Inappropriate care in European ICUs: confronting views from nurses and junior and senior physicians.
BACKGROUND
ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power.


METHODS
We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations.


RESULTS
By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups.


CONCLUSIONS
ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.
Department of Geriatrics, Ghent University Hospital, Ghent, Belgium. Electronic address: ruth.piers@ugent.be.
Ruth D
RD
Piers
Medical ICU, Hôpital Saint-Louis and University Paris-7, Paris, France.
Elie
E
Azoulay
Department of Intensive Care, University Hospitals and University of Geneva, Geneva, Switzerland.
Bara
B
Ricou
School of Nursing, Hadassah-Hebrew University, Jerusalem, Israel.
Freda
F
DeKeyser Ganz
Medical ICU, Hôpital Saint-Louis and University Paris-7, Paris, France.
Adeline
A
Max
Department of Anaesthesiology and Critical Care Medicine, Tettnang Hospital, Tettnang, Germany.
Andrej
A
Michalsen
Serviço Cuidados Intensivos 1, Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal.
Paulo
P
Azevedo Maia
Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland.
Radoslaw
R
Owczuk
Imperial College NHS Trust, Centre for Perioperative Medicine and Critical Care Research, Charing Cross Hospital, London, England.
Francesca
F
Rubulotta
Service des Soins Intensifs Medico-Chirurgicaux et Oncologie Thoracique, Institut Jules Bordet, Brussels, Belgium.
Anne-Pascale
AP
Meert
Department of Medical Oncology, University Medical Center Groningen, Groningen, The Netherlands.
Anna K
AK
Reyners
Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
Johan
J
Decruyenaere
Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium.
Dominique D
DD
Benoit
D000328:Adult; D001291:Attitude of Health Personnel; D002055:Burnout, Professional; D003430:Cross-Sectional Studies; D005060:Europe; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007362:Intensive Care Units / Q000592:standards*; D007400:Interprofessional Relations; D007588:Job Satisfaction; D008297:Male; D008875:Middle Aged; D009726:Nurses / Q000523:psychology*; D015279:Organizational Culture; D005791:Patient Care / Q000592:standards; D010348:Patient Care Team / Q000592:standards*; D010820:Physicians / Q000523:psychology*; D011361:Professional Competence; D011787:Quality of Health Care; D012189:Retrospective Studies; D011795:Surveys and Questionnaires; D019564:Unnecessary Procedures; D000078329:Workforce