Table 3 Similarities and conflicts of staff and patients' perspectives within themes

Psychological skills

 Relationship-building

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Both staff and patients focused on investing in genuine relationships as the key facilitator. However, only staff referred to the reading of patient notes as a means of understanding patients

 Emotional skills and understanding people

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Some staff presented evidence of negative biases towards the effectiveness of de-escalation in patients with certain diagnoses (e.g. schizophrenia). Patients felt strongly this bias resulted in staff medicalising benign behaviour

Behavioural regulation

 Debriefing and collaborative de-escalation planning/

*

Only staff commented on the need for de-escalation planning and mandated debriefing to improve practise

Social influences

 Formal power structures as barriers

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Both staff and patients discussed how power imbalances in the staff-patient relationship acted as a barrier to de-escalation, with exclusion decision-making around medication being the primary example discussed. Staff also felt un-qualified staff (e.g. healthcare assistants) could be useful in diffusing conflict resulting from the power struggle between patients and nurses

 Ward manager role-modelling

*

Only staff highlighted the need for support, recognition and modelling of vulnerability from ward managers

 Informal power structures as barriers

**

Only staff highlighted the usefulness of the HCA role due to reduced power difference. Both groups discussed supplementary staff (e.g. bank) with patients perceiving outsiders as useful for diffusing conflict, whereas permanent staff presented a negative bias towards ‘non-regulars’

Environmental context and resources

 Physical environment

**

Claustrophobic ward environments and, interestingly, the usefulness of open access to seclusion for de-escalation was commented on by both groups

 Resourcing

**

Staff spoke in length regarding how low permanent staffing numbers affecting capacity for de-escalation, and patients indirectly commented on low staffing as a barrier to staff engagement

Professional role and identity

 Beliefs about professionalism

**

Balancing professional boundaries with emotional presence was a key concern among staff, with some perceiving length of service to impact negatively on staff-patient relationships. Patients commented on this aspect only noting that some staff appeared to care less overtime

Beliefs about consequences

 Beliefs about safety

*

Staff presented contradictory views that more restrictive practises (e.g. seclusion) maintained the safety of the ward by removing the possibility of later escalation, but they also perceived these practises to be dangerous due to risks of injury

Reinforcement

 Thanks and recognition

**

Patients encouraged saying thanks over monetary rewards and both groups acknowledged staff feelings of being undervalued