In a recent survey, nurses report that new titration management standards cause patient harm and unnecessary stress amongst already taxed critical care nurses
Drug titration is the process of adjusting the dose of a medication for maximum benefit. In 2017, The Joint Commission (TJC), a nonprofit organization that regularly reviews and accredits health care organizations to ensure and advance patient safety and quality of care, issued revised guidelines on the management of titrated medications. The changes were an effort to optimize patient safety.
The revised guidelines shifted autonomy away from nurses; requiring physician orders for practices once decided by nurses. Specifically, nurses could no longer determine the frequency of titration or the amount to increase or decrease medication infusion. These actions had previously been determined on a case-by-case basis at the bedside by a nurse, taking into account each patient’s individual needs and response to medications. Concerned nurses formed a research team to investigate any unintended consequences of these new standards.
In two articles published within the September 2021 issue of the American Journal of Critical Care, the authors, who work at health care systems across the United States, report that the vast majority of nurse-respondents said the changes in titration management standards reduced their ability to provide timely adjustments to the medications, resulting in adverse consequences, including harm to patients.
“One of the most disturbing findings of this study was that nurses felt compelled to falsify records in order to keep patients safe,” said lead author Judy Davidson, DNP, RN and a nurse-scientist at UC San Diego Health.
Adherence to TJC medication titration standards did not serve the patient or the nursing profession as a whole, the authors wrote. The respondents, they said, made clear that when nurses are able to use their extensive training and critical thinking skills while functioning at the top of their scope of practice, everyone benefits: patients, staff, faculty and health system.
In the first paper, based on responses from 781 nurses, 80 percent said the new titration standards caused delays in patient care. 93 percent experienced moral distress by being prevented from doing what they felt was the right thing to do for patients.
In the second paper, 159 nurse testimonies were analyzed for themes. Responding nurses found the new rules eroded workplace wellness, diminished their professional status and increased both physical risk and nurse burnout — the latter already considered to be a serious industry issue.
These papers, said the authors, highlight the harm that over-regulation can cause to patients and professionals. They suggest that the current practice of issuing a call for comments on new standards is insufficient.
“We propose that in the future new regulations and standards be pilot-tested prior to implementation to prevent unintended consequences such as these,” said Laura Chechel, MSN, RN, nurse manager of the cardiovascular intensive care unit at UC San Diego Health.
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