Use of simulation in training on violence in nursing practice

Integrative review of literature that met methodological guideline to answer the question: can simulation help nursing students and workers understand and deal with workplace violence? It was developed search strategies from Boolean operators and terms related to simulation and violence at work, which were inserted into CINAHL, MEDLINE and ProQuest Central along with the other filters. Two independent reviewers selected the studies using criteria and there was an analysis of the level of evidence.

Results

Nine studies were selected and showed the flexibility of the simulation by the possibility of using it with different purposes in training. It was identified in the studies the use of many simulation resources, as well as the approach of different topics of violence. The settings with patients or aggressors and violence starting with the patient were the most frequent. The studies pointed out benefits of the simulation, but not all results were consensual.

Conclusion

Simulation is a resource capable of helping nursing students and professionals to deal with cases of workplace violence, preventing it to occur or reducing damage. Studies on this topic are recent and several research needs emanate from the alliance between simulation and violence at work, some of which are highlighted in this review and that may guide the gathering of stronger evidence.

Professional training; Simulation training; Patient simulation; Workplace violence; Health personnel; Nurse practitioners

Database	Search strategy	Filters	Results
MEDLINE (PubMed)	((((((((simulation) OR “simulation technology”) OR “Patient Simulation”) OR simulations) OR “simulated patients”) OR “Simulation Training”) OR “High Fidelity Simulation Training”)) AND ((((((((((“Workplace Violence”) OR “lateral violence”) OR “horizontal violence”) OR Aggression) OR “physical violence”) OR “Physical Abuse”) OR “verbal abuse”) OR “Sexual Harassment”) OR Bullying) OR mobbing)	MEDLINE. Language: English, Portuguese, Spanish, French, Italian. Humans. Date: without limit until December 2017. The following article types were excluded: Addresses, Autobiography, Bibliography, Biography, Books and Documents, Dictionary, Festschrift, Legislation, News, Newspaper Article. Other types were held (Case Reports; Classical Article; Clinical Study; Clinical Trial; Clinical Trial, Phase I; Clinical Trial, Phase II; Clinical Trial, Phase III; Clinical Trial, Phase IV; Comment; Comparative Study; Controlled Clinical Trial; Corrected and Republished Article; Dataset; Directory; Duplicate Publication; Editorial; Electronic Supplementary Materials; English Abstract; Evaluation Studies; Government Publications; Guideline; Historical Article; Interactive Tutorial; Interview; Introductory Journal Article; Journal Article; Lectures; Legal Cases; Letter; Meta-Analysis; Multicenter Study; Observational Study; Patient Education Handout; Periodical Index; Personal Narratives; Portraits; Practice Guideline; Pragmatic Clinical Trial; Published Erratum; Randomized Controlled Trial; Research Support, American Recovery and Reinvestment Act; Research Support, N.I.H., Extramural; Research Support, N.I.H., Intramural; Research Support, Non-U.S. Gov’t; Research Support, U.S. Gov’t, Non-P.H.S.; Research Support, U.S. Gov’t, P.H.S.; Research Support, U.S. Government; Retracted Publication; Retraction of Publication; Review; Scientific Integrity Review; Systematic Reviews; Technical Report; Twin Study; Validation Studies; Video-Audio Media; Webcasts; Overall; Congresses; Consensus Development Conference; Consensus Development Conference, NIH; Clinical Conference.	97 (1964-2017)
ProQuest Central	(ab(simulation) OR ab(“simulation technology”) OR ab(“Patient Simulation”) OR ab(simulations) OR ab(“simulated patients”) OR ab(“Simulation Training”) OR ab(“High Fidelity Simulation Training”)) AND (ab(“Workplace Violence”) OR ab(“lateral violence”) OR ab(“horizontal violence”) OR ab(Aggression) OR ab(“physical violence”) OR ab(“Physical Abuse”) OR ab(“verbal abuse”) OR ab(“Sexual Harassment”) OR ab(Bullying) OR ab(mobbing))	Language: English (Portuguese, Spanish, French, Italian –inexistent); Polish e Russian were excluded. Date: until 2017. The following article types were excluded: news, dissertation/thesis. The other types were maintained (article, feature, commentary, correspondence, working paper/pre-print, editorial, general information).	75 (1978-2017)
CINAHL	S1 AB simulation OR AB “simulation technology” OR AB “Patient Simulation” OR AB simulations OR AB “simulated patients” OR AB “Simulation Training” OR AB “High Fidelity Simulation Training” S2 AB “Workplace Violence” OR AB “lateral violence” OR AB “horizontal violence” OR AB Aggression OR AB “physical violence” OR AB “Physical Abuse” OR AB “verbal abuse” OR AB “Sexual Harassment” OR AB Bullying OR AB mobbing	Language: English (Portuguese, Spanish, French, Italian – inexistent). Date: until 2017.	12 (2008-2017)

Category	Study Data*	Base/Theory	Design/ Measurement	Participants	Measures	Simulation Debriefing	Violence topic	Synthesis of results and SE**
Category I	S1⁽²⁷⁾ Martinez (2017) United States	Kolb’s experiential theory	Pilot study, without control group, pre and post	Nursing students	MHNCCS◊; questionnaires built for the study	Simulated setting Y‡	Excited psychiatric patient	Confidence and knowledge increased after the simulation. In some cases, the results of the evaluation of knowledge remained the same or were smaller in post-simulation than in pre-simulation. SE: II.
	S3⁽¹⁴⁾ Wong et al (2015) United States(?)†	Kolb’s experiential knowledge theory	Survey-based design, pre and post	Emergency team workers	Management of Aggression and Violence Attitude Scale - MAVAS	Simulated settings, excited patients Y	Patient violence	Three constructs improved substantially: internal/biomedical factors, external/team factors, and situational/interactive perspectives. Behavior reactions regarding the management of patient violence was not statistically significant. SE: II.
	S4⁽²⁸⁾ Kotora et al (2014) United States	Department of Homeland Security’s IS:907 Active Shooter course	Quasi-experimental study with mixed, pre and post methods	Nurses, residents and medical students	Questionnaire elaborated (face validity)	Training with didactic methods and setting Y	Active shooter(s) in a hospital emergency unit	It was identified a statistically significant difference between the pre and post-implementation in relation to the questionnaire scores. There was no difference in the nurses’ scores. SE: II.
	S5⁽²⁹⁾ Mallette et al (2011) Canada	Kirkpatrick model Bandura self-efficacy theory	Experimental efficacy study, with control group, pilot study, pre and post	Nurses of a hospital	Questionnaire: demographic; reliable; knowledge (content validity); from the proposal of the National League for Nursing; Virtual-World Debriefing Questionnaire; The Global Rating Scale	Role play and practice in virtual patient unit Y	Horizontal violence at work (among nurses)	For the participants, all strategies were profitable. The participants’ satisfaction was greater in the e-learning method with virtual world experiential learning. The authors considered this combination an effective proposal to promote knowledge and skills regarding horizontal violence. SE: II.
	S6⁽¹³⁾ Nau et al (2010) Germany	Evidences and elements for program; educational theories; descriptions from the Universities ‘and Colleges’ Staff Development Agency; objectives, contents and methods	Pre and post-test design within and among groups, without control group, pre and post	Nursing students	Deescalating Aggressive Behaviour Scale (DABS)	Settings with simulation patients NSǂ	Deescalating Aggressive patients	Training participants managed setting A and B significantly better compared to the untrained. In some cases, there was a great improvement after implementation, while in others it was not verified or the performance was lower. SE: II.
	S9⁽³³⁾ McConville et al (2006) United Kingdom(?)	Self-efficacy theory	Pre and post-test design, without separation into control group or experimental, pre and post	Nursing students	Instruments developed for the study	Video clip NS	Nurses dealing with potentially difficult and sensitive patients	Results related to aggressive patient management were not statistically significant. However, pre and post-video clip analysis indicated that the average related to self-efficacy in dealing with aggressive patients increased after the module (3.04 vs 3.33). SE: II.
Category II	S2⁽³⁰⁾ Ulrich et al (2017) United States	-	Qualitative exploratory study, post	Senior nursing students	Reflection worksheet built for the study	Role play simulation Y	Bullying in nursing practice	Researchers concluded that the simulation was an effective pedagogy and promoted learning in the cognitive and affective dimensions. SE: III.
	S7⁽³¹⁾ Dickens et al (2009) United Kingdom	Authors have replicated previous publication, but have made some changes considering local variations	Audit study, cross-sectional Measurement during the setting	Participants from a psychiatric hospital	Demographics and experience data Audit tools have been developed	Simulated settings (violent aggressor) Y	Simulated Assault	14% used the correct procedures they learned previously to escape the assault in 10 seconds. 80% even not using the techniques they learned managed to escape within 10s. The probability of escaping from the use of any resource was significantly lower in the nursing team than in other clinical or nonclinical workers. SE III.
	S8⁽³²⁾ Moule et al (2008) United Kingdom	-	Study with mixed methods Assessment at one of the OSCE stationsǁ; Post	Nursing students pre-record and mentors	Vignettes, OSCE, experience assessment tool and marking sheet; Individual interviews	Simulation sessions Y	Management of violence/ aggression (one of the sessions)	Students and mentors received the simulation in a positive way. Mentors considered the learning from the simulation was multifaceted, allowing both practical development and acquisition of knowledge about teamwork, providing an opportunity to work collaboratively and to promote student confidence. SE: III.

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[1] Corresponding author Maiara Bordignon E-mail: bordignonmaiara@gmail.com