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Using simulation to introduce nursing students to caring for victims of elder abuse and intimate partner violence.


Learning experiences about domestic violence may not be readily available to nursing students at their traditional clinical sites. Faculty at an associate degree nursing program developed and implemented elder abuse and intimate partner violence simulation scenarios for a Health Systems Concepts course. Learning objectives focused on assessment, safety, communication, education, and legal responsibilities for nurses. After the simulation, students participated in debriefing, completed student evaluations, and responded to three questions about the experience in their reflective journals. Faculty and students expressed satisfaction with this method of learning about domestic violence.


Simulation--Elder Abuse--Scenario--Nursing Education--Intimate Partner Violence


Each year more than 10 million women and men in the United States are victims of physical violence by an intimate partner (Centers for Disease Control and Prevention, 2015). Recent studies reported that 7.6 percent to 10 percent of study participants had experienced elder abuse during the previous year (Department of Health and Human Services [DHHS], 2015). Health care professionals often miss signs of elder abuse and intimate partner violence due to lack of knowledge and training (DeBoer, Kothari, Kothari, Koestner, & Rhose, 2013; DHHS; Starr, 2010).

Nurses are often the first health care providers to interact with victims of abuse. Thus, they are in a position to identify abuse and save the lives of victims and their family members by screening for, providing safety education about, and reporting abuse when required by law (DeBoer et ah, 2013; Starr, 2010). While the need to educate future nurses in domestic violence detection and intervention is evident, learning experiences in these areas may not be readily available to students at their traditional clinical sites.

A search of the literature for the period 2009 to 2014 using the terms simulation, nursing education, elder abuse, intimate partner violence, domestic violence, case study, and scenario in various combinations resulted in no articles on the use of simulation for educating nursing students about domestic violence. Starr (2010) did state that elder care simulation was being developed for a bachelor of nursing elective course on elder abuse but did not share any specifics of the planned scenario(s). Therefore, faculty at our community college associate degree nursing program made the decision to develop simulation scenarios for a summer 2014 Health Systems Concepts nursing course to provide students with planned clinical learning experiences in domestic violence.


Nurse faculty collaborated with the simulation coordinator to develop two scenarios, one on intimate partner violence and the other on elder abuse. Learning objectives for the intimate partner violence scenario focused on the following: 2014 National Patient Safety Goals (2014 NPSGs) used by accredited facilities to focus on patient safety issues (see Joint Commission, 2015 for current goals), nursing assessment, therapeutic communication, finding and offering referrals for needed resources and support services, and identifying and providing safety measures/policies in the organization. Learning objectives for the elder abuse scenario were: meeting 2014 NPSGs, identifying critical assessment findings, locating and reading facility policies for reporting suspected abuse, initiating abuse reporting to a charge nurse, and using the Situation Background Assessment Recommendation (SBAR) format for professional communication.

All 28 students in the course were familiar with the equipment and the method of simulation and had completed an assigned domestic violence worksheet. They were scheduled for the simulations in groups of three and drew randomly from one of three nursing student roles (assessor, recorder, or communicator). Both scenarios were completed during the course of one day. The intimate partner scenario lasted 30 minutes followed by a 50-minute debriefing. Students were then given a 15-minute break and were assigned to a different role for the 30-minute elder abuse scenario, which was also followed by a 50-minute debriefing.

Intimate Partner Violence Scenario

The first scenario utilized a moderate-fidelity manikin simulating a 26-year-old female who came to the emergency department to rule out ankle fractures from reportedly tripping and falling down her front steps. The simulation coordinator stayed out of student view and provided the voice of the manikin patient. As the students assessed the patient and questioned her about her multiple bruises and reddened areas (created with powdered eye shadow over a layer of dried rubber cement on the manikin's skin), she admitted that her husband had been jealous of her since he had lost his job. She had been working double shifts to make up for the lost income.

A second faculty member acted as a clinical nursing instructor and was available for student questions and consultation. The instructor asked questions about assessment data and gave the students copies of a local facility abuse policy, a list of community resources, and an abuse assessment tool (Basile, Hertz, & Back, 2007). Students then returned to the bedside to use therapeutic communication, gather additional information, offer community resources, and complete the abuse assessment tool.

The patient insisted she was all right and refused to implicate her husband. The scenario ended with the patient asking to call her husband to take her home from the hospital.

During debriefing, the simulation coordinator facilitated discussion by asking the students to describe the learning objectives they had met, what the group did well, what they found most disturbing, what the nurse's role was, what were some ways to open communication with the patient, which safety issues to consider, and what were the available community services. The facilitator and clinical instructor clarified and corrected unexpected and unsafe behaviors. Students were also asked to discuss what they would do differently if they could repeat the scenario and to provide at least one take-home point they had learned that they could use in their clinical practice.

Elder Abuse Scenario

The second scenario had a high-fidelity manikin simulating an 86-yearold male who had been left at the hospital by his daughter for increased confusion. The simulation coordinator provided the voice of the manikin out of student view. The clinical instructor had an elder abuse assessment tool (James J. Peters VA Medical Center, n.d.) and a local facility abuse policy available for students as they discussed with her their initial assessment findings of unexplained skin lesions.

The students then returned to the patient to collect additional data and complete the abuse assessment tool. The scenario concluded after the students discussed the results of their findings with the nursing instructor in preparation for mandatory reporting to a charge nurse. Debriefing was facilitated by the simulation coordinator, who asked a series of questions from a debriefing template based on the elder abuse learning objectives.

Following this debriefing, students remained in the debriefing room and completed a 13-item evaluation of the simulation. The questionnaire was adapted from evaluation tools offered upon request by the National League for Nursing Simulation Innovation Resource Center (SIRC) (


Nursing values the principle of self-awareness in care delivery as one way for the nurse to identify internal barriers to caring for clients. Self- awareness promotes improved practice (Barbour, 2013). As faculty designed this simulation experience, we agreed that learning how to care for victims of domestic violence would require students to use self-awareness.

Three clinical reflection questions were chosen for students to address in their written journals after their simulation experience:

* Describe your feelings as you interacted with each simulated patient.

* How do you believe that your feelings affected your nursing care delivery?

* If given the opportunity and based on your previous reflections, what would you change about your approach with the simulated patients?

We found that students needed encouragement to complete more thorough physical assessments in the first scenario. During their initial assessment, many missed signs of redness and bruising on the patient's inner thighs and perineum. While some students were at first uncomfortable asking about the patient's sexual and abuse history, most were more confident when following the abuse assessment tool questions. During the second scenario, all groups conducted a more complete physical assessment and asked more questions of the patient before consulting with the instructor.

The students thoughtfully addressed each question of the reflective journal assignment. Statements describing their feelings included: "I was angry with the person hurting him"; "I could not believe that she would stay with him"; "I might not have listened enough"; and "I was so sad that I might have missed something in my assessment." Examples of what students would do differently included: "I would listen better" and "I would do a better head-to-toe assessment."

Written comments on student evaluations of the simulations included: "It really helped me get a feel for what it might be like to be in a situation where abuse is obvious and referrals need to be given"; "It was believable because there are times when we are not going to have all of the info we would like to have"; and "Great for learning about things I have not seen in practice." Responding to Likert-type evaluation items, all students agreed that the learning experiences were helpful and effective.


Intimate partner violence and elder abuse are issues that confront nurses today. Educating nursing students to recognize victims of abuse can prepare them to identify and appropriately care for these patients. Because students may not encounter abuse victims during traditional clinical experiences, faculty at our community college associate degree nursing program provided simulated learning experiences to introduce students to caring for victims of intimate partner violence and elder abuse. The scenarios reinforced the importance of focusing on thorough assessment, safety, communication, education, and legal responsibilities for nurses. Both faculty and students expressed satisfaction with this method of learning, and we plan to use these scenarios for future classes of nursing students.

doi: 10.5480/15-1609

Susan G. Bryant, MSN, RN, CNE, CHSE, is a faculty member and coordinates simulation, Associate Degree Nursing, Davidson County Community College, Lexington, North Carolina. Kim H. Benson, MSN, RN, is director, Associate Degree Nursing, Davidson County Community College. The authors gratefully acknowledge the contributions of Kaye Fuson for originating the idea of domestic violence simulation and of Samantha Ogle for assisting in the development of the scenarios. For more information, write to


Barbour, J. F. (2013). The making of a butterfly: Reflective practice in nursing education. International Journal for Human Caring, 17(3), 7-12.

Basile, K. C., Hertz, M. F., & Back, S. E. (2007). Intimate partner violence and sexual violence victimization assessment instruments for use in health care settings. Version 1.0. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Centers for Disease Control and Prevention, Injury Prevention & Control: Division of Violence Prevention. (2015). The National Intimate Partner and Sexual Violence Survey. Retrieved from

DeBoer, M. I., Kothari, R., Kothari, C., Koestner, A. L., & Rhose, Jr., T. (2013). What are barriers to nurses screening for intimate partner violence? Journal of Trauma Nursing, 20(3), 155-160. doi:10.1097/JTN.0b013e3182a7b5c3

Department of Health and Human Services, National Center on Elder Abuse, Administration on Aging. (2015). Statistics/data. Retrieved from www.ncea.

James J. Peters VA Medical Center, (n.d.). Geriatrics, palliative care and interprofessional teamwork curriculum. Module #18: Elder abuse and neglect (pp.305323). Retrieved from

Joint Commission. (2015). 2015 national patient safety goals. Retrieved from www.

Starr, L. A. (2010). Preparing those caring for older adults to report elder abuse. Journal of Continuing Education in Nursing, 41(5), 231-235. doi:10.3928/00220124-20100423-06
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Author:Bryant, Susan G.; Benson, Kim H.
Publication:Nursing Education Perspectives
Article Type:Report
Geographic Code:1USA
Date:Nov 1, 2015
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