All the information in this presentation is confidential © 2015 / Copyrights VanBerlo

by Koen Bogers and Rosèl van den Berg

Alarm fatigue / sound experience by IC nurses

The Hague, 23-1-2018

All the information in this presentation is confidential © 2017 / Copyrights VanBerlo

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› About 1 alarm in every

11 minutes

› 135 alarms per patient

per day

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› Alarm fatigue, resulting

in fatigue and stress for

nurses

› Between March and

June 2010, more than

73 deaths related to

alarms of US hospitals*.

› Current literature

focuses on quantitative

data

› Qualitative study about

alarm experience by

ICU nurses

*According to a research by MAUDE

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Introduction | Qualitative research

Insights |

› Who is the Intensive care (IC) nurse?

› Utility of alarms

› Personal preference in alarm management

› Soundscapes at the ICU

› Explaining alarm fatigue

Recommendations | How to improve the IC?

ContentQualitative study about alarm fatigue

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Sound experience by IC nurses | set-up:

IntroductionQualitative research

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Sound experience by IC nurses | objective:

Uncovering the contextual factors andperception of the alarm fatigue problem by IC nurses, to provide qualitative insight and advice for regulators, hospital and designers.

We took one specific article and ‘the appraisal theory model’ as a starting point for our research.

The article (Nurses' Perceptions … Fatigue (Sowan et al., 2015)) includes

a list of alarm fatigue factors stated by nurses. The interview guide &

sensitizing booklet adapted to this list.

The appraisal theory model describes the psychological steps of how

‘stressors’, in this case sounds, would possibly result in coping behavior

and reappraisal.

Sound experience by IC nurses | Literature research

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We did three observation studies at the Erasmus MC’s ICUs during different moments of a day shift.

Observation studies revealed insights about the dynamics and key

activities of a nurse’s day work shift.

Semi-structured interviews in the context itself allowed direct questions

about real time event and mental triggers for nurses to explain about

their experience with sounds at the IC.

Sound experience by IC nurses | Observations & semi-structured interviews

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We interviewed seven (former) IC nurses to get first hand insights into sound experience.

Participants:

1: female / 20 years IC experience2: female / 18 years IC experience3: male / 15 years IC experience4: male / 1,5 years IC experience5: male / 10 years IC experience6: female / 6 years IC experience7: male / 25 years IC experience

Sound experience by IC nurses | Structured interviews

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An audio recorder and ‘sensitizing booklet’ with small assignments prepared nurses for the interview.

IC nurses were asked to fill out a booklet with one questions a day for

over a week. These continuous questions required nurses to become

extra aware of the ICU sounds during the week before the interview.

The sensitizing booklet contained questions such as ‘describe the

different sound moments throughout your work shift’, ‘record the most

remarkable sounds at the ICU’ and ‘what are in your opinion related

factors towards alarm management?’

Sound experience by IC nurses | Sensitizing booklets

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Data was clustered it into insights and big themes or placed onto timelines or a psychological model.

Sound experience by IC nurses | Sensitizing booklets

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The insights clusters, timeline and psychological model (of the

appraisal theory) allowed to create an overall understanding of different

topics related to the alarm fatigue problem.

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Sound experience by IC nurses | synthesis:

Who is the IC nurse?Insights

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Sound experience by IC nurses | synthesis:

InsightsUtility of alarms

Problems with alarms

Not all alarms that a nurse hears are medically actionable. Many of the alarms a nurse hears don’t represent something that they immediately have to take care of. These alarms can eventually start causing a ‘boy who cries wolf’ effect and hereby cause alarm fatigue. There are several reasons for such unactionable alarms.

Patient/nurse induced alarms

Certain alarms are caused by a movement the patient make or when patients are being treated, and equipment is handled by nurses or doctors. In such cases the alarm does not represent

what is happening to the patient. A sound that should usually be associated with a problem with one of the patient's vitals, can now actually mean a patient is responding as expected to medication. The alarms and the attention they ask of the nurse do not take into account how much information a nurse already has.

Limitations of sensors

Sensors that are used to monitor patients may get disconnected

or may malfunction. Examples are the oxygen saturation sensor on the patient’s finger that is disconnected. Though it is important to know that all sensors work, alarms also occur when nurses

know the sensor has come of during treatment.

Incomplete information from monitor

The patient monitor will sound an alarm based on a range of vitals that are measured. Since each of these values has a set of boundaries, the alarm will often go of when just one of these

values exceeds a boundary. The nurse however, needs more

nuanced information about the combination of several values to be able to judge the urgency of the problem. The result is that most of the alarms the monitor produces are switched off

because they don’t require action.

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Sound experience by IC nurses | synthesis:

InsightsPersonal preference in Alarm management

Personal preferences in alarm management

Nurses can influence the number of alarms they hear by changing the boundaries at which the monitor sounds an alarm for a certain value. Each nurse has their own approach to these settings. There are several reason for why they might choose one over the other.

Personal preferences in alarm management

Settings WideNarrow

Rely on intuitionRely on alarms Alarms vs. intuition

Low sensitivity Sensitivity to sound High sensitivity

Playing it safe Experience Confident

Disciplined Being neat and organized Nonchalant

Sensitive to stress Stress Resistant to stress

How different nurses manage their alarms differently has several reasons.

Personal preferences in alarm management

Settings WideNarrow

Rely on intuitionRely on alarms Alarms vs. intuition

Low sensitivity Sensitivity to sound High sensitivity

Playing it safe Experience Confident

Disciplined Being neat and organized Nonchalant

Some nurses like doing their work according to the alarms they hear. Others prefer to rely more on their clinical intuition and base some decisions on how they can see their patient is doing.

“Ik voel me veilig door alarmen”

“Je klinische blik is veel belangrijker dan de monitor”

Personal preferences in alarm management

Settings WideNarrow

Rely on intuitionRely on alarms Alarms vs. intuition

Low sensitivity Sensitivity to sound High sensitivity

Playing it safe Experience Confident

Disciplined Being neat and organized Nonchalant

People are different from each other when it comes to how many sounds they can endure. Some nurses don’t mind hearing many alarms because they don’t mind sounds in general.

“Alarmgeluiden hebben niet echt veel negatieveinvloed op me”

“Ik hoor elk geluid, zelfs dat van de koelkast”

Personal preferences in alarm management

Settings WideNarrow

Rely on intuitionRely on alarms Alarms vs. intuition

Low sensitivity Sensitivity to sound High sensitivity

Playing it safe Experience Feeling in control

Disciplined Being neat and organized Nonchalant

As nurses gain experience at the ICU their need for reaffirmation from alarms decreases. Nurses who just start working at the ICU can feel safe because of alarms.

“Mijn alarmen staan altijd heel strak. Zo kan ikiemand goed bewaken.”

“Op een gegeven moment heb je het wel ondercontrole. Je vertrouwt dan wat je hebt ingesteld.”

Personal preferences in alarm management

Settings WideNarrow

Rely on intuitionRely on alarms Alarms vs. intuition

Low sensitivity Sensitivity to sound High sensitivity

Playing it safe Experience Feeling in control

Disciplined Being neat and organized Nonchalant

In alarm management, one can be very disciplined and consistent. Nurses have different styles due to differences in how strictly they adhere to alarm management agreements.

“Soms horen mensen alarmen niet eens en zijn zeslordiger.”

“We hebben bijvoorbeeld de afspraak dat je bepaalde alamen uit zet bij bloed afnem.”

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Sound experience by IC nurses | synthesis:

InsightsSoundscapes at the ICU

• Each shift starts with a handover in which the nurses who are about to start are updated

• In the handover, nurses from two shifts are at the nurse station

• The handover can be quite loud due to talking and many people walking around.

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Sound experience by IC nurses | synthesis:

InsightsExplaining alarm fatigue

Model of stress and coping

Developed by Richard Lazarus (1989), the transactional model of stress and coping describes how stimuli can be perceived by people. Depending on a person's appraisal of the stressor and their available recourses to respond, they can experience stress.

The model is used together with findings from the observations and interviews to understand how alarms fatigue occurs and how sounds can cause stress on the ICU.

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Sound experience by IC nurses | conclusions:

RecommendationsHow to improve the ICU?

Thank you for your attention

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Sound experience by IC nurses | conclusions:

AppendixPhotos of clusters

Who is the IC nurse? / Technology, knowledge & Thrills