This Article Full Text Full Text (PDF) Online Supplement All Versions of this Article: 200810-1614OCv1 180/9/853    most recent Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Google Scholar Articles by Azoulay, E. PubMed PubMed Citation Articles by Azoulay, E.

Prevalence and Factors of Intensive Care Unit Conflicts

The Conflicus Study

Élie Azoulay¹, Jean-François Timsit², Charles L. Sprung³, Marcio Soares⁴, Kateina Rusinová⁵, Ariane Lafabrie¹, Ricardo Abizanda⁶, Mia Svantesson⁷, Francesca Rubulotta⁸, Bara Ricou⁹, Dominique Benoit¹⁰, Daren Heyland¹¹, Gavin Joynt¹², Adrien Français², Paulo Azeivedo-Maia¹³, Radoslaw Owczuk¹⁴, Julie Benbenishty³, Michael de Vita¹⁵, Andreas Valentin¹⁶, Akos Ksomos¹⁷, Simon Cohen¹⁸, Lidija Kompan¹⁹, Kwok Ho²⁰, Fekri Abroug²¹, Anne Kaarlola²², Herwig Gerlach²³, Theodoros Kyprianou²⁴, Andrej Michalsen²⁵, Sylvie Chevret²⁶, Benoît Schlemmer¹ for the Conflicus Study Investigators and for the Ethics Section of the European Society of Intensive Care Medicine^*

¹ AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, Paris, France; ² INSERM U823, Hopital Michallon, CHU de Grenoble, Grenoble, France; ³ Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel; ⁴ Intensive Care Unit, Instituto Nacional de Câncer, Rio de Janeiro, Brazil; ⁵ Department of Anesthesiology and Critical Care Medicine, Medical ICU, Prague University Hospital, Prague, Czech Republic; ⁶ Servei de Medicina Intensiva, Hospital Universitario Asociado General de Castellón, Castellón, Spain; ⁷ Centre for Health Care Sciences, Orebro University Hospital, Orebro, Sweden; ⁸ Policlinico University Hospital Catania, Italy; ⁹ Department of Intensive Care, Geneva University Hospitals and University of Geneva, Geneva, Switzerland; ¹⁰ Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan Ghent, Belgium; ¹¹ Department of Medicine, Queen's University, Kingston, Ontario, Canada; ¹² Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong; ¹³ Department of Anesthesia and Intensive Care, Hospital de S. João, Porto, Portugal; ¹⁴ Department of Anaesthesiology and Intensive Therapy, Medical University of Gdansk, Gdansk, Poland; ¹⁵ University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; ¹⁶ General and Medical Intensive Care Unit, II, Medical Department, KA Rudolfsftiftung, Juchgasse, Vienna, Austria; ¹⁷ Semmelweis University, Surgical Intensive Care Unit, Budapest, Hungary; ¹⁸ Department of Medicine, University College London, London, United Kingdom; ¹⁹ Clinical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia; ²⁰ Intensive Care Unit, Royal Perth Hospital, Perth, Australia; ²¹ Intensive Care Unit, CHU Fatouma Bourguiba, Monastir, Tunisia; ²² Department of Anaesthesia and Intensive Care Medicine, Helsinki University Central Hospital, Helsinki, Finland; ²³ Department of Anesthesia, Intensive Care Medicine, and Pain Management, Vivantes Klinikum Neukölln, Berlin, Germany; ²⁴ Department of Computer Science, University of Cyprus, Nicosia, Cyprus; ²⁵ Department of Anesthesiology and Critical Care Medicine, HELIOS Spital, Überlingen/See, Germany; ²⁶ Biostatistical Department, U717 INSERM, AP-HP, Paris 7 University, Saint-Louis Hospital, Paris, France

Correspondence and requests for reprints should be addressed to Élie Azoulay, M.D., Ph.D., AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France. E-mail: elie.azoulay{at}sls.ap-hop-paris.fr

Rationale: Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs.

Objectives: To record the prevalence, characteristics, and risk factors for conflicts in ICUs.

Methods: One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries).

Measurements and Main Results: Conflicts were perceived by 5,268 (71.6%) respondents. Nurse–physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings.

Conclusions: Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

Key Words: end-of-life • caregivers • nurses • family members • burnout

AT A GLANCE COMMENTARY Scientific Knowledge on the Subject Conflicts in the intensive care unit create obstacles to good communication and decision making and may threaten the quality of care. However, no study has evaluated the prevalence of, or the factors associated with, ICU conflicts. What This Study Adds to the Field Up to 70% of intensivists reported conflicts. These conflicts are perceived as severe in more than half the cases, and they are associated with increased job strain.