According to a study in the December issue of JAMA, a survey of nurses and physicians in intensive care units (ICUs) in Europe and Israel suggested that the perception of inappropriate care was common, for example, excess intensity of care for a patient, and that these perceptions were linked to inadequate communication, decision sharing, and job autonomy.

Background information in the article states that:

“Clinicians perceive the care they provide as inappropriate when they feel that it clashes with their personal beliefs and/or professional knowledge. 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.”

The extent of perceived inadequate care in the ICU is unknown.

Ruth D. Piers, M.D., of Ghent University Hospital, Gent, Belgium, and her team decided to determine the prevalence and characteristics of perceived inappropriateness of care among clinicians in ICUs. On the 11 May 2010, the researchers surveyed 1,953 ICU nurses and physicians in 82 adult ICUs in 9 European countries including Israel who provided bedside care.

The survey included questions regarding perceived inappropriateness of care as defined in a specific patient-care situation in which the clinician acts in a manner contrary to his or her personal and professional beliefs.

From 1,651 clinicians who responded, 439 or 27% reported to have perceived inappropriateness of care in at least 1 patient, whilst from 1,218 nurses who completed the questionnaire, 300 or 25% reported perceived inappropriateness of care. 132 or 32% of the 407 ICU physicians who provided care also reported to have perceived inappropriateness of care in at least 1 of their patients.

Overall, 397 clinicians completed 445 perceived inappropriateness of care questionnaires. The most frequent reported reason for perceived inappropriateness of care was reported by 65% as perceived disproportionate care, with 89% perceiving the amount of care as excessive and 11% as insufficient.

38% felt that ICU care would be more beneficial to other patients than those currently receiving it, which was the second most common reason for perceived inappropriateness of care. Physicians felt significantly more distributive injustice compared with nurses.

The findings indicated that numerous factors were independently linked to lower perceived inappropriateness of care rates. These included:

  • decisions regarding symptom control shared by nurses and physicians instead of being made just by physicians
  • good collaboration between physicians and nurses
  • nurses involvement in end-of-life decisions
  • freedom to decide how to perform work-related tasks
  • perceived lower workload amongst nurses only

The researchers write:

“In conclusion, perceived inappropriateness of care is common among nurses and physicians in ICUs and is significantly associated with an intent to leave the current clinical position, suggesting a major impact on clinician well-being. The main reported reason for perceived inappropriateness of care is a mismatch between the level of care and the expected patient outcome, usually in the direction of perceived excess intensity of care.”

They continue writing ICU managers challenge 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.”

Scott D. Halpern, M.D., Ph.D., of the University of Pennsylvania in Philadelphia, writes in an accompanying editorial that:

“..although the report by Piers et al provides a hazy lens through which to view appropriateness of care, it yields more clarity than prior studies. Thus, the greatest contribution of [this study] may be to provide the clarion call needed to spur more rigorous study of what happens to clinicians and the care they provide when requests for care do not resonate with clinicians’ conceptions of appropriateness. Such clinician-centered outcomes research, in other words, may usefully supplement the patient’s perspective in gauging the quality of health care delivery.”

Written by Petra Rattue