ICU nurses’ experiences, practices and support needs in ventilator alarm management: a qualitative study

Abstract

Objectives

To explore intensive care unit (ICU) nurses’ experiences, practices and support needs in ventilator alarm management.

Design

A qualitative descriptive study using semi-structured individual interviews and conventional content analysis.

Setting

A tertiary hospital ICU in Beijing, China.

Participants

Fifteen ICU nurses with direct experience in caring for mechanically ventilated patients and managing ventilator alarms were recruited through purposive sampling.

Results

Analysis of the interview data using a more granular line-by-line coding approach generated 113 initial codes, which were organised into 17 code categories, 15 subthemes and 5 main themes. The five themes were (1) from alarm recognition to risk prioritisation, (2) knowledge gaps behind routine alarm responses, (3) multilevel barriers to accurate ventilator alarm management, (4) role boundaries and collaborative alarm management and (5) moving from reactive response to precision alarm management. Nurses prioritised alarms that directly threatened airway patency, ventilation or oxygenation, such as airway obstruction, circuit disconnection and apnoea ventilation. Although participants were generally able to recognise common alarm names and perform initial bedside troubleshooting, they reported challenges in identifying underlying causes, interpreting ventilator parameters and waveforms and managing alarms in complex patient-, procedure-, device- and environment-related situations. Ventilator alarm management was shaped by professional role boundaries, with nurses mainly responsible for patient assessment and nursing-manageable troubleshooting, while ventilator mode, parameter and alarm-limit adjustments were usually escalated to physicians or other senior team members. Participants expressed the need for standardised alarm assessment pathways, clear escalation criteria, layered and scenario-based training and system-level support for sustainable alarm safety.

Conclusions

Ventilator alarm management among ICU nurses is a dynamic clinical process involving alarm recognition, risk prioritisation, interpretation, bedside troubleshooting and interprofessional escalation. Supporting nurses to move from reactive alarm response toward more precise and systematic alarm management requires both individual competence development and organisational support, including structured pathways, targeted training and multidisciplinary alarm governance.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study provides ventilator-specific qualitative insight into intensive care unit (ICU) nurses’ alarm recognition, prioritisation, troubleshooting, escalation practices and support needs.

• A granular line-by-line coding approach was used, together with an expanded codebook, saturation assessment and trustworthiness strategies, to enhance analytic transparency.

• The study was conducted in a single ICU, which may limit transferability to settings with different staffing models, ventilator technologies or alarm governance policies.

• Findings were based on self-reported experiences and were not supplemented with direct observation, ventilator alarm log data or objective response-time measures.

Introduction

Ventilator alarms are auditory and visual signals generated by mechanical ventilation systems to alert healthcare professionals to ventilator malfunction, inappropriate settings or changes in a patient’s respiratory status.¹,⁴ In intensive care units (ICUs), these alarms are essential safety mechanisms because mechanically ventilated patients may deteriorate rapidly when airway patency, ventilation or oxygenation is compromised.⁵ Timely recognition and response to high-risk alarms, such as airway obstruction, circuit disconnection or apnoea ventilation, are therefore critical to patient safety.^{2 4 5}

However, ventilator alarms occur within an alarm-dense ICU environment.⁶,⁸ Nurses are required to respond not only to ventilator alarms but also to alarms from physiological monitors, infusion pumps, renal replacement therapy machines and other life-supporting devices.⁹,¹¹ Frequent alarms, particularly non-actionable or transient alarms, may contribute to sensory overload, alarm burden and alarm fatigue.^{7 12 13} These problems may reduce healthcare professionals’ ability to distinguish clinically important alarms from background noise and may delay recognition of alarms requiring urgent intervention.¹⁴

Previous research on clinical alarms has mainly focused on alarm frequency, alarm fatigue, non-actionable alarms and technical or organisational strategies to reduce alarm burden.¹⁰¹⁵,¹⁸ Existing reviews have also synthesised ICU nurses’ general experiences of alarm management and strategies for reducing alarm fatigue.^{11 19} Nevertheless, less is known about how ICU nurses interpret specific ventilator alarms in real time, how they prioritise alarms according to perceived risk, how they distinguish patient-related, device-related and procedure-related causes and when they escalate alarm management to physicians, respiratory therapists or senior nurses.^{4 7 9 19 20} These aspects are particularly important because ventilator alarm management is not only a technical response to device signals but also a process of clinical reasoning, role negotiation and interprofessional collaboration.

In many ICU settings, nurses are the first healthcare professionals to hear, recognise and respond to ventilator alarms. Their alarm management practices may be influenced by knowledge of ventilator parameters and modes, professional level, clinical exposure, device characteristics, environmental noise, workload and institutional role boundaries.^{9 21} Understanding nurses’ experiences, practices and support needs is therefore necessary for developing targeted training programmes, standardised escalation pathways and system-level strategies for safer ventilator alarm management.¹⁶

This study aimed to explore ICU nurses’ experiences, practices and support needs in ventilator alarm management. Specifically, it examined how ICU nurses recognise and prioritise ventilator alarms in clinical practice, the challenges they encounter when interpreting and responding to alarms and the support and training they need to improve ventilator alarm management.

Methods

Design

A qualitative descriptive study design was used to explore ICU nurses’ experiences, practices and support needs in ventilator alarm management. This design was considered appropriate because the study aimed to obtain a detailed description of nurses’ perceptions and clinical experiences grounded in everyday practice, without imposing a predefined theoretical framework.²² Semi-structured individual interviews were conducted to allow participants to describe their experiences while enabling the interviewer to further explore emerging issues related to alarm recognition, prioritisation, response and support needs. The study was reported in accordance with the Standards for Reporting Qualitative Research (SRQR). The completed SRQR checklist is provided in online supplemental file 1.

Setting

This study was conducted in the ICU of a tertiary general hospital in Beijing, China. The ICU has an average capacity of 15 beds and provides care for critically ill adult patients, including those requiring invasive or non-invasive mechanical ventilation. The usual nurse-to-patient ratio is approximately 1:2. The unit is equipped with multiple life-supporting and monitoring devices, including mechanical ventilators, bedside physiological monitors, infusion pumps, enteral feeding pumps and renal replacement therapy devices. Commonly used ventilator brands in the unit include Dräger, Hamilton, Maquet and Mindray.

In daily clinical practice, nurses are responsible for continuous bedside monitoring, initial assessment of ventilator alarms, basic troubleshooting of nursing-manageable causes and timely escalation to physicians or other team members when ventilator parameters or modes require adjustment. Ventilator mode and parameter adjustment in the study setting are mainly physician-led. Nurses generally do not independently adjust ventilator modes, key ventilator parameters or alarm limits. Their role focuses on recognising alarms, assessing patient status, checking ventilator circuits, performing nursing interventions such as suctioning or circuit management and notifying physicians, respiratory therapists or senior nurses when alarms persist or patient status changes.

Participants and sampling

Purposive sampling was used to recruit ICU nurses with direct experience in caring for mechanically ventilated patients and managing ventilator alarms. The inclusion criteria were (1) registered nurses working in the ICU, (2) at least 1 year of clinical nursing experience, (3) direct involvement in the care of mechanically ventilated patients and (4) willingness to participate and provide informed consent. Nurses who were on extended leave or who had no experience in ventilator alarm management were excluded.

Sampling aimed to achieve variation in gender, years of nursing experience, professional title and institutional clinical nursing competency level. Data collection and analysis were conducted iteratively. During the analytic process, the research team continued purposive sampling to enhance sample heterogeneity and confirm the stability of the developing thematic framework. A total of 15 ICU nurses participated in the final analysis. Participant IDs were assigned according to the chronological order of interview completion, from P01 to P15.

Data collection

Data were collected through face-to-face semi-structured individual interviews between November 2025 and May 2026. The interview guide was developed based on a review of relevant literature, discussion within the research team and the study objectives. The guide focused on nurses’ experiences with ventilator alarms, alarm recognition and prioritisation, challenges in alarm management, attitudes toward ventilator alarms, alarm response and escalation practices and perceived support and training needs. The interview guide is presented in table 1.

Table 1. Semi-structured interview guide.

Interview domain	Interview questions
Experiences with ventilator alarms	What types of ventilator alarms do you most commonly encounter in your daily ICU practice? Can you describe situations in which ventilator alarms are triggered during routine care?
Alarm recognition and prioritisation	How do you usually identify the cause of a ventilator alarm? Which ventilator alarms do you consider most urgent and why?
Challenges in ventilator alarm management	What difficulties or challenges do you encounter when managing ventilator alarms? Are there situations in which ventilator alarms are difficult to recognise or respond to promptly?
Attitudes toward ventilator alarms and alarm safety	How do you feel when ventilator alarms occur during your work? What impact do ventilator alarms have on your nursing workflow and patient care?
Alarm management practices and escalation	What actions do you usually take when a ventilator alarm occurs? Under what circumstances do you seek assistance from physicians or other team members?
Perceived support needs	In which areas do you feel additional support or training is needed for ventilator alarm management? What types of training or resources would you find most helpful?

ICU, intensive care unit.

Before formal data collection, pilot interviews were conducted to assess the clarity and relevance of the interview questions. Minor refinements were made to improve question wording and interview flow. The pilot interview data were not included in the final analysis. All formal interviews were conducted in a quiet and private room within the hospital. Before each interview, participants were informed of the study purpose, voluntary nature of participation, confidentiality measures and their right to withdraw at any time. Written informed consent was obtained from all participants, including consent for audio recording.

Interviews were conducted by a researcher with training in qualitative research and experience in critical care nursing. The interviewer worked in the same ICU but did not have a direct supervisory relationship with the participants and was not involved in their performance appraisal or professional evaluation. Open-ended questions were used to encourage participants to describe their clinical experiences in their own words. Probing questions were used when clarification or elaboration was needed. Field notes were recorded after each interview to document contextual information, non-verbal cues and preliminary analytic reflections.

Data analysis

Audio recordings were transcribed verbatim and checked against the recordings for accuracy. All identifiable information was removed from the transcripts, and participants were assigned anonymised codes from P01 to P15 according to the chronological order of interview completion.

Data were analysed using conventional content analysis. NVivo 12 software (QSR International, Melbourne, Australia) was used to support data management and organisation. All transcripts were analysed using a granular line-by-line coding approach to enhance coding depth and preserve participants’ original meanings. Two researchers independently read the transcripts multiple times for data immersion. Meaning units relevant to ventilator alarm recognition, interpretation, response and support needs were identified and coded close to participants’ original expressions. Similar initial codes were then compared, merged and grouped into subthemes, which were further abstracted into broader themes.

Coding results were compared between the two researchers, and discrepancies were resolved through discussion until consensus was reached. A third senior researcher reviewed the coding framework and thematic structure. Member checking was conducted by returning the transcribed interview texts or key interpreted content to participants for verification. Participants were asked to confirm whether the transcripts and interpretations accurately reflected their views and experiences. No substantial disagreement or request for major revision was raised during this process.

Data collection and analysis proceeded iteratively. Saturation was assessed at both code and theme levels. Code-level saturation was considered when consecutive interviews yielded no substantively new codes. Theme-level saturation was considered when no new subthemes or main themes emerged and the existing thematic structure was supported by participants with different genders, professional levels and clinical experiences. The saturation assessment and analytic decision trail are presented in online supplemental table S2. The expanded codebook generated during analysis is presented in online supplemental table S3.

Trustworthiness

Several strategies were used to enhance trustworthiness. Credibility was strengthened through repeated reading of transcripts, independent coding by two researchers, comparison of coding results, team discussion, member checking and selection of representative quotations to support each theme and subtheme. Dependability was supported by maintaining an audit trail, including interview transcripts, field notes, coding records, versions of the coding framework, analytic memos, team discussion notes and sampling decisions. Confirmability was enhanced through reflexive note-taking and repeated checking of themes against the original transcripts. Transferability was supported by providing detailed information on the study setting, participant characteristics, professional levels and the clinical context of ventilator alarm management. Detailed trustworthiness strategies are provided in online supplemental table S4.

Reflexivity

The interviewer was a critical care nurse with qualitative research training and familiarity with ICU clinical workflows. Although the interviewer worked in the same ICU as the participants, there was no direct supervisory relationship, and the interviewer was not responsible for participants’ work allocation, performance appraisal or professional evaluation. Participants were informed that their responses would remain confidential and would not affect their employment, professional evaluation or relationship with the research team. To reduce the potential influence of pre-existing clinical assumptions, the interviewer recorded field notes after each interview, and the research team held regular debriefings to discuss emerging interpretations, potential biases and analytic decisions.

Patient and public involvement

Patients and the public were not involved in the design, conduct, reporting or dissemination plans of this study. The study focused on ICU nurses’ professional experiences, practices and support needs in ventilator alarm management.

Results

Participants

A total of 15 ICU nurses participated in the final analysis. Participant IDs were assigned according to the chronological order of interview completion, from P01 to P15. Participants varied in age from their 20s–40s, with diverse ICU nursing experience and professional competency levels. The sample included 11 female and 4 male nurses. Most participants held a bachelor’s degree, and one participant held a master’s degree. Professional titles included junior title, intermediate title and senior title. Participants’ institutional clinical nursing competency levels included N1 (n=4), N2 (n=5), N3 (n=3) and N4 (n=3). Demographic and professional characteristics of participants are presented in table 2, and the individual participant profile by interview sequence is provided in online supplemental table S1.

Table 2. Demographic and professional characteristics of participants (n=15).

Characteristic	Category/statistic	N (%) or value
Age, years	Mean (SD)	33.2 (6.4)
	Median (range)	32 (24–46)
Gender	Female	11 (73.3%)
	Male	4 (26.7%)
Marital status	Married	10 (66.7%)
	Unmarried	5 (33.3%)
Education	Bachelor’s degree	14 (93.3%)
	Master’s degree	1 (6.7%)
Year of nursing experience	Median (range)	10 (2–26)
Professional title	Junior title	8 (53.3%)
	Intermediate title	6 (40.0%)
	Senior title	1 (6.7%)
Professional level	N1	4 (26.7%)
	N2	5 (33.3%)
	N3	3 (20.0%)
	N4	3 (20.0%)

Note: Participant IDs were assigned according to the chronological order of interview completion. N1–N4 indicate the institutional clinical nursing competency levels used in the study hospital. These levels are determined by clinical experience, post-competency, training completion and institutional assessment, rather than years of ICU experience alone.

ICU, intensive care unit.

Themes

Analysis of the 15 interviews using a granular line-by-line coding approach generated 113 initial codes. These codes were further organised into 17 code categories, 15 subthemes and five main themes. The five main themes were (1) from alarm recognition to risk prioritisation, (2) knowledge gaps behind routine alarm responses, (3) multilevel barriers to accurate ventilator alarm management, (4) role boundaries and collaborative alarm management and (5) moving from reactive response to precision alarm management. The thematic framework is presented in table 3, and representative quotations supporting each subtheme are provided in table 4. The saturation assessment and analytic decision trail are provided in online supplemental table S2, and the expanded codebook generated during analysis is provided in online supplemental table S3.

Table 3. Themes and subthemes of ICU nurses’ ventilator alarm management experiences.

Main themes	Subthemes	Description
Theme 1. From alarm recognition to risk prioritisation	1.1 High-priority alarms threatening ventilation and oxygenation safety	Nurses prioritised alarms that directly threatened airway patency, ventilation or oxygenation, such as airway obstruction, circuit disconnection, apnoea ventilation and severe airway pressure abnormalities.
	1.2 Ventilation parameter-related alarms requiring contextual judgement	Alarms related to tidal volume, minute ventilation, respiratory rate, PEEP, oxygen concentration and waveform changes required interpretation in relation to patient condition and ventilator settings.
	1.3 Transient or procedure-related alarms that still require vigilance	Alarms triggered by nebulisation, suctioning, coughing, turning or patient movement were often transient, but nurses considered that they still required assessment to avoid missing true deterioration.
Theme 2. Knowledge gaps behind routine alarm responses	2.1 Understanding alarm names but not always underlying causes	Nurses could usually identify alarm names from screen prompts, but were sometimes uncertain about the underlying causes, especially when patient factors and device factors overlapped.
	2.2 Limited interpretation of parameters, waveforms and ventilator modes	Some nurses reported limited understanding of PEEP, minute ventilation, ventilator waveforms, blood gas interpretation and differences between ventilation modes.
	2.3 Differences across professional levels and clinical exposure	Alarm interpretation varied by professional level, ICU exposure and frequency of caring for mechanically ventilated patients; less experienced nurses tended to focus on tubing, humidification and visible problems.
Theme 3. Multilevel barriers to accurate ventilator alarm management	3.1 Device-related barriers	Ageing ventilators, sensor failure, low alarm volume, similar alarm sounds, brand-specific interfaces and false or intermittent alarms affected alarm recognition and response.
	3.2 Environmental and workflow barriers	ICU noise, isolation rooms, multiple simultaneous device alarms, busy shifts, new patient admissions and limited bedside visibility made alarm detection and troubleshooting more difficult.
	3.3 Patient- and procedure-related complexity	Patient agitation, coughing, human–ventilator asynchrony, deep sedation, COPD/ARDS physiology, prone positioning, transport, nebulisation and suctioning complicated alarm interpretation.
Theme 4. Role boundaries and collaborative alarm management	4.1 Initial bedside assessment and nursing troubleshooting	Nurses usually assessed the patient first, checked oxygen saturation and vital signs, inspected circuit connections, relieved kinking, drained condensate, suctioned the airway and ensured humidification.
	4.2 Escalation to physicians, respiratory therapists and senior nurses	When alarms persisted or involved mode and parameter adjustment, nurses sought support from physicians, respiratory therapists or senior nurses.
	4.3 Professional role boundary in ventilator parameter adjustment	Nurses generally did not independently adjust ventilator modes, alarm limits or key parameters; their role focused on monitoring, early detection and initial troubleshooting.
Theme 5. Moving from reactive response to precision alarm management	5.1 Standardised alarm assessment and escalation pathways	Nurses expressed a need for stepwise troubleshooting procedures, high-risk alarm response algorithms, predefined escalation criteria and safety checks before ventilator use.
	5.2 Layered and scenario-based training needs	Participants preferred bedside teaching, simulation, real ventilator demonstrations, case-based debriefing, repeated online learning and tiered training for different professional levels.
	5.3 System support for sustainable alarm safety	Suggested system-level supports included equipment maintenance, alarm audibility optimisation, brand-specific quick cards, alarm prompt functions, team collaboration and regular competency assessment.

ARDS, acute respiratory distress syndrome; COPD, chronic obstructive pulmonary disease; ICU, intensive care unit; PEEP, positive end-expiratory pressure.

Table 4. Themes, subthemes and representative quotations.

Theme	Subtheme	Representative quotation
Theme 1. From alarm recognition to risk prioritisation	1.1 High-priority alarms threatening ventilation and oxygenation safety	“Airway obstruction and circuit disconnection should be prioritised because some patients completely depend on the ventilator to maintain ventilation.” (P06, N2)
	1.2 Ventilation parameter-related alarms requiring contextual judgement	“A low minute ventilation alarm needs to be interpreted together with respiratory rate and tidal volume. It may also be related to deep sedation or insufficient spontaneous breathing.” (P04, N1)
	1.3 Transient or procedure-related alarms that still require vigilance	“During nebulisation, the ventilator may alarm for tidal volume abnormalities. Although we usually know it is related to nebulisation, there is still a risk that other problems may be overlooked.” (P05, N4)
Theme 2. Knowledge gaps behind routine alarm responses	2.1 Understanding alarm names but not always underlying causes	“The most difficult part is not recognising the alarm name itself, but understanding the real reason behind the alarm.” (P04, N1)
	2.2 Limited interpretation of parameters, waveforms and ventilator modes	“I only know some basic alarms. I do not know much about deeper knowledge, such as ventilator waveforms and clinically relevant interpretation.” (P12, N3)
	2.3 Differences across professional levels and clinical exposure	“For new nurses, they may know that the ventilator is alarming, but they may not know why the alarm occurs or how to identify the underlying cause.” (P01, N4)
Theme 3. Multilevel barriers to accurate ventilator alarm management	3.1 Device-related barriers	“Aging equipment may cause false alarms. For example, the circuit is not actually disconnected, but the ventilator still indicates disconnection.” (P06, N2)
	3.2 Environmental and workflow barriers	“When the isolation room door is closed, nurses at the nursing station may not hear the alarm.” (P06, N2)
	3.3 Patient- and procedure-related complexity	“Alarms often occur before and after suctioning. At that time, it is difficult to distinguish whether the alarm is caused by suctioning or by a change in the patient’s respiratory condition.” (P07, N2)
Theme 4. Role boundaries and collaborative alarm management	4.1 Initial bedside assessment and nursing troubleshooting	“When handling an alarm, I first check the alarm type, then check whether the ventilator is properly connected to the patient, and then identify the specific cause.” (P01, N4)
	4.2 Escalation to physicians, respiratory therapists and senior nurses	“If the patient’s oxygenation is poor, the ventilator continues to alarm, or the airway pressure remains high after suctioning, we ask the doctor to assess the patient further.” (P12, N3)
	4.3 Professional role boundary in ventilator parameter adjustment	“When human–ventilator asynchrony occurs in clinical practice, ventilator parameters and alarm limits are usually adjusted by physicians.” (P15, N3)
Theme 5. Moving from reactive response to precision alarm management	5.1 Standardised alarm assessment and escalation pathways	“I hope the device can provide more specific prompts after an alarm occurs, such as showing step-by-step suggestions for troubleshooting.” (P09, N1)
	5.2 Layered and scenario-based training needs	“I hope training can include bedside teaching and real ventilator demonstrations, showing the troubleshooting process while simulated alarms occur.” (P03, N2)
	5.3 System support for sustainable alarm safety	“It would help if alarm sounds and warning lights were more clearly differentiated, and if high-risk alarms could be distinguished from ordinary reminder alarms.” (P02, N4)

Note: Quotations were translated from Chinese into English by the research team and checked against the original transcripts. P, participant; N1–N4, institutional clinical nursing competency levels.

Theme 1. From alarm recognition to risk prioritisation

Participants described ventilator alarm management as a process of moving from hearing or seeing an alarm to judging its clinical urgency. Although nurses usually relied on ventilator screen prompts and alarm sounds to identify alarm types, they did not treat all alarms as having the same degree of urgency. Instead, they prioritised alarms according to their perceived threat to airway patency, effective ventilation and oxygenation.

High-priority alarms threatening ventilation and oxygenation safety

Alarms involving airway obstruction, circuit disconnection, apnoea ventilation, severe airway pressure abnormalities and rapidly falling oxygen saturation were consistently regarded as requiring immediate attention. These alarms were perceived as high risk because they could directly interrupt ventilation or oxygen delivery. Nurses emphasised that for patients who were highly dependent on mechanical ventilation, delayed recognition of such alarms could lead to rapid deterioration. As one participant stated,

Airway obstruction and circuit disconnection should be prioritised because some patients completely depend on the ventilator to maintain ventilation (P06, N2).

Ventilation parameter-related alarms requiring contextual judgement

Participants also reported frequently encountering alarms related to tidal volume, minute ventilation, respiratory rate, airway pressure, oxygen concentration, positive end-expiratory pressure (PEEP) and waveform changes. Unlike obvious circuit disconnection or obstruction, these alarms required nurses to interpret ventilator parameters together with the patient’s condition, ventilator mode, sedation level, respiratory effort and blood gas results. For example, a low minute ventilation alarm could indicate reduced tidal volume, decreased respiratory rate, deep sedation, poor spontaneous breathing or inappropriate ventilator settings. One nurse explained,

A low minute ventilation alarm needs to be interpreted together with respiratory rate and tidal volume. It may also be related to deep sedation or insufficient spontaneous breathing (P04, N1).

This suggests that nurses’ prioritisation was not only alarm-type-based but also embedded in bedside clinical judgement.

Transient or procedure-related alarms that still require vigilance

Participants noted that some alarms occurred during routine nursing procedures or transient patient behaviours, such as nebulisation, suctioning, coughing, turning or patient movement. These alarms were often expected and self-limiting, but nurses still considered them worthy of assessment because transient alarms could mask genuine clinical problems. For instance, nebulisation could trigger tidal volume-related alarms, and suctioning could cause temporary changes in ventilation parameters. One participant reflected,

During nebulisation, the ventilator may alarm for tidal volume abnormalities. Although we usually know it is related to nebulisation, there is still a risk that other problems may be overlooked (P05, N4).

This finding indicates that nurses recognised the need to balance practical experience with continued vigilance.

Theme 2. Knowledge gaps behind routine alarm responses

Although participants were generally able to recognise common alarm names and perform initial bedside checks, many described limitations in understanding the mechanisms behind alarms. Knowledge gaps were especially evident in interpreting ventilator parameters, waveforms, modes and alarm causes when multiple patient-related and device-related factors overlapped.

Understanding alarm names but not always underlying causes

Participants often identified alarms by reading the ventilator screen or recognising warning sounds. However, recognising the alarm label did not necessarily mean understanding the cause. Some nurses described being able to see that an alarm was related to high pressure, low pressure, low tidal volume or minute ventilation, but being uncertain about whether the underlying cause was patient deterioration, circuit leakage, cuff pressure, ventilator setting, sensor failure or a procedure-related transient change. One participant summarised this difficulty by saying,

The most difficult part is not recognising the alarm name itself, but understanding the real reason behind the alarm (P04, N1).

Limited interpretation of parameters, waveforms and ventilator modes

Participants described limited confidence in interpreting deeper ventilator information, including PEEP, minute ventilation, respiratory waveforms, alarm thresholds, blood gas results and differences between ventilation modes. Some nurses reported that they could perform basic troubleshooting, such as checking the circuit or suctioning but were less confident in linking ventilator parameters to pathophysiological changes. A participant stated,

I only know some basic alarms. I do not know much about deeper knowledge, such as ventilator waveforms and clinically relevant interpretation (P12, N3).

Another participant expressed uncertainty about matching ventilation modes to patient condition, noting,

What I feel weak in is how to match the patient’s condition with the ventilator mode, such as when to use Pressure Control (PC), Volume Control (VC), Pressure Support (PS) or Synchronized Intermittent Mandatory Ventilation (SIMV) (P07, N2).

Differences across professional levels and clinical exposure

Alarm interpretation varied according to nurses’ professional level, clinical exposure and frequency of caring for mechanically ventilated patients. Less experienced nurses tended to focus on visible or nursing-manageable issues such as tubing, humidification, condensate and suctioning. More experienced nurses were more likely to consider patient condition, ventilator mode, alarm priority and the need for escalation. However, even experienced nurses reported that knowledge of complex ventilator parameters and waveform interpretation required repeated learning and clinical exposure. One senior participant observed,

For new nurses, they may know that the ventilator is alarming, but they may not know why the alarm occurs or how to identify the underlying cause (P01, N4).

This suggests that alarm competence develops through both formal training and repeated bedside experience.

Theme 3. Multilevel barriers to accurate ventilator alarm management

Participants reported that accurate ventilator alarm management was influenced by interacting device-related, environmental, workflow, patient-related and procedure-related factors. These barriers could reduce alarm detectability, complicate cause identification or delay troubleshooting.

Device-related barriers

Device-related issues included ageing ventilators, sensor failure, low alarm audibility, similar alarm sounds across devices, brand-specific interfaces and false or intermittent alarms. Participants reported that some ventilators generated alarms without obvious clinical or circuit-related causes, requiring nurses to repeatedly check tubing, connections and device components. Such device-related uncertainty could increase workload and reduce confidence in alarm interpretation. One participant described this experience as,

Aging equipment may cause false alarms. For example, the circuit is not actually disconnected, but the ventilator still indicates disconnection (P06, N2).

Environmental and workflow barriers

Environmental and workflow factors also affected alarm recognition. Participants described ICU noise, multiple simultaneous device alarms, isolation room doors, busy shifts, admissions of new patients, bedside procedures and limited visibility of ventilator tubing as potential barriers. Alarms could be difficult to hear when patients were in isolation rooms or when nurses were temporarily away from the bedside. One participant stated,

When the isolation room door is closed, nurses at the nursing station may not hear the alarm (P06, N2).

These findings indicate that alarm management depends not only on individual vigilance but also on the physical and organisational environment in which alarms occur.

Patient- and procedure-related complexity

Patient factors such as agitation, coughing, human–ventilator asynchrony, deep sedation, insufficient spontaneous breathing, postoperative recovery from anaesthesia, chronic obstructive pulmonary disease (COPD), acute respiratory distress syndrome (ARDS) and poor lung compliance complicated alarm interpretation. Participants also described procedure-related alarms during suctioning, nebulisation, turning, transport, humidification management and bedside invasive procedures. In these situations, nurses needed to judge whether the alarm reflected a transient procedural effect or a clinically meaningful change in respiratory condition. One participant explained,

Alarms often occur before and after suctioning. At that time, it is difficult to distinguish whether the alarm is caused by suctioning or by a change in the patient’s respiratory condition (P07, N2).

This illustrates the complexity of interpreting alarms in real clinical contexts where patient condition and care procedures interact.

Theme 4. Role boundaries and collaborative alarm management

Participants described ventilator alarm management as a collaborative process shaped by professional role boundaries. Nurses were usually the first to recognise and respond to alarms but ventilator mode, parameter and alarm-limit adjustments were generally led by physicians. Alarm management therefore involved both independent nursing troubleshooting and timely escalation to other professionals.

Initial bedside assessment and nursing troubleshooting

The initial nursing response usually followed a practical sequence: assess the patient, check oxygen saturation and vital signs, inspect the ventilator circuit, identify disconnection or kinking, drain condensate, suction the airway, check humidification and reconnect tubing when needed. Nurses emphasised that patient safety should be assessed before focusing only on the ventilator screen. One participant described this approach as follows:

When handling an alarm, I first check the alarm type, then check whether the ventilator is properly connected to the patient, and then identify the specific cause (P01, N4).

These actions were considered within nurses’ routine responsibilities and were aimed at resolving common nursing-manageable causes.

Escalation to physicians, respiratory therapists and senior nurses

When alarms persisted, patient oxygenation worsened, airway pressure remained abnormal after suctioning, blood gas results were concerning or ventilator mode and parameters required adjustment, nurses sought help from physicians, respiratory therapists or senior nurses. Escalation was not viewed as passive dependence but as part of safe collaborative practice when alarms exceeded nursing-manageable causes. As one participant stated,

If the patient’s oxygenation is poor, the ventilator continues to alarm, or the airway pressure remains high after suctioning, we ask the doctor to assess the patient further (P12, N3).

Professional role boundary in ventilator parameter adjustment

Most participants stated that they did not independently adjust ventilator modes, key parameters or alarm limits. This boundary reflected institutional practice and professional responsibility in the study setting. Nurses described their role as monitoring, early detection, initial troubleshooting and timely reporting but physicians were responsible for decisions regarding ventilator mode, parameters and alarm thresholds. One participant explained,

When human–ventilator asynchrony occurs in clinical practice, ventilator parameters and alarm limits are usually adjusted by physicians (P15, N3).

This finding highlights that ventilator alarm management is embedded in interprofessional role negotiation.

Theme 5. Moving from reactive response to precision alarm management

Participants expressed a need to move beyond reactive responses to individual alarms toward more precise, standardised and system-supported ventilator alarm management. Their support needs included structured assessment pathways, scenario-based training and organisational or technological support.

Standardised alarm assessment and escalation pathways

Participants wanted clearer and more standardised approaches to alarm assessment. Suggested supports included stepwise troubleshooting procedures, high-risk alarm response algorithms, predefined escalation criteria, individualised alarm-limit settings, safety checks before ventilator use and standardised circuit inspection. Some participants hoped that ventilators or local protocols could provide more specific prompts to guide nurses through troubleshooting. One nurse stated,

I hope the device can provide more specific prompts after an alarm occurs, such as showing step-by-step suggestions for troubleshooting (P09, N1).

Layered and scenario-based training needs

Training needs were repeatedly expressed across professional levels. Participants preferred practical, repeated and scenario-based training, including bedside teaching, simulation, real ventilator demonstrations, case-based debriefing, online review materials and tiered training for nurses at different competency levels. Rather than relying solely on theoretical lectures, participants wanted training that reproduced real alarm situations and demonstrated the complete process of recognition, judgement, troubleshooting and escalation. One participant noted,

I hope training can include bedside teaching and real ventilator demonstrations, showing the troubleshooting process while simulated alarms occur (P03, N2).

System support for sustainable alarm safety

Beyond individual training, participants also described the need for system-level support. Suggested strategies included equipment maintenance, optimisation of alarm audibility, clearer differentiation of alarm sounds and warning lights, brand-specific quick reference cards, alarm prompt functions, team collaboration and regular competency assessment. Such supports were seen as necessary for sustainable alarm safety in routine ICU work. One participant suggested,

It would help if alarm sounds and warning lights were more clearly differentiated, and if high-risk alarms could be distinguished from ordinary reminder alarms (P02, N4).

Discussion

This qualitative descriptive study explored ICU nurses’ experiences, practices and support needs in ventilator alarm management. Through granular line-by-line analysis of 15 interviews, 113 initial codes were organised into 17 code categories, 15 subthemes and 5 main themes. The findings show that ventilator alarm management is not merely a technical response to device signals but a dynamic clinical process involving risk appraisal, interpretation of alarm mechanisms, bedside troubleshooting, professional role boundaries, interprofessional escalation and system-level support. By focusing specifically on ventilator alarms, this study extends existing alarm fatigue literature, which increasingly conceptualises alarm fatigue as a complex patient safety and workforce issue shaped by alarm exposure, work conditions, device factors and organisational strategies,²³ and provides a more detailed understanding of how ICU nurses recognise, prioritise and respond to ventilator alarms in real clinical contexts.

Clinical prioritisation beyond alarm labels

A key finding of this study was that ICU nurses did not respond to ventilator alarms only according to the alarm name displayed on the device. Instead, participants prioritised alarms according to their perceived threat to airway patency, ventilation and oxygenation. Alarms such as airway obstruction, circuit disconnection, apnoea ventilation and severe airway pressure abnormalities were regarded as requiring immediate attention because they could rapidly compromise effective ventilation. This finding is consistent with previous literature indicating that ventilator alarms differ in priority and clinical significance and that alarms associated with ventilation failure or airway compromise require prompt recognition and intervention.^{2 4 5}

This finding adds nuance to previous research that has mainly described alarm frequency, duration, priority distribution or alarm burden. Although such studies are important for quantifying the scale of alarm problems, they do not fully explain how nurses make real-time judgements when multiple alarms and clinical cues occur simultaneously.^{2 15} Our findings suggest that alarm prioritisation is a form of bedside risk appraisal. Nurses integrated the alarm type with patient oxygenation, respiratory effort, sedation status, ventilator mode and immediate clinical context. Therefore, ventilator alarm response should be understood not simply as a reaction to device output but as a form of clinical reasoning.

Participants also described transient or procedure-related alarms during nebulisation, suctioning, coughing, turning and patient movement. Although these alarms were often expected or self-limiting, nurses still considered them to require assessment. This is important because clinically meaningful deterioration may be hidden within frequent transient or non-actionable alarms. Previous studies have shown that excessive non-actionable alarms contribute to alarm fatigue and may reduce the salience of critical alarms.^{7 10 14 24} Recent scoping review evidence further suggests that alarm fatigue is associated with alarm overload, delayed or missed responses, staff stress and the need for combined educational, technical and organisational mitigation strategies.²³ Therefore, alarm management strategies should not aim only to reduce alarm numbers but also to support nurses in distinguishing expected transient alarms from alarms that signal true clinical deterioration.

From basic recognition to interpretive competence

Another important finding was the distinction between recognising an alarm and understanding its underlying cause. Participants were generally able to identify common alarm names from screen prompts or alarm sounds. However, some nurses were uncertain whether the cause of an alarm was related to patient deterioration, circuit leakage, cuff pressure, ventilator settings, sensor failure or a procedure-related transient change. This distinction is clinically important. Recognising the alarm label may prompt an initial response, but understanding the underlying mechanism is necessary for accurate troubleshooting, appropriate escalation and prevention of recurrent alarms.

Participants reported knowledge gaps in interpreting ventilator parameters, waveforms, PEEP, minute ventilation, alarm thresholds, blood gas results and ventilation modes. These findings are consistent with previous studies suggesting that ICU nurses are central to mechanical ventilation monitoring but may have variable levels of confidence and competence in ventilator-related decision-making.²⁰ Recent reviews have also shown that nurses’ alarm management is influenced by knowledge, training, clinical experience and organisational support.^{9 19} Empirical evidence from ICU nurses further indicates that alarm fatigue and alarm response are associated with work-related and professional factors, reinforcing the need to consider nurses’ clinical exposure and competency development when designing alarm management interventions.²⁵ Our findings further indicate that knowledge gaps are not limited to isolated technical concepts; rather, they occur at the intersection of alarm signals, patient physiology and ventilator function.

Differences across professional levels and clinical exposure were also evident. Less experienced nurses tended to focus on visible and nursing-manageable problems, such as tubing disconnection, humidification, condensate and suctioning. More experienced nurses were more likely to consider patient condition, ventilator mode, alarm priority and escalation needs. However, even experienced participants reported uncertainty in advanced areas such as waveform interpretation and mode selection. This suggests that ventilator alarm competence develops progressively through both formal training and repeated bedside exposure. Training programmes should therefore be layered according to nurses’ professional levels and should move beyond general lectures to include practical interpretation of parameters, waveforms and clinical scenarios.

Alarm management as a system-level challenge

The findings also show that accurate ventilator alarm management is shaped by multiple interacting system-level factors. Device-related barriers included ageing ventilators, sensor failure, low alarm volume, similar alarm sounds, brand-specific interfaces and false or intermittent alarms. These problems can reduce alarm detectability, increase uncertainty and require repeated bedside checking. Previous literature has emphasised that alarm safety is influenced by alarm system design, alarm audibility, usability, priority configuration and device governance.^{4 16} Broader alarm fatigue evidence also highlights technical improvements, alarm customisation and protocol adjustment as key strategies for reducing alarm burden.²³ In settings where several ventilator brands are used, differences in interfaces and alarm logic may further increase cognitive workload.

Environmental and workflow barriers were also prominent. Participants described ICU noise, multiple simultaneous device alarms, isolation rooms, busy shifts, new patient admissions, bedside procedures and limited visibility of ventilator circuits as factors that could delay alarm recognition or complicate troubleshooting. ICU noise and alarm density have long been recognised as contributors to alarm burden and sensory overload.⁸ More recent evidence suggests that alarm burden is related not only to individual responsiveness but also to the broader nursing work environment and staffing conditions.¹¹ Studies among ICU nurses have similarly identified work-related and organisational factors as contributors to alarm fatigue supporting the need to address alarm management at the unit and system levels.²⁵ These findings support a systems’ perspective: even highly vigilant nurses may face difficulty recognising and interpreting alarms when the environment is noisy, alarms are poorly differentiated or workflow demands are high.

Patient- and procedure-related complexity further increased the difficulty of alarm interpretation. Patient agitation, coughing, human–ventilator asynchrony, deep sedation, insufficient spontaneous breathing, postoperative recovery, COPD, ARDS and poor lung compliance could all affect ventilator parameters and alarm activation. Similarly, suctioning, nebulisation, prone positioning, turning, transport and humidification management could trigger alarms or make circuit assessment more difficult. These findings indicate that procedure-related alarms should not be simply dismissed as false alarms. They may be expected but they still require clinical judgement because they occur in contexts where patient condition and nursing procedures interact.

Cognitive load theory provides a useful lens for interpreting these findings. ICU nurses must process auditory alarms, visual prompts, patient signs, ventilator parameters, competing device alarms and ongoing nursing tasks under time pressure. Frequent non-actionable alarms and environmental noise may consume limited attentional resources, thereby reducing the capacity to detect clinically important signals.¹² A recent qualitative study of ICU nurses further described alarm fatigue as a dynamic cognitive process involving cognitive reserve deficit, cognitive load balance and cognitive overload, with alarm demands and available support resources shaping nurses’ coping capacity.²⁶ Therefore, interventions that rely only on individual vigilance are unlikely to be sufficient. Effective ventilator alarm management requires system-level strategies addressing equipment configuration, alarm audibility, environmental design, workflow, staffing and procedural protocols, consistent with recent evidence that alarm fatigue mitigation requires combined educational, technical, protocol-based and organisational interventions.²³

Role boundaries, escalation and interprofessional safety

This study found that ventilator alarm management was shaped by clear professional role boundaries. Nurses were usually the first to recognise alarms and perform bedside assessment, including checking oxygen saturation, vital signs, circuit connections, tubing kinking, condensate, airway secretions and humidification. These initial actions were considered within nurses’ routine responsibilities and were aimed at resolving common nursing-manageable causes. However, ventilator mode, key parameter and alarm-limit adjustments were generally physician-led.

This role boundary may function as a safety safeguard. Ventilator parameter adjustment requires integration of patient physiology, blood gas results, disease condition and ventilation strategy. Inappropriate adjustment may place patients at risk. Therefore, escalation to physicians, respiratory therapists or senior nurses when alarms persist or patient status worsens should not be interpreted as passive dependence but as part of safe interprofessional practice. This is consistent with literature highlighting the importance of nurses’ monitoring role in mechanical ventilation and the value of effective nurse–physician communication in patient safety.^{20 27}

At the same time, role boundaries may also have unintended consequences. When nurses are rarely involved in ventilator parameter adjustment or mode-related discussions, they may have fewer opportunities to develop deeper understanding of ventilator mechanisms. This may partly explain why some participants reported limited confidence in interpreting waveforms, modes and alarm thresholds. Therefore, maintaining safe professional boundaries should not mean limiting nurses to basic troubleshooting. Instead, interprofessional education, case review and shared discussion of alarm events may help nurses understand the rationale behind parameter adjustment while preserving appropriate decision-making authority.

Implications for precision and sustainable alarm safety

Participants expressed a strong need to move from reactive responses to individual alarms toward more precise, standardised and system-supported alarm management. They suggested stepwise troubleshooting procedures, high-risk alarm response algorithms, predefined escalation criteria, safety checks before ventilator use and individualised alarm-limit settings. These suggestions are consistent with recommendations that alarm management should include appropriate alarm parameter setting, surveillance strategies, alarm priority differentiation and institutional governance.^{4 16}

Training needs were also repeatedly identified. Participants preferred bedside teaching, simulation, real ventilator demonstrations, case-based debriefing, repeated online learning and tiered training for nurses at different competency levels. This reflects the practical nature of ventilator alarm management. Nurses need not only theoretical knowledge but also repeated exposure to realistic alarm scenarios in which they can practise recognition, judgement, troubleshooting and escalation. This is particularly important because alarm-related cognitive demands may exceed nurses’ available cognitive resources when support systems and coping resources are insufficient.²⁵ Recent intervention research has shown that structured approaches to ventilator alarm management may reduce alarm fatigue among ICU nurses.¹⁷ Our findings further suggest that training should be layered, scenario-based and linked to clinical decision-making rather than limited to general theoretical instruction.

System-level support is equally important. Participants suggested equipment maintenance, clearer differentiation of alarm sounds and warning lights, brand-specific quick reference cards, alarm prompt functions, team collaboration and regular competency assessment. These recommendations align with recent alarm safety literature emphasising that alarm-related risks arise from interactions among technology, environment, workflow and human factors rather than from individual behaviour alone.^{9 11 16} Therefore, safer ventilator alarm management requires coordinated interventions across individual, team and organisational levels.

Limitations

This study has several limitations. First, it was conducted in a single ICU of a tertiary hospital in Beijing, China. The findings may be influenced by the local staffing model, ventilator brands, alarm management practices and physician-led ventilator adjustment workflow, which may limit transferability to ICUs with different organisational structures, staffing ratios, ventilator technologies or alarm governance policies. Second, the findings were based on nurses’ self-reported experiences and may therefore be affected by recall bias and social desirability bias. Although interviews provided insight into nurses’ perceptions and clinical reasoning, they may not fully reflect actual bedside behaviours in all clinical situations. Third, this study did not include direct observation, ventilator alarm log data or objective measures of alarm response time. Future studies combining interviews with observation, alarm log analysis or simulation-based assessment may provide a more comprehensive understanding of ventilator alarm management. Fourth, although purposive sampling included nurses with different genders, years of nursing experience, professional titles and competency levels, the sample remained relatively small. Male nurses were included to enhance sample heterogeneity, but the study was not designed to compare gender differences. Larger multi-centre studies are needed to explore how gender, professional level, ICU experience, institutional policy and interprofessional role arrangements influence ventilator alarm management. Finally, this study focused only on ICU nurses’ perspectives. Future research should include physicians, respiratory therapists, biomedical engineers and other relevant stakeholders to inform more comprehensive multidisciplinary alarm management strategies.

Conclusion

This qualitative study provides an in-depth understanding of ICU nurses’ experiences, practices and support needs in ventilator alarm management. The findings show that ventilator alarm management is not a simple technical response to device signals but a dynamic process involving alarm recognition, risk prioritisation, interpretation of alarm mechanisms, bedside troubleshooting, role boundaries and interprofessional escalation. Nurses were able to identify common ventilator alarms and prioritise alarms that threatened ventilation and oxygenation, but they also reported challenges in understanding underlying causes, interpreting parameters and waveforms and managing alarms in complex patient-, procedure-, device- and environment-related situations.

These findings highlight the need to support ICU nurses in moving from reactive alarm response toward more precise and systematic ventilator alarm management. Structured alarm assessment pathways, clear escalation criteria, layered and scenario-based training and system-level support for equipment maintenance, alarm audibility and multidisciplinary collaboration may help improve nurses’ alarm interpretation and response. Strengthening both individual competence and organisational alarm governance is essential for safer ventilator alarm management and patient safety in critical care settings.

The funder had no role in the study design, data collection, data analysis, data interpretation, manuscript preparation or the decision to submit the manuscript for publication.

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.