https://doi.org/10.1177/10783903241308529
Journal of the American Psychiatric
Nurses Association
2025, Vol. 31(2) 121­–127
© The Author(s) 2025
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DOI: 10.1177/10783903241308529
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	Quality Improvement Manuscript
Introduction
There is substantial evidence in the literature that
addresses the rising levels of violence in the health care
system, especially emergency departments and inpatient
psychiatry with more than 30% of nurses either witnessing
or being victimized by violence (Abu, 2023; Aljohani
et al., 2021; Richmond et al., 2012). Acts of aggression
related to acute psychiatric illness often inflict physical
and psychological trauma on patients and staff (Aljohani
et al., 2021; Wong et al., 2015). In addition, the fear for
one’s own safety and lack of confidence in the use of deescalation
skills has become a major contributor to nurses
leaving our profession (Li et al., 2019; Mitchell et al.,
1308529JAPXXX10.1177/10783903241308529Journal of the American Psychiatric Nurses AssociationBowllan et al.
research-article2025
1
Nancy M. Bowllan, EdD, MSN, RN, University of Rochester Medical
Center, Rochester, NY, USA
2
Heather P. O’Brien, MS, RN NPD-BC, University of Rochester
Medical Center, Rochester, NY, USA
3
Courtney Blackwood, MS, RN NE-BC, University of Rochester
Medical Center, Rochester, NY, USA
4
Wendi F. Cross, PhD, University of Rochester Medical Center,
Rochester, NY, USA
5
Patrick Walsh, PhD, MPH, University of Rochester Medical Center,
Rochester, NY, USA
Corresponding Author:
Nancy M. Bowllan, Nurse Educator/Clinical Nurse Specialist,
University of Rochester Medical Center, Department of Psychiatry,
601 Elmwood Avenue, Rochester, NY 14642, USA.
Email: nancy_bowllan@URMC.rochester.edu
Implementation and Evaluation of a
High-Fidelity, Interprofessional
Simulation Project Using Standardized
Patients to Address Aggression in a
Psychiatric Emergency Department
Nancy M. Bowllan1
, Heather P. O’Brien2
, Courtney Blackwood3
,
Wendi F. Cross4
, and Patrick Walsh5
Abstract
INTRODUCTION: Increased aggression in a regional Comprehensive Psychiatric Emergency Program (CPEP) led
to a significant rise in physical assaults, restraints, and use of security personnel. Root cause analysis revealed a
need for more extensive training on de-escalation, teamwork and communication. AIMS: This quality improvement
project evaluated the impact of an interprofessional, high-fidelity simulation project on interdisciplinary collaboration
to manage de-escalation and aggression safely and effectively. METHODS: Interdisciplinary team members (N = 171
nurses, psychiatrists, social workers, crisis specialists, and safety officers) participated in a 2.5-hr educational initiative
that included Crisis Prevention Intervention (CPI) and Team Strategies and Tools to Enhance Performance and Patient
Safety (TeamSTEPPS) interventions, high-fidelity simulation using standardized patients, observation, and debriefing.
Quantitative data collection and analysis included the use of the Confidence in Coping with Patient Aggression
Instrument (CCPAI), TeamSTEPPS Perception Questionnaire (T-TPQ), pre–post data on restraints, injuries, and an
educational survey. A qualitative analysis of debriefing themes was also performed. RESULTS: Statistically significant
improvement was noted in individuals’ confidence to manage aggression. In addition, data collected over a 5-month
period before and after simulation demonstrated a 35% reduction in restraints and a 52% reduction in injuries.
Interestingly, quantitative evidence revealed no changes in perceptions of teamwork. Results from the educational
survey highlighted the positive impact of standardized patients and debriefing, and gaining new insights into patient
care. Qualitative analysis of debriefing themes revealed educational opportunities to improve communication, role
clarity, de-escalation, and insights into patient impact. CONCLUSION: The use of high-fidelity simulation with
standardized patients has the potential to strengthen interdisciplinary collaboration to safely manage aggression in an
acute psychiatric setting.
Keywords
simulation, aggression, psychiatry, education
122	 Journal of the American Psychiatric Nurses Association 31(2)
2020).The 2020American Psychiatric NursesAssociation
Position Statement on Violence Prevention underscores
the ethical and professional responsibility to facilitate and
implement interventions and strategies to reduce and ultimately
prevent violence. Further highlighted was the
importance of teaching and promoting violence prevention
approaches and skills for nurses (American
Psychiatric Nurses Association [APNA], 2020).
Simulation-based education has been shown to
improve interpersonal and team communication, and
improve patient safety (International Nursing
Association for Clinical Simulation and Learning
[INACSL], 2016; Kaplonyi et al., 2017; Mitchell et al.,
2020; Thomson et al., 2013; Vestal et al., 2017; Wong
et al., 2015; Young et al., 2022). The use of standardized
patients enhances a high-fidelity simulation experience
by providing a highly structured, scripted level of realism
and intensity to the training. These standardized
patients are actors or lay persons who are trained to roleplay
a variety of mental health conditions and crisis situations.
They are further coached on providing feedback
to participants immediately following the simulation.
Participants have reported the use of standardized
patients in training is more beneficial than didactic lectures
or other written learning resources (Jee et al.,
2018; Lewis et al., 2017; Shawler, 2008). This immersive
educational experience using standardized patients
provides a realistic and safe opportunity to improve
competence in de-escalation skills, interdisciplinary
teamwork, and communication during a behavioral crisis.
An additional important aspect of simulation is
debriefing which plays a critical role by providing a safe
and respectful space following the experience to engage
in self-reflection, critical thinking, cognitive development,
role clarity, and communication to enhance clinical
practice (Clapper & Knowles, 2010; Fanning &
Gaba, 2007; Neill & Wotton, 2011).
The Comprehensive Psychiatric Emergency Program
(CPEP) used for this project was implemented in a large
northeast medical center. Clinical care is provided by an
interdisciplinary team of psychiatric nurses, psychiatrists,
social workers, crisis specialists, and public safety officers.
Since 2020, there has been a significant increase in
CPEP admissions for assessment, crisis management, and
triage to inpatient or outpatient services. Parallel with
this, there has been a rise in aggression, assaults, restraints,
patient/staff injuries, use of safety officers, and staff turnover.
Following a major incident in late 2020, a root cause
analysis revealed a significant need for more extensive
interprofessional training on de-escalation, teamwork,
leadership, and communication. Although there is significant
data in the literature to support the positive impact of
high-fidelity simulation with students and residents
(Thomson et al., 2013; Vestal et al., 2017), there is a
scarcity of publications on the integration of high-fidelity
simulation using standardized patients in a psychiatric
emergency department with interdisciplinary clinical
teams. The aim was to describe the development, implementation,
and evaluation of a high-fidelity simulation
using standardized patients with an interdisciplinary
CPEP team to improve safe clinical practice.
Methods
Design
Led by psychiatric nursing leadership, an interdisciplinary
task force was established that included a lead psychiatrist,
psychiatric nurses, social workers, department of
public safety, and crisis specialists. The psychology simulation
laboratory director, and a diversity and inclusion
specialist provided ongoing consultation. The overarching
goal was to develop an educational quality improvement
project that would address the management of potential
aggression and improve interdisciplinary collaboration
and safety for patients and staff. Quantitative and qualitative
data analysis was used to evaluate outcomes.
Participants
Individuals from all health care disciplines in CPEP were
eligible to participate. Travelers and temporary employees
were excluded. Participants included psychiatric nurses,
psychiatric nurse practitioners, psychiatrists, psychiatric
residents, social workers, psychiatric technicians, crisis
specialists, and security personnel. Standardized patients
who had worked at the medical center in other educational
mental health initiatives were used to assist with training.
An institutional determination checklist was used and
determined the Institutional Review Board (IRB) approval
was not required for this quality improvement project.
Setting
The setting used for this high-fidelity simulation education
consisted of the Department of Psychiatry simulation laboratory,
technician room, and the observation/debriefing
room. Life-size cardboard people were placed in the simulation
laboratory room along with a large mural of the view
of the CPEP nurse’s station from the patient waiting area.
In addition, the hallway adjacent to the simulation laboratory
room depicted the nurse’s station in CPEP and needed
equipment. All patient supplies such as the vital signs
machine, laptop on wheels, bed board, personal hygiene
items, towels, gowns, snacks, simulated medications, and a
restraint bed were available in the identified nursing station.
There was a designated space for the interdisciplinary
team to discuss clinical assessments, plan of care, and role
Bowllan et al.	 123
responsibilities during simulation. A 45-min debriefing
session in a large conference room followed the simulation
and the facilitator explored perceptions, roles, and feelings
to improve understanding and clinical competence when
working within a team to manage a behavioral crisis.
Data Collection
Two instruments were used to collect quantitative data
before and after the simulation. The TeamSTEPPS
Teamwork Perception Questionnaire (T-TPQ) is a 35-item
survey that assesses knowledge, performance, and attitude
related to leadership, communication, situation
monitoring, and mutual support (Agency for Healthcare
Research and Quality, 2020; Battles & King, 2010). The
Confidence in Coping with PatientAggression Instrument
(CCPAI) is a 10-item Likert-type scale intended to measure
the potential impact of simulation on participants’
confidence in managing aggression during a behavioral
crisis (Thackrey, 1987). Permission was granted for both
instruments. Study data were collected and managed
using REDCap (Research Electronic Data Capture) electronic
data capture tools hosted at the University of
Rochester Medical Center ( P. A.Harris et al., 2009;
R.Harris et al., 2019). REDCap is a secure, web-based
software platform designed to support data capture for
research studies.
Instruments were completed at the beginning of the
simulation session using a QR code and REDCap technology
for data collection. The Confidence in Coping
instrument was also completed following the simulation
session to assess the initial impact of the intervention on
confidence. The second TeamSTEPPS Perception survey
was administered electronically 3 months following the
intervention to assess the prolonged impact on various
dimensions of teamwork. A 10-item, Likert-type scale
educational survey developed by the authors was also
completed. Per institutional policy, all restraint and injury
data were documented on a standardized form and
reported daily. Authors were able to access these data and
compare findings for 5 months prior to the simulation to
5 months following the simulation.
In addition to quantitative measures, a qualitative
analysis using a focus group approach for each of the
debriefing sessions occurred. Notes were taken by an
identified scribe, an advanced practice psychiatric nurse.
Procedures
The International Nursing Association for Clinical
Simulation and Learning (INACSL): Standards of Best
Practice was the framework used for this project and
included simulation design, outcomes and objectives,
facilitation, debriefing, and participant evaluation
(INACSL, 2016). Meeting biweekly for several months,
the interdisciplinary task force developed the following
learning outcomes: (a) Describe and demonstrate effective
communication skills during a behavioral emergency,
including identifying barriers, increasing self-awareness
of own beliefs and personal responses, along with the elements
of TeamSTEPPS, (b) Describe and demonstrate
effective interdisciplinary teamwork during a behavioral
emergency, including role clarity, leadership, respect,
collaboration, and elements of TeamSTEPPS, (c) Apply
effective violence mitigation and de-escalation techniques
during a behavioral emergency incorporating
Crisis Prevention Intervention (CPI) de-escalation techniques,
(d) Demonstrate ability to share thoughts and
feelings during the debriefing related to caring for aggressive
patients, engaging in self-reflective practice, using a
non-judgmental approach when discussing differing perspectives
and challenges, and engaging in conversation to
explore unique considerations when working with persons
of varying cultures, races, and genders.
There was a total of 17 sessions held over a 2-month
period. Notably, 14 staff per session were divided into
two distinct interdisciplinary teams. One team participated
in a 15-min simulation followed by an 8-min feedback
session. The simulation was observed by the second
team via closed-circuit television in a conference room.
Following this, teams were switched. This provided an
opportunity to experience two simulations, one through
direct participation and one through observation facilitating
a richer debriefing discussion. Figure 1 depicts this
simulation process. A 45-min debriefing session was held
at the end of the simulation experience with both groups
participating together.
All participants were required to review a 1-hr online
Crisis Prevention Institute (CPI) module on de-escalation
prior to simulation. At the beginning of each simulation,
an overview of the process was provided along with the
highlights of CPI de-escalation strategies (Crisis
Prevention Institute, 2016) and TeamSTEPPS elements
(Agency for Health care Research and Quality, 2020). In
addition, clear mutual expectations were posted and
reviewed to promote a supportive, safe learning experience.
Standardized patients were paid an hourly rate for
training and education on psychiatric clinical conditions
and behaviors to be demonstrated. CPEP scenarios were
developed using expert psychiatric nurses’ clinical experiences
and input from CPEP nursing leadership input
and the lead security officer. Two male and one female
standardized patients were hired. In consultation with the
simulation laboratory director, two female and two male
escalating agitation clinical scenarios were developed
with scripts. Clinical presentations included psychosis
with the risk of physical violence toward others, a patient
attempting self-harm behavior with a sharp object, and a
124	 Journal of the American Psychiatric Nurses Association 31(2)
patient experiencing mania with a significant trauma history,
threatening to harm others. All scenarios involved
refusing medication, as this is a significant challenge in
CPEP. To align with high-fidelity simulation standards of
practice, standardized patients were also trained to lead
an 8-min feedback session with each clinical group following
simulation.
To ensure each high-fidelity simulation experience was
facilitated in a structured, time-framed, and consistent
manner, four distinct roles were developed. The
Observation Instructor set up the simulation space, welcomed
participants, directed them to begin pre-surveys
using a QR code, oriented staff to the environment, and
monitored the observation group.The Facilitator Instructor
coordinated all simulation sessions, communicated group
expectations and individual roles, described workflow,
distributed self-reflection worksheets following each simulation,
and assisted with debriefing through observation
and note-taking. The Debriefing Instructor had no direct
contact with participants during the simulation, remained
in the simulation production room to observe, take notes,
stop the simulation if needed, and facilitate debriefing
sessions with all participants. The debriefing instructor
followed an established framework and process for
debriefing based on a review of the literature (Clapper &
Knowles, 2010; Fanning & Gaba, 2007; Neill & Wotton,
2011; Rudolph et al., 2006).An additional significant role
was the Simulation Laboratory Director who oversaw the
simulation laboratory environment and technology.
Communication and teamwork were key to a successful
simulation experience. For each of the 17 simulation sessions,
a worksheet was created with dates, names of staff
and assigned roles for the session, names of participants
by discipline for the session, simulation technician staff,
the standardized patient assigned for the session, and a
summary of which scenarios would be run that day. Two
scenarios were chosen per session based on the training
the assigned standardized patient had received. To promote
fidelity to the process, a folder was created and given
out at each session with laminated instructions for each
instructor’s assigned role, resources for their specific
duties, and a session worksheet.
Analysis
Demographic and descriptive statistics of participants
were performed and summary statistics were calculated
for survey measurement tools. Paired data were used to
assess outcome measure changes over study time periods
with nonparametric Wilcoxon signed-rank tests and
t-tests, depending on variable distribution. Data were
analyzed using IBM SPSS Statistics (Version 29).
Quantitative analysis was completed by an expert psychologist
in statistical analysis. Thematic analysis was
used to analyze the notes transcribed during debriefing
sessions. Three senior psychiatric nurses analyzed these
notes independently to identify concepts and recurrent
emerging themes during the debriefing process. An additional
session was held to discuss individual findings,
merge themes, and identify key concepts.
Figure 1.  Timeframe of Simulation.
Bowllan et al.	 125
Results
Quantitative Findings
A total of 171 CPEP staff participated in a 2.5-hr highly
structured high-fidelity simulation in a dedicated simulation
laboratory area. This included 50 (95%) psychiatric
nurses/technicians, 16 (59%) psychiatrists, 29 (97%)
residents, 29 (67%) social workers, 4 (100%) nurse practitioners,
12 (86%) crisis specialists, and 31 (100%) security
personnel. Survey data were collected from 160
simulation participants, of whom the participation rates
for both pre- and post-surveys were 89.3% and 50.3%,
respectively.
For participants with both pre- and post-simulation
CCPAI participant scores, the median scores (range) were
67.00 (29.00–110.00) before and 76.00 (27.00–110.00)
after the simulation A Wilcoxon signed-rank test on
paired pre–post data indicated confidence to manage
aggression was significantly higher after the simulation
than before the simulation (z = −8.01, p < .01). For the
TeamSTEPPS Perception survey data, the mean of T-TPQ
participant scores was 3.84 ± 0.66) pre-simulation and
3.76 ± 0.56 3 months post-simulation. Comparative analysis
with a paired t-test did not indicate a significant
change pre-simulation and 3 months post-simulation
(t(67) = 1.23, p = .22) on teamwork, communication, and
leadership development. The educational survey findings
reflected a 66.0%–83.0% positive response to this highfidelity
simulation for learning and confidence (Table 1).
In addition, data on the use of restraints and staff injuries
were compared before and after the simulation. A
total of 243 restraints were documented over a 5-month
period before the simulation and 158 restraints were documented
over a 5-month period following the simulation
demonstrating an overall reduction in restraints by 35%.
A total of 23 injuries were reported over a 5-month period
before the simulation and 8 injuries were reported over a
5-month period following the simulation demonstrating a
52% reduction in staff injuries.
Qualitative Findings
The analysis of notes transcribed during debriefing sessions
revealed prominent themes. Participants discussed
varying degrees of tolerance for aggression by staff
resulting in a negative impact on both patients and teamwork
(Theme 1). For example, an experienced nurse who
accepts a patient becoming more agitated due to underlying
fear and frustration versus a newer nurse who intervenes
quickly at any sign of aggression with more
restrictive measures, such as a request for immediate
security intervention or potential restraint, based on their
own fear or uncertainty. This contributes to frustration
between coworkers and increased agitation by the patient
due to inconsistent responses to escalating aggression. A
standardized set of expectations with corresponding consistent
levels of intervention may reduce this concern.
The repeated use of unclear language that is agitating to
patients, such as “We need to follow the process,” with no
further explanation can result in increased confusion, distrust,
and agitation by the patient (Theme 2). Participants
described a lack of trust across disciplines based on varying
degrees of training and repeated turnover (Theme 3)
and a consistent lack of understanding of who is in charge
during a behavioral crisis (Theme 4). This was evident in
the lack of identifying a leader for the behavioral crisis
and confusion as to each discipline’s role. Role clarification
during a behavioral crisis with clear identification of
a leader would potentially improve safety for both
patients and staff. An additional theme (Theme 5) identified
by some staff was a sense of being devalued, if not
“invisible,” as a member of the clinical team. Staff
describe this contributed to feeling demoralized and
burnt out. This can further heighten staff frustration,
turnover, and inability to provide quality, safe care.
Continuous supervision and strengthening the value of
each team member has the potential to improve this concern.
Qualitative analysis revealed a need for further education
on communication, role clarity, de-escalation,
Table 1.  Educational Survey Results for Agree/Strongly Agree.
Question n %
The standardized patient experience helped me feel confident in my ability to use the skills 109 73.6
The standardized patient experience was realistic 113 76.4
Feedback from the standardized patient was helpful 112 82.4
Overall, the standardized patient experience will positively affect my work/role 116 79.5
Debriefing provided a safe opportunity to further explore my thoughts and feelings 129 87.8
I feel more confident working with the interdisciplinary team during a crisis 113 78.5
I feel confident applying effective violence mitigation and de-escalation techniques during a crisis 105 71.9
I feel more confident integrating racial/ethnic and multicultural approaches into my role 97 66.0
Today’s discussion gave me new insights and experiences of patients, families, and coworkers 118 79.6
Participation in this experience was a meaningful way to learn 122 83.0
126	 Journal of the American Psychiatric Nurses Association 31(2)
self-awareness, and insights into the impact on patient
care. In all sessions, observation revealed the power of a
collective experience to enhance perspectives, reduce the
sense of isolation, and improve communication.
Discussion
The purpose of this case was to describe in detail the
development, implementation, and evaluation of a highfidelity
simulation using standardized patients with an
interdisciplinary psychiatric emergency department team.
As previously noted, simulation is well supported in the
literature as an educational tool for teaching students and
professional staff at all levels of practice. The findings in
this report suggest the use of high-fidelity simulation provided
in “real time” with standardized patients is a safe
and effective learning experience for interdisciplinary
clinical teams to strengthen knowledge, skills, and attitudes
related to caring for aggressive patients (Lewis
et al., 2017; Mitchell et al., 2020; Young et al., 2022).
Furthermore, the findings suggest high-fidelity simulation
using standardized patients followed by a debriefing
process, enhance participants’ level of confidence and
comfort when responding to aggression, and improve
interdisciplinary communication and self-reflective practice
(Mitchell et al., 2020; Thomson et al., 2013).
As noted in the educational survey findings, participants
provided substantial positive support for the use of
standardized patients and a focused debriefing process as
an important and meaningful educational experience to
strengthen overall learning and confidence in managing
aggression. This finding has been supported previously in
the literature (Simulated Interprofessional Team Training,
2017; Young et al., 2022). It is important to further underscore
the substantial reduction in restraints and staff injuries
reported in the findings. This lends additional support
to the positive impact of high-fidelity simulation with
standardized patients on the staff’s improved competence
to manage potentially aggressive patients while maintaining
a higher level of safety. This is a substantive finding as
there is a lack of evidence in the literature that directly
correlates the use of high-fidelity simulation training with
standardized patients to a reduction in restraints and
injuries.
Several strategies were used to strengthen the intervention
and its fidelity including (a) clearly defined roles
and interventions of simulation providers, (b) two identified
individuals in the facilitator role or debriefing process
for all sessions, (c) training standardized patients and
providing set scripts, and (d) all debriefing instructors
participated in the training and followed a clear, written
framework for facilitation.
One limitation to this study was that it was single-site
study, therefore findings are not generalizable to the
larger population. An additional limitation is related to
data collected from TeamSTEPPS Perception Survey
data. Due to the lack of significance in comparing teamwork
data between pre–post measures, a correlation
between the impact of high-fidelity simulation on the
improvement in multiple teamwork dimensions could not
be made. Consideration for alternative methods to obtain
follow-up survey data could assist with improving
response rates.
Conclusion
Considering the rise in aggression and potential harm in
emergency departments, institutions must commit to educational
initiatives for clinicians beyond traditional
didactic approaches. The use of high-fidelity simulation
using standardized patients to address behavioral emergencies
provides a unique and engaged learning experience
that can strengthen interdisciplinary clinical practice
while potentially reducing harm to patients and staff.
Furthermore, including measurable outcome data specific
to the use of restraints and injuries when implementing
high-fidelity simulation with standardized patients
has the potential to provide further data to evaluate the
efficacy of interventions implemented to reduce restraint
use and injuries to staff and patients.
Author Roles
All authors contributed to the conception or design of the
study or to the acquisition, analysis, or interpretation of the
data. All authors drafted the manuscript or critically revised
the manuscript, and gave final approval of the version that
was submitted for publication. All authors agree to be
accountable for all aspects of the work, ensuring integrity and
accuracy.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
ORCID iDs
Nancy M. Bowllan https://orcid.org/0009-0007-5361-4005
Wendi F. Cross https://orcid.org/0000-0001-5873-4937
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