Article Text
PDF
Abstract
Aim Junior doctors joining EDs are required to rapidly acquire new knowledge and skills, but there is little research describing how this process can be facilitated. We aimed to understand what would make ED formal induction and early socialisation more effective.
Methods Qualitative study; informal interviews of junior doctors, consultants and nursing staff and direct observation of clinical interactions, induction and training in a single ED in an English Emergency Department between August and October 2019. We used constant comparison to identify and develop themes.
Findings New junior doctors identified that early socialisation should facilitate patient safety and a safe learning space, with much of this process dependent on consultant interactions rather than formal induction. Clear themes around helpful and unhelpful consultant support and supervision were identified. Consultants who acknowledged their own fallibility and maintained approachability produced a safe learning environment, while consultants who lacked interest in their juniors, publicly humiliated them or disregarded the junior doctors’ suggestions were seen as unhelpful and unconstructive.
Conclusion Effective socialisation, consistent with previous literature, was identified as critical. Junior doctors see consultant behaviours and interactions as key to creating a safe learning space.
- emergency department
- education
- teaching
- emergency department management
- safety
Data availability statement
Data are available upon reasonable request.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
Statistics from Altmetric.com
WHAT IS ALREADY KNOWN ON THIS TOPIC
Inducting new staff into large organisations happens faster when there is explicit attention to socialisation.
Despite the regular movement of doctors between hospital departments, the most effective way of inducting and integrating doctors into emergency medicine is not known.
WHAT THIS STUDY ADDS
In this qualitative study at an ED in England, we found new doctors pay more attention to day-to-day interactions and socialisation than formal induction.
Behaviours of consultants impact effective integration of new staff in a hierarchical staff model.
Consultant behaviours that explicitly acknowledge uncertainty and improve psychological safety are important to allow staff to quickly develop.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Explicitly acknowledging the uncertainties of emergency clinical practice should be part of most induction and early socialisation programmes. Identifying and encouraging specific behaviours from senior doctors around uncertainty and fallibility will lead to more effective integration of new staff, facilitate learning and contribute to patient safety.
Introduction
Despite the annual movement of large numbers of doctors in the NHS and healthcare systems worldwide, little is known about the new doctors’ perspective on their integration into their new working environment. Many will undergo a formal induction to the work environment, but there is also a need to introduce newcomers to the culture and practices of a specific group, build relationships and a sense of belonging and acceptance over a longer period. Most prior research has focused on preparing doctors for a single aspect of acute care, or the evaluation of initial training in acute care skills.1 The efficient delivery of the technical and required aspects of hospital induction has also received attention.2 However, an ED is an ‘ultra-adaptive environment’ where risk is embraced and managed, and in such an environment people’s skills and capabilities take precedence over rigid processes.3 Little is known about the perspectives of the rotating junior doctors about induction and socialisation1 4
Understanding early socialisation is important because of its rapid influence and lasting effects on newcomers as they move from outsider to ‘integrated and effective insider’. Socialisation affects job performance and satisfaction, organisational commitment and retention.5 For the newcomer, socialisation is a problem of uncertainty reduction, making the work environment more predictable for both task content and social relations6 In the ED, full of ‘diagnostic uncertainty, high decision density and cognitive load, time and resource limitations, interruptions, frequent transitions of patient care, and poor feedback’, the challenge of uncertainty reduction for newcomers is acute.7
Failure to guide new doctors effectively through early socialisation in the ED risks increasing uncertainty, with negative consequences for patient safety and the well-being of both new and supervising doctors.8 We aimed to understand early socialisation from the perspective of new doctors.
Methods
This qualitative study took place following the 2019 August induction of new doctors at the Emergency Department of Addenbrooke’s Hospital, Cambridge, seeing around 120 000 patients per year. During the study, the ED employed 42 junior doctors and 23 full-time equivalent consultants. The first author, who conducted the observations, visited the department 14 times between August and November, including three full induction days, for a total of 62 hours. The research objective of trying to understand the perspective of new doctors about induction and early interactions was explained to participants. All participants were guaranteed anonymity, and consent was reconfirmed.
The first author performed observations and informal interviews with new doctors, experienced ED doctors, nurses and consultants, across all shifts. Specifically planned, semistructured interviews were not used. Observed interactions between, for example, new doctors and consultants as they discussed patients, were often used as a trigger for interviews, often with a question such as: ‘how did that conversation go?’ after a new doctor talked to a consultant. However, open questions were also used, such as asking a consultant ‘How do you find working with the new doctors?’ with more specific follow-up questions as required. A consultant’s meeting to review new doctor progress was observed, as well as formal departmental and hospital induction sessions. Nurses were interviewed to determine their impression of consultant and new junior doctor behaviours. Contemporaneous handwritten notes were taken on conversations and observations.
The research is informed by grounded theory: an approach which does not offer a single research method and exists in several variants. All versions, including the current study, share four core ideas. Emergence (‘follow the data’ rather than impose preconstructed categories): no formal interview schedule was constructed in advance of conversations. The interviewer has no medical training and to minimise bias, no literature on EDs or medical induction and socialisation was consulted. Constant comparison (iterate between research data, both existing and emerging, and the literature, to ‘ground’ (inform and support) the analysis). Theoretical sampling (select data sources for relevance to the emerging model (validating, adjusting or extending); emphasise quality and relevance of the source rather than frequency). Finally, theoretical saturation (stop data collection and analysis when themes are repeated but no new themes appear). ‘In vivo’ codes, terms used by informants during conversations, were used to stay close to their experience.
The perspectives of the three types of participants were triangulated to help develop themes. Following Gioia et al,9 we explicitly demonstrate how theoretical concepts were derived from interview data (see figures 1 and 2). Coding was carried out by the first author and then assessed by two coauthors.
Unhelpful consultant behaviours.
Unhelpful consultant behaviours: data display.
Patient and public involvement
No patient involvement.
Results
The 2-day departmental formal induction programme was mainly technical and factual, with a session on ‘Pitfalls in Emergency Medicine’. A sample programme is available in the online supplemental material. When new doctors were asked about induction, responses were uniformly brief and ranged from neutral to mildly positive. The accompanying shrugs suggested this was not a fruitful line of inquiry. Questions about the impact of consultant behaviour produced greater engagement so this line of enquiry was followed. The conversations revealed clear themes about what consultant behaviours facilitated good induction and socialisation. New doctors’ reactions to consultant attitudes and behaviour are organised below into ‘helpful’ and ‘unhelpful’ categories. Figure 3 shows the consultant behaviours regarded as helpful.
Supplemental material
Valued consultant behaviours.
Positive consultant behaviours
Positive consultant behaviours were reported in five areas (figure 3).
Empathetic
Consultant empathy was valued, especially where consultants conveyed they understood the challenges faced by new doctors.
The management of stressors when fires are going on all around them, …can still say to the new shift ‘Welcome. Everyone had a drink?’ (Junior doctor)
I went through the same thing. (Consultant)
Interested
From the point of view of junior doctors, interested consultants paid attention to new doctors’ experience and personal aims. Some consultants stated they used this information to place these doctors in positions that met their development needs.
But there’s something really nice about someone … saying, ‘What do you think of this ECG?’ ‘Could be this, could be this.’ ‘Yeah that’s good, but actually, have you seen this, I think that could be…’ That’s a really useful bit of training and that’s very consultant dependent … The priority that is or isn’t placed on that is really quite marked. (Junior doctor)
At the start of the shift you need to ask what their background is, what their interests are.
Anyone got any requests about where they want to work? (Consultant)
Fallible
Consultants who talked about personal challenges and fallibility were also valued by new doctors. One trainee described a consultant who recalled their own experience.
He would … talk about his difficult patients in a way that … enabled me to do that back with him. It wasn’t me going to someone that I know has been doing this for twenty years and knows all the answers. It was me going to someone who last week asked me for help with something similar. (Junior doctor)
His ability to show that he wasn’t perfect and to show respect for my input. (Junior doctor)
Approachable
The ability of consultants to switch appropriately from being ‘professional’ to being sociable, joking and having ‘a bit of banter’ was appreciated by new doctors and senior nurses. These behaviours help flex the formal hierarchy and open up learning spaces. A consultant underlined the importance of being open to challenge in relation to patient safety.
They know when to be social and when to be professional. (Junior doctor)
Consultant X is very approachable, never judges me as a junior doctor, teaches and doesn’t criticise. (Junior doctor)
If they (new doctors) think that you’re on a pedestal and you’re perfect, no-one’s ever going to question what you do. In medicine, at three o’clock in the morning, when you’ve been up for twenty hours, you need people to question what you’re doing … We work in such a high-risk environment anyone can make a mistake, however good you are, however experienced you are. (Consultant)
The best consultants are ‘team-workers … bounce ideas of us, listen to suggestions, and come up with plans … are approachable and make suggestions to us.’ (Senior nurse)
Creates learning spaces
The importance of creating learning space, getting juniors to work through problems rather than ‘always giving the solution’, was noted by consultants and juniors.
Consultant X will never tell doctors was the plan is He won’t spoon feed them at all. Why do you want those tests? Then what will you do? (Junior doctor)
Sometimes I’m guilty of saying the diagnosis is this. I spend too much time telling them what to do. It’s about explaining why we do stuff. (Consultant)
Unhelpful consultant behaviours
Most new doctors drew on experiences in other hospitals to answer this question (or were diplomatic enough) (figure 4).
Valued consultant behaviours: data display.
Indifferent
A lack of empathy was highlighted, for example, consultants challenging why tasks were taking time. An apparent indifference to the challenges faced by new staff and a failure to see that what is simple for a consultant might be complex and time consuming for a new doctor.
Why are you spending so much time? Because of course they’ve seen it before. (Junior doctor)
Poor decisions about when and how to criticise were noted, though the need for criticism was not disputed. It is difficult to help new doctors learn if there is a weak understanding of what the challenge looks like from their perspective and if they receive poorly judged feedback.
There’s a lack of humility in doing it publicly. (Junior doctor)
Invisible and unhelpful
Consultants who were not available to support new doctors were criticised by junior doctors and other consultants.
They tell you to work things out on your own. (Junior doctor)
The worst consultants are not there when I need them, they’re impatient. (Junior doctor)
They’ll be off doing all the admin that I do in my own time … they go home fairly early in the evening and there’s an expectation you won’t be calling them. (Consultant)
Unpredictable
Junior doctors reported that unpredictable reactions by consultants were a barrier to learning and getting feedback.
If they’re unpredictable you stop going to them. (Junior doctor)
Scare and humiliate
Junior doctors reported that consultants can use their experience and hierarchical power in a perceived attempt to intimidate.
I think most people can name at least one consultant that they fear. (Junior doctor)
One emergency medicine consultant remarked that new doctors from other departments, frightened of disturbing their senior staff, came to the ED for advice. Junior doctors who were ‘terrified’, ‘humiliated’ or felt ‘inferior’ admitted that they avoided asking questions and did not ‘open up’ when they had problems.
New doctor appraisal
A consultant’s meeting 30 days after new doctors arrived provided additional insights into initial assessments of competence. These included: how well new doctors dealt with uncertainty and anxiety (‘attitudes’ to learning clinical competence, overconfidence and underconfidence) and situational awareness. There was concern where junior doctors appeared to have unwarranted confidence in their abilities. There were no explicit criteria for assessment, nor were there timelines for what new doctors might be expected to know and do by when, nor explicit remedies. However, two findings emerged relating to anxiety in a complex, uncertain environment.
We learn by getting things wrong.
You’ll make mistakes and you can’t worry about it.
Discussion
We aimed to understand socialisation of new doctors in an ED. Junior doctors rotate in most medical training environments worldwide and their integration into an ongoing, complex work environment has not been well studied. Despite having undergone a formal induction, we found that both negative and positive experiences turn on the desire of new doctors for conditions which support both professional learning and patient safety. These are more set by the behaviours and attitudes of the consultants than the formal induction programme.
Five consultant qualities were identified as helpful: creating a learning space, empathy, interest, admitting fallibility and being approachable. The unhelpful behaviours mirrored these—lack of interest, overconfidence, disregarding junior doctor input, being unapproachable, or scaring or humiliating them. Unhelpful behaviours were seen as unsafe.
Our findings align well with research exploring psychological safety in teams10–12: a shared belief ‘that the team is safe for interpersonal risk taking’. This increases the chances of ‘effortful, interpersonally risky, learning behavior such as help seeking, experimentation, and discussion of error’, the behaviours that need to be rapidly established in an effective ED. In hospital settings, psychological safety is associated with ‘learn-how’ activities such as ‘experimentation and collaborative problem-solving’. A meta-analysis covering 22 000 individuals and around 5000 groups found significant and positive associations between psychological safety and learning behaviour, work engagement, information sharing, creativity, commitment, satisfaction and task performance: conditions which support the technical and social uncertainty reduction effort required during socialisation.13
This safety must be balanced by a respect for challenge, for not spoon-feeding new doctors. It is important here to avoid a false dichotomy between supporting and challenging. Cumulatively, the five behaviours in figure 3 help create an environment which facilitates quick and safe learning. They mitigate power imbalances and help demonstrate ‘leader inclusiveness’,14 as well as minimising worries newcomers might have about being ‘humiliated or rejected’. They also facilitate new doctor contributions.15
However, learning behaviour, such as sharing information, discussing errors, asking questions, seeking help and asking for feedback, rather than projecting confidence, carries risks. Admitting fallibility can be seen as ignorant (you ask questions), incompetent (you ask for help and make mistakes), negative (you point out mistakes) or disruptive (you ask for feedback and insist on sharing information).
The concern that calling for help indicates failure to cope is borne out in other US and UK studies.16 17 In medicine, ‘the perceived need for impression management to protect one’s professional image is extremely high’, partly because the impression projected can affect respect, promotion and rewards. These factors reinforce the value of consultants explicitly sharing both their evaluation criteria and their own vulnerabilities with new doctors.
In the ED, formal power differences exist which inhibit newcomers from speaking up. While the positive behaviours support ‘structure without rigidity’,11 the unhelpful behaviours and attitudes reinforce hierarchal difference, close learning space, discourage information seeking and put patient safety at risk.
The unhelpful consultant behaviours that we identified are consistent with other research in healthcare settings. ‘Scare and humiliate’ behaviours block ‘mutual self-disclosure’ and hinder the process of ‘team learning’.11 The willingness of newcomers to join in problem-solving also weakens in hostile conditions,18 disengagement is more likely19 and learning behaviour is reduced.20 Autocratic behaviour, inaccessibility or a failure to acknowledge vulnerability all can contribute to team members’ reluctance to incur the interpersonal risks of learning behaviour.10 21 22 Achieving a switch to ‘leader inclusiveness’ is known to have a positive effect in underperforming hospital units.15 Creating a safe learning environment and maintaining patient safety are symbiotic.
A meta-analysis of socialisation research5 emphasises the importance of three key indicators of newcomer adjustment: self-efficacy (learning tasks, confidence in the role), social acceptance (feeling liked and trusted) and, more technically, role clarity (understanding tasks, task priorities and time allocation).
Our work, together with existing literature, allows us to make some tentative recommendations about how to quickly and safely induct and socialise new doctors to an ED. We accept that the benefit of these is not quantified or proven by our work, we also acknowledge that early integration of new doctors must also include aspects of mandatory training (eg, fire safety) and administration (information technology training, etc).
Consultants should talk explicitly about inherent uncertainty in clinical practice: unpredictability; the necessity of deciding with incomplete, shifting information; repeated novelty; weighing of probabilities; trapped risk; and the challenge of managing yourself in these conditions. These behaviours would lead to ‘a more affirmative attitude towards doubting’12 and the sharing of doubt between hierarchical levels. An explicit distinction needs to be made between technical, scientific knowledge, and clinical judgement, with an emphasis on the difference between knowing facts and the challenge of acquiring experience, confidence and skill over time. Acknowledgement of consultant fallibility is likely to be seen by new doctors as supportive and helpful. Confidential mortality and morbidity meetings are a good vehicle for this. There is a fundamental distinction to be made between knowledge, ‘all sharp edges, confident certainty, and clean light’, and wisdom, where we are ‘learned about our ignorance’ and share the craft and its ways of thinking through uncertainty.23
Involving new doctors in decisions should facilitate rapid learning. Team leaders actively seeking out knowledge from lower status team members encourages speaking out.
Clarify consultant support for new doctors and explain how learning spaces will be created through challenge, questions, opportunities to try and ‘live’ explanations of why and how consultants make decisions. Share consultant values and objectives with new doctors. Conversely, explicitly state what the consultant body aim to avoid: a lack of empathy; being invisible, unavailable, unhelpful; being unpredictable in our responses (though we get tired and stressed, too); scaring and humiliating; creating unsafe work conditions by not listening, or by discouraging dialogue. Consultants should reason out loud, talking through their analysis and decision processes and inviting comment in order to facilitate learning.
Explicitly facilitate social relations. Social acceptance is an important indicator of newcomer adjustment and associated with other positive work outcomes. It may be helpful to consider an ice breaker social event when new doctors arrive and using a photo board of staff members. Identifying staff levels explicitly using lanyards or badges may also be helpful.
Clarify and set expectations at induction. Reducing uncertainty could include clarifying development targets over time, distinguishing, where possible, between technical knowledge and experiential learning over time (help seeking; situational awareness; differential diagnosis under pressure). Saying how new doctors will be evaluated in relation to, for example, situational awareness and help-seeking behaviour versus overconfidence is also important. Clear staged assessment criteria and a strong value attached to help seeking are important. So, ‘In the first weeks we welcome a lot of help-seeking. After that we will give guidance on where and how it can be modified.’
Limitations
This is a small qualitative study in a single department. We did not formally assess the degree to which new doctor perceptions of successful socialisation might align with, or diverge from, those of consultants and this would be a useful follow-up investigation. Nor did we link consultant behaviours to specific trainee needs, such as coping with uncertainty in diagnosis. The attitudes of new doctors to formal induction and its relationship to motivation and integration were not fully explored.
Conclusions
New doctors see their worth mirrored back to them in consultant behaviours and reactions. It is by paying more systematic attention to these early work experiences, rather than refining formal induction, that EDs are likely to get the strongest motivational gains. The most highly regarded consultants in this study are both knowledgeable and wise, and help ‘age the new physician as rapidly as possible’. We noted consultant behaviours that keep doctors immature by shutting down learning and increasing their anxiety and sense of incompetence. The starting point for bringing the social and technical back into balance, and enhancing learning and patient safety in early socialisation, is challenging. Consultants must be willing to make their own fallibility discussable, to ‘come clean and talk dirty’.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Ethics approval
This study did not require formal ethical review, following the decision tree found on the Health Research Agency website.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
Handling editor Ellen J Weber
X @dradrianboyle
Correction notice In July 2024, this article was republished under a CC-BY-NC open access licence. The year 2018 in the methods section of the abstract was also updated to 2019.
Contributors KG initiated and planned the project and analysed the data. KG and AAB wrote the report. KG, AAB and RM all reviewed the results and approved the final paper. AAB is guarantor of the paper.
Funding AAB's time was supported by the NIHR Cambridge Biomedical Research Centre. Open access fees were provided by the Addenbrooke's Emergency Department Research Fund.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.