A survey of nurses and physicians in ICUs in Europe and Israel indicated that a perception of inappropriate care, such as excess intensity of care for a patient, was common, and that these perceptions were associated with inadequate decision sharing, communication and job autonomy.

“Clinicians perceive the care they provide as inappropriate when they feel that it clashes with their personal beliefs and/or professional knowledge,” researchers wrote in the Dec. 28 issue of JAMA. “Intensive care unit workers who provide care perceived as inappropriate experience acute moral distress and are at risk for burnout. This situation may jeopardize the quality of care and increase staff turnover.”

Noting that the extent of perceived inappropriateness of care in the ICU is unknown, Ruth D. Piers, MD, of Ghent University Hospital in Belgium, and colleagues conducted a study to determine the prevalence and characteristics of perceived inappropriateness of care among ICU clinicians.

The study consisted of an evaluation on May 11, 2010, of 82 adult ICUs in nine European countries and Israel. The participants were 1,953 ICU nurses and physicians providing bedside care who were surveyed regarding perceived inappropriateness of care, defined as a specific patient-care situation in which the clinician acts in a manner contrary to his or her personal and professional beliefs.

Of the 1,651 clinicians who provided responses, 439 (27%) reported perceived inappropriateness of care in at least one patient. Of the 1,218 nurses who completed the perceived inappropriateness of care questionnaire, 300 (25%) reported perceived inappropriateness of care. Of the 407 ICU physicians who provided care, 132 (32%) reported perceived inappropriateness of care in at least one of their patients.

In all, 397 clinicians completed 445 perceived inappropriateness of care questionnaires. Perceived disproportionate care was the most common reported reason (65%) for perceived inappropriateness of care. In 89% of these cases, the amount of care was perceived as excessive, compared to 11% of cases in which it was perceived as insufficient.

Feeling that other patients would benefit more from ICU care than the present patient was the second most common reason (38%) for perceived inappropriateness of care. This feeling of distributive injustice was significantly more common among physicians than among nurses, the authors wrote.

Analysis indicated that several factors were independently associated with lower perceived inappropriateness of care rates: decisions about symptom control shared by nurses and physicians as opposed to being made by the physicians only; involvement of nurses in end-of-life decisions; good collaboration between nurses and physicians; work autonomy, meaning freedom to decide how to perform work-related tasks; and perceived lower workload (only among nurses).

“In conclusion, perceived inappropriateness of care is common among nurses and physicians among ICUs and is significantly associated with an intent to leave the current clinical position, suggesting a major impact on clinician well-being,” the authors wrote.

The authors added that the challenge for ICU managers is “to create ICUs in which self-reflection, mutual trust, open communication and shared decision-making are encouraged in order to improve the well-being of the individual clinicians and, thereby, the quality of patient care.”

To read a study summary and access the study via subscription or purchase, visit http://bit.ly/rTr6Sy.