Nursing Scope of Practice

I know of no physician who hasn’t learned something valuable from a more experienced nurse. Not an almost medical student doctor, a newbie “intern,” or an on-the-job training resident physician. So why does the Joint Commission believe those physicians should entirely direct nurses? And who is the Joint Commission anyway?

Let’s start with the easy question, who is the Joint Commission. They are an organization that provides accreditation for hospitals. I am proud to say its origins are with a surgeon, Ernest Codman, who in the early 1900s had the novel idea that you could improve your surgical practice and care by keeping records of treatments and outcomes. At mid-century, the Joint Commission on Accreditation of Hospitals was formed by merging similar accreditation groups founded by physicians or hospitals. But its real strength came in 1965 when accreditation by JCAH became a requirement for Medicare payments. 

Hospitals are reviewed every three years in an “unannounced” survey. Of course, unannounced is not the same as unexpected. There is no hospital I have been affiliated with that didn’t know it was coming and paint the necessary walls, remove the unallowed stretchers in the hall, review with the principals about to be interviewed what to say, and make sure all the reams of protocols and regulations were ready for review. 

To summarize, they are a voluntary collection of “stakeholders” who are empowered through our federal government to accredit hospitals for the Medicare program. 

“The hospital accreditation industry has been under heightened scrutiny since last year when an investigation from the Wall Street Journal found that the Joint Commission, which accredits nearly 80% of U.S. hospitals, rarely pulls accreditation for providers even when violations of Medicare requirements are found. The paper found that just 1% of facilities not in compliance in 2014 lost accreditation.” 

Modern Healthcare 2018

They are a non-profit (remember that is a tax status, not a revenue statement) that recognized a $6 million profit from their consulting arm that advises hospitals on preparing for accreditation and $16 million for their accreditation arm.

How tightly must physicians control or supervise nurses?

To understand this question, a bit of background. Critical care patients, like those requiring ventilators from COVID-19, are usually placed on various intravenous medications given continuously, as drips, rather than episodically every hour or so. These medications support our blood pressure or heart rate and provide sedation. They have a therapeutic range, usually measured in amounts/body weight, and are given using intravenous pumps that provide a constant infusion rate. For the most part, once it is decided to use one of these drips, the concentrations, starting doses and upper limits are protocol-driven – determined by the hospital staff.

Critical care is very personalized medicine, and those intravenous drips need to be titrated, adjusted to the patient lying in bed. Some require more medication to be sedated, some less. Some require higher doses of medication to maintain sufficient blood pressure, others less. 

The Joint Commission wants all of those medication parameters, including how fast or slow to turn them up or down, to be controlled by physicians. Critical care nurses object and published a survey of the American Association of Critical-care Nurses members on the topic. The study has many flaws, the least of which is its small sample size, roughly 0.5% of the membership. But that does not mean that their concerns are not warranted or flag deeper problems. 

“Critical care nurses perceive TJC [the Joint Commission] medication titration standards to adversely impact patient care and contribute to moral distress.”  

70% of the nurses had deviated from physician orders to “meet patient needs,” 84% had requested revision of those orders to “ensure compliance.” 68% reported suboptimal care in following the orders. I find the term moral distress a bit overblown. It is defined as “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right court of action.” As a self-employed surgeon, those constraints made me change the playing field; I went to a different institution. Hospital-employed nurses do not have the same options, so perhaps that bind makes for nursing moral distress when I feel more anger.

Who should decide on these medical decisions?

Should physicians approve all of these decisions? That might work in teaching hospitals or hospitals with 24-hour in-person coverage in their intensive care units. But that is not the case for a majority of hospitals. In those instances, a nurse would have to contact the physician to get approval. And contacting physicians while it has become more text-based still requires time. Heaven help you if you have to call a physician and wind up in the telephone chain madly pressing the button for “I am a nurse” instead of the button for “rescheduling an appointment.” 

I have to agree with the nurses on this one,

“nurses are uniquely positioned at the bedside – assessing patients, titrating medications, and then reassessing – to determine the optimal doses to meet patients' targeted clinical parameters.”

Why should a physician be required instead of an equally knowledgeable nurse? Some might argue about the equally knowledgeable part, but a hospital-based certification program would address those issues. Physician assistants, who now wish to be called physician associates to remove the stigma of assisting, have less didactic training than critical care nurses and have far more latitude in treating patients. Of course, physician assistants are supervised; but that supervision can be miles, minutes, or hours away. 

Nurses certified in critical care should have more autonomy. The fact of their experience and training outweighs the background knowledge they obtained in getting that Bachelors of Nursing degree. To be accreditated by the AACR, you need 1,750 hours of direct patient care of critically ill patients in the last two years, 850 in the last year. 

The nurses raise one other important question. What is the scientific basis for the JC’s requirements? An admittedly cursory search fails to produce observational studies comparing nursing experience to critical care outcomes. As physicians continue to turn patient management over to advanced nurse practitioners, physician assistants, and specialty nurses, like the critical care nurses, we need to get outcome data on their work. That’s what Dr. Codman did, and we should do.

Source: Survey of Nurses’ Experiences Applying The Joint Commission’s Medication Management Titration Standards American Journal of Critical Care DOI: 10.4037/ajcc2021716