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Trial registered on ANZCTR

Registration number
Ethics application status
Date submitted
Date registered
Date last updated
Date data sharing statement initially provided
Date results information initially provided
Type of registration
Retrospectively registered

Titles & IDs
Public title
Simulation training to manage challenging behaviours in children with autism.
Scientific title
Simulation-based education for staff managing challenging behaviours of children with autism spectrum in the hospital setting: A Pilot and Feasibility Study of a cluster Randomised Controlled Trial.
Secondary ID [1] 300322 0
Nil known
Universal Trial Number (UTN)
Trial acronym
Linked study record

Health condition
Health condition(s) or problem(s) studied:
challenging behaviour 315929 0
aggression 315930 0
autism 316060 0
Condition category
Condition code
Mental Health 314201 314201 0 0
Autistic spectrum disorders

Study type
Description of intervention(s) / exposure
Simulation-based education for staff in managing challenging behaviours of children with autism spectrum disorder (ASD) in the hospital setting.

Staff training programs designed to teach best practice principles in the management of clinical aggression in paediatric acute care settings is warranted however evidence on training effects in general hospital settings is scant. There are a number of reviews of aggression management training programs in the psychiatric and mental health settings however the results cannot be generalised to the acute setting or further extrapolated to the paediatric setting due to the different types of care provided in each facility and prior training of staff. In addition, aggression management training programs designed for nursing staff working with children with neurodisabilities are rarely described in the literature. Simulation training may be an effective educational tool to practice de-escalation skills in a high fidelity situation. The benefit of simulation-based education for communication skills has been shown to improve patient safety in a number of studies. There is a paucity of literature in the use of simulation-based education to teach de-escalation communication techniques to staff working with children and young people, particularly those with ASD, in the acute care setting.

The training intervention will consist of two components.
1. A web-based learning package, developed using ArticulateTM software, about management of challenging behaviours in children and young people with autism (with and without intellectual disability (ID) ) in the hospital setting as pre-reading. The learning package was developed by an advanced practice nurses who specialises in neurodevelopmental disabilities and has extensive education and training experience. The content was reviewed by three health care clinicians who are autism experts with revisions made prior to commencement of the study. The online learning package has been designed to increase learner’s knowledge about autism. It provides tips on how to communicate with children with autism, especially when they are scared, frustrated or angry. It is estimated that it will take learners about 30 minutes to complete. The package consists of one module and includes short case studies with questions and answers to apply knowledge learnt within the training module. A weblink to the online package is sent to participants via email. Study participants complete the online learning package individually during work hours but prior to the simulation training. Participants will be reminded via email each week for three weeks to complete the package and the surveys during the study period. Nurse educators for the wards participating in the study will also follow up with study participants, reminding them to complete the training during the study period.

2. This will be followed by a 1.5 hour simulation-based group education session to manage challenging behaviours in an adolescent with autism including two separate simulation exercises each followed by a facilitated reflective debrief which explores what the participants did well, what were the challenges and what they will do differently next time. The training will be conducted in the hospital Simulation Centre, conducted by the Simulation Faculty and Code Grey Coordinator with an actor playing the role of the patient. The simulation exercises will be recorded using SportstecTM software. The Simulation Faculty staff are all highly trained and experienced in delivering simulation training. The Code Grey Coordinator is the hospital lead for aggression management and is highly experienced in aggression management procedures and training. The simulation-based training will be delivered twice to enable participants to attend a training session that is scheduled at a time most suitable to them.

Intervention code [1] 316601 0
Comparator / control treatment
Participants allocated to the comparator/control treatment in this study will only receive a web-based learning package in the same format offered to the intervention group participants.

Control group

Primary outcome [1] 322584 0
The study will be judged feasible if the following criteria are met:

1. Randomisation: more than 10% recruitment rate from ward staff. A total of 160 staff from the two selected wards will be eligible to participate in the study. We aim to recruit 10 staff to each arm of the study.
2. Completion: Less than 20% attrition rate with survey completion rate of at least 80%; Focus group participation rate of at least 50% of total participants
3. Acceptability: High acceptability of the intervention among participants as indicated by 80% of scores 4 (good) out of 5 or higher in survey data
4. Data collection: follow-up survey response rate of at least 30% with acceptability and confidence levels maintained; Ward data collection rate of at least 80% of total shifts during study time in each ward
5. Low contamination from intervention participants as evidenced by participant report

Instrument: Pre-/Post-/Follow-up surveys designed specifically for this study. Survey includes “Confidence in Coping with Patient Aggression Instrument” (Thackrey, 1987), short answer questions and free text to assess: self-perceived levels of confidence and competence in managing aggression in a young person with autism and intellectual disability and acceptability of the simulation and web-based education.
Timepoint [1] 322584 0
Study period is for 3 months from delivery of training intervention.
Secondary outcome [1] 378990 0
Secondary outcomes will provide data about the participants reactions and behaviour changes due to exposure to the training:
1. Confidence & Competence: 80% of participants reporting increased confidence levels and positive qualitative comments.

Instrument: Post-training/Follow-up surveys designed specifically for this study. Survey includes “Confidence in Coping with Patient Aggression Instrument” (Thackrey, 1987), short answer questions and free text to assess: self-perceived levels of confidence and competence in managing aggression in a young person with autism and intellectual disability and acceptability of the simulation and web-based education.

Timepoint [1] 378990 0
Immediately after and up to three months post-training.
Secondary outcome [2] 379974 0
2. Data collection: 80% reporting of number of Code Grey activations and the number of successful de-escalation episodes not requiring a Code Grey activation with description of context and outcome for each incident. Participant use of de-escalation skills during simulations using De-escalating Aggressive Behaviours Scale – English modified version (EMDABS).
a. De-escalating Aggressive Behaviours Scale – English modified version (EMDABS),
b. Linkage to hospital reports,
c. Ward data collection instrument developed for this study.
Timepoint [2] 379974 0
One month prior to training and up to three months post-training.

Key inclusion criteria
Clinical nurses who work in two general medical and surgical wards will be invited to participate in the study. Eligible nurses will be those who are responsible for providing direct clinical care for ward patients.
Minimum age
18 Years
Maximum age
No limit
Both males and females
Can healthy volunteers participate?
Key exclusion criteria
Nurses from these wards are excluded if they are not responsible for direct patient care e.g. care coordinators, advanced practice nurses and nurses in charge of the shift.

Study design
Purpose of the study
Educational / counselling / training
Allocation to intervention
Randomised controlled trial
Procedure for enrolling a subject and allocating the treatment (allocation concealment procedures)
Randomisation conducted once recruitment completed by researcher not involved in study.
Methods used to generate the sequence in which subjects will be randomised (sequence generation)
Simple randomisation - coin toss
Masking / blinding
Open (masking not used)
Who is / are masked / blinded?

Intervention assignment
Other design features
Not Applicable
Type of endpoint(s)
Statistical methods / analysis
We plan to recruit 10 staff to each arm of the study. This sample size, based on our experiences in Phase 1 of this study, is a good size for a pilot and feasibility study to assess recruitment, contamination and data collection.

Primary outcomes: Percentages will be calculated, with 95% confidence intervals, to estimate recruitment, retention, outcomes survey response rate and the precision of those estimates. We will treat the Likert scores as categories and dichotomise the 11 and 5 point scale responses. Changes in confidence and competence will be compared statistically (Chi squared test) using before and after data, to compare the proportion of those who have high confidence at baseline between the two arms, and at follow-up.

Secondary outcomes: The Code Grey data and daily aggression data will be analysed using descriptive statistics, including descriptions of the clinical journey for children and young people who trigger more than one code grey response. We will report if aggression de-escalation attempts are recorded each shift on each ward as planned. The EMDABS data will be analysed using mean values and statistical significance tests used to compare results.

Recruitment status
Active, not recruiting
Date of first participant enrolment
Date of last participant enrolment
Date of last data collection
Sample size
Accrual to date
Recruitment in Australia
Recruitment state(s)
Recruitment hospital [1] 15666 0
The Royal Childrens Hospital - Parkville
Recruitment postcode(s) [1] 29075 0
3052 - Parkville

Funding & Sponsors
Funding source category [1] 304747 0
Name [1] 304747 0
Australian Government Research Training Program
Address [1] 304747 0
The University of Melbourne
Grattan Street,
Parkville, Victoria 3010
Country [1] 304747 0
Funding source category [2] 304749 0
Name [2] 304749 0
Elizabeth and Vernon Puzey Scholarship
Address [2] 304749 0
The University of Melbourne
Grattan Street,
Parkville, Victoria 3010
Country [2] 304749 0
Primary sponsor type
The Royal Children's Hospital, Melbourne
50 Flemington Road,
Parkville, Victoria, 3052
Secondary sponsor category [1] 305061 0
Name [1] 305061 0
Address [1] 305061 0
Country [1] 305061 0

Ethics approval
Ethics application status
Ethics committee name [1] 305167 0
Research Ethics and Governance
Ethics committee address [1] 305167 0
The Royal Children's Hospital
50 Flemington Road
Parkville, Victoria, 3052
Ethics committee country [1] 305167 0
Date submitted for ethics approval [1] 305167 0
Approval date [1] 305167 0
Ethics approval number [1] 305167 0

Brief summary
Our project is about using simulation training to teach nursing staff how to manage children with autism who are aggressive in hospital. Simulation training is the process where participants practise a set of skills in a simulated learning environment. Participants can test out their skills to see what works and what doesn’t in a safe environment, without any risk to patients.

In this study we will provide training to clinical nurses who provide direct patient care. The intervention group will receive a web-based learning package on working with children with autism and challenging behaviours and a 1.5 hour simulation training session. The comparator group will receive the web-based training only. We will ask the participants to complete a short survey before the training, immediately after the training and again at three months after the training to find out what they thought of the training and whether it increased their confidence in managing aggression. We will also collect data from the participants’ wards about aggressive episodes.
Trial website
Trial related presentations / publications
Public notes

Principal investigator
Name 99466 0
Prof Fiona Newall
Address 99466 0
The Royal Children's Hospital
50 Flemington Road
Parkville, Victoria 3052
Country 99466 0
Phone 99466 0
+61 9345 6716
Fax 99466 0
+61 9345 5606
Email 99466 0
Contact person for public queries
Name 99467 0
Ms Marijke Mitchell
Address 99467 0
The Royal Children's Hospital
50 Flemington Road
Parkville, Victoria 3052
Country 99467 0
Phone 99467 0
+61 9345 5898
Fax 99467 0
+61 9345 5871
Email 99467 0
Contact person for scientific queries
Name 99468 0
Ms Marijke Mitchell
Address 99468 0
The Royal Children's Hospital
50 Flemington Road
Parkville, Victoria 3052
Country 99468 0
Phone 99468 0
+61 9345 5898
Fax 99468 0
+61 9345 5871
Email 99468 0

Data sharing statement
Will individual participant data (IPD) for this trial be available (including data dictionaries)?
No/undecided IPD sharing reason/comment
What supporting documents are/will be available?
Study protocol
Informed consent form
Ethical approval
How or where can supporting documents be obtained?
Type [1] 6519 0
Study protocol
Citation [1] 6519 0
Link [1] 6519 0
Email [1] 6519 0
Other [1] 6519 0
Attachment [1] 6519 0
Type [2] 6520 0
Informed consent form
Citation [2] 6520 0
Link [2] 6520 0
Email [2] 6520 0
Other [2] 6520 0
Attachment [2] 6520 0
Type [3] 6521 0
Ethical approval
Citation [3] 6521 0
Link [3] 6521 0
Email [3] 6521 0
Other [3] 6521 0
Attachment [3] 6521 0
Summary results
Have study results been published in a peer-reviewed journal?
Other publications
Have study results been made publicly available in another format?
Results – basic reporting
Results – plain English summary