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.
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In seven studies, psychotropic medication was used to manage behaviours and BPSD.
“In seven studies, psychotropic medication was used to manage behaviours and BPSD [49, 53, 57, 63, 65, 80, 81].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [80]
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.
“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].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [80]
The importance of a holistic assessment of any underlying needs such as pain or constipation which may be causing distress was highlighted by healthcare professionals.
“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].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [80]
Difficulties identified included establishing a clear diagnosis, communication difficulties and increased sensitivity to the side effects of psychotropic medication in older people.
“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.”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [80]
Doctors and nurses were of the view that assessing whether psychotropic medication was appropriate in older people was challenging.
“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].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [80]
Doctors and nurses acknowledged the use of psychotropics such as antipsychotics or benzodiazepines helped manage nurse workload by managing the resident's BPSD or insomnia.
“However, doctors and nurses acknowledged the use of psychotropics such as antipsychotics or benzodiazepines helped manage nurse workload by managing the resident’s BPSD or insomnia [59, 80, 81].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [80]
Doctors believed that nurses with a better understanding of BPSD, non-drug interventions and the risks and benefits of psychotropic medication may be less likely to request drug treatment.
“Doctors believed that nurses with a better understanding of BPSD, non-drug interventions and the risks and benefits of psychotropic medication may be less likely to request drug treatment [53, 62, 80, 81].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [80]
Where older people rejected interventions such as bereavement counselling, doctors expressed a lack of alternatives.
“Where older people rejected interventions such as bereavement counselling, doctors expressed a lack of alternatives [54–56, 80].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [80]
Some stakeholders stated that doctors often relied on nurses' judgement to inform decision-making, with little mention of other staff involved in the older people's care.
“Some stakeholders stated that doctors often relied on nurses’ judgement to inform decision-making, with little mention of other staff involved in the older people’s care [62, 80, 81].”
From Stakeholders' views on the use of psychotropic medication in older people: a systematic review (2022) · cites this paper as [80]
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“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.”
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- Authors
- Walsh, B., Dahlke, S., O’Rourke, H., & Hunter, K. F.
- Affiliations
- University of Alberta (CA)
- Corresponding author
- Dahlke, Sherry
- Venue
- Journal of Clinical Nursing
- Publisher
- Wiley
- Published
- 2020-09-18
- Volume
- 31
- Issue
- 13-14
- Pages
- 2024-2035
- ISSN
- 0962-1067 (ISSN-L)
- 1365-2702
- OpenAlex
- W3035955056
- Cited by
- 11
- References
- 65
- Citations by year
- 2024: 4 · 2023: 2 · 2022: 3 · 2021: 2
- FWCI
- 0.70
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Clinical Nursing (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Keywords
- acute care nurses, nursing decision-making, psychotropic drugs, as-needed medication, behavioral and psychological symptoms of dementia, physical restraint, organizational routines, older adults, drug prescribing
- MeSH terms
- Aged, Attitude of Health Personnel, Dementia, Hospitalization, Humans, Nurses, Psychotropic Drugs, Qualitative Research
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