Personalization as Benefit theme, in which there may be a tradeoff of flexibility and comfort for objectivity and privacy when implementing internal coaches. However, it is worth noting that at least one prior study has suggested that participants may prefer coaches with relatable experiences, at least by EM residents [28]. Regardless, the themes identified from the qualitative data provide excellent guidelines for coaching program growth.

Overall, this pilot study is uniquely positioned among the professional coaching literature by its use of internal coaches, assessment of physicians in varying stages of professional development, and specific focus on job satisfaction and burnout within emergency medicine. In a recent systematic review of coaching in emergency medicine, 13 studies were identified, but most of these assessed nursing or educational settings [29]. No studies assessed the broader physician population and outcomes of our study. Yet, our study also supports several of the findings identified in the review, including concerns about role tensions for the clinician coaches.

With the lessons learned from this pilot study and further cycles of coaching conducted since completion of the surveys, we see a number of avenues for subsequent research. These include longitudinal surveys to assess the sustainability versus degradation of coaching impacts on individuals over time, especially after coaching concludes, as well as direct comparison of individual coaching versus group coaching outcomes and a qualitative investigation of the experience of internal coaches. A randomized trial could be considered once these additional analyses are complete, as they could inform the development of specific aims and methods. Based on positive feedback from our coaching program participants and supportive evidence from studies outside of emergency medicine, we strongly recommend offering professional coaching to individuals who express interest. However, it is essential to identify participants who are genuinely invested in the process, as the benefits of coaching are most often realized through thoughtful and intentional engagement. While our findings do not indicate a clear advantage of internal versus external coaches, our experience demonstrates that internal coaching is both feasible and effective within an academic emergency medicine setting. Departments should carefully evaluate the costs of training and compensating internal coaches compared to hiring external ones, recognizing that the most appropriate model may depend on the size of the department and anticipated participation. To increase engagement, future coaching programs should consider offering strategic incentives for participants, such as protected time or fulfillment of academic or professional requirements. Finally, although the overall number of participants was limited, we received overwhelmingly positive feedback on group coaching. Group coaching not only promotes engagement and comradery but also potentially offers a more cost-effective approach that should be considered in future iterations.

Limitations

First, the single-center nature of this study limits generalizability. Moreover, while this study appropriately selected surveying as the methodology based on criteria presented by Phillips [30], the possible relationship between participant nonresponses and the questions themselves introduces the potential for nonresponse bias [31]. Specifically, it is conceivable that some potential respondents chose to forego survey completion because of feelings of burnout or poor job satisfaction.

The overall response rates for the baseline and follow-up surveys were about one-third of eligible respondents. Of respondents, 15 individuals participated in both the baseline and follow-up surveys, and not all of these participated in coaching. Ideally, more eligible individuals would have participated in both surveys to provide a better understanding of the programmatic effect on physician wellness. Future studies should endeavor to increase baseline and follow-up survey response rates from the same individuals and follow trends over time. Also, while voluntary participation in the program introduces the possibility of selection bias, willing participation of both client and coach is foundational to professional coaching practice and as such was maintained. Thus, participants were not randomized to intervention or control groups, furthering the potential for participation bias.

In this study, MBI scores greater than 3 were used to identify burnout among EM physicians. Though this less restrictive cutoff and two-question assessment is highly correlated with the complete 22-item MBI instrument, this shortened tool is not a comprehensive assessment of burnout as suggested by Li-Sauerwine et al. [20] Given the high-intensity environment of EM and ongoing stress within the field as described by Bacher [24], a rapid assessment tool that reduces survey length and time investment is beneficial to this area of research. Regardless, using the summative 2 question score may have missed more subtle presentations of burnout which could be captured by the full MBI-HSS.

The qualitative theme Cost of Internalization highlighted legitimate concerns of an internal coaching program. While participants were given the option to select their coach, the majority did not specify a preference and were therefore paired with a coach a priori. In cases where the match may not have been ideal, participants may have been hesitant to request a change due to concerns about possible social repercussions. While confidentiality concerns are a known threat to internal coaching programs, we attempted to mitigate these concerns by allowing selection of coaches, re-emphasizing our commitment to confidentiality.

Finally, this program required significant departmental investment. An external coaching company was hired to train and certify the internal coaches and provide continued support and development of them. The latter ongoing cost will likely decrease over time as our internal coaches gain more experience. Additionally, faculty coaches receive ongoing departmental salary support to ensure the sustainability of this program. Further research could provide a more advanced cost-effective comparative analysis, to align with the financial capabilities and organizational priorities of individual academic EM departments.

Conclusion

Our pilot study did not demonstrate a reduction in burnout or an increase in job satisfaction following the implementation of our pilot coaching program. However, individual physicians noted benefits, particularly through the exchange of diverse experiences, and expressed concerns about the use of faculty coaches. This study highlights some of the barriers and advantages to designing and implementing a coaching program for emergency medicine physicians. However, meaningfully reducing burnout and enhancing job satisfaction among emergency medicine physicians will likely require a multifaceted approach that not only addresses individual well-being through targeted programs but also tackles systemic challenges contributing to physician distress.

Data availability

All datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

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