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Aims: To explore inpatient staff's understanding and implementation of positive risk management., Background: Risk management is an essential skill for staff working in acute mental health inpatient settings. National policies advocate the use of positive risk management as a form of collaborative, recovery-focused risk management. However, little is known about how staff understand, operationalize, and use positive risk management in practice., Design: Qualitative reflexive thematic analysis study., Methods: The authors recruited a purposive sample of healthcare professionals working in acute inpatient settings (N = 16) in 2019 across three National Health Service Trusts in the North-West of England. Participants completed semi-structured interviews which were analysed using reflexive thematic analysis., Results: The analysis generated three themes: (a) within staff barriers; (b) within service user barriers; and (c) delivery in practice., Conclusion: Understanding and implementation of positive risk management was dependant on multiple factors, including staffs' beliefs about mental health, levels of worry and anxiety, and amount of experience and seniority. Staff were more likely to use positive risk management with service users that they perceived as being trustworthy and less risky. Use of positive risk management was reliant on the support practitioners received, how able they were to view situations from multiple perspectives, and the degree to which they felt able to prioritize positive risk management., Impact: Although staff expressed the desire and intention to practice positive risk management, the current study highlights challenges around operationalization and implementation. The authors discuss the clinical implications of the findings., (© 2021 The Authors. Journal of Advanced Nursing published by John Wiley & Sons Ltd.)