Introduction
Policies increasingly focus on staff‐patient interactions during one‐to‐one psychiatric nursing observations as an opportunity for therapeutic engagement – yet if and how this is feasible is unknown.

Aim
This study aimed to integrate staff and patient perspectives to determine what factors facilitate or impede therapeutic engagement during one‐to‐one observation.

Method
Thematic analysis of qualitative interviews with 31 psychiatric inpatient staff at different levels of seniority and 28 inpatients spanning a range of diagnoses and risk profiles.

Results
Negative experiences of observation were characterized by a reciprocal dynamic where both patients and staff withdrew from interactions, having felt the other did not want to engage with them. Staff and patients agreed that these difficulties could be overcome when staff showed patients that they cared, gradually building trust through simple demonstrations of compassion and ‘normalizing’ conversation about everyday things. This approach helped patients to feel safe enough to open up about their distress, which in turn helped staff to better understand their experiences and work with them to find solutions.

Implications for practice
Engagement during observation could be facilitated if staff receive more supervision in understanding difficult dynamics that impede rapport‐building and in managing their emotions towards patients they experience as “hard‐to‐engage”.