P.r.n. medication use in a psychiatric high-dependency unit following the introduction of a nurse-led activity programme

Nurse-led physical health interventions for people with mental illness: an integrative review of international literature

BACKGROUND

People experiencing mental illness receive physical healthcare from nurses in a variety of settings including acute inpatient, secure extended care, forensic, and community services. While nurse-led clinical practice addressing sub-optimal consumer physical health is salient, a detailed understanding and description of the contribution by nurses to physical health interventions in people experiencing mental illness is not clearly articulated in the literature.

AIMS

The aim of this integrative review is to describe the state of knowledge on nurse-led physical health intervention for consumers, focusing on nursing roles, nursing assessment, and intervention settings.

METHODS

A systematic search of six databases using Medical Subject Headings from 2001 and 2022 inclusive was conducted. The Mixed Methods Appraisal Tool (MMAT) was utilised for quality appraisal.

RESULTS

Seventy-four studies were identified as "nurse-led". Interventions were most common among community settings (n = 34, 46%). Nurses performed varied roles, often concurrently, including the collection of 341 physical health outcomes, and multiple roles with 225 distinct nursing actions identified across the included studies. A nurse as lead author was common among the included studies (n = 46, 62%). However, nurses were not always recognised for their efforts or contributions in authorship.

CONCLUSIONS

There is potential gap in role recognition that should be considered when designing and reporting nurse-led physical health interventions.

Nurse-Led Physical Health Interventions for People with Mental Illness: A Scoping Review of International Literature

People with mental illness have a higher prevalence of co-occurring physical health conditions and poor health behaviors, leading a mortality gap of up to 16 years, compared with the general population. Nurses working in mental health settings play an important role in addressing factors influencing sub-optimal physical health. Therefore, this scoping review aimed to identify nurse-led physical health interventions and align interventions to eight recognized physical healthcare priority areas (i.e. Equally Well in Victoria Framework). A systematic search strategy was used to identify relevant literature. Data extraction included alignment to the Equally Well priority areas, research design, and indication of co-design (meaningful and collaborative involvement of consumers and significant others) and recovery-oriented practice (focusing on needs and goals of a consumer's recovery journey). All included papers (n = 74) were aligned to at least one of eight Equally Well priority areas. Papers were predominately quantitative (n = 64, 86%), with the remainder mixed methods (n = 9, 9%) or qualitative (n = 4, 5%). Most papers were aligned to improving metabolic health and support to quit smoking. One study focused on nurse-led intervention designed to reduce falls. Recovery-oriented practice was evident in six papers. No paper described evidence of co-design. A research gap was identified for nurse-led intervention to reduce falls and improve dental/oral care. Relative to mental healthcare policy, there is a need for future nurse-led physical health research to be co-designed and include recovery-oriented practice. Evaluation and description of future nurse-led physical interventions should seek to report perspectives of key stakeholders as these remain relatively unknown.

Experiences of mental health professionals and patients in the use of pro re nata medication in acute adult mental healthcare settings: a systematic review

BACKGROUND

The use of pro re nata (PRN) medication, a medication that is given when needed, as opposed to medication that is given at a regular time, is surrounded by claims of misuse and poor accountability within the mental health setting. Gaining insight into and understanding of the experiences of health professionals' and patients' use of PRN medication will assist in contributing to improving education and safety around this common intervention.

OBJECTIVES

To analyze and synthesize the best available evidence on the perspectives of patients and mental health professionals (MHPs) with their experiences of PRN medication in mental health settings.

INCLUSION CRITERIA TYPES OF PARTICIPANTS

Participants considered for inclusion in this review include MHPs working in, and adult patients admitted to, an acute adult mental healthcare setting.

PHENOMENA OF INTEREST

This review will consider studies that investigated the experience of MHPs' and patients' use of PRN medication in acute adult mental healthcare settings.

TYPES OF STUDIES

The current review will consider studies that focused on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.

CONTEXT

The context of the review is acute adult mental healthcare settings with no restriction on geographical location.

SEARCH STRATEGY

The search strategy aims to find both published and unpublished studies. The databases searched include CINAHL, PubMed, Scopus, PsycINFO and Embase. A gray literature search included ProQuest Dissertations and Theses, Mednar and Google Scholar.

METHODOLOGICAL QUALITY

Papers selected for retrieval were assessed by two independent reviewers for methodological validity before inclusion in the review using the standardized critical appraisal instrument from the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI).

DATA EXTRACTION

The standardized data extraction tool from the JBI-QARI was used to extract data from the papers.

DATA SYNTHESIS

Qualitative research findings were pooled using the JBI-QARI. This involved the aggregation of findings to generate a set of statements that represented that aggregation, through assembling the findings rated according to their quality and categorizing these findings by similarity in meaning. These categories were then subjected to a meta-synthesis to produce a single comprehensive set of synthesized findings that can be used as a basis for evidence-based practice.

RESULTS

Four studies were included in the systematic review. Two studies each from both groups' perspective. These experiences were combined in one synthesis to look at the issues from mutual perspectives. A total of 40 findings were extracted from these four studies. The findings were grouped into 10 categories and five synthesized findings were developed.

CONCLUSION

Pro re nata medication use among MHPs and service users is subject to many variables from individual decision making to organizational policies. There are many factors that contribute to MHPs prescribing and administering PRN medications and patients had views and opinions on their use of PRN medication in the acute mental health setting.

Interventions following a high violence risk assessment score: a naturalistic study on a Finnish psychiatric admission ward

BACKGROUND

Patient aggression and violence against staff members and other patients are common concerns in psychiatric units. Many structured clinical risk assessment tools have recently been developed. Despite their superiority to unaided clinical judgments, staff has shown ambivalent views towards them. A constant worry of staff is that the results of risk assessments would not be used. The aims of the present study were to investigate what were the interventions applied by the staff of a psychiatric admission ward after a high risk patient had been identified, how frequently these interventions were used and how effective they were.

METHODS

The data were collected in a naturalistic setting during a 6-month period in a Finnish psychiatric admission ward with a total of 331 patients with a mean age of 42.9 years (SD 17.39) suffering mostly from mood, schizophrenia-related and substance use disorders. The total number of treatment days was 2399. The staff assessed the patients daily with the Dynamic Appraisal of Situational Aggression (DASA), which is a structured violence risk assessment considering the upcoming 24 h. The interventions in order to reduce the risk of violence following a high DASA total score (≥4) were collected from the patients' medical files. Inductive content analysis was used.

RESULTS

There were a total of 64 patients with 217 observations of high DASA total score. In 91.2% of cases, at least one intervention aiming to reduce the violence risk was used. Pro re nata (PRN)-medication, seclusion and focused discussions with a nurse were the most frequently used interventions. Non-coercive and non-pharmacological interventions like daily activities associated significantly with the decrease of perceived risk of violence.

CONCLUSION

In most cases, a high score in violence risk assessment led to interventions aiming to reduce the risk. Unfortunately, the most frequently used methods were psychopharmacological or coercive. It is hoped that the findings will encourage the staff to use their imagination when choosing violence risk reducing intervention techniques.

Nursing interventions in inpatient psychiatry

The successful application of the Nursing Interventions Classification (NIC) in inpatient psychiatry depends on whether the classification adequately describes nursing care in this setting. The present study aimed to identify nursing interventions mentioned in journal articles on psychiatric inpatient nursing care and to compare these with the labels, definitions and activities described in the NIC to elucidate how well the classification covers these interventions. The MedLine, PsychInfo, Cochrane and CINAHL databases were searched for journal articles about nursing care in the adult inpatient setting. A qualitative content analysis approach was used to indentify nursing interventions in the articles. About 84% of the statements (terms and definitions) are encompassed by the interventions listed by the NIC. Very few interventions need to be added to the NIC classification or necessitate a reorganization of the taxonomy. Nevertheless, the further development of the NIC will promote its use in the daily work of psychiatric nurses and enhance the quality of nursing care in the inpatient setting.

Mechanical restraint--which interventions prevent episodes of mechanical restraint?- a systematic review

PURPOSE

To identify interventions preventing mechanical restraints.

DESIGN AND METHODS

Systematic review of international research papers dealing with mechanical restraint. The review combines qualitative and quantitative research in a new way, describing the quality of evidence and the effect of intervention.

FINDINGS

Implementation of cognitive milieu therapy, combined interventions, and patient-centered care were the three interventions most likely to reduce the number of mechanical restraints.

PRACTICE IMPLICATIONS

There is a lack of high-quality and effective intervention studies. This leaves patients and metal health professionals with uncertainty when choosing interventions in an attempt to prevent mechanical restraints.

Pro re nata use in a psychiatric intensive care unit

Pro re nata (PRN) or 'as required' medication is a regular part of mental health nursing practice. This retrospective study accessed data recorded for all PRN being given to patients within an eight-bed psychiatric intensive care unit. Data from the same consecutive 4-month period from 2005 and from 2007-2009 were analysed for trends in overall rates, time of administration, and type of medication given. PRN administration was identified to each patient, but no demographic information was analysed. Results of this study demonstrated a gradual decline in the total number of PRN given, reducing from an average of 314 PRN per month in 2005, to 181 PRN per month in 2009. The typical number of patients per month receiving any PRN did not change, with 41 out of a total of 72 patients receiving at least one PRN in 2005, and 40 out of 64 patients receiving PRN in 2009. These results suggest that over the study timeframe, nurses became more selective as to which patients received PRN. This discussion examined the possible reasons for this result, including unit leadership style, changes in staffing levels, a new nursing model and group programme, and the relocation to a new facility.

Nursing phenomena in inpatient psychiatry

Little is known about the question if the nursing diagnosis classification of North American Nursing Association-International (NANDA-I) describes the adult inpatient psychiatric nursing care. The present study aimed to identify nursing phenomena mentioned in journal articles about the psychiatric inpatient nursing care and to compare these phenomena with the labels and the definitions of the nursing diagnoses to elucidate how well this classification covers these phenomena. A search of journal articles took place in the databases MedLine, PsychInfo, Cochrane and CINAHL. A qualitative content analysis approach was used to identify nursing phenomena in the articles. Various phenomena were found in the articles. The study demonstrated that NANDA-I describes essential phenomena for the adult inpatient psychiatry on the level of labels and definitions. However, some apparently important nursing phenomena are not covered by the labels or definitions of NANDA-I. Other phenomena are assigned as defining characteristics or as related factors to construct nursing diagnoses. The further development of the classification NANDA-I will strengthen the application in the daily work of psychiatric nurses and enhance the quality of nursing care in the inpatient setting.

Psychogeriatric inpatient unit design: a literature review

BACKGROUND

In many parts of the world the provision of psychogeriatric inpatient units (PGUs) remains limited. More units will be required over coming decades given rapid population aging.

METHODS

Medline (1950-2010), psycINFO (1806-2009), EMBASE (1980-2009) and CINAHL (1982-2009) were searched for papers about PGU design. Selected non-peer reviewed literature such as government reports and unpublished academic dissertations were also reviewed. Data were also obtained from the literature related to general adult psychiatry inpatient units where there was limited information from studies of units designed for older people. Over 200 papers were reviewed and 130 were included.

RESULTS

There are few good quality studies to guide the design of acute PGUs and much of the existing literature is based on opinion and anecdote or, at best, based on observational studies. Randomized controlled studies comparing different designs and assessing outcomes are virtually non-existent. Several studies have identified violence and trauma resulting from hospitalization as significant problems with current acute PGU care. Despite its limitations the available literature provides useful guidance on how PGU design can optimize patient and staff safety and improve clinical outcomes.

CONCLUSIONS

There are significant problems with current acute PGUs, and patient mix on existing units is an important issue. Future research should examine patient and staff perceptions of different PGU ward environments, the relationship between ward design and clinical outcomes, the effects of segregating patients with challenging behaviors in dementia and the benefits or otherwise of gender segregation.

Changing utilization of pro re nata ('as needed') sedation in a child and adolescent psychiatric inpatient unit

OBJECTIVE

The primary purpose of the present study was to examine changes in utilization of pro re nata (PRN; 'as required') sedation over time within a child and adolescent psychiatric inpatient unit. The secondary purpose was to assess whether changes in PRN sedation were related to changing patient characteristics.

METHODS

A retrospective chart review examined 257 medical charts from a child and youth mental health inpatient service over two time periods (wave I, n = 122; wave II, n = 135) and collected data on PRN sedation, patient characteristics and routine medications.

RESULTS

Over time a significant reduction was observed in the proportion of patients prescribed PRN sedation from 70% to 54% (p < 0.01), and a reduction in the proportion of patients given PRN sedation from 46% to 26% (p < 0.01). The most commonly administered drug was chlorpromazine in wave I, and diazepam in wave II. Multivariate analysis indicated that reductions in PRN sedation occurred independently of changes in patient characteristics.

CONCLUSIONS

High utilization rates of PRN sedation are not inevitable in a child and adolescent psychiatric inpatient unit and may be reduced over time. Changing utilization of PRN sedation occurred independently from changing patient characteristics. More treatment outcome studies are required to optimize use of PRN sedation in young people.

Use of pro re nata medications in acute inpatient care

OBJECTIVES

Available evidence suggests that the use of 'as needed' (PRN; from the Latin pro re nata: for an occasion that has arisen) medications has remained a standard aspect of treatment in acute inpatient mental health units over a number of years despite lack of evidence from controlled clinical trials. The practice is one in which doctors and nurses are interdependent; that is, while doctors prescribe the medications, professional nurses are the ones who make the clinical decisions to administer them. The aim of the present study was to provide a detailed description of the circumstances surrounding the use of PRN medications across four inpatient units in Sydney.

METHODS

The medical records of all patients admitted for >24h during a 2 month period were retrospectively audited for details regarding prescriptions and administrations of PRN medications.

RESULTS

A total of 420 records were reviewed, producing a total of 3868 PRN medication administrations. Ninety-seven per cent of all patients were prescribed PRN medications and 93.8% were prescribed regular medications. The most frequently prescribed medications were second-generation antipsychotics for regular use along with benzodiazepine for PRN use. Nearly 84% of patients received at least one PRN medication during their admission, while patients diagnosed with personality disorder received more PRNs per day. The most common reason for PRN administration was patient agitation. The results indicated poor documentation in the prescription and documentation of PRN administrations. Also, the findings show that a small subset of the patients (5%) received >30% of all PRN medications.

CONCLUSION

PRN medication use has endured as standard practice and the results of the present study are consistent with the reported frequency of use increasing slightly over the years. The combination of second-generation antipsychotics as regular medications and benzodiazepines for PRN medication is consistent with recommended treatment guidelines. The small subset of patients who were overrepresented in the PRN administrations is noteworthy.