Framework for Nursing in General Practice
4 Induction and Initial Preparation for Role
The Quality and Outcomes Framework of the new GMS contract rewards practices for ensuring that all new staff receive a period of induction. Induction has three broad goals:
To help the new member of staff understand their own role
To provide clear guidance on where they fit within the organisation as a whole
To enable them to work safely and effectively within the new work environment
An effective period of induction training helps ensure that new members of staff quickly become confident and competent in their role.
In the context of practice nursing, induction is particularly important. Practice nursing staff come to their roles from a wide variety of backgrounds, often bringing with them a broad range of clinical skills and knowledge. However working in general practice is a unique environment, requiring both a sound understanding of primary care and a variety of clinical skills that are often not part of other nursing roles. There is also little commonality between practices around nursing roles, so even experienced practice nurses moving to a new practice are likely to need to acquire new clinical skills or to deploy their existing skills in different ways. Changing skill mix within practice teams is likely in the future to result in even greater diversity of roles, each with quite different needs in terms of induction and initial preparation.
This chapter explores both initial induction to the practice and the role specific elements necessary to develop confident and competent members of the team. It is based on standard 2.1 and draws in part from the Partnership Information Network draft induction training guidelines: http://www.show.scot.nhs.uk/spf/PIN%20Consultation%20Docs/GDG%20-%20Induction%20Training%20-%20Draft3.PDF
Potential benefits of a general practice induction programme
Providing a consistent and comprehensive system of introduction to the practice for all new staff.
Welcoming staff to the practice and provide an overview of the key goals of the practice.
Ensuring that all staff have an awareness of legal, occupational and Health and Safety requirements which are necessary for effective functioning within their roles, e.g. fire and emergency procedures.
Providing staff with information to assist them in becoming familiar with their working environment.
Providing a reference source and contact person in the first few months of employment.
Enabling staff to play a safe and effective role in their employment as soon as possible.
Induction acknowledges the obligation that the practice as employer has to the new employee. Likewise the employee has a responsibility to continue to develop knowledge and competence commensurate with the role occupied beyond the early stages of the induction programme. A commitment to the induction process by the practice is essential to its success. Simply ticking things off a checklist is unlikely to achieve much, whereas investing some time and effort in supporting a new member of staff should pay dividends in terms of future commitment to the practice and the contribution that the individual will make to achieving its goals.
The Induction Process
Induction can be seen as falling into two distinct phases, the core induction phase which will contain components such as practice orientation, health and safety and human resource issues and the role specific phase, which focuses on clinical practice issues and the consolidation of the competencies necessary to be effective in the role.
The Core Induction Programme
To introduce the employee to the organisation, with particular emphasis on organisational orientation, health and safety and human resource issues.
This would normally take place during the first few weeks in post (although it may take longer if the individual is working part time hours). During this period, it is helpful for the new practice nurse to have a named individual within the practice who is their main point of contact and who supports them through the programme. This could be a senior practice nurse, practice manager or GP, depending on the role of the nurse and size and structure of the practice.
Topics that practices may wish to cover in induction include:
Relevant aspects of national and local policy: including for example GMS contract, Partnership for Care, local health plans and CHP plans.
Physical orientation to the practice: getting to know the building, facilities and equipment.
Team working: meeting colleagues and exploring own and others roles.
Practice structure and reporting arrangements: management arrangements including sickness/absence reporting and communication channels.
Policies and procedures: exploring organisation policies and procedures, both written and unwritten.
Clinical procedures and protocols: beginning to explore those that apply particularly to the post.
Health & safety: ensuring that the new employee understands own and practice responsibilities and policies.
Learning and personal development: including arrangements for appraisal and opportunities for learning, networking and clinical supervision.
Clinical governance issues: including accountability, arrangements for handling complaints, patient feedback and incidents.
A model checklist is provided on the CD ROM, which can be adapted by practices to meet their own requirements.
Support with induction
Much of the core programme will need to be delivered specifically within the practice. For larger practices, with a significant turnover of staff, it may be worth developing a pack of written material that could be used with new staff. This core pack has the added benefit of being a readily available resource when introducing locum or agency staff to the practice.
Many NHS Boards already have structured staff induction programmes in place. Not all of this will be relevant to practice nurses, although aspects around national and local policy will. As CHPs develop, there may be merit in practices looking to involve staff in joint local induction programmes, which have the added benefit of enabling the new nurse to develop local networks.
Role Specific Induction and Preparation
To allow the new employee time to settle into the practice with a particular emphasis on the development and consolidation of role specific competencies.
This second phase of induction is in many ways the most important, yet it is often the most problematic for practices. It is essentially about enabling the nurse to develop and consolidate the knowledge and skills necessary to be effective in the post. It is typically regarded as taking around six months to complete and may include elements of orientation, training and education. If the nurse has specific gaps in knowledge or competence that need to be addressed, it may take longer.
Each general practice is a unique working environment, so even an experienced practice nurse may need to develop new competencies to be effective in her role. For someone new to the field of practice nursing the range of new skills may be considerable.
Identifying learning needs
The first step in developing a role specific induction programme is in identifying the learning needs of the new member of staff. This will require a degree of honesty from the new starter as well as an openness to provide support from the practice.
The NHS Knowledge and Skills Framework (KSF) developed as part of the proposed implementation of Agenda for Change is a helpful resource to practices in identifying the knowledge and skills necessary to develop competence. If agreed, this framework sets out the minimum knowledge and skills expected in the first twelve months of employment, and the fully developed knowledge and skills the post holder is expected to achieve over time. KSF profiles have been developed which match the skill mix model and model job descriptions. These are included on the CD ROM and the full detail of the KSF to which they refer is available at: http://www.show.scot.nhs.uk/sehd/paymodernisation/Documents/knowledge-skills-framework.pdf
At an early stage in the induction programme, nurses should map their current knowledge and skills against the requirements of the post. Professional nursing input to this process, either from a more senior member of the practice nursing team or an external source will help to produce an agreed plan, which is in effect the nurse's first personal development plan. It might be particularly useful to the practice to seek advice from any nurse member of the interview panel as she/he will have formed a good understanding already of the likely strengths and development needs of the nurse.
A simple induction training form is provided on the CD ROM. It is intended to be used to record development needs and a plan for addressing them. This could be completed within the initial induction period and form a basis for the practice and nurse to sign up to a development plan to meet any identified learning needs. Unless there are significant skills gaps, which should be apparent at interview, most of the role specific induction would normally take place within the practice environment, with support from other members of the team and where appropriate external expertise. It should be organised and overseen by the nurse's immediate manager/supervisor with support where appropriate from a professional mentor.
It is important for all members of the practice team to participate in supporting the nurse through the development stage, recognising that this is an important time in building relationships and developing effective teamwork. It may be helpful to discuss with the practice team what opportunities there are to help the new nurse to meet any identified learning needs.
Professional support, supervision and mentorship
The extent of learning required during the first six months in post will vary considerably, dependent on the previous experience of the nurse. In some cases it may simply be necessary for the nurse to adapt her/his skills to meet the structures and protocols of the new practice. In others there may be significant skills gaps. Proper professional support and mentorship during this period can help the transition to safe and effective practice. Engaging the skills of an experienced nurse to act as mentor can help in supporting the new practice nurse to develop safe, competent nursing practice.
The mentor's role can include:
Agreeing learning objectives with the nurse and the practice.
Providing time for regular supervisory sessions.
Facilitating access to learning opportunities, which may include visits outside the practice.
Observing practice and encouraging critical reflection on performance.
Providing structured feedback to the nurse and identifying further learning needs.
Mentorship should normally be time limited and is not a substitute for more formal learning where that is indicated.
Practice nurse access to structured mentorship has to date been very varied, with some areas offering a well structured induction programme and others having little professional support. CHPs, with their new role to provide professional leadership across the partnership will have an important role in facilitating access to appropriate mentorship for practice nurses. Further development will also be needed to ensure a cohort of practice nurse mentors with the appropriate skills. Forthcoming guidance on the subject of mentorship and clinical teaching by the NMC will help inform that development.
Concluding the induction period
It is useful for the core induction period and, where appropriate, any longer period of role specific induction to be concluded with a review. The purpose of the review is to consider whether the goals were met and agree any outstanding development needs that should form part of the nurse's personal development plan. To aid this, the new nurse should be encouraged to maintain a reflective journal comprising incidents that relate to personal and professional experiences. Keeping a journal will facilitate critical reflection and promote self assessment. Themes and issues identified in the journal will form a basis for discussion at review. The review should normally be led by the person within the practice who the nurse reports to, with input from the nurse's mentor where applicable. Further detail on reflective practice and journals is available in chapter 6.
Keeping a record of the induction, which could include a signed core induction checklist and a completed role specific induction checklist and learning plan will help the practice demonstrate compliance with GMS Quality and Outcome Framework standards. A record should also be kept by the nurse as part of her/his Personal Professional Profile.
Induction for locum and agency staff
Because each practice is different, even the most experienced practice nursing staff can find it difficult moving between practices. It is therefore vital that locum staff have some basic induction to the practice. The length and nature of this will obviously vary dependent on whether they are to cover a single shift or to provide a year's maternity leave cover. Obviously role specific induction training will not be possible with other than long term locums. A three stage process is therefore outlined that could help ensure that locum practice nurses are able to function safely and effectively.
1. The first stage is to be very specific about the duties to be fulfilled and ensure before appointment that the nurse has the necessary competencies. Permanent practice nursing staff can help in defining this in relation to specific areas of responsibility. Doing this in advance would ensure that there is clarity in the event of an unexpected absence.
2. Stage two is to have clearly set out operating procedures for every clinic or area of practice nursing responsibility. This would ensure that incoming nurses with the necessary skills have the detailed information to hand about how the practice handles any specific area of practice.
3. The third and final stage is to have a practice induction summary that covers all of the main points of the core induction programme in a simple folder. This would also help with new permanent staff members. Any locum nurse should be met by a named person in the practice, who will be the locum's main point of contact and who would be responsible for physical orientation and introducing the locum nurse to key staff.