{"paper_id":"47561110-4fd9-490f-909a-e6dd0b1fe205","body_text":"ICU Nurses’ Knowledge, Attitudes, and Practices in Identifying Patient–Ventilator Asynchrony: A Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article ICU Nurses’ Knowledge, Attitudes, and Practices in Identifying Patient–Ventilator Asynchrony: A Cross-Sectional Study Jie Peng, Xianming Ge, Jiuhong Ma, Huimin Wu, Weiwei Peng, Yi Wang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8008446/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background： Patient–ventilator asynchrony (PVA) is a common complication of mechanical ventilation, with an incidence of approximately 23%, and has been linked to ventilator-induced lung injury, weaning failure, prolonged hospitalization, and increased mortality. Consequently, accurate recognition and timely management of PVA can directly influence therapeutic effectiveness and clinical outcomes. Objective: This study evaluated ICU nurses’ competencies in identifying PVA through ventilator waveform monitoring, with a focus on their knowledge, attitudes, and clinical practices. It also examined how gender, clinical experience, and mechanical ventilation training influenced these competencies. Methods: A multicenter cross-sectional study was conducted from December 2023 to April 2025 in the intensive care units of ten tertiary hospitals across six provincial-level regions in China. Data collection included demographic characteristics, a validated assessment of PVA recognition ability, and standardized scales evaluating nurses’ attitudes and practices. Results: Among the 250 nurses recruited, 212 returned valid responses, yielding an effective response rate of 84.8%. Overall, nurses demonstrated limited ability in recognizing PVA (pass rate: 44.81%), moderately positive attitudes (60.85%), and suboptimal practices (44.34%). Male nurses outperformed females in PVA recognition ( P < 0.05). Nurses with ≥5 years of experience and those who had received mechanical ventilation training showed significantly better performance in all domains, with those trained for over 100 hours exhibiting the most substantial gains. Additionally, significant positive correlations were identified among recognition ability, attitudes, and clinical practice ( P < 0.001). Conclusions: ICU nurses showed insufficient competency in identifying PVA, as well as in related attitudes and clinical implementation. Mechanical ventilation training emerged as a key driver for improving these domains. Integrating targeted training into the standardized ICU nurse education system may enhance ventilator management quality and improve patient outcomes. Clinical trial number Not applicable. ICU nurses patient–ventilator asynchrony ventilator waveform analysis cross-sectional study specialized training 1. Introduction Mechanical ventilation remains a cornerstone of respiratory support in critically ill patients. Yet, patient–ventilator asynchrony (PVA) is a widespread complication, with an incidence as high as 23%, and has been linked to ventilator-induced lung injury, weaning failure, prolonged hospitalization, and increased mortality [ 1 , 2 ] . Accurate recognition and timely management of PVA are therefore essential. Effective intervention can minimize unnecessary sedation and analgesia, reduce respiratory muscle load, shorten the duration of mechanical ventilation, and lower mortality [ 3 , 4 ] . Although esophageal pressure monitoring and diaphragm electromyography are recognized as gold standards for identifying PVA, their invasive nature and high cost hinder routine clinical use [ 5 ] . As a non-invasive and real-time alternative, ventilator waveform analysis holds promise for detecting PVA, though its diagnostic accuracy is heavily reliant on the clinician’s expertise [ 6 ] . Studies have revealed substantial inter-individual variability in clinicians’ ability to identify PVA, with 25%–30% unable to detect common types. However, specialized training in mechanical ventilation has been shown to significantly improve recognition accuracy [ 7 – 9 ] . In China, the majority of intensive care units (ICUs) lack dedicated respiratory therapists. As a result, ICU nurses assume responsibility for the routine management and monitoring of mechanical ventilation, including standard procedures such as airway suctioning, sedation and analgesia titration, timely reporting of PVA to physicians, and assisting in ventilator parameter adjustments [ 10 ] . Consequently, nurses’ competence, attitudes, and clinical practices in PVA recognition are of paramount importance, as they can directly influence therapeutic outcomes and patient prognosis. Despite their central role, most research in this domain has focused on respiratory therapists and physicians. ICU nurses, who serve as the primary bedside caregivers for mechanically ventilated patients, remain underrepresented in studies examining the ability, attitudes, and practices related to PVA recognition through ventilator waveform analysis. This study employed a multicenter cross-sectional design to evaluate ICU nurses’ ability, attitudes, and clinical practices regarding the identification of PVA via ventilator waveform analysis. It further investigated the impact of gender, clinical experience, and mechanical ventilation training on these domains. 2. Materials and Methods 2.1 Study Design This cross-sectional study was conducted between December 2023 and April 2025 in the intensive care units (ICUs) of 10 tertiary Class A hospitals across six provincial-level administrative regions in China. The study adhered to ethical guidelines and regulations, including the Declaration of Helsinki, and received approval from the Ethics Committee of Jiangxi Cancer Hospital (Approval No. 2023KY123; approval date: July 10, 2023). Participants were provided with an informed consent form that detailed the study's objectives, assured them of the confidentiality and anonymity of their responses, and informed them of their right to withdraw at any time. Completion and submission of the questionnaire were taken as evidence of informed consent. 2.2 Study Participants Inclusion criteria: nurses who were registered; had ≥6 months of direct experience caring for invasively mechanically ventilated patients; and had independently managed ≥50 such patients.Exclusion criteria: student, rotating, and visiting/advanced-training nurses; non-ICU personnel; and those who had participated in related research within the previous 3 months. 2.3 Data Collection and Instruments The research team first engaged ICU head nurses at each participating site and obtained their support. Head nurses then circulated a study notice and a link to the Wenjuanxing (Questionnaire Star) online survey via unit WeChat groups. The notice summarized the study objectives and highlighted anonymity and voluntary participation. Interested nurses accessed the link, reviewed the electronic informed consent, and completed the questionnaire online.The survey questionnaire was developed specifically for this study based on a comprehensive review of relevant literature [11-14] . The English version of the questionnaire is available as Supplementary File 1 and has been cited in the manuscript. It consists of the following sections: • Demographics: gender, age, and educational background; • Clinical experience: ICU years of service and prior participation in mechanical-ventilation training; • ICU type; • PVA recognition section: ten clinical ventilator waveform images were selected to cover six common PVA patterns—ineffective triggering, auto-triggering, double triggering, excessive flow, insufficient flow, and delayed cycling—plus a normal waveform. Ten single-best-answer items were created (1 point each; total 10). Performance was classified as low (0–4), moderate (5–7), or good (8–10); • Attitudes and practices: each was assessed using a 10-item Likert 5-point scale (maximum 50), with levels defined as low (≤35), moderate (36–44), and high (≥45). All nurses completed the assessment independently. Items were presented in random order, with a 20-minute time limit.The full English version of the questionnaire is provided as Supplementary File 1 and can be accessed via the journal’s supplementary material portal 2.4 Instrument Validation The questionnaire was independently reviewed and validated by 12 critical care experts responsible for mechanical ventilation ( 5 respiratory and critical care physicians, 3 respiratory therapists, and 4 ICU nursing specialists with extensive ventilation experience ). It showed excellent internal consistency ( overall Cronbach’s α = 0.922 ), with α values of 0.920, 0.862, and 0.897 for the ability, attitude, and practice domains, respectively. Two-week test–retest reliability for these domains was 0.856, 0.942, and 0.926, indicating strong reliability. ICU experience was categorized as low (<5 years), moderate (5–10 years), and high (>10 years). Mechanical-ventilation training was defined as accredited classroom instruction, simulation workshops, or online courses (excluding informal training such as self-study or ad hoc bedside guidance) and was grouped as <100 hours or >100 hours.The questionnaire was distributed via a Wenjuanxing online link, which also provided a brief description of the study objectives. All personal information was anonymized before data collection, and participation was emphasized as voluntary. All assessments were conducted on site; each participant completed the test independently in a quiet ICU room under the supervision of study personnel. Only one attempt was permitted per participant, and completion was strictly limited to 20 minutes. 2.5 Statistical analysis All statistical analyses were performed using SPSS version 26.0. The Shapiro–Wilk test was applied to assess the normality of data distribution. Continuous variables with normal distribution were reported as mean ± standard deviation (SD), whereas those with non-normal distribution were presented as median and interquartile range (IQR). Categorical variables were summarized as frequencies and percentages. For comparisons between groups, independent-sample t-tests or one-way analysis of variance (ANOVA) were used for normally distributed data, while the Mann–Whitney U test or Kruskal–Wallis H test was applied for non-normally distributed data. The chi-square test or Fisher’s exact test was employed for categorical variables. A two-tailed P-value < 0.05 was considered statistically significant, with the significance threshold set at α = 0.05. 3. Results 3.1 Baseline characteristics of ICU nurses ( Table 1 ): We included 250 nurses and analyzed 212 valid questionnaires, for an effective response rate of 84.80%. The largest subgroup was the general ICU ( 28.30% ), followed by EICU ( 18.40% ), RICU ( 16.51% ), CCU ( 13.21% ), and other ICUs ( 23.58% ). Women constituted 74.53% of the sample and men 25.47%. Most participants were 25–35 years old ( 70.28% ). Education was predominantly bachelor’s degree ( 81.60% ), with fewer holding a junior college diploma ( 14.62% ) or a master’s degree ( 3.78% ). ICU tenure was distributed as < 5 years ( 20.28% ), 5–10 years ( 41.51% ), and > 10 years ( 38.21% ). Overall, 39.62% had received mechanical ventilation training ( 22.17% for < 100 hours; 17.45% for > 100 hours ). 3.2 Overall scores for PVA recognition, attitudes, and practice ( Table 2 ): ICU nurses demonstrated a generally low level of PVA recognition. Attitudes toward ventilator waveform monitoring were moderately positive. Clinical practice performance was suboptimal, indicating substantial scope for improvement. 3.3 Association between PVA recognition and nurse characteristics ( Table 3 ): On the ventilator waveform recognition test, male nurses achieved higher mean scores than female nurses ( P < 0.05 ), suggesting a sex-related difference. Nurses with ICU tenure < 5 years scored lower than those with 5–10 or > 10 years, whereas the 5–10 and > 10 groups did not differ ( P = 0.908 ). These findings indicate that recognition improved with experience and then plateaued. Mechanical ventilation training was associated with higher recognition scores: trained nurses outperformed untrained nurses ( P < 0.001 ), and those with > 100 hours of training scored higher than those with < 100 hours ( P < 0.05 ). 3.4 Association between ICU nurses’ attitudes toward ventilator waveform monitoring and their characteristics ( Table 4 ) No significant sex difference in attitudes was observed ( P = 0.097 ). Attitude scores increased with ICU tenure and then plateaued. Nurses who received relevant training scored higher than those without training, and those with > 100 hours of training outperformed those with < 100 hours ( P < 0.001 ). 3.5 Association between ventilator waveform monitoring practice and nurse characteristics ( Table 5 ) Practice performance was significantly associated with ICU tenure, completion of mechanical ventilation training, and training duration, but not with sex. Trained nurses scored higher than untrained nurses ( P < 0.001 ), and those with > 100 hours of training demonstrated better clinical practice. 3.6 Correlation among overall PVA recognition, attitudes, and practice ( Table 6 ) Significant positive correlations were found among PVA recognition, attitudes, and practice ( P < 0.001 ). Greater recognition was linked to more positive attitudes toward waveform monitoring and more standardized clinical practice. 4. Discussion This multicenter cross-sectional survey showed that ICU nurses had a generally low ability to identify PVA using ventilator waveforms. Attitudes toward waveform monitoring were moderately positive, whereas clinical practice was suboptimal and required improvement. These results were consistent with multiple international studies in recent years [14,15] , suggesting that deficiencies in knowledge, attitudes, and practices related to ventilator waveforms were widespread among healthcare personnel globally. Several factors likely contributed to these gaps. First, ventilator-waveform interpretation was highly specialized and remained challenging even for experienced clinicians [16] . Second, most ICUs in China did not employ dedicated respiratory therapists; consequently, nurses assumed portions of the monitoring workload. Traditional nursing education emphasized basic procedures, with limited training in respiratory therapy and ventilatory support. Instruction on dynamic, abstract content—such as waveforms—was especially scarce, leaving nurses ill-prepared to manage complex patterns in practice. Additionally, some nurses lacked initiative and confidence in waveform interpretation and at times considered it outside their professional remit [13,14] . Within this context, nurses’ mastery of waveform knowledge, their perceived importance of monitoring, and their clinical performance were further constrained. The ability to interpret ventilator waveforms, along with professional attitudes and clinical practice, was critical and should not have been overlooked. Prior studies showed that frequent PVA prolonged mechanical ventilation and increased mortality. Specific forms of PVA—such as ineffective triggering and insufficient flow—raised the work of breathing, impaired ventilation and oxygenation, provoked discomfort and agitation, increased sedative requirements, and could precipitate ventilator-associated lung injury, thereby undermining treatment efficacy [17-20] . Accordingly, as the primary bedside observers, nurses who recognized PVA promptly and initiated basic measures or alerted physicians for parameter adjustment markedly improved the safety and effectiveness of mechanical ventilation. By contrast, when nurses lacked PVA recognition skills, asynchrony often went undetected and the optimal time for intervention was missed. This study found that male nurses scored higher than female nurses. Previous research suggested [21] that sex could influence clinicians’ confidence and self-assessment in procedural skills. Although female nurses had knowledge and clinical experience comparable to their male counterparts, they tended to adopt a more cautious decision-making style when operating complex equipment such as ventilators. At times, this caution led them to consider a broader set of possibilities during PVA recognition, which might have reduced diagnostic accuracy [14,22] . In ICUs without respiratory therapists, ventilator maintenance and troubleshooting were typically handled by the nursing team. Cultural norms often regarded female nurses as particularly strong in fundamental care, patient communication, and team coordination, whereas male nurses were viewed as having relative strengths in device operation and troubleshooting. In our cohort, technical tasks—such as ventilator troubleshooting—were frequently assigned to male nurses, potentially cultivating tacit skills in waveform interpretation [23-25] . Because we did not collect data to test these mechanisms, prospective studies are warranted. Our results showed that clinical experience and prior training differentially influenced nurses’ PVA recognition, attitudes, and clinical practice. Nurses with ICU tenure > 5 years scored lower for PVA recognition, attitudes, and practice than those with ≥ 5 years, whereas scores did not differ between the 5–10 and > 10 year groups ( P > 0.05 ). These findings suggested that, even without formal training, accumulated clinical experience could improve PVA recognition, professional attitudes, and clinical practice to a degree; however, the improvements were limited, indicating an experience-related plateau. This pattern aligned with surveys by Zelalem et al. [26] and Liu et al. [27] , which demonstrated that training in mechanical ventilation yielded gains that surpassed those from experience alone. Training in mechanical ventilation was therefore pivotal, with a positive time–effect relationship: nurses who completed > 100 hours scored higher than those with < 100 hours. Further analysis revealed significant positive correlations among PVA recognition, attitudes, and practice. Greater recognition was associated with more positive attitudes toward ventilator waveform monitoring and more standardized clinical practice; these domains were tightly interconnected and mutually reinforcing. This linkage has meaningful implications for structured education: programs that concurrently strengthen knowledge and initiative are most likely to improve clinical behaviors, enabling efficient translation from theory to competence and reinforcing patient safety [28,29] . This study confirmed that training in mechanical ventilation was pivotal for improving ICU nurses’ PVA recognition, attitudes, and practice. Targeted training ensured that nurses across backgrounds and experience levels reached a high standard of PVA recognition, enabling earlier detection of problems, timely interventions, enhanced patient–ventilator synchrony, reduced discomfort, and a lower risk of related complications [30,31] . It also helped optimize nursing workforce allocation, ensuring that patients received high-quality respiratory monitoring irrespective of the on-duty nurse’s seniority, thereby fostering more equitable ICU nursing quality. Moreover, such programs promoted the use of standardized terminology when identifying PVA and describing abnormalities, which improved the efficiency and accuracy of communication with physicians and strengthened team collaboration. Nevertheless, this study had several limitations. First, all participants were drawn from tertiary A hospitals; ICU nurses from primary or secondary institutions were not included, which limited the generalizability of the results. Second, PVA recognition was assessed with static ventilator-waveform images that differed from dynamic bedside monitoring and might have under- or overestimated nurses’ true performance. Attitudes and practices were measured using self-administered questionnaires, which may have introduced social-desirability bias. Although we examined key factors, we could not fully control for potential confounders such as unit workload and institutional teaching resources. Finally, the cross-sectional design precluded causal inference, and several variables relied on self-report, introducing potential bias. Future studies should use randomized controlled designs to evaluate the effects of training on nurses’ PVA recognition and patient outcomes ( e.g., duration of mechanical ventilation, ICU length of stay ). The sampling scope should also be expanded to include hospitals at different tiers and multiple ICU units to enhance generalizability. In addition, evaluation tools that mirror real clinical contexts should be developed, and determinants of stagnant practice despite positive attitudes ( e.g., staffing, workload, unit culture ) should be investigated, to strengthen ventilatory management and drive critical-care nursing toward more precise and standardized practice. This study delineated the current status of ICU nurses’ PVA recognition, attitudes, and practice, identified their key determinants, and underscored the central role of training. Accordingly, we recommended integrating mechanical-ventilation training into standardized ICU-nurse curricula to strengthen PVA recognition and response, thereby improving ventilatory management quality and patient outcomes. Declarations Funding This research received no external funding. Conflicts of Interest The authors declare that they have no conflicts of interest. Ethics Approval and Consent to Participate The study was approved by the Ethics Committee of Jiangxi Cancer Hospital (Approval No. 2023KY123; July 10, 2023). All participants provided informed consent. The study adhered to the Declaration of Helsinki. Consent for Publication Not applicable. Data Availability The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request. Author Contribution J.P: Conceived the initial research direction, led the on-site data collection (including distributing questionnaires to ICU nurses and collating first-hand practice records), drafted the first version of the manuscript, and participated in sorting out data related to mechanical ventilation management.X.G: Co-designed the research protocol (with a focus on optimizing indicators for respiratory support and ventilator asynchrony identification), participated in the clinical interpretation of patient-ventilator asynchrony data, and revised the manuscript to ensure accuracy from the critical care physician perspective.J.M: As the corresponding author, designed the overall research framework, supervised the entire research process (including ethical review coordination), coordinated the statistical guidance provided by the institutional statistics department, critically revised the manuscript for academic rigor, and finalized the submission version.H.W: Assisted in targeted data collection (focusing on ICU clinical nurses’ practical operation details of ventilator management), organized and verified clinical practice-related data, and reviewed the manuscript to ensure consistency with real clinical scenarios.W.P: Participated in data collection related to ICU staff training (aligning with the study’s focus on nurses’ knowledge and attitudes), assisted in checking the completeness and validity of collected data, and reviewed the manuscript for logical coherence.Y.W: Aided in the preliminary collation and screening of ventilator waveform data (matching the research keyword \"ventilator waveform analysis\"), participated in standardized data entry, and reviewed the manuscript for clarity of content. 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Nurs Crit Care. 2018;23(5):245–55. 10.1111/nicc.12346 . Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table.docx ApprovalbytheResearchEthicsCommittee.docx SupplementaryFile1.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 26 Dec, 2025 Reviewers agreed at journal 18 Dec, 2025 Reviews received at journal 16 Dec, 2025 Reviewers agreed at journal 13 Dec, 2025 Reviews received at journal 10 Dec, 2025 Reviewers agreed at journal 05 Dec, 2025 Reviewers invited by journal 05 Dec, 2025 Editor invited by journal 10 Nov, 2025 Editor assigned by journal 05 Nov, 2025 Submission checks completed at journal 05 Nov, 2025 First submitted to journal 05 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8008446\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":556899540,\"identity\":\"d851e7f4-eb51-43bd-b899-da04d1d20da5\",\"order_by\":0,\"name\":\"Jie Peng\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Jiangxi Cancer Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jie\",\"middleName\":\"\",\"lastName\":\"Peng\",\"suffix\":\"\"},{\"id\":556899541,\"identity\":\"77d3940c-2daa-48d6-9d6d-1f575105e792\",\"order_by\":1,\"name\":\"Xianming Ge\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyUlEQVRIiWNgGAWjYBAC+/7GhgMSBmw89u0NRGoxkDjc+MCigk/GgOcAsVoY0psNKs7I2RhIJBCpxZzhYJvEzTYzHnPJxxtvMNTYRBPUYtnc2CY5sy2Nx3J2WrEFw7G03AaCeg4cbJOWbDvGw3A7x0yCseEwMVoS26T/tv3nYbh5hkgtBgcSmw0kzrDxGNzgIVKL5IyDjQ8kKth4JHuAfkkgxi/8/O0PQFFpz89+eOONDzU2RPgF2ZFERw2SFlJ1jIJRMApGwcgAAMKqQSqHtDqqAAAAAElFTkSuQmCC\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Bengbu Medical University,\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Xianming\",\"middleName\":\"\",\"lastName\":\"Ge\",\"suffix\":\"\"},{\"id\":556899542,\"identity\":\"9eab16fd-3e65-4aff-b49d-66f7df130be0\",\"order_by\":2,\"name\":\"Jiuhong Ma\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"The First Affiliated Hospital of Nanchang 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15:40:14\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":11453,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"ApprovalbytheResearchEthicsCommittee.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8008446/v1/4924c604f46e26582d980bbd.docx\"},{\"id\":97877384,\"identity\":\"37e913be-6964-4322-aafc-57aaf9d5ec6f\",\"added_by\":\"auto\",\"created_at\":\"2025-12-10 11:38:11\",\"extension\":\"docx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":585085,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"SupplementaryFile1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8008446/v1/d518e57d63f44ff9abc1fe95.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"ICU Nurses’ Knowledge, Attitudes, and Practices in Identifying Patient–Ventilator Asynchrony: A Cross-Sectional Study\",\"fulltext\":[{\"header\":\"1. Introduction\",\"content\":\"\\u003cp\\u003eMechanical ventilation remains a cornerstone of respiratory support in critically ill patients. Yet, patient\\u0026ndash;ventilator asynchrony (PVA) is a widespread complication, with an incidence as high as 23%, and has been linked to ventilator-induced lung injury, weaning failure, prolonged hospitalization, and increased mortality \\u003csup\\u003e[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]\\u003c/sup\\u003e. Accurate recognition and timely management of PVA are therefore essential. Effective intervention can minimize unnecessary sedation and analgesia, reduce respiratory muscle load, shorten the duration of mechanical ventilation, and lower mortality \\u003csup\\u003e[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e]\\u003c/sup\\u003e. Although esophageal pressure monitoring and diaphragm electromyography are recognized as gold standards for identifying PVA, their invasive nature and high cost hinder routine clinical use \\u003csup\\u003e[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e]\\u003c/sup\\u003e. As a non-invasive and real-time alternative, ventilator waveform analysis holds promise for detecting PVA, though its diagnostic accuracy is heavily reliant on the clinician\\u0026rsquo;s expertise \\u003csup\\u003e[\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e]\\u003c/sup\\u003e. Studies have revealed substantial inter-individual variability in clinicians\\u0026rsquo; ability to identify PVA, with 25%\\u0026ndash;30% unable to detect common types. However, specialized training in mechanical ventilation has been shown to significantly improve recognition accuracy \\u003csup\\u003e[\\u003cspan additionalcitationids=\\\"CR8\\\" citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e]\\u003c/sup\\u003e.\\u003c/p\\u003e\\u003cp\\u003eIn China, the majority of intensive care units (ICUs) lack dedicated respiratory therapists. As a result, ICU nurses assume responsibility for the routine management and monitoring of mechanical ventilation, including standard procedures such as airway suctioning, sedation and analgesia titration, timely reporting of PVA to physicians, and assisting in ventilator parameter adjustments \\u003csup\\u003e[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]\\u003c/sup\\u003e. Consequently, nurses\\u0026rsquo; competence, attitudes, and clinical practices in PVA recognition are of paramount importance, as they can directly influence therapeutic outcomes and patient prognosis. Despite their central role, most research in this domain has focused on respiratory therapists and physicians. ICU nurses, who serve as the primary bedside caregivers for mechanically ventilated patients, remain underrepresented in studies examining the ability, attitudes, and practices related to PVA recognition through ventilator waveform analysis.\\u003c/p\\u003e\\u003cp\\u003eThis study employed a multicenter cross-sectional design to evaluate ICU nurses\\u0026rsquo; ability, attitudes, and clinical practices regarding the identification of PVA via ventilator waveform analysis. It further investigated the impact of gender, clinical experience, and mechanical ventilation training on these domains.\\u003c/p\\u003e\"},{\"header\":\"2. Materials and Methods\",\"content\":\"\\u003cp\\u003e2.1 Study Design\\u003c/p\\u003e\\n\\u003cp\\u003eThis cross-sectional study was conducted between December 2023 and April 2025 in the intensive care units (ICUs) of 10 tertiary Class A hospitals across six provincial-level administrative regions in China. The study adhered to ethical guidelines and regulations, including the Declaration of Helsinki, and received approval from the Ethics Committee of Jiangxi Cancer Hospital (Approval No. 2023KY123; approval date: July 10, 2023). Participants were provided with an informed consent form that detailed the study's objectives, assured them of the confidentiality and anonymity of their responses, and informed them of their right to withdraw at any time. Completion and submission of the questionnaire were taken as evidence of informed consent.\\u003c/p\\u003e\\n\\u003cp\\u003e2.2 Study Participants\\u003c/p\\u003e\\n\\u003cp\\u003eInclusion criteria: nurses who were registered; had ≥6 months of direct experience caring for invasively mechanically ventilated patients; and had independently managed ≥50 such patients.Exclusion criteria: student, rotating, and visiting/advanced-training nurses; non-ICU personnel; and those who had participated in related research within the previous 3 months.\\u003c/p\\u003e\\n\\u003cp\\u003e2.3 Data Collection and Instruments\\u003c/p\\u003e\\n\\u003cp\\u003eThe research team first engaged ICU head nurses at each participating site and obtained their support. Head nurses then circulated a study notice and a link to the Wenjuanxing (Questionnaire Star) online survey via unit WeChat groups. The notice summarized the study objectives and highlighted anonymity and voluntary participation. Interested nurses accessed the link, reviewed the electronic informed consent, and completed the questionnaire online.The survey questionnaire was developed specifically for this study based on a comprehensive review of relevant literature \\u003csup\\u003e[11-14]\\u003c/sup\\u003e. The English version of the questionnaire is available as Supplementary File 1 and has been cited in the manuscript. It consists of the following sections:\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e• Demographics: gender, age, and educational background;\\u003c/p\\u003e\\n\\u003cp\\u003e• Clinical experience: ICU years of service and prior participation in mechanical-ventilation training;\\u003c/p\\u003e\\n\\u003cp\\u003e• ICU type;\\u003c/p\\u003e\\n\\u003cp\\u003e• PVA recognition section: ten clinical ventilator waveform images were selected to cover six common PVA patterns—ineffective triggering, auto-triggering, double triggering, excessive flow, insufficient flow, and delayed cycling—plus a normal waveform. Ten single-best-answer items were created (1 point each; total 10). Performance was classified as low (0–4), moderate (5–7), or good (8–10);\\u003c/p\\u003e\\n\\u003cp\\u003e• Attitudes and practices: each was assessed using a 10-item Likert 5-point scale (maximum 50), with levels defined as low (≤35), moderate (36–44), and high (≥45).\\u003c/p\\u003e\\n\\u003cp\\u003eAll nurses completed the assessment independently. Items were presented in random order, with a 20-minute time limit.The full English version of the questionnaire is provided as Supplementary File 1 and can be accessed via the journal’s supplementary material portal\\u003c/p\\u003e\\n\\u003cp\\u003e2.4 Instrument Validation\\u003c/p\\u003e\\n\\u003cp\\u003eThe questionnaire was independently reviewed and validated by 12 critical care experts responsible for mechanical ventilation ( 5 respiratory and critical care physicians, 3 respiratory therapists, and 4 ICU nursing specialists with extensive ventilation experience ). It showed excellent internal consistency ( overall Cronbach’s α = 0.922 ), with α values of 0.920, 0.862, and 0.897 for the ability, attitude, and practice domains, respectively. Two-week test–retest reliability for these domains was 0.856, 0.942, and 0.926, indicating strong reliability.\\u003c/p\\u003e\\n\\u003cp\\u003eICU experience was categorized as low (\\u0026lt;5 years), moderate (5–10 years), and high (\\u0026gt;10 years). Mechanical-ventilation training was defined as accredited classroom instruction, simulation workshops, or online courses (excluding informal training such as self-study or ad hoc bedside guidance) and was grouped as \\u0026lt;100 hours or \\u0026gt;100 hours.The questionnaire was distributed via a Wenjuanxing online link, which also provided a brief description of the study objectives. All personal information was anonymized before data collection, and participation was emphasized as voluntary. All assessments were conducted on site; each participant completed the test independently in a quiet ICU room under the supervision of study personnel. Only one attempt was permitted per participant, and completion was strictly limited to 20 minutes.\\u003c/p\\u003e\\n\\u003cp\\u003e2.5 Statistical analysis\\u003c/p\\u003e\\n\\u003cp\\u003eAll statistical analyses were performed using SPSS version 26.0. The Shapiro–Wilk test was applied to assess the normality of data distribution. Continuous variables with normal distribution were reported as mean ± standard deviation (SD), whereas those with non-normal distribution were presented as median and interquartile range (IQR). Categorical variables were summarized as frequencies and percentages. For comparisons between groups, independent-sample t-tests or one-way analysis of variance (ANOVA) were used for normally distributed data, while the Mann–Whitney U test or Kruskal–Wallis H test was applied for non-normally distributed data. The chi-square test or Fisher’s exact test was employed for categorical variables. A two-tailed P-value \\u0026lt; 0.05 was considered statistically significant, with the significance threshold set at α = 0.05.\\u003c/p\\u003e\"},{\"header\":\"3. Results\",\"content\":\"\\u003cp\\u003e3.1 Baseline characteristics of ICU nurses ( Table 1 ):\\u003c/p\\u003e\\n\\u003cp\\u003eWe included 250 nurses and analyzed 212 valid questionnaires, for an effective response rate of 84.80%. The largest subgroup was the general ICU ( 28.30% ), followed by EICU ( 18.40% ), RICU ( 16.51% ), CCU ( 13.21% ), and other ICUs ( 23.58% ). Women constituted 74.53% of the sample and men 25.47%. Most participants were 25–35 years old ( 70.28% ). Education was predominantly bachelor’s degree ( 81.60% ), with fewer holding a junior college diploma ( 14.62% ) or a master’s degree ( 3.78% ). ICU tenure was distributed as \\u0026lt; 5 years ( 20.28% ), 5–10 years ( 41.51% ), and \\u0026gt; 10 years ( 38.21% ). Overall, 39.62% had received mechanical ventilation training ( 22.17% for \\u0026lt; 100 hours; 17.45% for \\u0026gt; 100 hours ).\\u003c/p\\u003e\\n\\u003cp\\u003e3.2 Overall scores for PVA recognition, attitudes, and practice ( Table 2 ):\\u003c/p\\u003e\\n\\u003cp\\u003eICU nurses demonstrated a generally low level of PVA recognition. Attitudes toward ventilator waveform monitoring were moderately positive. Clinical practice performance was suboptimal, indicating substantial scope for improvement.\\u003c/p\\u003e\\n\\u003cp\\u003e3.3 Association between PVA recognition and nurse characteristics ( Table 3 ):\\u003c/p\\u003e\\n\\u003cp\\u003eOn the ventilator waveform recognition test, male nurses achieved higher mean scores than female nurses (\\u003cem\\u003e\\u0026nbsp;P\\u003c/em\\u003e \\u0026lt; 0.05 ), suggesting a sex-related difference. Nurses with ICU tenure \\u0026lt; 5 years scored lower than those with 5–10 or \\u0026gt; 10 years, whereas the 5–10 and \\u0026gt; 10 groups did not differ (\\u003cem\\u003eP\\u003c/em\\u003e= 0.908 ). These findings indicate that recognition improved with experience and then plateaued. Mechanical ventilation training was associated with higher recognition scores: trained nurses outperformed untrained nurses (\\u003cem\\u003e\\u0026nbsp;P\\u003c/em\\u003e \\u0026lt; 0.001 ), and those with \\u0026gt; 100 hours of training scored higher than those with \\u0026lt; 100 hours ( \\u003cem\\u003eP\\u0026nbsp;\\u003c/em\\u003e\\u0026lt; 0.05 ).\\u003c/p\\u003e\\n\\u003cp\\u003e3.4 Association between ICU nurses’ attitudes toward ventilator waveform monitoring and their characteristics ( Table 4 )\\u003c/p\\u003e\\n\\u003cp\\u003eNo significant sex difference in attitudes was observed (\\u003cem\\u003e\\u0026nbsp;P\\u0026nbsp;\\u003c/em\\u003e= 0.097 ). Attitude scores increased with ICU tenure and then plateaued. Nurses who received relevant training scored higher than those without training, and those with \\u0026gt; 100 hours of training outperformed those with \\u0026lt; 100 hours ( \\u003cem\\u003eP\\u003c/em\\u003e \\u0026lt; 0.001 ).\\u003c/p\\u003e\\n\\u003cp\\u003e3.5 Association between ventilator waveform monitoring practice and nurse characteristics ( Table 5 )\\u003c/p\\u003e\\n\\u003cp\\u003ePractice performance was significantly associated with ICU tenure, completion of mechanical ventilation training, and training duration, but not with sex. Trained nurses scored higher than untrained nurses ( \\u003cem\\u003eP\\u003c/em\\u003e \\u0026lt; 0.001 ), and those with \\u0026gt; 100 hours of training demonstrated better clinical practice.\\u003c/p\\u003e\\n\\u003cp\\u003e3.6 Correlation among overall PVA recognition, attitudes, and practice ( Table 6 )\\u003c/p\\u003e\\n\\u003cp\\u003eSignificant positive correlations were found among PVA recognition, attitudes, and practice ( \\u003cem\\u003eP\\u0026nbsp;\\u003c/em\\u003e\\u0026lt; 0.001 ). Greater recognition was linked to more positive attitudes toward waveform monitoring and more standardized clinical practice.\\u003c/p\\u003e\"},{\"header\":\"4. Discussion\",\"content\":\"\\u003cp\\u003eThis multicenter cross-sectional survey showed that ICU nurses had a generally low ability to identify PVA using ventilator waveforms. Attitudes toward waveform monitoring were moderately positive, whereas clinical practice was suboptimal and required improvement. These results were consistent with multiple international studies in recent years\\u003csup\\u003e\\u0026nbsp;[14,15]\\u003c/sup\\u003e, suggesting that deficiencies in knowledge, attitudes, and practices related to ventilator waveforms were widespread among healthcare personnel globally. Several factors likely contributed to these gaps. First, ventilator-waveform interpretation was highly specialized and remained challenging even for experienced clinicians\\u003csup\\u003e\\u0026nbsp;[16]\\u003c/sup\\u003e. Second, most ICUs in China did not employ dedicated respiratory therapists; consequently, nurses assumed portions of the monitoring workload. Traditional nursing education emphasized basic procedures, with limited training in respiratory therapy and ventilatory support. Instruction on dynamic, abstract content—such as waveforms—was especially scarce, leaving nurses ill-prepared to manage complex patterns in practice. Additionally, some nurses lacked initiative and confidence in waveform interpretation and at times considered it outside their professional remit \\u003csup\\u003e[13,14]\\u003c/sup\\u003e. Within this context, nurses’ mastery of waveform knowledge, their perceived importance of monitoring, and their clinical performance were further constrained.\\u003c/p\\u003e\\n\\u003cp\\u003eThe ability to interpret ventilator waveforms, along with professional attitudes and clinical practice, was critical and should not have been overlooked. Prior studies showed that frequent PVA prolonged mechanical ventilation and increased mortality. Specific forms of PVA—such as ineffective triggering and insufficient flow—raised the work of breathing, impaired ventilation and oxygenation, provoked discomfort and agitation, increased sedative requirements, and could precipitate ventilator-associated lung injury, thereby undermining treatment efficacy \\u003csup\\u003e[17-20]\\u003c/sup\\u003e. Accordingly, as the primary bedside observers, nurses who recognized PVA promptly and initiated basic measures or alerted physicians for parameter adjustment markedly improved the safety and effectiveness of mechanical ventilation. By contrast, when nurses lacked PVA recognition skills, asynchrony often went undetected and the optimal time for intervention was missed.\\u003c/p\\u003e\\n\\u003cp\\u003eThis study found that male nurses scored higher than female nurses. Previous research suggested\\u003csup\\u003e\\u0026nbsp;[21]\\u003c/sup\\u003e that sex could influence clinicians’ confidence and self-assessment in procedural skills. Although female nurses had knowledge and clinical experience comparable to their male counterparts, they tended to adopt a more cautious decision-making style when operating complex equipment such as ventilators. At times, this caution led them to consider a broader set of possibilities during PVA recognition, which might have reduced diagnostic accuracy \\u003csup\\u003e[14,22]\\u003c/sup\\u003e. In ICUs without respiratory therapists, ventilator maintenance and troubleshooting were typically handled by the nursing team. Cultural norms often regarded female nurses as particularly strong in fundamental care, patient communication, and team coordination, whereas male nurses were viewed as having relative strengths in device operation and troubleshooting. In our cohort, technical tasks—such as ventilator troubleshooting—were frequently assigned to male nurses, potentially cultivating tacit skills in waveform interpretation \\u003csup\\u003e[23-25]\\u003c/sup\\u003e. Because we did not collect data to test these mechanisms, prospective studies are warranted.\\u003c/p\\u003e\\n\\u003cp\\u003eOur results showed that clinical experience and prior training differentially influenced nurses’ PVA recognition, attitudes, and clinical practice. Nurses with ICU tenure \\u0026gt; 5 years scored lower for PVA recognition, attitudes, and practice than those with ≥ 5 years, whereas scores did not differ between the 5–10 and \\u0026gt; 10 year groups (\\u003cem\\u003e\\u0026nbsp;P\\u003c/em\\u003e \\u0026gt; 0.05 ). These findings suggested that, even without formal training, accumulated clinical experience could improve PVA recognition, professional attitudes, and clinical practice to a degree; however, the improvements were limited, indicating an experience-related plateau. This pattern aligned with surveys by Zelalem et al. \\u003csup\\u003e[26]\\u003c/sup\\u003e and Liu et al. \\u003csup\\u003e[27]\\u003c/sup\\u003e, which demonstrated that training in mechanical ventilation yielded gains that surpassed those from experience alone. Training in mechanical ventilation was therefore pivotal, with a positive time–effect relationship: nurses who completed \\u0026gt; 100 hours scored higher than those with \\u0026lt; 100 hours.\\u003c/p\\u003e\\n\\u003cp\\u003eFurther analysis revealed significant positive correlations among PVA recognition, attitudes, and practice. Greater recognition was associated with more positive attitudes toward ventilator waveform monitoring and more standardized clinical practice; these domains were tightly interconnected and mutually reinforcing. This linkage has meaningful implications for structured education: programs that concurrently strengthen knowledge and initiative are most likely to improve clinical behaviors, enabling efficient translation from theory to competence and reinforcing patient safety \\u003csup\\u003e[28,29]\\u003c/sup\\u003e.\\u003c/p\\u003e\\n\\u003cp\\u003eThis study confirmed that training in mechanical ventilation was pivotal for improving ICU nurses’ PVA recognition, attitudes, and practice. Targeted training ensured that nurses across backgrounds and experience levels reached a high standard of PVA recognition, enabling earlier detection of problems, timely interventions, enhanced patient–ventilator synchrony, reduced discomfort, and a lower risk of related complications \\u003csup\\u003e[30,31]\\u003c/sup\\u003e. It also helped optimize nursing workforce allocation, ensuring that patients received high-quality respiratory monitoring irrespective of the on-duty nurse’s seniority, thereby fostering more equitable ICU nursing quality. Moreover, such programs promoted the use of standardized terminology when identifying PVA and describing abnormalities, which improved the efficiency and accuracy of communication with physicians and strengthened team collaboration.\\u003c/p\\u003e\\n\\u003cp\\u003eNevertheless, this study had several limitations. First, all participants were drawn from tertiary A hospitals; ICU nurses from primary or secondary institutions were not included, which limited the generalizability of the results. Second, PVA recognition was assessed with static ventilator-waveform images that differed from dynamic bedside monitoring and might have under- or overestimated nurses’ true performance. Attitudes and practices were measured using self-administered questionnaires, which may have introduced social-desirability bias. Although we examined key factors, we could not fully control for potential confounders such as unit workload and institutional teaching resources. Finally, the cross-sectional design precluded causal inference, and several variables relied on self-report, introducing potential bias. Future studies should use randomized controlled designs to evaluate the effects of training on nurses’ PVA recognition and patient outcomes ( e.g., duration of mechanical ventilation, ICU length of stay ). The sampling scope should also be expanded to include hospitals at different tiers and multiple ICU units to enhance generalizability. In addition, evaluation tools that mirror real clinical contexts should be developed, and determinants of stagnant practice despite positive attitudes ( e.g., staffing, workload, unit culture ) should be investigated, to strengthen ventilatory management and drive critical-care nursing toward more precise and standardized practice.\\u003c/p\\u003e\\n\\u003cp\\u003eThis study delineated the current status of ICU nurses’ PVA recognition, attitudes, and practice, identified their key determinants, and underscored the central role of training. Accordingly, we recommended integrating mechanical-ventilation training into standardized ICU-nurse curricula to strengthen PVA recognition and response, thereby improving ventilatory management quality and patient outcomes.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eFunding\\u003c/p\\u003e\\n\\u003cp\\u003eThis research received no external funding.\\u003c/p\\u003e\\n\\u003cp\\u003eConflicts of Interest\\u003c/p\\u003e\\n\\u003cp\\u003eThe authors declare that they have no conflicts of interest.\\u003c/p\\u003e\\n\\u003cp\\u003eEthics Approval and Consent to Participate\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was approved by the Ethics Committee of Jiangxi Cancer Hospital (Approval No. 2023KY123; July 10, 2023). All participants provided informed consent. The study adhered to the Declaration of Helsinki. \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for Publication\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\\n\\u003cp\\u003eData Availability\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eJ.P: Conceived the initial research direction, led the on-site data collection (including distributing questionnaires to ICU nurses and collating first-hand practice records), drafted the first version of the manuscript, and participated in sorting out data related to mechanical ventilation management.X.G: Co-designed the research protocol (with a focus on optimizing indicators for respiratory support and ventilator asynchrony identification), participated in the clinical interpretation of patient-ventilator asynchrony data, and revised the manuscript to ensure accuracy from the critical care physician perspective.J.M: As the corresponding author, designed the overall research framework, supervised the entire research process (including ethical review coordination), coordinated the statistical guidance provided by the institutional statistics department, critically revised the manuscript for academic rigor, and finalized the submission version.H.W: Assisted in targeted data collection (focusing on ICU clinical nurses\\u0026rsquo; practical operation details of ventilator management), organized and verified clinical practice-related data, and reviewed the manuscript to ensure consistency with real clinical scenarios.W.P: Participated in data collection related to ICU staff training (aligning with the study\\u0026rsquo;s focus on nurses\\u0026rsquo; knowledge and attitudes), assisted in checking the completeness and validity of collected data, and reviewed the manuscript for logical coherence.Y.W: Aided in the preliminary collation and screening of ventilator waveform data (matching the research keyword \\\"ventilator waveform analysis\\\"), participated in standardized data entry, and reviewed the manuscript for clarity of content.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eDocci M, Rodrigues A, Dubo S, Ko M, Brochard L. 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Impact of a Mechanical Ventilation Curriculum on Respiratory Therapist Recognition of Patient-Ventilator Asynchrony. Respir Care. 2022;67(12):1597\\u0026ndash;602. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.4187/respcare.09903\\u003c/span\\u003e\\u003cspan address=\\\"10.4187/respcare.09903\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eAwang S, Alias N, DeWitt D, et al. Design of a Clinical Practice Guideline in Nurse-Led Ventilator-Weaning for Nursing Training. Front Public Health. 2021;9:726647. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.3389/fpubh.2021.726647\\u003c/span\\u003e\\u003cspan address=\\\"10.3389/fpubh.2021.726647\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003cli\\u003e\\u003cspan\\u003eGuilhermino MC, Inder KJ,Sundin D. Education on invasive mechanical ventilation involving intensive care nurses: a systematic review. Nurs Crit Care. 2018;23(5):245\\u0026ndash;55. \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003e10.1111/nicc.12346\\u003c/span\\u003e\\u003cspan address=\\\"10.1111/nicc.12346\\\" targettype=\\\"DOI\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTables are available in the Supplementary Files section.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-nursing\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"nurs\",\"sideBox\":\"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/nurs/default.aspx\",\"title\":\"BMC Nursing\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"ICU nurses, patient–ventilator asynchrony, ventilator waveform analysis, cross-sectional study, specialized training\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8008446/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8008446/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground：\\u003c/strong\\u003ePatient–ventilator asynchrony (PVA) is a common complication of mechanical ventilation, with an incidence of approximately 23%, and has been linked to ventilator-induced lung injury, weaning failure, prolonged hospitalization, and increased mortality. Consequently, accurate recognition and timely management of PVA can directly influence therapeutic effectiveness and clinical outcomes.\\u003cstrong\\u003e\\u0026nbsp;\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eObjective: \\u003c/strong\\u003eThis study evaluated ICU nurses’ competencies in identifying PVA through ventilator waveform monitoring, with a focus on their knowledge, attitudes, and clinical practices. It also examined how gender, clinical experience, and mechanical ventilation training influenced these competencies.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods: \\u003c/strong\\u003eA multicenter cross-sectional study was conducted from December 2023 to April 2025 in the intensive care units of ten tertiary hospitals across six provincial-level regions in China. Data collection included demographic characteristics, a validated assessment of PVA recognition ability, and standardized scales evaluating nurses’ attitudes and practices.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults: \\u003c/strong\\u003eAmong the 250 nurses recruited, 212 returned valid responses, yielding an effective response rate of 84.8%. Overall, nurses demonstrated limited ability in recognizing PVA (pass rate: 44.81%), moderately positive attitudes (60.85%), and suboptimal practices (44.34%). Male nurses outperformed females in PVA recognition (\\u003cem\\u003eP\\u003c/em\\u003e \\u0026lt; 0.05). Nurses with ≥5 years of experience and those who had received mechanical ventilation training showed significantly better performance in all domains, with those trained for over 100 hours exhibiting the most substantial gains. Additionally, significant positive correlations were identified among recognition ability, attitudes, and clinical practice (\\u003cem\\u003eP\\u003c/em\\u003e \\u0026lt; 0.001).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusions:\\u003c/strong\\u003e ICU nurses showed insufficient competency in identifying PVA, as well as in related attitudes and clinical implementation. Mechanical ventilation training emerged as a key driver for improving these domains. Integrating targeted training into the standardized ICU nurse education system may enhance ventilator management quality and improve patient outcomes.\\u003c/p\\u003e\\n\\u003cp\\u003eClinical trial number\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable.\\u003c/p\\u003e\",\"manuscriptTitle\":\"ICU Nurses’ Knowledge, Attitudes, and Practices in Identifying Patient–Ventilator Asynchrony: A Cross-Sectional Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-12-10 11:38:06\",\"doi\":\"10.21203/rs.3.rs-8008446/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-12-26T10:33:42+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"47135961674875711904840717570537435063\",\"date\":\"2025-12-18T08:20:25+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-12-16T12:48:20+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"338560715918113703689760256599895098889\",\"date\":\"2025-12-13T18:15:58+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2025-12-10T10:12:32+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"186610983942298566180839727570005728520\",\"date\":\"2025-12-05T21:59:23+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2025-12-05T11:31:15+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvited\",\"content\":\"\",\"date\":\"2025-11-10T06:31:14+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2025-11-05T14:45:22+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2025-11-05T14:19:17+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"BMC Nursing\",\"date\":\"2025-11-05T13:13:58+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"bmc-nursing\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"nurs\",\"sideBox\":\"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)\",\"snPcode\":\"\",\"submissionUrl\":\"https://www.editorialmanager.com/nurs/default.aspx\",\"title\":\"BMC Nursing\",\"twitterHandle\":\"@BMC_series\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC Series\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"92c1f619-9dd8-4045-8df0-4c096a53a69c\",\"owner\":[],\"postedDate\":\"December 10th, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2025-12-10T11:38:06+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-12-10 11:38:06\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8008446\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8008446\",\"identity\":\"rs-8008446\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}