Journal of Psychosocial Nursing and Mental Health Services

CNE Article Supplemental Data

Implementing a Workplace Violence Simulation for Undergraduate Nursing Students: A Pilot Study

Angel Johann Solorzano Martinez, DNP, MSN, MBA, RN, CNS

Abstract

Click here to read a Letter to the Editor about this article. 

Click here to read a Letter to the Editor about this article.

Workplace violence (WPV) is an undesired phenomenon affecting nurses and nursing students. Nursing simulations allow students to learn and practice skills in a controlled setting. The development of the pilot study, “Mental Health Nursing Simulation on Workplace Violence,” is presented. A simulated scenario using a standardized patient (SP) behaving as an agitated psychiatric patient was developed for undergraduate nursing students enrolled in a psychiatric nursing course. The simulation aimed to enhance students' knowledge about WPV, increase their confidence and ability to recognize signs of aggression, practice evidence-based interventions to de-escalate agitated patients, and evaluate the simulation. Surveys and the Mental Health Nursing Clinical Confidence Scale were used to measure the aims yielding qualitative and quantitative data. An increase in students' confidence and knowledge was obtained post-simulation. Students rated the simulation as useful. The use of a SP created an experiential learning environment for participants. [Journal of Psychosocial Nursing and Mental Health Services, 55(10), 39–44.]

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Abstract

Click here to read a Letter to the Editor about this article. 

Click here to read a Letter to the Editor about this article.

Workplace violence (WPV) is an undesired phenomenon affecting nurses and nursing students. Nursing simulations allow students to learn and practice skills in a controlled setting. The development of the pilot study, “Mental Health Nursing Simulation on Workplace Violence,” is presented. A simulated scenario using a standardized patient (SP) behaving as an agitated psychiatric patient was developed for undergraduate nursing students enrolled in a psychiatric nursing course. The simulation aimed to enhance students' knowledge about WPV, increase their confidence and ability to recognize signs of aggression, practice evidence-based interventions to de-escalate agitated patients, and evaluate the simulation. Surveys and the Mental Health Nursing Clinical Confidence Scale were used to measure the aims yielding qualitative and quantitative data. An increase in students' confidence and knowledge was obtained post-simulation. Students rated the simulation as useful. The use of a SP created an experiential learning environment for participants. [Journal of Psychosocial Nursing and Mental Health Services, 55(10), 39–44.]

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A recent report from the Occupational Safety and Health Administration (OSHA; 2015) indicates that health care workers face a significant risk of encountering workplace violence (WPV). In 2014, a nationwide survey conducted on 3,765 nurses and nursing students by the American Nurses Association (ANA; 2015) found that 43% of respondents had “been verbally and/or physically threatened by a patient or family member of a patient” (p. 4). Nursing students and inexperienced nurses are more likely to encounter incidents of WPV in their clinical settings (Unal, Hisar, & Gorgulu, 2012). Long periods of time spent during patient contact have been correlated with increased rates of WPV (Phillips, 2016). During training, nursing students visit various health care settings for clinical rotations. Their inexperience, recurrent changes in clinical settings, recurrent patient contact, and need to work with new patients make them more vulnerable to encounter episodes of WPV (Magnavita & Heponiemi, 2011).

Providing appropriate training to nursing students to manage incidents of WPV is imperative for their safety in psychiatric nursing clinical rotations. The ANA (2015) recommends the implementation of interventions aiming to prevent and mitigate “incivility, bullying, and workplace violence” (p. 6). Enhancing nursing students' knowledge about evidence-based interventions to manage and prevent WPV can improve their critical thinking, assessment skills, and performance while interacting with agitated patients.

The current article describes the components of the Mental Health Nursing Simulation on WPV (MHNSWPV). The use of a standardized patient (SP) and training provided is explained. A theoretical framework using Kolb's (1984) experiential theory provides guidance for the simulation. The MHNSWPV aims offer an overview of the project; the instructional strategies used are presented; and the setting and participants are described. Instruments, data collection methods, evaluation, and results are presented.

Mental Health Nursing Simulation on Workplace Violence

A nursing simulation using real-life scenarios allows nurse educators to teach essential nursing skills for caring for patients with mental illness (Brown, 2015). In a mental health nursing course, the use of simulations for nursing students may supplement the theory content during the encounters, with SPs exhibiting symptoms of mental illness in a controlled setting (Doolen, Giddings, Johnson, Guizado de Nathan, & Badia, 2014). In addition, mental health nursing is unique because of the unpredictability of patients' behaviors and their diverse human responses (Alexander & Dearsley, 2014). SPs may also add emotional and behavioral components to the scenarios in a nursing simulation (Sideras et al., 2013). Therefore, a WPV mental health nursing simulation using a SP can provide students an opportunity to build knowledge and skills to be applied in their clinical rotations.

Debriefing is a critical component of participants' learning processes during a simulation. Current literature about the practice of debriefing in nursing simulations is robust (Fey & Jenkins, 2015; Forneris et al., 2015; Kirkbakk-Fjær, Hedelin, & Moen, 2016; Schwindt & McNelis, 2015). As part of participants' learning experiences during simulations, debriefing can be facilitated by the project leader as well as the SP after each encounter.

Goh, Selvarajan, Chng, Tan, and Yobas (2016) reported that the use of SPs in mental health nursing simulations can augment students' confidence while practicing their communication and assessment skills. The MHNSWPV using a SP was developed to provide a hands-on experience for undergraduate nursing students. Nursing students were able to practice their therapeutic communication skills, assess their confidence level, develop their assessment skills in recognizing signs and symptoms of aggression, and use evidence-based interventions. The MHNSWPV may prepare nursing students to manage and prevent incidents of WPV in their psychiatric nursing clinical rotation settings.

Nursing Simulation With a Standardized Patient

The SP is an individual who has been coached to behave as a patient with a specific health condition during a simulation (Brown, 2015). Using SPs during simulations is a useful approach to allow participants to apply their knowledge to practice. According to Foronda, Liu, and Bauman (2013), nursing simulation has gained acceptance in nursing education as an effective means to increase confidence and knowledge in undergraduate nursing students. Nursing simulations have the potential to create an experiential learning environment by having students practice skills (Rutherford-Hemming, 2012).

Background

Kolb's (1984) experiential theory provided the framework for the simulation. Experiential theory states that learning is better assimilated by directly participating and practicing (Kolb, 1984). Concrete experience, reflective observation, abstract conceptualization, and active experimentation structure are the learning cycle stages of experiential learning theory (Kolb, 1984). All stages were incorporated in the MHNSWPV, providing participants the opportunity to practice learned evidence-based skills.

Mental Health Nursing Simulation on Workplace Violence Program Aims

The MHNSWPV had several aims: enhance students' confidence in managing agitated patients, augment students' knowledge on evidence-based interventions to de-escalate agitated patients, promote students' ability to assess signs of aggression displayed by the SP, use evidence-based interventions to de-escalate an agitated patient, and evaluate the usefulness of the nursing simulation scenario with the SP.

Instructional Strategies

Components

Instructional strategies for participants were based on the current literature on nursing simulations and were designed by the author (A.J.S.M.) who was the facilitator for the simulation. Participants' encounters with the SP were 5 minutes in duration. Participants did not know how the SP would behave.

The simulation included documents describing the objectives for participants (Table A, available in the online version of this article). McCutcheon, Lohan, Traynor, and Martin (2015) reported that online, face-to-face, or blended teaching methodologies may lead to higher or similar outcomes in increasing students' clinical skills compared with traditional teaching methods. A blended method was used in the simulation with completion of materials via e-mail and in-person.

Mental Health Nursing Simulation on Workplace Violence's Objectives

Table A:

Mental Health Nursing Simulation on Workplace Violence's Objectives

A presentation titled, “Managing Workplace Violence with Evidence-Based Interventions (MWVEBI),” was developed and sent via e-mail to all participants. The MWVEBI presentation covered topics about WPV, how it affects nurses and nursing students, learning theories (i.e., social learning theory [Bandura, 1977] and experiential theory [Kolb, 1984]), WPV trends, and current research on evidence-based skills used to prevent and manage incidents of WPV. Participants reviewed the MWVEBI presentation, and completed online pre- and post-assessment surveys, which were developed by the facilitator to assess their knowledge on the subject.

The SP was provided with training topics prior to the simulation (Table B, available in the online version of this article). In addition, a document with the SP's fictional medical, psychiatric, and psychosocial history (Table C, available in the online version of this article) was created by the facilitator to provide background about the SP to participants. The document was sent via e-mail 1 week prior to the simulation. Participants also received a document outlining their role and responsibilities (Table D, available in the online version of this article).

Training Topics for the SPTraining Topics for the SPTraining Topics for the SP

Table B:

Training Topics for the SP

SP's Personal, Social, Medical, and PsychiatricSP's Personal, Social, Medical, and Psychiatric

Table C:

SP's Personal, Social, Medical, and Psychiatric

Participants' Role in the Mental Health Nursing Simulation on Workplace Violence (MHNSWPV)

Table D:

Participants' Role in the Mental Health Nursing Simulation on Workplace Violence (MHNSWPV)

Setting

The simulation was conducted at a public university's nursing department in a large urban city on the U.S. west coast. The nursing simulation laboratory was selected for the availability of media and audiovisual equipment. A classroom equipped with a computer projector for video streaming was used for the debriefing session.

Participants

Participants were undergraduate nursing students (N = 15) currently enrolled in a psychiatric nursing course taught in the second semester at the selected university. Three male and 12 female nursing students between the ages of 18 and 54 were included. The simulation was given prior to their psychiatric nursing clinical rotations in their designated clinical sites. Participants were recruited based on their assigned psychiatric nursing clinical day matching the scheduled simulation day. No students declined to participate.

Ethical Considerations

Written permission and Institutional Review Board exemption from the Human and Animal Protections Department of the institution were obtained prior to the simulation. All participants voluntarily signed consent forms 1 week prior to the simulation and were given the opportunity to ask questions, raise concerns, and decline participation in the simulation. No students declined to participate.

Standardized Patient Training Specifics

The SP was educated about the different phases of the assault cycle via written materials provided by the facilitator. The assault cycle phases include triggering, escalation, crisis, recovery, and post-crisis depression (Kaplan & Wheeler, 1983). The SP was also instructed about the specific behaviors to be displayed during the recordings (Table B).

Two rehearsal sessions between the facilitator and SP took place to ensure the performance included specific behaviors needed during the simulation. The first and second rehearsals took place 3 weeks and 1 week, respectively, prior to the simulation. Each rehearsal session lasted 2 hours. Feedback and suggestions were provided to the SP about performance roles and feedback to provide participants.

Selection of the Standardized Patient and Performance Roles

The selected SP was a trained individual who had experience working in nursing simulations at the university, and had three major roles to perform. The SP's first role was simulating various behaviors representing the different stages of the assault cycle while being recorded alone to show how the assault cycle could be manifested by an individual without any interventions. The SP's second role included performing the role of an agitated patient with a diagnosis of schizophrenia during each of the encounters with participants. The SP's third role was to provide 2-minute feedback to each pair of participants about their performance immediately after each encounter (Table B).

Simulation Experience

The 4-hour nursing simulation was conducted on 1 day and split into two sections. The first 2 hours were divided into 10-minute intervals to accommodate all participants in an organized manner. Participants were given the option to partner with another student and select their desired time for their encounter. One participant had to complete the simulation encounter without a partner because there were only 15 participants. All participants were instructed to follow the nursing simulation objectives (Table A). Each encounter was recorded and timed for 5 minutes followed by 2 minutes of feedback provided by the SP.

On each encounter, the SP displayed symptoms of schizophrenia, signs of anxiety, tension, aggression, and challenging behaviors (Table B). Expectations for participants included using evidence-based interventions to de-escalate the SP, ensuring participants' safety, and practicing therapeutic communication skills. After all encounters were completed, the remaining 2 hours were used for the debriefing session with the facilitator.

Debriefing After Simulation

Debriefing was critical to assess participants' experience during the simulation and provide feedback. The debriefing process took place in a classroom setting by playing the recordings of each of the encounters and the SP performing the assault cycle phases. Debriefing provided an opportunity for the facilitator to identify participants' strengths, highlight positive aspects about their performance, and discuss opportunities for further development during the simulation. The facilitator also identified the different signs of aggression as well as the five phases of the assault cycle that were performed by the SP. The facilitator provided suggestions to improve participants' performance, address therapeutic communication skills, and use safety measures and evidence-based interventions to manage incidents of WPV.

Evaluation of the Effectiveness of the Simulation

Instruments and Data Collection

Participants' confidence was assessed using the Mental Health Nursing Clinical Confidence Scale (MHNCCS) developed by Bell, Horsfall, and Goodin (1998) (Table E, available in the online version of this article). The MHNCCS is a validated tool containing 20 items with scores ranging from 1 (confident) to 4 (completely confident) that can be used to measure nursing students' confidence (Bell et al., 1998). The MHNCCS was converted to a Likert-type survey format to be completed by participants before and after the simulation. Permission from the main author (A. Bell) to use the MHNCCS was obtained via e-mail.

Clinical Confidence Rating ScalePlease circle the number that best describes how confident you are about your ability to perform each of the following aspects of care for a patient in the clinical setting.

Table E:

Clinical Confidence Rating Scale

Please circle the number that best describes how confident you are about your ability to perform each of the following aspects of care for a patient in the clinical setting.

The facilitator also designed a 13-item knowledge assessment questionnaire to assess participants' knowledge about WPV pre- and post-simulation (Table F, available in the online version of this article). A questionnaire containing open-ended questions was also created to assess participants' ability to recognize the different phases of the assault cycle (Table G, available in the online version of this article). Students were also asked to evaluate their simulation experience with an open-ended questionnaire. Microsoft® Word was the selected software used to create the surveys needed for the simulation. Qualtrics® was the software used to distribute surveys to students via e-mail and collect and store data.

Knowledge Assessment QuestionnairesKnowledge Assessment QuestionnairesKnowledge Assessment Questionnaires

Table F:

Knowledge Assessment Questionnaires

Questionnaire Assessing Signs of Aggression and Identifying the Stages of the Assault Cycle

Table G:

Questionnaire Assessing Signs of Aggression and Identifying the Stages of the Assault Cycle

 

Data Analysis

Qualitative and quantitative data were obtained from participants. Qualitative data included participants' written opinions, evaluation of the SP's performance, and their experience during the simulation. Participants' confidence levels were measured via pre- and post-assessment surveys using the MHNCCS. Participants completed the pre-assessment survey before the simulation, and post-assessment surveys were completed 6 weeks after the simulation. The yielded results were statistically analyzed with SPSS version 22 using paired t tests. Participants' knowledge was assessed from their responses on the pre- and post-knowledge assessment questionnaires based on the MWVEBI presentation's content.

Findings

The MHNSWPV was successfully implemented in the selected university in 1 day. Each participant completed the simulation as planned. The SP performed all assigned roles as stated in the training documents. Participants' training and outlining of the simulation's objectives ensured their ability to use evidence-based interventions during each encounter to de-escalate the SP's agitated behavior. Among those interventions were verbal de-escalation skills, therapeutic communication skills, limit setting, and deep breathing techniques.

Assessment of participants' ability to recognize signs of aggression was obtained by tabulating their responses according to the SP's recording of the phases of the assault cycle. For each phase of the assault cycle, the SP performed a determined number of behaviors. Each participant successfully identified the five phases of the assault cycle portrayed by the SP. The behaviors displayed by the SP during the escalating phase were the most difficult for participants to identify because they were only able to recognize an average of 3.53 of six behaviors. Participants were most successful identifying behaviors from the recovery phase, with an average of 2.4 of three behaviors.

Participants' confidence levels were obtained from the responses yielded from the pre- and post-knowledge assessment questionnaire using the MHNCCS. On average, participants showed an increase in confidence levels from pre-assessment (mean = 30.15, SD = 7.876, range = 15 to 60) and post-assessment (mean = 45.13, SD = 6.906, range = 15 to 60). A paired t test was performed using mean values from participants' responses from the pre- and post-knowledge assessment questionnaires using the MHNCCS. The paired t test calculations showed a statistically significant increase in confidence level among participants from pre- to post-measures (t = 5.68; p < 0.0001) (Table H, available in the online version of this article).

MHNCCS' Statistical Analysis

Table H:

MHNCCS' Statistical Analysis

Participants' knowledge about WPV was assessed using pre- and post-knowledge assessment questionnaires on the content presented in the MWVEBI presentation (Table F). Their responses were tabulated and percentage values were assigned to score their responses. Overall, participants reported an increase in knowledge in most of the 13 questions, ranging from 6% to 53%. Participants demonstrated an increase in knowledge for five questions. Results from an additional five questions remained the same between pre- and post-assessment knowledge questionnaires. Three responses obtained from participants were lower on the post-assessment questionnaire compared to the pre-assessment questionnaire. The lower scores obtained in the post-assessment questionnaire were not fully understood; an assumption is discussed in the limitations section.

Participants' rating of the simulation was assessed via survey. Each participant responded positively to the experience with the SP yielding similar responses. Some responses were that the simulation was “helpful” and a “good learning experience.” Several participants also reported that interacting with the SP allowed them to “practice de-escalation skills.”

Application of Experiential Theory

All stages of Kolb's (1984) experiential theory were included and assessed during the simulation. Participants' learning experience was enhanced by practicing skills and knowledge learned. The concrete experience stage was implemented by creating the MWVEBI presentation, which provided new knowledge about WPV to participants. The abstract conceptualization stage occurred when participants thought about how to apply the learned concepts during the simulation. The active experimentation stage ensued when participants used therapeutic communication and de-escalation skills to manage the SP's agitated behavior. The reflective observation component occurred during debriefing with the facilitator.

Discussion

Mental health nursing simulations have the potential to enhance nursing students' skills and confidence in preparation for their psychiatric nursing clinical rotations. The simulation's implementation and completion demonstrates its feasibility for use in a nursing simulation laboratory at an educational institution. The different stages of Kolb's (1984) experiential learning theory were practical and applicable for the simulation. Participants demonstrated an increase in confidence after participating in the simulation, enhancing their preparation for their clinical rotation. Similar to other studies by Sideras et al. (2013), Doolen et al. (2014), and Alexander and Dearsley (2014), the MHNSWPV supplemented additional knowledge in the nursing curriculum and provided an opportunity for participants to intervene with evidence-based interventions to manage the unpredictable agitated behaviors exhibited by the SP. Training nursing students about prevention and management of WPV can help prepare them to manage such incidents prior to the beginning of their clinical rotation in psychiatric settings. Reinforcement of new knowledge learned by participants about WPV is recommended to enhance its retention among participants.

Limitations

The MHNSWPV had several limitations. The small number of participants (N = 15) limited the amount of data collected. Gender disparities occurred in this project, as female students comprised the majority of the sample (n = 12). The subjective responses provided by female and male participants may have the potential for bias toward violence and aggression. In addition, seven students were already assigned to have their psychiatric nursing clinical rotation with the facilitator during that semester, which may have created a potential for biases in their responses obtained during the simulation experience. Lower scores obtained in the post-assessment questionnaire may have occurred because participants did not fully re-review the documents provided to reinforce the new WPV knowledge learned. Qualitative surveys used to assess students' experiences in the simulation were developed solely for this simulation. The simulation did not include a control group.

Implications for Practice

Due to the increased likelihood that nurses may experience WPV in clinical settings, a WPV training program tailored for this population should be made mandatory to address this unwanted phenomenon. Scenarios and the use of a SP could be added as part of a clinical competence training for practicing nurses. Nurses should be taught the latest evidence-based skills to manage WPV in their competency training. Having nurses practice evidence-based skills in simulated scenarios supervised by experienced trainers can enhance their ability to use those skills to successfully manage future incidents of WPV in clinical settings.

Conclusion

Nursing simulations with a SP provide an experiential learning experience for students using a more realistic approach in a managed setting. Future encounters with potentially violent psychiatric patients in nursing clinical rotations may cause concern for some students. As a result, a nursing simulation with mental health scenarios can provide students a learning environment to practice learned evidence-based interventions, which may prepare them to interact with potentially aggressive patients in their clinical rotations. The use of the MHNCCS instrument validated the confidence enhancement findings found among participants. New mental health nursing research studies using SPs in simulations are needed to continue disseminating knowledge about WPV in nursing curricula at graduate and undergraduate levels. The MHNSWPV adds to the current literature on mental health nursing simulations using SPs.

References

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Mental Health Nursing Simulation on Workplace Violence's Objectives

Two nursing students will have an encounter with the SP. Each encounter is timed for five minutes. You are required to interview the SP to obtain information for a care plan that you need to work on about this patient who has been diagnosed with schizophrenia. During the simulation with the SP, the students will perform the following: <list-item>

Proper Introduction

</list-item><list-item>

Ensure patient's safety and your own

</list-item><list-item>

Assess for signs of aggression

</list-item><list-item>

Use of clinical judgement and critical thinking skills

</list-item><list-item>

Interview the patient to obtain patient's history of medical conditions, psychiatric problems, medications, and psychosocial data for their care plan.

</list-item><list-item>

Employ evidence-based interventions learned from the MWVEBI online presentation as needed.

</list-item>

Training Topics for the SP

Background <list-item>

Overview of the nursing simulation project

</list-item><list-item>

Education about workplace violence in nursing

</list-item><list-item>

A script outlining the patient's history which included her diagnosis of schizophrenia, substance abuse, poor family support, multiple psychiatric admissions, and living in community settings.

</list-item><list-item>

Education about the diagnosis of schizophrenia and its symptoms. Evidence-based interventions that nursing students could employ during the simulation.

</list-item><list-item>

Scenario and simulation objectives

</list-item><list-item>

Signs of aggression to be displayed as an agitated patient according to each of the stages of the assault cycle by Kaplan & Wheeler (1983) while being recorded. (role 1)

</list-item>
Controlled Environment <list-item>

Attire during the simulation

</list-item><list-item>

Simulation room's physical environment emulating a hospital room

</list-item><list-item>

Appropriate boundaries including no physical contact with the students during the simulation

</list-item>
Role-play and Performance <list-item>

Role-play scenarios were conducted by the facilitator to ensure that the SP's performance matched with the desired behavior of an agitated patient. Among the agitated behaviors that the SP employed during each of the simulation encounters included: raising her tone of voice, approaching closely to the students, verbally challenging the students, yelling, displaying agitation, restlessness, clenching of the fists, and pacing in the room. (role 2)

</list-item><list-item>

Discussions and feedback about performance during the role-play sessions with the facilitator ensued.

</list-item><list-item>

Coaching about verbal feedback after each encounter with the nursing students. (role 3)

</list-item>
Mental Health Nursing Simulation on Workplace Violence Document for the Standardized Patient (SP)
MHNSWPV Summary Information
Setting: Simulation lab for the encounters with the participants and a classroom at the School of Nursing's building for debriefing with the facilitator at the end of the encounters. Room set up: A simulation room that mimics a hospital room with a door. The room will have a bed with sheets, a bedside table, and two chairs. Equipment: Audio visual recording devices Media Personnel: The media personnel will be in charge of the recording process and to announce the ending of each of the scenarios after five minutes. Participants: Second semester nursing students
Participants' Expectations:
The participants will be asked to interview a patient diagnosed with schizophrenia who has a history of violence to create a care plan for the patient. Then students will ask questions about medical and psychiatric history, medications, prior hospitalizations, violence, etc.
SP's Expectations:
Encounter time: 5 minutes to perform the role of an agitated patient with history of violence and Schizophrenia for the nursing students Debriefing time: 2 minutes to provide feedback to students about their performance during the simulation
SP's Script
Actress: Hired female SP Background information: Refer to Table C for SP's personal, social, medical and psychiatric background information Role: Perform the role of an agitated patient with history of violence and Schizophrenia Setting: Simulation room portraying a hospital's room. Positioning: Sitting position in bed Attire: Dressed in nursing scrubs Starting point: Students will knock the door of the chosen simulation room, and the SP will say “come in” Role details: Answer 5 questions asked by the participants, then, begin to get agitated and verbally challenge the students in a threatening manner. Move around the simulation room as needed. Do not touch the students and do not let the students touch you. Time: Wait for “time is up” announcement from media personnel

SP's Personal, Social, Medical, and Psychiatric

Patient Social and Medical Background: Mary Smith is a 40 y/o single straight female, born and raised in the US. Mother is diseased, she was diagnosed with dementia at age 65. Father is diseased. He had a history of alcoholism. She has been the only child. She does not have any family members around the area. She has a poor support system. She has never been married. She does not have any children. She only speaks English. She is 5 feet tall and weighs 100 pounds. She currently lives in a residential treatment facility in San Francisco. She is unemployed. Her only source of income is SSDI for which she receives approximately $900 a month. The money she receives covers her stays at residential treatment facilities. She has Medi-Cal insurance. Psychiatric Background: At the age of 22, during her college years, she was diagnosed with schizophrenia paranoid type. She has been receiving psychiatric treatment since then. She has been living in a number of residential treatment facilities where she is assigned to do chores, attend group activities, receive therapy and psychiatric care by a psychiatric nurse practitioner. She tends to be impulsive at times. Her mood fluctuates from being cheerful to angry in a matter of seconds when she is not taking any medications. She has a history of a suicide attempt by overdosing on her prescribed medications which she attempted a year ago claiming that it was a way to escape from the voices she hears. She has been previously hospitalized for at least 10 times in several locked inpatient psychiatric units during the last decade. She has a history of poly-substance abuse (PSA) using cocaine and marijuana for the last 5 years. She drinks 3 to 4 beers when she has access to alcohol. She smokes 1/2 pack of cigarettes whenever she can get access to cigarettes. She claims that using drugs, drinking and smoking help her forget about hearing voices. Recent hospitalization. She stopped taking her Zyprexa 10 mg BID, Depakote 500 mg BID, and Cogentin 1 mg BID several weeks ago, which lead to a de-compensation of her psychotic symptoms. The staff members at the Residential facility where she was living called 911 after she slapped other clients at the residential facility because they were making fun of her erratic behavior. She was brought to the hospital by the paramedics and has been hospitalized in the locked inpatient psychiatric unit for the last two days. On admission, she was placed on a 5150 (a 72 hold for psychiatric treatment). The psychiatrist resumed her medications Depakote 500 mg BID, Cogentin 1 mg BID and Zyprexa 10 mg which she has been reluctant to take since admission, but has taken them with encouragement. Since admission, she has been experiencing auditory hallucinations of command type telling her to hurt “young people”. She hears male and female voices and they are intermittent in frequency. She denies visual hallucinations, suicidal ideation. She verbally contracted not to harm self, but could not contract not to harm other people in the unit. Her mood and affect have been irritable and labile. She is alert and oriented to person, time and place. She has also been experiencing paranoid and persecutory delusions feeling that she is being followed by a number of law enforcement agencies. She knows the medications she is taking, but does not believe they help her, and she is not trusting the staff nurses as she believes they are trying to “poison” her with the medications they are giving her. While in the hospital, she has experienced episodes of anger and rage at times requiring PRN medications to calm her down. She knows she has been previously diagnosed with paranoid schizophrenia.

Participants' Role in the Mental Health Nursing Simulation on Workplace Violence (MHNSWPV)

Main objective: <list-item>

Conduct an interview with a potentially violent patient (SP) with a diagnosis of Schizophrenia to complete the required assignment.

</list-item>
Required Assignment: <list-item>

Based on the SP's history provided, the participants are expected to obtain information from the SP. Information gathered will be used for a care plan assignment focusing on a patient with history of violence and Schizophrenia.

</list-item>
Participants' Role: <list-item>

Assume the role of a nursing student in the inpatient psychiatric unit where the SP is receiving treatment.

</list-item><list-item>

Interview the SP to write a care plan on Mary Smith since she is a patient who has a history of violence and a diagnosis of Schizophrenia.

</list-item><list-item>

Inquire about SP's current hospitalization, social, medical, psychiatric history, current medications, violence, substance abuse, mental status, during the allotted time.

</list-item>
Competence Skills: <list-item>

Therapeutic Communication Skills

</list-item><list-item>

Assessment and recognition of signs of aggression

</list-item><list-item>

Verbal de-escalation skills

</list-item><list-item>

Therapeutic Approaches to de-escalate patients

</list-item><list-item>

Safety techniques

</list-item>

Clinical Confidence Rating Scale

Please circle the number that best describes how confident you are about your ability to perform each of the following aspects of care for a patient in the clinical setting.

Not at all confident Somewhat confident Moderately confident Very confident
1. I can communicate effectively with clients with a mental health problem. 1 2 3 4
2. I can carry out a comprehensive psychosocial assessment of clients. 1 2 3 4
3. I can conduct a mental status examination. 1 2 3 4
4. I can develop a nursing care plan on the basis of my assessment. 1 2 3 4
5. I can assist clients with a mental illness to clarify treatment goals. 1 2 3 4
6. I am able to provide basic counseling for clients with a mental illness. 1 2 3 4
7. I am able to be empathicwith clients with a mental illness. 1 2 3 4
8. I can provide information and education for clients regarding their diagnosis. 1 2 3 4
9. I am able to assist clients to develop living skills. 1 2 3 4
10. I have a basic knowledge of antipsychotic medications and their side-effects. 1 2 3 4
11. I am able to provide client education regarding the effects and side-effects of medications. 1 2 3 4
12. I can conduct a suicide risk assessment. 1 2 3 4
13. I can handle patients who are verbally aggressive. 1 2 3 4
14. I am able to establish my own personal boundaries when relating to clients with a mental illness. 1 2 3 4
15. I can seek support from other members of the mental health team. 1 2 3 4

Knowledge Assessment Questionnaires

Knowledge Assessment Questionnaire Questions used in the EBNSTWV Responses from participants N=15 students Pre-assessment Responses from participants N=15 students Post-assessment Analysis from pre and posttest responses
Workplace violence is best defined as: ➢ 93% of the participants answered correctly ➢ 93% of the participants answered correctly No increase from baseline
Patient-initiated violence is the most common form of violence encountered by nurses in clinical settings. ➢ 60% of the participants answered correctly ➢ 80% of the participants answered correctly A 20% increase was obtained from baseline
The most common forms of violence that nurses may experience are ➢ 40% of the participants answered correctly ➢ 40% of the participants answered the question correctly No increase from baseline
Compared to current data about the general working population in the United States, healthcare workers have the lowest incidents of violence ➢ 93% of the participants answered correctly ➢ 87% of the participants students answered the question correctly A 6 % decrease from baseline was obtained
Nurses are at a lower risk of encountering workplace violence compared to other healthcare personnel. Select the best answer ➢ 93% of the participants answered correctly ➢ 87% of the participants answered the question correctly A 6% decrease from baseline was obtained
Nursing students are less likely to encounter incidents of workplace violence during their training. Select the best answer ➢ 67% of the participants answered correctly ➢ 93% of the participants answered correctly A 26% increase from baseline was obtained
Incidents of workplace violence are carefully documented by nurses every time it occurs to prevent future incidents in the workplace. Select the best answer ➢ 40% of the participants answered correctly ➢ 47% of the participants answered correctly A 7% increase from baseline was obtained
The most common clinical settings where incidents of workplace violence take place are: ➢ 80% of the participants answered correctly ➢ 87% of the participants answered correctly A 7% increase from baseline was obtained
After encountering an incident of workplace violence, nurses most commonly experience some of the following: ➢ 93%% of the participants answered correctly ➢ 93% of the participants answered correctly No increase from baseline was obtained
Which of the following approaches can best help a nurse/nursing student effectively manage an incident of workplace violence being perpetrated by a patient? ➢ 100% of the participants answered correctly ➢ 100% of the participants answered correctly Equal percentage from baseline
Based on the scientific literature, training nursing personnel on management and prevention of workplace violence can potentially reduce the number of such incidents occurring in healthcare settings. ➢ 93%% of the participants answered correctly ➢ 80% of the participants answered correctly A 13% decrease from baseline was obtained
Which of the following verbal de-escalation techniques can best manage an aggressive client? ➢ 100% of the participants answered correctly ➢ 100% of the participants answered correctly Equal percentage from
Which of the following technique can best manage an agitated patient threatening to hurt the nurse? ➢ 40% of the participants answered correctly ➢ 93% of the participants answered correctly A 53% increase from baseline was obtained

Questionnaire Assessing Signs of Aggression and Identifying the Stages of the Assault Cycle

<list-item>

What were some of the signs of aggression displayed by the SP that you identified during the scenario?

</list-item><list-item>

What were the phases of the assault cycle identified in the scenario?

</list-item><list-item>

Write the behaviors displayed by the SP in the triggering phase?

</list-item><list-item>

Write the behaviors displayed by the SP in the escalating phase?

</list-item><list-item>

Write the behaviors displayed by the SP in the crisis phase?

</list-item><list-item>

Write the behaviors displayed by the SP in the recovery phase?

</list-item><list-item>

Write the behaviors displayed by the SP in post-crisis and depression phase?

</list-item>

Knowledge Assessment results using The Assault Cycle

Column A Column B Column C Column D
Knowledge Assessment Conducted SP's alone Performance of the Assault Cycle stage (A recording played for the participants) Post simulation written questionnaire averaged results from participants N=15 after watching the recording Analysis of the averaged participants' responses

Recognition of Signs of Aggression The SP performed behaviors according to each of the phases of the assault cycle: Number of Signs displayed by the SP
Triggering phase: 6 signs Triggering phase: All the participants recognized an average of 3.53 signs out of 6. Triggering phase: The average recognition of signs during this phase was 58.33%
Escalating phase: 6 signs Escalating phase: All the participants recognized an average of 3.06 signs out of 6 Escalating phase: The average recognition of signs during this phase was 51%.
Crisis phase: 4 signs Crisis phase: All the participants recognized an average of 2.6 signs out of 4 Crisis phase: The average recognition of signs during this phase was 65%.
Recovery phase: 3 signs Recovery phase: All the participants recognized an average of 2.4 signs out of 3 Recovery phase: The average recognition of signs during this phase was 80%.
Post-crisis depression phase: 5 signs Post-crisis depression phase: All the participants recognized an average of 3.26 signs out of 5 Post-crisis depression phase: The average recognition of signs during this phase was 65%.

Recognition of the assault cycle phases All the five phases of the Assault Cycle by Kaplan and Wheeler (1983) were performed by the SP. <list-item>

All the participants were successfully able to identify all the phases of the assault cycle portrayed by the SP.

</list-item>
100 % recognition of all the stages of the assault cycle was attained from the students showing their knowledge about the different phases of the assault cycle.
  

MHNCCS' Statistical Analysis

MHNCCS N Mean Standard Deviation Stand. Error Mean
Pre total 15 30.15 7.876 2.034
Post total 15 45.13 6.906 1.783
Paired t-tests pre and post intervention
MHNCCS N Mean Standard Deviation Stand. Error Mean t df p
Pre and Post Totals 15 −14.933 10.187 2.630 −5.677 14 <0.0001
Authors

Mr. Solorzano Martinez is Psychiatric Nurse, Inpatient Adult Psychiatric Unit, Saint Francis Memorial Hospital and California Pacific Medical Center, and Psychiatric Nursing Clinical Instructor, Samuel Merritt University, San Francisco State University, and University of San Francisco, San Francisco, California.

The author has disclosed no potential conflicts of interest, financial or otherwise. Funding for this manuscript was made possible (in part) by Grant Numbers 5T06SM060559-05 and 1T06SM061725-01 from the Substance Abuse and Mental Health Services Administration. The views expressed in written training materials or publications and by speakers and moderators do not necessarily reflect the official policies of the U.S. Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

The author acknowledges Pamela Minarik, PhD, RN, CNS, FAAN, Fang-yu Chou, PhD, RN, and Giovanna de Oliveira, PhD, PMHNP, ANP, RN, for their professional guidance in the development of the manuscript.

Address correspondence to Angel Johann Solorzano Martinez, DNP, MSN, MBA, RN, CNS, Psychiatric Nurse, Psychiatric Nursing Clinical Instructor, San Francisco State University, School of Nursing, 1600 Holloway Avenue, San Francisco, CA 94132; e-mail: asolorza@sfsu.edu.

Received: April 20, 2017
Accepted: June 27, 2017
Posted Online: August 24, 2017

10.3928/02793695-20170818-04

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