The art of NHS inductionBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c274 (Published 03 February 2010) Cite this as: BMJ 2010;340:c274
- Emma Stanton, psychiatry specialist registrar, seconded to the chief medical officer1,
- Claire Lemer, paediatric registrar2
Emma Stanton and Claire Lemer look at how the NHS does induction, and how it should change
Induction to the NHS is a rite of passage for each of the 15 000 doctors starting new jobs every August. At present, induction is formulaic and uninspiring. A valuable opportunity is being lost to introduce new colleagues to the vision for the NHS, to develop insight into the local healthcare organisation and population health needs, and to create a sense of teamwork and institutional loyalty.
A review of hospital induction programmes in the Anglia region showed that trainees valued being given certain information when they started a new job.1 Box 1 shows the topics that junior doctors wished to be included in the early stages of an induction programme.
Box 1: Topics to cover on day one of an induction programme1
Service processes and procedures—Ordering investigations; hospital forms and notes; service departments; admission and transfer 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—Cardiopulmonary resuscitation; hospital computer
Professional and financial concerns—P45; contracts; indemnity.
A questionnaire completed by 107 consultants and 121 specialist registrars from two teaching hospitals in the East Midlands found junior doctors “were seen as not prepared for starting work, especially in regard to clinical and practical skills and the more challenging communication skills.”2 The experiences of six foundation year doctors describing their first day at work in August 2009 suggests that there is more the NHS could do to improve the quality of induction.3
This article reviews what induction means for Generation Y and presents the findings of an online survey comparing the induction experiences of junior doctors and NHS management trainees.
Generation Y style
Most junior doctors are from Generation Y (aged up to 28 years). Research on what “Gen Y” want from the workplace, from a 26 question survey of 2521 respondents, is shown in figure 1⇓.4 This suggests that Gen Y think differently to Generation X (aged up to 42 years) and the baby boomers (aged up to 62 years) about work, learning, and relationships. Up to 80% of Gen Y who were surveyed said that a good induction was important when starting a new job. Induction was considered more important than earning lots of money or fast promotion.
How Gen Y learn best is when it is fun or through mentoring or coaching (fig 2⇓). When considering redesigning induction programmes, it is important to note that computer based learning and classroom style learning are unpopular with Gen Y. The survey described below showed that 55% of junior doctors received online training as part of their induction. Negative comments received about this were that such modules were frequently “poorly written,” “irrelevant,” and “long winded and took up large amounts of personal time.”
Junior doctors’ experiences of induction compared with NHS management trainees’
In September 2009, 42 junior doctors completed an online survey about their most recent experiences of induction (from BAMMbino, www.bamm.co.uk). Sixty two NHS management trainees completed the same questions, shown in box 2, in November 2009.
Box 2: Induction survey questions
1. On a scale of 0 to 10, with 0 being the worst and 10 being the best, how would you score your most recent induction programme? Why?
2. What percentage of your most recent induction programme was spent on functional training such as fire safety?
3. Was patient safety discussed at your induction programme?
4. Please tick if you met either of these people during your induction programme?
5. Did you receive any online training either before or as part of your induction programme? If yes, what did this consist of?
6. Did your induction programme teach you more about your organisation and the patients you will be working for so that you can work more effectively?
7. Do you feel part of a team as a result of your induction programme?
8. Do you feel more inspired about your job as a consequence of your induction programme? Why?
9. Does the organisation you are working for have a vision that was clearly stated during your induction programme?
10. Please state what you think the point of your most recent induction was.
The findings are stark—no attempts to inspire and create institutional loyalty; limited attempts to explore the local health organisation and population health needs; and an overall cynical reaction to induction. Of note, medical trainees seem more detached from the process than their managerial colleagues, perhaps because the managers are more likely to meet a senior executive face to face during induction. Only 19% of junior doctors met the chief executive of their trust at induction, whereas more than 50% of management trainees reported meeting the chief executive during their induction.
Figure 3⇓ shows that NHS management trainees are more positive about their most recent induction experiences when asked to score them out of 10, with 0 being the worst and 10 being the best. The most frequent score given by management trainees was 8 out of 10 (21% of responders), whereas the most frequent score given by junior doctors was 3 out of 10 (24% of responders). Induction for NHS graduate management trainees introduces participants to all aspects of the organisation. This includes acute and mental health care, primary care trusts, and the ambulance service. This provides new management trainees with an overview of the whole organisation, which is not currently part of junior doctors’ induction.
Forty nine per cent of junior doctors and 66% of management trainees spent less than one fifth of their induction on functional training, such as fire safety. Despite recent high profile cases of poor patient safety at Mid Staffordshire and Basildon and Thurrock Foundation Trusts, 40% of junior doctors surveyed did not recall patient safety being discussed at their most recent induction. More than 80% of management trainees, however, did discuss patient safety at their induction.
On the basis of the findings of this small survey, the majority of junior doctors (57%) were not taught about their organisation and the patients they would be working for, compared with only 21% of management trainees. Disappointingly, more than two thirds of junior doctors did not feel part of a team as a result of their induction programme. Nearly half of management trainees did not feel part of a team following their induction experience.
More than 80% of junior doctors and 47% of management trainees did not feel more inspired about their jobs after their induction programme. More than two thirds of junior doctors and management trainees were unable to recall a vision for the organisation they work for clearly stated during their induction. When asked about the point of induction, both sets of responses were infused with cynicism: “tick box exercise,” “to ‘protect’ the trust rather than to help patients or make me feel more welcome.” Online training was described as “very long winded and annoying induction modules.”
Onboarding: learning from other organisations
The NHS has yet to embrace the potential benefits of induction, although there are signs that this is changing. North Middlesex University Hospital is moving towards unified corporate induction, where all staff are inducted together rather than in professional silos.
Other industries have focused time and attention on this area because of the relationship between induction, absenteeism and staff retention, and employee productivity. The Aberdeen Group (a leading provider of research on global technology) found that “90 per cent of employees make their decision to stay at the company within the first 6 months.”5 High performing companies turn these crucial months into a positive experience before the employee even sets foot in the company. The Aberdeen Group found that high performing organisations were 35% more likely to have a “new hire programme.” Within this programme there were four key components for success: beginning before day one (that is, the process of introducing the environment should begin before the doctor starts work); continuing for at least six months; making “socialisation” part of the process; and identifying the important business issues and making these part of the programme. The Aberdeen Group call this process of immersion and induction “onboarding.”
It is clear that there are key differences between this approach and induction into the NHS. Successful onboarding focuses on reaffirming an employee’s decision to join an organisation—the findings of the above survey show that the NHS appears to be having the opposite effect. Onboarding seeks to immerse the new recruit into the institutional culture—it is clear from the survey that those experiencing NHS induction, however, lack information about the corporate culture of the NHS. Furthermore, onboarding seeks to make process issues, such as paperwork, easy, and links induction to appraisal and assessment or personal development: both of which lack emphasis in NHS induction.5
Achieving these core features does not need to rely on complex technology or expensive interventions. It requires a shift from a procedure driven process to one where the aim is to welcome new employees, to capture hearts and minds, and to enthuse.
Many organisations have made inroads into this with simple strategies such as issuing welcoming DVDs, providing books and information on the history of the organisation, ensuring access to executives, particularly in less formal settings, and, most importantly, celebrating the new recruits. Box 3 shows the experiences of a junior doctor’s induction to a secondment at McKinsey and Company management consultants.
Box 3: Induction to McKinsey and company
My induction to McKinsey and Company began in the board room. A small group of new arrivals spent over a week immersing ourselves in the corporate culture, being provided with the tools of the trade—a laptop, a BlackBerry, and a credit card—and learning about the values of the company alongside the practical skills needed to start work. At the end of long days spent grappling with Excel were opportunities to socialise, meet key individuals, and be made to feel welcome and special.
Recommendations for the future
The findings of this small survey suggest that induction programmes for junior doctors could learn from the induction programmes provided for NHS management trainees. The NHS could also look to other organisations to learn about successful approaches to engaging employees. The Gen Y research shows that induction is important and that Gen Y-ers learn best when it is fun and multisensory, and through their peers.
At the heart of improving induction is a shift towards a culture where institutional loyalty is sought. Following the example of corporate induction in other industries, the NHS could make a number of small alterations to achieve this.
Following the corporate example means starting induction early, as well as changing the language of job offers from a bureaucratic function to an enthusiastic welcome, and doing so as soon as possible to allow doctors to make the necessary changes to their lives.
Learning from John Lewis, the department store, one further practical suggestion for improving junior doctors’ engagement with the NHS, and to do so early on, is to create an induction DVD. This would introduce new employees to their organisation, clearly stating the background and aims of the NHS through brief interviews with key senior leaders such as David Nicholson, chief executive of the NHS; Bruce Keogh, medical director of the NHS; and Liam Donaldson, chief medical officer. Sending such a DVD before junior doctors’ induction would inspire them and help to develop a wider awareness of the environment in which they will be working. It also allows for the induction process to focus on core business issues, reminding doctors of what is important for the NHS.
Following the example of the North West Deanery, making the deanery the sole employer would reduce the unnecessary and time consuming paperwork, such as repeatedly filling out occupational health forms. This would considerably streamline the induction process.
Finally, following the lead of organisations such as the North Middlesex, integrating staff induction not only improves teamwork and a sense of belonging, but, by reducing the number of inductions required, means that there is possibly more likelihood of senior executives attending.
Too often, induction for junior doctors consists of a single day of formal didactic presentations that alienate our valuable workforce before they have set foot on the wards. This article presents the case for a radical overhaul of the way in which junior doctors are inducted into the NHS. There is a need to make induction fun, inspiring, and to cover crucial aspects of quality, including patient safety and teamwork, together with providing an opportunity to meet senior leaders within the local organisation, such as the medical director and the chief executive.