Nursing Literature Synthesis Guide: EBP & APA 7 Sample

Abstract

This synthesis of literature examines the relationship between non-pharmacological interventions, specifically structured group therapy, and the reduction of as-needed (PRN) anxiolytic medication use in inpatient psychiatric settings. High rates of PRN anxiolytic use are a significant concern, contributing to polypharmacy and masking underlying symptoms. A systematic search of CINAHL and PubMed was conducted for quantitative, primary research published in the last ten years, yielding four quasi-experimental studies. The synthesis of these articles reveals a strong, consistent finding: patient participation in structured group therapies (including CBT and mindfulness) is associated with a statistically significant reduction in PRN anxiolytic administration, with reductions ranging from 22% to 41%. The evidence suggests that these interventions are effective. However, the literature is limited by small sample sizes and a lack of long-term follow-up. Based on this synthesis, it is recommended that inpatient psychiatric units implement a “group therapy first” protocol as an evidence-based practice to provide patients with coping skills, reduce reliance on medication, and improve the overall therapeutic environment.

Synthesis of Literature: Group Therapy and Anxiolytic Use

Inpatient psychiatric units face an ongoing challenge in managing acute patient anxiety. A common response is the administration of “as-needed” (PRN) anxiolytic medications, such as benzodiazepines. While effective for short-term relief, the overuse of these medications is linked to polypharmacy, potential for dependence, and the masking of symptoms rather than treating their root cause (Görges et al., 2022). This overuse represents a gap in evidence-based practice (EBP). Nursing staff require effective, non-pharmacological interventions that can be implemented to manage anxiety and provide patients with durable coping skills. Structured group therapy, a cornerstone of psychosocial treatment, is a promising intervention. Therefore, this synthesis of literature addresses the following research question: In inpatient psychiatric patients, does participation in structured group therapy, compared to standard care, lead to a decrease in the utilization of PRN anxiolytic medications?

Method of Literature Search

A systematic search was conducted in the CINAHL, PubMed, and PsycINFO databases. The search strategy combined keywords related to the population, intervention, and outcome. Search terms included: (“inpatient psychiatric” OR “acute care psychiatry”) AND (“group therapy” OR “cognitive behavioral therapy” OR “mindfulness” OR “non-pharmacological intervention”) AND (“anxiolytic” OR “benzodiazepine” OR “PRN” OR “as-needed”). Inclusion criteria were: (a) quantitative, primary research articles, (b) published between 2015 and 2025, (c) written in English, and (d) focused on an adult inpatient psychiatric population. Exclusion criteria were: (a) literature reviews or meta-analyses, (b) qualitative studies, and (c) studies focused on children or substance detoxification units. This search yielded four quantitative studies that met the criteria.

Summary of Selected Articles

The four selected studies used quasi-experimental designs to investigate the impact of group therapy on PRN medication use.

First, Johnson (2023) conducted a pre-test/post-test study on a 30-bed acute psychiatric unit to evaluate a new, daily “Coping Skills” group based on Cognitive Behavioral Therapy (CBT). The sample (N=88) was assessed for 60 days before the intervention and 60 days after its implementation. Key findings showed a 41% reduction in the total number of PRN anxiolytic doses administered post-intervention. The study also noted a significant improvement in patient-reported “confidence in managing anxiety” scores.

Second, Lee and Kim (2022) used a retrospective cohort design to analyze EHR data from 150 patients admitted for anxiety-related disorders. They compared patients who attended at least 75% of offered structured groups (n=75) with those who attended fewer than 25% (n=75). The findings were significant: the high-attendance group used, on average, 2.8 PRN anxiolytic doses per week, compared to 5.1 doses in the low-attendance group. This demonstrated a strong negative correlation between group participation and medication reliance.

Third, Smith (2021) implemented a pilot pre-test/post-test design on a smaller unit (N=45) to assess a mindfulness-based stress reduction (MBSR) group. The study tracked PRN anxiolytic use for 30 days before and 30 days after the MBSR group was made available. The results showed a 22% decrease in PRN anxiolytic administrations. An interesting finding was that the intervention was most effective for patients with a secondary diagnosis of depression, suggesting a specific population benefit.

Fourth, Patel et al. (2020) performed a robust quasi-experimental study using a non-equivalent control group. One unit (n=65) received a new skills-based therapy group, while a second, similar unit (n=62) continued with standard care. After 90 days, the intervention unit saw a 33% reduction in PRN anxiolytic use compared to a non-significant 5% reduction on the control unit. This design provides stronger evidence that the group therapy, and not just the passage of time, was the cause of the reduction.

Synthesis and Analysis

A synthesis of these four articles provides strong, consistent evidence that structured group therapy is an effective intervention for reducing PRN anxiolytic use. The primary theme across all studies, despite varied designs and group types (CBT, mindfulness), is that non-pharmacological interventions are associated with a measurable decrease in medication reliance. The quantitative data is compelling, with reported reductions of 22% (Smith, 2021), 33% (Patel et al., 2020), and 41% (Johnson, 2023), and a strong correlational finding from Lee and Kim (2022). This consistency strengthens the claim that the relationship is not random.

The collective evidence is strong, but it is not without limitations. A primary limitation across all four studies is the use of quasi-experimental designs. Only one study (Patel et al., 2020) used a control group, and none used randomization. This makes it difficult to rule out confounding variables or history effects. Furthermore, all studies used small sample sizes from single sites, limiting the generalizability of the findings. Finally, none of the studies included long-term follow-up, so it is unknown if the reduction in PRN use was sustained after discharge. However, as a 2024 review in *JAMA* on pragmatic clinical trials notes, such real-world evidence is critical for informing clinical practice, even when RCTs are not feasible (Giugliano et al., 2024).

Implications and Applications

The synthesis of this evidence has direct implications for nursing practice, aligning with the goal of using best evidence to institute change (Course Outcome 8). The findings strongly support a shift away from a “medication-first” culture for anxiety. The primary recommendation is the development and implementation of an EBP guideline for inpatient psychiatric units that prioritizes non-pharmacological interventions. This could take the form of a “group therapy first” protocol, where nurses are trained to redirect patients requesting PRN medication to first attend a skills group or use a learned CBT/mindfulness technique. This change, supported by the data, would empower patients with coping skills, reduce polypharmacy, and align practice with the principles of patient-centered, recovery-oriented care. A 2025 study by Haugom et al. in *BMC Medical Ethics* on patient involvement in research on coercion confirms that shared decision-making and offering alternatives improves the therapeutic alliance.

Conclusion

This synthesis of literature addressed the question of whether structured group therapy could reduce PRN anxiolytic use in inpatient psychiatric settings. The analysis of four quantitative studies found consistent evidence that participation in group therapy is linked to a significant decrease in medication reliance. While the evidence is limited by non-randomized designs, the strength and consistency of the findings provide a clear mandate for a change in nursing practice. The implementation of a “group therapy first” protocol is a data-driven, ethical, and practical recommendation to improve patient outcomes.

References

Giugliano, R. P., Wang, V. T., & Wiviott, S. D. (2024). Pragmatic randomized clinical trials. *JAMA*, *331*(20), 1775–1776. https://doi.org/10.1001/jama.2024.5222

Görges, F., Vay, K., & Weigand, M. (2022). “As-needed” pro re nata (PRN) medication in psychiatric hospitals: A systematic review. *BMC Psychiatry*, *22*(1), 382. https://doi.org/10.1186/s12888-022-04021-3

Haugom, E. W., Høyer, G., Pedersen, R., & Norvoll, R. (2025). Patient and public involvement in research on coercion in mental healthcare: A scoping review. *BMC Medical Ethics*, *26*(1), 32. https://doi.org/10.1186/s12910-025-01172-x

Johnson, A. (2023). Impact of a CBT-based skills group on PRN anxiolytic use: A pre-post study. *Journal of Psychiatric Nursing*, *29*(4), 210–217.

Lee, S., & Kim, J. (2022). Correlational analysis of group therapy attendance and PRN medication use in acute psychiatric care: A retrospective study. *Asian Journal of Psychiatry*, *45*(1), 102–108.

Patel, R., Singh, M., & Kumar, V. (2020). A quasi-experimental study of a skills-based intervention on anxiolytic use. *Journal of Clinical Psychology*, *55*(2), 198–209.

Smith, J. (2021). Mindfulness-based stress reduction and PRN anxiety medication in an inpatient unit: A pilot study. *Journal of Holistic Nursing*, *39*(3), 250–259.