Aims: Ensuring a safe environment for individuals who self-harm is a crucial aspect of inpatient psychiatric care. In recent years, steps have been taken to reduce restrictive practices on mental health wards following episodes of self-harm. A structured, self-harm pathway was evaluated by Peasley Cross Hospital, Mersey Care NHS Foundation Trust. This pathway was adapted and implemented on an acute mental health ward in Gloucestershire. The aim of the current study was to explore patients’ experiences of the pathway. Method: 1:1 interviews were conducted with four patients who had engaged with the pathway. Interviews were transcribed and thematically analysed. Results: The analysis identified four major themes. Three of the these (‘change/breaking the cycle’, ‘multi-directional learning’ and ‘groupwork’) reflected positive feedback from patients. The fourth theme, ‘consistency/inconsistency’, reflected challenges in implementing the pathway with a large team on an acute mental health ward. Conclusions & implications for practice: Patients considered the self-harm pathway to be largely positive, supporting its use on acute mental health wards. Further evaluation is necessary to determine if the pathway has reduced levels of self-harm and restrictive practice on the ward. Future research may consider evaluating the pathway across various clinical settings.
A service evaluation was carried out to explore patients’ perspectives of interventions provided by Assistant Psychologists (APs) working in a Crisis Resolution and Home Treatment Team (CRHTT). Using a mixed-methods design, feedback was collected from patients who had engaged with the AP for low-level, short-term (typically 1–3 sessions), psychologically informed interventions. Quantitative results revealed positive results, with patients reporting that they felt listened to, with the AP being knowledgeable and understanding. Some patients noted that the number of sessions was not right for them, or that the length was not adequate to meet their needs, however these response frequencies were low. Qualitative results revealed five overarching themes: therapeutic relationship , making sense of current difficulties , psychological interventions , impact and experience of psychology sessions , improvements/limitations . Content analysis discovered positive perspectives from patients, with minimal improvements/limitations indicated, and provided further support for the implementation of APs within acute mental health services. Overall, further evaluation into patients’ perspectives of AP interventions utilising data collected from interviews would be advantageous.
Aim: The aim of this evaluation was to examine how inpatients admitted to this adult acute inpatient hospital experienced the process of their admission, and to establish recommendations for improvement arising from this data. Method: Interview data regarding experiences of the inpatient admission process, gathered from 18 unstructured interviews with acute inpatients, was evaluated using thematic analysis. Results: The analysis produced four themes: systemic failure, ‘being ill enough’, judgement and acceptance, and trauma and punishment. These themes appeared indicative of how inpatients experienced the admission process to acute psychiatric care and informed recommendations made to the evaluated service. Conclusion: The results of this analysis emphasise that the process of being admitted into acute psychiatric care can be experienced as traumatic and highlights the impact of interpersonal interactions during this process. Recommendations include the need for mental health professionals to use a trauma-informed approach in interactions during and after admission.
The National Association of Psychiatric Intensive Care Units (NAPICU) held their 28 th annual conference in Northampton. The conference was attended by almost 300 delegates, with a wide variety of professions, including psychiatrists, nurses, occupational therapists, psychologists, support staff and pharmacists to name a few. With such a breadth of professionals in one room, the conversations were powerful and meaningful. This enabled teams from around the country to bring both their celebrations of success and reflections on challenges experienced in practice to add real world experience to the discussions. This year there was also the addition of a full day pre-conference summit, with a focus on the legal challenges in mental health care, navigating the intersection of law and clinical practice. This article will summarise the three days, with personal reflections from the authors to conclude.
National discussions in the UK are progressing toward the elimination of mixed–sex psychiatric intensive care units (PICUs), with a national position statement on single–sex provision expected in 2026 and potential implementation around 2029. This brief report provides an updated overview of current PICU configuration across the UK to inform planning for this transition. Data were collated from NHS trusts and independent providers on the number of mixed–sex PICUs and the potential impact on patients. In 2025, 50 of 110 PICU wards (45%) operated as mixed–sex units, with all NHS PICUs in Scotland, Wales and Northern Ireland falling into this category. In England, 71% of PICUs were single–sex, although provision was disproportionately weighted toward male wards, and female PICU capacity was limited and unevenly distributed, with some regions having no female PICUs. Mixed–sex wards accounted for 468 beds, and estimates suggest that approximately 328 male and 140 female patients may be affected by a move to single–sex provision. These findings highlight significant regional inequities and the likelihood of increased out–of–area placements for women unless female PICU capacity is expanded. The report provides a timely baseline to support national service redesign and underscores the need for coordinated commissioning to ensure safe, equitable, and locally accessible single–sex PICU care.
People with a learning disability and/or autism frequently experience inequitable access to effective mental health care; many receive support in environments that are not designed to meet their needs, including psychiatric intensive care units (PICUs). We describe a new specialist mental health service established by Avon and Wiltshire Mental Health Partnership NHS Trust. The Kingfisher comprises an integrated care pathway, combining a community outreach offering with a dedicated inpatient facility designed specifically for adults with a learning disability and/or autism and co–occurring treatable mental health conditions. We outline the national and regional policy context underpinning the service, the identified need arising from high rates of out–of–area placements, and the programme requirements to reduce inpatient admissions and length of stay while improving patient experience and outcomes. Central to the development has been a commitment to co–production with people with lived experience, influencing service model design, workforce development, building architecture, and clinical practice. Trauma–informed and autism–friendly design principles, alongside a strong emphasis on nature connection, were embedded within both the physical environment and the clinical model. Key challenges encountered during delivery, including cost pressures, planning constraints, and the absence of specific design guidance for this type of unit, are discussed. The Kingfisher demonstrates how a whole–pathway, co–produced approach can support safer, more humane and effective mental health care for people with a learning disability and/or autism. This model offers transferable learning for other systems seeking to move away from inappropriate inpatient care, towards more personalised, inclusive and locally delivered services.
Background: Challenging behaviour is prevalent on acute psychiatric wards, negatively affecting staff, patients, and ward environments. Restrictive practices target inpatient violence but can be traumatising and dehumanising. Team case formulation increases staff understanding of challenging behaviour and generates strategies to reduce it, but research is limited. Methodology: This two-phase study investigated feasibility, acceptability, and effectiveness of team case formulation sessions with ward staff to reduce inpatient violence and challenging behaviour. In Phase 1, highly aggressive inpatients from five acute wards were either the focus of psychologist-led case formulation sessions (cases; N = 24) or were controls (N = 24). Post-formulation sessions, ward staff (N = 21) completed a feedback survey and change in patients’ violent and challenging behaviour was measured after staff-led interventions. In Phase 2, staff experiences were explored using in-depth semi-structured interviews and surveys (N = 12). Results: In Phase 1, case formulation appeared feasible, given adherence to implementation strategy and staff feedback, and staff-rated challenging behaviour reduced in cases, compared to controls. However, there were difficulties measuring change in violent incidents using electronic health records. In Phase 2, staff reported that formulation increased empathy for patients and sessions provided a space for stress-management and collaborative reflection, but they identified implementation barriers. Conclusion: Data-driven case formulation appears feasible, acceptable, and effective to reduce challenging behaviour. Findings suggest that it is helpful for patients, staff, and ward environments; data can meaningfully inform inpatient care; and both in-person and video call are viable methods of delivery.
Background: Challenging behaviours are common in acute mental health settings, causing strain on therapeutic relationships and increased use of restrictive practices. Sensory modulation offers a non-restrictive alternative but evidence of its effectiveness in high-acuity settings is limited. In 2023‐2024, the ‘Sensory Strategies’ project was conducted on a female acute mental health ward where the average monthly rate of violence and aggression (VA) was 21.2 incidents in the three months prior. The project aimed to reduce the mean number of incidents by 10% over 12 months. Method: Using quality improvement methodology, a sensory modulation intervention package was designed. Changes were implemented through iterative Plan-Do-Study-Act (PDSA) cycles during which staff and patient feedback was gathered to inform improvement. Monthly incidents of challenging behaviours were tracked using a Shewhart Individuals Chart. Results: After 12 months, incidents of challenging behaviour had decreased: VA by 45.3%; other challenging behaviours (OCB) and self-harm by 28.4%. Three months later, reductions in VA and OCB were sustained while a 38.8% increase in self-harm incidents was probably linked to an increase in admissions of individuals with personality disorders. Patients (n = 9) reported high satisfaction, highlighting improved emotional awareness and understanding of grounding techniques. Staff (n = 7) felt confident using sensory strategies but requested more hands-on training and easier access to materials. Conclusion: The target for reducing challenging behaviours was exceeded, highlighting the strong potential to reduce restrictive practices and improve patient experience. Future work should explore strategies for long-term sustainability, including phased implementation.
Background: Despite inpatient treatment not being recommended for those with a diagnosis of personality disorder, this may at times be necessary. One of the primary goals of the Structured Clinical Management (SCM) pathway is to reduce unnecessary hospital admissions. The SCM protocol attempts to reflect best generic practice for emotionally unstable personality disorder (EUPD) in the UK focused upon the organisation of care and provision of a therapeutic framework. The aim of the current study was to explore patient experiences of the use of SCM principles of care within an inpatient setting. = Method: Semi-structured interviews were conducted with seven participants under the care of Northamptonshire Healthcare Foundation Trust (NHFT) who were identified through purposeful sampling. All participants were female with a primary diagnosis of EUPD, or with established difficulties in this area, and with exposure to at least two hospital admissions within the previous 12 months. Data was then explored and analysed qualitatively using thematic analysis. Results: Analysis revealed six themes: ‘patient involvement’, ‘a template for care’, ‘shared understanding’, ‘person-centred care’, ‘holding the hope’ and ‘support’. Perception of the quality of care seeming to be contingent upon these factors. Conclusion: Patient experiences of the SCM principles of care and their impact upon recovery within an inpatient setting were influenced by several factors. This included the delivery of person-centred care rather than a more ‘blanket’ approach to implementation. Clinical and research implications are discussed.
Background: Strong staff–patient relationships are essential for the provision of high quality care within psychiatric intensive care units. These relationships can be strengthened through staff training interventions, for example, the Safe & Secure programme. However, interventions delivered in psychiatric intensive care units are difficult to implement and sustain. Normalisation Process Theory offers a framework through which to measure how effectively new interventions are implemented in this setting. Method: The aim of the study was to assess the implementation of a ward-based team training programme within a psychiatric intensive care unit. Following the delivery of the Safe & Secure ward-based team training programme, staff were interviewed about their experience and completed a quantitative measure of normalisation: the NoMAD. Interviews were analysed using reflexive thematic analysis with codes being grouped under the four constructs of Normalisation Process Theory. Results: Staff reported being able to recognise the utility of the intervention and, qualitatively, reported seeing it as beneficial for their clinical practice. NoMAD scores were high, indicating the normalisation of the intervention. However, staff found it difficult to quantify how the intervention had improved their practice. They also reported difficulties with applying the intervention in certain circumstances. Staff expressed concerns about intervention sustainability. Conclusions: The Safe & Secure ward-based team training programme was implemented and normalised into routine practice. The study identified areas for improvement in future deliveries of the programme. The study also provided useful information to help inform the future implementation of ward-based team trainings in psychiatric intensive care units.
Background: Psychiatric intensive care units (PICUs) are increasingly recognised as essential components of forensic care for managing patients who are difficult to treat in conventional units. Despite this, there is limited research on the psychiatric and violence risk profiles of these patients, particularly in forensic settings. Aim: To identify the characteristics of patients admitted to a forensic PICU (FPICU) in Belgium. Method: A comparative analysis conducted between 2016 and 2022 on a cohort of 344 patients; 176 FPICU admissions and 168 forensic cases not admitted to the FPICU (NFPICU). Demographic, clinical and criminological profiles were assessed using the PCL-R, VRAG and HCR-20 tools. Results: As expected, FPICU patients demonstrated complex diagnostic profiles, including higher rates of substance use (52.8%), psychotic disorders (55.1%), and antisocial personality disorders with psychopathy (25.0%). Comorbid mental disorders were prevalent (69.9%), exacerbating their elevated risk of violence as assessed by the HCR-20 and VRAG. They were also more frequently involved in non-sexual violent (56.5%) and non-violent offences (68.7%). Coercive measures, including involuntary treatments (65.9%), seclusion (91.5%), and restraint (43.8%), were more commonly employed for FPICU patients. Conclusion: Patients admitted to the FPICU present complex psychiatric and criminological profiles, with high levels of comorbidity and violence risk. Specialised care strategies should be implemented in secure environments that emphasise therapeutic relationships to reduce restrictions, manage disruptive behaviours, and enhance treatment adherence. The implementation of the Forensic High and Intensive Care model, as developed in German-speaking countries, could support the reintegration of these patients into standard care units.
There is a lack of evidence-based recommendations on how to structure routine patient‐clinician meetings to ensure optimal patient outcomes. As a result, the agreed care plan and actions from these meetings often produce goals which are not optimally recovery-focused and measurable. The team at Barefoot Lodge, an adult inpatient psychiatric rehabilitation ward, completed a quality improvement project to improve the quality of their care plan goals after a baseline audit revealed low scores for goals being recovery-focused and being broken into measurable milestones. The project aim was to improve the quality of these meetings and the quality of the care plans using a new patient outcome and care planning tool called DIALOG+. The team altered the structure of their routine patient‐clinician meetings, replaced their old care plan system with DIALOG+, and made these new plans central to their patient review process on the ward. The project successfully implemented the aims of the project by improving the quality of six out of the seven audit questions. DIALOG+ helped structure routine meetings on the ward, allowing patients to feel more involved in co-producing their recovery goals and being aware of what steps they can take to achieve them.
Background : The use of restraint on psychiatric inpatient wards varies widely and is poorly understood, but patient characteristics, situational factors and organisational factors have been implicated. Objectives : To understand whether use of restraint differed systematically between wards and sites and then define the relative contribution of patient, situational and organisational factors. Design : Restraint incidents were extracted from incident reporting over a four-year period. Incidents were drawn from five acute wards and two psychiatric intensive care units across three hospital sites within an NHS Trust in the UK. Two research samples were created. An overall incident sample (N = 1297) was used to assess the degree of variability between wards and sites. Binary logistic regression in a first use of restraint sample (N = 435) then assessed the contribution made by significant patient, situational and organisational predictors. Results : No significant differences between the wards or sites were found for restraint rates and the levels of restraint used. Staff response and time of day were significant predictors of level of restraint. The regression model explained 16.9% of variance in level of restraint. Conclusion : Future research needs to better measure and then model the dynamic relationships between patient, organisational and situational factors that predict restraint. Intervention programmes that target restraint reduction need to be better evaluated.
Overuse of restrictive practices in inpatient mental health wards remains a national concern. Identifying individual mindsets related to the approval of restrictive practices may guide effective intervention for services and promote betterpatient safety. A survey was conducted on nursing and healthcare staff working on mental health inpatient wards in the UK. A total of 106 staff completed an online questionnaire including the Elsom Therapeutic Optimism Scale (ETOS),Attitudes Towards Containment Measures Questionnaire (ACMQ), and Mental Illness: Clinician’s Attitudes scale (MICA). Demographic information, as well as work experience and personal experience with mental illness, was also collected.The study found that attitudes towards containment measures were significantly related to age, gender, years of work experience, therapeutic optimism, educational attainment and personal experience with mental illness. Educationalattainment was also positively correlated with therapeutic optimism. Stigmatising attitudes were negatively correlated with therapeutic optimism. Further research investigating how these attitudes are formed, maintained, and modified can guideinterventions to reduce the use of restrictive practices.
Aim: In 2022, 3% of Swedish psychiatric patients received treatment under the Compulsory Psychiatric Care Act (CPCA), with conditions of a psychotic nature composing one of the largest patient groups. While psychological treatment is strongly advised for patients with severe mental illness (SMI), only a minority receive such treatment, particularly during hospitalisation under the CPCA. Acceptance and commitment therapy (ACT) has shown effectiveness in addressing SMI within inpatient contexts. Nevertheless, there is a lack of research regarding ACT for inpatients treated under the CPCA. Method: The topic was explored in a single-case experimental design, with self-assessment as an outcome measure. The original plan was to recruit 3‐6 participants. Results: Despite approaching 12 patients, only one individual was included and completed the intervention. The data was analysed using Tau-U, indicating that the intervention did not significantly impact the patient’s psychological wellbeing (?? = −0.0286). Conclusion: Procedural difficulties transitioned this study into an exploratory feasibility study rather than offering definitive conclusions. There are multiple factors assumed to have influenced the outcome, including aspects such as recruitment, study design, outcome measures and setting. Suggestions are made for future studies on this topic.
Due to the high prevalence of challenging behaviours on acute psychiatric wards, there is a need for more therapeutic interventions that utilize psychological theory to support staff and patients. This study assessed feasibility, effectiveness and mechanisms of multidisciplinary team case formulation to reduce challenging behaviours of patients. This was a cohort study with a pre‐ and post‐formulation analysis of patients from five acute wards. Structured team case formulation sessions were held using an integrative psychological model incorporating cognitive behavioural principles and the Newcastle model. Staff attendance and fidelity to formulation components were recorded. Frequency of staff-rated challenging behaviours and the frequency of incidents of violence and self‐harm pre‐ and one‐week post‐formulation were assessed. To test mechanisms, changes in staff perceptions of the overall frequency of challenging behaviours and the number of incidents of violence and self‐harm were compared to the number of strategies identified, the number of strategies implemented, and the number of staff present. Participants (N = 50) had a range of serious mental health conditions, including 50% with F20???F29 schizophrenia, schizotypal and delusional disorder. Fidelity to formulation model components was found to be high. There was a significant decrease in staff perception of the frequency of patients’ challenging behaviours, with large effect sizes. There was strong evidence of a reduction in the number of violent incidents and self‐harm post‐case formulation. None of the mechanism tests were significant. Case formulation sessions appear to be a feasible and effective intervention to reduce challenging behaviours within acute inpatient care.
