Aims Despite initial promise, Workplace Based Assessments (WPBAs) have been criticised for failing to discriminate between trainees. With a largely summative component they have often been viewed as tick-box exercises of limited learning value1. Increasingly, reflection and good quality formative feedback are considered essential elements of medical learning2,3. We wanted paediatric trainees to be involved in designing new WPBAs that allow trainees to learn more from feedback and reflection, and remove the summative aspect of assessments. Methods Two areas for improvement were identified through discussion with trainees: safeguarding and written communication. Evidence of safeguarding experience and competence is becoming increasingly important, and yet was often challenging for trainees to bring to the summative Case Based Discussion (CBD) environment. The paper-based Sheffield Assessment Instrument for Letters (SAIL) was felt to be outdated and did not demonstrate adequate flexibility with the many forms of communication which trainees now use such as email for social care referrals. Two new tools were designed in conjunction with the RCPCH Assessment Methodology Working Group. Results The new assessment tools, Safeguarding CBD and Discussion of Correspondence (DOC) have subsequently been incorporated into the GMC-approved national assessment pilot. This new assessment style, referred to as ‘Supervised Learning Events’ (SLEs) allows trainees to select a learning opportunity from their own clinical practice and discuss this freely with a trainer, focussing on agreed learning objectives, and providing a forum for reflection unhampered by summative assessment. Conclusion These new tools will be evaluated and refined during the 2013–14 RCPCH Assessment National Pilot through focus groups and surveys. This was a fantastic opportunity for us as trainees to engage in a national policy development process. We hope that trainees will be involved in the evaluation of the new SLEs and to assist the RCPCH to continue its work to make SLEs a seamless part of training and professional development. References Macaulay C, Winyard P. Reflection: tick-box exercise or learning for all? British Medical Journal 2012:Nov 12. GMC. Good Medical Practice 2013. Goodyear HM, Bindal T, Wall D. How useful are structured electronic portfolio templates to encourage reflective practice? Medical Teacher 2013;35:71–73.

The cost of malnutrition and associated disease has been estimated to be more than £7.3 billion in 2003; the majority of this expenditure was due to treatment of malnourished patients in hospital and long-term care (£3.8 billion) (1) . Given this profound economic impact and the emergence of evidence that improving patient nutrition can reduce hospital stay and complications, national campaigns have raised awareness of malnutrition in an attempt to reduce its prevalence in UK hospitals (2,3) . National guidance includes risk assessment for malnutrition for all new hospital admissions. Patients at risk of malnutrition include those who have eaten little or nothing for five or more days or are likely to eat little or nothing in the following 5 d (4) . We considered that inpatients who are 'Nil by Mouth' (NBM) represent a particularly high risk cohort for malnutrition. The aims of our study included assessment of (i) the prevalence and duration of NBM, (ii) whether the indication was appropriate, (iii) whether these patients had been screened for malnutrition risk on admission, (iv) whether alternative nutritional supplementation had been arranged and (v) whether the Nutrition Multidisciplinary Team were adequately involved in patient care. We audited four wards (two general medical, one acute stroke unit and one surgical) within Barnet Hospital on two separate occasions, encompassing 192 patients in total. We recorded the time from when a patient was made NBM until the advent of alternative nutritional replacement, with 42 % of patients failing to receive optimal alternative supplementation as per best practice guidelines. We also identified delays in the involvement of speech and language therapists and dietitians in the care of some patients who were NBM, finding this to be associated with a delay in the provision of alternative nutritional replacement in 32 % of patients. Following our analysis, a number of clinical practice recommendations were considered; for example methods for improvement of (i) risk screening, (ii) more prompt involvement of the Nutrition Multidisciplinary Team and (iii) documentation of nutritional parameters in the medical notes. Together with our key findings, these were disseminated in the following ways; (i) presentation and discussion at the quarterly Nutrition Steering Committee Meeting, (ii) presentation at the Medical Grand Round and (iii) design of a promotional leaflet for nursing staff, distributed by hospital matrons.In conclusion, in a district general hospital, a significant proportion of inpatients are made NBM, particularly the elderly. Often they are NBM for more than 5 d, with variable delays in both obtaining assessment from dietitians and speech and language therapists and providing alternative nutritional replacement to meet their needs. We have therefore recommended that an IR1 form is completed if a patient is NBM for five or more days without provisional of alternative means of nutritional support.

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