Policy impact: When policy fails

Students' perceptions of a community health advocacy skills building activity: A descriptive analysis

BACKGROUND

Skills to promote advocacy, a nursing competency, are vital to today's cohorts of nursing students, who often struggle with discourse. Opportunities to develop, defend, and rebut science-based arguments enhance resilience and self-efficacy when advocating for health policy. A community health discussion activity was developed to enhance advocacy skills in undergraduate and graduate nursing students at a midwestern university.

OBJECTIVES

The purposes of this study were to explore students' perceptions of the benefits of a discussion activity about a controversial health issue, and to describe the impact of the opportunities to form valid arguments using empirical evidence on students' perceptions of their ability to be advocates.

DESIGN

Cross-sectional post-activity survey evaluation.

SETTINGS

Enrollment in a community health nursing course.

PARTICIPANTS

Students from two undergraduate (n = 110) and one graduate (n = 20) nursing cohorts.

METHODS

Following completion of the online discussion activity, students were invited to provide feedback on their perceptions of activity benefits. Descriptive analyses were conducted.

RESULTS

Undergraduate and graduate nursing students reported the activity helped them learn to form a valid argument using scientific evidence (88.6 %), use credible sources when forming their own opinions (91.7 %), and begin to see themselves as advocates for improving the health of individuals and communities (87.1 %).

CONCLUSIONS

Online discussion boards are potential venues for development of advocacy skills.

What the Joint Commission Medication Management Titration Standards Mean to Quality Care for Complex Patients

ABSTRACT

The Joint Commission (TJC), the nation's largest healthcare accreditor, was founded in the 1950s. Its Standards for Medication Management (MM) of titratable medications focused on prescriptive ordering practices versus reliance on nurse clinical decision making. The use of measurable endpoints to guide nurse decision making regarding medication titration has been the standard of care since the inception of TJC. Evidence to support altering these practice patterns is lacking. Using the 6 aims for the healthcare system (safe, timely, effective, efficient, equitable, and patient-centered) from the National Academy of Medicine, formerly the Institute of Medicine, and the American Association of Critical-Care Nurses Healthy Work Environment essential standards (skilled communication, true collaboration, effective decision making, appropriate staffing, meaningful recognition, authentic leadership), this article examines the impact of TJC MM standards on system design in critical care environments.

Thematic Analysis of Nurses' Experiences With The Joint Commission's Medication Management Titration Standards

BACKGROUND

For decades, medication titration has been within nurses' scope and practice. In 2017 The Joint Commission (TJC) revised elements for orders for the titration of continuous intravenous medications.

OBJECTIVES

To explore the practice and perceptions of nurses regarding TJC standards for titration of continuous intravenous medications.

METHODS

Nurses with experience titrating medications completed an investigator-designed, validated cross-sectional survey. Inductive thematic analysis was conducted in order to analyze the open-ended comments from that quantitative survey.

RESULTS

From among 730 completed surveys, 159 comments were received. Analysis of the comments yielded 3 levels of abstraction. Two overarching themes were harm and professionalism. Additional abstraction for the harm theme revealed categories of erosion of workplace wellness, moral dilemma, and patient safety, which were coded as relating to workplace stress, workload, burnout/turnover, physical risk, inefficiency, demeaning/devalued, falsification of records, problematic orders, burden of documentation, suboptimal care, delay in care, individualized care, and provider availability. Within the professionalism theme, categories of autonomy and nurse proficiency were identified, with 7 associated codes: top of scope, critical thinking, overregulation, teamwork, education, registered nurse knowledge, and novice registered nurse guidance.

CONCLUSIONS

The standards from TJC impose harm by eroding workplace wellness and introducing moral dilemmas and patient safety concerns. Professionalism is threatened through limits on scope and autonomy. Further advocacy is necessary in order to resolve unanticipated consequences related to the titration standards.

Survey of Nurses' Experiences Applying The Joint Commission's Medication Management Titration Standards

BACKGROUND

Critical care nurses titrate continuous infusions of medications to achieve clinical end points. In 2017, The Joint Commission (TJC) placed restrictions on titration practice, decreasing nurses' autonomous decision-making.

OBJECTIVES

To describe the practice and perceptions of nurses regarding the 2017 TJC accreditation/regulatory standards for titration of continuous medication infusions.

METHODS

A survey of nurses' experiences titrating continuous medication infusions was developed, validated, and distributed electronically to members of the American Association of Critical-Care Nurses.

RESULTS

The content validity index for the survey was 1.0 for relevance and 0.95 for clarity. A total of 781 nurses completed the survey; 625 (80%) perceived titration standards to cause delays in patient care, and 726 (93%) experienced moral distress (mean [SD], 4.97 [2.67]; scale, 0-10). Among respondents, 33% could not comply with titration orders, 68% reported suboptimal care resulting from pressure to comply with orders, 70% deviated from orders to meet patient needs, and 84% requested revised orders to ensure compliance. Suboptimal care and delays in care significantly and strongly (regression coefficients ≥0.69) predicted moral distress.

CONCLUSIONS

Critical care nurses perceive TJC medication titration standards to adversely impact patient care and contribute to moral distress. The improved 2020 updates to the standards do not address delays and inability to comply with orders, leading to moral distress. Advocacy is indicated in order to mitigate unintended consequences of TJC medication management titration standards.