Patient participation in pro re nata medication in psychiatric inpatient settings: An integrative review

Nurses' and patient' descriptions about forms of power in pro re nata medication participation in forensic psychiatric care: A qualitative secondary analysis

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.

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.

Practical Considerations of PRN Medicines Management: An Integrative Systematic Review

Background and objectives: Highly widespread use of pro re nata (PRN) medicines in various healthcare settings is a potential area for improper medication prescription and administration leading to patient harm. This study aimed to summarize and integrate the findings of all relevant individual studies regarding the practical considerations of PRN medicines management including strategies and interventions by healthcare professionals for safe prescription, dispensing, administration, monitoring, and deprescription of PRN medicines in healthcare settings. Methods: An integrative systematic review on international databases were performed. Electronic databases including Web of Knowledge, Scopus, PubMed (including MEDLINE), and Cinahl were searched to retrieve articles published until end of May 2021. Original qualitative, quantitative, and mixed methods studies written in English were included with a focus on PRN medicines management in healthcare settings. Research synthesis using the narrative method was performed to summarise the results of included studies. Results: Thirty-one studies on PRN medicines in healthcare settings by different healthcare providers were included after the screening of the databases based on eligibility criteria. They were published from 1987 to 2021. The majority of studies were from Australia, the United States, Canada, and the United Kingdom and were conducted in psychiatric settings. Given variations in their purposes, methods, and outcomes, the research synthesis was conducted narratively based on diversities and similarities in findings. Eight categories were developed by the authors as follows: "PRN indications and precautionary measures," "requirements of PRN prescription," "interventions for PRN administration," "monitoring and follow up interventions," "deprescription strategies," "healthcare professionals' role," "participation of patients and families," and "multidisciplinary collaboration." Each category consists of several items and describes what factors should be considered by healthcare professionals for PRN medicines management. Conclusion: The review findings provide insights on the practical considerations of PRN medicines management in clinical practice. The suggested list of considerations in our review can be used by healthcare professionals for optimal PRN medicines management and safeguarding patient care.

Older Adults Living in Sheltered Housing's Experiences of Involvement in Pro Re Nata Decisions. A Narrative Positioning Analysis

Decisions regarding pro re nata medications might be challenging due to the complex nature of the practice. The aim of this study was to expand our understanding of the experiences of older people living in sheltered housings with regard to shared decision-making concerning pro re nata medications. In this study, we conducted in-depth interviews with residents living in Norwegian sheltered housings. The analysis was inductive, based on a narrative positioning analysis. Twelve residents were interviewed, and three narratives representing participants’ variation are presented. People take different positions in shared decision-making of pro re nata medication, and they position themselves variously at different levels and situations. Prevailing master narratives affect the residents’ positions in shared decision-making. Contrasts in older adults’ experiences indicate that shared decision-making is not straightforward and is highly reliant on the context. Seemingly, they wish to be involved and not involved at the same time, a contradiction that healthcare providers need to consider.

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.

PRN Medicines Optimization and Nurse Education

Medicines management is a high-risk and error prone process in healthcare settings, where nurses play an important role to preserve patient safety. In order to create a safe healthcare environment, nurses should recognize challenges that they face in this process, understand factors leading to medication errors, identify errors and systematically address them to prevent their future occurrence. ''Pro re nata'' (PRN, as needed) medicine administration is a relatively neglected area of medicines management in nursing practice, yet has a high potential for medication errors. Currently, the international literature indicates a lack of knowledge of both the competencies required for PRN medicines management and the optimum educational strategies to prepare students for PRN medicines management. To address this deficiency in the literature, the authors have presented a discussion on nurses' roles in medication safety and the significance and purpose of PRN medications, and suggest a model for preparing nursing students in safe PRN medicines management. The discussion takes into account patient participation and nurse competencies required to safeguard PRN medication practice, providing a background for further research on how to improve the safety of PRN medicines management in clinical practice.

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.