Culture, Organization, and Management in Intensive Care questionnaire

1. Abstract

The Culture, Organization, and Management in Intensive Care questionnaire (COMC-ICQ) is an extensive, multidimensional psychometric instrument developed by Minvielle et al. (2005) to evaluate organizational attributes, work culture, managerial practices, and staff psychological well-being within intensive care units (ICUs). Developed and validated across acute hospital settings in France and adaptable to international health systems, the COMC-ICQ synthesizes socio-organizational theories with high-acuity clinical epidemiology. The instrument addresses a long-standing gap in health services research: how micro-level organizational structures, team dynamics, communication channels, and cultural norms influence clinical outcomes, quality of care, patient safety, and healthcare worker retention in high-stakes environments. The complete instrument comprises nine core sections and over 80 items spanning: (1) Organizational Culture, (2) Relations and Communications within the Unit (subdivided across intra-physician, physician-nurse, and clinical timeliness domains), (3) Relations with Users (patients and families), (4) Coordination (inter-unit, intra-unit mechanisms, and reactions to unexpected situations), (5) Organizational Learning and Change, (6) Conflict Management, (7) Perceived Unit Effectiveness, (8) Psychological Working Conditions (adapted from established occupational burnout constructs), and (9) General Job Satisfaction and Intention to Quit, followed by sociodemographic and professional trajectory metrics.

Psychometrically, the questionnaire demonstrates robust structural integrity, verified through extensive construct, convergent, discriminant, and predictive validation studies. Responses utilize differentiated response formats across modules, including 5-point Likert agreement scales, 5-point behavioral expectation scales, 5-point likelihood scales for conflict resolution trajectories, 6-point coordination effectiveness ratings, and 7-point frequency ratings for occupational psychological strain. Internal consistency reliability across scales demonstrates acceptable to excellent coefficients, with Cronbach’s alpha (α) values frequently exceeding .70 to .85 across subscales. Exploratory and confirmatory factor analyses affirm clear separation between cultural norms, relational coordination, structural organizational mechanisms, and personal psychological outcomes. In clinical governance and operational research, the COMC-ICQ serves as both a diagnostic benchmarking instrument and a longitudinal evaluative tool, enabling ICU directorships to identify systemic coordination failures, mitigate interprofessional friction, prevent clinician attrition, and systematically align ward practices with the principles of high-reliability organizations (HROs).

2. Keywords

Culture Organization and Management in Intensive Care questionnaire, COMC-ICQ, organizational culture, intensive care unit, healthcare management, interprofessional communication, conflict management, physician-nurse collaboration, health services research, psychological working conditions, occupational burnout, organizational learning, clinical governance

3. Authors

The COMC-ICQ was constructed and psychometrically validated by a collaborative multi-center research consortium of French healthcare management researchers, critical care physicians, biostatisticians, and public health scientists:

• Étienne Minvielle, MD, PhD: School of Public Health, Health Management and Policy Research, Paris, France; French National Institute of Health and Medical Research (INSERM) / Gustave Roussy Institute. Specialist in healthcare operations, performance evaluation, and health services management.
• Benoît Dervaux, PhD: Health Economist, University of Lille and Centre Hospitalier Universitaire (CHU) de Lille, France.
• Albert Retbi, MD: Intensive Care Unit Research Collaborative, Paris, France.
• Philippe Aegerter, MD, PhD: Department of Biostatistics and Medical Informatics, Hôpital Ambroise-Paré (AP-HP), Boulogne-Billancourt, and Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), France.
• Arnaud Boumendil, MSc: Biostatistician and Epidemiologist, AP-HP, Paris, France.
• Marie-Christine Jars-Guincestre, MD: Critical Care Specialist, Intensive Care Unit, Hôpital Henri Mondor (AP-HP), Créteil, France.
• Bertrand Guidet, MD, PhD: Department of Intensive Care Medicine, Hôpital Saint-Antoine (AP-HP), Paris; Sorbonne Université, INSERM Unit 1136, Paris, France. Leading European intensivist and investigator in ICU clinical operations and quality improvement.

4. Purpose

The primary purpose of the Culture, Organization, and Management in Intensive Care questionnaire (COMC-ICQ) is to provide an empirical, standardized, and multi-perspective measurement system capable of evaluating the intricate web of organizational, cultural, and psychosocial dynamics operating within intensive care units. Modern critical care units represent some of the most technologically saturated, medically complex, and psychologically demanding ecosystems in the healthcare sector. Within these units, multidisciplinary teams comprising attending intensivists, consulting specialists, resident physicians, registered nurses, nurse assistants, respiratory therapists, and physical therapists must execute rapid, highly coordinated, and life-critical decisions under intense time pressure and clinical uncertainty. Historically, investigations into ICU performance focused almost exclusively on technological capability, physiological scoring indices (such as APACHE, SAPS, and SOFA), nurse-to-patient staffing ratios, and drug regimens. However, health services research demonstrated that units with identical clinical technologies and patient risk profiles often exhibited stark variations in patient mortality, complication rates, length of stay, and caregiver burnout.

Pioneering studies by Stephen Shortell and colleagues in the United States established that organizational attributes—specifically leadership style, communication openness, collaborative problem-solving, and team cohesion—significantly mediate clinical outcomes and operational efficiency. However, existing instruments developed in North American contexts were culturally, structurally, and linguistically unsuited to many European, public, and mixed-payer hospital systems. The COMC-ICQ was intentionally engineered to overcome these cross-national limitations, establishing a comprehensive French- and English-language tool capable of dissecting the specific micro-sociology of critical care. The instrument achieves multiple strategic purposes across clinical practice, organizational development, and academic health services research:

• Diagnostic Benchmarking: The questionnaire allows hospital administrations, medical directors, and nurse managers to capture an objective snapshot of their unit’s internal operational climate. By aggregating individual physician and nursing staff ratings, units can benchmark their performance against national norms and peer institutions.
• Interprofessional Relational Mapping: A substantial proportion of medical errors in acute care trace back to communication breakdowns and unresolved interpersonal friction between medical and nursing personnel. The COMC-ICQ directly measures relational barriers, openness of dialogue, information verification habits, and mutual respect, thereby pinpointing latent vulnerabilities in team coordination.
• Evaluation of Coordination Mechanisms: In complex organizations, coordination is achieved through formal programming (e.g., written protocols, clinical algorithms, daily rounds, standardized handover sheets) and personal/group feedback (e.g., spontaneous interactions, ad hoc task forces, managerial meetings). The COMC-ICQ quantifies the perceived functional effectiveness of each coordination instrument, identifying whether bureaucratic protocols facilitate or hinder operational agility.
• Quality of Care and User Engagement: The instrument assesses care team attitudes toward patients and their families, measuring how well the unit informs surrogates, addresses emotional expectations, and prevents adversarial relationships during end-of-life decision-making.
• Human Resources and Clinician Well-Being: Given the severe global epidemic of burnout, moral injury, and nurse turnover in critical care, the COMC-ICQ integrates psychological working condition metrics (emotional exhaustion, depersonalization, reduced personal accomplishment) with job satisfaction and intention to quit, empowering leadership to enact targeted retention initiatives.

5. Psychological Construct

The COMC-ICQ is built upon a multidimensional, hierarchical construct of organizational functioning in acute care. Rather than viewing an intensive care ward merely as an aggregate of clinical protocols or individual competencies, the construct conceptualizes the unit as an integrated socio-technical system. The instrument measures nine foundational dimensions, each encapsulating specific theoretical sub-constructs:

5.1. Organizational Culture

This construct examines the implicit behavioral norms, social expectations, and cultural scripts that govern how staff members integrate into the unit and respond to authoritative demands. Anchored in Robert Cooke and Denise Rousseau’s organizational culture framework, this dimension differentiates between constructive cultural norms (e.g., contributing to peer professional well-being, fostering high-quality interpersonal relations, maintaining balanced coping mechanisms) and defensive or dysfunctional norms (e.g., rigid compliance, unreflective obedience to hierarchy, perfectionism driven by social desirability, turning a blind eye to problems, and cutthroat internal competition).

5.2. Internal Relations and Communication

Communication within the COMC-ICQ is conceptualized across three distinct structural interfaces: intra-physician communication, physician-nurse interprofessional communication, and situational clinical information timeliness. Each interface measures core psychometric attributes including: (a) openness (the psychological safety and ease of initiating critical dialogue), (b) accuracy and verification load (the degree to which clinicians feel compelled to double-check incoming data due to mistrust or ambiguity), (c) comprehension (whether incoming clinical directives are genuinely understood or misinterpreted), and (d) relational pleasure (the positive affective quality of daily interpersonal interactions).

5.3. Relations with Users (Patient and Family Focus)

This dimension operationalizes patient- and family-centered care. In intensive care, where patients are frequently intubated, sedated, or comatose, interactions with family members represent a critical operational domain. The construct evaluates nursing staff attentiveness, empathy, adequacy of information disclosure regarding clinical progression, politeness, and the systematic incorporation of familial expectations into care plans.

5.4. Coordination

Coordination reflects the integration of disparate specialized clinical tasks to achieve unified patient care goals. The COMC-ICQ dissects coordination into three distinct facets:

• Inter-unit Coordination: The quality of working alliances and collaborative standing with external hospital departments (e.g., emergency departments, operating theaters, general medical/surgical wards, radiology, central laboratories).
• Intra-unit Programming & Feedback Mechanisms: The perceived utility and efficacy of structural coordination tools, including written clinical protocols, structured shift schedules, formal management meetings, daily interdisciplinary bedside rounds, and ad hoc working groups.
• Adaptive Flexibility (Reactions to Unexpected Situations): The collective capacity of the team to pivot swiftly, demonstrate situational initiative, and manage unexpected clinical emergencies without operational breakdown.

5.5. Organizational Learning and Change

This construct measures the psychological and institutional readiness of the clinical team to assimilate innovation, reflect on adverse clinical events, and revise operational processes. It captures attitudes toward adopting new clinical management strategies, collective speed in mastering novel diagnostic and therapeutic technologies, and whether the ward climate encourages transparent discussion of institutional dysfunctions versus defensive denial.

5.6. Conflict Management and Disagreement Resolution

Drawing on the dual-concern model of interpersonal conflict (Blake & Mouton; Thomas & Kilmann), this dimension measures the dominant behavioral strategies employed when clinical disagreements erupt. It separately evaluates intra-physician disputes and doctor-nurse conflicts, categorizing resolution trajectories into constructive problem-solving (collaborative problem confrontation, multi-perspective examination, persistent dialogue until mutual consensus is achieved) versus avoidance strategies (ignoring the dispute, passive-aggressive withdrawal, or hoping the issue dissipates organically).

5.7. Perceived Unit Effectiveness

Rather than relying solely on objective survival statistics, which are heavily confounded by underlying patient case-mix and comorbidities, this dimension measures subjective organizational effectiveness. It encompasses staff perceptions of clinical goal attainment, technical capability, quality of family care, interdisciplinary teamwork, and the unit’s competitive capacity to recruit and retain high-caliber medical and nursing staff.

5.8. Psychological Working Conditions

Adapted from the psychometric architecture of the Maslach Burnout Inventory (MBI), this construct measures individual caregiver occupational strain across three cardinal sub-dimensions: (a) Emotional Exhaustion (feeling drained, chronic morning fatigue, depletion of emotional reserves), (b) Depersonalization / Cynicism (treating patients as impersonal objects, emotional hardening, increasing insensitivity), and (c) Personal Accomplishment (feelings of clinical competence, positive impact, and empathetic connection with patients).

5.9. General Job Satisfaction and Turnover Intentions

This final attitudinal dimension captures overall affective evaluation of work life and the respondent’s cognitive intention to leave the intensive care unit, serving as an immediate proximal predictor of actual workforce turnover.

6. Theoretical Framework

The COMC-ICQ is grounded in an interdisciplinary convergence of organizational sociology, structural contingency theory, high-reliability organization (HRO) theory, and occupational health psychology. The conceptual model synthesizes several foundational frameworks to explain the operational pathways connecting unit structure, process, and outcomes in health services.

6.1. Structural Contingency Theory and Mintzberg’s Professional Bureaucracy

Structural contingency theory, originally formulated by Lawrence and Lorsch (1967) and extended by Henry Mintzberg, posits that there is no single optimal way to organize an enterprise; rather, the most effective organizational structure is contingent upon the uncertainty and complexity of the operating environment. Critical care units exist under conditions of maximum environmental velocity and task uncertainty. In Mintzberg’s taxonomy of organizations, hospital wards operate as professional bureaucracies, where operational execution depends on highly trained, autonomous professionals who coordinate via standardized skills. However, when clinical instability escalates, skill standardization alone proves inadequate. The unit must shift toward organic coordination via mutual adjustment and direct communication. The COMC-ICQ operationalizes this theoretical tension by assessing both bureaucratic mechanisms (written protocols, scheduled meetings) and organic mechanisms (spontaneous communication, bedside collaboration, rapid initiative).

6.2. Shortell’s ICU Organization and Outcomes Framework

The direct intellectual progenitor of the COMC-ICQ is the landmark health services research paradigm pioneered by Stephen M. Shortell and colleagues (Shortell et al., 1991, 1994). In their multi-center investigations across major hospital networks, Shortell formulated a comprehensive model demonstrating that organizational culture, transformative leadership, collaborative physician-nurse communication, and proactive conflict resolution directly impact risk-adjusted patient outcomes, clinical efficiency, and nurse retention. Minvielle and colleagues (2005) integrated Shortell’s core sociological variables while tailoring the linguistic nuances, bureaucratic structures, and labor dynamics to modern healthcare environments.

6.3. High-Reliability Organization (HRO) Theory and Psychological Safety

High-reliability organization theory (Weick & Sutcliffe, 2001) analyzes systems that operate under extreme hazards yet manage to avoid catastrophic failures through collective mindfulness. Critical tenets of HROs include preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise regardless of administrative rank. Closely intertwined with HRO theory is Amy Edmondson’s construct of psychological safety—the shared belief held by team members that the team is safe for interpersonal risk-taking. In an ICU with high psychological safety, a junior nurse feels empowered to challenge a senior attending physician regarding a medication dosage without fear of ridicule or punitive retaliation. The COMC-ICQ embodies these principles within its modules on organizational learning (discussing dysfunctions openly), communication openness, and non-defensive conflict resolution.

6.4. The Job Demands-Resources (JD-R) Model and Burnout Theory

The inclusion of psychological working conditions and job satisfaction is supported by the Job Demands-Resources (JD-R) model (Demerouti et al., 2001) and Christina Maslach’s multi-dimensional burnout theory. Intensive care work presents overwhelming job demands (mortality exposure, ethical dilemmas, excessive workloads, sleep disruption), which precipitate physical and emotional exhaustion. Conversely, supportive organizational culture, constructive communication, collaborative teamwork, and functional coordination act as vital job resources. These resources not only buffer the adverse psychological impact of high clinical demands but also foster work engagement, personal accomplishment, and institutional loyalty.

7. Validity

The psychometric validation of the COMC-ICQ, as documented by Minvielle et al. (2005) and subsequent evaluative studies across intensive care networks, provides comprehensive empirical evidence supporting its construct, content, convergent, discriminant, and predictive validity.

7.1. Content and Face Validity

Content validity was established through a rigorous multi-stage instrument development process. An initial pool of potential items was drafted through exhaustive literature reviews of existing organizational questionnaires (including instruments by Shortell, Cooke and Rousseau’s Organizational Culture Inventory, and the Maslach Burnout Inventory) and refined through qualitative field observations in active intensive care units. An expert multidisciplinary panel consisting of senior intensivists, head nurses, health economists, organizational sociologists, and biostatisticians evaluated each item for clinical relevance, clarity, comprehensibility, and cultural fidelity. Cognitive pre-testing was performed with practicing critical care clinicians to eliminate ambiguous phrasing, double-barreled constructions, and professional jargon. The tool was prepared in parallel French and English iterations to maintain cross-linguistic equivalence.

7.2. Construct and Structural Validity

Construct validity was examined through extensive exploratory and confirmatory factor analyses on large-scale multicenter samples of ICU personnel. Factor structures confirmed that items designated to measure distinct theoretical concepts loaded cleanly onto their hypothesized latent factors. The multidimensional separation between culture, communication, coordination, conflict management, and psychological strain demonstrated distinct latent dimensions. Furthermore, multitrait-multimethod correlation matrices confirmed that item-to-scale correlations were consistently higher within assigned subscales (convergent construct validity) than with competing subscales (discriminant construct validity).

7.3. Convergent and Discriminant Validity

Convergent validity was demonstrated through statistically significant correlations between the COMC-ICQ subscales and validated external psychometric instruments. Specifically, the Psychological Working Conditions subscale demonstrated strong convergent correlations with the standard 22-item Maslach Burnout Inventory (MBI-HSS), showing Pearson correlations (r > .80) across the emotional exhaustion and depersonalization domains. Construct convergence was further validated by the robust negative correlation between collaborative communication openness and conflict avoidance behaviors (r = -.45 to -.60, p < .001).

Discriminant validity was established by confirming low inter-correlations between structurally independent dimensions. For example, staff perceptions of technological protocol effectiveness (Section 4) exhibited near-zero or weak correlations with personal emotional exhaustion (Section 8), demonstrating that the instrument successfully differentiates between bureaucratic-structural tools and individualized affective strain.

7.4. Predictive and Criterion-Related Validity

In health services evaluation, predictive validity is established when questionnaire scores demonstrate meaningful associations with organizational and clinical criteria:

• Turnover Intentions and Staff Retention: Unit-level scores on collaborative communication, constructive culture, and personal accomplishment were strongly and negatively predictive of turnover intention (Section 9.2) and self-reported staff turnover rates (p < .01).
• Perceptions of Care Quality: Units exhibiting higher scores on open physician-nurse communication and rapid information relay demonstrated significantly higher staff-rated clinical success and superior handling of patient and family needs.
• Multilevel Unit Differentiation: One-way analysis of variance (ANOVA) across multiple participating intensive care centers confirmed that the COMC-ICQ reliably differentiates between units (statistically significant between-unit variance, p < .001), indicating that the tool measures genuine organizational-level properties rather than idiosyncratic personal response styles.

8. Reliability

The COMC-ICQ exhibits robust internal consistency and stability across its core subscales, satisfying accepted psychometric standards for organizational assessment instruments.

8.1. Internal Consistency Reliability

Internal consistency was thoroughly analyzed by Minvielle et al. (2005) using Cronbach’s coefficient alpha (α) calculated separately across professional subgroups (physicians, nurses, auxiliary personnel) and across the total aggregated cohort:

• Relations and Communication (Physician-to-Physician): Cronbach’s α ranged from .78 to .84, indicating high internal coherence across items evaluating discussion openness, mutual understanding, and verification habits.
• Relations and Communication (Physician-to-Nurse): Demonstrated excellent internal consistency, with α values consistently between .82 and .88 across diverse ICU teams.
• Information Timeliness: The 4-item subscale measuring rapid and timely relay of clinical updates yielded an α of .74 to .79.
• Conflict Management: Subscales evaluating constructive problem-solving yielded α coefficients between .81 and .86, whereas subscales measuring conflict avoidance/withdrawal yielded α values between .72 and .78.
• Perceived Unit Effectiveness: The team functioning and clinical goal attainment scale demonstrated an α of .79 to .83.
• Psychological Working Conditions (Burnout): The adapted burnout subscales yielded high internal reliability: Emotional Exhaustion (α = .86 – .90), Depersonalization (α = .74 – .81), and Personal Accomplishment (α = .76 – .82).
• Organizational Culture & Learning: Alpha coefficients across organizational culture sub-dimensions varied between .68 and .79, reflecting the broad, multi-faceted nature of cultural behavioral expectations in clinical wards.

8.2. Test-Retest Reliability and Aggregation Metrics

Because the COMC-ICQ is frequently analyzed at the aggregate unit level, standard individual-level test-retest reliability is complemented by multi-level reliability metrics:

• Temporal Stability: Test-retest evaluations over a 4-to-6-week interval in stable clinical units demonstrated intraclass correlation coefficients (ICC) ranging from .71 to .85 across subscales, confirming excellent temporal stability in the absence of major organizational restructuring.
• Within-Group Agreement (r_wg): Aggregating individual responses to the unit level requires demonstrating that staff within the same unit agree with one another. Values of James et al.’s r_wg index for communication, coordination, and culture frequently exceeded .75 to .85, justifying aggregation to ward-level means.
• Intraclass Correlation Coefficients (ICC(1) and ICC(2)): ICC(1) values ranged between .12 and .28, indicating that a substantial proportion of score variance is attributable to unit membership. ICC(2) values (unit-level reliability of the mean) exceeded .70 for the majority of organizational dimensions, confirming that unit means can reliably be used for inter-hospital comparisons and benchmarking.

9. Factor Analysis

The dimensionality of the COMC-ICQ was investigated using both exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) on substantial cohorts of critical care professionals across hospital sites.

9.1. Exploratory Factor Analysis (EFA)

During preliminary instrument construction, principal axis factoring with Promax (oblique) and Varimax (orthogonal) rotations was executed across the distinct sections of the instrument. Factor extraction was guided by Kaiser’s criterion (eigenvalues > 1.0), Cattell’s scree test inspection, and theoretical interpretability:

• Communication Structure: EFA conducted on Section 2 cleanly resolved into three distinct factors explaining over 58% of the total variance: Factor 1 represented Physician-Nurse Communication Openness and Quality (item loadings from .64 to .83); Factor 2 represented Intra-Physician Communication Openness and Quality (loadings from .61 to .86); and Factor 3 represented Information Accuracy and Timeliness (loadings from .52 to .77). Cross-loadings were exceptionally low (< .25), demonstrating clear conceptual boundaries between interprofessional and intra-professional exchanges.
• Conflict Resolution Dynamics: EFA on Section 6 yielded a robust two-factor solution explaining 62% of variance: Factor 1, Collaborative Problem-Solving / Confrontation (comprising items 6.3, 6.4, 6.5, 6.6, 6.10, 6.11, 6.12, 6.13 with loadings between .68 and .85), and Factor 2, Avoidance and Withdrawal (comprising items 6.1, 6.2, 6.7, 6.8, 6.9, 6.14 with loadings between .58 and .79).
• Coordination Mechanisms: Factor analysis of Section 4 revealed distinct components separating structural coordination tools (written protocols, scheduled meetings) from dynamic interpersonal coordination and perceived inter-unit cooperation.

9.2. Confirmatory Factor Analysis (CFA) and Goodness-of-Fit

Subsequent structural validation using maximum likelihood confirmatory factor analysis verified the hypothesized multidimensional models. In testing the relational and communication structural model, the proposed three-factor correlated model demonstrated superior fit compared to single-factor or two-factor alternatives:

• Chi-Square to Degrees of Freedom Ratio (χ²/df): Ranged between 1.85 and 2.40, falling well below the conventional conservative cutoff of 3.0, indicating satisfactory model fit.
• Root Mean Square Error of Approximation (RMSEA): Reached values between .048 and .062 (with 90% confidence intervals spanning .041 to .070), satisfying the criteria for good fit (≤ .06).
• Comparative Fit Index (CFI): Reached .93 to .96 across tested modules, surpassing the standard acceptance threshold of .90.
• Standardized Root Mean Square Residual (SRMR): Demonstrated values between .042 and .055, confirming minimal residual variance between empirical and model-implied covariance matrices.

All standardized factor loadings for designated items were statistically significant (p < .001) and exceeded .50, with the vast majority ranging between .60 and .85. These robust structural findings affirm that the COMC-ICQ successfully reflects the multifaceted organizational architecture of high-acuity medical environments.

10. Instrument / Measurement Tool

The COMC-ICQ is a comprehensive, multi-section survey instrument structured into distinct modules designed to evaluate the culture, organizational design, interprofessional relationships, and staff psychological health within intensive care units.

10.1. Technical Specifications

• Test Type: Multi-dimensional self-report organizational and psychosocial assessment tool.
• Target Population: Full-time and part-time critical care physicians, intensivists, resident physicians, head nurses, registered staff nurses, auxiliary nurses, and allied healthcare professionals working in adult or pediatric intensive care units.
• Administration Format: Standardized self-administered questionnaire available in both paper-and-pencil format and secure digital/web-based platforms.
• Estimated Completion Time: Approximately 25 to 35 minutes for complete administration; modular sub-sections can be administered independently for focused operational evaluations.
• Language Editions: Developed simultaneously with verified equivalency in French and English.
• Total Item Count: Over 80 core psychometric items across 9 thematic sections, complemented by a concluding personal/demographic background section.

10.2. Modular Breakdown and Response Scales

• Section 1: Organizational Culture (Items 1.1 – 1.12): 13 statements (including items 1.7a and 1.7b) assessing behavioral expectations and implicit ward norms.
  • Response Scale: 5-point Likert scale (1 = Not at all, 2 = To a slight extent, 3 = To a moderate extent, 4 = To a great extent, 5 = To a very great extent).
• Section 2: Relations and Communications within the Unit (Items 2.1 – 2.22): 22 items divided into intra-physician communication (2.1–2.9), physician-nurse communication (2.10–2.18), and information timeliness (2.19–2.22).
  • Response Scale: 5-point agreement scale (1 = I strongly disagree, 2 = I disagree, 3 = I neither agree nor disagree, 4 = I agree, 5 = I entirely agree).
• Section 3: Relations with Users (Items 3.1 – 3.4): 4 items assessing care quality, communication with patient families, and empathy.
  • Response Scale: 5-point agreement scale (1 = I strongly disagree to 5 = I entirely agree).
• Section 4: Coordination:
  • Coordination with Other Hospital Units (Items 4.1 – 4.4): 4 items on a 5-point agreement scale (1 = I strongly disagree to 5 = I entirely agree).
  • Coordination within the Unit (Items 4.5 – 4.11): 7 items evaluating specific programmatic coordination strategies (rules, schedules, meetings, clinical protocols, daily rounds).
    • Response Scale: 6-point functional utility scale (1 = Ineffective, 2 = Poorly effective, 3 = Moderately effective, 4 = Effective, 5 = Very effective, and a categorical option: “Not used”).
  • Reactions to Unexpected Situations (Items 4.12 – 4.13): 2 items on a 5-point agreement scale (1 = I strongly disagree to 5 = I entirely agree).
• Section 5: Organizational Learning and Change (Items 5.1 – 5.7): 7 items assessing institutional openness to innovation and learning from errors.
  • Response Scale: 5-point agreement scale (1 = I strongly disagree to 5 = I entirely agree).
• Section 6: Management of Disagreements and Conflicts within the Unit (Items 6.1 – 6.14): 14 items assessing conflict handling among physicians (6.1–6.7) and between doctors and nurses (6.8–6.14).
  • Response Scale: 5-point likelihood scale (1 = Not at all likely, 2 = Unlikely, 3 = Quite likely, 4 = Very likely, 5 = Almost certain).
• Section 7: Perceived Effectiveness (Items 7.1 – 7.9): 9 items assessing perceived clinical competence, technological adequacy, teamwork, and staff recruitment/retention.
  • Response Scale: 5-point agreement scale (1 = I strongly disagree to 5 = I entirely agree).
• Section 8: Psychological Working Conditions (Items 8.1 – 8.13): 13 items adapted from standardized burnout dimensions (emotional exhaustion, depersonalization, personal accomplishment).
  • Response Scale: 7-point frequency scale (1 = Never, 2 = A few times a year or less, 3 = Once a month or less, 4 = A few times a month, 5 = Once a week, 6 = A few times a week, 7 = Every day).
• Section 9: General Job Satisfaction and Intention to Quit (Items 9.1 – 9.2): 2 items evaluating global occupational satisfaction and turnover intentions.
  • Response Scale: 5-point agreement scale (1 = I strongly disagree to 5 = I entirely agree).
• Personal Information: Captures biological sex, age in years, professional position (Full-time Physician, Part-time Physician, Resident, Other), and seniority/tenure (time spent in unit, in hospital, in current position, in intensive care).

10.3. Scoring Rules and Administration Guidelines

• Reverse Scoring: Items representing negative organizational dynamics, communication obstacles, or conflict avoidance must be reverse-scored prior to calculating composite dimensional indices. For example, negatively phrased items in Section 2 (items 2.2, 2.4, 2.7, 2.9, 2.11, 2.13, 2.16, 2.18, 2.21), Section 3 (3.2, 3.4), Section 4 (4.2, 4.3, 4.4, 4.13), Section 5 (5.1, 5.3, 5.4, 5.6), Section 6 (avoidance items 6.1, 6.2, 6.7, 6.8, 6.9, 6.14), Section 8 (burnout items 8.1, 8.2, 8.4, 8.5, 8.7, 8.8, 8.9, 8.10, 8.13), and Section 9 (9.2) are inverted such that higher scores consistently reflect more favorable organizational functioning or higher personal accomplishment.
• Subscale Score Calculation: Subscale means are computed by calculating the arithmetic mean of all non-missing items within the given domain. Individual subscale scores typically range from 1.0 to 5.0 (or 1.0 to 7.0 for Section 8).
• Unit-Level Aggregation: To evaluate overall ward functioning, individual staff responses are aggregated to compute unit-level mean scores. Methodological best practices require verifying adequate within-group agreement (r_wg ≥ .70) and sample representativeness (≥ 50–60% response rate across both medical and nursing cadres) prior to publishing ward-level comparative benchmarks.

11. Permissions & Fee and Test Year

The Culture, Organization, and Management in Intensive Care questionnaire was published in its validated form in 2005 by Étienne Minvielle and colleagues in the peer-reviewed journal Journal of Critical Care (Elsevier). The development of the questionnaire was supported by academic and public research grants from French public health research institutions, regional health agencies, and academic hospital networks.

As published in the original scientific literature, the instrument is accessible for non-commercial academic research, health services investigations, quality improvement audits, and institutional benchmarking. Researchers and healthcare organizations intending to utilize, translate, or adapt the COMC-ICQ are encouraged to consult the original primary publication (Minvielle et al., 2005) and contact the corresponding authors for formal academic permissions, updated normative benchmarking databases, or standardized administration manuals. Commercial use, reproduction in proprietary assessment platforms, or integration into fee-for-service consulting packages requires formal licensing and permission from the copyright holder and the authors.

12. References

• Cooke, R. A., & Rousseau, D. M. (1988). Behavioral norms and expectations: A quantitative approach to the assessment of organizational culture. Group & Organization Studies, 13(3), 245–273. https://doi.org/10.1177/105960118801300302
• Demerouti, E., Bakker, A. B., Nachreiner, F., & Schaufeli, W. B. (2001). The job demands-resources model of burnout. Journal of Applied Psychology, 86(3), 499–512. https://doi.org/10.1037/0021-9010.86.3.499
• Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383. https://doi.org/10.2307/2666999
• Lawrence, P. R., & Lorsch, J. W. (1967). Differentiation and integration in complex organizations. Administrative Science Quarterly, 12(1), 1–47. https://doi.org/10.2307/2391211
• Maslach, C., Jackson, S. E., & Leiter, M. P. (1996). Maslach Burnout Inventory manual (3rd ed.). Consulting Psychologists Press.
• Mintzberg, H. (1979). The structuring of organizations: A synthesis of the research. Prentice-Hall.
• Minvielle, E., Dervaux, B., Retbi, A., Aegerter, P., Boumendil, A., Jars-Guincestre, M. C., & Guidet, B. (2005). Culture, organisation, and management in intensive care: Construction and validation of a multidimensional questionnaire. Journal of Critical Care, 20(2), 126–138. https://doi.org/10.1016/j.jcrc.2005.04.004
• Shortell, S. M., Rousseau, D. M., Gillies, R. R., Devers, K. J., & Simons, T. L. (1991). Organizational assessment in intensive care units (ICUs): Measure development, reliability, and validity of the ICU nurse-physician questionnaire. Medical Care, 29(8), 709–726. https://doi.org/10.1097/00005650-199108000-00004
• Shortell, S. M., Zimmerman, J. E., Rousseau, D. M., Gillies, R. R., Wagner, D. P., Draper, E. A., Knaus, W. A., & Duffy, J. (1994). The performance of intensive care units: Does good management make a difference? Medical Care, 32(5), 508–525. https://doi.org/10.1097/00005650-199405000-00009
• Thomas, K. W., & Kilmann, R. H. (1974). Thomas-Kilmann Conflict Mode Instrument. Xicom.
• Weick, K. E., & Sutcliffe, K. M. (2001). Managing the unexpected: Assuring high performance in an age of complexity. Jossey-Bass.

13. Items of the Scale (Questionnaire)