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Safewards Training in Victoria, Australia

A Descriptive Analysis of Two Training Methods and
Subsequent Implementation
Justine Fletcher, MPsych(Clin), BPsych(Hons); John Reece, PhD, MAPS;
Stuart A. Kinner, PhD, BA(Hons); Lisa Brophy, PhD, MPolLaw, BBSc, BSW; and
Bridget Hamilton, PhD, RN, BPsychN, BN(Hons)

I
ABSTRACT npatient mental health care has
Safewards is a psychosocial intervention designed to improve practice and staff– been evolving during the past 2 de-
cades in English-speaking countries,
patient interactions in mental health wards. However, evidence regarding the
with substantial efforts being made to
impact of training on implementing change initiatives in this setting is mixed. reduce restriction (Baker et al., 2014;
Pre- and post-training surveys were completed by staff from 18 inpatient wards Duxbury et al., 2019; Ramluggun &
across seven health services in Victoria, Australia. Fidelity audits were undertak- Chalmers, 2018; Wale et al., 2011).
Initiatives to reduce restrictive in-
en to assess implementation of Safewards into routine practice. Staff knowledge,
terventions, such as forced medica-
confidence, and motivation increased significantly from pre- to post-training, tion, seclusion, and restraint (Bowers,
with no difference between two different methods of training. Most wards were 2009; Cowman et al., 2017; Happell
implementing six or more of the interventions at the end of the trial. A struc- & Harrow, 2010), and shifts toward a
recovery-oriented approach have been
tured approach to training, with flexibility of delivery options, produced posi-
two significant policy and practice
tive changes in staff and translation to practice. Substantial investment in train- change initiatives in Australia and
ing from government and organizations appears to strengthen the uptake and internationally (Australian Human
impact of training, and the current study provides evidence that the interven- Rights Commission, 1993; Boumans
et al., 2015; LeBel et al., 2014; Oster
tions were implemented as intended. [Journal of Psychosocial Nursing and Mental
et al., 2016). Evidence-based interven-
Health Services, 58(12), 32-42.] tions to facilitate improvements in in-

32 Copyright © SLACK Incorporated

patient mental health care have been
used to support and implement policy
and practice changes. Development of
psychosocial interventions and subse-
quently training inpatient staff in psy-
chosocial interventions, is a common
method to enable the transfer of policies
into practice (Edmunds et al., 2013).
Training mental health staff in psy-
chosocial interventions can result in
more positive attitudes toward patients,
increased knowledge and confidence of
staff to work in new ways (Bradshaw et
al., 2007; Doyle et al., 2007; Meadows
et al., 2019), implementation of the
target interventions (Redhead et al.,
2011), and positive outcomes for con-
sumers (Azeem et al., 2011). However,
training in psychosocial interventions
alone is not always sufficient to bring
about changes in practice (Brennan &
Gamble, 1997; Peters et al., 2013). An
Australian study of transfer of a Col-
laborative Recovery Model training
into mental health services to increase
recovery orientation found low rates
of translation of training into routine
practice (37% over 5 months) (Uppal
et al., 2010). Key barriers identified in
the study were institutional constraints,
lack of staff knowledge and confidence
after collaborative recovery training,
and lack of motivation to implement
the new protocol. This finding illus-
trates that research about training in
psychosocial interventions is mixed.
One effective model of facilitating dis-
semination of evidence-based interven-
tions to health care professionals, increas-
ing staff knowledge, improving clinical
behavior, and improving outcomes for
consumers is the train-the-trainer model
(Pearce et al., 2012). In this model, an
expert leads a training event involv-
ing practitioners who then train their
colleagues and implement the new in-
tervention locally. Pearce et al. (2012)
also found that a multifaceted approach
involving interactive components and
course materials was most effective.
THE VICTORIAN SAFEWARDS TRIAL
In 2014 in Australia, the Victo-
rian Government initiated the Vic-
torian Safewards Trial to support
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 58, NO. 12, 2020
mental health services to achieve the
goal of reducing the use of restrictive
interventions, in line with the 2014
Mental Health Act. In the Victorian
Safewards Trial, wards in seven health
services were given funding and access
to Safewards training via a 3-day train-
the-trainer workshop. Wards then par-
ticipated on an opt-in basis to imple-
ment Safewards over a 12-week trial
period, with follow up for 1 year.
Safewards was developed in the
United Kingdom after extensive re-
views of the literature and empirical
research regarding conflict and con-
tainment events in acute inpatient
mental health wards (Bowers, 2014;
Bowers et al., 2014). Safewards pro-
vides a conceptual framework and 10
psychosocial interventions designed
to reduce conflict and use of contain-
ment strategies in acute inpatient
mental health wards (Bowers, 2014).
(For a full description of the model,
see Fletcher et al. [2017].) Fidelity of
implementation refers to how faith-
fully Safewards is reproduced during
implementation in each context. To
date, fidelity results are mixed from as
few as two or three interventions be-
ing implemented (Price et al., 2016),
to as many as seven or eight interven-
tions being implemented (Kipping et
al., 2018; Maguire et al., 2018). The
uptake and quality of training has
been one variable suggested as impact-
ing the level of fidelity of Safewards
implementation (Higgins et al., 2018;
Kipping et al., 2018; Maguire et al.,
2018; Price et al., 2016).
The researchers were commissioned
to conduct an evaluation in the con-
text of “real-world” conditions of the
inpatient unit, thus the evaluators had
limited control of study conditions
and were required to navigate com-
plexities that occur with unexpected
changes. This real-world evaluation of
all components of the Victorian Safe-
wards Trial found that seclusion rates
were reduced by 36% in the Safewards
project wards by 12-month follow up
(Fletcher et al., 2017). Further research
was required to illuminate the condi-
tions that were relevant in producing
these positive findings. Hence, the cur-
rent study has two aims: (1) to evaluate
whether Safewards training increased
staff knowledge, confidence, and mo-
tivation to implement the Safewards
model and 10 interventions; and (2) to
assess the degree to which training was
translated into practice. The current
article reports on the evaluation of lo-
cal health service training efforts. The
process of training adopted by local
health services in the Victorian Safe-
wards Trial provides a unique oppor-
tunity to add to the literature about
Safewards training and the subsequent
impact on implementation.
METHOD
Study Setting and Participants
The current study took place in
seven health services that opted into
a trial of Safewards, involving 18 of
68 wards in Victoria. Inpatient men-
tal health wards providing services to
adolescent, adult, and aged acute and
secure extended care units were in-
volved. The anticipated pool of nurs-
ing and allied staff employed across
the 18 wards at the time of the train-
ing was approximately 400 individuals.
Training took place over a 4-month pe-
riod, from November 2014 to February
2015. It consisted of two parts: a central
train-the-trainer program, followed by
local health service training.
Train-The-Trainer
Three train-the-trainer days were
commissioned by the Victorian Gov-
ernment. Clinical nurse educators
(CNEs) and select ward staff from each
health service attended the training,
which covered the Safewards model
and 10 interventions (Table 1).
In this jurisdiction, the CNE is a dis-
tinct role, differentiated in the employ-
ment award and professional structure.
Typically, CNEs are nurses recruited
from clinical specialist roles; they have
mental health specialist postgradu-
ate qualifications at either Graduate
Diploma or Master’s level. CNEs are
members of their service level (local)
nurse education team, with access to a
statewide community of practice. The
33
 12-Week Implementation Phase
TABLE 1 After the training phase, the trial
SAFEWARDS INTERVENTIONSa phase involved monitoring all wards
Intervention Description Purpose implementing the Safewards interven-
tions during a 12-week period, from
Mutual Help Patients offer and receive Strengthens patient
March to May 2015. The goal stated
Meeting mutual help and support community; opportunity to
by the Victorian Government was that
through a daily, shared give and receive help.
all wards would implement all 10 Safe-
meeting.
wards interventions from the start of
Know Each Other Patients and staff share some Builds rapport, connection, the 12 weeks and would have embed-
personal interests and ideas and sense of common ded Safewards into routine practice af-
with each other, displayed in humanity. ter the 12-week trial.
unit common areas.
Clear Mutual Patients and staff work Counters some power Study Design and Ethical Considerations
Expectations together to create mutually imbalances; creates a The current study used a pragmatic
agreed aspirations that apply stronger sense of shared real-world evaluation design to inves-
to both groups equally. community. tigate both training methods, using a
Calm Down Staff support patients to draw Strengthen patient non-matched pre-post survey design;
Methods on their strengths and use/ confidence and skills to the surveys were online and sent out by
learn coping skills before the cope with distress. the local trainers. There was concern
use of PRN medication or that staff would not complete the sur-
containment. vey if they believed they could be iden-
tified, so the evaluators did not require
Discharge Before discharge, patients Strengthens patient
staff to identify themselves. There was
Messages leave messages of hope for community; generates
an optional question allowing staff to
other patients on a display in hope.
make a unique code using their date of
the unit.
birth and suburb, but most staff chose
not to enter this code. Therefore, we
were not able to match pre- and post-
centralized policy branch developed a staff attending the train-the-trainer training survey data. Health services
train-the-trainer package and deliv- workshops to plan and implement lo- self-selected into the training method
ered this to CNEs and other nurses in cal training, in agreement with man- that was most suitable to the organi-
local Safewards implementation roles. agers of the participating wards. The zation’s needs. Figure 1 presents the
In addition, training materials primary goal was to train all staff work- summary of the Safewards project com-
were provided for use in local health ing on the wards. Hence, two methods ponents and data collection timeline.
service training. To ensure fidelity to were used to train local staff in Safe- Ethics approval was obtained from the
Safewards, the training package used wards: health services provided a full University of Melbourne Human Eth-
the freely available UK Safewards day of training to ward staff (top-up in- ics Sub-Committee (ID 1443604), as
material (Safewards, 2015), which in- service sessions were offered by some well as Victorian Human Research Eth-
cludes an array of practical exercises services to ensure coverage of staff ics Multi-site (ID 15225L) approval for
and opportunities for brainstorming who could not attend a whole day ses- each of the involved health services.
implementation ideas. The materials sion), from this point forward referred
were organized by each of the 10 inter- to as “1-day plus in-service,” or they Data Sources and Collection
ventions to enable each health service provided multiple short in-service ses- Three sources of data were collected:
to tailor the process of training to best sions, referred to as “in-service.” Most pre-training surveys, post-training sur-
suit local circumstances. commonly, one in-service session cov- veys, and a fidelity checklist. The pre-
ered two Safewards interventions, and and post-training survey questions were
Local Health Service Training five sessions would be considered the developed by the research team, based
Training was provided within each optimal number to cover the 10 inter- on the components of Safewards and
health service to staff who would be ventions. Both methods of training of- previous research findings about impor-
implementing Safewards. The Victo- fered the same content multiple times, tant constructs related to training staff
rian Government did not provide a set to ensure coverage of all shift-working in health care.
process for the delivery of Safewards staff. Notwithstanding differences in Pre-Training Staff Survey. The pre-
training in the health services; rather, training delivery, staff in all services training survey included questions
this was left to the discretion of the received similar training content. about staff knowledge, confidence, and

34 Copyright © SLACK Incorporated

motivation to implement the Safewards
model and each of the 10 interven-
tions (response scale: 1 = none, 2 = fair,
3 = good, 4 = very good, 5 = excellent),
and demographic and professional role
questions. This survey was completed
prior to undertaking the training. This
survey was administered between De-
cember 2014 and February 2015.
Post-Training Staff Survey. The post-
training survey included the questions
from the pre-training survey, as well as
additional quantitative questions relat-
ed to the frequency with which staff in-
tended to implement each intervention
(1 = never, 2 = rarely, 3 = sometimes,
4 = usually, 5 = always), and staff sat-
isfaction with their training experience
(e.g., interactive group activities, clar-
ity of trainers, group discussions, imple-
mentation planning activities, respons-
es to questions) and materials (e.g.,
written handouts, PowerPoint® slides,
UK videos) provided (1 = none, 2 = fair,
3 = good, 4 = very good, 5 = excellent).
Staff also had the opportunity to pro-
vide written responses about their ex-
perience with each component of the
training. Staff completed the survey at
the completion of training. The survey
was open until April 2015.
Fidelity Checklist. The fidelity check-
list is a 14-item, standardized audit tool
used by the UK Safewards Trial team
(Bowers et al., 2015). This observational
tool is completed during a walkthrough
of the ward, designed to assess if each of
the interventions is being implemented.
The fidelity checklist was slightly altered
for the Victorian trial. In the UK trial, an
additional end of shift measure, the Pa-
tient Staff Conflict Checklist (PSCC),
was gathered, and the records were used
to inform some components of the fidel-
ity checklist. However, in the Victorian
trial it was not feasible to use the PSCC,
so all reference to it was removed from
the fidelity checklist. Independent ob-
servational walkthroughs of each ward
involved in the trial were conducted by
members of the research team (J.F., B.H.)
at four points during the project (T1, T3,
T4, T6), and local educators completed
T2 and T5. The research team using the
fidelity checklist maintained a process of
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 58, NO. 12, 2020
TABLE 1 (CONTINUED)
SAFEWARDS INTERVENTIONSa
Intervention Description Purpose
Soft Words Staff take great care with their Reduces a common
tone and use of collaborative flashpoint (i.e., a time or
language. Staff reduce the situation when something
limits faced by patients, could go wrong, often seen
create flexible options, and as a trigger that signifies
use respect if limit setting is potential conflict); builds
unavoidable. respect, choice, and dignity.
Talk Down De-escalation process focuses Increases respect,
on clarifying issues and collaboration, and mutually
finding solutions together. positive outcomes.
Staff maintain self-control,
respect, and empathy.
Positive Words Staff say something Increases positive
positive in handover about appreciation and helpful
each patient. Staff use information for colleagues
psychological explanations to to work with patients.
describe challenging actions.
Bad News Staff understand, proactively Reduces impact of
Mitigation plan for, and mitigate the common flashpoints; offers
effects of bad news received extra support.
by patients.
Reassurance Staff touch base with every Reduces a common
patient after every conflict flashpoint; increases
on the unit and debrief as patients’ sense of safety and
required. security.
a
Adapted from Victoria Department of Health and Human Services Safewards training
resources (access https://www2.health.vic.gov.au/mental-health/practice-and-service-quality/
safety/safewards/training-resources).
cross checking their observations and re- 1 to 5, and together these 11 compo-
solved any differences in interpretation as nents result in a potential total score
a team to enable consistency of ratings. of 55. Weighted averages were used to
The timing of data collection is depicted evaluate the impact of training on staff
in Figure 1. knowledge, confidence, and motiva-
tion; and intention to implement for
Data Analysis the entire sample. The same approach
The authors calculated composite was used to understand the impact of
scores, for each construct, of a total 55 the two methods of training on staff
points using data from the survey ques- knowledge, confidence, motivation,
tions. There is one composite score and satisfaction; and intention to im-
for each of the following: knowledge, plement the Safewards model.
confidence, motivation, and satisfac- The fidelity checklist scores each in-
tion (post-training survey only); and tervention 1 to 10, with 100 being the
intention to implement the Safewards highest possible total score. Data from
model and 10 interventions (post- the fidelity checklist were analyzed by
training survey only). The model and training method to assess if the method
interventions each received a score of of training had an impact on the fidel-
35
Figure 1. Safewards project and data collection timeline.
TABLE 2
NUMBER OF HEALTH SERVICES, WARDS, AND STAFF FOR EACH
TRAINING METHOD
Staff Surveys (%)
Training Method Health Services Wards Pre Post
In-service 3 7 101 (37) 82 (54)
1-day plus in-service 4 11 174 (63) 71 (46)
ity of implementation. Fidelity data et al., 2017), these rely on knowledge
were also analyzed to assess the transfer of which participants have provided
of training into routine practice, with matched data and which have not,
higher fidelity scores over time indicat- which was not the case in the current
ing higher transfer of training. study. Although we are aware of the
A range of univariate and multivari- potential problem with correlated error
ate parametric statistical tests were per- in analyzing the data in this way, it was
formed. All assumptions (e.g., normal- believed that the reported approach
ity and homogeneity of variance) were provided the best alternative for an in-
adequately met for these analyses. An ferential analysis of the results.
effect size measure and its associated
95% confidence interval (CI) are re- RESULTS
ported for each significance test. ␣ was The current study reports on 275
set at 0.01 for each analysis to compen- staff who attended local health service
sate for multiple testing. training and completed the pre-training
Because of the partially overlapping survey, and 153 staff who completed
nature of the design—that is, some the post-training survey, reflecting a re-
participants provided data at pre- and sponse rate of approximately 60% and
post-training, whereas others provided 34%, respectively, of those who poten-
data at only one time point—and the tially received training across the seven
inability to match results at the two health services.
time points, the data were analyzed us- Table 2 indicates the distribution
ing a between-subjects framework. Al- of health services, wards, and pre- and
though there are methods for analyzing post-training surveys to each of the two
partially overlapping designs (Derrick training methods. Three services chose
36
to use the in-service method, and four
services the 1-day plus in-service train-
ing approach. Thus, more wards were
exposed to the 1-day plus in-service
training method.
Demographic characteristics of
survey participants are presented in
Table 3. Most participants were female
and spoke English as their first language.
The type of professional role of staff was
similar among pre- and post-training
survey participants; however, the 1-day
plus in-service training group had no
peer or consumer workers and had a
slightly higher rate of associate nurse
unit managers. A substantial number of
staff identified as other; these staff were
most frequently occupational therapists,
social workers, or psychologists.
Post-training surveys were received
from two health services that deliv-
ered in-service training and four health
services that delivered 1-day plus
in-service training. Table 4 shows the
number of training events that post-
training survey participants reported
attending at their local health service.
Fifty-nine percent of staff working in
health services with the 1-day plus in-
service training method reported at-
tending one training session. Similarly,
60% of staff who worked in health
services delivering multiple in-service
training sessions attended between two
and five sessions. A further 20% attend-
ed between six and 11 sessions; 19% of
the in-service training staff reported at-
Copyright © SLACK Incorporated
 TABLE 3
PARTICIPANT CHARACTERISTICS
n (%)
In-Service 1-Day Plus In-Service
Pre-Training Post-Training Total Pre-Training Post-Training Total
Characteristic (n = 101) (n = 82) (n = 183) (n = 174) (n = 71) (n = 245)
Gender
Male 38 (37.6) 29 (35.4) 67 (36.6) 45 (25.9) 20 (28.2) 65 (26.5)
Female 63 (62.4) 48 (58.5) 111 (60.7) 129 (74.1) 50 (70.4) 179 (73.1)
Other 0 (0) 3 (3.7) 3 (1.6) 0 (0) 0 (0) 0 (0)
Missing 0 (0) 2 (2.4) 2 (1.1) 0 (0) 1 (1.4) 1 (0.4)
Language
English 82 (81.2) 66 (80.5) 148 (80.9) 156 (89.7) 64 (90.1) 220 (89.8)
Other 19 (18.8) 13 (15.9) 32 (17.5) 18 (10.3) 6 (8.5) 24 (9.8)
Missing 0 (0) 3 (3.7) 3 (1.6) 0 (0) 1 (1.4) 1 (0.4)
Professional role
Nurse unit 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
manager
Associate nurse 9 (8.9) 6 (7.3) 15 (8.2) 17 (9.8) 11 (15.5) 28 (11.4)
unit manager
Clinical nurse 3 (3) 3 (3.7) 6 (3.3) 3 (1.7) 2 (2.8) 5 (2)
educator
Clinical nurse 0 (0) 2 (2.4) 2 (1.1) 1 (0.6) 0 (0) 1 (0.4)
specialist
RN 47 (46.5) 42 (51.2) 89 (48.6) 81 (46.6) 33 (46.5) 114 (46.5)
Enrolled nurse 12 (11.9) 12 (14.6) 24 (13.1) 31 (17.8) 8 (11.3) 39 (15.9)
Consumer 2 (2) 0 (0) 2 (1.1) 0 (0) 0 (0) 0 (0)
consultant
Peer worker 0 (0) 1 (1.2) 1 (0.5) 0 (0) 0 (0) 0 (0)
Other 25 (24.8) 13 (15.9) 38 (20.8) 37 (21.3) 13 (18.3) 50 (20.4)
Missing 3 (3) 3 (3.7) 6 (3.3) 4 (2.3) 4 (5.6) 8 (3.3)

tending only one session. This finding
indicates that staff from the in-service
training group received substantially
less training than would be considered
optimal for coverage of the Safewards
model and 10 interventions.
Impact of Training on Knowledge,
Confidence, and Motivation
On average, staff reported that their
knowledge and confidence were good
in the pre-training surveys and very
good in the post-training surveys. Mean
self-reported motivation to implement
Safewards increased from very good be-
fore training to excellent after training
(Figure 2).
Figure 3 displays staff ratings of
knowledge, confidence, and motiva-
tion before and after training, stratified
by training method. Prior to training,
both groups rated themselves as average
to good on measures of knowledge and
confidence; this increased to very good
after training. Motivation increased
from good to excellent after training.
This pattern of change was consistent
across both groups.
Single-factor between-subjects
analysis of variance (ANOVA) con-
ducted separately on the pre- and
post-training scores for knowledge,
confidence, and motivation found no
significant differences across the seven
service sites. Site location was, there-
fore, excluded from all subsequent
models for either nesting or covariance
purposes.
Impact of training was analyzed us-
ing a 2 ⫻ 2 between-subjects multivari-
ate ANOVA (MANOVA). The scores
on knowledge, confidence, and motiva-

JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 58, NO. 12, 2020 37

 significant multivariate phase main
TABLE 4 effect (⌳ = 0.68, F[3, 571] = 88.08,
TRAINING RECEIVED BY POST-SURVEY RESPONDENTS p < 0.001, ␩p2 = 0.32, 95% CI [0.25,
n (%) 0.37]) with significant univariate re-
Number of Training
sults found for all three outcomes:
Events Attended In-Service 1-Day Plus In-Service knowledge (F[1, 573] = 263.46,
1 16 (19) 42 (59) p < 0.001, ␩2 = 0.32, 95% CI [0.26,
2 to 5 49 (60) 25 (35) 0.37]); confidence (F[1, 573] = 193.97,
6 to 11 17 (21) 4 (6) p < 0.001, ␩p2 = 0.25, 95% CI [0.20,
0.31]); and motivation (F[1, 573] =
Total 82 (100) 71 (100)
45.09, p < 0.001, ␩p2 = 0.07, 95% CI
[0.04, 0.12]). These results were all in
the direction of pre- to post-training
improvement, with the strongest effect
evident in knowledge improvement.
Using a Pearson’s correlation, we found
no significant relationship between
number of sessions attended and post-
intervention scores.

Satisfaction With Training

Figure 2. Pre- and post-training mean knowledge, confidence, and motivation.
Figure 3. Mean knowledge, confidence, and motivation pre- and post- training, per
training model.
tion formed the multivariate outcome.
The two factors were phase (pre- ver-
sus post-intervention) and training
mode (whole day versus in-service).
No significant multivariate or univari-
ate phase by training method interac-
tions or training method main effects
were evident. There was, however, a
Both groups expressed satisfaction
(on average good to very good) with
most aspects of the training, particu-
larly the clarity of the trainers, the way
their questions were answered, and the
group discussions (Figure A, available
in the online version of this article).
With regard to training method,
participants who engaged in whole-
day training (mean = 3.41, SD = 0.87,
range = 1 to 5) were found to be sig-
nificantly more satisfied with the train-
ing videos than in-service participants
(mean = 2.91, SD = 1.24, range = 1 to 5)
(t[166] = 3.03, p = 0.003, d = 0.47,
95% CI [0.16, 0.77]). This was the only
significant difference related to train-
ing method. No significant correlations
were found between number of training
sessions and satisfaction.
Significant differences in two as-
pects of satisfaction were found across
the seven sites: written materials
(F[6, 161] = 2.91, p = 0.01, ␩p2 = 0.25,
95% CI [0.01, 0.16]) and training
videos (F[6, 161] = 3.94, p = 0.001,
␩p2 = 0.25, 95% CI [0.02, 0.20]). For
written materials, Health Service
5 reported the highest level of sat-
isfaction (mean = 4.67, SD = 0.58,
range = 1 to 5), with Health Service 1
(mean = 3.40, SD = 0.76, range = 1 to 5)
and Health Service 3 (mean = 3.27,
SD = 0.59, range = 1 to 5) reporting

38 Copyright © SLACK Incorporated

the lowest (Figure B, available in the
online version of this article). The pat-
tern was different for training videos,
with Health Service 6 (mean = 4.06,
SD = 1.06, range = 1 to 5) and Health
Service 7 (mean = 4.00, SD = 0.00,
range = 1 to 5) reporting the high-
est level of satisfaction, and Health
Service 2 the lowest (mean = 2.86,
SD = 1.23, range = 1 to 5) (Figure
C, available in the online version of
this article).
Results of a within-subjects ANOVA
showed an overall significant difference
in mean satisfaction levels across the
eight items (⌳ = 0.55, F[7, 161] = 18.80,
p < 0.001, ␩p2 = 0.45, 95% CI [0.32,
0.52]), with the highest overall level of
satisfaction being reported for clarity of
the trainers (mean = 3.96, SD = 0.91,
range = 1 to 5), and the lowest for the
training videos (mean = 3.15, SD = 1.10,
range = 1 to 5).
Finally, an exploratory factor analy-
sis on the seven satisfaction items re-
vealed that all items were associated
with a single factor that accounted for
65% of variance with all communali-
ties >0.50, indicating that responses
to the satisfaction items were different
dimensions of a single underlying satis-
faction construct.
Implementing Safewards into Routine
Practice
Regardless of the training method,
staff on average reported that they could
envisage including Safewards into their
practice usually (in-service: mean = 47,
SD = 7.12, range = 10 to 50; 1-day
plus in-service: mean = 46, SD = 6.86,
range = 10 to 50). There were no sig-
nificant differences between the two
training methods on either the total
frequency score or on any of the 11
individual frequency items. Similarly,
there were no significant differences
across the seven training sites on any
frequency items, and no significant cor-
relations between the number of training
sessions taken and any frequency item.
A within-subjects ANOVA found
a significant difference across the 11
mean frequency scores (⌳ = 0.75, F[10,
159] = 5.41, p < 0.001, ␩p2 = 0.25,
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 58, NO. 12, 2020
95% CI [0.10, 0.32]). Despite this sig-
nificant difference, the actual range
between the highest and lowest fre-
quency items was not large, with
use of bad news mitigation record-
ing the lowest mean (mean = 4.04,
SD = 0.88, range = 1 to 5) and use of
reassurance the highest (mean = 4.42,
SD = 0.69, range = 1 to 5). Figure D
(available in the online version of this
article) illustrates the mean score for
the extent to which participants in
each training group could envisage in-
corporating each Safewards interven-
tion into their practice.
Similar to the satisfaction items, an
exploratory factor analysis found that the
11 frequency items loaded onto a single
factor accounting for 62% of observed
variance with all communalities >0.50.
Results from the Fidelity Checklist at
the end of the 12-week trial period are
presented by ward in Figure E (avail-
able in the online version of this arti-
cle). The 1-day plus in-service training
wards (n = 11) showed an average fidel-
ity of 82 (SD = 18.54, range = 0 to 100)
and implemented between four and
10 interventions. In-service wards
(n = 7) showed an average fidelity of
77 (SD = 15.49, range = 0 to 100) and
implemented between five and 10 in-
terventions.
No significant difference in fidel-
ity was found between the two types of
training methods or across the training
sites. In addition, there was no signifi-
cant association between the number of
visits and either training method or site.
A trend analysis was used to model
the change in fidelity scores across the
six visits. Of the five trends tested, only
the first order linear trend was found
to be significant (F[1, 84] = 29.18,
p < 0.001, ␩p2 = 0.25, 95% CI [0.11,
0.40]), indicating that fidelity increased
in a consistent linear pattern with in-
creasing visits. This pattern is evident
in Figure F (available in the online
version of this article).
DISCUSSION
The current study evaluated
Safewards training in two parts: (1) the
impact of training on staff knowledge,
confidence, and motivation, as well as
intention to implement and satisfac-
tion with training; and (2) implemen-
tation of Safewards in practice. Staff
who participated in local health service
training reported significant pre- to
post-training improvements in their
knowledge of the Safewards model
and 10 interventions, as well as their
confidence and motivation to imple-
ment Safewards into their practice. We
observed no difference between staff
who received a 1-day plus in-service
training method compared with an in-
service training method on any of these
outcomes. However, satisfaction with
training videos was significantly higher
for the 1-day plus in-service training
group. Other observed differences in
satisfaction were between health ser-
vices and not related to the training
method. An exploratory factor analy-
sis indicated that all satisfaction items
were related to the one construct of
satisfaction.
Staff believed they would usually in-
corporate Safewards interventions into
their practice regardless of the method
of training they received or the health
service they worked in. Small but sig-
nificant differences were found between
the degree to which each intervention
may be delivered, with staff reporting
bad news mitigation to be the least fre-
quently incorporated intervention and
reassurance being the most incorporated
intervention. There was some vari-
ability regarding the fidelity checklist.
Three wards from each group were im-
plementing between four and six of the
10 Safewards interventions by the end
of the 12-week trial. This low fidelity oc-
curred despite some of these wards hav-
ing access to the same training sessions
as other wards in the same health ser-
vice that were implementing between
eight and 10 interventions. As such,
variability in fidelity was not shown to
be a function of the training method.
Rather, these findings suggest that other
(unmeasured) factors influenced transla-
tion into practice. The degree to which
Safewards was being implemented by
the end of the 12-month follow-up pe-
riod showed a significant linear trend
39
overtime. There was no significant dif-
ference found between the methods of
training or health service and the degree
to which the interventions were being
implemented in the 9 months after the
implementation phase.
These findings are encouraging from
a health service perspective as the re-
sults reveal that, regardless of which
method of training staff received, it had
a positive impact on staff knowledge,
confidence, and motivation. Notwith-
standing that a small number of wards
had low implementation fidelity at the
end of the implementation phase, at
the end of the follow-up phase most
wards had also successfully translated
their training into routine practice.
The findings of the current study are
consistent with previous studies that
have shown evidence of training in
psychosocial interventions leading to
practice change (Bradshaw et al., 2007;
Doyle et al., 2007; Kipping et al., 2018;
Maguire et al., 2018; Redhead et al.,
2011).
Implementation science explores
many factors beyond training that may
have an impact on practice change,
such as organizational buy-in at a senior
level, staff turnover, actual and per-
ceived time constraints, and other com-
peting change agendas (Damschroder
et al., 2009; Sadeghi-Bazargani et al.,
2014; Weatherson et al., 2017). Previ-
ous evaluation reporting has identified
a number of factors that may have im-
pacted implementation of Safewards in
Victoria, including lack of support from
nurse unit managers to release staff
for training, organizational barriers to
spending allocated funds to support
purchase of materials for implementa-
tion, and staff ambivalence about some
interventions (Hamilton et al., 2016).
Implementation of Safewards has prov-
en challenging in some settings, with
prior studies noting that a larger invest-
ment in training would likely have im-
proved staff understanding of the mod-
el and buy-in and thus implementation
success (Higgins et al., 2018; Price et
al., 2016).
Fidelity to implementation in the
UK Safewards Trial was reported to be
40
38% with associated reductions in con-
flict and containment events (Bowers
et al., 2015). The UK trial relied on re-
search assistants conducting in-service
training and staff accessing materials
that were freely available online (James
et al., 2017). In contrast, the Victorian
Government contracted trainers to
collate all UK training materials, cre-
ate learning activities, and deliver a
train-the-trainer workshop to a small
group of nurse educators from each
health service participating in the trial.
Educators were provided with the ma-
terials they would need to deliver train-
ing to staff at their health service. This
streamlined approach resulted in staff
at each ward receiving similar materi-
als and training presentations, regard-
less of the method of training delivery.
The flexibility in training delivery en-
sured that training could be delivered
in a way that accommodated the needs
and goals of each health service and
ward—a key factor when attempting to
train all shift-working staff. It appears
that this flexibility in training method
and taking a team-based approach im-
proved the uptake of this intervention.
Furthermore, the current study in-
volved a ward team being trained in
the implementation of Safewards. This
team training approach is in contrast
to the collaborative recovery model
reported by Uppal et al. (2010), in
which individual staff accessed train-
ing and volunteered to be part of the
evaluation and subsequently, low rates
of translation of training into routine
practice were observed. Hence, the cur-
rent study provides an indication that
transfer of training into practice may
be more successful when using a team-
based approach. Further evidence from
the current study highlights that “suc-
cessful” training (as indicated by im-
provements in knowledge, confidence,
and motivation) is a vital foundation
to the successful implementation of
Safewards and other psychosocial prac-
tice change initiatives.
Practice change initiatives often
falter because of staff resistance to en-
gaging with new methods of practice
(Corrigan et al., 2001); however, this
trend was not evident in the Victorian
trial. There are some possible explana-
tions for the success of this trial. First,
the investment from the Victorian
Government sent a clear message to
services and staff that Safewards was
valued, and that they had “top down”
support for implementation. Second,
gathering staff in groups for interac-
tive training may create shared mo-
tivation and vision to make practice
changes. In this case, group training
may have provided opportunities for
staff with reservations about the mod-
el and interventions to raise questions
and problem solve how implementa-
tion may work in their own workplace
(Hamilton & Manias, 2007). This no-
tion is consistent with findings from
Grundy et al. (2017), who evaluated
a staff training package and conclud-
ed that staff were grateful for having
team-oriented time enabling reflec-
tion of current practice. The format of
training that involved work teams in
interactive exercises is “an acceptable
and engaging format for learning for
mental health professionals” (Grundy
et al., 2017, p. 365). Kipping et al.’s
(2018) findings concur with this,
where a cocreation approach to imple-
mentation that involved substantial
investment in staff training also re-
sulted in staff buy-in and high fidelity.
STRENGTHS AND LIMITATIONS
A key methodological strength of
this real-world study is the independent
observation measuring transfer of train-
ing into routine practice using a fidelity
checklist. The current study also had
some limitations. First, we were unable
to match data across pre- and post-
training surveys, thus precluding use
of more powerful statistical methods.
Second, as the surveys were voluntary
there was varying representation across
wards, which may have impacted find-
ings; for example, staff who participat-
ed may have been more or less positive
than those who did not. Given these
methodological limitations, the degree
to which these findings can be general-
ized to other mental health inpatient
settings is unclear.
Copyright © SLACK Incorporated

PRACTICE IMPLICATIONS
The method of training adopted in
the Victorian Safewards Trial adds to
the body of knowledge about Safewards
training and its subsequent positive
impact on implementation. The cur-
rent study also adds to the mental
health training literature more broadly.
Training with structured content that
allowed for flexibility of delivery pro-
vided optimal conditions for reaching a
large number of inpatient shift-working
staff. Importantly, the approach of
training staff teams as opposed to in-
dividuals appears to strengthen trans-
fer of training into practice, and thus
has a positive impact on the fidelity of
implementation to the Safewards mod-
el and its 10 interventions. Safewards
training enables nurses to directly focus
on prevention of conflict, a previously
under-theorized but key area of rela-
tional work in mental health nursing.
Using fidelity measures to assess the
impact of training and the extent to
which the intervention has been ad-
opted in practice can support staff to
use reflective practices to monitor the
impact of Safewards and promote posi-
tive change.
CONCLUSION
Despite the current study’s limita-
tions, it is clear that this training was
well received, and that participants
were ready and motivated to implement
Safewards, regardless of the method of
training. Substantial investment by the
Victorian Government to develop and
implement a train-the-trainer package
has provided a sound foundation from
which staff across seven health services
in metropolitan and regional Victoria
have been trained and subsequently
successfully implemented Safewards.
Interactive group training for Safewards
successfully improved the knowledge,
confidence, and motivation of staff
to implement Safewards into routine
practice, resulting in the staff teams im-
plementing a high number of Safewards
interventions successfully and quickly.
Where services are embarking on im-
plementation of Safewards or other
psychosocial interventions in inpatient
JOURNAL OF PSYCHOSOCIAL NURSING • VOL. 58, NO. 12, 2020
settings, there is a noteworthy lesson
from this study regarding the impact of
substantial investment in training.
Future research in this area would be
strengthened by ensuring that all pre-
and post-training data are in matched
pairs to allow for more detailed statis-
tical analysis to be conducted into the
impact of the dose of training and lo-
cal cultural differences. In addition,
future research should link training ef-
fort with detailed implementation data,
including the service environment and
key stakeholder involvement. Such a
link could inform a range of explana-
tions as to why the training effort in
the Victorian Safewards Trial has led
to strong and sustained implementa-
tion over the short- and long-term with
associated significant reductions in the
use of seclusion (Fletcher et al., 2017).
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Ms. Fletcher is Research Fellow, Dr. Brophy is
Honorary Principal Research Fellow, Centre for
Mental Health, Dr. Kinner is Professor, Melbourne
School of Population and Global Health, and Dr.
Hamilton is Associate Professor, Centre for Psy-
chiatric Nursing, School of Health Sciences, The
University of Melbourne, Parkville, Victoria; and
Dr. Reece is Professor of Psychological Science,
Australian College of Applied Psychology, Mel-
bourne, Victoria. Dr. Kinner is also Professor and
Head, Justice Health Group, Centre for Adoles-
cent Health, Murdoch Children’s Research Insti-
tute, Parkville, Victoria, Adjunct Professor, Griffith
Criminology Institute, Griffith University, Honor-
ary Professor, Mater Research Institute-UQ, Uni-
versity of Queensland, Queensland, and Associate
Professor, School of Public Health and Preventive
Medicine, Monash University, Melbourne, Victoria;
and Dr. Brophy is also Professor, School of Allied
Health, Human Services and Sport, La Trobe Uni-
versity, Melbourne, Victoria.
The authors have disclosed no potential
conflicts of interest, financial or otherwise. This
independent evaluation was financially supported
by the Office of the Chief Mental Health Nurse, in
the Department of Health and Human Services,
Government of Victoria. This article forms part
of the work toward a PhD, which is supported
through an Australian Government Research
Training Program Scholarship. Ms. Fletcher is
supported by NHMRC PhD Research Scholarship
1133627. Dr. Kinner is supported by NHMRC
Research Fellowship APP1078168.
The researchers are indebted to staff and
consumers at the trial sites, for cooperation with
fidelity measurement.
Address correspondence to Justine Fletcher,
MPsych(Clin), BPsych(Hons), Research Fellow,
Centre for Mental Health, Level 4, 207 Bouverie
Street, Carlton, Victoria, 3053, Australia; email:
justine.fletcher@unimelb.edu.au.
Received: March 24, 2020
Accepted: June 29, 2020
doi:10.3928/02793695-20201013-08
Copyright © SLACK Incorporated
 3.90
Questions answered to your satisfaction
3.72

3.27
Adequate time allowed for questions
3.32

3.65
Group discussions
3.68

4.01
Clarity of the trainers
3.79

3.54
Power point slides
3.51

3.56
Interactive group activities
3.61

2.83
Videos
3.34

3.70
Written materials
3.54

0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00
Participants rating on 5-point likert scale

Inservice (n=82) One day (n=71)

Figure A. Mean satisfaction of training components, per training model.

 5.00

4.50

4.00

3.50
Mean satisfaction rating

3.00

2.50

2.00

1.50

1.00

0.50

0.00
1 2 3 4 5 6 7
Ward

Figure B. Mean satisfaction with written materials by ward.

 5.00

4.50

4.00

3.50
Mean satisfaction rating

3.00

2.50

2.00

1.50

1.00

0.50

0.00
1 2 3 4 5 6 7
Ward

Figure C. Mean satisfaction with videos by ward.

 Safewards Model 4.16
4.17

Reassurance 4.45
4.39

Soft Words 4.40

4.20

Discharge Messages 4.23

4.01

Calm Down Methods 4.45

4.25

Mutual Help Meeting 4.26

3.97

Know Each Other 4.18

4.24

Bad News Mitigation 4.00

4.03

Positive Words 4.38

4.30

Talk Down 4.29

4.18

Clear Mutual Expectations 4.26

4.04

1.00 1.50 2.00 2.50 3.00 3.50 4.00 4.50 5.00

Participants rating on 5-point likert scale

Inservice (n=82) One day (n=71)

Figure D. Frequency with which staff could envisage implementing Safewards into their practice
after participating in training, by training type.
 100 97 100
95 95
90 90 89 89 90 90
90 86 86.5

80

70 65 65
Total fidelity scores

60
60 57.5
55

50 45

40

30

20

10

0
one day plus in-service (n = 11 wards) in-service (n = 7 wards)
Individual wards

Figure E. Fidelity score of each ward at the end of the 12-week trial, per training model.
 100

90

80

70
Mean Fidelity

60

50

40

30

20

10

0
Visit 1 Visit 2 Visit 3 Visit 4 Visit 5 Visit 6
Visit Number
Figure F. Mean fidelity across visits.
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.