Patient participation in pro re nata medication in forensic psychiatric care: A nursing document analysis

Abstract

Accessible summary 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.

Developing a Feasible and Credible Method for Analyzing Healthcare Documents as Written Data

“…Qualitative methods are applicable when the purpose is to understand and describe emerging patterns, categories, or themes on the study topic ( Coffey, 2014 ; Häggman-Laitila, 2003 ; Häggman-Laitila et al, 2010 ; Kaae & Traulsen, 2015 ; Miller & Alvarado, 2005 ). Quantitative methods can be used to describe statistics or interpret phenomenon ( Häggman-Laitila et al, 2019 , 2020 ; Hipp et al, 2020 , 2021 ; Olson, 2012 ; Toivonen et al, 2020 ).…”

“…In addition, we used our experience of carrying out 14 studies using document analysis to examine the feasibility and credibility of the method. These document analyses employed qualitative and quantitative methods and used documents such as patient records or plans ( Häggman-Laitila, 2003 ; Häggman-Laitila et al, 2010 , 2019 , 2020 ; Hipp et al, 2020 , 2021 ; Puustinen et al, 2021 ; Toivonen et al, 2020 ; Turjamaa et al, 2015 ), healthcare steering documents ( Kallio et al, 2018 , 2020 ), clients’ complaints ( Kangasniemi et al, 2022 ), and administrative healthcare decisions ( Papinaho et al, 2021 , 2022 ).…”

Administration of pro re nata medications by the nurse to incapacitated patients: An ethical perspective

“…"Pro re nata" (PRN) medication administration is a main responsibility of nurses and has been described as the administration of medications based on the patient's immediate need instead of administration at predetermined times 16,17 . After the prescription of PRN medications by the physician, the nurse makes a collaborative decision with participation of the patient regarding medication administration 17,18 . PRN medicines management has been recognized by international healthcare associations as an appropriate method for the management of physical and psychological suffering among patients with acute and chronic healthcare conditions [19][20][21] .…”

“…16,17 After the prescription of PRN medications by the physician, the nurse makes a collaborative decision with participation of the patient regarding medication administration. 17,18 PRN medicines management has been recognised by international healthcare associations as an appropriate method for the management of physical and psychological suffering among patients with acute and chronic healthcare conditions. 19–21…”

“…PRN medication errors are characterised by not mentioning the reason behind medication administration and ambiguities in steps taken to manage the administration process, as well as to monitor their effects and side effects after administration. 25,26 Coercion in the administration, 27 and over-administration of PRN medications, when medication is not the first choice for treatment 18,28 are quite common. Inappropriate use of PRN medications is associated with polypharmacy and longer stays in nursing homes with a median of 2.1 years.…”