Improving quality in hospital induction programmesBMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7131.2 (Published 21 February 1998) Cite this as: BMJ 1998;316:S2-7131
Effective doctors must master the hospital infrastructure as well as their specialty. Simon Ward analyses the course that helps junior doctors make smooth transitions between jobs
An effective and high quality introduction to a new place of work intuitively seems a sensible idea. Meeting new staff and finding out their individual practices and patterns of work ought to help the efficiency of the hospital and the smooth running of a department, while at the same time facilitating an untroubled handover of responsibilities and patient care. These are noble aims but they are not always satisfied. Almost every doctor will remember finding out peculiarities about a post that they wished they had known at the start of their job. Things go wrong or are delayed, staff and patients get frustrated, complaints may start, and all while the new staff are “finding their feet.” These difficulties are particularly prevalent in the NHS around August and February each year, as fresh intakes of trainees come to terms with the challenges of their new jobs. A risk management strategist or a quality control expert would have much to comment on.
Quality of induction patchy
An induction programme is mandatory for new preregistration house officers.1 Induction is also recommended for all other new trainees, although the programme content and format are not specified in detail.2-7 Most hospitals currently run some form of induction programme, but their length and content vary.3 It would be reassuring to think that this variety is due to a prior assessment of the differing expectations, needs, and requirements of the diverse group of trainees encountered at induction programmes, but there is little evidence to support this. More likely reasons for the diversity in programmes are differences in published lists of suggested topics,1 5 or the differing availability of local speakers, or simply tradition and political correctness. What published research there is on induction3 8 concentrates solely on preregistration house officers and does not discuss the lost and breeding tribe of senior house officers.9 10
Currently most program-mes and topics are chosen by senior staff, though there are recommendations which suggest that trainees should be involved in the planning, selection, implementation, and evaluation.8 11
Programmes generally consist of a single induction day which usually has a busy schedule of formal didactic presentations,3 8 which can easily lead to boredom and information overload. These induction programmes are often repeated on successive batches of trainees and there is little evidence that programmes are evaluated for their usefulness or value to the trainees who attend.3
Doctors want it-here's how
In order to investigate some of these problems, the Training of Doctors in Hospital project at the University of Cambridge School of Education, undertook structured interviews on senior house officers from different specialities in five hospitals in the Anglia region.12,13 Trainees were asked to rate the value of induction topics, collated from the literature, on joining a new hospital job. Preferences for presentation style and format were invited. They were also asked at what stage in their post the topics would be best provided.
The findings of this study suggest that trainees value certain information at the beginning of a new job and wish it to be provided during the early stages of an induction programme: the information that allows the trainees to survive and work effectively from the first day in post (see boxes).
Topics to cover on day one of an induction programme.
Service processes and procedures
Ordering investigations, hospital forms and notes, service departments, admitting and transferring procedures, discharge drugs and procedures
Understanding hospital services
Bleeps, switchboard, car parking, ID, support staff
Personal and comfort requirements
Accommodation, housekeeping, catering facilities
Orientation to the new environment
Mess and hospital facilities, timetables, rota
Essential practical skills
CPR and hospital computer
Professional and financial concerns
P45, contracts, indemnity
Coordination and integration between the general hospital induction and individual department introductions was conspicuous by its absence.
Information concerning professional development, education and training, exams, and careers advice was highly valued, but was considered to be most appropriately given a few weeks later, once trainees had settled into their post (see boxes). Trainees wanted to make sure that these topics were actually provided at this later stage, however, and not forgotten or neglected due to pressures of service or other commitments.
Speak, write, act
Written information that supplemented the formal verbal presentations and was restricted to essential information was highly valued. Much of this information can be contained in a pocket sized trainee handbook, which can usefully be partly written by outgoing trainees. Varied methods of presentation and delivery were most popular, with a combination of written and verbal information with practical demonstrations: “hands on” melange of cardio-pulmonary resuscitation skills and training on the hospital computer are highly valued activities.
Allowing time for networking, making friends, and chatting among past and present peers was endorsed. This helps new staff to begin to develop informal systems of peer support and advice, as well as learning any idiosyncratic information about a particular post. All of these lead to the growth of an espirit de corps, which is essential for good teamwork and collaboration and consequently for easing the grind of service workload.
Many of these findings are consistent with sound educational theory and adult learning methods14: for example, assessing trainees' needs, using a variety of methods to promote interest and learning, and keeping the topics orientated around practical, meaningful, and relevant issues. The Cambridge study also highlights the value of learning by informal methods from peers and networking. It is also important to attend to the disparate needs of new staff, while at the same time monitoring, evaluating, and adapting a flexible programme according to changing needs and circumstances over time.
A universal and unadaptable programme cannot come close to these ideals. Overall, the findings suggest that induction should not be thought of as a one off, first day event, but rather as a staged programme continuing into the post. Thus stage one, on day one, can provide key service information. This is followed by stage two, which is provided after a week or two and focuses on education and training issues, for example trainee and trainer expectations or how to develop learning and training opportunities.12 13 Attendance during stage two can be increased by using established lunchtime educational slots and the added incentive of food.
Well structured training
Some of the inevitable anxieties at the start of a new job can be relieved by an effective and appropriate job induction. A lot of new information must be assimilated by the trainees in a short space of time and a trainee handbook can be very useful for this.
The process of induction can be facilitated by a well designed programme, coordinated with introductions at the department level. Such an organised programme then allows trainees to settle into their job more quickly and easily. They receive the information they need at a time when they need it and in a format that makes the process valuable and interesting. The trainees can then become integrated into the local system more promptly, can make a more effective and competent contribution to the service commitment, and can also gain more from the training provided.
Topics to cover a few weeks after trainees are in post
Generic skills, information technology, ethics
Education and training
Study leave, meeting educational supervisor and clinical tutor
Exams and courses
Trainees ought to be more involved in the running of induction programmes, especially now that there is an overlap between incoming and outgoing preregistration house officers. Although some effort and commitment are required to develop and sustain a useful and relevant induction, the potential benefit over the ensuing months can be enormous.
Policy makers should consider the role of incentives more carefully before moving to increase the physician workforce by increasing medical school entry, argue two economists in a recent Nuffield Trust report.
They also support the calls for measures of the supply of physician services in other ways than the present raw numbers or whole time equivalents, preferably so that clinical and non-clinical work can be distinguished. This might allow for more delegation and teamwork, particularly in primary care.
The economic analysis on which the report is based is illustrated with a line diagram that purports to show that the number of whole time equivalent physicians proportionately increases in line with the physician wage rate. Life may not be quite so simple: although the report accuses policy makers of ignoring “fundamental micro economic relationships,” the sums of money that must be paid to prevent: (a) women bearing children; (b) disillusioned doctors leaving the NHS or emigrating, and (c) overburdened doctors taking early retirement are, mysteriously, not explicitly stated. Finally, the report makes the sensible point that policy makers cannot ignore the European and global dimensions of their decisions: there is an urgent need to calculate balances of physician supply and demand within the EU and to re-examine the current policy of deprecating “reverse foreign aid” (in which doctors trained in the developing world are recruited for the health services of wealthy countries).
Maynard A, Walker A. The physician workforce in the United Kingdom: issues, prospects and policies. London: Nuffield Trust, 1997.
The Anglia and Oxford Postgraduate Medical and Dental Education Committee funded this study.