Impact of perceived inappropiate cardiopulmonary resuscitation on emergency clinicians’ intention to leave the job: Results from a cross-sectional survey in 288 centres across 24 countries

doi:10.1016/j.resuscitation.2020.10.043

Resuscitation

Volume 158, January 2021, Pages 41-48

https://doi.org/10.1016/j.resuscitation.2020.10.043 Get rights and content

Abstract

Introduction

Cardiopulmonary resuscitation (CPR) in patients with a poor prognosis increases the risk of perception of inappropriate care leading to moral distress in clinicians. We evaluated whether perception of inappropriate CPR is associated with intention to leave the job among emergency clinicians.

Methods

A cross-sectional multi-centre survey was conducted in 24 countries. Factors associated with intention to leave the job were analysed by conditional logistic regression models. Results are expressed as odds ratios with 95% confidence intervals.

Results

Of 5099 surveyed emergency clinicians, 1836 (36.0%) were physicians, 1313 (25.7%) nurses, 1950 (38.2%) emergency medical technicians. Intention to leave the job was expressed by 1721 (33.8%) clinicians, 3403 (66.7%) often wondered about the appropriateness of a resuscitation attempt, 2955 (58.0%) reported moral distress caused by inappropriate CPR. After adjustment for other covariates, the risk of intention to leave the job was higher in clinicians often wondering about the appropriateness of a resuscitation attempt (1.43 [1.23−1.67]), experiencing associated moral distress (1.44 [1.24−1.66]) and who were between 30−44 years old (1.53 [1.21−1.92] compared to <30 years). The risk was lower when the clinician felt valued by the team (0.53 [0.42−0.66]), when the team leader acknowledged the efforts delivered by the team (0.61 [0.49−0.75]) and in teams that took time for debriefing (0.70 [0.60−0.80]).

Conclusion

Resuscitation attempts perceived as inappropriate by clinicians, and the accompanying moral distress, were associated with an increased likelihood of intention to leave the job. Interprofessional collaboration, teamwork, and regular interdisciplinary debriefing were associated with a lower risk of intention to leave the job.

ClinicalTrials.gov; No.: NCT02356029

Introduction

The provision of cardiopulmonary resuscitation (CPR) to patients with severe comorbidities and frailty has greatly increased since its first introduction more than 50 years ago. Data from the Danish Cardiac Arrest Registry collected between 2001 and 2011 show a threefold increase in bystander CPR and of return of spontaneous circulation among patients 80 years or older, but at the same time a significant decline in 1-year survival.¹ The incidence of CPR attempts in nursing homes also increased over the past several decades; in Denmark the incidence quadrupled from 3.5% in 2002 to 16.5% in 2014 while in Japan the proportion of cardiac arrests treated in nursing homes increased from approximately 12% to almost 20% in a time span of approximately 5 years.2, 3 In the largest series reported thus far, none of the 2575 resuscitated nursing home residents had a good 1-year functional recovery.⁴ Data from Japan and North America show that 13–20% of the resuscitated cardiac arrest patients are aged 73 years or older and have an unwitnessed cardiac arrest with a non-shockable rhythm, resulting in a favorable neurological outcome of 0.5% or even less.5, 6, 7 All these data suggest that patients often undergo resuscitation attempts without taking into account the dismal prognosis of the patient.

Inappropriate resuscitation attempts, defined as CPR attempts that are disproportionate to the expected prognosis of the patient in terms of survival or quality of life, are not only detrimental to patients, but can also cause moral distress to emergency clinicians. According to the definition provided by Jameton, moral distress is a challenge that arises when one knows the right thing to do ethically or medically, but institutional and external constraints make it nearly impossible to pursue the right course of action.⁸ Frequent exposure to similar patient care situations and/or a professional environment not acknowledging the distress may lead to deficient coping mechanisms and accumulation of moral distress. This may be associated with burn-out of the clinician and employee attrition, resulting in a decreased quality of care provided to current and future patients (Fig. 1).9, 10, 11, 12, 13

The purpose of this study was to determine whether frequent perception of inappropriateness of CPR and the presence of moral distress due to this perception are associated with intention to leave the job among clinicians working on prehospital and emergency department resuscitation teams. Secondary aims were to evaluate if the association differed according to the profession, age, and gender of the clinician.

Section snippets

Study design and participants

The REAPPROPRIATE study is an international multi-centre cross-sectional survey conducted in 24 countries (Austria, Belgium, Chile, Cyprus, Czech Republic, Finland, France, Germany, Greece, Hungary, Iceland, Israel, Japan, The Netherlands, Norway, Poland, Republic of Ireland, Romania, Serbia, Slovak Republic, Spain, Sweden, the United Kingdom, and the United States). The study population consisted of clinicians, defined as healthcare professionals working as caregivers for patients who are

Results

Of the 5882 clinicians participating, 5099 (86.7%) completed all selected survey items. Physicians, nurses, and emergency medical technicians (including paramedics) accounted for 1836 (36.0%), 1313 (25.7%) and 1950 (38.2%) of surveyed clinicians, respectively (Table 1).

Of the 5099 clinicians, 1721 (33.8%) responded that they had thoughts about leaving their current job, 3403 (66.7%) stated that they often wondered about the appropriateness of a resuscitation attempt, and 2955 (58.0%) reported

Discussion

In this large international multi-centre cross-sectional survey we found that 66.7% of clinicians working in prehospital and emergency department settings endorsed often questioning the appropriateness of a resuscitation attempt, and 58% reported moral distress in case of resuscitation attempts which they perceived as inappropriate. Moreover, we found that 33.8% of clinicians have thoughts about leaving their current job. The intention to leave the job was associated both with frequent

Conclusion

We found that resuscitation attempts perceived as inappropriate by clinicians, and the extent to which such attempts are reported to cause moral distress, is associated with increased likelihood of a clinician’s intention to leave the job. Interprofessional collaboration, teamwork, and regular interdisciplinary debriefing can potentially reduce the risk of staff attrition. It is paramount to decrease the number or duration of inappropriate resuscitation attempts through improved assessment of

Funding source

RP is supported by Fund Marie-Thérèse De Lava, King Baudouin Foundation, Belgium. DDB received a senior clinical investigators grant (1800513N) from the Research Foundation Flanders (FWO).

Author contributions

PD, KM, RP, SH, PDP and DDB designed the study. All authors except JS and JD contributed to the final version of the survey. All authors except KM, RP, JS, PDP, JD and DDB contributed to the data collection. PD, KM, RP, JD, DDB and JS analysed and interpreted the data. JS performed the statistical analysis. PD did the literature search and wrote the first draft of the report. PD and JS structured the tables and figures. All authors reviewed the draft, contributed to the revision of the report

Conflicts of interest

CAB is employed by the Regional Competence Centre for Acute Medicine in Western Norway (RAKOS) with financial support from the Norwegian Directorate of Health. He has participated in Global Resuscitation Alliance meetings sponsored by the Laerdal Foundation for Acute Medicine, TrygFonden and EMS2018. CD is Deputy Medical Director of the National Ambulance Service of the Republic of Ireland. The other authors declared no conflicts of interest.

Acknowledgements

The European Resuscitation Council Research Net was helpful in facilitating the European part of our research network. We are indebted to Bram Gadeyne who developed the secured survey website. National coordinators and collaborators are listed in Supplementary data Appendix C.

References (40)

M. Pape et al.
Survival after out-of-hospital cardiac arrest in nursing homes—a nationwide study
Resuscitation
(2018)
E. Andrew et al.
Long-term functional recovery and health-related quality of life of elderly out-of-hospital cardiac arrest survivors
Resuscitation
(2018)
K. Shibahashi et al.
A potential termination of resuscitation rule for EMS to implement in the field for out-of-hospital cardiac arrest: an observational cohort study
Resuscitation
(2018)
B. Grunau et al.
North American validation of the Bokutoh criteria for withholding professional resuscitation in non-traumatic out-of-hospital cardiac arrest
Resuscitation
(2019)
N.K. Glober et al.
A simple decision rule predicts futile resuscitation of out-of-hospital cardiac arrest
Resuscitation
(2019)
P.M. Dodek et al.
Moral distress in intensive care unit professionals is associated with profession, age, and years of experience
J Crit Care
(2016)
P. Druwé et al.
Perception of inappropriate cardiopulmonary resuscitation by clinicians working in emergency departments and ambulance services: the REAPPROPRIATE international, multi-centre, cross sectional survey
Resuscitation
(2018)
R.D. Piers et al.
Inappropriate care in European ICUs: confronting views from nurses and junior and senior physicians
Chest
(2014)
C.A. Marco et al.
Prehospital resuscitation practices: a survey of prehospital providers
J Emerg Med
(2003)
M. Lin et al.
High prevalence of burnout among US emergency medicine residents: results from the 2017 National Emergency Medicine Wellness Survey
Ann Emerg Med
(2019)

L.L. Bossaert et al.

European Resuscitation Council guidelines for resuscitation 2015: section 11. The ethics of resuscitation and end-of-life decisions

Resuscitation

(2015)

M. Wissenberg et al.

Survival after out-of-hospital cardiac arrest in relation to age and early identification of patients with minimal chance of long-term survival

Circulation

(2015)

S. Okabayashi et al.

Outcomes of patients 65 years or older after out-of-hospital cardiac arrest based on location of cardiac arrest in Japan

JAMA Netw Open

(2019)

A. Jameton

Nursing practice: The ethical issues

(1984)

R.D. Piers et al.

Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians

JAMA

(2011)

D.S. Tawfik et al.

Evidence relating health care provider burnout and quality of care

Ann Intern Med

(2019)

H. Jiang et al.

Satisfaction, burnout and intention to stay of emergency nurses in Shanghai

Emerg Med J

(2017)

D. Lu et al.

Impact of burnout on self-reported patient care among emergency physicians

WestJEM

(2015)

P.S. Jones et al.

An adaptation of Brislin’s translation model for cross-cultural research

Nurs Res

(2001)

C.A. Marco et al.

Ethical issues of cardiopulmonary resuscitation: current practice among emergency physicians

Acad Emerg Med

(1997)

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There is a global shortfall of nurses. Despite national targets to increase nurse training and retention, the numbers leaving the profession continue to rise. Emergency departments (EDs) consistently record above average staff-turnover. Meanwhile descriptions of moral distress amongst emergency nurses are increasing. It is vital to consider the long-term emotional and psychological impact of moral distress on the emergency nursing workforce. However, the events which trigger moral distress in the emergency department may differ from those described in other clinical areas. A clearer understanding of the effects of moral distress on intention to leave could help identify those at risk and inform decisions on interventions designed to mitigate moral distress, aiding nurse retention and the organisational stability of health services.
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We analyzed 6,931 female and 14,548 male out-of-hospital cardiac arrest (OHCA) patients from Dutch and Swedish registries, and validated in 10,772 female and 21,808 male Danish OHCA patients. Performance measures were calculated for ALS-TOR in relation to 30-day survival. Recursive partitioning analysis was performed with the ALS-TOR criteria, as well as age, comorbidities, and additional resuscitation characteristics (e.g. initial rhythm, OHCA location). Finally, we explored if we could reduce the number of ALS-TOR criteria without loss of prognostic value.
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For both women and men, the ALS-TOR has high specificity and low miss rate for predicting 30-day OHCA survival. We could not improve the classification with additional characteristics. Employing a simplified version may decrease the number of futile transports to the hospital.
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In-hospital resuscitation events have complex and enduring effects on clinicians, with implications for job satisfaction, performance, and burnout. Ethically ambiguous cases are associated with increased moral distress. We aim to quantitatively describe the multidisciplinary resuscitation experience.
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In-hospital healthcare professionals’ experiences of resuscitation events are varied and complex. Aspects of task load burden including mental and physical demand, performance, and frustration contribute to overall and moral distress, deserving greater attention in clinical contexts.
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Citation Excerpt :
The feeling of inappropriateness about some aspects of critical care can further development of MD among ICU staff.9 Previous research in different health sectors found that this feeling has negative consequences for HCPs, teams and health systems.3,8,25 In view of the above, it is crucial to have valid and reliable tools to explore the causes of MD among HCPs in order to design effective interventions.10
To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs).
Cross-sectional, prospective study.
ICUs in Spain.
HCPs currently working in Spanish ICUs.
A 55-item questionnaire was electronically distributed.
The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS).
In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40–135) than for nurses (61, IQR 35–133, p = 0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46–163 vs. 61, IQR 32–117; p < 0.001). The MMD-HP-SPA was inversely correlated with the HECS (r = −0.277, p < 0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD.
In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.
Evaluar el desasosiego moral (DM) entre los profesionales sanitarios que trabajan en UCI en España.
Estudio prospectivo transversal.
UCI en España.
Profesionales sanitarios que actualmente trabajan en UCI españolas.
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En total 1.065 profesionales sanitarios de cuidados intensivos completaron el cuestionario. Tres de 4 hipótesis de validez fueron apoyadas. El DM fue significativamente mayor entre los médicos (80, IQR 40-135) que entre las enfermeras (61, IQR 35-133, p = 0,026). El DM fue significativamente más alto para aquellos médicos que estaban considerando dejar su puesto de trabajo (78, IQR 46-163 vs. 61, IQR 32-117; p < 0,001). El MMD-HP-SPA se correlacionó inversamente con el HECS (r = –0,277, p < 0,001). Un análisis factorial exploratorio reveló una estructura de 4 factores, evidenciando los niveles de paciente, equipo y sistema del DM.
En este estudio los intensivistas refirieron niveles de DM más altos que las enfermeras. Se deben implementar estrategias para mejorar el clima ético en las UCI y corregir otros factores relacionados con el fin de mitigar el DM en lo que atañe al paciente, al equipo y al sistema. Ambos grupos de profesionales manifestaron una intención relevante de abandonar su puesto de trabajo debido al DM. Se necesitan más estudios para determinar en qué medida el DM influye sobre su deseo de abandonar su puesto de trabajo.
Validation and psychometric properties of the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA)
2022, Medicina Intensiva
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View all citing articles on Scopus

¹: Please see Supplementary data, Appendix C for collaborators of the REAPPROPRIATE study group.

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Clinical paperImpact of perceived inappropiate cardiopulmonary resuscitation on emergency clinicians’ intention to leave the job: Results from a cross-sectional survey in 288 centres across 24 countries

Abstract

Introduction

Methods

Results

Conclusion

Introduction

Section snippets

Study design and participants

Results

Discussion

Conclusion

Funding source

Author contributions

Conflicts of interest

Acknowledgements

Resuscitation

Resuscitation

Resuscitation

Resuscitation

Resuscitation

J Crit Care

Resuscitation

Chest

J Emerg Med

Ann Emerg Med

Resuscitation

Survival after out-of-hospital cardiac arrest in relation to age and early identification of patients with minimal chance of long-term survival

Circulation

Outcomes of patients 65 years or older after out-of-hospital cardiac arrest based on location of cardiac arrest in Japan

JAMA Netw Open

Nursing practice: The ethical issues

Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians

JAMA

Evidence relating health care provider burnout and quality of care

Ann Intern Med

Satisfaction, burnout and intention to stay of emergency nurses in Shanghai

Emerg Med J

Impact of burnout on self-reported patient care among emergency physicians

WestJEM

An adaptation of Brislin’s translation model for cross-cultural research

Nurs Res

Ethical issues of cardiopulmonary resuscitation: current practice among emergency physicians

Acad Emerg Med

Clinical paper
Impact of perceived inappropiate cardiopulmonary resuscitation on emergency clinicians’ intention to leave the job: Results from a cross-sectional survey in 288 centres across 24 countries