Nurses' Clinical Alarm-Related Behaviors and Their Associated Factors in Malawian Critical Care Units: A Cross-Sectional Study.

BACKGROUND: Understanding nurses' clinical alarm-related behaviors is crucial for enhancing patient safety in critical care settings. These settings operate under significant constraints that profoundly influence how nurses prioritize and respond to alarms. While suboptimal alarm management has been extensively studied in well-resourced settings, research remains scarce in resource-constrained settings. This study aimed to evaluate nurses' clinical alarm-related behaviors and their associated factors in critical care units within resource-limited contexts. METHODS: An analytical cross-sectional study was conducted among 434 nurses recruited via multistage stratified random sampling from five hospitals in Malawi. Data were collected using validated scales for alarm behaviors, knowledge, attitudes, fatigue, burnout, and resilience measurements. Data were analyzed using descriptive statistics, Pearson's correlation, and multiple linear regression with backward elimination to identify independent factors influencing clinical alarm-related behavioral scores, with statistical significance set at p < 0.05. RESULTS: The mean clinical alarm-related behavioral score was 68.89 ± 9.72 out of 85. Factors independently associated with higher behavioral scores included working in the ICU (β = 5.47, 95% CI: 0.61 to 10.33, p  = 0.027), resilience (β = 0.18, 95% CI: 0.07 to 0.29, p = 0.001), positive attitude (β = 0.36, 95% CI: 0.21 to 0.51, p = 0.001), implemented alarm management protocol (β = 4.54, 95% CI: 2.83 to 6.24, p < 0.001), and having experienced alarm-related adverse events in the last 2 years (β = 2.02, 95% CI: 0.28 to 3.75, p = 0.023). Conversely, greater years of nursing experience (β = -0.39, 95% CI: -0.75 to -0.03, p = 0.032) and higher knowledge scores (β = -0.93, 95% CI: -1.47 to -0.38, p < 0.001) were associated with lower behavioral scores. The model explained a substantial proportion of the variance in alarm-related behaviors (R2 = 0.673). CONCLUSION: These results indicate that effective alarm-related behaviors extend beyond technical knowledge and competence and require multifaceted support. Interventions may benefit from comprehensive, system-level strategies that integrate standardized protocols, tailored training to bridge knowledge-practice gaps, resilience-building program, and efforts to foster positive attitudinal shifts among nurses. Such targeted approaches hold strong potential to optimize clinical alarm-related behaviors, mitigate risks such as delayed responses, and ultimately enhance patient safety in resource-limited critical care environments. IMPLICATIONS FOR NURSING MANAGEMENT: The findings of this study call for nurse managers and hospital administrators to consider implementing debriefing protocols following any alarm-related incident. By reinforcing positive attitudes (through leadership, peer support, and recognition) and integrating resilience-building programs, these strategies may enhance proactive alarm behaviors and ultimately improve patient safety in resource-limited critical care settings.