Ethical climate and intention to leave among critical care clinicians: an observational study in 68 intensive care units across Europe and the United States

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Abstract

Purpose

Apart from organizational issues, quality of inter-professional collaboration during ethical decision-making may affect the intention to leave one’s job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics.

Methods

Perceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self-assessment questionnaire, together with job characteristics and intent to leave as a sub-analysis of the Dispropricus study. The validated ethical decision-making climate questionnaire included seven factors: not avoiding decision-making at end-of-life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self-reflective physician leadership, active decision-making at end-of-life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within ICUs, within the different countries.

Results

Of 3610 nurses and 1137 physicians providing ICU bedside care, 63.1% and 62.9% participated, respectively. Of 2992 participating clinicians, 782 (26.1%) had intent to leave, of which 27% nurses, 24% junior and 22.7% senior physicians. After adjustment for country, ICU and clinicians characteristics, mutual respect OR 0.77 (95% CI 0.66- 0.90), open interdisciplinary reflection (OR 0.73 [95% CI 0.62–0.86]) and not avoiding EOL decisions (OR 0.87 [95% CI 0.77–0.98]) were all associated with a lower intent to leave.

Conclusion

This is the first large multicenter study showing an independent association between clinicians’ intent to leave and the quality of the ethical climate in the ICU. Interventions to reduce intent to leave may be most effective when they focus on improving mutual respect, interdisciplinary reflection and active decision-making at EOL.

Electronic supplementary material

The online version of this article (10.1007/s00134-019-05829-1) contains supplementary material, which is available to authorized users.

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Most cited references 28

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Teacher Recruitment and Retention: A Review of the Recent Empirical Literature

L. Santibanez, C. Guarino, G. A. Daley (2006)

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Explaining burnout and the intention to leave the profession among health professionals – a cross-sectional study in a hospital setting in Switzerland

Oliver Hämmig (2018)

Background Burnout and the intention to leave the profession are frequently studied outcomes in healthcare settings that have not been investigated together and across different health professions before. This study aimed to examine work-related explanatory factors or predictors of burnout and the intention to leave the profession among health professionals in general, and nurses and physicians in particular. Methods Cross-sectional survey data of 1840 employees of six public hospitals and rehabilitation clinics recorded in 2015/16 in German-speaking Switzerland were used. Multiple logistic and stepwise linear regression analyses were performed to estimate the relative risks (odds ratios) and standardized effects (beta coefficients) of different workloads and work-related stressors on these outcomes and to study any possible mediation between them. Results On average, one in twelve health professionals showed increased burnout symptoms and every sixth one thought frequently of leaving the profession. Temporal, physical, emotional and mental workloads and job stresses were strongly and positively associated with burnout symptoms and thoughts of leaving the profession. However, the relative risks of increased burnout symptoms and frequent thoughts of leaving the profession were highest in the case of effort-reward and work-life imbalances. In fact, these two work-related stress measures partly or even largely mediated the relationships between exposures (workloads, job stresses) and outcomes and were found to be the strongest predictors of all. Whereas a work-life imbalance most strongly predicted burnout symptoms among health professionals (β = .35), and particularly physicians (β = .48), an effort-reward imbalance most strongly predicted thoughts of leaving the profession (β = .31–36). A substantial part of the variance was explained in the fully specified regression models across both major health professions and both outcomes. However, explained variance was most pronounced for burnout symptoms of physicians (43.3%) and for frequent thoughts of leaving the profession among nurses and midwives (28.7%). Conclusions Reducing workload and job stress, and particularly reward frustration at work, as well as the difficulties in combining work and private lives among health professionals, may help to prevent them from developing burnout and/or leaving the profession and consequently also to reduce turnover, early retirement, career endings and understaffing in healthcare settings.

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Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians.

Ruth Piers (2011)

Clinicians in intensive care units (ICUs) who perceive the care they provide as inappropriate experience moral distress and are at risk for burnout. This situation may jeopardize patient quality of care and increase staff turnover. To determine the prevalence of perceived inappropriateness of care among ICU clinicians and to identify patient-related situations, personal characteristics, and work-related characteristics associated with perceived inappropriateness of care. Cross-sectional evaluation on May 11, 2010, of 82 adult ICUs in 9 European countries and Israel. Participants were 1953 ICU nurses and physicians providing bedside care. 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, as assessed using a questionnaire designed for the study. Of 1651 respondents (median response rate, 93% overall; interquartile range, 82%-100% [medians 93% among nurses and 100% among physicians]), perceived inappropriateness of care in at least 1 patient was reported by 439 clinicians overall (27%; 95% CI, 24%-29%), 300 of 1218 were nurses (25%), 132 of 407 were physicians (32%), and 26 had missing answers describing job title. Of these 439 individuals, 397 reported 445 situations associated with perceived inappropriateness of care. The most common reports were perceived disproportionate care (290 situations [65%; 95% CI, 58%-73%], of which "too much care" was reported in 89% of situations, followed by "other patients would benefit more" (168 situations [38%; 95% CI, 32%-43%]). Independently associated with perceived inappropriateness of care rates both among nurses and physicians were symptom control decisions directed by physicians only (odds ratio [OR], 1.73; 95% CI, 1.17-2.56; P = .006); involvement of nurses in end-of-life decision making (OR, 0.76; 95% CI, 0.60-0.96; P = .02); good collaboration between nurses and physicians (OR, 0.72; 95% CI, 0.56-0.92; P = .009); and freedom to decide how to perform work-related tasks (OR, 0.72; 95% CI, 0.59-0.89; P = .002); while a high perceived workload was significantly associated among nurses only (OR, 1.49; 95% CI, 1.07-2.06; P = .02). Perceived inappropriateness of care was independently associated with higher intent to leave a job (OR, 1.65; 95% CI, 1.04-2.63; P = .03). In the subset of 69 ICUs for which patient data could be linked, clinicians reported received inappropriateness of care in 207 patients, representing 23% (95% CI, 20%-27%) of 883 ICU beds. Among a group of European and Israeli ICU clinicians, perceptions of inappropriate care were frequently reported and were inversely associated with factors indicating good teamwork.

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Author and article information

Contributors

Bo Van den Bulcke:

ORCID: http://orcid.org/0000-0001-5379-8886

bo.vandenbulcke@uzgent.be

Journal

Journal ID (nlm-ta): Intensive Care Med

Journal ID (iso-abbrev): Intensive Care Med

Title: Intensive Care Medicine

Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )

ISSN (Print): 0342-4642

ISSN (Electronic): 1432-1238

Publication date (Electronic): 5 November 2019

Publication date PMC-release: 5 November 2019

Publication date (Print): 2020

Volume: 46

Issue: 1

Pages: 46-56

Affiliations

[1 ]GRID grid.410566.0, ISNI 0000 0004 0626 3303, Department of Intensive Care Medicine, , Ghent University Hospital, ; De Pintelaan 185, Ghent, Belgium

[2 ]GRID grid.46699.34, ISNI 0000 0004 0391 9020, King’s College Hospital, ; London, UK

[3 ]GRID grid.4830.f, ISNI 0000 0004 0407 1981, Department of Medical Oncology, University Medical Center Groningen, , University of Groningen, ; Groningen, The Netherlands

[4 ]GRID grid.411798.2, ISNI 0000 0000 9100 9940, Department of Anesthesiology and Intensive Care, First Faculty of Medicine, , Charles University in Prague and General University Hospital in Prague, ; Prague, Czech Republic

[5 ]GRID grid.417271.6, ISNI 0000 0004 0512 5814, Department of Intensive Care Medicine, Institute of Regional Research, , Vejle Hospital, ; Vejle, Denmark

[6 ]GRID grid.1649.a, ISNI 000000009445082X, Department of Anaesthesiology and Intensive Care, , Sahlgrenska University Hospital, ; Gothenburg, Sweden

[7 ]GRID grid.10825.3e, ISNI 0000 0001 0728 0170, University of Southern Denmark, ; Odense, Denmark

[8 ]GRID grid.413328.f, ISNI 0000 0001 2300 6614, Hôpital Saint-Louis and University Paris-7, ; Paris, France

[9 ]GRID grid.239395.7, ISNI 0000 0000 9011 8547, Department of Anesthesia, Critical Care, and Pain Medicine, , Beth Israel Deaconess Medical Center and Harvard Medical School, ; Boston, MA USA

[10 ]Service des Medicine Interne, Soins Intensifs et Urgences Oncologiques, Institut Jules Bordet, ULB, Brussels, Belgium

[11 ]GRID grid.412824.9, ISNI 0000 0004 1756 8161, SCDU Anestesia e Rianimazione, Azienda and Ospedaliero Universitaria, , Maggiore della Carità, ; Novara, Italy

[12 ]GRID grid.11804.3c, ISNI 0000 0001 0942 9821, Semmelweis University Budapest, ; Budapest, Hungary

[13 ]Intensive Care Department, Hospital S.António, Porto, Portugal

[14 ]Tettnang Hospital, Tettnang, Germany

[15 ]GRID grid.5645.2, ISNI 000000040459992X, Department of Intensive Care Medicine, , Erasmus MC University Medical Center Rotterdam, ; Rotterdam, The Netherlands

[16 ]GRID grid.5342.0, ISNI 0000 0001 2069 7798, Faculty of Psychology and Educational Sciences, Department of Personnel Management, Work and Organizational Psychology, , Ghent University, ; Ghent, Belgium

[17 ]GRID grid.5342.0, ISNI 0000 0001 2069 7798, Department of Applied Mathematics, Computer Science and Statistics, Faculty of Sciences, , Ghent University, ; Ghent, Belgium

[18 ]GRID grid.8991.9, ISNI 0000 0004 0425 469X, London School of Hygiene and Tropical Medicine, ; London, UK

[19 ]GRID grid.5342.0, ISNI 0000 0001 2069 7798, Department of Psycho-analysis and Clinical Consulting, Faculty of Psychology and Educational Sciences, , Ghent University, ; Ghent, Belgium

[20 ]GRID grid.410566.0, ISNI 0000 0004 0626 3303, Department of Geriatric Medicine, , Ghent University Hospital, ; Ghent, Belgium

Author information

Bo Van den Bulcke http://orcid.org/0000-0001-5379-8886

Article

Publisher ID: 5829

DOI: 10.1007/s00134-019-05829-1

PMC ID: 6954133

PubMed ID: 31690968

SO-VID: 4fd82c6f-67c3-4596-9379-4047cdaa1286

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

History

Date received : 28 June 2019

Date accepted : 10 October 2019

Funding

Funded by: ESCIM/ECCRN clinical research award

Funded by: FWO senior clinical investigators grant

Award ID: 1800513N

Award Recipient : Dominique Benoit

Custom metadata

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: intent to leave,ethical climate,interdisciplinary reflection,decision-making,respect

Data availability:

ScienceOpen disciplines: Emergency medicine & Trauma

Keywords: intent to leave, ethical climate, interdisciplinary reflection, decision-making, respect

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Ethical climate and intention to leave among critical care clinicians: an observational study in 68 intensive care units across Europe and the United States

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Preventive and Emergency Medicine Insights

Most cited references 28

Teacher Recruitment and Retention: A Review of the Recent Empirical Literature

Explaining burnout and the intention to leave the profession among health professionals – a cross-sectional study in a hospital setting in Switzerland

Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians.

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Cited by 40

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