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Workplace Violence Training Using Simulation

Brown, Robin G., BSN, RN, CHEP; Anderson, Shauna, MSN, RN, NE-BC; Brunt, Barbara, MA, MN, RN-BC, NE-BC; Enos, Trish, BS, BSN, RN, CPHQ; Blough, Keith, MBA; Kropp, Denise, BS, CCRP

AJN The American Journal of Nursing: October 2018 - Volume 118 - Issue 10 - p 56–68
doi: 10.1097/01.NAJ.0000546382.12045.54
Cultivating Quality

Workplace violence in health care settings is increasing dramatically nationwide. In response, an interdisciplinary team at an Ohio health system developed and piloted a model of training to address workplace violence. The model included classroom learning, a code silver (person with a weapon or a hostage situation) simulation training, and hands-on self-defense techniques. Based on data collected in the pilot, the team revised the model to offer a more comprehensive approach; the new, revised training program is known as Violence: enABLE Yourself to Respond. The team designed four distinct five-minute simulation scenarios depicting a range of threats from “escalating behavior” to “active shooter” and enacted them with standardized participants (health care personnel trained to perform specific behaviors in educational scenarios). Immediately after each simulation, the instructors facilitated a debriefing of the participants. Participants' pre- and post-training program self-evaluations of how prepared they felt to react to violent situations, as well as experts' evaluations of the participants' performance in simulations, provided evidence of the effectiveness of the model. Analysis of the data demonstrated a statistically significant positive difference in both participants' perception of their preparedness and experts' evaluation of their performance. The combination of classroom learning and simulation training is an effective, evidence-based method to prepare employees to respond when a situation escalates to violence, including the use of a weapon. This approach was designed for acute care but can be adapted to other settings. Skills learned can be used in both personal and professional life.

This article describes how an interdisciplinary team at an Ohio health system developed and piloted a training program to address workplace violence, which included classroom learning, simulation training, and hands-on self-defense techniques.

Robin G. Brown is manager of environment of care safety and emergency preparedness; Shauna Anderson is a unit director of nursing; Trish Enos is system director of performance improvement and quality assurance; and Keith Blough is chief of protective services and police—all at Summa Health System, Akron, OH. Barbara Brunt is an education consultant with Brunt Consulting Services, also in Akron, and Denise Kropp is a research associate, family and community medicine, at Northeast Ohio Medical University, Rootstown. Contact author: Robin G. Brown, The authors have disclosed no potential conflicts of interest, financial or otherwise.



Workplace violence against medical professionals is a daily occurrence nationwide.1 According to the Occupational Safety and Health Administration (OSHA), health care workers are exposed to job-related violence at a high rate, experiencing half of all workplace assaults.2 People often freeze or panic in response to acts of aggression, assault, or other acts of violence, including shots fired or active shooters, but with education and practice in simulated workplace violence scenarios, health care and hospital personnel can develop the mindset of survivors, empowering themselves to respond effectively to threats and mitigate harm.

An interdisciplinary team (including coauthors RGB, SA, TE, and KB) at an Ohio health system developed a workplace violence training model that included classroom learning, simulated-violence scenarios, and hands-on defense techniques. Classroom learning focused on how to avoid losing critical thinking abilities in stressful situations and overcome fear-related inaction. In lecture and discussion sessions, instructors provided insights into the survivor's mindset and offered students methods for developing a framework of response to violent actions. Students learned to prepare mentally for unexpected acts of aggression or violence, including shootings. In the simulated-violence scenarios, students learned they have permission to break the rules of ordinary behavior, take control, and protect themselves and others in a violent situation. “Breaking the rules” could include throwing a fire extinguisher at the perpetrator or using medical equipment as a defense weapon.

This program development and evaluation initiative examined the effectiveness of a modified workplace violence training program.

Literature review. A review of the literature focused on the extent of the problem, available educational resources, various workplace violence prevention and response programs, and the rationale for including an active shooter scenario in the training program.

Nursing is a high safety risk occupation; 25% of the nurses who completed the three-year American Nurses Association (ANA) Health Risk Appraisal Survey reported they'd been physically assaulted at work by a patient or family member.3 According to the U.S. Government Accountability Office (GAO), “In 2013, the most recent year [for which] data were available, private-sector health care workers in in-patient facilities, such as hospitals, experienced workplace violence–related injuries requiring days off from work at an estimated rate at least five times higher than the rate for private-sector workers overall.”4 According to the Centers for Disease Control and Prevention, workplace violence injury rates rose for all health care workers between 2012 and 2014, with nurses and nursing assistants experiencing the greatest increase.5 Among nursing assistants the rate nearly doubled.

A Joint Commission Sentinel Event Alert on physical and verbal violence against health care workers issued earlier this year stated that because reporting is voluntary, the actual number of violent incidents involving health care workers is probably higher than the number reported.6 In addition to outlining the incidence of and factors that contribute to workplace violence, the alert contained seven suggestions for defining, reporting, and preventing the problem, and for supporting those who are subject to it. Two of the suggestions were to identify quality improvement initiatives to reduce incidents of workplace violence and to educate all staff in deescalation, self-defense, and response to emergency codes.

According to a study of U.S. hospital-based shootings from 2000 to 2011 conducted by Kelen and colleagues, “Health care providers and employees are unlikely to be victims of indiscriminate violence. In fact, unlike those [on] education campuses, most hospital shootings have an intended specific target.”7 The study found that nearly three-quarters of such shooting events were “highly targeted (grudge, suicide, ill relative, escape attempt). Only about a fifth of all victims were employees, and few of these were physicians or nurses.”

In a study of workplace violence in an urban community hospital system employing over 5,000 nurses, Speroni and colleagues found that 76% of the 762 nurses who completed a survey had experienced some form of violence, including verbal and physical assault, perpetrated by patients or visitors in the preceding year.8 The researchers concluded that hospitals need to improve workplace violence prevention and deescalation education and incident reporting procedures.

In an overview of health care workers’ exposure to physical and verbal aggression, Iennaco and colleagues concluded that because of the complexity of the problem, a variety of reporting and measurement strategies are needed to better understand aggression exposure.9 Their suggestions included determining the number of aggressive events per unit, patient, and worker; noting information about the perpetrator and characteristics of the event; and informing both patients and staff of interventions used to manage aggressive events and their consequences.

Many program development resources are available to help prepare individuals and organizations, including hospitals, for acts of violence. These include training videos; response campaigns like Run, Hide, Fight ( developed by the U.S. Department of Homeland Security; and collaborative guidance documents like Active Shooter Planning and Response: Learn How to Survive a Shooting Event in a Healthcare Setting from the Healthcare and Public Health Sector Coordinating Council (HPHSCC).10 Various organizations including OSHA, the GAO, and the FBI have provided guidance on program development, prevention, and early detection of potentially violent situations and response options when violence escalates.2, 4, 11 In 2015, the ANA issued a position statement on incivility, bullying, and workplace violence that outlined individual and shared roles and responsibilities of RNs and employers in creating and sustaining a culture of respect.12

Phillips conducted a review of current knowledge about workplace violence in various health care settings and found that “to date, most research has been directed at quantifying the problem and attempting to profile perpetrators and their victims.”1 Few studies have focused on interventions to reduce violence. In conducting our literature review, we found only four programs that described interventions for violence prevention.

Intervention programs. Among health care workers, ED nurses are one group that experiences violence frequently. Koller, focusing on violence prevention education, made several recommendations, two of which seem especially relevant to helping nurses manage potentially violent patients13:

  • Learn to recognize and evaluate the behaviors of a potentially violent patient.
  • Identify nurses’ behaviors that may trigger patient violence.

Ramacciati and colleagues completed an extensive review of the literature on current approaches to reducing risk of physical violence toward ED staff and concluded that the evidence supporting the use of existing violence reduction interventions is weak, and further research is needed to identify more effective ways to promote a safe ED work environment.14

Parker discussed the use of Safety Team Assessment Response (STAR) codes to recognize and respond to potentially violent patients, visitors, and staff.15 The education program for this safety protocol included a classroom presentation, a 20-minute simulation, and a debriefing session. One limitation of the STAR rollout was a lack of data collection and analysis to determine whether nurses initiated the STAR codes more appropriately after completing the program.

Wong and colleagues discussed an interprofessional curriculum focused on improving teamwork and staff attitudes toward patients’ physical violence using simulation-enhanced education.16 The program began with an introductory lecture on deescalation techniques and restraint placement as well as core tenets of interprofessional collaboration. The researchers conducted two simulation scenarios using standardized participants (SPs)—health care personnel trained to perform specific behaviors in educational scenarios—followed by structured debriefing. They then compared pre- and postintervention survey responses to assess changes in staff attitudes. This intervention was successful in improving ED staff members’ attitudes toward behavioral emergency care.

The HPHSCC advocates the use of simulations and scenarios in preparing health care workers to respond effectively to outbreaks of violence and recommends that each member of the health care team know the available response options before an incident occurs, thereby enabling quick selection of a decisive course of action when faced with a real threat.10 According to the HPHSCC, “Active shooter situations are unpredictable and evolve quickly. Because of this, individuals must be prepared to deal with an active shooter situation before law enforcement personnel arrive on the scene…. Healthcare facilities should also plan for other gun-related incidents (e.g., a single shot fired, possession of a weapon on campus).”10 Health care facilities must prepare their employees with the tools and responses necessary for self-preservation when any such incidents occur. According to the U.S. Department of Health and Human Services (HHS), “Everyone should be trained first to run away from the shooter, if possible, encouraging others to follow. If that is not possible, they should seek a secure place to hide and deny the shooter access. As a last resort, each person must consider whether he or she can and will fight to survive, incapacitate the shooter, and protect others from harm.”17 HHS also notes: “Training provides the means to regain composure, recall at least some of what has been learned, and commit to action.”

Training can cultivate the critically important “survivor mindset,” an unwavering commitment and effort to do whatever it takes to survive and get out of the situation as a means of saving lives. According to Wax and colleagues,18

“Initially, one must recognize danger and rapidly assess the situation. Forcefully and clearly communicate in plain language to all in danger the nature of the threat and clear instructions on necessary actions to protect themselves (Gun! Get out!). Subsequent responses will be affected by one's location and position relative to escape routes, exits, safe areas, and the shooter. Three basic options will be available—run, hide, or fight.”

Based on our review of the literature, it was clear there were no established programs that provided a solution sufficient to our needs in a health care setting where hiding is complicated by the need to protect patients and access to rooms with locks is limited. In addition, we felt compelled to focus attention on the need for potential victims of violence to accept the reality of the situation in order to act quickly and effectively.

Purpose of the study. We determined that because of the increasing incidence of workplace violence nationwide our organization, Summa Health System in Akron, Ohio, should proactively address the possibility of such occurrences with a violence prevention program. Administrators tasked an interdisciplinary team to develop such a program. The result was the development and piloting of a code silver simulation training to address workplace violence (code silver is used in many hospitals in the United States, including in Ohio, to signify the presence of a person with a weapon or a hostage situation). The training model was based on the response options available to health care workers in situations of escalating violence—accept, barricade, leave, engage. We chose these options purposefully so that the resulting acronym, ABLE, would enhance participants’ recollection during stressful situations. The first step—as emphasized in the training—is to accept that the potential or actual violence is happening, then to react to actual violence by choosing either to barricade behind a closed door or leave the area to ensure staff and patient safety. Finally, if none of these options are viable, the remaining choice is to engage the perpetrator to disrupt or end the violence.

Based on data collected in the pilot, the team revised the model to provide a more comprehensive response to violent situations. The team determined it needed a name that would encapsulate its purpose, as well as a new acronym for easy recall (similar to the acronym used in the code silver drills, ABLE). To emphasize a more active response, the team named the program Violence: enABLE Yourself to Respond, or enABLE. The enABLE program—ongoing in our health system—begins with a simulation to engage students and establish a baseline of responses. After the initial simulation, the first three response options, accept, barricade, and leave, are thoroughly reviewed in the first classroom lecture session. Students then engage in additional simulations to apply the concepts learned, and the instructors facilitate structured debriefings immediately after each simulation. Conditions in the final simulation repeat those in the initial simulation, providing an opportunity for students to practice using the newly instilled “survivor's mindset” and the response options they've learned. As noted above, the last response option is to physically engage with an aggressor. When no other options are available, fighting back to neutralize the threat may be the best choice to ensure survival.

In this study we aimed to demonstrate the effectiveness of using the enABLE model, which comprises classroom learning, simulation scenarios, and hands-on defense techniques, to prepare nurses and other health care personnel to respond to a violent situation when deescalation techniques are ineffective.

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The pilot program. In 2013, Summa Health convened a workplace violence task force to consider the issues and develop an action plan. Representatives from the ED and the behavioral health nursing, human resources, risk management, protective services and police (security), legal services, workers’ compensation, safety, quality, and emergency preparedness departments met and developed a mission statement, goals, and objectives.

A smaller team that was focused on education included representatives from the nursing, safety, quality, emergency preparedness, and security departments. This team developed a series of short simulation scenarios to serve as code silver drills. Each subsequent simulation grew in intensity to build the students’ response capabilities. The code silver drill simulation site was a closed nursing unit that had been converted to offices.



The first students in the pilot program were nursing and ancillary staff from one nursing unit. All students were screened before participating, using a modified trauma screening tool adapted from Brewin and colleagues19 to ensure that vulnerable students had the opportunity to consider not participating. Psychiatrists reviewed the tool and provided feedback on its validity for the screening (see The Trauma Screening Tool 19). In this phase of the program, the screenings were conducted with each participant face-to-face. The simulation was strictly voluntary and participants could opt out at any time. Very few participants declined to participate.

Afterward, the team identified two significant issues with the pilot program: low participation and a less than ideal environment. Code silver drills took about 90 minutes to complete. Group size was often only six or seven participants. The number of managers functioning as actors often equaled or exceeded the number of students. Participation was low because of students’ reluctance to come in from home for a 90-minute program or leave their work assignments for this length of time. While feedback and outcomes were excellent, the pilot program reached an insufficient number of employees. In addition, an empty inpatient unit setting was not ideal. There was limited control of passersby, employees needed to pass through the simulation site to gain access to other areas, and noises generated by the simulation could be misinterpreted by staff as a real event. Also, when students appropriately closed themselves in a room and barricaded the door, they were no longer able to observe and learn.

The education team brainstormed strategies to address these challenges. A 90-minute program with low attendance was not sustainable. Moreover, the hospital system was expending considerable personnel resources on several safety programs with a similar focus, self-defense classes, and code silver drills. The team determined that combining all existing programs into one would resolve many challenges and potentially result in a higher quality, more comprehensive program.

The revised training program. To consolidate efforts and standardize the hospital system's approach, the education team designed a four-hour training program with 3.66 continuing nursing education contact hours. The revised model—enABLE—had two primary objectives: to increase health care workers’ confidence in their reactions to violence by building a framework of response, and to move students away from a victim's mindset toward a survivor's mindset.

In 2014, the hospital built a 10,000-square-foot simulation center in a newly acquired corporate office center. The center's open-plan design enabled the construction of a portable nursing unit equipped with patient rooms, a hallway, and a nurses’ station. The mock unit was designed by the education team. The walls, made from one-inch-thick, 48-inch-high corrugated cardboard sheets, were temporary and could easily be moved or removed, which enabled participants who sheltered in patient rooms to continue to observe the simulation. The doors needed to be both fully functional and easily removable by simulation center staff when not in use; the contractor designed and built doorways with metal frames and lightweight, hollow-core wooden doors. Reinforcement was added to the doors after a person acting as an aggressor easily made holes while pounding on one.

Each patient room was equipped to mimic a typical inpatient room, with a bed, an over-bed table, a cart with a monitor, a chair, and a linen basket. Telephones were installed at each headboard to mimic the phone typically available in a patient's room. The phones were routed to the simulation center's control room, where an instructor acted as the hospital operator. The hallway area was equipped with a wheelchair, walkers, a crash cart, iv poles, and other common hospital items. The simulation center was also fully equipped to record video from various angles.

All classes in the education program were scheduled through the hospital's learning management system, where all students completed their mandatory trauma prescreening and self-assessment and watched a short video about a hospital shooting incident created by the MESH Coalition.20 The self-assessment consisted of four questions on the participants’ baseline perception of preparedness, answerable using a five-point Likert scale (responses ranged from 1 = not at all prepared to 5 = very much prepared). The questions were:

1. If today you had a workplace violence situation (hostage/person with a weapon/active shooter), how prepared are you?

2. How prepared are you to protect yourself?

3. How prepared are you to protect your patients?

The responses for the last question ranged from 1 = not at all confident to 5 = very confident:

4. How confident are you in your ability to immediately be able to get help during a workplace violence situation?

The same evaluation tool was administered to students after completion of the program to measure their perception of their capabilities after the training.

The classroom maximum was 24 students. During simulations, the students acted as patients, visitors, clinicians, and ancillary staff. The unit manager and escalating aggressor roles were played by instructors. Instructors were all hospital employees with expertise in law enforcement, safety, simulation, behavioral health patient care, or nonviolent crisis intervention, and all had a wide variety of teaching experience, including hands-on defense techniques. Instructors and simulation center personnel helped to prepare the students for their revolving roles in each scenario. Costuming for the various roles included hospital pajamas for patients, lab coats for clinical personnel, and T-shirts for visitors. Protective services officers participated as responders to the simulation unit.

Instructors started the program with a brief introduction and welcome. Three instructors consistently filled the SP roles in the scenarios. The first was the nursing unit manager, who demonstrated behaviors that weren't appropriate and that shouldn't be considered an example for others to follow. The second and third roles were an escalating patient and a visitor. The instructors then told students to go from the classroom to the adjacent simulated nursing unit for a simulation to establish their performance baseline. The instructors provided rules for the simulation, including limits on physical contact between students and instructors (they were not to physically engage with one another). The instructors divided the students into three groups and assigned roles and costumes to wear to depict patients, clinical staff (nurses, physicians), environmental services, visitors, and others. An orientation to the simulation area included an overview of the simulated nursing unit (patient rooms, the nurses’ station, the hallway), exit pathways, functional phones, and how to call the simulation telephone operator. The instructors took care to provide sufficient orientation to the space without giving too much direction to students on how to respond.

The instructors then showed students the solid plastic replica handgun to be used in the simulation, allowing them to examine it closely and handle it if they wanted to. Students were also instructed to call “time out” to remove themselves from or stop the simulation in the event they became too uncomfortable, fearful, or wished to end their participation. Students were excused from engaging in simulations with no questions asked; they also had the option of watching the simulation from the safety of the control room. (These students were encouraged to rejoin the others during the debriefing sessions after each scenario, and they could choose to participate in subsequent simulations. After observing one scenario, some chose to participate and others to continue to observe.) Instructors also paid close attention to nonverbal cues (such as avoiding eye contact, trembling, shying away from the aggressor, perspiring, and not participating) that might indicate fear levels beyond what was expected.

The instructors provided students with a comprehensive overview of how people react to threats of violence and the variety of response options available. To enable students to consider how they felt and responded (or didn't respond) during the initial simulation scenario, the instructors also provided information on why people fail to react appropriately to threats and the role of intuition in guiding responses to violence. Discussion and instruction on techniques of physical engagement with a threatening or violent person were purposefully delayed until after all the simulations were completed.

Details of the enABLE scenarios. The education team developed four distinct five-minute simulation scenarios that ranged from “escalating behavior” to an “active shooter” situation. These are described in detail in a reference tool devised to enable instructors to maintain the consistency of the simulations (see The enABLE Simulations Reference Tool for Instructors at

In the first scenario, conducted during the first 15 minutes of the four-hour program, students were introduced to an SP in the role of a violent person with a handgun. In this scenario, a patient has died, and her husband is upset at this outcome. The scenario starts as the husband arrives on the unit, demanding to speak with whoever is responsible. He quickly becomes angry and starts to yell. The SP playing the role of the nurse manager inappropriately confronts the husband, telling him to calm down, then firmly touches his chest, a gesture signaling an evaluator to start the timer for the purpose of measuring the participants’ performance. The husband then pulls a gun on the nurse manager. He continues to yell and wave his weapon around until help (security or law enforcement) arrives.

Table 1

Table 1

This scenario was conducted before classroom training to establish students’ performance baseline. Most students tended to freeze or stand and watch rather than react effectively. The instructors evaluated students’ performance using a tool developed and refined by task force and simulation experts (see Table 1). The fourth and final scenario was identical to the first, and instructors evaluated students’ performance using the same tool to measure whether students’ gained knowledge and demonstrated competence.

After the initial simulation scenario, protective services leaders and experts in personal safety and security gave a 90-minute lecture that included a discussion of options when staff is faced with a dangerous situation or when deescalation techniques fail.

In the second scenario, the SP playing the role of the patient is upset that she isn't receiving proper pain control. She calls her husband, and when he arrives on the unit the patient escalates her behavior and starts to throw medical equipment. She grabs her iv pole to use as a weapon against the staff.

In the third scenario, the person playing the role of the husband arrives on the unit after his wife has called to tell him she'd just been informed she has a terminal illness. The husband is visibly upset, yelling that staff members are killing his wife. After the person playing the role of the unit manager attempts to deescalate the situation, the husband says loudly, “You are all dead,” then leaves the unit (exits the simulation lab). After 90 seconds, he returns and begins to shoot his simulated firearm. Typically, not all points of entry will have been sufficiently barricaded by students (the correct response to the husband's threat is to barricade all points of entry and call security). The shots are simulated by the shooter, who simply says, “Bang.” The first shooting victims are the unit manager and the nurse, who—carefully—fall to the ground, mortally wounded. The husband subsequently rages around the unit, yelling and pounding on doors (which should be barricaded). No students are shot or verbally assaulted. Direct interactions between the husband and the students are limited to avoid overstressing any individual students. The husband does not verbally assault or otherwise threaten the students acting as his wife and other family members. When law enforcement officers arrive, they aim at the husband and say “Bang” when he raises his weapon to shoot them. This ends the third simulation scenario.

Figure 1.

Figure 1.

The fourth scenario is the same as the initial scenario. Repeating the scenario gives students an opportunity to practice the lessons learned from the lectures, prior simulations, and debriefings and allows the team conducting the training to determine the program's effectiveness by comparing students’ performance in the last scenario with their baseline performance in the first. A selection of scenes from a simulation scenario showing students’ before and after performances can be seen in Figure 1.

After the second, third, and fourth scenarios, the lead instructor conducted a structured debriefing in which students were encouraged to reflect on their experiences, reactions, and feelings in the simulations and their responses to the threat. The debriefing included predetermined objectives for progressive learning in each subsequent simulation experience. It also allowed for reviews of the strategies learned in the lectures and reinforced their implementation in the simulations.

To avoid injuries to students and instructors, hands-on defense techniques were taught only after the last scenario, in the last hour of the course. Techniques taught included individual moves to escape common holds, such as choke holds, wrist grabs, and hair pulls. Techniques also included physical actions to repel or “take down” an aggressor—the latter a series of moves that result in the aggressor being off balance, forced to the ground, and restrained. Instructors also taught a team approach or “swarm technique” to apply when subduing an aggressor was necessary or the only available option. All students had the opportunity to practice these defensive techniques with other students, under the instructor's observation and coaching.

Data gathering and analysis. The process of gathering data for the measurement of class performance evolved. Instructors identified a specific starting point to measure class response times, which was when the person playing the role of the nurse manager inappropriately touched the patient's husband's chest. This gesture also served as a definitive marker to signal the person playing the husband to escalate the level of his response to an intensity sufficient to warrant the ABLE responses from the students. A staff member in the control room started a timer at the moment of the chest touch, and at that point, the person in the role of the telephone operator began to expect telephone calls from students requesting support. The instructors collaboratively monitored timeliness, the number of calls made to report the husband's escalating behavior, and the specific content of the students’ communications. The timeliness of participant responses was measured by using stopwatches and control room communications.

Security officers—typically two officers equipped with simulated weapons—were stationed in the control room and awaited direction from the control room instructors before responding to the simulation area. There were typically three control room instructors: one staff member acting as the telephone operator; and two monitoring the simulation, listening to the students’ incoming messages to the telephone operator, monitoring the stopwatch to time the students’ responses, and telling the security officers when to respond. The telephone operator announced, “code violet” (violent person) or “code silver” (person with a weapon or a hostage situation) using an overhead speaker system in the simulation area. The telephone operator immediately communicated all information or requests from student callers to the security officers. If, in the first or second simulation, students didn't provide sufficient details regarding the presence of a weapon or the description of the person whose behavior was escalating, officers arriving on the scene acted surprised that a weapon had been drawn or shots fired. The instructor in the control room delayed the security officers’ arrival on the unit by at least 30 seconds to be more consistent with the reality of officers having to respond to an actual incident from more distant hospital locations.

The instructors’ process, including monitoring the simulation from the control room, ensuring that the telephone operator responds appropriately to students’ calls and communicates accurately to the security officers, and evaluating student responses, is critical to the success of the program and requires practice. The roles and responsibilities of each control room instructor should be well defined in advance to avoid missing certain trigger points (such as the moment when the nurse touches the husband's chest, signaling the operator to start the timer) for both measurement purposes and simulation facilitation.

Data were collected using both quantitative and qualitative measures. Participants’ pre– and post–training program self-assessment responses were analyzed using frequency distributions and χ2 analysis. Three instructors viewed the initial and final simulations live from the control room and reviewed video recordings to score each question regarding students’ performance and also conducted the qualitative analysis. The responses were analyzed by using the McNemar test for each item, as well as χ2 and Fisher exact tests. The McNemar test is a within-subjects test of equality of proportions for before-and-after situations.

Ethical considerations. A four-step process was designed to minimize the risk of harm to students. A prescreening self-evaluation was mandatory for all students. Before and during the program, students were instructed on how to opt out of involvement in the simulations. During demonstrations and simulations, instructors closely monitored students for signs of stress that were greater than expected. If instructors observed a participant exhibiting signs of stress, the instructor gave the participant the opportunity to observe rather than participate in simulations. Those who exhibited stress were given information on contacting the employee assistance program for further follow-up. The care and well-being of the students was our highest priority.

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Table 2

Table 2

The quantitative analysis of the pre– and post–training program student self-assessments was conducted on the responses of 196 and 136 students, respectively. All four questions had statistically significant differences in frequency distributions in pre– and post–training program analyses, indicating that students felt better prepared and more confident after the program (see Table 2).

In response to question 1 (“If today you had a workplace violence situation, how prepared are you?”), only 6% of students reported they were well to very well prepared before their participation in the program compared with 62% following their participation in the program. In response to question 2 (“How prepared are you to protect yourself?), 11% of students reported they were well to very well prepared before the program compared with 61% following the program. In response to question 3 (“How prepared are you to protect your patients?”), 9% of students before the program versus 51% following the program reported being well to very well prepared. And in response to question 4 (“How confident are you in your ability to immediately be able to get help during a workplace violence situation?”), 8% of students before the program versus 39% after the program reported they were very confident.

Table 3

Table 3

Table 3 presents the qualitative results of the first class of 24 students. There were statistically significant improvements (P < 0.05) in four out of seven critical actions between the first and final simulations, including calling protective services, closing patient-room doors, yelling “Gun!” and positioning oneself near an escape route. Critical actions that did not show statistically significant improvement were providing adequate descriptions of the aggressor, having all students escape to a safe area, and barricading room doors with a bed in at least two of three rooms.

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The aim of this study was to demonstrate the effectiveness of using lecture, hands-on defense techniques, and simulations to prepare nurses and other health care personnel to respond to a violent situation where deescalation techniques are ineffective. Both the participants’ responses and the qualitative reviewers’ observations demonstrated the effectiveness of this approach. Following participation in the enABLE training program, students indicated they were better prepared to deal with violent situations, and reviewers’ observations of the students’ performance in the scenarios indicated enhanced ability to respond to the situation. Students benefited from a combination of classroom instruction and well-designed simulations that meet the standards of best practice.21

Health care simulation provides a realistic and safe venue to address issues surrounding workplace violence. Our findings were consistent with those of other studies. According to Wong and colleagues, “Simulation-based education can both directly influence participant attitudes and encourage interprofessional teamwork due to its inherent ability to impact learners’ cognitive frames and promote peer-to-peer dialog during structured debriefing.”16

Each scenario built on the previous one, allowing students to learn from their mistakes and offering an opportunity in subsequent simulations to correct responses that may have put staff members or others in harm's way. Students may experience fear or anxiety from interactions with an out-of-control person. In the simulations, despite the fear, students learned to react and not freeze or shut down. They learned they have the ability to save themselves and others. Students debriefed by sharing their feelings and reactions after each scenario, building teamwork and problem-solving skills. Coaching and open discussion among the students revealed common perceptions and misconceptions.

Repetitive exposure to varied escalating and violent situations helped students establish a survivor's mindset and muscle memories of responses that included accepting the reality of what's happening, barricading if one cannot leave, and engaging the aggressor if barricading or leaving fails. (Muscle memory is the ability, acquired through practice, to repeat a specific movement with improved efficiency and accuracy.) The teaching of defense techniques was instrumental in providing skills with which to engage an aggressor and in building confidence.

Simulation-based education with structured debriefing improves participants’ attitudes and promotes teamwork.16 According to Decker and colleagues, “Research provides evidence that the debriefing process is the most important component of a simulation-based learning experience.”22 It's important to formalize the topics discussed in each debriefing to provide the appropriate amount of guidance; it isn't helpful to provide so much guidance that the students are led through the next scenario. The researchers provided several criteria for best practices in the debriefing process. The debriefing should be22

  • facilitated by a person or persons competent in the debriefing process and who observed the simulation.
  • conducted in an environment that supports confidentiality, trust, open communication, self-analysis, and reflection.
  • based on a structured framework for debriefing.
  • congruent with the students’ objectives and the outcomes of the simulation-based learning experience.

As part of ongoing evaluation of the program, participant feedback is collected through the learning management system; all responses from the first enABLE class indicated that participants felt the simulations were beneficial. Comments from students included the following:

“I feel like this course should be taught to everyone in the health system. It was very informative and helpful in preparing for the possibility of a violent intruder, not just at work but outside of the workplace as well.”

“Utilizing the simulation lab for this exercise was very effective…. It made the content real instead of abstract and provided opportunity for the participants to apply their knowledge and ask questions they may not have had if they hadn't experienced the feelings provoked by the simulations.”

Lessons learned. Starting the four-hour program with a simulation provides an effective method of immediately engaging students in the classroom session and a way to accurately evaluate baseline performance. Use of structured debriefings after each simulation augments students’ learning. Having predetermined talking points based on the events of the scenario provides an accumulative learning experience in which lessons learned from the previous simulation can be applied to the next. This allows students to steadily build on their skill set.

Conducting simulation scenarios involving escalating violence, including the use of a replica handgun, is much safer in the controlled environment of a simulation center. Communication to others whose work location is adjacent or near the center is essential. Those that might hear yelling and pounding noises must be fully informed that simulations are being conducted to ensure that no one is needlessly alarmed or put at risk for injury because it wasn't understood that a simulation was taking place.

Simulation center facilities capable of replicating an inpatient nursing unit or a clinical office setting are extremely helpful in participant learning. Ideally, such a facility would include hallways; walls that don't extend to the ceiling; exits; rooms with doors; and standard equipment, such as beds and telephones. Structural walls and doors impede learning when students are unable to observe parts of the simulation; chest-high simulated walls provide the appearance of a patient room and a safe space yet permit continued participant observation and learning.

Limitations. Although we did not determine whether the participants retained the knowledge and skills gained in our workplace violence training program over time, we are planning to test for retention of the information learned. We are also considering testing whether allowing program participants to have ongoing access to videos of the simulations improves retention.

The group setting allows students to follow others’ behavior, which may interfere with the formation of muscle memory. All of our evaluations were of the group's performance; we did not conduct evaluations of individuals’ performance.

The simulated nursing unit is both an asset and a limitation in that it cannot mimic all workplace locations perfectly. Some students work on units with glass walls, and others work in clinical and nonclinical office settings. Exit strategies for different locations are discussed during debriefings. Being in an environment unlike one's customary workplace during a simulation may reduce the effectiveness of the learning.

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This workplace violence training program development and evaluation initiative showed improved results in coping with violent situations. In today's health care environment, real-life situations like the simulated scenarios are increasingly likely to occur. A combination of lecture, hands-on demonstration, and simulation is an effective approach to better prepare nurses and other health care personnel to deal with such occurrences.

This evidence-based approach can be replicated in a variety of settings. Although the simulation was designed for acute care, in our health system individuals from a variety of departments including clinical, nonclinical, executive, and support staff attended and benefited from participation in the program. The knowledge and skills gained can be used in both personal and professional life.

To see a short video of the first of the four simulation scenarios in Summa Health System's workplace training program, go to The “nursing unit” in the video includes one patient room in the foreground, the nurses’ station (a table with chairs) directly across from it, and two more patient rooms on the right. In this scene, staff respond to a visitor's escalating violent behavior. After the simulation, students complete a self-assessment to establish their performance baseline.

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simulation; training program; workplace violence

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