To train the participants in managing an aggressive patient with a diagnosis of schizophrenia. The focus is on de-escalation, safety and teamwork to resolve the situation effectively while ensuring the safety of other patients and staff.

Characters

Patient: A homeless young man with frostbite on his legs, suffering from schizophrenia and experiencing hallucinations. After a blood test, he becomes aggressive, convinced that someone is trying to harm him. He starts throwing objects and yelling.

Staff: Two nurses must cooperate to manage the situation. Their goal is to de-escalate the aggression, ensure safety and guide the patient outside, where a psychiatric team is waiting.

Setting

A busy emergency department with two other patients in nearby beds, separated by

curtains. These patients are unable to evacuate themselves and may become distressed

by the commotion.

Roles Key Behaviours

Aggressive Patient:

Portray realistic agitation and paranoia.

Escalate behaviour in response to perceived threats but respond when the nurses demonstrate empathy and understanding and be persuaded to exit the room.

Nurse 1 (Senior nurse)::

Take the lead in managing the patient’s aggression.

Use de-escalation strategies such as active listening, empathy and simple, clear communication. Signal for additional help as needed.

Nurse 2 (Junior nurse): :

Support Nurse 1 by ensuring the safety of other patients and managing the environment.

Assist in calming the aggressive patient using non-verbal support or simple tasks (e.g., offering water, removing potential hazards).

Coordinate discreetly with Nurse 1 to call for external help or adjust the environment for safety.

Warm-up

As a warm-up, ask the students to brainstorm as a group the de-escalation techniques and strategic positioning that could be used before handing them the role cards.

(In the real-life best practice example this role-play is based on, the situation developed as follows:

“In the immediate response, staff maintained a safe personal distance and took flight, the police were contacted, and management (chief and lead physician) were notified.

The patient escaped from the bed and ran to the corridor. The staff had already moved the patients from the waiting room into ambulances. The patient, under the influence of hallucinations, ran down the corridor, tried to break the door and attacked the plexiglass wall of the triage area.

After this attack, a staff member shouted: “What's going on?” The patient replied: “Where is the one who is supposed to kill me?” The staff member replied: “He's outside, you must go outside!”

The patient ran outside where security and police were already waiting.

Simulation Flow

Setup

Arrange the room with a bed for the aggressive patient, props for throwing (non-dangerous items like paper cups, gauze) and curtains separating the two other “patients.”

Place Nurse 1 and Nurse 2 near the patient’s area, prepared to respond when the aggression begins.

Introduction

Brief each participant on their role privately. Emphasize their goals and behaviours.

Stress to the nurses the importance of prioritizing safety and avoiding physical confrontation.

Execution

The simulation begins with the patient showing signs of agitation, escalating to throwing objects and yelling.

Nurses must work together to de-escalate the patient and guide him outside while ensuring the safety of other patients.

Resolution

The simulation ends when the patient leaves the room to meet the psychiatric team, or if the nurses successfully de-escalate the situation to a manageable level.

By the end of the simulation, the participants should be able to:

1. Demonstrate the ability to recognise early signs of escalating aggression in patients ensuring timely intervention.
2. Demonstrate effective use of empathy, active listening and non-threatening communication to calm an aggressive patient
3. Prioritize the safety of staff, patients and the aggressive individual by following appropriate safety protocols and environmental awareness
4. Collaborate effectively with a colleague to manage the situation, including signalling for external help when necessary
5. Maintain composure and professionalism under pressure during a high-stress situation

Possible Distractors or Additional Cues

Think of an institutional/ hospital guideline, policy or protocol which could inadvertently create challenges for smooth management of an aggressive patient. Ask the students to think about how this policy might impact their response and ask them to apply it during the simulation.

1. Self-reflection – the participants share their immediate emotional reactions to the simulation
2. Analysis - explore together what happened during the simulation and why certain actions were taken and their outcomes.
3. Highlight the strengths demonstrated by the students and identify areas for improvement.
4. Summarize main learning points from the session.