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29-12-2011 | Article

Many intensive care clinicians concerned over inappropriate care


Free abstract

MedWire News: A significant number of clinicians working in intensive care units (ICUs) believe that some patients receive inappropriate care, report researchers.

"Clinicians perceive the care they provide as inappropriate when they feel that it clashes with their personal beliefs and/or professional knowledge," explain Ruth Piers (Ghent University Hospital, Gent, Belgium) and colleagues. "ICU workers who provide care perceived as inappropriate experience acute moral distress and are at risk for burnout."

Their study, published in JAMA, involved ICU clinicians in Belgium, France,Germany, Israel, Italy, Malta, Poland, Portugal, Switzerland, and the Netherlands. The investigation took place on the same day in each of these countries except Israel, and each ICU was assigned a "local investigator" to recruit the clinicians.

Three questionnaires were used: the ICU questionnaire, completed by the local investigator regarding the ICU characteristics; the clinician questionnaire, which recorded the clinicians' personal characteristics; and the perceived inappropriateness questionnaire, through which the clinicians reported their views.

In the 82 ICUs that participated, 1651 clinicians responded. Of these, 439 (27%) reported perceived inappropriateness of care in at least one of their patients. In addition, 1218 nurses completed the perceived inappropriateness questionnaire, of whom 300 (25%) reported such inappropriateness.

The most common reason given for this inappropriateness was perceived disproportionate care, reported in 65% of cases. Of these, 89% of responders thought they were providing over and above the level of care required, while the remaining 11% thought the care they were giving was insufficient.

The second most common reason was feeling that other patients might benefit from a current patient's place in the ICU, cited in 38% of cases. A significantly greater proportion of clinicians than nurses reported feeling this (44 vs 34%).

More nurses than clinicians were distressed by the perception of inappropriate care (68 vs 55%). Perceived inappropriateness of care was independently associated with a higher level of intentional resignation; indeed 9% of clinicians had left a previous job because of disagreements over patient care.

"In our study, the variability in perceived inappropriateness of care was largely associated with differences in the ethical environment across ICUs," say Piers and team. "For example, perceived inappropriateness of care was less common in ICUs in which physicians and nurses had a certain degree of job autonomy, an acceptable workload, and a high level of interdisciplinary collaboration and decision making."

The researchers conclude: "Perceived inappropriateness of care is a subjective factor that does not necessarily indicate a failure to adhere to recommendations for patient care but that may serve as a marker for inadequate communication, decision sharing, and job autonomy within the ICU."

By Chloe McIvor