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Med Educ Online
Med Educ Online
Medical Education Online
1087-2981
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10.1080/10872981.2024.2407656
2407656
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Research Article
Research Article
Strategies to foster stakeholder engagement in residency coaching: a CFIR-Informed qualitative study across diverse stakeholder groups
M. SASNAL ET AL.
MEDICAL EDUCATION ONLINE
https://orcid.org/0000-0003-0035-6990
Sasnal Marzena a b
https://orcid.org/0000-0002-6753-2859
Jensen Rachel M. c
https://orcid.org/0000-0003-0408-1509
Mai Uyen T. a
https://orcid.org/0000-0002-4868-4152
Gold Carl A. d
https://orcid.org/0000-0001-6347-2601
Nassar Aussama K. c
https://orcid.org/0000-0002-0508-6339
Korndorffer James R. c
https://orcid.org/0000-0001-5795-2940
Morris Arden M. a
https://orcid.org/0000-0002-8816-1700
Miller-Kuhlmann Rebecca K. d
a Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine , Stanford, CA, USA
b Center for Research on Education Outcomes, Stanford University , Stanford, CA, USA
c Department of Surgery, Stanford University School of Medicine , Stanford, CA, USA
d Department of Neurology & Neurological Sciences, Stanford University School of Medicine , Stanford, CA, USA
CONTACT Rebecca K. Miller-Kuhlmann millerrk@stanford.edu Department of Neurology and Neurological Sciences, Stanford Neuroscience Health Center, 213 Quarry Rd, Palo Alto, CA 94304
22 9 2024
2024
22 9 2024
29 1 2407656Integra21 9 2024
Integra21 9 2024
04 4 2024
15 8 2024
18 9 2024
© 2024 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
2024
The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

ABSTRACT

Introduction

Coaching interventions in graduate medical education have proven successful in increasing technical and communication skills, reducing errors, and improving patient care. Effective stakeholder engagement enhances the relevance, value, and long-term sustainability of interventions, yet specific strategies for stakeholder engagement remain uncertain. The purpose of this article is to identify strategies to foster engagement of diverse stakeholder groups in coaching interventions.

Material and Methods

We conducted 35 semi-structured interviews between November 2021 and April 2022 with purposively sampled key stakeholders that captured participants’ perspectives on physicians’ communication training needs, roles, and involvement in, as well as contextual factors, facilitators, barriers, and improvement strategies of the multi-departmental Communication Coaching Program at our institution. We utilized the Consolidated Framework of Implementation Research to guide data collection and analysis. An analytic approach relied on team-based thematic analysis with high inter-coder agreement between three raters (Cohen’s kappa coefficient 0.83). Several validation techniques were used to enhance the credibility and trustworthiness of the study.

Results

Analysis of transcribed interviews with stakeholders directly involved in the Communication Coaching Program, including 10 residents, 10 faculty coaches, 9 medical education leaders, and 8 programmatic sponsors, revealed five key engagement strategies: (1) embrace collaborative design, (2) enable flexible adjustments and modifications, (3) secure funding, (4) identify champions, and (5) demonstrate outcomes. Additionally, a patient-centered approach to delivering the best possible patient care emerged as a primary objective that linked all stakeholder groups.

Discussion

Evaluating the experiences of key stakeholders in the Communication Coaching Program helped identify targetable strategies to facilitate participant engagement across all organizational levels. The analysis also revealed universal alignment around the importance of providing high-quality patient care. Insights from this work provide guidance for clinical training programs moving toward the implementation of coaching interventions.

KEYWORDS

graduate medical education (GME)
communication coaching
program evaluation
stakeholder engagement
qualitative interview study
The author(s) reported there is no funding associated with the work featured in this article.
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pmcIntroduction

Coaching is an increasingly utilized training modality and educational intervention in graduate medical education (GME) [1–8]. Coaching in this setting consists of learner-driven longitudinal guidance and support wherein a coach partners with a learner for clinical observations, feedback, goal setting, and facilitated development toward reaching their full potential. Coaching has been proven to enhance actual and perceived technical skills, strengthen communication abilities, reduce medical errors, facilitate skill acquisition, and positively influence residents’ comprehension of patient needs, contributing to better patient care [9–11].

Effective stakeholder engagement plays a pivotal role in driving the success of medical education interventions [12–15]. The benefits of effective stakeholder engagement include improved knowledge sharing, resource mobilization, and alignment with evolving individual and organizational goals, needs, and limitations [16,17]. Notably, involving diverse stakeholders in the medical school or residency curricula design ensures their relevance and value to those involved [18,19]. Collaborative partnerships with key actors further facilitate programs’ long-term sustainability and applicability [18,20]. Moreover, integrating stakeholders’ insights contributes to better-informed decision-making, fostering a comprehensive understanding of intervention contexts and potential barriers [21,22].

When implementing complex medical education interventions such as new coaching programs, effective stakeholder engagement emerges as a critical tool to enable the navigation of real-world challenges through collective wisdom [23]. In medical education settings, several groups of stakeholders (trainees, faculty, administrators, external partners) must interact effectively. Tensions may emerge among stakeholders due to different expectations and roles [24–26]. Navigating these diverse and sometimes conflicting goals can challenge stakeholder engagement and satisfaction [25–27]. Existing research underlines the imperative of striking a delicate balance among the diverse interests of faculty, trainees, and educational and administrative leaders in designing interprofessional education programs, reinforcing the significance of addressing multifaceted stakeholder considerations [28]. However, specific strategies for achieving this balance and facilitating stakeholder engagement remain uncertain.

The purpose of this article is to identify strategies to foster stakeholder engagement in coaching interventions based on our experiences with a multi-departmental GME Communication Coaching Program. By exploring insights from key stakeholders that resonate with this unique context, we aim to contribute to the growing research on effective coaching interventions in medical education settings and provide guidance to leaders interested in creating similar initiatives.

Materials and methods

Study design and setting

This qualitative study draws from a larger project evaluating the neurology and surgery residency Communication Coaching Programs at our institution and involves multilayered collaboration between the academic medical center and multiple departments within the medical school [4,29,30]. A full description of the program can be found in Nassar et al. Briefly, within the Communication Coaching Program, each neurology and surgery resident is matched with a faculty coach with the expectation of completing 5–8 coaching sessions annually. Coaches and residents receive training in relationship-centered communication prior to participation in the program. Additionally, coaches receive continuous training and support aimed at developing coaching skills, salary support to meet the demands of coaching, and a stipend for group activities or meals to build rapport with trainees, as detailed in a referred publication [29]. Each coaching session consists of four components: (1) the coach’s direct observation of the resident-patient encounter, (2) facilitated self-reflection on the resident’s communication performance, (3) targeted feedback from the coach, and (4) the resident’s self-identified goal setting [5,29].

We conducted a 2-phase evaluation of the Communication Coaching Program, including (1) baseline and follow-up surveys among residents and coaches and (2) a qualitative interview study with key program stakeholders. The initial study, reported in detail in Gold et al., demonstrated increased confidence in communication skills and other non-technical skills and improved perception of faculty feedback quality among residents after 1–3 years of coaching [31]. The following qualitative study aimed to further evaluate program and implementation efforts from a pragmatic standpoint.

Sampling and study participants

We used a key informant purposive sampling strategy to identify study participants based on their knowledge and involvement in the Communication Coaching Program [32]. Participants were recruited via email by the communication coaching directors (C.A.G. and A.K.N.) and the senior research analyst (M.S.). In addition, the heterogeneity of the sample (representations of various roles and functions in the program) allowed for achieving variation in dimensions of interest [32].

The qualitative study was framed within the Consolidated Framework for Implementation Research (CFIR), which categorizes 39 implementation constructs into five domains. These constructs serve as influential factors in implementation outcomes and provide a structured approach for assessing implementation context, evaluating progress, and explaining findings in research and quality improvement efforts. CFIR, in particular, differentiates between the intervention’s inner and outer settings [18,33–35]. The inner setting describes direct and active forces influencing the intervention, whereas the outer setting captures macro-level factors surrounding the inner setting [18,23]. In the context of our program, we identified resident coachees and faculty coaches as the inner-setting stakeholders. Medical education leaders and programmatic sponsors who provided support outside the act of coaching comprised the outer-setting stakeholders, as presented in Figure 1. Figure 1. Stakeholder groups: mapping with CFIR nner and outer settings.

Interviews

Interview questions were developed based on the CFIR concepts with input from experienced medical education and evaluation researchers. They were then pilot-tested among a few individuals knowledgeable about the subject but not directly involved in the communication coaching program under study.

Semi-structured interviews lasted between 30 and 45 minutes and captured stakeholders’ perspectives on physicians’ communication training needs, roles and involvement, facilitators and barriers to implementation, and strategies for programmatic improvement. Interviews were conducted by a research analyst experienced in qualitative methods (M.S.) between November 2021 and April 2022 via the ZOOM videoconference platform (Versions: 5.8.4 (2421)-5.10.3 5.10.3 (6420), Zoom Video Communications, Inc., San Jose, California, USA, 2021–2022), and then audio-recorded, professionally transcribed, and deidentified for analysis. Each interview participant verbally consented to participate in the study and be recorded. The study was classified by the local Institutional Review Board (IRB) as a Quality Improvement Project and exempt from the IRB review. Interview questions are presented in Appendix 1.

Analysis

We performed a rigorous team-based thematic analysis, which was organized using NVivo qualitative software (Version Pro Enterprise, QSR International Pty Ltd, Massachusetts, USA, 2020) [36]. The first part of the analytical process included the development of a codebook by the three raters (M.S., a PhD-level qualitative methodologist and social scientist; R.M.J., an MD-level surgical education fellow; and U.T.M., a BS-level social science researcher) in the following steps: (1) they independently coded four interviews, taking an inductive approach to immerse themselves in the data and search for meaning and essential patterns; (2) after several team discussions, R.M.J., deductively developed the first draft of the codebook by coding the same four interviews using CFIR domains and constructs as codes; (3) M.S. and U.T.M., using the first draft of the codebook as a guide, also deductively coded those four interviews [37]. During this phase of the analysis, they frequently met to compare coding and discuss ambiguities. Codes were removed, added, and merged as needed, and definitions and usage of the codes were agreed upon and refined; (4) a 20-item codebook based on the CFIR 1.0 framework and adapted to the content of the interviews with the Communication Coaching Program’s stakeholders was developed iteratively, followed by discussion and approval by the whole analytics team (C.A.G., A.K.N., J.R.K., A.M.M., and R.K.M.).

Next, the codebook was used to access the inter-coder agreement, measured by calculating Cohen’s kappa coefficient. It was assessed by running a code comparison query between M.S., R.M.J., and U.T.M. after independent coding of three new interviews. They met after coding each interview to discuss challenges and ambiguities and further refine the codebook. With each successive interview being coded, the coefficient increased (the average kappa, calculated as a mean of kappa between each pair of researchers, was 0.76 for interview #1, 0.77 for interview #2, and 0.92 for interview #3). After a ‘perfect’ (0.83) inter-rater agreement [38] was achieved for the three interviews, all remaining transcripts were split between M.S., R.M.J., and U.T.M., and each coded 11–12 interviews applying the final 20-item codebook. No new codes were identified from this point forward. The codebook is presented in Appendix 2, and the prevalence of categories and codes upon the completion of the coding process is provided in Appendix 3.

Validation techniques were used to enhance the credibility and trustworthiness of the study. These included prolonged engagement with data, triangulation of research and participants, utilization of a theoretical framework, team consensus on codes and themes, documentation of all steps of the analytical process, independent coding, and seeking of disconfirming evidence [39].

Results

Participant characteristics

We conducted 35 interviews with stakeholders directly involved in the Communication Coaching Program including 10 residents, 10 faculty coaches, 9 medical education leaders, and 8 programmatic sponsors from the neurology and surgery departments, broader medical school, and academic medical center, as depicted in Table 1.Table 1. Participant characteristics (n = 35).

Department	Stakeholder Group	Total	
Resident
Coachees	Faculty
Coaches	Medical Education
Leaders	Programmatic
Sponsors	
Neurology	6	4	4	2	16	
Surgery	4	6	5	1	16	
Other1	0	0	0	5	5	
Total	10	10	9	8	372	
Note. 1programmatic sponsors from the department of pediatrics (2), medical school (1), and academic medical center (2); 2one participant held various roles (coach, medical education leader, and programmatic sponsor) and was counted thrice; therefore, the total in the table is greater than the total number of participants.

Each distinctive stakeholder group played a different role in developing and implementing the Communication Coaching Program, and thus, engagement levels varied across the groups. For example, residents, the primary recipients of the program, received coaching and feedback on their communication skills. Coaches were responsible for observing resident-patient encounters and providing coaching and feedback. Medical education leaders planned and executed the initiative, coordinated day-to-day programmatic efforts on the departmental level, and facilitated stakeholder collaboration. Programmatic sponsors provided encouragement and financial support.

Strategies to foster stakeholder engagement

The analysis revealed five strategies to facilitate stakeholder engagement, which are presented below. Additionally, Table 2 includes examples of direct comments from participants to further illustrate strategies.Table 2. Strategies to facilitate stakeholder engagement.

Strategy	Exemplary Quotations	
Strategy 1: Embrace Collaborative Design to Ensure the Program’s Relevance and Alignment with Local Needs, Interests and Motivations	The residents had a wish to improve their communication skills, we’ve done formal focus group needs assessment… Then we had designed this across departments […] to show that it was something that could help all different kinds of positions. Then we had sought an inclusive group of faculty to be the coaches and had open applications and an interview process […] included residency program directors and chief residents, so there’s a resident prospective on who should be a coach … All of these were … attempts at being inclusive for the various stakeholders that were helpful in securing engagement and increasing the validity of the program, even before it launched. R09 (Medical Education Leader, Neurology)

I feel like the opportunity to make that impact for the future generation is very important. R08 (Coach, Surgery)

	
Strategy 2: Enable Flexible Adjustments and Modifications to Enhance Stakeholder Perceived Value	If it’s tailored to what they feel is important, then there will be obviously more buy in and engagements, and that could differ by what year the person is, maybe what specialty they’re in. R26 (Resident, Neurology)

I think some of the things that we’ve focused on … would be appropriate for a first-year resident to focus on, but I think when you progress to your third, fourth, fifth year … , more of a focus on how you lead a team, or your communication skills in the operating room or those sorts of things or even job skills … Those are the things that I think would be more appropriate when you get to become a senior resident. R34 (Resident, Surgery)

Uniqueness that we’ve had […] comes to the way our residents work compared to the neurology and pediatrics, for example, their day is more regimented and controlled … . The model that they have created doesn’t necessarily fit with our model. R12 (Medical Education Leader, Coach, Programmatic Sponsor, Surgery)

	
Strategy 3: Secure Funding to Improve Participation Ability and Coach-Resident Relationships	Having dedicated funding slash dedicated resources is very important just because it allows me to focus my limited amount of time … , dedicate specifically a portion of that to coaching and communication skills. R28 (Coach, Surgery)

Funding is key. If the funding is not there, then what coaching is would have to change. It would be very difficult to sustain specific faculty directly observing residents in setting aside for developing these relationships with their resident coachees. R09 (Medical Education Leader, Neurology)

	
Strategy 4: Identify Champions to Facilitate Stakeholder Acceptance and Navigate Change	Engagement from other faculty might be a barrier … If people see it role-modeled that communication is less important, they might minimize wanting to spend time training … or paying attention in this area. Meanwhile, if they see other faculty who really highly engage in and understand the importance of communication, then they might hold it more highly. R19 (Programmatic Sponsor, Pediatrics)

	
Strategy 5: Demonstrate Outcomes to Validate the Positive Impact of the Program.	Successful outcome would be residents that feel confident in leading a conversation and confident that they can be flexible in changing the direction of a conversation. R01 (Coach, Neurology)

One [factor] would be that the participants feel like they gain something, they learn something, they’re better at something, that subjective assessment. Then the second area would be objective. That you have some outcome you can measure that shows there was an effect. I think you need both of those… Value demonstration. R21 (Programmatic Sponsor, Neurology)

I think … , if … , by the time I’m graduating, I sense a change in the surgical culture, where people are notably nurturing each other, helping each other thrive, respectful and happy to be at work together, and are saying things where you can clearly see they’re inspired by each other, I think that would be a success. R35 (Resident, Surgery)

	

Strategy 1: embrace collaborative design to ensure the program’s alignment with stakeholders’ needs, interests and motivations

According to participants, stakeholders’ input was incorporated into the program’s design phase. The Communication Coaching Program leaders made deliberate attempts ‘at being inclusive for the various stakeholders … even before it launched’ (R09, Medical Education Leader, Neurology). For example, residents contributed insights through the needs assessment and were keenly interested in coaching on communication, specifically, guiding the direction and shape of the program. Expert stakeholders from an established coaching program in a third department (Pediatrics) were involved early in the process, which allowed leaders to build on prior successes rather than starting from scratch. The inclusivity extended to the selection of faculty coaches, involving an open application and interview process, engaging residency program directors and chief residents. Such a collaborative involvement of stakeholders fostered a sense of ownership and inclusion.

Stakeholders’ coproduction of the program highlighted their diverse reasons for engagement. Residents were driven by a desire to acquire new skills needed in their medical practice, build confidence, and improve patient encounters. It was essential to frame the program in a way that was helpful to them, fostering relationships with coaches and mentors and providing opportunities to enhance their communication skills. Coaches sought personal growth as physicians while guiding and mentoring residents to become better communicators. They were motivated to improve residents’ feedback skills and contribute to the department by playing a role in the professional growth of a new generation of doctors as ‘the opportunity to make that impact for the future generation is very important.’ (R08, Coach, Surgery). Additionally, coaches recognized the value of communication in medicine and believed it was inadequately taught in medical schools. For the Communication Coaching Program leaders and residency program directors, engaging in the communication program provided valuable experience in leading a program and contributed to the unique offerings during residency, potentially attracting prospective residents. They were interested in enhancing communication skills in medicine in general and believed that coaching could effectively advance adult learners. Recognizing effective communication as a factor contributing to reducing misunderstandings and errors, those stakeholders considered it a central aspect of residency education.

Strategy 2: enable flexible adjustments and modifications to enhance stakeholder perceived value

Respondents emphasized that while the program should be designed to address pressing issues in a feasible way considering local resources and limitations, it should also remain flexible during the implementation phase to allow for adjustments and modifications in response to evolving circumstances or emerging needs. For instance, respondents shared that the differences between neurology and surgery, with each having different program structures, schedules, and hours due to the distinct nature of their residency programs, were more significant than expected despite careful pre-implementation preparations. The ‘one-size-fits-all approach’ was deemed unsuitable, urging a more practical strategy. For example, one respondent noted that the model tailored for neurology and pediatrics didn’t align with the unpredictable schedule of surgical residents (R12, Medical Education Leader, Surgery). Surgery coaches and residents did, in fact, encounter logistical challenges in finding suitable meeting times across various clinical spaces, contributing to stress. To mitigate these issues, the surgery program adopted more flexible strategies around scheduling. For example, one surgery coach openly permitted residents to ‘cancel last second or…don’t even show up [for the coaching session, if they left the] OR late’ (R05, Coach, Surgery).

Additionally, participants pointed out the importance of tailoring the program to the changing communication needs of stakeholders (due to the progression of the training, for example) to ensure its value and relevance. Junior residents expressed interest in patient communication, while senior residents aimed to enhance team communication, leadership skills, and interview tactics for job or fellowship opportunities. Interviewed residents also mentioned the necessity of involving them in the evaluation process and making changes based on their feedback, such as allowing more flexibility regarding coaching topics or settings.

Strategy 3: secure funding to improve participation ability and coach-resident relationships

Participants highlighted the importance of adequate financial support from sponsors in promoting engagement among inner-setting stakeholders. Time limitations emerged as a significant barrier for both coaches and residents, hindering their participation, even when they acknowledged the program’s value. Challenges in scheduling meetings compounded this issue, emphasizing the need for institutional support to provide the necessary structure and resources to overcome these constraints. Securing funding for administrative support to assist with scheduling coaching sessions and handling administrative tasks emerged as a key recommendation to alleviate the burden on busy coaches and residents.

Dedicated time for coaching, financially supported by programmatic sponsors, was underscored as one of the most critical factors facilitating coaches’ participation. This support allowed them to allocate the time and effort required by the program by reducing their workload in other areas. As one coach highlighted, ‘thanks to the very gracious financial supports … , [coaches] have more time … [and] work fewer weeks in the ICU’ (R04, Coach, Neurology). Residents, who were not provided secured time to participate in the program, emphasized the need for dedicated time to fully leverage coaching opportunities.

Participants also emphasized the positive impact of providing stipends for coaches to cover resident-related needs, such as meals. Small acts of kindness, like buying a resident a cup of coffee or treating the whole team to lunch, played a crucial role in building coach-resident relationships and fostering a trusting environment, as noted by one respondent (R24, Programmatic Sponsor, Academic Medical Center). Furthermore, ensuring funding was highlighted not only as a way to enhance stakeholder participation but also as an absolute necessity for program sustainability.

Strategy 4: identify champions to facilitate stakeholder acceptance and navigate change

The early identification of champions was considered vital for securing initial stakeholder engagement, as they could effectively advocate for the program and model the desired behaviors. Participants emphasized that the process of integrating new ideas often meets resistance due to a lack of trust and uncertainty about the potential impacts. In these moments of apprehension and resistance, champions become instrumental in navigating change and offering guidance amid uncertainty. Participants stressed the importance of dedicated advocates who could motivate and engage others in the program.

Study participants identified a diverse array of champions. Leadership support from residency program directors emerged as pivotal for gaining buy-in from the broader medical community and ensuring smooth execution. Also, the Communication Coaching Program leaders were singled out as the ‘face’ of the program, guiding implementation efforts. Respondents also stressed that, given potential barriers to engagement from faculty, having faculty champions advocating for the program could be key to encouraging other faculty members’ buy-in. As one participant mentioned, ‘If they see other faculty who really highly engage in and understand the importance of communication, then they might hold it more highly.’ (R19, Programmatic Sponsor, Pediatrics). Finally, senior residents were considered influential advocates who could share success stories and encourage junior residents to participate actively. According to another respondent, ‘if you can get … senior residents … to buy into this and start promoting it, it’ll … make it a lot easier to get the junior residents to do it’ (R16, Medical Education Leader, Surgery).

Strategy 5: demonstrate outcomes to validate the positive impact of the program

Participants underscored the significance of demonstrating the program’s success in reinforcing engagement and ensuring a return on investment of time from inner-setting stakeholders and resources from outer-setting stakeholders. Although measuring communication improvement was acknowledged as challenging in general, respondents noted some potential methods of measurement, ranging from direct resident observations and patient surveys to resident surveys, interviews, and comprehensive evaluations. Programmatic sponsors and medical education leaders expressed interest in more ‘concrete’ outcomes, such as improving patient satisfaction, efficiency, and quality improvement scores.

Respondents universally stressed the need for the program’s validation through its impact on residents. They suggested a blend of resident-centered subjective measures, including perceived or observed enhancements in leading conversations, building rapport with patients and family, increased confidence levels, and reduced stress in challenging situations. The ultimate aspiration, as expressed by one participant, was to graduate trainees who embody compassion, active listening, rapport-building skills, empathy, and effectiveness in accomplishing tasks (R15, Medical Education Leader, Neurology).

Stakeholders across roles also believed that the Communication Coaching Program had the potential to foster a positive cultural change within the system. Examples included envisioning a shift in surgical culture augmenting collaboration, mutual support, respect, happiness at work, and inspiration among colleagues (R35, Resident, Surgery). Another participant highlighted the shift from a ‘performance mindset’ to a ‘growth mindset,’ fostering a culture of lifelong learning and enhancing physician well-being (R19, Programmatic Sponsor, Pediatrics).

Patient-centered approach as a primary objective

Amid diverse motivations and needs, the central idea of patient-centeredness linked all stakeholders, emphasizing the collective commitment to delivering the best possible patient care. Communication skills have been identified as a crucial aspect of providing quality care, according to all groups of participants. Better communication with patients and other teams would improve patient care (R33, Resident, Surgery). Effective communication helps providers build rapport and relationships with patients, which fosters trust, care, and support. It also enables providers to understand patient goals and tailor care to meet their needs (R10, Medical Education Leader, Neurology). Stakeholders’ comments on the importance of a patient-centered approach are further illustrated in Figure 2. Figure 2. Stakeholder commitment to patient-centered care.

Discussion

Implementing a new program that is both successful and sustainable requires careful orchestration and engagement of a host of stakeholders [12–22]. Our qualitative study, conducted through interviews with key stakeholders in our institution’s Communication Coaching Program, offers practical strategies for fostering stakeholder engagement. These strategies are interrelated and reinforce each other.

The findings showcase the importance of meaningful and iterative involvement of stakeholders throughout the entire implementation process, which supports prior research on the coproduction of medical education and training [16,20,40–42]. As this work underscores, stakeholder engagement should start at the beginning of the design process, where collaborative efforts with the intended learners not only improve programmatic quality through tightening the alignment between programmatic offerings and existing educational gaps but also instill a sense of ownership in the program, organically fostering local learner champions. Additionally, collaborative design with the institutional stakeholders in a position to fund the program ensures that the program is in line with institutional objectives, increasing the likelihood of ongoing funding. Furthermore, given the difficult logistics of aligning coach and coachee schedules in a busy, complex clinical environment, funding to protect both the coach and coachee’s time is important. This, in turn, underscores the importance of rigorous programmatic evaluation, which requires its own resources, to assess return on investment and further secure funding for the program [43–46].

The partnership between the neurology and surgery resident coaching programs has highlighted the need for ongoing programmatic iteration, which is consistent with other studies [30,44,45]. These residency programs operate in different clinical settings, with different attending and resident schedules, communication needs, and departmental and training program cultures. Hence, for this structure to succeed in other departments or institutions, it must be viewed as an adaptable blueprint rather than a firm set of rules.

Finally, while this robust qualitative study was conducted in the context of engaging stakeholders toward a communication coaching program specifically, a review of the lessons learned – attention to collaborative design, enablement of iteration, attainment of financial support, and identification of local champions – strike as having strong potential for broad applicability to educational endeavors in inevitable complex systems with layers of stakeholders. Moreover, in an environment where the coachee, coach, the coaching program leaders, and organizational leaders endorsed quite distinct motivations, providing quality care for patients emerged as a universal area of alignment. Therefore, keeping the patient in the center of focus can highlight shared goals above areas of divergence [47].

There are a few limitations to our approach. While this robust qualitative inquiry included perspectives at many levels of training and organization leadership, a limitation and important future direction is the inclusion of patient perspectives. It should also be noted that qualitative research, by its nature, is non-representative, although the large quantity (35) of interviews among diverse stakeholders allowed for capturing a broad spectrum of perspectives. Finally, this work was completed within a single institution, albeit within two departments with different cultures and structures. This reiterates the importance of adapting any programmatic blueprint carefully to local needs, which will be of increased importance for dissemination between institutions.

In conclusion, the successful implementation of our Communication Coaching Program relied on engaging stakeholders at all organizational levels throughout the entire implementation process. A rigorous qualitative analysis among 35 different stakeholders revealed diverse perspectives, with universal alignment around the overarching objective of delivering quality care to patients. These strategies for stakeholder engagement hold significance as more programs transition toward implementing coaching interventions.

Supplementary Material

Supplementary Material.docx

Acknowledgments

The authors would like to thank Mystique Smith-Bentley RN, MBA and the Office of Patient Experience at Stanford University for their championship of coaching programming.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Due to the sensitive nature of the qualitative data collected for this study, we have chosen not to share it publicly. This decision was made to protect the confidentiality and privacy of the participants and uphold ethical considerations.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/10872981.2024.2407656
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