Humanistic Care in the Intensive Care Unit: A Qualitative Study

Background: Nurses working in intensive care units do their main part of the job using medical equipment. Nursing scholars have raised concerns about the decline and lack of attention to humanistic care in nursing. One of the threatening factors can be the high attention of nurses to the use of technology, especially in intensive care. Up to now, there has been little investigation of the nurses' perceptions of this phenomenon. The aim of the study was, therefore, to explore the perceptions of nurses and attendants of humanistic care in the intensive care unit. Methods: The present study was a qualitative conventional content analysis (COREQ guidelines) conducted in. an intensive care unit in a hospital in Qazvin, Iran, in 2019. Data was collected using unstructured interviews and eld notes and then analyzed using the Elo-Kyngäs method in 2008. Findings: Continuous and comparative analysis of the data led to the extraction of 4 main themes as follows: 1) Insucient understanding of nurses and patients’ families of each other's roles, needs, and expectations; 2) The use of personal and situational reasoning rather than ethical principles; 3) Caring stagnation, and 4) Satisfaction with care. Conclusion: The ndings of the study indicated that due to insucient equipment, high workloads, and anxieties, nurses and attendants might not be able to understand each other’s roles and expectations. If it is not resolved properly, this situation will end in conicts and stagnation in healthcare. Patients admitted to an intensive care unit are usually in critical health conditions. However, nurses feel satised with the outcome of their jobs when those patients are discharged from the hospital with a stable health condition. Shedding more light on the humanistic care status in intensive care units in Iran, the results of this research can be applied to health professionals and nursing managers.


Background
Human caring in nursing is not considered solely as a feeling, approach, or even what one kindly desires to possess. From the moral point of view, caring in nursing is an ideal whose aim is to protect, enhance, and preserve decency. It is, therefore, an ethical and philosophical enterprise de ning nurses and individuals over time and in various conditions [1].
The utilization of humanism in clinical medicine leads to the potential evolution of patients' care, workplace culture, and clinical education [2]. The analysis of theoretical and research evidence indicates an urgent need for refocusing attention on human care and strengthening the humanism in healthcare systems, especially in nursing, as the largest health profession which plays a leading role in healthcare systems. Therefore, preserving and promoting human values in nursing can be a step towards strengthening these values and humanizing the whole healthcare system in a country [3].
In contrast, dehumanization implies depersonalization, in which the illness treatment is viewed as the sole target of therapeutic care. A few out of many causes of dehumanization are the "dictatorship of Page 3/20 technology", which ends in considering patients as "things", super-specialization, the application of economic value-based criteria to healthcare administration, and the refutation of the idea that the endurance and death of patients can affect relatives and experts equally [4].
Dehumanization versus humanistic care can be realized best in intensive care units (ICU). Patients admitted to the ICU have critical conditions and vulnerabilities. The ICUs with high-tech equipment can cause job burnout for nurses and as a result, the nurses working in highly technological environments might abandon the humanistic aspects of their patients' care [5]. Recent scienti c advances, coupled with increased awareness of cultural and social diversity, have led to a range of available treatment options; however, such developments sometimes lead to an adverse imbalance between science, technology, and humanism in the clinical practice and has made humanistic excellence a major challenge in nursing [5,6].
Martos et al. believe that humanism demands a holistic approach. Patients are not the only ones suffering from a disease in the intensive care unit, but their families and healthcare providers are also affected by their conditions. In this case, healthcare providers are seen as the centerpiece of the deteriorating process of human care [4].
Due to the technical nature of the intensive care unit, the concept of patient-centered nursing cannot be applied in its true sense in the eld of intensive care. Technology strongly affects the patients' physiological status and violates patient-centered caring [7,8]. Hence recognizing two abilities technical and emotional that should be adjusted and fused in critical care. The scholarly discussion has emerged over the strain among caring and technology [9].
Humanism in health care is not an ideology, but it is related to the individuals' interactions and their lifestyles, and includes the moral quality and commitment that individuals consider as a whole [4]. Therefore, it is necessary to pay attention to the fact that humanism cannot be in the form of law, but must be built in the culture of the ICUs [10].
What makes humanistic excellence a major challenge in nursing is the inconsistency of some aspects of modern healthcare and human guidelines. Nursing experts have attempted to resolve this challenge by presenting human-centered theories [5].
Evidence shows that most patients experience non-human behaviors such as lack of compassion, concern, and affection while they need to be cared for [11]. It indicates that the wellbeing framework is itself a source of suffering [12].
In this regard, studies have been published about critical care nurses' experiences of providing care for adults, Crilly et al. in qualitative evidence synthesis found three analytical themes: sometimes machines get all the attention, with experience the patient becomes the focus and technology can't save everybody [13]. Extensive research has shown that a number of qualitative studies provide nurses' efforts to nd balance when caring in a fully technological environment [8,9,[14][15][16][17].
In line with differences in care perspectives, Bagherian et al. showed a positive relationship between care characteristics and the effect of technology in the nurses. Care feature scores were higher in single female nurses. Although scores of care characteristics decreased with age and work experience, care commitment was higher in older, more experienced nurses. In addition, female nurses had a better view of the effect of technology on care. In contrast, young and experienced nurses had a negative view of the effects of technology on nursing care [18]. The Locsin's theory of technological competence and features that delivering care in critical care needs nurses to actively keep in balance deserve attention for the client while managing machines. The purpose of theory as caring in nursing is to know persons as caring who are participants in their care, rather than simply objects of care. Experienced nurses gain this harmonious and can offer support to novice nurses. Critical care nurse orientation plans should be based on a holistic approach to technology and care has been discussed dualism [19,20].
In Iran, like other countries in the world, ICUs are very advanced in terms of equipment and nurses are quite skilled in using them, but the number of nurses is not enough compared to the number of beds and critically ill patients. The presence of expert nurses who have obtained specialized courses in the ward is low and most nurses are employed due to mere experience. The unwritten law about forbid or limited visitation applied to these wards, which according to the views of physicians and nurses and their concerns about the transmission of infection and possibly disruption of care. Therefore, families are not able to visit their patients directly and are often informed about their patient's condition through their physician and remote observation (behind the window).
According to the ndings of the reviewed studies, the effect of cultural and organizational conditions on the experiences and demonstration of humanistic care and the described situation of ICUs in the study environment, it is important to understand the importance of humanistic care in every eld by taking into account the cultural and structural differences to enable and contribute to better humanistic care. To this purpose, this study attempts to explain perceptions of nurses and patient's families of humanistic care in intensive care units.

Methods
A conventional qualitative content analysis approach was used in the present study. As naturalistic paradigms and qualitative methods take into account the dynamic and multiple nature of the reality under investigation and consider multiple constructs of a phenomenon as possible, they are believed to be useful to study the lesser-known domains [21,22].

Setting and Participants
Data were collected using semi structured face to face interviews through purposive sampling with 17 nurses who worked in the morning, afternoon and night shifts, in an adult ICU in a teaching hospital and 4 attendants who were primary caregivers and had direct contact with nurses and physicians and 4 alert patients (Glasgow Coma Scale (GCS=13-15) and had hospital length of stay more than 48 hours. The key characteristics of the participants are displayed in Table 1. Each interview last approximately 25-120 minutes. Field note observations were also recorded in the intensive care unit of a healthcare teaching center from November 2018 to May 2019 in Qazvin city in Iran.

Data collection
Semi structured interviews were conducted with nurses and patients and families to collect the data. All the interviews started asking an open-ended and general question from the participants. The questions of the interview guide were general (Box 1). Interviews continued until data saturation was reached and no new codes could be identi ed (from participant 25). Field note observations were also recorded in the intensive care unit to complete and deepen the interview data. They are intended as objective evidence that gives meaning and aid in the understanding of the humanistic care phenomenon. Field notes allowed us to access the perceptions of the subjects and record what they observed unobtrusively.

Data Analysis
The data obtained from the interviews were analyzed after they were recorded and transcribed word by word according to the Elo-Kyngäs method [23]. This method includes three steps: 1. Preparation, 2.
Organization and 3. Abstraction. During the preparation stage, the whole interview, which could be a good context for semantic units, was selected as the most appropriate unit of analysis. Each interview was read several times so that the researcher could go deeply into the participants' perceptions. At the organization stage, open coding was performed by re-reading the interviews, taking notes, and writing labels on the margins. The labels were then recorded on the code sheet. Grouping began after several interviews were read. Additional labels and categories evolved by repeating the abovementioned stages for each new interview. After comparing and merging categories belonging to a group, the number of initial categories was reduced. The sub-categories with similar themes were grouped as one category. Each category was then named by words representing its content characteristics. The abstraction process continued until four main themes were extracted ( Table 2). The nurse's attempt to save a patient at the request of the family and the nursing office for a longer period of time Bed 9 as a bradycardia patient and attracted my attention. I informed the nurse and I said you were doing nothing for Bed 9.The nurse said he was expired. His family had a wedding today and we injected him atropine to get him alive until the end of wedding, They demanded the nursing office not to ruin the wedding if possible…(Field note 28) Helping the expedition of deaths of irreversible patients and the final stage Taking care of patients with a low level of consciousness is useless and only takes our time and energy. Our colleagues say if he is sent to the ward, he will be soon expired (Nurse Ms. N) The physician's refusal to comply with the nurse's request to expedite the death of an irreversible patient An internist came to the ward today and the head nurse said: Doctor, you should send the bed 10 patients, who are being in a bad condition, to the general ward where they should decide what to do. They insisted, but the physician did not accept to send the patient to the ward. The patient had severe rectal bleeding…The doctor said how I could send the patient...The head nurse said: He would waste a lot of money and energy. They are too skinny, and we have nothing to give them, so they become thin, and catch sore. More human attention to regretful and young suicide patients If a patient is more conscious, younger, or entered unwanted to this ward, like the suicide patients, and it is the main cause of their death, when they are put under the ventilated machine, they say please save us, we want to live, I am regretful, so the caring is done further. These cases give us the motivation to provide care to treat them (Nurse Ms. Gh)

Rigor
Long-term engagement of the researchers for a year in the eld and spending enough time communicating with participants during data collection helped the researchers to build trust and understanding in participants and enabled deep data collection. According to Lincoln and Guba's criteria [24], maximum variance sampling is based on features such as age, work experience, and the position was used to con rm the transferability of the ndings. To ensure that the analysis accurately re ected the participants' experiences, the codes extracted from each interview were controlled and reviewed by the participants during data collection and analysis, and necessary changes were made in data interpretations based on participants' suggestions. To provide dependability and con rmability of data, two nurses who were expert in conducting research and had working experience in the intensive care unit reviewed parts of the raw data including interviews and analytical products, namely initial codes and categories.

Findings Findings
Analysis of the data yielded 367 initial codes, 16 categories, and 4 main themes including "insu cient 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 su cient 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 satis ed the patients and themselves and they felt satis ed when being in and out of the ward.
Insu cient understanding of nurses and attendants of each other's roles, needs, and expectations The ndings 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 ve attributes including "families' insistence on the follow-up of situation and treatment", "Ignoring families ", "Unnecessary and disturbing presence of families", "lack of skill and willingness to interact and guide", and "voluntary participation in care".
Families' insistence on the follow-up of situation and treatment 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. The families were allowed to visit the patient, but, nurses were opposed to the family to meet the patient.
"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).

Ignoring families
During the patients' care, their attendants are often forgotten. It was found that the attendants' needs are forgotten 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).

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).
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.

Lack of skills and willingness to interact and guide
Communicating with and informing the attendants about the patients' conditions in the intensive care unit are 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 quali cations. This can cause major problems such as con icts, 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 was scared and said that "I must consult with my family and I could not decide alone" (Field note 2).

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 eld 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).
The use of personal and situational reasoning rather than ethical principles Some ndings indicated that ethical decision-making is challenging in complex conditions of the patients in the ICU. Factors such as complexity of the situation, tendency to save energy and time in di cult 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 stress in the intensive care unit and neglect of nurses' roles and rights lead to insu cient efforts by the nurses to meet all the needs of patients in the intensive care unit, nurses' fatigue, and mistrust. This theme is included "insu cient nurse care to meet all patients' needs in the intensive care unit", "patients' mistrust in the nurse's sayings" ,"neglect of the nurses' roles and rights"," diversity and intensity of work stresses in the intensive care unit", "focus on the unconscious patient's body. Many nurses try to do many caring affairs carelessly and routinely in response to not being seen in the workplace. 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.

Insu cient 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 insu cient 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 di cult for me, and it affects my spirit. I am not used to it as them" (Patient, a 43-year-old man with Guillain-Barré syndrome).
Patients' mistrust in the 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 a nurse. She said, "Give it to me, but it was too hot". The nurse told her to 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 di cult 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 a lack of drugs, no devices and doctors take our time for calling and nding 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 the 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
This theme is characterized by "gratitude and spiritual excellence from receiving internal and external feedback", "answer to the call of conscience", "patient-nurse mutual consideration and appreciation", "sensitivity to patients' needs and vulnerabilities". Although nurses work with high pressure and are overworked in the intensive care unit, they become satis ed 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 bene ts 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.).
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 nd it, I'll apologize for being annoyed..." (Nurse Ms. Agh.).

Sensitivity to patients' needs and vulnerabilities
Nurses complain about the inability to resolve the patients' problems.
"There was a young woman who had 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 re ux and could eat nothing. She was thirsty and we could give her nothing, and we saw his gradual death" (Nurse Ms.N.).

Discussion
The Findings indicated that the nurses and attendants insu cient understanding of nurses and patients' families 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 as perceptions of nurses and attendants of humanistic care. Researchers in other studies considered the perceptions of care providers and recipients mostly in cases where patients had su cient consciousness, but it was less performed in the intensive care unit, and particularly with patients with insu cient consciousness.
In line with the inadequate understanding of nurses and attendants roles, needs, and expectations, Martos et al. in Spain indicated that professional performance in medicine and activity in intensive care improved communication not only among caregivers in that ward but also with caregivers in other wards of the hospital and patients and their families. Furthermore, patients and their families promoted caring motivation by caring tools and helped to promote humanistic care in the intensive care unit [4]. The results contradicted the ndings of the present study as a category "Lack of skills and willingness to interact and guide" between nurses and families in the intensive care unit.
Moreover, Wong et al. conducted a grounded theory study indicating that families of patients in the ICUs primarily sought information and awareness in their interactions with the nurses. Employees sought supportive ways to interact with families owing to interpersonal communication and skills [25]. Although the two studies by Martos et al. and Wong et al. achieved notable success in understanding and responding to the needs of families in the ICUs, different changes can be made in any environment depending on organizational and cultural conditions. It is necessary to use the experience of others, including these studies, and perform appropriate interventions to resolve the problem according to organizational and cultural conditions.
One of the ndings of the present study was "Unnecessary and disturbing presence of families" and "Ignoring families" relating to the following theme," insu cient understanding of nurses and patients' families of each other's roles, needs and expectations". Unlike the present study, other studies emphasized that health is based on a patient-centered and family-centered system [26,27]. Spreen et al. explained the principles and standards of visiting in the intensive care unit, stating that the "open visit" policy was an urgent need for patients and families in the intensive care unit. Clinical guidelines in many countries recommend open care policy in the intensive care unit in line with family-centered care [28,29]. Other studies also indicated that families needed participation, and their presence was not only a nuisance but also useful and effective [30,31].
Despite these standards and valid ndings and evidence, in Iran, there are still restrictions on open visiting that need to be standardized by training or removing organizational barriers.
As related to the theme, "The use of personal and situational reasoning rather than ethical principles", the ndings indicated that nurses were sometimes in uenced by emotional or cross-sectional demands of families and, in ethical con icts; they acted personally with outcome-centered and emotional reasoning.
It is always emphasized that in the adherence to professional ethics, patients have rights in the healthcare system that must be respected and protected, and this cannot depend on providers' personal preference and desire [32].
Consistent with the ndings of the present study, "Facing moral contradictions in saving life" in one study by Falcó-Pegueroles et al. found ethical con ict is an intrinsic problem, but it is strongly in uenced by speci c variables and environmental conditions. Nurses' participation in decision-making when patients have critical conditions appears to be a protective factor against ethical con icts [33]. It is important to note why nurses sometimes tend to like the earlier death of patients, or in some cases, make the patients alive with medical interventions due to the family requests; why they are more inclined to serve the youth, and, on the contrary, the elderly are less considered. These two concepts seem to be particularly internalized in the intensive care. Although it creates apparent logical reasoning for nurses, it causes ethical challenges and internal con icts, and thus makes nursing less humanistic and without the purpose of being good and peaceful death. Chamberlin found that useless or potentially inappropriate care was associated with neglecting patients, relatives, and colleagues, and burnout-related behavior [34].
Since, in some cases, nurses are confronted with irrational demands of the patient's family, understanding the concept of humanistic care [17] helps them make appropriate clinical decisions.
Another theme found in this study was "caring preference in young and conscious patients". We can address one study by Khademi et al.[35] Indicating the severity of disease threat, vulnerability, and weakness of supportive resources. Such conditions (age groups, such as children and the elderly, and the absence of family members at patients' beside) mean the need for careful and long-term care. Unlike the present study, this may vary based on the nurses' personality traits that are nurse-related factors in human care delivery, namely care de nition, differentiation, absent nurses, analysis orientation, routine orientation, restriction, and invisibility in the hourglass model [36].
Consistent with the ndings of the present study, "care preference in young and conscious patients", Laerkner et al. [37] Indicated that despite the complexity of care, nurses preferred taking care of conscious patients.
Consistent with our ndings, insu cient care by nurses to meet the needs of all patients in the ICUs is a characteristic of caring stagnation. Khademi et al. indicated that claims and unsuccessful selfcompensation for rights occur overtime after the right violation [5]. The violation has three main dimensions, namely "caring stagnation", "mechanical care" and "disrespect"; and patients' rights -as social rights -determine the quality and access to healthcare [38]. The rights violated in hospital settings can lead to patient/ family rights violations and care stagnation. Salazar states that many factors can lead to impersonal care in organizational or personal contexts based on the hourglass model. Humanistic care can be changed to impersonal care or vice versa depending on the orientation of nurses in caring practice and some elements in the organizational context [36].
Another nding of our study was "satisfaction with care", which was aligned with the ndings of Khademi et al. In some cases, nurses are involved with the process of unsparing response to situations that are in uenced by the synergy of education/learning and situation. In addition to satisfaction, especially receiving care bene ts and rewards, it also means achieving an aspect of spiritual rights and satisfaction [35].
In line with the ndings of our study about the "patient-nurse mutual respect and appreciation", an ethnographical study by Laerkner et al. found three main themes including "a sense of ability", familiarity with unknown situations", and " being conscious of their surroundings" [39]. The patients were able to interact and gain a sense of ability since the early days of the disease. They appreciated the compassionate and caring nurses who cared for them and involved them in affairs. The patients were aware of the activities around them, felt unable while being neglected by staff, and were affected by the sufferings of other patients. They were interconnected as they woke up to their inability and lack of power alongside con icting factors such as physical weakness, technology, location, and communication aspects.

Limitation
Since qualitative studies are dependent on the eld case of study, and participants were only from a special unit, and also due to the patients' poor conditions, they could not be interviewed; hence, the researcher sought to validate the data by observing and attending the unit.

Implications and recommendations for practice
Humanistic care programs in Intensive Care should be individualized for each setting, Unit and group.
Each gathering of professionals ought to break down its boundaries and troubles, and determine how far it wishes or can go. A great organization is basic, with the rami cations of the same number of members as conceivable, causing them to feel as dynamic members in this great change. Inadequate understanding of the patient / family and nurses of each other's needs, expectations, and tasks, caring stagnation, and emotional ethical decisions are the most important issues and barriers in humanistic care in the intensive care unit.
These ndings apply to health professionals and nursing managers, and can provide a good understanding of the humanistic care in the intensive care unit and will help them to determine where to start and what issues to focus on if they aim to improve the situation to improve the quality of care.

Conclusion
The ndings of the present study, especially the concept of care stagnation, indicated that the humanistic care in the intensive care unit did not emerge and was not provided with its true essence and meaning. An underlying cause of this issue was the nurses and families' inadequate understanding of their mutual roles, needs, expectations, and even limitations of each other, since it allowed nurses to consider personal and situational reasoning based on the limitations rather than on ethics and patients and attendants' needs and preferences, resulting in feeling and understanding the care stagnation. Despite this result, nurses feel an unexpected feeling contrary to the nature of care, which is satisfaction, due to experience and observation of patients' health improvement. Although this paradoxical feeling is the outcome and implication of the care process, it may be the result of changes in the conditions of ICU patients.
Abbreviations ICU: Intensive Care Unit GCS: Glasgow Coma Scale Declarations Ethics approval and consent to participate Code of ethics (IR.TMU.REC.1397.182.) was obtained from Tarbiat Modares University, and the research environment license was received. The importance, purpose, and method of research were explained. The interviews were recorded. Participants' informed consent obtained was written. Con dentiality and anonymity at all stages were met and the time and place of interviews were mutually decided. The participants were free to participate in or to withdraw from attendance. The researcher's characteristics and the way of access to results were explained to the participants.

Consent to publish
Not applicable.

Availability of data and materials
The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The author(s) declared no potential con icts of interest concerning the research, Authorship and/or publication of this article.

Funding
The author(s) received no nancial support for the research, authorship and/or publication of this article.

Authors' contributions
All of the authors initially developed the concepts with contributions. Hasandoost interacted with the participants, performed interviews, carried out transcriptions, and the initial analysis. Mohammadi & khademi and seddighi assisted in the reviewing of the coding scheme. Hasandoost wrote the initial draft with contributions from all authors during the editing procedure. All authors provided comments and approved the nal version