The Administration of Pro re nata Medication by Mental Health Nurses: A Thematic Analysis

Abstract

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.

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

“…One exploratory study found that PRNs were often prescribed to reassure nurses rather than to meet the clinical need of the patient (Baker et al, 2007). Jimu and Doyle’s (2019) mental health nursing participants felt ill‐equipped to apply non‐pharmacological interventions and their autonomy and decision‐making were threatened when physicians wrote specific orders that did not allow them latitude in PRN administration.…”

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

“…However, there are often inconsistencies between prescription notes and administration records, which can overshadow attempts to assess the effectiveness of PRNs, due to a lack of data on the effect of PRNs on patients' outcomes [52]. 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].…”

“…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].…”

“…PRN medication is associated with dementia diagnosis, older age, polypharmacy, and a longer length of stay in nursing homes [8,25]. Additionally, higher rates of PRN administration have been associated with high dependency in daily living activities [25], individual care homes [12,26], polypharmacy, increased risk of dependence, overdose, and overuse of medications [4,8,24,27], but more exploration is needed [25,26]. PRN can be linked to administration without the patient's consent or full disclosure of relevant information about PRN medications, particularly to patients suffering from cognitive impairments [3,28].…”