Resistance to changing practice from pro re nata prescriptions to patient group directions in acute mental health settings


  • Conflict of interest: The authors declare no conflict of interest.

O. Price, School of Nursing, Midwifery and Social Work, University of Manchester, Room 6.332, Jean McFarlane Building, University Place, Oxford Road, Manchester M13 9PL, UK, E-mail:


Accessible summary

  • Poor practice associated with pro re nata (PRN) prescriptions in mental health is common and has serious health consequences for mental health service users.

  • Patient group directions (PGDs) are structured prescribing protocols which increase nurses' accountability for practice associated with the supply of medicines and may improve practice in this area.

  • Attempts to replace PRN with the PGD throughout two mental health trusts were met with significant resistance by registered mental health nurses. The reasons for this were associated with anxieties over increased responsibility for practice, concerns related to the ‘medicalization’ of the nursing role and the increased paperwork associated with the PGD.


Poor practice associated with pro re nata (PRN) prescriptions in mental health is known to be common and can increase the risk of serious and potentially fatal side effects. A contributing factor to poor practice is the lack of a clear chain of accountability between the decision to prescribe and administer PRN prescriptions. To address this problem, a patient group direction (PGD) for acute behavioural disturbance (lorazepam 0.5–2 mg) and staff training materials were developed. The intention was to replace PRN prescriptions with the PGD in two mental health trusts. One of the potential benefits of this would be the removal of the contribution of PRN to high and combined dose antipsychotic prescriptions. This proposal, however, was met with significant resistance in both trusts and did not replace PRN as a result. A series of interviews and focus groups were conducted with 16 RMNs working in the two trusts, to explore the reasons why the PGD was met with resistance. Senior nurses perceived resistance to be associated with anxieties over increased responsibility for decision making. Junior nurses reported concerns regarding the medicalization of the nursing role, the paperwork associated with the PGD and the training approach used. Future efforts to implement PGDs in mental health settings must carefully consider the methods for engaging effectively with participating organizations, in terms of managing change and completing the necessary groundwork for successful implementation.