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Harm of Over-Regulation of ICU Nursing Practice


In a recent survey, nurses report that new intravenous infusion titration management standards cause patient harm and unnecessary stress among already taxed critical care nurses.


Drug titration is the process of adjusting the dose of a medication to achieve maximum benefit without adverse effects. In 2017, The Joint Commission, a nonprofit organization that 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 made in a well-intentioned attempt to optimize patient safety.


The revised guidelines shifted autonomy away from nurses; requiring physician orders for practices once decided upon by ICU nurses. Specifically, nurses could no longer determine the frequency of titration or the amount to increase or decrease the medication infusion.


These actions had previously been determined on a case by case basis at the bedside by the nurse taking into account each patient’s individual needs and response to medications. Concerned nurses formed a research team to investigate the unintended consequences of these new standards.



In two articles published in the September 2021 issue of the American Journal of Critical Care, the authors, who work at health care systems and schools of nursing across the United States, report that the vast majority of respondents experienced that 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”, says Judy Davidson, DNP, RN. lead author on the paper and nurse scientist for UC San Diego Health.


Adherence to The Joint Commission medication titration standards did not serve the patient or the nursing profession as a whole. The respondents made it clear that when nurses are able to use their extensive training and critical thinking skills functioning at the top of their scope of practice everyone benefits, including patients, staff, faculty and the 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% experienced moral distress by being prevented from doing what they felt was the right thing to do for patients.


In the second paper, 159 testimonies of nurses 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 a serious industry issue.

These papers highlight the harm that over-regulation can cause to patients and professionals. Authors 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.” states co-author Sandra K. Hanneman, PhD, RN, FAAN, Jerold B. Katz Distinguished Professor for Nursing Research, Research Department, Cizik School of Nursing, UTHealth. Daniel L. Arellano, PhD, RN, ACNP-BC, assistant professor, Department of Undergraduate Studies, Cizik School of Nursing, also is co-author on the paper reporting the survey results.


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