Managing Challenging Patient/Family Behavior Using REBELS

Disruptive behaviors in hospitalized patients and their families are becoming more frequent. Health care providers working in an acute care hospital in Southern California voiced safety concerns in caring for the behaviorally challenging patients and families. Annual education needs assessment for registered nurses showed 59% of nurses surveyed rated management of disruptive behavior as a top educational need.

In response to the needs assessment, staff were surveyed regarding management of challenging patient and family behavior. Results revealed staff felt a lack of confidence, lack of knowledge and skills, and lack of support regarding managing challenging patient and family behavior. According to the survey, staff had a difficult time letting go of negative feelings after a challenging encounter. Anecdotally, staff expressed decreased job satisfaction attributed to these challenging interactions. It was imperative to empower the bedside staff with an evidence-based method to help improve their skillset and confidence in managing challenging patient and/or family behavior.

Using the define, measure, analyze, improve, and control process, the unit practice council (UPC) identified root causes of challenging behavior and honed in on the importance of empathy and boundary setting. With safety as top priority, the UPC identified a communication method as a strategy to de-escalate patient/family reactivity, potentially decreasing the need for security-assisted interventions. The recognize, empathize, boundary, emphasize, language, solution (REBELS) technique is an evidenced-based de-escalation communication method. In order to standardize the unit staff response during challenging interactions, the UPC created an instructional video outlining the aspects of the REBELS method. The video consisted of narration explaining the rationale for each step and demonstrated how to use the technique in actual patient and family encounters. The video was mandatory for staff to view. Compliance as well as comprehension was assessed during the annual competency evaluation program. Each staff member was required to return demonstrate each aspect of the REBELS technique during a simulation of a challenging patient encounter. Performance was audited by a UPC member and recorded on a handwritten audit tool. Remediation for staff who were unable to successfully return demonstrate was completed by the clinical nurse specialist at a later date.

Following implementation of REBELS education in August 2018, survey data has shown an increase in positive response. Staff surveys in July 2019 showed confidence in managing challenging behavior had increased by 18%, knowledge/skills with setting boundaries had increased by 27%, feeling supported by leadership had increased by 27%, and ability to let go of negativity following an event had increased by 23%. Although there was a slight decrease in positive responses to survey questions in February 2020, overall outcomes continued to show improvement when compared to pre-data.
The 2019 education needs assessment for registered nurses showed 4% of nurses surveyed rated management of disruptive behaviors as a top educational need, compared to 59% in 2018.

Communication encouraging empathy, boundaries, and mutual respect empowers staff to manage challenging behavior, resulting in a safer environment. REBELS was recognized by the hospital’s executive leadership team and has been implemented house-wide as a best practice.