A Structured and Data-driven approach to Onboarding - experiences from the Danish Hospital Sector
Written by Julie Salskov Andersen and Christian Harpelund
Onboarding Group is currently conducting an industry study of onboarding in the Danish healthcare sector. Our preliminary study, carried out at one of Denmark's largest hospitals, has already shown that parts of the Danish hospital sector experience immense challenges when it comes to attracting and retaining new employees.
The solution to these challenges is not clear, as Danish hospitals are a very complex environment. Nonetheless, we know from our studies and from international research that structured onboarding has both quick and positive effects in the form of better retention of talent, greater commitment, enhanced well-being - and ultimately better ways of working.
Danish hospitals, as well as Danish companies, are increasingly investing in a professional approach to attracting and recruiting new employees. But when it comes to onboarding, and understanding the challenges and pitfalls that new employees face in the early period of their employment, there is usually great room for improvement. Onboarding deals with everything that happens when a new employee is hired and needs to be integrated into the workplace. In many cases, this effort is limited and randomly organized.
A high pace working environment
In a study conducted by the Danish Nursing Council in May 2019 (published on dr.dk on July 5, 2019), the focus is on how many Danish nurses are at risk of experiencing a poor start to their working life as a nurse. Some of the challenges are explained by the fact that the hospital system is under severe pressure. The staff at the hospital are forced to speed up the pace of work, which rarely leaves time or resources to take proper care of the new colleagues, and thereby to ensure that knowledge and skills are passed on. In the same article, labor market researcher at Aalborg University, Henning Jørgensen, highlights that introductory courses are a vital prerequisite for nurses to have a successful experience in their first employment:
“I think one of the crucial things are these introductory courses. And there are many who do not actually get an introductory course when they begin at a new department because of the hustle and bustle out there, and that is a disaster.” (Jørgensen, Henning in Nue, Josephine, 2019).
The Danish Nursing Council's analysis finds that 1 in every 12 in a cohort of recently graduated nurses succumbed to stress within the first year. Based on 1,120 responses, this corresponds to 8% who were on sick leave for a shorter or longer time due to psychological factors in the working environment (Source: dsr.dk). This emphasizes the need for competent and well-structured onboarding, especially when it comes to younger and recently graduated nurses.
It's all about contributing
One of the hospitals participating in the industry study is Herlev-Gentofte hospital, which has a clear wish to raise the standard of onboarding for their new employees. In an interview conducted by Onboarding Group, the hospital’s Head of Patient Care and Organization, Sidsel Rasborg Wied, points to the importance of the new employee being able to contribute to the core tasks as soon as possible - which she emphasizes will benefit everyone. For Sidsel, this is one of the primary reasons for embarking on the project:
“There is nothing worse than going to work feeling that you are not delivering anything - and in such a classic introduction process you can easily go to work for two, three, four weeks without really contributing anything other than to walk beside someone who is doing something”.
She further adds that it’s especially important when working with onboarding in the healthcare sector, that patients at all times feel safe and in good hands - even in the encounter with a new employee. It takes a lot of work to fully master the procedures and processes for patient safety etc. Sidsel emphasizes that working with onboarding they have been forced to rethink processes and look for areas where new employees can contribute 100 percent from day one or two. From a psychological perspective, this will help to maintain the motivation, energy, and momentum which we know the new employee brings with her when she enters the organization.
Two weeks or ten months
Asked what insights the study so far has brought them, Sidsel says they have realized that the 14 days introductory program they have previously run in some departments did not mean that new employees have been properly onboarded*. Our studies with the Danish hospitals show that on average it takes more than 10 months for the new employee to feel properly onboarded – that is, to feel she has gained good enough insight into the organization’s goals, values, rules, procedures, technical terms and so on, and has established good enough networking relationships, to be able to contribute as expected of her. Thus, onboarding extends far beyond the 14-day programs that many organizations tend to do.
Structure, culture, and competencies
Many onboarding programs are narrowly focused on critical areas such as rules and procedures, which is one of the tendencies that we expect to find in the hospital sector. However, with this study, we wish to take a step further and to broaden the understanding of what is important when onboarding new employees. In our onboarding model*, the six dimensions of culture, rules, collaboration, network, performance, and competencies are all made important and necessary dimensions in a successful onboarding experience.
Our preliminary study showed that the pervasive challenges in onboarding facing the hospital sector are how to give new hires an understanding of the culture of the organization, and the experience of contributing enough (and early enough) in their employment, as well as the experience of being equipped with all skills they need.
From data to action
For Sidsel and her colleagues, it has been crucial to work with onboarding as a data-driven process. Sidsel mentions that this is a general orientation working in the health sector, but adds:
"... with the onboarding part, we have worked a bit in the blind (...) so it will be a gift to add that to those processes as well".
In line with the analysis from the Danish Nursing Council, Sidsel points out:
“We are talking about a Health Sector which in many ways is under pressure, with departments that have to recruit 5, 10, 15 every single month. There is a need for professionalisation and systematisation, and also a need to acknowledge to ourselves that it could be done better. We actually have a burning platform to do this."
One of the people who help to redesign onboarding at Herlev and Gentofte Hospital is Senior Chief Nurse Sussi Løvgreen Larsen. Together with her colleague Charlotte Åkerstrøm, she has driven the development of the project in practice. The two have run a series of workshops focusing on different areas of action, with the intention of challenging the current understanding of onboarding. In an interview, Sussi talks about how employee involvement in the project has been crucial. As she puts it: "They have to grasp the meaning around it - they have to see it work." Hence, the basic idea has been to invite "those who actually carry out the onboarding" to be part of the workshops.
A catalyst for a tsunami
We asked Sussi what she thought was different about onboarding at a hospital compared to other types of organisations. She answered that within the hospital sector there is a challenge because of the historically sharp division between the respective categories of staff: doctors, nurses, social and healthcare helpers, etc. In reality, the groups must work incredibly closely together - in the literal sense of working with life and death. Hence the traditional way of differentiating between categories of professions may not always be helpful. For the new employee, this adds another layer of complexity to the onboarding. She becomes a member of her own professional group, however, in practice, she is also part of a wider group and relies heavily on several other professions. Sussi points out:
“Why can't a doctor be a buddy for a nurse? - why does it have to be the same profession? It's really interesting! This silo thinking is simply so old and needs to be challenged."
She anticipates that working with onboarding across the organization can be a catalyst for "a tsunami" within the organization that could potentially help to break down some of the ruling structures and ways of doing things.
Generic Human Properties
One of the basic ideas in the hospital's new onboarding design is to optimize the interaction between three key roles: the Manager, the Mentor, and a Buddy. The three roles take care of the organizational, professional and social part of the onboarding task respectively. This design will facilitate an inter-disciplinary collaboration that will support the successful welcoming and integration of the new employee. This design has triggered both enthusiasm and concern. Enthusiasm, because it provides clarity about roles and responsibilities. Concern, because of its potential to challenge the deeply installed power relations and old ways of thinking within the hospital sector.
Yet, working with onboarding has helped to legitimise a move across those boundaries, thereby strengthening collaboration across professions, functions, departments, etc. Sussi further emphasizes that onboarding speaks to the use of generic human characteristics more than characteristics associated with a profession. At the centre of everything they do at the hospital is the patient, who must always be well taken care of.
An organizational curveball
During the interview, Sussi mentions that employees who have been part of the workshops have expressed pride in being involved in onboarding activities that have proven to be successful. This is also part of Sussi’s personal drive working on the development of the project:
“Something that has intrigued me with this way or method that we have chosen - i.e. inviting people across the organisation to be part of working groups - is that people have voluntarily said 'see what we have' and proudly shown what in particular is working for them.”
“It's fun to challenge systems that have been around for hundreds of years and then simply throw a curveball like ‘onboarding’. I think I have been allowed to see things both from the inside out - and from the outside in, because we have been provided with data on onboarding, we have brought knowledge and models into the work, thus giving ourselves a new challenge too.”
Doing onboarding with pleasure
Onboarding in a hospital is on a complex scale. Preparing new employees to face vital decisions in their work with patients, including sometimes in stressful situations, requires a lot. Nevertheless, it is not so much complexity, but rather joy that characterizes our conversations with both Sussi and Sidsel. Overall, there has been a great pleasure in revisiting the hospital's approach to onboarding. Our last question to Sidsel is whether it has been difficult for important stakeholders to buy into the project. She answers:
“There has been joy in discovering that working with onboarding can be used to face some things that we find difficult. Not least for those employees who have been here for many years and who can easily get exhausted by having to introduce new people month after month.”
Contributors and purpose of the study
A big thank you to Sidsel Rasborg Wied, Head of Patient Care and Organization, and Leading Senior Chief Nurse Sussi Løvgreen Larsen, both from Herlev and Gentofte Hospital, for participating in these conversations with Onboarding Group.
At Onboarding Group, we work with several Danish hospitals to understand and develop their onboarding. The purpose is to investigate and analyse the experience of being onboarded at specific hospitals, and in the Danish hospital sector in general. With the survey, we reach out to employees who have been hired within the last 12 months and collect data on what they experienced - and when - in relation to their onboarding. The analysis aims to provide both deeper insight and tangible directions for potential improvement. The participants in the study gain insight into their own onboarding situation, a data benchmark, as well as knowledge sharing across the participating hospitals.
The output of the study includes:
- Where are the challenges? Professions, roles, etc.
- When are there challenges? From day 0 to day 365
- What are the challenges? Culture, network, competence, etc.
- Areas of success and mapping of resources
Specifically, the study answers:
- What is 'time-to-onboarding' for the new employees?
- Are there any critical periods in the onboarding experience that require special attention?
- How many new employees in the last 12 months have unnecessarily left their jobs due to poor onboarding?
- Which of the 6 dimensions and 18 underlying attributes contribute to the good onboarding experience and where is there potential for improvement?
- Which key factors drive a good onboarding experience?
- Are there significant differences across units, departments, ages, roles, geography, etc. - and if so, where should the focus be in terms of improvement and sharing of best practice?
- How is the hospital’s onboarding compared to others in the sector?
* Onboarding is the process that starts after the employment contract is signed and ends when the new employee feels fully integrated into the role. Onboarding consists of six dimensions. They include feeling like part of the culture; knowing and understanding the rules; feeling socially connected and being able to collaborate with your colleagues, partners, customers, etc; feeling that one is contributing; developing relevant skills; and being able to deliver the desired results.
* See an illustration of the Onboarding Model beneath and watch a 2 minutes introduction to the model
- Nue, Josephine (2019, July 5). Located on August 8, 2019, at https://www.dr.dk/nyheter/indland/nye-sygeplejersker-bukker-under-stress-det-foerste-aar
- Danish Nursing Council Analysis (DSR): Located on August 12, 2019, at https://dsr.dk/sites/default/files/50/notat_sygemelding_pga_psykisk_arbedsmiljoe.pdf