Analysis of the data yielded 367 initial codes, 16 categories and 4 main themes including “insufficient understanding of nurses and attendants of each other's roles, needs, and expectations”, “the use of personal and situational reasoning rather than ethical principles”, “caring stagnation” and “satisfaction with care". The extracted themes indicated that nurses and attendants did not have sufficient understanding of each other's roles, needs, and expectations due to the existing conditions in the ward and that the nurses neglected the professional ethics in caring and employed personal reasoning. Caring stagnation was found in the observations of caring behaviors and their interpretations. However, under the critical conditions of the patients and the ward, the nurses sought to provide humanistic care and satisfied the patients and themselves and they felt satisfied when being in and out of the ward.
- Insufficient understanding of nurses and attendants of each other's roles, needs, and expectations
The findings revealed that the attendants insisted on tracking the status and treatment of their patients, and were willing to be present at their patients’ bedside and cooperate in the care procedure. However, the attendants were neglected by the personnel and their presence was considered unnecessary and obtrusive to patients’ care. The nurses were unable or unwilling to communicate and inform them (attendants). It was indicated that nurses did not understand the needs and desires of attendants, and the attendants did not understand the nurses' working conditions, measures, constraints, and needs. This theme has five attributes including “persistence by attendants in follow-up and treatment”, “neglect of attendants”, “unnecessary presence and their disturbance”, “lack of skill and willingness to interact and guide”, and “voluntary participation in care”.
1-1- Families' insistence on follow-up of situation and treatment
The important findings were follow-up and insistence on knowing the patients’ status in various forms, such as visiting the patients at visiting hours, watching the patient briefly from behind the window, and waiting behind closed doors for a doctor’s visit. Limiting the visiting hours to two days a week for a quarter of an hour in the intensive care unit was a major challenge for the families. Visitation restriction was a major challenge not only for the families but also for the nurses, as it was opposed to the family's willingness to meet the patient. The families were allowed to visit the patient due to their persistence, but the insistence led to the nurses' frustration.
“The attendant was looking from the glass door. I asked “What do you want?”, he said “Nothing I just want to see my son.” ...I said “It's not the visiting time.” He said “I can see through the window if possible.” He could see his son through the window with the coordination of ward nurses and happiness could be seen on his face” (male 72-year-old family 2).
1-2- Ignoring families
During the patients' care, their attendants are often forgotten. It was found that the attendants’ needs are forgetten and they are left without any support, education and caring programs.
“A patient's attendant came to see her patient and started crying. The service guard shouted and told her not to cry there. She took her cry with herself and went to the nursing station to ask a question. The nurse did not look at her and said “I do not have time” ...and then the attendant left the ward ”(Field note 1).
1-3- Unnecessary and disturbing presence of families
The participants' experiences revealed many events, beliefs and attitudes affecting the nurses' humanistic performance, such as the belief in the uselessness and harmful presence of family members at the patient bedside, the consideration of family members as those with low health literacy, requiring them to spend extra energy to justify the attendants, and disturbance in care processes due to the presence of families.
“Unfortunately, the level of our people's culture is low, and they lack health literacy and if we want to tell them what is going on, you have to spend your time and energy” (Nurse Ms.A).
In fact, this complaint about the lack of understanding is mutual. In other words, the attendants complain about being ignored, and the nurses complain that the attendants do not understand their professional roles and responsibilities, and thus they consider their presence disruptive to their professional duties.
1-4- Lack of skills and willingness to interact and guide
Communicating with and informing the attendants about the patients' conditions in the intensive care unit is a highly important issue that is often overlooked. Some nurses are unable to provide appropriate care or are reluctant to perform their professional duties owing to their inability and lack of interactive and educational qualifications. This can cause major problems such as conflicts, complaints, fears and doubts about decision-making for families and attendants.
“The ward nurse asked for the consent of tracheotomy from the attendant of bed 3. The attendant was confused and did not know what the tracheotomy was. The more the nurse tried to explain, the little she understood. There was no one in the ward to have the tracheotomy, therefore, the attendant scared and said that “I must consult with my family and I could not decide alone”. (Field note 2).
1-5- Voluntary participation in care
Contrary to the previous characteristic, many attendants frequently visit the care unit and query the staff in order to help with the patients’ care. The field observations indicated that some attendants asked the nurses if they could cooperate in caring. Some nurses also said that attendants had a strong desire to improve their patient status; therefore, they were more alert and could attend the ward whenever needed.
“A young girl was suffering from hypoxia following a cardiac arrest. The patient's husband, who was also very young, was trying to use the olive oil to make her skin greasy to prevent scarring. He frequently asked questions from nurses what you need to prepare for the patient and was often present in the hospital” (Field note 3).
- Replacing ethics with personal and situational reasoning
Some findings indicated that ethical decision-making is challenging in complex conditions of the patients in the ICU. Factors such as complexity of situation, tendency to save energy and time in difficult working conditions, nurses' emotions and feelings, demands of patients’ families and the supervisors orders complicate the process of reasoning and ethical decision-making by nurses. Replacing ethics with personal and situational reasoning was experienced in two ways explained in (Table 2(.
- Caring stagnation
This theme indicates that the variety and intensity of work stresses in the intensive care unit and neglect of nurses' roles and rights lead to insufficient efforts by the nurses to meet all the needs of patients in the intensive care unit, nurses' fatigue and mistrust. In fact, many nurses try to do many caring affairs negligently as their working routines. When nurses realize that there is no difference between them and other nurses who deliberately or undeliberately do clinical affairs carelessly, they change their attitudes to their job. This issue sometimes leads to care stagnation.
- Insufficient nurse care to meet all patients' needs in the intensive care unit
There is an inadequate attempt of nurses to meet all the needs of patients in the intensive care unit such as nutrition and skin care so that the insufficient supervision was exercised after delegating authority to the unprofessional staff.
A patient was saddened by seeing the death of others.
“Well, everybody here is dying every day, and they cover the patients and take them; and I think they are waiting in line. It is ordinary for very ordinary nurses, but it is difficult for me, and it affects my spirit. I am not used to it like them” (Patient, 43-year-old man with Guillain-Barré syndrome).
- Patients’ mistrust in nurse's sayings
Some patients, who are hospitalized for a long time in the ward, lose their trust in nurses, and insist and repeat their demands.
“It was the last hour of my shift, when I visited bed 9 for saying goodbye. The patient was under tracheotomy and was conscious. She said “I want sweet tea”. I prepared tea with the help of a service worker and nurse. She said “Give it to me, but it was too hot”. The nurse told her let it to become cold, and then we take it. She said “No, just now”. I told her that it was hot and showed it. The nurse saw that she was upset and poured some tea with a syringe into her mouth and gavaged the remaining" (Fieldnote7).
- Neglect of the nurses' roles and rights
Cases such as stressful and difficult working conditions in the intensive care unit, lack of staff, and overwork cause nurses to feel that managers neglect their rights.
“The shifts are better now, but fewer working hours are effective. Nurses should have a regular program of entertainment. The shortcomings should be overcome. When for example, there is the lack of drug, no devices and doctors take our time for calling and finding a physician. If you come home late at night, I cause much stress; you have left the kids, and your life and had these tensions; or the number of beds for nurses should be decreased, and the routine of ICU should be adhered” (Nurse Ms.D.).
- Diversity and intensity of work stresses in the intensive care unit
Some nurses pointed out the impact of environmental stressors on patients’ care.
“For example, my personal experience is that when stress comes to life, my whole day collapses, everything is messed up, my patient work and everything gets messed up, but on days with more energy for patients, I'll feel that the patient's clinical situation would become better” (Nurse Ms.M).
- Focus on the unconscious patient's body
Most nurses focus on physical care of patients and forget communication with non-conscious patients.
“We had a mental patient, we were asked to talk to her quietly, have good behavior, and explain what we were going to do for her, but we don't give an explanation for the unconscious patient, because we think it is unnecessary” (Nurse Ms.N.).
- Satisfaction with care
Although nurses work with high pressure and are overworked in the intensive care unit, they become satisfied with patients whose care is successful and in case of patients’ improvement as well as positive reactions such as patient and family appreciation.
- Gratitude and spiritual excellence from receiving internal and external feedback
Nurses believe that patient care is accompanied by spiritual rewards and benefits for themselves and their families.
“When you take care of a patient who is not conscious, you provide care and know God knows, but if a patient is conscious and prays for you, you become so happy. For example, the patient says God bless you and protect your children, and patients become happy with you…, all these things affect your life and are useful for your children and family” (Staff Ms.N.).
4.2 Answer to the call of conscience
Nurses noted a feeling of torment after failing to perform clinical measures for patients.
“In fact, I had no special thought before, even when I was a student, I studied indifferently, but I thought what happened if one of my beloved ones became ill, so I found that the Karma exists. It is easy to abdicate the responsibilities, but the sense of responsibility does not allow doing everything” (Nurse Ms.Kha).
- Patient-nurse mutual consideration and appreciation
Apology to patients after performing aggressive procedures and the patients’ appreciation of care provided by nurses led to the creation of this category.
“Since I was long working in the intensive unit, for example, when a patient was in sleep mode, I put my hand on her shoulder and say dear mother I am putting your suction; dear mother I am doing the venipuncture. Additionally, when I search for an arterial blood vessel and cannot find it, I'll apologize for being annoyed...”(Nurse Ms.Agh.).
- Sensitivity to patients' needs and vulnerabilities
Nurses complain about inability to resolve the patients' problems.
“There was a young woman who had the breast cancer. She had the worst possible expire. She was in my mind due to her chemotherapy and septicemia. She was conscious until the last moment, and the tracheotomy was totally performed for her. We had a lot of sympathy for her. She had reflux and could eat nothing. She was thirsty and we could give her nothing, and we saw his gradual death” (Nurse Ms.N.).