A comprehensive but succinct orientation is vital for junior doctors as they rotate through jobs during the early postgraduate years.
The orientation process will become increasingly relevant in Australia with the change of work patterns to shorter hours and rotating shift rosters.
Although orientation is often thought to be suboptimal, there is limited research published on this important process.
Feedback from junior doctors suggests that formalised orientation programs at the start of term are highly valued.
Junior doctors themselves should be involved in the development and delivery of the orientation program.
Junior doctors appreciate the participation of senior staff in the orientation program, but much of it can be overseen by registrars, nursing staff and allied health staff.
Use of a standardised proforma with peer-to-peer delivery can facilitate a smooth orientation.
For doctors, the early postgraduate years are a dynamic and challenging time. Junior doctors (those in postgraduate years 1–4) must adjust to change as they rotate through different clinical units every 2–3 months, while at the same time maintaining a high standard of patient care. This makes a relevant and effective orientation process, together with a patient handover, critically important.
The orientation process is a requirement of most hospital policies, and is usually reviewed during accreditation inspections of term rotations by state postgraduate medical councils. An orientation program can vary between specialties, but may include an explanation of unit processes and protocols, introduction to key personnel, guidelines for seeking help with patient care, and “housekeeping” information about unit meetings, clinics and theatre lists.
The benefits of a successful orientation process extend to the junior doctor, clinical units and the hospital as a whole. The timely introduction of personnel may facilitate effective teamwork and thus a supportive atmosphere for interns in a vulnerable phase of their career. Clinical care of patients can be optimised if standard practices and pathways are closely followed. The handover process also provides benefits such as debriefing opportunities and continuing medical education.1
It is surprising that there has been limited research on clinician orientation and clinical handovers, given the change in work patterns to shorter hours and rotating shift rosters. Previous studies in medical, nursing and ambulance care have noted variable quality of handover, but strong support for effective handover.2-4 One of the resolutions of the British Medical Association national Junior Doctors Conference in 2003 was “to specifically consider the issue of patient handover, and garner examples of good practice; all those with responsibility for the planning of doctors’ rotas to ensure appropriate handover periods are in place”.5 Effective orientation and handover become increasingly important as junior doctors are faced with patients with more complex, multiple comorbidities, rising service demands because of workforce shortages, and a growing need to teach undergraduates as they move through the system.
The concerns of Australian junior doctors about effective term orientation were addressed in research conducted at Sir Charles Gairdner Hospital, Western Australia, in 2004, and the Southern Health Network, Victoria, in 2006. These studies give us a clearer idea of what junior doctors want and need in start-of-term orientation and handover. Both studies used semi-structured surveys and interviews to represent the views of more than 100 junior doctors in postgraduate years 1–4, together with further input from senior medical and nursing staff. The themes that emerged from these studies are shown in Box 1.
These themes may be at variance with start-of-term orientations that are currently run in many hospitals. In general, the research showed that junior doctors value the existing orientation process, but have suggestions for improvement.
The research identified that a formal but succinct orientation is preferred, supported by a written or electronic package for future reference, and ongoing practical support from all members of the team. Despite the administrative burden of maintaining this package, it was felt that it needed to be constantly updated, involving junior staff where possible. Distributing the written package several days before the commencement of the rotation was thought to improve the efficiency of the actual orientation day.
Junior doctors regarded input from the previous incumbent as a key component in orientation to the new rotation. They valued “street knowledge” such as a particular consultant’s preferences, and “tips” on effective preparation for clinical meetings and ward practices that may not be explicitly stated in manuals written by senior staff. Where possible, “face-to-face” contact with the previous junior doctor was preferred for patient handover and for a smooth transition to the rotation. They felt this should occur in “protected time” and that rostering may need to be modified to meet this requirement. Potential solutions to geographical barriers (such as when an intern is on a rural rotation) identified by junior doctors included teleconferencing, videoconferencing or emailing (also applicable for conflicting shifts).
While the involvement of senior medical staff in the initial orientation process was seen as valuable, it was not thought necessary for the unit head to assume a predominant role. It was felt that the most appropriate role for senior medical staff was to provide a formal but genuine welcome at the start of term, followed by ongoing personal support, appraisal and mentoring.
This whole orientation process could be formalised by the use of an “orientation template” that can be handwritten or used electronically. The aspects of the orientation relating to clinical handover of patients can be addressed electronically6 and guided by documents such as the “Safe handover: safe patients” guidelines recently published by the Australian Medical Association.7 A generic term-to-term, junior doctor-to-junior doctor orientation template developed from the research described above is shown in Box 2. Such a template could equally be applied to registrars in their term changeovers. Arguably a greater challenge is the national development of a single generic orientation template that could then be modified as required at different sites.
1 Start-of-term orientation — outcome of structured interviews
Formal orientation is highly desirable and valued by junior doctors.
Orientation is frequently perceived as inadequate.
Responsibility is inconsistently shared between outgoing and ingoing doctors.
Written orientation material is often out of date.
The roles of the whole team, including nursing staff, are valued in orientation.
There are problems in communicating issues involving difficult personalities and protocols.
Examples of the best orientation procedures identified have active involvement of junior doctors and are face to face.
A written, succinct orientation package should be provided before junior doctors begin a term rotation.
Packages should be developed and updated with active involvement of junior doctors.
These packages need constant updating.
Responsibility for handover/orientation is shared by both incoming and outgoing junior doctors, who should make sure they contact each other.
Face-to-face, peer-to-peer orientation is the preferred format where possible.
Senior medical staff involvement can be restricted to editing the written package and ensuring a formal and genuine welcome.
2 Junior doctor (JMO) to junior doctor start-of-term orientation checklist
The purpose of this checklist is to facilitate a comprehensive JMO-to-JMO unit orientation performed, where possible, in person. It is designed to supplement existing documents and its contents should be discussed with your Head of Department. Remember that both the incoming and outgoing JMO have a responsibility to ensure that effective orientation and clinical handover occurs.
Following the example below, use this checklist with additional space for notes to discuss the day-to-day activities of the unit and familiarise the incoming JMO to their new job. The orientation checklist can be printed off and completed by hand, or ideally, be completed electronically as a living document.
- 1. O’Connell B, Penney W. Challenging the handover. Recommendations for research and practice. Collegian (Royal College of Nursing, Australia) 2001; 8: 14-19.
- 2. Sherlock C. The patient handover: a study of form, function and efficiency. Nursing Standard 1995; 52: 33-36.
- 3. Thakore S, Morrison W. A survey of the perceived quality of patient handover by ambulance staff in the resuscitation room. Emerg Med J 2001; 18: 293-296.
- 4. Roughton VJ, Severs MP. The junior doctor handover: current practices and future expectations. J R Coll Physicians Lond 1996; 30: 213-214.
- 5. British Medical Association. Junior doctors committee annual report 2004. Priority resolutions from the 2003 junior doctors conference. 2004. http://www.bma.org.uk/ap.nsf/Content/jdcannualreport2004 ~priorityresolutions2003 (accessed Nov 2006).
- 6. Cheah LP, Amott DH, Pollard J, Watters DAK. Electronic medical handover: towards safer medical care. Med J Aust 2005; 183: 369-372.
- 7. Australian Medical Association. AMA clinical handover guide — safe handover: safe patients. Guidance on clinical handover for clinicians and managers. 2007. http//www.ama.com.au/handover (accessed Feb 2007).
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.