- Email: [email protected]
Should the Nurse Prescribe?
758
financial provision from a unified board ? In Scotland all hospitals are under regional boards; and, even in the region where the teaching hospital has apparently been treated least openhandedly, opinion in that hospital is on the whole for retaining the existing system. After all, teaching hospital and regional-board hospital share the same primary objective-namely, to treat patients (though the teaching hospital may be entitled to choose its patients), and the dual system makes for wasteful duplication and ill-feeling. And if those working in regional-board hospitals regard the teaching hospital next door with ill-disguised envy, those in the teaching hospital are beginning to reciprocate no less keenly. A teaching hospital with a budget of, say, a million and a half pounds may find it harder to embark on new ventures than does a regional board with a budget of, say, E25 million. Thus, some of the most impressive new special departments, with formidable research programmes, are to be found in regional-board hospitals. What, then, is the teaching hospital to do ? It can strive to remain a truly general hospital, relying on the specialists from the regional centres to run, so to speak, small branch surgeries in the teaching hospital; or it can resign itself to becoming a hotch-potch of sizeable special units, looking largely to the surrounding regionalboard hospitals to fill the gaps in teaching material. This dilemma is inescapable for the teaching hospitals, which, while they still have a few counters in hand, might do well to come to terms with their regional neighbours. A real alliance would encourage the necessary integration of clinical research and teaching effort; it would still the jealousies which in some regions have prevented joint action; and it would help the regional-board hospitals which, through closer association with the high standard of teaching hospitals, would be stimulated to look to their own.
hope that the two groups of hospitals will together at once: the two are beginning to realise the advantages of closer association, but all history denies the chance of a speedy union. What we can reasonably hope is that the financing of both groups shall be more keenly and frankly appraised. In particular, none of our leaders has yet publicly answered the question: Is the hospital service to be allowed to slide into the second-rate, and, if so, why ? We
cannot
come
Should the Nurse Prescribe? IN most hospitals it is accepted practice that no drug is to be given without prescription on the treatment sheet. But in some institutions prescribing by nurses is not only tolerated by doctors but also claimed as a traditional right by nurses-a view not countenanced by the subcommittee of the Central Health Services Council,l which included nursing representatives among its members. Those who believe in the nurse’s " right " to prescribe (and this includes some consultants) may feel that prescription of simple remedies on a treatment 1. Central Health Services Council: Report of the Joint Subcommittee on the Control of Dangerous Drugs and Poisons in Hospitals. H.M. Stationery Office, 1958.
sheet amounts to a vote of no confidence in the nursing staff. Yet the arguments for strict control of prescribing are so cogent that it is hard to see how they can reasonably be rejected. Prescribing drugs is a skill-an increasingly complex one-for which the medical curriculum aims to fit the doctor, but for which the nursing curriculum does not aim to fit the nurse. Moreover, the doctor is answerable in law for ill-effects of the drugs he prescribes, and he is assured of the help of powerful defence societies if his treatment is called in question; but whose is the responsibility when a patient is harmed by a drug given by a nurse on her own authority-the consultant in charge, the hospital management committee, or the nurse herself ? Again, no doctor can treat his patients properly and efficiently unless he knows at all times exactly which drugs the patient is being given and which drugs they are not being given. Apparently innocuous drugs when given without his knowledge may confuse diagnosis. A single dose of an iodidecontaining expectorant can invalidate the results of a radioactive test of thyroid function, even weeks or months after being given. Salicylates can increase the cellular content of the urine,2and this could lead to an erroneous diagnosis of serious renal disease. Some antacids at times cause diarrhoea, easily explained when the treatment sheet records their prescription, but not otherwise. Similarly, occult medication " may interfere with treatment. When the low-sodium diet was in vogue, it took considerable effort by the dietitian and chef to produce a diet containing no more than 0-5 g. per day of sodium. But not infrequently their intentions were thwarted by nurses who gave unprescribed carminatives or antacids, unaware that a mixture with no mention of sodium in its name might still contain more of that substance than a whole day’s ration of a salt-free diet. There are even more serious aspects than confusion of diagnosis or neutralisation of treatment. Salicylates are a possible cause of gastrointestinal haemorrhage, antacids can aggravate some forms of renal disease; and these are not the only drugs which are at times given without having been prescribed. Nurses who have become used to certain drugs being given as adjuvants to other drug treatment (potassium citrate with sulphonamides; ammonium chloride before mercurial diuretics) may decide for themselves that the combined therapy should be given, even when it has not been prescribed. Potassium citrate can be quite dangerous in renal impairment; and, though mercurials are useful in ridding cirrhotic patients of ascites and oedema, ammonium chloride can be lethal in liver disease. Reports on toxic reactions to drugs increase weekly, particularly those dealing with damage to the foetus. Doctors find it very difficult to keep abreast of publications on the subject. Are nurses able to do so ? Despite the powerful arguments against permitting nurses to prescribe drugs, there remain those who "
the practice. Presumably they agree that a line must be drawn somewhere. Is the right to prescribe to be restricted to ward sisters ?But what is to happen countenance
2.
Scott, J. T., Denman, A. M., Dorling, J. Lancet, 1963,i, 344.
759
when the ward sister is off duty : is the right to be deputed, and, if so, how far down the line ? Quite obviously, some rules have to be formulated. Again, the
supporters of prescribing by nurses must surely admit that the types of drug to be given without a doctor’s oe subject to some sort of control; hence another set of rules is needed. But there is deeper water yet. When a drug is contraindicated in a particular case, how can the doctor ensure that it is not given? By a written ban on the treatment sheet ?If the drug is one which the nurses are accustomed to giving without permission, is there any guarantee that they will read the treatment sheet of the patient ? Or is the ban to be verbal? If so, can the doctor be quite certain that everyone who might give the drug will learn of the prohibition ? Allowing nurses to give simple drugs can thus become a very complex matter. How much simpler to keep to a system whereby a doctor, after considering a case, prescribes on a treatment sheet those drugs to be given at regular intervals and those (including a named analgesic, a named hypnotic, and aperients-perhaps unspecified) which may be given if and when requiredthese drugs, and only these drugs, being given by the nursing staff. This system has the virtues of being completely straightforward, and of leaving nothing to chance. The treatment sheet becomes what it should be: an accurate and valuable record for both medical and medicolegal purposes.
prescription
must
Annotations NORADRENALINE AND THE FCETAL HEART
VARIATIONS in the foetal heart-rate are widely used as a guide to foetal wellbeing, and the onset of bradycardia during labour is a common signal for obstetric intervention. Indeed, there is a high correlation between bradycardia and fcetal hypoxia; our knowledge of this is backed by sound experimental evidence.1 But occasionally variations in rhythm in the antenatal period occur either spontaneously or after abdominal palpation or external version. Thus foetal bradycardia during labour may also, from time to time, be innocent. Nevertheless, few obstetricians would care to take a chance on this; so a mother may sometimes be delivered with unnecessary haste, perhaps by cassarean section, because of the mistaken belief that her baby is in danger. For this reason recent work on maternal factors which may influence foetal heart-rate is to be welcomed. As long ago as 1932, Clark2 noted in animals that injection of adrenaline into the mother affected the fcetal heart-rate. He ascribed this to minute amounts of catecholamine crossing the placental barrier, but his interpretation was subsequently doubted by Young and her colleagues. 1Their experiments led them to conclude that changes in the foetal heart-rate following maternal dosage with catecholamines are secondary to hypoxia caused by uterine arterial constriction. Even though Beard5 arrived tentatively at the same conclusion, the foetal bradycardia he observed following noradrenaline infusion 1. 2. 3. 4. 5.
Born, G. V. R., Dawes, G. S., Mott, J. C. J. Physiol. 1956, 134, 149. Clark, G. A. ibid. 1932, 74, 391. Dornhorst, A. C., Young, I. M. ibid. 1952, 118, 282. Martin, J. D., Young, I. M. ibid. 1960, 152, 1. Beard, R. W. Brit. med. J. 1962, i, 443.
into pregnant women (a procedure theoretically not without risk s-8) was similar to the response of the newborn infant to this drug 9 10; so Clark’s interpretation was not ruled out. The situation in the human has
been partially clarified by Sandler et al.," who showed that a proportion of administered 4C-noradrenaline crossed the placental barrier where it could be detected in afferent cord blood. Efferent blood showed very little radioactivity attributable to noradrenaline, which presumably had been bound or inactivated during its passage through foetal tissues. Sandler et al. did not consider it justifiable to carry out such experiments in the presence of a normal foetus. Their procedures were thus confined to clinical circumstances incompatible with foetal survival; so choice and availability of material were of necessity restricted. Despite these limitations, noradrenaline appeared to reach the foetus in a concentration convincing enough to raise once more the possibility of its contributing to changes in foetal heartrate during the stress of labour. Whether such an access of noradrenaline to the foetal circulation could ever have survival value for the foetus is doubtful; indeed, there is some evidence that low concentrations may harm the hypoxic foetus. While moderate hypoxia, at least in the sheep, brings a limited compensatory mechanism into play-an increase in umbilical bloodflow 12-severe hypoxia brings about an increase in umbilical vascular resistance with a consequent decrease in umbilical blood-flow, probably mediated by the release of noradrenaline or adrenaline into the circulation from foetal catecholamine-producing tissues. IS Hypoxic vessels may respond to biologically active amines differently from vessels with a normal oxygen supply. Monoamine oxidase, the enzyme responsible in part at least for the in-vivo inactivation of catecholamines,14 is very sensitive to reduced oxygen tension 15 and the placental enzyme is no exception 16; its concentration is decreased in at least one pathological state 17 associated with a heightened vascular responsiveness to noradrenaline18 _toxsemia of pregnancy. Such a decrease might lead to a damaging build-up of amine. Even though the umbilical circulation is known to be sensitive to the catecholamines,19 20 it is considerably more responsive to another amine also inactivated by monoamine oxidase which is well represented in the maternal circulation-5-hydroxytryptamine.2O-26 Perhaps the work of Sandler et al.ll ought to be extended, substituting a labelled version of this amine for noradrenaline. now
Dawes, G. S. ibid. p. 636. Beard, R. W. ibid. p. 1275. Cibils, L. A., Pose, S. V., Zuspan, F. P. Amer. J. Obstet. Gynec. 1962, 84, 307. 9. Karlberg. P., Moore, R. E., Oliver, T. K. Acta pœdiat., Stockh. 1962, 51, 284. 10. Karlberg, P., Moore, R. E., Oliver, T. K. J. Physiol. 1962, 165, 47P. 11. Sandier, M., Ruthven, C. R. J., Contractor, S. F., Wood, C., Booth, R. T., Pinkerton, J. H. M. Nature, Lond. 1963, 197, 598. 12. Dawes, G. S. Amer. J. Obstet. Gynec. 1962, 84, 1634. 13. Comline, R. S., Silver, M. J. Physiol. 1961, 156, 424. 14. Axelrod, J. in Ciba Foundation Symposium on Adrenergic Mechanisms (edited by J. R. Vane, G. E. W. Wolstenholme, and M. O’Connor); p. 28. London, 1960. 15. Kohn, H. I. Biochem. J. 1937, 31, 1693. 16. Thompson, R. H. S., Tickner, A. ibid. 1949, 45, 125. 17. Sandler, M., Coveney, J. Lancet, 1962, i, 1096. 18. Mendlowitz, M., Altchek, A., Naftchi, N., Spark, R. Amer. J. Obstet. Gynec. 1961, 81, 643. 19. von Euler, U. S. J. Physiol. 1938, 93, 129. 20. Panigel, M. Amer. J. Obstet. Gynec. 1962, 84, 1664. 21. Aström, A., Samelius, U. Brit. J. Pharmacol. 1957, 12, 410. 22. Rodegra, H., Röder, G., Schmermund, H. J. Arch. exp. Path. Pharmak. 1957, 232, 285. 23. Schmermund, H. J., Rodegra, H., Soehring, K. Arch. Gynäk. 1959, 191, 6. 7. 8.
457.
Goerke, J. A., McKean, C. M., Margolis, A. J., Glendening, M. B., Page, E. W. Amer. J. Obstet. Gynec. 1961, 81, 1132. 25. Gautieri, R. F., Ciuchta, H. P. J. pharm. Sci. 1962, 51, 55. 26. Pepeu, G., Giarman, N. J. J. gen. Physiol. 1962, 45, 575. 24.
financial provision from a unified board ? In Scotland all hospitals are under regional boards; and, even in the region where the teaching hospital has apparently been treated least openhandedly, opinion in that hospital is on the whole for retaining the existing system. After all, teaching hospital and regional-board hospital share the same primary objective-namely, to treat patients (though the teaching hospital may be entitled to choose its patients), and the dual system makes for wasteful duplication and ill-feeling. And if those working in regional-board hospitals regard the teaching hospital next door with ill-disguised envy, those in the teaching hospital are beginning to reciprocate no less keenly. A teaching hospital with a budget of, say, a million and a half pounds may find it harder to embark on new ventures than does a regional board with a budget of, say, E25 million. Thus, some of the most impressive new special departments, with formidable research programmes, are to be found in regional-board hospitals. What, then, is the teaching hospital to do ? It can strive to remain a truly general hospital, relying on the specialists from the regional centres to run, so to speak, small branch surgeries in the teaching hospital; or it can resign itself to becoming a hotch-potch of sizeable special units, looking largely to the surrounding regionalboard hospitals to fill the gaps in teaching material. This dilemma is inescapable for the teaching hospitals, which, while they still have a few counters in hand, might do well to come to terms with their regional neighbours. A real alliance would encourage the necessary integration of clinical research and teaching effort; it would still the jealousies which in some regions have prevented joint action; and it would help the regional-board hospitals which, through closer association with the high standard of teaching hospitals, would be stimulated to look to their own.
hope that the two groups of hospitals will together at once: the two are beginning to realise the advantages of closer association, but all history denies the chance of a speedy union. What we can reasonably hope is that the financing of both groups shall be more keenly and frankly appraised. In particular, none of our leaders has yet publicly answered the question: Is the hospital service to be allowed to slide into the second-rate, and, if so, why ? We
cannot
come
Should the Nurse Prescribe? IN most hospitals it is accepted practice that no drug is to be given without prescription on the treatment sheet. But in some institutions prescribing by nurses is not only tolerated by doctors but also claimed as a traditional right by nurses-a view not countenanced by the subcommittee of the Central Health Services Council,l which included nursing representatives among its members. Those who believe in the nurse’s " right " to prescribe (and this includes some consultants) may feel that prescription of simple remedies on a treatment 1. Central Health Services Council: Report of the Joint Subcommittee on the Control of Dangerous Drugs and Poisons in Hospitals. H.M. Stationery Office, 1958.
sheet amounts to a vote of no confidence in the nursing staff. Yet the arguments for strict control of prescribing are so cogent that it is hard to see how they can reasonably be rejected. Prescribing drugs is a skill-an increasingly complex one-for which the medical curriculum aims to fit the doctor, but for which the nursing curriculum does not aim to fit the nurse. Moreover, the doctor is answerable in law for ill-effects of the drugs he prescribes, and he is assured of the help of powerful defence societies if his treatment is called in question; but whose is the responsibility when a patient is harmed by a drug given by a nurse on her own authority-the consultant in charge, the hospital management committee, or the nurse herself ? Again, no doctor can treat his patients properly and efficiently unless he knows at all times exactly which drugs the patient is being given and which drugs they are not being given. Apparently innocuous drugs when given without his knowledge may confuse diagnosis. A single dose of an iodidecontaining expectorant can invalidate the results of a radioactive test of thyroid function, even weeks or months after being given. Salicylates can increase the cellular content of the urine,2and this could lead to an erroneous diagnosis of serious renal disease. Some antacids at times cause diarrhoea, easily explained when the treatment sheet records their prescription, but not otherwise. Similarly, occult medication " may interfere with treatment. When the low-sodium diet was in vogue, it took considerable effort by the dietitian and chef to produce a diet containing no more than 0-5 g. per day of sodium. But not infrequently their intentions were thwarted by nurses who gave unprescribed carminatives or antacids, unaware that a mixture with no mention of sodium in its name might still contain more of that substance than a whole day’s ration of a salt-free diet. There are even more serious aspects than confusion of diagnosis or neutralisation of treatment. Salicylates are a possible cause of gastrointestinal haemorrhage, antacids can aggravate some forms of renal disease; and these are not the only drugs which are at times given without having been prescribed. Nurses who have become used to certain drugs being given as adjuvants to other drug treatment (potassium citrate with sulphonamides; ammonium chloride before mercurial diuretics) may decide for themselves that the combined therapy should be given, even when it has not been prescribed. Potassium citrate can be quite dangerous in renal impairment; and, though mercurials are useful in ridding cirrhotic patients of ascites and oedema, ammonium chloride can be lethal in liver disease. Reports on toxic reactions to drugs increase weekly, particularly those dealing with damage to the foetus. Doctors find it very difficult to keep abreast of publications on the subject. Are nurses able to do so ? Despite the powerful arguments against permitting nurses to prescribe drugs, there remain those who "
the practice. Presumably they agree that a line must be drawn somewhere. Is the right to prescribe to be restricted to ward sisters ?But what is to happen countenance
2.
Scott, J. T., Denman, A. M., Dorling, J. Lancet, 1963,i, 344.
759
when the ward sister is off duty : is the right to be deputed, and, if so, how far down the line ? Quite obviously, some rules have to be formulated. Again, the
supporters of prescribing by nurses must surely admit that the types of drug to be given without a doctor’s oe subject to some sort of control; hence another set of rules is needed. But there is deeper water yet. When a drug is contraindicated in a particular case, how can the doctor ensure that it is not given? By a written ban on the treatment sheet ?If the drug is one which the nurses are accustomed to giving without permission, is there any guarantee that they will read the treatment sheet of the patient ? Or is the ban to be verbal? If so, can the doctor be quite certain that everyone who might give the drug will learn of the prohibition ? Allowing nurses to give simple drugs can thus become a very complex matter. How much simpler to keep to a system whereby a doctor, after considering a case, prescribes on a treatment sheet those drugs to be given at regular intervals and those (including a named analgesic, a named hypnotic, and aperients-perhaps unspecified) which may be given if and when requiredthese drugs, and only these drugs, being given by the nursing staff. This system has the virtues of being completely straightforward, and of leaving nothing to chance. The treatment sheet becomes what it should be: an accurate and valuable record for both medical and medicolegal purposes.
prescription
must
Annotations NORADRENALINE AND THE FCETAL HEART
VARIATIONS in the foetal heart-rate are widely used as a guide to foetal wellbeing, and the onset of bradycardia during labour is a common signal for obstetric intervention. Indeed, there is a high correlation between bradycardia and fcetal hypoxia; our knowledge of this is backed by sound experimental evidence.1 But occasionally variations in rhythm in the antenatal period occur either spontaneously or after abdominal palpation or external version. Thus foetal bradycardia during labour may also, from time to time, be innocent. Nevertheless, few obstetricians would care to take a chance on this; so a mother may sometimes be delivered with unnecessary haste, perhaps by cassarean section, because of the mistaken belief that her baby is in danger. For this reason recent work on maternal factors which may influence foetal heart-rate is to be welcomed. As long ago as 1932, Clark2 noted in animals that injection of adrenaline into the mother affected the fcetal heart-rate. He ascribed this to minute amounts of catecholamine crossing the placental barrier, but his interpretation was subsequently doubted by Young and her colleagues. 1Their experiments led them to conclude that changes in the foetal heart-rate following maternal dosage with catecholamines are secondary to hypoxia caused by uterine arterial constriction. Even though Beard5 arrived tentatively at the same conclusion, the foetal bradycardia he observed following noradrenaline infusion 1. 2. 3. 4. 5.
Born, G. V. R., Dawes, G. S., Mott, J. C. J. Physiol. 1956, 134, 149. Clark, G. A. ibid. 1932, 74, 391. Dornhorst, A. C., Young, I. M. ibid. 1952, 118, 282. Martin, J. D., Young, I. M. ibid. 1960, 152, 1. Beard, R. W. Brit. med. J. 1962, i, 443.
into pregnant women (a procedure theoretically not without risk s-8) was similar to the response of the newborn infant to this drug 9 10; so Clark’s interpretation was not ruled out. The situation in the human has
been partially clarified by Sandler et al.," who showed that a proportion of administered 4C-noradrenaline crossed the placental barrier where it could be detected in afferent cord blood. Efferent blood showed very little radioactivity attributable to noradrenaline, which presumably had been bound or inactivated during its passage through foetal tissues. Sandler et al. did not consider it justifiable to carry out such experiments in the presence of a normal foetus. Their procedures were thus confined to clinical circumstances incompatible with foetal survival; so choice and availability of material were of necessity restricted. Despite these limitations, noradrenaline appeared to reach the foetus in a concentration convincing enough to raise once more the possibility of its contributing to changes in foetal heartrate during the stress of labour. Whether such an access of noradrenaline to the foetal circulation could ever have survival value for the foetus is doubtful; indeed, there is some evidence that low concentrations may harm the hypoxic foetus. While moderate hypoxia, at least in the sheep, brings a limited compensatory mechanism into play-an increase in umbilical bloodflow 12-severe hypoxia brings about an increase in umbilical vascular resistance with a consequent decrease in umbilical blood-flow, probably mediated by the release of noradrenaline or adrenaline into the circulation from foetal catecholamine-producing tissues. IS Hypoxic vessels may respond to biologically active amines differently from vessels with a normal oxygen supply. Monoamine oxidase, the enzyme responsible in part at least for the in-vivo inactivation of catecholamines,14 is very sensitive to reduced oxygen tension 15 and the placental enzyme is no exception 16; its concentration is decreased in at least one pathological state 17 associated with a heightened vascular responsiveness to noradrenaline18 _toxsemia of pregnancy. Such a decrease might lead to a damaging build-up of amine. Even though the umbilical circulation is known to be sensitive to the catecholamines,19 20 it is considerably more responsive to another amine also inactivated by monoamine oxidase which is well represented in the maternal circulation-5-hydroxytryptamine.2O-26 Perhaps the work of Sandler et al.ll ought to be extended, substituting a labelled version of this amine for noradrenaline. now
Dawes, G. S. ibid. p. 636. Beard, R. W. ibid. p. 1275. Cibils, L. A., Pose, S. V., Zuspan, F. P. Amer. J. Obstet. Gynec. 1962, 84, 307. 9. Karlberg. P., Moore, R. E., Oliver, T. K. Acta pœdiat., Stockh. 1962, 51, 284. 10. Karlberg, P., Moore, R. E., Oliver, T. K. J. Physiol. 1962, 165, 47P. 11. Sandier, M., Ruthven, C. R. J., Contractor, S. F., Wood, C., Booth, R. T., Pinkerton, J. H. M. Nature, Lond. 1963, 197, 598. 12. Dawes, G. S. Amer. J. Obstet. Gynec. 1962, 84, 1634. 13. Comline, R. S., Silver, M. J. Physiol. 1961, 156, 424. 14. Axelrod, J. in Ciba Foundation Symposium on Adrenergic Mechanisms (edited by J. R. Vane, G. E. W. Wolstenholme, and M. O’Connor); p. 28. London, 1960. 15. Kohn, H. I. Biochem. J. 1937, 31, 1693. 16. Thompson, R. H. S., Tickner, A. ibid. 1949, 45, 125. 17. Sandler, M., Coveney, J. Lancet, 1962, i, 1096. 18. Mendlowitz, M., Altchek, A., Naftchi, N., Spark, R. Amer. J. Obstet. Gynec. 1961, 81, 643. 19. von Euler, U. S. J. Physiol. 1938, 93, 129. 20. Panigel, M. Amer. J. Obstet. Gynec. 1962, 84, 1664. 21. Aström, A., Samelius, U. Brit. J. Pharmacol. 1957, 12, 410. 22. Rodegra, H., Röder, G., Schmermund, H. J. Arch. exp. Path. Pharmak. 1957, 232, 285. 23. Schmermund, H. J., Rodegra, H., Soehring, K. Arch. Gynäk. 1959, 191, 6. 7. 8.
457.
Goerke, J. A., McKean, C. M., Margolis, A. J., Glendening, M. B., Page, E. W. Amer. J. Obstet. Gynec. 1961, 81, 1132. 25. Gautieri, R. F., Ciuchta, H. P. J. pharm. Sci. 1962, 51, 55. 26. Pepeu, G., Giarman, N. J. J. gen. Physiol. 1962, 45, 575. 24.