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Perception of inappropriate care frequent among ICU workers

CHICAGO A survey of nurses and physicians in intensive care units (ICUs) in Europe and Israel indicated that the 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, according to a study in the December 28 issue of JAMA.

"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," according to background information in the article. The extent of perceived inappropriateness of care in the ICU is unknown.

Ruth D. Piers, M.D., of Ghent University Hospital, Gent, Belgium, and colleagues conducted a study to determine the prevalence and characteristics of perceived inappropriateness of care among clinicians in ICUs. The study consisted of an evaluation on May 11, 2010, of 82 adult ICUs in 9 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 percent) reported perceived inappropriateness of care in at least 1 patient. Of the 1,218 nurses who completed the perceived inappropriateness of care questionnaire, 300 (25 percent) reported perceived inappropriateness of care. Of the 407 ICU physicians who provided care, 132 (32 percent) reported perceived inappropriateness of care in at least 1 of their patients.

In all, 397 clinicians completed 445 perceived inappropriateness of care questionnaires. Perceived disproportionate care was the most common reported reason (65 percent) for perceived inappropriateness of care; in 89 percent of these cases, the amount of care was perceived as excessive and in 11 percent as insufficient. Feeling that other patients would benefit more from ICU care than the present patient was the second most common reason (38 percent) for perceived inappropriateness of care. This feeling of distributive injustice was significantly more common among physicians than among nurses, the authors write.

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 (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 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," the researchers write.

The authors add 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."

(JAMA. 2011;306[24]:2694-2703. Available pre-embargo to the media at

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Perceived Inappropriateness of Care in the ICU

In an accompanying editorial, Scott D. Halpern, M.D., Ph.D., of the University of Pennsylvania, Philadelphia, writes 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."

(JAMA. 2011;306[24]:2725-2726. Available pre-embargo to the media at

Editor's Note: Please see the article for additional information, including financial disclosures, funding and support, etc.

To contact Ruth D. Piers, M.D., email To contact editorial author Scott D. Halpern, M.D., Ph.D., call Jessica Mikulski at 215-349-8369 or email


Contact: Ruth D. Piers, M.D.
JAMA and Archives Journals

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