Multi-disciplinary perceptions of patient group directions as a replacement for the pro re nata prescribing of antipsychotic medications in acute mental health settings

Development of Toddlers' Smartphone Flow State Scale: Parent Report Form

Toddlers come into contact with smartphones by the time they are 10 months old, and smartphones eventually become a part of the daily lives of toddlers because they are used as parenting tools and are also attractive toys. Routine exposure to these electronic devices may lead to excessive immersion, which can cause smartphone dependence when toddlers grow up. Based on Csikszentmihalyi’s concept of flow, we aimed to develop a new scale to measure the flow phenomenon in toddlers who are exposed to smartphones. We attempted to identify the constituent factors of a toddler’s flow in smartphones through a literature review, observations, and interviews. Initially, 32 questions were screened from the field verification stage and interviews; the final 20 questions were selected by combining technical statistics, exploratory factor analysis, and expert feasibility. We also found five eligible constituent factors, namely, a playfulness-oriented experience, reaction limited by concentration, and intentional pursuit to achieve the goal, assimilate into the virtual world, and acquire desire-fulfilling skills. We then performed a confirmatory factor analysis on our parent-reported toddlers’ smartphone flow state scale. To secure the criterion-related validity, the correlation between our scale and the preexisting smartphone dependence measurement tool for toddlers was evaluated. Cronbach’s α value of the toddlers’ smartphone flow state scale was 0.95 (each factor was verified as 0.79–0.92 and the explanatory power was 72.21%). The test–retest reliability was found to be stable with the intraclass correlation (ICC) coefficient value of 0.78 (p < 0.001). Our research findings suggest that this novel smartphone flow state scale for toddlers could be a valid and reliable tool for measuring how toddlers feel the flow phenomenon while using smartphones. Furthermore, our results could contribute to the development and evaluation of the interventions that prevent side effects from smartphone overflow in toddlers.

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

Pro re nata (PRN) medication is widely used and studied in psychiatric care, but our knowledge about patient participation in its administration is fragmented. The aim of this integrative review was to describe and synthesize previous knowledge of patient participation in PRN in psychiatric inpatient settings. We conducted both electronic and manual searches, using the CINAHL, Scopus, PsycINFO, and PubMed databases, and eight scientific journals. Searches were limited to the English language, to the years 2006-2016, and to selected papers using inclusion, exclusion, and quality criteria. We identified 16 relevant papers, and these showed that patient participation included patient-related starting points, including the patients' willingness to participate and their knowledge of the medication. The patients' participation in PRN practices was demonstrated by the opportunity to request PRN and to refuse any PRN that was offered. Patient participation was shown to be linked to certain situations where PRN was recommended. The role that the professionals played in patient participation included interacting with patients, providing counselling and alternatives for PRN. Our results also revealed that coercion was used administering PRN. The existing literature exposed challenges that need to be addressed if patient participation in the use of PRN medication is to be effectively achieved in psychiatric inpatient settings. Equal partnerships between patients, nurses, and physicians are an essential part of this process, and further research into PRN medication is urgently needed, particularly studies that focus on patients' experiences.

Resistance to changing practice from pro re nata prescriptions to patient group directions in acute mental health settings

Poor practice associated with pro re nata (PRN) prescriptions in mental health is known to be common and can increase the risk of serious and potentially fatal side effects. A contributing factor to poor practice is the lack of a clear chain of accountability between the decision to prescribe and administer PRN prescriptions. To address this problem, a patient group direction (PGD) for acute behavioural disturbance (lorazepam 0.5-2 mg) and staff training materials were developed. The intention was to replace PRN prescriptions with the PGD in two mental health trusts. One of the potential benefits of this would be the removal of the contribution of PRN to high and combined dose antipsychotic prescriptions. This proposal, however, was met with significant resistance in both trusts and did not replace PRN as a result. A series of interviews and focus groups were conducted with 16 RMNs working in the two trusts, to explore the reasons why the PGD was met with resistance. Senior nurses perceived resistance to be associated with anxieties over increased responsibility for decision making. Junior nurses reported concerns regarding the medicalization of the nursing role, the paperwork associated with the PGD and the training approach used. Future efforts to implement PGDs in mental health settings must carefully consider the methods for engaging effectively with participating organizations, in terms of managing change and completing the necessary groundwork for successful implementation.