Raising concerns is an important part of being a doctor and part of the GMC ‘Good Medical Practice’ guidelines, however as a trainee it often comes with specific challenges. Historically trainees are often left feeling that their concerns are not taken seriously and there is no resolution to problems raised. Here we present the findings of a scoping exercise undertaken as part of a Quality Improvement project exploring these issues within a large mental health Trust.

Trainees across all training grades from Foundation doctors to higher trainees were invited to engage in virtual focus groups specific to their training programme. Contributions were analysed anonymously using a thematic analysis approach by two independent coders. Quantitative data were also gathered using an online survey to capture trainees who had been unable to attend a focus group.

Key results included:

• • A total of 6 focus groups were attended by more than 35 trainees, with high turnout particularly within Foundation trainees and CT1 doctors.

• • Three key themes were identified from the qualitative data: difficulties with the process of raising concerns, fear of the consequences and challenging the culture of the organisation.

• • It was noted that senior trainees felt more comfortable with the process of raising concerns compared with junior colleagues but were more apathetic about the impact of doing so.

• • 12 trainees completed the online survey. Of these, 6 (50%) reported having had patient safety concerns and 7 (58%) had had concerns about their training.

• • The most common reported barriers to raising concerns were the impact on working relationships (67%), lack of support (50%) and fear of repercussions on their training (50%). 42% of respondents were unsure of how to raise concerns.

• • Trainee suggestions for change included improved information for trainees and trainers about the process for raising concerns, sharing of feedback about concerns raised more widely and regular opportunity to meet with key stakeholders.

The majority of trainees had experienced concerns about either patient safety or training issues. It will be necessary to address the multiple barriers highlighted to enable trainees to feel more confident and able to raise concerns. Increasing awareness of escalation processes, improving the processes themselves and fostering a supportive environment which encourages and supports trainees to raise concerns will be important given the implications for patient safety and trainee well-being.

To assess if patients are offered appropriate and adequate NRT (nicotine replacment therapy) upon admission to an acute adult inpatient ward.

To evaluate the number of adverse events occurring which are related to mandatory temporary abstinence from cigarette smoking on inpatient wards.

Not all patients are able or willing to quit smoking when admitted to secondary care. In line with NICE Guidance, psychiatric inpatients should not be permitted to smoke inside the hospital building or outside on hospital grounds. NRT is the most widely used smoking cessation aid. It aims to temporarily replace the nicotine from cigarettes to reduce motivation to smoke and nicotine withdrawal symptoms.. NRT should be offered to patients who need support with nicotine withdrawal during an inpatient stay. Trust guidelines state nursing staff are able to administer NRT to patients on admission without prescription, reducing cravings and withdrawal symptoms such as agitation and anxiety which can lead to adverse events such as aggressive behaviour. Cravings may result in the patients self-discharging or absconding from the ward to smoke.

A retrospective review of electronic records was conducted of all inpatients admitted to two acute adult units over a three month period (65 patients). Patients were identified as smokers or non-smokers. Search words used included: ‘smoking’, ‘NRT’, ‘nicotine’, ‘cig’ to search for relevant entries. Data collected included whether NRT was offered and given by nursing staff on admission and adverse events related to smoking.

Data from 65 patient admissions were reviewed (31 males, 34 females, mean age 37 years). 37 (57%) patients were identified as smokers. NRT was offered and accepted by 17% of patients on admission and not recorded in 77% of admissions. NRT was declined when offered by 3% of patients.

Adverse events related to smoking occurred in 38% of ‘smoking’ patients. 40% of these adverse events occurred in first 72 hours of admission. Adverse events include verbal conflicts, physical aggression towards nursing staff and smoking in patient areas.

The majority of patients were not offered NRT on admission or this was not accurately documented in clinical notes. When offered NRT, a large proportion of patients accepted it demonstrating its acceptability amongst this patient group. There is a high rate of adverse events related to smoking on wards. More accurate documentation is required to ensure NRT is being sufficiently offered to patients to reduce possible withdrawal symptoms and adverse events.