Exploring acute care nurses’ decision‐making in psychotropic PRN use in hospitalised people with dementia

Abstract

Aims and objectives To understand how acute care nurses make decisions about administering “as‐needed” (PRN) psychotropic medications to hospitalised people with dementia (PWD). Background Behavioural and psychological symptoms of dementia occur in approximately 75% of PWD admitted to acute care. Despite this, few studies provide insight into the use and prevalence of psychotropic use in acute care. Design A qualitative descriptive design was used to explore acute care nurses’ decision‐making about PRN psychotropic medication administration to PWD. Methods Semi‐structured interviews were conducted with eight nurses from three acute care medical units in a large tertiary hospital in Western Canada. Conventional content analysis was used to develop three themes that reflect nurses’ decision‐making related to administering PRNs to hospitalised PWD. COREQ guidelines were followed. Results Three themes of legitimising control, making the patient fit and future telling were developed. Legitimising control involved medicating undesirable behaviours to promote the nurses’ perceptions of safety. Making the patient fit involved maintaining routine and order. Future telling involved pre‐emptively medicating to prevent undesirable behaviours from escalating. Nurses provided little to no mention of assessing for physical causes contributing to behaviours. PRNs were seen as a reasonable alternative to physical restraints and were frequently used. Additionally, organisational and unit routines greatly influenced nurses’ decision‐making. Conclusions These findings provide an initial understanding of how nurses make decisions to administer PRN medications to hospitalised older people and may inform prescribing practices. There were novel findings about the lack of assessment prior to PRN administration, and the nurses’ collective response in decision‐making. More research is needed to better understand the complexities of nurses’ decision‐making, to assist in the development of interventions for nursing practice.

Stakeholders’ views on the use of psychotropic medication in older people: a systematic review

“…The most frequent indications for psychotropic prescribing were depression in nine studies [ 50 , 51 , 55 , 56 , 60 , 62 , 73 , 74 , 82 ], sleeping disorders in seven [ 54–56 , 59 , 63 , 74 , 82 ] and anxiety in six [ 54–56 , 73 , 74 , 82 ]. In seven studies, psychotropic medication was used to manage behaviours and BPSD [ 49 , 53 , 57 , 63 , 65 , 80 , 81 ].…”

“…A range of benefits of psychotropic medicines were identified by patients, family caregivers and healthcare professionals including enabling normal functioning of patients [ 55 , 56 ], allowing family caregivers and healthcare professionals to feel that they were doing something to help [ 51 , 74 ], treating sleep disorders [ 49 , 53 , 55 , 56 , 59 , 63 , 80 ], managing aggressive and agitated behaviour and maintaining health and safety [ 49 , 53 , 57 , 65 , 80 , 81 ]. Findings suggested that there was variation with medication class with antipsychotics being seen by healthcare professionals as a last resort, but benzodiazepines being prescribed more freely [ 59 ].…”

“…Findings also suggested differences between healthcare professional groups with nurses seeming more likely than doctors to encourage use of psychotropic medicines in some situations [ 62 , 81 ]. Some doctors expressed the view that prescribing medication to aid sleep helped care home staff more than care home residents and preferred alternative approaches such as giving space to residents to wander safely at night [ 53 , 59 , 63 , 80 ]. They reported being in a challenging situation trying to minimise inappropriate prescribing while having to stay conscious of the risk to and safety of nursing home staff, carers and other residents [ 53 , 81 ].…”

“…Doctors and nurses were of the view that assessing whether psychotropic medication was appropriate in older people was challenging [ 49 , 53–56 , 62 , 65 , 80–82 ]. Difficulties that were identified included: establishing a clear diagnosis [ 56 , 62 ], communication difficulties [ 56 , 80 ] and the increased sensitivity to the side effects of psychotropic medication in older people. Doctors and nurses were of the view that greater vigilance was necessary for this population.…”

“…Many doctors referred to the process of a risk–benefit analysis [ 53–56 , 59 , 65 , 82 ]. The importance of a holistic assessment of any underlying needs such as pain or constipation which may be causing distress was also highlighted by healthcare professionals [ 49 , 53 , 57 , 80 , 81 ]. However, nurses and doctors’ opinions to treat differed at times.…”