Murthy Adhiyaman: Mandatory training—the elephant in the room

The phrase “mandatory training” hits a raw nerve in almost all health professionals. What used to be a fire lecture and training in cardiopulmonary resuscitation has now proliferated into a ridiculous number of courses and has metastasized to many domains of our work like an incurable cancer. As Clare Gerada recently said in her BMJ column, the process of mandatory training is in need of fundamental review.

One should do around 15-20 mandatory training modules (thankfully some of them are only once every few years) and most of them have no relevance whatsoever to our day to day work. Compliance with mandatory training has been made part of the annual appraisal, even though the General Medical Council does not stipulate any mandatory training as a requisite for the revalidation process. Some organizations have even linked mandatory training with study leave entitlement.

Each module might take an hour to complete. An average district general hospital has around 200-300 consultants and specialty doctors. If everyone does 10-12 modules a year, that amounts to approximately  3000 hours spent on mandatory training. When extrapolated to primary care clinicians, trainees, nursing staff, allied health professionals and administrative staff, thousands of hours are spent on mandatory training every year.

One would be hard pressed to find noteworthy evidence that mandatory training actually improves patient care, except of course for resuscitation and fire drills. So, in the absence of any benefit to our patients, it is a colossal waste of invaluable NHS resources.

Ironically, what is learnt in mandatory training is completely different to what one would witness in practice. For example, infection control is absolutely essential and everyone should be aware of the basic principles. But one visit to an emergency department would be enough to question the organizational view on this. It is very common to see patients lined up on trolleys along the corridors with very little physical space between them, patients huddled together in a cluttered room, and sometimes trolleys stacked close to toilets or outside single rooms harbouring patients with infections.

Information governance is another example. Protecting confidentiality is paramount in our work, but it does not apply in overcrowded departments where patients are assessed on trolleys in corridors with little or no screens between them. Loose sheets of paper with clinical information fly around. On the wards, the screens around the patients do not provide any sound barrier and we routinely break bad news to patients by the bedside. When doing cognitive assessments, we often get answers from a patient in the next bed. Secretaries work in open spaces and take or give confidential messages in a room full of people where sensitive information is easily heard.

Even though doing a module on “Treat me fairly” or “Equality and diversity” ticks a box, there is little evidence to say that it changes one’s views and actions. Some private organizations exploit the idea of mandatory training and charge for these training modules for new starters

Since divisional managers are usually tasked with improving the compliance of staff doing mandatory training, they frequently organize a whole day of training so that staff can get most of the modules done in a single day. This comes at the cost of cancelling their normal duties.  

Most of the modules are now available online, but the systems that support them are incredibly unfriendly to use. The browsers are often incompatible with the learning systems and, frustratingly, a module may need to be repeated a few times to confirm completion.   

There is no rule for who decides which of these modules make their way on to the list. The occurrence of a critical incident might trigger a module on a particular subject. If there is no critical evaluation of the array of mandatory training modules, there is a real danger that the list will continue to proliferate. In the future there might even be modules for how to write a treatment sheet, fill in the clerking proforma, do a board round, identify early discharges, send referrals, teach students. The list is endless.

Organizations should differentiate between learning and enforced training. Any kind of learning is only appreciated if people are keen to learn that particular subject. It is time that the health care organizations see the elephant in the room: staff hate mandatory training and it will only become an effective way of learning if the modules are kept short, simple and relevant to staff.

Murthy Adhiyaman is a geriatrician at Glan Clwyd Hospital, North Wales. Twitter: @adhiyamanv

Competing interests: None declared