Table 2.

Results of thematic analysis, separated into high rating and low rating for NICE and BPS guidance

1. NICE guidance: themes identified by participants who rated guidance highly (either 4 or 5 on a Likert scale)

1.a Theme: Generic positive statements (N = 22): ‘Good to have a reference to refer to’ – Nurse Subtheme: Positive statements with caveats (N = 6) ‘It outlines the relevant points well. The problem is, I'm not sure how many front line staff have read them (and I include CP colleagues in that)’. – Clinical Psychologist

1.b Accessibility (N = 6) ‘Easily accessible and understandable, can refer others to them, supports challenges with some approaches’ – Admiral nurse

1.c Miscellaneous (N = 9) ‘Are becoming more detailed as they evolve to be more meaningful’ – Nurse

2. NICE guidance: the same themes identified by participants who rated guidance either high or low

2.a Medical Model high ratings/endorsement – not overly focused on a medical approach (N = 4) ‘They emphasis non‐pharmacological approaches to distress and so help to validate the Stress & Distress work’ – Clinical Psychologist low ratings/endorsement – overly focused on a medical approach (N = 13) ‘Medical model focus little emphasis on psychological approaches to distressed behaviour’ – Nurse

2.b Evidence base high ratings/endorsement – provides good information re. evidence (N = 3) ‘Gives a framework and guidance for what the evidence‐base suggests is best practice’ – Assistant Psychologist low ratings/endorsement – provides poor information re. evidence (N = 2) ‘Modest evidence for limited recommended approaches’ – Clinical Psychologist

3. NICE guidance: themes identified by participants who rated guidance low (either 1 or 2 on a Likert scale)

3.a Lacks detail/clarity/specificity (N = 19) ‘Guidance is very brief, limited detail , little to work with when developing clinical standards for care’ – OT

3.b Implementation problems (N = 7) ‘They offer a reference point, but they are seldom implemented’ – Other ‘Implementation and lack of user design’ – Psychiatrist

3.c Miscellaneous (N = 9) ‘The content shows little grasp of behavioural a management and understanding’ – Clinical Psychologist

4. BPS guidance: themes identified by participants who rated guidance highly (either 4 or 5 on a Likert scale)

4.a Structure (N = 10) ‘It helps identify what level of input is needed and which professional can provide that input…’ – Nurse ‘It gives a structure to care and a starting point to intervene. If one thing doesn't work you have a guide as to what to try next that is at the most appropriate level needed for an individual’ – Assistant Psychologist

4.b Timely (N = 7) ‘We changed our referral pathway to stepped care model and it has enabled us to meet the person's needs in a more timely manner’ – OT

4.c Detailed and clear guidance (N = 5) ‘Much more detail and recognition of different types of input that may be needed’ – OT

4.d Miscellaneous (N = 12) ‘This is a very useful document to use with Managers etc who do not understand BtC because it emphasises the importance of specialist services. However, it's usefulness is limited because it does not help identify who is most appropriate for what service, just what services should do’ – Clinical Psychologist

5. BPS guidance: themes identified by participants who rated guidance low (either 1 or 2 on a Likert scale)

5.a Implementation problems (N = 4) ‘They are useful as a conceptualisation but not easy to apply in practice’ – Clinical Psychologist

5.b Lack of awareness of guidance (N = 3) ‘A good model, but not being commissioned locally so limited impact’ – Clinical Psychologist

5.c Lack of person‐centred approach (N = 2) ‘They do not have a strong person centred/enduring‐self element to them, and miss the complexity of the care relationships. Too reductionist’ – Clinical Psychologist

5.d Miscellaneous (N = 6) ‘Lot of barriers’ – Clinical Psychologist ‘Little guidance on how to manage behaviours that challenge’ – Nurse