Patient Participation in Pro Re Nata Medication in Forensic Psychiatric Care: Interview Study with Patients and Nurses

Abstract

Pro re nata (PRN, as-needed) medication is commonly used in forensic psychiatric inpatient care, but little is known about the participation of patients in its prescription and administration. This study describes patient participation in PRN medication treatment in forensic psychiatric inpatient care. Data were collected during interviews with 34 inpatients and 19 registered nurses in a Finnish forensic psychiatric hospital. The data underwent inductive content analysis. We found that patient participation in PRN was related to patients' individual needs and health conditions, and the use of PRN involved private decisions made in the social context of the ward. PRN was an integrated part of daily care, and it involved three stakeholders, namely patients, nurses, and physicians; however, the role of patients in this collaboration was undefined. The administration events for PRN were multiform, and depended on the level of agreement between patients and nurses on the need for PRN. In the future, more attention should be paid to how to motivate patients and provide them with equal opportunities to be involved in the planning of PRN, and to optimize shared decision making so that the expertise of both patients and nurses is utilized in the administration and evaluation of PRN.

Nurses' use of pro re nata medication in adult acute mental healthcare settings: An integrative review

“…A study by Casol et al (2021) found only one third of psychotropic PRN prescription had indications for administration, which left nurses without guidance. Two studies highlighted an issue with doctors making changes with the PRN medication without discussing it with the nurses and patient, and it resulted in conflicts when a patient requested PRN medications that were no longer available (Hipp & Kangasniemi, 2022; Jimu & Doyle, 2019).…”

“…Nurses commented that the psychotropic PRN medications were an essential treatment when patients are too aggressive, too unwell, symptoms too intense or acutely psychotic, because patients are likely unable to engage in alternative interventions or participate in the decision for PRN medication (Barr et al, 2018; Martin et al, 2018; Martin et al 2018b). Nurses believed that medication was the most effective intervention for insomnia and psychotic symptoms (Martin et al, 2018) and giving PRN medications is a way to avoid violent behaviour and the further restrictive practices like seclusion, as well as to maintain the therapeutic relationships and avoid conflicts (Barr et al, 2018; Hipp & Kangasniemi, 2022; Martin et al, 2018b). Environmental factors also were a key motivator to use PRN medications, and reasons included the staffing level and staff skills (Barr et al, 2018), patient restriction (such as seclusion), and smoking bans in the ward (Hipp & Kangasniemi, 2022).…”

“…Nurses believed that medication was the most effective intervention for insomnia and psychotic symptoms (Martin et al, 2018) and giving PRN medications is a way to avoid violent behaviour and the further restrictive practices like seclusion, as well as to maintain the therapeutic relationships and avoid conflicts (Barr et al, 2018; Hipp & Kangasniemi, 2022; Martin et al, 2018b). Environmental factors also were a key motivator to use PRN medications, and reasons included the staffing level and staff skills (Barr et al, 2018), patient restriction (such as seclusion), and smoking bans in the ward (Hipp & Kangasniemi, 2022). Lastly, two studies which included PRN medications for psychiatric and physical conditions found pain was the main reason for PRN medication administration, which accounted for 42% in a forensic psychiatric hospital and 28.3% in geriatric psychiatric hospital for patients with mood and thought disorders (Harper et al, 2017; Hipp et al, 2020).…”

“…Finally, PRN medication administration usually requires consent (Vaismoradi et al, 2021), even though the literature shows that consent is not always documented (Martin et al, 2018a) or obtained (Cleary et al, 2012, as cited in Hipp & Kangasniemi, 2022 p. 2). PRN medications can pose a risk to patient care outcomes if not used with caution.…”

“…PRN medications can pose a risk to patient care outcomes if not used with caution. While mental health nurses can administer psychotropic PRN medications at their discretion, there have been criticisms of misuse and over‐reliance on PRN medications, which some say also neglects spiritual, psychological, and social needs (Barlow, 2014; Hipp & Kangasniemi, 2022; McDougall et al, 2022).…”