Psychological safety on mental health wards: more than preventing harm

How I’m feeling psychologically or mentally really isn’t important as long as I’m not dead, as long as I get discharged alive, it doesn’t matter what’s happened to me along the way…there isn’t that understanding, I don’t think, of psychological safety in services, which is really odd considering it’s a psychological-based illness. (Berzins et al., 2020, p. 4)

Keeping patients safe is a key priority in mental health wards, but safety is often focused on preventing physical risk and reducing incidents such as self-harm, suicide, or risk from other patients. This is sometimes done by using restrictive practices like restraint, seclusion, observations, tranquilisation, locked doors, and limiting the belongings patients can have with them. Whilst these methods are intended to protect people from harm, they can have negative physical and psychological consequences for both staff and patients (Butterworth et al, 2022).

From the perspective of patients, feeling safe extends beyond measures to prevent physical harm but also involves being listened to, respected and involved in decisions about their care (Vogt et al., 2024; Berzins et al., 2020). Patients have described experiencing and witnessing restrictive practices as distressing and sometimes even re-traumatising (Vogt et al., 2024). Interventions have been developed with the aim of reducing reliance on restrictive practices but sometimes staff may feel they are necessary to manage immediate risk.

There is a growing body of research on restrictive practices, but their relationship with psychological safety from the perspective of patients has not yet been explored. Griffin et al. (2025) aimed to address this gap by exploring the impacts of receiving and witnessing restrictive practices on psychological safety in UK inpatient mental health settings and what can be done to make restrictive practices psychologically safe.

Feeling safe extends beyond measures to prevent physical harm.

Methods

The authors conducted semi-structured interviews with adults who experienced restrictive practices and had been discharged from UK adult inpatient mental health services no longer than 6 months ago. The study was advertised on social media, and people who were interested had to email the lead researcher to take part. Participants providing consent were compensated £30 for completing the interview. The topic guide, to steer the questions asked in the interview, was developed from reviewed literature and the researchers. People with lived experience were involved in designing the study at various stages. Interviews were recorded, transcribed verbatim and checked for accuracy. The transcripts were analysed using Braun and Clarke’s (2021) reflexive thematic analysis, an approach to qualitative analysis which highlights the researcher’s active role in interpreting the data and generating themes which are shaped by their assumptions and experiences.

Results

18 former patients were interviewed with experience in inpatient care across the UK. Participants were predominantly female (n=13), White-British (n=15), and employed full-time in mental health services, healthcare, or social work (n=9). 4 themes were generated from the interviews with participants.

Reactive over proactive care: seeing the behaviour and not exploring the reason for it

• Participants felt that in high-risk situations, such as self-harm incidents, staff reactions did not consider the thoughts and feelings that led to the behaviour and felt they were responded to with violence.
• Expressing frustration led to consequences like cancelling leave, so people did not feel safe enough to honestly express their emotions.
• Locked wards made patients feel unsafe and worsened distress.
• Physical interventions such as restraint felt like a default, convenient reaction to behaviour with little consideration for the context or effort to de-escalate the situation beforehand.
• In instances where staff communicated before restrictive practices were used, patients felt like this supported psychological safety and relationships with staff.

A chaotic environment cannot provide safety for patients and staff

• Participants described the ward as a chaotic environment.
• When patients were not involved in decisions about their care this led to further incidents and distress.
• Disagreements between staff, understaffed wards, and inconsistent decision making created an uncertain and unpredictable environment where psychological safety could not be prioritised.
• This weakened the therapeutic alliance and staff decisions about treatment were perceived as ill-informed, not considered, and resulted in a default to restrictions.

Psychological impact of the (perceived) power imbalance between staff and patients

• Some participants felt that restrictive practices were used by staff to demonstrate their power and made to feel punished for behaviour that was a symptom of their mental illness.
• Patients often saw restrictions on their belongings or meaningful activities as controlling, particularly when no explanation was given and blanket rules were applied without considering individual risk.
• This led some patients to respond by rebelling to regain a sense of power.
• The lack of control over personal decisions was a distressing experience for many patients.

Emotionally all in it together, for better or worse

• Former patients said that because of the constant contact with others on the ward, relationships with peers and staff were intensified.
• Relationships played an important role in either enhancing or undermining psychological safety. For example, close relationships with other patients allowed for peer support, but it also meant that witnessing upsetting interactions between peers and staff caused fear, distress, and negatively impacted patients’ own psychological safety.
• Patients felt staff disapproved of relationships between peers, and an ‘us vs them’ mindset was common.
• The ward was experienced by patients as an emotionally heightened and interconnected environment.

Finally, the authors also conceptualised psychological safety alongside people with lived experience of inpatient mental health wards. They said that psychological safety is:

Feeling validated in your experience of the world and the belief you will be treated fairly based on your individual needs. Being psychologically safe provides protection from lasting psychological harm from your environment. It’s not just about being physically safe but being protected from events that may have lasting effects in the future.

When staff communicated before using restrictive practices, this supported psychological safety.

Conclusions

The authors concluded:

1. Perceived physical risk is elevated in this setting, but containing this risk should not come at the expense of the psychological safety of patients.
2. Restrictive practices may be needed in crisis situations, but cause fear, distress, and trauma when psychological safety is not considered.
3. Physical safety is prioritised over psychological safety.
4. When restrictive practices are necessary, psychological safety can be improved by good communication and empathy.

Psychological safety can be improved by good communication and empathy.

Strengths and limitations

Strengths

• Patient and public involvement – People with lived experience were involved in developing materials, conceptualising psychological safety and reviewing the findings. This is important in ensuring the procedures and findings are relevant and meaningful for service-users.
• Appropriate qualitative methodology – Semi-structured interviews and reflexive thematic analysis were well-suited for the research goal of understanding the subjective experiences of patients. Using qualitative methods allowed participants to provide detailed accounts that may not have been captured through quantitative methods.
• Breadth of experiences – Researchers encouraged participants to discuss any ward experience they felt was restrictive, rather than being limited to predefined interventions. This meant that a wide range of experiences, including ones that may have been potentially less common, were able to be captured.

Limitations

• Sampling bias – People were required to actively reach out to researchers to take part. This means individuals with strong views and negative experiences may have been more likely to take part. The sample is also biased towards people with access to social media and those who are better able or more confident to volunteer to articulate their ideas.
• Sample not representative of the wider inpatient population – Participants were predominantly White-British, female, and half were in full-time employment. Additionally, half of the participants had experience working in health and social care roles, meaning the sample is heavily biased towards people whose roles may have influenced how they interpreted their experiences. Their experiences and interpretations may differ from those of the wider inpatient population.
• Limited exploration of witnessed restrictive practices – Participants spoke less about witnessing restrictive practices than experiencing first hand, and when they did, their discussions were mainly based on restraint. This means the study gives us limited insight into the effects a broad range of restrictive practices can have on patients.

The sample included in this research brought a specific set of characteristics.

Implications for practice

The findings of this study highlight the need for more staff training focused on psychological safety. Accounts of patients in this study, alongside other research, reflect views that the function of inpatient wards is to stabilise patients and reduce immediate physical risk rather than to be a therapeutic place (Berry et al., 2022). Regular staff training and supervision should focus on trauma-informed psychological models, understanding the effect of restrictive practices, and working collaboratively as much as possible with patients.

Managing risk should emphasise approaches to de-escalate situations. Approaches to reducing aggression in its escalation phase should include validation, empathy, confirming autonomy, problem-solving, and reframing (Price et al., 2024). By using these techniques, staff can reduce reliance on restrictive practices and encourage a more psychologically safe environment.

Another key takeaway from this qualitative study is that communication is incredibly important. In practice, staff should make efforts to ensure that they communicate effectively by making sure decisions are consistent and fully explained to patients. In instances where restrictive practices are used, everyone involved should be debriefed to prevent long-lasting harm. Staff should aim to retain as much patient choice as possible and involve patients in discussions and decisions about their care.

Consistent with a wealth of other research, the perspectives of patients and staff highlight the need for a fundamental change in the culture of managing risk on psychiatric inpatient wards to enhance psychological safety. However, understaffed, stretched wards can make implementing some of these changes difficult. Evidence for programmes that aim to reduce restrictive practices (Ward-Stockham et al., 2022) and, as we blogged recently, to enhance compassionate care is limited. Substantially more research is needed to promote practices that support therapeutic rather than restrictive care.

Good communication is key to enhancing feelings of psychological safety.

Statement of interests

Charis Palmer declares no conflicts of interest. Grammarly was used in the editing of this blog which uses generative AI.

Edited by

Simon Bradstreet.

Links

Primary paper

Griffin, B. et al. (2025) Exploring How the Psychological Safety of Patients Is Impacted by Restrictive Practices in Inpatient Mental Healthcare: A Qualitative Study, International Journal of Mental Health Nursing, 34(6), p. e70148.

Other references

Berry K, Raphael J, Haddock G. et al (2022) Exploring how to improve access to psychological therapies on acute mental health wards from the perspectives of patients, families and mental health staff: qualitative study. BJPsych Open 2022; 8(4):e112.

Berzins, K. et al. (2020) A qualitative exploration of mental health service user and carer perspectives on safety issues in UK mental health services, Health Expectations, 23(3), pp. 549–561.

Braun V, Clarke V. (2021) Thematic Analysis: A Practical Guide. London: Sage.

Butterworth, H., Wood, L. and Rowe, S. (2022) Patients’ and staff members’ experiences of restrictive practices in acute mental health in-patient settings: systematic review and thematic synthesis, BJPsych Open, 8(6), p. e178.

Price, O. et al. (2024) De-escalating aggression in acute inpatient mental health settings: a behaviour change theory-informed, secondary qualitative analysis of staff and patient perspectives, BMC Psychiatry, 24, p. 548.

Vogt, K. S. et al. (2024) ‘Safer, Not Safe’: Service Users’ Experiences of Psychological Safety in Inpatient Mental Health Wards in the United Kingdom, International Journal of Mental Health Nursing, 33(6), pp. 2227–2238.

Ward-Stockham, K. et al. (2022) Effect of Safewards on reducing conflict and containment and the experiences of staff and consumers: a mixed-methods systematic review, International Journal of Mental Health Nursing, 31, pp. 199–221.

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