Interventions aiming to reduce or prevent intent to leave among the ICU workforce should focus on improving their ethical climate. |
Introduction
Methodology
Ethics
Data collection and ethical climate instruments
Data analysis
Univariate analysis
Multivariate analysis
Variables | Overall | Intent to job leave | p value | |
---|---|---|---|---|
Yes | No | |||
Overall respondent | n = 2992 | n = 782 (26.1%) | n = 2210 (73.9%) | |
Country level | ||||
General economic factors (25th–75th percentile) | ||||
Percentage of inhabitants > 65 year | 18.0 (18.0–20.0) | 18.0 (18.0–20.0) | 18.0 (18.0–20.0) | 0.823 |
Number of ICU beds/100,000 inhabitants | 6.7 (6.4–15.9) | 6.7 (6.0–12.5) | 6.7 (6.4–15.9) | 0.016 |
GDP** per inhabitant (dollar) (× 1000) | 41.8 (30.8–48.1) | 41.8 (30.8–51.8) | 41.8 (30.7–48.1) | 0.159 |
GDP health expediture (%) | 10.6 (9.7–11.7) | 9.8 (9.7–11.3) | 11.2 (9.7–12.9) | < 0.001 |
GDP health expenditure per capita (x 1000) | 5.1 (3.2–6.1) | 5.1 (3.2–6.1) | 5.1 (3.2–6.1) | 0.498 |
Big Mac index*** | 4.3 (4.0–4.8) | 4.4 (4.0–4.9) | 4.3 (4.0–4.8) | < 0.001 |
Geographical region (%) | ||||
Northern Europe | 674 (22.5%) | 228 (33.8%) | 446 (66.7%) | < 0.001 |
Western Europe/VS | 1468 (49.1%) | 337 (22.9%) | 1131 (77.1%) | |
Central Europe | 513 (17.1%) | 123 (23.9%) | 390 (76.1%) | |
Southern Europe | 337 (11.3%) | 94 (27.9%) | 243 (72.1%) | |
Hospital level (%) | ||||
Hospital type | ||||
University | 1787 (59.7%) | 458 (25.6%) | 1329 (74.4%) | 0.671 |
University affiliated | 364 (12.2%) | 104 (28.6%) | 260 (71.4%) | |
Hospital | 749 (25.0%) | 201 (26.8%) | 548 (73.2%) | |
Private | 92 (3.1%) | 19 (20.7%) | 73 (79.3%) | |
Total beds in hospital | ||||
< 250 | 147 (4.9%) | 40 (27.2%) | 107 (72.8%) | < 0.001 |
250–499 | 689 (23.0%) | 207 (30.0%) | 482 (70.0%) | |
500–749 | 581 (19.4%) | 168 (28.9%) | 413 (71.1%) | |
> 750 | 1575 (52.6%) | 367 (23.3%) | 1208 (76.7%) | |
ICU level (25th–75th percentile) | ||||
General | ||||
Number of beds per ICU | 13.0 (9.0–22.0) | 12.0 (9.0–16.0) | 13.0 (9.0–24.0) | < 0.001 |
Severity of illness | ||||
ICU mortality in 2013 (in %) | 13.0 (8.0–18.0) | 14.0 (8.0–18.0) | 13.0 (8.0–18.0) | < 0.001 |
Length of stay in 2013 (in days) | 4.0 (3.1–6.0) | 4.6 (3.1–6.0) | 4.0 (3.0–6.0) | 0.057 |
Organizational factors | ||||
Staffing | ||||
Patient to nurse ratio | 1.7 (1.0–2.0) | 1.5 (1.0–2.0) | 2.0 (1.0–2.0) | 0.311 |
Patient to junior physician ratio | 4.0 (2.0–6.0) | 4.0 (2.0–5.8) | 4.0 (2.0–6.0) | 0.073 |
Patient to senior physician ratio | 6.0 (3.0–8.0) | 6.0 (3.0–8.0) | 7.0 (3.0–8.0) | 0.109 |
Part- of fulltime psychologist available | 1760 (58.8%) | 479 (61.3%) | 1281 (57.9%) | 0.118 |
Physician salary (Euro x 1000) (15 years of working experience) | 5.0 (3.2–7.3) | 4.9 (3.2–6.3) | 5.0 (3.2–7.3) | 0.005 |
Nurse salary (Euro x 1000) (15 years of working experience) | 2.5 (1.9–2.8) | 2.6 (1.9–2.9) | 2.5 (1.9–2.8) | 0.013 |
Ethical decision-making climate (%) | ||||
Good | 535 (17.9%) | 162 (30.3%) | 373 (69.7%) | 0.607 |
Average with nurse involvement at EOL | 1253 (41.9%) | 332 (26.5%) | 921 (73.5%) | |
Average without nurse involvement at EOL | 302 (10.1%) | 65 (21.5%) | 237 (78.5%) | |
Poor | 902 (30.1%) | 223 (24.7%) | 679 (75.3%) | |
Clinicians level (%) | ||||
Age (25th–75th percentile) | 38.0 (30.0–47.0) | 37.0 (30.0–45.0) | 39.0 (30.0–48.0) | 0.002 |
Male gender | 858 (28.7%) | 224 (26.1%) | 634 (73.9%) | 0.99 |
Having a partner | 2300 (76.9%) | 561 (24.4%) | 1739 (75.6%) | < 0.001 |
Having children | 1754 (58.6%) | 431 (24.6%) | 1323 (75.4%) | 0.023 |
Religion | ||||
Non-religious | 1190 (39.8%) | 299 (25.1%) | 891 (74.9%) | 0.587 |
Roman catholic | 687 (22.9%) | 184 (26.8%) | 503 (73.2%) | |
Protestant | 534 (17.8%) | 150 (28.1%) | 384 (71.9%) | |
Greek-orthodox | 179 (5.9%) | 36 (20.1%) | 143 (79.9%) | |
Muslim | 30 (1.0%) | 11 (36.6%) | 19 (63.4%) | |
Jewish | 9 (0.3%) | 4 (44.4%) | 5 (65.6%) | |
Budhist | 10 (0.3%) | 3 (33.3%) | 7 (66.6%) | |
Other | 162 (5.4%) | 51 (31.5%) | 111 (68.5%) | |
I do not wish to answer | 191 (6.4%) | 44 (5.6%) | 147 (6.7%) | |
Belief important to very important in attitude towards EOL | 453 (15.1%) | 132 (23.0%) | 321 (77.0%) | 0.128 |
Role | ||||
Nurses | 2275 (76.0%) | 615 (27.0%) | 1660 (73.0%) | 0.043 |
Junior physicians | 308 (10.3%) | 74 (24.0%) | 234 (76.0%) | |
Senior physicians | 409 (13.7%) | 93 (22.7%) | 316 (77.3%) | |
Years of experience in the ICU (25th–75th percentile) | 8.0 (3.0–16.0) | 7.0 (3.0–13.8) | 8.0 (3.0–18.0) | 0.001 |
Working conditions (25th–75th percentile) | ||||
Hours working in a week | 38.0 (32.0–40.0) | 38.0 (35.0–40.0) | 38.0 (32.0–40.0) | 0.048 |
Night shifts per month | 5.0 (3.0–7.0) | 5.0 (3.0–7.0) | 5.0 (3.0–7.0) | 0.256 |
Day shifts during weekend per month | 3.0 (2.0–4.0) | 4.0 (2.0–5.0) | 3.0 (2.0–4.0) | < 0.001 |
Involved in research or ICU working group | 1084 (36.2%) | 285 (26.3%) | 799 (73.7%) | 0.919 |
Ever been involved in medico-legal claim | 258 (8.6%) | 75 (29.1%) | 183 (70.9%) | 0.295 |
Results
Model including EDMCQ clusters | Model including EDMCQ factors | |
---|---|---|
Country | ||
Big mac index | 1.65 [1.05,2.60]b | 1.86 [1.14,2.88]b |
Healthcare expenditure per capita (divided by 100) | NS | NS |
Percentage over 65 years | NS | NS |
Hospital | ||
Number of beds | NS | NS |
ICU | ||
Patient to nurse ratio | NS | 0.76 [0.61,0.95]b |
Patient to junior physician ratio | NS | NS |
Psychologist available | NS | NS |
Total number of beds ICU | NS | NS |
ICU mortality in 2013 | 1.03 [1.003,1.05]b | 1.03 [1.005,1.05]b |
Ethical climate | ||
Good | 0.58 [0.35,0.96]b | – |
Average+ | 0.68(0.46–0.99)b | – |
Average− | 0.62 [0.40,0.98]b | – |
Poor | 1 | – |
Factors EDM climate | ||
Not avoiding EOL decisions | – | 0.87 [0.77,0.98]b |
Mutual respect | – | 0.77 [0.66,0.90]c |
Open interdisciplinary reflection | – | 0.73 [0.62,0.86]d |
Self-reflective leadership | – | NS |
Ethical awareness | – | NS |
Active decision making | – | 0.87 [0.75,1.006]a |
Active involvement of nurses | – | NS |
Clinician | ||
Medicolegal claim | NS | NS |
Age | 0.98 [0.97,0.99]d | 0.98 [0.97,0.99]d |
Gender | NS | NS |
Hours worked per week | NS | NS |
Belief | ||
(Very) important | NS | NS |
Not religious | NS | NS |
Not (very) important | NS | NS |
Professional role | ||
Nurse | 0.27 [0.09,0.82]b | 0.18 [0.06,0.55]b |
Junior doctor | 0.27 [0.06,1.12]a | 0.22 [0.05,1.01]a |
Senior doctor (Ref) | 1 | 1 |
Interaction between professional role and hours worked per week* | ||
Nurse | 1.03 [1.01–1.06]b | 1.03 [1.01–1.06]c |
Junior doctor | 1.02 [0.99–1.05]a | NS |
Senior doctor (Ref) | 1 | 1 |
Intercept of model | 0.12 [0.01,1.11]a | 0.11 [0.01,1.21]a |