‘Forced to Lie’: Med Titration Standards Put Critical Care Nurses on Shaky Ground~Survey finds nurses feeling “moral distress” at “profoundly unrealistic” standards

BY SHANNON FIRTH

SEE: https://www.medpagetoday.com/washington-watch/washington-watch/94342;

republished below in full unedited for informational, educational & research purposes:

Most critical care nurses (CCN) reported that they departed from "profoundly unrealistic" medication management titration standards -- and then later asked for the orders to be revised for compliance, a cross-sectional survey found.

In a cross-sectional survey of 781 CCNs that took place from January to September 2020, 70% of the respondents said they "deviated from orders to meet patient needs," and 84% later asked for revised orders to maintain compliance, according to Judy Davidson, DNP, RN, of the University of California San Diego Health.

Davidson and colleagues also found that 80% said that titration standards were causing delays in patient care, while 33% said they could not comply with titration orders, and 68% said pressure to comply with the standards led to the delivery of "suboptimal" care, they reported in the American Journal of Critical Care.

"One of the most frightening things [from the study] was that [nurses] are being forced to lie in their documentation to get the patient what they need...falsifying the records, which is a huge violation," Davidson told MedPage Today. "If the Joint Commission came in and found that, it could shut the [care center] down."

Nurses found to be lying in their documentation also risk losing their licenses or their jobs, she added.

"We should not be putting nurses into a situation where they feel that they have to falsify records to get what the patient needs," Davidson, a member of the Society for Critical Care Medicine (SCCM), said.

For the survey, Davidson's group found that 93% of AACN respondents reported "moral distress" -- defined as "distress that occurs when you think you're being prevented from doing the right thing" -- from pressure to adhere to the standards instead of applying nurses' own clinical judgment. Davidson and colleagues noted that "suboptimal care and delays in care significantly and strongly... predicted moral distress."

Changing Standards

In January 2018, The Joint Commission (TJC) issued MM 04.01.01, which prevented nurses from independently titrating the increment or the frequency of medication, and required doctors to predict medication titration.

"The problem with that is you can't predict it in advance... no two patients are alike," Davidson explained. Some patients may do well enough with starting on a low dose and titrating up, while others need a higher dose from the outset, she noted. Additionally, many patients are given more than one drug at a time, so predicting how they will respond to such a "drug cocktail," is also a challenge, she said.

TJC updated the titration standards multiple times in 2020 in collaboration with the American Association of Critical-Care Nurses (AACN). The changes "softened" the standards and reduced some of the burdens on nurses, Davidson said, for example, by allowing "batch documentation" (also known as "block charting") -- recording multiple incremental doses in one batch rather than immediately after each dose.

As of January 2021, nurses can now decide the order of titration when multiple infusions are required, and "intermittently pause and restart titration infusions" if hospital policy allows it or an order is given to describe the restart dose, Davidson and her colleagues noted in the study.

The survey revealed nurses' major concern was the lack of autonomy over the frequency and the amount of titration.

"It's not like they ignored us, the research wasn't complete yet," Davidson said, of the Joint Commission. "Those changes are great, but they don't actually tackle the issues that are causing harm."

'No-Win Situation'

Davidson and colleagues also conducted a thematic analysis to better understand the "practices and perceptions" around the commission's titration standards, and identified two key themes: Harm, such as concerns for patient safety, and professionalism, including the "erosion of workplace wellness."

The surveyed nurses were often "frustrated by being unable to comply with the standards, unable to provide safe care, and fearful of reprimand for deviating from orders," the authors stated in a separate American Journal of Critical Care article.

And many facilities don't have doctors on their units, which forces nurses to have to wait for a reply before they can intervene, Davidson noted.

More than a year after the standards were announced, Davidson said she was still hearing rumblings about this "no-win situation" in which nurses couldn't adhere to the standards, and middle managers, whose job it is to hold nurses accountable, felt conflicted because they also knew how difficult the standards were to follow.

This titration problem was a hot topic in the SCCM nursing section blog, so Davidson suggested conducting a survey and sharing that data with the commission.

"Somebody's got to say the emperor has no clothes on," Davidson said.

Some of the comments the authors compiled were:

"Due to [T]JC finding, we are forced to lie about what we are doing. [For] example, if [a] patient is crumping and [the] order is to titrate [Levophed] by 1, I am going to titrate how I need to keep [the] patient alive and then fake my documentation."

"The vasoactive drips are the worst. The ordered titration frequency as well as the allowed dose for titration would result in people dying if we didn't take some liberties. Telling us that all we have to do is get the DR. to rewrite the order is an insult. When your patient's BP is in the toilet that is not the time to be chasing after a DR. to ask him to rewrite a drip order."

Comments also described how the current standards contribute to "suboptimal workplace wellness" as a result of "increases in workload, burnout, physical risks, and inefficiencies; and a sense of nursing practice being devalued."

And more than one respondent argued that nurses are often more proficient in titrating infusions than the clinicians giving the orders:

"In my experience, the providers writing the titration amounts and frequency have little or no experience with actually titrating [intravenous] drops at the bedside. These strict titration parameters do not take into account differences between patients (sensitivity to med[ications], pain med[ication] tolerance, other hemodynamic issues, etc.) -- which is why nursing judgment/autonomy should not be limited by these TJC requirements."

Some respondents suggested that the standards, which they said are both stressful and demoralizing to nurses who expected more autonomy, may drive nurses out of the profession:

"The titration parameters recommended by TJC are profoundly unrealistic in an ICU setting. Nurses in an ICU setting have received the training and classes to be able to titrate an infusion without strict parameters. Furthermore, TJC continues to raise the standards to the point of discouraging nurses away from the bedside while preventing CMS from paying hospitals who desperately need their pay."

Not all of those surveyed had negative things to say about the standards, with one respondent stating: "I have found no issue with the change. If anything it's easier because I don't have to go to a separate reference to look up how frequently the med[ication] can be titrated or by how much."

However, that was only one of three positive comments, according to Davidson and colleagues.

Limitations of the survey included its non-experimental design, online sampling, and the fact that it was distributed through a professional organization. Because of the survey's design and sampling methods, it was not possible to estimate a response rate, according to the authors.

Davidson said she hopes the commission will work with her group to "evaluate the situation" through a quality-improvement approach.