What do junior doctors want in start-of-term 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.