Perceptions of Appropriateness of Care Among European and Israeli Intensive Care Unit Nurses and Physicians
Perceptions of Appropriateness of Care Among European and Israeli Intensive Care Unit Nurses and Physicians
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DOI：
10.1001/jama.2011.1888
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发表时间：
2011-12-28
影响因子：
120.7
通讯作者：
Benoit, Dominique D.
中科院分区：
文献类型：
--
作者：
Piers, Ruth D.;Azoulay, Elie;Benoit, Dominique D.
重症监护病房 (ICU) 中的临床医生如果认为自己提供的护理不当，就会遭受道德困扰，并面临倦怠的风险。这种情况可能会危及患者的护理质量并增加员工流动率。 目的 确定 ICU 临床医生中感知不当护理的普遍程度，并确定与感知不当护理相关的患者相关情况、个人特征和工作相关特征。 设计、设置和参与者 2010 年 5 月 11 日对 9 个欧洲国家和以色列的 82 个成人 ICU 进行横断面评估。参与者是 1953 名提供床边护理的 ICU 护士和医生。 主要结果测量 感知到的护理不当，定义为临床医生以与其个人和专业信念相反的方式行事的特定患者护理情况，使用为本研究设计的调查问卷进行评估。 1651 名受访者的结果（中位响应率，总体为 93%；四分位数范围，82%-100% [中位数为 93%]护士和 100% 医生]），总共 439 名临床医生报告了至少 1 名患者的护理不当（27%；95% CI，24%-29%），1218 名临床医生中有 300 名是护士（25%），407 名医生中有 132 名（32%），26 名缺少描述职称的答案。在这 439 人中，有 397 人报告了 445 种与感知不当护理相关的情况。最常见的报告是认为护理不成比例（290 种情况 [65%; 95% CI, 58%-73%]，其中 89% 的情况报告“过度护理”，其次是“其他患者会受益更多”（168 种情况 [38%; 95% CI, 32%-43%]）。与护士和医生认为护理率不适当相关的是由护士和医生指导的症状控制决策。仅医生（比值比 [OR]，1.73；95% CI，1.17-2.56；P=.006）；护士参与临终决策（OR，0.76；95% CI，0.60-0.96；P=.02）；护士和医生之间良好的合作（OR，0.72；95% CI， 0.56-0.92；P=.009）；以及决定如何执行工作相关任务的自由度（OR，0.72；95% CI，0.59-0.89；P=.002）；而高感知工作量仅与护士显着相关（OR，1.49；95% CI，1.07-2.06；P=.02）。与较高的离职意向独立相关（OR，1.65；95% CI，1.04-2.63；P=.03）。在可关联患者数据的 69 个 ICU 子集中，临床医生报告称 207 名患者接受了不适当的护理，占 883 个 ICU 床位的 23%（95% CI，20%-27%）。 结论 在一组欧洲和以色列 ICU 中。临床医生经常报告不适当护理的看法，并且与表明良好团队合作的因素呈负相关。 JAMA 2011；306(24):2694-2703。
Context 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.Objective 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.Design, Setting, and Participants 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.Main Outcome Measure 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.Results 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.Conclusion 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. JAMA. 2011;306(24):2694-2703