Nursing A Concept analysis

Running head: A CONCEPT ANALYSIS OF ALARM FATIGUE IN NURSES 1

ALARM FATIGUE 2

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A Concept Analysis on Alarm Fatigue in Nurses

Kristina Salerno

Wagner College

A Concept Analysis of Alarm Fatigue in Nurses

Introduction

The purpose of this paper is to examine the concept of alarm fatigue in nurses who work in acute care settings. Alarm fatigue in nursing has been a subject of concern for many years, especially due to advancements in technology, yet, remains an ongoing problem within the field. Nurses in acute care settings, such as telemetry and intensive care units, are constantly challenged working in noisy environments. Factors that contribute to this type of environment include cardiac monitor alarms, clinical mobile devices, ventilator alarms, IV pumps, tube feeding machine, bed alarms, and call bells. These technologies were designed to improve patient safety, yet nurses who are constantly faced with the alarms throughout their shift, may develop alarm fatigue. Consequently, these alarms reduce their efficacy and patient safety outcomes may decrease due to nurses experiencing alarm fatigue. This paper will explore the significance and definition of the concept of alarm fatigue, defining attributes, antecedents, consequences, and theoretical relevance in nursing.

Definition of Concept

When defining the concept of “alarm fatigue” as a whole, it is important to first understand the meaning of each word on an individual basis. According to the Merriam-Webster dictionary, the word, “alarm” is defined as, “a signal (such as a loud noise or flashing light) that warns or alerts,” “a device that signals,” and “a warning notice.” Synonyms of the word, alarm, include: “alert, signal, and warning” (Merriam-Webster, n.d. -a). The Merriam-Webster dictionary defines “fatigue” as, “a weariness or exhaustion from labor, exertion, or stress.” Synonyms of this word include: “burnout, exhaustion, and tiredness” (Merriam-Webster, n.d. -b).

When combining these two terms, it creates a concept that heavily affects nurses throughout the world. “Alarm fatigue” is not defined in dictionaries such as the Merriam-Webster dictionary; however, this concept has been studied by clinical researchers who have created their own definition. One definition that accurately describes this concept is from The American Journal of Maternal Child Nursing. The author of this article defines alarm fatigue as that it, “occurs when a clinician becomes desensitized to the alarm stimulus and ignores the alarm, overrides the alarm, or has a delayed response to the alarm” (McCartney, 2012). The sounds of excessive alarms in stressful environments, such as telemetry and intensive care units, can cause nurses to go into sensory overload. Medical devices can alarm so frequently, that nurses can miss or delay the very things that were designed to improve patient safety. Many alarms that nurses encounter throughout their shift are false alarms. In fact, studies show that presence of false and/or clinically insignificant alarms ranges from 80-99% (Cvach, 2012). The alarms, which contribute to creating this noisy environment, often serve as a distraction and interfere with nurses’ job performance and can lead to errors and adverse consequences. These frequent, and often false alarms, cause a reduction in responding, known as the “cry wolf effect.” (Cvach, 2012). These false positive alarms contribute to desentization, caregiver apathy, and mistrust.

Many literature review articles outline and define the concept of “alarm fatigue” in similar ways; however, it is important to define an operational definition of this concept. Through the synthesis of information, such a definition can be formulated. Alarm fatigue can be defined as a phenomenon in which nurses experiencing frequent alarms from medical devices develop sensory overload and desensitization, which, in turn, can lead to adverse and consequential effects on their patients. (Nicely done.)

Defining Attributes

Defining attributes are characteristics that appear in a concept repeatedly in literature review. There are several defining attributes of the concept of alarm fatigue in nurses working in acute care settings. The definition of this concept takes note of some of its defining attributes: “Alarm fatigue is a multifactorial problem related to the rapid proliferation of alarming devices, use of alarm limits that are unnecessarily narrow or not standardized, and exacerbated by high rates of false or nonactionable alarms” (Johnson et al., 2017, p.1). The most significant defining attributes of the concept of alarm fatigue include: working in an environment with constant, repetitious sounds, false, nonactionable alarms, and desensitization to these frequently sounding alarms. Nurses working in acute care settings, such as telemetry and intensive care units, work in noisy environments with multiple alarms going off for up to twelve hours. These alarms, which are meant to improve patient safety, often get ignored or delayed responses by the nurses because many times, the alarms are false. Nurses become desensitized by these sounds, which can result in poor patient outcomes if the alarm was, in fact, real and significant.

These defining attributes allow for broader insight into the concept of alarm fatigue of nurses in acute care settings. Each defining attribute listed is essential to this concept, especially in nursing. This concept and its attributes are so significant, that leaders of the Joint Commission established “alarm safety system” as a hospital priority as of July 1, 2014. The Joint Commission’s 2014 National Patient Safety Goal included elements of performance, such as identifying the risk for patient harm if the alarm signal is not attended to or if it malfunctions, potential for patient harm based on incident history, and whether specific alarm signals are needed or unnecessarily contribute to alarm noise and alarm fatigue (Johnson et al., 2017). With gathering input from staff as well as relevant data, the Joint Commission worked to publish the best practices and guidelines for nurses at risk or who have already fallen victim to alarm fatigue.

Model Case

“Kim, a newly graduated Registered Nurse, begins her career working on a telemetry unit. Unlike other medical-surgical units, telemetry units require patients to be placed on cardiac monitors. Nurses are responsible for closely monitoring the patients, as their conditions are more acute than those on other units. As a new graduate, Kim is given a month on orientation with a preceptor. Her preceptor, Nancy, has been working on the unit for a year, and has developed the knowledge and skills needed to provide quality care. On Kim’s first day of orientation, she was surprised to hear how noisy the unit was. Telemetry monitor alarms, clinical mobile devices that signal when cardiac monitors go off , IV and tube feeding pumps, bed alarms, ventilators, and call bells constantly sounded in the unit. Kim asked her preceptor, ‘How are you able to concentrate and work when you are surrounded by all this noise every day?’ Nancy responded, ‘You get used to it. I used to be conscious of all these sounds, but over time, it gets tuned out.’ Towards the end of her orientation, Kim was responsible for caring for five patients with minimal assistance from Nancy. One shift, Kim was having a busy day, and her clinical mobile device was constantly alarming. Every time the cardiac monitor and mobile device alarmed, Kim and Nancy immediately checked on the patients to assess their status. They noticed that these alarms were mostly false. Towards the end of their shift, the mobile device signaled and Kim and Nancy did not respond immediately, because they assumed it was false, like most of the alarms that day. After a few minutes, the nurses went to check on that patient, and to their surprise, they found the patient to have supraventricular tachycardia. The patient’s heart rate was sustained in the 170s and was experiencing severe chest pain and palpitations. The nurses called the Rapid Response Team, who helped stabilize the patient. Like many nurses, Kim and Nancy fell victim of alarm fatigue.”

Antecedents are events that take place before the occurrence of the concept. In the model case, several antecedents are noted. One key antecedent to alarm fatigue is the noisy work environment. Kim was surrounded by constantly sounding alarms such as cardiac monitors, clinical mobile devices, and call bells. Working in such an environment makes it very difficult for nurses to provide quality care. This type of environment promotes many outlets of distraction, yet nurses are required to concentrate on the task at hand under these circumstances. Another significant antecedent is the false positive alarms of the medical devices. At the beginning of her shift, Kim was immediately attending to the alarms, but after noticing a pattern of many false positive alerts, her response time was increasing. Lastly, the nurse-patient ratio is considered an antecedent to this model case. Kim was required to care for five telemetry patients. The more patients a nurse has to care for equates to more alarms the nurse is exposed to and needs to attend to.

Consequences are events that take place as a result of the occurrence of the concept. Kim is working in an acute care setting. This type of environment tends to be very noisy and distracting. Noise pollution and frequent disruptions of care processes lead to errors, which ultimately contribute to adverse events and consequences (Wilken et al., 2017). Alarm fatigue caused Kim to become desensitized to the very alarms that were designed to keep the patients safe. Her response time increased due to the constantly sounding false positive alarms. Kim assumed that like most of the alarms that went off that day, that the true alarm was false. Immediately responding to this alarm could have prevented the adverse complication. Nancy also experienced alarm fatigue and desensitization. This is evident when she tells Kim, “You get used to it. I used to be conscious of all these sounds, but over time, it gets tuned out.” Alarm fatigue causes continuous stress and unnecessary work, leading to staff dissatisfaction, which results in decreased staff health, high staff turnover rate, and high levels of burnout (Wilkin et al., 2017).

Empirical Relevance

The family health model that strongly correlates to the concept of alarm fatigue is Florence Nightingale’s environmental theory, Nightingale was one of the first nurses to document the impact of the built environment on patients (Zborowsky, 2014). In her book, Notes on Nursing: What it is and What it is Not (1946), Nightingale explains how the environment affects a patient's health and that it is the nurses’ responsibility to maintain an optimal environment for healing. Some environmental factors that significantly contribute to health outcomes include the air, light, noise, cleanliness, and nutrition. The environmental theory is a systems model that focuses on the patient in the center, surrounded by aspects of the environment all in balance (See Figure 1). If one element is out of balance, the patient becomes stressed, and it is the nurse’s responsibility to do what is needed to bring back balance to the patient’s surrounding environment to relieve the stress (Zborowsky, 2014). The concept of alarm fatigue specifically focuses on noise, one of the environmental factors that contribute to health outcomes. Nightingale wrote, “Unnecessary noise, or noise that creates an expectation in the mind, is that which hurts a patient. Intermittent noise, or sudden and sharp noise, in these as in all other cases, affects far more than continuous noise–noise with jar far more than noise without.” (Nightingale, 1946, p.56).

Just as loud noise negatively affects patients’ health, it also affects the nurses’ performance. Nightingale wrote, “Unnecessary noise, then, is the most cruel absence of care which can be inflicted either on sick or well” (Nightingale, 1946, p.60) In acute care settings, nurses often experience alarm fatigue from working in noisy environments. Many of the noises heard in acute care settings are loud and sudden. Most of the noises heard are from medical devices such as cardiac monitors, clinical mobile devices, and IV pumps, to name a few. Nurses who experience alarm fatigue become desensitized to the very alarms that are supposed to improve patient safety. This may cause nurses to ignore these alarms, causing delay in treatment to patients who may be decompensating. Unsafe working environments result in increased safety risks and poor patient outcomes.

It is just as important to maintain a quiet environment for patients to heal as it is for nurses to work in. “Physical aspects of nurses’ work environment significantly impact their ability to perform their job and, as a result, impact patient care outcomes” (Zborowsky, 2014). It is important that initiatives be created to help redesign work environments to decrease the risk of error and increase value added time for the nurse. Nurses’ time is better spent at the bedside, providing the care and education needed to improve patient outcomes (Zborowsky, 2014). Florence Nightingale’s environmental theory was designed to have the patient in the center surrounded by many factors that affect their health; however, nurses can be placed in the center as well. The surrounding environmental factors such as noise, cleanliness, light, and ventilation affect the nurses’ ability to provide quality patient care to their patients. It is important to create and maintain quiet, optimal environments for nurses to conduct their work safely and efficiently. This can decrease the amount of nurses who experience alarm fatigue and promote their health and wellness, as well as those of their patients.

Bibliography

Cvach, M. (2012). “Monitor alarm fatigue: An integrative review.” Biomedical Instrumentation & Technology 46 (4): 268–77. Retrieved from https://doi.org/10.2345/ 0899-8205-46.4.268

Johnson, K. R., Hagadorn, J. I., & Sink, D. W. (2017). Alarm safety and alarm fatigue. Clinics in Perinatology, 44(3), 713–728. Retrieved from https://ezproxy.wagner.edu:2310/10.10 16/j.clp.2017.05.005

McCartney, P. (2012). Clinical alarm management. The American Journal of Maternal Child Nursing, 37(3), 202. Retrieved from https://ezproxy.wagner.edu:2310/10.1097 /NMC.0b013e31824 c5b4a

Merriam-Webster. (n.d. -a) Alarm. In Merriam-Webster.com dictionary. Retrieved from https://www.merriam- webster.com/dictionary/alarm

Merriam-Webster. (n.d. -b) Fatigue. In Merriam-Webster.com dictionary. Retrieved from https://www.merriam- webster.com/dictionary/fatigue

Nightingale, F. (1946). Notes on nursing: What it is, and what it is not. New York: Appleton-Century

Wilken, M., Hüske-Kraus, D., Klausen, A., Koch, C., Schlauch, W., Röhrig, R. (2017). Alarm fatigue: Causes and effects. Studies in Health Technology and Informatics, 243:107-111. Retrieved from https://pubmed.ncbi.nlm.nih.gov/28883181/

Zborowsky, T. (2014). The legacy of Florence Nightingale’s environmental theory: Nursing research focusing on the impact of healthcare environments. Health Environments Research & Design Journal, 7(4), 19–34. Retrieved from https://ezproxy.wagner.edu:231 0/10.1177/193758671400700404

Appendix A

Figure 1: Florence Nightingale’s Environmental Theory. From https://nurseslabs.com/florence- nightingales-environmental-theory/