Purpose

This guide is designed to support trusts develop and implement their enhanced therapeutic observation and care (ETOC) policy. Trusts should create ETOC policies that are living documents, enabling ongoing implementation and continuous improvement that responds to local needs. The information in this guide is applicable to all clinical settings.  

Context

In September 2024, NHS England launched a multi-year ETOC improvement programme to help organisations make local, clinically led, patient-centred improvements to their ETOC provision. This improvement guide to developing a local ETOC policy was co-designed with a group of experienced clinical leaders. For further information about resources and the improvement programme, please visit the ETOC website. Additional resources can be accessed by joining the Nursing Directorates ETOC FutureNHS page (FutureNHS login required).

Effective leadership and oversight

Demand for ETOC often locally referred to as enhanced care, 1:1s, cohorting or specialing has been growing. The rise is largely driven by an ageing population and increasingly complex care needs.

While ETOC plays a vital role in keeping patients safe, it must be used with care. If not applied or monitored, it can affect a patient’s rights and autonomy. Additionally, it can place unnecessary demand on resources and potentially impacts on the availability of resources for other wider healthcare needs.

Nurse leaders have emphasised the need for strong leadership and oversight to ensure ETOC is always delivered in a person-centred and proportionate way. Effective oversight starts with clear policies and robust data. Good data helps organisations to track trends, understand how ETOC is being used and make informed decisions. Clear policies promote consistency, accountability and alignment with best practice.

Enhanced therapeutic observation and care: A guide to improving data collection and reporting provides practical advice on how organisations can use data to strengthen oversight from ward-to-board.

A clear ETOC policy should define how the approach is used in practice. Both evidence and input from nurse leaders stress that ETOC should be seen as a therapeutic intervention – not just a way to manage risk.

 5 concepts should guide ETOC local policy development:  

• person-centred care – ETOC should be tailored to an individual patient’s needs and used with their consent whenever possible
• proportionality – interventions should be regularly reviewed and applied in the least restrictive way necessary to ensure safety. This not only helps protect patient dignity and rights but also supports efficient use of staff and resources    
• equity, diversity, and inclusion – policies should promote cultural safety by recognising protected characteristics and ensuring staff are trained in assessing and delivering ETOC to patients from a diverse range of backgrounds
• co-production – ETOC policies should be developed with patients, carers, and those with lived experience to reflect needs and perspectives that have been shaped by their realities
• plain English – policies should be clear, succinct and accessible to all stakeholders to foster transparency and shared understanding

These principles should be embedded in all ETOC policies and standard operating procedures (SOPs).

To support organisations in reviewing and developing their ETOC policies, a policy guide checklist is included in Appendix 1. It can be used to quickly compare existing policies against the recommended elements outlined in this guide.

A selection of case studies showcasing local examples of ETOC policy development are included in Appendix 2. These real-world examples illustrate how different organisations have approached the design and implementation of their policies, offering practical insights for others undertaking similar work.

What are the components of a good ETOC policy?

Drawing on insights from NHS England’s ETOC improvement programme, the guide recommends 6 key components that should be covered in trusts’ ETOC policies:

• purpose and scope
• roles and responsibilities
• process description
• types of enhanced observations
• training, competencies and support
• governance and oversight mechanisms

Component 1: purpose and scope

Why is this section important?

The opening section sets the foundation for the ETOC policy. It should be concise and focused on helping the user understand the policy’s aim and audience.

Key information for this section

Enhanced therapeutic observation and care definition

There is currently no single, universally agreed definition of enhanced therapeutic observation. However, it is essential that your policy clearly defines what is meant by enhanced therapeutic observation and care (ETOC) in your organisation. This will promote a shared understanding and consistent application.

The Mental Health Act Code of Practice (2015) remains the most widely cited reference, defining ETOC as a therapeutic intervention aimed at reducing risk and promoting recovery through meaningful engagement, such as conversation, help with activities, and addressing individual concerns.

Current evidence and practice emphasise a shift from passive observation to active therapeutic engagement, prioritising relational over restrictive care and adopting individualised, person-centred approaches – with the view that these changes will improve patient outcomes, enhance the safety and quality of care, support staff experience and foster positive organisational cultures.

Purpose

Concisely state the aim of the policy to help staff understand why it exists and how it should be used.

Scope

Specify where and to whom the policy applies, such as inpatient settings, relevant patient groups and clinical staff. This will ensure consistency and promote safe care delivery.

Policy statement

Clearly outline the organisation’s principles and guidelines for ETOC. Use plain language, avoid jargon, and aim for clarity and precision.

Legal requirements

The policy statement needs to capture that ETOC must be used in line with the least restrictive principle, for the shortest time necessary. A lawful and ethical approach requires a personalised assessment process that respects each person’s rights, dignity and individual needs.

With this in mind, the statement should align with related policies and legal requirements, including the Mental Health Act (1983), Mental Capacity Act (2005), the Human Rights Act (1998), Use of Force Act (2018) and Children Act (1989). NHS England’s website has guidance to support the implementation of the Mental Capacity Act in acute trusts for adults with a learning disability.

Supporting documents

Include hyperlinks to essential documents, such as standard operating procedures, related policies, and equality and quality impact assessments. Provide a sentence of context explaining what each document is and why it is useful. This will provide staff with direct access to key resources.

Consider using flowcharts or infographics to visually represent the policy’s operation and related procedures. These tools, are used by several organisations, offer staff quick and effective guidance in practice, Best practice guidance for designing accessible infographics is available on the Government Analysis Function website.

Component 2: roles and responsibilities

Why is this section important?

Clearly defining roles and responsibilities ensures that everyone understands their part in delivering safe and effective ETOC. This supports accountability, reduces ambiguity and establishes consistent practice across teams.  Experience shows this approach fosters an open, inclusive culture and helps ensure effective ward-to-board governance.

Key information for this section

Who is responsible for the policy

An executive officer should be responsible to oversee the policy’s development, approval and communication. In most instances this is likely to be either the Chief Nursing Officer or the Chief Medical Officer, although the trust should ultimately determine who is best suited to this role. This includes overseeing its implementation into local governance structures to monitor adherence to the policy, patient outcomes, and overall effectiveness. The policy should be reviewed in line with the organisations usual timeframes for clinical policies. Current national guidelines, legislation and best practice suggest a three-year review cycle.

Who is responsible for the assessment and care planning process

The policy must specify which registered healthcare professionals are accountable for ETOC assessment and care planning. Responsibility for care planning is outside the scope of practice for nursing associates (NA’s) and non-registered staff; they have a core role in the delivery of ETOC provision.

The role of the multidisciplinary team

The policy should define the role of the multidisciplinary team across care settings, including registered nurses, specialist staff (such as psychiatric liaison teams) and support workers. Co-ordination should be supported through local agreements and operational tools, such as standard operating procedures and referral pathways, to ensure continuity of care.

Who is responsible for overseeing ETOC

Local clinical oversight should be by registered professionals such as the divisional director of nursing or head of nursing to ensure adherence to their ETOC procedures.

While these senior nurses provide overall clinical governance, the nurse in charge on the ward is responsible for allocating ward staff to perform observations, ensuring the skill mix is safe and appropriate for both the ward and patient, ensuring that staff have regular breaks and overseeing that all documentation, structured handovers, and staff debriefs are completed.

The policy should also specify who is responsible for managing staffing requests to ensure ETOC provision meets patient needs.

Who is responsible for delivering ETOC

Staff involved in ETOC delivery must be trained and competent, particularly in therapeutic interventions, the relevant legal frameworks and de-escalation. The policy should set out training, competency expectations and supervision structures to facilitate proportionate and effective resourcing.

• registered staff with the exception of NAs, are responsible for the assessment and planning stages of ETOC delivery. They also hold a supervisory role for other staff groups involved in providing patient-facing ETOC delivery, including unregistered and temporary staff
• unregistered staff play a vital role in the delivery of ETOC, but this should be under the direct guidance and supervision of registered staff.
• temporary staff should be effectively inducted into new clinical areas, trained to deliver therapeutic care, and supervised by staff responsible for oversight

Who is responsible for supporting ETOC

Support may come from the patient’s network, including family, friends, advocates as well as ancillary assistance from volunteers. The policy should explain how care and risk plans are shared with these stakeholders to ensure consistent, person-centred care.

Component 3: process description

Why is this section important?

A standardised, structured approach to ETOC assessment, care planning, risk management and review is essential to ensure patients receive the right level of observation based on their individual needs. This helps minimise unwarranted variation, supports consistent decision-making and promotes safety, dignity and recovery.

Regular reviews and clear documentation also strengthen accountability and ensure that care remains proportionate and responsive over time.

Key information for this section

ETOC assessment

Each ETOC plan should clearly define its purpose, outline the frequency and intensity of observations over a 24-hour period, and consider less intrusive approaches during night-time hours where appropriate.

Assessments must be person-centred, with informed consent sought wherever possible. Even when a legal framework such as the Mental Capacity Act is in place, and regardless of the patient’s capacity, efforts should be made to involve them in the decision-making process and obtain their consent. Where consent cannot be given, decisions must be guided by the appropriate legal framework.

All assessments should be clearly documented to ensure consistency, accountability and shared decision-making within the multidisciplinary team to promote continuity of care.

Person-centred care planning and risk management

ETOC should be embedded within a comprehensive, patient-centred care plan that includes risk management and must never be applied in isolation or as a default intervention.

While risk management is a key consideration, this should be balanced with a therapeutic purpose. Every aspect of an enhanced observation plan, including the level and nature of observation during personal activities such as toileting, must be proportionate to the specific, assessed risks posed by the individual.

A blanket approach to privacy restriction is prohibited. Any decision to reduce or remove privacy must be clearly justified, time-limited, documented in the patient’s care plan, and subject to immediate review as the individual’s risk profile changes.

Care planning should be developed in collaboration with the patient and their support network, including families and carers, and guided by any advance decisions to enhance continuity of care. Advice and guidance on how to provide therapeutic engagement and intervention during ETOC delivery will be explored further in the upcoming guide on person-centred assessment and therapeutic care.

Review, re-assessment, increase and discontinuation

Given the restrictive nature of ETOC, continuous review is critical. Nursing leaders recommend: 

• reviews should happen every 24 hours at a minimum, ideally at every shift, including re-assessment of the clinical presentation to ensure interventions remain necessary and proportionate 
• internal, local MDT oversight for any case lasting more than 1 week to achieve collective agreement that ETOC provision is proportionate and least restrictive. Where multiple care agencies support the care, they should be involved in the review and decision-making process  
• clear criteria for the increase, reduction or discontinuation of ETOC, agreed upon by the wider MDT 

Documentation processes

Effective implementation of these components relies on clear, timely record-keeping. The policy should specify requirements for ETOC documentation and structured handovers to ensure continuity of care and a defined escalation process for managing concerns in and out of office hours.

We have heard from nurse leaders that the successful implementation of these elements relies on clinical decision-making. Drawing on evidence from the literature, nurse leaders have identified these 10 core considerations for clinicians undertaking an ETOC assessment, care planning, risk management and review (Illustrated in Appendix 3):

• environmental considerations
• patient history
• patient and family involvement
• therapeutic interventions
• person-centred care planning
• legal frameworks
• assessment tools
• decision-making tools
• clinical judgement
• staffing

It is important to note that these core considerations are not exhaustive and may be supplemented with local knowledge of good practice.

Further information on these considerations will be published shortly, as part of therapeutic care improvement guide.

Component 4: types of enhanced observations

Why is this section important?   

Evidence and practice highlight significant variation in the language and terminology used to describe enhanced observation. To reduce this inconsistency, the ETOC policy should include a clear approach and standardised local definition to enhanced care. This helps minimise unwarranted variation and strengthens oversight of ETOC delivery across the organisation.

Key information for this section

The nature, patient and clinical environment informs the approach to observations. Trusts should therefore consider which observation would best support their patient population: General, intermittent, continuous within eyesight, and within arm’s length. Factors to consider when allocating observations individually includes privacy, dignity, risk management, safety of patient and/or others, and therapeutic benefits.

Evidence shows some technical recommendations are provided for specific settings, with the following sources noting some variations in this space:

• the Mental Health Code of Practice (Section 26.28-25, 2014) highlights that levels of observation and risk should be regularly reviewed to ensure individual distress is minimised, and a record of decisions agreed in relation to increasing or decreasing the observation
• the “Violence and aggression: short-term management in mental health, health and community settings” NICE guidelines (Section 1.4.11, 2015) set out definitions for 4 levels of observation that should be used in inpatient psychiatric wards (including general adult wards, older adult wards, psychiatric intensive care units and forensic wards):
  • low‑level intermittent observation: the baseline level of observation in a specified psychiatric setting. The frequency of observation is once every 30 to 60 minutes
  • high‑level intermittent observation: usually used if a service user is at risk of becoming violent or aggressive but does not represent an immediate risk. The frequency of observation is once every 15 to 30 minutes
  • continuous observation: usually used when a service user presents an immediate threat and needs to be kept within eyesight or at arm’s length of a designated one‑to‑one staff member, with immediate access to other members of staff if needed
  • multi-professional continuous observation: usually used when a service user is at the highest risk of harming themselves or others and needs to be kept within eyesight of 2 or 3 staff members and at arm’s length of at least 1 staff member

The application of enhanced observation should function as a dynamic risk management strategy, not a blanket intervention. Trusts will need to supplement existing recommendations and frameworks with guidance and worked examples in their policies. 

Component 5: training, competencies and support

Why is this policy important?

Enhanced observations are a clinical intervention. Clearly defined training, competency requirements, and staff wellbeing support ensure staff are equipped to deliver therapeutic, person-centred care. Standardising these expectations across the organisation promotes consistency and quality in ETOC delivery, ensuring all patients receive appropriate care.

Further detail on the training, competencies and staff support will be provided in the upcoming guide on training and education.

Key information for this section

Training for oversight

Staff overseeing ETOC must be competent in review processes, debriefing, restorative support, local assessment procedures, and the legal frameworks. The nurse in charge plays a critical role in operational oversight on the ward, including allocating staff to deliver observations, ensuring a safe and appropriate skill mix, overseeing accurate documentation, and debriefing and supporting the team.

Training for assessment and planning care

Registered healthcare professionals should be competent in assessment, care planning, risk assessment and using the relevant documentation. They should be appropriately inducted into local ETOC procedures.

Training for care delivery

Staff delivering enhanced care must receive role-specific training tailored to their clinical setting and the needs of the patient groups they are supporting. This training could include therapeutic engagement, recognising early signs of physical and mental health deterioration, reducing restrictive practices, and safeguarding both children and adults. In addition, staff should be familiar with the organisation’s ETOC standard operating procedure to ensure consistent and safe delivery of care.

Competency assessment

Competency assessments help ensure staff have the knowledge and skills needed to deliver ETOC safely and effectively. These assessments should be linked to training completion and ongoing performance in key areas such as therapeutic engagement. As technology becomes more integrated into care delivery, staff must be appropriately trained in using relevant digital systems. This includes electronic health records, decision support tools and digital assessment platforms.

Staff wellbeing

Staff conducting observations may experience stress and emotional fatigue. Supervision and reflective practice have been shown to reduce staff burnout and support the quality of ETOC delivery. The policy should outline the procedure for post-incident debriefs and the structured support systems available to staff, such as safety huddles, supervision and wellbeing support through existing trust structures, such as occupational health.

Specialist training for specific populations and environments

Additional training should be available for staff working with specific patient groups, such as those who refer to themselves as neurodiverse. Those who identify with a learning disability, children and young people, those with eating issues or disorders, frailty, dementia, or complex mental health needs.

The policy should also include role-specific content tailored to different clinical environments such as emergency departments and acute mental health wards.

Inclusion of temporary and agency staff

Temporary and agency staff frequently deliver ETOC and should therefore receive the same level of training as substantive staff.

Families, support networks and volunteers

Families and carers should have access to information or sessions explaining ETOC and understand their role in supporting the patient. Volunteers, where offering ancillary support, should be appropriately trained and supported.

Component 6: governance and oversight mechanisms

Why is this section important?

Nurse leaders highlight the importance of having oversight of multiple aspects of ETOC delivery, including financial, workforce, quality and safety perspectives.

The policy should outline how adherence to the policy will be monitored and provide an overview of the governance and oversight structures that will support the regular evaluation of ETOC delivery.

Key information for this section

Compliance and accountability mechanisms

Establish mechanisms such as audits, incident reviews, and defined escalation procedures to ensure policy adherence and continuous improvement. The policy should outline audit frequency, scope, methodology, and responsibilities (such as quality improvement teams).

This also includes reviewing care plans and observation records to ensure consistency and quality.

Consistency across associated policies and standard operating procedures

Ensure alignment by linking the ETOC policy with related organisational policies and standard operating procedures (such as those relating to safe staffing).

Governance and reporting mechanisms

Set out the governance structures responsible for oversight, such as sub-board groups or clinical committees, and define how ETOC data and audit findings will inform action planning.

Data collection and analysis

Include a clear framework for collecting and analysing data on enhanced care delivery (such as patient numbers, observation types, duration, staffing levels, demographics, and reasons for use). This should also encompass clinical indicators, such as patient and staff incidents to monitor safety and effectiveness.

Refer to Enhanced therapeutic observation and care: A guide to improving data collection and reporting for further detail.

Feedback mechanisms and continuous improvement

Describe how learning from incidents will be captured and embedded into practice, including support and involvement of all staff (including temporary or agency workers) in post-incident reviews.

Incorporate tools for gathering and reviewing staff and patient experience – such as complaints, compliments, and surveys (including Your Opinion Counts) – to inform continuous refinement of policy and practice.

Appendix 1 – Developing a local policy

This ‘at a glance’ list of policy principles, providing organisations with an overview of things to consider including in the policy. 

Purpose and Scope

• define enhanced observations. This should be a both a therapeutic intervention and risk-management strategy, emphasising its person-centred and proportionate application
• state the purpose of the policy
• define the scope of the policy (who it applies to and where it applies)
• include a policy statement, outlining your organisation’s principles and guidelines for ETOC
• reference relevant legal frameworks (such as Human Rights Act 1998, Mental Health Act 1983, Mental Capacity Act 2005, Use of Force Act 2018)
• include hyperlinks to essential documents (standard operating procedures, equality and quality impact assessments, related policies, process flowcharts)

Roles and responsibilities

• identify a named policy lead and confirm how often policy will be reviewed (current national guidelines, legislation and best practice suggest a three-year review cycle)
• define the responsibilities of registered professionals involved in assessment and care planning
• describe expectations for multi-disciplinary working
• outline responsibilities for staff overseeing ETOC, including a) nurse in charge duties (for example, rotation observation roles including regular breaks) b) shift-level review of ETOC cases c) local MDT oversight of ETOC cases exceeding 1 week
• define responsibilities for staff delivering ETOC including registered, unregistered, and temporary staff
• describe processes for involving families, carers and volunteers in supporting ETOC

Process description

• outline a structured approach to ETOC assessment, care planning and risk management, including decision-making about how to initiate, adjust or end ETOC.
• define documentation expectations including structured handovers and escalation processes.
• outline tools and principles for delivering high quality ETOC processes at a local level.

Types of enhanced observations

• describe the local classification of observation levels
• reference relevant practice guidance (such as, Mental Health Act Code of Practice and NICE guidelines)

Training, competencies and support

• outline competency and training expectations for those involved in overseeing the implementation of care (such as legal frameworks and review processes)
• outline competency and training requirements for staff delivering ETOC (such as therapeutic engagement, de-escalation, communication and safeguarding)
• describe staff wellbeing support structures (such as clinical supervision, debriefs, reflective practice)
• include information on specialist training for staff working with specific patient groups (such as children and patients with memory problems)
• explain how temporary staff are included in training and competency programmes
• outline support given to families, support networks and volunteers to understand their role in ETOC

Governance and oversight mechanisms

• define compliance and accountability processes (such as audits, incident reviews, and escalation protocols)
• outline associated organisational policies
• describe governance and reporting structures (such as board sub-committees)
• provide a framework for data collection and analysis including a) frequency, duration and rationale for ETOC. b) staffing and patient demographics. c) clinical indicators (such as patient and staff incidents)
• outline mechanisms for continuous improvement informed by patient and staff feedback

Appendix 2 – Local examples of policy development

Patient experience, engagement and voice within policy

Humber Teaching NHS Foundation Trust has been exploring how patient experience and feedback can inform robust, evidence-based policy.

The trust has recently begun to review its ETOC policy and is working with those receiving care to understand what good looks like to develop its policy model of “supportive engagements”. This journey of improvement aims to result in a truly collaborative policy that meets the needs of all the people who will be impacted by its implementation.

Learning points

Language and accessibility

The trust has reviewed its policy from a patient perspective, making the language and layout clear and accessible to all. This means the policy can be used by different groups, including patients, families and staff. 

Clear policy statement

Terms like “zonal engagement” were replaced with easy-to-understand descriptions, such as “structured activity throughout the day”. This approach means that the people accessing enhanced care can read and understand the policy.

Iterative process

The trust will continue to refine and review the policy in line with the work they do with patients and families.

Activity and engagement

The first stage of this work is based on strong evidence that increasing activity and engagement helps reduce risk in these types of inpatient and forensic settings. The proposed change identifies 3 streams within the “supportive engagement model”:

• active and engaged wards – offering structured opportunity for activity throughout every day as a standard
• personalised engagement levels – based on individual risks and patient-led needs
• safety checks – regular checks throughout the shifts for patient safety, recognising that this is supportive of meeting staff’s needs alongside patients’ needs

Supporting staff put the policy into practice

Cumbria, Northumberland, Tyne and Wear (CNTW) NHS Foundation Trust has been developing its policy to support staff to deliver effective enhanced care. Their review aims to influence practice and engage patients to make sure the policy is robust and useful. 

Learning points

Resources

CNTW have developed patient leaflets and flashcards as part of their policy. Staff can use them when delivering enhanced care to support patient engagement and understanding. The trust has ensured staff are aware of these resources and used them in practice. 

Access

All staff working for CNTW have access to the Enhanced Care policy. This ensures care is standardised across substantive and temporary staffing. 

Engaging staff with training and competency principles

The University Hospitals of Leicester NHS Trust (UHL) has developed and implemented training and competencies to support its ETOC policy. The goal was to create a consistent, person-centred and safety-driven approach to enhanced observation across the organisation.

Learning points  

Training and competency framework

The policy includes mandatory training modules, suggested upskilling behaviours and handover expectations. It is supported by a competency framework that covers knowledge, patient care and safety considerations.

The training aims to embed compassionate care values, clarify roles and responsibilities, equip staff with practical tools for therapeutic engagement and support professional development.

Stakeholder engagement

Key challenges included shifting staff mindsets from passive observation to active engagement, selecting suitable individuals for the ETOC role and managing training capacity.

To help overcome this, the trust involved stakeholders (patients, families and staff) in training design, making competencies meaningful with real-life scenarios. Focusing on practical training also improved staff engagement.

Policy governance and monitoring

East and North Hertfordshire NHS Trust has developed and implemented monitoring mechanisms and governance structures to support the effective provision of ETOC.

The ETOC policy was initiated in 2015 to support enhanced patient observation and care. The policy was built iteratively, incorporating feedback from various stakeholders and adapting to different clinical areas.

Learning points

Monitoring mechanisms

The Trust developed stringent ETOC assessment processes and risk assessment processes. It also implemented shorter shifts for staff working with challenging patients.

Feedback and adaptation

The Trust tracked continuous feedback from staff, patients, and relatives to adjust the policy.

Data monitoring

The Trust monitored key quality indicators to understand the impact of iterative policy changes. This included data such as patient falls, incidents of violence and aggression and staff incidents.

Governance structure (leadership and oversight)

The ETOC team reported to senior leaders. This high-level programme visibility and oversight allowed the programme to be successfully expanded to other areas like Surgery, Children’s and Maternity. 

Policy compliance board

The final policy was reviewed and approved by a board, including representatives from nursing, education and safeguarding. 

Staff engagement

The trust addressed initial resistance through increasing awareness, training and support. This resulted in increased staff confidence and capability. To ensure the policy was adopted, it encouraged feedback (patients, families and staff) and made iterative changes to accommodate different clinical areas. 

Appendix 3 – ETOC components

Figure 2: Components available to registered professionals to guide ETOC assessment, person-centred care planning and risk management and review.

The image shows 10 core considerations for clinicians undertaking an ETOC assessment, care planning, risk management and review.

These are:

• environmental considerations
• patient history
• patient and family involvement
• therapeutic interventions
• person-centred care planning
• legal frameworks
• assessment tools
• decision-making tools
• clinical judgement
• staffing