Journal of Nursing Education

Major Article 

Kirkpatrick's Evaluation of Teaching and Learning Approaches of Workplace Violence Education Programs for Undergraduate Nursing Students: A Systematic Review

Sandra Johnston, PhD, RN; Amanda Fox, PhD, RN



Education in the tertiary setting that is specifically focused on prevention and responding to workplace violence during clinical practice may increase nursing students' ability to respond to violence in the workplace. Kirkpatrick's model of evaluation categorizes outcomes into four levels. Educational impact provides valuable feedback to educators that may assist with development and improvement of teaching methods.


This review is based on the PRISMA guidelines for conducting a systematic review. Inclusion criteria included articles that (a) were written in the English language, (b) were peer reviewed, (c) described an educational program relating to workplace violence in an undergraduate nursing program, and (d) were published between 2000 and 2019.


Six studies met the criteria for inclusion in this review.


Simulation emerged as a learning and teaching strategy that may be effective in teaching about workplace violence. Future studies should aim to evaluate the effects of education on behavior change and transfer to practice. [J Nurs Educ. 2020;59(8):439–447.]



Education in the tertiary setting that is specifically focused on prevention and responding to workplace violence during clinical practice may increase nursing students' ability to respond to violence in the workplace. Kirkpatrick's model of evaluation categorizes outcomes into four levels. Educational impact provides valuable feedback to educators that may assist with development and improvement of teaching methods.


This review is based on the PRISMA guidelines for conducting a systematic review. Inclusion criteria included articles that (a) were written in the English language, (b) were peer reviewed, (c) described an educational program relating to workplace violence in an undergraduate nursing program, and (d) were published between 2000 and 2019.


Six studies met the criteria for inclusion in this review.


Simulation emerged as a learning and teaching strategy that may be effective in teaching about workplace violence. Future studies should aim to evaluate the effects of education on behavior change and transfer to practice. [J Nurs Educ. 2020;59(8):439–447.]

Workplace violence (WV) has been described as violent acts directed toward persons at work or on duty, including physical and verbal abuse (Brann & Hartley, 2017, p. 85). There is significant research that identifies nurses not only experience violence directed at them from patients, their family, or caregivers, but also from colleagues, peers, and supervisors (Ferri et al., 2016; Phillips, 2016; Wressell et al., 2018).

In the health care environment, incidents of aggression and violence occur at particularly high rates in emergency departments (Beattie et al., 2019; Nelson, 2014) and psychiatric wards (d'Ettorre & Pellicani, 2017). Incidents of assault are correlated with the amount of time that a staff member spends in contact with patients; therefore, nurses are particularly vulnerable to episodes of workplace violence (Phillips, 2016). Undergraduate nursing students who undertake a significant component of their nursing course in the clinical area are therefore at risk of exposure to incidents of violence, inclusive of sexual harassment and verbal abuse, while on clinical placement (Graj et al., 2019).

The effects of workplace violence go beyond the initial physical or emotional impact, with increased absenteeism, attrition, and reduced productivity being some of the negative outcomes (Shea et al., 2017). Increased incidents of workplace violence undermine the recruitment and retention efforts in the nursing profession in a time of predicted impending global shortage of the nursing workforce (World Health Organization, 2015). Given the significant physical and social burden imposed by workplace violence, it is imperative that nursing students are educationally prepared to recognize and manage these events (Clark et al., 2013).

Nurses, midwives, and assistants in nursing have the right to expect that employers will provide information, training, and education to staff on workplace policies and procedures to address workplace violence. This should include developing capacity to respond to incidents, specific training to support patients with dementia and/or delirium, measures to prevent and control risks of violence, and to defuse situations in deescalation techniques (Australian Nursing Midwifery Foundation, 2018). Similarly, a duty of care exists for providers of undergraduate nursing education to adequately prepare students for violent encounters. Therefore, it is timely for this review to examine the current evidence available on the curriculum content and teaching and learning delivery approaches.

Providing education in the tertiary setting that is specifically focused on prevention, identification, and responding to violence may increase nursing students' ability to respond to violence in the workplace, both as a student and once graduated (Sanner-Stiehr & Ward-Smith, 2017). As a minimum, exposure to this content may increase nursing student confidence and perceived ability to manage violent situations. A recent scoping review identified that although a significant investment in guidance resources has been made by government and nongovernment bodies related to the recommended use of WV prevention and management strategies in health care, the efficiency of these resources is yet to be established (Morphet et al., 2018), including within undergraduate nursing education (Searby et al., 2019), justifying this review.

Evaluation of educational impact on student behavior and practice provides valuable feedback that assists with development and improvement of learning and teaching strategies. To capture outcome measures, Kirkpatrick's (1967) framework for evaluation has been adopted. This framework contains four levels of evaluation: Reaction (Level 1), which pertains to how participants liked the educational program; Learning (Level 2), which relates to the degree to which participants acquired the intended knowledge, skills, and attitudes based on the educational program; Behavior (Level 3), which measures the degree to which participants demonstrated a change in behavior; and Results as impact from training (Level 4), which evaluates learning transfer to the clinical setting attributable to the educational program (Yardley & Dornan, 2012).

This framework was utilized so that identified articles within this review could be categorized to aid analysis and presentation of findings with a view to identifying learning formats and outcomes that could inform educational strategies. The framework was applied to guide the extraction and synthesis of the data. It was not used to inform collection or limit the type of data sought.

The goal of this article is to report a systematic review and evaluate the literature currently published on educational programs within undergraduate nursing courses that address workplace violence prevention and management. The review will assess which programs were most effective and reported key outcomes such as change in knowledge, understanding, skills, and behavior, as well as program features associated with effectiveness in order to make recommendations for practice and research.


Aim and Review Question

The aim of this review was to search, extract, appraise, and synthesize research relating to workplace violence education in undergraduate nursing education to answer the following question: In undergraduate nursing education, what workplace violence programs have reported the highest level outcomes, according to Kirkpatrick's (1967) training evaluation model?

Protocol and Registration

This systematic review was registered through an international database of prospectively registered systematic reviews, PROSPERO, and was performed according to the recommendations for the Preferred Items for Systematic Reviews and Meta Analyses (PRISMA) statement (Moher et al., 2015).

Search Strategy

This review was undertaken using the PRISMA checklist and guidelines for conducting a systematic review in conducting this research (Moher et al., 2015). A comprehensive search was conducted in July 2019 of the following databases: CINAHL®, PsycINFO®, Scopus®, EMBASE, and PubMed®. Electronic searches were supplemented by a manual search of individual reference lists and an Internet search using the Google™ Scholar search engine. Search terms included the following key words: threatening behavior, verbal aggression, physical aggression, occupational aggression, workplace aggression, occupational violence, workplace violence, workplace assault, occupational assault, confrontation, intimidation, nursing students, student nurses, undergraduate student nurses, baccalaureate nursing education, diploma nursing education, prevention, intervention, treatment, deterrence, avoidance, training, deescalation strategies, or deescalation technique. Truncation symbols were used where appropriate. The search strategy can be found in Table 1. For the purpose of this review, workplace violence was characterized to violent acts including physical and verbal abuse but not bullying.

Search Strategy

Table 1:

Search Strategy

Inclusion and Exclusion Criteria

Manuscripts were included in the review based on the following criteria: (a) were written in the English language, (b) were peer reviewed, (c) described an educational program relating to workplace violence in an undergraduate nursing program, and (d) were published between 2000 and July 2019. The time frame of 2000 to 2019 was strategically applied because management of nursing workplace incivility is a relative new area of study among decades of workplace violence research, with most incivility management research occurring after 2000 (Armstrong, 2018). Additionally, educational programs that are relatable to the current teaching and learning approaches, learning platforms, and contemporary societal expectations were considered imperative. The exclusion criteria were (a) studies relating to education on managing bullying behaviors, and (b) studies that did not provide information about the characteristics, content, approaches to teaching and learning, and an evaluation of the education delivered.

Data Extraction and Assessment of Quality of Evidence

The inclusion criteria were assessed by the review team (S.J., A.F). Data extraction from studies that met inclusion criteria was performed by the primary reviewer (S.J) and validated by the secondary reviewer (A.F). Authors were blinded to each other's appraisals. Studies assessed as valid were appraised by two reviewers (S.J., A.F.) using the relevant Joanna Briggs Institute Critical Appraisal instruments, based on the study design (Moola et al., 2017). All final studies achieved at least a cut off score of 7 of a possible 11 “yes” results for the appraisal criteria. A third reviewer (a university Library Liaison Officer in health) resolved any discrepancies in each stage of this process.


Data were extracted from the articles and entered into an Excel® spreadsheet to record the citation, study design, population/sample, outcome measures, broad results, limitations, and study quality. Primary outcomes of interest were characteristics, content, teaching and learning approaches utilized, and evaluation of the educational program delivered to undergraduate nursing students about workplace violence. Heterogeneity across studies in data reporting and outcomes prevented meta-analysis; therefore, results are presented narratively.


A total of 585 titles and abstracts were initially identified with six studies included in the final review. A flowchart of the search and selection process is illustrated in the PRISMA flowchart (Figure 1).

PRISMA flow diagram.

Figure 1.

PRISMA flow diagram.

Study Types

Of the six studies, two studies included pretest–posttest design (Martinez, 2017; Nau et al., 2010), one repeated-measures longitudinal design (Beech & Leather, 2003), one mixed-methods study (Brann & Hartley, 2017), one single descriptive case study design (Jonas-Dwyer et al., 2017), and one exploratory posttest paper (Lyng et al., 2012).

The characteristics, participants, aim, details of the education, level of evaluation, and results are presented in Table 2.

Characteristics of Included StudiesCharacteristics of Included Studies

Table 2:

Characteristics of Included Studies

Methodological Quality of Studies

The final articles were evaluated for methodological quality using the Joanna Briggs Institute Critical Appraisal checklist matched to the type of study. The final six studies were considered to be of good quality overall (Table 3).

Results of the Johanna Briggs Institute (JBI) Critical Appraisal Checklist

Table 3:

Results of the Johanna Briggs Institute (JBI) Critical Appraisal Checklist

Participant Types

The included studies all used convenience sampling with sample sizes ranging from 15 (Martinez et al., 2017) to 80 (Beech & Leather, 2003). Study participants were all undergraduate nursing students enrolled in one of the following courses: a diploma course (Beech & Leather, 2003), a Bachelor of Nursing course (Brann & Hartley, 2017; Lyng et al., 2012; Nau et al., 2010), a Master of Nursing entry to practice course (Brann & Hartley, 2017), an undergraduate psychiatric nursing course (Martinez, 2017), or a graduate entry nursing program (Jonas-Dwyer et al., 2017).

Types of Education Provided

Of the six included studies, five educational programs were found to include theoretical and practical components (Beech & Leather, 2003; Jonas-Dwyer et al., 2017; Lyng, 2012; Martinez, 2017; Nau et al., 2010), with only one course delivering theoretical information only (Brann & Hartley, 2017). The shortest course was the online National Institute for Occupational Safety and Health, which consisted of 13 units (each consisting of a 15- to 20-minute online module), estimated to take 3 hours to complete (Brann & Hartley, 2017). This educational program did not have to be completed in one setting and could be accessed over a 4-week period and included interactive video real-life cases (aggressive family members, homicidal patient, cognitively impaired patient, and patient with inappropriate sexual behaviors) in addition to written content about personal safety and violence recognition cues.

Martinez (2017) reported the delivery of an online presentation, “Managing workplace violence with evidence-based interventions,” prior to students participating in a 4-hour nursing workshop. Included in the workshop was a 2-hour simulation with a standardized patient (SP), in which the SP displayed symptoms of schizophrenia, anxiety, aggression, and challenging behavior. Two minutes of individual feedback was provided, followed by a 2-hour group debrief by the facilitator who identified the different signs of aggression, the five phases of the assault cycle performed by the SP, and suggestions on how to improve communication and safety measures when treating aggressive patients.

Jonas-Dwyer et al. (2017) delivered a training program based on the Management of Aggression Training Program (MOAT) being delivered to health professionals at a tertiary teaching hospital. The program was delivered over 1 day, which included brainstorming, group sessions, and a practical session (2.5 hours) of deescalation skills.

Lyng et al. (2012) developed a new program tailored to prepare first-year nursing students (n = 207) to recognize and respond to situations that could potentially escalate to aggression and violence during clinical practice. Within this program, theory was delivered in two 1-hour lectures, in addition to a 4-hour workshop consisting of small-group work. The teaching strategies used included videos of escalation and deescalation scenarios, games to demonstrate topics such as personal space or recognition of nonverbal cues, discussion, reflection of the important key messages, and role-plays to practice deescalation with the opportunity for peer feedback. Beech's and Leather's (2003) study implemented the “Prevention and management of aggression and violence in health care settings” program, a 3-day training course that included theoretical concepts and practical, verbal and nonverbal breakaway skills, and nonprovocative behavioral approaches. Nau et al. (2010) conducted a training program, “Aggression management training,” which had the educational aims of prevention, assessment of the occurrence of WV, treating the patient, and coping and aftercare. The program consisted of 24 hours in total, delivered face to face over a 1-week period. Educational sessions included lectures, physical skills training, group work, and six SP simulation scenarios. Specific content from each of the studies is depicted in Table 4.

Course Content

Table 4:

Course Content

Level of Evaluation According to Kirkpatrick's Four-Level Model

The outcomes of the education programs have been categorized according to the four levels of Kirkpatrick's (1967) evaluation model: Level 1, participant reactions; Level 2, learning; Level 3, behavior; and Level 4, results. If a study reported more than one level of evaluation, the highest level achieved has been reported.

Level 1: Participant Reactions. The secondary outcome of the study by Martinez (2017) was participant satisfaction of the simulated learning experience. An online survey of open-ended questions was used to ascertain students' perceptions, with all respondents (n = 15) reacting positively to this teaching methodology. The primary outcome of the study is reported below.

Level 2: Learning. An increase in knowledge was the primary outcome of interest to Martinez (2017), who aimed to determine the efficacy of a WV training program using pretest–posttest evaluation. Students (n = 15) completed a pretest prior to watching the online presentation and immediately completing a posttest of a researcher-developed 13-item survey based on the content presented, with results indicating an overall increase in content knowledge. At a later time, students undertook a pretest using the Mental Health Nursing Clinical Confidence Scale (MHNCCS), then participated in a 5-minute SP simulated learning experience. Six weeks postsimulation, a posttest MHNCCS survey was completed, with results indicating a statistically significant increase in confidence and perceived ability in managing episodes of WV (p < .001).

Brann and Hartley (2017) evaluated nursing student (n = 48) change in awareness of WV as a problem, as well as knowledge of prevention and deescalation using a pretest–posttest survey based on principles of the theory of planned behavior. This previously developed survey included 10 knowledge questions and three awareness items to evaluate learning. The mean time frame for completion of the posttest was 11 days from the pretest date, and a second posttest survey was completed 4 weeks after the immediate posttest was completed. Mean knowledge scores differed significantly between precourse and both postcourse time points. Mean knowledge scores decreased slightly when comparing the immediate posttest score to the 4-week posttest score; however, the increase from pretest to 4-week posttest was still significant.

The effectiveness of the MOAT program was evaluated by Jonas-Dwyer et al. (2017) using a pretest–posttest study design. A researcher-developed survey evaluated participant perceptions (n = 18) of learning and skill acquisition in relation to the management of aggression and violence in the workplace. The survey, comprising 16 items, was conducted immediately before the WV training program and immediately on completion. There was a statistically significant increase in participants' perceptions of capability to prevent and manage workplace violence incidents after the training. A postclinical placement survey was completed after participants' first and second clinical placements. The postclinical placement surveys divided 31 items into three subscales, designed to investigate student experiences of aggressive and violent episodes experienced during clinical placement, confidence in coping with patient aggression, and their perception of how they would manage an aggressive or violent episode. The majority of students agreed they had learned required verbal communication and deescalation skills in the event of a violent episode on placement.

Beech and Leather (2003) aimed to establish the immediate and medium-term knowledge gains after delivery of a 3-day training program on prevention and management of workplace aggression. A repeated measures longitudinal design was used to obtain data from three cohorts of nurses (n = 240) at four time points over an 8-month period. A researcher-developed tool was used to evaluate student ability to identify risk factors in aggressive situations and was administered twice before the training, at completion of training, and 3 months following attendance at two 3-week clinical placements. The tool required students to consider two aggression scenarios and identify risk factors within the scenarios and use open-ended responses to measure declarative knowledge and evidence of mental mapping. An additional 24 Likert-type statements were included to measure attitudes, perceived behavioral competence, and confidence. Statistically significant changes were demonstrated at the completion of the training program and at the 3-month follow-up in a number of areas, including number of risk factors identified, and five factors identified from the questionnaire statements, including knowledge on maintaining personal safety, prediction and prevention, practical ability, self-respect and staff rights, and provocative approach.

Lyng (2012) used a researcher-developed questionnaire of 17 statements to evaluate learning from the Managing Challenging Situations in Practice program. Using a posttest-only survey, the authors reported that for each activity, more than 80% of participants agreed or strongly agreed that the activity achieved the aim of increasing knowledge, particularly reinforcing understanding of different stages of the aggression cycle and noting nonverbal cues.

Level 3: Behavior. Using a cross-sectional and longitudinal two groups before and after design, Nau et al. (2010) evaluated video recordings of nursing student performance in deescalating aggressive patients in a simulated environment. Nursing students (n = 78) were divided into groups and managed one of two SP scenarios. Both groups then participated in the same WV training prior to participating in the other, unknown aggressive SP scenario. Assessors were blinded as to whether participants in each video had been recorded prior to or after training and used a standardized rating tool, the Deescalating Aggressive Behavior Scale. There was a statistically significant performance improvement for every criterion on the 7-item scale between pre- and posttraining scenarios. However, it should be noted that although an improvement in behavior was seen, a good performance score was still not achieved after training.

Level 4: Results. No studies examined nurse education of workplace violence to this level.


This systematic review sought to identify, classify, and report the resultant outcomes of workplace violence training programs in undergraduate education programs. The most frequently (four studies) evaluated outcome among the identified studies was learning (Level 2), with only one study evaluating participant reaction (Level 1). One study evaluated the impact of the educational program on participant behavior (Level 3) in the simulated environment only, and no study evaluated whether learning had transferred to the clinical setting resulting in a reduction in WV events. The absence of Level 4 studies is not surprising given that studies that do achieve the goal of transfer to practice are difficult to design and execute. These studies often require the ability to control real-life conditions so that behaviors can be demonstrated (Morris et al., 2011). This raises not only ethical but also safety issues. In this review, the range of study designs, the nature of study designs (no control group in any study), and a lack of standardized method of development, implementation, and evaluation of the studies exclude direct comparison or strong conclusions to be drawn. Regardless of this, some features of the training programs may inform future WV training.

Among the studies that evaluated participant learning, the duration of the training was relatively short. Knowledge was improved immediately posteducation and generally noted to be maintained. This is a positive finding, as most courses are already content heavy. The addition of a short educational component may still have potential to increase nursing students' ability to respond to episodes of violence (Sanner-Stiehr & Ward-Smith, 2017).

In the majority of studies, simulation or scenario-based learning was featured as a learning and teaching strategy where the learners interacted with people, simulators, or computers to accomplish learning goals representative of the learner's real-world responsibilities. A well-known benefit of simulated learning is the associated debriefing, where learners are assisted to reflect and identify aspects of performance that went well in addition to identifying areas for improvement and consider how this learning may be useful in future situations (Johnston et al., 2017). Given that simulation now is an integral component of nursing education (dos Santos Almeida et al., 2018) incorporating aspects of WV training within simulation scenarios may be a promising method of providing education on key issues, such as recognizing at risk behaviors and triggers, communication, and deescalation (Morphet et al., 2018) that may be used when on clinical practice. The use of standardized patient simulation in workplace violence education programs has shown promising results within other nursing groups, such as advanced practice nurses (Kowitlawakul et al., 2015) and emergency room nurses (Wu et al., 2019). In these studies, the realistic performance of the standardized patients contributed to the study participant's formulation of appropriate and habitual responses to different forms of workplace violence. Standardized patient as a specific form of simulation may have similar benefits in undergraduate nursing education and be helpful in eliciting participant authentic responses and aiding in preparation to address workplace violence and is an area worthy of further investigation.

A secondary finding in this review was that incident reporting, postincident response, and support were not well covered in WV programs. It is acknowledged that WV in health care is underreported (Phillips, 2016). To negate the tendency to normalize WV, education to prioritize the reporting of WV incidents must be emphasized (Hogarth et al., 2016).


This review had several limitations. The search strategy was limited to English language studies and did not include unpublished abstracts from conference proceedings or grey literature. Only studies between 2010 and 2019 were included. Our review included only six studies with different study designs and outcomes, thus preventing us from conducting a meta-analysis. The quality of evidence is variable, with no studies using control groups. Although the majority of studies suggested that learning had occurred, it must be tempered with the fact that other factors, such as the course being self-paced (Brann & Hartley, 2017), may have influenced it; therefore, there is no way of knowing whether factors such as other training or communication with others doing the same course may have influenced participant responses. Learning was also evaluated after participants undertook clinical placement (Jonas-Dwyer et al., 2017; Martinez, 2017); therefore, questionnaire responses may have been influenced by the learning that occurred during clinical placement experiences, in particular, when placements were undertaken in high-risk areas of mental health, where exposure to WV may have been high. Behavior was seen only in the simulated environment (Nau et al., 2010), and although training was seen to be useful as indicated by an improvement in pre- and posttest scores, performance scores that were in the range of a good performance were still not achieved.


WV is prevalent in health care; therefore, education of undergraduate nurses in prevention and management of WV is essential. This review evaluated outcomes of WV educational programs and identified effective features of training. Although no strong conclusions were able to be drawn, simulated learning has emerged as a learning and teaching strategy that may potentially contribute to increased knowledge of WV. This approach may easily be implemented given the frequent use of simulation in existing nursing education programs. Incident reporting and postincident follow-up should be an integral component of WV education.


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Search Strategy

Search No.Search Terms
S1Threaten* behavior OR verbal aggression OR physical aggression
S2Occupational aggression OR workplace aggression OR occupational violence OR workplace violence
S3Workplace assault OR occupational assault
S4Confrontation OR intimidation
S5(Nursing students or student nurses or undergraduate student nurses) OR baccalaureate nursing education OR diploma nursing education
S6(Prevention or intervention or treatment or program) OR deterrence OR avoidance OR training OR deescalation strategies OR deescalation technique
S7(Prevention or intervention or treatment or program) ORdeterrence OR avoidance OR training OR deescalation strategies OR deescalation technique) AND (S1 AND S5 AND S6)
S11S8 AND S9
S12(S4 AND S5 AND S6) AND (S8 AND S10)
S13S8 AND S10
S14S9 AND S10
S15S8 AND S9 AND S10
S16S1 OR S2 OR S3 OR S4
S17(S1 OR S2 OR S3 OR S4) AND (S5 AND S6 AND S16)

Characteristics of Included Studies

Study and CountryStudy Design and AimSampleInstructional Strategies and DurationEvaluationResultsKirkpatrick Level
Beech & Leather (2003), United KingdomRepeated measures longitudinal variable baseline design; tested pre, day 1 of course, day 3 of course, and follow up (3 months) aimed to measure immediate and long-term effects of training program on knowledge, attitudes, increasing self-esteem and confidence, skills243 diploma-level nurses3-day course “Prevention and Management of Aggression and Violence in Health Care Settings,” which included group discussion, lecture, handouts, self-awareness questionnaires, role-play, skills demonstration, and practice24 Likert scale questions evaluating responses to two different aggression scenariosStatistically significant changes in scores between completion of training and 3 month follow-up in maintaining personal safety (p< .001), prediction and prevention (p< .001), practical ability (p< .001) and using non-provocative approach2
Brann & Hartley (2017), United StatesMixed-methods – pretest–posttest (tested immediately postcourse and 4 weeks postcourse) and focus groups. Aim was to increase awareness of the problem of workplace violence and increase knowledge of prevention and deescalation of workplace violence48 nursing students enrolled in BN or entry to practice MN3-hour online National Institute for Occupational Safety and Health education program consisting of interactive video real-life cases and reading informationSurvey based on Theory of Planned Behavior measuring awareness (three questions) and knowledge (10 questions) of OVMean awareness scores different significantly between precourse, immediately postcourse, and 4 weeks postcourse (p< .001). Mean knowledge scores increased between precourse and both postcourse time points (p< .001)2
Jonas-Dwyer et al. (2017), AustraliaPretest–posttest and two subsequent postclinical placement surveys18 graduate entry nursing students7-hour “Management of Aggression Training” program including individual reflection, sharing of experiences, group work, brainstorming activities, and practical training of deescalation and physical breakaway techniquesSurvey 1 and 2 included a 19-item questionnaire of three demographic questions and 16 program evaluation and perception of knowledge and skill posttraining. Survey 3 included 31 items—confidence in coping with patient aggression, student experiences of aggressive and violent episodes during clinical placement, and student perceptions of managing violent of aggressive episodesStatistically significant improvements in self-reports of the ability to recognize and manage aggressive situations (p< .0005)2
Lyng et al. (2012), IrelandExploratory207 nursing students6 hours “Managing Challenging Situations in Practice” Two 1-hour lectures plus a 4-hour workshop, which included videos, games, quizzes, role-plays, discussion17-item questionnaire evaluating level of agreement to determine whether the learning activity met its aim83.4% of participants agreed/strongly agreed knowledge of aggression cycle was reinforced; 81.3% agreed/strongly agreed course content reinforced importance of noting nonverbal cues. Similar scores noted for perceived skills improvements2
Martinez (2017), United StatesPretest–posttest study. Aim to enhance confidence in managing agitated patients, increase knowledge of signs of aggression, and use of evidence-based deescalation interventions15 nursing studentsOnline presentation on OV. 4-hour learning session, which included 5-minute standardized patient encounter with 2 minutes of individual plus 2-hour group debriefing for all participantsResearcher-developed questionnaire assessing knowledge relating to online presentation. Mental Health Nursing Clinical Confidence Scale, 20-item scale to measure confidence and ability to recognize phases of assault cycle relating to simulation experience100% of respondents responded positively to the simulation. Increase in knowledge in most of 13 questions of topics covered in online presentation. Statistically significant increase in confidence and perceived ability in managing episodes of OV post simulation (p< .001)1 and 2
Nau et al. (2010), GermanyPretest–posttest within and between groups design aimed to enhance knowledge of OV and increase knowledge on recognition aggression, use interventions to deescalate78 nursing students24 1-hour sessions delivered over 1 week involving lectures, skills training using standardized patient simulationDe-Escalating Aggressive Behavior Scale, comprising 7 items using a 5-point Likert scaleStatistically significant improvement in performance levels in students who did a skills scenario relating specifically to the training they had for scenario 1 (p< .001) and scenario 2 (p< .001)3

Results of the Johanna Briggs Institute (JBI) Critical Appraisal Checklist

StudyJBI Appraisal Tool Used to AssessNo. of Affirmative Results
Beech & Leather (2003)Cohort studies8/11
Brann & Hartley (2017)Quasi-experimental studies8/9
Jonas-Dwyer et al. (2017)Cohort studies9/11
Lyng et al. (2012)Text and opinion papers6/6
Martinez (2017)Quasi-experimental studies7/9
Nau et al. (2010)Quasi-experimental studies8/9

Course Content

Specific Course ContentStudy

Beech & Leather (2003)Brann & Hartley (2017)Jonas-Dwyer et al. (2017)Lyng et al. (2012)Martinez (2017)Nau et al.(2010)
Phases of aggression/assault cyclexxxx
Risk factors, causes, and triggersxxxxxx
Warning signs of escalation to aggression and violencexxxxxx
Nonphysical interventions and deescalation techniques (including verbal and nonverbal communication)xxxxxx
Self-awareness, self-controlxxxx
Practical skillsxxxxx
Sensitivity to racial, cultural, social, and spiritual needsxxx
Incident reportingx
Post event response/supportxxx
Legal issuesxxx

Dr. Johnston is Director of Clinical Partnerships, School of Nursing, Queensland University of Technology, and Institute of Health and Biomedical Innovation, Brisbane, and Dr. Fox is Postgraduate Course Coordinator, Centre for Health Care Transformation, Queensland University of Technology, Brisbane, Queensland, Australia.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank Sarah Howard, Health Librarian, Queensland University of Technology, for advice in the completion of this review.

Address correspondence to Sandra Johnston, PhD, RN, Director of Clinical Partnerships, School of Nursing, Queensland University of Technology, Victoria Park Road, Brisbane, Queensland 4059, Australia; email:

Received: January 22, 2020
Accepted: May 04, 2020


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