Effective therapeutic engagement is viewed as a partnership relationship between staff and patients, with shared decision-making and recovery-focused goals.

The relationship is based on mutual trust, respect and negotiation, enabling patients to solve problems and enhance their coping capacity with the aim of building a meaningful life.

Understanding individual needs and preferences, through meaningful effective engagement and relationships built on trust, is important when considering the impact that mental health staff have on patients’ experiences of self-harm and suicidal behaviours while they are in mental health wards and wards for people with a learning disability. The therapeutic engagement questionnaire (TEQ), developed by Kingston University London, is designed to support staff in their therapeutic engagement activity and understand how it is experienced by people who use services.

The dynamic on mental health wards and wards for people with a learning disability can be complex and difficult. This can lead to difficult relationships between staff and patients that can be obstacles to effective therapy. A review of literature on inpatient self-harm in 2011 identified staff-related issues linked to self-harming behaviour, including use of bank and agency staff, low levels of qualified staff, and increases in staff absence.

The review also looked at research into nursing staff experiences. The authors noted that staff found managing self-harm challenging. They often felt uncomfortable with interventions such as observations or restrictive practices.

Staff also described experiencing negative emotions towards patients who self-harmed, and a fear of suicide. These difficult emotional responses resulted in more distant nurse/patient relationships. Poor understanding of self-harm and a lack of support when working with self-harm was also highlighted as a problematic factor. Staff need access to supportive supervision and the opportunity to engage in reflective practice.

Barriers to therapeutic relationships included:

• lack of choice of nurse (for example, gender of nursing staff)
• communication issues (including language, both due to differences in first language and use of jargon)
• absence of regular ward staff and reliance on temporary staff
• poor staff attitudes.

These reviews suggest that values are intrinsic to safe care and a supported workforce is essential to manage and reduce self-harm, including by ligature, on mental health wards and wards for people with a learning disability. Further research into workforce implications and ligature harm reduction on inpatient wards is required.

Psychological safety

Creating a psychologically safe culture offers direct benefits to staff and the health care it provides. Psychological safety can be broadly defined as ‘a climate in which people are comfortable expressing themselves’. It has importance in mental health in empowering staff, patients and families to voice their suggestions, concerns and anxieties.

When we consider the importance of candour and a learning culture among the workforce to improve learning and reduce ligature associated risks, the importance of psychological safety becomes clear.

Inpatient health care can be a high-risk environment. Staff rely on interprofessional and interdisciplinary relationships to manage risk effectively in environments where errors can result in significant harm or even death.

Despite the seemingly obvious benefits of psychological safety, a culture of blame and fear is still prevalent in far too many healthcare organisations. This in turn is detrimental to patient experience, staff morale and organisational safety.

In today’s healthcare organisations NHS England describes the importance of workplace compassion at all levels, from strategic planning, policies and procedures through to the way words are used in everyday conversations across organisations, and the importance of kindness and compassion in all settings.

Therapeutic engagement and relationships play an important role in helping to create a psychologically safe culture and environment where staff and people using services can feel able to speak up and ensure maximum involvement in their care.