Abstract
Review question/objective: What are the experiences of mental health professionals' and patients' use of pro re nata (PRN) medication in acute adult mental health care settings?
Background: Pro re nata is a Latin phrase meaning "for an unforseen need or contingency".1 The most common type of PRN medication administered by mental health professionals in acute mental health care settings are psychotropic medications. Psychotropic comes from the Greek word Psycho, a combining form meaning "psyche", which indicates the mind, soul or spirit as opposed to the body and from the Greek word "tropo" or tropos which means "turning". Hence what turns the mind.1 Psychotropic medications affect chemical levels in the brain, which can affect mood, perception and behavior.1
When a physician writes an order for PRN medication, they write orders for one or more psychotropic medications to be given at the discretion of the nurse, provided that the indicated specifications are met. The underlying rationale behind the use of PRN orders is that nursing staff need to be able to administer psychotropic medications in a timely manner to prevent or contain agitated or violent patients in an acute psychiatric ward without having to first call a physician.2
There have been several areas of research on the administration of PRN medication in acute mental health settings.
Authors of a quantitative Cochrane systematic review compared "as required" medication regimens with regular medication regimens for seriously mentally ill people in hospital. Twenty-two papers were included in the review. Within the papers included in the review it was reported that:
- The use of "as required" regimens of psychotropic medication for disturbed behaviour, distress or agitation is widespread within psychiatric units.3
- Twenty-three percent of psychiatric hospital inpatients received at least one PRN dose of psychotropic medication during their stay.4
- Of those in secure psychiatric care, up to 50% receive "as required" medication during their admission.5
- Once a PRN regimen is instigated, medication is administered frequently, about 10 times per person, and most of these administrations occur in the first four days of admission.6
The authors of the systematic review found that although the practice of using "as required" medication is common there is no good evidence of whether this is the best way of helping people to be less agitated when compared to being given a regular dose of medication.7
While the Cochrane systematic review examined the effectiveness of PRN medication for seriously mentally ill people, Baker conducted a best evidence synthesis on drug use/administration of PRN medication in mental health wards.8 Best evidence synthesis involves the analysis of quantitative papers supplemented by a review of broader literature which may result in a qualitative analysis.8
Six major themes emerged from that review: frequency of administration, administration during the 24-hour day, administration associated with length and stage of admission, rationales for administration, medicines administered (including route of administration), effects and side-effects of medicines administered.
The authors of the review found that administration of psychotropic PRN varies widely and appears to be influenced by many factors. They also indicated that there is a lack of understanding of the clinical decision-making process that nurses use when administering PRN medication. Some of the variables included the frequency of administration PRN medication, high users of PRN medication, administration during the 24-hour day, administration associated with length and stage of admission, documented reasons for the administration of PRN psychotropic medications, medicines administered, and route of administration.8
Other research conducted on the use of PRN medication includes retrospective studies in which case notes were audited and administration practices were examined.9-10 Other studies have looked at antecedents to PRN administration, activities to reduce PRN medication administration and literature reviews.11-13
Much of the research conducted on administration of PRN medication within mental health care settings has focused on quantitative research and the nurse's perspective. The patient's experience of PRN medication use in adult acute mental health care settings is an area that is lacking in understanding. Few studies have explored the administration of PRN medication from a patient's point of view.
A qualitative study using semi structured interviews to collect data succeeded in gaining an understanding of inpatients in acute mental health units who had recently taken PRN medication. The research found that:
- in acute inpatient mental health services, registered nurses frequently make clinical decisions regarding administration of PRN medication;
- nurses use their assessment skills and discretion to determine if a patient needs extra medication; and
- from the perspective of patients, interactions surrounding the immediate administration of PRN medication were inadequate, in that half of the interviewees were simply told to take the medication and three quarters said that, in their experience, formal consent was not properly sought.14
A study into service users experience of "as needed" psychotropic medications in acute mental health care settings interviewees highlighted the value of "as needed" medications. The process that was associated with their use was, however, perceived as confusing and stigmatising. Service users had limited understanding of the process and felt unsupported in their attempts to use alternative approaches.15
The study concluded that nurses should take into account the issues of power and control when administering "as needed" medication and that the provision of adequate treatment information should be a priority to enable informed choices to be made about this form of medication.15
There remains a lack of understanding towards the clinical decision making process involved that leads a mental health professional to administer a PRN medication. The aim of this systematic review is to provide a deeper understanding of the circumstances and factors that influence a mental health professional and their use of PRN medication. More specifically:
- Do they make these decisions solely or seek input from others?
- Do they feel confident in their own decision making when administering PRN medications?
- What medication do they choose - if there is a choice - between two or more PRN medications?
- What dosage and what route of administration do nurses use and why?
This systematic review will endeavour to find evidence for the use of PRN medications by mental health professionals including the clinical decision making process when administering PRN medication. In addition, this review will endeavour to find evidence for patients' understanding and viewpoints' on the use of PRN medication.
Gaining an understanding into mental health professionals' and patients' use of PRN medications is important as the literature shows that there are many variables in the administration of PRN medication in acute adult mental health care settings. Understanding how a patient feels about this practice and understanding how mental health professionals make decisions within this practice is important and currently lacking in research. This review will endeavour to provide a deeper level of understanding of the topic.
This qualitative systematic review protocol will endeavour to search the literature for the best available qualitative evidence of the experiences of mental health professionals' and patients' use of PRN medication in acute mental health care settings.
The search of relevant databases has not found any current or planned reviews on the same topic.
Article Content
Inclusion criteria
Types of participants
This review will consider studies that include mental health professionals who are working in an acute adult mental health care setting as well as adults who are admitted into an acute adult mental health care setting. The patients will include those who are under involuntary treatment orders.
Types of intervention(s)/phenomena of interest
This review will consider studies that investigate the experience of mental health professionals and patients' use of PRN medication in acute mental health care settings.
Types of studies
This review will consider studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, action research and feminist research.
Search strategy
The search strategy aims to find both published and unpublished studies. A three step search strategy will be utilised in this review. An initial limited search of MEDLINE and CINAHL will be undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference list of all identified reports and articles will be searched for additional studies. Only studies published in English will be considered for inclusion in this review. Studies published in the last 30 years from 1984 and prior to April 2014 will be considered for inclusion in this review.
The databases to be searched include:
CINAHL
PubMed
Embase
Scopus
Psycinfo
The search for unpublished studies will include:
ProQuest dissertation and theses
Mednar
Google Scholar
Initial keywords to be used will be:
Nursing OR nursing staff OR nurses OR nurse OR clinician OR mental health nurses
AND
Pro Re Nata, OR clinical decision making OR PRN medication OR medication administration
AND
Mental health
AND
Qualitative OR qualitative and experience OR lived experience OR perception OR perceived OR understanding OR ethnography OR phenomenology OR feminist and research OR critical and research OR action and research
Assessment of methodological quality
Papers selected for retrieval will be assessed by two independent reviewers for methodological validity prior to inclusion in the review using the standardized critical appraisal instrument, the Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) (Appendix I). Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer.
Data collection
Data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI (Appendix II). The data extracted will include specific details about the phenomena of interest, populations, study methods and outcomes of significance to the review question and specific objectives.
Data synthesis
Qualitative research findings will, where possible, be pooled using JBI-QARI. This will involve the aggregation or synthesis of findings to generate a set of statements that represent that aggregation, through assembling the findings rated according to their quality, and categorising these findings on the basis of similarity in meaning. These categories are then subjected to a meta-synthesis in order to produce a single comprehensive set of synthesised findings that can be used as a basis for evidence-based practice. Where textual pooling is not possible the findings will be presented in narrative form.
Conflicts of interest
None to declare
Acknowledgements
As this systematic review forms partial submission for the degree award of Masters of Clinical Science, a secondary reviewer will be utilized for critical appraisal.
References
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