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Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate*

Hamric, Ann B. PhD, RN, FAAN; Blackhall, Leslie J. MD, MTS

doi: 10.1097/01.CCM.0000254722.50608.2D
Clinical Investigations

Objective: To explore registered nurses’ and attending physicians’ perspectives on caring for dying patients in intensive care units (ICUs), with particular attention to the relationships among moral distress, ethical climate, physician/nurse collaboration, and satisfaction with quality of care.

Design: Descriptive pilot study using a survey design.

Setting: Fourteen ICUs in two institutions in different regions of Virginia.

Subjects: Twenty-nine attending physicians who admitted patients to the ICUs and 196 registered nurses engaged in direct patient care.

Interventions: Survey questionnaire.

Measurements and Main Results: At the first site, registered nurses reported lower collaboration (p < .001), higher moral distress (p < .001), a more negative ethical environment (p < .001), and less satisfaction with quality of care (p = .005) than did attending physicians. The highest moral distress situations for both registered nurses and physicians involved those situations in which caregivers felt pressured to continue unwarranted aggressive treatment. Nurses perceived distressing situations occurring more frequently than did physicians. At the second site, 45% of the registered nurses surveyed reported having left or considered leaving a position because of moral distress. For physicians, collaboration related to satisfaction with quality of care (p < .001) and ethical environment (p = .004); for nurses, collaboration was related to satisfaction (p < .001) and ethical climate (p < .001) at both sites and negatively related to moral distress at site 2 (p = .05). Overall, registered nurses with higher moral distress scores had lower satisfaction with quality of care (p < .001), lower perception of ethical environment (p < .001), and lower perception of collaboration (p < .001).

Conclusions: Registered nurses experienced more moral distress and lower collaboration than physicians, they perceived their ethical environment as more negative, and they were less satisfied with the quality of care provided on their units than were physicians. Provider assessments of quality of care were strongly related to perception of collaboration. Improving the ethical climate in ICUs through explicit discussions of moral distress, recognition of differences in nurse/physician values, and improving collaboration may mitigate frustration arising from differences in perspective.

From the University of Virginia Schools of Nursing and Medicine, Charlottesville, VA.

Supported, in part, by intramural funds from the University of Virginia Schools of Nursing and Medicine and the UVA School of Nursing Alumni Association, Charlottesville, VA.

The authors have not disclosed any potential conflicts of interest.

© 2007 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins