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I N S P I R I N G C H A N G E

14 l Nursing2015 l Volume 45, Number 9 www.Nursing2015.com

Promoting a perception of quietness on a telemetry unit By Cecilia Inman, BSN, RN-BC

A PATIENT’S RESPONSE to noise, which can be associated with both physiologic and psychological stress, may result in patient dissat- isfaction. In response to quality indicators showing low patient satisfaction related to quietness at night on a telemetry unit, a quality improvement initiative was con- ducted using an evidence-based survey to identify and transform patient dissatisfiers.

Ongoing monitoring of practice changes showed that a few sources of noise remained unchanged. How- ever, patients’ perceptions of noise levels are demonstrating sustainable improvements. The results validate the idea that quality improvement focusing on perceptions of noise can promote practice changes that ad- vance patient satisfaction related to hospital quietness.

Staff vs. patient perspectives In the hospital setting, noise reduc- tion strategies have primarily focused on environmental factors and prac- tice changes based on healthcare staff members’ perceptions.1,2 In one recent study, efforts focused on re- ducing equipment noise and pro- moting quiet behavior in patient care areas resulted in a brief improvement in patient satisfaction scores, but improvements proved difficult to sustain.1

Another hospital measured noise levels in medical-surgical units be- fore and after implementing nurse- driven noise reduction strategies. The study found a decrease in unit noise levels but failed to validate

whether patients perceived this as a benefit.2

Research on patients’ perception of noise and how this impacts their satisfaction has been limited. In the patient-centered studies focused on noise reduction strategies, investiga- tors have recommended surveying patients to better understand their perception of noise and to guide the quality improvement process.3,4

When considering only the staff perspective on noise and results of patient satisfaction surveys such as the Hospital Consumer Assessment of Healthcare Providers and Systems survey, patients’ experiences can be misinterpreted. Initial noise reduction strategies have traditionally focused on increasing staff awareness of noise, announcing quiet hours at night, and decreasing environmental sounds; for instance, from doors closing and equipment being transported in the halls. However, when we conducted a survey from patients’ perspectives to address their experiences and percep- tions, it was evident that noise reduc- tion strategies had to be redirected because patients identified different sources of noise. (See Bothersome noises perceived by patients.)

Patient-centered approach A starting point to ascertain patients’ perspective of noise was to conduct a survey over a 3-month period. A sur- vey tool was developed using the re- cent literature to determine patients’ perceptions of quietness in and near their room during the day, evening, and night and to identify noises per- ceived as bothersome.5

The unit staff worked together to distribute and collect the surveys during morning bedside rounding. The results were brought to the unit’s quality council so members could discuss patient-perceived noises and design noise reduction strategies to improve patient satisfac- tion. In response to the surveys, staff implemented a few practice changes. • Equipment alarming time. Pa- tients reported that I.V. pump alarms caused bothersome noises. Staff started to use I.V. pump cords to connect the pumps to the central call bell system and promptly alert staff at the nurses’ station of the alarming pump’s location. This prac- tice change decreased the equipment alarm time and improved nurses’ response time. Nurses also commit- ted to changing I.V. sites that con- tributed to frequently alarming I.V. pumps and restricted patient arm mobility. • Coordination of care. Patient dissatisfaction with obtaining blood specimens was associated with in- terrupted sleep and specifically with the phlebotomy staff turning on the lights and awakening them without any notice. Implementing a multi- disciplinary approach, healthcare providers and phlebotomy staff en- acted two practice changes. Blood specimens scheduled to be obtained at night were assessed to differenti- ate critical tests from noncritical ones that could be deferred until morning. Phlebotomists were re- quested to confirm with nursing the necessity of obtaining blood speci- mens after 2300. With this strategy,

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noncritical lab tests could be re- scheduled under the new guidelines to better coordinate care during the night (that is, with medication administration) to reduce interrup- tions of sleep. • The roommate effect. Strategies to decrease noises caused by a roommate focused on plugging headphones into the TV remotes before a patient’s admission. This practice change set the expectation for every patient to use headphones while watching TV. Instead of trying to limit the number of visitors in shared patient rooms, we consistent- ly encouraged patients with more than two visitors to use waiting areas for visits. • Setting patient expectations. Using scripting was essential to changing patients’ noise perception. Scripting, or setting patient expecta- tions, can be used to inform and ed- ucate each patient in advance about nursing tasks required during the night. Scripting eliminates the element of surprise: When patients expect a sleep interruption due to their plan of care, they’re more likely to under- stand and accept being awakened during the night.

We used scripting to further dem- onstrate to patients our efforts to better coordinate their care while taking into consideration their need for rest and uninterrupted time for sleep. For example, we routinely informed patients that vital signs would be taken at 0500 and any bloodwork needed would be ob- tained and medications administered at the same time.

Patients were informed of our efforts to support their rest but told to expect hourly rounding to ensure their safety and to continue to meet their care needs. For example, we explained the use of I.V. pump alarm cords to improve staff response time

and decrease noise. Patients were encouraged to request help to get out of bed during the night.

Changes in unit culture Patient surveys (N = 723) were col- lected continuously from June 2011 until November 2012 and analyzed periodically after each major practice change. These surveys demonstrat- ed that patient satisfaction had improved and changes in practice were being sustained. In part, sustainability was attributed to providing ongoing staff education and regularly reporting the initia- tive’s outcomes. Staff meetings and huddles provided opportunities to reinforce the success of the practice changes, which were supported by the evidence from the survey re- sults. After implementing the initial practice changes, staff was informed of the improvements in the patients’ experience. For example, 7% more patients rated the noise level as “very quiet” during the day, 8% during the evening, and 12% dur- ing the night from November 2011 through January 2012.

Staff champions were recruited early to fortify the practice changes. Unit-based champions encourage everyone, including visitors, volun- teers, and nonnursing staff, to maintain practice changes by in- creasing everyone’s knowledge and awareness.

We placed posters in patient rooms asking, Is it quiet in your room? The poster included suggestions about how patients and families could help reduce noise and what staff actions to expect for a quiet, healing environment for every pa- tient. This supported staff account- ability for practice changes.

The sustainability of the practice changes was measured through on- going surveys focusing on quiet- ness. These results demonstrated that although not all bothersome noises could be changed or elimi- nated, patients’ perceptions showed consistent improvement over a 24- hour period. The results were dis- played as bar graphs and trends in patient ratings during various times of the day or shifts were compared with the initial (baseline) noise

Bothersome noises perceived by patients

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assessment. (See Visualizing patients’ perceptions of noise.)

Discussion The results of this quality improve- ment initiative show how a patient- centered approach was applied effectively to identify noises per- ceived as bothersome and how sur- vey results guided the development of unit-based practice changes and continuous monitoring of the out- comes. We attribute positive changes to scripting and other individualized approaches to prevent unexpected experiences and demonstrate efforts to coordinate patient care.

Efforts to implement practice changes were strengthened by education to increase staff awareness of the effects of noise and make quietness a “24-hour initiative.” Unit champions bolstered staff efforts. The success of the quality initiative depended on all nursing staff transitioning the new practice changes into their standards and nursing care because surveys sup- ported the practice changes. This required ongoing discussions about survey results and continuously rein- forcing practice changes, creating accountability among staff.

As staff took ownership of this initiative, they reminded each other to plug in an I.V. alarm cord or to be quieter in the nurses’ station. An important next step to ensure the sustainability of this initiative was carrying forward the standards of care to new staff orientation, inte- grating the practice changes into the unit culture.

Limitations Limitations of the study were the varying time intervals and number of surveys in each period. In the last 7 months (May to November 2012), the results were based on 135 surveys; in the

Visualizing patients’ perceptions of noise Perceived noise rating during the day

Perceived noise rating during the evening

Perceived noise rating during the night

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0 Very Quiet Quiet Good/Neutral Loud

Day: 0700–1500

Jun ‐ Aug 2011 Nov 2011‐ Jan 2012 Feb ‐ Apr 2012 May ‐ Nov 2012

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0 Very Quiet Quiet Good/Neutral Loud

Evening: 1500–2300

Jun ‐ Aug 2011 Nov 2011‐ Jan 2012 Feb ‐ Apr 2012 May ‐ Nov 2012

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0 Very Quiet Quiet Good/Neutral Loud

Night: 2300–0700

Jun ‐ Aug 2011 Nov 2011‐ Jan 2012 Feb ‐ Apr 2012 May ‐ Nov 2012

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preceding 3 months (February to April 2012), results were based on 252 surveys.

During the initial survey, patients didn’t cite sounds from the telemetry monitoring as bothersome nor did the survey list these. Monitor noise was considered to be included as originating from the nurses’ station. As the quality improvement initiative progressed, patients would occasion- ally ask about the beeping sounds at the station and were surprised to learn the sounds were associated with the telemetry monitoring process. A future consideration in a telemetry unit should include an additional survey question asking about patients’ perceptions of inter- ruptions and noises related to fre- quent electrode and battery changes.

Another limitation was an incon- sistent use of the I.V. pump alarm cords toward the end of the survey collection period. The I.V. pump alarm cords began to fail after a pe- riod of use, and staff stopped using the cords routinely due to frustra- tion. The clinical engineering de- partment collaborated with our unit to develop a troubleshooting meth- odology for staff to quickly identify and resolve the problem and re- establish the regular use of the cords. An important lesson is the im- portance of addressing reported bar- riers to practice changes in a timely fashion to prevent staff frustration and failure to sustain a practice change.

Next steps Our unit is focusing on the future, and fine-tuning and updating prac- tice changes. For example, we’ve de- veloped a troubleshooting guide for nursing staff to assess the functional- ity of the I.V. pump alarm cords. Staff has also been educated on quick res- olutions to cord failure and prompt replacement of the I.V. pump alarm

cords as soon as they fail. Nurses adopted this practice quickly.

Today the expectation on our unit has been consistently set for all levels of staff so that we can sustain and maintain a culture committed to quietness. The orientation of new employees is very important. We’re using a competency-based tool that ensures that every new orientee learns about our practices and expectations during the unit orienta- tion. After orientation, the unit- based educator reviews best practices on our unit, including those related to quietness with the orientee.

The nursing staff continues to reassess patient perception with in- termittent surveys. The results let nurses address any new dissatisfiers in patient perceptions and reinforce the effects and the value our practice changes continue to have on patients’ experiences. ■

REFERENCES

1. Murphy G, Bernardo A, Dalton J. Quiet at night: implementing a nightingale principle. Am J Nurs. 2013;113(12):43-51.

2. Richardson A, Thompson A, Coghill E, Chambers I, Turnock C. Development and implementation of a noise reduction intervention programme: a pre- and postaudit of three hospital wards. J Clin Nurs. 2009;18(23):3316-3324.

3. Li SY, Wang TJ, Vivienne Wu SF, Liang SY, Tung HH. Effi cacy of controlling night-time noise and activities to improve patients’ sleep quality in a surgical intensive care unit. J Clin Nurs. 2011; 20(3-4):396-407.

4. Spence J, Murray T, Tang AS, Butler RS, Albert NM. Nighttime noise issues that interrupt sleep after cardiac surgery. J Nurs Care Qual. 2011;26(1):88-95.

5. Dube JA, Barth MM, Cmiel CA, et al. Environmental noise sources and interventions to minimize them: a tale of 2 hospitals. J Nurs Care Qual. 2008;23(3):216-224.

Cecilia Inman is a unit-based educator/clinical nurse IV at Maine Medical Center in Portland, Me.

The author thanks the staff members of R9 West at Maine Medical Center who were key supporters implementing this quality improvement study as a team. Special thanks to Eira Kristiina Hyrkas for her mentorship and thoughtful review of this manuscript and Cathy Palleschi who encouraged and supported efforts in implementing this project.

The author has disclosed that she has no fi nancial relationships related to this article.

DOI-10.1097/01.NURSE.0000470423.32557.f0