2025/3, стр. 312 - 327

PARADIGMS FOR SOFT SKILLS ENHANCEMENT IN MILITARY HEALTHCARE

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Introduction

Military medical education has several distinctive characteristics that set it apart from civilian medical education. These characteristics reflect the unique requirements of military service and the necessity to prepare medical professionals for high-stress environments, rapid decision-making, and efficient functionality under resource constraints (Cole et al. 2024). Furthermore, military physicians must work closely with various types of people, often in multicultural teams. For this reason, military medical education requires the mastery of a specific set of soft skills, which, with quality training, should develop into effective abilities.

Soft skills are also known as people’s skills or non-technical skills. They are a cluster of productive personality traits that characterize one’s relationships in a milieu. They define your relationship with others or how you approach life and work. In healthcare, a physician’s communication abilities significantly impact patient satisfaction and are essential for fostering effective doctor-patient relationships. Physicians who lack key soft skills, such as emotional intelligence, trustworthiness, communication, and approachability, often struggle to earn the respect and trust of their patients (Sarla 2019). Furthermore, Research on AI implementation in public administration highlights the necessity of well-defined leadership roles and strategic planning, principles that are equally applicable to the development of soft skills and social competence in military healthcare (Stoyanova & Stefanova 2025).

In this context, the study emphasizes the essential soft skills that military physicians must develop, beginning with a key factor that drives the need for these skills – namely, their interaction with five specific focus groups:

– Work team in the relevant medical facility/division;

– The Armed Forces of the Republic of Bulgaria;

– Civilian citizens of the Republic of Bulgaria;

– Foreign contingent on the territory of the country;

– Multinational military contingent and civilians in an international environment.

The presence of this factor shapes the personality of the military doctor as different as a pattern of behavior, as a decision-making style, as receptiveness to the world and the novelties, and above all, as a capacity to interact effectively in different social environments. This naturally highlights the importance of the soft skills inherent in the individual and underscores the relevance of the research focus.

This study aims to define the most requested soft skills in military healthcare by outlining the skills gap in the field. Based on the results obtained, it is recommended that additional approaches be proposed to enhance these skills, ensuring the development of a fully qualified workforce for the Military Medical Academy. The proposed measures can improve the educational process in the specialty “Medical Support of the Armed Forces.”

The main tasks of the research are as follows:

1) To identify the gap in soft skills through an analysis of the interviews and completed surveys conducted.

2) To define the required soft skills in military healthcare.

3) To propose approaches for further development of these skills throughout the educational process of the cadets in the “Medical Support of the Armed Forces” specialty.

Research Methodology

The research takes the form of 74 individual, semi-standardized interviews with an additional survey part. The interviewed persons are heads of medical facilities, heads of medical departments, and physicians from their staff. The research is conducted in:

– Military Medical Academy – Sofia and regional hospital units as follows:

– Military Hospital – Varna

– Military Hospital – Plovdiv

– Military Hospital – Pleven

– Military Hospital – Sliven

The results were processed using qualitative and quantitative analysis methods. Meaningful categories and units of analysis were structured. Categories used for analysis refer to semantic concepts and phrases that group similar units in use. The units of study are semantic or qualitative units of text content (words) that form the analytical categories.

Findings

The first question intends to outline the basic needs of military healthcare regarding personal qualities, skills, and capabilities. Through the method of qualitative analysis, four key demands are identified based on the frequency of statements in the responses to the question, “What are the main personal capabilities that you want the military doctors from specialty “Medical Support of the Armed Forces” to possess when entering your structure?” (Fig. 1).

The first three identified capabilities are core aspects of social competence and require developing soft skills, and this explains why the study focuses exclusively on these areas. The ability to work under pressure demands the full utilization of the individual’s resources and is therefore considered a limitation of the study (Nedeva 2018).

Regarding the first stated need – capability for teamwork – it is essential to understand how medical professionals interpret the term thoroughly. To explore this topic, the interviewed physicians were asked, “What does it take for a medical team to be eective?” (Fig. 2).

The results show that understanding the ability to work in a team is interpreted mainly as a psychological state of experiencing unity (100%), expressed through the meaning units of teamwork, oneness, understanding, solidarity, consensus, collegiality, and collectivity. Another essential component is eective communication (100%) conveyed through verbal expressions such as clear, ecient, strong, and engaging communication. Furthermore, the individual must be able to perceive himself as an interdependent part of a group rather than as an independent unit. Military physicians understand this as dedication (97%) to the idea, task, and personal aspirations and, above all, as a dedication to the team and the organization. This ability should be expressed above all in the pursuit of common goals (96%) and shared responsibility (91%) among the members of medical teams. To achieve this kind of group interaction, the interviewed physicians point to tolerance, support, and shared responsibility, whose fundamental basis is the soft skill empathy (85%), from which trust in interpersonal relations is born. They should be accompanied by positive behavior of correctness, appreciation, respect for the dignity and rights of others, patience, and flexibility, which can be summarized in soft skill ethics (85%). Empathy and ethics are foundational to the practice of military healthcare. Military physicians must be deeply empathetic not only toward their patients but to each other, too. When an ethical attitude is manifested in the team, it should be regardless of rank, nationality, or affiliation.

Last but not least, the results highlight organizational skills (82%) as the next critical need for achieving productive collaboration among medical teams. As soft skills, organizational skills refer to the ability to effectively plan, prioritize, and manage tasks and time. When team members are organized, tasks are clearly defined, and resources are effectively managed, it creates a sense of structure and purpose.

Achieving a state of teamwork where positive emotions, a sense of belonging, and a desire to engage with the team are present is known as group cohesion. Its presence enables complementary and interchangeability among team members – which is essential for performing high-quality tasks in medical institutions. Group cohesion is characterized by core values such as harmony, loyalty, integrity, selfsacrifice, and a focus on relationships, all of which foster effective teamwork and contribute to task performance.

The research of G‰chter, Starmer, and Tufano identifies beliefs rather than social preferences as the primary mechanism through which factors proxied by group cohesion influence group performance (G‰chter, Stamer & Tufano 2024). Pines innovatively applied the concept of coherency as an organizing principle to group analysis, which enables higher levels of functioning in contrast to the more primitive and undifferentiated group formations that are based on cohesion (Ezquero 2010). The concept of group coherency is highlighted as an organizing principle that promotes more profound understanding and more mature levels of functioning, which are key to healthy relationships, personal growth, and group development (Ezquero 2024).

It should be noted that teamwork mainly arises from the socialization process and is strongly influenced by the social culture. This may explain the explicit need for it, as from the perspective of Bulgarian folk psychology and Western influence, Bulgaria is increasingly defined as a country with an emerging individualistic rather than collectivist culture (Hofstede, 2025). Моreover, a wealth of research and history shows that many leaders have behavioral traits, including domination, hottemperedness, persistence, and uncompromisingness, naturally making teamwork difficult.

То identifies what hinders teamwork and prevents its development, the study asked: “From a human perspective, what is the biggest barrier to the medical team being eective?” (Fig. 3).

The respondent‘s answers are directly related to the required capabilities, reinforcing the cadets‘ need for effective teamwork as a central soft skill. The highest percentage scores are distinguished by complicated interpersonal relationships (36%), followed by problem communication (31%), and lack of organizational skills (24%). The lack of motivation is also defined by 10 % of military physicians.

To gain a deeper understanding of the specifics of the most prominent component, “Complex Interpersonal Relationships,” Figure 4 presents a decomposition of the meaning categories that form it.

Through a qualitative analysis approach, the study highlights individualism as the key category of meaning that hinders teamwork and group cohesion. The term “individualism” itself describes the understanding that freedom of thought and action for each individual’s freedom of thought and action, rather than collective effort and responsibility, is the most important characteristic of society. It is characterized by placing the needs of the individual above the needs of the group and prioritizing tasks over people and relationships. It advocates for the rights and independence of individuals, asserting that each person should have the freedom to pursue their own goals and desires without undue interference from society or institutions. The semantic units that define this category in the research are the indicated “I” instead of “We,” a strong desire for self-actualization, disregarding the opinion of others, imposing personal views and interests, dominance, and measuring the importance of others in terms of their usefulness alone. The consequences of the presence of individualism lead to conflict and expressed distance towards other team members, formation of micro-groups, uneven workload based on personal attitude, and subsequently to the division of the team.

It should be noted that the rest of the causes of complications in interpersonal relationships, such as gossip (72%), conflict (58%), and aggression (22%), are due to a lack of emotional intelligence. It is no coincidence that this topic is so important today, and its treatment is included in all modern training. Emotional intelligence (EI) refers to the ability to perceive, express, understand, and manage emotions. However, over the past three decades, different ways of conceptualizing EI have emerged, which are mainly summarized in three models: ability (developed by Mayer and Salovey), trait (Petrides and Furnham), and mixed (Bar-On & Goleman), (Bru-Luna 2021).

Emotional intelligence is vital in managing medical and social issues in a military context. Given the unique stressors in military environments, like combat injuries and mental harm, where these issues can be exacerbated due to high stress, long working hours, and exposure to trauma, disagreements may arise over medical decisions, resource allocations, or interpersonal dynamics. They may impact patient care and team effectiveness. Untreated and unaddressed conflict can result in patient care being delayed, misunderstood, and incorrectly administered. In addition, unresolved conflict is one of the factors that can contribute to burnout syndrome among military doctors, negatively influencing their psychological and emotional well-being.

On the other hand, aggression may be expressed verbally or through passiveaggressive responses, especially when an individual feels highly stressed, frustrated, burnt out, or unresolved conflict. This eventually leads to a toxic working environment wherein employees feel unsafe and unsupported. In extreme situations, actual physical violence may erupt among members, destroying much of the team spirit required for teamwork to succeed.

At the same time, gossip depletes cohesion and trust, breeds mistrust and misunderstanding, ultimately undermines morale, and creates factions within the team. In a military context, gossip can go even further and begin to affect issues such as the chain of command, undermining the authority that must be maintained at all costs. This can be very damaging for high-stakes environments, such as military deployment or a place with active combat. A physician who doesn’t realize their feelings’ impact can be passively involved in gossip and help nurture a toxic environment. Gossip is primarily rooted in jealousy, feelings of inferiority, or perceived threat from the other party. It relates to emotional intelligence components such as self-awareness, recognition of one’s emotions, self-motivation, and relationship management.

Military physicians with highly developed emotional intelligence can address conflict calmly and constructively. They will likely be better at recognizing the emotional undercurrents that fuel conflict and can intervene early, facilitating productive dialogue among team members (Hammer, Bennett & Wiseman 2003). They can also encourage empathy, helping each person understand the perspective of others and guiding the team toward collaborative solutions. The possession of these skills helps military physicians handle the issues mentioned above while fostering a supportive, effective, and collaborative psychological climate in the medical team (Kirby et al. 2011).

One of the expected and available psychological characteristics of military doctors is that they are strong individuals with bright personalities, different abilities, and multifaceted interests. A fundamental requirement is working through these differences in multiple and diverse teams, regardless of personal preferences, attitudes, and sympathies. This is a necessary challenge for the cadets in training, as they must be able to apply this skill not only in the medical facility or unit in which they work but also in the five identified focus groups. This constitutes a guideline for the preparation, above all in terms of teamwork, which is expressed not only in people working together but also in complementing each other, learning from each other, and helping each other. In essence, this is the core of social competence.

To explore further the soft skills gap in military healthcare, our study presents the empirical data from the survey, based on the following question: „As a peopleoriented profession, an essential part of a military doctor‘s job is interacting with patients and colleagues. In this regard, do you think the department you work in needs additional education and training in some of the following areas?”

The results highlight specific areas for further development, mainly in the sphere of communication approaches (39%), including features of verbal, non-verbal communication, and persuasive communication, which correspond directly with the already stated second demand in Figure 1 of our survey. Moreover, additional training in conflict resolution (21%), stress resilience (20%), and self-preservation of personality (16%) is situated as the following requirement, which also correlates with the results from Figures 3 and 4. Only 5% of military physicians think that their department doesn’t need any kind of additional training in soft skills.

The communication gap described above is indeed critical to military health operations. First, it contributes to misunderstandings in inpatient consultations that may lead to misdiagnosis, medical errors, or inappropriate treatment. Second, it can lead to ineffective collaboration between multidisciplinary teams and other units within the military and international or allied forces. Third, considering the clear hierarchical chain of command, it may delay passing information from higher to lower levels (and vice versa) within the required time. Last but not least, this particular gap may affect the clarity of moral obligations and decisions in ethically complex situations, such as caring for prisoners of war or life-or-death triage.

Improving communication skills in military healthcare is essential to interact, diagnose, and treat patients appropriately and to collaborate effectively within diverse, multicultural teams. This could ensure that healthcare and professional cooperation are coordinated across units and organizations, especially in multinational operations where teams must work together despite different protocols, practices, and cultural traits.

In this regard, strong developed intercultural competence can contribute to the overall success of military missions. Through understanding the existing cultural diversities, military doctors can build trust, minimize the chances of misunderstandings, and address medical and psychological challenges with sensitivity and professionalism. This is extremely important during peacekeeping operations, where building positive relationships with local populations is key to success. The individual is often an unconscious bearer of cultural specificity (Hofstede 2025) and his ability to function effectively across different cultures (Whaley & Davis 2007) and to think and act cross-culturally appropriately (Hammer, Bennett & Wiseman 2003) is what constitutes full-grown intercultural competence.

In military operations, especially in foreign deployments or peacekeeping missions, physicians must understand and respect cultural differences to provide effective and ethical care and build strong collaboration with multinational teams. Considering this particular specific, developing intercultural competence during the training of future military doctors is essential for their successful professional implementation.

All results obtained so far are related to the ability to work with people, the third stated need (Figure 1) of our research. This naturally led to our interest in further exploring the knowledge about human nature and psychological types in medical teams, asking the following question: “What theories for determining personality types and behavior do you know, and which of them do you apply in your practice?” (Fig. 6).

A higher percentage (89%) of military doctors indicate that they don’t know any theories of personality types. In comparison, only 8% are aware of the temperament theory, 2% are aware of Karl Jung‘s theory, and 1% are aware of Hans Eysenck‘s theory. These results outline a significant gap in psychological knowledge about human nature and personality types. Theoretical knowledge in this field is mandatory because the social sense is a soft skill that develops on its basis, and when mastered, it should evolve into social intelligence. The term describes the ability to recognize and understand the emotions and needs of others (social awareness) and to manage interpersonal relationships effectively by acting wisely in social situations (social facility) (Goleman 2010). In his theory of multiple intelligences, Howard Gardner proposed that social intelligence is one of the many types of intelligence humans possess (Gardner 2012). In 1920, Columbia University psychologist Edward Thorndike pointed out that “the best mechanic in a factory may fail as a foreman for lack of social intelligence” (Goleman & Boyatzis 2008).

From a military perspective, social intelligence is essential for effective patient care, maintaining cohesion within military units, and ensuring mission success. Military physicians must provide care that addresses patients’needs (Bricnell & Cain 2020). Social intelligence enables them to deliver psychologically, emotionally, and socially sensitive treatment, ensuring a holistic approach to care. This is especially important as military personnel may face psychological conditions such as PTSD, depression, or anxiety (Cole et al. 2024). Furthermore, military physicians may sometimes have to mediate disputes or get involved in high-stakes conflicts with soldiers who may have very strong or intense feelings. Being able to steer such situations with diplomacy, tact, and emotional intelligence can help keep things in order and attention on what is needed when a crisis arises. In essence, social intelligence is the core of the people-oriented role of a military physician.

Conclusion

The main highlights of this study emphasize social competence as the most desired demand in military medical training. The revealed gaps define the soft skills that require further enhancement, such as teamwork, collectivity, empathy, ethics, communicational approaches, emotional regulation, self-awareness, cultural awareness, adaptability, social sense, and open-mindedness. Essentially, when mastered, these skills shape the heart of social competence.

To expand the knowledge in the required field and to improve the training process of the cadets in the specialty “Medical Support of the Armed Forces,” the following approaches are proposed:

– As part of the leadership training program, teams should be formed with tasks that require cadets to visit regional hospitals and divisions within the Military Medical Academy’s system. This will facilitate future inter-institutional collaboration and system efficiency. Along with being the most effective way to train the required soft skills, the tasks discussed should also incorporate an academic component, such as team research, to stimulate and develop cadet’s academic abilities and accomplishments.

– To assign more group tasks, discussions, provocations, and debates throughout the education process to encourage cadets to navigate and synchronize differing viewpoints and behavior styles. This approach will help foster collaboration and effective communication, enhance critical thinking, and further develop teamwork abilities, ensuring cadets learn to work effectively in diverse team dynamics.

– Enhance training in psychological science by deepening theoretical knowledge about the nature of human essence, the diversity of psychological types and categories, and the interconnections between the psyche, consciousness, and behavior. This approach will contribute to the more comprehensive development of the essential social sense, fostering a deeper understanding of interpersonal dynamics and improving the ability to navigate social interactions effectively.

– To develop these skills in practice, cadets should be able to engage with patients at the Military Hospital-Varna as part of the leadership training program or the “Written and verbal communication” course. This will be done through specific tasks, under the supervision of the assigned instructor, and following a predetermined communication structure. However, cadets will not provide any medical advice or diagnosis. This training aims to practically apply the theoretical knowledge gained about human behavior and the use of an individualized approach in communication with others.

– To advance intercultural competence, creating a specialized course that provides in-depth knowledge on cultural awareness, specific cultural characteristics, and a broader understanding of various religions and traditions is recommended. Additionally, the course should be accessible to active military physicians within the Military Medical Academy system.

– To enhance cadets’ motivation and professional knowledge in military medicine and the multicultural environment, they need access to current mentors and leaders. In this regard, organizing periodic lectures delivered by distinguished guest speakers with experience in international missions, both from the global community and the Military Medical Academy team, would be beneficial.

In conclusion, by strengthening the soft skills that underpin the ability to interact effectively with others, military health training programs can significantly enhance the capability of military physicians to navigate the complex and multifaceted challenges they encounter while caring for patients. These skills, including communication, empathy, and collaboration, are essential in fostering a supportive and responsive healthcare environment. Soft skills play a crucial role in military medicine, improving the functioning and cohesion of medical teams and elevating the quality of patient care. They contribute to healthcare professionals’ adaptability, resilience, and emotional intelligence, enabling them to effectively address the unique demands of military settings and perform under pressure in diverse, highstress environments.

Acknowledgements

The author would like to thank Rear Admiral Prof. Dr. Ventsislav Mutafchiyski, PhD, FACS – Head of the Military Medical Academy – and Flotilla Admiral Prof. Dr. Boyan Mednikarov – Head of the Nikola Vaptsarov Naval Academy at the time of the research, for their outstanding support in organizing and conducting this study during its implementation. Special thanks also go to the cadets of “Medical Support of the Armed Forces” – Officer Candidate Adriana Baltanova and Officer Candidate Gabriela Kirova, whose commitment and cooperation played a key role in the success of the study and without their valuable contribution, the successful implementation of this study would not have been possible.

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