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

Nurses' use of pro re nata medication in adult acute mental healthcare settings: An integrative review

This integrative review explores the current pro re nata (PRN) medication practice in acute adult mental health settings. PRN medication is commonly used in acute mental health settings but there is lack of evidence of effectiveness of this practice. PRN medications have a number of adverse effects and increase the risk of morbidity in patients with a mental illness. Articles were identified from MEDLINE, CINAHL, Scopus, PubMed, PsycINFO, and Web of Science database. The STROBE critical appraisal tool was used to evaluate the quality of evidence, and inductive thematic analysis was used to extract main themes. Five themes regarding prescription practices, poor documentation, reasons to administer, medication misuse, and insufficient use of non-pharmacological interventions emerged among the 12 eligible articles. The study identified PRN medication practice gaps in adult mental health settings included insufficient documentation practice, underuse of therapeutic non-pharmacological interventions, and significant variability in PRN medication practice across the mental health professionals due to different levels of knowledge and experience.

Use of a Novel Standardized Administration Protocol Reduces Agitation Pro Re Nata (PRN) Medication Requirements: The Birmingham Agitation Management (BAM) Initiative

BACKGROUND

Agitation management is a principal challenge on inpatient psychiatric units. Overreliance on common prescribing strategies of pro re nata (PRN) medication administration is problematic, given the tendencies to have overlapping or unclear indications.

OBJECTIVE

Piloted project to determine whether a standardized protocol for agitation intervention may reduce PRN medication administration.

METHODS

The Birmingham Agitation Management (BAM) interdisciplinary team uniquely connected the Brøset Violence Checklist (BVC) for assessment of agitation severity to a standardized PRN medication order set. Nurses on the piloted unit were trained on how to score the BVC and administer medications. Patients were assessed by the BVC every 4 hours and, based on their score, would receive no medication, low-dose benzodiazepine, high-dose benzodiazepine, or high-dose benzodiazepine plus antipsychotic. The primary end point compared the number of PRNs administered after novel protocol implementation with a retrospective cohort. Secondary measures included analysis of medication-related effects, seclusion, and physical restraint rates.

RESULTS

377 patients were included in the final analyses (184 pre-BAM, 193 BAM intervention group). No significant differences were seen in patient characteristics between groups. The total number of PRNs administered decreased by 42.5%, with both the mean and median number of administrations decreasing significantly (95% confidence interval [CI] = [1.68-5.75]; P < 0.001). A trend was noted between the number of PRNs administered and seclusion rates, but did not reach statistical significance (95% CI = [-7.28 to 60.31]; P = 0.124).

CONCLUSIONS

In seemingly the first initiative of its kind, we found that a standardized agitation management protocol can help decrease the total number of PRN administrations for agitation without worsening of restraint rates and may possibly reduce the risk of adverse effects. These results require validation in specific, larger populations.

Using Evidence: A Nursing Assessment Protocol for Acute Geropsychiatric Patients

INTRODUCTION

The Centers for Disease Control and Prevention estimates that approximately 20% of the United States population lives with at least one mental health issue. The most common mental illnesses affecting older Americans include anxiety, cognitive, and mood disorders. These patients may exhibit behaviors indicating agitation or anxiety during necessary hospital stays that warrant de-escalation techniques and appropriate medications to help manage emergent symptoms.

AIMS

This quality improvement intervention was intended to demonstrate enhancement of the nursing assessment and reassessment of patients demonstrating symptoms of agitation and anxiety requiring intervention.

METHODS

Assessment of the established nursing practice demonstrated compromised patient safety and led to planning and implementation of a new practice standard that incorporated an evidence-based tool. Nurses utilized a protocol that employed the Pittsburgh Agitation Scale to augment documentation of the nursing assessment for patients exhibiting symptoms of marked anxiety and agitation.

RESULTS

Following a 3-month trial, chart audits were completed to assess results of the protocol's implementation. Significant improvement was noted in the nursing assessment process as evidenced in required documentation of nursing assessment and reassessment including use of the protocol.

CONCLUSIONS

Implementing standards to guide nursing care can support both patient safety and professional practice.

Agreement of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) With NICU Nurses' Assessments

BACKGROUND

Objective assessment tools should standardize and reflect nurses' expert assessments. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and the Neonatal Infant Pain Scale (NIPS) are valid measures of pain. The N-PASS also provides a sedation subscale.

PURPOSE

The objective of this study was to determine N-PASS clinical validity and utility by evaluating agreement of N-PASS scores with bedside nurses' assessments of pain/agitation and sedation in a 64-bed tertiary neonatal intensive care unit.

METHODS

Fifteen bedside nurses trained to use the N-PASS and the NIPS prospectively completed 202 pain/agitation and sedation assessments from a convenience sample of 88 infants, including chronically ventilated, medically fragile infants. N-PASS and NIPS scores were obtained simultaneously but independently of nurse investigators. Bedside nurses also made recommendations about infants' pain and sedation management.

RESULTS

There was moderate agreement between N-PASS pain scores and nurses' recommendations (κ= 0.52), very strong agreement between N-PASS sedation scores and nurses' recommendations (κ= 0.99), and very strong associations between N-PASS pain and NIPS scores (P< .001). Bedside nurse and independent investigator interrater reliability was good for N-PASS pain and NIPS scores (intraclass correlation coefficient [ICC] = 0.83, ICC = 0.85) and excellent for N-PASS sedation (ICC = 0.94). During 93% of assessments, bedside nurses reported that the N-PASS reflected the level of infant sedation well or very well.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The N-PASS provides an easy-to-use, valid, and reliable objective measure of pain and sedation that reflects nurses' assessments. Additional studies using the N-PASS are needed to verify results and the influence of the N-PASS on pain and sedation management for medically fragile infants with chronic medical conditions.

Patient participation in pro re nata medication in forensic psychiatric care: A nursing document analysis

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.

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.].

Exploring acute care nurses' decision-making in psychotropic PRN use in hospitalised people with dementia

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.

Pro Re Nata Medication Use in Acute Care Adolescent Psychiatric Unit

Objective: Evidence to support the use of pro re nata (PRN) medication is limited, and the details of PRN use (indication, frequency of administration, patient characteristics) are rarely reported, particularly in youth populations. The goal of this study was to report on the pattern of PRN use over 6 years in an acute care psychiatric unit for adolescents. Methods: A retrospective chart review of patients' records from November 2012 to October 2018 was conducted. Variables extracted from electronic medical records included age, gender, race/ethnicity, clinical rating scores at admission (on a subset of patients), length of stay, psychotropic and nonpsychotropic PRN medication administration, timing of administration, discharge diagnosis, and discharge medication. Results: Records from 2961 individuals with a total 3937 admissions were analyzed. A total of 62% of admissions had at least one PRN medication administration. Severity of symptoms, as indicated by higher scores on clinical rating scales at admission, longer length of stay, and readmission were related to high PRN use. Patients with bipolar spectrum disorders received more psychotropic and nonpsychotropic PRN medications than other patients. Patients who were high psychotropic PRN users were also high nonpsychotropic PRN users. Conclusion: Despite the lack of clear evidence in support of the efficacy of PRN medications, they commonly used to control symptoms in acute care inpatient settings. Youth with severe symptoms utilized not only psychotropic PRN medication but also nonpsychotropic PRN more frequently, suggesting a possible role of systemic disorder among youth with serious mental illness. More research is necessary to examine the efficacy of PRN medications for managing targeted symptoms.

PRN Medicines Management for Psychotropic Medicines in Long-Term Care Settings: A Systematic Review

Many medications are prescribed and administered PRN (pro re nata, as needed). However, there are few integrative reviews to inform PRN psychotropic medication use in long-term care facilities and nursing or care homes. Accordingly, this integrative systematic review aimed to improve our understanding of PRN medicines management with a focus on psychotropic medications (antipsychotics, sedatives, anxiolytics, and hypnotics) in long-term care settings. Keywords relating to PRN in English, Norwegian, and Spanish were used, and articles published between 2009 and 2019 were retrieved. Based on the inclusion criteria, eight articles were used for data analysis and synthesis. This review offers a description of PRN prescription and administration of psychotropic medications in long-term care. Variations were observed in the management of PRN psychotropic medications based on residents’ underlying health conditions and needs, duration of use, and changes between medications and doses. Neither the reasons for PRN prescription and administration nor the steps taken to identify and manage any associated adverse reactions or adverse drug events were reported. Further initiatives are needed to improve PRN medicines management to explore factors that affect PRN prescription and administration and to develop appropriate PRN guidelines to prevent harm and improve the safety of people living in long-term care facilities.

The Administration of Pro re nata Medication by Mental Health Nurses: A Thematic Analysis

Pro re nata (PRN) medication is medication administered by nurses as required commonly in response to a patient's symptoms or behaviour including insomnia, agitation or anxiety. There is a paucity of research around the process of PRN administration in mental health settings in Ireland and international evidence suggests inconsistencies in practices. This study aimed to explore the process of PRN medication administration by mental health nurses. Using a qualitative descriptive design, semi-structured interviews were undertaken with 19 mental health nurses in three acute inpatient units in one mental health service in Ireland. Most participants reported undertaking an assessment of the patient before administering PRN medication; however, many also reported having observed incidents of poor practice. There was evidence of some interdisciplinary sensitivities around instructions regarding the use of PRN medications between doctors who prescribed them and nurses who dispensed them. A need for service improvements were also identified including the use of alternative strategies to PRN use such as de-escalation techniques and education around psychopharmacology. PRN medication is commonly used in mental health settings; however, this study suggests that there is potential for improvement in relation to how it is prescribed and administered. Overuse of PRN medication has been associated with increased morbidity. Mental health nurses are required to carefully consider whether PRN medication is warranted in the first instance and how its use might impact on patients.

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.

Sound as a supportive design intervention for improving health care experience in the clinical ecosystem: A qualitative study

PURPOSE

Most prior hospital noise research usually deals with sound in its noise facet and is based merely on sound level abatement, rather than as an informative or orientational element. This paper stimulates scientific research into the effect of sound interventions on physical and mental health care in the clinical environment.

METHODS

Data sources comprised relevant World Health Organization guidelines and the results of a literature search of ISI Web of Science, ProQuest Central, MEDLINE, PubMed, Scopus, JSTOR and Google Scholar.

RESULTS

Noise induces stress and impedes the recovery process. Pleasant natural sound intervention which includes singing birds, gentle wind and ocean waves, revealed benefits that contribute to perceived restoration of attention and stress recovery in patients and staff.

CONCLUSIONS

Clinicians should consider pleasant natural sounds perception as a low-risk non-pharmacological and unobtrusive intervention that should be implemented in their routine care for speedier recovery of patients undergoing medical procedures.