Judith Johnson

Safety incidents on mental health wards can harm patients, staff and organisations. An extensive body of research to improve the understanding of this issue frequently focuses on patient characteristics and staffing numbers. Exploration of the impact of staff and team characteristics may generate valuable new insights. The review aimed to describe the international evidence around the relationships between safety incidents on mental health wards, and staff and team characteristics, to answer the question, “How do staff and team characteristics relate to safety incidents in adult inpatient mental health settings?”. Systematic integrative review of the published literature focused on adult inpatient mental health settings globally. CINAHL, Cochrane, Embase, Medline, PsycINFO and Web of Science were searched (1999 onwards). Data were analysed using inductive narrative synthesis, comprising data reduction, display and comparison. Quality appraisal was conducted using the Mixed Methods Appraisal Tool. 135 papers (80 quantitative; 46 qualitative; nine mixed methods studies) across 33 countries met the eligibility criteria. Most reported staff perspectives of incidents (n = 54) or retrospective analysis of routine hospital data (n = 40). Four themes were developed: (1) Team profile: composition, working patterns and culture; (2) Personal and professional profiles of individual staff; (3) Impact of staff communication and behaviour; (4) Factors affecting staff communication and behaviour. Evidence was most consistent around the impact of staff’s verbal and paraverbal communication, availability to patients and empathy. There was more evidence around the impact of staffing numbers, demographics of staff and staff experience but this was largely inconsistent, making the direction of impact unclear. This review examined a large body of international evidence demonstrating inconsistent findings around staffing numbers and demographic characteristics. An emerging body of evidence focused on the impact of interpersonal characteristics and team culture offers potential explanations for the discrepancies surrounding fixed characteristics and team numbers. This suggests possible reasons why focusing on staffing ratios, for instance, may not yield the expected safety outcomes.

Background: Medical students experience high rates of burnout and mental health distress, with approximately half reporting burnout, one-third experiencing depression, and one-tenth having suicidal thoughts. These issues are exacerbated during clinical placements and contribute to workforce attrition after qualification. Existing interventions are largely generic and show limited effectiveness. Thumos, a cognitive-behavioural therapy-based intervention specifically tailored for healthcare professionals and medical students, addresses the stressful situations intrinsic to medical training and practice. This randomised controlled trial will evaluate whether Thumos improves psychological resilience, confidence in dealing with stressful situations, burnout, and depression in medical students compared with services as usual (SAU). Methods/design: Two hundred and twenty UK medical students in a year that contains a clinical placement of a week or longer will be recruited nationally from UK medical schools. Participants will be randomised 1:1 to receive either Thumos (two online group workshops and one individual video/phone call) or SAU. Assessments will occur at baseline, post-intervention, 4-month, and 9-month follow-up. The primary outcome is psychological resilience measured by the Brief Resilience Scale at 4-month follow-up. A mixed-methods process evaluation will assess acceptability and feasibility. Discussion: To our knowledge, this is the first randomised controlled trial of an intervention specifically designed to prepare medical students for stressful clinical events. If effective, Thumos could potentially be adapted for medical students in other countries. Trial identifier and registry name: ISRCTN12744098: https://www.isrctn.com/ISRCTN12744098 ; An evaluation of a cognitive-behavioural intervention for medical students

A fundamental limitation of modern conversational AI is its limited capacity to demonstrate sustained empathy in long-form interactions. We propose SCIRAG (Semantic Context Improvisational Retrieval-Augmented Generation), a feedback-driven retrieval framework for adaptive empathic dialogue. It employs a dual-loop retrieval framework, iteratively optimizing a static counseling dataset through user metadata and feedback memory refinement. To enhance contextual alignment, we deploy retrieval adaptation, enabling the model to retain and leverage past conversational cues based on user preferences. When integrated with Mixtral-8x7B, SCIRAG improves human-rated empathic understanding by +1.26 points and empathic response by +1.00 point on the RoPE scale, while increasing acceptability by +7.66 points compared to a fine-tuned non-RAG baseline. Automatic evaluation further shows gains in semantic alignment (BERTScore-F1 +0.11) and fluency (perplexity reduced from 19.1 to 12.3). We also present EMPATHIC , a dataset of unscripted, therapeutic conversations. Unlike conventional datasets that contain only 2-4 dialogue turns per conversation, EMPATHIC provides extended conversational trajectories (50+ turns per session), allowing models to learn long-range coherence and empathic listening. The proposed dataset will be publicly released.

Keeping people safe is a core purpose of inpatient mental health services and therefore managing self-harm is an everyday concern for organisations delivering this care. Recent research on patient safety in inpatient mental health settings has largely focused on the use of restrictive interventions applied at an individual level including restraint, seclusion, rapid tranquilisation, and enhanced patient observations. Limited focus has been given to organisation-wide practices which aim to manage self-harm. This scoping review therefore aims to identify what practices are operating at this level. Across the 32 publications identified for inclusion, 43 practices were identified which operated to directly prevent self-harm, or to control the behaviours of staff and patients with the aim of preventing it. These included a broad range of practices such as environmental design measures, staff training, and leadership oversight of safety information. Whilst this review does not draw conclusions on the effectiveness or prevalence of the use of the identified practices, it provides a useful overview of the toolkit of practices available to organisations for managing self-harm. It also notes that most of the practices identified took a restrictive approach to prevention, which suggests that future research could consider alternative and more positive approaches.

The global shortage of healthcare professionals disproportionately affects low/middle income countries. Bangladesh is facing critical health workforce shortages, exacerbating workload and the risk of doctors' burnout. However, there is a lack of qualitative research into causes of occupational burnout in Bangladeshi doctors. This study investigated the factors contributing to burnout among Bangladeshi doctors. An exploratory approach was employed using Reflexive Thematic Analysis with a Critical Realist approach. Fifteen semi-structured interviews were conducted with Bangladeshi doctors (general practitioners, cardiologists, surgeons, and paediatricians). Data were collected in English or Bangla and analysed using Atlas.ti version 24. Four themes were developed: (1) the postgraduate phase is a pressure pinch-point, (2) there is limited awareness of mental health issues and insufficient support, (3) high workload and competing demands, (4) unhelpful public attitudes and media narratives. Findings highlight structural, cultural, and organizational factors driving burnout. Addressing burnout in Bangladeshi doctors requires systemic and policy-level interventions. Mental health support, workload management strategies, and public awareness initiatives are critical to improving doctors' well-being and sustaining the healthcare workforce in Bangladesh. Overall, the study offers the first in-depth qualitative account of how intersecting structural and cultural pressures shape doctors' experiences of burnout in Bangladesh.

Restrictive practices are used to contain risk and maintain physical safety on inpatient mental health wards, but have been shown to negatively impact patient well‐being and trust. Researchers and professionals have suggested that inpatient mental healthcare focuses on physical safety at the expense of psychological safety. The relationship between restrictive practices and psychological safety has not yet been explored. This study aimed to explore the impacts of receiving and witnessing restrictive practices on psychological safety, to understand what could be done to make restrictive practices psychologically safe. Eighteen semi‐structured interviews were carried out with former patients (aged 20–60 years) who had been discharged for longer than 6 months from adult inpatient mental healthcare in the United Kingdom. Data were analysed using reflexive thematic analysis. Four themes were generated: (1) Reactive over proactive care: seeing the behaviour and not exploring the reason, (2) A chaotic environment cannot provide safety for patients and staff, (3) Psychological impact of the (perceived) power imbalance between staff and patients and (4) Emotionally all in it together, for better or worse. The results support that physical risk is heightened in inpatient settings, but containing this should not come at the expense of psychological safety. Supportive communication and giving small acts of control to patients should be prioritised to enhance the psychological safety of patients.