Negotiating power in mental health inpatient settings: an analysis of communication during episodes of conflict.

Abstract

Background and Aims: Individuals in mental health settings may display behaviours of distress, agitation or aggression. Healthcare staff respond using verbal and non-verbal communication, known as de-escalation. However, de-escalation is not evidence based, it’s success in practice varies and there is an imbalance of power between staff and patients during these interactions. The aim of this study is to examine staff’s verbal communication during de-escalation incidents recorded on mental health wards, to identify what communication practices are associated with de-escalation success.

Method: Analysis of recorded de-escalation incidents (n=76) involving one patient and one (or multiple) staff members. Recordings were captured on adult acute mental health wards using body cameras worn by staff. Staff verbal communication was analysed using a speech coding framework developed as part of this study, for analysis of de-escalation incidents. The framework was inductively and deductively developed based on communication theories and the communication practices evident in the footage. De-escalation success was operationalised as a reduction in the frequency of patient escalation behaviours. A Principal Components Analysis (PCA) examined patterns across the speech behaviours in the framework. Mixed Model Regression Analysis examined the relationship between staff speech and de-escalation success adjusting for ward and incident duration.

Results: PCA revealed three main categories of staff speech: (i) speech which decreases the agency of patients (ii) speech which increases the agency of patients and develops a shared understanding (iii) speech designed to decrease staffs’ own agency to align with that of the patient. Agency increased behaviour was associated with decreased escalation of patients. Specifically, for each Agency increasing behaviour displayed by staff, escalation occurrence reduced by 18% (Exp B =0.82, p<.01).
Discussion: Staff using communication designed to increase the agency of patients is associated with de-escalation success. This provides empirically supported evidence that will inform de-escalation training and practice.

Thesis is embargoed until 31 December 2026.

Date of Award	Dec 2025
Original language	English
Awarding Institution	Queen's University Belfast
Sponsors	National Institute for Health and Care Research
Supervisor	Benjamin Brew (Supervisor) & Mary Lavelle (Supervisor)