As evidenced in the articles in this special issue of the Journal of Psychosocial Nursing and Mental Health Services, the introduction of benzodiazepines (BZDs) into a plan of care can quickly turn into chronic use and dependence. This is a particular issue in long-term care and during hospitalization where BZDs are often initiated (Arnold et al., 2017). Although data in the United States specific to inpatient psychiatric treatment and BZD use are scarce, international research demonstrates individuals are often prescribed BZDs following psychiatric hospitalization (Peters, Knauf, Derbidge, Kimmel, & Vannoy, 2015) and given BZDs as a pro re nata (PRN) medication during their hospital stay (Haw & Wolstencroft, 2014; Martin, Arora, Fischler, & Tremblay, 2017; Stewart, Robson, Chapin, Quirk, & Bowers, 2012).
As nurses often make the final determination on when a PRN medication is given, they have an obvious role in BZD initiation or continuation during hospitalization. As such, nurses have a unique opportunity to help patients decrease BZD use or find alternative ways to manage issues around sleep, anxiety, or agitation—situations where a PRN BZD might be introduced. Indeed, researchers examining PRN medication use have suggested how inpatient nurses might increase nonpharmacological approaches to patient distress, anxiety, or insomnia (Martin, Ham, & Hilton, 2018). Yet, although opportunities exist for nursing intervention around BZD use, there is relatively scant recent U.S. literature on inpatient psychiatric nurses' proactive approach to the issue. Why has reducing BZD use not been championed by inpatient psychiatric nurses?
BZD use during inpatient hospitalization is supported by several subtle factors: attitudes that have grown around BZD use, the perceived effectiveness of the medication to address difficult situations, and barriers to using alternative nonpharmacological methods. These dynamics are examined herein, and suggestions are offered for how nurses might initiate a research-based strategy for reducing BZD use during inpatient psychiatric treatment.
Attitudes and Reasoning Around Dispensing PRN BZD
Inpatient psychiatric nurses regularly dispense PRN BZD (Martin et al., 2017), yet there is little study in the United States about the reasoning that supports their decision to administer this medication. Perhaps due to overuse and heightening side effect profile in the older adult population, considerable research has been conducted around BZD use in long-term care. Investigators recognizing the pivotal role of nurses questioned RNs about their participation in dispensing BZDs, beginning with an exploration of their beliefs and attitudes around BZD use (Anthierens, Grypdonck, De Pauw, & Christiaens, 2009). During interviews and focus groups, participants indicated they did not view BZDs as problem medications. Over time, nurses had apparently become accustomed to individuals using BZDs for sleep and experienced them as routine practice. They also saw their use as an easy option with not many side effects. The investigators concluded nurses' perceptions around BZD use were influenced by their attitudes, perceptions of practice, and knowledge about the medication. It should be noted that viewing BZDs as drugs with little negative downside is not exclusive to nursing. Researchers in the United States report that high-rate prescribers also believe BZDs are effective with few adverse effects and harm risk (Anderson, Stowasser, Freeman, & Scott, 2014).
These themes were also evident in a recent study of Australian inpatient psychiatric nurses and their perceptions on PRN medications to manage acute distress (Barr, Wynaden, & Heslop, 2018). Twenty-seven nurses completed a survey about their attitudes around PRN medications. One pronounced theme was the need for PRN medications to manage distress and agitation during the acute phase of illness, with nurses viewing these medications as an integral part of treatment. An important element of PRN medication use was participants' conflicted attitudes around alternative strategies to address agitation. They named several barriers to the alternative strategies, including organizational factors (e.g., the unit's inadequate staffing discouraged trying what might be more time-consuming methods). Nurses also believed they needed additional education to learn nonpharmacological methods that could effectively help patients regain calm.
One overarching theme of these investigations is nurses' concern for providing some comfort to patients. Indeed, in several studies, nurses cite their use of PRN medications was in response to patients' acute distress (Martin, Arora, et al., 2018). This motivation comes to the fore when nurses attempt to help patients with insomnia. Sleep problems are prevalent on inpatient psychiatric units. Insomnia is a risk factor for a range of mental illness conditions (e.g., depression, anxiety) as well as a psychiatric condition that impacts sleep architecture (Murphy & Peterson, 2015). When interviewed about sleep problems in outpatient settings, prescribers and patients discussed the challenge of sleep disturbance and the difficulty in managing the inability to rest (MacDonald et al., 2015). In MacDonald et al.'s (2015) study, although patients and prescribers were interested in nonpharmacological alternatives, they believed alternative strategies were likely not strong enough, costly, time consuming, and largely ineffective. Thus, when confronted with trying to help a patient fall asleep, it should not be surprising that inpatient nurses may view BZDs as the most viable alternative for a difficult problem.
Alternative Approaches for Sleep and Anxiety
Another aspect of PRN medication use on inpatient units is consideration of what interventions were used prior to giving a PRN BZD. Initial studies on this issue reported a belief in the use of nonpharmacological approaches, such as de-escalation for an agitated patient, but relatively low incidence of nurses' use of alternative means (Usher, Baker, & Holmes, 2010). One difficulty in alternative methods research is that traditionally, findings depended on nurses' chart notes of the strategies used prior to offering a PRN medication, documentation which is typically infrequent (Lindsey & Buckwalter, 2012). Researchers who interviewed nurses about their use of PRN medications, particularly for sleep and anxiety, found that nurses attempted to offer nonpharmacological interventions to patients, but only approximately one half of the time and frequently the strategy was not evidence based; for example, “support” was a frequently used intervention for agitation, anxiety, and insomnia (Martin, Ham, et al., 2018). Again, beliefs entered into the picture, mainly around the effectiveness of alternative strategies to manage intense symptoms. Nurses also believed that in instances when the medication was requested by patients, they were dealing with a question of honoring patient choice.
Examining Decision Making Around PRN Medication use
A related issue to BZD use is the broader concern around psychiatric nurses' clinical reasoning supporting PRN medication administration. Investigations of what type of patients receive PRN medications and under what circumstances report myriad possible factors influence nurses' decisions (e.g., the patient's presenting behavior, ward atmosphere) (Stewart et al., 2012). Nurses' decisional process prior to PRN medication use has been questioned on several fronts, including whether nurses have sufficient knowledge of best practices or clinical guidelines (Usher, Baker, Holmes, & Stocks, 2009). In the Usher et al. (2009) study, investigators found that the decision to administer a PRN medication can be based more on clinical experience and habit rather than evidence-based practice. These findings echo a longstanding concern that discrepancies exist between why PRN medications are ordered and why they are given (i.e., PRN medications are prescribed based on the patient's history, mental state, and risk assessment but given by nurses more often based on safety, level of patient distress, and their familiarity with the patient) (Baker, Lovell, & Harris, 2007). Thus, several factors influence nurses' decision making around administrating PRN medications at any particular time with any particular patient. As the issue of PRN medications on inpatient units is revisited around BZDs, nurses' decisional process should be one element in modeling quality improvement around the problem.
Talking with Patients about BZD Use
Nurses hold the responsibility to respond to but also collaborate with patients on how to ameliorate experiences troubling them, such as sleep disturbance and anxiety. Existing data around collaboration and the patient's view are complex. Individuals hospitalized on psychiatric inpatient units have been asked about their experience of receiving PRN medications (Cleary, Horsfall, Jackson, O'Hara-Aarons, & Hunt, 2012; Martin, Ham, et al., 2018). In the study by Cleary et al. (2012), 40 patients talked about their experience and opinion of receiving PRN medication. Patients generally viewed the medication as helpful, particularly given that in many instances the PRN medication was intended to help with anxiety or sleep. Yet, although patients often acknowledge they requested the medication, at times, patients also perceive there is lack of formal consent and choice during the process (Martin, Ham, et al., 2018). When asked directly, patients also said they would appreciate more information about the medication or discussion of alternatives to PRN medications (Cleary et al., 2010). There is ample room for increasing collaboration around PRN medications particularly via discussion of alternative means to manage anxiety and sleep.
Nurses also have an important role in raising the level of concern with patients who, while hospitalized, are continuing their home pattern of regularly using BZDs. There are many approaches to broaching the issue with patients. Most nurses are familiar with Substance Use, Brief Intervention and Referral to Treatment (SBIRT). SBIRT is an evidence-based program that includes screening, brief intervention, and referral for treatment, and is used to identify patients who are at risk for or who have substance use disorders. This approach is an effective platform for suggesting one's concerns around the amount of substances patients are using and query their thoughts around decreasing use (Bagøien et al., 2013). Many hospitals have SBIRT trainings available to nursing staff or perhaps one of the core techniques (e.g., motivational interviewing) (Darnell, Dunn, Atkins, Ingraham, & Zatzick, 2016).
Even without formal training in SBIRT, nurses can use some of the basics of the method to talk to patients about their BZD use. Suggested approaches are readily available online (access https://archives.drugabuse.gov/initiatives/about-addiction-performance-project/talking-to-patients-about-their-drug-use). As with any interaction, good communication skills and engagement are essential. Nurses should take time to center themselves, be present with patients, and send the intent they are there to listen (Delaney, Shattell, & Johnson, 2017). Nurses could then move into a discussion around BZD use particularly to gain a sense of patients' perception of their BZD use and the factors that support it. Finally, nurses should express concerns in the most straightforward way possible. Such an approach to conversations around BZD use should become a component of standard patient education.
Using Alternative Strategies to Manage Anxiety and Insomnia
As seen in the study by Cleary et al. (2012), patients are interested in alternative ideas on how to manage issues such as anxiety and insomnia and to some extent nurses are open to the concept. As noted, nurses often see the alternatives as not as effective, complicated to initiate, and time consuming. Meredith et al. (2018) noted workplace cultures may favor the use of traditional approaches in addressing behaviors.
Although it is beyond the scope of the current article to review nonpharmacological alternatives to BZD use, they are easily found in the literature. These approaches range from sensory means to help dampen agitation to mindfulness to calm thoughts (Martin, Arora, et al., 2018). The evidence base supporting alternative means is growing, particularly around methods such as mindfulness. The newer adaptions of mindfulness interventions draw on technology, making it easier to implement on a busy unit, as well as introducing techniques in a way patients can use following discharge (Mistler, Ben-Zeev, Carpenter-Song, Brunette & Friedman, 2017). Strategies such as sound or soft soothing music have likely been used by many units. Suggested implementation now goes beyond having a portable stereo system in the hallway and toward designing units with an ecology that includes systems to deliver self-soothing sounds (Iyendo, 2017).
Innovative approaches are also emerging aimed at educating staff on alternative nonpharmacological methods. Staff reluctance to use alternative methods may involve practical barriers (e.g., time) but also attitudes, perceived level of knowledge, and confidence in using such approaches. A team of investigators recently reported an e-learning program to teach staff about the theory and use of sensory modulation approaches in mental health settings (Meredith et al., 2018). They report that following completion of the e-learning program, participants demonstrated improved attitudes, increased knowledge, and improved confidence in using sensory approaches. Such e-learning programs may provide a needed boost in the use and acceptance of alternative methods.
International research indicates that administration of BZD PRN medications is a frequent occurrence on inpatient units yet remains an under researched area in the United States. Mounting a research agenda on BZD use during inpatient treatment would involve several actions. First to conduct the basic research, more data are needed about BZD use on U.S. inpatient psychiatric units. European studies report that from 66% to 90% of patients receive a PRN medication during hospitalization (Martin et al., 2017; Stewart et al., 2010). Models for such data collection are readily available (Martin et al., 2017). Data on frequency, reasons for use, suggested alternative strategies, and effectiveness of the medication would establish an important baseline for quality improvement and also raise awareness of the issue.
More attention should be directed to the decision making of nurses around BZD use and the underlying attitudes that motivate behaviors. Organizational factors should also be examined, particularly ones that may contribute to PRN medication use over alternative strategies. Models for inquiry are available in the literature with useful tools to assess attitudes, knowledge, and organizational factors that contribute to PRN medication use (Barr et al., 2018). Researchers, however, should not divorce the issue of PRN medication use from the complexity of the inpatient nursing role. Thus, investigations should explore the issue within the broader picture of workplace environment, ward culture, and staffing levels.
Investigators should also take care to differentiate between BZD PRN and intramuscular (IM) PRN medication use for situations of high conflict where the medications are used for acute episodes or in emergency situations (Ross, Bowers, & Stewart, 2012). Use of PRN medications to reduce agitation, distress, or aggression in individuals who are acutely disturbed and managing psychosis should also be isolated from BZD PRN medication use (Douglas-Hall & Whicher, 2015). Of course, there would be some overlap in use of BZD PRN medications for agitation versus emergency IM PRN medications, but when possible they should be addressed as separate issues, as the incidents that precipitate their use are different as are the strategies to reduce their use (Ross et al., 2012).
Another persistent theme in the literature is the poor documentation around PRN medication use, both the alternative methods attempted prior to administration of the PRN medication and the effectiveness of the medication. Recent studies where the electronic medical record (EMR) required a comment after PRN administration report that 25% of the time comments on the effectiveness of the medication were lacking (Martin et al., 2017). When comments were entered, >50% of the time nurses noted the PRN medication was ineffective or the effect was pending (Martin et al., 2017). Poor documentation impacts BZD use in many ways. With insufficient charting it is difficult to know exactly why the drug was given, alternative approaches that were attempted, the situations where it was helpful, and when a PRN medication was ineffective. Within any EMR redesign, how to improve PRN documentation and best use the data to institute quality improvement change should be considered.
Nurses also have a clear role in educating patients about BZD use. Should an individual be admitted with a history of using BZDs, nurses could use the hospitalization event to discuss the medications, question their use as a PRN medication, and explore alternatives for sleep, agitation, or anxiety. As stated, nurses may need additional education on using SBIRT–like coaching and alternative means. It need not be all one-on-one education; unit leadership should also consider group education around techniques such as mindfulness.
Nurses should assure that the culture of the unit encourages patients to be collaborators in all aspects of their treatment, including decisions around PRN medication use. This overarching recovery goal is particularly relevant in helping patients manage distress and difficult issues such as sleep disturbance. When collaboration is the norm, staff behaviors encourage joint decision making that empowers patients. Strategies to improve sleep hygiene and manage anxiety should begin during inpatient treatment and be refined based on patient preference.
Inpatient nurses should be initiating the conversation around how best to address BZD use during psychiatric hospitalization. As administration of PRN medications is a frequent nursing intervention, it is also critical that nurses set the inpatient research agenda. As suggested, they might begin by establishing baseline rates, nursing attitudes, and the use of alternative nonpharmacological methods. This approach should generate data on best practices, which could be evaluated in single-site quality improvements projects and larger multi-site studies.
- Anderson, K., Stowasser, D., Freeman, C. & Scott, I. (2014). Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: A systematic review and thematic synthesis. BMJ Open, 4(12), e006544. https://doi.org/10.1136/bmjopen-2014-006544 PMID: doi:10.1136/bmjopen-2014-006544 [CrossRef]25488097
- Anthierens, S., Grypdonck, M., De Pauw, L. & Christiaens, T. (2009). Perceptions of nurses in nursing homes on the usage of benzodiazepines. Journal of Clinical Nursing, 18(22), 3098–3106. https://doi.org/10.1111/j.1365-2702.2008.02758.x PMID: doi:10.1111/j.1365-2702.2008.02758.x [CrossRef]19538562
- Arnold, I., Straube, K., Himmel, W., Heinemann, S., Weiss, V., Heyden, L. & Nau, R. (2017). High prevalence of prescription of psychotropic drugs for older patients in a general hospital. BMC Pharmacology & Toxicology, 18(1), 76. https://doi.org/10.1186/s40360-017-0183-0 PMID: doi:10.1186/s40360-017-0183-0 [CrossRef]29202811
- Bagøien, G., Bjørngaard, J. H., Østensen, C., Reitan, S. K., Romundstad, P. & Morken, G. (2013). The effects of motivational interviewing on patients with comorbid substance use admitted to a psychiatric emergency unit: A randomised controlled trial with two year follow-up. BMC Psychiatry, 13(1), 93. https://doi.org/10.1186/1471-244X-13-93 PMID: doi:10.1186/1471-244X-13-93 [CrossRef]
- Baker, J. A., Lovell, K. & Harris, N. (2007). Mental health professionals' psychotropic pro re nata (p.r.n.) medication practices in acute inpatient mental health care: A qualitative study. General Hospital Psychiatry, 29(2), 163–168. https://doi.org/10.1016/j.genhosppsych.2006.12.005 PMID: doi:10.1016/j.genhosppsych.2006.12.005 [CrossRef]17336666
- Barr, L., Wynaden, D. & Heslop, K. (2018). Nurses' attitudes towards the use of PRN psychotropic medications in acute and forensic mental health settings. International Journal of Mental Health Nursing, 27(1), 168–177. https://doi.org/10.1111/inm.12306 PMID: doi:10.1111/inm.12306 [CrossRef]
- Cleary, M., Horsfall, J., Jackson, D., O'Hara-Aarons, M. & Hunt, G. E. (2012). Patients' views and experiences of pro re nata medication in acute mental health settings. International Journal of Mental Health Nursing, 21(6), 533–539. https://doi.org/10.1111/j.1447-0349.2012.00814.x PMID: doi:10.1111/j.1447-0349.2012.00814.x [CrossRef]22583694
- Darnell, D., Dunn, C., Atkins, D., Ingraham, L. & Zatzick, D. (2016). A randomized evaluation of motivational interviewing training for mandated implementation of alcohol screening and brief intervention in trauma centers. Journal of Substance Abuse Treatment, 60, 36–44. https://doi.org/10.1016/j.jsat.2015.05.010 PMID: doi:10.1016/j.jsat.2015.05.010 [CrossRef]
- Delaney, K. R., Shattell, M. & Johnson, M. E. (2017). Capturing the interpersonal process of psychiatric nurses: A model for engagement. Archives of Psychiatric Nursing, 31(6), 634–640. https://doi.org/10.1016/j.apnu.2017.08.003 PMID: doi:10.1016/j.apnu.2017.08.003 [CrossRef]29179832
- Douglas-Hall, P. & Whicher, E. V. (2015). ‘As required’ medication regimens for seriously mentally ill people in hospital. Cochrane Database of Systematic Reviews, 12, CD003441. https://doi.org/10.1002/14651858.CD003441.pub3 PMID:26689942
- Haw, C. & Wolstencroft, L. (2014). A study of the use of sedative PRN medication in patients at a secure hospital. Journal of Forensic Psychiatry & Psychology, 25(3), 307–320. https://doi.org/10.1080/14789949.2014.911948 doi:10.1080/14789949.2014.911948 [CrossRef]
- Iyendo, T. O. (2017). Sound as a supportive design intervention for improving health care experience in the clinical ecosystem: A qualitative study. Complementary Therapies in Clinical Practice, 29, 58–96. https://doi.org/10.1016/j.ctcp.2017.08.004 PMID: doi:10.1016/j.ctcp.2017.08.004 [CrossRef]29122270
- Lindsey, P. L. & Buckwalter, K. C. (2012). Administration of PRN medications and use of nonpharmacologic interventions in acute geropsychiatric settings: Implications for practice. Journal of the American Psychiatric Nurses Association, 18(2), 82–90. https://doi.org/10.1177/1078390312438768 PMID: doi:10.1177/1078390312438768 [CrossRef]22442015
- MacDonald, J., Garvie, C., Gordon, S., Huthwaite, M., Mathieson, F., Wood, A. J. & Romans, S. (2015). ‘Is it the crime of the century?’: Factors for psychiatrists and service users that influence the long-term prescription of hypnosedatives. International Clinical Psychopharmacology, 30(4), 193–201. https://doi.org/10.1097/YIC.0000000000000073 PMID: doi:10.1097/YIC.0000000000000073 [CrossRef]25918885
- Martin, K., Arora, V., Fischler, I. & Tremblay, R. (2017). Descriptive analysis of pro re nata medication use at a Canadian psychiatric hospital. International Journal of Mental Health Nursing, 26(4), 402–408. https://doi.org/10.1111/inm.12265 PMID: doi:10.1111/inm.12265 [CrossRef]
- Martin, K., Arora, V., Fischler, I. & Tremblay, R. (2018). Analysis of non-pharmacological interventions attempted prior to pro re nata medication use. International Journal of Mental Health Nursing, 27(1), 296–302. https://doi.org/10.1111/inm.12320 PMID: doi:10.1111/inm.12320 [CrossRef]
- Martin, K., Ham, E. & Hilton, N. Z. (2018). Staff and patient accounts of PRN medication administration and nonpharmacological interventions for anxiety. International Journal of Mental Health Nursing, 27(6), 1834–1841. https://doi.org/10.1111/inm.12492 PMID: doi:10.1111/inm.12492 [CrossRef]29851211
- Meredith, P., Yeates, H., Greaves, A., Taylor, M., Slattery, M., Charters, M. & Hill, M. (2018). Preparing mental health professionals for new directions in mental health practice: Evaluating the sensory approaches e-learning training package. International Journal of Mental Health Nursing, 27(1), 106–115. https://doi.org/10.1111/inm.12299 PMID: doi:10.1111/inm.12299 [CrossRef]
- Mistler, L. A., Ben-Zeev, D., Carpenter-Song, E., Brunette, M. F. & Friedman, M. J. (2017). Mobile mindfulness intervention on an acute psychiatric unit: Feasibility and acceptability study. Journal of Medical Internet Research-Mental Health, 4(3), e34. https://doi.org/10.2196/mental.7717 PMID:28827214
- Murphy, M. J. & Peterson, M. J. (2015). Sleep disturbances in depression. Sleep Medicine Clinics, 10(1), 17–23. https://doi.org/10.1016/j.jsmc.2014.11.009 PMID: doi:10.1016/j.jsmc.2014.11.009 [CrossRef]26055669
- Peters, S. M., Knauf, K. Q., Derbidge, C. M., Kimmel, R. & Vannoy, S. (2015). Demographic and clinical factors associated with benzodiazepine prescription at discharge from psychiatric inpatient treatment. General Hospital Psychiatry, 37(6), 595–600. https://doi.org/10.1016/j.genhosp-psych.2015.06.004 PMID: doi:10.1016/j.genhosppsych.2015.06.004 [CrossRef]26139289
- Ross, J., Bowers, L. & Stewart, D. (2012). Conflict and containment events in inpatient psychiatric units. Journal of Clinical Nursing, 21(15–16), 2306–2315. https://doi.org/10.1111/j.1365-2702.2012.04073.x PMID: doi:10.1111/j.1365-2702.2012.04073.x [CrossRef]22788564
- Stewart, D., Robson, D., Chaplin, R., Quirk, A. & Bowers, L. (2012). Behavioural antecedents to pro re nata psychotropic medication administration on acute psychiatric wards. International Journal of Mental Health Nursing, 21(6), 540–549. https://doi.org/10.1111/j.1447-0349.2012.00834.x PMID: doi:10.1111/j.1447-0349.2012.00834.x [CrossRef]22863295
- Usher, K., Baker, J. A. & Holmes, C. A. (2010). Understanding clinical decision making for PRN medication in mental health inpatient facilities. Journal of Psychiatric and Mental Health Nursing, 17(6), 558–564. https://doi.org/10.1111/j.1365-2850.2010.01565.x PMID: doi:10.1111/j.1365-2850.2010.01565.x [CrossRef]20633084
- Usher, K., Baker, J. A., Holmes, C. & Stocks, B. (2009). Clinical decision-making for ‘as needed’ medications in mental health care. Journal of Advanced Nursing, 65(5), 981–991. https://doi.org/10.1111/j.1365-2648.2008.04957.x PMID: doi:10.1111/j.1365-2648.2008.04957.x [CrossRef]19291187