The use and nursing management of benzodiazepines in acute, mental health inpatient care: a discussion

Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement

The clinical documentation of patients' mental status, behaviour and functioning is a fundamental aspect of inpatient mental health care. It is an important source of information-sharing with the interprofessional team and used by other clinicians within the circle of care to guide their decision-making process. Given the body of evidence highlighting concerns about the quality of nursing documentation and the growing literature demonstrating the presence of bias in healthcare, it is critically important that we examine the impact of this bias in nursing practice. The primary objective of this study was to determine whether clinical decisions and judgements change when nurses read documentation that is either biased or neutral. Using a quantitative, observational study that used surveys to collect data, participants were exposed to two patient vignettes and six clinical notes associated with each patient (notes were written with either biased or neutral language) and asked to make clinical decisions and judgements. Results from 199 nurse participants from a tertiary mental health hospital revealed a notable relationship between the type of notes read (biased vs. neutral) and clinical practice, namely, participants reading biased notes were less likely to offer health teaching when administering pro re nata (PRN) medication for sleep. We also found differences in decision-making and judgements based on the type of note read depending on years of experience and type of education. The results indicate that biased language in nursing documentation can influence other clinicians' decisions and judgements about patients, thereby indicating a cascade of bias.

Staff and patient accounts of PRN medication administration and non-pharmacological interventions for anxiety

Most psychiatric inpatients will receive psychotropic PRN medication during their hospital stay for agitation, anxiety, and/or insomnia. While helpful in some cases, caution is warranted with regard to PRN use due to inherent risks of additional medication; therefore, experts advise that non-pharmacological interventions should be attempted first where indicated. However, research to date highlights that, in practice, non-pharmaceutical approaches are attempted in a minority of cases. While some information is known about the practice of PRN administration and the use of and barriers to implementing non-pharmacological interventions for treating acute psychiatric symptoms, full understanding of this practice is hampered by poor or altogether missing documentation of the process. This study used interviews with patients and staff from two psychiatric hospitals to collect first-person accounts of administering PRN medication for anxiety, thereby addressing the limitations of relying on documented notation found in previous research. Our results indicate that nurses are engaging in non-pharmacological interventions more often than had previously been captured in research. However, the types of strategies suggested are not typically evidence based and further, only happening approximately half the time. The barriers to providing such care are centred on two main beliefs about client choice and efficacy of these non-medical strategies. Implications for research and practice are discussed.

Analysis of non-pharmacological interventions attempted prior to pro re nata medication use

The aim of the present study was to elucidate what non-pharmacological interventions are applied by nursing staff prior to the administration of psychotropic pro re nata (PRN) medication. Best practices would instruct clinical staff to provide non-pharmacological strategies, such as de-escalation and skills coaching, as the first response to patient distress, anxiety, or agitation. Non-pharmacological strategies might be safer for patients, promote more collaborative relationships, and facilitate greater skills development for managing symptoms. The literature has highlighted that poor documentation of pre-PRN administration interventions has limited our understanding of this practice, but evidence suggests that when this information is available, non-pharmaceutical approaches are not being attempted in the majority of cases. This is troubling given that, while clinically appropriate in some instances, PRN have been subject to criticism and lack critical evidence to support their use. The current study is a continuation of our previous work, which examined the reason, frequency, documentation, and outcome (e.g. effectiveness, side-effects) of PRN medication use at our facility. A chart review was conducted to understand what happens prior to the administration of PRN medication at our facility across all inpatient units over the course of 3 months. Results support previous findings that non-pharmacological interventions are poorly documented by front-line staff and are seemingly used infrequently. The use of these interventions differs by patient presentation (e.g. agitation, insomnia), and most often include supportive measures. The findings suggest that both documentation and intervention practices of nursing staff require further investigation and adjustment to align with best practices.

Descriptive analysis of pro re nata medication use at a Canadian psychiatric hospital

Pro re nata (PRN), a Latin phrase meaning 'as needed', is used to describe medications that might be used in specific situations, in addition to regularly-scheduled medications, such as when a patient is particularly anxious, experiencing insomnia, or suffering pain. While helpful in some circumstances, PRN are associated with an increased risk of morbidity, overuse, dependence, and polypharmacy. There is also a dearth of medical literature describing current practices and trends of PRN administration in mental health facilities, especially in Canada, and the literature that does exist is limited by poor documentation practices. Therefore, the primary objective of the current study was to understand the reason (purpose), frequency, use, documentation practices, and outcome (i.e. effectiveness, side-effects) of PRN medication use on inpatient units. Data were pulled to capture a snapshot of PRN administrations over a 3-month period, and included information related to the administration of the PRN medication, such as time of administration, type and dose of PRN medication, and prescribed indication, as well as patient-specific information. Results indicated that approximately 8200 psychotropic PRN medications were administered during the designated 3-month time period, and over 90% of patients received at least one PRN. Most of these were benzodiazepines, followed by antipsychotics. Further analyses were conducted to determine other characteristics of PRN use patterns and to provide a baseline of understanding that will inform future research to investigate the practice of PRN administration to psychiatric inpatients.

De-escalation: A survey of clinical staff in a secure mental health inpatient service

De-escalation is an important tool for preventing aggression in inpatient settings but definitions vary and there is no clear practice guideline. We aimed to identify how clinical staff define and conceptualize de-escalation, which de-escalation interventions they would use in aggressive scenarios, and their beliefs about the efficacy of de-escalation interventions. A questionnaire survey (n = 72) was conducted using open and closed questions; additionally, clinical vignettes describing conflict events were presented for participants to describe their likely clinical response. Qualitative data were subject to thematic analysis. The major themes that de-escalation encompassed were communication, tactics, de-escalator qualities, assessment and risk, getting help, and containment measures. Different types of aggression were met with different interventions. Half of participants erroneously identified p.r.n. medication as a de-escalation intervention, and 15% wrongly stated that seclusion, restraint, and emergency i.m. medication could be de-escalation interventions. Those interventions seen as most effective were the most commonly used. Clinical staff's views about de-escalation, and their de-escalation practice, may differ from optimal practice. Use of containment measures and p.r.n. medication where de-escalation is more appropriate could have a negative impact; work is needed to promote understanding and use of appropriate de-escalation interventions based on a clear guideline.

Demographic and clinical factors associated with benzodiazepine prescription at discharge from psychiatric inpatient treatment

OBJECTIVE

We sought to characterize diagnostic and treatment factors associated with receiving a prescription for benzodiazepines at discharge from a psychiatric inpatient unit. We hypothesized that engaging in individual behavioral interventions while on the unit would decrease the likelihood of receiving a benzodiazepine prescription at discharge.

METHOD

This is an observational study utilizing medical chart review (n=1007) over 37 months (2008-2011). Descriptive statistics characterized patient demographics and diagnostic/prescription frequency. Multivariate regression was used to assess factors associated with receiving a benzodiazepine prescription at discharge.

RESULTS

The sample was 61% female with mean age=40.5 (S.D.=13.6). Most frequent diagnoses were depression (54.7%) and bipolar disorder (18.6%). Thirty-eight percent of participants engaged in an individual behavioral intervention. Benzodiazepines were prescribed in 36% of discharges. Contrary to our hypothesis, individual behavioral interventions did not influence discharge benzodiazepine prescriptions. However, several other factors did, including having a substance use disorder [odds ratio (OR)=0.40]. Male sex (OR=0.56), Black race (OR=0.40) and age (OR=1.03) were nonclinical factors with strong prescribing influence.

CONCLUSION

Benzodiazepines are frequently prescribed at discharge. Our results indicate strong racial and sex biases when prescribing benzodiazepines, even after controlling for diagnosis.

Nursing interventions in inpatient psychiatry

The successful application of the Nursing Interventions Classification (NIC) in inpatient psychiatry depends on whether the classification adequately describes nursing care in this setting. The present study aimed to identify nursing interventions mentioned in journal articles on psychiatric inpatient nursing care and to compare these with the labels, definitions and activities described in the NIC to elucidate how well the classification covers these interventions. The MedLine, PsychInfo, Cochrane and CINAHL databases were searched for journal articles about nursing care in the adult inpatient setting. A qualitative content analysis approach was used to indentify nursing interventions in the articles. About 84% of the statements (terms and definitions) are encompassed by the interventions listed by the NIC. Very few interventions need to be added to the NIC classification or necessitate a reorganization of the taxonomy. Nevertheless, the further development of the NIC will promote its use in the daily work of psychiatric nurses and enhance the quality of nursing care in the inpatient setting.

Patients' views and experiences of pro re nata medication in acute mental health settings

In the present study, we interviewed 40 patients in acute inpatient mental health settings regarding their experience of, and views about, receiving pro re nata (PRN) medication. Patient requests for PRN were primarily to relieve anxiety or to aid sleep, and the majority of the participants (80%) could describe a situation where this medication was very helpful. From the perspective of patients, interactions surrounding the immediate administration of PRN medication were inadequate, in that half of the interviewees were simply told to take the medication, and three-quarters said that, in their experience, formal consent was not commonly sought. Three-quarters of respondents came up with alternatives to PRN, and half wanted more information about the medication itself. These findings could contribute to improved nursing assessment for PRN medication need, administration, and monitoring.

Nursing phenomena in inpatient psychiatry

Little is known about the question if the nursing diagnosis classification of North American Nursing Association-International (NANDA-I) describes the adult inpatient psychiatric nursing care. The present study aimed to identify nursing phenomena mentioned in journal articles about the psychiatric inpatient nursing care and to compare these phenomena with the labels and the definitions of the nursing diagnoses to elucidate how well this classification covers these phenomena. A search of journal articles took place in the databases MedLine, PsychInfo, Cochrane and CINAHL. A qualitative content analysis approach was used to identify nursing phenomena in the articles. Various phenomena were found in the articles. The study demonstrated that NANDA-I describes essential phenomena for the adult inpatient psychiatry on the level of labels and definitions. However, some apparently important nursing phenomena are not covered by the labels or definitions of NANDA-I. Other phenomena are assigned as defining characteristics or as related factors to construct nursing diagnoses. The further development of the classification NANDA-I will strengthen the application in the daily work of psychiatric nurses and enhance the quality of nursing care in the inpatient setting.

A descriptive study of anxiolytic and hypnotic prescribing according to age and sex

Objective

Benzodiazepines are primarily indicated for the treatment of anxiety states and as hypnotics. Their inappropriate use often relates to duration and manner of use. Few studies have attempted to assess the prevalence of benzodiazepine prescribing in South Africa. The primary aim of the study was to examine the prevalence of sedative/hypnotic prescribing according to patient age and sex in a primary care setting. Setting South African private healthcare patients.

Method

An exposure cohort drug utilisation study was conducted. Prescription data were obtained from a South African private medical aid administrator. Descriptive statistics were used in the data analysis.

Key findings

Prescription records (n = 27 080) of 8084 patients in 2004 who were prescribed one or more benzodiazepines were retrospectively analysed. The average age of patients receiving benzodiazepines was 43.17 years (standard deviation (SD) 14.42 years). Benzodiazepine prescribing was more common in females (55.64% of patients were female). There was an increase in prescriptions per patient with increasing age, peaking at an older age among females. Diazepam (13.36%), zopiclone (13.19%) and oxazepam (12.03%) were the most frequently prescribed active ingredients. The majority of benzodiazepine hypnotics were prescribed in quantities of up to 14 units (tablets or capsules), while the benzodiazepine-related drugs zolpidem and zopiclone were prescribed in quantities of up to 30 units. Anxiolytics were often prescribed in quantities of 20 to 30 units.

Conclusion

Anxiolytics were prescribed in greater quantities than hypnotics. An increase in anxiolytic/hypnotic prescriptions and quantities of tablets/capsules occurred with increasing age. The trends and differences that were detected in the prescribing of benzodiazepines warrant further investigation in larger patient populations, especially with respect to the choice of agent, duration of treatment and patient age.

Exploration of therapeutic interventions that accompany the administration of p.r.n. ('as required') psychotropic medication within acute mental health settings: a retrospective study

Within acute mental health settings, pro re nata (p.r.n.) 'as required' medication is a widely used adjunct to regular treatment plans, and is administered at the discretion of a registered nurse. However, there is concern that some orders may benefit staff more than patients by providing a 'quick fix' to compensate for inadequate therapeutic programmes. Previous authors assert that p.r.n. medication administration should not be the first line of action, but should be used when other less invasive interventions such as de-escalation, talking, or separation from the group are unsuccessful. This project explored the occurrence of p.r.n. medication administration and the type of alternative therapeutic interventions that are documented as accompanying its administration. A retrospective 1-month chart audit was undertaken for a cohort of inpatients in a 20-bed mental health facility attached to a regional hospital in New South Wales, Australia. Forty-seven patients (73.4%) received p.r.n. medication at least once, with a total of 309 doses of p.r.n. medication administered during this time. There were wide variations in the documented rationales, and for nearly three-quarters (73%) of p.r.n. medication administrations, no other therapeutic intervention was documented as occurring prior to administration.

Service users' experiences of 'as needed' psychotropic medications in acute mental healthcare settings

AIMS

This paper reports a study which aimed to explore service users' views and experiences of the processes associated with the prescription and administration of 'as needed' (p.r.n.) psychotropic medications in acute mental health settings.

BACKGROUND

Few studies have explored the use of 'as needed' medication in acute mental healthcare settings. Such medication is frequently requested by service users, but the literature is unclear about the reasons for these requests or service users' experiences of this treatment.

METHOD

A convenience sample of 22 inpatients participated in face-to-face semi-structured interviews exploring their treatment experiences of 'as needed' psychotropic medication in acute mental health settings in a large city in the United Kingdom in 2005. Thematic content analysis was carried out.

RESULTS

Interviewees highlighted the value of 'as needed' medications. However, the process associated with their use was perceived as confusing and stigmatizing. Service users had limited understanding of and felt unsupported in attempts to use alternatives approaches. Additionally, the decision-making and information-giving processes were unclear to them, which raises issues of power and control in acute mental health settings.

CONCLUSIONS

Nurses should take account of the issues of power and control when administering 'as needed' medication. The provision of adequate treatment information should be a priority to enable informed choices to be made about this form of medication.

Sedative-hypnotic treatment in an acute psychiatric setting: comparison with best practice guidance

OBJECTIVE

The aim of this study was to review treatment patterns of sedative-hypnotic agents within an acute adult inpatient psychiatric service, compare prescribing with best-practice recommendations for use and explore potential interventions.

SETTING

Two urban acute inpatient psychiatric units in the Waitemata community.

METHOD

A retrospective review of all consecutive admissions to these two adult psychiatric units was conducted during the period 1st January to 30th June 2002. Patient demographics, diagnosis and sedative-hypnotic treatment data were extracted from clinical files. Average benzodiazepine daily dose was calculated for each admission in diazepam equivalents (Diaz(e)).

MAIN OUTCOME MEASURES

Sedative-hypnotic treatment administered, duration of treatment, average daily dose, and discharge treatment.

RESULTS

Data from 257 patients and 293 admissions were analysed. Almost all admissions (86.7%) involved treatment with a sedative-hypnotic. A benzodiazepine was prescribed for 82.6% of admissions, of which 64.9% was administered on an "as-needed (prn)" basis. Zopiclone was used in 56.7% of admissions, of which 83.7% was "as-needed (prn)" treatment. Most benzodiazepine treatment was with a single agent (61.6%) and lorazepam was the most frequently prescribed (54.8%). Over two-thirds of admissions used benzodiazepine treatment for 50% or less of the admission duration. The duration of treatment was shortest in those with a diagnosis of schizophrenia/schizoaffective disorder. Almost two-thirds of admissions were discharged without any prescription for sedative-hypnotic treatment.

CONCLUSION

The use of sedative-hypnotic treatment in the acute adult inpatient psychiatric environment compared favourably with best practice recommendations regarding dose, duration of treatment and discharge treatment. The study identified key areas for intervention by clinical pharmacists to ensure appropriate use of sedative-hypnotics including in-service education, regular review of all sedative-hypnotic treatment and discharge medication planning.