Coaching models, theories, and structures: An overview for teaching faculty in the emergency department and educators in the offices.

Coaching is rapidly advancing in medical education as a relational process of facilitating sustainable change and growth. Coaching can support learners in emergency medicine at any stage by improving self-reflection, motivation, psychological capital, and goal creation and attainment. Different from the traditional models of advising and mentoring, coaching may be a new model for many educators. An introduction to key coaching concepts and ways they may be implemented in emergency medicine is provided. Experienced coaches employ a diverse array of models and techniques that may be new to novice coaches. This article summarizes a variety of coaching models, theories, and content areas that can be adapted to a coachee's needs and the situational context-be it the fast-paced emergency department or the faculty member's office.

INTRODUCTION

Continuous improvement of learning and performance is critical to the development of physicians. Coaching can accelerate this process. Coaching is the relational process of facilitating sustainable change and growth that supports learners by improving self‐reflection, motivation, and goal‐setting. Experienced physicians working with an executive, leadership, or well‐being coach may set goals to develop their leadership skills and improve well‐being. , Emergency physicians can also engage in performance coaching, in which their technical or clinical skills undergo direct observation with critique and generation of an improvement plan However, even medical learners such as students and residents have begun to benefit from coaching techniques, as their anticipated path of professional identity formation involves expanding their skills and knowledge through self‐reflection and self‐actualization.

Because the coaching role is distinct from other educational roles of advisor, mentor, counselor, and teacher, it is important to have an understanding of the definition and purpose of each. Advising is an issue‐focused relationship dependent on what the learner needs to know or asks, based on the advisor's expertise. Mentoring is a longitudinal relationship focused on the learner's development, based on the mentor's experience the mentee is interested in. Often, the mentor is a role model. Coaching is the art and science of facilitating positive, sustainable change and growth to realize full potential, including optimal learning, development, performance, and well‐being. The coaching process generates self‐awareness, discovery, and self‐determination, in contrast to mentoring, which focuses more on guiding and advising.

Coaches work with coachees to articulate and affirm a coachee's personal vision, values, meaning, or purpose. They help coachees improve self‐awareness and evaluate strengths, skills, and performance via review of objective assessments. Coaches help coachees identify opportunities for change and development, create and evolve plans and goals, and provide accountability. Finally, coaches create a partnership of trust and respect, building an “alliance” with a coachee.

In the past few years, academic coaching programs in undergraduate and graduate medical education have blossomed. , , , These may take the form of highly resourced, structured coaching programs incorporating certified coaches. However, coaching techniques can be applied in any conversation with a learner, even by someone who is not a paid or formally trained coach, even in the context of a busy emergency department (ED). With so many coaching theories and styles at the coach's disposal, what particular tools might be most high yield? More specifically, how might an EM educator apply these tools either in the fast‐paced environment of the ED or in a longitudinal coaching program to help develop the learner? In this paper, we review a selection of coaching models and coaching topics, so that coaches, and educators using coaching techniques, may select among established areas to customize their approach. The author group comprises physicians in medical education who have trained as coaches and/or have created coaching programs or are coaches with advanced certification and leadership roles in a national coaching organization. The models, resources, and tools selected were deemed the most foundational, helpful, and important for coaches to be aware of. Once the theory and science behind different models are understood, an educator can be alert to the various situations and context in which coaching might be applied.

COACHING MODELS

Educators can adapt a variety of theory‐based coaching models and tools to coachees' needs. Each approach has particular strengths and may pair well with the challenges faced and goals desired by the coachee. Developing skill and expertise with these approaches expands a coach's repertoire (presented alphabetically below). While formal education and often certification can be sought in each of these, they differ from therapy in that professional training is not required to employ them.

Acceptance and commitment coaching, based on acceptance and commitment therapy, helps coachees mindfully respect, accept, and compassionately experience their difficult emotions, rather than avoiding, or struggling against them. Useful when the coachee is overwhelmed by their emotions, the process helps a coachee move past difficult emotions to identify personal values and goals, motivating commitment to action that aligns with what is meaningful and important for their future.

Appreciative inquiry is a strengths‐based approach (in contrast to a problem‐focused approach) where the coach guides a coachee through a review of positive or successful past experiences, identifying the strengths and resources a coachee engaged and the conditions at play, defining a vision or dream for the future that incorporates these conditions into an action plan. This is an approach that can be useful when the coachee is unable to see positive actions for moving forward on a challenge.

Cognitive behavioral coaching is a set of techniques that starts with guided discovery that increases the coachee's self‐awareness of thinking, emotions, and behaviors. It leads to an understanding of how a coachee's beliefs and perspectives determine and distort their reactions. This is useful when the coach wants to help the coachee reframe the perspectives and then experiment with new mindsets and behaviors.

Decisional balance is a model useful when the coachee is considering a change. The coach helps a coachee identify the pros (motivators) and cons (obstacles that reduce confidence), along with their relative weights. Combined with realistic strategies to overcome the change, the process helps a coachee to effect change.

With emotional intelligence techniques, the coach helps a coachee identify and accept their emotions, understand the unmet needs signaled by unpleasant emotions, and see these as opportunities to learn and grow, thereby shifting patterns of emotional reactivity. Similarly, the coach helps a coachee amplify and harvest positive emotions to improve psychological capital.

The GROW model is a four‐step inquiry. First, a coachee decides where they wish to go (the Goal) and describes where they are currently (Reality). The coachee then explores various routes (the Options) to the goal destination. In the final step, the coachee commits to the plan of action and prepares for obstacles on the way (the Way forward).

Health and wellness coaching is useful in motivating lifestyle change by facilitating coachee understanding their current state of health and well‐being, developing a vision for optimal health, understanding why optimal health is personally valuable, identifying strengths and resources to enhance self‐efficacy, and embarking on a path of behavioral experiments that generate a sustainable, health‐promoting lifestyle.

The immunity‐to‐change model is an advanced form of cognitive behavioral coaching where a coachee identifies goal‐sabotaging behaviors that create an immunity to change. The coachee then tests ways to shift the beliefs that contribute to sabotaging behavior, eventually overcoming the immunity.

Intentional change theory is a five‐step leadership coaching model useful for building motivation for self‐change—discover one's vision for one's ideal self, understand the gap between the real self today and the desired future self, create a learning agenda, experiment with and practice new habits, and get support, both social and environmental.

Motivational interviewing is a conversational approach designed to evoke intrinsic motivation for change, rather than extrinsic motivation, which can inadvertently trigger resistance. It includes techniques of open inquiry, active listening, and a variety of reflections and affirmations, all encouraging a coachee to find their own reasons for change and then commit to the desired change.

Nonviolent communication is a model of emotional self‐management that uses four steps. The coach prompts a coachee first to share a story, usually laced with both factual and emotional content. The coachee then separates the facts from the arising emotions, first recounting the unedited narrative and then retelling the story with facts and without emotions. The coachee next identifies and names the emotions that first accompanied the facts. Last, the coachee identifies the unmet needs conveyed by each emotion and finally makes a request to meet the unmet needs. This method teaches coachees how to productively use their emotions in making changes.

Role play can be used to practice scenarios in which a coachee might set a goal to perform better. With the coach playing the part of another person, a coachee can practice potentially troublesome interactions. This can allow a coachee to build experience and confidence and offer a structured approach to examining different interactions from multiple perspectives (see Table 1 for resources on each coaching model). Table 2 offers examples of each model used in practice.

TABLE 1

Coaching model resources

Acceptance and commitment coaching	Emotional Agility: Get Unstuck, Embrace Change, and Thrive in Work and Life 19
Appreciative inquiry	Appreciative Inquiry: A Positive Revolution in Change 20
Cognitive behavioral coaching	Cognitive behavioral coaching 21
Decisional balance	Changing to Thrive: Using the Stages of Change to Overcome the Top Threats to Your Health and Happiness 22
Emotional intelligence	Primal Leadership: Unleashing the Power of Emotional Intelligence 23
GROW model	Coaching for Performance: The Principles and Practice of Coaching and Leadership 24
Health and wellness coaching	Health & Wellness Coach Certifying Examination: Content Outline with Resources 14
Immunity to change	Efficacy of immunity‐to‐change coaching for leadership development 25
Intentional change theory	Helping People Change: Coaching with Compassion for Lifelong Learning and Growth 16
Motivational interviewing	Motivational Interviewing: Helping People Change 26
Nonviolent communication	The Center for Nonviolent Communication 27
Role play	Guide to Running Role Plays 18

TABLE 2

Summary of content areas and potential questions that exemplify each technique

Content area	Context	Suggested prompts and reflection questions
Well‐being and lifestyle	Helpful when learners wish to improve their well‐being. The coach evokes motivation and confidence for health behaviors.	“In what ways would you be better able to reach your goals if you got enough sleep?” “What's worked previously in finding time to exercise?”
Resilience	Focuses on the ability to adapt well and recover quickly after stress or adversity, a key skill in medicine given the numerous challenges ahead.	“How have you overcome similar challenges in the past?” “How can who you are when you are at your best inform your actions here?” “When you look back on this period of your life, what are your main lessons?”
Mindfulness	The coach helps a coachee develop greater awareness of their patterns of reactivity, question the veracity of their thoughts, and build compassion for self and others. 11	“How do you know that your beliefs that you are an imposter are true?” “What benefits emerge when you are more compassionate and less judgmental toward your patients?”
Self‐compassion	Encouraging learners to feel self‐compassion is critical as medical training emphasizes compassion for others but not typically for self. The coach might introduce tools such as the self‐compassion break. 12	“What would a compassionate stance toward yourself look like?” “What would you say if this was happening to a close friend?”
Clinical skills coaching	Learners often focus on deficits, which undermines confidence and self‐esteem. Coaching focuses on what was done well rather than deficits.	“How can you apply the strengths that helped you learn skill x to skill y?” “What would mastery of this skill look like?”
Strength‐based coaching	Learners suffering from imposter syndrome may not be aware of their strengths. The VIA (values in action) character strengths framework is one example of a way to facilitate strength‐based conversations. 13	“What strengths have you used in the past that you can bring to your program or career?” “How can you use your strengths to move toward your goals?”
Self‐management and emotional regulation	Helps a coachee gain comfort with their emotional life.	“What emotions come up for you around this?” “How can you remind yourself that this challenging emotion will pass?” “How does what you are experiencing look from the stance of an observer?”
Time management	A specific area of self‐management includes time management. A coachee can identify obstacles to time management, and the coach can guide them in managing competing elements of coachee's lives. 14	“How do you want to spend your time and prioritize your energy?”
Leadership skills	In helping a coachee develop leadership skills, authentic self‐knowledge helps guide actions.	“If you were the captain of your ship, how would you act?” “What's most important for you?”
Academic coaching	Promotes informed self‐assessment and goal‐setting and aligns well with a competency‐based education framework	“Which areas are you strongest in?” “How can you apply prior learning to areas of challenge?”
Growth mindset	Coaching builds a growth mindset, moving beyond fixed concepts of ability. 15	“When you see this challenge as an opportunity, what's possible?” “What can you learn from this feedback/setback?”

COACHING CONTENT AREAS

Just as there are a wide variety of coaching models, there is a wide range of content areas for coachees to explore through inquiry using open questions. We summarize several coaching topics and provide examples of inquiry in Table 3.

TABLE 3

Examples of each coaching model in practice for EM educators

Coaching model	Context	Possible approach
Acceptance and commitment coaching	Student avoids signing up for unstable patients because she is afraid she will make a mistake	Coach helps student realize that she can be afraid AND still care for and learn to manage unstable patients
Appreciative inquiry	Resident with imposter syndrome believes they are not capable of mastering code leadership	Coach helps them recall a similar skill they performed well and unpack steps to get them there
Cognitive behavioral coaching	Student jumps to premature closure for patients with shortness of breath as had patient die recently from unrecognized pulmonary embolus	Coach helps student question the validity of their conclusion by questioning their perspective and belief
Decisional balance	Resident trying to decide if a critical care fellowship is the right choice as a career	Coach drives resident to question the pros and the cons of this career for them to help them make a decision
Emotional intelligence	Fellow is upset by the evaluations they received on not being a team player and believe they get along great with the team	Coach helps the fellow identify and accept their emotions, understand the unmet needs signaled by unpleasant emotions and see these as opportunities to learn and grow
The GROW model	Student first day on the emergency medicine rotation and is overwhelmed as does not know the expectations on what to learn	Coach helps student set a short‐term goal on what they wish to accomplish the first week of the rotation
Health and wellness coaching	Resident is unable to return to normal sleep pattern after night shifts	Coach works with resident on prioritizing health goals
The immunity to change	Resident assumes that to improve efficiency, they have to be a poor communicator with patients	Coach helps resident see that these are not diametrically opposed goals
Intentional change theory	Student wants a structured approach to making changes and wants a series of meetings for accountability	Coach offers the five‐step process as a tangible way forward
Motivational interviewing	Student wants to firm up specialty plans but is not yet ready to commit to EM or any one field	Coach explores ambivalence and barriers to commitment
Nonviolent communication	Resident had an embarrassing encounter where a nurse questioned him in front of a patient	Coach guides the resident in the retelling, gradually separating emotion from fact
Role play	Resident feels uncomfortable breaking bad news to families	Coach serves as family member for resident to practice with, then uses coaching techniques to consolidate experience and set learning goal

These are just a few content areas amenable to coaching. The coaching relationship may be limited to one of these domains, or the coach may explore several domains in combination, depending on a coachee's needs.

Getting started

While a formal coaching program within a clerkship or residency offers a structured approach to coaching over time, we encourage every clinical teacher who may not be part of a formal coaching program to try out coaching techniques when they teach and debrief with their learners in the ED. Faculty can seek out faculty development workshop opportunities, and online resources exist as well.

What's next in coaching in medical education

As the above models and tools become more widely used in medical education, next steps for the community include measuring coaching outcomes of each of these approaches, including the creation of instruments and materials to support the training and assessment of coaches as well as program evaluation.

CONCLUSION

All learners have potential to benefit from any coaching model, technique, or content, but an optimal fit of approach and learner's needs is more likely to accelerate positive results. Educators would benefit from understanding each of these models and topics to have a complete toolkit at hand and address a variety of learner needs. We encourage faculty to gain facility with, and intentionally employ, techniques that theoretically match the desired goals and challenges the learner brings to the coaching intervention.

AUTHOR CONTRIBUTION

All those listed as authors are qualified for authorship; all those who are qualified to be authors are listed.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.