Beyond Standardization: A Qualitative Study Using the i-PARIHS Framework and User Profiles to Improve Invasive Arterial Blood Pressure Monitoring Accuracy

Beyond Standardization: A Qualitative Study Using the i-PARIHS Framework and User Profiles to Improve Invasive Arterial Blood Pressure Monitoring Accuracy | 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 Beyond Standardization: A Qualitative Study Using the i-PARIHS Framework and User Profiles to Improve Invasive Arterial Blood Pressure Monitoring Accuracy Ming Yu, Yuling Zhang, Rong Tang, Jing Ji, Lili Jiang, Suping Cai, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7720386/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Apr, 2026 Read the published version in BMC Nursing → Version 1 posted 10 You are reading this latest preprint version Abstract Background Invasive arterial blood pressure (IBP) monitoring is vital in critical care, yet its accuracy is frequently compromised in practice. While previous studies have focused on technical comparisons or procedural standardization, a systematic understanding of the multifaceted barriers and facilitators from frontline nurses' perspectives is lacking. Aims To comprehensively explore factors influencing IABP monitoring accuracy through the lens of the i-PARIHS framework and to develop ICU nurse user profiles to inform tailored improvement strategies. Study Design: A descriptive qualitative study. Semi-structured interviews were conducted with 24 ICU nurses from a tertiary hospital in China between June and August 2025. Data analysis followed a two-step approach: directed content analysis guided by the i-PARIHS framework, followed by clustering analysis to construct distinct user profiles. Results Four themes aligned with i-PARIHS were identified: the dual nature of the innovation (value vs. risk), varied recipient competency, contextual barriers (e.g., lack of protocols), and facilitation strategies. Furthermore, three nurse profiles emerged: 1) The Experience-Guarded Expert (highly skilled but reliant on personal experience, cautious about risks), 2) The Seeking-Guidance Practitioner (knows standards but struggles with application, desires clear tools), and 3) The System-Advocating Catalyst (focuses on root causes and systemic solutions). Each profile exhibited unique needs and barriers. Conclusions Improving IABP accuracy requires a move beyond one-size-fits-all approaches. The integration of the i-PARIHS framework with user profiling provides a powerful strategy for developing targeted interventions. Tailoring support to the specific characteristics of different nurse profiles—such as providing decision aids for Practitioners and engaging Catalysts in quality improvement—is essential for enhancing patient safety. Relevance to Clinical Practice: The findings provide nurse managers with a framework for systematically assessing barriers to accurate IBP monitoring. Crucially, the identified user profiles enable a shift from generic training to precision interventions, guiding leaders to tailor support—such as simplified job aids for less confident staff and leadership roles for system-oriented nurses—to address specific needs, thereby enhancing monitoring reliability and patient safety. invasive arterial blood pressure monitoring i-PARIHS framework qualitative research user profile intensive care units nursing Figures Figure 1 1 Introduction Invasive arterial blood pressure (IABP) monitoring is a cornerstone of hemodynamic management in intensive care units (ICUs), providing continuous and real-time data that directly informs critical treatment decisions [ 1 ] . Despite its theoretical precision, the accuracy of IABP in clinical practice is often suboptimal, influenced by factors ranging from operator technique and system calibration to the interpretation of waveforms [ 2 ] . This gap between theoretical potential and actual performance poses a significant risk to patient safety. Successful implementation of complex clinical practices like IABP monitoring is often analyzed using determinant frameworks. The Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework posits that successful implementation (SI) is a function of the interaction between the Innovation (I), the Recipients (R), and the Context (C), all of which require tailored Facilitation (Fac) [ 3 , 4 ] . While the i-PARIHS framework offers a comprehensive structure for understanding implementation challenges, its "Recipients" construct often remains abstract, overlooking the significant heterogeneity among frontline staff in terms of their knowledge, attitudes, and behaviors [ 5 ] . Existing research on IABP monitoring has predominantly focused on comparing its numerical values with non-invasive methods or detailing technical procedures [ 6 ] . Few studies have systematically explored the multifaceted influences on its accuracy from the perspective of those who perform and interpret it daily—ICU nurses. Crucially, even when barriers are identified, intervention strategies often fail to account for the diversity among nurses, leading to generic solutions with limited effectiveness [ 7 ] . Therefore, this study aimed to bridge this gap by employing a qualitative design guided by the i-PARIHS framework. Our objectives were two fold: first, to systematically identify the barriers and facilitators to accurate IABP monitoring; and second, to move beyond a homogenous view of nurses by constructing data-driven user profiles. The user profile methodology originates from the fields of user experience research and human factors engineering. It involves integrating multidimensional data to construct representative user archetypes, thereby transforming abstract user characteristics into concrete, identifiable personas [ 7 ] . In this study, we introduced this approach to deeply analyze the diversity within the ICU nurse population and identify nurse subgroups with distinct cognitive patterns, behavioral characteristics, and need preferences. These profiles will illuminate distinct patterns of needs and challenges, providing a foundational evidence base for developing precisely tailored strategies to improve the quality of IABP monitoring. 2 Aims and Objectives of Study The aim of this study is to gain an in-depth understanding of the factors influencing the accuracy of IABP monitoring from the perspective of ICU nurses. By exploring nurses' firsthand experiences, this research seeks to identify the multilevel barriers and facilitators to achieving reliable IBP measurements. The objectives are to systematically analyse these factors using the i-PARIHS framework, to develop distinct user profiles of ICU nurses based on their approaches and challenges, and to provide evidence that can guide the development of tailored strategies for education and quality improvement. The primary research questions guiding this study are: What are the experiences of ICU nurses regarding the factors that affect the accuracy of IBP monitoring in their clinical practice? How can these experiences be synthesised to construct meaningful user profiles that inform targeted interventions? These questions are designed to explore the complex interplay between the technology, the individual clinician, and the clinical environment, ultimately aiming to generate insights for enhancing the quality and safety of hemodynamic monitoring. 3 Design and Methods 3.1 Developing the Interview Outline Based on the research objectives and a comprehensive review of the literature on IBP monitoring, we drafted a preliminary semi-structured interview guide. To ensure the relevance and comprehensiveness of the questions, the draft outline was reviewed by a nursing professor specializing in qualitative research methodologies and two associate chief nurses with extensive expertise in critical care and hemodynamic monitoring [ 8 ] . The outline was revised and finalized according to the experts' feedback regarding question clarity, flow, and coverage of key topics. Prior to the formal interviews, pilot interviews were conducted with three ICU nurses to test the appropriateness and comprehensibility of the questions. These pilot interviews were used solely for refining the interview guide and their data were not included in the final analysis. The final interview guide is presented in Table 1 . Table 1 Semi-structured interview guide Can you describe your main experiences and feelings when performing IBP monitoring? How do you determine whether an IBP reading is reliable or accurate during clinical operations? In your opinion, what are the key factors that influence the accuracy of IBP monitoring? What core competencies do you believe an operator must possess to ensure monitoring accuracy? What suggestions or ideas do you have for improving the accuracy of IBP monitoring in our unit? 3.2 Setting and Sample This study was conducted between June and August 2025 in the intensive care unit of a Grade III-B tertiary hospital in China. A purposeful sampling strategy was employed to recruit 24 registered nurses working in the ICU. The sample size was determined by the principle of data saturation, whereby interviews were discontinued when no new thematic information emerged from three consecutive participants [ 9 ] . The inclusion criteria were: (1) nurses who had obtained registered nurse qualifications; (2) nurses with at least one year of hands-on experience in operating or managing invasive arterial blood pressure (IBP) monitoring devices. The exclusion criteria were: (1) nurses who were unavailable to participate in the study (e.g., on extended leave); (2) nurses not directly involved in IBP monitoring care (e.g., those solely responsible for medical order processing or unit management); (3) nurses who were pregnant or lactating. After distributing invitation letters and obtaining written informed consent, 24 nurses were enrolled in the study. The final sample comprised 24 female participants, with ages ranging from 27 to 46 years. Detailed demographic characteristics of the participants are presented in Table 2 . Table 2 Demographic and Professional Characteristics of Participants (n = 24) ID Education Level Professional Title Clinical Ladder Years of Experience Age (years) 1 Bachelor's Chief Nurse N4 26.9 46 2 Bachelor's Senior Nurse N3 13.6 36 3 Bachelor's Senior Nurse N3 17.8 38 4 Bachelor's Senior Nurse N3 16.9 37 5 Bachelor's Senior Nurse N2(2) 13.9 34 6 Bachelor's Senior Nurse N3 11.9 34 7 Bachelor's Senior Nurse N3 11 34 8 Bachelor's Senior Nurse N2(2) 9.9 32 9 Bachelor's Senior Nurse N2(2) 9.6 32 10 Bachelor's Senior Nurse N2(2) 9 32 11 Bachelor's Senior Nurse N2(2) 9.9 32 12 Bachelor's Senior Nurse N2(2) 9 31 13 Bachelor's Senior Nurse N2(2) 8 30 14 Bachelor's Nurse N2(1) 8.7 29 15 Bachelor's Nurse N2(2) 8 28 16 Bachelor's Senior Nurse N2(1) 6.9 28 17 Associate's Nurse N2(1) 6.7 27 18 Bachelor's Nurse N2(1) 7.9 27 19 Bachelor's Nurse N2(1) 7.6 27 20 Associate's Nurse N2(1) 6.7 27 21 Bachelor's Nurse N2(1) 8.4 29 22 Bachelor's Senior Nurse N3 11.8 36 23 Bachelor's Nurse N2(2) 9 29 24 Bachelor's Senior Nurse N2(2) 11.9 32 Note:The "Clinical Ladder" (e.g., N2, N3, N4) is a hierarchical system used in the study context to classify nurses based on their clinical competence and expertise. N2 is often subdivided into levels 1 and 2. 3.3 | Data Collection Data were collected through individual, face-to-face, semi-structured interviews using the finalized interview guide. Prior to each interview, the researcher thoroughly explained the study's purpose, procedures, and the principles of voluntary participation and confidentiality to the participants. The interviews were conducted by a nursing graduate student who had received formal training in qualitative research methods. The interviewer had no supervisory relationship with the participants. Written informed consent was obtained from all participants, including permission for audio-recording. The interviews were scheduled in advance at a time convenient for the participants and were held in a private, quiet room within the hospital to ensure an undisturbed environment. Each interview lasted between 20 and 60 minutes. All interviews were audio-recorded and subsequently transcribed verbatim for analysis, with any identifying information removed to protect participant anonymity. 3.4 | Data Analysis The analysis of the interview data was conducted in two distinct phases to address the research objectives comprehensively. In the first phase, directed content analysis was employed, guided by the core constructs of the i-PARIHS framework (Innovation, Recipients, Context, and Facilitation) as initial coding categories [ 10 ] . This approach was selected for its utility in validating or extending existing theoretical frameworks. The process involved: (1) repeated reading of the transcribed texts to achieve immersion and obtain a sense of the whole; (2) identifying meaningful segments of text relevant to the research question; (3) coding these segments using the pre-specified i-PARIHS categories, while remaining open to new codes that emerged from the data; (4) grouping codes into sub-themes and themes within the framework's structure; and (5) defining and naming the themes. In the second phase, to address the heterogeneity among nurses, a two-step cluster analysis was performed [ 11 ] . Salient characteristics, attitudes, and behavioral patterns identified from the coded transcripts for each participant were extracted as variables. This analytical technique, suitable for mixed variable types, was used to identify natural groupings within the participant pool. The resulting clusters were then synthesized into distinct user profiles, with their defining features visualized using word clouds to illustrate the predominant characteristics of each group [ 12 ] . To ensure the trustworthiness of the analysis, multiple discussions were held among the research team to review and refine the coding and thematic structure. Furthermore, member checking was conducted by inviting two participants to provide feedback on the preliminary findings, enhancing the credibility of the results. To construct the group profiles, representative variables were extracted from the characteristics of each cluster as descriptive tags. The importance of each tag was determined by its frequency within the cluster. These tags were then visualized using WordArt to generate word clouds. In this visual representation, the font size of a tag corresponds to its frequency, thereby intuitively highlighting the core characteristics of each group profile and providing an accessible summary of the qualitative findings. 3.5 Quality Control Multiple strategies were employed to ensure the trustworthiness and rigor of the study, guided by the criteria established by Lincoln and Guba for qualitative research. Prior to data collection, the researchers engaged in bracketing to set aside preconceived notions and theoretical knowledge about IBP monitoring, maintaining an open and neutral stance throughout the research process. During the study, the primary researcher practiced ongoing reflexivity by maintaining a journal to document and critically examine how her role as a nursing student and her clinical experiences might influence data collection and interpretation, thereby enhancing the confirmability of the findings. Regular peer debriefing sessions were conducted among the research team, which included the primary investigator, a senior qualitative research expert, and a critical care nursing specialist. These sessions involved reviewing the coding schemes, discussing emerging themes, and challenging interpretations to reduce researcher bias and ensure the dependability of the analysis. Additionally, member checking was performed by presenting the preliminary findings to two participants who confirmed that the identified themes accurately reflected their experiences, thereby enhancing the credibility of the results. An audit trail documenting all analytical decisions was maintained throughout the research process to ensure transparency and replicability. 4 Ethical Considerations This study was approved by the Ethics Committee of Rudong Hospital Affiliated to Xinglin College of Nantong University (Approval No. [2024]伦审第(7)号) on 10 September 2025. All participants provided written informed consent prior to their participation. The study purpose, procedures, risks and benefits were fully explained, and participants were assured of their right to withdraw at any time without penalty. Confidentiality was maintained through de-identification of all data and secure storage of recordings and transcripts. The research was conducted in accordance with the Declaration of Helsinki and relevant institutional guidelines to ensure the protection of participants' rights and welfare. 5 Findings Through a rigorous analytical process, four principal themes and ten corresponding subthemes were identified, each aligning with the core constructs of the i-PARIHS framework. The findings are presented below, structured according to these thematic categories. 5.1 Theme One: The Dual Nature of the Innovation: Inherent Value and Procedural Complexity This theme encapsulates the paradoxical nature of IBP monitoring, characterized by its recognized clinical superiority counterbalanced by significant operational challenges and risks that impede its optimal application. 5.1.1 Unmatched Value in Hemodynamic Monitoring Nurses consistently affirmed the indispensable role of IBP in the management of critically ill patients, particularly those experiencing hemodynamic instability or requiring vasoactive drug support. The technology was praised for delivering continuous, real-time data deemed more reliable, sensitive, and actionable than non-invasive alternatives, thereby serving as a critical foundation for advanced life support decisions. One nurse articulated this essential value, stating: "In our ICU, for patients in shock or on high-dose vasoactive drugs, invasive blood pressure is our 'eyes' and 'steering wheel'. It's more sensitive and more reliable." (N1) Another participant emphasized its profound clinical impact, noting: "There have been many instances where relying on the radial artery catheter enabled us to salvage patients. In such critical moments, you realize this technology is invaluable, despite its complexities." (N22) 5.1.2 Operational Risks and Clinical Apprehensions Conversely, the technical difficulties and potential complications associated with IBP monitoring—including challenging puncture procedures, thrombosis, infection, and bleeding—were frequently cited as major concerns. These apprehensions were particularly acute for patients with poor vascular access, such as those in shock or with significant edema, leading to higher perceived failure rates and amplified risks. A nurse described the procedural challenges: "Arterial puncture presents the greatest challenge, especially in edematous or shocked patients where vessels are collapsed and difficult to palpate or visualize. Multiple unsuccessful attempts not only increase difficulty but also cause patient discomfort." (N17) This perception of risk directly influenced clinical decision-making, occasionally favoring more conservative approaches: "A cost-benefit assessment sometimes leads us to choose non-invasive monitoring for relatively stable patients, as catheterization entails inherent risks and significantly increases the nursing workload." (N14) 5.2 Theme Two: Recipient Heterogeneity: Disparities in Knowledge and Clinical Decision-Making This theme reveals significant variations among nurses in their understanding of IBP monitoring and their approaches to clinical decision-making, highlighting the human factors that influence protocol adherence. 5.2.1 Disparities in Knowledge and Skill Base Substantial differences were observed in nurses' comprehension of the standardized operational procedures for IBP monitoring. While basic operational knowledge was common, the ability to internalize these standards into a robust knowledge framework for troubleshooting was inconsistent, particularly among less experienced nurses. One nurse expressed uncertainty in complex situations: "I know the steps for invasive arterial pressure monitoring, but when faced with a distorted waveform or a sudden change in pressure, I'm not entirely clear on the underlying reasons or the systematic approach for analysis." (N5) A lack of confidence in practical skills was also evident, as another nurse shared: "Even now, when I need to perform an arterial puncture, I feel apprehensive, worried that my technical skill might be insufficient and could delay critical care." (N16) 5.2.2 Experience-Driven Practice versus Systematic Thinking** A key finding was the prevalent reliance on personal experience rather than a standardized, systematic analytical process when addressing fluctuations in arterial pressure. This unstructured decision-making model resulted in variable—and potentially risky—troubleshooting sequences among different nurses. One nurse described this experience-based approach: "It primarily relies on experiential judgment. After seeing many cases, you develop a general sense of what indicates an artifact versus a genuine patient deterioration." (N7) The lack of a unified protocol was further highlighted by another participant: "I have a general mental checklist for troubleshooting, but the sequence varies from person to person—whether to check the sensor position first, flush the line, or immediately call the physician. It's largely based on individual (groping/figuring things out independently)." (N13) 5.2.3 Family Cognizance and Involvement in Decision-Making** The study identified family members as crucial participants in the medical decision-making process, whose understanding and speed of decision-making directly impacted the timely application of IBP. Obtaining informed consent from families, which involves explaining the necessity and risks of the procedure, was a necessary step that could paradoxically become a delaying factor during critical moments. A nurse illustrated this tension: "The most agonizing situation is when a patient's blood pressure plummets, urgently requiring invasive monitoring, but the family members are hesitant, constantly making calls to consult others, or repeatedly asking, 'Are there any other options?' We are racing against time to save the patient while simultaneously dedicating significant effort to communication and explanation, which is an extremely distressing process." (N13) 5.3 Theme Three: Contextual Gap: The Chasm Between Standards and Clinical Reality This theme highlights the significant systemic and environmental factors that hinder the consistent application of IBP monitoring standards, focusing on the disconnect between formal protocols and the realities of clinical practice. 5.3.1 Absence of Standardized Processes and Quality Control A pronounced "know-do gap" was identified, where ideal nursing standards starkly contrasted with complex clinical realities. This gap was attributed not to a lack of willingness but to a systemic failure in embedding standardized protocols seamlessly into high-workload workflows. Nurses frequently had to make pragmatic compromises in clinical priorities when facing multiple tasks and time pressures. One nurse explained this predicament: "The standards represent an ideal state, but when the unit is busy with a high patient census, it becomes very difficult to strictly adhere to every single guideline." (N15) The lack of procedural oversight was noted as a contributing factor: "Even if we don't follow the standard procedure completely, as long as the waveform is generally usable, there is rarely any audit to check whether the operation fully complied with the protocol." (N11) 5.3.2 | Cognitive and Cultural Environment of 'Approximate Accuracy' A cultural tolerance for "approximate accuracy" was observed, where some nurses did not fully prioritize strict adherence to precision standards. This was underpinned by an insufficient recognition of the importance of rigorous calibration and a misplaced reliance on the inherent accuracy of the technology itself. One nurse commented on this mindset: "There's a tendency to think 'close enough is good enough'; we can use the non-invasive pressure as a reference, so there's no need to be overly meticulous." (N17) Another revealed a common misconception regarding responsibility for accuracy: "We subconsciously feel that this is a high-tech product calibrated perfectly at the factory; we just need to use it. Those meticulous calibration and validation procedures are the responsibility of the manufacturer and engineers, not really related to us bedside operators." (N22) 5.3.3 Real-World Constraints of Economic Factors The substantial direct cost of IBP monitoring was identified as a significant practical constraint, imposing a financial burden on patients and directly influencing clinical decision-making, particularly in cases with uncertain indications. Economic considerations became a key factor in selecting monitoring strategies. A nurse expressed the moral dilemma faced: "For patients with significant financial difficulties, seeing their distress, we will first attempt non-invasive monitoring if the clinical condition permits, to alleviate their financial pressure. It's helplessness of reality." (N16) This economic influence extended to prescribing practices: "For patients with high out-of-pocket expenses and poor economic conditions, physicians are more cautious when ordering the procedure. Whether a technology gets used can sometimes genuinely depend on the patient's financial situation." (N4) 5.4 Theme Four: Facilitation: Building a Systematic Support Ecosystem This theme synthesizes nurses' explicit recommendations for enabling the successful and sustained implementation of accurate IBP monitoring, focusing on the necessary structures, educational shifts, and cultural changes required for systemic improvement. 5.4.1 Providing Structured Tools to Empower Clinical Decision-Making A strong, consistent call emerged for translating abstract written standards into intuitive, executable clinical tools. Nurses highlighted the need to reduce cognitive load and standardize practice through job aids that guide action, especially during troubleshooting. The desire for clarity over complexity was emphasized: "What we lack most now is not another standard document, but a foolproof, step-by-step operational guide." (N14) Another nurse used a vivid metaphor to express the need for accessible expertise: "I dream of having a 'kung fu secret manual'—something that transforms the expert's knowledge and experience into a flowchart that every one of us can easily understand and follow." (N13) 5.4.2 Implementing Advanced Thinking Training to Drive Competency Transformation The identified training needs evolved beyond fundamental operational skills towards cultivating higher-order clinical reasoning and systematic decision-making abilities. Nurses expressed a desire for training that mirrors the complexities of real-world practice. One participant suggested a case-based approach: "Current training always focuses on teaching us *what* to do. I wish instructors would present a real, complex case with messy, poor-quality waveforms and walk us through the troubleshooting process step-by-step." (N6) Another advocated for immersive simulation to bridge the gap between knowledge and instinct: "Could we develop high-fidelity simulations? This would help us practice until the knowledge we learn becomes an instinctive reaction." (N21) 5.4.3 Establishing a Supportive Management System and Culture to Ensure Sustainability Nurses identified that the enduring implementation of standards hinges on establishing a foundational system built on a psychologically safe, just culture, championed by leadership and reinforced with adequate resources. This would create a virtuous cycle of incident reporting, feedback, and quality improvement. The critical role of leadership was underscored: "The attitude of the leadership is the weather vane. Staff will immediately recognize whether this initiative is being taken seriously." (N24) The need for enabling conditions, not just demands, was also highlighted: "Managers cannot only make demands without providing support. They need to create the time and environment that allows us to do our jobs properly." (N10) Specific systemic interventions were proposed, such as: "We could establish a weekly IBP quality meeting where we collectively review waveforms and assess quality." (N19) Finally, the principle of a just culture was deemed essential: "The most critical thing is to establish a blame-free culture. The purpose of reporting incidents should be to improve the system, not to punish individuals." (N2) 5.5 Development of ICU Nurse User Profiles Based on the i-PARIHS Framework Cluster analysis of the interview data from the 24 participating nurses, based on differences in their cognition, behaviors, attitudes, and needs regarding IBP monitoring, yielded three distinct clusters with good quality (silhouette score > 0.5). This analysis led to the construction of three ICU nurse user profiles: the Experience-Guarded Expert, the Guidance-Seeking Practitioner, and the System-Advocating Catalyst. Visual representations of these profiles are presented in Fig. 1 , and a comparative summary of their key characteristics is provided in Table 3 . Table 3 Comparison of Characteristics Among Three ICU Nurse User Profiles Characteristic Experience-Guarded Expert Guidance-Seeking Practitioner System-Advocating Catalyst Age (years), Mean ± SD 36.6 ± 4.9 27.8 ± 0.8 31.4 ± 1.6 Professional Title, n (%) Senior Nurse: 87.5% (7/8) Nurse: 88.9% (8/9) Senior Nurse: 85.7% (6/7) Chief Nurse: 12.5% (1/8) Senior Nurse: 11.1% (1/9) Nurse: 14.3% (1/7) Clinical Ladder, n (%) N3: 75.0% (6/8) N2(1): 77.8% (7/9) N2(2): 100% (7/7) N4: 12.5% (1/8) N2(2): 22.2% (2/9) N2(2): 12.5% (1/8) Years of Experience, Mean ± SD 14.5 ± 5.9 7.6 ± 0.9 10.5 ± 1.7 Core Characteristics Relies on personal experience; practices cautiously; highly risk-averse Understands standards but struggles with application; lacks confidence; desires guidance Possesses systematic thinking; focuses on process optimization; potential change agent Seniority & Confidence High seniority; confident in operation but employs personalized decision-making Generally low seniority; demonstrates low confidence in puncture and waveform interpretation Varied seniority; has a clear认知 (awareness) of own abilities Decision-Making Mode Experience-driven: "You know from seeing it many times." Indecisive and confused: "My heart beats fast [feel nervous], unsure which step to take first." Systematic analysis: Advocates for "standardized troubleshooting flowcharts." Perception of the Technology Acknowledges its value but applies it conservatively after weighing risks Acknowledges its value but feels daunted by the technical difficulty Deeply understands its advantages and limitations; strives to maximize its efficacy Perception of the Environment Accepts the status quo of lacking quality control; highly adaptive Deeply affected by high-workload environment; feels powerless to adhere to standards Strongly perceives lack of systemic support; is a vocal advocate for change Core Needs Desires practical skills for complication prevention Most desires structured tools (e.g., "foolproof guide") and practical, hands-on training Desires to participate in system optimization Note: The "Clinical Ladder" is a hierarchical system used in the study context to classify nurses based on their clinical competence and expertise. N2 is often subdivided into levels 1 and 2. Terms in parentheses indicate the original Chinese key terms for clarity. 6 Discussion 6.1 The Duality of Technological Innovation: Concurrent Clinical Merits and Inherent Risks Aligned with the 'Innovation' construct of the i-PARIHS framework, our analysis reveals that IABP monitoring embodies a fundamental duality. On one hand, it demonstrates irreplaceable value in the management of hemodynamically unstable patients, providing continuous, reliable, and sensitive hemodynamic data. This capacity led nurses to regard it as a 'gold standard' in critical care, underscoring its relative advantage and implementation potential [ 13 ] . Conversely, the technique's operational complexity and associated risks—such as challenging puncture, thrombosis, and infection—were significant concerns. These were particularly pronounced in patients with poor vascular access, increasing procedural difficulty, failure rates, and the nurses' psychological burden. This risk-profile consequently fostered a more conservative application in patients with borderline indications [ 14 ] . This inherent "merit-risk paradox" directly influences the technology's clinical implementation outcomes. The effective use of IABP demands considerable operator skill, confidence, and a supportive practice environment. Therefore, promoting IABP requires not only highlighting its clinical benefits but also systematically addressing its inherent risks. Future strategies should focus on standardised training, the development of clinical decision support tools, and the optimisation of complication prevention protocols to mitigate uncertainties and fully realise its monitoring potential. 6.2 Recipient Heterogeneity in Cognition and Decision-Making: Multifaceted Clinical Implications Our findings illuminate that nurses, as the direct implementers of IABP technology, significantly influence its application quality through their knowledge structures, decision-making patterns, and communication efficacy with patients' families. This aligns with existing evidence indicating that variations in recipients' professional knowledge, skill sets, and resource availability critically impact the effectiveness of evidence-based practice implementation [ 15 ] . While junior nurses generally mastered basic operational procedures, they commonly lacked systematic analytical capabilities for interpreting abnormal waveforms and navigating complex clinical scenarios, coupled with pronounced insecurity regarding puncture techniques. Furthermore, the interview results revealed a prevalent experience-oriented, rather than evidence-based, approach to clinical decision-making. When confronted with blood pressure fluctuations, nurses predominantly relied on individual experience, leading to significant variations in clinical troubleshooting pathways. This non-standardized decision-making model introduces potential clinical risks [ 16 ] . Additionally, family members, as external recipients, directly impacted the timeliness of monitoring through their understanding of IABP and the efficiency of their decision-making processes [ 17 ] . This indicates that the effectiveness of technology implementation hinges not only on nurses' clinical expertise but also on their communication skills and ability to obtain truly informed consent. These findings suggest that strategies to enhance IABP quality must extend beyond conventional skill-based training. It is imperative to establish an advanced cultivation system centered on developing clinical decision-making competence. This can be achieved by creating standardized decision-support tools and incorporating dedicated communication training, thereby systematically improving nurses' clinical judgment, operational confidence, and family management skills to optimize the overall implementation efficacy of IABP technology. 6.3 Multi-level Contextual Constraints: The Combined Impact of Systemic, Cognitive, and Economic Barriers The findings demonstrate that the accuracy of IABP monitoring is significantly constrained by environmental factors operating at multiple levels. At the organizational level, the absence of systematic quality control mechanisms, combined with high-workload clinical environments, compromised adherence to standard operating procedures [ 17 – 18 ] . Nurses were often forced to compromise technical standards when prioritizing clinical tasks, and a lack of procedural feedback meant that quality management remained largely "incident-driven" rather than focused on "process control" [ 19 ] . At the cultural-cognitive level, a concerning underestimation of the importance of precision monitoring was observed among some nurses. An operational inertia characterized by acceptance of "approximate accuracy," coupled with a tendency to attribute the accuracy of disposable sensors solely to factory calibration rather than bedside practice, undermined the internal motivation to pursue technical excellence [ 20 ] . This cognitive deviation directly eroded the sense of personal responsibility for monitoring quality. At the external environmental level, economic pressures emerged as a tangible constraint on clinical decision-making [ 21 ] . When the cumulative cost of a procedure posed a significant burden to economically disadvantaged patients, clinicians demonstrated a tendency towards more conservative treatment options in cases with borderline indications, reflecting a pragmatic dilemma within resource-limited settings [ 22 ] . These insights indicate that improving IABP monitoring quality cannot rely solely on enhancing individual operator competence. There is an urgent need to develop high-level quality assurance systems at the organizational level, reshape professional cognition regarding precision monitoring at the cultural level, and explore policy-level mechanisms to alleviate patient financial burden. Only through such a multi-faceted approach can a truly supportive environment for best practices be established. 6.4 Multi-level Facilitation Strategies: Integrating Tool Empowerment, Cognitive Transformation, and Organizational Support Our findings indicate that establishing a quality improvement system for IABP monitoring requires systematic advancement across three interconnected dimensions: tool empowerment, training transformation, and cultural restructuring. First, nurses strongly advocated for translating expert knowledge into explicit, accessible formats through structured decision-support tools [ 23 ] . Substantial evidence confirms that standardized operating guidelines and troubleshooting algorithms can effectively reduce cognitive load, unify practice standards, and establish the foundation for consistent, normative clinical decision-making [ 24 , 25 ] . Second, the training paradigm requires a fundamental shift from technical skill acquisition to cultivating advanced clinical reasoning [ 26 ] . High-fidelity simulation training based on authentic clinical cases can foster systematic diagnostic capabilities in complex situations, enabling the internalization of knowledge into practice [ 26 ] . Finally, establishing supportive management systems and a "just culture" is imperative. Research demonstrates that leadership engagement and resource allocation provide essential institutional backing, while non-punitive incident reporting systems and routine quality feedback mechanisms form the cultural core, collectively creating a virtuous cycle that sustains practice standards [ 28 ] . These insights underscore that enhancing IABP monitoring quality necessitates an integrated, multi-level facilitation framework combining operational, educational, and systemic strategies. Through operationalizable, institutionalized, and culturally embedded approaches, we can ultimately achieve standardized and precise monitoring practices. 6.5 Implications for Precision Management: Leveraging User Profiles for Targeted Interventions The construction of user profiles in this study transforms abstract interview data into concrete nurse group characteristics, revealing three distinct target populations that require differentiated approaches for improving IABP monitoring accuracy. For the Experience-Guarded Experts, strategies should focus on leveraging their clinical expertise as valuable departmental resources [ 29 ] . Management approaches could include engaging them as mentors in high-fidelity simulation training, where they can share their experience in managing complex situations [ 30 ] . Simultaneously, introducing evidence-based decision support tools can help integrate their personal experience with standardized protocols, thereby reducing decision-making variations [ 31 ] . The Guidance-Seeking Practitioners represent the most promising target for intervention efficacy, demonstrating strong learning motivation but lacking adequate support. Management priorities should address their urgent need for structured tools and advanced training. Developing clear, visual IABP operation checklists, troubleshooting flowcharts, and implementing case-based repetitive simulation training can rapidly enhance their competence and confidence, effectively bridging the knowledge-practice gap. The System-Advocating Catalysts serve as potential agents for systemic change. Management should actively solicit their input, involve them in IABP quality control committees or process improvement projects, and delegate specific responsibilities [ 32 ] . Engaging these nurses in developing a blame-free incident reporting culture and establishing regular quality feedback meetings can transform individual systematic thinking into organizational continuous improvement momentum [ 33 ] . This profile-based approach enables precision management strategies that move beyond one-size-fits-all solutions, potentially enhancing the effectiveness and efficiency of quality improvement initiatives in critical care settings. 7 Implications for Practice and Research This study underscores the critical importance of a systematic and differentiated approach to improving invasive arterial blood pressure (IBP) monitoring accuracy in ICU settings. By identifying distinct nurse user profiles, our findings suggest that moving beyond one-size-fits-all training toward precision interventions tailored to specific nurse characteristics may significantly enhance implementation effectiveness. For clinical practice, healthcare institutions should develop targeted strategies based on the identified profiles: providing structured decision aids and simulation training for Guidance-Seeking Practitioners; engaging Experience-Guarded Experts in peer mentoring while introducing evidence-based protocols; and empowering System-Advocating Catalysts through quality improvement initiatives. Establishing a supportive organizational culture with leadership engagement, non-punitive reporting systems, and regular feedback mechanisms is essential for sustaining practice change. Future research should focus on validating and refining these user profiles in diverse clinical settings, and developing and testing tailored interventions for each profile. Longitudinal studies are needed to examine how profile-based strategies affect long-term clinical outcomes, including monitoring accuracy, complication rates, and patient safety indicators. Additionally, research should explore the organizational factors—such as resource allocation, leadership support, and clinical governance structures—that influence the sustainability of profile-based quality improvement initiatives across different healthcare contexts. These efforts will contribute to building a more nuanced understanding of implementation science in critical care nursing, ultimately supporting the development of more effective, personalized approaches to quality enhancement. 8 Conclusion This study, grounded in the i-PARIHS framework, elucidates the multifaceted factors influencing the accuracy of invasive arterial blood pressure (IBP) monitoring in critical care settings. Our findings reveal a critical gap between the availability of standardized operational procedures and the lack of standardized decision-making protocols in clinical practice. This has resulted in heavy reliance on individual experiential judgment among nurses, compounded by insufficient systematic quality control and an underdeveloped just culture. These insights underscore the necessity for healthcare managers to develop comprehensive, systematic facilitation strategies to enhance IBP monitoring quality. A significant contribution of this research is the development of distinct user profiles, which demonstrate considerable heterogeneity within the nursing population regarding IBP monitoring practices. This heterogeneity necessitates tailored, profile-specific interventions rather than a one-size-fits-all approach. Implementing structured decision-support tools can standardize clinical judgment, while case-based training programs can foster the internalization of advanced decision-making competencies. When complemented by robust quality control mechanisms and a supportive safety culture, these strategies can effectively transform IBP monitoring from mere data generation to the production of clinically reliable information. As a single-center study, these findings should be interpreted within the context of its limitations. Future research should employ multi-center designs and mixed-methods approaches to validate and extend these findings. Further investigation is needed to comprehensively explore both barriers and facilitators to accurate IBP monitoring, which will inform the development of targeted implementation strategies. Ultimately, such efforts will facilitate the translation of evidence into clinical practice, thereby enhancing the accuracy of hemodynamic monitoring and improving patient safety outcomes in critical care environments. Declarations Consent Written informed consent was obtained from all participants prior to their inclusion in the study. Conflicts of Interest The authors declare no conflicts of interest. Ethics Approval and Consent to Participate This study was approved by the Medical Ethics Committee of Rudong County People's Hospital (Approval No. 2025-007) on 10 September 2025. Written informed consent was obtained from all participants prior to their inclusion in the study. All methods were performed in accordance with the relevant guidelines and regulations. Consent for Publication Not applicable. Competing Interests The authors declare that they have no competing interests. Additional Information Correspondence and requests for materials should be addressed to Ronghui Geng. Funding This work was supported by the Nantong Social Livelihood Science and Technology Plan (MSZ2024131) and the Nantong Municipal Health Commission Research Project (QN2024058). Author Contribution Ming Yu and Yuling Zhang contributed equally to this work. Study conception and design were performed by Ming Yu and Yuling Zhang. Data collection and analysis were conducted by Ming Yu, Yuling Zhang, Jing Ji, Lili Jiang, Suping Cai, and Ronghui Geng. The first draft of the manuscript was written by Ming Yu and Yuling Zhang. Rong Tang provided supervision and critical revision of the manuscript. Lingling Jiang coordinated the study and provided administrative support. All authors reviewed and approved the final manuscript. Ronghui Geng serves as the corresponding author and takes responsibility for the integrity of the work. Acknowledgements The authors gratefully acknowledge the contributions of the ICU nurses who participated in this study. Data Availability The datasets generated and analyzed during the current study are not publicly available due to containing information that could compromise participant privacy but are available from the corresponding author upon reasonable request. References Ule J, Huppe T, Thiel J, et al. Implementing prehospital invasive arterial blood pressure monitoring in critically ill patients-a prospective observational first year analysis[J]. Scand J Trauma Resusc Emerg Med. 2025;33(1):145. Wang J, Zhang J, Zhang Y, et al. Feasibility and safety analysis of distal radial arterial catheterization for arterial pressure monitoring in ICU[J]. J Clin Monit Comput. 2025;39(4):767–74. Young AM, Byrnes A, McRae P, et al. Use of the i-PARIHS framework in nutrition and dietetics research and practice: A citation analysis of the literature and case studies[J]. Nutr Clin Pract; 2025. Hu M, Hu J, Sun P, et al. Analysis of Barriers to Evidence Transformation and Countermeasures for MARSI Prevention in Tracheal Intubated Patients Based on the i-PARIHS Framework[J]. J Multidiscip Healthc. 2025;18:5949–59. Chays-Amania A, Schwingrouber J, Melnyk BM, et al. Mapping Implementation Strategies and Outcomes When Using Evidence Based Practice Implementation Models in Nursing Settings: A Scoping Review[J]. Worldviews Evid Based Nurs. 2025;22(3):e70050. Freer R, Frost O, Sreenivas A et al. Mechanical Circulatory Support Devices versus Standard Medical Therapy for Treatment of Myocardial Infarction Complicated by Cardiogenic Shock: a Network Meta-Analysis[J]. Eur Heart J Qual Care Clin Outcomes, 2025. Becker L, Bzhilyanskaya V, Sharman A, et al. Intra-Arterial Versus Noninvasive Blood Pressure Monitoring: A Systematic Review and Meta-Analysis[J]. Am J Crit Care. 2025;34(4):e6–23. Wei J. Analysis of the Behavioral Performance and Social Support of Patients in Online Health Communities From User Profile Perspectives: Comparative Study[J]. J Med Internet Res. 2025;27:e68074. Papalamprakopoulou Z, Dang TH, Gonzalez CJ, et al. Long-Term Benefits Following Hepatitis C Cure Through Facilitated Telemedicine; Experiences of People With Opioid use Disorder Five Years After Achieving a Sustained Virological Response[J]. Health Expect. 2025;28(5):e70404. Gustavson AM, Miller MJ, Boening N, et al. Identifying factors influencing emerging innovations in hospital discharge decision making in response to system stress: a qualitative study[J]. BMC Health Serv Res. 2024;24(1):1293. Zhou Y, Tian X, Tang Y, et al. Exploring supply and demand imbalance of community-based older adult care: an observational study in Chongqing, China[J]. Front Public Health. 2025;13:1581039. Cebrino J, Portero De La Cruz S. A worldwide bibliometric analysis of published literature on workplace violence in healthcare personnel[J]. PLoS ONE. 2020;15(11):e242781. Delmas C, Vandenbriele C, Baudry G. Time to rethink the prioritization of IABP patients in heart allocation systems worldwide?[J]. J Heart Lung Transpl. 2025;44(10):1674–8. Haber EN, Sonti R, Simkovich SM, et al. Accuracy of Noninvasive Blood Pressure Monitoring in Critically Ill Adults[J]. J Intensive Care Med. 2024;39(7):665–71. Wilandh E, Skinnars Josefsson M, Persson Osowski C, et al. Improving hospital food and meal provision: a qualitative exploration of nutrition leaders' experiences in implementing change[J]. BMC Health Serv Res. 2025;25(1):410. Jeffko M, Younus I, Bansal A, et al. Measuring Decisional Regret in Orthopedic Surgery: Tools, Time Points, and Score Interpretation[J]. Orthopedics. 2025;48(4):e153–61. Tie H, Zhang J. Characterization and factors influencing the uncertainty of intolerable in older adults with multimorbidity: A Cross-sectional study[J]. BMC Geriatr. 2025;25(1):706. Kazemi FZ, Mohsenipouya H, Hosseinnataj A, et al. Perceived Organizational Support as a Factor in Managing Work-Family Conflict and Enhancing Occupational Well-Being: Findings From Iranian Nurses[J]. Int J Nurs Pract. 2025;31(5):e70061. Salari A, Vagharseyyedin SA, Sabeghi H. Informatics competency, attitudes toward evidence-based practice, and clinical decision-making skills in nurses[J]. Health Inf J. 2025;31(3):1227866521. Li Y, Li Q, Zhang L, et al. Development of a Risk Assessment Index System of Non-Specific Neck-Shoulder Pain in Physicians and Nurses: A Delphi and Analytic Hierarchy Process Study in China[J]. Pain Manag Nurs; 2025. Siopi SA, Antonitsis P, Karapanagiotidis GT, et al. Cardiac Failure and Cardiogenic Shock: Insights Into Pathophysiology, Classification, and Hemodynamic Assessment[J]. Cureus. 2024;16(10):e72106. Dehmer SP, Egan BM, Hardy B et al. Predicted Cardiovascular and Economic Impacts of the Measure Accurately, Act Rapidly, and Partner with Patients Program to Improve Hypertension Control[J]. Am J Prev Med, 2025:108132. Moralez GM, Amado F, Liu VX, et al. Data-Driven Quality of Care in the ICU: A Concise Review[J]. Crit Care Med; 2025. Hara K, Tachibana R, Kumashiro R, et al. Lasting impact of undergraduate operating room shadowing on novice nurses: a ChatGPT-supported qualitative study[J]. BMC Nurs. 2025;24(1):1151. Hssain AA, Bahramnezhad F, Vahedian-Azimi A, et al. ECMO specialist' challenges towards acquired infections during extracorporeal membrane oxygenation: An international qualitative ECMO infection study[J]. Intensive Crit Care Nurs. 2025;91:104148. Yu Y, Qiao Y, Zhu Y, et al. The impact of unfolding case studies combined with think-aloud strategies on the clinical reasoning and self-directed learning abilities of postgraduate students: A mixed methods study[J]. Nurse Educ Pract. 2024;80:104132. Chua WL, Tan RXR, Liaw SY, et al. Blending of virtual reality with high-fidelity simulation for interprofessional team training: A mixed methods study[J]. Nurse Educ Today. 2025;155:106857. Bail K, De Fernandes Barreto J, Hants L et al. A Digital Alert Feedback System (Aged Care Electronic Dashboard Information Tool, ACED-IT) to Enhance Quality Nursing Care: Participatory Action Research[J]. J Clin Nurs, 2025. Ames ML, Sundermeir SM, Staffier KL et al. Education strategies to facilitate lifestyle medicine practice within health systems: a multiple case study of US health systems[J]. Transl Behav Med, 2025,15(1). Chiu P, Chu S, Yang C, et al. Peer-assisted learning in critical care: a simulation-based approach for postgraduate medical training[J]. Med Educ Online. 2025;30(1):2497333. Trinkley KE, Maestas Duran D, Zhang S, et al. Application of Nudges to Design Clinical Decision Support Tools: Systematic Approach Guided by Implementation Science[J]. J Med Internet Res. 2025;27:e73189. Billiau L, Taghon D, Duprez V, et al. Instruments for measuring head nurses' competencies in a hospital setting: a scoping review[J]. BMC Nurs. 2025;24(1):1069. Jantzen D, Marcellus L, Damianos D, et al. Registered nurses' experiences of organizational change in acute care settings: a qualitative systematic review[J]. JBI Evid Synth; 2025. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 18 Apr, 2026 Read the published version in BMC Nursing → Version 1 posted Editorial decision: Revision requested 09 Mar, 2026 Reviews received at journal 05 Mar, 2026 Reviewers agreed at journal 13 Feb, 2026 Reviews received at journal 04 Feb, 2026 Reviewers agreed at journal 16 Jan, 2026 Reviewers invited by journal 14 Nov, 2025 Editor invited by journal 04 Nov, 2025 Editor assigned by journal 03 Oct, 2025 Submission checks completed at journal 03 Oct, 2025 First submitted to journal 26 Sep, 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. 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1","display":"","copyAsset":false,"role":"figure","size":1072646,"visible":true,"origin":"","legend":"\u003cp\u003eICU Nurse User Profiles\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7720386/v1/412cdd1eaf0d8c31a3990594.jpeg"},{"id":107350793,"identity":"32407cbf-b22e-4b39-8c0b-3222349968b3","added_by":"auto","created_at":"2026-04-20 16:04:40","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1601983,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7720386/v1/0ad8751f-949b-428c-8d15-23f89f7f821c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Beyond Standardization: A Qualitative Study Using the i-PARIHS Framework and User Profiles to Improve Invasive Arterial Blood Pressure Monitoring Accuracy","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eInvasive arterial blood pressure (IABP) monitoring is a cornerstone of hemodynamic management in intensive care units (ICUs), providing continuous and real-time data that directly informs critical treatment decisions\u003csup\u003e[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/sup\u003e. Despite its theoretical precision, the accuracy of IABP in clinical practice is often suboptimal, influenced by factors ranging from operator technique and system calibration to the interpretation of waveforms\u003csup\u003e[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/sup\u003e. This gap between theoretical potential and actual performance poses a significant risk to patient safety.\u003c/p\u003e\u003cp\u003eSuccessful implementation of complex clinical practices like IABP monitoring is often analyzed using determinant frameworks. The Integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) framework posits that successful implementation (SI) is a function of the interaction between the Innovation (I), the Recipients (R), and the Context (C), all of which require tailored Facilitation (Fac)\u003csup\u003e[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]\u003c/sup\u003e. While the i-PARIHS framework offers a comprehensive structure for understanding implementation challenges, its \"Recipients\" construct often remains abstract, overlooking the significant heterogeneity among frontline staff in terms of their knowledge, attitudes, and behaviors\u003csup\u003e[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eExisting research on IABP monitoring has predominantly focused on comparing its numerical values with non-invasive methods or detailing technical procedures\u003csup\u003e[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]\u003c/sup\u003e. Few studies have systematically explored the multifaceted influences on its accuracy from the perspective of those who perform and interpret it daily\u0026mdash;ICU nurses. Crucially, even when barriers are identified, intervention strategies often fail to account for the diversity among nurses, leading to generic solutions with limited effectiveness\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTherefore, this study aimed to bridge this gap by employing a qualitative design guided by the i-PARIHS framework. Our objectives were two fold: first, to systematically identify the barriers and facilitators to accurate IABP monitoring; and second, to move beyond a homogenous view of nurses by constructing data-driven user profiles.\u003c/p\u003e\u003cp\u003eThe user profile methodology originates from the fields of user experience research and human factors engineering. It involves integrating multidimensional data to construct representative user archetypes, thereby transforming abstract user characteristics into concrete, identifiable personas\u003csup\u003e[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]\u003c/sup\u003e. In this study, we introduced this approach to deeply analyze the diversity within the ICU nurse population and identify nurse subgroups with distinct cognitive patterns, behavioral characteristics, and need preferences. These profiles will illuminate distinct patterns of needs and challenges, providing a foundational evidence base for developing precisely tailored strategies to improve the quality of IABP monitoring.\u003c/p\u003e"},{"header":"2 Aims and Objectives of Study","content":"\u003cp\u003eThe aim of this study is to gain an in-depth understanding of the factors influencing the accuracy of IABP monitoring from the perspective of ICU nurses. By exploring nurses' firsthand experiences, this research seeks to identify the multilevel barriers and facilitators to achieving reliable IBP measurements. The objectives are to systematically analyse these factors using the i-PARIHS framework, to develop distinct user profiles of ICU nurses based on their approaches and challenges, and to provide evidence that can guide the development of tailored strategies for education and quality improvement.\u003c/p\u003e\u003cp\u003eThe primary research questions guiding this study are:\u003c/p\u003e\u003cp\u003eWhat are the experiences of ICU nurses regarding the factors that affect the accuracy of IBP monitoring in their clinical practice?\u003c/p\u003e\u003cp\u003eHow can these experiences be synthesised to construct meaningful user profiles that inform targeted interventions?\u003c/p\u003e\u003cp\u003eThese questions are designed to explore the complex interplay between the technology, the individual clinician, and the clinical environment, ultimately aiming to generate insights for enhancing the quality and safety of hemodynamic monitoring.\u003c/p\u003e"},{"header":"3 Design and Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Developing the Interview Outline\u003c/h2\u003e\u003cp\u003eBased on the research objectives and a comprehensive review of the literature on IBP monitoring, we drafted a preliminary semi-structured interview guide. To ensure the relevance and comprehensiveness of the questions, the draft outline was reviewed by a nursing professor specializing in qualitative research methodologies and two associate chief nurses with extensive expertise in critical care and hemodynamic monitoring\u003csup\u003e[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u003c/sup\u003e. The outline was revised and finalized according to the experts' feedback regarding question clarity, flow, and coverage of key topics. Prior to the formal interviews, pilot interviews were conducted with three ICU nurses to test the appropriateness and comprehensibility of the questions. These pilot interviews were used solely for refining the interview guide and their data were not included in the final analysis. The final interview guide is presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSemi-structured interview guide\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"1\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCan you describe your main experiences and feelings when performing IBP monitoring?\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHow do you determine whether an IBP reading is reliable or accurate during clinical operations?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn your opinion, what are the key factors that influence the accuracy of IBP monitoring?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhat core competencies do you believe an operator must possess to ensure monitoring accuracy?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhat suggestions or ideas do you have for improving the accuracy of IBP monitoring in our unit?\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Setting and Sample\u003c/h2\u003e\u003cp\u003eThis study was conducted between June and August 2025 in the intensive care unit of a Grade III-B tertiary hospital in China. A purposeful sampling strategy was employed to recruit 24 registered nurses working in the ICU. The sample size was determined by the principle of data saturation, whereby interviews were discontinued when no new thematic information emerged from three consecutive participants\u003csup\u003e[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe inclusion criteria were: (1) nurses who had obtained registered nurse qualifications; (2) nurses with at least one year of hands-on experience in operating or managing invasive arterial blood pressure (IBP) monitoring devices. The exclusion criteria were: (1) nurses who were unavailable to participate in the study (e.g., on extended leave); (2) nurses not directly involved in IBP monitoring care (e.g., those solely responsible for medical order processing or unit management); (3) nurses who were pregnant or lactating.\u003c/p\u003e\u003cp\u003e After distributing invitation letters and obtaining written informed consent, 24 nurses were enrolled in the study. The final sample comprised 24 female participants, with ages ranging from 27 to 46 years. Detailed demographic characteristics of the participants are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographic and Professional Characteristics of Participants (n\u0026thinsp;=\u0026thinsp;24)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEducation Level\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProfessional Title\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eClinical Ladder\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYears of Experience\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChief Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e37\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e31\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssociate's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAssociate's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor's\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003eNote:The \"Clinical Ladder\" (e.g., N2, N3, N4) is a hierarchical system used in the study context to classify nurses based on their clinical competence and expertise. N2 is often subdivided into levels 1 and 2.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e3.3 | Data Collection\u003c/h2\u003e\u003cp\u003eData were collected through individual, face-to-face, semi-structured interviews using the finalized interview guide. Prior to each interview, the researcher thoroughly explained the study's purpose, procedures, and the principles of voluntary participation and confidentiality to the participants. The interviews were conducted by a nursing graduate student who had received formal training in qualitative research methods. The interviewer had no supervisory relationship with the participants. Written informed consent was obtained from all participants, including permission for audio-recording. The interviews were scheduled in advance at a time convenient for the participants and were held in a private, quiet room within the hospital to ensure an undisturbed environment. Each interview lasted between 20 and 60 minutes. All interviews were audio-recorded and subsequently transcribed verbatim for analysis, with any identifying information removed to protect participant anonymity.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e3.4 | Data Analysis\u003c/h2\u003e\u003cp\u003eThe analysis of the interview data was conducted in two distinct phases to address the research objectives comprehensively.\u003c/p\u003e\u003cp\u003eIn the first phase, directed content analysis was employed, guided by the core constructs of the i-PARIHS framework (Innovation, Recipients, Context, and Facilitation) as initial coding categories\u003csup\u003e[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/sup\u003e. This approach was selected for its utility in validating or extending existing theoretical frameworks. The process involved: (1) repeated reading of the transcribed texts to achieve immersion and obtain a sense of the whole; (2) identifying meaningful segments of text relevant to the research question; (3) coding these segments using the pre-specified i-PARIHS categories, while remaining open to new codes that emerged from the data; (4) grouping codes into sub-themes and themes within the framework's structure; and (5) defining and naming the themes.\u003c/p\u003e\u003cp\u003eIn the second phase, to address the heterogeneity among nurses, a two-step cluster analysis was performed\u003csup\u003e[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/sup\u003e. Salient characteristics, attitudes, and behavioral patterns identified from the coded transcripts for each participant were extracted as variables. This analytical technique, suitable for mixed variable types, was used to identify natural groupings within the participant pool. The resulting clusters were then synthesized into distinct user profiles, with their defining features visualized using word clouds to illustrate the predominant characteristics of each group\u003csup\u003e[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eTo ensure the trustworthiness of the analysis, multiple discussions were held among the research team to review and refine the coding and thematic structure. Furthermore, member checking was conducted by inviting two participants to provide feedback on the preliminary findings, enhancing the credibility of the results.\u003c/p\u003e\u003cp\u003eTo construct the group profiles, representative variables were extracted from the characteristics of each cluster as descriptive tags. The importance of each tag was determined by its frequency within the cluster. These tags were then visualized using WordArt to generate word clouds. In this visual representation, the font size of a tag corresponds to its frequency, thereby intuitively highlighting the core characteristics of each group profile and providing an accessible summary of the qualitative findings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Quality Control\u003c/h2\u003e\u003cp\u003e Multiple strategies were employed to ensure the trustworthiness and rigor of the study, guided by the criteria established by Lincoln and Guba for qualitative research. Prior to data collection, the researchers engaged in bracketing to set aside preconceived notions and theoretical knowledge about IBP monitoring, maintaining an open and neutral stance throughout the research process. During the study, the primary researcher practiced ongoing reflexivity by maintaining a journal to document and critically examine how her role as a nursing student and her clinical experiences might influence data collection and interpretation, thereby enhancing the confirmability of the findings.\u003c/p\u003e\u003cp\u003e Regular peer debriefing sessions were conducted among the research team, which included the primary investigator, a senior qualitative research expert, and a critical care nursing specialist. These sessions involved reviewing the coding schemes, discussing emerging themes, and challenging interpretations to reduce researcher bias and ensure the dependability of the analysis. Additionally, member checking was performed by presenting the preliminary findings to two participants who confirmed that the identified themes accurately reflected their experiences, thereby enhancing the credibility of the results. An audit trail documenting all analytical decisions was maintained throughout the research process to ensure transparency and replicability.\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Ethical Considerations","content":"\u003cp\u003e This study was approved by the Ethics Committee of Rudong Hospital Affiliated to Xinglin College of Nantong University (Approval No. [2024]伦审第(7)号) on 10 September 2025. All participants provided written informed consent prior to their participation. The study purpose, procedures, risks and benefits were fully explained, and participants were assured of their right to withdraw at any time without penalty. Confidentiality was maintained through de-identification of all data and secure storage of recordings and transcripts. The research was conducted in accordance with the Declaration of Helsinki and relevant institutional guidelines to ensure the protection of participants' rights and welfare.\u003c/p\u003e"},{"header":"5 Findings","content":"\u003cp\u003eThrough a rigorous analytical process, four principal themes and ten corresponding subthemes were identified, each aligning with the core constructs of the i-PARIHS framework. The findings are presented below, structured according to these thematic categories.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e5.1 Theme One: The Dual Nature of the Innovation: Inherent Value and Procedural Complexity\u003c/h2\u003e\u003cp\u003eThis theme encapsulates the paradoxical nature of IBP monitoring, characterized by its recognized clinical superiority counterbalanced by significant operational challenges and risks that impede its optimal application.\u003c/p\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e5.1.1 Unmatched Value in Hemodynamic Monitoring\u003c/h2\u003e\u003cp\u003eNurses consistently affirmed the indispensable role of IBP in the management of critically ill patients, particularly those experiencing hemodynamic instability or requiring vasoactive drug support. The technology was praised for delivering continuous, real-time data deemed more reliable, sensitive, and actionable than non-invasive alternatives, thereby serving as a critical foundation for advanced life support decisions. One nurse articulated this essential value, stating:\u003c/p\u003e\u003cp\u003e\"In our ICU, for patients in shock or on high-dose vasoactive drugs, invasive blood pressure is our 'eyes' and 'steering wheel'. It's more sensitive and more reliable.\" (N1)\u003c/p\u003e\u003cp\u003eAnother participant emphasized its profound clinical impact, noting:\u003c/p\u003e\u003cp\u003e\"There have been many instances where relying on the radial artery catheter enabled us to salvage patients. In such critical moments, you realize this technology is invaluable, despite its complexities.\" (N22)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e5.1.2 Operational Risks and Clinical Apprehensions\u003c/h2\u003e\u003cp\u003eConversely, the technical difficulties and potential complications associated with IBP monitoring\u0026mdash;including challenging puncture procedures, thrombosis, infection, and bleeding\u0026mdash;were frequently cited as major concerns. These apprehensions were particularly acute for patients with poor vascular access, such as those in shock or with significant edema, leading to higher perceived failure rates and amplified risks. A nurse described the procedural challenges:\u003c/p\u003e\u003cp\u003e\"Arterial puncture presents the greatest challenge, especially in edematous or shocked patients where vessels are collapsed and difficult to palpate or visualize. Multiple unsuccessful attempts not only increase difficulty but also cause patient discomfort.\" (N17)\u003c/p\u003e\u003cp\u003eThis perception of risk directly influenced clinical decision-making, occasionally favoring more conservative approaches:\u003c/p\u003e\u003cp\u003e\"A cost-benefit assessment sometimes leads us to choose non-invasive monitoring for relatively stable patients, as catheterization entails inherent risks and significantly increases the nursing workload.\" (N14)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e5.2 Theme Two: Recipient Heterogeneity: Disparities in Knowledge and Clinical Decision-Making\u003c/h2\u003e\u003cp\u003eThis theme reveals significant variations among nurses in their understanding of IBP monitoring and their approaches to clinical decision-making, highlighting the human factors that influence protocol adherence.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e5.2.1 Disparities in Knowledge and Skill Base\u003c/h2\u003e\u003cp\u003eSubstantial differences were observed in nurses' comprehension of the standardized operational procedures for IBP monitoring. While basic operational knowledge was common, the ability to internalize these standards into a robust knowledge framework for troubleshooting was inconsistent, particularly among less experienced nurses. One nurse expressed uncertainty in complex situations:\u003c/p\u003e\u003cp\u003e\"I know the steps for invasive arterial pressure monitoring, but when faced with a distorted waveform or a sudden change in pressure, I'm not entirely clear on the underlying reasons or the systematic approach for analysis.\" (N5)\u003c/p\u003e\u003cp\u003eA lack of confidence in practical skills was also evident, as another nurse shared:\u003c/p\u003e\u003cp\u003e\"Even now, when I need to perform an arterial puncture, I feel apprehensive, worried that my technical skill might be insufficient and could delay critical care.\" (N16)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e5.2.2 Experience-Driven Practice versus Systematic Thinking**\u003c/h2\u003e\u003cp\u003eA key finding was the prevalent reliance on personal experience rather than a standardized, systematic analytical process when addressing fluctuations in arterial pressure. This unstructured decision-making model resulted in variable\u0026mdash;and potentially risky\u0026mdash;troubleshooting sequences among different nurses. One nurse described this experience-based approach:\u003c/p\u003e\u003cp\u003e\"It primarily relies on experiential judgment. After seeing many cases, you develop a general sense of what indicates an artifact versus a genuine patient deterioration.\" (N7)\u003c/p\u003e\u003cp\u003e The lack of a unified protocol was further highlighted by another participant:\u003c/p\u003e\u003cp\u003e\"I have a general mental checklist for troubleshooting, but the sequence varies from person to person\u0026mdash;whether to check the sensor position first, flush the line, or immediately call the physician. It's largely based on individual (groping/figuring things out independently).\" (N13)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\u003ch2\u003e5.2.3 Family Cognizance and Involvement in Decision-Making**\u003c/h2\u003e\u003cp\u003eThe study identified family members as crucial participants in the medical decision-making process, whose understanding and speed of decision-making directly impacted the timely application of IBP. Obtaining informed consent from families, which involves explaining the necessity and risks of the procedure, was a necessary step that could paradoxically become a delaying factor during critical moments. A nurse illustrated this tension:\u003c/p\u003e\u003cp\u003e\"The most agonizing situation is when a patient's blood pressure plummets, urgently requiring invasive monitoring, but the family members are hesitant, constantly making calls to consult others, or repeatedly asking, 'Are there any other options?' We are racing against time to save the patient while simultaneously dedicating significant effort to communication and explanation, which is an extremely distressing process.\" (N13)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e5.3 Theme Three: Contextual Gap: The Chasm Between Standards and Clinical Reality\u003c/h2\u003e\u003cp\u003eThis theme highlights the significant systemic and environmental factors that hinder the consistent application of IBP monitoring standards, focusing on the disconnect between formal protocols and the realities of clinical practice.\u003c/p\u003e\u003cdiv id=\"Sec19\" class=\"Section3\"\u003e\u003ch2\u003e5.3.1 Absence of Standardized Processes and Quality Control\u003c/h2\u003e\u003cp\u003eA pronounced \"know-do gap\" was identified, where ideal nursing standards starkly contrasted with complex clinical realities. This gap was attributed not to a lack of willingness but to a systemic failure in embedding standardized protocols seamlessly into high-workload workflows. Nurses frequently had to make pragmatic compromises in clinical priorities when facing multiple tasks and time pressures. One nurse explained this predicament:\u003c/p\u003e\u003cp\u003e \"The standards represent an ideal state, but when the unit is busy with a high patient census, it becomes very difficult to strictly adhere to every single guideline.\" (N15)\u003c/p\u003e\u003cp\u003eThe lack of procedural oversight was noted as a contributing factor:\u003c/p\u003e\u003cp\u003e\"Even if we don't follow the standard procedure completely, as long as the waveform is generally usable, there is rarely any audit to check whether the operation fully complied with the protocol.\" (N11)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section3\"\u003e\u003ch2\u003e5.3.2 | Cognitive and Cultural Environment of 'Approximate Accuracy'\u003c/h2\u003e\u003cp\u003eA cultural tolerance for \"approximate accuracy\" was observed, where some nurses did not fully prioritize strict adherence to precision standards. This was underpinned by an insufficient recognition of the importance of rigorous calibration and a misplaced reliance on the inherent accuracy of the technology itself. One nurse commented on this mindset:\u003c/p\u003e\u003cp\u003e\"There's a tendency to think 'close enough is good enough'; we can use the non-invasive pressure as a reference, so there's no need to be overly meticulous.\" (N17)\u003c/p\u003e\u003cp\u003eAnother revealed a common misconception regarding responsibility for accuracy:\u003c/p\u003e\u003cp\u003e\"We subconsciously feel that this is a high-tech product calibrated perfectly at the factory; we just need to use it. Those meticulous calibration and validation procedures are the responsibility of the manufacturer and engineers, not really related to us bedside operators.\" (N22)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003e5.3.3 Real-World Constraints of Economic Factors\u003c/h2\u003e\u003cp\u003eThe substantial direct cost of IBP monitoring was identified as a significant practical constraint, imposing a financial burden on patients and directly influencing clinical decision-making, particularly in cases with uncertain indications. Economic considerations became a key factor in selecting monitoring strategies. A nurse expressed the moral dilemma faced:\u003c/p\u003e\u003cp\u003e\"For patients with significant financial difficulties, seeing their distress, we will first attempt non-invasive monitoring if the clinical condition permits, to alleviate their financial pressure. It's helplessness of reality.\" (N16)\u003c/p\u003e\u003cp\u003eThis economic influence extended to prescribing practices:\u003c/p\u003e\u003cp\u003e\"For patients with high out-of-pocket expenses and poor economic conditions, physicians are more cautious when ordering the procedure. Whether a technology gets used can sometimes genuinely depend on the patient's financial situation.\" (N4)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003e5.4 Theme Four: Facilitation: Building a Systematic Support Ecosystem\u003c/h2\u003e\u003cp\u003eThis theme synthesizes nurses' explicit recommendations for enabling the successful and sustained implementation of accurate IBP monitoring, focusing on the necessary structures, educational shifts, and cultural changes required for systemic improvement.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003e5.4.1 Providing Structured Tools to Empower Clinical Decision-Making\u003c/h2\u003e\u003cp\u003eA strong, consistent call emerged for translating abstract written standards into intuitive, executable clinical tools. Nurses highlighted the need to reduce cognitive load and standardize practice through job aids that guide action, especially during troubleshooting. The desire for clarity over complexity was emphasized:\u003c/p\u003e\u003cp\u003e\"What we lack most now is not another standard document, but a foolproof, step-by-step operational guide.\" (N14)\u003c/p\u003e\u003cp\u003eAnother nurse used a vivid metaphor to express the need for accessible expertise:\u003c/p\u003e\u003cp\u003e\"I dream of having a 'kung fu secret manual'\u0026mdash;something that transforms the expert's knowledge and experience into a flowchart that every one of us can easily understand and follow.\" (N13)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section3\"\u003e\u003ch2\u003e5.4.2 Implementing Advanced Thinking Training to Drive Competency Transformation\u003c/h2\u003e\u003cp\u003eThe identified training needs evolved beyond fundamental operational skills towards cultivating higher-order clinical reasoning and systematic decision-making abilities. Nurses expressed a desire for training that mirrors the complexities of real-world practice. One participant suggested a case-based approach:\u003c/p\u003e\u003cp\u003e\"Current training always focuses on teaching us *what* to do. I wish instructors would present a real, complex case with messy, poor-quality waveforms and walk us through the troubleshooting process step-by-step.\" (N6)\u003c/p\u003e\u003cp\u003eAnother advocated for immersive simulation to bridge the gap between knowledge and instinct:\u003c/p\u003e\u003cp\u003e\"Could we develop high-fidelity simulations? This would help us practice until the knowledge we learn becomes an instinctive reaction.\" (N21)\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003e5.4.3 Establishing a Supportive Management System and Culture to Ensure Sustainability\u003c/h2\u003e\u003cp\u003eNurses identified that the enduring implementation of standards hinges on establishing a foundational system built on a psychologically safe, just culture, championed by leadership and reinforced with adequate resources. This would create a virtuous cycle of incident reporting, feedback, and quality improvement. The critical role of leadership was underscored:\u003c/p\u003e\u003cp\u003e\"The attitude of the leadership is the weather vane. Staff will immediately recognize whether this initiative is being taken seriously.\" (N24)\u003c/p\u003e\u003cp\u003eThe need for enabling conditions, not just demands, was also highlighted:\u003c/p\u003e\u003cp\u003e\"Managers cannot only make demands without providing support. They need to create the time and environment that allows us to do our jobs properly.\" (N10)\u003c/p\u003e\u003cp\u003eSpecific systemic interventions were proposed, such as:\u003c/p\u003e\u003cp\u003e\"We could establish a weekly IBP quality meeting where we collectively review waveforms and assess quality.\" (N19)\u003c/p\u003e\u003cp\u003eFinally, the principle of a just culture was deemed essential:\u003c/p\u003e\u003cp\u003e\"The most critical thing is to establish a blame-free culture. The purpose of reporting incidents should be to improve the system, not to punish individuals.\" (N2)\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section2\"\u003e\u003ch2\u003e5.5 Development of ICU Nurse User Profiles Based on the i-PARIHS Framework\u003c/h2\u003e\u003cp\u003eCluster analysis of the interview data from the 24 participating nurses, based on differences in their cognition, behaviors, attitudes, and needs regarding IBP monitoring, yielded three distinct clusters with good quality (silhouette score\u0026thinsp;\u0026gt;\u0026thinsp;0.5). This analysis led to the construction of three ICU nurse user profiles: the Experience-Guarded Expert, the Guidance-Seeking Practitioner, and the System-Advocating Catalyst. Visual representations of these profiles are presented in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, and a comparative summary of their key characteristics is provided in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of Characteristics Among Three ICU Nurse User Profiles\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExperience-Guarded Expert\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGuidance-Seeking Practitioner\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSystem-Advocating Catalyst\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eProfessional Title, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSenior Nurse: 87.5% (7/8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse: 88.9% (8/9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSenior Nurse: 85.7% (6/7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChief Nurse: 12.5% (1/8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSenior Nurse: 11.1% (1/9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNurse: 14.3% (1/7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eClinical Ladder, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN3: 75.0% (6/8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN2(1): 77.8% (7/9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eN2(2): 100% (7/7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN4: 12.5% (1/8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eN2(2): 22.2% (2/9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eN2(2): 12.5% (1/8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYears of Experience,\u003c/p\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCore Characteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRelies on personal experience; practices cautiously; highly risk-averse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eUnderstands standards but struggles with application; lacks confidence; desires guidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePossesses systematic thinking; focuses on process optimization; potential change agent\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSeniority \u0026amp; Confidence\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh seniority; confident in operation but employs personalized decision-making\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGenerally low seniority; demonstrates low confidence in puncture and waveform interpretation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eVaried seniority; has a clear认知 (awareness) of own abilities\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDecision-Making Mode\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eExperience-driven: \"You know from seeing it many times.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIndecisive and confused: \"My heart beats fast [feel nervous], unsure which step to take first.\"\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eSystematic analysis: Advocates for \"standardized troubleshooting flowcharts.\"\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerception of the Technology\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAcknowledges its value but applies it conservatively after weighing risks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAcknowledges its value but feels daunted by the technical difficulty\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDeeply understands its advantages and limitations; strives to maximize its efficacy\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerception of the Environment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAccepts the status quo of lacking quality control; highly adaptive\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDeeply affected by high-workload environment; feels powerless to adhere to standards\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStrongly perceives lack of systemic support; is a vocal advocate for change\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCore Needs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDesires practical skills for complication prevention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMost desires structured tools (e.g., \"foolproof guide\") and practical, hands-on training\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDesires to participate in system optimization\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003eNote: The \"Clinical Ladder\" is a hierarchical system used in the study context to classify nurses based on their clinical competence and expertise. N2 is often subdivided into levels 1 and 2. Terms in parentheses indicate the original Chinese key terms for clarity.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"6 Discussion","content":"\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003e6.1 The Duality of Technological Innovation: Concurrent Clinical Merits and Inherent Risks\u003c/h2\u003e\u003cp\u003eAligned with the 'Innovation' construct of the i-PARIHS framework, our analysis reveals that IABP monitoring embodies a fundamental duality. On one hand, it demonstrates irreplaceable value in the management of hemodynamically unstable patients, providing continuous, reliable, and sensitive hemodynamic data. This capacity led nurses to regard it as a 'gold standard' in critical care, underscoring its relative advantage and implementation potential\u003csup\u003e[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/sup\u003e. Conversely, the technique's operational complexity and associated risks\u0026mdash;such as challenging puncture, thrombosis, and infection\u0026mdash;were significant concerns. These were particularly pronounced in patients with poor vascular access, increasing procedural difficulty, failure rates, and the nurses' psychological burden. This risk-profile consequently fostered a more conservative application in patients with borderline indications \u003csup\u003e[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]\u003c/sup\u003e. This inherent \"merit-risk paradox\" directly influences the technology's clinical implementation outcomes. The effective use of IABP demands considerable operator skill, confidence, and a supportive practice environment. Therefore, promoting IABP requires not only highlighting its clinical benefits but also systematically addressing its inherent risks. Future strategies should focus on standardised training, the development of clinical decision support tools, and the optimisation of complication prevention protocols to mitigate uncertainties and fully realise its monitoring potential.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003e6.2 Recipient Heterogeneity in Cognition and Decision-Making: Multifaceted Clinical Implications\u003c/h2\u003e\u003cp\u003eOur findings illuminate that nurses, as the direct implementers of IABP technology, significantly influence its application quality through their knowledge structures, decision-making patterns, and communication efficacy with patients' families. This aligns with existing evidence indicating that variations in recipients' professional knowledge, skill sets, and resource availability critically impact the effectiveness of evidence-based practice implementation\u003csup\u003e[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]\u003c/sup\u003e. While junior nurses generally mastered basic operational procedures, they commonly lacked systematic analytical capabilities for interpreting abnormal waveforms and navigating complex clinical scenarios, coupled with pronounced insecurity regarding puncture techniques.\u003c/p\u003e\u003cp\u003eFurthermore, the interview results revealed a prevalent experience-oriented, rather than evidence-based, approach to clinical decision-making. When confronted with blood pressure fluctuations, nurses predominantly relied on individual experience, leading to significant variations in clinical troubleshooting pathways. This non-standardized decision-making model introduces potential clinical risks \u003csup\u003e[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u003c/sup\u003e. Additionally, family members, as external recipients, directly impacted the timeliness of monitoring through their understanding of IABP and the efficiency of their decision-making processes\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]\u003c/sup\u003e. This indicates that the effectiveness of technology implementation hinges not only on nurses' clinical expertise but also on their communication skills and ability to obtain truly informed consent.\u003c/p\u003e\u003cp\u003eThese findings suggest that strategies to enhance IABP quality must extend beyond conventional skill-based training. It is imperative to establish an advanced cultivation system centered on developing clinical decision-making competence. This can be achieved by creating standardized decision-support tools and incorporating dedicated communication training, thereby systematically improving nurses' clinical judgment, operational confidence, and family management skills to optimize the overall implementation efficacy of IABP technology.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec30\" class=\"Section2\"\u003e\u003ch2\u003e6.3 Multi-level Contextual Constraints: The Combined Impact of Systemic, Cognitive, and Economic Barriers\u003c/h2\u003e\u003cp\u003eThe findings demonstrate that the accuracy of IABP monitoring is significantly constrained by environmental factors operating at multiple levels. At the organizational level, the absence of systematic quality control mechanisms, combined with high-workload clinical environments, compromised adherence to standard operating procedures\u003csup\u003e[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]\u003c/sup\u003e. Nurses were often forced to compromise technical standards when prioritizing clinical tasks, and a lack of procedural feedback meant that quality management remained largely \"incident-driven\" rather than focused on \"process control\" \u003csup\u003e[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eAt the cultural-cognitive level, a concerning underestimation of the importance of precision monitoring was observed among some nurses. An operational inertia characterized by acceptance of \"approximate accuracy,\" coupled with a tendency to attribute the accuracy of disposable sensors solely to factory calibration rather than bedside practice, undermined the internal motivation to pursue technical excellence\u003csup\u003e[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/sup\u003e. This cognitive deviation directly eroded the sense of personal responsibility for monitoring quality.\u003c/p\u003e\u003cp\u003eAt the external environmental level, economic pressures emerged as a tangible constraint on clinical decision-making\u003csup\u003e[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/sup\u003e. When the cumulative cost of a procedure posed a significant burden to economically disadvantaged patients, clinicians demonstrated a tendency towards more conservative treatment options in cases with borderline indications, reflecting a pragmatic dilemma within resource-limited settings\u003csup\u003e[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThese insights indicate that improving IABP monitoring quality cannot rely solely on enhancing individual operator competence. There is an urgent need to develop high-level quality assurance systems at the organizational level, reshape professional cognition regarding precision monitoring at the cultural level, and explore policy-level mechanisms to alleviate patient financial burden. Only through such a multi-faceted approach can a truly supportive environment for best practices be established.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003e6.4 Multi-level Facilitation Strategies: Integrating Tool Empowerment, Cognitive Transformation, and Organizational Support\u003c/h2\u003e\u003cp\u003eOur findings indicate that establishing a quality improvement system for IABP monitoring requires systematic advancement across three interconnected dimensions: tool empowerment, training transformation, and cultural restructuring.\u003c/p\u003e\u003cp\u003eFirst, nurses strongly advocated for translating expert knowledge into explicit, accessible formats through structured decision-support tools\u003csup\u003e[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]\u003c/sup\u003e. Substantial evidence confirms that standardized operating guidelines and troubleshooting algorithms can effectively reduce cognitive load, unify practice standards, and establish the foundation for consistent, normative clinical decision-making\u003csup\u003e[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSecond, the training paradigm requires a fundamental shift from technical skill acquisition to cultivating advanced clinical reasoning\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e. High-fidelity simulation training based on authentic clinical cases can foster systematic diagnostic capabilities in complex situations, enabling the internalization of knowledge into practice\u003csup\u003e[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eFinally, establishing supportive management systems and a \"just culture\" is imperative. Research demonstrates that leadership engagement and resource allocation provide essential institutional backing, while non-punitive incident reporting systems and routine quality feedback mechanisms form the cultural core, collectively creating a virtuous cycle that sustains practice standards\u003csup\u003e[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThese insights underscore that enhancing IABP monitoring quality necessitates an integrated, multi-level facilitation framework combining operational, educational, and systemic strategies. Through operationalizable, institutionalized, and culturally embedded approaches, we can ultimately achieve standardized and precise monitoring practices.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003e6.5 Implications for Precision Management: Leveraging User Profiles for Targeted Interventions\u003c/h2\u003e\u003cp\u003eThe construction of user profiles in this study transforms abstract interview data into concrete nurse group characteristics, revealing three distinct target populations that require differentiated approaches for improving IABP monitoring accuracy.\u003c/p\u003e\u003cp\u003eFor the Experience-Guarded Experts, strategies should focus on leveraging their clinical expertise as valuable departmental resources\u003csup\u003e[\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]\u003c/sup\u003e. Management approaches could include engaging them as mentors in high-fidelity simulation training, where they can share their experience in managing complex situations\u003csup\u003e[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]\u003c/sup\u003e. Simultaneously, introducing evidence-based decision support tools can help integrate their personal experience with standardized protocols, thereby reducing decision-making variations\u003csup\u003e[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe Guidance-Seeking Practitioners represent the most promising target for intervention efficacy, demonstrating strong learning motivation but lacking adequate support. Management priorities should address their urgent need for structured tools and advanced training. Developing clear, visual IABP operation checklists, troubleshooting flowcharts, and implementing case-based repetitive simulation training can rapidly enhance their competence and confidence, effectively bridging the knowledge-practice gap.\u003c/p\u003e\u003cp\u003eThe System-Advocating Catalysts serve as potential agents for systemic change. Management should actively solicit their input, involve them in IABP quality control committees or process improvement projects, and delegate specific responsibilities\u003csup\u003e[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]\u003c/sup\u003e. Engaging these nurses in developing a blame-free incident reporting culture and establishing regular quality feedback meetings can transform individual systematic thinking into organizational continuous improvement momentum\u003csup\u003e[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis profile-based approach enables precision management strategies that move beyond one-size-fits-all solutions, potentially enhancing the effectiveness and efficiency of quality improvement initiatives in critical care settings.\u003c/p\u003e\u003c/div\u003e"},{"header":"7 Implications for Practice and Research","content":"\u003cp\u003eThis study underscores the critical importance of a systematic and differentiated approach to improving invasive arterial blood pressure (IBP) monitoring accuracy in ICU settings. By identifying distinct nurse user profiles, our findings suggest that moving beyond one-size-fits-all training toward precision interventions tailored to specific nurse characteristics may significantly enhance implementation effectiveness.\u003c/p\u003e\u003cp\u003eFor clinical practice, healthcare institutions should develop targeted strategies based on the identified profiles: providing structured decision aids and simulation training for Guidance-Seeking Practitioners; engaging Experience-Guarded Experts in peer mentoring while introducing evidence-based protocols; and empowering System-Advocating Catalysts through quality improvement initiatives. Establishing a supportive organizational culture with leadership engagement, non-punitive reporting systems, and regular feedback mechanisms is essential for sustaining practice change.\u003c/p\u003e\u003cp\u003eFuture research should focus on validating and refining these user profiles in diverse clinical settings, and developing and testing tailored interventions for each profile. Longitudinal studies are needed to examine how profile-based strategies affect long-term clinical outcomes, including monitoring accuracy, complication rates, and patient safety indicators. Additionally, research should explore the organizational factors\u0026mdash;such as resource allocation, leadership support, and clinical governance structures\u0026mdash;that influence the sustainability of profile-based quality improvement initiatives across different healthcare contexts.\u003c/p\u003e\u003cp\u003eThese efforts will contribute to building a more nuanced understanding of implementation science in critical care nursing, ultimately supporting the development of more effective, personalized approaches to quality enhancement.\u003c/p\u003e"},{"header":"8 Conclusion","content":"\u003cp\u003e This study, grounded in the i-PARIHS framework, elucidates the multifaceted factors influencing the accuracy of invasive arterial blood pressure (IBP) monitoring in critical care settings. Our findings reveal a critical gap between the availability of standardized operational procedures and the lack of standardized decision-making protocols in clinical practice. This has resulted in heavy reliance on individual experiential judgment among nurses, compounded by insufficient systematic quality control and an underdeveloped just culture. These insights underscore the necessity for healthcare managers to develop comprehensive, systematic facilitation strategies to enhance IBP monitoring quality.\u003c/p\u003e\u003cp\u003eA significant contribution of this research is the development of distinct user profiles, which demonstrate considerable heterogeneity within the nursing population regarding IBP monitoring practices. This heterogeneity necessitates tailored, profile-specific interventions rather than a one-size-fits-all approach. Implementing structured decision-support tools can standardize clinical judgment, while case-based training programs can foster the internalization of advanced decision-making competencies. When complemented by robust quality control mechanisms and a supportive safety culture, these strategies can effectively transform IBP monitoring from mere data generation to the production of clinically reliable information.\u003c/p\u003e\u003cp\u003eAs a single-center study, these findings should be interpreted within the context of its limitations. Future research should employ multi-center designs and mixed-methods approaches to validate and extend these findings. Further investigation is needed to comprehensively explore both barriers and facilitators to accurate IBP monitoring, which will inform the development of targeted implementation strategies. Ultimately, such efforts will facilitate the translation of evidence into clinical practice, thereby enhancing the accuracy of hemodynamic monitoring and improving patient safety outcomes in critical care environments.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConsent\u003c/h2\u003e\u003cp\u003e Written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConflicts of Interest\u003c/h2\u003e\u003cp\u003eThe authors declare no conflicts of interest.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eEthics Approval and Consent to Participate\u003c/h2\u003e\u003cp\u003eThis study was approved by the Medical Ethics Committee of Rudong County People's Hospital (Approval No. 2025-007) on 10 September 2025. Written informed consent was obtained from all participants prior to their inclusion in the study. All methods were performed in accordance with the relevant guidelines and regulations.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eConsent for Publication\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAdditional Information\u003c/h2\u003e\u003cp\u003eCorrespondence and requests for materials should be addressed to Ronghui Geng.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis work was supported by the Nantong Social Livelihood Science and Technology Plan (MSZ2024131) and the Nantong Municipal Health Commission Research Project (QN2024058).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMing Yu and Yuling Zhang contributed equally to this work. Study conception and design were performed by Ming Yu and Yuling Zhang. Data collection and analysis were conducted by Ming Yu, Yuling Zhang, Jing Ji, Lili Jiang, Suping Cai, and Ronghui Geng. The first draft of the manuscript was written by Ming Yu and Yuling Zhang. Rong Tang provided supervision and critical revision of the manuscript. Lingling Jiang coordinated the study and provided administrative support. All authors reviewed and approved the final manuscript. Ronghui Geng serves as the corresponding author and takes responsibility for the integrity of the work.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eThe authors gratefully acknowledge the contributions of the ICU nurses who participated in this study.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due to containing information that could compromise participant privacy but are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUle J, Huppe T, Thiel J, et al. Implementing prehospital invasive arterial blood pressure monitoring in critically ill patients-a prospective observational first year analysis[J]. Scand J Trauma Resusc Emerg Med. 2025;33(1):145.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang J, Zhang J, Zhang Y, et al. Feasibility and safety analysis of distal radial arterial catheterization for arterial pressure monitoring in ICU[J]. J Clin Monit Comput. 2025;39(4):767\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYoung AM, Byrnes A, McRae P, et al. Use of the i-PARIHS framework in nutrition and dietetics research and practice: A citation analysis of the literature and case studies[J]. Nutr Clin Pract; 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHu M, Hu J, Sun P, et al. Analysis of Barriers to Evidence Transformation and Countermeasures for MARSI Prevention in Tracheal Intubated Patients Based on the i-PARIHS Framework[J]. J Multidiscip Healthc. 2025;18:5949\u0026ndash;59.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChays-Amania A, Schwingrouber J, Melnyk BM, et al. Mapping Implementation Strategies and Outcomes When Using Evidence Based Practice Implementation Models in Nursing Settings: A Scoping Review[J]. Worldviews Evid Based Nurs. 2025;22(3):e70050.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFreer R, Frost O, Sreenivas A et al. Mechanical Circulatory Support Devices versus Standard Medical Therapy for Treatment of Myocardial Infarction Complicated by Cardiogenic Shock: a Network Meta-Analysis[J]. Eur Heart J Qual Care Clin Outcomes, 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBecker L, Bzhilyanskaya V, Sharman A, et al. Intra-Arterial Versus Noninvasive Blood Pressure Monitoring: A Systematic Review and Meta-Analysis[J]. Am J Crit Care. 2025;34(4):e6\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWei J. Analysis of the Behavioral Performance and Social Support of Patients in Online Health Communities From User Profile Perspectives: Comparative Study[J]. J Med Internet Res. 2025;27:e68074.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePapalamprakopoulou Z, Dang TH, Gonzalez CJ, et al. Long-Term Benefits Following Hepatitis C Cure Through Facilitated Telemedicine; Experiences of People With Opioid use Disorder Five Years After Achieving a Sustained Virological Response[J]. Health Expect. 2025;28(5):e70404.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGustavson AM, Miller MJ, Boening N, et al. Identifying factors influencing emerging innovations in hospital discharge decision making in response to system stress: a qualitative study[J]. BMC Health Serv Res. 2024;24(1):1293.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhou Y, Tian X, Tang Y, et al. Exploring supply and demand imbalance of community-based older adult care: an observational study in Chongqing, China[J]. Front Public Health. 2025;13:1581039.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCebrino J, Portero De La Cruz S. A worldwide bibliometric analysis of published literature on workplace violence in healthcare personnel[J]. PLoS ONE. 2020;15(11):e242781.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDelmas C, Vandenbriele C, Baudry G. Time to rethink the prioritization of IABP patients in heart allocation systems worldwide?[J]. J Heart Lung Transpl. 2025;44(10):1674\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaber EN, Sonti R, Simkovich SM, et al. Accuracy of Noninvasive Blood Pressure Monitoring in Critically Ill Adults[J]. J Intensive Care Med. 2024;39(7):665\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWilandh E, Skinnars Josefsson M, Persson Osowski C, et al. Improving hospital food and meal provision: a qualitative exploration of nutrition leaders' experiences in implementing change[J]. BMC Health Serv Res. 2025;25(1):410.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJeffko M, Younus I, Bansal A, et al. Measuring Decisional Regret in Orthopedic Surgery: Tools, Time Points, and Score Interpretation[J]. Orthopedics. 2025;48(4):e153\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTie H, Zhang J. Characterization and factors influencing the uncertainty of intolerable in older adults with multimorbidity: A Cross-sectional study[J]. BMC Geriatr. 2025;25(1):706.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKazemi FZ, Mohsenipouya H, Hosseinnataj A, et al. Perceived Organizational Support as a Factor in Managing Work-Family Conflict and Enhancing Occupational Well-Being: Findings From Iranian Nurses[J]. Int J Nurs Pract. 2025;31(5):e70061.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalari A, Vagharseyyedin SA, Sabeghi H. Informatics competency, attitudes toward evidence-based practice, and clinical decision-making skills in nurses[J]. Health Inf J. 2025;31(3):1227866521.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Y, Li Q, Zhang L, et al. Development of a Risk Assessment Index System of Non-Specific Neck-Shoulder Pain in Physicians and Nurses: A Delphi and Analytic Hierarchy Process Study in China[J]. Pain Manag Nurs; 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSiopi SA, Antonitsis P, Karapanagiotidis GT, et al. Cardiac Failure and Cardiogenic Shock: Insights Into Pathophysiology, Classification, and Hemodynamic Assessment[J]. Cureus. 2024;16(10):e72106.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDehmer SP, Egan BM, Hardy B et al. Predicted Cardiovascular and Economic Impacts of the Measure Accurately, Act Rapidly, and Partner with Patients Program to Improve Hypertension Control[J]. Am J Prev Med, 2025:108132.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoralez GM, Amado F, Liu VX, et al. Data-Driven Quality of Care in the ICU: A Concise Review[J]. Crit Care Med; 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHara K, Tachibana R, Kumashiro R, et al. Lasting impact of undergraduate operating room shadowing on novice nurses: a ChatGPT-supported qualitative study[J]. BMC Nurs. 2025;24(1):1151.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHssain AA, Bahramnezhad F, Vahedian-Azimi A, et al. ECMO specialist' challenges towards acquired infections during extracorporeal membrane oxygenation: An international qualitative ECMO infection study[J]. Intensive Crit Care Nurs. 2025;91:104148.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYu Y, Qiao Y, Zhu Y, et al. The impact of unfolding case studies combined with think-aloud strategies on the clinical reasoning and self-directed learning abilities of postgraduate students: A mixed methods study[J]. Nurse Educ Pract. 2024;80:104132.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChua WL, Tan RXR, Liaw SY, et al. Blending of virtual reality with high-fidelity simulation for interprofessional team training: A mixed methods study[J]. Nurse Educ Today. 2025;155:106857.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBail K, De Fernandes Barreto J, Hants L et al. A Digital Alert Feedback System (Aged Care Electronic Dashboard Information Tool, ACED-IT) to Enhance Quality Nursing Care: Participatory Action Research[J]. J Clin Nurs, 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmes ML, Sundermeir SM, Staffier KL et al. Education strategies to facilitate lifestyle medicine practice within health systems: a multiple case study of US health systems[J]. Transl Behav Med, 2025,15(1).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eChiu P, Chu S, Yang C, et al. Peer-assisted learning in critical care: a simulation-based approach for postgraduate medical training[J]. Med Educ Online. 2025;30(1):2497333.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTrinkley KE, Maestas Duran D, Zhang S, et al. Application of Nudges to Design Clinical Decision Support Tools: Systematic Approach Guided by Implementation Science[J]. J Med Internet Res. 2025;27:e73189.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBilliau L, Taghon D, Duprez V, et al. Instruments for measuring head nurses' competencies in a hospital setting: a scoping review[J]. BMC Nurs. 2025;24(1):1069.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJantzen D, Marcellus L, Damianos D, et al. Registered nurses' experiences of organizational change in acute care settings: a qualitative systematic review[J]. JBI Evid Synth; 2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","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":"invasive arterial blood pressure monitoring, i-PARIHS framework, qualitative research, user profile, intensive care units, nursing","lastPublishedDoi":"10.21203/rs.3.rs-7720386/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7720386/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eInvasive arterial blood pressure (IBP) monitoring is vital in critical care, yet its accuracy is frequently compromised in practice. While previous studies have focused on technical comparisons or procedural standardization, a systematic understanding of the multifaceted barriers and facilitators from frontline nurses' perspectives is lacking.\u003c/p\u003e\u003ch2\u003eAims\u003c/h2\u003e\u003cp\u003eTo comprehensively explore factors influencing IABP monitoring accuracy through the lens of the i-PARIHS framework and to develop ICU nurse user profiles to inform tailored improvement strategies.\u003c/p\u003e\u003ch2\u003eStudy Design:\u003c/h2\u003e\u003cp\u003eA descriptive qualitative study. Semi-structured interviews were conducted with 24 ICU nurses from a tertiary hospital in China between June and August 2025. Data analysis followed a two-step approach: directed content analysis guided by the i-PARIHS framework, followed by clustering analysis to construct distinct user profiles.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFour themes aligned with i-PARIHS were identified: the dual nature of the innovation (value vs. risk), varied recipient competency, contextual barriers (e.g., lack of protocols), and facilitation strategies. Furthermore, three nurse profiles emerged: 1) The Experience-Guarded Expert (highly skilled but reliant on personal experience, cautious about risks), 2) The Seeking-Guidance Practitioner (knows standards but struggles with application, desires clear tools), and 3) The System-Advocating Catalyst (focuses on root causes and systemic solutions). Each profile exhibited unique needs and barriers.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eImproving IABP accuracy requires a move beyond one-size-fits-all approaches. The integration of the i-PARIHS framework with user profiling provides a powerful strategy for developing targeted interventions. Tailoring support to the specific characteristics of different nurse profiles\u0026mdash;such as providing decision aids for Practitioners and engaging Catalysts in quality improvement\u0026mdash;is essential for enhancing patient safety.\u003c/p\u003e\u003ch2\u003eRelevance to Clinical Practice:\u003c/h2\u003e\u003cp\u003eThe findings provide nurse managers with a framework for systematically assessing barriers to accurate IBP monitoring. Crucially, the identified user profiles enable a shift from generic training to precision interventions, guiding leaders to tailor support\u0026mdash;such as simplified job aids for less confident staff and leadership roles for system-oriented nurses\u0026mdash;to address specific needs, thereby enhancing monitoring reliability and patient safety.\u003c/p\u003e","manuscriptTitle":"Beyond Standardization: A Qualitative Study Using the i-PARIHS Framework and User Profiles to Improve Invasive Arterial Blood Pressure Monitoring Accuracy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-26 08:35:48","doi":"10.21203/rs.3.rs-7720386/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-09T11:03:06+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T14:52:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"195855795567256511390397790565528634704","date":"2026-02-13T20:35:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-04T16:47:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74580929913452975628648483402333971979","date":"2026-01-16T14:57:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-14T10:20:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-04T08:12:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-03T10:12:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-03T10:12:14+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2025-09-26T09:38:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","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":"b89754c4-ec2c-47eb-95db-1bd1676133c7","owner":[],"postedDate":"November 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:02:04+00:00","versionOfRecord":{"articleIdentity":"rs-7720386","link":"https://doi.org/10.1186/s12912-026-04674-0","journal":{"identity":"bmc-nursing","isVorOnly":false,"title":"BMC Nursing"},"publishedOn":"2026-04-18 15:59:03","publishedOnDateReadable":"April 18th, 2026"},"versionCreatedAt":"2025-11-26 08:35:48","video":"","vorDoi":"10.1186/s12912-026-04674-0","vorDoiUrl":"https://doi.org/10.1186/s12912-026-04674-0","workflowStages":[]},"version":"v1","identity":"rs-7720386","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7720386","identity":"rs-7720386","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}