To train the participants in managing an aggressive patient with 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 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, tries to open the window.

Staff:

Two paramedics 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 other patient in nearby bed, separated by curtains. This patient is unable to evacuate, 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 paramedics demonstrate empathy and understanding and be persuaded to exit the room.

Nurse 1 (Senior paramedic):

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 paramedic):

Support Paramedic 1 by ensuring the safety of other patients and controlling the environment.

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

Coordinate discreetly with Paramedic 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 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 to the corridor. The staff had already moved the patients from the waiting room to 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, someone from the personnel 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 other “patient”.

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

Introduction

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

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

Execution

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

Paramedics must work together to de-escalate the patient and guide him outside while ensuring the other patients remain safe.

Resolution

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

Learning outcomes

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

1. demonstrate effective use of empathy, active listening and non-threatening communication to calm an aggressive patient,
2. prioritize the safety of staff, patients and the aggressive individual by following appropriate safety protocols and environmental awareness,
3. collaborate effectively with a colleague to manage the situation, including signalling for external help when necessary,
4. 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 apply it.

Debriefing Plan

1. Self-reflection – the participants express their immediate emotional reactions to the simulation
2. Analysis - explore together what happened during the simulation and why.
3. Highlight strengths and areas for improvement.
4. Summarize main takeaways from the session.