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

Abstract

The aim of the present study was to elucidate what non-pharmacological interventions are applied by nursing staff prior to the administration of psychotropic pro re nata (PRN) medication. Best practices would instruct clinical staff to provide non-pharmacological strategies, such as de-escalation and skills coaching, as the first response to patient distress, anxiety, or agitation. Non-pharmacological strategies might be safer for patients, promote more collaborative relationships, and facilitate greater skills development for managing symptoms. The literature has highlighted that poor documentation of pre-PRN administration interventions has limited our understanding of this practice, but evidence suggests that when this information is available, non-pharmaceutical approaches are not being attempted in the majority of cases. This is troubling given that, while clinically appropriate in some instances, PRN have been subject to criticism and lack critical evidence to support their use. The current study is a continuation of our previous work, which examined the reason, frequency, documentation, and outcome (e.g. effectiveness, side-effects) of PRN medication use at our facility. A chart review was conducted to understand what happens prior to the administration of PRN medication at our facility across all inpatient units over the course of 3 months. Results support previous findings that nonpharmacological interventions are poorly documented by front-line staff and are seemingly used infrequently. The use of these interventions differs by patient presentation (e.g. agitation, insomnia), and most often include supportive measures. The findings suggest that both documentation and intervention practices of nursing staff require further investigation and adjustment to align with best practices.

Staff and patient accounts of PRN medication administration and non‐pharmacological interventions for anxiety

“…In our own work, we found that nurses documented their use of non‐pharmacological strategies before giving psychotropic PRN medication in only 38% of PRN administrations (Martin et al . ). The reasons for not attempting non‐pharmacological interventions could be due to a variety of factors.…”

Pro Re NataMedication Use in Acute Care Adolescent Psychiatric Unit

“…Despite a lack of evidence, the average reported rate of PRN administration on adult inpatient psychiatric units is around 70-80%, ranging from 20% to 100% (Baker et al 2008). Common PRN medications used on adult units include antipsychotic medications (first and second generation), anxiolytics, and hypnotics, with benzodiazepines being the most frequently used (Martin et al 2018).…”

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

“…For example, there are different perceptions and opinions amongst physicians that prescribe, and nurses that administer, PRN medication [4,55]. Additionally, there are controversies regarding the use of PRN medications and non-pharmacological strategies including counselling, distraction, verbal and non-verbal de-escalation, massage, and education [4,5,29,56,57]. The improvement of PRN prescription practice and promotion of PRN prescription and administration requires changes in the healthcare policies of patient safety in care homes [27,58,59], including the mandate of formalised, systematic checking of residents for potential ADRs [47,48].…”

“…PRN is categorized as unscheduled medication administration either alone or in addition to routine/regular prescriptions [1]. It is frequently used for medications prescribed by physicians and administered based on nurses' judgements of patients' needs [2][3][4][5][6][7], but PRN medications are sometimes self-administered or given by family or informal caregivers [2]. PRN is commonly used to prescribe medications required in particular conditions, such as a complement to regularly scheduled medications [8].…”