Improving Nurses attitudes to the use of PRN medication in acute mental health settings

PRN medication is usually prescribed by the physician for the nurse to administer at their discretion, the familiarity of PRN has now empowered patients to regularly request it. Research has shown that nurses rarely assess the patient and the presenting symptoms before giving them medication; this can cause patients to be overly dependent and focused on medication when they might not necessarily need it(Usher et al., 2001). I noticed this occurrence many times in practice. Once with an elderly man who had a diagnosis of vascular dementia, he would have episodes of being agitated and aggressive ; Usually in the morning. It became a habit for staff to give him medication to calm him down, so it’s easier for support workers to get him ready. Another instance was regarding a woman with a diagnosis of obsessive personality disorder. She would often ask staff for PRI medication because she’s feeling anxious and will become agitated if it’s not given. To avoid this staff, would give her medication instead of speaking with her or assessing, if she’s actually anxious.

 In acute mental health settings, the overuse of PRN psychotropic medication can 

cause polypharmacy and excessive dosing. Research has shown excessive dosing of psychotropic medication increases the risk of side effects such as Neurological malignant syndrome(Fujita et al., 2013). Neurological Malignant Syndrome is an uncommon fatal side effect of treatment with psychotropic medication, and it is characterised by nervous system dysfunction, delirium, muscle rigidity and an altered mental state. NMS is associated with the use of more than one antipsychotic in a patient’s treatment; this can come in the form of regular or PRN medication. Tse et al.(2015) found that 39% of NMS cases were in patients who were taking more than one antipsychotic drug at a time. This is usually the case for patients who are already prescribed regular psychotropic medication and PRN psychotropic medication. The evidence-based research regarding the risks of PRN medication and polypharmacy drastically outweighs research that backs the effectiveness of PRN psychotropic medication; thus, the continuous use of PRN psychotropic medication when treating patients reduces the quality of person-centred care we are providing as nurses as patient safety is compromised. 

Nurses’ understanding of the medications, their attitudes toward the patient, and the patient’s condition are all thought to be related to the delivery of PRN psychiatric medications(Usher et al., 2001). When translated, Pro re nata(PRN) means ‘as needed, whenever necessary’. In psychiatric nursing practice, this is used in the context of medication administration, stating that a particular medication can be given to alleviate patient distress or manage aggressive behaviour –if required(‘Administration of PRN Medication: A Descriptive Study of Nursing Practice’, 1999). However, it has been misused in acute mental health settings. One of the root causes identified was staff not being able to handle ‘challenging’ patients due to staffing issues and time constraints . Research done in a London hospital found that PRN medication was mainly used to help patients sleep or as a preventative measure in patients known to have aggressive and escalating behaviour. It was found that only 30% of PRN medication was administered to patients who actually presented with aggressive behaviour(Stewart et al., 2012). 

PRN medication is usually prescribed by the physician for the nurse to administer at their discretion, the familiarity of PRN has now empowered patients to regularly request it. Research has shown that nurses rarely assess the patient and the presenting symptoms before giving them medication; this can cause patients to be overly dependent and focused on medication when they might not necessarily need it(Usher et al., 2001). I noticed this occurrence many times in practice. Once with an elderly man who had a diagnosis of vascular dementia, he would have episodes of being agitated and aggressive ; Usually in the morning. It became a habit for staff to give him medication to calm him down, so it’s easier for support workers to get him ready. Another instance was regarding a woman with a diagnosis of obsessive personality disorder. She would often ask staff for PRI medication because she’s feeling anxious and will become agitated if it’s not given. To avoid this staff, would give her medication instead of speaking with her or assessing, if she’s actually anxious.

 In acute mental health settings, the overuse of PRN psychotropic medication can 

cause polypharmacy and excessive dosing. Research has shown excessive dosing of psychotropic medication increases the risk of side effects such as Neurological malignant syndrome(Fujita et al., 2013). Neurological Malignant Syndrome is an uncommon fatal side effect of treatment with psychotropic medication, and it is characterised by nervous system dysfunction, delirium, muscle rigidity and an altered mental state. NMS is associated with the use of more than one antipsychotic in a patient’s treatment; this can come in the form of regular or PRN medication. Tse et al.(2015) found that 39% of NMS cases were in patients who were taking more than one antipsychotic drug at a time. This is usually the case for patients who are already prescribed regular psychotropic medication and PRN psychotropic medication. The evidence-based research regarding the risks of PRN medication and polypharmacy drastically outweighs research that backs the effectiveness of PRN psychotropic medication; thus, the continuous use of PRN psychotropic medication when treating patients reduces the quality of person-centred care we are providing as nurses as patient safety is compromised. 

Nurses’ understanding of the medications, their attitudes toward the patient, and the patient’s condition are all thought to be related to the delivery of PRN psychiatric medications(Usher et al., 2001). When translated, Pro re nata(PRN) means ‘as needed, whenever necessary’. In psychiatric nursing practice, this is used in the context of medication administration, stating that a particular medication can be given to alleviate patient distress or manage aggressive behaviour –if required(‘Administration of PRN Medication: A Descriptive Study of Nursing Practice’, 1999). However, it has been misused in acute mental health settings. One of the root causes identified was staff not being able to handle ‘challenging’ patients due to staffing issues and time constraints . Research done in a London hospital found that PRN medication was mainly used to help patients sleep or as a preventative measure in patients known to have aggressive and escalating behaviour. It was found that only 30% of PRN medication was administered to patients who actually presented with aggressive behaviour(Stewart et al., 2012). 

PRN medication is usually prescribed by the physician for the nurse to administer at their discretion, the familiarity of PRN has now empowered patients to regularly request it. Research has shown that nurses rarely assess the patient and the presenting symptoms before giving them medication; this can cause patients to be overly dependent and focused on medication when they might not necessarily need it(Usher et al., 2001). I noticed this occurrence many times in practice. Once with an elderly man who had a diagnosis of vascular dementia, he would have episodes of being agitated and aggressive ; Usually in the morning. It became a habit for staff to give him medication to calm him down, so it’s easier for support workers to get him ready. Another instance was regarding a woman with a diagnosis of obsessive personality disorder. She would often ask staff for PRI medication because she’s feeling anxious and will become agitated if it’s not given. To avoid this staff would give her medication instead of speaking with her or assessing, if she’s actually anxious.

 In acute mental health settings, the overuse of PRN psychotropic medication can 

cause polypharmacy and excessive dosing. Research has shown excessive dosing of psychotropic medication increases the risk of side effects such as Neurological malignant syndrome(Fujita et al., 2013). Neurological Malignant Syndrome is an uncommon fatal side effect of treatment with psychotropic medication, and it is characterised by nervous system dysfunction, delirium, muscle rigidity and an altered mental state. NMS is associated with the use of more than one antipsychotic in a patient’s treatment; this can come in the form of regular or PRN medication. Tse et al.(2015) found that 39% of NMS cases were in patients who were taking more than one antipsychotic drug at a time. This is usually the case for patients who are already prescribed regular psychotropic medication and PRN psychotropic medication. The evidence-based research regarding the risks of PRN medication and polypharmacy drastically outweighs research that backs the effectiveness of PRN psychotropic medication; thus, the continuous use of PRN psychotropic medication when treating patients reduces the quality of person-centred care we are providing as nurses as patient safety is compromised.