Making Soft Skills a Part of the Curriculum of Healthcare Studies

In recent decades, it has been increasingly recognized that soft skills play an important role in healthcare education and must be developed alongside other professional skills. Furthermore, the contribution of emotional intelligence (EI) to the ability to adapt to the changing environment of the 21st century has been widely agreed upon. Yet, despite these findings, social–emotional intelligence (SEI) and related skills skills are not widely developed in healthcare education settings, and if at all, only in a limited way. The present chapter presents a model and a methodological tool (SE-SD) for the development of social–emotional skills (SEI) as part of existing healthcare curricula, applying a broad view of the healthcare professions and associated skills. Soft, social–emotional, skills are positioned as a relevant and integral part of healthcare courses, thereby avoiding the need for significant changes in existing curricula. The SEI development process is implemented in three stages: preparation, action and assessment. The tool allows learners to embark on a self-directed, yet supervised, learning and development process, and can be applied to a single course or through the entire study program. The incorporation of a soft skill development process into healthcare education programs could help health systems to adapt and to cope better with the challenges of the 21st century, both present and future.


Introduction
In the last decades, healthcare systems in the Western world have been undergoing constant, profound, local and global changes.These changes present new challenges to health systems and require them to adapt to the new and dynamic era of the 21st century.
Macro-level changes and consequent challenges include the digital revolution [1,2]; the need to work with, and alongside, technological innovations and artificial intelligence (AI) [3]; frequent reforms and changes to regulations (citation removed for blinding); an increase in life expectancy and other demographic changes; and the need to address all of these changes with limited resources and in face of increasing competition within health care organizations [4].
Micro-level challenges include changes in patients' consumerist approach and in patients' access to information, as well as changes in the power relations between patients and care-givers, and the entry of younger generations (Generations Y and Z) into the workplace.
In order to address these challenges and effectively carry out these systemic changes and prepare healthcare students and professionals to additional current and future changes, healthcare personnel need to adopt a wide range of new skills, and healthcare systems need to find effective ways to disseminate these skills among present and future employees [5].

Social-emotional skills and healthcare professions
Faced with the need to change and modify healthcare systems, one crucial set of skills that has been predominantly referred to is "soft skills".The term describes skills that are not strictly cognitive or technical [6] and ones that include both intrapersonal and interpersonal competencies [7].Thus, many of the soft skills which are now referred to as "critical skills" or "core skills", are included in the concept of Emotional Intelligence (EI).
In its essence, EI involves an optimal combination of emotion and thought and consists of one's ability to identify, use, understand and manage feelings in oneself and in others [8,9].Several models have proposed a set of emotional and social skills and competencies that are related to emotionally intelligent behaviors and outcomes in various fields, and which can be actively developed [10][11][12].Such skills typically include self-awareness, awareness of others (empathy), emotional management (self-regulation) and interpersonal communication.
In recent years, a broad body of research has highlighted the contribution of EI and social-emotional skills to areas such as physical and psychological health; interpersonal relationships; and effectiveness and success in academic studies and in a wide range of organizations, occupations and levels of employment [11,[13][14][15].In particular, a large number of studies have emphasized the importance of SEI for coping with challenges of the 21st century [16].
In the field of medicine, social-emotional skills have been linked to success across a wide range of positions and roles [17].Noted examples include links to effective performance under pressure, increased commitment to healthcare organizations, positive interpersonal communications, and effective teamwork among medical staff [18].Additional studies have pointed out correlations between SEI and better doctor-patient relations [19], fewer medical lawsuits [20], empathic treatment [21], precision in medical diagnoses and consequently in treatment [22], lower levels of situation-related anxiety in patients [23], higher levels of patient responsiveness to treatment, increased patient satisfaction and higher patient trust in healthcare staff [24].Yet despite the clear benefits offered by social-emotional skills in the healthcare professions, the social-emotional skills of medical students have often been noted to be similar or even lower than those of the average population [25], and at times were even noted to decrease during their studies [26].
Consequently, there has been a call to develop social-emotional intelligence among medical students, nursing students and medical management students [27].Nevertheless, to date, and despite a growing understanding of the importance of social-emotional skills to medical professions, the development of these skills has only captured a limited place in medical school curricula and in the training of healthcare staff.

Teaching social-emotional skills: academic and professional training
Until recently, both admissions to healthcare education programs and subsequent academic success were defined primarily on the basis of superior cognitive abilities.Traditional teaching, learning and assessment processes focused on knowledge and on cognitive abilities (citation removed for blinding).
However, in recent years, it has been increasingly recognized that cognitive and professional abilities are not sufficient criteria for success in medical schools and in the medical profession.Consequently, several hospitals have begun incorporating social-emotional skill development efforts as part of ongoing training for their medical teams [28].Several medical schools have also introduced admission measures that examine candidates' personal and interpersonal abilities [29] as well as courses for social-emotional skill development [30].Nevertheless, such efforts are still limited, due to time and overload constraints and to a lingering, mainly cognitive, focus.This paper will introduce the theoretical and methodological underpinning of a novel tool for the development of social-emotional skills, suitable for use among medical students and staff.

The Social-Emotional Skill Development Tool (SE-SD)
In order to integrate the development of social-emotional skills into existing academic and training curricula in a wide field of subjects, a unique Social-Emotional Skill Development tool (SE-SD) that is based on guidelines for effective practices in social-emotional development (e.g.[31,32]) has been recently developed.This tool is highly suited for healthcare education systems, in particular in light of the above-noted time constraints and the challenges imposed by a predominantly cognitive focus [2,33].
The SE-SD tool offers a broad perspective on the field of healthcare education and addresses the need for non-cognitive social-emotional skills in the field.In addition, it aims to complement and to work in synergy with existing training tools and to support other professional skills.It can be further viewed more broadly as a method and pedagogy for integrating the development of social-emotional skills in healthcare training.By doing so, it is expected to enable students to cope with a changing healthcare reality and thrive in it.

The social-emotional skill development tool: underlying principles
The SE-SD tool is based on eight underlying principles:

An inclusive theoretical framework
The theoretical framework at the basis of the SE-SD tool is the well-established Bar-On [11] model of Emotional-Social Intelligence.This framework, which addresses both behaviors and outcomes, has been noted to be especially suitable for educational settings [34,35] and has been employed successfully in the medical arena [36][37][38].It allows for a holistic and inclusive development approach that has been noted especially effective in SEI trainings [39].Similar to the Bar-On framework and associated tool (EQ-i), the SE-SD tool includes ten skills, nine such as emotional self-awareness and expression, self-regulation, empathy and interpersonal relations, social responsibility, flexibility, stress-tolerance, optimism and selfregard from the original Bar-On model (Figure 1) [11], with the addition of Growth Mindset.All linked to different aspects of various healthcare professions [25].The SE-SD skills are arranged in 4 major clusters: intrapersonal, inter-personal, adaptability and stress-management, to which the well-being indicator of the original model has been added.

A wide variety of pedagogical methods
In line with the inclusive model at its basis and the wide variety of socialemotional skills it includes, the SE-SD tool addresses a offers a wide range of development assignments and a wide range of methodical tools (such as dedicated articles, video clips, short interviews, reflective questions, real-life experimentation, etc.).This variability is in line with earlier studies where the successful development of social-emotional skills was noted to include both cognitive and emotional components and to require varied and experiential methods [40].

A curriculum-integrated approach
It has been widely acknowledged that SEI development cannot be achieved by means of a single workshop [41][42][43][44] and requires an extensive, routinised, longterm effort that provides time for learning, practicing and achieving development [31].A curriculum integrated approach allows for such extensive and long-term development efforts as well as for offering a contextual, rather than isolated, experience.
In line with these findings, the SE-SD tool has been designed to be integrated into existing course materials.This integrated approach helps students and instructors overcome time constraints as well as highlights the links between the targeted SEI skills and different aspects of the profession, making the development relevant and meaningful.Integration is achieved through two parallel processes: by linking specific social-emotional skills with the general course material; and through home assignments that target SEI development, are self-paced and are completed and evaluated at different points in time throughout the entire course.

A generic tool
Social-emotional skills have been noted to be relevant across a wide range of roles and positions in the field of healthcare [17].
Accordingly, the SE-SD tool, and in particular the assignments associated with each skill, were structured in a more general manner and therefore can be easily applied to a variety of subjects in the academic curriculum and can be integrated into a variety of healthcare academic courses, disciplines and academic levels.

Modularity
The SE-SD tool can be used in a modular and "spiral" manner in order to integrate a wide range of skills into different courses throughout the academic program.Such modularity is particularly suited to the development of social-emotional skills, a process noted to involve continuous and lifelong learning [45,46] and in which links between skills exist [11].Importantly, while the SE-SD tool can be used in isolation, as part of a single course or a number of courses, a multiyear, spiral SEI development program which corresponds with the desired graduate vision can enhance the overall effectiveness and sustainability of the SEI development process [31] and ultimately contribute to the quality of healthcare professionals.
The nature of healthcare studies supports such modularity as healthcare students may need to employ different SEI skills at different stages of their academic training (pre-clinical and clinical years for example).
Finally, assignments that form part of the SE-SD tool are constructed in a modular fashion, building up from theory to practice.This modular structure is built on the premise that theoretical knowledge provides a foundation for the development of SEI [44] and that effective social-emotional development should follow several steps: the acquisition of a theoretical basis; and an understanding of the concept of EI and the specific SEI skills as they are being targeted, achieved through theoretical assignments.These are followed by gaining understanding of the relevance of the targeted skills to the course material and to future practice through reflective assignments.Practical assignments then provide a step-by-step opportunity to develop and practice newly acquired skills.Ideally, these steps lead to changes in habits, attitudes and behaviors [31,44].

A formative tool
The SE-SD tool focuses on the process of SEI development rather than on its outcomes.It is assumed that social-emotional development is an on-going lifelong process which takes place within relationships (in this case, with the course instructor).It has been demonstrated that relationships that are based on trust, guidance, support and formative feedbacks enhance SEI development [12,32].As an inseparable part of the SE-SD tool, therefore, evaluations and feedbacks from course instructors provide formative comments which students can use in order to continue to progress and to refine their development process.All these elements have been noted to enhance SEI development [47] and motivation levels [31].
Academic assignments that integrate the SE-SD tool are evaluated based on their degree of completion and on the students' level of understanding of several elements: the concept of EI, the specific SEI skills that are being acquired, and the relevance of these skills to the particular healthcare profession at the center of the course.During the active development stage, students are evaluated based on their level of engagement and reflection.The importance of reflective learning has been previously highlighted [44], noting that reflections on thoughts, feelings and behaviors that underlie attitudes and habits, both personal and of others, enhance the development of SEI competencies.

A self-directed and self-paced process
As emotions, thoughts, competencies, behaviors and habits are all unique to each individual, it is recommended that social-emotional development processes include a focus on individual social-emotional skills [12,48].To this end, the SE-SD tool allows students to follow their own individual development path at their own pace, to start the development process from their own individual starting point, to focus on their own specific goals and to self-assess their progress.Self-directed processes encourage participants to be personally accountable for their progress and involve them in planning, carrying out and evaluating their own learning experiences.These elements, in turn, were noted to enhance motivation, which is key to social-emotional training success [12].
In order to manage their self-directed learning, students receive "road maps" (either in a digital form or in print) that outline their assignments and set specific points in time for evaluations and feedbacks.The assignments are order-dependent, as each assignment builds on the previous one, and the order in which assignments are offered is pre-determined.While students can follow the development process at their own pace, they are instructed to avoid completing their assignments all at once.This time-paced approach maximizes the effectiveness of the learning process, allowing students time for reflection and practice and providing instructors with at least two opportunities, at two different points in time, to deliver evaluations and feedbacks to students.

A flexible and dynamic tool
The SE-SD tool is both flexible and adaptable.The tool's flexibility is manifested in the choice of SEI skills that are to be associated with a given course, in the links drawn between these skills and the course materials, in the number of assignments chosen from the selection offered and in the variety of these assignments.The tool offers further flexibility in terms of feedbacks and evaluations: instructors can limit themselves to the two formal evaluations (intermediate and final) that are provided as part of the tool, but may choose to provide additional informal and more frequent feedbacks.Furthermore, additional skills to those offered in the model can be added, consistent with the principles embedded in the tool: designing developmental activities and assignments that would support knowledge acquisition and enhance the understanding of these skills, determining the relevance of the added skill to a particular course, and identifying starting points and goals for each of the participants.
Taken together, these features of the SE-SD allow healthcare education systems to include social-emotional development as a strategic plan for preparing students and workers for a changing professional reality.

Inculcating the model: methodological considerations
Skill-development processes often follow a sequence of stages that have been recognized to contribute to effective development (e.g.[31,41,47]).These include: preparation (gaining students' commitment, identifying needs, and jointly designing a development program); action (implementing the program -introduction and development); and evaluation.In the case of the SE-SD tool and healthcare education settings, these stages have been adapted to meet the specific requirements of various healthcare professions (Figure 2).

Preparation
The preparation stage begins with the selection of an SEI skill to be developed during a given course.This skill, selected by the course instructor from a list of social-emotional skills offered in the tool (Figure 1), is chosen based on its degree of relevance to the course material and its suitability in terms of the students' academic level.The course instructor then plans how to integrate the skill into the course material.For example, if integrated into a course that focuses on patient-caregiver relationships, the instructor may decide to discuss empathy as part of a segment that examines how to deliver difficult news to patients.
Lastly, the course instructor goes over the SE-SD assignment list and chooses assignments that correspond to the selected skill.
When a three-year process is involved, these steps are followed in group discussions where faculty members jointly decide on the skills to be introduced each year and the classes they most fit.

Action
The action stage includes two parts, introduction and development.

Introduction
This part of the action stage is designed to highlight the relevance and importance of SEI to the students and to promote motivation to participate in the EI development process.The course instructor begins by introducing the concept of social-emotional skills to the students, highlights the relevance of these skills to the course and notes their importance to students' overall growth and future careers in the 21st century.
Following these introductory remarks, the SE-SD model and tool are presented and the methods by which the development process will be incorporated into the course, both during class and by means of home assignments and their evaluation, are explained.The instructor notes the order by which the assignments are to be completed, the corresponding time frames, and the formative evaluation method by which they would be assessed.

Development
The development part of the action stage relies on individual home assignments that students are asked to carry out throughout the entire course.Students are instructed to complete the assignments in a pre-determined order and can only access subsequent assignments after completing the previous ones.In line with the structure of the SE-SD tool, the assignments include three hierarchical segments: Theoretical background, Exploration, and Practice.
• The theoretical background segment aims to provide the students with a solid theoretical basis for personal development.Students learn about the concept of EI and come to understand the targeted SEI skills and the mechanisms by which they may be employed.As part of this segment, students are encouraged to read relevant literature and to watch illustrative video presentations.For example, as part of a background segment on empathy, students may read a paper about the concept, watch a relevant video program, note the distinction between empathy, sympathy and compassion, and find out more about the mechanisms by which empathy is employed and its contribution to the healthcare professions.
• During the exploration segment, students proceed to explore the relevance of targeted EI skills to various healthcare professions.By answering a set of guiding questions and/or conducting short interviews with professional in the field, students are able to identify the relevance of any given skill to their course material, to their chosen profession and to present and future life outcomes.Finally, they are asked to identify their own individual starting point with respect to the targeted skill and to define the corresponding goals.The SE-SD tool provides a set of guiding questions and/or a short questionnaire that support this exploration process.For example, in the case of empathy, students are asked to identify links between empathy and healthcare professions, use guiding questions to evaluate the gains they are likely to derive from enhanced empathy, and assess their starting point with regards to the development process using an empathy questionnaire.
• The practice segment involves students in a wide range of activities, all aimed at developing the targeted SEI skill.This is the longest segment of the three, in line with Boyatzis [12,32] who noted the importance of experimenting with new behaviors for an effective social-emotional development process.The assignments that form the core of this segment are designed to develop cogniemotional and behavioral components of the targeted skill.For example, in the case of empathy, the students are asked to engage in empathic dialogues, take on another person's perspective (e.g. a patient or a team member), or examine case studies that center on interactions between patients and caregivers.The culminating assignment includes reflection and self-evaluation.

Evaluation
Finally, during the evaluation segment, students are provided with feedbacks and formative assessments that can help them further develop their socialemotional skills.These feedbacks and evaluations are provided by their course instructors at two points in time during each course: mid-term (which coincides with the goal-setting stage of the development process) and at the end of the course (after all assignments have been completed).These feedbacks are accompanied by self-evaluations.
As noted above, participant students are evaluated based on their level of commitment, efforts and engagement in the development process (as opposed to the level of development that has been achieved); their level of understanding of the targeted EI skill; and the level of personal and professional reflectiveness they demonstrate throughout the entire course.
Furthermore, beyond the mid-term and end-of-term evaluations, instructors can choose to provide additional evaluations and feedbacks in the course of the program, in accordance with available time resources.

Discussion
In light of the global changes and challenges that face many professionals in the 21st century, there is an increasing understanding that it is of primary importance to develop and foster social-emotional skills, also referred to as "soft skills", among workers in a wide range of fields.A prominent example is the field of healthcare.Skills that are likely to benefit healthcare professionals may include emotional self-awareness, self-regulation, empathy, and interpersonal relations.These, as well as other social-emotional skills, were noted to improve coping abilities, academic learning and professional effectiveness among both medical teams and healthcare management teams [49,50].
The importance of social-emotional skills to medical staff and to healthcare systems and their currently limited place in medical school curricula, call for a proactive initiative on the part of academic institutions.Such an initiative should address needs and challenges, both current and future, that face healthcare professionals and can transform medical schools from knowledge providers to leaders of cultural and social changes.
Given the noted difficulties to integrate the development of social-emotional skills into existing curricula in the field of healthcare, we propose a novel and holistic SE-SD tool that integrates social-emotional learning into existing curricula while overcoming time and workload barriers.
Furthermore, the assignments that form part of the SE-SD tool are prepared and provided ahead of time by the tool designers, and therefore instructors do not require any prior expertise in the field of social-emotional learning in order to implement the tool as part of their courses.
Effective implementation of social-emotional skill development programs has been noted to benefit from a supportive climate.It is therefore highly recommended that faculty is included in the proposed social-emotional training process.Socialemotional training is expected to heighten faculty awareness of the importance of the process, increase their willingness to take risks as they implement the SE-SD model in their respective institutions, and enable them to model socially-emotionally behaviors and to 'walk the talk' [49].All these were found to contribute to the development of social-emotional skills in students.
In addition to academic institutions which can take upon themselves to develop social-emotional skills in students and faculty, development of these skills should form an integral part of on-going professional training for both healthcare staff in post-academic settings.Such life-long learning will support earlier development efforts in academic institutions and will insure its sustainability.
Lastly, although research regarding the effectiveness of the SE-SD tool is still a work in progress, we believe that the use of integrative learning methodologies like the one described here would bring healthcare academic institutions and their graduates one step closer towards adapting to the 21st century and meeting its demands.
Making Soft Skills a Part of the Curriculum of Healthcare Studies DOI: http://dx.doi.org/10.5772/intechopen.98671

Figure 1 .
Figure 1.List of essential soft skills for healthcare professions.

Making
Soft Skills a Part of the Curriculum of Healthcare Studies DOI: http://dx.doi.org/10.5772/intechopen.98671

Figure 2 .
Figure 2. Process of model implementation.