APNA 25th Annual Conference October 21, Session 3014

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1 Clinical Decision Making to Manage Disruptive Behavior in Older Adults: What Psychiatric Nurses Say They Do vs. What They Document Dr. Pam Lindsey Assistant Professor Millikin University School of Nursing October 21, 2011 Acknowledgements: Dr. Kathleen Buckwalter, Professor Emerita, University of Iowa College of Nursing, Mentor The presenter acknowledges the Building Academic Geriatric Nursing Capacity (BAGNC) program, supported by the John A. Hartford Foundation and Atlantic Philanthropies, for support of her Claire M. Fagin Postdoctoral Fellowship, The present also acknowledges grant funding received from the The University of Iowa Gerontological Nursing Interventions Research Center (P30 NR003939) The presenter discloses no significant financial interest in any product or class of products discussed directly or indirectly in this presentation. 1 Background: Prevalence of P.R.N. Medication Administration 63-82% of psychiatric inpatients receive P.R.N (pro re nata or as needed psychotropic medications Psychiatric inpatients on general units receive an average of P.R.N.s per admission 2 P.R.N. Administration: A Common Part of Psychiatric Nursing Practice Autonomous nursing decision Much discretion on choice/timing of medication administration. Assumed to be a preferable, less invasive/risky alternative to manage behavior (versus restraint). Is it a safer alternative? Is it really just chemical restraint? 3 Lindsey 1

2 Prevalence of P.R.N. Psychotropics With Older Adults Common in long term care settings Prevalence among older adults on geropsychiatric units unknown 4 Risks Associated With P.R.N. Psychotropic Medications 2007 U.S. FDA report: 6894 deaths per year from ADRs 848 (12.3%) deaths due to psychotropic medications ADRs R/T psychotropic medications under-reported Study on medication errors in state psychiatric inpatient facilities 5 Risk of Psychotropic Medication Use with Older Adults 2005 Black box warning: atypical antipsychotic medications Risk for adverse reactions increases dramatically with the number of medications & increasing age Inappropriate use or excessive dosing in elderly Greater risk for adverse events ents Falls Oversedation Cognitive Impairment Cerebrovascular events EPS Mortality 6 Lindsey 2

3 Clinical Decision Making About P.R.N. Administration: What Do We Know? Majority of research: Australia & UK Lack evidence based protocols to guide nursing decision making Lack of information in psychiatric nursing textbooks Decisions based on prior experience, unit culture, influence from others 7 Nonpharmacologic Interventions with Older Adults Majority of research in long term care settings Few studies have focused on nonpharmacologic interventions with older adults in psychiatric settings 8 Clinical Decision Making About P.R.N. Psychotropic Administration in Geropsychiatric Settings Lack of research Older adults: most vulnerable to potential ti adverse effects 9 Lindsey 3

4 Aims of the Study To examine use and documented effects of P.R.N. psychotropic medications and nonpharmacologic interventions to manage behavioral and psychological symptoms in older adults hospitalized on two geropsychiatric units To examine geropsychiatric nurses clinical decision making process in managing behavior symptoms in older adults (PRN medications & nonpharmacologic interventions) 10 Method Design: Exploratory Descriptive Retrospective Chart Audits Semi-structured Interviews with RNs Settings: 2 Geropsychiatric Inpatient Units Sample: 108 Charts & 22 Nurses Instruments: Chart Audit Form & Guided Interview (decision making questions,event recall, vignettes) Procedure 11 Event Recall Questions How did you first become aware? What were you thinking/feeling? What do you think others were thinking/feeling? Process of thinking for your intervention? How would you act in a similar situation In an ideal situation? 12 Lindsey 4

5 Results: Interviews RNs described a decision making process Used nursing process Focus on using least restrictive alternatives first Response Themes to Decision Making Questions 13 Results: Chart Audits Prevalence of P.R.N. Medication Administration Site A: 67.3% pts Mean: 7.31 Site B: 75% pts Mean: 8.32 Types of Medications Administered Site A: Benzodiazepines, Atypical Antidepressants, Atypical Antipsychotics Site B: Atypical Antipsychotics & Benzodiazepines Documented rationale for P.R.N. administration Site A: 81.3% Not documented Site B: 55.3% Not documented 14 Results: Chart Audits Documented Effects of P.R.N. administration Site A: 92.4% Not documented Site B: 47.5% Not documented Documented Nonpharmacologic Interventions Site A: 69% Not documented Site B: 64% Not documented 15 Lindsey 5

6 Discussion Disparity between what nurses say they do vs. what is documented High reliance on P.R.N. medications Lack of documentation regarding reason for administration or effects of medication Quality Indicator? 16 Implications Need for further research in U.S. Need for improved documentation Need for education about clinical decision making regarding administration of P.R.N. administration Need for evidence based research/protocols regarding P.R.N medication administration Legal implications 17 Questions? 18 Lindsey 6