Story by Mackenzie Thomas
Photos by Jinrui Liu
A patient was in pain, frustrated because she felt like no one was listening to her.
Emily Barksdale, a nursing student at UNC-Chapel Hill at the time, walked in and asked the patient to describe her pain, and to help her and the other providers understand her frustration.
The patient turned and looked Barksdale straight in the eye before exclaiming, “WHAT? Are you trying to psychoanalyze me, bitch?”
But it wasn’t real.
It was a simulation, Barksdale said, recreating workplace violence that nurses can encounter in the field. Simulations have been implemented in nursing programs across North Carolina—and nationwide— to provide nurses with hands-on training in how to deal with everything from running codes to handling potentially violent patients.
In January, the School of Nursing at UNC-Chapel Hill, along with UNC Medical Center and UNC Health Rex, ran its first sessions of a new program for nursing students and health care staff to better address workplace violence.
It’s one thing to learn about workplace violence prevention and de-escalation practices in the classroom, said Valerie Howard, dean of the UNC School of Nursing. But you can’t really solidify those skills until you experience a situation that forces you to put that knowledge to the test. “It’s almost like using theater to teach nurses,” Howard said.
Though workplace violence prevention and de-escalation are already taught and practiced in many nursing schools across the country, including UNC-CH, there is a dire need for this kind of immersive, hands-on training. A 2023 survey from National Nurses United shows that 8 in 10 nurses have experienced at least one type of workplace violence within the past year, and 6 in 10 RNs reported either considering or actually leaving their job— or the profession itself— due to workplace violence.
The prevalence of workplace violence is why schools like East Carolina University and UNC-CH have been enhancing their nursing programs, and it’s why UNC-CH rolled out this grant-funded program utilizing the “tag team” approach in the spring.
“We know that one out of every four nurses will experience some sort of workplace violence during their career. That could be physical, mental, emotional abuse,” Howard said. “It could be harassment, bullying. It’s not always just the physical violence that we think of.”
Though the grant’s funding for the program ended in July and administrators have been reviewing the results, Howard said she’d like to continue the program after receiving overwhelmingly positive feedback from students. She believes more training like this has the potential to improve retention and decrease burnout of nurses everywhere.
How it started
For years, workplace violence was just considered part of the job, said Bonnie Meadows, president of the North Carolina Nurses Association and a nurse with more than 20 years of experience.
“Back in the day, when I first started, it was, ‘Oh well, it comes with the territory, it goes with the job,’” Meadows said. “And honestly, our wording towards that, it probably has just recently changed.”
And violence didn’t always come from the patient, Meadows said.
“I love working with doctors all day long. I love working with surgeons, all the things. But we used to make it okay when they would just get upset and throw instruments and do all of these things,” Meadows said. “You would talk about it, but you wouldn’t really talk about it.”
Howard recalled a similar culture when she worked as a nurse in the emergency room roughly three decades ago.
“We really didn’t talk about the violence that occurred in the workplace. It was a part of your job as a nurse, and you just had to deal with it,” Howard said. “And you might have had an abusive patient or a co-worker or something happen, you just moved on from that, and no one really addressed it. No one took it seriously.”
Fast-forward to the spring of 2024, when Howard and members of nursing leadership from UNC Medical Center and UNC Health Rex—all part of a partnership known as the Tar Heel Academic Practice Partnership— came together at a retreat and expressed their desire to work on something that could make an impact on nursing practice and the profession.
That’s when the topic of workplace violence came up, Howard said.
After the TAPP retreat, the nonprofit organization AARP issued a call for grant proposals for the AARP Health Equity and Nursing Innovation Fund, Howard said. TAPP and the NC Future of Nursing Action Coalition, an initiative to improve health care through nursing in the state, submitted a proposal and, in July 2024, were one of 12 recipients awarded the grant nationwide. They received $25,000, an amount matched by UNC Health’s Robert A. Ingram Institute for Equitable Healthcare Access, and they put those funds toward developing the simulation training program, according to a press release.
After roughly six months of developing, testing, and having the scenarios reviewed by the Coalition and other experts, three workplace violence scenarios were created, Howard said.
The first scenario dealt with a verbally abusive, confrontational parent of a child patient who was being involuntarily committed; the second—the one Barksdale participated in— dealt with a patient experiencing severe pain, and the situation escalated because the patient felt like health care providers weren’t listening; the third dealt with a co-worker trying to bully the nurse into doing something that didn’t align with policy, Howard said.
The training was voluntary, and multiple sessions were run throughout the spring semester for nursing students, Howard said. The number of participants per group varied, but Barksdale said her group had roughly 25 people total.
“We thought that we could do this maybe three times and get our 150. That was our goal, to get 150 participants,” Howard said. “As it turns out, nurses have very busy schedules.”
How it works
While some simulations use manikins—models that replicate human anatomy—this training only utilizes human actors.
“When people think of simulation, they think about what’s happening downstairs in our sim lab, right, the beds, the manikin laying there,” Howard said. “We hired actors to come in and to portray these instances of workplace violence with nurses, and we had an audience sitting there. We did this in a classroom, very low budget, low cost, but very realistic.”
The simulation training received overwhelmingly positive feedback from nursing students, Howard said.
“All but a few of the participants, and when I say a few, I’m talking one or two, agreed that the training was extremely valuable: the pre-briefing that we did, the actual scenario, and then the debriefing, and they felt like this could translate into practice,” Howard said. “The results were very positive.”
Even if a student isn’t actively participating in a scenario, the interactive nature of the training— referred to as the “tag team” approach—requires them to remain engaged, Howard said. While half of the room can be tagged into the scenario by the director or another student at any moment to help, the other half of the room writes suggestions for the actors on note cards and gives them to the director. If the suggestion aligns with learning objectives, it will be incorporated into the scenario. The length of the scenarios varied, with some as short as five minutes, others as long as 20 minutes.
“You really do have to pay attention,” Howard said. “You immerse yourself in that situation. Everyone’s there to learn, that’s what we believe in simulation.”
East Carolina University’s College of Nursing uses a variation on the tag team method in their simulations, said Benjamin Abel, a spokesman for the college, and describes the overall training as “multifaceted in every encounter, asking students to complete their medical tasks with a consideration of the psychosocial dynamics of each experience.”
ECU has also received positive feedback for its simulation training program, which incorporates instances of workplace violence, said Bimbola Akintade, dean of the ECU College of Nursing.
“Technology has come a long way. Our manikins can sweat, they can blink, they have pulses,” Akintade said. “The technology is realistic, but then the way the case studies are presented and how it flows, students very quickly get into it. Students enjoy it. We get really positive feedback from simulated experiences with our students.”
Sydney Rogers, an ECU alumna who graduated in May, praised the training for providing opportunities to learn in a safe environment.
“Yeah, they’re really good. I like simulations,” Rogers said. “They give you an idea of what you could do better, and you don’t have the fear of messing up with an actual patient. Instead, you’re with an actor, you’re with some sort of dummy, and you can mess up there, than actually messing up in the real field. So they’re really helpful.”
Even so, Akintade said there is still room for improvement.
“We are currently revising our curriculum. All schools and colleges of nursing across the country are doing that to incorporate competency based education,” Akintade said. “So it’s already included, but there are opportunities to further expand on that.”
Though many positive learning experiences can be gained from workplace violence training, and participants are never in any real physical danger, Howard said it’s important to note the mental and emotional toll it can take on students.
“This can induce trauma, because when you are even just portraying the role of a nurse, and you have an actor who is playing the role of someone else yelling at you, there was some throwing of things, loud voices, this is what nurses and clinicians deal with sadly in the clinical setting,” Howard said. “We had to make sure that we were supporting all the learners, because this can be definitely triggering.”
The emotional toll was evident on some students’ faces even after just a couple of scenarios, Howard said, which is why time was built in to decompress after the second scenario in addition to the debriefs. On-call chaplains were made available to students as well. Having those emotional well-being resources in place to support students is crucial for this kind of training, Howard said.
“If a training was invoking these strong feelings and emotions, you can only imagine what happens in the clinical setting, in the real life setting, when these things happen,” Howard said.
How training can improve, and what it will mean for the future of nursing education
The grant funding for UNC-CH’s simulation training program ended in July, Howard said. As they have reviewed the results of the training, Howard said she would love to continue it in the future, incorporating more scenarios and rolling it out to the entire state, offering it to nurses and even other kinds of health care workers. Right now, the program’s future looks bright.
“I just presented to all the chief nursing officers of UNC Health, and they are very interested in sustaining this program and replicating it and rolling it out even to more hospitals, to more health care workers,” Howard said.
If given the green light, Howard said they have everything they need to continue the program, including a facilitator’s manual created using some of the grant funding to provide directions on how to implement this program in the future. The program would supplement the de-escalation training that is already a part of UNC-CH’s curriculum.
Akintade said he would like to see more discussion of workplace violence earlier in nursing students’ education.
“I think there’s more room, and maybe not waiting until it’s about time for them to graduate,” Akintade said. “Maybe we can introduce that earlier, which gives them the opportunity to advocate even in clinical, ever before they experience this as nurses.”
North Carolina is expected to face one of the worst nursing shortages in the nation, with current projections showing a 22% shortage in 2037, according to a 2024 report from the Bureau of Health Workforce. Better equipping nurses to handle workplace violence with training like this could help remedy that, and have a lasting positive impact on the profession, Howard said.
“Workplace violence is impacting retention and turnover,” Howard said. “So if we can address this and get a handle on it, there’s a good chance that we might be able to have more resilient nurses, decrease burnout, increase retention, decrease turnover on the units.”
The training is already making a positive impact on students’ learning. Barksdale, who graduated from the nursing school in May, said simulations are a great way to prepare students for interacting with people in real-world situations.
“If I’m going to be in a job where I’m up on my feet interacting with people, what better way to learn just anything, workplace violence related or not?” Barksdale said. “What better way to learn things than to be up on my feet and interacting with human beings?”
