Alarm Fatigue and Nurses

Alarm Fatigue Theories in nursing generally center on the relationship of four concepts -- nursing, environment, person and health. These concepts are interrelated and impact one another in diverse ways, often seen in issues of nursing when problems arise that require analysis. The issue of alarm fatigue is one problem in nursing that touches on each of these four concepts.

Alarm fatigue can be defined as exhaustion that occurs for nurses when they are exposed to many alarms throughout their shift, which causes "sensory overload" and the nurses to develop a "non-existent response to alarms" (Horkan, 2014, p. 83). Complacency and dissension can follow in the nursing workplace as too many alarms for nurses can render them unresponsive. Alarms are needed in nursing because they alert nurses and care providers to emergency situations that require immediate action and intervention, especially in the intensive care unit.

However, nurses and staff work in an environment that is filled with numerous types of alarms with a range of significance. In facilities where alarms are constant, the risk of nurses "tuning them out" is higher (Horkan, 2014, p. 84). The significance of this throughout the intensive care unit nurses fail to adequately respond to alert systems, which puts patients at risk: this is especially problematic because as Horkan (2014) points out, "preventable medical errors are among the top 10 causes of death in healthcare facilities" (p. 84).

Nurses affected by alarm fatigue in the ICU may involuntarily contribute to this risk factor. Patients unfortunately are on the receiving end of alarm fatigue and face the most significant risk -- namely that they will require emergency attention and nurses will not respond appropriately because of alarm fatigue. Patient safety concerns associated with nursing alarm fatigue are risk of neglect and inattention which leads to the occurrence of an otherwise preventable mishap that harms the patient.

One solution to combating alarm fatigue to increase patient safety among hospitalized patients throughout the ICU is to introduce patient specific assessment to limit excessive alarms and background noise. This would reduce sound noise in the ICU and lower the risk of alarm fatigue setting in. Adoptive and Innovation Theory Rogers' Diffusion of Innovations Rogers' Diffusion of Innovations theory holds that innovation can be communicated through diffusion based on the social setting, innovation itself, advantage that it serves, relative complexity, and the degree to which it is compatible.

According to the theory, there is a five-step process that can be utilized in order to facilitate diffusion. Applied to the context of alarm fatigue within the ICU, the step-process would consist of the following: 1) Knowledge of staff 2) Persuasion of staff 3) Decision-making 4) Implementation of evidence-based practice 5) Confirmation of the newly implemented practice The first step, knowledge of staff, is wherein an understanding of the nurses who would be utilizing the patient specific assessment tool is obtained. Understanding the staff is critical to effective and efficient implementation.

If the staff and the tool are not good fits, the implementation will not be a success. Knowing the nurses' needs, their desires, what they require in terms of assessing patients and receiving warnings or alarms -- all of this is essential at the outset because it provides a basic foundation upon which the innovation can be established. Otherwise the risk of staff rejecting the assessment is unaddressed. Foreknowledge of what to expect can help avoid obstacles in the future.

The second step, persuasion of staff, is built upon the knowledge of the staff obtained in the first step. In order to persuade a group, it is imperative that something be known about that group. Persuading nurses to accept an assessment tool that they have no desire to utilize will be less difficult if that lack of desire is properly understood. Knowing why the nurses feel or think a certain way can be highly instrumental in persuading them to alter their cognitive or emotional processes.

The third step, decision-making, involves making a decision about whether the staff will adopt the new assessment. The staff ultimately must decide for itself to accept the innovation as it is their workplace that is under question. The fourth step, implementation, consists of the assessment being put into use by the staff. This step requires oversight, training, and support to ensure that the implementation is effective and efficient with little to no risk of failure.

The final step, confirmation, depends upon conducting an evaluation of the results of the implementation of the assessment and whether or not the data indicates that the assessment produces positive effects among nurses and patients. Significance of Rogers' Diffusion of Innovations Theory for the ICU and Alarm Fatigue The significance of Rogers' Diffusion of Innovations Theory in the ICU as it pertains to alarm fatigue is evident in a number of ways: First, there are nursing implications for combating alarm fatigue.

Diffusion of Innovations Theory provides an approach that facilitates the identification and understanding of those implications, providing a real solution to address the issue. Nursing implications for combating alarm fatigue are: 1) it reduces the risk associated with preventable medical errors that stem from alarm fatigue, 2) it allows nurses to respond more efficiently to alarms and thereby avoid overburden due to noise and warning, and 3) it reduces the stress of the workplace environment associated with response to monitoring signals.

Second, the theory is significant as it provide an approach to the issue of quality of care considerations for implementation of evidence-based practice to address fatigue concerns. Considerations associated with patient safety are that the patient's well-being is given top-priority as a result of this approach; the patient is less likely to suffer from preventable medical errors if nurses do not suffer from alarm fatigue.

Considerations associated with patient satisfaction are that the patient is more likely to be satisfied with response times and care given to them by nurses if nurses are not feeling overburdened by noise (alarms) in their workplace environment (Despins, Scott-Cawiezell, Rouder, 2010). As Ryherd, Waye and Ljungkvist (2008) show in their assessment of noise and the perceived work environment in a neurological intensive care unit, alarms and other noises can serve as "occupational problems" for nurses and "hinder recovery among patients" (p. 747).

The researchers in their study measured sound levels and conducted occupant evaluations in an ICU to determine the impact of sound/noise on nursing efficiency and patient satisfaction. The findings of the study indicated that staff viewed noise as a contributing factor to their stress in the workplace environment. The ramifications of nurses' stress on patient quality of care were described by Ryherd et al. (2008) as significant and the environment of the ICU with its alarm aids and noises was described as "disruptive" by patients, according to the study (p. 747).

This indicates that Rogers' Diffusion of Innovations Theory could be appropriately applied in the ICU setting in order to gain an adequate knowledge of the staff, tools to persuade, the ability to make a decision, implement the innovation, and assess its effectiveness. Despins et al. (2010) discuss using a theoretical framework for detecting patient risk by nurses in their study of "how nurses detect and interpret patient risk signals" (p. 465).

As the researchers indicate, patients face significant risk of preventable medical mishaps when nurses are fatigued by noise in their workplace environment. What the researchers find in their analysis of the relevant literature pertinent to nurses' identification of patient risk signals is that nurses operate more effectively and efficiently when patient safety is their organization's number one priority (Despins et al., 2010).

The researchers conclude, therefore, that organizational factors such as insistence on patient safety as a top priority are highly influential in a "nurses' ability to detect risk in complex healthcare settings" because the organization's prioritization provides nurses with a psychological sifting mechanism by which they can "block out" noises so as to focus on alarms that require attention. This can enable the reduction of risk associated with preventable medical errors.

The study by Horkan (2014) analyzes the relationship between alarm fatigue and patient safety and finds that a "safety culture" is essential in reducing the risk of patient harm as a consequence of nursing alarm fatigue (p. 84). Horkan (2014) recommends that alarm protocols be established and staff trained to follow these protocols as part of the organization's safety culture.

The researcher observes, however, that there is no existing evidence to "support specific guidelines for individualizing alarm settings" and thus Horkan (2014) calls for more research on nurses in order to determine the appropriate and safe parameters for alarm settings "that may be customized for patients" (p. 85). This study indicates that there is a significant need for Rogers' Theory to be utilized as an approach in addressing the situation and filling the gap in research, identified by Horkan (2014).

Patient Specific Assessment Tool A patient specific assessment tool must be developed in order to better understand the need for patient specific alarms and the parameters for alarm settings, as Horkan (2014) has noted. In order to provide this tool, the problem must be viewed in terms of the overall objective and desired outcome. The outcome is to reduce risk associated with preventable medical errors caused by nursing alarm fatigue. The proposed solution is to introduce patient specific assessment to limit excessive alarms and background noise.

The patient specific assessment tool is therefore to be used to reduce alarm fatigue and improve the quality of care provided by nurses to patients. An appropriate theoretical construct for developing the patient specific assessment tool is Rogers' Diffusion of Innovations Theory, which provides a five-step process for understanding the nurses' situation, grounds for persuasion, decision-making, implementation and review.

The patient risk detection theory is also helpful in developing an assessment tool for determining patient specific alarms, and recommended setting parameters can be devised according to the practical observational assessments regarding signal detection (Despins et al., 2010). The findings of Despins et al. (2010) indicate that such a development is possible through a thorough examination of relevant literature. It essentially underlines the steps provided by the Diffusion of Innovations theoretical concept.

Determining a need for patient specific alarms would also be made possible by the utilization of a survey tool, which could be distributed among nurses to assess their views on such alarms as part of the first step of Rogers' theoretical construct. This tool could provide quantitative data with Likert-scale responses, but it could also be supported by a literature review of relevant research on the issue of patient specific alarms.

Both tools can be utilized to provide adequate information for assessment that can then be used in step two of Rogers' process -- the persuasion step. Setting parameters for the alarms would depend upon evidence retrieved from actual implementation, following a trial-period in which results and outcomes are recorded and assessed. This would be part of the final step -- the review stage. The tool for assessing adequate parameters could also be a survey tool, and this could be given to both nurses (and staff) and patients post-discharge.

A qualitative assessment could also be utilized in order to provide a deeper understanding of the effect of parameters -- and this data could be obtained at the end of the survey, using open-ended questions. Steps three and four would rest on the outcome of step two, and assuming that the nursing staff is persuaded to implement the suggested solution, steps three and four can be taken with proper oversight and unified efforts of the staff and administration.

Thus, an assessment that aids nursing staff to determine patient specific alarms and recommended setting parameters is very possible in this situation. With Rogers' Diffusion of Innovations Theory acting as a guide, what is needed is a metric-based data collection tool that can provide quantifiable information, which can then be assessed to learn whether there is a causal-comparative relationship between patient specific alarms and the reduction of alarm fatigue and its attendant risks.

A qualitative collection of information would also be helpful in providing additional measurements of the extent to which the implementation is helpful in reducing alarm fatigue. Both types of data collection can provide the necessary means to perform an assessment of the innovation. A Likert-scale response survey would be an appropriate tool for this assessment, and could include several items with a 1-5 response range from strongly disagree to strongly agree.

This would provide quantitative data, while open-ended questions, allowing the sampled population to elaborate in their own words on their sense of the usefulness of patient specific alarms would provide qualitative data. For the sample, nurses could be surveyed. Patients could also be sampled post-discharge in order to collect their perspective on the quality of care that they received while in the ICU. Each sample's data could be analyzed for correlation, using a Pearson r-test, to see if there is any statistically significant correlation in the findings.

Survey couple with a meta-analysis of relevant literature would best serve as the tools for developing an appropriate assessment for this type of innovation. Since there is no existing information on "individualizing alarm settings" (Horkan, 2014, p. 85), the data has to be collected as part of this assessment and can be done so following the theory of.