Digital Gaze and Vicarious Trauma Among Intensive Care Unit Nurses in Alarm-Monitoring Ecologies: Qualitative Interview Study.

Abstract

Intensive care units (ICUs) rely on continuous physiological monitoring and frequent alarms to detect patient deterioration. Although alarm fatigue has been widely discussed as a patient safety and workflow issue, less is known about how monitoring systems shape nurses' attention, visibility, perceived accountability, emotional strain, and recovery after distressing events. Understanding these experiences is important for designing safer monitoring displays, alarm behavior, communication routines, and future AI-supported systems. This study aimed to explore how ICU nurses experience continuous monitoring and alarms as a digital work environment, with particular attention to digital gaze, vicarious trauma-related emotional strain, perceived accountability, and design-relevant system needs. We conducted a qualitative interview study with 15 ICU nurses from a tertiary hospital in Hangzhou, China. Semistructured interviews probed 6 topics: everyday monitoring routines and alarm exposure; responses to alarms, patient deterioration, and death; perceived pressure related to visible physiological data; after-shift experiences following distressing events; coping and recovery strategies; and suggestions for alarm governance and monitoring system design. Data were analyzed using reflexive thematic analysis. Four themes were generated. First, continuous monitoring created a form of digital gaze in which nurses maintained constant watch, experienced alarm-driven interruptions, and felt that visible physiological data made bedside responses open to scrutiny. Second, patient deterioration and death were experienced partly through monitoring technologies, including weakening waveforms, escalating alarms, numerical decline, and eventual silence. Third, monitoring-related stress extended beyond the ICU through lingering alarm sounds, monitor images, personal resonance, and work-related messages after shifts. Fourth, participants described recovery strategies but also emphasized system-level needs, including clearer alarm prioritization, fewer nonactionable alerts, gentler auditory design, more useful trend displays, postresuscitation buffering, and better digital communication boundaries. Continuous monitoring and frequent alarms shaped ICU nurses' work beyond workflow disruption and patient safety. Alarm-intensive care should be understood as a digital health and sociotechnical design issue that affects attention, perceived accountability, emotional strain, and recovery. Future monitoring systems should be co-designed and evaluated not only for alarm reduction and technical accuracy but also for how displays, alarm behavior, work-related communication, and AI-supported tools affect clinicians' work, recovery, and perceived surveillance.