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"Where Withstanding is Difficult, and Deserting Even More": Head Nurses’ Phenomenological Description of Intensive Care Units

Introduction: The intensive care unit is one of the specialized units in hospitals where head nurses are responsible for both motivating the personnel and providing high quality care. Understanding of the lived experiences of head nurses could help develop new assumptions of the ICU. The present study was therefore conducted to describe the lived experiences of head nurses working in ICU. Methods: In this phenomenological study, data were collected through unstructured in-depth interviews with 5 ICU head nurses in Northern Iran and then analyzed using 7 steps Colaizzi’s method. Results: Despite the "distressing atmosphere of the ICU", the "difficulty of managing the ICU" and the "difficulty of communication in the ICU", which encourages the "desire to leave the unit" among ICU head nurses, the "desire to stay in the unit" is stronger and head nurses are highly motivated to stay in the unit because the unit "develops a feeling of being extraordinary", "creates an interest in providing complicated care to special patients", "facilitates the spiritual bond", "develops a professional dynamism" and "creates an awareness about the nature of intensive care" among them. Conclusion: According to the result, ICU head nurses are still inclined to work in the unit and achieve success in spite of the problems that persist in working in the ICU. As the individuals’ motivation can be the backbone of organizations, and given that individuals with a high enthusiasm for success are productive, hospital managers can take advantage of this strength in choosing their head nurses.


Introduction
The intensive care units (ICUs) are the main component of the healthcare system. 1 These units are specialized departments providing special care including treatment and monitoring for patients with critical or unstable conditions. 2 ICU patients are the most vulnerable patients who are often unable to perform their normal human functions. These patients need the best-quality treatments and have the right to expect to receive not only treatments, but also a specific care accompanied by kindness and empathy. 3 The special characteristics of these units make employed nursing workforce face different barriers which impact on the performance of optimal care 4,5 and result in their desire to change their workplace. The researchers propose ICU managers to be the agents responsible for developing nurses desire to continue working in these departments. 6 It should be noted, however, that the head nurse's role is recognized as one of the most complicated roles in the healthcare system. 7 The vast working scope of head nurses in clinically critical situations, decision-making for saving lives, solving complicated problems, thinking under critical conditions such as setting priorities, clinical decision-making, data adjustment and turning theory into practice put head nurses under a lot of stress, which might have the effect of disrupting their performance, 8 decreasing the quality of their professional life and thus causing job dissatisfaction and burnout. The duty of head nurses is to continually meet the needs of patients and their families and frequently interact on an intensely emotional level with all the different aspects of life. 9 Although many studies have been conducted on the role of head nurses in motivating ICU personnel and on the mental stresses resulting from working in this particular unit, there is no qualitative studies which investigated head nurses' particular experiences of the meaning of an ICU through a descriptive or exploratory approach. The question therefore arose as to how a person in charge of both coordinating and supervising special nursing care and motivating the personnel to provide the optimum care describes the ICU. The descriptive phenomenological method enables the researcher to discover individuals' experiences of daily life and answer the question. 10 From a knowledge development perspective, the study of head nurses' experiences is important for three reasons.
First, other studies had, for the most part, quantitative approach and focused on the experiences of nurses. Although these quantitative findings are instructive, however, they do not provide an empirical understanding of the nature or essence of the ICU head nurses experience per se. because discovering human emotions, views and values through quantitative or positivistic approaches is rather difficult. 11 Qualitative studies, however, are organized, subjective efforts for discovering the meaning of daily experiences. 12 As such, phenomenology offers an important shift from a positivist causeeffect focus to one of human subjectivity and discovering the meaning of actions. 13 Second, the discovery of head nurses' experiences of the ICU can develop knowledge of the subject beyond the existing assumptions. Given that the ability of the health care system to evaluation, support and promotion of head nurses performance is contingent on a clear understanding of the experiences of ICU head nurses, this gap in our clinical knowledge is problematic and warrants further study. This approach is especially appropriate considering the paucity of research examining this particular group and the need for a fundamental understanding of their lived experience; and third, as Lopez and Wuilis argued, the phenomenological approach is a suitable approach for nursing science and phenomenology seeks to understand the unique experiences of people in their real life. 14 The present study was therefore conducted to describe the lived experiences of ICU head nurses.

Materials and methods
Considering the objective of the study, which is "to describe the lived experiences of ICU head nurses", phenomenology was used as the methodological framework of the study. Phenomenology is derived from the inductive descriptive approach and originates in phenomenological philosophy. This method is used for studding of the people's daily experiences and facilitate the perception of phenomena that occur normally in their own normal conditions. 15 In this approach, researchers use a broad definition of a phenomenon that involves nearly all the events experienced by individuals. 16 In the present study, participants were selected through purposive sampling. Purposive sampling is used to reach a deeper understanding while having access to rich sources of information. 17 Only individuals with sufficient years of experience and recent experience of working in ICUs were interviewed, because the goal was to select those rich in information (with lived experiences) who could actively participate in the study and help the researcher to better understand the concept. 18 Participants included 5 ICU head nurses with at least two years of experience in these units. Given that sample size cannot be predetermined in qualitative studies, and since sampling continues until no new description can be added for the phenomenon, 19 data collection for this study also continued until data Journal of Caring Sciences, June 2016; 5 (2), 133-143|135 saturation had occurred and no new description could be added for the phenomenon. The researcher tried to select a diverse range of participants in order to achieve rich and unique narrations of a specific experience. 20 Data were collected through unstructured, in-depth, face-to-face interviews. The unstructured in-depth interview is the most common method of data collection in phenomenological studies and begins with a broad general question about the lived daily experiences of participants. In this method, the researcher allows the free flow of information with an open mind and without any pressures. 19 The guiding questions was as following "In your experience, what does an ICU look like? How do you feel when you hear the word 'ICU'?" Probing questions used during the interviews included "Please elaborate. What does this mean? Can you clarify your feelings with an example?" The researcher recorded the interviews with a tape recorder and then transcribed them for analysis.
In a phenomenological study, just like other types of qualitative studies, data analysis follows a regular pattern of repeated data collection and simultaneous analysis. 21 7-step Colaizzi's method (cited by Shosha, 2012) was used to analyze the data. All the descriptions provided by the participants were first read several times in order to get a better grasp of them and for the purpose of familiarization with their content. The important sentences related to the studied phenomenon were extracted from each text. These statements were written on a separate sheet of paper with the page and line numbers cited. Meanings were formulated from these important sentences. The formulated meanings were classified into categories, thematic clusters and themes. The findings were then integrated in order to give a more thorough explanation of the phenomenon under study and the main structure of the phenomenon was then described. 22 Table 1 shows an example of the formation of one of the subthemes.
To increase the rigor of the study, participants and research collaborators both reviewed the data. Each participant received a copy of her own interview text and was asked to review and confirm its content. All participants confirmed the content of their interviews. The researcher endeavored to ensure the consistency of the findings through such actions as giving feedback to participants and asking for the research team to review the findings. To determine the conformability of the findings, the researcher endeavored to fully explain all the stages of the study, including data collection, data analysis and the formation of themes, so that others could audit the study through reading it. To achieve a more favorable transferability of the data, purposive sampling was adopted and the researcher made efforts to select the study participants from a more diverse background in terms of their years of service and workplace.
This study was approved by the ethics committee of Tarbiat Modarres University. A written consent was taken from all participants for the interview after they were sufficiently informed on the study.
The researcher obtained the allowance of the hospital authorities and the nursing office before entering the research environment and beginning the study. During the transcription of the recorded interviews, all the names were converted into codes that were then used for referring to participants during the analysis of the data and the expression of results. Participants were ensured of the confidentiality of their information and the publication of the study results without any references to their names.

Results
Over 320 initial themes were extracted from data analysis. Once the overlapping themes were integrated or eliminated, the themes were classified into 8 categories and two main themes. Data analysis showed that the ICU denoted two seemingly contradictory themes based on the lived experiences of the head nurses. The themes include: the desire to leave the unit (deserting) and the desire to stay in the unit (withstanding). Three main categories including the "distressing atmosphere of the ICU", the "difficulty of managing the ICU"and the "difficulty of communication in the ICU" were involved in the formation of "the desire to leave the unit" theme. Five main categories, including the "creating a feeling of being extraordinary", "creating an interest in providing complicated care to special patients", "the nature of intensive care as a facilitator of the spiritual bond", "developing a professional dynamism" and "creating an awareness about the nature of intensive care" were involved in the formation of "the desire to stay in the unit" theme. Table 2 shows the formation of all the subcategories, categories and final themes.

The desire to leave the ICU (deserting)
The categories forming this theme include experiences that make working difficult for an ICU head nurse. These categories are the "distressing atmosphere of the ICU", the "difficulty of managing the ICU" and the "difficulty of communication in the ICU". Two excerpts of the statements made by the head nurses are provided as an example: "I'm really tired of working in the ICU. I want to go." (P1). If someone tells me they want to send me to the general ward, I may get relieved at first …" (P5).

The distressing atmosphere of the ICU
According to the lived experiences of participants, the special nature of the ICU, the overall difficulty of working in the ICU and the ICU as a reminder of unpleasant emotional experiences make the ICU a burdensome department to work in for head nurses. The "burdensomeness" factor along with the "painful status of patients in the ICU" and the "mental fatigue of nurses in the ICU" made the head nurses participating in this study to associate the ICU with a "distressing atmosphere." "… The patients here depress you. Everyone has relatives, and when one sees the patients' miseries, they bring her down. My father has been dead for less than a year. And I am still reminded of him when I see the patients and then I become depressed" (P2). "… They bring a child in a coma. Right now, we have 4-5 mothers who have recently given birth to a child, myself included. When these guys do stuff for the patients they cry" (P5). "The ICU, though, has a continuing responsibility working on critically-ill patients. Just the fact that you think to yourself, the same patient with his unstable level of consciousness will be in this unit after two months is really difficult and depressing" (P1).

The difficulty of managing the ICU
Based on the experiences of participants, the factors making the management of the ICU difficult for the head nurses included the "complexities of managing physical resources of the ICU", the "complexities of managing intensive care" and the "complexities of managing human resources".
The participants stated that there were too many sensitive devices and equipment in the ICU, and the care provided in this unit Moreover, the experiences of participants showed that the management of the care provided in the ICU is also very complicated. They believed that the ICU head nurse should be very accurate, fast and of high mind-practice harmony, so that she can both develop a care program based on the nursing science and fully supervise the care provided in the unit. "You should constantly be on the look-out. Your hands, feet and mind should work in harmony. You should imagine the patient from all aspects possible and do their frequent follow-ups with the highest degree of sensitivity and accuracy" (P2).

"… A minimal negligence, such as the failure to fully observe sterility during suction causes pulmonary infection and lengthens the duration of dependency on the device.…. A small inappropriate movement while repositioning the patient may cause irreversible complications in spinal cord injury patients" (P1).
According to the participants, the third factor making the management of the ICU difficult is comprised of the complexities of the management of human resources. They proposed the unskilled novice nurses in the unit as their concerns for management.
They believed that the education provided during the school years was not enough for working in the ICU, and also believed that the constant displacement of the ICU personnel made the ICU head nurses have to constantly struggle with novice nurses, which takes a lot of time and energy from the head nurses for preparing these nurses and makes the organization of the human resources appropriate for special patients difficult. "…I can't manage this unit perfectly with this mixture of personnel. For example, a 17-year old girl was brought with a knife rupture in her heart that needed more than 3 personnel because she was shocked and in terrible conditions. At the same time, 2 other critically ill patients were brought in. What do you think will happen if the number of personnel and their specialties don't match the number of patients? Many tasks wouldn't be done, that's for sure" (P4).
The experiences of head nurses indicated that the nature of the ICU complicates interprofessional and interpersonal communication, which makes communication in the ICU difficult.

On the complexities of interprofessional communication, one said, "Each patient in the ICU has several doctors who may give different and even contradictory prescriptions. Their routines might vary with those of the others ... I should arrange them" (P. 5).
The following quotations show the difficulty of developing a peaceful atmosphere among impatient and irritable nurses and also the difficulty of creating an interest in the nurses for working in the ICU. "There are critically-ill patients in the ICU, in a closed environment, and then isolated, exhausted personnel. So the head nurse has to be more careful, rigorous and kind" (P3). "There is a lot of stress in the ICU because of the large number of personnel, the heavy workload, the doctors' coming and going, and the critical conditions of patients. The guys have also become depressed and impatient because of how much they've worked with critically-ill patients" (P1).

The desire to stay in the ICU (with standing)
Participants proposed that the nature of providing care in the ICU is such that they still want to stay in the unit and continue their work despite the discussed difficulties of working in the ICU. The categories involved in the formation of this theme include "creating a feeling of being extraordinary", "being interested in providing complicated care to special patients", "the nature of intensive care as a facilitator of the spiritual bond", "developing a professional dynamism" and "creating an awareness about the nature of intensive care". Two excerpts of the statements made by the head nurses are provided as an example: "… I still like the ICU very much though. I don't want to go to another unit" (P1). "Although it has had such impact on my mood, I still like to work in the ICU" (P5).

2.1.
Creating a feeling of being extraordinary Participants expressed that working in the ICU allows them to understand the patients' needs without their request, talk with the critically-ill and comatose patients and feel useful by deeming patient care in the ICU unique. All these factors signify that the ICU head nurse feels extraordinary. "I can feel the comatose patient. In other words, you can talk to the patients, not the case here; you should feel instead of patient and then do your work on him. You should hear his voice without him even calling you out and uttering his needs" (P5).

Interest in providing complicated care to special patients
The experiences of participants showed that head nurses should be interested in caring for critically-ill patients if they want to work in the ICU, and that they should maintain this interest while on the job because ICU patients need to be cared for by nurses who have an interest in caring for them. "I like to work with ICU patients. I feel that these patients need to be cared for or supervised by motivated people. So I think I'm useful. When someone wants to work in the ICU, she has to be both interested and motivated" (P2).

The nature of intensive care as a facilitator of the spiritual bond
Participants argued that the clinical conditions of ICU patients encouraged the personnel to turn to spirituality and to say prayers in order to gain the positive effects of communication with God.

The difficulty of communication in the ICU
"A head nurse can bring her nurses closer to spirituality in her own way, especially since we deal with dying patients a lot here and we can feel peaceful through the remembrance of God and through saying prayers. I encourage the guys here to say certain prayers for themselves and even at the patients' bedside" (P3).

Developing a professional dynamism
According to the participants, another reason for staying in the ICU was the development of a professional dynamism through working in the ICU, as working in the ICU promoted studying and selflearning activities, developed a willingness to search for knowledge in various resources and increased the motivation for learning through attendance in training courses. "…When I became an ICU head nurse, I found that I couldn't keep going like I always had. And so I began studying and tried to improve my knowledge. I read a lot and still do" (P4). "I try not to miss anything; I try to read and study as much as possible so that I can improve my knowledge and also use the experiences of previous head nurses and other strong colleagues. Once a new case comes in, I'm interested in learning, even from the doctors and others" (P5).

Creating an awareness about the nature of intensive care
Awareness refers to the proper understanding of motivational forces behind an action, thought or behavior and is developed through understanding the real nature of the thing. Participants described the nature of intensive care as keeping the head nurses conscientious in work, making them value the principles of care more and developing a care perspective for them. These three factors promote professional attitude and, alongside obliging to abide by the moral codes, create a proper understanding of the nature of intensive care, which is the same as awareness.
"In the ICU, you can only work with your conscience awakened. I mean, you should be sensitive to anything you see and follow up with it, and all seemingly minor things should be important to you and you shouldn't let anything slide and you should do your very best, even if it's beyond your duties" (P5). "This is a ward where everything has be in its own place, and everything should be excellent with no deficiencies. Every nurse should be at her patient's bedside and participate directly in all care practices, from repositioning to bathing and …" (P4).

Discussion
The purpose of the present study was to answer the question, "How do head nurses describe the ICU?" The findings showed that ICU head nurses' perception of the meaning of the ICU is double and paradoxical. They perceived the nature of intensive care in this unit in a way that makes them desire to stay and continue working in the ICU despite the difficulties that make them want to leave the unit. Although they found it difficult to stay and work in the ICU, they found it more difficult to leave the unit. They believed that working in the ICU required more learning, which made them study more and seek information from various resources in order to develop a professional dynamism.
It should be noted that developing a professional dynamism is a satisfying goal for people in search of success, because dynamism is the main key for motivating people. This finding confirms McClelland's theory; because according to McClelland's theory, the need to achieve success is one of the three motivational factors for work that increases the individuals' interest in performing a task, organizing their physical and social environment, overcoming the barriers and outpacing others and competing with them through striving to perform better. 23 whereas the present study also showed that ICU head nurses perceive the difficulties of working in the ICU as an opportunity to develop professional dynamism and achieve success, and that they foster in themselves the motivation or desire to stay in the unit.
The majority of ICU patients are not fully conscious; they are feeble and agonized and miss their loved ones; and they do not have enough control and dignity. 24 The interest in providing care to these patients, which was one of the reasons for participants for staying in the ICU, can be discussed from two aspects. First, as mentioned before, head nurses seem to make efforts toward achieving success as a motivational factor for work. People with an intense need for success avoid performing the simple tasks; instead, they seek to perform challenging tasks and try to perform better through reflecting more deeply on these tasks. 23 Working with ICU patients is complicated due to the specificity of the patients' conditions and is therefore suitable for individuals seeking success (i.e. ICU head nurses). Second, participants also described the care provided in the ICU as a facilitator of the spiritual bond because it involves providing care to dying patients and could end in some mystical experiences. In recent years, spirituality has become known as a human dimension of individuals and has received an increasing attention regarding its role in the individual's health and wellbeing. 25 Creating a spiritual bond with the omnipotent God ensures people that a powerful force is always taking care of them. 26 Moreover, the effects of individuals' spiritual and religious beliefs on their interpretation of events facilitate compatibility with the events that have occurred and their acceptance. 27 In this regard, participants of the present study preferred working in the ICU to leaving it because it facilitated their spiritual bond. The other findings of this study pertained to experiences described by participants as the reasons for their desire to leave the ICU. These experiences make a head nurse's job more difficult. The distressing atmosphere of the ICU was one such experiences. In their phenomenological study, Hov et al., described the status of ICU patients as distressing. 28 Griffiths also described providing care to distressed, ill patients as difficult. 29 These findings indicate that the ICU patients are suffering all over the world. So, caring for these patients is difficult and complex for our nurses like other nurses, 30 and the ICU head nurse is responsible for providing a specific care accompanied by kindness and empathy for this unique patient. 3 Head nurses are thus under a lot of mental stress, making it difficult for them to continue working in the ICU.
Another experiences was the difficulty of communication in the ICU. The complicated status of ICU patients urges the development of proper interprofessional and interpersonal communication in order to provide high-quality nursing care to these patients and reach the optimum level of cooperation. 24 Other studies also highlights the importance of interprofessional cooperation in the ICU. [31][32][33] Participants of the present study also found working in the ICU difficult considering their central role in developing this cooperation and preventing conflicts and solving contradictions arising from the complicated nature of communication in this unit.
The studied participants also described the difficulty of managing resources, human workforce and the practice of care in the ICU as the third experiences motivating them to leave the unit. It seems that the difficulty of managing the ICU is due to the excessive sense of responsibility required by its head nurses. The excessive sense of responsibility is one of the most personal stressors in head nurses 34 that decreases their job satisfaction and increases the desire to take leaves of absence from work 35 and also deteriorates the quality of their professional life, which is accompanied by job dissatisfaction and burnout, 9 these findings were also confirmed by the participants of the present study.
The generalizability of the findings of the present study is low due to the particular design of the study and its limited number of participants. The purpose of a phenomenological study, however, is not to generalize its findings; rather to describe the experiences of individuals and the meanings they associate with their experiences.

Conclusion
The findings of the present study showed that, despite the "distressing atmosphere of the ICU", the "difficulty of managing the ICU" and the "difficulty of communication in ICU", ICU head nurses were more motivated to stay in the unit and continue their work.
In fact, despite all the problems of working in the unit, ICU head nurses desire to stay in the unit and continue their work so as to achieve success. Considering that people's motivation for achieving success can be the backbone of most organizations, and given that individuals with a high enthusiasm for success are productive, hospital managers can take advantage of this strength in choosing their head nurses, so that they can provide high-quality care for their patients in the ICU.

Acknowledgments
The present study was part of a PhD thesis approved by the Faculty of Medicine, Tarbiat Modares University. Hereby, the researchers would like to express their gratitude to the university authorities for all the support they provided, and to all the participants who presented their valuable experiences to us, and also to the authorities of Amol hospitals for cooperating with the researchers in getting in touch with the participants.

Ethical issues
None to be declared.