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Neonatal Pharmacology and Nursing in Russia
INTERNATIONAL CONNECTIONS
Neonatal Pharmacology and Nursing in Russia Marina Boykova, MSc, RN and Carole Kenner, DNS, RNC-NIC, FAAN
Our world is shrinking due to computerized linkages and the mobility of society. Information is shared rapidly around the world. Issues surrounding newborn and infant nursing are global. In efforts to acknowledge the international community, each Newborn and Infant Nursing Review issue will feature a column that highlights care-related issues from a featured country or region of the world. This article focuses on Russia. Newborn and infant health issues are global ones. To review issues occurring in different areas of the world, a different area of the globe will be featured that addresses Newborn and Infant Nursing Review's theme-oriented topic. This month, Russia will be featured. Our guest author is Ms. Marina Boykova, MSc, RN, and Regional Network Contact for the Council of International Neonatal Nurses for Russia. This month's article focuses on Neonatal Pharmacology. Keywords: Pharmacology; Neonatal
Nursing involves the use of a strong scientific base for patientcentered care. These scientific underpinnings must be taught and internalized. Pharmacology is just one of these courses. Pharmacology is just as critical if not more so than other basic sciences such as anatomy, physiology, pathology, and microbiology. A good knowledge in pharmacology is required to be a good nurse and professional; otherwise, care can be dangerous for patients. Neonatal nurses, as all nurses, need to be aware about contemporary pharmacological therapies. This article describes educational and practical issues in Russian nursing related to pharmacology and its importance for neonatal care.
Nursing Curricula and Pharmacology in Russia To become a nurse in Russia after basic school education, one can earn a diploma in nursing. Diploma education takes 2 years and 10 months. A student has to undertake numerous subjects. In short, the Russian nursing curriculum at the basic level includes anatomy, physiology, microbiology, genetics, pharmacology with compounding, hygiene and health promoFrom the University of Oklahoma College of Nursing, Oklahoma City, OK; Neonatal Intensive Care Unit, Children's Hospital #1, St. Petersburg, Russia; University of Oklahoma, Norman, OK; and the Council of International Neonatal Nurses, Inc., Edmond, OK. Address correspondence to Carole Kenner, DNS, RNC-NIC, FAAN, University of Oklahoma, College of Nursing, 1100 N. Stonewall Ave., Oklahoma City, OK 73117. E-mails: [email protected], [email protected]. © 2009 Elsevier Inc. All rights reserved. 1527-3369/08/0901-0283$36.00/0 doi:10.1053/j.nainr.2008.12.004
tion, epidemiology and infectious diseases, obstetrics and gynecology, venereal and skin diseases, ophthalmology and ear-nose-throat diseases, physiotherapy and massage, internal and surgical medicine, intensive care and anesthesiology, psychology and psychiatry, ethics and philosophy of nursing, and the nursing process—more than 30 subjects appear in the transcript. In total, there are 5184 study hours for a full program, 60% of it are practical and laboratory sessions.1 General pharmacology starts in the second year of study and has 80 hours dedicated to theory, 20 hours of it being practical and laboratory sessions. Clinical pharmacology occurs in the third year and has 48 study hours. It is a compulsory subject along with Latin and Latin terminology, which constitutes 40 hours.1 Studying pharmacology, nursing students receive information about the main drug classes, some knowledge about pharmacokinetics and pharmacodynamics, mechanisms of action, routes of administration, possible adverse effects, some information about incompatibility as well as compounding, and simple prescribing. Nursing students also learn calculation technique, for instance, how to dissolve antibiotics to a needed dose for a patient or to calculate the needed insulin dose. It should be noted that the dosage regimen given to students is for adults usually but not for newborns. Not much of neonatal pharmacology is studied in nursing schools; most pharmacology is given with relation to adults and pediatric patients. There are also deficits in the nursing literature regarding neonatal pharmacology. Fortunately, a couple of years ago, the neonatal drug manual (NEOFAX)2 was translated into Russian language, and now nurses can use this reference book in their practice. (We use NEOFAX—A Manual of Drugs Used in Neonatal Care, 2006, 19th ed., translated in Moscow, Veretyea Publishers).
Practical Perspectives and Responsibilities of the Nurse Nurses at the practical settings can administer medicines only after a physician's prescription is written. No independent drug prescription and administration are allowed in Russia. Nurses can do simple drug dissolution for the required dosage prescribed by physician: antibiotics or insulin, sometimes the nurse can change a glucose concentration. The nurse usually gives a pill or injection to a patient or can prepare a mix of solutions for intravenous infusions or parenteral nutrition as prescribed by physician. No calculations of flow rates based on the weight or age are taught or allowed for nurses to perform, for example, dopamine or fentanyl are always calculated by physicians. More independency is allowed to ‘fieldshers’—some kind of nurse practitioners who work in rural areas and ambulance services. They are taught how to calculate and perform some drug prescription in special fieldsher's schools.
Neonatal Pharmacology Practice Current pharmacological management of common medical conditions in the Neonatal Intensive Care Unit (NICU) is usually studied when the newly employed nurse receives orientation within the unit. The nurse is given information about the most common neonatal medicines. These include surfactant, anticonvulsants, prostaglandin E1, indomethacin, dopamine, and dobutamine to fill the gap left by the basic education that focused on the adult. It is not sufficient knowledge for the neonatal nurse. For instance, nurses sometimes cannot relate pulmonary edema and hemorrhage with the surfactant administration (as the consequence of rapid fall in pulmonary vascular resistance and increased blood flow through the patent ductus arteriousus) because their knowledge is limited to knowing the diagnosis and drugs used to treat the disease and performing doctor's orders only. In practice, again, the nurse is not allowed to perform any calculations without the physician's order. The nurse is not allowed to describe the drug's action or possible effects to parents of NICU patients because this is with the purview of the physician who provides patient/family teaching. Such limitation of nurse autonomy and responsibility lead to negative aspects of nursing as a profession especially for those nurses who select a specialty such as neonatal care. Inability to perform complex calculations (mg/kg/day) makes a nurse unable to understand and report adverse drug events or overdose, for instance. Of course, as everywhere, the nurse can make mistakes with dissolution of drugs, identification of tags on the medications, in routes of administration due to some missed aspects in their education or knowledge deficits of the importance of certain aspects of the drug or drug therapy. However in Russia, there is no form for reporting adverse drug events in NICU nursing documentation. There is no monitoring and quality improvement strategy that exists. Thus, these practices tend to hinder the care. From personal experience, a big problem is drug incompatibility because
NEWBORN
there is no adequate nursing literature that exists to explain potential problems. Nurses often have to use medical literature that is written in complicated language, which is far above the general knowledge a Russian nurse has received, for instance, incompatibility of aminoglycoside antibiotics and heparin flushing that leads to removal of the intravenous catheter due to sediment or thiopental sodium (sometimes better known as sodium pentothal, Abbott Laboratories, Columbus, OH) for management of seizures in asphyxia that clots the lines when used with amikacin. In addition, another problem is tissue necrosis due to fast or wrong administration of the drug through the vessel—like in cases with dopamine, high-concentration glucose, or sodium bicarbonate infused via peripheral veins, just because the concentration and osmolarity may have not been considered before starting infusions. Such information is often not included in the nursing curricula, and until nurses have specific knowledge in neonatal pharmacology and have specific manuals, the negative events will occur and our babies will suffer complications of drug therapy. A lot of drugs exist, and nurses can get lost trying to administer them, let alone understand the actions, potential side effects, or complications. Nursing manuals on neonatal drugs and pharmacology therapy of neonatal patients are lacking here in Russia. It is critical to the well-being of our patients that nurses in Russia receive better training and education in pharmacology that is specific to neonatal care. They also need to have a better working knowledge of pharmacology from the theory to the practical application. They need to understand the rationale for a drug's use through interactions with other drugs. Russian nurses have a long way to go to be considered well educated in pharmacotherapeutics.
Conclusion Limiting educational possibilities and the lack of autonomy of nurses cannot bring benefits to neonatal patient care. Nurses should have a good knowledge of neonatal pharmacology to understand the consequences of the drug's actions. Nurses need to have a possibility to report adverse drug events with no fear of reprisal or punishment. Better pharmacological education is needed as is the enhancement and growth of nursing autonomy. In times when there are vast amount of new drugs available, neonatal nurses should be aware of contemporary pharmacological therapies for NICU patients, otherwise patient safety and quality of care will be compromised.
References 1. Ministry of Health Care and Ministry of Education, Russian Federation. State educational standard for middle level professions – nursing, basic level. Moscow; 2002 (№ 020406- B). 2. Young TE, Mangum B. NeoFax. 21st ed. New York: Physician's Desk Reference Publishers, John Wiley & Sons; 2008.
& INFANT NURSING REVIEWS, MARCH 2009
9
Neonatal Pharmacology and Nursing in Russia Marina Boykova, MSc, RN and Carole Kenner, DNS, RNC-NIC, FAAN
Our world is shrinking due to computerized linkages and the mobility of society. Information is shared rapidly around the world. Issues surrounding newborn and infant nursing are global. In efforts to acknowledge the international community, each Newborn and Infant Nursing Review issue will feature a column that highlights care-related issues from a featured country or region of the world. This article focuses on Russia. Newborn and infant health issues are global ones. To review issues occurring in different areas of the world, a different area of the globe will be featured that addresses Newborn and Infant Nursing Review's theme-oriented topic. This month, Russia will be featured. Our guest author is Ms. Marina Boykova, MSc, RN, and Regional Network Contact for the Council of International Neonatal Nurses for Russia. This month's article focuses on Neonatal Pharmacology. Keywords: Pharmacology; Neonatal
Nursing involves the use of a strong scientific base for patientcentered care. These scientific underpinnings must be taught and internalized. Pharmacology is just one of these courses. Pharmacology is just as critical if not more so than other basic sciences such as anatomy, physiology, pathology, and microbiology. A good knowledge in pharmacology is required to be a good nurse and professional; otherwise, care can be dangerous for patients. Neonatal nurses, as all nurses, need to be aware about contemporary pharmacological therapies. This article describes educational and practical issues in Russian nursing related to pharmacology and its importance for neonatal care.
Nursing Curricula and Pharmacology in Russia To become a nurse in Russia after basic school education, one can earn a diploma in nursing. Diploma education takes 2 years and 10 months. A student has to undertake numerous subjects. In short, the Russian nursing curriculum at the basic level includes anatomy, physiology, microbiology, genetics, pharmacology with compounding, hygiene and health promoFrom the University of Oklahoma College of Nursing, Oklahoma City, OK; Neonatal Intensive Care Unit, Children's Hospital #1, St. Petersburg, Russia; University of Oklahoma, Norman, OK; and the Council of International Neonatal Nurses, Inc., Edmond, OK. Address correspondence to Carole Kenner, DNS, RNC-NIC, FAAN, University of Oklahoma, College of Nursing, 1100 N. Stonewall Ave., Oklahoma City, OK 73117. E-mails: [email protected], [email protected]. © 2009 Elsevier Inc. All rights reserved. 1527-3369/08/0901-0283$36.00/0 doi:10.1053/j.nainr.2008.12.004
tion, epidemiology and infectious diseases, obstetrics and gynecology, venereal and skin diseases, ophthalmology and ear-nose-throat diseases, physiotherapy and massage, internal and surgical medicine, intensive care and anesthesiology, psychology and psychiatry, ethics and philosophy of nursing, and the nursing process—more than 30 subjects appear in the transcript. In total, there are 5184 study hours for a full program, 60% of it are practical and laboratory sessions.1 General pharmacology starts in the second year of study and has 80 hours dedicated to theory, 20 hours of it being practical and laboratory sessions. Clinical pharmacology occurs in the third year and has 48 study hours. It is a compulsory subject along with Latin and Latin terminology, which constitutes 40 hours.1 Studying pharmacology, nursing students receive information about the main drug classes, some knowledge about pharmacokinetics and pharmacodynamics, mechanisms of action, routes of administration, possible adverse effects, some information about incompatibility as well as compounding, and simple prescribing. Nursing students also learn calculation technique, for instance, how to dissolve antibiotics to a needed dose for a patient or to calculate the needed insulin dose. It should be noted that the dosage regimen given to students is for adults usually but not for newborns. Not much of neonatal pharmacology is studied in nursing schools; most pharmacology is given with relation to adults and pediatric patients. There are also deficits in the nursing literature regarding neonatal pharmacology. Fortunately, a couple of years ago, the neonatal drug manual (NEOFAX)2 was translated into Russian language, and now nurses can use this reference book in their practice. (We use NEOFAX—A Manual of Drugs Used in Neonatal Care, 2006, 19th ed., translated in Moscow, Veretyea Publishers).
Practical Perspectives and Responsibilities of the Nurse Nurses at the practical settings can administer medicines only after a physician's prescription is written. No independent drug prescription and administration are allowed in Russia. Nurses can do simple drug dissolution for the required dosage prescribed by physician: antibiotics or insulin, sometimes the nurse can change a glucose concentration. The nurse usually gives a pill or injection to a patient or can prepare a mix of solutions for intravenous infusions or parenteral nutrition as prescribed by physician. No calculations of flow rates based on the weight or age are taught or allowed for nurses to perform, for example, dopamine or fentanyl are always calculated by physicians. More independency is allowed to ‘fieldshers’—some kind of nurse practitioners who work in rural areas and ambulance services. They are taught how to calculate and perform some drug prescription in special fieldsher's schools.
Neonatal Pharmacology Practice Current pharmacological management of common medical conditions in the Neonatal Intensive Care Unit (NICU) is usually studied when the newly employed nurse receives orientation within the unit. The nurse is given information about the most common neonatal medicines. These include surfactant, anticonvulsants, prostaglandin E1, indomethacin, dopamine, and dobutamine to fill the gap left by the basic education that focused on the adult. It is not sufficient knowledge for the neonatal nurse. For instance, nurses sometimes cannot relate pulmonary edema and hemorrhage with the surfactant administration (as the consequence of rapid fall in pulmonary vascular resistance and increased blood flow through the patent ductus arteriousus) because their knowledge is limited to knowing the diagnosis and drugs used to treat the disease and performing doctor's orders only. In practice, again, the nurse is not allowed to perform any calculations without the physician's order. The nurse is not allowed to describe the drug's action or possible effects to parents of NICU patients because this is with the purview of the physician who provides patient/family teaching. Such limitation of nurse autonomy and responsibility lead to negative aspects of nursing as a profession especially for those nurses who select a specialty such as neonatal care. Inability to perform complex calculations (mg/kg/day) makes a nurse unable to understand and report adverse drug events or overdose, for instance. Of course, as everywhere, the nurse can make mistakes with dissolution of drugs, identification of tags on the medications, in routes of administration due to some missed aspects in their education or knowledge deficits of the importance of certain aspects of the drug or drug therapy. However in Russia, there is no form for reporting adverse drug events in NICU nursing documentation. There is no monitoring and quality improvement strategy that exists. Thus, these practices tend to hinder the care. From personal experience, a big problem is drug incompatibility because
NEWBORN
there is no adequate nursing literature that exists to explain potential problems. Nurses often have to use medical literature that is written in complicated language, which is far above the general knowledge a Russian nurse has received, for instance, incompatibility of aminoglycoside antibiotics and heparin flushing that leads to removal of the intravenous catheter due to sediment or thiopental sodium (sometimes better known as sodium pentothal, Abbott Laboratories, Columbus, OH) for management of seizures in asphyxia that clots the lines when used with amikacin. In addition, another problem is tissue necrosis due to fast or wrong administration of the drug through the vessel—like in cases with dopamine, high-concentration glucose, or sodium bicarbonate infused via peripheral veins, just because the concentration and osmolarity may have not been considered before starting infusions. Such information is often not included in the nursing curricula, and until nurses have specific knowledge in neonatal pharmacology and have specific manuals, the negative events will occur and our babies will suffer complications of drug therapy. A lot of drugs exist, and nurses can get lost trying to administer them, let alone understand the actions, potential side effects, or complications. Nursing manuals on neonatal drugs and pharmacology therapy of neonatal patients are lacking here in Russia. It is critical to the well-being of our patients that nurses in Russia receive better training and education in pharmacology that is specific to neonatal care. They also need to have a better working knowledge of pharmacology from the theory to the practical application. They need to understand the rationale for a drug's use through interactions with other drugs. Russian nurses have a long way to go to be considered well educated in pharmacotherapeutics.
Conclusion Limiting educational possibilities and the lack of autonomy of nurses cannot bring benefits to neonatal patient care. Nurses should have a good knowledge of neonatal pharmacology to understand the consequences of the drug's actions. Nurses need to have a possibility to report adverse drug events with no fear of reprisal or punishment. Better pharmacological education is needed as is the enhancement and growth of nursing autonomy. In times when there are vast amount of new drugs available, neonatal nurses should be aware of contemporary pharmacological therapies for NICU patients, otherwise patient safety and quality of care will be compromised.
References 1. Ministry of Health Care and Ministry of Education, Russian Federation. State educational standard for middle level professions – nursing, basic level. Moscow; 2002 (№ 020406- B). 2. Young TE, Mangum B. NeoFax. 21st ed. New York: Physician's Desk Reference Publishers, John Wiley & Sons; 2008.
& INFANT NURSING REVIEWS, MARCH 2009
9