Training of Nursing Students in the Approach and De-escalation of Psychomotor Agitation in Severe Mental Disorder through Clinical Simulation

Training of Nursing Students in the Approach and De-escalation of Psychomotor Agitation in Severe Mental Disorder through Clinical Simulation | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Training of Nursing Students in the Approach and De-escalation of Psychomotor Agitation in Severe Mental Disorder through Clinical Simulation Pablo Del Pozo-Herce, Iván Santolalla-Arnedo, Eva García Carpintero-Blas, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7923440/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background Addressing psychomotor agitation is a key competency in the mental health setting. Clinical simulation allows nursing students to train in a safe environment, favouring the learning of verbal restraint and de-escalation strategies. This methodology improves decision-making, therapeutic communication, teamwork and patient safety. Integrating this training strengthens professional preparation for situations of high emotional complexity. Methods Qualitative descriptive phenomenological descriptive study through focus groups and reflective narratives. A thematic analysis was performed via ATLAS-ti.24. Results Three thematic blocks with their categories were identified: (T1) recognition and initial coping with psychomotor agitation and (T2) de-escalation strategies and communication skills. (T3) Reflecting on the nursing role and decision making in crisis contexts. Conclusions Clinical simulation allows nursing students to train their approach to psychomotor agitation in a safe environment. It favours symptom recognition, decision making, teamwork and emotional control. The participants integrated theory and practice, developing communication skills and ethical reflection. The experience strengthens professional preparation in mental health. Its systematic inclusion in nursing education is recommended. simulation nursing mental health education skills Figures Figure 1 1. Introduction Psychomotor agitation is a complex and challenging clinical situation that requires rapid, safe and professional action by healthcare personnel. It manifests itself through excessive, disorganized and/or disproportionate motor activation, accompanied, in many cases, by emotional and cognitive alterations such as irritability, confusion, anger or alterations in the course and/or content of thought [ 1 , 2 ] This phenomenon can appear in multiple care settings, although it is especially prevalent in mental health units, emergency departments and crisis care devices. Nontherapeutic management can aggravate the condition and generate an escalation, enhancing dimensions such as disinhibition, lability and/or aggressiveness [ 1 , 3 – 5 ] and require the application of pharmacological and/or physical restraint measures, which generate greater clinical risks for the patient and the care team, as well as ethical/legal conflicts [ 6 ]. In this context, the nursing professional plays a key role not only in the prevention of episodes and early detection of signs of agitation but also in the implementation of de-escalation strategies that reduce the clinical picture associated with agitation and resolving episodes therapeutically and with high safety standards [ 6 – 8 ] In relation to the acquisition of these competencies, related to patient care for the prevention of episodes of agitation and/or crisis intervention, it is essential to enhance the theoretical/practical skills and knowledge of undergraduate nursing students to develop teaching resources that improve the acquisition of skills and safety to address these situations in clinical practice, avoiding compromising interventions and generating ineffective or even iatrogenic interventions [ 9 ]. Faced with this challenge, clinical simulation has emerged as an innovative pedagogical methodology that allows the recreation of realistic situations in a controlled and safe environment, where students can practice, make mistakes and learn without putting patients at risk [ 10 – 12 ]. Through simulation, it is possible to train not only technical skills but also communicative, emotional and ethical competencies essential for a humanized approach to episodes of agitation. Simulation-based teaching resources promote meaningful learning, encourage reflective decision making and improve student self-confidence [ 13 , 14 ]. In particular, simulation scenarios focused on the de-escalation of psychomotor agitation provide a unique opportunity for future professionals to explore their own reactions to psychological and behavioral conditions, as well as organic strategies, coping strategies and emotional self-regulation as tools of care [ 15 , 16 ]. In this context, the postsimulation debriefing process becomes a key space for knowledge integration, self-assessment and the collective construction of learning. Training through clinical simulation techniques in the approach to psychomotor agitation allows students to confront, from a formative perspective, three major dimensions of care in crisis situations. First, initial recognition and coping, which includes early identification of signs and symptoms, management of one's own emotional reactions and assessment of perceived risk during the intervention. Second, the development of de-escalation strategies and communication skills, including the use of verbal and nonverbal techniques, emotional control, professional attitudes and the obstacles encountered when intervening from a noncoercive perspective, is needed. Finally, the lived experience allows a deep reflection on the nursing role and decision-making in critical contexts, where the importance of interdisciplinary work, the ethical implications of the use of restraint measures and the connection between the simulated scenario and the preparation for real professional practice are explored [ 17 , 18 ]. Despite the growing interest in incorporating clinical simulation in mental health training, few qualitative studies have delved into the experiences of nursing students after they participated in these training. Understanding how they interpret and re-signify these scenarios can provide valuable insight for optimizing curricular designs, improve the quality of teaching and promoting safer, ethical and person-centered professional practice. Therefore, the present study aims to explore, from a qualitative perspective, the experiences, perceptions and learning of nursing students who participated in a clinical simulation focused on the approach and de-escalation of psychomotor agitation. The aim is to contribute to the development of teaching strategies that improve the learning process of future professionals facing situations of high emotional load and complexity, promoting interventions based on evidence, empathy, safety and respect for the person. 2. Materials and methods 2.1 Study design A descriptive phenomenological qualitative study was conducted with the aim of exploring the perceptions and experiences of students during clinical simulation of the mental health of patients with psychomotor agitation [ 19 ]. This design is based on the need to understand how future professionals interpret and make sense of their experiences during these formative practices, which represent complex scenarios that combine clinical, emotional and ethical elements. The phenomenological approach allows capturing the essence of these experiences from the participant's perspective without imposing external interpretations, which favours a richer and contextualized understanding of the phenomenon [ 20 ]. 2.2 Experience or Role of Researchers The research team consisted of 7 women and 4 men, including 3 professionals with experience in qualitative research design (EGCB; ATR; PDPH) and 5 professionals specializing in mental health nursing (PDPH; ISA; CITG; MAM; BAN). The data were triangulated by two external researchers (RJV; RRDV). The positioning of the researchers was established in terms of the theoretical framework, their beliefs, previous experience, and personal motivations for participating in the research. The entire team participated in the evaluation of each stage of the research process to reduce researcher bias. 2.3 Participants and sampling Nonprobability and purposive sampling were performed by selecting participants for their ability to provide relevant information in response to the research questions [ 21 ]. The inclusion criteria were as follows: (a) third-year undergraduate students in nursing and (b) enrolled in mental health nursing at a Spanish university. Students were selected because of their knowledge of and exposure to clinical simulation in mental health. Voluntary participation was offered to all the students. Recruitment was conducted until data saturation was reached [ 22 ]. 2.4 Data collection To capture the richness and complexity of the students' experiences during the clinical simulations in mental health, a multiple and integrative data collection strategy was employed, which is typical of qualitative approaches framed in phenomenology. Focus groups (FGs) were conducted during the simulation, supplemented by the researchers' field notes and participants' written reflective narratives. This qualitative approach to data collection allowed for a deeper and more contextualized understanding of the lived experiences during the simulations. The FGs provided space for interaction among participants, facilitating the emergence of different opinions and perceptions. Researchers' field notes, along with individual reflective narratives, added layers of understanding by capturing direct observations and personal perspectives. Data were collected between May 16 and June 19, 2025, in the setting of a simulated academic environment with controlled conditions designed to represent realistic and challenging clinical situations in the mental health setting. Each FG consisted of 10–11 participants led by a moderator and an observer. The moderator posed questions to which each participant responded by speaking in turn. The observer supported the moderator, identified key points and took notes. A topic guide was used, which was focused enough to collect information about the study area but open enough to stimulate discussion and interaction among participants (Table 1 ). However, data collection in qualitative studies is flexible; consequently, during the focus groups, the moderator asked about those areas of interest that participants raised in relation to the research question [ 19 , 22 ]. The sessions were audio- and video-recorded with the prior permission of the participants. The average duration of each FG was 54 minutes, with 2 focus groups being conducted, at which point no new information emerged from the data analysis. Table 1 Interview Guide. Post-Clinical simulation phase 1. What emotions and thoughts did you experience when faced with the situation of psychomotor agitation? 2. How did you interpret the reasons why the patient was in this state of agitation? What meaning do you think this agitated behavior had for you? 3. What were your intervention objectives at that moment? 4. What strategies did you use to manage the situation? 5. What verbal or nonverbal techniques did you use during the de-escalation? 6. What difficulties did you encounter when trying to intervene? 7. Do you consider that your action was appropriate? Why? 8. What possible alternatives would you have considered doing? 9. How do you relate this experience to the professional role of nursing in real situations? 10. What lessons did you learn from the scenarios and how do you think this influences your clinical preparation? 11. What did you do at that moment and why did you decide to act in that way? 12. What was that experience of “being a nurse” like at that moment? In turn, the focus groups were complemented with field notes taken by the researchers during the development of the simulations and the subsequent moments of reflection. These notes made it possible to record not only verbal aspects but also gestural, emotional and contextual aspects that enriched the interpretation of the speeches. In addition, the students who had participated in the simulation-based experience voluntarily made a written reflective narrative through the Blackboard virtual campus, answering the following open questions: What skills do they believe they developed or strengthened during this simulation, what moments did they consider most challenging or complex during the simulation, what moments did they consider most challenging or complex during the simulation, and what moments did they consider most challenging or complex during the simulation? Twenty-two reflective narratives were collected, with a total of 25231 written words. These narratives provided space for introspection and self-awareness, revealing emotional experiences, perceived ethical dilemmas and internal learning processes. 2.4.1 High-Fidelity Simulation Procedure The central objective of the simulation scenario was to train students in the approach, management and intervention of psychomotor agitation episodes. This training was conducted through experiences based on clinical mental health simulation, where students developed specific nursing competencies to respond effectively to psychomotor agitation situations. To this end, two high-fidelity clinical simulation scenarios were developed, taking into account the NANDA, NOC, and NIC taxonomy [ 23 ] related to each other (Table 2 ). Both the NIC taxonomy interventions and the nursing activities served as a guide to discuss student performance during the debriefing phase [ 24 ]. The actor who assumed the standardized patient role was previously trained by professors specializing in mental health [ 25 ]. They developed scripts and expertly impersonated various scenarios, providing participants with realistic and enriching experiences to enhance their clinical skills [ 26 ]. All the clinical simulation sessions adhered to the best practices proposed by the International Association for Nursing Clinical Learning and Simulation (INACSL) throughout its four phases [ 27 ]: prebriefing, briefing, development of the simulated scenario and debriefing. These phases were carried out and supervised by two university professors with experience in clinical simulation methodology. Notably, in the prebriefing phase, a psychologically safe context was fostered, in accordance with the guidelines of Rudolph et al. [ 28 ]. Similarly, the debriefing phase was conducted following the good judgment model, which allows participants to make mistakes and discuss them as valuable and capable and allows instructors to show their experience and make constructive criticism so that meaningful and reflective learning is promoted, in which participants and instructors relate new experiences and knowledge with those they already possess [ 28 , 29 ]. Through simulated scenarios, they learn to recognize warning signs, assess the level of risk and make sound decisions about necessary interventions and de-escalation. With respect to the promotion of reflection and feedback performed in debriefing, reflection is promoted, and constructive feedback is provided [ 30 ]. Moreover, the use of a safe environment allows for the reflection and practice of mental health interventions [ 31 ]. This allows students to analyse their actions, identify areas for improvement, and understand how their interventions could impact real situations. Table 2 Simulated scenario, NANDA-I 2024–2026 (NANDA-I Taxonomy) Nursing Interventions Classification (NIC) and outcomes (NOC) and related nursing activities for resolution. Simulated Scenario 1 NANDA Intervention NOC Outcomes Nursing Activities 51-year-old male, diagnosed with paranoid schizophrenia, involuntarily admitted five days ago after severe behavioral disturbances in public. Since admission, he has had delusions of harm: he believes that the CIA is after him, that cameras are recording him and that the staff is involved in a conspiracy to harm him. He refuses medication, no insight. Altered thought processes (00493) Ineffective regulation of emotions (00372) Behavior management (4350) Management of delusions (6450) Cognitive restructuring (4700) Environmental management: safety (6486) Medication management (2380) Anxiety self-management (1402) Communication (0902) Social interaction skills (1502) Self-control of distorted thinking (1403) Adherence behavior (1600) - Observe the patient's behavior, identify signs of escalation and assess the risk of aggression. - Use verbal de-escalation techniques to reduce anxiety, such as active listening and providing reassuring responses. - Assess thought content and evaluate cognitive restructuring. - Facilitate a safe and calm environment for the patient, avoiding stimulus overload. Simulated Scenario 2 (continued scenario 1) NANDA Intervention NOC Outcomes Nursing Activities The patient starts banging on the door and screaming. The nursing team enters the room, the patient becomes aggressive, refusing any attempt at intervention. The mechanical restraint protocol is activated. The patient is physically restrained at five points to ensure his safety. During the process, he maintains delirious speech, believing that he is being neutralized by a “conspiracy” and by the CIA. Risk of violence directed at others (00138) Risk of non suicidal self-injurious behavior (00468) Ineffective impulse control (00222) Physical restraint (6580) Crisis intervention (6160) Agitation level (1214) Self-restriction of aggression (1401) Knowledge of personal safety (1809) Impulse self-control (1405) - Emotional support and verbal restraint. -Proceed with physical restraint following protocol to ensure patient and team safety. - Document in detail the actions taken and the patient's behavior. 2.5 Data analysis The analysis process was based on an inductive thematic analysis approach aimed at identifying and describing the students lived experiences during the clinical simulation focused on psychomotor agitation in mental health. Data collection included the complete and carefully reviewed verbatim transcription of the focus groups (FGs), the field notes elaborated by the researchers during the simulation and reflection sessions, and the reflective written narratives provided by the students in response to open-ended questions asked through the virtual campus. All the data were stored, organized and managed with the support of specialized software for qualitative analysis ATLAS.ti v24 [ 32 ]. The analysis began with an exploratory and immersive reading of the documents, with the aim of becoming familiar with the narratives and capturing the general meaning of the experiences narrated. Open coding was subsequently performed, in which text fragments containing significant or relevant information to answer the research question were identified [ 33 ]. This first phase made it possible to generate descriptive codes that emerged directly from the data without forcing preconceived categories. The codes were defined, refined and classified according to their frequency, depth and relationship with the phenomenon under study. In the second phase, the codes were grouped into categories according to their semantic and conceptual affinity, allowing the detection of recurrent patterns, tensions and nuances in the participants' experiences. These categories gave rise to the construction of central themes, understood as units of meaning that condense the essential dimensions of the lived experience of intervention in cases of psychomotor agitation. Finally, an integrative synthesis was performed, in which the emerging themes were articulated to offer a structured and explicit description of the perceptions, emotions, learning and challenges experienced by the students. This process of analysis made it possible not only to respond to the objectives of the study but also to capture the depth and richness of the phenomenon experienced, in line with the principles of qualitative phenomenology. Three researchers, experts in qualitative research (P.D.P.-H, E.G.C.-B, A.T.-R), developed the whole process of eliciting themes and categories independently, ending the process with the exchange of both and a consensus on the final decisions of the analysis. In the case of divergence of opinions, the identification of the theme was based on consensus among the members of the research team. 2.6 Ethical considerations Ethical authorization to conduct the research was obtained from the Ethics Committee of the La Rioja Center for Biomedical Research (Ref. CEImLAR PI 812). All participants provided written consent before participating in this study. To ensure anonymity and confidentiality, a code was assigned to each participant in the FGs and reflective narratives (NRs). 2.7 Criteria for rigor The study was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) [ 34 ]. Data triangulation was applied among the researchers involved in the analysis, and the analysis process was subjected to review by independent researchers to ensure credibility. Transferability was ensured by a detailed description of the research setting, as well as the participants, context and method. Confirmability was achieved by introducing variability in participants' experiences; each researcher conducted the reading and analysis independently, contrasting and then reaching agreement on emerging themes and subthemes [ 35 ]. 3. Results 3.1. Demographic data Among the total number of nursing students, 40 met the criteria, 22 (55%) ultimately participated, and data saturation was reached. Those participants who did not attend the simulation were due to various reasons, such as lack of time, work shifts or other reasons. The majority of the participants were women (17 (77.27%)), whereas 5 participants were men (22.73%). They ranged in age from 20–29 years (mean age = 20.4; SD = ± 1.8). The discrepancy between students and genders is due mainly to the fact that the majority of students enrolled in the profession at Spanish universities are women. The participants were in their third year of nursing. 3.2. Themes Three thematic blocks with their categories were identified: 1) Recognition and initial coping with psychomotor agitation. 2) De-escalation strategies and communication skills. 3) Reflecting on the nursing role and decision-making in a crisis context. See Table 3 . Table 3 Themes and categories. Themes (T) Categories T 1 Recognition and initial coping of psychomotor agitation. Early identification of signs and symptoms of agitation Student's emotional reactions to the crisis. Risk perception and level of alertness during the simulation. T 2 De-escalation strategies and communication skills Use of verbal and nonverbal de-escalation techniques Professional attitudes and emotional control during the intervention Difficulties encountered when applying de-escalation interventions T 3 Reflection on the nursing role and decision making in crisis contexts Teamwork and interdisciplinary coordination Ethical reflection on the use of restraint measures Connection between simulation and clinical practice preparation Theme 1. Recognition and initial coping with psychomotor agitation. Early identification of signs and symptoms of agitation The students showed a growing ability to observe indicators of psychomotor agitation, such as verbal and nonverbal language, disorganized speech or verbal hostility. They recognized the complexity of adequately interpreting these signs without falling into judgement or haste, which generated a first awareness of the type of clinical observation needed in mental health. Some participants identified clear symptoms: “The patient was having delusions” (NR22) and “I assumed it was a delusion of persecution and harm” (NR5). Others understood the emotional dimension of living with delusions: “He had a delusion of persecution and prejudice... that the CIA is persecuting him... it is hard to hear these things because the person experiences it as something real” (FG2-5). These experiences also generated reflections on the management of therapeutic communication: “The patient referred that there were cameras and that he was being watched; he had delusions and delusions of persecution” (FG2-2). “He said that the CIA was after him and asked us if we were from the CIA” (FG2-3). “I screwed up, because I told her that there were cameras... I fed back her delusion” (FG1-3). The students began to identify relevant clinical elements, such as the preservation of certain cognitive functions: “She had altered thinking but her memory was preserved, so we could have gone that way” (FG1-4). They also highlighted the need to develop specific communication skills: “It is very difficult for me because you have to be careful with words... if you go into his delirium, it is enhanced” (FG2-4). This observation capacity also led to a rethinking of the perception of risk: “When I go in there and see him so agitated, I realize that we are not dealing with something mild but that there is a real risk” (FG2-6). The simulation helped to experience the progression of the psychotic state: “He was very agitated... I would not do mechanical restraint, but I would start with verbal restraint” (FG1-3). From the clinical interpretation, several participants reported that agitation was understood as part of a psychopathological process: “Because of symptoms such as motor restlessness, delusions, hallucinations” (NR7), “As a common process within a mental pathology such as schizophrenia” (NR10). This perspective allowed some students to integrate previously acquired theoretical knowledge with lived situations, recognizing diagnostic patterns and appropriate clinical responses. However, other students emphasized a more empathic and emotional approach to agitation, prioritizing emotional containment of the patient over diagnostic interpretation. “Trying to understand from empathy the patient's situation and the emotions he was experiencing at that moment” (NR20), “I empathized with the disease” (NR18). This emotional disposition did not imply a renunciation of clinical observation but rather a way of humanizing the therapeutic encounter. Some testimonies reflected an orientation clearly focused on the patient's well-being: “I did not get to interpret his specific motives; my goal was to calm him down and accompany him so that he felt in a safe and controlled environment, I thought about his well-being and not about the causes” (NR14). Students’ emotional reactions to the crisis. Exposure to an agitated situation provoked intense emotional responses in the students: fear, anxiety, anguish or helplessness, as they did not feel prepared to intervene effectively: “I went in with fear... I had never seen paranoid schizophrenia in the acute phase” (FG2-1). “I felt bad because I wanted to help, but I did not know how” (FG2-4). “I experienced it as very distressing; there was no way to get him out of his delirium” (FG1-4). Several participants expressed frustration and discomfort at not having the necessary tools to act, which resulted in feelings of disorientation and ineffectiveness: “I have felt sorry for not knowing how to help him... and courage for not having the tools” (FG1–4). “I felt lost... I did not know how to help him” (FG2-10). “It is that you make a mistake and at any moment everything can get complicated” (FG2-11). The pressure of the environment and the need to act as a team under high-stress conditions were also noted as challenges: “I had a hard time working as a team in a situation like this... there is a lot of tension” (FG2–8). Individual reflections deepen that emotional impact: “I felt so small in front of him, not because of his size, but because I did not know how to act without hurting him” (NR5). “There was a moment when I became so distressed that I felt like I was going to block out altogether” (NR11). “I thought I was not prepared for these situations, but I also understood that no one is 100% prepared” (NR19). “I felt real fear that I might react badly, and I did not know how to disguise it” (NR17). Some students used defense mechanisms such as nervous laughter and subsequently reflected on their own limits: “I laughed because I did not know what to do, but he thought I was making fun and asked me to leave...it was very hard” (FG1–7). “I know that in front of a real patient, I cannot do that, and if it happens to me, I have to get out and let another colleague intervene” (FG2-8). These experiences led to a process of self-reflection on one's own emotional limits: “I realized that laughing was a way to protect myself, but I have to learn to channel it in another way” (NR2). “Seeing my emotional boundaries has not been pleasant, but necessary” (NR16). Risk perception and level of alertness during the simulation. The clinical simulation generated a degree of realism that was sufficiently high for many students to forget that they were in a controlled environment, which led to a significant increase in their level of alertness, vigilance and emotional tension. This realism was perceived as a determining factor in the activation of behavioral responses close to those that would occur in a real situation: “I got into the role, it seemed very real, I did not think it was a simulation” (FG1–2). The need to anticipate possible risks led to self-protection behaviors: “I stood near the door in case he tried to leave, as a safety barrier” (FG1–6). “I was very alert all the time, I felt that something could truly happen” (FG2-3). This emotional activation also allowed some students to become more confident in their observation and coping skills: “I am calmer now that I have seen how the patient behaves and what you can find” (FG2-1). However, in other cases, realism caused frustration and a sense of professional inadequacy: “I felt sorry for not knowing how to help him... and courage for not having the tools” (FG1–2). Situations in which the patient showed disorganized or persecutory behaviors also led some participants to withdraw preemptively: “There was a moment when the patient was referential with me and I preferred to leave” (FG2-10). The increased emotional stress affected decision making in a variable way, depending on the degree of emotional self-regulation of each participant. While some managed to overcome the initial nervousness and focus on the patient's needs, “I was very nervous at the beginning, but when we saw that he needed us, I became more focused” (FG1–9). Others reported blockages that affected their technical performance: “I was so tense that I forgot the constants... then I realized that it was not the priority” (FG1–5). At the individual level, several students expressed surprise at the intensity of their own physiological and cognitive reactions to the simulation: "I did not know that a simulation could seem so real. My palms were sweating and everything" (NR12). "I was surprised at my level of alertness. I was all the time thinking about escape routes and danger signs" (NR22). Others shared experiences of initial blocking followed by almost automatic activation of responses: “The tension blocked me at first, but then I started functioning almost by instinct” (NR15). "I could not think clearly. I felt I had to do something now, even though I did not quite know what" (NR3). Theme 2. De-escalation strategies and communication skills. Use of verbal and nonverbal de-escalation techniques The students explained how they consciously applied verbal techniques (respectful, nonconfrontational, nonconfrontational language, centered on reality, avoiding the promotion of delusional content) and nonverbal techniques (body posture, control of space and environment) to generate a safer environment: “We try to create an alliance by saying that he is in a safe place” (FG2–10). The importance of humanizing the bond through small gestures that acknowledge the patient's identity was also highlighted: “I asked him for his name... many times patients depersonalize...” (FG1–4). “We did not lie, we told him there were cameras for security, but we did not play along” (FG2-9). They also recognized the usefulness of silences and control of the number of interveners to minimize excessive stimulation: “We tried to have only one person speak so that they would not get more upset to reduce stimuli” (FG1-1). Real-time decision making was key at times, especially when it was perceived that the interaction was not effective: “When I saw that we were not getting out of the loop, I told her that I was going to the nurse's station, that I was available if she needed anything” (FG2-6). This strategy allowed students to practice controlled withdrawal skills, protecting both the patient and the team. The students demonstrated a conscious application of relational strategies aimed at preserving the patient's dignity, promoting safety and facilitating the intervention. From the beginning of the interaction, the personalization of the bond was prioritized as a way to avoid clinical depersonalization: “When entering, I introduced myself and called him by name to avoid depersonalization” (FG2-7). This attitude was complemented by an explicit intention to generate an environment of trust and support: “I have tried to make him see that we are here to help him, creating a safe environment” (FG2-3). Negotiation skills were also identified as a useful tool to promote patient collaboration, especially in relation to taking medication: “I tried to negotiate so that he would take the medication and ask him what he needed” (FG1-6). In parallel, a sensitivity towards the patient's personal space was observed, avoiding invasive behaviors: “I wanted to leave space so as not to overwhelm him” (FG1-1). Individual reflections delve into the personal experience of these strategies, revealing an emotional and technical learning process. Some students highlighted how the perception of the patient's condition overrode their own fears, prioritizing the need for help: “I was not afraid because seeing the patient so disorganized I could only think that we had to help him” (NR22). Others recognized that these practical skills surpassed what they learned in theoretical training: “I learned how to act verbally and bodily with the patient, things that they do not teach you in theory and that I consider to be more useful” (NR13). An awareness of the impact of nonverbal language and general attitudes during clinical interaction was also evident: “I have realized that nonverbal language and verbal restraint have an enormous impact if used well” (NR15). “Tone, attitude, not jumping in with your delusion... all of that is more important than I thought” (NR7). Professional attitudes and emotional control during the intervention One of the lessons most valued by the students was the importance of managing one's own emotional state during crisis situations. Many emphasized that self-control not only is fundamental for personal well-being but also directly influences the development of therapeutic interventions. The ability to recognize one's own limits and act accordingly was interpreted as a strength rather than a weakness: “I think I have done terribly... I have leaned on my companions” (FG1–9). “If that happens to me, I'd rather leave the room” (FG2-7). There was also a growing awareness of the value of silence, presence and clinical humility when one does not have all the answers: “I think that if I do not know something, it is better to be silent and accompany” (FG2-8). The need to establish a close but clear relationship was also recognized: “I did not want him to see me as an authority figure, but I wanted him to know that if at some point I have to set a limit, he knows that I will do it” (FG2-9). Learning about asking for help occupied a central place in the reflections of several participants, who identified this action as part of the professional role in training: “I have not asked for help out of ignorance; I am a student... next time I will ask for it” (FG2-4). “I have realized that I have to know how to ask for help” (FG2-1). The experience also made it possible to project the learning towards future situations: “I think that I have taken away knowledge to be able to deal with it in another similar situation” (FG2–3). Personal reflections reinforced the need for such emotional self-regulation: “I have learned that it is important not to get carried away by panic or tension but to remain calm for the good of the patient” (NR12). Others discovered their capacity for self-regulation in the context of a context they initially perceived as unapproachable: "I saw myself in the situation and thought I would not know what to do, but I was surprised by my calm reaction. That taught me that I can also handle myself well emotionally." (NR3). Finally, the awareness emerged that one's emotions are reflected in clinical interaction: "I have realized that if I get out of control, the patient notices it too. I have to learn to be centered even if I am nervous inside." (NR6). Difficulties are encountered when applying de-escalation interventions. Despite their theoretical knowledge, several students reported difficulties in effectively applying de-escalation strategies. Intense emotions, uncertainty about how to act and frustration at not seeing immediate results were common barriers: “I did not know how to prioritize... I focused on taking the tension instead of listening to the patient” (FG1-5). Even so, some expressed their commitment to the therapeutic presence: “Even though I did not know how to act, I did not want to leave the patient alone” (FG2-7). The feeling of helplessness in the face of the perceived lack of impact was also recurrent: “I still feel helpless... I feel that I have not helped him as much as possible” (FG2-6). Others identified specific errors in decision making: “I let him take the medication and the situation get out of control” (FG2-4), whereas some chose to prioritize bonding over technical tasks: “I saw that it was impossible to take him constant and I preferred to focus on his discomfort” (FG1-9). The difficulty in asking for help and the disorganization of the team at key moments were also noted: “I thought I could solve it by myself... but I did not ask for help” (FG1-2); “We had previously planned the roles, but we got blocked” (FG2-1). Individual reflections reinforced the experience of these difficulties. Some students expressed insecurity about how to initiate the interaction: “I felt clumsy, as if I did not know how to start talking to him without making the situation worse” (NR10). Others evidenced the gap between theoretical knowledge and actual practice: “I thought that with the phrases we had learned it was going to be enough, but at the time I did not know how to use them well” (NR20). Fear of aggravating the situation sometimes led to inaction: “I was afraid of saying something that would provoke him more, so I kept quiet... but then I regretted not having said anything” (NR17). Finally, some highlighted the value of vicarious learning: "I knew what to do, but I was blocked by nerves. Then, I saw how my classmates did it, and I learned by watching" (NR21). Theme 3. Reflection on the nursing role and decision making in crisis contexts. Teamwork and interdisciplinary coordination Collaborative work emerged as a fundamental aspect both in the focus groups and in the individual experiences of the students, being configured as a pillar for effective intervention in situations of psychomotor agitation. Clear assignment of roles, prior coordination and mutual support were repeatedly identified as elements that enhance the responsiveness of the team. One student highlighted strategic planning as key to addressing the situation: “Before that, we organized who was going to which limb and asked for help” (FG1–8). This prior order not only facilitated the intervention but also avoided chaos and minimized risks for both the patient and the team. Reflection on coordination highlights the interdependence of actions: “I have realized the importance of teamwork... if the strategy is not coordinated, in the end it has repercussions for the patient” (FG2–9). Likewise, the diversity of perspectives and resources contributed by each member was valued: “There are many alternatives for working with the patient... what I cannot think of, can come from another colleague” (FG2-2). However, not all participants found this process easy; some identified difficulties in the group dynamics: “I found it difficult to work as a team... we were all trying to talk to him” (FG2–4), which indicates the need to strengthen communication and leadership skills within the group. On the other hand, the experience was also positive for those who were able to integrate their role in a reflective manner: “I felt good working in a team... but I had to think very carefully about what to say” (FG2-5). However, the tension and stress generated in the simulation resulted in occasional blockages, despite the planning: “We had previously planned the roles but we got blocked” (FG2-1), showing that real practice demands flexibility and constant adaptation. From the individual perspective, mutual support contributes to increasing feelings of security and professional competence. One student expressed, “I felt comfortable and safe most of the time, as I had a very competent and competent team” (NR12). Another highlighted the positive impact of this experience for her professional future: "It has given me much more confidence. I feel more prepared to face similar situations in the future" (NR16). These collaborative experiences fostered the development of a professional identity oriented toward teamwork and the joint construction of the therapeutic alliance, which are essential aspects of mental health care. In the words of one of the participants, “I truly liked it, we worked as a team, we coordinated... and worked on the therapeutic alliance” (FG1–4). Ethical reflection on the use of containment measures Physical restraint, considered a measure of last resort, elicited profound ethical reflection among the students. A clear preference for more respectful and less invasive alternatives was evident, although at the same time, the importance of having clear protocols for its application in extreme situations was recognized. One participant expressed the need to follow established indications when other options fail: “The drug has not been effective, so being increasingly agitated, we have followed the mechanical containment protocol” (FG1–4). However, others expressed reluctance toward this measure, preferring verbal strategies rather than physical restraint: “I would not do mechanical restraint, but I would do verbal restraint” (FG1–3). Ethical dilemmas were also raised about communication with the patient in these circumstances, questioning sincerity and respect: “Can you offer him that he will be safe if you are there? Or is that lying?” (FG2-8). In addition, errors in the execution of restraint were recognized, leading to self-criticism and reflection on the need to improve procedures: “The mechanical restraint was not complete...we were overconfident and that needs to be reviewed” (FG2-1). Individual reflections complemented this picture, reinforcing the tension between respect for the patient and the need for safety. One student commented, “The objectives of the intervention were to calm him down” (NR22), whereas another explained the change in strategy in the face of the impossibility of verbal de-escalation: “My main objective was to try to do a verbal de-escalation, but clearly when we entered the scene that was almost impossible... Already when we saw that a verbal de-escalation could not be done, the main objective was to contain him mechanically so that he would not run away or hurt himself or others.” (NR9). Another noted, “The main goal was the well-being and safety of the patient and staff” (NR1). Connection between simulation and preparation for clinical practice. The experience was unanimously valued as transformative and preparatory for the professional reality. From the group analysis, “I take away that it will be useful in life... so as not to block myself” (FG2-7). “I am super grateful... I have realized that being authoritarian is not useful and that it has given me tools” (FG2-5). “I was surprised by the simulation... pure impotence, and I am left with knowing how to negotiate with the patient” (FG1-2). “I was angry that I did not take part in the simulation... but I look forward to the next intervention” (FG1–10). “I take away many positive things and others to improve, but I feel more confident” (FG1–5). “I leave very happy...knowing what I can deal with comes in handy” (FG2-9). “I am sure that if it happens to me in real life, I will have some flashbacks” (FG2-10). “It has served me well... I have already worked in psychiatry, and this reinforces me” (FG1-3). “I take away learning that can come in handy for tomorrow” (FG1–8). “I think the key is to inform the patient of everything we are going to do” (FG1-8). From the individual reflections, the increase in self-confidence further deepened: “Very positive, greater security when acting, reduction of fear, I went from being afraid of an aggression to wanting to intervene, it allowed me to know exactly what to do and what not to do, proper attitude of trust and coordination with the team, I gained confidence and enjoyed the practice”. (NR10). "It is something I highlight above all else. Before the simulation, I did not consider myself capable or sufficient to intervene in psychomotor agitation. However, after this experience, I am convinced that if I am involved in one, I can contribute something." (NR15). “Now I have more tools to face a situation of this type, and I even consider doing an internship in a mental health unit.” (NR20). “It has not truly influenced me too much; what I do think is that, owing to this simulation, a situation similar to this one will not catch me so helpless, although I would still have my doubts about how to act (clearly much less than I would have if I had not participated in this simulation).” (NR14). “More confident and secure in being able to deal with situations similar to those in the simulation.” (NR1). It is thus articulated how simulation not only improves technical and coordination skills but also represents a key space for strengthening self-efficacy and reaffirming professional identity as nursing professionals prepare to act in crisis contexts. These results highlight the complexity of nursing interventions in clinical simulation contexts in mental health, highlighting the need for effective strategies and the exploration of various alternatives for addressing situations of psychomotor agitation. From the analysis carried out with the ATLAS.ti program, three main themes were identified that structure the students' experience during the simulation: 1) Recognition and initial coping with psychomotor agitation. 2) De-escalation strategies and communication skills. 3) Reflecting on the nursing role and decision-making in crisis contexts. These results illustrate the complexity of the intervention, highlighting the importance of effective strategies and the consideration of various alternatives to address simulated mental health situations. All of them are interrelated with each other and with the simulation using the ATLAS-Ti program (Fig. 1 ). 4. Discussion The findings of this study confirm the pedagogical and emotional value of clinical simulation in the training of nursing students in mental health crisis situations [ 36 , 37 ] as is the case for psychomotor agitation in the context of severe mental disorders. An analysis of the narratives that emerged in the focus groups revealed that the simulation experience not only allows the application of technical knowledge but also generates an experiential space of emotional confrontation, ethics and professionalism that favours meaningful learning [ 38 ]. One of the main contributions of this experience was the students' awareness of the complexity of the phenomenon of psychomotor agitation and the importance of evidence-based therapeutic intervention both preventively and to restore the patient's health, avoid serious complications arising from the episodes and promote clinical safety and occupational health [ 5 , 39 ]. The possibility of experiencing realistic behavioral escalation in a controlled environment made it possible to develop clinical observation and communication skills, identify early signs of mental alteration and adjust the intervention to the patient's needs. This type of training places the student in an active role, promotes critical thinking and exposes him/her to decision-making with ethical, communicative and emotional repercussions [ 40 ]. In line with previous studies, participants stated that the simulation generates a high emotional impact, activating reactions such as anguish, fear, insecurity, blockage or helplessness [ 41 ]. Far from being obstacles, these emotions were recognized by the students themselves as a fundamental part of the learning process, allowing them to explore their own limits, formative needs and coping styles. This finding reinforces the idea that clinical simulation, which is well designed and accompanied by an adequate debriefing phase, can act as a catalyst for students' emotional and professional development [ 42 ]. Another highlight was the acquisition of communication skills focused on verbal de-escalation/containment. Students experienced the usefulness of tools such as active listening, reality orientation, use of the patient's name and emotional validation as pillars for de-escalating the crisis. This experience allowed them to understand that addressing agitation is not reduced to behavioral control but requires communication skills and an empathic and professional attitude [ 43 ]. The intervention of not reinforcing delirium, orienting the patient in reality, maintaining the therapeutic bond, ensuring safety and maintaining the patient's dignity even in moments of mental disorganization was valued as one of the most significant lessons learned. Within this framework, important ethical reflections emerged regarding the use of coercive measures such as physical restraint. Although participants recognized the need to resort to it in extreme cases, they expressed their discomfort and concern about its application, expressing a clear preference for verbal and environmental strategies from positive behavioral support [ 44 , 45 ] centered on the person. This ethical-professional awareness, which emerges from experience, is key to training professionals capable of providing humanized and respectful care, even in contexts of high clinical demand [ 7 , 8 ]. Teamwork was consolidated as a fundamental axis of the intervention. Prior coordination, role assignment, nonverbal communication and emotional support among colleagues were elements that increased the perception of safety and efficacy during the simulation. This learning is especially relevant in mental health, where an interdisciplinary approach is necessary to sustain complex interventions and prevent the emotional overload of staff [ 46 ]. In addition, the simulation made it possible to highlight the internal tensions between what was learned theoretically and the student's spontaneous reactions in a realistic environment [ 47 ]. Some participants recognized that, at first, they adopted authoritarian or unempathetic attitudes, only to later identify, owing to debriefing and reflection, that these strategies were ineffective and even counterproductive. This process of personal and professional discovery was experienced as an opportunity to review assumptions, incorporate more appropriate tools and strengthen a nursing identity on the basis of care, respect and emotional support [ 48 ]. Finally, this study reinforces the need to integrate clinical simulation as a structural part of the undergraduate degree in nursing, especially in the area of mental health [ 49 , 50 ]. Simulation involves not only rehearsing procedures but also allowing the student to assume a professional role, manage emotions, make decisions in critical situations and exercise leadership by working in a team. By doing so in a safe environment, with teacher accompaniment and critical reflection, simulation becomes a comprehensive training space where technical knowledge merges with the ethical, emotional and relational dimension of care, resulting in meaningful and humanized learning in care [ 51 ]. 5. Strengths and limitations of the study The main strengths of this study lie in its innovative approach to mental health care training by proposing a change in the traditional model of university teaching in this field through the incorporation of realistic clinical simulation scenarios. This type of intervention allows nursing students to face complex situations, such as psychomotor agitation, in a safe and controlled environment, favouring meaningful and experiential learning. Likewise, the simulation contributes to strengthening the clinical, communicative and emotional competencies of the students prior to their incorporation into the professional setting, which reinforces their security and confidence in the management of patients in crisis. Among the limitations of the study, it should be noted that the research was carried out exclusively with nursing students at a Spanish university, so the results cannot be generalized to other academic or geographic contexts. This work collects the perceptions of students in a high-fidelity scenario focused on intervention in the face of an episode of psychomotor agitation. It would be interesting to extend this line of qualitative research on a larger scale, incorporating new simulated clinical cases related to different mental health disorders, as well as to complement these findings with quantitative studies that evaluate the impact and efficacy of simulation as an educational strategy in nursing education. 6. Conclusions Clinical simulation has proven to be an effective pedagogical tool for preparing nursing students to address psychomotor agitation, especially in the mental health field. The experience allowed participants to recognize clinical and warning signs, manage their emotions, apply verbal de-escalation strategies and reflect on their professional role in psychiatry and mental health services. The students valued the simulation as an opportunity to integrate theory and practice, strengthen teamwork and acquire greater confidence in decision making. Likewise, important ethical reflections on the use of restraint measures were generated, and a formative process that transcended the technical process was evidenced, enhancing more humanized and competent nursing. These findings support the systematic inclusion of clinical simulations in training programs as a way to improve the quality of care, patient safety and emotional preparation of future professionals. 7. Patents Institutional Review Board Statement The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of the Center for Biomedical Research of La Rioja (Ref. CEImLAR PI 812). Informed Consent Statement : Informed consent was obtained from all the student nurses involved in the study. Conflicts of interest: The authors declare that they have no conflicts of interest. Funding: This research received no external funding. Author Contribution Conceptualization, I.S-A. and P.D.P.-H.; methodology, P.D.P-H., E.G.C-B. and A.T-R.; software, R.J-V. and A.T-R.; validation, T.S‒S., C.I.T-G., E.G-C and M.A-M.; formal analysis, E.G.C-B. ; investigation, I.S-A. and P.D.P.-H.; resources, I.S-A., C.I.T-G. and R.J-V.; data curation, R.R.D-V., B.A-N., E.G-C, and C.I.T-G. ; writing—original draft preparation, I.S-A. and P.D.P-H.; writing—review and editing, E.G.C.-B. and B.A-N.; visualization, C.I.T.-G. and M.A-M. ; supervision, I.S.-A. and P.D.P.-H.; project administration, I.S.-A., P.D.P.-H. and R.R.D-V; funding acquisition, C.I.T-G. and R.J-V. “All authors have read and agreed to the published version of the manuscript.” Acknowledgements: The authors acknowledge all the students who took part in this study. Data availability statement: Not applicable. References Huber CG, Hochstrasser L, Meister K, Schimmelmann BG, Lambert M. Evidence for an agitated-aggressive syndrome in early-onset psychosis correlated with antisocial personality disorder, forensic history, and substance use disorder. Schizophr Res. 2016;175:198–203. 10.1016/j.schres.2016.04.027 . Garrote-Cámara ME, Santolalla-Arnedo I, Ruiz de Viñaspre-Hernández R, Gea-Caballero V, Sufrate-Sorzano T, del Pozo-Herce P, Garrido-García R, Rubinat-Arnaldo E. Juárez Vela R. Psychometric characteristics and sociodemographic adaptation of the Corrigan Agitated Behavior Scale in patients with severe mental disorders. Front Psychol. 2021;12:779277. 10.3389/fpsyg.2021.779277 . Caqueo-Urízar A, Fond G, Urzúa A, Boyer L, Willians D. Violent behavior and aggression in schizophrenia: prevalence and risk factors a multicentric study from three Latin-American countries. Schizophr Res. 2016;178:23–8. 10.1016/j.schres.2016.09.005 . Ostinelli EG, D’Agostino A, Shokraneh F, Salanti G, Furukawa TA. Acute interventions for aggression and agitation in psychosis: study protocol for a systematic review and network meta-analysis. BMJ Open. 2019;9:e032726. Garrote-Cámara ME, Juárez-Vela R, Rodríguez-Muñoz PM, Pérez J, Sánchez-González JL, Rubinat-Arnaldo E, Navas-Echazarreta N, Sufrate-Sorzano T, Santolalla-Arnedo I. NANDA nursing diagnoses associated with the occurrence of psychomotor agitation in patients with severe mental disorder: a cross-sectional study. BMC Nurs. 2023;22(1):292. 10.1186/s12912-023-01434-2 . Garrote-Cámara ME, Gea-Caballero V, Sufrate-Sorzano T, Rubinat-Arnaldo E, Santos-Sánchez JÁ, Cobos-Rincón A, Santolalla-Arnedo I, Juárez-Vela R. Clinical and sociodemographic profile of psychomotor agitation in mental health hospitalization: a multicentre study. Int J Environ Res Public Health. 2022;19:15972. 10.3390/ijerph192315972 . Vieta E, Garriga M, Cardete L, Bernardo M, Lombraña M, Blanch J, Martínez-Arán A. Protocol for the management of psychiatric patients with psychomotor agitation. BMC Psychiatry. 2017;17:328. Correcher PS. Protocolo diagnóstico y terapéutico del paciente agitado. Med-Programa Form Médica Contin Acreditado. 2019;12:5017–20. Cant RP, Cooper SJ. Use of simulation-based learning in undergraduate nurse education: an umbrella systematic review. Nurse Educ Today. 2017;49:63–71. 10.1016/j.nedt.2016.11.015 . Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ. Technology-enhanced simulation for health professions education: a systematic review and meta-anal. Kolb D. Experiential learning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall; 1984. Palés Argullos J, Gomar Sancho C. El uso de las simulaciones en educación médica. Rev Teoría la Educ Educ y Cult en la Soc la Inf. 2010;11(2):147–69. Lockertsen Ø, Løvhaug L, Davik NK, Bølgen BR, Færden A, Skarstein S. Second-year undergraduate nursing students' experiences with clinical simulation training in mental health clinical practice: a focus group study. Nurse Educ Pract. 2023;66:103534. 10.1016/j.nepr.2022 . Neale J. What is the evidence for the use of simulation training to teach communication skills in psychiatry? Evid Based Ment Health. 2019;22(1):23–5. 10.1136/ebmental-2018-300075 . Dois Castellon A, Farias Cancino A, Fuentes Olavarría D. Aporte de pacientes psiquiátricos simulados al proceso de enseñanza-aprendizaje: percepción de estudiantes de enfermería. Index Enferm. 2016;25(4). Hermanns M, Lilly ML, Crawley B. Using clinical simulation to enhance psychiatric nursing training of baccalaureate students. Clin Simul Nurs. 2011;7(2):41–6. Binham H, O'Brien AJ. Educational intervention to decrease stigmatizing attitudes of undergraduate nurses towards people with mental illness. Int J Ment Health Nurs. 2018;27(1):311–9. Corso SJF, Delgado MB, Gómez-Restrepo C. Uso de pacientes simulados en psiquiatría. Rev Colomb Psiquiatr. 2012;41:52–68. Korstjens I, Moser A. Series: practical guidance to qualitative research. Part 2: context, research questions and designs. Eur J Gen Pract. 2017;23:274–9. Henriques CMDG, Botelho MAR, Catarino HDCP. Phenomenology as a method applied to nursing science: research study. Cien Saude Colet. 2021;26(2):511–9. 10.1590/1413-81232021262.41042 . Creswell JW, Poth CN. Qualitative inquiry and research design: choosing among five approaches. 4th ed. Thousand Oaks, CA: Sage; 2018. Moser A, Korstjens I. Series: practical guidance to qualitative research. Part 3: sampling, data collection and analysis. Eur J Gen Pract. 2018;24:9–18. NANDA International. Diagnósticos enfermeros: definiciones y clasificación 2024–2026. 13th ed. Edición hispanoamericana. Elsevier; 2024. Butcher HK, Bulechek GM, Dochterman JM, Wagner CM. Nursing Interventions Classification (NIC). 2nd ed. St. Louis, MO: Elsevier; 2018. Luebbert R, Perez A, Andrews A, Webster-Cooley T. Standardized patients versus mannequins in mental health simulation. J Am Psychiatr Nurses Assoc. 2023;29(4):283–9. 10.1177/10783903231183322 . Alshehri FD, Jones S, Harrison D. The effectiveness of high-fidelity simulation on undergraduate nursing students' clinical reasoning-related skills: a systematic review. Sittner BJ, Aebersold ML, Paige JB, Graham LL, Schram AP, Decker SI, Lioce L. INACSL standards of best practice for simulation: past, present, and future. Rudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014;9:339. Maestre JM, Rudolph JW. Theories and styles of debriefing: the good judgment method as a tool for formative assessment in healthcare. Rev Esp Cardiol. 2015;68:282–5. Kirkbakk-Fjær K, Hedelin B, Moen ØL. Undergraduate nursing students' evaluation of the debriefing phase in mental health nursing simulation. Issues Ment Health Nurs. 2016;37:360–6. Ng R, O'Reilly CL, Collins JC, Roennfeldt H, McMillan SS, Wheeler AJ, El-Den S. Mental Health First Aid crisis role-plays between pharmacists and simulated patients with lived experience: a thematic analysis of debrief. Soc Psychiatry Psychiatr Epidemiol. 2023;58. Friese S. Qualitative data analysis with ATLAS.ti. 3rd ed. London: SAGE; 2019. Braun V, Clarke V. What can thematic analysis offer health and wellbeing researchers? Int J Qualitative Stud Health Well-being. 2014;9:26153. Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349–57. Morse JM. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res. 2015;25:1212–22. Lilly ML, Hermanns M, Crawley B. Clinical simulation in psychiatric-mental health nursing: post-graduation follow up. J Psychosoc Nurs Ment Health Serv. 2016;54:40–6. Harvey T. Adoptando la simulación en la educación de enfermeras de salud mental: un enfoque personalizado para abordar el genérico. Nurse Educ Pract. 2023;71:103698. 10.1016/j.nepr.2023.103698 . Zhang X, Wang H. Efectividad comparativa de las técnicas de simulación de salud mental en la educación de enfermería: una revisión sistemática y metaanálisis. Int J Ment Health Nurs. 2025;34(1):E13502. 10.1111/inm.13502 . Pompili M, Ducci G, Galluzzo A, Rosso G, Palumbo C, De Berardis D. The management of psychomotor agitation associated with schizophrenia or bipolar disorder: a brief review. Int J Environ Res Public Health. 2021;18:4368. Lockertsen Ø, Løvhaug L, Davik NK, Bølgen BR, Færden A, Skarstein S. Second-year undergraduate nursing students' experiences with clinical simulation training in mental health clinical practice: a focus group study. Nurse Educ Pract. 2023;66:103534. 10.1016/j.nepr.2022.103534 . Heyman I, Webster BJ, Tee S. Curriculum development through understanding the student nurse experience of suicide intervention education: a phenomenographic study. Nurse Educ Pract. 2015;15:498–506. Piot MA, Dechartres A, Attoe C, Romeo M, Jollant F, Billon G, Cross S, Lemogne C, Layat Burn C, Michelet D, Guerrier G, Tesniere A, Rethans JJ, Falissard B. Effectiveness of simulation in psychiatry for nursing students, nurses and nurse practitioners: a systematic review and meta-analysis. J Adv Nurs. 2022;78(2):332–47. 10.1111/jan.14986 . Godzik CM, Solomon J, Yacinthus B. Using standardized mental health patient simulations to increase critical thinking and confidence in undergraduate nursing students. Arch Psychiatr. 2023;43:76–80. Walsh RS, McClean B, Doyle N, Ryan S, Scarborough-Lang SJ, Rishton A, Dagnall N. A thematic analysis investigating the impact of positive behavioral support training on the lives of service providers: It makes you think differently. Front Psychol. 2019;10:2408. 10.3389/fpsyg.2019.02408 . Constantino JN, Strom S, Bunis M, Nadler C, Rodgers T, LePage J, Cahalan C, Stockreef A, Evans L, Jones R, Wilson A. Toward actionable practice parameters for dual diagnosis: principles of assessment and management for co-occurring psychiatric and intellectual/developmental disability. Curr Psychiatry Rep. 2020;22(2):9. 10.1007/s11920-020-1127-8 . Felton A, Wright N. Simulation in mental health nurse education: the development, implementation and evaluation of an educational innovation. Nurse Educ Pract. 2017;26:46–52. 10.1016/j.nepr.2017.06.005 . Dawood E, Alshutwi SS, Alshareif S, Shereda HA. Nurs Rep. 2024;14(2):1424–38. 10.3390/nursrep14020107 . Evaluación de la efectividad de la simulación estandarizada de pacientes como método de enseñanza en enfermería psiquiátrica y de salud mental. Ferrara P, Terzoni S, Ruta F, Poggi AD, Destrebecq A, Gambini O, D’Agostino A. Nursing students’ attitudes towards suicide and suicidal patients: a multicentre cross-sectional survey. Nurse Educ Today. 2022;109:105282. Koch C, Meier S, Fischer C, Brich J. Simulated patients to demonstrate common stroke syndromes: accurate and convincing. Cerebrovasc Dis. 2023;55:1–8. Lawton AJ, Greco L, Airaldi R, Tulsky JA. Development of an actor rehearsal guide for communication skills courses. BMJ Palliat Care. 2024;15:1–8. Farooq S, Tharani A, Begum S, Parpio Y. Implementation of simulation: a contemporary strategy to enhance clinical skills of undergraduate students in mental health nursing. Issues Ment Health Nurs. 2020;41(8):736–40. 10.1080/01612840.2019.1710011 . Additional Declarations No competing interests reported. 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UNIE","correspondingAuthor":false,"prefix":"","firstName":"Eva","middleName":"García","lastName":"Carpintero-Blas","suffix":""},{"id":565247552,"identity":"f3cfa56b-075f-455e-87c2-2d33ea553580","order_by":3,"name":"Alberto Tovar-Reinoso","email":"","orcid":"","institution":"University of UNIE","correspondingAuthor":false,"prefix":"","firstName":"Alberto","middleName":"","lastName":"Tovar-Reinoso","suffix":""},{"id":565247556,"identity":"143a2775-ad9b-4c72-8a04-ef60d831d11c","order_by":4,"name":"Raúl Juárez-Vela","email":"","orcid":"","institution":"University of La Rioja","correspondingAuthor":false,"prefix":"","firstName":"Raúl","middleName":"","lastName":"Juárez-Vela","suffix":""},{"id":565247558,"identity":"016549bb-ffeb-496a-bd5c-5af802704f25","order_by":5,"name":"Marta Apilanez-Monge","email":"","orcid":"","institution":"University Hospital San Pedro, Rioja Health System (SERIS)","correspondingAuthor":false,"prefix":"","firstName":"Marta","middleName":"","lastName":"Apilanez-Monge","suffix":""},{"id":565247560,"identity":"1a373777-e540-41db-bdbb-7e4048fa7193","order_by":6,"name":"Clara Isabel Tejada-Garrido","email":"","orcid":"","institution":"University of La Rioja","correspondingAuthor":false,"prefix":"","firstName":"Clara","middleName":"Isabel","lastName":"Tejada-Garrido","suffix":""},{"id":565247561,"identity":"da3e5845-1c69-40aa-9d12-3dbeee4477f2","order_by":7,"name":"Teresa Sufrate-Sorzano","email":"","orcid":"","institution":"University Hospital San Pedro, Rioja Health System (SERIS)","correspondingAuthor":false,"prefix":"","firstName":"Teresa","middleName":"","lastName":"Sufrate-Sorzano","suffix":""},{"id":565247562,"identity":"ffbe09ff-1723-4ea8-81ab-47f0b35dc16c","order_by":8,"name":"Elena Garrote-Cámara","email":"","orcid":"","institution":"University Hospital San Pedro, Rioja Health System (SERIS)","correspondingAuthor":false,"prefix":"","firstName":"Elena","middleName":"","lastName":"Garrote-Cámara","suffix":""},{"id":565247563,"identity":"3db2567e-e759-43d9-af6c-b71650923435","order_by":9,"name":"Beatriz Angulo-Nalda","email":"","orcid":"","institution":"University Hospital San Pedro, Rioja Health System (SERIS)","correspondingAuthor":false,"prefix":"","firstName":"Beatriz","middleName":"","lastName":"Angulo-Nalda","suffix":""},{"id":565247567,"identity":"f3a80cad-d48c-4af6-b76d-7a93c338d568","order_by":10,"name":"Regina Ruiz Viñaspre-Hernández","email":"","orcid":"","institution":"University of La Rioja","correspondingAuthor":false,"prefix":"","firstName":"Regina","middleName":"Ruiz","lastName":"Viñaspre-Hernández","suffix":""}],"badges":[],"createdAt":"2025-10-22 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16:33:37","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":168902,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7923440/v1/53417c9e5d5da3e1d00fc45b.html"},{"id":99219476,"identity":"cc90d296-5dbc-4cc7-8e34-71d3b0983132","added_by":"auto","created_at":"2025-12-30 09:29:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":451048,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eQualitative Data Analysis.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7923440/v1/facdfef97c4272a8cbb204be.png"},{"id":99323967,"identity":"21b518fc-14bb-4731-9dcf-ca15b5072716","added_by":"auto","created_at":"2025-12-31 16:46:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1341596,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7923440/v1/55d97e57-ef23-42ae-b8d3-b04456b8296c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Training of Nursing Students in the Approach and De-escalation of Psychomotor Agitation in Severe Mental Disorder through Clinical Simulation","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePsychomotor agitation is a complex and challenging clinical situation that requires rapid, safe and professional action by healthcare personnel. It manifests itself through excessive, disorganized and/or disproportionate motor activation, accompanied, in many cases, by emotional and cognitive alterations such as irritability, confusion, anger or alterations in the course and/or content of thought [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e] This phenomenon can appear in multiple care settings, although it is especially prevalent in mental health units, emergency departments and crisis care devices. Nontherapeutic management can aggravate the condition and generate an escalation, enhancing dimensions such as disinhibition, lability and/or aggressiveness [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] and require the application of pharmacological and/or physical restraint measures, which generate greater clinical risks for the patient and the care team, as well as ethical/legal conflicts [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this context, the nursing professional plays a key role not only in the prevention of episodes and early detection of signs of agitation but also in the implementation of de-escalation strategies that reduce the clinical picture associated with agitation and resolving episodes therapeutically and with high safety standards [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] In relation to the acquisition of these competencies, related to patient care for the prevention of episodes of agitation and/or crisis intervention, it is essential to enhance the theoretical/practical skills and knowledge of undergraduate nursing students to develop teaching resources that improve the acquisition of skills and safety to address these situations in clinical practice, avoiding compromising interventions and generating ineffective or even iatrogenic interventions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFaced with this challenge, clinical simulation has emerged as an innovative pedagogical methodology that allows the recreation of realistic situations in a controlled and safe environment, where students can practice, make mistakes and learn without putting patients at risk [\u003cspan additionalcitationids=\"CR11\" citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Through simulation, it is possible to train not only technical skills but also communicative, emotional and ethical competencies essential for a humanized approach to episodes of agitation. Simulation-based teaching resources promote meaningful learning, encourage reflective decision making and improve student self-confidence [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn particular, simulation scenarios focused on the de-escalation of psychomotor agitation provide a unique opportunity for future professionals to explore their own reactions to psychological and behavioral conditions, as well as organic strategies, coping strategies and emotional self-regulation as tools of care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In this context, the postsimulation debriefing process becomes a key space for knowledge integration, self-assessment and the collective construction of learning. Training through clinical simulation techniques in the approach to psychomotor agitation allows students to confront, from a formative perspective, three major dimensions of care in crisis situations. First, initial recognition and coping, which includes early identification of signs and symptoms, management of one's own emotional reactions and assessment of perceived risk during the intervention. Second, the development of de-escalation strategies and communication skills, including the use of verbal and nonverbal techniques, emotional control, professional attitudes and the obstacles encountered when intervening from a noncoercive perspective, is needed. Finally, the lived experience allows a deep reflection on the nursing role and decision-making in critical contexts, where the importance of interdisciplinary work, the ethical implications of the use of restraint measures and the connection between the simulated scenario and the preparation for real professional practice are explored [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the growing interest in incorporating clinical simulation in mental health training, few qualitative studies have delved into the experiences of nursing students after they participated in these training. Understanding how they interpret and re-signify these scenarios can provide valuable insight for optimizing curricular designs, improve the quality of teaching and promoting safer, ethical and person-centered professional practice. Therefore, the present study aims to explore, from a qualitative perspective, the experiences, perceptions and learning of nursing students who participated in a clinical simulation focused on the approach and de-escalation of psychomotor agitation. The aim is to contribute to the development of teaching strategies that improve the learning process of future professionals facing situations of high emotional load and complexity, promoting interventions based on evidence, empathy, safety and respect for the person.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Study design\u003c/h2\u003e \u003cp\u003eA descriptive phenomenological qualitative study was conducted with the aim of exploring the perceptions and experiences of students during clinical simulation of the mental health of patients with psychomotor agitation [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This design is based on the need to understand how future professionals interpret and make sense of their experiences during these formative practices, which represent complex scenarios that combine clinical, emotional and ethical elements. The phenomenological approach allows capturing the essence of these experiences from the participant's perspective without imposing external interpretations, which favours a richer and contextualized understanding of the phenomenon [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2 Experience or Role of Researchers\u003c/h2\u003e \u003cp\u003eThe research team consisted of 7 women and 4 men, including 3 professionals with experience in qualitative research design (EGCB; ATR; PDPH) and 5 professionals specializing in mental health nursing (PDPH; ISA; CITG; MAM; BAN). The data were triangulated by two external researchers (RJV; RRDV). The positioning of the researchers was established in terms of the theoretical framework, their beliefs, previous experience, and personal motivations for participating in the research. The entire team participated in the evaluation of each stage of the research process to reduce researcher bias.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3 Participants and sampling\u003c/h2\u003e \u003cp\u003eNonprobability and purposive sampling were performed by selecting participants for their ability to provide relevant information in response to the research questions [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe inclusion criteria were as follows: (a) third-year undergraduate students in nursing and (b) enrolled in mental health nursing at a Spanish university. Students were selected because of their knowledge of and exposure to clinical simulation in mental health. Voluntary participation was offered to all the students. Recruitment was conducted until data saturation was reached [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4 Data collection\u003c/h2\u003e \u003cp\u003eTo capture the richness and complexity of the students' experiences during the clinical simulations in mental health, a multiple and integrative data collection strategy was employed, which is typical of qualitative approaches framed in phenomenology. Focus groups (FGs) were conducted during the simulation, supplemented by the researchers' field notes and participants' written reflective narratives. This qualitative approach to data collection allowed for a deeper and more contextualized understanding of the lived experiences during the simulations. The FGs provided space for interaction among participants, facilitating the emergence of different opinions and perceptions. Researchers' field notes, along with individual reflective narratives, added layers of understanding by capturing direct observations and personal perspectives. Data were collected between May 16 and June 19, 2025, in the setting of a simulated academic environment with controlled conditions designed to represent realistic and challenging clinical situations in the mental health setting.\u003c/p\u003e \u003cp\u003eEach FG consisted of 10\u0026ndash;11 participants led by a moderator and an observer. The moderator posed questions to which each participant responded by speaking in turn. The observer supported the moderator, identified key points and took notes. A topic guide was used, which was focused enough to collect information about the study area but open enough to stimulate discussion and interaction among participants (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). However, data collection in qualitative studies is flexible; consequently, during the focus groups, the moderator asked about those areas of interest that participants raised in relation to the research question [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The sessions were audio- and video-recorded with the prior permission of the participants. The average duration of each FG was 54 minutes, with 2 focus groups being conducted, at which point no new information emerged from the data analysis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eInterview Guide.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-Clinical simulation phase\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1. What emotions and thoughts did you experience when faced with the situation of psychomotor agitation?\u003c/p\u003e \u003cp\u003e2. How did you interpret the reasons why the patient was in this state of agitation? What meaning do you think this agitated behavior had for you?\u003c/p\u003e \u003cp\u003e3. What were your intervention objectives at that moment?\u003c/p\u003e \u003cp\u003e4. What strategies did you use to manage the situation?\u003c/p\u003e \u003cp\u003e5. What verbal or nonverbal techniques did you use during the de-escalation?\u003c/p\u003e \u003cp\u003e6. What difficulties did you encounter when trying to intervene?\u003c/p\u003e \u003cp\u003e7. Do you consider that your action was appropriate? Why?\u003c/p\u003e \u003cp\u003e8. What possible alternatives would you have considered doing?\u003c/p\u003e \u003cp\u003e9. How do you relate this experience to the professional role of nursing in real situations?\u003c/p\u003e \u003cp\u003e10. What lessons did you learn from the scenarios and how do you think this influences your clinical preparation?\u003c/p\u003e \u003cp\u003e11. What did you do at that moment and why did you decide to act in that way?\u003c/p\u003e \u003cp\u003e12. What was that experience of \u0026ldquo;being a nurse\u0026rdquo; like at that moment?\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn turn, the focus groups were complemented with field notes taken by the researchers during the development of the simulations and the subsequent moments of reflection. These notes made it possible to record not only verbal aspects but also gestural, emotional and contextual aspects that enriched the interpretation of the speeches. In addition, the students who had participated in the simulation-based experience voluntarily made a written reflective narrative through the Blackboard virtual campus, answering the following open questions: What skills do they believe they developed or strengthened during this simulation, what moments did they consider most challenging or complex during the simulation, what moments did they consider most challenging or complex during the simulation, and what moments did they consider most challenging or complex during the simulation? Twenty-two reflective narratives were collected, with a total of 25231 written words. These narratives provided space for introspection and self-awareness, revealing emotional experiences, perceived ethical dilemmas and internal learning processes.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section3\"\u003e \u003ch2\u003e2.4.1 High-Fidelity Simulation Procedure\u003c/h2\u003e \u003cp\u003eThe central objective of the simulation scenario was to train students in the approach, management and intervention of psychomotor agitation episodes. This training was conducted through experiences based on clinical mental health simulation, where students developed specific nursing competencies to respond effectively to psychomotor agitation situations. To this end, two high-fidelity clinical simulation scenarios were developed, taking into account the NANDA, NOC, and NIC taxonomy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e] related to each other (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Both the NIC taxonomy interventions and the nursing activities served as a guide to discuss student performance during the debriefing phase [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The actor who assumed the standardized patient role was previously trained by professors specializing in mental health [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. They developed scripts and expertly impersonated various scenarios, providing participants with realistic and enriching experiences to enhance their clinical skills [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll the clinical simulation sessions adhered to the best practices proposed by the International Association for Nursing Clinical Learning and Simulation (INACSL) throughout its four phases [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]: prebriefing, briefing, development of the simulated scenario and debriefing. These phases were carried out and supervised by two university professors with experience in clinical simulation methodology. Notably, in the prebriefing phase, a psychologically safe context was fostered, in accordance with the guidelines of Rudolph et al. [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Similarly, the debriefing phase was conducted following the good judgment model, which allows participants to make mistakes and discuss them as valuable and capable and allows instructors to show their experience and make constructive criticism so that meaningful and reflective learning is promoted, in which participants and instructors relate new experiences and knowledge with those they already possess [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThrough simulated scenarios, they learn to recognize warning signs, assess the level of risk and make sound decisions about necessary interventions and de-escalation. With respect to the promotion of reflection and feedback performed in debriefing, reflection is promoted, and constructive feedback is provided [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Moreover, the use of a safe environment allows for the reflection and practice of mental health interventions [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This allows students to analyse their actions, identify areas for improvement, and understand how their interventions could impact real situations.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSimulated scenario, NANDA-I 2024\u0026ndash;2026 (NANDA-I Taxonomy) Nursing Interventions Classification (NIC) and outcomes (NOC) and related nursing activities for resolution.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSimulated Scenario 1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNANDA\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNOC Outcomes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eNursing Activities\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51-year-old male, diagnosed with paranoid schizophrenia, involuntarily admitted five days ago after severe behavioral disturbances in public. Since admission, he has had delusions of harm: he believes that the CIA is after him, that cameras are recording him and that the staff is involved in a conspiracy to harm him. He refuses medication, no insight.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAltered thought processes (00493)\u003c/p\u003e \u003cp\u003eIneffective regulation of emotions (00372)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBehavior management (4350)\u003c/p\u003e \u003cp\u003eManagement of delusions (6450)\u003c/p\u003e \u003cp\u003eCognitive restructuring (4700)\u003c/p\u003e \u003cp\u003eEnvironmental management: safety (6486)\u003c/p\u003e \u003cp\u003eMedication management (2380)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnxiety self-management (1402)\u003c/p\u003e \u003cp\u003eCommunication (0902)\u003c/p\u003e \u003cp\u003eSocial interaction skills (1502)\u003c/p\u003e \u003cp\u003eSelf-control of distorted thinking (1403)\u003c/p\u003e \u003cp\u003eAdherence behavior (1600)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- Observe the patient's behavior, identify signs of escalation and assess the risk of aggression.\u003c/p\u003e \u003cp\u003e- Use verbal de-escalation techniques to reduce anxiety, such as active listening and providing reassuring responses.\u003c/p\u003e \u003cp\u003e- Assess thought content and evaluate cognitive restructuring.\u003c/p\u003e \u003cp\u003e- Facilitate a safe and calm environment for the patient, avoiding stimulus overload.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSimulated Scenario 2\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e(continued scenario 1)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNANDA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eNOC Outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eNursing Activities\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe patient starts banging on the door and screaming. The nursing team enters the room, the patient becomes aggressive, refusing any attempt at intervention. The mechanical restraint protocol is activated. The patient is physically restrained at five points to ensure his safety. During the process, he maintains delirious speech, believing that he is being neutralized by a \u0026ldquo;conspiracy\u0026rdquo; and by the CIA.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisk of violence directed at others (00138)\u003c/p\u003e \u003cp\u003eRisk of non suicidal self-injurious behavior (00468)\u003c/p\u003e \u003cp\u003eIneffective impulse control (00222)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePhysical restraint (6580)\u003c/p\u003e \u003cp\u003eCrisis intervention (6160)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAgitation level (1214)\u003c/p\u003e \u003cp\u003eSelf-restriction of aggression (1401)\u003c/p\u003e \u003cp\u003eKnowledge of personal safety (1809)\u003c/p\u003e \u003cp\u003eImpulse self-control (1405)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e- Emotional support and verbal restraint.\u003c/p\u003e \u003cp\u003e-Proceed with physical restraint following protocol to ensure patient and team safety.\u003c/p\u003e \u003cp\u003e- Document in detail the actions taken and the patient's behavior.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.5 Data analysis\u003c/h2\u003e \u003cp\u003eThe analysis process was based on an inductive thematic analysis approach aimed at identifying and describing the students lived experiences during the clinical simulation focused on psychomotor agitation in mental health. Data collection included the complete and carefully reviewed verbatim transcription of the focus groups (FGs), the field notes elaborated by the researchers during the simulation and reflection sessions, and the reflective written narratives provided by the students in response to open-ended questions asked through the virtual campus. All the data were stored, organized and managed with the support of specialized software for qualitative analysis ATLAS.ti v24 [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The analysis began with an exploratory and immersive reading of the documents, with the aim of becoming familiar with the narratives and capturing the general meaning of the experiences narrated. Open coding was subsequently performed, in which text fragments containing significant or relevant information to answer the research question were identified [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. This first phase made it possible to generate descriptive codes that emerged directly from the data without forcing preconceived categories. The codes were defined, refined and classified according to their frequency, depth and relationship with the phenomenon under study.\u003c/p\u003e \u003cp\u003e In the second phase, the codes were grouped into categories according to their semantic and conceptual affinity, allowing the detection of recurrent patterns, tensions and nuances in the participants' experiences. These categories gave rise to the construction of central themes, understood as units of meaning that condense the essential dimensions of the lived experience of intervention in cases of psychomotor agitation. Finally, an integrative synthesis was performed, in which the emerging themes were articulated to offer a structured and explicit description of the perceptions, emotions, learning and challenges experienced by the students. This process of analysis made it possible not only to respond to the objectives of the study but also to capture the depth and richness of the phenomenon experienced, in line with the principles of qualitative phenomenology.\u003c/p\u003e \u003cp\u003eThree researchers, experts in qualitative research (P.D.P.-H, E.G.C.-B, A.T.-R), developed the whole process of eliciting themes and categories independently, ending the process with the exchange of both and a consensus on the final decisions of the analysis. In the case of divergence of opinions, the identification of the theme was based on consensus among the members of the research team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e2.6 Ethical considerations\u003c/h2\u003e \u003cp\u003e Ethical authorization to conduct the research was obtained from the Ethics Committee of the La Rioja Center for Biomedical Research (Ref. CEImLAR PI 812). All participants provided written consent before participating in this study. To ensure anonymity and confidentiality, a code was assigned to each participant in the FGs and reflective narratives (NRs).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e2.7 Criteria for rigor\u003c/h2\u003e \u003cp\u003eThe study was conducted in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Data triangulation was applied among the researchers involved in the analysis, and the analysis process was subjected to review by independent researchers to ensure credibility. Transferability was ensured by a detailed description of the research setting, as well as the participants, context and method. Confirmability was achieved by introducing variability in participants' experiences; each researcher conducted the reading and analysis independently, contrasting and then reaching agreement on emerging themes and subthemes [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Demographic data\u003c/h2\u003e \u003cp\u003eAmong the total number of nursing students, 40 met the criteria, 22 (55%) ultimately participated, and data saturation was reached. Those participants who did not attend the simulation were due to various reasons, such as lack of time, work shifts or other reasons. The majority of the participants were women (17 (77.27%)), whereas 5 participants were men (22.73%). They ranged in age from 20\u0026ndash;29 years (mean age\u0026thinsp;=\u0026thinsp;20.4; SD\u0026thinsp;=\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8). The discrepancy between students and genders is due mainly to the fact that the majority of students enrolled in the profession at Spanish universities are women. The participants were in their third year of nursing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Themes\u003c/h2\u003e \u003cp\u003eThree thematic blocks with their categories were identified: 1) Recognition and initial coping with psychomotor agitation. 2) De-escalation strategies and communication skills. 3) Reflecting on the nursing role and decision-making in a crisis context. See Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThemes and categories.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThemes (T)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRecognition and initial coping of psychomotor agitation.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEarly identification of signs and symptoms of agitation\u003c/p\u003e\u003cp\u003eStudent's emotional reactions to the crisis.\u003c/p\u003e\u003cp\u003eRisk perception and level of alertness during the simulation.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDe-escalation strategies and communication skills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e Use of verbal and nonverbal de-escalation techniques\u003c/p\u003e\u003cp\u003eProfessional attitudes and emotional control during the intervention\u003c/p\u003e\u003cp\u003eDifficulties encountered when applying de-escalation interventions\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eT 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReflection on the nursing role and decision making in crisis contexts\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTeamwork and interdisciplinary coordination\u003c/p\u003e\u003cp\u003eEthical reflection on the use of restraint measures\u003c/p\u003e\u003cp\u003eConnection between simulation and clinical practice preparation\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 1. Recognition and initial coping with psychomotor agitation.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEarly identification of signs and symptoms of agitation\u003c/span\u003e \u003c/p\u003e \u003cp\u003e The students showed a growing ability to observe indicators of psychomotor agitation, such as verbal and nonverbal language, disorganized speech or verbal hostility. They recognized the complexity of adequately interpreting these signs without falling into judgement or haste, which generated a first awareness of the type of clinical observation needed in mental health.\u003c/p\u003e \u003cp\u003eSome participants identified clear symptoms: \u0026ldquo;The patient was having delusions\u0026rdquo; (NR22) and \u0026ldquo;I assumed it was a delusion of persecution and harm\u0026rdquo; (NR5). Others understood the emotional dimension of living with delusions: \u0026ldquo;He had a delusion of persecution and prejudice... that the CIA is persecuting him... it is hard to hear these things because the person experiences it as something real\u0026rdquo; (FG2-5). These experiences also generated reflections on the management of therapeutic communication: \u0026ldquo;The patient referred that there were cameras and that he was being watched; he had delusions and delusions of persecution\u0026rdquo; (FG2-2). \u0026ldquo;He said that the CIA was after him and asked us if we were from the CIA\u0026rdquo; (FG2-3). \u0026ldquo;I screwed up, because I told her that there were cameras... I fed back her delusion\u0026rdquo; (FG1-3). The students began to identify relevant clinical elements, such as the preservation of certain cognitive functions: \u0026ldquo;She had altered thinking but her memory was preserved, so we could have gone that way\u0026rdquo; (FG1-4). They also highlighted the need to develop specific communication skills: \u0026ldquo;It is very difficult for me because you have to be careful with words... if you go into his delirium, it is enhanced\u0026rdquo; (FG2-4).\u003c/p\u003e \u003cp\u003eThis observation capacity also led to a rethinking of the perception of risk: \u0026ldquo;When I go in there and see him so agitated, I realize that we are not dealing with something mild but that there is a real risk\u0026rdquo; (FG2-6). The simulation helped to experience the progression of the psychotic state: \u0026ldquo;He was very agitated... I would not do mechanical restraint, but I would start with verbal restraint\u0026rdquo; (FG1-3).\u003c/p\u003e \u003cp\u003e From the clinical interpretation, several participants reported that agitation was understood as part of a psychopathological process: \u0026ldquo;Because of symptoms such as motor restlessness, delusions, hallucinations\u0026rdquo; (NR7), \u0026ldquo;As a common process within a mental pathology such as schizophrenia\u0026rdquo; (NR10). This perspective allowed some students to integrate previously acquired theoretical knowledge with lived situations, recognizing diagnostic patterns and appropriate clinical responses. However, other students emphasized a more empathic and emotional approach to agitation, prioritizing emotional containment of the patient over diagnostic interpretation. \u0026ldquo;Trying to understand from empathy the patient's situation and the emotions he was experiencing at that moment\u0026rdquo; (NR20), \u0026ldquo;I empathized with the disease\u0026rdquo; (NR18). This emotional disposition did not imply a renunciation of clinical observation but rather a way of humanizing the therapeutic encounter. Some testimonies reflected an orientation clearly focused on the patient's well-being: \u0026ldquo;I did not get to interpret his specific motives; my goal was to calm him down and accompany him so that he felt in a safe and controlled environment, I thought about his well-being and not about the causes\u0026rdquo; (NR14).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStudents\u0026rsquo; emotional reactions to the crisis.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eExposure to an agitated situation provoked intense emotional responses in the students: fear, anxiety, anguish or helplessness, as they did not feel prepared to intervene effectively: \u0026ldquo;I went in with fear... I had never seen paranoid schizophrenia in the acute phase\u0026rdquo; (FG2-1). \u0026ldquo;I felt bad because I wanted to help, but I did not know how\u0026rdquo; (FG2-4). \u0026ldquo;I experienced it as very distressing; there was no way to get him out of his delirium\u0026rdquo; (FG1-4). Several participants expressed frustration and discomfort at not having the necessary tools to act, which resulted in feelings of disorientation and ineffectiveness: \u0026ldquo;I have felt sorry for not knowing how to help him... and courage for not having the tools\u0026rdquo; (FG1\u0026ndash;4). \u0026ldquo;I felt lost... I did not know how to help him\u0026rdquo; (FG2-10). \u0026ldquo;It is that you make a mistake and at any moment everything can get complicated\u0026rdquo; (FG2-11). The pressure of the environment and the need to act as a team under high-stress conditions were also noted as challenges: \u0026ldquo;I had a hard time working as a team in a situation like this... there is a lot of tension\u0026rdquo; (FG2\u0026ndash;8).\u003c/p\u003e \u003cp\u003eIndividual reflections deepen that emotional impact: \u0026ldquo;I felt so small in front of him, not because of his size, but because I did not know how to act without hurting him\u0026rdquo; (NR5). \u0026ldquo;There was a moment when I became so distressed that I felt like I was going to block out altogether\u0026rdquo; (NR11). \u0026ldquo;I thought I was not prepared for these situations, but I also understood that no one is 100% prepared\u0026rdquo; (NR19). \u0026ldquo;I felt real fear that I might react badly, and I did not know how to disguise it\u0026rdquo; (NR17).\u003c/p\u003e \u003cp\u003eSome students used defense mechanisms such as nervous laughter and subsequently reflected on their own limits: \u0026ldquo;I laughed because I did not know what to do, but he thought I was making fun and asked me to leave...it was very hard\u0026rdquo; (FG1\u0026ndash;7). \u0026ldquo;I know that in front of a real patient, I cannot do that, and if it happens to me, I have to get out and let another colleague intervene\u0026rdquo; (FG2-8). These experiences led to a process of self-reflection on one's own emotional limits: \u0026ldquo;I realized that laughing was a way to protect myself, but I have to learn to channel it in another way\u0026rdquo; (NR2). \u0026ldquo;Seeing my emotional boundaries has not been pleasant, but necessary\u0026rdquo; (NR16).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eRisk perception and level of alertness during the simulation.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe clinical simulation generated a degree of realism that was sufficiently high for many students to forget that they were in a controlled environment, which led to a significant increase in their level of alertness, vigilance and emotional tension. This realism was perceived as a determining factor in the activation of behavioral responses close to those that would occur in a real situation: \u0026ldquo;I got into the role, it seemed very real, I did not think it was a simulation\u0026rdquo; (FG1\u0026ndash;2). The need to anticipate possible risks led to self-protection behaviors: \u0026ldquo;I stood near the door in case he tried to leave, as a safety barrier\u0026rdquo; (FG1\u0026ndash;6). \u0026ldquo;I was very alert all the time, I felt that something could truly happen\u0026rdquo; (FG2-3). This emotional activation also allowed some students to become more confident in their observation and coping skills: \u0026ldquo;I am calmer now that I have seen how the patient behaves and what you can find\u0026rdquo; (FG2-1). However, in other cases, realism caused frustration and a sense of professional inadequacy: \u0026ldquo;I felt sorry for not knowing how to help him... and courage for not having the tools\u0026rdquo; (FG1\u0026ndash;2). Situations in which the patient showed disorganized or persecutory behaviors also led some participants to withdraw preemptively: \u0026ldquo;There was a moment when the patient was referential with me and I preferred to leave\u0026rdquo; (FG2-10).\u003c/p\u003e \u003cp\u003eThe increased emotional stress affected decision making in a variable way, depending on the degree of emotional self-regulation of each participant. While some managed to overcome the initial nervousness and focus on the patient's needs, \u0026ldquo;I was very nervous at the beginning, but when we saw that he needed us, I became more focused\u0026rdquo; (FG1\u0026ndash;9). Others reported blockages that affected their technical performance: \u0026ldquo;I was so tense that I forgot the constants... then I realized that it was not the priority\u0026rdquo; (FG1\u0026ndash;5).\u003c/p\u003e \u003cp\u003eAt the individual level, several students expressed surprise at the intensity of their own physiological and cognitive reactions to the simulation: \"I did not know that a simulation could seem so real. My palms were sweating and everything\" (NR12). \"I was surprised at my level of alertness. I was all the time thinking about escape routes and danger signs\" (NR22). Others shared experiences of initial blocking followed by almost automatic activation of responses: \u0026ldquo;The tension blocked me at first, but then I started functioning almost by instinct\u0026rdquo; (NR15). \"I could not think clearly. I felt I had to do something now, even though I did not quite know what\" (NR3).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 2. De-escalation strategies and communication skills.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eUse of verbal and nonverbal de-escalation techniques\u003c/span\u003e \u003c/p\u003e \u003cp\u003e The students explained how they consciously applied verbal techniques (respectful, nonconfrontational, nonconfrontational language, centered on reality, avoiding the promotion of delusional content) and nonverbal techniques (body posture, control of space and environment) to generate a safer environment: \u0026ldquo;We try to create an alliance by saying that he is in a safe place\u0026rdquo; (FG2\u0026ndash;10). The importance of humanizing the bond through small gestures that acknowledge the patient's identity was also highlighted: \u0026ldquo;I asked him for his name... many times patients depersonalize...\u0026rdquo; (FG1\u0026ndash;4). \u0026ldquo;We did not lie, we told him there were cameras for security, but we did not play along\u0026rdquo; (FG2-9).\u003c/p\u003e \u003cp\u003eThey also recognized the usefulness of silences and control of the number of interveners to minimize excessive stimulation: \u0026ldquo;We tried to have only one person speak so that they would not get more upset to reduce stimuli\u0026rdquo; (FG1-1). Real-time decision making was key at times, especially when it was perceived that the interaction was not effective: \u0026ldquo;When I saw that we were not getting out of the loop, I told her that I was going to the nurse's station, that I was available if she needed anything\u0026rdquo; (FG2-6). This strategy allowed students to practice controlled withdrawal skills, protecting both the patient and the team.\u003c/p\u003e \u003cp\u003eThe students demonstrated a conscious application of relational strategies aimed at preserving the patient's dignity, promoting safety and facilitating the intervention. From the beginning of the interaction, the personalization of the bond was prioritized as a way to avoid clinical depersonalization: \u0026ldquo;When entering, I introduced myself and called him by name to avoid depersonalization\u0026rdquo; (FG2-7). This attitude was complemented by an explicit intention to generate an environment of trust and support: \u0026ldquo;I have tried to make him see that we are here to help him, creating a safe environment\u0026rdquo; (FG2-3). Negotiation skills were also identified as a useful tool to promote patient collaboration, especially in relation to taking medication: \u0026ldquo;I tried to negotiate so that he would take the medication and ask him what he needed\u0026rdquo; (FG1-6). In parallel, a sensitivity towards the patient's personal space was observed, avoiding invasive behaviors: \u0026ldquo;I wanted to leave space so as not to overwhelm him\u0026rdquo; (FG1-1).\u003c/p\u003e \u003cp\u003eIndividual reflections delve into the personal experience of these strategies, revealing an emotional and technical learning process. Some students highlighted how the perception of the patient's condition overrode their own fears, prioritizing the need for help: \u0026ldquo;I was not afraid because seeing the patient so disorganized I could only think that we had to help him\u0026rdquo; (NR22). Others recognized that these practical skills surpassed what they learned in theoretical training: \u0026ldquo;I learned how to act verbally and bodily with the patient, things that they do not teach you in theory and that I consider to be more useful\u0026rdquo; (NR13). An awareness of the impact of nonverbal language and general attitudes during clinical interaction was also evident: \u0026ldquo;I have realized that nonverbal language and verbal restraint have an enormous impact if used well\u0026rdquo; (NR15). \u0026ldquo;Tone, attitude, not jumping in with your delusion... all of that is more important than I thought\u0026rdquo; (NR7).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eProfessional attitudes and emotional control during the intervention\u003c/span\u003e \u003c/p\u003e \u003cp\u003eOne of the lessons most valued by the students was the importance of managing one's own emotional state during crisis situations. Many emphasized that self-control not only is fundamental for personal well-being but also directly influences the development of therapeutic interventions. The ability to recognize one's own limits and act accordingly was interpreted as a strength rather than a weakness: \u0026ldquo;I think I have done terribly... I have leaned on my companions\u0026rdquo; (FG1\u0026ndash;9). \u0026ldquo;If that happens to me, I'd rather leave the room\u0026rdquo; (FG2-7). There was also a growing awareness of the value of silence, presence and clinical humility when one does not have all the answers: \u0026ldquo;I think that if I do not know something, it is better to be silent and accompany\u0026rdquo; (FG2-8). The need to establish a close but clear relationship was also recognized: \u0026ldquo;I did not want him to see me as an authority figure, but I wanted him to know that if at some point I have to set a limit, he knows that I will do it\u0026rdquo; (FG2-9).\u003c/p\u003e \u003cp\u003eLearning about asking for help occupied a central place in the reflections of several participants, who identified this action as part of the professional role in training: \u0026ldquo;I have not asked for help out of ignorance; I am a student... next time I will ask for it\u0026rdquo; (FG2-4). \u0026ldquo;I have realized that I have to know how to ask for help\u0026rdquo; (FG2-1). The experience also made it possible to project the learning towards future situations: \u0026ldquo;I think that I have taken away knowledge to be able to deal with it in another similar situation\u0026rdquo; (FG2\u0026ndash;3).\u003c/p\u003e \u003cp\u003ePersonal reflections reinforced the need for such emotional self-regulation: \u0026ldquo;I have learned that it is important not to get carried away by panic or tension but to remain calm for the good of the patient\u0026rdquo; (NR12). Others discovered their capacity for self-regulation in the context of a context they initially perceived as unapproachable: \"I saw myself in the situation and thought I would not know what to do, but I was surprised by my calm reaction. That taught me that I can also handle myself well emotionally.\" (NR3). Finally, the awareness emerged that one's emotions are reflected in clinical interaction: \"I have realized that if I get out of control, the patient notices it too. I have to learn to be centered even if I am nervous inside.\" (NR6).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eDifficulties are encountered when applying de-escalation interventions.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eDespite their theoretical knowledge, several students reported difficulties in effectively applying de-escalation strategies. Intense emotions, uncertainty about how to act and frustration at not seeing immediate results were common barriers: \u0026ldquo;I did not know how to prioritize... I focused on taking the tension instead of listening to the patient\u0026rdquo; (FG1-5). Even so, some expressed their commitment to the therapeutic presence: \u0026ldquo;Even though I did not know how to act, I did not want to leave the patient alone\u0026rdquo; (FG2-7). The feeling of helplessness in the face of the perceived lack of impact was also recurrent: \u0026ldquo;I still feel helpless... I feel that I have not helped him as much as possible\u0026rdquo; (FG2-6). Others identified specific errors in decision making: \u0026ldquo;I let him take the medication and the situation get out of control\u0026rdquo; (FG2-4), whereas some chose to prioritize bonding over technical tasks: \u0026ldquo;I saw that it was impossible to take him constant and I preferred to focus on his discomfort\u0026rdquo; (FG1-9). The difficulty in asking for help and the disorganization of the team at key moments were also noted: \u0026ldquo;I thought I could solve it by myself... but I did not ask for help\u0026rdquo; (FG1-2); \u0026ldquo;We had previously planned the roles, but we got blocked\u0026rdquo; (FG2-1).\u003c/p\u003e \u003cp\u003eIndividual reflections reinforced the experience of these difficulties. Some students expressed insecurity about how to initiate the interaction: \u0026ldquo;I felt clumsy, as if I did not know how to start talking to him without making the situation worse\u0026rdquo; (NR10). Others evidenced the gap between theoretical knowledge and actual practice: \u0026ldquo;I thought that with the phrases we had learned it was going to be enough, but at the time I did not know how to use them well\u0026rdquo; (NR20). Fear of aggravating the situation sometimes led to inaction: \u0026ldquo;I was afraid of saying something that would provoke him more, so I kept quiet... but then I regretted not having said anything\u0026rdquo; (NR17). Finally, some highlighted the value of vicarious learning: \"I knew what to do, but I was blocked by nerves. Then, I saw how my classmates did it, and I learned by watching\" (NR21).\u003c/p\u003e \u003cp\u003e \u003cb\u003eTheme 3. Reflection on the nursing role and decision making in crisis contexts.\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eTeamwork and interdisciplinary coordination\u003c/span\u003e \u003c/p\u003e \u003cp\u003eCollaborative work emerged as a fundamental aspect both in the focus groups and in the individual experiences of the students, being configured as a pillar for effective intervention in situations of psychomotor agitation. Clear assignment of roles, prior coordination and mutual support were repeatedly identified as elements that enhance the responsiveness of the team.\u003c/p\u003e \u003cp\u003eOne student highlighted strategic planning as key to addressing the situation: \u0026ldquo;Before that, we organized who was going to which limb and asked for help\u0026rdquo; (FG1\u0026ndash;8). This prior order not only facilitated the intervention but also avoided chaos and minimized risks for both the patient and the team. Reflection on coordination highlights the interdependence of actions: \u0026ldquo;I have realized the importance of teamwork... if the strategy is not coordinated, in the end it has repercussions for the patient\u0026rdquo; (FG2\u0026ndash;9).\u003c/p\u003e \u003cp\u003eLikewise, the diversity of perspectives and resources contributed by each member was valued: \u0026ldquo;There are many alternatives for working with the patient... what I cannot think of, can come from another colleague\u0026rdquo; (FG2-2). However, not all participants found this process easy; some identified difficulties in the group dynamics: \u0026ldquo;I found it difficult to work as a team... we were all trying to talk to him\u0026rdquo; (FG2\u0026ndash;4), which indicates the need to strengthen communication and leadership skills within the group. On the other hand, the experience was also positive for those who were able to integrate their role in a reflective manner: \u0026ldquo;I felt good working in a team... but I had to think very carefully about what to say\u0026rdquo; (FG2-5).\u003c/p\u003e \u003cp\u003eHowever, the tension and stress generated in the simulation resulted in occasional blockages, despite the planning: \u0026ldquo;We had previously planned the roles but we got blocked\u0026rdquo; (FG2-1), showing that real practice demands flexibility and constant adaptation. From the individual perspective, mutual support contributes to increasing feelings of security and professional competence. One student expressed, \u0026ldquo;I felt comfortable and safe most of the time, as I had a very competent and competent team\u0026rdquo; (NR12). Another highlighted the positive impact of this experience for her professional future: \"It has given me much more confidence. I feel more prepared to face similar situations in the future\" (NR16).\u003c/p\u003e \u003cp\u003eThese collaborative experiences fostered the development of a professional identity oriented toward teamwork and the joint construction of the therapeutic alliance, which are essential aspects of mental health care. In the words of one of the participants, \u0026ldquo;I truly liked it, we worked as a team, we coordinated... and worked on the therapeutic alliance\u0026rdquo; (FG1\u0026ndash;4).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEthical reflection on the use of containment measures\u003c/span\u003e \u003c/p\u003e \u003cp\u003ePhysical restraint, considered a measure of last resort, elicited profound ethical reflection among the students. A clear preference for more respectful and less invasive alternatives was evident, although at the same time, the importance of having clear protocols for its application in extreme situations was recognized.\u003c/p\u003e \u003cp\u003eOne participant expressed the need to follow established indications when other options fail: \u0026ldquo;The drug has not been effective, so being increasingly agitated, we have followed the mechanical containment protocol\u0026rdquo; (FG1\u0026ndash;4). However, others expressed reluctance toward this measure, preferring verbal strategies rather than physical restraint: \u0026ldquo;I would not do mechanical restraint, but I would do verbal restraint\u0026rdquo; (FG1\u0026ndash;3).\u003c/p\u003e \u003cp\u003eEthical dilemmas were also raised about communication with the patient in these circumstances, questioning sincerity and respect: \u0026ldquo;Can you offer him that he will be safe if you are there? Or is that lying?\u0026rdquo; (FG2-8). In addition, errors in the execution of restraint were recognized, leading to self-criticism and reflection on the need to improve procedures: \u0026ldquo;The mechanical restraint was not complete...we were overconfident and that needs to be reviewed\u0026rdquo; (FG2-1).\u003c/p\u003e \u003cp\u003eIndividual reflections complemented this picture, reinforcing the tension between respect for the patient and the need for safety. One student commented, \u0026ldquo;The objectives of the intervention were to calm him down\u0026rdquo; (NR22), whereas another explained the change in strategy in the face of the impossibility of verbal de-escalation: \u0026ldquo;My main objective was to try to do a verbal de-escalation, but clearly when we entered the scene that was almost impossible... Already when we saw that a verbal de-escalation could not be done, the main objective was to contain him mechanically so that he would not run away or hurt himself or others.\u0026rdquo; (NR9). Another noted, \u0026ldquo;The main goal was the well-being and safety of the patient and staff\u0026rdquo; (NR1).\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eConnection between simulation and preparation for clinical practice.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe experience was unanimously valued as transformative and preparatory for the professional reality. From the group analysis, \u0026ldquo;I take away that it will be useful in life... so as not to block myself\u0026rdquo; (FG2-7). \u0026ldquo;I am super grateful... I have realized that being authoritarian is not useful and that it has given me tools\u0026rdquo; (FG2-5). \u0026ldquo;I was surprised by the simulation... pure impotence, and I am left with knowing how to negotiate with the patient\u0026rdquo; (FG1-2). \u0026ldquo;I was angry that I did not take part in the simulation... but I look forward to the next intervention\u0026rdquo; (FG1\u0026ndash;10). \u0026ldquo;I take away many positive things and others to improve, but I feel more confident\u0026rdquo; (FG1\u0026ndash;5). \u0026ldquo;I leave very happy...knowing what I can deal with comes in handy\u0026rdquo; (FG2-9). \u0026ldquo;I am sure that if it happens to me in real life, I will have some flashbacks\u0026rdquo; (FG2-10). \u0026ldquo;It has served me well... I have already worked in psychiatry, and this reinforces me\u0026rdquo; (FG1-3). \u0026ldquo;I take away learning that can come in handy for tomorrow\u0026rdquo; (FG1\u0026ndash;8). \u0026ldquo;I think the key is to inform the patient of everything we are going to do\u0026rdquo; (FG1-8).\u003c/p\u003e \u003cp\u003eFrom the individual reflections, the increase in self-confidence further deepened: \u0026ldquo;Very positive, greater security when acting, reduction of fear, I went from being afraid of an aggression to wanting to intervene, it allowed me to know exactly what to do and what not to do, proper attitude of trust and coordination with the team, I gained confidence and enjoyed the practice\u0026rdquo;. (NR10). \"It is something I highlight above all else. Before the simulation, I did not consider myself capable or sufficient to intervene in psychomotor agitation. However, after this experience, I am convinced that if I am involved in one, I can contribute something.\" (NR15). \u0026ldquo;Now I have more tools to face a situation of this type, and I even consider doing an internship in a mental health unit.\u0026rdquo; (NR20). \u0026ldquo;It has not truly influenced me too much; what I do think is that, owing to this simulation, a situation similar to this one will not catch me so helpless, although I would still have my doubts about how to act (clearly much less than I would have if I had not participated in this simulation).\u0026rdquo; (NR14). \u0026ldquo;More confident and secure in being able to deal with situations similar to those in the simulation.\u0026rdquo; (NR1).\u003c/p\u003e \u003cp\u003eIt is thus articulated how simulation not only improves technical and coordination skills but also represents a key space for strengthening self-efficacy and reaffirming professional identity as nursing professionals prepare to act in crisis contexts.\u003c/p\u003e \u003cp\u003eThese results highlight the complexity of nursing interventions in clinical simulation contexts in mental health, highlighting the need for effective strategies and the exploration of various alternatives for addressing situations of psychomotor agitation. From the analysis carried out with the ATLAS.ti program, three main themes were identified that structure the students' experience during the simulation: 1) Recognition and initial coping with psychomotor agitation. 2) De-escalation strategies and communication skills. 3) Reflecting on the nursing role and decision-making in crisis contexts. These results illustrate the complexity of the intervention, highlighting the importance of effective strategies and the consideration of various alternatives to address simulated mental health situations. All of them are interrelated with each other and with the simulation using the ATLAS-Ti program (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe findings of this study confirm the pedagogical and emotional value of clinical simulation in the training of nursing students in mental health crisis situations [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] as is the case for psychomotor agitation in the context of severe mental disorders. An analysis of the narratives that emerged in the focus groups revealed that the simulation experience not only allows the application of technical knowledge but also generates an experiential space of emotional confrontation, ethics and professionalism that favours meaningful learning [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. One of the main contributions of this experience was the students' awareness of the complexity of the phenomenon of psychomotor agitation and the importance of evidence-based therapeutic intervention both preventively and to restore the patient's health, avoid serious complications arising from the episodes and promote clinical safety and occupational health [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The possibility of experiencing realistic behavioral escalation in a controlled environment made it possible to develop clinical observation and communication skills, identify early signs of mental alteration and adjust the intervention to the patient's needs. This type of training places the student in an active role, promotes critical thinking and exposes him/her to decision-making with ethical, communicative and emotional repercussions [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn line with previous studies, participants stated that the simulation generates a high emotional impact, activating reactions such as anguish, fear, insecurity, blockage or helplessness [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Far from being obstacles, these emotions were recognized by the students themselves as a fundamental part of the learning process, allowing them to explore their own limits, formative needs and coping styles. This finding reinforces the idea that clinical simulation, which is well designed and accompanied by an adequate debriefing phase, can act as a catalyst for students' emotional and professional development [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Another highlight was the acquisition of communication skills focused on verbal de-escalation/containment. Students experienced the usefulness of tools such as active listening, reality orientation, use of the patient's name and emotional validation as pillars for de-escalating the crisis. This experience allowed them to understand that addressing agitation is not reduced to behavioral control but requires communication skills and an empathic and professional attitude [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. The intervention of not reinforcing delirium, orienting the patient in reality, maintaining the therapeutic bond, ensuring safety and maintaining the patient's dignity even in moments of mental disorganization was valued as one of the most significant lessons learned.\u003c/p\u003e \u003cp\u003eWithin this framework, important ethical reflections emerged regarding the use of coercive measures such as physical restraint. Although participants recognized the need to resort to it in extreme cases, they expressed their discomfort and concern about its application, expressing a clear preference for verbal and environmental strategies from positive behavioral support [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e] centered on the person. This ethical-professional awareness, which emerges from experience, is key to training professionals capable of providing humanized and respectful care, even in contexts of high clinical demand [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Teamwork was consolidated as a fundamental axis of the intervention. Prior coordination, role assignment, nonverbal communication and emotional support among colleagues were elements that increased the perception of safety and efficacy during the simulation. This learning is especially relevant in mental health, where an interdisciplinary approach is necessary to sustain complex interventions and prevent the emotional overload of staff [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition, the simulation made it possible to highlight the internal tensions between what was learned theoretically and the student's spontaneous reactions in a realistic environment [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Some participants recognized that, at first, they adopted authoritarian or unempathetic attitudes, only to later identify, owing to debriefing and reflection, that these strategies were ineffective and even counterproductive. This process of personal and professional discovery was experienced as an opportunity to review assumptions, incorporate more appropriate tools and strengthen a nursing identity on the basis of care, respect and emotional support [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, this study reinforces the need to integrate clinical simulation as a structural part of the undergraduate degree in nursing, especially in the area of mental health [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. Simulation involves not only rehearsing procedures but also allowing the student to assume a professional role, manage emotions, make decisions in critical situations and exercise leadership by working in a team. By doing so in a safe environment, with teacher accompaniment and critical reflection, simulation becomes a comprehensive training space where technical knowledge merges with the ethical, emotional and relational dimension of care, resulting in meaningful and humanized learning in care [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e].\u003c/p\u003e"},{"header":"5. Strengths and limitations of the study","content":"\u003cp\u003eThe main strengths of this study lie in its innovative approach to mental health care training by proposing a change in the traditional model of university teaching in this field through the incorporation of realistic clinical simulation scenarios. This type of intervention allows nursing students to face complex situations, such as psychomotor agitation, in a safe and controlled environment, favouring meaningful and experiential learning. Likewise, the simulation contributes to strengthening the clinical, communicative and emotional competencies of the students prior to their incorporation into the professional setting, which reinforces their security and confidence in the management of patients in crisis.\u003c/p\u003e \u003cp\u003eAmong the limitations of the study, it should be noted that the research was carried out exclusively with nursing students at a Spanish university, so the results cannot be generalized to other academic or geographic contexts. This work collects the perceptions of students in a high-fidelity scenario focused on intervention in the face of an episode of psychomotor agitation. It would be interesting to extend this line of qualitative research on a larger scale, incorporating new simulated clinical cases related to different mental health disorders, as well as to complement these findings with quantitative studies that evaluate the impact and efficacy of simulation as an educational strategy in nursing education.\u003c/p\u003e"},{"header":"6. Conclusions","content":"\u003cp\u003eClinical simulation has proven to be an effective pedagogical tool for preparing nursing students to address psychomotor agitation, especially in the mental health field. The experience allowed participants to recognize clinical and warning signs, manage their emotions, apply verbal de-escalation strategies and reflect on their professional role in psychiatry and mental health services. The students valued the simulation as an opportunity to integrate theory and practice, strengthen teamwork and acquire greater confidence in decision making. Likewise, important ethical reflections on the use of restraint measures were generated, and a formative process that transcended the technical process was evidenced, enhancing more humanized and competent nursing.\u003c/p\u003e \u003cp\u003e These findings support the systematic inclusion of clinical simulations in training programs as a way to improve the quality of care, patient safety and emotional preparation of future professionals.\u003c/p\u003e"},{"header":"7. Patents","content":"\u003ch2\u003eInstitutional Review Board Statement\u003c/h2\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of the Center for Biomedical Research of La Rioja (Ref. CEImLAR PI 812).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed Consent\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eStatement\u003c/strong\u003e: Informed consent was obtained from all the student nurses involved in the study.\u003c/p\u003e\n\u003ch2\u003eConflicts of interest:\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no conflicts of interest.\u003c/p\u003e\n\u003ch2\u003eFunding:\u003c/h2\u003e\n\u003cp\u003eThis research received no external funding.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eConceptualization, I.S-A. and P.D.P.-H.; methodology, P.D.P-H., E.G.C-B. and A.T-R.; software, R.J-V. and A.T-R.; validation, T.S‒S., C.I.T-G., E.G-C and M.A-M.; formal analysis, E.G.C-B. ; investigation, I.S-A. and P.D.P.-H.; resources, I.S-A., C.I.T-G. and R.J-V.; data curation, R.R.D-V., B.A-N., E.G-C, and C.I.T-G. ; writing\u0026mdash;original draft preparation, I.S-A. and P.D.P-H.; writing\u0026mdash;review and editing, E.G.C.-B. and B.A-N.; visualization, C.I.T.-G. and M.A-M. ; supervision, I.S.-A. and P.D.P.-H.; project administration, I.S.-A., P.D.P.-H. and R.R.D-V; funding acquisition, C.I.T-G. and R.J-V. \u0026ldquo;All authors have read and agreed to the published version of the manuscript.\u0026rdquo;\u003c/p\u003e\n\u003ch2\u003eAcknowledgements:\u003c/h2\u003e\n\u003cp\u003eThe authors acknowledge all the students who took part in this study.\u003c/p\u003e\n\u003ch2\u003eData availability statement:\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHuber CG, Hochstrasser L, Meister K, Schimmelmann BG, Lambert M. Evidence for an agitated-aggressive syndrome in early-onset psychosis correlated with antisocial personality disorder, forensic history, and substance use disorder. Schizophr Res. 2016;175:198\u0026ndash;203. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.schres.2016.04.027\u003c/span\u003e\u003cspan address=\"10.1016/j.schres.2016.04.027\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarrote-C\u0026aacute;mara ME, Santolalla-Arnedo I, Ruiz de Vi\u0026ntilde;aspre-Hern\u0026aacute;ndez R, Gea-Caballero V, Sufrate-Sorzano T, del Pozo-Herce P, Garrido-Garc\u0026iacute;a R, Rubinat-Arnaldo E. Ju\u0026aacute;rez Vela R. Psychometric characteristics and sociodemographic adaptation of the Corrigan Agitated Behavior Scale in patients with severe mental disorders. Front Psychol. 2021;12:779277. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyg.2021.779277\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2021.779277\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCaqueo-Ur\u0026iacute;zar A, Fond G, Urz\u0026uacute;a A, Boyer L, Willians D. Violent behavior and aggression in schizophrenia: prevalence and risk factors a multicentric study from three Latin-American countries. Schizophr Res. 2016;178:23\u0026ndash;8. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.schres.2016.09.005\u003c/span\u003e\u003cspan address=\"10.1016/j.schres.2016.09.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOstinelli EG, D\u0026rsquo;Agostino A, Shokraneh F, Salanti G, Furukawa TA. Acute interventions for aggression and agitation in psychosis: study protocol for a systematic review and network meta-analysis. BMJ Open. 2019;9:e032726.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarrote-C\u0026aacute;mara ME, Ju\u0026aacute;rez-Vela R, Rodr\u0026iacute;guez-Mu\u0026ntilde;oz PM, P\u0026eacute;rez J, S\u0026aacute;nchez-Gonz\u0026aacute;lez JL, Rubinat-Arnaldo E, Navas-Echazarreta N, Sufrate-Sorzano T, Santolalla-Arnedo I. NANDA nursing diagnoses associated with the occurrence of psychomotor agitation in patients with severe mental disorder: a cross-sectional study. BMC Nurs. 2023;22(1):292. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s12912-023-01434-2\u003c/span\u003e\u003cspan address=\"10.1186/s12912-023-01434-2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarrote-C\u0026aacute;mara ME, Gea-Caballero V, Sufrate-Sorzano T, Rubinat-Arnaldo E, Santos-S\u0026aacute;nchez J\u0026Aacute;, Cobos-Rinc\u0026oacute;n A, Santolalla-Arnedo I, Ju\u0026aacute;rez-Vela R. Clinical and sociodemographic profile of psychomotor agitation in mental health hospitalization: a multicentre study. Int J Environ Res Public Health. 2022;19:15972. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/ijerph192315972\u003c/span\u003e\u003cspan address=\"10.3390/ijerph192315972\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVieta E, Garriga M, Cardete L, Bernardo M, Lombra\u0026ntilde;a M, Blanch J, Mart\u0026iacute;nez-Ar\u0026aacute;n A. Protocol for the management of psychiatric patients with psychomotor agitation. BMC Psychiatry. 2017;17:328.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorrecher PS. Protocolo diagn\u0026oacute;stico y terap\u0026eacute;utico del paciente agitado. Med-Programa Form M\u0026eacute;dica Contin Acreditado. 2019;12:5017\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCant RP, Cooper SJ. Use of simulation-based learning in undergraduate nurse education: an umbrella systematic review. Nurse Educ Today. 2017;49:63\u0026ndash;71. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nedt.2016.11.015\u003c/span\u003e\u003cspan address=\"10.1016/j.nedt.2016.11.015\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ. Technology-enhanced simulation for health professions education: a systematic review and meta-anal.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKolb D. Experiential learning: experience as the source of learning and development. Englewood Cliffs, NJ: Prentice-Hall; 1984.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePal\u0026eacute;s Argullos J, Gomar Sancho C. El uso de las simulaciones en educaci\u0026oacute;n m\u0026eacute;dica. Rev Teor\u0026iacute;a la Educ Educ y Cult en la Soc la Inf. 2010;11(2):147\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLockertsen \u0026Oslash;, L\u0026oslash;vhaug L, Davik NK, B\u0026oslash;lgen BR, F\u0026aelig;rden A, Skarstein S. Second-year undergraduate nursing students' experiences with clinical simulation training in mental health clinical practice: a focus group study. Nurse Educ Pract. 2023;66:103534. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nepr.2022\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2022\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeale J. What is the evidence for the use of simulation training to teach communication skills in psychiatry? Evid Based Ment Health. 2019;22(1):23\u0026ndash;5. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/ebmental-2018-300075\u003c/span\u003e\u003cspan address=\"10.1136/ebmental-2018-300075\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDois Castellon A, Farias Cancino A, Fuentes Olavarr\u0026iacute;a D. Aporte de pacientes psiqui\u0026aacute;tricos simulados al proceso de ense\u0026ntilde;anza-aprendizaje: percepci\u0026oacute;n de estudiantes de enfermer\u0026iacute;a. Index Enferm. 2016;25(4).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHermanns M, Lilly ML, Crawley B. Using clinical simulation to enhance psychiatric nursing training of baccalaureate students. Clin Simul Nurs. 2011;7(2):41\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBinham H, O'Brien AJ. Educational intervention to decrease stigmatizing attitudes of undergraduate nurses towards people with mental illness. Int J Ment Health Nurs. 2018;27(1):311\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCorso SJF, Delgado MB, G\u0026oacute;mez-Restrepo C. Uso de pacientes simulados en psiquiatr\u0026iacute;a. Rev Colomb Psiquiatr. 2012;41:52\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKorstjens I, Moser A. Series: practical guidance to qualitative research. Part 2: context, research questions and designs. Eur J Gen Pract. 2017;23:274\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHenriques CMDG, Botelho MAR, Catarino HDCP. Phenomenology as a method applied to nursing science: research study. Cien Saude Colet. 2021;26(2):511\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1590/1413-81232021262.41042\u003c/span\u003e\u003cspan address=\"10.1590/1413-81232021262.41042\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCreswell JW, Poth CN. Qualitative inquiry and research design: choosing among five approaches. 4th ed. Thousand Oaks, CA: Sage; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoser A, Korstjens I. Series: practical guidance to qualitative research. Part 3: sampling, data collection and analysis. Eur J Gen Pract. 2018;24:9\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNANDA International. Diagn\u0026oacute;sticos enfermeros: definiciones y clasificaci\u0026oacute;n 2024\u0026ndash;2026. 13th ed. Edici\u0026oacute;n hispanoamericana. Elsevier; 2024.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eButcher HK, Bulechek GM, Dochterman JM, Wagner CM. Nursing Interventions Classification (NIC). 2nd ed. St. Louis, MO: Elsevier; 2018.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLuebbert R, Perez A, Andrews A, Webster-Cooley T. Standardized patients versus mannequins in mental health simulation. J Am Psychiatr Nurses Assoc. 2023;29(4):283\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/10783903231183322\u003c/span\u003e\u003cspan address=\"10.1177/10783903231183322\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlshehri FD, Jones S, Harrison D. The effectiveness of high-fidelity simulation on undergraduate nursing students' clinical reasoning-related skills: a systematic review.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSittner BJ, Aebersold ML, Paige JB, Graham LL, Schram AP, Decker SI, Lioce L. INACSL standards of best practice for simulation: past, present, and future.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRudolph JW, Raemer DB, Simon R. Establishing a safe container for learning in simulation: the role of the presimulation briefing. Simul Healthc. 2014;9:339.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaestre JM, Rudolph JW. Theories and styles of debriefing: the good judgment method as a tool for formative assessment in healthcare. Rev Esp Cardiol. 2015;68:282\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirkbakk-Fj\u0026aelig;r K, Hedelin B, Moen \u0026Oslash;L. Undergraduate nursing students' evaluation of the debriefing phase in mental health nursing simulation. Issues Ment Health Nurs. 2016;37:360\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNg R, O'Reilly CL, Collins JC, Roennfeldt H, McMillan SS, Wheeler AJ, El-Den S. Mental Health First Aid crisis role-plays between pharmacists and simulated patients with lived experience: a thematic analysis of debrief. Soc Psychiatry Psychiatr Epidemiol. 2023;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFriese S. Qualitative data analysis with ATLAS.ti. 3rd ed. London: SAGE; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBraun V, Clarke V. What can thematic analysis offer health and wellbeing researchers? Int J Qualitative Stud Health Well-being. 2014;9:26153.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19:349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorse JM. Critical analysis of strategies for determining rigor in qualitative inquiry. Qual Health Res. 2015;25:1212\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLilly ML, Hermanns M, Crawley B. Clinical simulation in psychiatric-mental health nursing: post-graduation follow up. J Psychosoc Nurs Ment Health Serv. 2016;54:40\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHarvey T. Adoptando la simulaci\u0026oacute;n en la educaci\u0026oacute;n de enfermeras de salud mental: un enfoque personalizado para abordar el gen\u0026eacute;rico. Nurse Educ Pract. 2023;71:103698. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nepr.2023.103698\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2023.103698\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang X, Wang H. Efectividad comparativa de las t\u0026eacute;cnicas de simulaci\u0026oacute;n de salud mental en la educaci\u0026oacute;n de enfermer\u0026iacute;a: una revisi\u0026oacute;n sistem\u0026aacute;tica y metaan\u0026aacute;lisis. Int J Ment Health Nurs. 2025;34(1):E13502. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/inm.13502\u003c/span\u003e\u003cspan address=\"10.1111/inm.13502\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePompili M, Ducci G, Galluzzo A, Rosso G, Palumbo C, De Berardis D. The management of psychomotor agitation associated with schizophrenia or bipolar disorder: a brief review. Int J Environ Res Public Health. 2021;18:4368.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLockertsen \u0026Oslash;, L\u0026oslash;vhaug L, Davik NK, B\u0026oslash;lgen BR, F\u0026aelig;rden A, Skarstein S. Second-year undergraduate nursing students' experiences with clinical simulation training in mental health clinical practice: a focus group study. Nurse Educ Pract. 2023;66:103534. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nepr.2022.103534\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2022.103534\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHeyman I, Webster BJ, Tee S. Curriculum development through understanding the student nurse experience of suicide intervention education: a phenomenographic study. Nurse Educ Pract. 2015;15:498\u0026ndash;506.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePiot MA, Dechartres A, Attoe C, Romeo M, Jollant F, Billon G, Cross S, Lemogne C, Layat Burn C, Michelet D, Guerrier G, Tesniere A, Rethans JJ, Falissard B. Effectiveness of simulation in psychiatry for nursing students, nurses and nurse practitioners: a systematic review and meta-analysis. J Adv Nurs. 2022;78(2):332\u0026ndash;47. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/jan.14986\u003c/span\u003e\u003cspan address=\"10.1111/jan.14986\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGodzik CM, Solomon J, Yacinthus B. Using standardized mental health patient simulations to increase critical thinking and confidence in undergraduate nursing students. Arch Psychiatr. 2023;43:76\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalsh RS, McClean B, Doyle N, Ryan S, Scarborough-Lang SJ, Rishton A, Dagnall N. A thematic analysis investigating the impact of positive behavioral support training on the lives of service providers: It makes you think differently. Front Psychol. 2019;10:2408. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fpsyg.2019.02408\u003c/span\u003e\u003cspan address=\"10.3389/fpsyg.2019.02408\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConstantino JN, Strom S, Bunis M, Nadler C, Rodgers T, LePage J, Cahalan C, Stockreef A, Evans L, Jones R, Wilson A. Toward actionable practice parameters for dual diagnosis: principles of assessment and management for co-occurring psychiatric and intellectual/developmental disability. Curr Psychiatry Rep. 2020;22(2):9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11920-020-1127-8\u003c/span\u003e\u003cspan address=\"10.1007/s11920-020-1127-8\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFelton A, Wright N. Simulation in mental health nurse education: the development, implementation and evaluation of an educational innovation. Nurse Educ Pract. 2017;26:46\u0026ndash;52. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.nepr.2017.06.005\u003c/span\u003e\u003cspan address=\"10.1016/j.nepr.2017.06.005\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDawood E, Alshutwi SS, Alshareif S, Shereda HA. Nurs Rep. 2024;14(2):1424\u0026ndash;38. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/nursrep14020107\u003c/span\u003e\u003cspan address=\"10.3390/nursrep14020107\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Evaluaci\u0026oacute;n de la efectividad de la simulaci\u0026oacute;n estandarizada de pacientes como m\u0026eacute;todo de ense\u0026ntilde;anza en enfermer\u0026iacute;a psiqui\u0026aacute;trica y de salud mental.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFerrara P, Terzoni S, Ruta F, Poggi AD, Destrebecq A, Gambini O, D\u0026rsquo;Agostino A. Nursing students\u0026rsquo; attitudes towards suicide and suicidal patients: a multicentre cross-sectional survey. Nurse Educ Today. 2022;109:105282.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoch C, Meier S, Fischer C, Brich J. Simulated patients to demonstrate common stroke syndromes: accurate and convincing. Cerebrovasc Dis. 2023;55:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLawton AJ, Greco L, Airaldi R, Tulsky JA. Development of an actor rehearsal guide for communication skills courses. BMJ Palliat Care. 2024;15:1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFarooq S, Tharani A, Begum S, Parpio Y. Implementation of simulation: a contemporary strategy to enhance clinical skills of undergraduate students in mental health nursing. Issues Ment Health Nurs. 2020;41(8):736\u0026ndash;40. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/01612840.2019.1710011\u003c/span\u003e\u003cspan address=\"10.1080/01612840.2019.1710011\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"simulation, nursing, mental health, education, skills","lastPublishedDoi":"10.21203/rs.3.rs-7923440/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7923440/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAddressing psychomotor agitation is a key competency in the mental health setting. Clinical simulation allows nursing students to train in a safe environment, favouring the learning of verbal restraint and de-escalation strategies. This methodology improves decision-making, therapeutic communication, teamwork and patient safety. Integrating this training strengthens professional preparation for situations of high emotional complexity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQualitative descriptive phenomenological descriptive study through focus groups and reflective narratives. A thematic analysis was performed via ATLAS-ti.24.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree thematic blocks with their categories were identified: (T1) recognition and initial coping with psychomotor agitation and (T2) de-escalation strategies and communication skills. (T3) Reflecting on the nursing role and decision making in crisis contexts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eClinical simulation allows nursing students to train their approach to psychomotor agitation in a safe environment. It favours symptom recognition, decision making, teamwork and emotional control. The participants integrated theory and practice, developing communication skills and ethical reflection. The experience strengthens professional preparation in mental health. Its systematic inclusion in nursing education is recommended.\u003c/p\u003e","manuscriptTitle":"Training of Nursing Students in the Approach and De-escalation of Psychomotor Agitation in Severe Mental Disorder through Clinical Simulation","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-30 09:29:53","doi":"10.21203/rs.3.rs-7923440/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-12-24T07:30:36+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-28T10:21:53+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-24T09:20:35+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-24T09:18:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-10-22T12:10:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a26f1aec-858e-43b2-a29c-ee7aa5746bb7","owner":[],"postedDate":"December 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-12-30T09:29:54+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-30 09:29:53","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7923440","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7923440","identity":"rs-7923440","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}