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.

Department of Anaesthesiology and Critical Care Medicine Tettnang Hospital Tettnang Germany

Department of Anaesthesiology and Intensive Care 1st Faculty of Medicine Charles University Prague and General University Hospital Prague Prague Czech Republic

Department of Anaesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden

Department of Anaesthesiology and Intensive Care Sygehus Lillebælt Vejle Sygehus Vejle Denmark

Department of Anesthesia Critical Care and Pain Medicine Beth Israel Deaconess Medical Center and Harvard Medical School Boston Massachusetts USA

Department of Anesthesiology and Intensive Therapy Semmelweis University Budapest Budapest Hungary

Department of Applied Mathematics Computer Sciences and Statistics Faculty of Sciences Ghent University Ghent Belgium

Department of Intensive Care Erasmus MC University Medical Center Rotterdam Rotterdam The Netherlands

Department of Intensive Care Hospital de Santo António Porto Portugal

Department of Intensive Care Medicine Ghent University Hospital Ghent Belgium

Department of Medical Oncology University of Groningen Groningen Netherlands

Department of Personnel Management Work and Organizational Psychology Ghent University Ghent Belgium

Department of Psychoanalysis and Clinical Consulting Faculty of Psychology and Educational Sciences Ghent University Ghent Belgium

Department of Psychoanalysis and Clinical Consulting Ghent University Ghent Belgium

Geriatrics Department of Internal Medicine Ghent University Hospital Ghent Belgium

Institute of Health Research University of Southern Denmark Odense Denmark

King's College Hospital London UK

Medical Intensive Care Unit Hôpital Saint Louis and University Paris 7 Paris France

Medical Surgical Intensive Care Unit Hopital NordSaint Etienne University Hospital Saint Etienne France

SCDU Anestesia e Rianimazione Azienda Ospedaliero Universitaria 'Maggiore della Carità' Novara Italy

Service des Soins Intensifs et Urgences Oncologiques Institut Jules Bordet ULB Bruxelles Belgium

BMJ Qual Saf. 2018 Oct;27(10):766-770. doi: 10.1136/bmjqs-2018-007905. PubMed

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