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#KeyLIMEPodcast 361: Onboard Like An Overachiever!

Ensuring the best orientation for trainees in a new clinical setting is an essential part of ensuring quality education and patient safety… and rotating through multiple clinical settings is a fundamental part of the training experience. However, despite it being a common and necessary experience, medical education literature shows that the transitions through these settings involve anxiety, high cognitive load, wasted time, disrupted continuity of care, new relationships, and patient safety risks. The study presented in this week’s episode looks to determine how we can get better at this, by identifying strategies used by clinical supervisors to support and integrate new trainees they work with. 

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KeyLIME Session 361

Listen to the podcast

Reference

Wiese A et al. Orientation of medical trainees to a new clinical environment (the ready-steady-go model): a constructivist grounded theory study. BMC Med Ed. (2022) 22:37. 

Reviewer

Jason R. Frank (@drjfrank)

Background

Remember that first day? Might have been the first day of high school, or first day on a job…How lost you felt. Looking around for a friendly face, someone to orient you, find your locker, maybe where the bathroom is, where to put your Teenage Mutant Ninja Turtles lunch box…Brings back memories.

Rotating through a Variety of clinical settings is considered an essential ingredient in training. It provides breadth of clinical experiences and exposure to a variety of practices and settings. However, the #meded lit is filled with evidence that health professional careers are filled with these kinds of transitions, and we don’t do them well. Transitions involve anxiety, high cognitive load, wasted time, disrupted continuity of care, new relationships, and patient safety risks (errors and patient mortality!). Supervisors and educational leaders are often criticized for neglecting the arrival of a learner to a new program, hospital, or service. How can we do this better? Is there any evidence to guide us?

Purpose

Enter Wiese and Bennett from University College Cork, Ireland:  they set out to identify the strategies used by clinical supervisors to support and integrate new trainees they work with. The paper is: “Orientation of medical trainees to a new clinical environment (the ready-steady-go model): a constructivist grounded theory study,” and its in BMC Med Ed 2022.

Key Points on the Methods

This is a constructivist grounded theory (CGT) paper. The authors identified and interviewed 15 clinical supervisors from 3 different medical specialties (GI, EM, & Psych). (For Jon: PurPOsive sampling on this one!) They used typical CGT procedures (e.g. iteration, constant comparison, and theoretical sampling to develop an understanding of the data. They sought out community resonance via a presentation at a meded conference.

In this Irish setting, trainees rotate through “posts” or clinical placements of ~3-6 months each.

The authors defined their terminology and provided a reflexivity statement.

Key Outcomes

The authors developed the “Ready-Steady-Go” model for onboarding new learners to clinical care teams.
• Ready: ensuring that learners have the required knowledge and skills;
• Steady: adapted, comfortable, and integrated into the new workplace and clinical team, including socialization;
• Go: safely participating in practice.

Supervisors described both formal (e.g. guideline review as a group) and informal (e.g. tacit preferences conveyed to an individual) orientation practices, both with the overall goals of achieving safe and efficient contributions. Orientation activities could be collective or individual, structured, or ad hoc, or all the above. They acknowledged a “steep learning curve” for trainees. Supervisors engaged in monitoring and progressive entrustment of individual trainees. The process was described as taking about 4-6 weeks (which is longer than some entire rotations in N. America).

Barriers to successful onboarding included:
• limited personnel, time, and resources;
• schedules and shiftwork;
• rapid rotations;
• service pressures;
• trainees with impaired insight into limitations;
• trainee inexperience.

Key Conclusions

The authors conclude…the Ready-Steady-Go model provides new insights into a neglected phenomenon in HPE. Education leaders can use the model to design better transitions, and researchers can build on this work for greater understanding of this aspect of #meded.

Spare Keys – other take home points for clinician educators

  1. This is a standard CGT paper with simple methods others could use
  2. This paper is an example of using problems identified in the clinical environment for scholarship and exploration of concepts.

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