There were thirty-seven participants (12 interviews; three focus groups). Twenty-five staff (Table 1) participated in three focus groups (duration range 56-186 minutes; frontline-clinical staff = 5, MDT = 11, PMVA specialists = 9).
Table 1. Socio-demographic characteristics of staff
|
|
|
|
|
n
|
%
|
Gender
|
|
11
|
44
|
|
Male
|
11
|
44
|
|
Female
|
14
|
56
|
Age (years)*
|
|
|
|
|
18-29
|
6
|
24
|
|
30-39
|
2
|
8
|
|
40-49
|
8
|
32
|
|
50+
|
9
|
36
|
Occupation
|
|
|
|
|
Nurse
|
2
|
8
|
|
Healthcare assistant
|
3
|
12
|
|
Psychiatrist
|
4
|
16
|
|
Psychologist
|
4
|
16
|
|
Occupational therapist
|
2
|
8
|
|
Psychology student
|
1
|
4
|
|
PMVA instructor
|
9
|
36
|
Clinical experience (years)**
|
|
|
|
|
<12 months
|
2
|
8
|
|
1-5 years
|
4
|
16
|
|
6-10 years
|
2
|
8
|
|
11-20 years
|
7
|
28
|
|
21+ years
|
10
|
40
|
Age(years)*: M=42.56; SD=12.52
|
|
|
Clinical experience (years)**:M=16.02; SD=10.70
|
|
|
Eight patients (Table 2) participated in interviews, which lasted between 24 and 58 minutes (mean = 36 minutes).
Table 2. Socio-demographic characteristics of patients
|
|
|
|
|
n
|
%
|
Age (years)*
|
|
|
|
|
|
|
|
|
18-29
|
2
|
25
|
|
30-39
|
4
|
50
|
|
40-50
|
2
|
25
|
Ethnicity
|
|
|
|
|
Black or British -Caribbean
|
1
|
12.5
|
|
Black or British - African
|
1
|
12.5
|
|
White-British
|
6
|
75
|
Received interventions
|
|
|
|
|
Physical restraint
|
7
|
87.5
|
|
Compulsory medication given by injection
|
4
|
50
|
|
Seclusion
|
8
|
100
|
|
PRN medication
|
6
|
75
|
|
Increased observation
|
7
|
87.5
|
Self-reported Diagnosis
|
|
|
|
|
Psychotic disorders
|
2
|
25
|
|
Dual diagnosis (psychotic and personality disorder)
|
2
|
25
|
|
Dual diagnosis (Personality and mood disorder)
|
1
|
12.5
|
|
Multiple diagnoses (personality, mood and anxiety disorder)
|
2
|
25
|
|
Multiple diagnoses (personality, mood, psychotic and anxiety disorder)
|
1
|
12.5
|
Length of stay in hospital
|
|
|
|
|
<12 months
|
1
|
12.5
|
|
1-5 years
|
3
|
37.5
|
|
6-10 years
|
1
|
12.5
|
|
10+ years
|
3
|
37.5
|
Age(years)*: M=35.8; SD=7.14
|
|
|
|
Two carers participated in face-to-face interviews and two in telephone interviews (Table 3), which lasted between 31 and 42 minutes (mean = 38 minutes)
Table 3. Socio-demographic characteristics of carers
|
|
|
|
|
n
|
%
|
Gender
|
|
|
|
|
Female
|
4
|
100
|
|
|
|
|
Age(years)*
|
|
|
|
|
40-50
|
2
|
50
|
|
50+
|
2
|
50
|
Ethnicity
|
|
|
|
|
Black or Black British - Caribbean
|
1
|
25
|
|
White- British
|
2
|
50
|
|
Mixed - White and Black Caribbean
|
1
|
25
|
Details for person cared for:
|
|
|
|
Age (years)
|
|
|
|
|
18-29
|
1
|
25
|
|
30-39
|
1
|
25
|
|
40+
|
2
|
50
|
Ethnicity
|
|
|
|
|
Black or British Caribbean
|
1
|
25
|
|
Mixed - white and Black Caribbean
|
1
|
25
|
|
White- British
|
2
|
50
|
Diagnosis category
|
|
|
|
|
Psychotic disorders
|
2
|
50
|
|
Dual-diagnosis (psychotic and personality disorder)
|
2
|
50
|
Received interventions
|
|
|
|
|
Physical restraint
|
3
|
75
|
|
Compulsory medication given by injection
|
2
|
50
|
|
Seclusion
|
3
|
75
|
|
PRN medication
|
1
|
25
|
|
None
|
0
|
0
|
Age(years)*:
M=58; SD=5.47
|
|
|
|
Four themes and 15 subthemes (barriers and facilitators) across eight domains of the TDF [22] and spanning all COM-B areas [21] were identified. These are summarised in Table 4 and presented below with supporting quotes identified by participant number (e.g. P1), gender and participant group/role. The ‘memory, attention and decision-processes’; ‘physical skills’; ‘goals’; ‘beliefs about consequences’; ‘beliefs about capabilities’ and ‘optimism’ and ‘reinforcement’ domains of the TDF did not emerge from the data as particular targets for behaviour change in this setting. Participants overwhelmingly discussed de-escalation in the context of managing violence and aggression, rather than for self-harm, absconding, rule-breaking, medication-refusal, suspected or proven alcohol/substance misuse.
Table 4. Barriers and facilitators to effective de-escalation using the TDF [22]
COM-B
|
Theme
|
Sub-theme (barriers and facilitators)
|
TDF
|
Capability
|
Building relationships: knowing the patient and knowing yourself
|
Creating an authentic relationship across social distance: rapport versus compassionate engagement
|
Psychological skills
|
|
|
An individualised de-escalation approach
|
Psychological skills
|
|
|
Knowing about the patient: stigmatising attitudes
|
Knowledge
|
|
|
Patient trauma
|
Knowledge
|
|
|
Managing emotions
|
Knowledge
|
|
|
An ethos of positive risk-taking and least restrictive practice
|
Behavioural regulation
|
Opportunity
|
Filling the void: high-security as an inherently deprived environment
|
Organisational resources
|
Environmental context and resources
|
|
|
The ward environment
|
Environmental context and resources
|
|
Dynamic relationships
|
Power and control over patients
|
Social influences
|
|
|
A supportive and collaborative workforce
|
Social influences
|
|
|
Gender and de-escalation
|
Social influences
|
Motivation
|
Keeping everyone safe
|
Early intervention: recognising warning signs
|
Social/professional role
|
|
|
De-escalation: an inbuilt and ongoing process
|
Intentions
|
|
|
Staff traumatisation
|
Emotion
|
|
|
Boundaries: the function of ‘consistency’
|
Social/professional role
|
Capability
Theme: Building relationships: knowing the patient and knowing yourself
- i) Creating an authentic relationship across social distance: rapport versus compassionate engagement
The dominant view among all participants was that a strong therapeutic relationship is most important, with successful de-escalators being perceived as sincere and credible in how they relate to patients:
“if you are switching something on and it’s not something that you believe in yourself people pick up on that… it is a more long-term thing than just an acute attribute you switch on and off because someone has kicked off” (P25, female, psychologist).
This acknowedgement of authentic staff-patient relationships as foundational to de-escalation is complicated by staff fears about becoming close to patients in a way that could create co-dependency and become “burdensome” for staff (P14, male, nurse). Staff members across groups felt that it was important to maintain social and emotional distance from patients; there was recognition that a detached or cognitive form of empathy was necessary for understanding patients, however affective empathy (or sympathy) which necessarily involves emotional engagement with patients was seen as a risk factor for boundary violations:
“You can learn empathy as long as it does not show as sympathy […] because if you have walked a mile in their shoes you are going to start to feel sympathy, if you have shared the experiences and that’s when boundaries are crossed and so on and so on […] so if you start showing sympathy then it can be, that gets over a long period of time it gets picked at and picked at until you have shared information that you shouldn’t have shared (P11, male, healthcare-assistant)
In the context of this perceived conflict between staff’s need to maintain distance from patients and to build a credible relationship necessary for de-escalation, staff focused on the importance of having ‘rapport’ with patients; a less emotionally engaged style of interaction characterised by staff as a combination of ‘banter’, humour and doing ‘day-to-day tasks’ together.
Although the concept of ‘rapport’ as key for de-escalation was consistently emphasized across the different staff groups, patients reported that staff attempts to create this superificial form of familiarity were a frequent cause of staff-patient conflict, and resultant use of restrictive practices. The disjunct between the power-imbalance inherent in staff-patient relationships, and the more informal style of interaction staff saw as constituting rapport-building was often so jarring to patients that they interpreted it as a deliberate provocation:
“Sometimes it can feel like they are rubbing things in. They will come in telling you stuff about their lives outside and, you know, trying to crack jokes with you which are kind of inappropriate” (P30, patient, assertive rehabilitation ward)
“Especially when staff will go ‘how’s your mum DELETED NAME, you know I don’t see my mum, why do you ask you know what I mean or when are you next seeing your mum, they know I don’t see her so them sort of things are kind of insensitive and it’s not like they are doing it accidentally they know.” (P28, patient, assertive rehabilitation)
In contrast to staff anxieties about over-identification, patients emphasised the need for staff to be both emotionally present (e.g. expressing genuine concern) and actively engaged (e.g. frequent one-to-one conversations) in order to promote trust and respect. Psychology staff were often named by patients as most likely to elicit trust, as they frequently engaged emotionally with patients through the use of questions which communicated sincere interest and compassion:
“Talking about my thoughts when I’m low, thoughts when I’m high. Which leads on to other things, other conversations, they’re the right conversations.” (P29, patient, assertive rehabilitation ward)
- ii) An individualised de-escalation approach
The value of a patient-centered approach to de-escalation was highlighted across all groups on the basis that an approach successful for one patient (e.g. to be given time and space) may not be for another. Staff and carers suggested that this is achieved by ensuring that each shift includes staff with different interpersonal styles and skills.
“if you are doing your rota make sure you’ve got a combination of staff that can work on different things that are able to handle different situations and stuff” (P34, carer)
Frontline clinical staff valued advance directives, which involve the patient in collaborative de-escalation planning, to identify i) potential triggers and early warning signs of aggression and ii) preferences for de-escalation/ management.
iii) Knowing about the patient: stigmatising attitudes
Staff reflected on how labels such as “mad, bad or sad” (P1, male, PMVA instructor) were often used to relate to people with psychotic, personality and depressive disorders respectively, resulting in dichotomous attitudes towards patients seen to have “illness-related” or “non-illness-related” aggression. Aggression in the context of psychosis was typically attributed to acute mental distress and elicited more sympathetic and less punitive responses compared to patients with a diagnosis of personality disorder:
“Someone who is suffering from psychosis… staff tend to sympathise…. so if they (patients) say something in the heat of the moment and its quite personal… staff understand they are unwell. But someone who might say the same but who staff perceive as just ‘bad’, staff take it quite personally… it becomes an emotive situation” (P1, male, PMVA instructor)
The underlying assumption that the behaviour of patients with a diagnosis of personality disorder was attributable to deliberate and malicious intent, not distress, meant that such behaviour was seen as “manipulative” and “demanding” by staff, leading to unsympathetic responses. The combination of a false attribution of control and a negative moral judgment about patients is exemplified in the concept of ‘team-splitting’, where differences in particular staff-patient relationships are interpreted as a deliberate attempt to undermine the unity of the staff team:
“With my ward being personality disorder, one of the biggest challenges that we have is team splitting and having the patients pay a lot of attention to some staff members in a positive way and then in a negative way to others, deliberately putting the team at loggerheads” (P12, female, healthcare facilitator).
Participants from all groups highlighted the need for increased staff knowledge and understanding of personality disorders in order to counter stigmatising attitudes.
- iv) Patient trauma
All participants discussed the importance of acknowledging that most patients in high-secure settings will have experienced significant lifetime trauma and adverse childhood events (ACEs). Staff and carers spoke about the value of reframing aggressive behaviours in terms of a survival function in response to situational and/or relational triggers, especially among individuals with a personality disorder. Patients felt that heavy-handed approaches and the over-use of alarm bells may cause fear and retraumatise victims, thereby increasing aggressive behaviours:
“Being surrounded by like 5 members of staff when you are feeling agitated. I don’t think that helps …… it puts peoples’ back up and makes people go in to defence mode. A lot of patients have had traumatic lives, had things done to them” (P28, patient, assertive rehabilitation ward)
- v) Managing emotions
The ability of staff to regulate their emotions during conflict situations was seen by all groups as essential. Specific communication skills were noted as important, in particular speaking in a calm and controlled manner; giving simple and direct instructions; maintaining a composed exterior with open and non-threatening body-language. Overt displays of anxiety, fear and frustration in staff were widely perceived to escalate aggression. One patient described how visible anxiety in a staff member triggered instrusive thoughts and some distressing ambvialence about his own capacity for self-control, e.g.:
“The fact that he was clearly letting me know that he feared I was going to do something made me question whether I was gonna do something.” (P28, patient, assertive rehabilitation ward)
However, staff reflected on the difficulties of remaining emotionally neutral in response to personally-directed and sustained verbal abuse. Knowing when to ‘step back’ (P23, female, Psychiatrist) was important in this situation.
“(It) is about how personal it feels…depending on the nature of what people say, what is personally tolerable and not tolerable to you… that’s a big issue. Its particularly difficult for people who are consistently on the receiving end of really personal aggression” (P23, female, Psychiatrist)
The negative impact on staff anxieties of emotive language in nursing notes, handovers and debriefs was also noted:
“The doctor said ‘I just want to point out that this individual likes to fight and he’s very capable’. I sat there and I thought ‘wow, the anxieties that you’ve just released right at the end of the debrief’…It was really frustrating” (P5, female, PMVA instructor)
Staff agreed that ‘debriefs’ and ‘safety huddles’ are important safe areas in which they can express emotions and seek support from peers to regulate their emotions:
“It is so important to have that debrief and ask how everybody feels about it (incident) because if you go home without talking about it, it festers overnight” (P12, female, healthcare-facilitator)
- vi) An ethos of positive risk-taking and least restrictive practice
Although there was a clear emphasis on positive risk taking and least restrictive practices at more senior levels of the organisation, there was evidence that this has not been effectively translated at ward level. Staff described a lack of clarity surrounding the principles of least restictive practice and positive risk taking and a blame culture that created fear and confusion:
“If someone had an incident and was secluded then … we would maybe stop them from going off ward the day after … because ‘you did something wrong, therefore you shouldn’t get the nice thing you wanted to do’, but then that seems being very punitive so then ok so you were secluded yesterday but you’re ok today we’ll send you off to do something. And then something happens in that area…. then ‘why did you let them go, they were secluded yesterday?’” (P13, female, healthcare-facilitator)
Opportunity
Theme: Filling the void: high-security as an inherently deprived environment
Participants from all groups perceived the confinement and rules within high-secure settings to be barriers to de-escalation. Staff members often referred to the highly regimented nature of high-secure settings, where even the most basic items such as toothbrushes are monitored, which seemed to create some pessimism among staff about the opportunities for reduced conflict and enhanced de-escalation, a pessimism that importantly wasn’t shared, to the same extent, by patients.
“if we wrote our wish list, what we would describe is a low-secure hospital, but we are not…. we take lot away from patients. They live with very little, almost no, privacy and no access to some of the most basic things that we take for granted” (P21, female, Psychologist)
- i) Organisational resources
A commonly identified barrier to effective de-escalation was insufficient stafftime and meaningful activity. A shortage of staff members alongside excess bureaucracy was perceived as causing an over-reliance on restrictive interventions. Participants reported the frequent cancellation of off-ward activities caused by lack of staff. Staff identified enforced idleness as a major cause of avoidable conflict.
“I could probably count maybe one of my patients at the moment who goes to the gym because that’s who’s been cleared. They are not getting any physical exercise or anything other than Xbox, food, TV…now we struggle to get them out of bed because there is nothing for them to do” (P11, male, healthcare-facilitator)
There was a perception that, owing to problems with recruitment, staff with little or no mental health knowledge or experience were employed, and that this was a barrier to de-escalation:
“They have no experience at all of working in a psychiatric hospital, no training and don’t know about mental illness or personality disorders… then we’re expecting them to go on to wards and be able to de-escalate.” (P21, female, Psychologist)
- ii) The ward environment
Patient views of the ward environment varied depending on where they were located. Those on assertive rehabilitation tended to have favorable impressions, highlighting the quiet, low-stimulus environment as conducive to de-escalation. Physical environments that had a range of accessible areas and activities (e.g. cooking) to use during times of distress were highly valued. Patients valued the relative freedom on these wards:
“I think it’s better because you can do more stuff. You can cook, you can make hot drinks whenever you like, stay up later. It makes you feel a bit more free” (P28, patient, assertive rehabilitation ward)
In contrast, open-ward layouts were often likened to “fishbowls” with nowhere to “escape”. Patients felt these environments reduced their dignity. Specifically, when incidents were witnessed by their peers, shame was experienced. Moreover, the close proximity of bedrooms can mean that conversations aren’t confidential. The restrictions of living in a confined space for a long period of time with other volatile individuals left patients feeling that aggressive behaviour was sometimes inevitable.
“In (open-wards)… It’s all like everyone is in everyone’s business and personal space all the time. Here (assertive-rehabilitation) there are actually places you can go to get away and go to the quiet room and you can have time out and stuff like that” (P28, patient, rehabilitation ward)
Theme: Dynamic relationships
- i) Power and control over patients
Carers and patients felt that some staff were preoccupied with maintaining custody, control and setting unneccessary limits on patient behaviour rather than on providing therapeutic care.
Many patients felt that de-escalation techniques are not used because certain staff rely on restrictive practices to assert their dominance, citing the use of coercive staff behaviours in the context of punishment and refusal to comply. Some patients and carers felt that there were staff who deliberately provoked patients in order to elicit a reaction which would justify the use of restrictive interventions.
“There are some who enjoy it. You know, you get the odd policeman who enjoys the ego, who is corrupt…... It’s power - there are certain people who are not good when they are given power” (P36, Carer)
Some staff felt that patients could develop an impression of individual staff members as especially coercive because those individuals were over-relied upon for involvement in aggression management interventions.
It’s generally the same people who get picked all the time, they are always one step behind in building that relationship with that individual (patient)…they associate that staff member as being the one that will restrain you” (P14, male, nurse)
- ii) A supportive and collaborative workforce
Participants across staff groups perceived that collaboration across the MDT was an essential facilitator of de-escalation. This included formalised opportunities (e.g. Care Plan Approach meetings) to promote a shared understanding of the patient’s diagnosis, triggers and personal difficulties. A supportive, transparent and proactive approach to care planning was particuarly valued in terms of increasing insight into difficuties and how to support change, fostering motivation and decreasing the likelihood of inconsistency in care approaches.
“Psychology has moved to a much more active role within clinical teams. We have more opportunities to interface with the managers and the team leaders through team meetings and CPAs…we share ideas and work with these ideas and come to suggestions that might be helpful and tolerable.” (P15, female, Psychologist)
Staff described the importance of feeling supported by management structures and how this influences an ethos of motivation, confidence and resilience within ward teams. A useful tool in this respect was having frequent supervision that promoted openness, validated emotional distress and avoided penalising staff for taking sick leave. However, this was not always felt to be the case; the use of the ‘Bradford’ sickness-monitoring system, in particular, was considered by fronline staff to be punitive and to result in anxiety and stress that was not regarded as helpful psychological preparation for de-escalation:
“When you go sick you lose your enhancements, you end up getting paid less, your Bradford Score goes up then you get pulled into meetings…you then get worried and you start working and the next thing you know you have a cold and you drain yourself even further. It’s a massive snowball effect” (P14, male, nurse)
iii) Gender and de-escalation
The impact of staff gender on de-escalation was discussed by staff and patient participants, both in terms of the importance of a balanced gender mix, and the relationship between gender and perceived threat. Patients reported feeling powerless and scared when their behaviour was escalating. Feelings of safety were enhanced by the presence of staff they could trust; patients reported that such persons were often, though not always, female. This was partially attributed to women’s perceived enhanced de-escalation skills, however women were also less likely to be seen as dominant or threatening, reducing patient’s fear and sense of powerlessness:
“This comes back to again when they treat males and females differently they don’t expect a threat to come from a female they expect it from the males, so they are always on guard for most males.” (P13, female, healthcare assistant)
However, the perception of female staff members as more vulnerable often elicited feelings of over-protection amongst both patients and male colleagues, which could escalate situations of potential conflict:
“A lot of the patients would say something like ‘if that patient gave you trouble I would sort them out for you’. You have to say, ‘no don’t do that I’m fine don’t worry about me’. They can be quite protective particularly of female staff because they see us as being more vulnerable” (P13, female, healthcare facilitator)
Motivation
Theme: Keeping everyone safe
- i) Early intervention: recognising warning signs
Most participants believed that the best way of avoiding a cycle of escalation, aggression and containment was to prevent it through risk-assessment. Behaviours such as clenched fists, gritted teeth and pacing were highlighted as useful indicators for staff assessing the urgency of early intervention.
Patients and carers commonly reported that staff are too reactive to escalating situations. There was agreement that the first step should be for staff to ask the reason for escalating behaviour, through adopting a gently enquiring style whilst avoiding preconceptions about the causes. Participants across all groups recommended greater time and space be offered and a greater tolerance of escalated behaviour, including voicing frustration through shouting or exercise.
“When you see a patient who looks distressed, you should try and calm them down before it gets worse….. even if it feels hard to communicate with them at the time because they are speaking in a certain way, just approach them slowly, don’t rush, don’t be too strong, be soft and settled and try and understand how he is feeling.” (P26, patient, admission ward)
- ii) De-escalation: an inbuilt and ongoing process
A dominant view across all participant groups was that de-escalation is a daily, ongoing process and “way of being” rather than a simple skill. It was felt that de-escalation techniques should not be considered in isolation from other aspects of staff-patient relationships and processes that help maintain a safe and therapeutic environment. These include ensuring: a thoughtful, open and consistent therapeutic milieu; a safe environment and a constant vigilance to the patient’s triggers and vulnerabilities:
“We see de-escalation as diffusing an actual incident whereas we try to say to staff ‘you work a whole shift, think of all the moments when you’ve being able to avoid, distract, diffuse’. You know, they’re de-escalating all the time…” (P2, male, PMVA instructor)
iii) Staff traumatisation
Staff across groups identified how the resultant trauma from being a victim of, or witnessing, an assault was a key barrier to effective de-escalation:
“I think that a real challenge for an organisation where staff are battered verbally, emotionally and sometime literally physically on a day-to-day basis. To keep coming back and keep trying to take the heat out of a situation again and again, when you have been at genuine risk yourself is an enormous ask of people” (P23, female, Psychiatrist)
The consequent emotional detachment and numbing as a result of trauma was perceived as being to some extent adaptive in enabling staff to continue to work in environments which were traumatising:
“I think the trouble is if you have been seriously injured you shut down your feeling abilities, it’s the only way you can come back to work” (P23, female, Psychiatrist)
However, staff detachment or ‘burnout’ because of trauma was felt, across all participant groups, to affect staff’s perception of patients, making them less optimistic about engaging in de-escalation and potentially resulting in the pre-emptive use of restrictive measures:
“If staff are burnt out then it’s going to affect the way they perceive that individual” (P15, female, Psychologist)
“Whether the staff is aware of what is actually going on inside of them or whether their whole thing is ‘well I’m feeling something I’ve got to put it on the patient, I know how to deal with them’ […] rather than consider; ‘am I kind of putting too much on the patient?’ […] the issue is not the patient it’s actually me!” (P34, female, carer)
- iv) Boundaries: the function of ‘consistency’
Discussion of staff consistency in boundary and behavioural limit-setting featured prominently across all participant groups. Staff expressed the view that inconsistencies in rule and policy application and differences in conflict resolution styles could be barriers to de-escalation. However the value of consistency was predominantly explained by staff in terms of preventing patients from ‘pushing boundaries’ in order to deliberately undermine the staff team. Staff described consistent boundary maintenance as a tool for maintaining ingroup cohesion in the face of a patient group who were assumed to be hostile, rather than the therapeutic, emotional or even safety function this practice addressed:
“Some will push boundaries with one staff member over another… so you will find that they play staff off against each other. If one member of staff says ‘no’ they will try a different member of staff that might say ‘yes ’. It’s making sure that everyone is on the same page really” (P12, female, healthcare facilitator)
“Some (patients) will push boundaries with one staff member over another” (P14, male, nurse)
Patients described the importance of staff consistency in terms of not wanting themselves to be accused by staff of “pushing boundaries”, particularly in cases where rules for staff and patients were markedly different:
“If staff come in and you give them a compliment sometimes they can take that the wrong way…someone (patient) can come out of their room and staff will say ‘Oh that’s a nice shirt you have on today’ and that’s fine but then you can have a member of staff come in and you can say ‘Oh you’re looking nice today’ and they say ‘You can’t say that’. Why not? It’s just being normal, you know what I mean? Just giving a compliment, they say that’s pushing boundaries. …that can happen quite often” (P30, patient, assertive rehabilitation ward).
However in situtions of conflict, PMVA instructors acknowledged the importance of being flexible in rule and limit-setting with patients:
“So not to be punitive in approach - ‘you will do it and you’re going to do it this way’ – so, if I thought I could resolve the situation by getting a patient a cake or something that I thought would give me a favourable outcome then within the realms of what you can do; then I would do that” (PMVA Instructor, F3)