Alarm fatigue in Nursing

Abstract
This paper provides a literature review of the topic of alarm fatigue and alarm management. The sources used were all published from 2016 onward and dealt in some way with alarm fatigue or with the challenges of alarm management. The papers were selected using databases ProQuest, PubMed, Springer, NCBI, and ScienceDirect. The keywords used for searching were “alarm fatigue,” “alarm management,” and “alarm fatigue patient safety.” The results of the review showed that alarm fatigue is represented as a serious problem for nurses for multiple reasons: 1) it prevents them from paying close attention to alarms that could be serious and thus there is a risk of not responding in a time of real crisis; 2) it can lead to patient safety errors, as nurses seek to avoid the constant wave of alarms by altering their volume or sensitivity; 3) it can cause problems with morale; and 4) there is no evidence-based practice or guidance that has been recommended for dealing with alarm fatigue. In short, there is no clear way to address alarm fatigue, and researchers differ on the extent to which alarm management can be effectively utilized. This literature review concludes that there is an obvious need for alarm fatigue to be addressed. The PICO question it asks is: For nurses in an in-patient general hospital, does alarm management (differentiating the priority of alarms) compared to no alarm management have an impact on alarm fatigue?

Keywords: alarm fatigue, alarm management, managing alarm fatigue, alarm fatigue patient safety

Introduction
Alarm fatigue is an expression that consists of two terms that have two very different meanings. Alarm is a term that conveys a meaning of surprise and a state of alert and that communicates a need to respond immediately. Fatigue is a term that conveys the opposite meaning—weariness, lack of responsiveness, inability to act due to tiredness. When put together the expression “alarm fatigue” suggests a quite troubling phenomenon particularly when it occurs among nurses: nurses are trained to respond to alarms and provide needed care to patients when an alarm sounds; however, because of the fact that there are now so many different alarms constantly going off in a unit, nurses can become indifferent or unresponsive to them, which can put patients at risk. Because alarm fatigue is a relatively new problem in nursing research, it is still unclear as to how it affects nurses (Lewandowska et al., 2020). While there has been ample literature published on the issue, the extent to which it is an actual problem for nurses and, if it is, what can be done about it are questions that have let to be substantially answered (Hravnak et al., 2018). As researchers have shown, it is unclear how precisely to manage alarms so as to prevent fatigue (Cho, Kim, Lee & Cho, 2016). This study thus addresses the gap in the literature by focusing specifically on the problem of whether alarms can be managed to reduce alarm fatigue. It is an important question to ask because patient safety is the ultimate issue here: if alarm fatigue is not prevented, patient safety can suffer as a result.
Review of Literature
The literature on alarm fatigue and alarm management shows that alarm fatigue is a problem for nurses and for patient safety, and that alarm management may have potential to address the situation but so far there are questions remaining (Baker & Rodger, 2020; Cho et al., 2016; Hravnak et al., 2018; Lewandowska et al., 2020). The key to understanding this issue is to first understand alarm fatigue, what it is, and how and why it occurs. Then one can begin to examine the possible solution of alarm management to see what researchers have found about that.
Alarm fatigue is said to be caused by sensory overload: nurses are often surrounded by various alarms that go off throughout their shift. Because there are so many similar alarms sounding, nurses can become tired of them or fatigued by them so that they do not respond to alarms with the same vigor and assertiveness required for patient safety (Baker & Rodger, 2020). Baker and Rodger (2020) examine the ins and outs of alarm fatigue by conducting a qualitative literature review of the subject. They look at what other researchers have found and show that often one cause of alarm fatigue is that nurses do not even know whose job it is to respond to certain alarms. They have trouble differentiating one sound from another or recognizing whose role it is to respond (Baker & Rodger, 2020). Another issue is that if a nurse is busy, that nurse might simply assume that the next closest nurse will respond to the alarm; so there is a lack of communication, understanding and protocol in nurse workstations regarding how to react to alarms (Bakere & Rodger, 2020). That is one reason Cho et al. (2016) have found that alarm management can be prone to failure. Human error is still an issue no matter what system is in place. It is the same with trying to manage a computer system safely: firewalls may be in place, but systems can still be hacked because of errors committed on the part of end users. End users are always the riskiest factor in the equation, and in alarm management it is no different: nurses are still only human and must be trained thoroughly to understand their roles, the different alarms, when to respond and so on, and all of that takes time and comes on top of already existing training that must be implemented for new nurses (Cho et al., 2016). Additionally, new technology and monitoring devices can change everything and lead to disruptions that throw off carefully cultivated response protocols and systems in place.
Hravnak et al. (2018) in their study of alarm fatigue point out that most of bedside alarms are non-actionable, which means there is no need for immediate response. This fact is what causes nurses to ignore alarms as well, as they experience sensory overload due to a constant stream of alarms all shift long that serve no real purpose. This becomes a problem when an actual issue does arise and nurses fail to respond because they believe it to be another non-actionable issue, same as all the others (Hravnak et al., 2018). Hravnak et al. (2018) provide a qualitative literature review of what is currently going on in the field with respect to addressing the challenges of alarm fatigue. They identify the different causes and show why they are complex. They also examine some of the current solutions being suggested by researchers. They acknowledge that decreasing non-actionable alarms is the most important thing, as this is what primarily leads to alarm fatigue. Hravank et al. (2018) note that some researchers have suggested customizing alarms around a new baseline so that alarms do not go off as frequently whenever a minor change from a normal state is detected; however, other researchers have indicated that this approach does not significantly alter outcomes. Thus, the challenge of understanding whether alarm management is effective remains. One potential solution suggested by Hravank et al. (2018) is artifact discrimination, which involves machine learning. Smart alarms is another option suggested. However, these all involve tech upgrades and new systems that come with costs.
Lewandowska et al. (2020) show in their systematic review of literature on alarm fatigue that nurses feel overwhelmed by a constant wave of alarms and that they feel this constant wave is what drags down their performance. This is an important point to keep in mind because it indicates that rather than assist nurses in doing their jobs alarms actually interfere with their jobs, thus raising the question of whether alarms are really even necessary (Lewandowska et al., 2020). Yet the biggest problem that Lewandowska et al. (2020) observed in their systematic review is that having to monitor and use modern equipment takes up so much of nurses’ time that they feel could be better spent tending to patients. They are discouraged and demoralized by having to spend time on advanced computer equipment and by having to pay attention to all the alarms that go with this equipment. They feel a lot of it is unnecessary and only put into use because the facilities’ managers felt it was necessary, as they were likely pressured by sales representatives to buy it. In other words, nurses have a strong distaste for all the modern equipment that they believe gets in the way of their ability to actually nurse. They ignore alarms for that reason.
Oliveira, Machado, Santos and Almeida (2018) conducted a quantitative observational study over the course of 7 hours, in which they viewed 20 different patient beds during the course of time. The researchers found that out of 103 alarms activated, two-thirds of them were fatigued. The multi-parameter monitor was the device that most often gave alarms. The conclusion of the researchers was that relevant alarms may go ignored, which can compromise the safety of the patient. The problem of alarm fatigue is not addressed in the study other than in its impact on patient safety. How to address alarm fatigue is not the focus—but clearly the researchers indicate that there is a need for that issue to be addressed.
Torabizadeh, Yousefinya, Zand, Rakhshan and Fararooei (2017) arrive at the same conclusion in their study of alarm fatigue and its impact on nurses’ ability to do their jobs. However, in the study by Torabizadeh, they focused on developing an adequate psychometric questionnaire for nurses that could be used to better measure how alarm fatigue is impacting them. Their study produced good results in terms of validity and reliability, and thus they concluded that researchers could use their questionnaire to measure alarm fatigue in nurses. This is thus an important study because it provides researchers with a tool for measuring alarm fatigue by questionnaire method instead of trying to figure out new metrics on their own.
Sowan et al. (2017) attempted to answer that question by conducting a descriptive study with a survey of 30 nurses on 4 different ICUs. The nurses reported having a lack of confidence in the machines and that nearly half of the nurses did not know what the majority of the functions on the machines did. In other words, there was a sever lack of understanding about what these machines were for and what they are made to facilitate. The researchers concluded that clearly nurses need more training about these machines and what their functions are. The hypothesis with this regard is that by training them to understand the machines better, the nurses may have more understanding of what the machines are used for, how they work, and how to respond to different alarms more appropriately. The problem again arises, however, that training is time consuming and costly and facilities are already under pressure to cut costs. Although more training with these machines might seem sensible, the reality is that it probably will not happen across the board (Sowan et al., 2017).
Van Pelt and Weinger (2017) reported on a conference of professionals involving distractions among health care workers. One major finding of the conference was that alarm fatigue is a serious problem because it is difficult for nurses to tell the difference between a false alarm and a true alarm. Alarm thresholds and volumes, moreover, can be tampered with by nurses and this can impact responsiveness. As there has been no standardized, evidence-based protocol implemented to address alarm fatigue related issues, the problem persists. How to address the issue is the main question that this study and all the other studies reviewed herein ultimately drive towards.
PICO Question
The PICO question for this study is: For nurses in an in-patient general hospital, does alarm management (differentiating the priority of alarms) compared to no alarm management have an impact on alarm fatigue?
Methodology
For this study, the University library portal was used for conducting searchers for scholarly literature on the topic of alarm fatigue and alarm management. The goal of the search was to obtain the most recent studies published on this subject so as to see what the gaps in the literature were and what needed to be explored further in the research department.
Databases searched were ProQuest, PubMed, Springer, NCBI, and ScienceDirect. Keywords used to conduct the searchers included: “alarm fatigue,” “alarm management,” “alarm fatigue patient safety,” and “alarm fatigue prevention.” Keywords were selected based on the topic of the research study.
Inclusion criteria were set for studies published no earlier than 2016; studies had to be published in English, and had to be published in peer-reviewed journals. Studies that only discussed alarm fatigue were included as an option for review if there were too few studies found that discussed alarm management as a prevention strategy for alarm fatigue. In the end, four studies on alarm management were included and four studies on alarm fatigue and its affect on nurses and patient safety were included.
Exclusion criteria consisted of studies older than five years, studies not did not discuss alarm fatigue or alarm management in their titles and/or abstracts, and studies that were published in non-peer-reviewed journals. In total, eight studies on alarm fatigue were selected for review in this paper.
Evaluation/Recommendation
It is evident from the results of this literature review that some intervention is required in order to address the problem of alarm fatigue. However, because it is unknown what sort of intervention can best solve the problem, more work is needed in this area. Researchers should be focusing on identifying methods of intervention that can reduce the risk of alarm fatigue for nurses. To understand what might work, it is helpful to evaluate the sticking points.
First off, there is an unfamiliarity among nurses with many of the machines used in alarms. Nurses are not trained to understand these machines perfectly; however, they are not likely to receive such training as a great many tasks are expected of them and they are not given knowledge about every aspect of the tools they use. They are taught what to monitor and how to respond, but beyond that there is little direction. Nurses clearly need more guidance in this area.
Second, nurses are met with a constant wave of alarms during their shifts and this can be physically, emotionally and morally overwhelming. It is natural that nurses should want to turn down the volume on these alarms as they are often false alarms caused by too sensitive machines. Nurses train themselves to ignore them just to keep their sanity. This raises the question of why these machines, which by all accounts are programmed to be sensitive, are in use in the first place.
Third, nurses feel that these computers, alarms and machines take too much of their time and that they actually keep them from tending to their patients in a better way. Instead of spending time with patients and tending to their needs, they spend half their time filling out forms on the computer and having to ignore their patients while they do so. This hurts their patients’ sense of self and it pains nurses to have to ignore patients while they follow protocols and put information into machines. Nurses would like fewer computer interactions and more patient-interaction.
What all of this means is that nurses are being overwhelmed by machines and these machines are adding unnecessary burden to their shoulders and preventing them from engaging with patients in a healthy way. Often these machines are introduced into an environment not for patient safety but rather for facility safety; they facilities believe that these machines will reduce the risk of medical malpractice.
The problem is that they are also increasing the risk of nurse demoralization and alarm fatigue. Alarm fatigue can in turn bring about the very thing that the facilities do not want to see happen. Thus, in some ways it is a Catch-22 situation. The question is what can the health care industry do about it?
One possible way to address this situation is to come up with an effective way to manage alarms. Alarm management may consist of using a system of differentiated alarm sounds that can help nurses better deal with the environment in which they are working so that there is less trouble in terms of providing quality care. More research is needed on alarm management and its effect on reducing or preventing alarm fatigue among nurses.
Conclusion
Alarm fatigue is a major problem among nurses that researchers are spending more time focusing on. They have found that it does impact patient safety, but the problem is that there is to date no clear evidence-based solution to the problem. More research should be conducted in terms of how alarm management can be implemented to prevent alarm fatigue. Alarm management approaches have differed among researchers in the past, but one option is to differentiate the priority of alarms. This may require tweaking current machine learning and enabling machines to better understand what type of alterations from the norm to ignore or to communicate to staff. Every aspect of this problem has to be studied in more detail because it may not be just a matter of training nurses to understand their machines or to differentiate alarm sounds. However, nurses do need better training in terms of understanding their roles when an alarm sounds. If a nurse is busy and another nurse is nearby when an alarm sounds, both nurses need to know what to do in that situation. Nursing protocols need to be standardized, but that cannot be done until there is evidence-based practice that has been validated in research and in the field.
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