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Perceptions of Ethical Decision-Making Climate Among Clinicians Working in European and U.S. ICUs: Differences Between Nurses and Physicians*

Jensen, Hanne Irene PhD1,2; Hebsgaard, Stine MD3,4; Hansen, Tina Charlotte Bitsch MHH5; Johnsen, Rikke Frank Aagaard MD2; Hartog, Christiane S. MD6,7; Soultati, Ioanna MD8,9; Szucs, Orsolya MD10; Wilson, Michael E. MD11; van den Bulcke, Bo MPsych, MA12; Benoit, Dominique D. PhD12; Piers, Ruth PhD13

doi: 10.1097/CCM.0000000000004017
Clinical Investigations

Objectives: To examine perceptions of nurses and physicians in regard to ethical decision-making climate in the ICU and to test the hypothesis that the worse the ethical decision-making climate, the greater the discordance between nurses’ and physicians’ rating of ethical decision-making climate with physicians hypothesized to rate the climate better than the nurses.

Design: Prospective observational study.

Setting: A total of 68 adult ICUs in 13 European countries and the United States.

Subjects: ICU physicians and nurses.

Interventions: None.

Measurements and Main Results: Perceptions of ethical decision-making climate among clinicians were measured in April-May 2014, using a 35-items self-assessment questionnaire that evaluated seven factors (empowering leadership by physicians, interdisciplinary reflection, not avoiding end-of-life decisions, mutual respect within the interdisciplinary team, involvement of nurses in end-of-life care and decision-making, active decision-making by physicians, and ethical awareness). A total of 2,275 nurses and 717 physicians participated (response rate of 63%). Using cluster analysis, ICUs were categorized according to four ethical decision-making climates: good, average with nurses’ involvement at end-of-life, average without nurses’ involvement at end-of-life, and poor. Overall, physicians rated ethical decision-making climate more positively than nurses (p < 0.001 for all seven factors). Physicians had more positive perceptions of ethical decision-making climate than nurses in all 13 participating countries and in each individual participating ICU. Compared to ICUs with good or average ethical decision-making climates, ICUs with poor ethical decision-making climates had the greatest discordance between physicians and nurses. Although nurse/physician differences were found in all seven factors of ethical decision-making climate measurement, the factors with greatest discordance were regarding physician leadership, interdisciplinary reflection, and not avoiding end-of-life decisions.

Conclusions: Physicians consistently perceived ICU ethical decision-making climate more positively than nurses. ICUs with poor ethical decision-making climates had the largest discrepancies.

1Institute of Regional Health Research, University of Southern Denmark, Odense, Denmark.

2Department of Anaesthesiology and Intensive Care, Lillebaelt Hospital, University Hospital of Southern Denmark, Kolding, Vejle and Middelfart, Denmark.

3Department of Anaesthesiology and Intensive Care, Kolding Hospital, Kolding, Denmark.

4Department of Anaesthesiology and Intensive Medicine, Odense University Hospital, Odense, Denmark.

5Department of Anaesthesiology and Intensive Care, Holbæk Hospital, Holbæk, Denmark.

6Department of Anesthesiology and Intensive Care Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.

7Klinik Bavaria Kreischa, Kreischa, Germany.

8ICU “M.E.TH.A” University General Hospital of Thessaloniki, Thessaloniki, Greece.

9ICU Department of Anaesthesiology and Intensive Care Clinic of Aristotele University of Thessaloniki, Thessaloniki, Greece.

10Semmelweis University, 1st Department of Surgery, Budapest, Hungary.

11Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN.

12Department of Intensive Care Medicine, Ghent University Hospital and Ghent University, Ghent, Belgium.

13Department of Geriatrics, Ghent University Hospital and Ghent University, Ghent, Belgium.

*See also p. 1804.

This work was carried out in 68 adult ICUs in 13 European countries and the United States. Please see the Acknowledgments section at the end of the article for details.

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Dr. Benoit received funding from the Research Foundation Flanders (1800513N and 1800518N) and from ESICM/European Critical Care Research Network clinical research award. Dr. Piers received funding from Fund Marie-Thérèse De Lava, King Baudouin Foundation, Belgium. Dr. Hartog received funding from the German Federal Ministry of Education and Research via the Center for Sepsis Control and Care (FKZ 01EO1002) and a grant from the Innovation Funds of the German Federal Joint Committee (FKZ 91VSF17010). The remaining authors have disclosed that they do not have any potential conflicts of interest.

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