Effective foundation trainee local inductions: room for improvement?

© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 193–197 193193

Junior Doctors

Effective foundation trainee local inductions: room for improvement? Helen Thomson , Blackpool Victoria Hospital , Blackpool , UK Jessica Collins , Salford Royal Hospital , Salford , UK Paul Baker , North Western Deanery, Piccadilly Place , Manchester , UK

SUMMARY Background : We aimed to evaluate whether UK foundation trainees receive local unit inductions, and their timing, content and value. Methods : We used published literature and guidelines from the UK ’ s General Medical Council ( GMC ) and National Health Service Litigation Authority ( NHSLA ) to identify key topics to be covered at the induction. We surveyed all foundation doctors in the North Western Foundation School and used questionnaires to assess inductions for the posts starting in December 2011. Results : The total response rate was 45 per cent, but this covered

100 per cent of the programmes and departments in the school: 22 per cent received an induction before their post; 10 per cent received no induc-tion whatsoever. There was a large difference between how useful trainees fi nd most topics and how often they were pro-vided. Some departments use more interactive formats in induction, such as e–learning and practical workshops. Overall, trainees expressed very positive views about the potential value of induc-tions, and 88 per cent felt that inductions should be standardised. Trust monitoring of inductions often appears to be unreliable.

Discussion : Timely, good-quali-ty inductions can potentially reduce service delays and improve patient safety. Inductions currently appear not to be prioritised in the trusts studied, and they are not focused on the needs of train-ees. Local inductions are currently suffering from a lack of guidelines into their imple-mentation. From this study we have drawn up a set of guide-lines for local induction and a template for an induction booklet. We recommend induc-tions should contain a minimum set of essential topics, be multidisciplinary, include more trainee input and be monitored more effectively.

Trust monitoring of inductions often appears to be unreliable

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194 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 193–197

INTRODUCTION

The UK Foundation Programme is the fi rst 2 years of training for doctors

after medical school, during which trainees rotate through six posts. It is a bridge between university and speciality training. This period of transition is very stressful for trainees who frequently change jobs, and worry about handling administrative and clinical demands with little knowledge of many routine procedures. Studies have found good-quality local inductions can reduce this stress. 1,2

Most trainees receive trust inductions at the very beginning of their training, but as they rotate through different depart-ments it is important that they also receive separate departmen-tal inductions. If doctors have little understanding of how things run locally then this may lead to delays and mistakes, and ulti-mately may compromise patient care. Good induction allows for better quality and care, 3–5 and several serious patient safety incident investigations have implicated the poor induction of the doctors involved as being a key contributory factor. 6–8

AIMS

1 . To fi nd out the proportion of foundation trainees actually receiving local inductions, and how timely such inductions are.

2 . To discover the typical content of departmental inductions and which topics are viewed as useful.

3 . To explore trainees’ views on the value of local inductions.

METHODS

We surveyed all foundation (year–1 and -2) trainees in the North Western Deanery, a large foundation school of 1100 train-ees in the north of England. The school consists of 13 programmes

each based at an acute trust. We collected responses by a combi-nation of distributing question-naires at teaching sessions and an online version. Information was also gathered about the methods used for induction.

When developing the stand-ards for induction, we reviewed the North Western Deanery ’ s 2001 Gold Standard for Induction guidelines, 3 General Medical Council (GMC) recommenda-tions, 4,9 published literature, 10,11 and the National Health Service Litigation Authority (NHSLA) Risk Management policy. 12

RESULTS

The total number of responses for the main survey was 459 (45%). All of the local departments in all programmes were represented.

Timing of inductions We found that 22 per cent of trainees received an induction before the start of their placement (range 7–44%): 63 per cent occurred in the fi rst week (range 52–83%); 5 per cent occurred around 2 weeks into the pro-gramme (range 0–22%); and in 10 per cent (range 1–32%) of cases there was no induction at all.

Content of inductions At least 81 per cent of responders found each topic included very useful or quite useful.

In many areas there was a big difference between how useful trainees rated topics to be and how often departments provided them. Figure 1 summarises this information.

Trainees’ views on inductions The majority of trainees reported fi nding local inductions useful (47% found them ‘very use-ful’ and 44% found them ‘quite useful’).

Around 64 per cent of trainees thought inductions improve clinician confi dence in the fi rst few weeks (18% felt that they improved in confi dence a lot, and 46% felt they improved a little).

Moreover, 74 per cent of responders felt that inductions improve patient safety (13%

Studies have found good-quality local

inductions can reduce stress

0 20 40 60 80 100

Special requirementsCrash trolley

Consent procedureFire proceduresContact details

Location of care protocolsTour of dept

Intro to key staffRole limitations

Security proceduresSickness & absence

On call dutiesWeekly timetable

Speciality specific adviceAnnual & study leave

Role & duties

Included in induction Rated as useful

Figure 1 . How often each topic was included in inductions across the whole study, and how often trainees rated each topic as ‘very useful’ or ‘quite useful’ ( n = 459)



thought they do not improve safety and 13% did not know).

When asked whether induc-tions should be standardised, 88 per cent felt that they should.

Regarding the consequences of omitting inductions, wasted time, decreased productivity and problems gaining access to systems were most commonly mentioned.

We found that 73 per cent of responders were aware of a monitoring process for their inductions. Some responders thought that the monitoring processes in place were ineffec-tive. Comments such as ‘monitor-ing takes place by tick sheets, which people just fi ll in usually weeks or months afterwards, without real thought’ were typical.

We contacted the medical education departments of the trusts to confi rm which systems of monitoring were in place for inductions. Nearly all have monitoring in place. Education departments sometimes collect attendance sheets and content lists, or assess inductions through end-of-placement feedback. Some trusts hold induction committees, in which department leads and the postgraduate department discuss ways to improve the process. However, a few trusts appear not to monitor inductions, or simply ensure that health and safety requirements are met.

Induction format Some departments set aside whole days for induction, some-times off site. These included a series of mini-lectures. Figure 2 shows the methods used for induction. The category ‘Other’ included: e–mails containing relevant department policies and protocols, seniors including orientation in weekly department teaching, DVDs and practical workshops. Induction booklets included prescribing checklists,

common scenarios and frequently asked question (FAQ) sections. Two trusts’ postgraduate depart-ments universally collect informa-tion from each post holder and collate it for a regularly updated booklet.

Consultants delivered the majority of inductions. Figure 3 shows the staff involved in inductions. ‘Other staff’ included skills facilitators, managerial staff, administrators, midwives, IT staff, middle-grade doctors and pharmacists.

DISCUSSION

Currently, trusts appear to guide the content of local inductions,

with consequent variation in content and quality. If the trainees were to guide them they might have a different focus, and likewise senior doctors may have different views on appropriate content and delivery. The feed-back from a large North Western Deanery study conducted in 2001 was that there should be more multidisciplinary input. 3 A ward manager can deliver much of the necessary information and nurs-ing staff could have an important role. Another previous recommen-dation was that trainees should receive a formal handover from the out-going trainee.

The use of a regularly updated booklet could make inductions

Trainees should receive a formal handover from the out-going trainee

Lecture

Shadowing

Department guides

e-Learning

Mini-lectures

Handout/booklet

Informal chat

Department based

Other

Figure 2 . The methods used for induction, discounting ‘on-the-job’ inductions ( n = 130)

Outgoing post-holder

Senior doctor

Ward manager

Senior nursing staff

Other staff

Figure 3 . Staff involved in the inductions ( n = 130)


196 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 193–197

easier to deliver. This could be issued as a mandatory component of the induction and would be easy to monitor.

There is evidence to support the use of case presentations, paper-based patient management problems, and treasure hunt-style hospital orientation. 13,14 E–learn-ing is helpful when used in combination with other meth-ods. 15 There is less evidence to support the use of a full day of didactic teaching in induction. Trainees prefer departments to deliver education, training and skills a week or two later rather than at induction. 16 It is valuable to allow trainees time for networking in inductions. 16

Ultimately, a successful programme is one that uses varied methods, a combination of written and verbal information, and a practical element, and remains interesting and focused to the needs of the trainees.

Limitations to the study Other than the North Western Deanery study of 2001 there were limited regional guidelines to follow. 3 The quality of inductions probably suffers from this.

Our results might differ from those of current monitoring undertaken by the trusts sur-veyed. Results from trust moni-toring may be falsely high as there is often pressure on trainees to return these forms in order to get systems access.

If repeated, certain questions need clarifying on the question-naire. It is likely that some trainees included informal inductions when responding to the questionnaires, so the fi gures for missed ‘formal’ induction might be higher. Some trainees may also have ranked compo-nents as less useful because they were poorly delivered, whereas if topics had been covered more comprehensively their view might have been different.

CONCLUSION

Trusts in this sample are failing to reliably provide local inductions for the majority of their junior doctors at the beginning of the place-ment, and a signifi cant proportion of junior doctors are receiving no induction at all. Furthermore, when inductions are provided, they often do not include content that new doctors might want.

It appears that the current monitoring of inductions by trusts is sometimes incomprehen-sive or unreliable.

Feedback about the potential value of inductions from trainees was very positive, and this appears to be an important topic to trainees. For junior doctors, improvements in the standard of inductions could result in fewer delays in the provision of service and a potential reduction in risk to patients.

If the standard of inductions is to improve there needs to be more guidance on content and implementation. The ideal would be a form of standardisa-tion, with room for fl exibility, but also with a minimum level that is monitored in a more autonomous way.

Trainees should have more input into the content of induc-tions and should be involved in the implementation. The focus of change to the process should consider a multidisciplinary approach and different modes of information handover (both paper and verbal).

Guidelines for local induction Combining the North Western Deanery Gold Standards for Induction , the guidance from both the GMC and the NHSLA, with the views expressed by trainees in a North Western Deanery local inductions audit,

A successful [induction]

programme is one that uses

varied methods

Box 1. Essential items for local induction, produced from NHSLA and trainee recommendations NHSLA recommended:

• Fire procedures

• Crash trolley location and contents

• Tour of department and introduction to equipment

• Log-ins for computers, security codes, security of belongings

• Refreshments, staff rooms

• Leave arrangements and forms

• Sickness and absence procedures

Trainee recommended:

• Introduction to key members of team

• Local policies/protocols/guidelines

• Trainees’ role and roles of others in team

• Role limitations

• Consent procedures

• Speciality-specifi c advice

• On call duties

• Rota

• Weekly timetables/meetings

• Useful telephone numbers



Inductions should be multi-disciplinary, including administrative and nursing staff

these guidelines are recom-mended for departmental induc-tions for foundation doctors. They represent the minimum standards for inductions; how-ever, we recognise the need for variation and fl exibility within different departments.

All trainees should receive a departmental induction before each post commences.

Inductions should include all the items shown in Box 1.

Departments should also give information to trainees in booklet form, containing a list of useful contacts and department-specifi c advice and information, and this should be updated for each new trainee in the post. Trusts could consider including items from their mandatory training in the booklet.

Inductions should be multidisciplinary, including administrative and nursing staff, as well as a senior doctor. There should be a ‘handover’ from the out-going doctor in the post.

Trusts should monitor the performance of departments through an induction checklist. There should be no restrictions to the responses on this monitoring: i.e. trainees’ passwords should not be withheld pending the return of these forms. This would shift the responsibility for the inductions from the trainees to

the department, as inductions are a patient-safety issue and the departments should take responsibility.

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Corresponding author ’ s contact details: Dr Helen Thomson, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool Victoria Hospital, Whinney Heys Road, Blackpool, Lancashire, FY3 8NR, UK. E-mail: [email protected]

Funding: None.

Confl ict of interest: None.

Ethical approval: The survey was a simple service evaluation, and participation was voluntary. Participants were fully informed of the nature of the audit, that the data would be confi dential and not traceable, and they knew the uses to which it would be put. Formal ethics approval was obtained from the NHS North West Strategic Health Authority Research Governance and Ethics Committee.

doi: 10.1111/tct.12104
