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Ethical decision-making climate in the ICU : theoretical framework and validation of a self-assessment tool

(2018) BMJ QUALITY & SAFETY. 27(10). p.781-789
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Abstract
Background: Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU). Objectives: To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates. Methods: Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups. Results: Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1%) and 717 (62.9%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner. Conclusions: The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians' behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.
Keywords
INTENSIVE-CARE-UNIT, OF-LIFE CARE, MORAL DISTRESS, NURSES PERCEPTIONS, PALLIATIVE CARE, COMMUNICATION, PHYSICIANS, TEAM, COLLABORATION, LEADERSHIP

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Citation

Please use this url to cite or link to this publication:

Chicago
Van den Bulcke, Bo, Ruth Piers, Hanne Irene Jensen, Johan Malmgren, Victoria Metaxa, Anna K Reyners, Michael Darmon, et al. 2018. “Ethical Decision-making Climate in the ICU : Theoretical Framework and Validation of a Self-assessment Tool.” Bmj Quality & Safety 27 (10): 781–789.
APA
Van den Bulcke, B., Piers, R., Jensen, H. I., Malmgren, J., Metaxa, V., Reyners, A. K., Darmon, M., et al. (2018). Ethical decision-making climate in the ICU : theoretical framework and validation of a self-assessment tool. BMJ QUALITY & SAFETY, 27(10), 781–789.
Vancouver
1.
Van den Bulcke B, Piers R, Jensen HI, Malmgren J, Metaxa V, Reyners AK, et al. Ethical decision-making climate in the ICU : theoretical framework and validation of a self-assessment tool. BMJ QUALITY & SAFETY. 2018;27(10):781–9.
MLA
Van den Bulcke, Bo, Ruth Piers, Hanne Irene Jensen, et al. “Ethical Decision-making Climate in the ICU : Theoretical Framework and Validation of a Self-assessment Tool.” BMJ QUALITY & SAFETY 27.10 (2018): 781–789. Print.
@article{8554692,
  abstract     = {Background: Literature depicts differences in ethical decision-making (EDM) between countries and intensive care units (ICU). 
Objectives: To better conceptualise EDM climate in the ICU and to validate a tool to assess EDM climates. 
Methods: Using a modified Delphi method, we built a theoretical framework and a self-assessment instrument consisting of 35 statements. This Ethical Decision-Making Climate Questionnaire (EDMCQ) was developed to capture three EDM domains in healthcare: interdisciplinary collaboration and communication; leadership by physicians; and ethical environment. This instrument was subsequently validated among clinicians working in 68 adult ICUs in 13 European countries and the USA. Exploratory and confirmatory factor analysis was used to determine the structure of the EDM climate as perceived by clinicians. Measurement invariance was tested to make sure that variables used in the analysis were comparable constructs across different groups. 
Results: Of 3610 nurses and 1137 physicians providing ICU bedside care, 2275 (63.1\%) and 717 (62.9\%) participated respectively. Statistical analyses revealed that a shortened 32-item version of the EDMCQ scale provides a factorial valid measurement of seven facets of the extent to which clinicians perceive an EDM climate: self-reflective and empowering leadership by physicians; practice and culture of open interdisciplinary reflection; culture of not avoiding end-of-life decisions; culture of mutual respect within the interdisciplinary team; active involvement of nurses in end-of-life care and decision-making; active decision-making by physicians; and practice and culture of ethical awareness. Measurement invariance of the EDMCQ across occupational groups was shown, reflecting that nurses and physicians interpret the EDMCQ items in a similar manner. 
Conclusions: The 32-item version of the EDMCQ might enrich the EDM climate measurement, clinicians' behaviour and the performance of healthcare organisations. This instrument offers opportunities to develop tailored ICU team interventions.},
  author       = {Van den Bulcke, Bo and Piers, Ruth and Jensen, Hanne Irene and Malmgren, Johan and Metaxa, Victoria and Reyners, Anna K and Darmon, Michael and Rusinova, Katerina and Talmor, Daniel and Meert, Anne-Pascale and Cancelliere, Laura and Zubek, L{\`a}szl{\'o} and Maia, Paolo and Michalsen, Andrej and Decruyenaere, Johan and Kompanje, Erwin JO and Azoulay, Elie and Meganck, Reitske and Van de Sompel, Ari{\"e}lla and Vansteelandt, Stijn and Vlerick, Peter and Vanheule, Stijn and Benoit, Dominique},
  issn         = {2044-5415},
  journal      = {BMJ QUALITY \& SAFETY},
  keyword      = {INTENSIVE-CARE-UNIT,OF-LIFE CARE,MORAL DISTRESS,NURSES PERCEPTIONS,PALLIATIVE CARE,COMMUNICATION,PHYSICIANS,TEAM,COLLABORATION,LEADERSHIP},
  language     = {eng},
  number       = {10},
  pages        = {781--789},
  title        = {Ethical decision-making climate in the ICU : theoretical framework and validation of a self-assessment tool},
  url          = {http://dx.doi.org/10.1136/bmjqs-2017-007390},
  volume       = {27},
  year         = {2018},
}

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