Promoting Confidence in Managing Clinical Aggression at a Paediatric Hospital Using High Fidelity Simulation-Based Education

Saturday, 21 July 2018: 9:30 AM

Marijke J. Mitchell, MN, RN
Neurodevelopment & Disability, Department of Paediatrics, Royal Children's Hospital, The University of Melbourne, Murdoch Children's Research Institute, Parkville, Melbourne, Australia
Katrina Williams, PhD
Neurodevelopment & Disability; Department of Paediatrics, Royal Children's Hospital, The University of Melbourne, Murdoch Children's Research Institute, Parkville, Melbourne, Australia
Fiona H. Newall, PhD, MN, BSc (Nsg), RN
Department of Paediatrics, Department of Nursing, The Royal Children's Hospital, Murdoch Childrens Research Institute, The University of Melbourne, Melbourne VIC, Australia
Jenni Sokol, MBBS
Simulation Program, Department of Paediatrics, Royal Children's Hospital, The University of Melbourne, Parkville, Melbourne, Australia


Children and young people exhibit challenging behaviours daily in the hospital environment which may result in injury or distress for the child and their family (Johnson, Bekhet, Robinson & Rodriguez, 2014; Johnson & Rodriquez, 2013). Challenging behaviour has been defined as behaviour which is “of such intensity, frequency or duration as to threaten the quality of life and/or the physical safety of the individual or others, and which is likely to lead to responses that are restrictive, aversive or result in exclusion” (Royal College of Psychiatrists, British Psychological Society, & Royal College of Speech and Language Therapists, 2007). Occupational violence and aggression (OVA) in hospitals is increasing globally (Evans, 2017) with one Australian study (N=4891) reporting 67% of nurses experienced OVA in the preceding 12 months and nearly 20% experiencing it on a weekly or daily basis (Shea, Sheehan, Donohue, Cooper & De Cieri, 2017).

The training program prior to this study, to manage clinical aggression (Code Grey response), involved a full day of lectures and short skill sessions. All new security staff, graduate nurses, and the mental health ward staff managing these patients are required to attend this training annually, whilst other nursing staff involved in managing clinical aggression, are encouraged to attend. Despite delivery of this program, code grey activations are increasing each year.

The purpose of introducing a high fidelity simulation experience to this training is to provide participants with an interactive learning experience in a clinical setting without patient risk. This style of training is important as it utilizes a learner focused, safe educational environment and has been shown to improve patient safety and staff confidence in non-technical skills (Lamb et al, 2015; Siassakos et al, 2011).

This study aimed to assess if the addition of a high fidelity 2 hour simulation training program designed to provide participants with experience in managing challenging behaviours in a hospitalized young person, increased confidence and perceived competence in managing challenging behaviours.


Two separate simulation exercises (of escalating difficulty) were delivered utilising a professional actor to play the role of the adolescent within the Management of Clinical Aggression (MOCA) training days. A structured debrief at the completion of each exercise was led by 2 trained members of the Simulation Faculty. Participants completed a written survey prior to, at completion of the simulation training program, and at 3-6 months following the MOCA training.

Ethical approval from the institution’s Human Research Ethics Committee was received (HREC 37142A). This study described confidence before and after the intervention and at follow-up using Likert scale questions. Themes were allocated for using qualitative methods for written comments.


Nine training days were conducted in 2017 with a total of 139 participants. Most (68%) participants had experienced clinical aggression as part of their routine work, with 51% overall reporting a lack of confidence managing these patients. Immediately following this training, 79% of all participants reported feeling more confident in managing clinical aggression. At an individual level, 47% reported a 1 point increase in confidence while 32% of participants reported a 2 or 3 point increase. Immediately following the training, 78% stated they felt they would be able to manage a situation involving clinical aggression. At 3-6 months following MOCA training, 65% of respondents (N=26) had been the recipient of clinical aggression. Continued confidence in managing clinical aggression was reported by 73% of respondents. Simulation based education was acceptable to participants with 100% stating they would recommend this training to colleagues. Reflective comments included: “extremely useful and practical,” “insightful, fun, thought-provoking,” and “engaging and practical,” “a great opportunity to be exposed to and practice a clinical aggression incident. The debrief/deconstruction of events was such an important learning experience.”


The high exposure to clinical aggression in this paediatric hospital reinforces the need for effective staff training. This is the first study of this kind and demonstrates high-fidelity simulation training increased confidence in participant’s ability to manage challenging behaviours of young people in the clinical setting with retention of perceived skills at 3-6 months following training.