ICU Nurses' Perceptions of Family‐Inclusive Outdoor Excursions: Enhancing Family Engagement and Humanisation in Intensive Care

ABSTRACT

Background

Patients hospitalised in an intensive care unit (ICU) are vulnerable to dehumanisation. To address this issue, our hospital introduced out‐of‐ICU activities, including outdoor garden visits with family members.

Aim

To explore ICU nurses' perceptions of family‐inclusive outdoor excursions for ICU patients regarding the excursions' impacts on patients, their family members, nurses and humanisation in intensive care.

Study Design

The data collected from each interview were analyzed using a qualitative descriptive approach with inductive coding to identify codes, subcategories, categories, and themes.

Findings

The analysis yielded 29 subcategories, 10 categories and 3 themes. The first theme was the excursion program's impacts on patients and families, including five categories: enhanced physical and psychological functions and overall recovery, exposure to pleasant and stimulating experiences, increased patient motivation, comfort and emotional relief for both patients and families and facilitation of active family engagement. The second theme was the excursion program's impacts on nurses, including three categories: recognition of the value of the outdoor excursions, expanded assessment of patients and families facilitated by outdoor excursions and appreciation for multi‐professional collaboration. The third theme was the excursion program's impacts on human connections, including two categories: facilitation of meaningful communication and promotion of humanisation in intensive care.

Conclusions

ICU nurses perceived that family‐inclusive outdoor excursions supported patients' recovery, facilitated family engagement, reinforced the recognition of patients as individuals rather than solely as clinical cases and advanced the humanisation of intensive care.

Relevance to Clinical Practice

Family‐inclusive outdoor excursions provide multifaceted benefits for patients, families and healthcare providers. These activities enhance patients' experiences of humane care, enable families to participate as active partners in care and strengthen interpersonal connections among patients, families and healthcare teams. Nurses consider multi‐professional collaboration to be very important for safe and effective excursions.

Impact Statements

• What is known about the topic

  • ○
    ICU patients are vulnerable to experiences of dehumanisation.
  • ○
    Outdoor gardens have been recognised as healing environments in intensive care settings.
  • ○
    Out‐of‐ICU activities can be provided safely, and multi‐professional staff perceive them as having multiple positive impacts, including the humanisation of care for both patients and families.
• What this paper adds

  • ○
    The outdoor environment fosters human connections among patients, families and healthcare professionals.
  • ○
    ICU nurses felt rewarded, rather than burdened, when facilitating patients' outdoor excursions.
  • ○
    Through family‐inclusive outdoor excursions, ICU nurses re‐recognised patients as persons, thereby enhancing the humanisation of intensive care.

1. Introduction

Patients who are receiving treatment in an intensive care unit (ICU) often feel dehumanised [1, 2] or disrespected [3]. The term ‘dehumanisation’ generally indicates depriving a person of positive human qualities or more concretely as viewing or treating a person as less than human and more like an object or non‐human animal [1, 2, 4]. Dehumanisation of patients often occurs among healthcare professionals unintentionally and unconsciously. The commonly described factors that contribute to dehumanisation in the medical field include dissimilarity, self‐defence mechanisms and a workplace culture. ICU patients are especially vulnerable to dehumanisation [1, 2] because their agency is frequently diminished; they may be unable to express their feelings or intentions, and they depend on life‐supporting equipment. These circumstances can lead healthcare providers to mistakenly assume that the patients are incapable, thus making the patients seem fundamentally different from those providing care. Such dissimilarity, particularly when combined with patients' diminished agency, is a recognised contributor to dehumanisation [1, 4].

Dehumanisation may also develop as a self‐defence mechanism in which healthcare professionals detach emotionally from patients in order to cope with the psychological stress that can accompany empathy [1, 2, 4, 5]. In addition, a task‐oriented workplace culture that is characterised by heavy workloads, tension, fragmented processes, and/or under‐empowered staff—along with the psychological distance created by technology and machinery—can further exacerbate dehumanisation [2, 6, 7].

Patients' dehumanisation may lead to serious consequences that include increased distress, fear, anxiety and dissatisfaction in both the patients and their family members; a loss of trust in the medical team; diminished patient motivation to recover and potentially worse clinical outcomes [2, 4].

2. Background

Outdoor gardens have increasingly been recognised as healing environments in intensive care settings [8]. It has also been reported that patient outings were associated with lower delirium severity [9]. The Intensive Care Society in the United Kingdom promotes patient outings to outdoor gardens as a humanising practice, and the Society provides guidance on taking critically ill‐patient outdoors [10]. In 2014, our 500‐bed teaching hospital in Nagoya, Japan, initiated an out‐of‐ICU activity program that provides, as part of early rehabilitation, outdoor excursions for ICU patients accompanied by their family member(s). In 2022, we also adopted the ICU ward slogan, ‘Let's aim for the humanization of intensive care!’ We have observed that these outdoor activities can be delivered safely [11]. In addition, our prior survey showed that healthcare providers from multiple professions perceived these excursion activities as contributing to patients' recovery process, alleviating family members' stress and promoting humanised care [12]. Together, these findings highlight the need for an in‐depth exploration of the underlying effects of family‐inclusive outdoor excursions.

3. Aim

Thus, the aim of this study was to explore in depth how ICU nurses perceive the impacts of a family‐inclusive outdoor excursion program on ICU patients, their family members, the nurses themselves and the humanisation of intensive care.

4. Design and Methods

4.1. Design

This study used an exploratory, descriptive qualitative design. This approach was chosen because it allows researchers to remain close to participants' own words while providing a comprehensive summary of their experiences. Semi‐structured individual interviews were used to enable the study participants to describe their perceptions of the family‐inclusive outdoor excursion program in depth while still allowing flexibility to follow new insights as they emerged. The Consolidated Criteria for Reporting Qualitative Research (COREQ) [13] were followed.

4.2. Setting and Sample

The study was conducted at the general ICU of a teaching hospital in Nagoya, Japan. The ICU treats a wide range of adult and paediatric patients, including medical, surgical and obstetric cases. Seven ICU nurses were recruited through purposive sampling. We selected nurses who had at least 3 years of ICU experience and prior experience accompanying patients on family‐inclusive outdoor excursions to ensure that all of the study's participants were sufficiently familiar with both routine ICU care and the excursion program. In Japan, nurses receive general nursing education as part of an undergraduate program, and newly graduated nurses may be assigned directly to intensive care units; the study participants' years of general nursing experience and ICU experience may therefore overlap.

4.3. Data Collection

Semi‐structured, one‐on‐one interviews of the participant ICU nurses were conducted remotely via web‐based video conferencing during March and April 2024. The interviews were carried out by one researcher (Y.O.) using a guided interview script (Table 1). The interview guide included questions on the nurses' demographic characteristics and the nurses' perceptions of family‐inclusive outdoor excursions. The interview guide was developed by the research team based on the study's aim, findings from our previous survey of the excursion program and a review of the relevant literature. The guide was reviewed by two qualitative research experts and refined for clarity and alignment with qualitative descriptive methodology. The guide was not pilot‐tested, and no changes were made during the data collection period. Each interview lasted approximately 40 min and was audio‐recorded in full.

TABLE 1.

Interview guide.

1. Demographic characteristics

Age

Gender

Years of experience as a nurse

Years of experience in the ICU

Approximate number of times accompanied ICU patients on outdoor excursions (< 9 or ≥ 10)

2. Perceptions of ICU patients' outdoor excursions with their family

What are your overall impressions of the outdoor excursions?

What do you think are the benefits of outdoor excursions for patients?

What do you think are the disadvantages of outdoor excursions for patients?

How do you prefer to interact with patients during outdoor excursions?

Have you observed changes in patients after outdoor excursions? If so, what changes have you noticed?

What do you think are the benefits of outdoor excursions for family members?

What do you think are the disadvantages of outdoor excursions for family members?

How do you prefer to interact with family members during outdoor excursions?

Have you observed changes in family members after outdoor excursions? If so, what changes have you noticed?

Has your perspective on humanity and nursing care changed after participating in outdoor excursions? If so, in what ways?

Abbreviation: ICU, intensive care unit.

4.4. Data Analysis

The data collected from each interview were analysed using a qualitative descriptive approach [14]. The analysis followed these steps:

1. Each interview was transcribed verbatim and de‐identified.

2. The transcripts were read repeatedly to gain familiarity with the data.

3. Meaning units were identified and initial codes were generated.

4. Initial codes with similar meanings were grouped together to form subcategories.

5. Subcategories were further consolidated into broader categories.

6. Categories were then synthesised into overarching themes. This process resulted in a preliminary coding framework developed by Y.O.

7. The transcripts and preliminary coding framework were reviewed by N.S.

8. The final coding framework was discussed and agreed upon by both researchers.

9. All participants were provided with the initial codes, subcategories, categories, and themes and asked to verify the accuracy and congruence of the findings with their experiences.

4.5. Ethical Considerations

Ethical approval for this study was obtained from the Institutional Review Board of Nagoya City University (approval no. 60‐23‐0056, 15 September 2023). All participants received an information sheet explaining the study's purpose and interview procedures, and written informed consent was obtained prior to participation. Participants were informed that participation was voluntary, that they could withdraw from the study at any time before data anonymisation, and that their information would be kept confidential and reported anonymously.

4.6. Rigour

The study's rigour and trustworthiness were ensured through strategies addressing credibility, dependability, confirmability and transferability. Credibility was enhanced through member checking: all participants were provided with the initial codes, subcategories, categories and themes and were asked to verify the accuracy and congruence of the findings with their experiences. Dependability was supported by a systematic and transparent analytic process, with each step of data analysis explicitly described. Confirmability was strengthened through independent review of the transcripts and preliminary coding framework by a second researcher (N.S.), followed by discussion and agreement on the final analytic structure. Transferability was supported by providing detailed descriptions of the study setting, sampling strategy and data collection process, enabling readers to assess the applicability of the findings to other contexts.

4.7. Reflexivity

Reflexivity was considered throughout the study. All of the interviews were conducted by a single researcher (Y.O.) who was not affiliated with the ICU and not employed at the hospital, whereas the second researcher (N.S.) was affiliated with the ICU and was familiar with the ICU's practices and the outdoor excursion program. We acknowledge that these differing professional positions could influence the interpretation of the collected data, and thus analytic decisions were discussed collaboratively and interpretations were grounded in the participants' verbatim accounts in order to enhance transparency and reflexive awareness.

4.8. Family‐Inclusive Outdoor Excursions

The ICU's family‐inclusive outdoor excursions are conducted after the completion of a structured assessment of the patients' stability. During morning multidisciplinary meetings, the haemodynamic and respiratory status of patients being considered for the excursions is evaluated based on predefined criteria (Tables S1 and S2), and the patients' family members are informed in advance and invited to participate when an excursion is planned.

For the excursion, the patient is transported to a rooftop garden located on the ICU rooftop by using a wheelchair selected according to the patient's ability to maintain head, neck and trunk control (Table S3). Each excursion is conducted by a multi‐professional team consisting of an ICU intensivist, an ICU nurse and a physiotherapist. For patients under mechanical ventilation, a clinical engineering technician accompanies this team to manage the ventilator. The patient's vital signs are continuously monitored by a transport monitor, and in‐hospital mobile phones are available for rapid response. Suction equipment is immediately accessible in the rehabilitation room adjacent to the garden.

After each excursion, an ICU nurse documents the patient's condition observed during and after the excursion in the patient's medical record and shares observations within the team to support the ongoing reflection and refinement of the excursion practice.

5. Findings

Table 2 presents the demographic characteristics of the seven ICU nurse participants. The mean age was 35.7 years (range 25–50 years). The mean years of nursing experience and ICU experience were 13.9 years (range 3–28 years) and 7.1 years (range 3–12 years), respectively. All the participants had accompanied ICU patients on outdoor excursions ≥ 10 times.

TABLE 2.

Demographic characteristics of participants (n = 7).

Age, average (range)	35.7 (25–50) years old
Gender	7 women, 0 men
Years of work experiences as a nurse, average (range)	13.9 (3–28) years
Years of work experiences in the ICU, average (range)	7.1 (3–12) years
Number of times accompanied in ICU patient's outdoor excursions, n (%)	~9 times 0 (0.0) 10 times ~7 (100.0)

Abbreviation: ICU, intensive care unit.

Based on the participants' verbatim transcripts, 29 subcategories and 10 categories were identified. These categories were further organised into three overarching themes: (1) the excursion program's impacts on patients and families (five categories), (2) the program's impacts on nurses (three categories) and (3) the program's impacts on human connections (two categories) (Table 3).

TABLE 3.

Impacts of family‐inclusive outdoor excursions.

Subcategories	Categories	Themes
Improved physical function	Enhanced physical and physiological functions and overall recovery	Impacts on patients and families
Improved physiological function
Improved sleep quality
Promotion of overall recovery
Absence of negative experiences during outdoor excursions
Pleasant sensory stimulation	Exposure to pleasant and stimulating experiences
Mental and emotional restoration
Expression of joy
Recognition of personal improvement	Increased patient motivation
Strengthened motivation to work towards recovery
Opportunities to reunite with loved ones	Comfort and emotional relief for both patients and families
Family's recognition of the patient's recovery
Facilitation of family visits	Facilitation of active family engagement
Increased desire among family members to be involved in care
Recognition of outdoor excursions as meaningful time deserving active nursing support	Recognition of the value of the outdoor excursions	Impacts on nurses
Promotion of participation in the activity
Communication of the day's schedule to the patient
Assessment of the outcomes of the activity
Experience of joy through patient engagement
Observation and assessment of the patient's condition	Expanded assessment of patients and families facilitated by outdoor excursions
Observation and assessment of the family's mental and emotional state
Documentation of observations for sharing with the team	Appreciation for multi‐professional collaboration
Recognition of the importance of multi‐professional collaboration for successful practice
Increased everyday conversations	Facilitation of meaningful communication	Impacts on human connections
Strengthened sense of closeness
Communication of updates on the patient's condition with family members
Recognition of the risk of dehumanisation	Promotion of humanisation in intensive care
Belief that nursing care should always treat the patient as a person
Enhanced sense of humanised care through outdoor excursions

5.1. Impacts on Patients and Families

The five categories with an impact on the ICU patients and their family members are summarised below.

5.1.1. Enhanced Physical and Physiological Functions and Overall Recovery

This category comprised five subcategories: the patients' improved physical function, improved physiological function, improved sleep quality, the promotion of overall recovery and the absence of negative experiences during the outdoor excursions.

In their interviews, the ICU nurses indicated that the outdoor excursions helped increase the patients' muscle strength and prevent joint contractures. The nurses indicated that the patients appeared to recognise their own progress and growing strength, and that the excursions promoted sputum expectoration and bowel movement. Several nurses noted improved sleep in the patients after their excursions, which could help reduce the patients' delirium. In some cases, the patients' overall condition improved, and treatment outcomes were favourable following excursions. Deterioration that was directly attributable to the outdoor excursions was rarely observed. For example, one nurse commented:

I think the outdoor excursion has a respiratory rehabilitation effect on some patients, because patients cough out sputum more. (P4)

Another nurse remarked:

It seems to me that on the day of the excursion, patients sleep better based on a sleep scale and their own feelings of deep sleep. (P7)

5.1.2. Exposure to Pleasant and Stimulating Experiences

This category comprised three subcategories: pleasant sensory stimulation, mental and emotional restoration and the expression of joy.

Our hospital's outdoor garden environment provides sunlight, fresh air, a breeze, greenery, flowers and birdsong, all of which stimulate patients through multiple senses and contribute to mental restoration. The nurses' interviews indicate that during the garden excursions, the patients' levels of consciousness often became clearer, supported by sensory stimulation and the change of scenery during their wheelchair trips through the garden. A nurse stated:

ICU patients appeared more relaxed and mentally restored during outdoor excursions, away from the constraints of the ICU environment with tubes, lines, and a respirator. They showed happy expressions when they sensed a pleasant breeze, felt the weather, and saw flowers in bloom. (P1)

Another nurse noted:

Patients who were drowsy in the ICU became more alert and responsive, sometimes even showing us a smile. (P3)

5.1.3. Increased Patient Motivation

This category comprised two subcategories: recognition of personal improvement and strengthened motivation to work towards recovery.

The ICU nurses reported that the outdoor excursions also helped patients realise they were getting healthier and stronger, perhaps because the experience resembled daily life. Some of the nurses also felt that the presence of one or more family members gave patients additional strength and motivation for treatment. A nurse explained:

Patients come to realize that they can move even under such a critical situation. So this [outdoor excursion] has a psychological supporting effect to boost patients' motivation. (P5)

Another expressed:

When family members who've been together for many years accompany the patient on outdoor excursions, the patient's motivation to work toward recovery and return home is often further enhanced. (P1)

5.1.4. Comfort and Emotional Relief for Both Patients and Families

This category comprised two subcategories: opportunities to reunite with loved ones and family members' recognition of the patient's recovery.

Meeting loved ones outdoors in a familiar, everyday setting rather than a machine‐filled ICU made the patients and their family members feel happier and more relaxed, according to the nurses. Family members could directly observe signs of recovery in the patients, and the nurses noticed positive changes in the patients' demeanour that are rarely seen inside the ICU. A nurse stated:

Meeting the family members outdoors often brings the patient a smile. (P5)

Another reported:

Family members recognize that the patient could come up here [to the outdoor garden] and not be bed‐ridden, and they feel relieved. (P2)

5.1.5. Facilitation of Active Family Engagement

This category comprised two subcategories: the facilitation of family visits and an increased desire among family members to be involved in the patients' care.

The interviews revealed that by witnessing patients' efforts during excursions, family members became more involved in the patient's recovery journey. They visited more frequently, joined other care activities and encouraged patients directly. A nurse described:

Sometimes family members encourage the patient, telling them that they will work together to overcome this situation. (P7)

5.2. Impacts on Nurses

Three categories were classified as having an impact on the ICU nurses' thinking and actions.

5.2.1. Recognition of the Value of the Outdoor Excursions

This category comprised five subcategories: the recognition of outdoor excursions as meaningful time deserving active nursing support, the promotion of participation in the activity, communication of the day's schedule to the patient, the assessment of the outcomes of the activity and the experience of joy through patient engagement.

The nurses confirmed that they regarded the family‐inclusive outdoor excursions as precious time for patients, and they aimed to ensure that the patients enjoyed each excursion fully. The nurses reported that they encouraged patients' participation in the excursions, explained the plan to the patients, contacted the patients' family members and carefully prepared for each excursion event. After each outdoor excursion, they asked the patients about their experience. Sharing this time with the patients and families was described as rewarding. For example, one nurse said:

I'm very happy to set up opportunities for patients to see their children or grandchildren in the garden, because they look forward to it. (P3)

Another noted:

I feel rewarded sharing the precious time in the garden with the patients and their family members. (P1)

5.2.2. Expanded Assessments of Patients and Families Facilitated by the Outdoor Excursions

This category comprised two subcategories: observation and assessment of the patient's condition and observation and assessment of the family members' mental and emotional state in a non‐task‐oriented, outdoor environment.

The ICU nurses noted that the implementation of the outdoor excursions also provided opportunities to gain insights into the patients' physical strength, personal background and personhood, as well as the family members' backgrounds and emotional states, such as signs of depression. In the relaxed outdoor setting, both the patients and their family members ‘opened up’ naturally, allowing the nurses to collect deeper, more personal information compared to the task‐oriented environment of the ICU. One nurse explained:

In the ICU, there is a tendency to ask patients about symptoms related to their illness, whereas outdoors, conversations naturally shift to what the patient likes or how they enjoyed their time before hospitalization, such as golfing or gardening. (P6)

Another nurse noted:

I check the family member's mental condition during the outings. (P4)

5.2.3. Appreciation for Multi‐Professional Collaboration

This category comprised two subcategories: the documentation of observations for sharing with the team, and the recognition of the importance of multi‐professional collaboration for successful practice.

After the excursions, the nurses shared their observations about the patients and families with other team members (e.g., occupational therapists, physicians, other nurses, psychologists, and social workers) through chart documentation. This facilitated a shared understanding of the patients' conditions and family situations and supported the development of individualised care plans within the multi‐professional team. The nurses also emphasised that high‐quality multi‐professional collaboration, supported by strong leadership, was essential for ensuring the safety and effectiveness of the outdoor excursions. One nurse reported:

I document patients' reactions during the excursion and information about their families so that other nurses and other professionals can understand the patients' conditions and families' situations. (P1)

Another nurse explained:

Multiprofessional teamwork with strong leadership helps us provide safe and successful outdoor excursions. (P2)

5.3. Impacts on Human Connections

The two categories were classified as impacting the human connections among patients, their family members and the healthcare professionals involved in the outdoor excursions, including ICU nurses and other professionals.

5.3.1. Facilitation of Meaningful Communication

This category comprised three subcategories: increased everyday conversations, strengthened sense of closeness and communication with family members regarding updates on the patient's condition.

The outdoor environment encouraged more casual conversations between the ICU patients and their family members. The nurses reported observing warmer, more affectionate interactions compared to those in the ICU. Healthcare professionals also joined in the conversations among the patients and their families, showing greater humanistic interest. These exchanges strengthened relationships and deepened the healthcare professionals' understanding of the patients' personhood. A nurse described:

Through the outdoor excursions, talks from family members to patients increase, and the distance between them becomes closer, like moving from watching with anxiety to standing right by the patient for support. (P1)

Another nurse stated:

I felt deeper connections between the patient and their family members, between the patient and nurses, and between the family members and nurses. (P6)

5.3.2. Promotion of Humanisation in Intensive Care

This category comprised three subcategories: recognition of the risk of ICU patient dehumanisation, the belief that nursing care should always treat the patient as a person, and an enhanced sense of humanised care through outdoor excursions.

The nurses recognised that the ICU environment can be hostile and dehumanising. They described feeling that the outdoor excursions with family members offered meaningful, humane experiences for patients and in particular, the excursions created opportunities for the patients, families and healthcare providers to connect. These experiences helped the nurses re‐acknowledge their patients as people with families, lives and social backgrounds, encouraging more humanised care. One nurse remarked:

In the ICU, I almost forget that the patient is a ‘person,’ but when I accompany outdoor excursions with their family members, I re‐recognize and view the patient as a ‘person’ who has family, a life, and a social background. (P6)

Another nurse described:

After accompanying the out‐of‐ICU activities several times, I think I'm now able to treat [the patients] in a humane manner, not in a task‐centered, impersonal manner. (P6)

6. Discussion

This study explored ICU nurses' perspectives on the impacts of family‐inclusive outdoor excursions on patients, their family members, nurses and the humanisation of intensive care. The findings suggest that ICU nurses perceived these excursions as offering multiple benefits for patients and families while enhancing family engagement and supporting the humanisation of care in the ICU setting.

In our hospital's ICU, family‐inclusive outdoor excursions have been implemented for over a decade as part of an out‐of‐ICU activity program aimed at early mobilisation and humanisation of intensive care. Earlier investigations by our group demonstrated the safety of these excursions [11] and described multi‐professional staff perceptions [12]. Building on this work, the present qualitative study provides in‐depth insight into ICU nurses' perceptions of these practices.

The seven participating ICU nurses perceived that the outdoor excursions contributed to patients' physical and physiological recovery, functioning as rehabilitation. Interestingly, some of the nurses noted that the outdoor excursions could improve the patients' sleep quality, which may be related to a report that outdoor therapy is associated with reduced delirium severity in ICU patients [9]. The nurses in the present study also described perceived psychological benefits, including reduced stress and enhanced motivation in patients. These perceptions align with reports that exposure to green and open spaces can reduce anxiety and stress, enhance cognitive function and promote overall well‐being of patients, as well as families and healthcare professionals [8, 15].

Family members of ICU patients frequently experience substantial psychological distress [16, 17]. The present study's participants noted that the patients' family members often expressed relief and joy during the excursions, which is consistent with a study demonstrating that this psychological distress can be alleviated through access to gardens or outdoor breaks [18]. Notably, the nurses in the present study used the outdoor excursion as an opportunity to assess and understand family members' psychological states in order to provide appropriate support [16, 17]. The nurses noted that family members became more actively engaged in supporting the patient's recovery in some cases after accompanying the patient on outdoor excursions, which is consistent with evidence suggesting that shared outdoor activities can strengthen family bonds [19]. This is very important because families serve not only as care partners but also as vital conduits linking patients to the community and society to which they will eventually return.

Our hospital's ICU nurses play a substantial role in patients' mobilisation, such as in the performance of active and passive range‐of‐motion exercises and to assist stable patients with sitting up, although physical therapy in the ICU is delivered primarily by physiotherapists. Transferring patients to a wheelchair typically requires close collaboration between nurses and physiotherapists due to patients' physical weakness, the presence of multiple lines and devices and/or the potential for hemodynamic instability. For intubated patients, collaboration with an intensivist is essential to manage risks such as accidental endotracheal tube dislodgement. This multi‐professional collaboration for a safe outdoor excursion requires a significant coordinating role of ICU nurses.

Gardens and outdoor spaces can function as platforms for social connection [10, 19], and the nurses in the present study described that the outdoor environment encouraged openness, fostered warm and friendly interactions and strengthened a sense of solidarity among those participating. This promotes a recognition of patients' personhood, which is a key component of humanised care provided with compassion and respect [20]. These shared experiences and understanding patients' personhood often prompted a shift in the nurses' perspectives—from viewing patients primarily as clinical cases or tasks to recognising them as individuals with rich life histories and social identities. This cognitive shift appears to reinforce and accelerate the process of humanising intensive care, as illustrated in our previously proposed conceptual framework (Figure 1), which is further supported by the present study's findings. Taken together, these findings suggest a broader conceptualisation in which not only family‐inclusive outdoor excursions but also other initiatives that enhance human connections among patients, families and healthcare professionals such as Get to Know Me boards [21], ICU diaries [22] and the 3 Wishes Project [23] may be incorporated into the framework as humanisation‐facilitating factors through enhanced human connection. In addition, education ([A], Figure 1) concerning the risk of dehumanisation and describing recommended practices (e.g., manuals of good practices [24] and guidelines on family‐centered care [17]) strengthens respectful and compassionate care, further reinforcing this cycle.

FIGURE 1.

The conceptual framework illustrating the process of humanisation of intensive care facilitated by family‐inclusive outdoor excursions. Adapted from Sasano et al. [12]: (1) Healthcare professionals recognise the patient as a human being. (2) This recognition fosters empathy, respect and compassionate care. (3) Compassionate care promotes positive interactions and human connections among patients, their family members and healthcare professionals. (4) Through these human connections, healthcare professionals further acknowledge their patients' personhood. This cycle promotes humanisation in intensive care. Family‐inclusive outdoor excursions serve as a platform for meaningful patient–family–healthcare professional encounters, thereby accelerating this cycle.

Finally, although earlier studies identified occasional transient adverse changes in patients' conditions [11] and concerns among healthcare professionals regarding disruptions to other duties [12] that may be associated with outdoor excursions, the ICU nurses in the present study did not report negative impacts of outdoor excursions, including concerns related to burnout, which has been associated with the emotional demands of humanised care [3, 6, 7, 25]. Instead, many of the nurses described their work as rewarding. This perception may be influenced by strong leadership, effective coordination, and teamwork, which contribute to psychological safety. Given that poor leadership and dysfunctional work environments are known contributors to burnout [25] and that healthcare professionals' well‐being directly affects patient‐ and family‐centred care [1, 16, 17, 25], these organisational factors may be critical for sustaining humanisation practices.

7. Study Limitations

There are several study limitations to consider. First, this was a small‐scale, single‐centre study using purposive sampling, and thus the findings may not be generalisable. Second, this was a perception‐based study of ICU nurses; the impacts on patients' recovery were not measured using established objective methods, and the perceptions of the patients and their family members were not studied. Third, although the interviewer was neither affiliated with the ICU nor employed at the hospital where the participants work, the study was conducted by an intensivist, which may have influenced the participants' responses and contributed to the limited expression of negative perceptions.

8. Implications and Recommendations for Practice

The findings of this study suggest that family‐inclusive outdoor excursions may contribute to a more humanised environment in intensive care settings by fostering meaningful human connections among patients, their family members and healthcare professionals. The outdoor environment provides a relaxed context that facilitates open communication, allowing ICU nurses to better understand patients' personhood beyond their illness. To ensure safety and effectiveness, strong multi‐professional collaboration, including clear role allocation and leadership, is essential when implementing such activities in clinical practice.

9. Conclusion

This study explored ICU nurses' perceptions of family‐inclusive outdoor excursions for ICU patients, regarding the nurses' perceived impacts on patients, families, nurses and the humanisation of intensive care. The ICU nurses perceived these excursions as supporting patients' recovery and comfort, facilitating active family engagement, and providing valuable opportunities to gain deeper insight into patients' personhood and family circumstances. The excursions were also perceived to strengthen human connections and to reinforce the nurses' recognition of their patients as individuals rather than clinical cases, thereby contributing to the humanisation of intensive care for patients, their family members, and healthcare professionals.

Funding

This work was supported by JSPS (Japan Society for the Promotion of Science) KAKENHI (23K08446).

Ethics Statement

Ethical approval for this study was obtained from the Institutional Review Board of Nagoya City University (approval no. 60‐23‐0056, 15 September 2023).

Consent

Written informed consent was obtained from all participants.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Table S1: Reference criteria for outdoor excursions in adult ICU patients.

Table S2: Exclusion criteria for outdoor excursions.

Table S3: Wheelchair selection criteria for outdoor excursions.

Data Availability Statement

The data supporting the findings of this study are available from the corresponding author upon reasonable request.