By Susan Haas MD, MS and Rachel Smith MS, PA-C
The SARS-CoV-2 pandemic has led to redeployment of thousands of U.S. clinicians to treat patients using new or updated skills and practicing in unfamiliar locations of the hospital. Optimal onboarding, particularly under the stressors of limited time and high levels of fear and anxiety, is crucial for the successful function of a newly created clinical team. Scant literature exists about physician onboarding in general.1,2 Failure to provide adequate onboarding can contribute to both patient and clinician harm. Seven physician leaders who recently developed and implemented programs of rapid onboarding described what they learned about their clinicians’ needs. Those lessons organized naturally into the categories of 1) responding effectively to fear and anxiety, 2) clarification of procedures for delivering care, and 3) intentional relationship building. Lessons learned from rapid onboarding bring into focus the mission critical components of onboarding any clinician needs when joining a new practice and provide guidance for hospitals in regions still facing surges in admissions.
Hospitals have had to rapidly redeploy clinicians to fill the need to care for the surge of COVID-19 patients. Physicians and advanced practice clinicians are providing clinical care in areas that are outside their primary area of expertise and/or in an unfamiliar setting. Clinical leaders have had to develop onboarding content and procedures rapidly and with few established procedures to turn to for guidance. Much has been written about the needs and perspectives of leaders planning changes in operations and staffing.3,4 We focus on the needs and perspective of staff for whom leaders need to plan. This unique, highly stressed onboarding that some clinicians and leaders have already encountered can, when examined, yield insights which will benefit clinicians and leaders who have not yet faced their COVID-19 surge.
Under routine, non-emergency circumstances onboarding for physicians is a non-standardized process, created and managed locally within individual hospital units.5,6 The onboarding processes generally focus on logistics such as parking, electronic health record use, privacy compliance training, and meeting other staff members. Multiple rapid redeployments caused by an impending surge in patients such as seen in the COVID-19 pandemic offer unique opportunities to evaluate onboarding systems “under stress” and learn which aspects are most important when time and resources are limited. We interviewed 6 leaders from 4 hospital systems in Boston and New York to better describe the onboarding needs of individual clinicians and summarized their insights into three key recommendations.
Three Key Recommendations for Onboarding for Redeployment under conditions of limited time and resources:
Proactively address the fears and anxiety of clinicians as they are redeployed
Leaders reported the degree of fear and anxiety among clinicians being onboarded as their greatest surprise. In addition to pandemic induced fears of becoming ill or transmitting disease to family members, the concerns all new clinicians face of harming patients or appearing incompetent were magnified by having new roles. One said, “Fear, anxiety, and uncertainty were the biggest issues.” Fortunately, leaders found a variety of methods to successfully address fear and anxiety:
- Actively Elicit and Respond to Concerns
- Conduct a pre-deployment open-ended survey to identify specific concerns of staff and then address each one. This survey can include questions that gauge areas in which the clinician is comfortable; this allows for some degree of self-stratification when preparing the staffing logistics of redeployment.
- Continue to keep open multiple and frequent lines of bilateral and multilateral communication using town halls, video conferences, walk rounds, and direct to you calls and email until every question has been answered. Map the frequency of group meetings to the “newness” of redeployment, generally once or twice a day at the beginning.
- Share Your Knowns and Unknowns
- State explicitly what is not known and how leaders are tracking to find out if it can be known. Typical unknowns include at what rate will providers and nurses call out sick? When will the surge begin and end? How will the patient population and their needs evolve over time?
- Point out energetic volunteers who have gone before them, and if possible include contact information so they can reach out and ask questions.
- Protect Them
- Make every effort to redeploy clinicians not more than “one degree of separation” from their current role.
- Reassure clinicians that they will not be asked to do something with which they are not comfortable. One leader commented that redeployees needed “Confidence they could do this and would be safe doing it. Everything else was gravy.”
- Provide a strong shadowing program. Give the newly redeployed clinician from 4 hours to one shift to shadow someone from the receiving team to learn the unit’s clinical workflow, meet the other unit staff, and observe the cultural norms of the unit.
- Ensure that every redeployed clinician can easily access “elbow” support at any time throughout the duration of redeployment from a clinician familiar with the disease and the operations of the unit. “You will never be alone.”
All patients are cared for by other human beings. Once those caregiving humans feel personally safe they can turn their full skills and humanity toward the patients.
Provide efficient, explicit onboarding based on clinician need for logistical as well as clinical information
The practice of medicine involves knowing both what needs to be done and also how to get it done. COVID-19 care involves learning about a single disease in the setting of rapid updates in information about pathophysiology and treatment. For clinicians redeployed to new sites of care, learning how to do the essential tasks (admit, order tests and consults, discharge, sign-out) and document them through the mechanism of an unfamiliar electronic medical record (EMR) or dictation system was their paramount interest. Leaders learned to focus on the needs expressed by clinicians through these actions:
- General Onboarding Content
- Create and document a systematic and standardized practice to ensure every clinician receives the same basic onboarding. A simple checklist can be used to confirm when each clinician has completed all items.
- Include basic logistics and operational knowledge specific to the care unit including protocols for transferring patients, emergency procedures, weekend coverage, and using the electronic medical record. Walk redeployed clinicians through the space to show where to eat and drink, location of bathrooms, retrieving scrubs, and locations of work units.
- General Onboarding Methods
- Provide “Just in time” documentation training where it is most likely to be used, whether this is EHR, dictation, paper or a combination. Clinicians report that training that is “abstract”, remote in time and location from where it will be used, leads to poor retention.
- Keep in mind different learning styles. Use multimodal tools including written documents, videos, text threads, videoconferencing, and town hall meetings to provide information.
- Be mindful of the lessons about the universal prevalence of fear and anxiety and create a space of psychological safety by ensuring that all questions are welcome and taken seriously at all times.
- COVID-19 Tools and Knowledge
- Adapt the baseline process to accommodate any special training required, such as management of ventilators or current management standards of chronic diseases such as heart or kidney failure.
- Offer special training options which individual clinicians may elect if useful. For example, a pediatrician may find ACLS reassuring. Offer review and practice of procedures such as central line placement and intubation. Practice can reassure ambulatory clinicians who will be working with inpatients that they will be able to provide long dormant skills if needed.
- Provide frequent, focused information on COVID-19 pathophysiology and treatment. One physician leader noted that a clinician is only learning about one new disease and “after a few times on call you’d seen all the phenotypes of COVID-19.”
- Provide both observation and supervised practice of donning and doffing PPE. Use staff experts such as OR nurses to teach at the highest level.
- Update electronic templates as new protocols are adopted.
We note that an organized and efficient onboarding can not only improve the performance of clinicians and reduce the risk of harm to patients, but that, along with the points addressed in the first topic, it can decrease the fear, anxiety and uncertainty for clinicians related to redeployment. Information about the logistics of care was sought out by far more clinicians than information about COVID-19 disease.
Ensure each redeployed clinician has working relationships with the many new care team members, both on and off the care unit.
Unique to the pandemic rapid redeployment, multiple members of both “sending” services and “receiving” units need to form many new relationships. The teams formed during redeployment have been formed quickly and include a variety of specialties and levels of training. The rapid onboarding process should be intentional about making these connections before or at the outset of the redeployment. Several best practices support the unique situation of rapid formation of teams of new people doing new tasks.7,8
- Making Successful Teams
- Put people in roles in which they can excel. Have them describe their strengths and unique talents to other team members when they meet.
- Construct hybrid teams intentionally with the broadest possible distribution of knowledge and skills; For example, mix attending physicians, resident physicians, and advanced practice providers from different specialties. Ensure clinicians with limited or remote experience caring for critically ill inpatients are paired with those who “know their way around” inpatient processes.
- Support flattening the hierarchy to allow all members to learn from and teach each other and to ensure no good ideas are missed.
- When rapidly onboarded, clinicians are being deployed to supplement existing teams ensure those teams are prepared for and welcome the new member(s).
- COVID-19 Team Specific
- Develop a system so people encased in full PPE to the point they cannot be identified can distinguish both the names and the roles of other people who are similarly encased.
- Team beyond the care unit. Several leaders told us that perceptions of inequality in shouldering the burden are common and may not be expressed publicly. Address the concern about potential “unfairness” by making known what others are doing that is out of line of sight and say “all are sharing in ways they can”
Building relationships does more than assist with onboarding, it also protects the well-being of clinicians. The experience of caring for patients with COVID-19 is unique and is shared among colleagues. Support at work that cannot be offered by a friend or partner who has not shared the experience can play a role in helping clinicians cope during this stressful time.9
The COVID-19 pandemic has provided opportunities to observe high volume, real time, focused onboarding and to identify the core needs of redeployed clinicians. Their fear of harming patients, of becoming infected and infecting their loved ones, and the greater need to understand the logistics of a new workplace than to learn about the disease were unanticipated findings. When leaders address fears, develop a needs-based onboarding program, and create effective teams they ensure the best outcomes for both patients and clinicians. These findings serve two purposes. First, they can help leaders in pre-surge geographic areas plan as they redeploy clinicians. Additionally, they serve more generally as a basis for advances in both practice and research into the limited research on clinician onboarding.
- Bender C, DeVogel S, Blomberg R. The socialization of newly hired medical staff into a large health system. Health Care Manage Rev. 1999;24(1):95-108. doi:10.1097/00004010-199901000-00009
- Lagoo J, Berry W, Henrich N, Gawande A, Sato L, Haas S. Safely Practicing in a New Environment: A Qualitative Study to Inform Physician Onboarding Practices [published online ahead of print, 2020 Mar 12]. Jt Comm J Qual Patient Saf. 2020;S1553-7250(20)30062-3. doi: 10.1016/j.jcjq.2020.03.002
- Kim M, Galler Rabinowitz L, Nagula S, et al. A Primer for Clinician Deployment to the Medicine Floors from an Epicenter of Covid-19. NEJM Catalyst. May 4, 2020. Accessed May 14, 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0180
- Fortman K. Crisis Plan for APPs reduces COVID-19 Exposure and risk. American Academy of Physician Assistants. April 15 2020. Accessed May 18 2020. https://www.aapa.org/news-central/2020/04/crisis-plan-for-apps-reduces-covid-19-exposure-and-risk/
- Kirk VG, Currie G, Dewey D, Howlett A, Lemieux L. Innovation in physician recruitment & wellness: a pilot orientation program. J Pediatr. 2013;162(4):664-665.e2. doi: 10.1016/j.jpeds.2013.01.001
- Hébert TM, Szymanski J, Mantilla J, et al. Onboarding for Pathology Residency Programs-The Montefiore Experience. Acad Pathol. 2016; 3:2374289516639979. Published 2016 Mar 21. doi:10.1177/2374289516639979
- Tom W, Albarran D, Salman N, Van Groenou A. Ensuring Mentorship of New Physicians in Their First Year: Constructs for New Mentoring Processes. Perm J. 2019; 23:18-122. doi:10.7812/TPP/18-122
- Goodwin GF, Blacksmith N, Coats MR. The science of teams in the military: Contributions from over 60 years of research. Am Psychol. 2018;73(4):322‐333. doi:10.1037/amp0000259
- Shanafelt T, Ripp J, Trockel M. Understanding and Addressing Sources of Anxiety Among Health Care Professionals During the COVID-19 Pandemic [published online ahead of print, 2020 Apr 7]. JAMA. 2020;10.1001/jama.2020.5893.