Table 6.

Barriers and facilitators to effective de-escalation using the TDF [27]

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: challenges within the high-secure 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