The Society of Critical Care Medicine and four other major critical care organizations have endorsed a seven-step process to resolve disagreements about potentially inappropriate treatments. The ...multiorganization statement (entitled: An official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units) provides examples of potentially inappropriate treatments; however, no clear definition is provided. This statement was developed to provide a clear definition of inappropriate interventions in the ICU environment.
A subcommittee of the Society of Critical Care Medicine Ethics Committee performed a systematic review of empirical research published in peer-reviewed journals as well as professional organization position statements to generate recommendations. Recommendations approved by consensus of the full Society of Critical Care Medicine Ethics Committees and the Society of Critical Care Medicine Council were included in the statement.
ICU interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient's neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment. This definition should not be considered exhaustive; there will be cases in which life-prolonging interventions may reasonably be considered inappropriate even when the patient would survive outside the acute care setting with sufficient cognitive ability to perceive the benefits of treatment. When patients or surrogate decision makers demand interventions that the clinician believes are potentially inappropriate, the seven-step process presented in the multiorganization statement should be followed. Clinicians should recognize the limits of prognostication when evaluating potential neurologic outcome and terminal cases. At times, it may be appropriate to provide time-limited ICU interventions to patients if doing so furthers the patient's reasonable goals of care. If the patient is experiencing pain or suffering, treatment to relieve pain and suffering is always appropriate.
The Society of Critical Care Medicine supports the seven-step process presented in the multiorganization statement. This statement provides added guidance to clinicians in the ICU environment.
To provide clinicians with evidence-based strategies to optimize the support of the family of critically ill patients in the ICU.
We used the Council of Medical Specialty Societies principles for the ...development of clinical guidelines as the framework for guideline development. We assembled an international multidisciplinary team of 29 members with expertise in guideline development, evidence analysis, and family-centered care to revise the 2007 Clinical Practice Guidelines for support of the family in the patient-centered ICU. We conducted a scoping review of qualitative research that explored family-centered care in the ICU. Thematic analyses were conducted to support Population, Intervention, Comparison, Outcome question development. Patients and families validated the importance of interventions and outcomes. We then conducted a systematic review using the Grading of Recommendations, Assessment, Development and Evaluations methodology to make recommendations for practice. Recommendations were subjected to electronic voting with pre-established voting thresholds. No industry funding was associated with the guideline development.
The scoping review yielded 683 qualitative studies; 228 were used for thematic analysis and Population, Intervention, Comparison, Outcome question development. The systematic review search yielded 4,158 reports after deduplication and 76 additional studies were added from alerts and hand searches; 238 studies met inclusion criteria. We made 23 recommendations from moderate, low, and very low level of evidence on the topics of: communication with family members, family presence, family support, consultations and ICU team members, and operational and environmental issues. We provide recommendations for future research and work-tools to support translation of the recommendations into practice.
These guidelines identify the evidence base for best practices for family-centered care in the ICU. All recommendations were weak, highlighting the relative nascency of this field of research and the importance of future research to identify the most effective interventions to improve this important aspect of ICU care.
IMPORTANCE: Significant health inequities persist among minority and socially disadvantaged patients. Better understanding of how unconscious biases affect clinical decision making may help to ...illuminate clinicians’ roles in propagating disparities. OBJECTIVE: To determine whether clinicians’ unconscious race and/or social class biases correlate with patient management decisions. DESIGN, SETTING, AND PARTICIPANTS: We conducted a web-based survey among 230 physicians from surgery and related specialties at an academic, level I trauma center from December 1, 2011, through January 31, 2012. INTERVENTIONS: We administered clinical vignettes, each with 3 management questions. Eight vignettes assessed the relationship between unconscious bias and clinical decision making. We performed ordered logistic regression analysis on the Implicit Association Test (IAT) scores and used multivariable analysis to determine whether implicit bias was associated with the vignette responses. MAIN OUTCOMES AND MEASURES: Differential response times (D scores) on the IAT as a surrogate for unconscious bias. Patient management vignettes varied by patient race or social class. Resulting D scores were calculated for each management decision. RESULTS: In total, 215 clinicians were included and consisted of 74 attending surgeons, 32 fellows, 86 residents, 19 interns, and 4 physicians with an undetermined level of education. Specialties included surgery (32.1%), anesthesia (18.1%), emergency medicine (18.1%), orthopedics (7.9%), otolaryngology (7.0%), neurosurgery (7.0%), critical care (6.0%), and urology (2.8%); 1.9% did not report a departmental affiliation. Implicit race and social class biases were present in most respondents. Among all clinicians, mean IAT D scores for race and social class were 0.42 (95% CI, 0.37-0.48) and 0.71 (95% CI, 0.65-0.78), respectively. Race and class scores were similar across departments (general surgery, orthopedics, urology, etc), race, or age. Women demonstrated less bias concerning race (mean IAT D score, 0.39 95% CI, 0.29-0.49) and social class (mean IAT D score, 0.66 95% CI, 0.57-0.75) relative to men (mean IAT D scores, 0.44 95% CI, 0.37-0.52 and 0.82 95% CI, 0.75-0.89, respectively). In univariate analyses, we found an association between race/social class bias and 3 of 27 possible patient-care decisions. Multivariable analyses revealed no association between the IAT D scores and vignette-based clinical assessments. CONCLUSIONS AND RELEVANCE: Unconscious social class and race biases were not significantly associated with clinical decision making among acute care surgical clinicians. Further studies involving real physician-patient interactions may be warranted.
Background. During a public health crisis, such as the COVID-19 pandemic, nurse leaders coordinate timely high-quality care, maintain profit margins, and ensure regulatory compliance while supporting ...the health and wellbeing of the nursing workforce. In a rapidly changing environment where resources may be scarce, nurse leaders are vulnerable to moral injury; however, organizational effectiveness may help to buffer moral challenges in healthcare leadership, thereby fostering greater moral resilience and reducing turnover intention. Aim. To understand mechanisms by which perceived organizational effectiveness contributes to nurse leaders’ moral wellness (i.e., moral injury and moral resilience) and thereby effects work outcomes (i.e., engagement, burnout, and turnover intention). Methods. A cross-sectional survey of nurse leaders (N = 817) from across the United States was conducted using a snowball methodology, independent t-tests, and structural equation modeling to examine theoretical relationships among moral injury, moral resilience, and organizational effectiveness. Results. Higher ratings on every facet of perceived organizational effectiveness were significantly related to greater moral resilience (p<0.001 for all t-tests) and lower moral injury (p<0.001 for all t-tests) among nurse leaders. Structural equation models indicated both moral resilience and moral injury were significant mediators of the relationship between organizational effectiveness and work outcomes. Moral resilience and moral injury significantly mediated the effect of organizational effectiveness on burnout. Moral resilience was also a significant mediator of the relationship between organizational effectiveness and moral injury. Conclusion. Dismantling organizational patterns and processes in healthcare organizations that contribute to moral injury and lower moral resilience may be important levers for increasing engagement, decreasing burnout, and reducing turnover of nurse leaders.
Nurses face many ethical challenges, placing them at risk for moral distress and burnout and challenging their ability to provide safe, high-quality patient care. Little is known about the ...sustainability of interventions to address this problem.
To determine the long-term impact on acute care nurses of a 6-session experiential educational program called the Mindful Ethical Practice and Resilience Academy (MEPRA).
MEPRA includes facilitated discussion, role play, guided mindfulness and reflective practices, case studies, and high-fidelity simulation training to improve nurses' skills in mindfulness, resilience, and competence in confronting ethical challenges. A prospective, longitudinal study was conducted on the impact of the MEPRA curriculum at 2 hospitals in a large academic medical system. The study involved surveys of 245 nurses at baseline, immediately after the intervention, and 3 and 6 months after the intervention.
The results of the intervention were generally sustained for months afterward. The most robust improvements were in ethical confidence, moral competence, resilience, work engagement, mindfulness, emotional exhaustion, depression, and anger. Some outcomes were not improved immediately after the intervention but were significantly improved at 3 months, including anxiety and empathy. Depersonalization and turnover intentions were initially reduced, but these improvements were not sustained at 6 months.
Many MEPRA results were sustained at 3 and 6 months after conclusion of the initial foundational program. Some outcomes such as depersonalization and turnover intentions may benefit from boosters of the intervention or efforts to supplement the training by making organizational changes to the work environment.
Ethical challenges in clinical practice significantly affect frontline nurses, leading to moral distress, burnout, and job dissatisfaction, which can undermine safety, quality, and compassionate ...care.
To examine the impact of a longitudinal, experiential educational curriculum to enhance nurses' skills in mindfulness, resilience, confidence, and competence to confront ethical challenges in clinical practice.
A prospective repeated-measures study was conducted before and after a curricular intervention at 2 hospitals in a large academic medical system. Intervention participants (192) and comparison participants (223) completed study instruments to assess the objectives.
Mindfulness, ethical confidence, ethical competence, work engagement, and resilience increased significantly after the intervention. Resilience and mindfulness were positively correlated with moral competence and work engagement. As resilience and mindfulness improved, turnover intentions and burnout (emotional exhaustion and depersonalization) decreased. After the intervention, nurses reported significantly improved symptoms of depression and anger. The intervention was effective for intensive care unit and non-intensive care unit nurses (exception: emotional exhaustion) and for nurses with different years of experience (exception: turnover intentions).
Use of experiential discovery learning practices and high-fidelity simulation seems feasible and effective for enhancing nurses' skills in addressing moral adversity in clinical practice by cultivating the components of moral resilience, which contributes to a healthy work environment, improved retention, and enhanced patient care.
Background Implicit bias is an unconscious preference for a specific social group that can have adverse consequences for patient care. Acute care clinical vignettes were used to examine whether ...implicit race or class biases among registered nurses (RNs) impacted patient-management decisions. Study Design In a prospective study conducted among surgical RNs at the Johns Hopkins Hospital, participants were presented 8 multi-stage clinical vignettes in which patients' race or social class were randomly altered. Registered nurses were administered implicit association tests (IATs) for social class and race. Ordered logistic regression was then used to examine associations among treatment differences, race, or social class, and RN's IAT scores. Spearman's rank coefficients comparing RN's implicit (IAT) and explicit (stated) preferences were also investigated. Results Two hundred and forty-five RNs participated. The majority were female (n = 217 88.5%) and white (n = 203 82.9%). Most reported that they had no explicit race or class preferences (n = 174 71.0% and n = 108 44.1%, respectively). However, only 36 nurses (14.7%) demonstrated no implicit race preference as measured by race IAT, and only 16 nurses (6.53%) displayed no implicit class preference on the class IAT. Implicit association tests scores did not statistically correlate with vignette-based clinical decision making. Spearman's rank coefficients comparing implicit (IAT) and explicit preferences also demonstrated no statistically significant correlation ( r = −0.06; p = 0.340 and r = −0.06; p = 0.342, respectively). Conclusions The majority of RNs displayed implicit preferences toward white race and upper social class patients on IAT assessment. However, unlike published data on physicians, implicit biases among RNs did not correlate with clinical decision making.
Abstract
Aims and objectives
To examine demographic and work characteristics of interdisciplinary healthcare professionals associated with higher burnout and to examine whether the four domains of ...moral resilience contribute to burnout over and above work and demographic variables.
Background
Healthcare professionals experience complex ethical challenges on a daily basis leading to burnout and moral distress. Measurement of moral resilience is a new and vital step in creating tailored interventions that will foster moral resilience at the bedside.
Design
Cross‐sectional descriptive design.
Methods
Healthcare professionals in the eastern USA were recruited weekly via email for 3 weeks in this cross‐sectional study. Online questionnaires were used to conduct the study. The STROBE checklist was used to report the results.
Results
Work and demographic factors, such as religious preference, years worked in a healthcare profession, practice location, race, patient age, profession and education level, have unique relationships with burnout subscales and turnover intention, with the four subscales of moral resilience demonstrating a protective relationship with outcomes above and beyond the variance explained by work and demographic characteristics.
Conclusions
Higher moral resilience is related to lower burnout and turnover intentions, with multiple work demographic correlates allowing for potential areas of intervention to deal with an increase in morally distressing situations occurring at the bedside. Additionally, patterns of significant and non‐significant relationships between the moral resilience subscales and burnout subscales indicate that these subscales represent unique constructs.
Relevance to clinical practice
Understanding the everyday, pre‐pandemic correlations of moral resilience and burnout among interdisciplinary clinicians allows us to see changes that may exist. Measuring and understanding moral resilience in healthcare professionals is vital for creating ways to build healthier, more sustainable clinical work environments and enhanced patient care delivery.
Background: Nursing faculty and clinicians are leaving the profession due to increased workload and burnout. Evidence-based interventions to build skills in resilience and well-being are encouraged; ...however, strategies to implement them in nursing curricula and nurse residency programs (NRPs) are not well known. Purpose: To understand the current state of resilience, well-being, and ethics content in the curriculum in schools of nursing and NRPs in the state of Maryland as part of a statewide initiative for Renewal, Resilience and Retention of Maryland Nurses (R 3 ). Methods: A descriptive survey was distributed to leaders of all Maryland nursing schools and NRP directors. Results: Respondents (n = 67) reported minimal resilience, well-being, and ethics content. Teaching modalities included lecture, journaling, mindfulness, and the code of ethics. Barriers included lack of faculty knowledge, low priority, time constraints, and limited resources. Conclusion: Resilience, well-being, and ethics content is limited in nursing curricula. Developing educator skills and best practices to foster resilience and ethical practice are needed.
Intensive care units (ICUs) are an appropriate focus of antibiotic stewardship program efforts because a large proportion of any hospital's use of parenteral antibiotics, especially broad-spectrum, ...occurs in the ICU. Given the importance of antibiotic stewardship for critically ill patients and the importance of critical care practitioners as the front line for antibiotic stewardship, a workshop was convened to specifically address barriers to antibiotic stewardship in the ICU and discuss tactics to overcome these. The working definition of antibiotic stewardship is "the right drug at the right time and the right dose for the right bug for the right duration." A major emphasis was that antibiotic stewardship should be a core competency of critical care clinicians. Fear of pathogens that are not covered by empirical antibiotics is a major driver of excessively broad-spectrum therapy in critically ill patients. Better diagnostics and outcome data can address this fear and expand efforts to narrow or shorten therapy. Greater awareness of the substantial adverse effects of antibiotics should be emphasized and is an important counterargument to broad-spectrum therapy in individual low-risk patients. Optimal antibiotic stewardship should not focus solely on reducing antibiotic use or ensuring compliance with guidelines. Instead, it should enhance care both for individual patients (by improving and individualizing their choice of antibiotic) and for the ICU population as a whole. Opportunities for antibiotic stewardship in common ICU infections, including community- and hospital-acquired pneumonia and sepsis, are discussed. Intensivists can partner with antibiotic stewardship programs to address barriers and improve patient care.
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