Purpose
This guide helps organisations strengthen their staff training and education as part of their wider system approach to enhanced therapeutic observation and care (ETOC).
It covers 4 areas that organisations should consider when developing an education and training programme for their specific clinical and operational context:
- who should be trained
- the 4 key components of any local training offer
- potential delivery mechanisms for training and education
- how to monitor the effectiveness of training and education
Appendix 1 provides a checklist of questions that organisations can use to review and develop their training offer.
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.
For further information about the improvement programme, please see the ETOC webpage.
Further resources can be accessed through the ETOC Programme page on FutureNHS (login required).
How ETOC training and education supports proactive care
Comprehensive ETOC training and education ensures staff have the skills and can build the confidence to assess a patient’s needs, then plan and provide safe, proportionate and meaningful therapeutic care.
This proactive delivery of care in a way that is supportive rather than restrictive can minimise patients’ emotional and physical distress and promotes their safety and dignity.
Local example – impact of comprehensive ETOC training
Somerset NHS Foundation Trust launched a 5-day development programme for healthcare support workers (HCSWs) delivering ETOC to address variation in their skills and confidence. This systematic and co-ordinated approach delivered through a combination of online learning, specialist teaching, immersive practice and reflection helped this workforce gain consistent skills for high-quality care.
Since its launch in 2023 ongoing ETOC costs across the organisation associated with temporary staffing has reduced by approximately £2.8m and staff report they are more confident in delivering ETOC. The trust has now embedded this training model for HCSW as a sustainable approach to improving ETOC across the organisation.Who requires ETOC training
The 3 groups of staff most involved in delivering ETOC and who should be provided with consistent ETOC education and training are those who:
- assess patients, plan care, make clinical decisions and oversee ETOC – for example, nurse in charge, registered nurses, allied health professionals, ETOC leads, executive managers, and board members
- deliver ETOC – for example, HCSWs and nursing associates
- provide additional non-clinical support – for example, volunteers and administrative staff
Although many aspects of training will be common to these 3 groups, each will need their training tailored to their specific settings and, where appropriate, the needs of individual patients or patient groups.
To standardise approaches, training should be provided to all substantive and temporary staff involved in delivering ETOC. However, as skill levels increase across substantive staff, particularly in areas that provide the most ETOC, their ability to better plan care and deliver it more effectively and efficiently may reduce the need for temporary staff.
Local example – ‘Time to care’ induction programme plus
University Hospitals Coventry and Warwickshire NHS Trust amended its 1-week induction for healthcare support workers (HCSWs) to include an ETOC focus. Induction sessions now cover the purpose and principles of ETOC, understanding behaviours, triggers, prevention, referrals and assessment processes, communication and documentation and are followed by 6-monthly refresher sessions to sustain and embed learning.
The revised induction HCSW programme has had strong staff engagement, has strengthened teamwork, and theory-to-practice application, which has resulted in high-quality care and positive patient experience. The programme has also had a significant impact on the effective use and distribution of staffing resource. Demand for ETOC has significantly reduced and bank shift requests have fallen from 200 a month to just 6 between March and September 2025.
Components of a local ETOC training offer
Based on learning from organisations that have significantly improved their ETOC training offer across diverse clinical settings, the 4 components of a comprehensive ETOC training offer are:
- therapeutic engagement and communication
- assessing patients and planning care
- patient and staff safety
- embedding learning in practice
Additionally, organisations providing ETOC in mental health and learning disability care settings may wish to refer to the enhanced care guiding principles produced by the National Mental Health and Learning Disability Nurse Directors Forum. The ETOC guide on principles of therapeutic care and assessment also provides useful information on training content.
Therapeutic engagement and communication
Why is this important?
Staff should be equipped with the relation and interpersonal skills to deliver active and engaged ETOC rather than passive observation. This training ensures the ETOC provision is safe and person-centred by providing staff with the skills to identify the underlying causes of behaviours. By understanding the drivers, staff can proactively manage distress in the least restrictive way possible.
Applies to: all staff groups, including those not directly involved in care.
Key considerations:
- person-centred approach
- compassion leadership and care
- active listening
- de-escalation principles
- establishing trust and building rapport
- non-verbal communication
- communication aids
- understanding diverse patient needs
- equity informed approach
- boundaries and professionalism
Training should:
- be tailored to clinical areas, diverse patient needs and groups – for example, children and young people may have very different needs to older people
- cover practical skills for starting conversations, utilising communication aids, managing interactions and maintaining empathy in busy clinical settings
- emphasise the need to involve patients and support networks – for example, by sharing their lived experience patients can give staff a better understanding of the potential positive and negative impacts that ETOC can have on them
- cover how to overcome barriers to communication, for example referring to interpreting services
- consider using trauma frameworks – for example, the Sussex Health and Care Integrated Care System trauma informed framework
- include existing training modules where appropriate – for example, The Oliver McGowan Mandatory Training on Learning Disability and Autism and Life Beyond the Cubicle: working well with families in mental health crises offer practical guidance on therapeutic engagement with patients, families and support networks and provide a strong foundation for staff development
- explain key legislation, such as The Mental Capacity Act (MCA) so staff understand key principles and how they apply to ETOC
Local example – the importance of lived experience
Humber Teaching NHS Foundation Trust required the 600 staff in its Adult Mental Health Division to complete a full day of family inclusive practice training, delivered by the family therapy team. The interactive sessions highlighted the importance of hearing the voices of patients, families and carers, and of building collaborative, patient-led therapeutic care.
In parallel, the trust introduced patient safety partners which involved volunteers with lived experience in the delivery of this training. Their involvement aligns with the NHS framework for involving patients in patient safety. These partners share insights from incidents with and raise awareness among staff of how inclusive, trauma-informed collaboration can prevent unintended harm and improve enhanced care delivery.
Assessing patients and planning care
Why is this important?
Training in assessing patients’ needs and planning their care is vital for the delivery of consistent, safe, effective and proportionate ETOC. Trained staff should be able to ensure that ETOC is only delivered where it is clinically judged to be necessary, and is based on patients’ assessment of need, for the right duration by the most appropriate members of staff. They will understand local governance, ETOC policies and standard operating procedures. They will be able to promote proactive care and appropriate step-down of care, while also managing risks and ensuring respect for the dignity and privacy of patients.
Those in oversight roles should be trained to analyse and validate staffing requests including skill mix so care meets patients’ needs. They should be able to review safety and quality trends, for example review cases of harm, that may be impacting on the delivery of ETOC care and require action.
Applies to: all staff, with additional considerations for those assessing patients, planning care, making clinical decisions and overseeing ETOC
Key considerations:
- personalised and collaborative approach to safety planning and risk management
- how ETOC is dynamically reviewed
- identifying triggers and early warning signs
- behaviour support plans
- environmental safety
Training for all staff should:
- ensure everyone understands their role and responsibilities in relation to local ETOC governance. This is also further information in the ETOC programme policy guide
- be relevant to the staff role and responsibility, and the patient groups they work with and the clinical setting they work in
- cover clinical risks, including how these should be mitigated and managed – for example, suicide, self-harm, falls, deterioration and deconditioning.
Training for those assessing patients, planning care, making clinical decisions and overseeing ETOC should cover how and when to:
- deliver local, dynamic ETOC assessments and safety plans with patients and their support networks
- initiate ETOC, with safeguards and regular reviews in place to ensure that the level and length of care remain appropriate (at a minimum, every 24 hours)
- safely and effectively discontinue or step-down ETOC
- determine the level of ETOC required and the most appropriate professional group (HCSWs, registered nurses, registered mental health nurses) to deliver that care and whether family or carers could support delivery
- ensure that delegated staff members have the skills to provide appropriate care and have been briefed on the patient’s individual care and safety plan
- clinically assess and validate staffing requirements, skill mix and ensure that care provision is safe and proportionate to patient needs
- triangulate diverse intelligence sources to understand trends and their impact on quality, safety and skill mix to determine required actions. See the ETOC data guide for further information and ETOC workforce planning and deployment guide (fifth in the series of the ETOC improvement guides)
- complete relevant documentation and use digital technology – for example, decision support tools, behaviour support plans, digital assessment platforms, care plans and safety plans
Training for those delivering ETOC should cover:
- monitoring and reporting on the plan of care, including any changes in presentation
- completing relevant documentation and using digital technology relevant to ETOC – for example, ‘abc’ behaviour charts, ‘this is me’ and health passport documentation – and ETOC record forms that cover the level and type of monitoring being performed
- consolidating learning in practice – for example, Leicester Partnership NHS Trust provides a virtual training session on fundamentals of ETOC, which is underpinned by staff competency assessments by a registered nurse
Local example – enhancing staff competence in mental health safety planning
Royal Surrey NHS Foundation Trust introduced an ETOC team consisting of a team lead to manage a team of registered mental health nurses (RMNs) and HCSWs supporting a 24/7 shift pattern. The RMNs are trained in assessment and safety planning to support clinical areas with reviewing patient requirements. Also, HCSWs trained in reporting and monitoring the plan of care were introduced to support clinical areas with the delivery of ETOC.
These teams have been introduced alongside a comprehensive training programme for staff in clinical areas to strengthen their competence in mental health awareness and behaviour management. This is delivered by the psychiatric liaison service, the enhanced care team and clinical educators and covers conditions such as depression, anxiety,
psychosis and self-harm. The programme promotes compassionate care, early detection and legal understanding, and emphasises documentation and debriefing. Staff learn how to challenge stigma, recognise complex behaviours and apply shared responsibility through practical techniques such as verbal de-escalation, distraction, appropriate medication and, as a last resort, safe holds.
The training has increased staff confidence, improved documentation quality, strengthened legal and ethical understanding, enhanced patient outcomes and fostered a more supportive and resilient care environment. This has given the trust the assurance that patients requiring ETOC have had a capacity assessment and appropriate risk assessment. Staffing meetings take place twice a day to review and validate the ETOC demand and at which all patients under ETOC are captured and recorded.
This is managed out of hours by the RMNs, Site Nurses and On Call team. This list is reviewed daily, and patients can be reviewed for de-escalation from ETOC with support of the clinical and ETOC team.
Patient and staff safety
Why is this important?
ETOC is a restrictive practice and all ETOC provision must comply with relevant legal and regulatory requirements. Inappropriate delivery can cause patients emotional and physical harm and pose risks to staff safety.
Staff need training in how to deliver ETOC in a way that protects patients from risks of emotional and physical harm and protects staff.
Applies to: all staff groups.
Key considerations:
- awareness of relevant legal frameworks
- safeguarding adults and children
- incident reporting/trends and learning
- understand lived experience of ETOC
- seeking and measuring patient and their support networks feedback
- personal and staff safety training in line with national guidance
Training should support staff to:
- understand how the legal frameworks governing restrictive interventions apply to different patient groups and clinical settings
- understand and an adopt an equity-informed approach to patient safety
- escalating and reporting missed opportunities and incidences related to poor outcomes or any associate harm when patients are under ETOC
- identify restrictive practices, especially in mental health and learning disabilities services
- maintain personal safety and professional boundaries. The requirements will differ between sectors and clinical settings, but examples are conflict resolution, breakaway and reducing restrictive interventions training, managing distressed and escalating behaviours
- appropriately report incidents and environmental risks related to the clinical setting
- understand how to enable patients and their support networks to provide feedback, express concerns and access advocates
Local example – impact of training in reducing restrictive interventions
Leeds Teaching Hospitals NHS Trust identified a post-pandemic rise in staff safety incidents linked to patients with increasingly complex mental health needs and low staff confidence in managing them. It introduced multidisciplinary, face-to-face training covering early issue identification, conflict resolution and safe holds, aligned with the Restraint Reduction Network guidance. This training combines theoretical knowledge, practical skills and physical interventions and targets high-risk areas to improve incident reporting and staff safety.
Since implementation, the trust has reduced its security contract costs by 90.7% and seen improved confidence and preparedness among staff and more positive patient–staff interactions, particularly in one-to-one care settings.
Embedding learning in practice
Why is this important?
The needs of patients requiring ETOC are often complex in nature, therefore, learning and training should be embedded into daily practice. This hands-on support and supervision when working with vulnerable patient groups, enables care which is tailored to the patient’s holistic needs. This also promotes staff wellbeing and fosters a culture of continuous improvement, where teams can adapt their skills to deliver the best care possible.
Applies to: all staff groups, with an emphasis on those in leadership roles
Key considerations:
- a stepped approach
- on the job training
- agile and innovative methods of delivery
- listening to experience of ETOC
Training should emphasise staff development and wellbeing. It can do so through a combination of approaches, such as:
- action learning sets (ALS): encourage problem-solving, enhance learning and create a supportive team environment
- coaching: improves performance, fosters accountability and supports continuous development
- hot/cold debriefs post-incident: promote psychological safety, facilitate team learning and reduce moral injury and compassion fatigue
- mentorship: builds leadership capacity, strengthens organisational culture and improves retention
- preceptorship: increases confidence, recognises staff value and supports skill development
- restorative support: supports development of empathy, active listening and collaborative problem-solving and can encourage the use of the PNA role
- supervision: ensures accountability, supports learning and enhances service delivery
- clinical supervision: recognised to be an important method of learning via reflective practice and staff support
- listening to the patient and support networks experience of ETOC
- safety huddles so learning from any incidents or issues takes place to ensure improvement and changes happen
Local example – action learning sets to support education and training
Great Ormond Street Hospital for Children NHS Foundation Trust uses ALS within preceptorship and wider support programmes. ALS bring 6–8 colleagues together in facilitated sessions to share challenges and receive feedback and reassurance. Each preceptorship day includes an ALS, with 4 sessions per programme, structured around check-ins, reflection and check-outs to plan next steps.
In October 2024, 24 ITU nurses from cardiac, paediatric and neonatal intensive care units participated in an ALS to address moral distress, emotional exhaustion and compassion fatigue. This fostered peer support, reflection and understanding across units, informed education teams and guided rostering and psychological support. Success criteria and positive feedback showed nurses have felt supported and are more reflective and appreciative of colleagues’ workloads. 95% of Neonatal Resuscitation Practitioners (NRPs) reported benefits to their practice.
Delivery mechanisms for ETOC training and education
Delivery mechanisms for ETOC training will depend on local need and organisational capacity. Organisations will often need to develop bespoke training programmes for their local context and should prioritise high impact, cost-effective training.
A multifaceted approach within existing local training provisions, delivered using a variety of mechanisms, will be needed to fully embed skills and competencies across an organisation so learning translates into practice.
Training programmes must be flexible enough to evolve as the extensive ETOC knowledge base continues to develop.
Different delivery mechanisms may include:
- inductions
- face-to-face, virtual or independent learning
- rapid or reactive training
- simulation training
- integration with existing training structures or bespoke ETOC training
- continuing professional development initiatives
- out-of-hours sessions
- refresher training
Local example – 7-minute ETOC briefings
University Hospitals Birmingham NHS Foundation Trust introduced 7-minute briefings to provide short, structured information to staff. These are delivered face-to-face, virtually and as a self-learning tool across all 105 inpatient wards. They support ETOC by informing staff about patient needs, risk assessments, enhanced care observation levels, meaningful engagement and sources of additional support, and are shared at handovers, on ward displays and as prompts in ward areas.
In response to requests from student nursing associates, the trust also developed more comprehensive training for those delivering ETOC.
Together, the briefings and targeted training have increased staff confidence, improved bank capacity and generated cost savings, while enhancing the quality and consistency of enhanced care across wards.
Monitoring the effectiveness of ETOC training and education
Monitoring the impact of ETOC training programmes is essential to ensure that staff have the training they require to meet the needs of patients. Where training is customised to match local needs, customised approaches to monitoring will need to be developed.
The training should be outlined in organisation’s ETOC policies, please see our ETOC programme policy guide for further information. ETOC training should also be considered when training needs analysis are undertaken to help inform areas of highest training need and ensure sufficient study time is allocated within the headroom.
As part of their monitoring of training, organisations should emphasise the development of mechanisms they can use to support continuous improvement. They should focus on making regular, simple and practical improvements to increase the effectiveness of their training.
Organisations could assess the effectiveness of their training and support continuous improvement with:
- reviews of existing training provision: to understand what already works well and what lessons have been learnt
- training needs analyses: to ensure that areas of highest needs are supported and there is sufficient study time allocated in the headroom
- pre- and post-training assessments: to measure confidence, evaluate training suitability and identify gaps
- surveys and questionnaires: to capture staff perceptions of competence and confidence, highlighting areas for enhancement
- measurements of patient impact including outcomes and experiences
- local audits or spot checks: to review the impact in the clinical setting to ensure care is personalised, proportionate, and least restrictive
- performance metrics: to identify skill gaps, target development needs and highlight incidents requiring reactive training
- feedback loops: to allow staff to co-design, test and refine training approaches
- close monitoring of ETOC intervention by reviewing clinical and safety indicators: to ensure the intervention is beneficial and there is no deterioration
Local example – audits to improve ETOC delivery
West London NHS Trust evaluated its ETOC training by auditing local processes to identify gaps and areas for improvement. Matrons and ward managers conducted walk rounds, compliance scoring and central analysis, feeding results into monthly ‘quality clinics’ where staff received feedback and examples of good practice. Frequently missed aspects – such as ETOC reviews, care plans, patient awareness and documentation – became the focus of change ideas monitored through PDSA cycles. Improvements included better use of Electronic Patient Records, targeted supervision, clear communication of system changes and clinical performance plans for staff needing extra support. Managers are encouraged to regularly discuss change plans in quality clinics, keeping continuous improvement central to effective ETOC delivery.
Appendix 1: Questions for organisations to ask when reviewing their training offer
Components of a local training offer
Consider the following questions:
Therapeutic engagement and communication
- Is training tailored for different clinical areas, diverse patient needs and groups?
- Does training cover practical skills for starting conversations, managing interactions and maintaining empathy in busy clinical settings?
- Do staff understand the barriers to communication and how to overcome these?
- Does training emphasise involving patients and support networks?
- Are trauma frameworks considered?
- Have pre-existing training modules been included?
Assessing patients and planning care
Do all staff:
- understand local ETOC governance and their own role and responsibilities?
- receive relevant training for the specific patient groups and clinical settings they work in?
- understand clinical risks and how these should be mitigated and managed?
Do registered healthcare professionals overseeing ETOC, assessing patients and making clinical decisions know how to:
- deliver local, dynamic ETOC assessments and safety plans in line with local policies?
- initiate ETOC with safeguards and regular reviews to support appropriate length and level of care?
- safely and effectively discontinue or step-down ETOC?
- determine the level of ETOC required and most appropriate professional group to deliver it?
- ensure delegated staff have the necessary skills to provide appropriate care?
- clinically assess and validate staffing requirements?
- triangulate intelligence sources to understand trends and their impact?
- complete relevant documentation and use appropriate digital technology?
Do staff delivering ETOC know how to:
- monitor and report on care plans and changes in presentation?
- complete the relevant documentation and use digital technology related to ETOC?
Patient and staff safety
- Do staff understand how the legal frameworks governing restrictive interventions apply to different patient groups and clinical settings?
- Do staff understand how to adopt an equity informed approach to patient safety? Do staff understand how to escalate, and report missed opportunities or any incidents related to poor outcomes or associated harm when patients are under ETOC?
- Can staff identify restrictive practices?
- Do staff maintain personal safety and professional boundaries?
- Can staff effectively and appropriately report incidents and environmental risks?
- Do staff understand the importance of seeking and measuring patient experience and feedback?
- Do staff understand the processes to enable patients and their support networks to provide feedback, express concerns and access advocates?
Embedding learning in practice
- Does training emphasise staff development and wellbeing?
- Is this promoted through a combination of approaches, applicable to different settings and training needs?
- Do staff have the opportunity to consolidate learning in practice?
- Are the processes in place to share learning from incidents or issues to ensure improvement and changes happen?
Delivery mechanisms for training and education
- Have the different models to train and educate staff been considered?
- Have staff been consulted to determine what models would work best for them?
- When training needs analysis are carried out to ensure that there is sufficient study time allocated in the headroom?
Monitoring the effectiveness of training
- How is training evaluated in the organisation and is continuous improvement central to this?
- Do the current evaluation mechanisms give an accurate picture of training needs?
- Which staff need to be involved to test and develop training?
- Is training monitored to provide regular quantifiable or qualifiable feedback?
- Is the training outlined in the ETOC policy and are procedures in place to monitor effectiveness?
- Has a training needs analysis been undertaken?
- Has adequate headroom been included in the training analysis to enable staff to undertake training?
Publication reference: PRN01862_iv