As part of a wider quality improvement project (QIP) aiming to improve trainees’ experiences with ‘Raising Concerns’ in a large mental health trust, we sought to improve the trainee representative (rep) structure. This would give trainees more transparent processes and provide intermediaries by which to raise concerns. Based on change ideas generated from our driver diagram, roles were created to coordinate meetings and represent specific groups of trainees and on-call rotas.

Prior to August 2022, there were an undefined number of ‘Senior House Officer’ (SHO) reps who were recruited informally by the Post-Graduate Medical Education Team. The duties of these reps were not clearly detailed. As part of our first ‘Plan, Do, Study, Act’ (PDSA) cycle, we identified groups of trainees that needed additional representation (International Medical Graduates [IMGs], Less than Full Time trainees [LTFT]) and introduced a Wellbeing Rep to cover all training grades. Specifically for SHOs, we introduced three core roles (Rota/Placement, Inclusion, and Social) and individual roles for the six on-call rotas. Following the implementation of this rep structure, we gathered quantitative data, including whether trainees had utilised the reps and how effective they were in raising concerns, and qualitative feedback. We gathered data from both the reps and the whole cohort of trainees. We then started another PDSA cycle in August 2023.

On a 1–5 scale (5 = very effective), the average response from trainees for how effective the trust reps were in supporting raising concerns was 3.8 (5 responders), with no trainees who responded feeling that any of the rep roles needed restructuring. However, the rep survey highlighted that the following roles needed restructuring: Rota/Placement rep, Social rep, and Rota reps. The Rota/Placement role was highlighted as being unnecessary due to the existence of individual rota reps, but there was a need for a ‘lead’ rep to coordinate rep meetings and induction. Unfortunately, a Social rep was not recruited, however it was identified that due to the importance of the role more than one trainee may be required to arrange social events.

Overall, the trainee response to the new rep structure has been neutral/effective, but we hope to obtain more responses in the next PDSA cycle. The rep feedback highlighted the need for coordinator roles to improve cohesion. The results have informed change ideas which we implemented in August 2023. The second PDSA cycle will be completed in July 2024.

Trauma is prevalent amongst early psychosis patients and associated with adverse outcomes. Past trials of trauma-focused therapy have focused on chronic patients with psychosis/schizophrenia and comorbid Post-Traumatic Stress Disorder (PTSD). We aimed to determine the feasibility of a large-scale randomized controlled trial (RCT) of an Eye Movement Desensitization and Reprocessing for psychosis (EMDRp) intervention for early psychosis service users.

A single-blind RCT comparing 16 sessions of EMDRp + TAU v. TAU only was conducted. Participants completed baseline, 6-month and 12-month post-randomization assessments. EMDRp and trial assessments were delivered both in-person and remotely due to COVID-19 restrictions. Feasibility outcomes were recruitment and retention, therapy attendance/engagement, adherence to EMDRp treatment protocol, and the ‘promise of efficacy’ of EMDRp on relevant clinical outcomes.

Sixty participants (100% of the recruitment target) received TAU or EMDR + TAU. 83% completed at least one follow-up assessment, with 74% at 6-month and 70% at 12-month. 74% of EMDRp + TAU participants received at least eight therapy sessions and 97% rated therapy sessions demonstrated good treatment fidelity. At 6-month, there were signals of promise of efficacy of EMDRp + TAU v. TAU for total psychotic symptoms (PANSS), subjective recovery from psychosis, PTSD symptoms, depression, anxiety, and general health status. Signals of efficacy at 12-month were less pronounced but remained robust for PTSD symptoms and general health status.

The trial feasibility criteria were fully met, and EMDRp was associated with promising signals of efficacy on a range of valuable clinical outcomes. A larger-scale, multi-center trial of EMDRp is feasible and warranted.

Raising a concern is an integral duty for a doctor. The General Medical Council guidelines on Good Medical Practice state that a culture should be promoted that allows “all staff to raise concerns openly and safely”. Appointment of Postgraduate Doctors in Training to Representative (Rep) positions can be an effective way to allow trainee voices to be heard. Here we present the results of a Development Half-Day created to empower Reps with the knowledge and confidence to represent peers effectively within a large mental health Trust. The training session was identified as a ”change idea” in a wider Quality Improvement Project (QIP) seeking to improve trainee confidence in raising concerns.

16 Postgraduate Doctors in Training Reps were invited to attend a Development Half-Day in November 2022. The day included talks on their roles and responsibilities, respectful challenge and maintaining well-being.

Quantitative and qualitative data were gathered using anonymous questionnaires completed before and after the session. The questionnaire contained 4 questions asking them to rate their knowledge of their role as a rep and confidence in raising trainee concerns. This was quantified using a 1-10 scale for each question with 1 being lowest confidence/knowledge and 10 being highest. Mean scores and standard deviations were calculated. A paired one-tailed t-test was used to assess the statistical significance of the difference in pre- and post-session scores.

9 Reps attended the Development Half-Day and completed the pre- and post-session questionnaires.

There was a statistically significant improvement between pre- and post-session scores for all questions (all p values <0.05). Importantly there was a significant increase in the confidence felt by reps in knowing where and who to raise trainee concerns to (p < 0.05).

Qualitative feedback indicated that attendees found the session useful and they appreciated that it was in-person. The only suggestion for improvement was for the session to have been held earlier, closer to when reps were initially appointed; this will be a change that will be implemented in the next “Plan, Do, Study, Act” cycle of the QIP.

Implementation of a Development Half-Day for Trainee Reps was shown to have a significantly positive impact on their confidence in their roles and their ability to respectively challenge seniors. The Reps additionally reported being better equipped at knowing where and who to raise concerns to. This will hopefully aid in their ability to signpost and empower other trainees to do the same.

As part of a wider Quality Improvement Project aiming to improve trainees’ experiences with ‘Raising Concerns’ in a large mental health trust, we sought to improve induction processes to make information on raising concerns more accessible when starting a new post. Based on change ideas generated from our driver diagram, peer-delivered information was identified as a useful tool, so a trainee-led session was introduced to the induction programme.

A 60-minute trainee-led session was integrated into the induction programme for Postgraduate Doctors in Training in August 2022. The session included sections on raising concerns, on-call advice and rota information. Following the induction, as part of our “Plan, Do, Study, Act” (PDSA) cycle, we sent a questionnaire to gather data from trainees, which covered quantitative measures, including overall helpfulness of the session and effectiveness of information on ‘raising concerns’, and qualitative feedback for how to improve the session. The session was replicated at both the December 2022 and February 2023 inductions, incorporating the feedback from each previous session.

On a 1-5 scale (5 = strongly agree), the average response for how helpful the trainee-led induction session was 4.5 from both the August and December 2022 inductions. 4 out of 6 responders from the August 2022 induction specifically mentioned the information on raising concerns as being particularly helpful. There was also feedback on improvements that could be introduced, such as increasing the amount of time for the session to allow for more questions. When asked to rate the helpfulness of the ‘raising concerns’ section, the average response was 4.83 and 4.50 for August and December 2022 inductions, respectively. Following the feedback from August 2022, we implemented changes to increase the duration to 90 minutes and include trainee reps in a separate ‘Question and Answer’ session. Unfortunately, there were only 2 responders to the December 2022 questionnaire due to a small intake, so we will evaluate data from February 2023 induction to analyse the effectiveness of changes made to the session and assess the need for further improvements.

Overall, the response to our trainee-led induction session has been positive, with good feedback both for the whole session and specifically relating to ‘raising concerns’. It has highlighted trainees’ appreciation for peer-delivered information and the need for more time in this session. The questionnaire from February 2023 induction will give more data on whether our improvements have been effective and provide ideas for future PDSA cycles.

Raising concerns is a duty for all doctors. However, a scoping exercise within a large mental health Trust demonstrated that trainees experience difficulties in raising both patient safety and training concerns. As part of a trainee-led quality improvement (QI) project within this Trust, our aim was to develop a pulse survey to capture the current likelihood of trainees raising concerns and factors influencing this.

An online survey was developed using ‘plan do study act’ (PDSA) methodology. The initial draft was informed by data from the Autumn 2021 scoping exercise. The survey was refined using a collaborative trainee-led approach. It was tested by trainees involved in the QI project followed by two other trainees and was revised accordingly.

Trainees across all training grades were invited to complete the survey through various communication channels. The pulse survey will be repeated monthly with a two-week response window.

Ten trainees out of 103 responded to the first pulse survey open from 18th to 31st January 2023 (response rate 9.7%). Seven respondents were core trainees and three were higher trainees.

Respondents were more likely to raise patient safety concerns than training concerns (average score of 3.8 out of 5, where 5 equals ‘very likely’, versus 3.4 out of 5 respectively). Of the three respondents who had experienced a patient safety concern in the past 2 weeks, only two had used any existing process to raise it. These data were replicated for training concerns.

No respondents were confident that effective action would be taken if they raised a training concern, while less than half of respondents were confident that effective action would be taken if it were a patient safety concern.

The reasons for the low response rate are likely varied. However, there may be some similar underlying reasons for low engagement in surveys and low engagement in raising concerns. Given this, a more negative picture of trainees’ likelihood of raising concerns may have been portrayed if more trainees engaged in the survey.

Engaging trainees to provide insight into their likelihood of raising concerns is challenging. Despite the low response rate, this initial pulse survey demonstrated that trainees continue to experience barriers to raising concerns. PDSA methodology will continue to be used to optimise the monthly pulse survey response rate. The key QI outcome measures will also be integrated into pre and post intervention surveys as a pragmatic approach to evaluate specific change ideas.

Prior to the COVID-19 pandemic, our research group initiated a pediatric practice-based randomized trial for the treatment of childhood obesity in rural communities. Approximately 6 weeks into the originally planned 10-week enrollment period, the trial was forced to pause all study activity due to the COVID-19 pandemic. This pause necessitated a substantial revision in recruitment, enrollment, and other study methods in order to complete the trial using virtual procedures. This descriptive paper outlines methods used to recruit, enroll, and manage clinical trial participants with technology to obtain informed consent, obtain height and weight measurements by video, and maintain participant engagement throughout the duration of the trial.

The study team reviewed the IRB records, protocol team meeting minutes and records, and surveyed the site teams to document the impact of the COVID-19 shift to virtual procedures on the study. The IRB approved study changes allowed for flexibility between clinical sites given variations in site resources, which was key to success of the implementation.

All study sites faced a variety of logistical challenges unique to their location yet successfully recruited the required number of patients for the trial. Ultimately, virtual procedures enhanced our ability to establish relationships with participants who were previously beyond our reach, but presented several challenges and required additional resources.

Lessons learned from this study can assist other study groups in navigating challenges, especially when recruiting and implementing studies with rural and underserved populations or during challenging events like the pandemic.

Discontinuation of antipsychotic medication may be linked to high risk of relapse, hospitalization and mortality. This study investigated the use and discontinuation of antipsychotics in individuals with first-episode schizophrenia in relation to cohabitation, living with children, employment, hospital admission and death.

Danish registers were used to establish a nationwide cohort of individuals ⩾18 years with schizophrenia included at the time of diagnosis in1995–2013. Exposure was antipsychotic medication calculated using defined daily dose and redeemed prescriptions year 2–5. Outcomes year 5–6 were analysed using binary logistic, negative binomial and Cox proportional hazard regression.

Among 21 351, 9.3% took antipsychotics continuously year 2–5, 38.6% took no antipsychotics, 3.4% sustained discontinuation and 48.7% discontinued and resumed treatment. At follow-up year 6, living with children or employment was significantly higher in individuals with sustained discontinuation (OR 1.98, 95% CI 1.53–2.56 and OR 2.60, 95% CI 1.91–3.54), non-sustained discontinuation (OR 1.25, 95% CI 1.05–1.48 and 2.04, 95% CI 1.64–2.53) and no antipsychotics (OR 2.00, 95% CI 1.69–2.38 and 5.64, 95% CI 4.56–6.97) compared to continuous users. Individuals with non-sustained discontinuation had more psychiatric hospital admissions (IRR 1.27, 95% CI 1.10–1.47) and longer admissions (IRR 1.68, 95% CI 1.30–2.16) year 5–6 compared to continuous users. Mortality during year 5–6 did not differ between groups.

Most individuals with first-episode schizophrenia discontinued or took no antipsychotics the first years after diagnosis and had better functional outcomes. Non-sustained discontinuers had more, and longer admissions compared to continuous users. However, associations found could be either cause or effect.

The ‘MRCPsych Course’ (Membership of the Royal College of Psychiatrists) is provided to all core trainees in psychiatry in Wales by the School of Psychiatry, Health Education and Improvement Wales (HEIW), now delivered online since the start of the COVID-19 pandemic. The aims of the HEIW MRCPsych course are: to prepare core trainees for the MRCPsych exams and to set a ‘robust platform’ for speciality training at the higher level in psychiatry. We undertook a quality assurance of the 2020/21 academic year to see how content and delivery of the course were serving these aims and make recommendations for improvement.

Over the course of one academic year we triangulated trainee feedback, lecturer feedback and peer review. Trainee and trainer feedback forms were sent out following every session. We developed standards and criteria for peer review and reviewed 10% of sessions. We conducted focus groups with trainees using mentimeter to structure a real time, anonymous interaction with parallel verbal and written discussions using a virtual meeting.

Trainee feedback forms were received for 31 lectures from an average of 11 trainees per session. 14 Lecturer feedback forms were received, and 48 trainees attended the two focus groups. 15 hours of teaching underwent peer review.

Lecture content was universally accurate and up to date and all teachers were fluent and engaging, with almost all incorporating research data, guidelines and inspiration for further learning.

Several lecturer feedback forms requested a curriculum be provided. Some trainees requested a more exam focused approach with more MCQs.

Trainees found online sessions more accessible and convenient. The major downside being that they no longer get to know each other and feel very anonymous, which makes peer support and interaction more difficult.

Interactive engagement was the lowest scored domain overall. Interaction seemed to work best when done as a continuous process from the start and when a variety of techniques were engaged. Trainee's suggestions for increasing interactivity included quizzes, polls, breakout rooms, use of interactive tools, and a general encouragement of cameras and microphones on and active discussion throughout the session.

Speakers had no problems using the technology to deliver an online session, this triangulated with their high confidence and high satisfaction reported by lectures with HEIW practical support. Trainees reported a high satisfaction with the quality of teaching on the course.

Our conclusions have informed changes which are currently being implemented and tested.

The coronavirus disease 2019 (COVID-19) pandemic and ensuing restrictions have negatively affected the mental health and well-being of the general population, and there is increasing evidence suggesting that lockdowns have led to a disruption of health services. In March 2020, South Africa introduced a lockdown in response to the COVID-19 pandemic, entailing the suspension of all non-essential activities and a complete ban of tobacco and alcohol sales. We studied the effect of the lockdown on mental health care utilisation rates in private-sector care in South Africa.

We conducted an interrupted time-series analysis using insurance claims from 1 January 2017 to 1 June 2020 of beneficiaries 18 years or older from a large private sector medical insurance scheme. We calculated weekly outpatient consultation and hospital admission rates for organic mental disorders, substance use disorders, serious mental disorders, depression, anxiety, other mental disorders, any mental disorder and alcohol withdrawal syndrome. We calculated adjusted odds ratios (OR) for the effect of the lockdown on weekly outpatient consultation and hospital admission rates and the weekly change in rates during the lockdown until 1 June 2020.

710 367 persons were followed up for a median of 153 weeks. Hospital admission rates (OR 0.38; 95% confidence interval (CI) 0.33–0.44) and outpatient consultation rates (OR 0.74; 95% CI 0.63–0.87) for any mental disorder decreased substantially after the introduction of the lockdown and did not recover to pre-lockdown levels by 1 June 2020. Health care utilisation rates for alcohol withdrawal syndrome doubled after the introduction of the lockdown, but the statistical uncertainty around the estimates was large (OR 2.24; 95% CI 0.69–7.24).

Mental health care utilisation rates for inpatient and outpatient services decreased substantially after the introduction of the lockdown. Hospital admissions and outpatient consultations for alcohol withdrawal syndrome increased after the introduction of the lockdown, but statistical uncertainty precludes strong conclusions about a potential unintended effect of the alcohol sales ban. Governments should integrate strategies for ensuring access and continuity of essential mental health services during lockdowns in pandemic preparedness planning.