Table 3 Example of how action cycles, key themes, and excerpts relate to one another.

Communication Action cycle one

Ward Manager: 'Communication within the ward is deficient at times...we seem to repeat the same information.'

Ward Manager: 'I have learnt to be more professionally mature and communicate with MDT, as an adult.

Interruptions Action cycle two

A. Doctors (e.g., 'concurrent ward rounds,' 'doctors working one nurse off another to get what they want'). B. 'Multiple interruptions at handover time from other professionals.'

Ward manager: 'Interruptions are so difficult to manage.'

Pain assessment Action cycle three Older peoples' needs

Nurse: 'Older people don't tell you about their pain.' Support worker: 'You have to get a nurse to repeat what the doctor says, they don't seem to understand.'

Nurse: 'We discuss how we can improve practice and how we may better help older patients to understand their care.'

Power imbalance Horizontal violence

Nurse: 'I want the ground rules to say that there will be no recriminations for opinions....if someone doesn't agree with you, then they can't make your life difficult.'

Nurse: 'We discuss issues and how to move forward as a team.'

Value Support Trust Respect

Support Worker: 'It's like you don't exist until someone wants something.'

Nurse: 'Increased support has been invaluable.

Threat

Lead Nurse: 'It's frustrating when insufficient time is given for new initiatives to be established.'

Nurse: 'Things in the ward are generally better.'

Autonomy

Nurse: 'Why is it I'm allowed to make a decision to give a patient paracetamol today, but not tomorrow when the senior nurse is on duty?'

Nurse: 'It's better now we delegate and support each other.'

Distorted perceptions

Nurse: 'We are under more pressure than anyone else.' Ward manager: 'We always consult everyone about what we do.'

Nurse: Thinking things through with you (facilitator) permitted a more appropriate response and resulted seeing things differently.'

Leadership Support Value

Ward manager: 'I was avoiding conflict but now see that avoidance has led to an increase in issues.' Nurse: 'You need to know whose decisions count.'

Ward managers: 'I've developed insight into how important it is for me to be a strong leader.'