The Meaning of Monitoring Among Patients and Their Families in Critical Care Units

Have you ever wondered what patients and their family members think about the array of monitoring devices used in intensive care units (ICUs)? Have you wondered whether monitors should be visible to patients or placed unobtrusively behind their bed or at a central monitoring station? Have you thought that many patients and their family members focus on the details of the vital signs displayed on monitors rather than on the “big picture” of their situation? If you have, the following case vignette and discussion should prove useful.

CASE VIGNETTE

Mr B, a 70-year-old retired car mechanic with coronary artery disease, was admitted to the cardiac care unit (CCU) to manage the sequelae of a large anterior wall myocardial infarction. He repeatedly craned his neck to see the readout of his heart rate and blood pressure on the monitoring devices that were mounted on the wall behind his bed. He felt compelled to check the numbers rather than settling for his nurse’s reassurances that his vital signs were stable. When his oxygen saturation monitor slipped off his finger, the alarm disrupted his ability to rest, and it provoked his anxiety. He wished that he could simply ignore the data on his hemodynamic state and let “ignorance be bliss.” The cardiology team requested a psychiatric consultation to assess and reduce his apprehension. After exploring his need for control and prior reactions to hospitalizations for cardiac complaints, the consultant assured him that he was neither in heart failure nor having arrhythmias. Much to Mr B’s surprise at finding that he had become less afraid, he removed his eyeglasses and placed them on a bedside table for the remainder of his stay in the CCU.

DISCUSSION

What Types of Monitoring Are Used in ICUs and How Might Such Monitoring Interfere With a Patient’s Physical Comfort?

Since the advent of ICUs more than 60 years ago, technological advances have improved patient outcomes and saved lives.¹ With improved patient surveillance, the number of monitoring devices and machines (eg, mechanical ventilators, infusion pumps, defibrillators, and heating/cooling systems) available has grown from 6 per patient in the early 1980s to 40 in 2011; moreover, this number continues to grow. These systems monitor physiological parameters; regulate intravenous (IV) infusions of medications, fluids, and blood products; and oversee invasive treatments (eg, mechanical ventilation, renal replacement therapy, and extracorporeal life support).² Physiological monitoring devices in the ICU display levels of blood pressure, oxygen saturation, heart rate, and respiratory rate, as well as electrocardiogram (EKG) waveforms. For those who require more invasive hemodynamic monitoring, data on mean arterial blood pressures, pulmonary artery pressures, and cardiac output are also displayed.³ Specific monitoring needs are dictated by each patient’s medical conditions and status, and the use of specific devices may vary across different types of ICU settings (eg, cardiovascular ICUs will have different areas of focus than neurological ICUs).

Unfortunately, sophisticated monitoring devices have led to an exponential increase in the number of alerts that indicate when values fall outside the normal range. One study found that 2,558,760 unique physiological alarms sounded in a single month in a 77-bed ICU.⁴ Many of these alarms indicated cardiac arrhythmia, but they were due to motion artifacts and still required a staff member to address and silence each alarm. On average, hundreds of alarms are sounded (ie, between 350 and 771 alarms) each day, with 63%–90% of these being “false alarms.”^5–7 The combination of ever-present monitoring equipment and staff activities contributes to noise pollution in the ICU. Ambient noise can jeopardize healing when the levels exceed 50–60 dB.^8,9 Exposure to loud noises in the ICU has been linked to physiological and psychiatric disturbances (eg, sleep dysregulation, delirium, decreased immune response, inflammation, cardiovascular disease, decreased respiratory function, and difficulty weaning from ventilatory support).^10–12 Noise levels also contribute to patient stress, which can elevate heart rate, blood pressure, and the need for sedatives.¹³

When (and Why) Are Observers or Sitters Needed to Supplement Monitoring Devices in the ICU?

The presence of monitoring devices in the ICU also requires that staff monitor and respond in a timely fashion to patient behaviors. “Observers” and “sitters” (typically nursing assistants or technicians) are often assigned for one-on-one monitoring to mitigate risks of falls, intentional or unintentional self-harm, interpersonal aggression, and elopement.^14,15 Although the literature on patients’ experience and satisfaction with sitters/observers is sparse, some patients welcome the company, while others experience being watched as an intrusion of their privacy (which can evoke embarrassment and shame). Those who are paranoid can become particularly distressed. Patients who are conversational and receptive to basic education and reorientation often appear to respond best to having sitters in the room. However, not all sitters will be skilled in these domains, and there is generally a lack of standardized approaches to studying the role of sitters/observers. Since one-on-one monitoring has not been uniformly beneficial, and is costly, alternative solutions (such as using remote visual monitoring by video camera and/or bed pressure sensor alarms) are commonly used. These alternatives allow for more remote monitoring and enhanced patient privacy, but they may risk slower response times due to the absence of staff at the bedside.¹⁵

How Are Patients, Family Members, and ICU Staff Instructed on the Sights and Sounds of Monitor Alarms and Their Significance?

The sights and sounds produced by monitor alarms in ICUs are interpreted differently by patients, families, and staff members. Educating each of these groups is crucial to reduce monitor-associated anxiety and ensure an appropriate response.¹⁶ Since there is no universal standard for how best to understand the output of monitors and since monitors vary significantly among units or institutions, approaches vary. The American Association of Critical-Care Nurses recommends that patients be instructed in the meaning of the parameters that devices monitor (eg, heart rate, blood pressure, oxygen saturation) and their normal ranges, as well as what the signal of abnormalities can represent. Alarms that sound frequently may induce stress in those who hear and see them.¹⁷ Thus, telling people that not all alarms indicate an emergency (eg, they may alert staff to a temporary change in position or a loose electrical lead) may reduce patients’ and families’ emotional and physiological responses to monitor alarms.¹⁸

Several institutions (eg, Memorial Sloan Kettering Cancer Center) have produced brochures to help educate patients and family members about the ICU environment. However, the information provided about monitoring devices is generally brief and refers patients back to their bedside nurses for more specific information.¹⁹ This may reassure some visitors, but others may still want to know more. Conversely, too much information may provoke higher anxiety levels for those prone to preoccupation. Regardless, patient and family education regarding monitoring devices falls largely on ICU staff. In busy ICUs, staff time to educate patients and family members is typically limited, which can lead to further challenges.²⁰ Further compounding these challenges is the broad range of patients that nurses work with, including many with cognitive or communication deficits, meaning that all education efforts require personalization to ensure that the information is provided in language that is comprehensible to the patient. For patients with cognitive deficits, information retention is another factor that may lead to patients needing serial reeducation.

Fortunately, ICU staff usually receive extensive training on ICU monitoring devices. Since nurses are often the first responders to alarms, they must know the status of their patients, learn how to differentiate between meaningful and false alarms, and know when and how to generate an appropriate course of action. Given that nurses are often exposed to hundreds of alarms each day, they are vulnerable to alarm fatigue (comprised by sensory and cognitive overload, desensitization to alarms, and missed alarms or delayed response).²¹ Efforts to address alarm fatigue include enhancing the design of alarms, decreasing the rates of false alarms, improving staffing ratios, and providing education and support to staff members.

Who Is Apt to Be Reassured by Monitoring Devices or Made More Anxious by Focusing on Data Points or Trends?

Patients in critical care units are often stressed by serious illnesses, sleep deprivation, difficulties in communication, pain, and loud, frequent, and unpredictable alarms from medical devices.¹¹ The sounds of repeated alarms in the ICU disrupt sleep quality, impair cognitive function, and perpetuate ineffective communications among patients and staff.¹¹ In addition, environmental stressors in ICUs adversely impact patient satisfaction with nursing care.²² The perceived annoyance of alarms is affected by who or what is responsible for triggering the alarm and is influenced by myriad factors (eg, physiological status, psychological status, personality, prior experiences).^23,24 In addition, a patient’s trust (or lack thereof) in their health care team is likely to affect their interpretations of various interventions. When patients trust their care team, additional monitoring can be reassuring. Conversely, when patients lack trust in their care team, they tend to be more likely to experience additional monitoring as intrusive or unhelpful.²⁵

Critically ill patients with a premorbid history of trauma are at elevated risk of developing trauma-related sequelae from their ICU stay.²⁶ Identifying patients with a history of trauma can be challenging given limited opportunities for extended interviews.²⁷ Since environmental stimuli (eg, alarms, lines, tubes, monitoring devices), communication barriers, and frequent physical examinations and interventions can diminish an individual’s sense of autonomy and bodily integrity, ICU staff can facilitate greater patient comfort by employing a trauma-informed approach for all patients (emphasizing safety, trustworthiness, collaboration, empowerment, and sensitivity to cultural, historical, and gender issues).^28,29 This approach often includes assigning staff consistently to the same patient (allowing for better relationship formation), having a thorough discussion about procedures prior to their performance, and reducing the number of monitors and alarms, which can improve alignment of patient and care team goals and priorities, further enhancing mutual trust.²⁹

How Do ICU Staff Use Monitors in the ICU?

A key difference between ICUs and other hospital units is the higher level of monitoring that patients receive, which allows health care teams to quickly observe alterations in physiology and intervene when needed.³⁰ For example, continuous monitoring of EKGs is used to identify arrhythmias and ischemia, as recommended by the American Heart Association for all patients with hemodynamic instability in ICUs or for those being mechanically ventilated. In addition, staff use invasive and noninvasive hemodynamic assessments (eg, arterial blood pressure, central venous pressure, and pulse oximetry) to evaluate tissue perfusion and oxygenation.³¹ This vigilant monitoring also ensures that therapies (eg, volume resuscitation, vasoactive infusions, and mechanical ventilation) are used safely.

When ICUs were first introduced in the late 1950s, nurses manually and intermittently monitored patients’ vital signs, as continuous measurement was neither available nor required for invasive procedures. Today, nearly all vital signs can be monitored accurately, noninvasively, and continuously. Moreover, modern monitoring systems interface with critical care information systems, which enable more efficient management of data and facilitate quality reporting and improvement.³⁰ Staff who interpret monitoring data can facilitate and adjust treatments based on their findings (eg, administration of fluids, vasopressors, sedatives, or ventilatory settings).^32,33 Some systems also explore data-driven predictive alerts, which may present interesting challenges as we continue to try to balance optimal patient physiology with optimal patient experience.³⁰

Routine monitoring extends to frequent evaluation of laboratory test results (eg, arterial blood gases, levels of lactate and glucose) using invasive and noninvasive (indirect) methods to assess tissue perfusion and metabolic status. For those at risk of neurological complications, specialized monitoring tools (eg, electroencephalograms, pupillometry, and cerebral perfusion pressure) are employed. ICU staff are trained to identify false alarms, sensor malfunctions, and the limitations of each monitoring modality, ensuring that clinical assessments are integrated with monitored data to inform decision-making.³⁴ The American College of Critical Care Medicine emphasizes the importance of positioning monitors for optimal staff access and direct visualization of the patient. Centralized and remote monitoring systems further enhance continuous surveillance, enable rapid responses to changes in a patient’s status, and improve the overall delivery of care.³⁵

Why Are Monitors Usually Placed Behind a Patient’s Bed Rather Than in Full View of the Patient?

To safeguard patients’ privacy and to minimize psychological stress, monitors are typically positioned behind the patient’s bed. The American College of Critical Care Medicine recommends that personal health information that is displayed on bedside screens be protected from unauthorized viewing by placing monitors so that sensitive data are not visible to patients and visitors. This design ensures compliance with privacy regulations and reduces inadvertent disclosures of confidential information.³⁶ Furthermore, limiting the patient’s direct view of monitors helps to reduce anxiety and the risk of delirium. Constant exposure to alarms, fluctuating vital signs, and medical data can contribute to psychological distress, which might worsen outcomes for critically ill patients. By optimizing the sensory environment (eg, minimizing unnecessary visual stimuli from monitors), ICUs can create an atmosphere that is more conducive to healing and aligns with best practices for critical care design.^35,36

How Often (and Why) Do Patients and Their Family Members Focus on the Numeric and Graphic Displays on Monitoring Devices?

Patients and family members in ICUs may frequently focus on the numeric displays of monitoring devices to feel that they are in control, rather than adrift in a helpless situation. Family members and patients, who typically lack an appreciation of their bodies’ pathophysiological processes, may attend to monitoring devices as though they were vigilant stakeholders.³⁷ Despite high nurse-to-patient ratios in ICUs, family members often rely on the sounds and flashing lights of medical devices to identify if their loved one is having a meaningful change in their clinical status so that they can notify members of their medical team.³⁸ If patients or families express concern about an alarm that ICU staff are not concerned about, staff may consider this an overreaction, but studies have shown that family members can also be astute observers of genuine breakdowns in medical care or related communication.³⁹ ICU staff may do well to recontextualize these “overreactions” as communications of concern and, in many cases, opportunities for further discussion and education about the patient’s status and course. Approaching it in this way helps maintain open lines of communication, which are often beneficial to the treatment relationship, and this practice is in line with the patient-centered approach of trauma-informed care outlined above.

Assessment of disease severity and prognosis are important physician roles in the care of critically ill patients. Nearly as important is the physician’s ability to describe their assessment in plain but specific language to the patient and family. Patients/families with low medical knowledge or health literacy are at risk for inadequate understanding.⁴⁰ Inadequate understanding, when combined with the emotional strain of a sick loved one, can put family members at risk for developing symptoms of anxiety, depression, and acute stress disorder.⁴¹ Not knowing enough to appreciate a loved one’s status and prognosis prompts many patients and their family members to monitor data streams intently in the hope of identifying trends (positive or negative) that may help them better understand the patient’s status. This process can variably evoke reassurance or concern, feelings that may not necessarily correlate with the patient’s true status if it is based on misinterpretations. In a patient-centered approach, it is important to consider that it is the patient or family’s perceived level of threat to health or support by the care team that tends to most directly determine their psychological reaction. Accordingly, educational and reassurance efforts need to consider not only the patient’s health status but also their perception of their health status, which ICU staff may need to inquire about to understand fully. This represents another opportunity for ICU staff to identify and intervene in these situations to improve family member knowledge and comfort.⁴²

When (and How) Can It Be Helpful for Patients and Their Family Members to Attend to the Data Displayed On Their Monitoring Devices?

Several studies describe educational efforts by ICU staff to orient families to the ICU environment and to foster positive outcomes (eg, less fear, better emotional regulation, and a greater sense of efficacy). One randomized controlled trial in a neonatal intensive care unit (NICU) demonstrated the benefit of teaching parents how to conduct simple pain assessments of their infants, helping them feel involved in their child’s care in a situation where many parents struggle with feeling powerless.⁴³ However, the study showed no reduction in NICU-related stress for family members of their infant.⁴³ A qualitative study in Australia found that when staff explained the purpose of IV drips and ventilators in the ICU, families became less uncertain and afraid and felt more in control.⁴⁴ Another qualitative study found that efforts at orientation to the ICU changed family perspectives of mechanical ventilators from a sign of death to one of healing and life.⁴⁵ Another qualitative study in the United States found that cardiorespiratory monitoring alarms in the pediatric ICU led to a wide range of family member experiences including hypervigilance, a desire to discuss their child’s care with the team, and reassurance that their child was being monitored.⁴⁶

During the COVID-19 pandemic, live-video feeds of patients and their bedside monitors were used at some hospitals to connect families remotely to their loved ones. One qualitative study interviewed family members about their experiences.⁴⁷ Common themes identified included frustrations due to difficulty communicating with their loved one, lack of touch and physical presence, and displeasure with the frequency and clarity of communication with the care team. However, these interventions also allowed patients and families to interact in a safe way that avoids the infection control risks of family’s physical presence.⁴⁷

As is true for family members, medical monitoring appears to be understood by patients as both required for safety and also a potential source of confusion, annoyance, and anxiety. A qualitative study from a CCU in Norway found that patients felt safest when the alarms from their monitors were responded to quickly by nurses, highlighting one potential way to mitigate patients’ negative responses to alarms.⁴⁸ Because ICU environments have been known to disturb patients’ rest and cognition, common nonpharmacologic interventions to reduce delirium risk involve reducing nocturnal sounds and removing medical monitoring devices once they are no longer necessary.^49,50

When (and How) Can It Be Harmful for Patients and Their Family Members to Be Overly Vigilant About the Data Displayed On Their Monitoring Devices?

ICUs are filled with the sights and sounds of physiological monitoring devices that are intended to safeguard patients through continuous surveillance.¹⁷ When the meaning or urgency of these displays is unclear, attention to these devices can promote worry and hypervigilance, disturb sleep, and erode trust in the health care team, which can affect psychiatric and medical sequelae that may persist beyond the ICU stay. This challenge can be further compounded by altered cognitive states such as delirium, in which patients’ thought processes may be significantly impaired and lead to description of alarms and monitor displays as frightening, linking them with traumatic ICU memories.⁵¹ These stressors can also erode perceptions of individualized care and reduce participation in recovery.⁵² Recent Pain, Agitation, Delirium, Immobility, and Sleep Disruption guidelines from the Society of Critical Care Medicine emphasize that nearly all critically ill patients experience pain, anxiety, agitation, delirium, immobility, and sleep disruption during their ICU stay.⁵³ Among these, anxiety is described as “one of the most distressing symptoms identified by adult ICU patients,” and it is further intensified by incessant alarms and the hypervigilance they provoke.⁵³

Desensitization to alarms is one way that hypervigilance is reduced.¹⁷ Patients and families, like clinicians, often become alarm-fatigued: Initially vigilant to every signal, they may eventually disengage, ignore alarms, or silence them, which inadvertently compromises safety. Families who remain at the bedside for prolonged periods are especially vulnerable to this vicious cycle, shifting from hypervigilance to detachment, which can further strain communication and trust with the care team. Numerical readouts can also become a focus of vigilance, yet without clinical training, families cannot distinguish benign fluctuations from signals of imminent danger.¹⁷ When these alarms sound without a visible response from staff, families may interpret the absence of intervention as neglect, eroding trust in the health care team and intensifying anxiety about their loved one’s condition.⁵¹

In some cases, these deleterious effects extend beyond ICU discharge. Patients’ ICU experiences can affect their risk for postintensive care syndrome (PICS), which encompasses enduring cognitive, physical, psychiatric, and social impairments after a course of critical care. Family members can similarly develop symptoms of PICS (termed PICS-F).⁵⁴ If these alarms cause too much distress for the patient or family, they may cause more harm than benefit. Recognizing alarm burden as a modifiable stressor highlights one opportunity to reduce immediate distress and potentially reduce long-term risks of PICS and PICS-F. While ICU staff may be hesitant to discontinue an alarm, an alternative may be to see if education and reassurance can decrease the patient or family’s negative response to alarms. If alarm-related distress persists, then altering alert parameters or using alternate alert methods may be considered. For example, reducing nonactionable alarms and individualizing thresholds can decrease noise burden.⁴ Structured communication that emphasizes trends rather than isolated values reassures families and reduces fixation on monitors.⁵³ Tailoring interventions to individual stress responses also enhances patient experiences, and when applied to alarms and monitoring, such strategies help temper hypervigilance and directly counter the distress patients and families report.^51,52 Earplugs have been associated with delayed onset and reduced rates of delirium, yet by blocking alarms, they manage symptoms of overload rather than the root cause.¹⁷ Addressing alarm burden reframes monitoring from a source of hypervigilance into an opportunity for understanding in participation in the healing process.

What Happened to Mr B?

Upon being transferred to the step-down unit, Mr B put his glasses on and prepared himself for the next phase of treatment and cardiac rehabilitation.

CONCLUSION

Although the advent of technical advances in ICUs has improved patient outcomes and saved lives, the number of devices (eg, mechanical ventilators, infusion pumps, heating/cooling systems) used to monitor patients has grown exponentially and unearthed a potential source of distress to patients and family members. The combination of ever-present monitoring equipment and staff activities contributes to noise pollution in the ICU, with its attendant physiological abnormalities. Nevertheless, staff who interpret data that are generated at the bedside and through centralized or remote monitoring stations can facilitate and adjust treatment (eg, administration of fluids, vasopressors, sedatives, or ventilatory settings) in a timely fashion. However, patients and families, like clinicians, often become alarm-fatigued: Initially vigilant to every signal, they may eventually disengage, ignore alarms, or silence them, which inadvertently compromises safety. As is true for family members, medical monitoring appears to be understood by patients as required for safety but also a potential source of confusion, annoyance, and anxiety. Accordingly, patient education is an essential task for ICU staff to ensure that patients and families are oriented to monitoring devices, their role in the patient’s care, and potential alarms and their meanings. For certain patients, such as those with low health literacy or cognitive deficits, routine reeducation may be necessary to ensure retention, and periodic inquiries can confirm patient comprehension and ensure that alarms are not a source of undue distress. Using a trauma-informed approach with patients can help ease distress by ensuring a sense of safety, fostering collaboration, building trust, and ensuring each patient’s care is individualized appropriately.

Article Information

Published Online: July 7, 2026. https://doi.org/10.4088/PCC.25f04175
© 2026 Physicians Postgraduate Press, Inc.
Submitted: December 23, 2025; accepted March 10, 2026.
To Cite: Dragonetti JD, Mastronardi KV, Ibrahim S, et al. The meaning of monitoring among patients and their families in critical care units. Prim Care Companion CNS Disord. 2026;28(4):25f04175.
Author Affiliations: Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina (Dragonetti); Atrium Wake Forest Baptist, Winston Salem, North Carolina (Dragonetti); Department of Psychiatry, LewisGale Medical Center, Salem, Virginia (Mastronardi, Braford, Browne); Department of Psychiatry, McGill University Health Care Center, Montreal, Canada (Ibrahim); Department of Internal Medicine and Psychiatry, Tulane University School of Medicine, New Orleans, Louisiana (Hammer); Department of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois (Bieber); The Pritzker Department of Psychiatry and Behavioral Health, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois (Bieber); Psychiatric Residency, Mount Sinai Morningside/West, New York, New York (Kiriella); Virginia Commonwealth University School of Medicine, Richmond, Virginia (Ganeshan); Dr. Kiran C. Patel College of Osteopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida (Weatherly); Virginia Tech, Blacksburg, Virginia (Thapar); Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts (Stern).
Corresponding Author: Joseph D. Dragonetti, MD, Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina ([email protected]).
Dragonetti, Mastronardi, Ibrahim, Hammer, Bieber, Braford, Kiriella, Ganeshan, Browne, Weatherly, and Thapar are co-authors; Stern is the senior author.
Financial Disclosure: None.
Funding/Support: None.

Clinical Points

• The American Association of Critical-Care Nurses recommends that patients be instructed in the meaning of the parameters that devices monitor (eg, heart rate, blood pressure, and oxygen saturation) and their normal ranges, as well as what the signal of abnormalities can represent.
• The American College of Critical Care Medicine recommends that personal health information that is displayed on bedside screens be protected from unauthorized viewing by placing monitors so that sensitive data are not visible to patients and visitors. This design ensures compliance with privacy regulations and reduces inadvertent disclosures of confidential information.
• Patients and family members in intensive care units (ICUs) frequently focus on the numeric displays of monitoring devices to feel that they are in control, rather than adrift in a helpless situation.
• When the meaning or urgency of monitor displays is unclear, attention to these devices can promote worry and hypervigilance, disturb sleep, and erode trust in the health care team, which can affect psychiatric and medical sequelae that may persist beyond the ICU stay.