1
|
Hipp K, Kangasniemi M, Varpula J, Lantta T. Nurses' and patient' descriptions about forms of power in pro re nata medication participation in forensic psychiatric care: A qualitative secondary analysis. Int J Ment Health Nurs 2024; 33:73-84. [PMID: 37661371 DOI: 10.1111/inm.13219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/13/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023]
Abstract
Despite there being an emphasis on patient participation in their own care, it has been a challenge in pro re nata (PRN, as the circumstance arises) medication in forensic psychiatric care. The power imbalance in treatment relationships can be a barrier to patient participation and should therefore be further explored. This qualitative descriptive study aimed to explore the aspect of power in the descriptions of patients and nurses interviewed in a Finnish forensic psychiatric hospital about patient participation in PRN. A qualitative secondary analysis was conducted through the semi-structured interviews of the patients (n = 34) and nurses (n = 19). The data were analysed with deductive content analysis. The Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines were used to ensure comprehensive reporting. The findings revealed that patients and health professionals may have conflicting goals in PRN and that they both use power to try to achieve them. Power in PRN was described in different forms, including authority, force, manipulation and persuasion. Based on our results, the power that health professionals have in PRN medication is particularly based on their legitimate authority and the hierarchical structures of the hospital environment. Patients also hold power in the dynamics of PRN medication care, but their position as a power holder can vary individually and situationally. Recognizing different forms of power and supporting patients with a decreased capacity for decision-making is essential for promoting high-quality and patient-centred forensic psychiatric nursing.
Collapse
Affiliation(s)
- Kirsi Hipp
- School of Health and Social Services, Häme University of Applied Sciences, Hämeenlinna, Finland
| | - Mari Kangasniemi
- Department of Nursing Science, University of Turku, Satakunta Hospital District, Turku, Finland
| | - Jaakko Varpula
- Department of Nursing Science, University of Turku, Satakunta Hospital District, Turku, Finland
| | - Tella Lantta
- Department of Nursing Science, University of Turku, Satakunta Hospital District, Turku, Finland
- Department of Nursing, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
| |
Collapse
|
2
|
Casol M, Tong A, Ng JCY, McGloin R. Characterization of Psychotropic PRN Medications in a Canadian Psychiatric Intensive Care Unit. J Am Psychiatr Nurses Assoc 2023; 29:103-111. [PMID: 34109871 DOI: 10.1177/1078390321994668] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pro re nata (PRN) antipsychotics and benzodiazepines are routinely used for the rapid stabilization of acutely agitated patients. Despite the popular use of PRN medications in mental health units, primary literature supporting efficacy and safety is poor, and there is no single universally accepted practice guideline. PRN psychotropic medications have the potential to cause adverse effects when used inappropriately. AIMS Our objective was to characterize the prescribing, administration, and documentation practices of PRN psychotropic medications in a psychiatric intensive care unit. METHODS We conducted a retrospective chart review of patients admitted to a 12-bed psychiatric intensive care unit between June and September 2018. All PRN antipsychotic and benzodiazepine orders, administrations, documentation practices, and attempted nonpharmacological strategies were assessed for each order and patient. Descriptive statistics were used to analyze data. RESULTS Thirty-two patients with a total of 123 physicians' orders and 1,179 PRN administrations of antipsychotics and benzodiazepines were reviewed. Of the total administrations, 720 (61%) were combinations with at least two psychotropic agents. Forty-one (33%) physicians' orders had a prescribed indication, and 559 (47%) administrations had an attempted nonpharmacological method prior to PRN administration. Eight patients (25%) had antipsychotic PRN orders, which exceeded the total daily maximum dose. Three adverse drug effects were attributed to PRN administration. CONCLUSIONS Areas of improvement that we identified included documentation practices of effectiveness of administered PRNs, prescriptions to include clear indications and dosage within the 24-hour maximum limits, and documentation of nonpharmacological methods utilized.
Collapse
Affiliation(s)
- Marina Casol
- Marina Casol, BSc (Pharm), ACPR, Surrey Memorial Hospital, Surrey, British Columbia, Canada
| | - Angela Tong
- Angela Tong, BSc (Pharm), ACPR, Surrey Memorial Hospital, Surrey, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada
| | - Joan C Y Ng
- Joan C. Y. Ng, BSc (Pharm), ACPR, PharmD, University of British Columbia, Vancouver, British Columbia, Canada; St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Rumi McGloin
- Rumi McGloin, BSc (Pharm), ACPR, PharmD, Surrey Memorial Hospital, Surrey, British Columbia, Canada; University of British Columbia, Vancouver, British Columbia, Canada
| |
Collapse
|
3
|
Hipp K, Repo-Tiihonen E, Kuosmanen L, Katajisto J, Kangasniemi M. Patient participation in pro re nata medication in forensic psychiatric care: A nursing document analysis. J Psychiatr Ment Health Nurs 2021; 28:611-621. [PMID: 33085793 DOI: 10.1111/jpm.12706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 08/11/2020] [Accepted: 09/30/2020] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN ON THE SUBJECT As-needed medication is commonly used for psychiatric inpatients' acute psychiatric and physical symptoms. Both patients and staff can initiate such medication. Earlier studies have focused on what and how as-needed medication has been used for psychiatric reasons. Little is known about how patients participate in planning, administration and evaluation of as-needed medication and its alternatives. Nursing documentation provides an insight into these practices. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE Long-term inpatients have an active role in initiating as-needed medication. However, patients and staff may have divergent opinions on the need for medication. Alternatives to medication are mostly proposed by staff, and the feedback on as-needed medication events is usually provided from nurses' point of view. WHAT ARE THE IMPLICATIONS FOR PRACTICE Patients' views on decision-making and evaluation should be noticed and documented more. Patient participation can be promoted by planning as-needed medication and its alternatives beforehand. ABSTRACT INTRODUCTION: Pro re nata (PRN) medication is unscheduled and used for acute physical and psychiatric symptoms. Previous studies have focused on the what and how of psychotropic PRN administration. Initiators of PRN events and occasions in which PRN was denied have rarely been studied. Thus, knowledge of patient participation in PRN is fragmented. AIM We aimed to describe and explain long-term psychiatric inpatients' participation in relation to planning and initiation of, as well as decisions and feedback on their PRN medication treatment. METHODS We retrieved data from patients' (n = 67) nursing documentation in a Finnish forensic psychiatric hospital in 2018. Data were analysed using statistical methods. RESULTS All patients were prescribed PRN, and they initiated half of the 8,626 PRN events identified, in a 1-year period. Non-pharmacological strategies were rarely (6%) documented, and most of them were initiated by staff (76%). Feedback on PRN was usually from a nurse's viewpoint (71%). Nurses' feedback was positive (80%) more often than patients' (50%). DISCUSSION Patient participation needs to be recognized throughout the PRN process. Future research could continue to explore patient participation in planning and evaluating their PRN medication. IMPLICATIONS FOR PRACTICE Patients participate in PRN by requesting medication. Their participation can be developed by supporting patients to communicate their choice of non-pharmacological methods, take the initiative for medication when needed and disclose their viewpoint on the effects of PRN.
Collapse
Affiliation(s)
- Kirsi Hipp
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
| | - Eila Repo-Tiihonen
- Niuvanniemi Hospital, Kuopio, Finland.,University of Eastern Finland, Kuopio, Finland.,University of Helsinki, Helsinki, Finland
| | - Lauri Kuosmanen
- Department of Nursing Science, Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Jouko Katajisto
- Department of Mathematics and Statistics, University of Turku, Turku, Finland
| | - Mari Kangasniemi
- Department of Nursing Science, Faculty of Medicine, University of Turku, Turku, Finland
| |
Collapse
|
4
|
Walsh B, Dahlke S, O'Rourke H, Hunter KF. Nurses' decision-making related to administering as needed psychotropic medication to persons with dementia: an empty systematic review. Int J Older People Nurs 2021; 16:e12350. [PMID: 33438810 DOI: 10.1111/opn.12350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/29/2020] [Accepted: 09/08/2020] [Indexed: 11/28/2022]
Abstract
Behavioural and psychological symptoms of dementia occur in approximately 75% of people with dementia admitted to acute care. Acute care nurses' decision-making regarding administering 'as needed' (pro re nata or PRN) psychotropic medications to persons with dementia are not well understood. This is an important clinical concern because 'as needed' medications are given at the discretion of the nurse. A comprehensive, systematic search and screen for studies that explored nurses' decision-making related to administering as needed psychotropic medication to persons with dementia in acute care settings was conducted. No studies that reported nurses' decision-making related to administration of as needed psychotropic medications to hospitalized persons with dementia were identified. In light of this, we present a discussion based on a narrative review of what is known on this topic from other settings, based on papers found in our original review. We will briefly explore what is needed in future research to address the gap in knowledge about nurse' decision-making related to administering as needed psychotropic medications. IMPLICATIONS FOR PRACTICE: Research is needed to understand and inform the decision-making process in the administration of as needed psychotropic medications to hospitalized persons with dementia.
Collapse
Affiliation(s)
- Brittany Walsh
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Hannah O'Rourke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | | |
Collapse
|
5
|
Sharma M, Wong XY, Bell JS, Corlis M, Hogan M, Sluggett JK. Trajectories of pro re nata (PRN) medication prescribing and administration in long-term care facilities. Res Social Adm Pharm 2020; 17:1463-1468. [PMID: 33223395 DOI: 10.1016/j.sapharm.2020.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/02/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Little is known about changes in pro re nata (PRN) medication prescribing and administration in residential aged care facilities (RACFs) over time. OBJECTIVE To determine the prevalence and factors associated with PRN medication administration in RACFs and examine changes over 12-months. METHODS Secondary analyses utilizing data from the SIMPLER randomized controlled trial (n = 242 residents, 8 RACFs) was undertaken. PRN medication data were extracted from RACF medication charts. Factors associated with PRN medication administration in the preceding week were explored using multivariable logistic regression. RESULTS At baseline, 211 residents (87.2%) were prescribed ≥1 PRN medication, with 77 (36.5%) administered PRN medication in the preceding week. PRN administration was more likely in non-metropolitan areas, and less likely among residents with more severe dementia symptoms and greater dependence with activities of daily living. No significant differences in overall PRN prescribing or administration in 162 residents alive at 12-month follow-up were observed. CONCLUSIONS Despite being frequently prescribed, the contribution of PRNs to overall medication use in RACFs is small. PRN prescribing and administration was relatively static over 12-months despite likely changes in resident health status over this period, suggesting further exploration of PRN prescribing in relation to resident care needs may be warranted.
Collapse
Affiliation(s)
- Monica Sharma
- University of South Australia, UniSA Clinical and Health Sciences, Adelaide, South Australia, Australia
| | - Xin Yee Wong
- University of South Australia, UniSA Clinical and Health Sciences, Adelaide, South Australia, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Megan Corlis
- University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia
| | - Michelle Hogan
- Helping Hand Aged Care, North Adelaide, South Australia, Australia
| | - Janet K Sluggett
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; University of South Australia, UniSA Allied Health and Human Performance, Adelaide, South Australia, Australia; Registry of Senior Australians (ROSA), Health Ageing Research Consortium, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia.
| |
Collapse
|
6
|
Walsh B, Dahlke S, O'Rourke H, Hunter KF. Exploring acute care nurses' decision-making in psychotropic PRN use in hospitalised people with dementia. J Clin Nurs 2020; 31:2024-2035. [PMID: 32860272 DOI: 10.1111/jocn.15477] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/30/2020] [Accepted: 08/19/2020] [Indexed: 12/01/2022]
Abstract
AIMS AND OBJECTIVES To understand how acute care nurses make decisions about administering "as-needed" (PRN) psychotropic medications to hospitalised people with dementia (PWD). BACKGROUND Behavioural and psychological symptoms of dementia occur in approximately 75% of PWD admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care. DESIGN A qualitative descriptive design was used to explore acute care nurses' decision-making about PRN psychotropic medication administration to PWD. METHODS Semi-structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses' decision-making related to administering PRNs to hospitalised PWD. COREQ guidelines were followed. RESULTS Three themes of legitimising control, making the patient fit and future telling were developed. Legitimising control involved medicating undesirable behaviours to promote the nurses' perceptions of safety. Making the patient fit involved maintaining routine and order. Future telling involved pre-emptively medicating to prevent undesirable behaviours from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviours. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organisational and unit routines greatly influenced nurses' decision-making. CONCLUSIONS These findings provide an initial understanding of how nurses make decisions to administer PRN medications to hospitalised older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses' collective response in decision-making. More research is needed to better understand the complexities of nurses' decision-making, to assist in the development of interventions for nursing practice.
Collapse
Affiliation(s)
- Brittany Walsh
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Sherry Dahlke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Hannah O'Rourke
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | | |
Collapse
|
7
|
Procaccini D, Rapaport R, Petty B, Moore D, Lee D, Kudchadkar SR. Design and Implementation of an Analgesia, Sedation, and Paralysis Order Set to Enhance Compliance of pro re nata Medication Orders with Joint Commission Medication Management Standards in a Pediatric ICU. Jt Comm J Qual Patient Saf 2020; 46:706-714. [PMID: 32653365 DOI: 10.1016/j.jcjq.2020.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 05/29/2020] [Accepted: 06/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND The use of pro re nata (PRN) medication orders increases nursing flexibility and efficiency of bedside patient care. However, misuse and/or ambiguity of PRN medication orders may increase the propensity for medication errors. The Joint Commission has Medication Management (MM) standards to mitigate such risks. This quality improvement study with a pre-post design aimed to increase compliance of PRN sedative and analgesic orders with use of failure mode and effects analysis (FMEA) and human factors risk assessment methodologies in a pediatric ICU (PICU). METHODS Staff education and a PICU analgesia, sedation, and paralysis order set, with predefined PRN orders, were implemented to enhance PRN medication compliance with Joint Commission MM standards. The primary goal was to achieve and maintain a weekly average compliance of ≥ 90%. Proportions of compliant PRN analgesic and sedative orders before and after interventions were compared. RESULTS Weekly average PRN orders compliance increased from 62.0% ± 9.2% to 77.7% ± 10.1% after staff education was implemented (p = 0.013). After order set implementation, weekly average compliance further increased to 93.2% ± 3.6% (p < 0.0001) and remained > 90% until the end of the study period. CONCLUSION Interdisciplinary synthesis using FMEA and human factors risk assessment is effective for identifying system failure modes associated with Joint Commission MM standard noncompliance. Implementation of an order set with forced functionality to include order information compliant with Joint Commission MM standards can enhance and maintain Joint Commission-compliant PRN medication orders.
Collapse
|
8
|
Martin K, Ham E, Hilton NZ. Staff and patient accounts of PRN medication administration and non-pharmacological interventions for anxiety. Int J Ment Health Nurs 2018; 27:1834-1841. [PMID: 29851211 DOI: 10.1111/inm.12492] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2018] [Indexed: 12/20/2022]
Abstract
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.
Collapse
Affiliation(s)
- Krystle Martin
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada.,University of Ontario Institute of Technology, Oshawa, Ontario, Canada
| | - Elke Ham
- Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada
| | - N Zoe Hilton
- Waypoint Centre for Mental Health Care, Penetanguishene, Ontario, Canada.,University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
9
|
Vaismoradi M, Amaniyan S, Jordan S. Patient Safety and Pro Re Nata Prescription and Administration: A Systematic Review. PHARMACY 2018; 6:E95. [PMID: 30158511 PMCID: PMC6163482 DOI: 10.3390/pharmacy6030095] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 08/20/2018] [Accepted: 08/24/2018] [Indexed: 12/14/2022] Open
Abstract
PRN is the acronym for 'pro re nata,' written against prescriptions whose administration should be based on patients' needs, rather than at set times. The aim of this systematic review was to explore safety issues and adverse events arising from PRN prescription and administration. Electronic databases including Scopus, PubMed [including Medline], Embase, Cinahl, Web of Science and ProQuest were systematically searched to retrieve articles published from 2005 to 2017. SELECTION CRITERIA we included all randomized controlled trials (RCTs) and studies with comparison groups, comparing PRN prescription and administration with scheduled administration, where safety issues and adverse events were reported. The authors independently assessed titles, abstracts and full-texts of retrieved studies based on inclusion criteria and risk of bias. Results were summarised narratively. The search identified 7699 articles. Title, abstract and full-text appraisals yielded 5 articles. The included studies were RCTs with one exception, a pre-test post-test experimental design. Patient populations, interventions and outcomes varied. Studies compared patient-controlled or routine administration with PRN and one trial assessed the effect of a practice guideline on implementation of PRN administration. More analgesia was administered in the patient-controlled than the PRN arms but pain reduction was similar. However, there was little difference in administration of psychotropic medicines. No differences between patient-controlled and PRN groups were reported for adverse events. The PRN practice guideline improved PRN patient education but non-documentation of PRN administration increased. This systematic review suggests that PRN safety issues and adverse events are an under-researched area of healthcare practice. Variations in the interventions, outcomes and clinical areas make it difficult to judge the overall quality of the evidence. Well-designed RCTs are needed to identify any safety issues and adverse events associated with PRN administration.
Collapse
Affiliation(s)
- Mojtaba Vaismoradi
- Faculty of Nursing and Health Sciences, Nord University, 8049 Bodø, Norway.
| | - Sara Amaniyan
- Faculty of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran 1419733171, Iran.
| | - Sue Jordan
- College of Human and Health Sciences, Swansea University, Swansea SA2 8PP, UK.
| |
Collapse
|
10
|
Barr L, Wynaden D, Heslop K. Nurses' attitudes towards the use of PRN psychotropic medications in acute and forensic mental health settings. Int J Ment Health Nurs 2018; 27:168-177. [PMID: 28337845 DOI: 10.1111/inm.12306] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2016] [Indexed: 01/23/2023]
Abstract
Many countries now have national mental health policies and guidelines to decrease or eliminate the use of seclusion and restraint yet the use of Pro Re Nata (PRN) medications has received less practice evaluation. This research aimed to identify mental health nurses' attitudes towards the use of PRN medications with mental health consumers. Participants were working in forensic mental health and non-forensic acute mental health settings. The "Attitudes towards PRN medication use survey" was used and data were collected online. Data were analysed using the Statistical Package Social Sciences, Version 22.0. Practice differences between forensic and other acute mental health settings were identified related to the use of PRN medications to manage symptoms from nicotine, alcohol and other drug withdrawal. Differences related to the useage of comfort rooms and conducting comprehensive assessments of consumers' psychiatric symptoms were also detected. Qualitative findings highlighted the need for increased accountability for the prescribing and administration of PRN medications along with more nursing education/training to use alternative first line interventions. Nurses administering PRN medications should be vigilant regarding the indications for this practice to ensure they are facilitating the consumer's recovery by reducing the use of all forms of potentially restrictive practices in the hospital setting. The reasons for using PRN medications and PRN administration rates must be continually monitored to avoid practices such as high dose antipsychotics use and antipsychotic polypharmacy to ensure the efficacy of the consumers' management plans on their health care outcomes.
Collapse
Affiliation(s)
- Lesley Barr
- State Forensic Mental Health Services, Perth, Western Australia, Australia
| | - Dianne Wynaden
- Nursing and Midwifery, Curtin University, Perth, Western Australia, Australia
| | - Karen Heslop
- Nursing and Midwifery, Curtin University, Perth, Western Australia, Australia
| |
Collapse
|
11
|
Martin K, Arora V, Fischler I, Tremblay R. Analysis of non-pharmacological interventions attempted prior to pro re nata medication use. Int J Ment Health Nurs 2018; 27:296-302. [PMID: 28247580 DOI: 10.1111/inm.12320] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/01/2017] [Indexed: 11/29/2022]
Abstract
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.
Collapse
Affiliation(s)
- Krystle Martin
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada
| | - Vinita Arora
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada.,Department of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Ilan Fischler
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada.,Department of Psychiatrity, University of Toronto, Toronto, Ontario, Canada
| | - Renee Tremblay
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada
| |
Collapse
|
12
|
Harper L, Reddon JR, Hunt CJ, Royan H. PRN Medication Administration in a Geriatric Psychiatric Hospital: Chart Review and Nursing Perspective. Clin Gerontol 2017; 40:392-400. [PMID: 28406368 DOI: 10.1080/07317115.2017.1311287] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To improve patient care/outcome, an evaluation was conducted of nursing procedures and protocols for pro re nata (PRN) medications. METHODS A 14-day chart review was conducted for 27 patients with mood and thought disorders (MTD) and for 24 patients with organic disorders (OD) at a geriatric psychiatric hospital, and a questionnaire was completed by 20 nurses. RESULTS 377 PRNs were administered to patients in the MTD and OD units (240 and 137, respectively). The majority of PRNs were administered during the evening shifts on the MTD unit and during the day shifts on the OD unit. Chart notes indicated the behavior requiring PRN administration was not always specifically described and therapeutic interventions were not often attempted before PRN administration. Inconsistency between chart notes and medication record books was noted in the majority of cases. It was often not known whether the PRN was initiated by the staff, patient, or family. PRNs were reported to be not effective in the majority of cases. CONCLUSIONS Documentation was suboptimal and effectiveness was poor. CLINICAL IMPLICATIONS It would be worthwhile to train all staff in a patient-centered or ecopsychosocial (i.e., non-pharmacological) model of care, which would provide staff alternatives to PRNs. In that context, it would be important to implement standards of practice into geriatric psychiatry inpatient settings for PRN administration and documentation.
Collapse
Affiliation(s)
- Lori Harper
- a Villa Caritas Hospital , Edmonton , Alberta , Canada
| | - John R Reddon
- b University of Alberta , Edmonton , Alberta , Canada
| | | | - Heather Royan
- a Villa Caritas Hospital , Edmonton , Alberta , Canada
| |
Collapse
|