Annie Altschul Collection

Background: Pro re nata (PRN) psychotropic medication is regularly prescribed and administered in inpatient mental health care. Approximately 80% of inpatients receive PRN psychotropic medications during an admission. The most frequently administered PRN medications are benzodiazepines and typical antipsychotics. The use of antipsychotic medications as PRN contributes to polypharmacy, high doses and potentially dangerous drug interactions. Previous research into this area has mainly been retrospective analysis of case notes, and has been hampered by poor quality and imprecise documentation. A Cochrane review concluded that PRN as a clinical intervention does not have a robust evidence-base. Aims: The aim of this study was to contribute to improving the practice of prescribing and administering psychotropic PRN medication in acute mental health wards through the development and testing of a good practice manual. Methods: This thesis employs a two phase design based on the Medical Research Council's complex intervention framework. The first phase developed a good practice manual. Four studies contributed to this, which included a literature review (best-evidence synthesis), interviews with the multi-disciplinary team (n=59) and service users (n=22), and a Delphi study with experts (n=18). The second phase used a pre-post test design to undertake an exploratory and acceptability trial of the manual. Results: In phase one (theory and modelling phase) nine themes of good practice emerged. These were: a) considering the patient (knowledge, preferences and choices); b) improving prescription quality; c) PRN as part of the clinical management plan; d) evaluating the effects and side effects of PRN; e) frequent review of PRN; f) enhanced documentation by the MDT; g) preventing distress when using PRN; h) PRN as a last resort encouraging the use of non-pharmacological interventions; and i) additional training and education is required for all clinical staff. In phase two (the exploratory and acceptability trial) 28 of 35 patients received 484 doses of PRN in the 10 week period. Patients had a mean of 3.6 prescriptions of 14 different PRN medications in 34 different dose combinations prescribed. Medication errors beyond poor quality of prescribing occurred in 23 of the 35 patients (65.7%). Prescription quality improved following the introduction of the intervention but quality of nursing notes reduced. Acceptability of the manual to both nursing and medical staff was high. Conclusions: This thesis demonstrates a systematic and rigorous mixed method approach to the development and testing of a good practice manual designed to enhance the use of PRN psychotropic medication.
Themes: Acute mental health; pro re nata (PRN); psychotropic medication

This thesis used constructivist grounded theory to analyse a mix of survey, literature and interview data with qualified prescribers to show that mental health nurses were not as competent in managing medicines as they assumed they were prior to becoming prescribers.
Themes: Mental health nursing; prescribing; concordance; adherence; grounded theory

Whilst there is evidence of a range of effective treatments available for people with severe mental health problems (SMHP), people frequently disengage from mental health services (MHS). This thesis investigates experiences of disengagement of people with SMHP and comprises two studies: 1) semi-structured interviews to elicit the experiences of people with SMHP and a history of disengagement from MHS; and 2) building on those findings, focus groups with staff from assertive outreach teams (specialising in providing care for people with SMHP and a history of disengagement).
The participants were those perceived as the most disengaged from MHS yet they were willing to engage with the research. Interpretative phenomenological analysis was used to develop themes for individual participants and then across the participants. Disengagement from MHS was part of a wider experience of a limited connection to social structures, including an ambivalent and complex relationship with MHS. There was a sense of sadness in all aspects of the participants’ experience but they had developed strategies to reinforce personal resilience and to reassert personal identity.
The findings of this thesis can be employed to better understand the context of disengagement from MHS and con sequentially better inform future engagement with this client group
Themes: Disengagement from mental health services; severe mental health problems; assertive outreach teams