A focused ethnography of the culture of inclusive caring practice in the intensive care unit

Abstract Aim To explore and understand the culture of nurses' multidimensional “caring‐for” practice in intensive care unit (ICU). Design A focused ethnography. Methods Data were collected from 35 Registered Nurses through participant observations, field notes, documentation reviews, interviews, informal conversations and Participants' additional information forms over 6 months in one ICU. Thematic data analysis was used. Findings Different dimensions of nursing caring in ICU were found. The inclusivity of a culture of nurses' “caring‐for” involved the following: oneself, patients and their families, different colleagues, and caring as ecological consciousness in the ICU environment and organization.


| INTRODUC TI ON
The concept "caring" is complex. Numerous theoretical and operational perspectives of caring within the context of nursing have emerged. The ongoing discussion about what constitutes caring within nursing practice domains is nowhere more evident than in the adult ICU specialization, where humanistic caring is juxtaposed with advanced technology. Caring in ICU has been discussed in terms of one entity as the patient (Cutler et al., 2013), their family (Mackie et al., 2017), nurses (Hales et al., 2018), health professionals (Handberg & Voss, 2018) or a couple of entities such as patients and nurses (Happ et al., 2014). However, ICU is not limited to caring for patients, their families and nursing staff. This study examines the multidimensional inclusive nature of caring in ICU.

| BACKG ROU N D
Several authors discussed different caring ICU entities from various perspectives, including patients' perspectives and experiences of care (Cutler et al., 2013), patients' descriptions of the art of nursing (Gramling, 2004), and patients' perceptions of nursing care quality as evidenced by nurse caring behaviours (Reiss, 2005). Other studies examined family members' satisfaction with critical care (Karlsson et al., 2011), family needs (Buckley & Andrews, 2011), family presence (Charlton, 2015) and family involvement in ICU (Mackie et al., 2017;Mitchell et al., 2017). Visiting hours and balance among the needs of patients, families and staff have also been explored (Nyholm & Koskinen, 2017).
The wider question of the conjunction of humanistic and technological aspects of caring, which characterizes ICU, is rarely addressed (Alasad, 2002;Nascimentol & Erdmann, 2009). Generally, the nature of caring in ICU discussed only one or two entities or topics. However, caring in ICU involves more than just patients, families and staff. This study looks at the wider range of caring in an ICU.
The purpose of this study is to explore and understand the culture of nurses' multidimensional caring in ICU.

| Design
A focused ethnography, widely acknowledged as a research method for studying behaviours and social interactions in health care, was used (Roberts, 2009). Focused ethnography has useful applications in primary care and hospital healthcare practices and is frequently used to determine ways to enhance care and care processes (Cruz & Higginbottom, 2013). The study was undertaken by the author Checklist was employed to report the study (File S1).

| Setting
The study was conducted at the adult ICU of a large private hospital in the Queensland metropolitan area, Australia.

| Sample
The ICU Clinical Nurse Manager (CNM) distributed recruitment letters to nursing staff and placed flyers around the nurses' stations and the staff tearoom. Letters and flyers outlined the study purpose, data collection process and Participant's time commitment. Then, the CNM introduced the researcher to the staff, with whom she had had no prior relationship. Each participant (P) received an information sheet, informed consent form and demographic questionnaire from the researcher.
Purposive sample was selected, and the inclusion criteria for participation were as follows: RNs, either gender; employed full-time; a minimum of 1 year experience in the unit; working rotating shifts; and willing to be interviewed and observed within the practice setting. Thirty-eight RNs consented to participate but three withdrew because of family issues and heavy workload commitment, resulting in 35 Ps, and Table 1 provides Ps' demographics.

| Data collection
Data were triangulated from different sources: P's observation, document reviews and interviews, and further written information from Ps was collected.
Unstructured observation was used to obtain detailed descriptions of behaviours as they occurred or shortly afterwards by completing a reflective journal or field notes (Borbasi & Jackson, 2012).
The observations included the physical ICU layout, characteristics of Ps, activities and social interactions, frequency, and duration of events, precipitating factors, organization, and incidents. Ps were observed closely for two shifts; with some being observed for more shifts because they interacted with other Ps and events. Document reviews coincided with the P observation period.
Documentation included patients' files, nurses' notes, charts, communication book, policies and procedures. Reviews focused on obtaining greater insight into nurses' responses to patients and their relatives. This allowed access to data was difficult to acquire through direct observation, interviewing and questioning (Holloway & Wheeler, 2010).
Pilot interviews with four Ps allowed me to pre-test and improve the interview guide and process before full implementation. The interviews were audio-recorded and arranged to suit the Ps' schedules.
Interviews were conducted at workplace (e.g. conference room) and Ps' homes). Interviews started with general questions to encourage Ps to discuss their experiences "What do you believe constitutes caring in ICU?" or "How would you describe caring practices/behaviours/attitudes in ICU?". Probes and prompts, such as "tell me more about that," were used to clarify content and augment the information provided. The interviews lasted 1-1.5 hr. I took notes before, during and after the interviews. There were 44 follow-up interviews to obtain further clarifications from observations. After the interviews, I asked the Ps to complete a P's additional written information form (PAWIF) if they wished to add further information. PAWIFs were only collected on completion of the data gathering process.
The researcher did not return the interview transcripts to participants for comments, as she conducted instant member checking through employing various strategies such as seeking clarification by probing, paraphrasing, using open-ended questions and listening with an interpretive intent during interviews.
Further, member checking was not used (McConnell-Henry et al., 2011). After 6 months of the fieldwork, no new data were forthcoming, and the study had reached data saturation (Polit & Beck, 2017).

| Data analysis
Assisted by NVivo 11 ® data management software, I analysed the data inductively and thematically in six phases: data immersion, coding, categorizing/sub-theming, theming, conceptual model development and reporting. Data were segmented, compared, contrasted, synthesized, categorized and conceptualized to identify common codes, subthemes and core themes, from which a mental map of the findings was constructed to capture the core concepts in the data set (Hennink et al., 2011).

| Trustworthiness
Ensuring trustworthiness includes credibility, dependability, confirmability, transferability, authenticity and reflexibility (Lincoln et al., 2011;Polit & Beck, 2017). Credibility was maintained by the prolonged engagement in the field and data triangulation (Polit & Beck, 2017). Dependability was achieved through consistency in the methods of data collection and analysis and triangulation.
Confirmability was achieved by checking of the codes and analysis to ensure data accuracy, relevance or meaning (Polit & Beck, 2008).
Transferability included a clear outline the study's context and the rationale for its undertaking, establishing the Ps inclusion criteria and articulating the analysed data. Authenticity was assured through obtaining dense and vivid descriptions beyond the researcher's reflexive journal and accurately analyse and represent them and involved ongoing consideration concerning context writing (Polit & Beck, 2017). Reflexivity is a critical self-reflection was assured through the use of reflective journaling about preconceived biases, preferences, and preconceptions that the researcher may have that could influence a situation or interpretation of data (Borbasi et al., 2005;Dowling, 2008;Polit & Beck, 2017).

| Reflexivity and the researcher's position
The researcher used reflexivity as an important tool that functions as a reminder that the researcher is an important part of the social world being studied (Hammersley & Atkinson, 2007). The researcher used the constant critical process of a researcher's self-reflection on personal biases, preferences, values and preconceptions that could affect the processes of data collection and analysis (Doyle, 2013;Polit & Beck, 2017). To preserve reflexivity, the researcher positioned herself through the research process by questioning herself continuously: how have I affected the process of the research, how has the research affected me and where am I now? As recommended by Mulhall et al. (1999). The researcher recorded her reflections in her field notes relating to different phases of data collection. These notes were important as they allowed the researcher to question her influence throughout data collection and analysis, management and final writing. For example, the researcher maintained reflexive notes of her assumptions and behaviours that might have influenced the interviews (Dowling, 2008). The researcher used reflexive practices and journaling as a tool to increase self-awareness and to monitor interactions between herself and the study participants (Smith-Sullivan, 2008). Reflexivity also assisted her in examining the contextual factors that constrained the relationships between herself and the participants (Finlay, 2002). As a part of reflexivity, the researcher consciously identified her role as a researcher collecting data from the unit. Therefore, reflexivity allowed her to be aware of her own personal characteristics, previous work experiences, age, gender and education, which had the potential to influence her relationships with the participants. Also, the researcher used a reflective journal to document experiences, fears, problems and general activities surrounding events in the field (Spradley, 1980). As well, the researcher wrote about her experiences of what happened in the unit and reflected on data collection and analysis methods. The researcher undertook reflective journaling before, during and after conducting data collection and analysis. The resulting journals created an account and an audit trail that outlined the progress of the research process (Dowling, 2006;Scott-Findlay and Estabrooks (2006)). This assisted the credibility of this study and reduced the potential for bias (Polit & Beck, 2017).
During the research, it was important that participants' experiences took precedence over the researcher's own expectations (Roberts, 2007). Therefore, the researcher focused on aspects of the interactions that participants appeared to find hard to articulate.
The researcher was mindful of how she presented herself, aware of social positioning within long-term care. For example, there was a situation where one of the participants communicated with a dying patient even though she was gasping for air until the last moment of her life. The participant then communicated the news of his wife's death to the patient's husband. The researcher discussed the participant's verbal and non-verbal communication (with both the dead patient and her husband) with the participant and also relayed her own interpretation to get feedback.
Bias is described as predisposition or partiality which can compromise any stage of the research process and produce a distortion of the findings (Polit & Beck, 2017). The researcher was mindful about the possible biases that could affect this study, and these were subsequently addressed from either the participant's or the researcher's side.
To addressing bias from the participants' side, the researcher was aware of the effect of her presence on the participants and the influence on the data (Hammersley & Atkinson, 2007). Therefore, the researcher was careful to minimize her influence on the participants.
Participants' lack of candour, or what is called the Hawthorn effect, was originally noted as a possible source of bias (Curry et al., 2009;Speziale, 2007). This occurs when the participant alters their normal behaviour due to their awareness of the researcher's presence or of the situation being scrutinized (Curry et al., 2009;Speziale, 2007).
To avoid the "observer effect" and reduce the Hawthorn effect, the researcher's role was non-intrusive for the participants (Holloway & Wheeler, 2010). This was achieved by the prolonged period of engagement in the unit and with participants. The more time the researcher spent in the unit, the more participants became used to her presence. At times, the researcher used the strategy of covert data collection (concealment) by observing while pretending to be engaged in other activities such as reviewing nurses' notes and charts or by observing participants from the nurses' station.
In addressing bias from the researcher's side, the researcher generally acknowledged her own subjectivity throughout the research process (Ogden, 2008). The researcher managed her bias by being conscious of her values and assumptions and suspending her internal (e.g. beliefs) and external (e.g. environmental factors) presuppositions, biases and experiences to describe the essence of caring in this ICU (Firmin, 2008). In addition, the researcher sought negative case data (Brodsky, 2008;Saumure & Given, 2008), which offered different interpretations of the data. This was experienced in different scenarios, as follows: The first scenario occurred when participant P29 was allocated to a patient who was a former nurse. This patient was admitted to ICU following a drug overdose because of her addiction. The researcher observed participant P29 treating the patient as an inferior and relaying the patient's story to her colleagues in an unprofessional man- The second scenario occurred during a bronchoscopy procedure in ICU. During this procedure, the surgeon and participant P11 discovered that a tiny piece of the bronchoscope was missing, and they needed to get another bronchoscope. As an observer with experience in the operating theatre, the researcher suggested use of a three-way stopcock connection to address this problem. The surgeon and the nursing team appreciated this idea at that time and obtained the three-way stopcock, which rectified the problem.
Unfortunately, it was later discovered that participant P11 complained about this intervention to the unit manager. This incident made the researcher very careful about her participation, even when it was useful. She reminded herself to remain in her role just as an observer and informed the unit manager that she would not interfere in the future. This incident affected the researcher for several days, and she reflected in the field notes to continuously remind herself to be cautious in her research role while conducting this study. Given these scenarios and the conflict in relation to her research position, the researcher realized that she needed to develop a greater capability for reflexivity and mindfulness by acknowledging her position and responding appropriately.

| Ethical considerations
Ethics approval was granted by the ethics committees of both the university and the hospital. Informed consent from each P was obtained prior to collecting data. Ps voluntarily agreed to participate by signing the informed consent. Ps could stop participation at any time without consequences. P's confidentiality during and after the study was protected by using pseudonyms and safeguarding data.
Patients and other personnel who were not the focus of this study were informed of the reason for the observer researcher's presence.

| FINDING S
To the Ps, the culture of "caring-for" included many dimensions ingrained as a valued part of ICU's overall caring. Objects of "caring-for" include oneself, patients, families and colleagues (nurses and other team members). Caring encompasses an ecological consciousness of the ICU environment and wider organization. The SUN model, Figure 1, provides a conceptualization of the various components.

| Caring for oneself
Most Ps described caring for oneself activities as a priority within ICU, without which caring for others would be compromised.
Caring and looking after oneself physically, emotionally and psy-  Almost all Ps agreed that they looked after their patients as they would look after themselves or a family member, "the way nurses look after their patients is the way we look after ourselves, and that is why we always strive to provide the best care possible" (P2).

| Caring for patients
Several Ps stated they preferred night shifts as it permits providing quality care with fewer distractions, which gives them more time with their patients than during a busy day shift, as P33 said "Night  P19: "It is ok to go, and hopefully, you are not in pain.
Someone is with you; you are not alone." Researcher: "You are talking to her." P19: "I found myself privileged to care for dying patients that you spend the last few moments with.
Their family members are not there, and therefore, they had somebody with them." "Sometimes families are just so stressed, and all you can do is to provide the information and to be empathic to them" (P3).

| Caring for families
Intensive care unit nurses participated in family meetings with health team members for clarification and decision-making, which was considered essential in providing care to families. P37 said: "usually, we arrange for relatives to talk to the doctor and arrange the time for a family conference." I witnessed nurses offer the assistance of the Chaplain or counsellor, informing family about the availability of different supportive resources: "we can always provide them with support from the nurse counsellor if they're really not coping and if they don't have a good network support, or we can bring the Chaplains into the fold, for their spiritual needs" (P3) "We can give the relatives accommodation across the road if they come from out of town. In addition, we can provide free parking tickets for them" (P1). to ensure they are safe in their practice".

| Caring for colleagues
An overarching collegial atmosphere of caring and respect existed throughout the observations and Ps' descriptions irrespective of the professional discipline. P9 articulated, "we need to look after our coworkers, whoever they are on our shift-doctors, physiotherapists, cleaners or the people delivering the meals-everybody has a job in ICU. So, we look after our team."

| Caring as ecological consciousness
Caring as ecological consciousness was manifested in two ways: caring for the unit environment and organization. Most of the Ps, especially in-charge nurses, articulated their commitment to caring for the organization by emphasizing their concern about the organization's budget for staff and resources. P7 stated, "If we are really busy, we require additional staff to be safe, but at the same time we have to consider the budget."

| D ISCUSS I ON
The findings from the current study (CS) presented different dimensions of nursing caring in ICU. The inclusivity of a culture of nurses' "caring-for" involved the following: oneself, patients and their fami- These findings were compatible with Mealer et al. (2012), who found that nurses seek solace and spiritual energy in difficult times through religious practices such as praying and found that ICU nurses used reiki and pastoral care for the effects of compassion satisfaction and fatigue, and moral distress.
Ps' emotional self-care included leaving work stress at the workplace and debriefing when required. Similarly, Mealer et al. (2012) found that Ps could separate work from their personal life as a counterbalance to work stress and self-care. Emotionally distancing oneself from stressful situations, including avoidance and using the psychosocial process of "protecting from stress," provides the necessary barrier for self-preservation (Mitchell, 2011;Siffleet et al., 2015).
"Caring-for" the patient. Providing person-centred care was a central concern for the study Ps-being with the person in their illness and acknowledging the person behind "the patient" and advocating on their behalf. Similar findings were described in other studies (Benner, 2002;Carvalho & Lunardi, 2009;Hasse, 2013;de Lima Guimarães et al., 2017), where providing a patient-centred approach to care was stressed. Ensuring patient safety, especially for unconscious patients and those on mechanical ventilation, was another area of concern to Ps, confirming findings by Gimenes et al. (2016) and Karlsson and Bergbom (2015).
Ps in the CS encountered difficulty attending to patients' psycho-emotional and especially spiritual needs at the EOL stage.
Studies focusing on EOL experiences for patients and nurses' ability to respond appropriately found nurses pay more attention to patients' physical than psychological and spiritual needs, especially in the EOL stage (Canfield et al., 2016;McCallum & McConigley, 2013;Tyler, 2017). Perceived ethical dilemmas concerning decisions to withhold treatment or prolong life to alleviate family distress while maintaining the quality of life for the patient added to nurses' already complex workload.
Similar findings were identified Campbell (2015) and Carvalho and Lunardi (2009). Amid such ethical dilemmas, Ps discussed their role as advocate in ensuring that the patients' needs are met, preserving the dignity of the person. Similarly, King and Thomas (2013) highlighted the importance of being truthful, advocating, remaining connected with the patient and making the death as comfortable, peaceful and dignified as possible. This includes being with dying patients, managing pain and comfort, attending to wishes, promoting earlier cessation of treatment and not initiating aggressive treatment (Beckstrand et al., 2006), exactly as noted in the CS.
Regarding "caring-for" family, Ps in this study aimed to keep the family well informed and updated about the patient's health.
Previous studies also noted the importance of providing and updating families with information about the patient (Attia et al., 2013;Cannon, 2011;Carlson et al., 2015). Also, Ps reported involving the family in their loved one's care included feeding, family conferences/meetings to discuss the person's condition and treatment. Ågård and Maindal (2009) and Davidson (2009) identified the need to involve the family in care and treatment decisions and promote the family's involvement in their loved one's daily care. Further, the need to respect, listen and adhere to the family's views and concerns was evident in previous studies (Cannon, 2011;Carlson et al., 2015;Davidson, 2009;Khalaila, 2014), in which attentive listening by nurses to relatives' needs was instrumental in alleviating the anxiety and distress of families in ICU. Ps in this study found identifying the level of support required by each family to meet their needs and expectations in the care of their loved ones important.
Consideration of the relatives' closeness to the patient informed determining the types of support and assistance needed. Åsa and Siv (2007), Blanchard and Alavi (2008), and Buckley and Andrews (2011) identified the closeness of the family members to the patient as vital in the provision ICU care, in addition to providing psychological support to families (Celik et al., 2008;Nordgren & Olsson, 2004). Ps in this study explicated that families rely on open communication, considered as core to building a trusting relationship between families and staff, which is imperative in working with the patient and family and facilitating understanding of the patient's condition and prognosis, especially at the EOL stage. Similar findings were reported in previous studies (Attia et al., 2013;Ranse et al., 2012;Rushton et al., 2007). A further consideration in developing a trusting, supportive relationship with family was in the area of family conflict (Attia et al., 2013;Esmaeili et al., 2014).
Ps' provision of care and support did not end when the patient died; sometimes, it continued beyond the patient's death with follow-up contact with the family to provide support, send flowers on behalf of the unit, and if appropriate and possible, attend the patient's funeral. Such findings were also identified in other studies, in which staff believed part of their role was to continue providing support and to advocate on behalf of the family if necessary (Bloomer & O'Connor, 2012;Fridh et al., 2007;Virginio et al., 2014).
"Caring-for" nurse colleagues. The consensus within the literature is that unit managers play a pivotal role in providing psychological, emotional and spiritual support for staff who are confronted daily with high levels of work stress (Efstathiou & Walker, 2014;Tirgari et al., 2013;Walker & Deacon, 2016 The unit manager and in-charge nurses paid attention to the allocation of workloads, particularly to staff rostered on 12-hr shifts, especially when nurses expressed concern about their workloads and patient safety concerns. Subsequently, workload was reviewed by the in-charge, and resources were allocated to minimize staff concerns. Similar findings were reported by Richardson et al. (2007) who found that nurses could safely work maximally three consecutive 12hr day shifts or four consecutive 12-hr night shifts.
The complexity of patients' care needs acts as additional workload. Patients become agitated based on their health status and a "no sedation" unit protocol. Complex care posed additional challenges, including the need to view patient care as an interdisciplinary responsibility (Laerknera et al., 2015). In such situations, Ps were quick to take over some caring responsibilities to ensure their colleagues were not exposed to unsafe practices.
"Caring-for" other health team colleagues. There was mutual respect between all health providers and different styles of communication for different situations in the CS, especially in critical times. Piquette et al. (2009)  attain personal satisfaction in their work but also helps them meet organizational goals (Schmalenberg & Kramer, 2007). I witnessed and Ps expressed that all nurses and health team members strove to provide a safe and healthy ICU environment through skilful communication, multidisciplinary team collaboration, appropriate staffing levels, effective decision-making, and authentic leadership, and maintaining physical and psychological safety for patients, families, and staff. The provision of a healthy environment has been cited as a priority in previous studies (Huddleston & Gray, 2016;Tracy & Ceronsky, 2001;Tremper, 2004), which meets the standards of The  (Kleinpell et al., 2016;Kossman & Scheidenhelm, 2008;Wikström et al., 2007).
"Caring-for" the organization. Nurses were mindful of wasteful stocking practices and endeavoured to establish and maintain waste management. This finding corroborated Morrow et al. 's (2013) findings that reducing waste was a concern for ICU nurses.
To my knowledge, this is the first study discusses different dimensions of nursing caring in ICU. The inclusivity of a culture of nurses' "caring-for" involved the following: oneself, patients and their families, different colleagues, and caring as ecological consciousness in the ICU environment and organization, specifically the latest one (ecological consciousness). Nevertheless, other studies discussed only one to two entities or topics of nursing caring in critical settings.

| Limitations
This study's only limitation is that the findings cannot be considered generalizable to the broader population because of the cultural differences in organization and critical care settings. However, this was the expectation of the study design.

| CON CLUS ION
• To date, this is the first study to address the inclusivity of a culture of multidimensional "caring-for" practice by ICU nurses, which is imperative for the provision of quality health care. This culture focuses on the healthcare needs of oneself, patient, family, multidisciplinary team members, ICU environment and organization.
• The study needs to be underpinned and enhanced in health systems and educational institutions, particularly caring for oneself, clinical environments and organizations.
• It is necessary to find consensus and strategies among health professionals regarding ethical considerations to the patient's rights and treatments in critical care settings, especially in the EOL stage.
• The significance of communicating with patients in the EOL stage is not limited to the time before and during patients' death but extends after their death.
• Reconsidering caring for the family as "an extension of caring for the patient" is significant.
• Intensive care unit nurses are encouraged to participate more effectively in family meetings for their patients' treatment and decision-making through their personality attributes, confidence, experiences and relationships with other health team members.
• Enhancing the health team members' caring sense as ecological consciousness of the clinical settings and health institutions and organizations is significant.
• The culture of inclusive nursing caring practices in ICU could have positive and negative effects on nursing staff and the efficiency of working time, quality of care provided and staff reactions.
This requires special consideration from clinicians, managers and policymakers.
• Further research is required to investigate the inclusive caring practices within different ICUs, particularly "caring-for" oneself, ICU environment and the organization.
Under the umbrella of nursing, nurses are caring for various entities. Unfortunately, usually nurses give the priority to care for others and other things first, and eventually they care for themselves.
There is a quote says, "you cannot serve from an empty vessel," however; it is customary for nurses to take care of others when they desperately need to look after themselves first. This could result with nurses' burnout, absenteeism, turnover, quitting from nursing profession and other negative consequences. At the end of this article, the author wishes to emphasize a recommendation of the necessity that nurses need to be compassionate and taking care of themselves first and foremost before caring for others. Nurses should have a balance in their lives. It is unfair to the nurses to oppress themselves, whether it is in professional or personal life . It is enough for nurses to play the candle's role that consumes itself in lighting others.
Enough is enough!

ACK N OWLED G EM ENTS
The author would like to thank Associate Professor Anthony Welch and Associate Professor Jennieffer Barr for their supervision, thoughtful guidance and encouragement through her PhD journey at Central Queensland University, Australia. The author sincerely thanks all the nurses who took the time to participate in this study and to share their opinions and experiences and gratefully acknowledges the Nurse Unit Manager of the Intensive Care Unit, and the participating hospital for making the study possible.

CO N FLI C T O F I NTE R E S T
The author declares no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are openly available