Understanding clinical decision making for PRN medication in mental health inpatient facilities

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.

Investigating the impact of cognitive bias in nursing documentation on decision-making and judgement

The clinical documentation of patients' mental status, behaviour and functioning is a fundamental aspect of inpatient mental health care. It is an important source of information-sharing with the interprofessional team and used by other clinicians within the circle of care to guide their decision-making process. Given the body of evidence highlighting concerns about the quality of nursing documentation and the growing literature demonstrating the presence of bias in healthcare, it is critically important that we examine the impact of this bias in nursing practice. The primary objective of this study was to determine whether clinical decisions and judgements change when nurses read documentation that is either biased or neutral. Using a quantitative, observational study that used surveys to collect data, participants were exposed to two patient vignettes and six clinical notes associated with each patient (notes were written with either biased or neutral language) and asked to make clinical decisions and judgements. Results from 199 nurse participants from a tertiary mental health hospital revealed a notable relationship between the type of notes read (biased vs. neutral) and clinical practice, namely, participants reading biased notes were less likely to offer health teaching when administering pro re nata (PRN) medication for sleep. We also found differences in decision-making and judgements based on the type of note read depending on years of experience and type of education. The results indicate that biased language in nursing documentation can influence other clinicians' decisions and judgements about patients, thereby indicating a cascade of bias.

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.

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.

Nurses' decision-making related to administering as needed psychotropic medication to persons with dementia: an empty systematic review

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.

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.].

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.

Reducing adverse medication events in mental health: Australian National Survey

AIM

To determine the extent to which evidence-based medication safety practices have been implemented in public and private mental health inpatient units across Australia.

METHODS

The Reducing Adverse Medication Events in Mental Health survey was piloted in Victoria, Australia, in 2015, and rolled out nationally in 2016. In total, 235 mental health inpatient units from all States and Territories in Australia were invited to participate. The survey included questions about the demographics of the mental health unit, evidence-based strategies to improve prescription writing, the administration and dispensing of medicines and pharmacy-led interventions, and also questions relating to consumer engagement in medication management and shared decision-making.

RESULTS

The response rate was 45% (N = 106 units). Overall, the survey found that 57% of the mental health units had fully or partially implemented evidence-based medication safety practices. High levels of implementation (80%) were reported for the use of standardized medication charts such as the National Inpatient Medication Chart as a way to improve medication prescription writing. Most (71%) of the units were using standardized forms for recording medication histories, and 56% were using designated forms for Medication Management Plans. However, less than one-fifth of the units had implemented electronic medication management systems, and the majority of units still relied on paper-based documentation systems.Interventions to improve medicine administration and dispensing were not highly utilized. Individual patient-based medication distribution systems were fully implemented in only 9% of the units, with a high reliance (81%) on ward stock or imprest systems. Tall Man lettering for labelling was implemented in only one-third of the units.Pharmacy services were well represented in mental health units, with 80% having access to onsite pharmacist services providing assessments of current medications and clinical review services, adverse drug reaction reporting and management services, patient and carer education and counselling, and medicines information services. However, pharmacists were involved in only half of medical reconciliations. Their involvement in post-discharge follow-up was limited to 4% of units.

CONCLUSIONS

Gaps in medication safety practices included limited use of individual patient supply systems for medication distribution, a high reliance on ward stock systems and high reliance on paper-based systems for medication prescribing and administration. With regards to service provision, clinical pharmacist involvement in medical reconciliation services, therapeutic drug monitoring and interdisciplinary ward rounds should be increased. Discharge and post-discharge services were major gaps in service provision.

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.

Nurses' attitudes towards the use of PRN psychotropic medications in acute and forensic mental health settings

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.

PRN Medication Administration in a Geriatric Psychiatric Hospital: Chart Review and Nursing Perspective

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.

The use and effectiveness of pro re nata psychotropic medications in children and adolescents: A systematic review

BACKGROUND

Published studies have not demonstrated the benefits of the practice of psychotropic PRN administration.

AIM

The goal of this study is to perform a systematic review on pro re nata (PRN) psychotropic medications administration in children and adolescents and examine the safety and effectiveness of this practice in child and adolescent psychiatric care units.

SETTINGS AND DESIGN

This is a systematic review.

MATERIALS AND METHODS

Several databases were searched till date. One hundred and sixty-five titles and abstracts were found and a total of 14 studies, for which most were retrospective, met the absolute criteria. The patients studied were children, adolescents and patients that presented to the emergency room or admitted as inpatient.

RESULTS

Indications for admission included aggression and agitation for all the studies. Most the medications used include haloperidol, olanzapine, diazepam, and risperidone. Commonly reported adverse effects following the administration of the PRN medications were sleepiness, acute dystonia, and drowsiness. The effectiveness of PRN medications, which was reported in four of reviewed studies, ranged from 30% to 50%.

CONCLUSION

Different effectiveness/outcome measures were used for all the studies; therefore, we could not generalize effectiveness across all the studies. Findings of the reviewed articles show the imperativeness of more research to evaluate the safety and effectiveness of PRN medications among child and adolescent populations.

Medicines management: an interview study of nurses at a secure psychiatric hospital

AIMS

To explore mental health nurses' knowledge, attitudes and clinical judgement concerning medicines management in an inpatient setting with a view to enhancing training.

BACKGROUND

Medicines management is a key role of mental health nurses, but little research has been conducted into their training needs.

DESIGN

An exploratory mixed-methods design was used involving individual interviews with participants to investigate their responses to hypothetical medicine administration scenarios.

METHODS

Interviews were held with a convenience sample of 50 Registered Nurses working in a specialist mental health hospital between November 2012-February 2013. Participants were presented with clinical vignettes describing eight scenarios they might encounter as part of their medicines management role and asked about how they would respond. Responses were assessed by two independent raters against ten quality standards underpinning the vignettes.

RESULTS

The median number of responses that were judged to demonstrate adequate awareness of associated quality standards was 4 (range 1-7), indicating that many participants did not appear to be aware of, or compliant with, current UK medicines management guidance and local policy. Many would not report a 'near miss' or medicines administration error. There was a lack of awareness of guidance on verbal prescribing, consent to treatment rules and the administration of off-label/unlicensed drugs. Past year attendance on a medicines management course, time since registration and self-reported knowledge of national standards for medicines administration did not discriminate between total score on the 10 quality standards.

CONCLUSION

The medicines management training needs of participants appeared not to be fully met by the existing learning sources. The use of vignettes to assess nurses' training needs requires evaluation in other settings.

Patients' views and experiences of pro re nata medication in acute mental health settings

In the present study, we interviewed 40 patients in acute inpatient mental health settings regarding their experience of, and views about, receiving pro re nata (PRN) medication. Patient requests for PRN were primarily to relieve anxiety or to aid sleep, and the majority of the participants (80%) could describe a situation where this medication was very helpful. From the perspective of patients, interactions surrounding the immediate administration of PRN medication were inadequate, in that half of the interviewees were simply told to take the medication, and three-quarters said that, in their experience, formal consent was not commonly sought. Three-quarters of respondents came up with alternatives to PRN, and half wanted more information about the medication itself. These findings could contribute to improved nursing assessment for PRN medication need, administration, and monitoring.