Simulation (sim) is an excellent but underused tool suited to key skills in psychiatry such as communication, managing agitated patients and exploring the mental-physical health interface. Access to complex psychiatric patients has always been challenging and this has been exacerbated by the current COVID-19 pandemic. This has further increased fear amongst students creating another barrier to engaging with psychiatric patients. Our aim of the study was to evaluate the use of simulation within psychiatry as the literature in this field is underrepresented compared to other medical specialities. We hope to advocate its use in future undergraduate training.

We developed 3 simulated scenarios for fourth year medical students; these involved identifying lithium toxicity and steroid-induced psychosis in ward settings and conducting an A&E risk assessment. The scenarios were developed following feedback from a focus group of foundation doctors on their psychiatry rotations. Data were collected pre- and post-simulation from a cohort of psychiatry students in this academic year. We assessed confidence levels in 7 domains using a 10-point Likert scale and obtained qualitative data to give context to the data collected.

81 and 83 students respectively completed the pre and post questionnaires. Quantitative data found that the student's confidence in all domains improved from pre to post simulation training. For example, confidence in performing a risk assessment improved from M = 4.12 to M = 7.04 and in making a basic management plan from M = 3.43 to M = 6.72. Qualitative data looked at skills gained, empathy and how the scenarios related to clinical practice. Key themes found improvements in de-escalation skills, handing over and self-reflection.

The study supports the evidence that high-fidelity simulation is an important education tool in psychiatry. As facilitators, we feel that confidence scores improved due to the debrief. The standard tool often used is the diamond debrief however we found we had to adapt this model due to fourth year students not having developed sufficient skills to reflect on complex psychiatric scenarios. Therefore, an adjusted debrief was developed featuring technical knowledge and constructive feedback. In the future, we hope to explore the long-term benefits of simulation and its impact on clinical practice.

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 ascertain if CTOs ensure that patients are effectively treated in the community and maintain stability in their mental health.

If a patient requires recall(+/- revocation) that this is done in a timely fashion in according to the 1983 Mental Health Act.

A number of studies have been inconclusive in determining the benefits of CTOs in reducing the re-admissions of “revolving door” patients In Assertive Outreach (AO). It is felt that CTOs have reduced readmission of patients due to the intensive input from community teams, decreased recall and subsequent revocation. Those admitted are thought to require fewer inpatient days. It is clear that many patients who require recall following non-engagement, non-compliance, will accept medication following RC review. However at present in BSMHFT patients can only be recalled if they are allocated a bed. Due to the national bed shortage, this has resulted in delays following decision to recall and thus early and effective treatment for patients. In this aspect it defeats the role of the CTO as per the 2007 MHA.

CTO data from 1st April 2018 to 31st March 2019 was obtained from all 6 AOT's in BSMHFT. The following factors were considered;

1. 1. Time between decision to recall by RC and recall to inpatient facility

2. 2. Number of recalls converted to revocations

3. 3. Number of inpatient bed days if revoked

4. 4. Number of admissions on CTO

5. 5. Patient/family agreement of CTO

98 CTO patients were recorded over this period. 19 out of 26 recalls had recall dates documented. 10 recalls were revoked due to relapse of mental illness. Average days from RC recall decision to actual recall or cancellation was 63.89 days. Main reasons for delay were bed unavailability and execution of warrant.

Following revocation, average inpatient bed days was 103.71. 41% of families agreed with CTOs, 36% of patients contested their CTO.

Over a quarter of patients on CTO were recalled to hospital however, less than half of these had their CTO revoked. The remainder accepted treatment following urgent community review whilst on the bed list. Evidently the majority of patients didn't need admission. With the ongoing bed crisis, alternative avenues need to be sought to ensure prompt treatment and prevent relapse.

A CTO suite designed for recall could be the solution for the future.