What are the factors that mental health nurses use when deciding to give pro re nata medication for patient agitation?

Background
Pro re nata medication is an established treatment for managing patient agitation and aggression in mental health inpatient settings. Studies suggest that PRN medication administration varies significantly, with two- thirds of people receiving PRN medication during hospitalisation. The type of medication, dose and reason for giving varies, with little relationship to patient signs, symptoms or diagnosis.

Aims
To explore the factors that mental health nurses use when making decisions to give PRN psychotropic medication.

Methods
The thesis comprises of three studies: a scoping review of the literature about PRN medication administration, and two empirical studies using theoretical frameworks and models from cognitive psychology in a sequential mixed methods design. Firstly, an evaluative survey was carried out. Secondly, cognitive task analysis methods were used in a think aloud study and knowledge audit to explore if variation could be explained by novice- expert differences in reasoning. The Recognition Primed Decision (RPD) model was used as a theoretical framework. Fifteen nurses from five NHS Trusts participated.

Results
Variation was found in nurses’ evaluations of severity of patient symptoms, likelihood of giving medication, and number of occasions medication would be given. The think aloud study highlighted that nurses’ decisions involved assessing how the situation with the patient had arisen using hypothetico- deductive reasoning. Experienced nurses also appeared to make decisions in accordance with the RPD model of situation recognition, using mental models and mental simulation to establish both what had led up to the situation as well as possible futures. Enhanced perceptual ability allowed them to pre-empt situations and act proactively to help patients. Novices, by contrast, were unable to imagine futures for the patient scenarios. This limited their overall understanding of the situation, resulting in a fragmented and reactive approach. Variation can be explained by novice- expert differences.