PURPOSE: Apart from organizational issues, quality of inter-professional collaboration during ethical decision-making may affect the intention to leave one's job. To determine whether ethical climate is associated with the intention to leave after adjustment for country, ICU and clinicians characteristics. METHODS: Perceptions of the ethical climate among clinicians working in 68 adult ICUs in 12 European countries and the US were measured using a self-assessment questionnaire, together with job characteristics and intent to leave as a sub-analysis of the Dispropricus study. The validated ethical decision-making climate questionnaire included seven factors: not avoiding decision-making at end-of-life (EOL), mutual respect within the interdisciplinary team, open interdisciplinary reflection, ethical awareness, self-reflective physician leadership, active decision-making at end-of-life by physicians, and involvement of nurses in EOL. Hierarchical mixed effect models were used to assess associations between these factors, and the intent to leave in clinicians within ICUs, within the different countries. RESULTS: Of 3610 nurses and 1137 physicians providing ICU bedside care, 63.1% and 62.9% participated, respectively. Of 2992 participating clinicians, 782 (26.1%) had intent to leave, of which 27% nurses, 24% junior and 22.7% senior physicians. After adjustment for country, ICU and clinicians characteristics, mutual respect OR 0.77 (95% CI 0.66- 0.90), open interdisciplinary reflection (OR 0.73 [95% CI 0.62-0.86]) and not avoiding EOL decisions (OR 0.87 [95% CI 0.77-0.98]) were all associated with a lower intent to leave. CONCLUSION: This is the first large multicenter study showing an independent association between clinicians' intent to leave and the quality of the ethical climate in the ICU. Interventions to reduce intent to leave may be most effective when they focus on improving mutual respect, interdisciplinary reflection and active decision-making at EOL.

Department of Anaesthesiology and Intensive Care Sahlgrenska University Hospital Gothenburg Sweden

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

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

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

Department of Geriatric Medicine Ghent University Hospital Ghent Belgium

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

Department of Intensive Care Medicine Ghent University Hospital De Pintelaan 185 Ghent Belgium

Department of Intensive Care Medicine Institute of Regional Research Vejle Hospital Vejle Denmark

Department of Medical Oncology University Medical Center Groningen University of Groningen Groningen The Netherlands

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

Faculty of Psychology and Educational Sciences Department of Personnel Management Work and Organizational Psychology Ghent University Ghent Belgium

Hôpital Saint Louis and University Paris 7 Paris France

Intensive Care Department Hospital S António Porto Portugal

King's College Hospital London UK

London School of Hygiene and Tropical Medicine London UK

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

Semmelweis University Budapest Budapest Hungary

Service des Medicine Interne Soins Intensifs et Urgences Oncologiques Institut Jules Bordet ULB Brussels Belgium

Tettnang Hospital Tettnang Germany

University of Southern Denmark Odense Denmark

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