Every mental health nurse is familiar with the term “p.r.n. medication,” but they may be less familiar with what constitutes best practice in relation to administration of p.r.n. medications. In 2010, the acute inpatient mental health services for a major metropolitan hospital in Australia moved from a 1960s-era building to a state-of-the-art, purpose-built facility. The move gave nursing staff an opportunity to reflect on their practice and ensure that optimal practice development occurred ahead of the change in clinical environments. During a number of facilitated planning days, nurses identified the practice associated with administration of p.r.n. (pro re nata) psychotropic medications within the ward as requiring clearer articulation. Against this background, the authors conducted a review of the literature, with two objectives: to identify and then communicate to the nurses the best evidence to support nursing practice in the new facility.
To identify and evaluate published studies relating to the use of p.r.n. medication, a narrative review of professional literature was undertaken. The major nursing, medical, and psychological databases were searched, including CINAHL, MEDLINE, PsycINFO, Embase, the Joanna Briggs Institute, and the Cochrane Library. The search terms used were prn, pro re nata, as required, as indicated, and as needed. These terms were searched individually and cross-referenced with psychotropic, medication, inpatients, acute, mental health, and psychiatric. The search focused on contemporary studies relevant to acute inpatient mental health care.
This article represents a synthesis of the narrative literature review. Here, the authors examine some of the key findings from the literature identified and provide analysis on their relevance to nursing practice.
Pro re nata is a Latin phrase meaning “for an occasion that has arisen.” In typical medical shorthand, it has come to mean “as required” or “as necessary.” Administration of p.r.n. medication is a typical practice on acute inpatient mental health units. P.r.n. medications are administered by nursing staff to alleviate symptoms, rather than for treatment of the underlying disorder. Although guided by the prescription, administration of p.r.n. medication is a relatively autonomous component of the nurse’s role. The decision to administer is generally one for the nurse. It is discretionary, and therefore involves the nurse’s judgment.
The drugs typically administered p.r.n. include antipsychotic, anxiolytic, and hypnotic agents (Curtis, Baker, & Reid, 2007). Differences were noted in the most common drugs administered. Benzodiazepines were found to be the most commonly administered p.r.n. medications in several studies (Baker, Lovell, & Harris, 2008; Curtis & Capp, 2003; Geffen et al., 2002; Stein-Parbury, Reid, Smith, Mouhanna, & Lamont, 2008). However, two studies identified antipsychotic agents as the most commonly administered p.r.n. medication (Chaichan, 2008; Thapa et al., 2003).
Benzodiazepines administered included lorazepam (Ativan®), clonazepam (Klonopin®), and diazepam (Valium®). Antipsychotic agents administered included olanzapine (Zyprexa®), haloperidol (Haldol®), and chlorpromazine (Thorazine®).
Frequency of Administration
The literature reviewed identified significant variations in rates of administration in clinical sites. Studies identified rates that ranged from 70% to 80% of patients received p.r.n. administration (Curtis & Capp, 2003; Curtis et al., 2007; Hales & Gudjonsson, 2004; O’Brien & Cole, 2004; Thapa et al., 2003; Thomas, Jones, Johns, & Trauer, 2006;) and 80% to 90% (Baker et al., 2008; Geffen et al., 2002; Stein-Parbury et al., 2008). Clinical sites included both acute inpatient units and high dependency (i.e., psychiatric intensive care) units.
Route of Administration
In those studies where the route of administration was identified, the majority reported the oral route as being the most common (Curtis & Capp, 2003; Curtis et al., 2007). Curtis and Capp (2003) identified intramuscular injection being used in 12% of p.r.n. medication administrations. No other routes were identified in the studies reviewed.
Time of Administration
The time of day when p.r.n. medication was most commonly administered varied substantially among the studies reported. Stein-Parbury et al. (2008) noted the highest percentage (32.3%) of p.r.n. medication administrations occurred between 8:00 p.m. and 11:59 p.m. Mullen and Drinkwater (2011) found the majority of p.r.n. medications were administered on the afternoon shift, whereas Curtis and Capp (2003) reported that most p.r.n. medications were given during the morning shift, peaking between 8:00 a.m. and 12:00 p.m. The authors also noted the least number of p.r.n. medications was administered on weekends (Saturday, 10.7%; Sunday, 10%), compared with rates of 16.9% on Thursdays (Curtis & Capp, 2003).
Reasons for Administration
The literature reviewed identified multiple factors that prompted nurses to administer p.r.n. medications to patients. Agitation was commonly identified as the main reason for p.r.n. medication administration (Curtis & Capp, 2003; Curtis et al., 2007; Geffen et al., 2002; O’Brien & Cole, 2004). Psychotic symptoms was identified as the primary reason by Stein-Parbury et al. (2008).
Several studies reported that a high percentage of nurses failed to record the reasons for administration in the clinical notes (Baker et al., 2008; Geffen et al., 2002; Stein-Parbury et al., 2008). For example, nurses failed to document the reason underlying administration of p.r.n. medication in 47% of administrations in one study examining several acute inpatient units (Stein-Parbury et al., 2008). However, on smaller acute observation units, increased levels of documentation accompanied the administration of p.r.n. medication, with failure rates reported at 9% and 14% in two studies (Curtis & Capp, 2003; O’Brien & Cole, 2004).
The decision-making processes that surround the administration of p.r.n. medication occur amid the complexities of patient-physician, patient-nurse, and nurse-physician interactions; patient history and mental state; local policy; and the operational demands of the clinical area (Hilton & Whiteford, 2008). Staff in Usher, Baker, Holmes, and Stocks’ (2009) study indicated that patients who displayed signs of aggression/agitation or had a psychotic disorder or elated mood were more likely to be administered p.r.n. medications. The decision to administer p.r.n. medication was also influenced by a patient’s level of distress, concern about patient safety and/or the safety of others in the environment, and patient request (Usher et al., 2009). Baker et al. (2007) found that some nurses administered p.r.n. medications regardless of patient factors, with one nurse manager stating, “When people are admitted it is still common practice to put lorazepam and haloperidol down without even an assessment. It’s just there because that’s what we do” (p. 164).
In their systematic review of p.r.n. medication regimens for hospitalized patients with serious mental illness, Chakrabarti, Whicher, Morrison, and Douglas-Hall (2007) identified that current practice is based on clinical experience and habit, rather than on high-quality evidence. Due to an absence of high-quality randomized trials, there is no evidence to demonstrate the effectiveness of psychotropic p.r.n. medications. While it is acknowledged that this is primarily an issue for the prescribers of such medications, it is essential for nurses to be cognizant of the effectiveness of the medications they administer when that administration is at their discretion.
In searching the evidence to guide practice in the new mental health facility, the authors found considerable variation in nursing practice related to administration of p.r.n. medications. This is common where there is a limited evidence base (Pearson, Field, & Jordan, 2007), as is the case here. In an area of practice that is undertaken with such regularity and with considerable potential impact on consumers, this points to the need for further research to establish what best practice is.
There are clear advantages related to p.r.n. administration in the clinical setting, as the practice allows nurses to respond quickly to acute symptoms in the clinical environment and may reduce the need for physical interventions such as restraint and seclusion (Baker et al., 2007). However, given the limited evidence base surrounding its efficacy as a treatment approach, p.r.n. medication administration may simply provide pharmaceutical restraint, rather than improved management and treatment.
One area of particular concern from the review was that nurses did not routinely document the use of this intervention. This leaves nurses open to the criticism of showing poor accountability in this area of practice. It may be indicative of confusion around the decision-making processes that underlie the administration of p.r.n. medication, which was identified in the facilitated planning days. Few studies support decision making in the administration of psychotropic p.r.n. medication; therefore, further research is clearly required on this area of nursing practice.
Because the initial objective of our team was to identify and then communicate to the nurses the best evidence to support nursing practice, best practice guidelines did seem a valid approach identified in the review. Where best practice guidelines on prescribing and administration of p.r.n. medication have been used on acute mental health units, prescription quality has been observed to improve, and staff reported it changed their clinical practice (Baker et al., 2008). Although the evidence of this approach is somewhat limited, it would seem to provide one solution to the nurses’ identified concern.
Conclusion and Clinical Implications
The administration of p.r.n. psychotropic medication is a regular part of the nurse’s role in acute inpatient mental health units. Although guided by prescription, the decision to administer is generally one for the nurse. In reviewing the evidence that can support this decision making, the authors found considerable variation within a limited evidence base. Therefore, it is important that nurses base their decisions about p.r.n. administration on sound clinical judgment.
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