Perceptions of nurses in nursing homes on the usage of benzodiazepines

Barriers and enablers towards benzodiazepine-receptor agonists deprescribing in nursing homes: A qualitative study of stakeholder groups

Background

Despite recommendations to deprescribe chronic benzodiazepine receptor agonists (BZRA) among older adults, the prevalence of their use in Belgian nursing homes (NHs) remains above 50%. The use of a behavioral science approach, starting with the evaluation of barriers and enablers for BZRA deprescribing, has the potential to decrease BZRA prescribing.

Objectives

To identify barriers and enablers for BZRA deprescribing perceived by the different stakeholders involved in nursing home care in Belgium.

Methods

In a purposive sample of 6 NHs, we conducted face-to-face interviews with general practitioners (GPs), and focus groups with other healthcare providers (HCPs), including nurses, pharmacists, occupational therapists, physical therapists, and with NH residents and relatives. All interviews with HCPs were analyzed through deductive thematic analysis, using the theoretical domains framework (TDF) as the coding framework. Residents' and relatives' interviews were analyzed using an inductive thematic approach.

Results

We interviewed 13 GPs, 35 other HCPs, 22 nursing home residents, and 5 relatives. Overall, 9 TDF domains were identified as most relevant among HCPs interviewed: Skills, Beliefs about capabilities, Goals, Memory attention and decision processes, Environmental context and resources, Social influences, Knowledge, Social/professional role and identity, and Beliefs about consequences. Five additional themes emerged from residents' and relatives' interviews: knowledge on medications used, communication with NH staff and GPs, perceived efficacy and necessity of BZRA, influence of the environment, and reluctance towards BZRA deprescribing. Some domains and themes differ between stakeholders (e.g., knowledge), while others match between groups (e.g., environmental aspects).

Conclusion

BZRA deprescribing is influenced by knowledge and skills gaps, automatic BZRA refilling, competing priorities, social challenges, environmental factors and poor nursing home residents involvement. Targeting these barriers will be a key step for implementation of BZRA deprescribing.

Barriers and enablers for deprescribing benzodiazepine receptor agonists in older adults: a systematic review of qualitative and quantitative studies using the theoretical domains framework

Background

Many strategies aimed at deprescribing benzodiazepine receptor agonists (BZRA) in older adults have already been evaluated with various success rates. There is so far no consensus on which strategy components increase deprescribing the most. Yet, despite an unfavourable benefit-to-risk ratio, BZRA use among older adults remains high. We systematically reviewed barriers and enablers for BZRA deprescribing in older adults.

Methods

Two reviewers independently screened records identified from five electronic databases—Medline, Embase, PsycINFO, CINAHL and the Cochrane library—and published before October 2020. They searched for grey literature using Google Scholar. Qualitative and quantitative records reporting data on the attitudes of older adults, caregivers and healthcare providers towards BZRA deprescribing were included. Populations at the end of life or with specific psychiatric illness, except for dementia, were excluded. The two reviewers independently assessed the quality of the included studies using the mixed-methods appraisal tool. Barriers and enablers were identified and then coded into domains of the theoretical domains framework (TDF) using a combination of deductive and inductive qualitative analysis. The most relevant TDF domains for BZRA deprescribing were then identified.

Results

Twenty-three studies were included 13 quantitative, 8 qualitative and 2 mixed-method studies. The points of view of older adults, general practitioners and nurses were reported in 19, 9 and 3 records, respectively. We identified barriers and enablers in the majority of TDF domains and in two additional themes: “patient characteristics” and “BZRA prescribing patterns”. Overall, the most relevant TDF domains were “beliefs about capabilities”, “beliefs about consequences”, “environmental context and resources”, “intention”, “goals”, “social influences”, “memory, attention and decision processes”. Perceived barriers and enablers within domains differed across settings and across stakeholders.

Conclusion

The relevant TDF domains we identified can now be linked to behavioural change techniques to help in the design of future strategies and health policies. Future studies should also assess barriers and enablers perceived by under-evaluated stakeholders (such as pharmacists, psychiatrists and health care professionals in the hospital setting).

Trial registration

This work was registered on PROSPERO under the title “Barriers and enablers to benzodiazepine receptor agonists deprescribing”. Registration number: CRD42020213035

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01206-7.

[Experiences when handling sleep medicines: Group discussions with nursing students about benzodiazepines and Z-drugs]

Experiences when handling sleep medicines: Group discussions with nursing students about benzodiazepines and Z-drugs Abstract. Background and aims: Helping patients who have difficulties falling or staying asleep is one of the challenges of hospital care. The goal of this study was to explore how nursing students experience patients' sleeping problems as well as the usage of sleep-inducing drugs, especially benzodiazepines and Z-drugs in the hospital setting. Methods: In four focus group discussions, we collected data exploring the experiences of nursing students with regards to sleeping problems and sleep-inducing drugs. The transcripts of the discussion were analysed, using documentary method. Results were finally summarized to main categories, using qualitative content analysis. Results: Students experience a generous distribution of sleep-inducing drugs, which are considered as the best possible solution for sleeping problems - in spite of weak evidence. Non-drug alternatives are seldom taught, are often unavailable on the ward and their use is rarely trained. Pharmacological knowledge is too shallow and / or the transfer of theoretical knowledge to practical action is unsuccessful. Sleep and sleeping problems, e. g. in contrast to pain management, are not a topic of priority in the hospital setting. Conclusions: More knowledge and greater sensibility about sleeping problems is needed. For example, nurses' training should incorporate knowledge about medications and non-drug alternatives and how to apply them in critical situations. Doctors and nurses should offer nursing students good role models in these situations.

Attitudes to Drug Use in Residential Aged Care Facilities: A Cross-Sectional Survey of Nurses and Care Staff

BACKGROUND

Residential aged care facility (RACF) staff are well placed to identify opportunities for more appropriate prescribing. However, little is known about their views of polypharmacy, deprescribing and specific medications.

OBJECTIVE

The objective of this study was to establish the beliefs and attitudes of RACF staff towards polypharmacy and medication use in residents.

METHODS

A cross-sectional survey was conducted on RACF staff in metropolitan New South Wales, Australia using a self-administered questionnaire. The questionnaire was drafted based on the available literature and research team expertise and then piloted by a mixed group of 13 RACF staff. The final version of the questionnaire consisted of 28 questions. A total of 38 RACFs were contacted about the study. The questionnaire was distributed to eligible RACF staff between October 2017 and October 2019. The RACF staff were eligible if they provided direct patient care to residents or worked as a facility manager. Participants were excluded if they had insufficient English language skills. The results were presented in two groups, the nursing and care staff, using descriptive statistics.

RESULTS

A total of 176 individuals from nine RACFs completed the questionnaire of whom 160 were eligible for study inclusion. Most considered polypharmacy to be five or more different tablets and capsules per day (95% nursing and 82% care staff respectively). A wide range of beliefs about medication use and deprescribing that centred on what constitutes appropriate polypharmacy was identified. Most thought that preventive medications were essential for residents. Most nurses agreed that sleeping tablets and pharmacological management of verbal aggression and wandering behaviours should be used less frequently whilst most care staff agreed that medications should be used more frequently to manage physical aggression.

CONCLUSIONS

To successfully and sustainably optimise medication use in RACF residents, it is important to consider the variation in views of nurses and care staff.

The Barriers and Facilitators of Different Stakeholders When Deprescribing Benzodiazepine Receptor Agonists in Older Patients-A Systematic Review

Treatment of older patients with benzodiazepines and Z-drugs (BZRA) is associated with an increased risk of side effects. However, this treatment is still used among these patients. Deprescribing can be a tool to reduce inappropriate medication. This review aims to identify and compare barriers and facilitators of stakeholders involved in BZRA deprescribing in older patients and uncover potential gaps in the research field. The search was conducted in PubMed, EMBASE, PsycINFO, and Cochrane Library. Ten articles based on qualitative data on BZRA deprescribing in older patients (≥65 years) published between 2005-2020 were included. Six articles referred to patients as stakeholders, two referred to physicians, and one to nurses and caregivers, respectively, indicating a need for more studies in the field. More barriers than facilitators were identified. Important findings were the patient willingness to deprescribe BZRA compared to physicians, who did not mention deprescribing to patients due to barriers such as expected patient resistance. Nurses mentioned barriers like lack of knowledge and the feeling that their options were not valued by physicians; education was found to be a shared deprescribing facilitator among the stakeholders. Being aware of deprescribing barriers and facilitators can be helpful in future successful deprescribing interventions.

Let's Talk About Benzodiazepine Use: Inpatient Psychiatric Nurses Initiating the Conversation

Inpatient psychiatric nurses regularly dispense pro re nata (PRN) medication to individuals during their psychiatric hospitalization. International studies indicate that 66% to 90% of patients receive PRN medications during hospitalization, a large percentage of which are benzodiazepines (BZDs). Although clear opportunities exist for nursing intervention to reduce BZD use, there is little recent U.S. literature on inpatient psychiatric nurses' proactive approach to the issue. The current article examines the factors that support BZD use during inpatient hospitalization, including nurses' attitudes around BZD use, the perceived effectiveness of the medication to address difficult situations, and the barriers to using alternative nonpharmacological methods. Suggestions are presented for how nurses might begin dialogues with patients around BZD use and alternative strategies to manage distress. It is recommended that the specialty initiate a research agenda for reducing BZD use during inpatient psychiatric treatment and champion the issue as a focus for systematic improvement efforts. [Journal of Psychosocial Nursing and Mental Health Services, 58(1), 33-38.].

Patient-reported factors associated with the desire to continue taking sleep-inducing drugs after hospital discharge: A survey of older adults

Purpose

To find out whether any prior experiences with sleep‐inducing drugs before hospitalization and positive experiences with these drugs during hospitalization influence a patient's wish to continue taking sleep‐inducing drugs after hospitalization.

Methods

We surveyed older hospital patients about use of sleep‐inducing drugs before, during, and after hospitalization and compared these answers with their hospital chart using the kappa statistic. The association between the wish to continue these drugs after discharge and the perceived benefits, experience of side effects, and prior experience with sleep‐inducing drugs was determined by multivariable logistic regression.

Results

Agreement between patient responses and the hospital file was high (κ = 0.7). Seventeen percent (83/483) of the participants reported prior experience before their hospital stay; 45% received a sleep‐inducing drug during hospitalization; 17% wished to continue taking them after discharge. Of the 400 patients who had no prior experience with sleep‐inducing drugs, 147 (37%) became first‐time users in the hospital, and 27% (40/147) of these wished to continue this medication after discharged. Strong predictors for this wish were the reduction of sleep onset problems (adjusted odds ratio, 6.26; 95% confidence interval, 2.38‐16.44) and any prior experience with sleep‐inducing drugs (4.08; 1.97‐8.48).

Conclusions

Many older patients become first‐time users of sleep‐inducing drugs in the hospital. Especially the experience of sleep onset improvements influences the wish to continue sleep‐inducing drug use after discharge. Avoiding first‐time use should become a goal of hospital policy and be taken into account when weighing the benefits and risks of sleep‐inducing drugs.

[Non-pharmacological treatment of hospital patients with sleeping problems - the nurse perspective]

Non-pharmacological treatment of hospital patients with sleeping problems - the nurse perspective Abstract.

BACKGROUND

Elderly patients suffer from sleep disturbances during hospitalization. These patients often receive hypnotics and sedatives; despite of the known risks and although non-pharmacological treatments are available.

AIM

The study investigates the experiences of nurses when using non-pharmacological treatments for elderly patients with sleeping problems.

METHODS

Semi-structured interviews with 13 nurses from a general hospital were analyzed according to Mayring's qualitative content analysis.

RESULTS

Nurses used a variety of non-pharmacological treatments for elderly inpatients with sleeping problems: (1) structural measures (regulation of temperature and light), (2) organizational measures (more time for conversation during the nightshift), (3) nursing measures (asking about night-time routines) and (4) household remedies. From the nurses' perspective, the more intensive contact required when applying non-pharmacological treatments can lead to higher patient satisfaction and a lower bell frequency during the night shift. Barriers result from limited time and personnel, a lack of standards and individual patient needs.

CONCLUSION

Nurses know several kinds of non-pharmacological treatments to help elderly inpatients sleep better. A lack of resources as well as a lack of professional consensus about the treatment of temporary sleeping disturbances can be an obstacle to their use. A professional climate should restrict the use of drugs for sleeping problems as far as possible.

The interplay of context factors in hypnotic and sedative prescription in primary and secondary care-a qualitative study

Purpose

Non-medical or contextual factors strongly influence physicians’ prescribing behavior and may explain why drugs, such as benzodiazepines and Z-drugs, are still frequently prescribed in spite of well-known adverse effects. This study aimed to explore which contextual factors influence the prescription of hypnotics and sedatives and to compare their role in primary and secondary care.

Methods

Understanding medical practices as games with specific rules and strategies and performed in a largely habitual, not fully conscious manner, we asked a maximum variation sample of 12 hospital doctors and 12 general practitioners (GPs) about their use of hypnotics and sedatives. The interviews were analyzed by qualitative content analysis.

Results

Hospital doctors’ and GPs’ use of hypnotics and sedatives was influenced by a variety of contextual factors, such as the demand of different patient groups, aims of management, time resources, or the role of nurses and peers. Negotiating patient demands, complying with administrative regulations, and finding acceptable solutions for patients were the main challenges, which characterized the game of drug use in primary care. Maintaining the workflow in the hospital and finding a way to satisfy both nurses and patients were the main challenges in secondary care.

Conclusions

Even if doctors try to act rationally, they cannot escape the interplay of contextual factors such as handling patient needs, complying with administrative regulations, and managing time resources. Doctors should balance these factors as if they were challenges in a complex game and reflect upon their own practices.

Electronic supplementary material

The online version of this article (10.1007/s00228-018-2555-9) contains supplementary material, which is available to authorized users.

Psychological factors related to nurses' intentions to initiate an antipsychotic or psychosocial intervention with nursing home residents

This study examined the validity of a psychological model for understanding nursing home providers' treatment choices when managing challenging dementia-related behaviors. Ninety-nine nurses from 26 long-term care facilities responded to a case study with their intentions to initiate an antipsychotic or psychosocial intervention and completed self-report measures of their attitudes, descriptive norms, self-efficacy, and outcome expectancies. The multi-level modeling results demonstrated that nurses with more positive outcome expectancies for the effect of an antipsychotic on resident behavior, and those with more positive attitudes towards antipsychotics, had greater intentions to initiate an antipsychotic. Intentions to initiate a psychosocial intervention were greater when nurses perceived a lower prevalence of antipsychotics and in facilities with nurses who collectively had higher self-efficacy to implement such interventions. The findings offer partial support for the proposed model and possible intervention targets to improve psychosocial intervention use and antipsychotic prescribing.

Benzodiazepine use in Belgian nursing homes: a closer look into indications and dosages

AIM

(1) To describe the prevalence of benzodiazepine use in Belgian nursing homes, with specific attention to indications and dosages. (2) To compare actual and recommended dosages of benzodiazepines for anxiety and insomnia. (3) To explore the risk profile for chronic benzodiazepine use in institutionalised older adults.

METHODS

Medication charts of 1,730 residents from 76 nursing homes in Belgium were collected and analysed, using the ATC classification. Drug name, indication and daily dosage were recorded. From authoritative international sources, we extracted for each drug and each indication a daily dosage recommended not to be exceeded in older adults for comparison with observed actual dosages.

RESULTS

Among the chronic benzodiazepine or z-drug (BZD/Z) users (50% of the residents), the leading indication was 'insomnia' (59% of the users) followed by 'anxiety' (17%) and 'unrest' (10%). In the chronic prescriptions of BZD/Zs indicated for insomnia, the actual daily dose exceeded the geriatric upper limit in 95% of lormetazepam prescriptions, 82% of zolpidem, 78% of zopiclone and 35% of lorazepam prescriptions. For anxiety, daily doses also exceeded the limit but not to the same extent. Multivariate analysis showed BZD/Z use was positively associated with pain (OR 1.58, 95% CI 1.27-1.97), constipation (OR 1.43, 95% CI 1.16-1.76) and depression (OR 1.68, 95% CI 1.35-2.08). Residents with dementia were less likely to receive a BZD/Z (OR 0.60, 95% CI 0.48-0.74).

CONCLUSION

Efforts to reduce the use of BZD/Zs in nursing homes should concentrate on insomnia, with interventions aimed at reducing too high prevalence of chronic use and too high daily dosages in this indication.