Abstract & Commentary

Perceived Inappropriateness of Care Among ICU Clinicians

By David J. Pierson, MD, Editor, Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle, is Editor for Critical Care Alert.

Synopsis: In this 1-day survey of clinicians working in 82 ICUs in 10 countries, one in four nurses and one in three physicians reported that they delivered inappropriate care to at least one patient that day. Perceived inappropriateness of care was less likely when there was effective interdisciplinary collaboration and teamwork in the unit.

Source: Piers RD, et al; APPROPRICUS Study Group of the Ethics Section of the ESICM. Perceptions of the appropriateness of care among European and Israeli intensive care unit nurses and physicians. JAMA 2011;306:2694-2703.

This study was a survey of all the physicians and nurses working in 82 adult ICUs on a particular day in 2010. It was conducted by a study group of the Ethics Section of the European Society of Intensive Care Medicine, and the ICUs involved were in nine European countries plus Israel. The objective was to determine the prevalence of perceived inappropriateness of care (that is, a specific patient-care situation in which the clinician acts in a manner contrary to his or her personal and professional beliefs), using a series of questionnaires.

The ICUs studied had a median of 11 beds each and 95% of them managed both medical and surgical patients. Hospitals ranged from fewer than 250 beds (11%) to more than 750 beds (34%), and were mainly university or university-affiliated (56%), most of the rest (38%) being public hospitals. Seventy-four percent of the ICUs were closed units, and trained intensivists were present in all, with a median patient-to-intensivist ratio of 3.3. Of 99 ICUs eligible for participation in the study, 82 did so, and of 1953 clinicians working on the day of the study, median participation per ICU was 100% for physicians and 93% for nurses.

Perceived inappropriateness of care of at least one patient was reported by 439 ICU clinicians (27%; 25% of nurses and 32% of physicians). In ICUs for which patient data could be linked to the clinicians working there, inappropriateness of care was reported in 23% of the beds on that day. Of the potential types of inappropriate care listed on the questionnaire, the one most commonly reported (in 65% of instances) was "disproportionate care," broken down into "too much care" (in 89% of situations) followed by "other patients would benefit more" (in 38%). When symptom control decisions were solely in the hands of physicians, this was strongly associated with perceived inappropriateness of care among both nurses and physicians. The latter was significantly less common when nurses were involved in end-of-life decision making, when good collaboration existed between nurses and physicians, and when there was individual clinician freedom in deciding how to perform work-related tasks. Nurses — but not physicians — who perceived their workloads to be excessive were also more likely to report inappropriate patient care. In both groups of clinicians, perceived inappropriateness of care was positively associated with higher intent to leave a job.

Study participants generally reported end-of-life decisions as being made too late or too infrequently. Among those reporting inappropriate care, a perceived failure to observe distributive justice (that is, allocating care to those who need it most and not to those who do not need it) was common, especially among physicians. However, in two-thirds of the instances in which a given patient received care from more than one participant in the study, only one of them perceived that the care was inappropriate. The prevalence of perceived inappropriateness of care varied widely across countries, and also across ICUs and among individual clinicians within a given country. No severity-of-illness-related measure, such as mortality or length of stay, correlated with perceived inappropriateness of care.


This large-scale observational study found that one in four ICU nurses and one in three physician intensivists believed that they delivered inappropriate care to at least one of their patients on the day of the survey. This belief was strongly correlated with certain features of the ICUs in which they worked, particularly with respect to collaboration and teamwork among physicians and nurses. Both physicians and nurses who reported that they provided inappropriate care were more likely to express the intention to leave the job in the near future.

The study also found wide variation in the prevalence of perceived inappropriateness of care — among the 10 participating countries, in different ICUs within countries, and even among clinicians in a particular ICU — as well as disagreement between clinicians caring for a given patient as to whether the care was inappropriate. This emphasizes the subjective nature of perceived inappropriateness of care, as well as the importance of individual differences, potentially influenced by cultural and other factors.

This study was carried out in Europe — omitting Scandinavia, Spain, and the United Kingdom — as well as in Israel, and the applicability of its findings to American ICUs and the clinicians who work in them is uncertain. Certainly there are substantial organizational and cultural differences. However, the finding that perceived inappropriateness of care was less likely in ICUs where there was collaboration, teamwork, and shared decision making certainly seems applicable everywhere.