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Students' perceptions and attitudes following a workplace violence simulation

Martinez, Angel Johann Solorzano, DNP, MSN, MBA, RN, CNS, PMHNP-BC; De Oliveira, Giovanna Cecilia, PhD, MSN, ANP-C, PMHNP-BC

doi: 10.1097/01.NURSE.0000554620.12970.08

Angel Johann Solorzano Martinez is an assistant professor at Nova Southeastern University in Miramar, Fla. Giovanna Cecilia De Oliveira is an assistant professor at the University of Miami in Coral Gables, Fla.

Adapted from Martinez AJS. Implementing a workplace violence simulation for undergraduate nursing students: a pilot study. J Psychosoc Nurs Ment Health Serv. 2017;55(10):39-44.

The authors have disclosed no financial relationships related to this article.

THE NATIONAL INSTITUTE for Occupational Safety and Health defines workplace violence (WPV) as “the act or threat of violence, ranging from verbal abuse to physical assaults directed toward persons at work or on duty.”1 WPV is prevalent in hospital settings and affects a variety of healthcare workers, especially those who perform direct care.2 A 2016 meta-analysis demonstrated that nurses in psychiatric settings are at an increased risk of violent encounters compared with those working in other settings.3 Similarly, nursing students may be susceptible to potentially violent incidents in clinical settings.4

This article presents a qualitative descriptive analysis based on unreported students' responses following a mental health nursing simulation on WPV, which was reported by coauthor Martinez in a previously published pilot study.5 It contributes to new evidence regarding students' perceptions on using a standardized patient (SP) in psychiatric nursing simulations.

An SP is someone trained to portray a patient with a specific illness or condition in a consistent, standardized manner. SPs are widely used in simulations by schools of nursing and medicine to help students learn to interact effectively with patients.6

Innovative educational modalities can help promote patient safety and prepare nursing students to manage and prevent incidents of WPV during their clinical rotations. Previous research has assessed students' perceptions and attitudes about the use of SPs in mental health simulations.7,8 However, the assessment of nursing students' perceptions focusing on prevention and management of WPV in these types of simulations is scarce. Using Braun and Clarke's benchmark thematic analysis, participants' responses to an open-ended question survey were examined to assess their perceptions, attitudes, and reactions following a simulation with an SP (see Qualitative survey).9

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The implementation of simulations in nursing education has been increasing.10 In 2015, a statewide survey demonstrated that 99.1% of 512 recent graduate respondents had simulation experiences during their prelicensure nursing program.11 The adoption of simulation experiences in mental health nursing, however, has been slow.8 The field of psychiatric nursing may pose challenges for students, including anxiety and apprehension about interacting with psychiatric patients and negative stereotypes about patients with mental illnesses.7,8,12,13

To address these challenges and promote students' safety during mental health nursing rotations, Martinez's simulation aimed to prepare students to manage and prevent WPV before they entered the clinical setting.5 The success of a simulation depends on how involved the participants feel.8 In a 2012 study, Choi noted that student responses to simulations can help researchers understand the benefits of the learning experience.14 Assessing the perceptions of Martinez's simulation participants can provide useful information about the effectiveness of this teaching modality before psychiatric nursing clinical rotations.5

Kolb's experiential learning theory, which emphasizes that knowledge is better acquired through practice, informed Martinez's simulation.5,15 The theory includes a four-stage learning cycle consisting of concrete experience, abstract conceptualization, active experimentation, and reflective observation (see Kolb's four-stage learning cycle).15,16

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Design and participation

Institutional review board exemption was granted for the simulation, and, according to university guidelines, a written consent was designed by Martinez with explanations provided to the participants.5 The participants consisted of 15 prelicensure, second-semester undergraduate nursing students enrolled in a psychiatric nursing course at the university.5 The group was made up of both female (n = 12) and male (n = 3) students, ranging from ages 18 to 54, and each had a prior simulation experience from other nursing courses.5 All consented voluntarily and could abstain from participating at any time during the study.5



Martinez designed and implemented the mental health nursing simulation, which started with a PowerPoint presentation on WPV.5 The participants were then given written materials containing evidence-based interventions to de-escalate agitated behaviors.5 These competencies included therapeutic approaches to de-escalating patients, therapeutic communication skills, verbal de-escalation, safety techniques, and education about recognizing and assessing signs of aggression.5

Each participant had a 5-minute encounter with an SP, which was video recorded.5 The SP performed the role of an agitated patient with schizophrenia and followed a script of agitated behaviors, including yelling, hand movements, pacing, and approaching the student (without physical contact to ensure safety and consistency).5 Once all encounters were completed, the footage was reviewed during a 2-hour debriefing with the facilitator.5

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Data analysis

A survey was developed with open-ended questions to assess students' perceptions about the psychiatric simulation. It was sent to the participants via email, and the obtained responses were stored in a password-protected software program employed by the facilitator.5

Due to the small number of students participating in the simulation, the authors selected a qualitative descriptive design for evaluation, which is useful for obtaining a direct depiction of a specific phenomenon.17 Thematic analysis was utilized to identify common themes in the responses, with researchers examining the data for related patterns of interest.9

Thematic and qualitative content analysis are common approaches for researchers working on qualitative descriptive studies.18 Responses from the participants were reviewed multiple times by the facilitator and another researcher to identify patterns. For reliability and trustworthiness in the findings, each party reviewed the responses separately. The data were further collated to identify codes, and themes were identified, clustered, and reviewed.

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All participants completed the open-ended question survey. After a series of discussions and clarifications, the authors reached a consensus. Four main themes emerged from the data analysis:

  • usefulness of the simulation
  • unsettling reactions to the SP's behaviors
  • performance assessment
  • preparation for clinical rotations.

Usefulness of the simulation. The mental health nursing simulation on WPV was designed to be applicable to psychiatric nursing clinical rotations.5 Participants valued the opportunity to practice evidence-based de-escalation interventions. These included therapeutic communication skills, such as maintaining a calm voice and encouraging the ventilation of emotions; verbal de-escalation skills, such as limit setting and redirection; and an emphatic approach, such as giving the patient time to process.

Unsettling reactions to the SP's behaviors. The agitated behaviors added an element of realism to the simulation, creating unsettled reactions among some of the participants. Several participants reported feeling nervous or anxious during the encounter, which was consistent with a 2014 study highlighting anxiety caused by interactions with psychiatric patients.12 Exposure to these behaviors in a controlled environment could help students better adjust their mindset before their clinical rotation.

Performance assessment. Playing back the footage during the debriefing session was viewed positively by participants. The recordings gave them an opportunity to see their mistakes, assess their performance by comparison, and learn from the experience.5 Facilitator feedback was also appreciated by participants, who found it helpful to improve their skills and become better equipped to manage potentially aggressive patients during clinical rotations.

Preparation for clinical rotations. The evidence-based content taught to participants before the simulation provided practical knowledge and skills. The behaviors displayed by the SP gave participants the chance to recognize several aggressive behaviors,which could be useful in employing early interventions for de-escalation.5

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Qualitative responses on the participants' simulation learning experience were typically favorable and provided useful information regarding their views and attitudes after participating.5 Notably, the students appreciated having an opportunity to practice de-escalation in a controlled setting.

In line with Kolb's experiential learning theory concepts, the realism promoted the application of the evidence-based skills they had learned before the simulation.5,15

The themes derived from the participants' responses to the simulation exercise concurred with other studies on mental health simulation using SPs.7,8,12,19 Similarly, the results concurred with a 2017 study that demonstrated that exposure to realistic scenarios allowed students to assume the responsibilities of providing psychiatric nursing care.20

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Implications for nursing education

The simulation pilot study offered a teaching modality for nursing faculty to enhance mental health nursing curricula.5 The development and implementation of new simulations that incorporate evidence-based interventions to address WPV is strongly recommended, as is the assessment of students' outcomes and performance with standardized instruments. Ensuring patient and student safety in clinical settings should be a priority for nurse educators. Appropriate training on the management and prevention of WPV should be mandatory for all nursing students before clinical rotations.5

Martinez highlighted several limitations and recommended cautious assessment.5 These included a small sample of participants within a single institution, as well as gender disparities that may restrict the transferability of the results to other nursing students. Additionally, no control group was used and no randomization occurred, which may have resulted in selection biases within the participants. Martinez also reported the possibility of biases in the responses obtained from participants assigned to the facilitator's clinical section.

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The use of a qualitative descriptive design in nursing research can help nurse educators assess students' perceptions and attitudes following a mental health nursing simulation. The use of SPs represents a viable teaching modality that could enhance students' knowledge and clinical skills. The participants' favorable responses highlighted the usefulness of simulation training on the management and prevention of WPV. Martinez's simulation study augmented student clinical competence in recognizing signs of patient aggression and agitation using evidence-based interventions.5

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Qualitative survey5

Following the mental health nursing simulation, participants responded to the following survey.

  1. How did the SP's agitated behavior make you feel?
  2. What type of agitated behaviors displayed by the SP challenged or concerned you the most?
  3. The presentation and handouts contained some nursing interventions used to de-escalate an agitated patient's behavior. How do you think they helped you de-escalate the SP's agitated behavior?
  4. State the verbal de-escalation skills that you feel helped you the most to de-escalate the SP's agitated behavior.
  5. State your ability to recognize signs of aggression during the simulation.
  6. What were your concerns or fears during the simulation scenario?
  7. What was your overall experience de-escalating the SP during the nursing simulation?
  8. In the debriefing session, how did watching the recording of your own performance help enhance your knowledge?
  9. How would you describe your learning experience during the simulation?
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