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This study aims to explore the perceptions of foundation doctors (FDs) in the United Kingdom (UK) surrounding raising concerns in the workplace. An online survey was sent to all FDs in the UK between February and March 2018. Respondents were asked what they had observed or experienced that had been ethically challenging during their foundation training. The qualitative responses were coded into themes. Reasons why FDs wished to raise concerns in the workplace included disagreements about clinical decisions within the team, insufficient availability of resources, lack of senior colleague support and having to work beyond their competencies. Challenges faced by FDs when raising concerns included organisational resistance to change, difficulties in communicating ideas to those higher up in the hierarchy and the emotional stress of whistleblowing regarding senior colleagues.Perceived consequences of raising concerns included negative impact on FDs' reputation and career, and fear of bullying. To overcome these barriers, changes within organisations at all levels must take place in order to provide an environment where FDs are encouraged to raise concerns and thus make positive changes to their work environments for themselves, their colleagues and patients.

This paper investigates the medical law and ethics (MEL) learning needs of Foundation doctors (FYs) by means of a national survey developed in association with key stakeholders including the General Medical Council and Health Education England. Four hundred sevnty-nine doctors completed the survey. The average self-reported level of preparation in MEL was 63%. When asked to rate how confident they felt in approaching three cases of increasing ethical complexity, more FYs were fully confident in the more complex cases than in the more standard case. There was no apparent relationship with confidence and reported teaching at medical school. The less confident doctors were no more likely to ask for further teaching on the topic than the confident doctors. This suggests that FYs can be vulnerable when facing ethical decisions by being underprepared, not recognising their lack of ability to make a reasoned decision or by being overconfident. Educators need to be aware of this and provide practical MEL training based on trainee experiences and real-world ethics and challenge learners’ views. Given the complexities of many ethical decisions, preparedness should not be seen as the ability to make a difficult decision but rather a recognition that such cases are difficult, that doubt is permissible and the solution may well be beyond the relatively inexperienced doctor. Educators and supervisors should therefore be ensuring that this is clear to their trainees. This necessitates an environment in which questions can be asked and uncertainty raised with the expectation of a supportive response.

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Introduction Quality person-centred care in those approaching the end of life includes consideration and anticipation of their preferred place of death and ceiling of care (CoC). This QI project to reduce inappropriate readmissions was prompted following the transfer of a palliative patient to the acute trust from a community hospital. Method Data was collected from the electronic patient record (EPR) at weekly intervals over a six month period, July to December. Electronic documentation of CoC from 507 records from a 24 bed community hospital was reviewed. Data collected included patient age, sex and whether a CoC decision entry had been made on the EPR during the community hospital inpatient stay. The appropriateness of readmissions over the same period was also analy sed. A weekly consultant geriatrician ward round was introduced focusing on advanced care planning with explicit decision making regarding preferred place of care. Results There were a total of 16 readmissions during the study period. 3 of these were deemed “inappropriate” following EPR review occurring in August, September and October. Subsequent review of electronic CoC July to October inclusive demonstrated a median completion rate of 20.5%. Following intervention there were no further inappropriate readmissions and the median CoC completion rate was 85%. Qualitatively, the consultant geriatrician managing the community hospital felt there had been a cultural shift where staff felt more comfortable managing complex palliative care. Conclusions Introduction of a weekly Consultant Geriatrician ward round in the community setting has led to a sustained improvement in CoC decision-making and documentation. As a result of this there have been no further inappropriate readmissions to the acute trust. This reflects the national guidance in patient centred palliative care. Further work including robust, qualitative assessment of staff attitude towards palliative care is needed to emulate this work at other local community hospitals.