CLINICAL ALARMS are crucial to patient care in hospital settings. Alarms alert healthcare professionals to potential patient-care issues using an undesirable noise for increased patient safety. The reactions to this noise can be equated to noise sensitivity.1 Alarm fatigue can be defined as a desensitization to alarm noises due to a high volume of false or nuisance alarms.2 It consists of two components: desensitization and alarm apathy, which may result from the overuse of alarm-based devices such as telemetry monitors. This article details a study on the impact of alarm fatigue on nursing students and discusses potential solutions to improve patient safety in clinical practice.
Alarm fatigue and alarm apathy may develop as healthcare professionals become overwhelmed by the number of alarm alerts, causing desensitization.2 Alarm desensitization can lead to delays in the response to alarms or overall neglect of alarms.2 Alarm fatigue has been equated to desensitization, as it is a multifactorial problem related to increased alarm devices in hospital settings.
As members of the clinical faculty who work with novice nursing students, the authors questioned the effect of repeated alarms and alerts on their students. It was unclear if the nursing students were affected by alarms or became desensitized to the sound. As such, it was essential to recognize the nature of alarm fatigue among nursing students before they enter the workforce.
The authors examined the scope of alarm fatigue among nurses in the literature.2,4-6 For example, one national study analyzed comments from 406 nurses about their perceptions of clinical alarms. The results identified interrelated themes in the responses, two of which described dissonance and desensitization. Often prompted by false alarms, the nurse participants became desensitized to the alarm sounds as a means of self-preservation.4
In another study, most nurses agreed that nonactionable alarms occurred frequently, disrupted patient care, and caused distrust in the alarms, sometimes prompting the nursing staff to disable them.5 These false and nuisance alarms contribute to alarm fatigue and apathy.
The literature was somewhat limited regarding the impact and recognition of alarm fatigue among nursing students. However, one experimental study noted and assessed nuisance alarms and the overall effect of alarms on learning activities among first semester nursing students. The students developed a greater awareness of alarms following a learning activity, but the findings indicated that student participants from the experimental and control groups perceived healthcare providers as having frequently ignored alarms. Additionally, the students' perceptions of false alarms occurred frequently and were significant in both groups. Although it is unclear how these students were able to distinguish a true alarm from a false alarm, the data supported the idea of alarm desensitization among nursing students.7
The authors developed this study to evaluate alarm fatigue in undergraduate nursing students and to add to the current body of knowledge. Its purpose was twofold:
- to explore whether alarm fatigue develops in nursing students between their first and last clinical exposures in hospital settings
- to determine if a history of healthcare work increased alarm fatigue.
The authors implemented a longitudinal quantitative survey among baccalaureate nursing students from a second semester cohort in the Southeastern US. The university's Internal Review Board approved the study, and the nursing students were informed about and consented to the study via a cover letter. The cover letter explained the purpose, confidentiality, and voluntary nature of the study, and informed participants that they could withdraw at any moment without consequence. The survey was administered before and after each clinical exposure. Data were collected at six points throughout the 18-month study. These data collection points occurred at the beginning (tq1) and end (tq2) of the second semester, the beginning (tq3) and end (tq4) of the third semester, and the beginning (tq5) and end (tq6) of the fourth semester. Each semester was 15 weeks long.
Nursing students completed a three-part survey, which included questions about demographics, previous healthcare employment, and their areas of interest in healthcare. In addition, a five-item Likert survey examined individual sensitivities to common alarm noises in the hospital. Sensitivity was defined as the physiologic or psychological state of an individual in response to noise.1 (See Likert survey: Alarm fatigue sensitivity.)
The alarm types were chosen based on a review of the literature to determine which safety alarms were most commonly ignored. These included call bells, bathroom alarms, fall and safety alarms, I.V. infusion pump alarms, and telemetry alarms.3,8 Because the literature was limited regarding validated tools specific to alarm recognition and fatigue among nursing students, the authors determined that the participants may be unable to comprehend questions pertaining to certain alarms. As such, a tool geared toward novice nursing students was created to address the alarm sensitivity and recognition in this population.
The self-reporting tool utilized a five-point Likert scale, with 1 describing no sensitivity and 5 describing extreme sensitivity. It was developed by the authors and reviewed by experienced researchers in the nursing faculty at the authors' institution. It was also evaluated for content validity during a pilot study, which used the instrument at the beginning of the program before any clinical exposures and after the final clinical exposure. Internal consistency was performed using Cronbach's alpha and indicated good reliability (alpha 1 = .885 and alpha 2 = .681). After the pilot study, it was reviewed again by the nursing faculty and instrument revisions were made based on their recommendations. For the current study, the instrument's overall reliability is estimated at alpha = .677. (See Reliability estimates.)
Data collection and analysis
Each semester course allowed 15 minutes of class time to complete and collect the surveys. The instrument gathered data on the types of alarms to which the nursing students were sensitive in hospital settings. Demographic information related to the students' previous healthcare experience and type of work were also elicited during the data collection process.
Data were entered and analyzed using the Statistical Package for Social Sciences (SPSS), version 24.9 These included assessments for changes in each survey question during each of the six points of measurement using a repeated-measure analysis of variance. A generalized linear model analysis and paired t-testing were also conducted. Independent sample t-tests assessed previous healthcare experiences and instrument reliability, and a multiple stepwise regression analysis further examined the statistical data. (See Key terms for statistical analysis.)
The cohort of 89 nursing students included 88 females and 1 male, ranging in age from 21 to 29. The participation rate ranged from 85% to 100%. The data demonstrated no statistically significant difference across the six points of measurement for the questions related to the call bell, bathroom call bell, fall and safety alarm, and telemetry alarm (P = less than .05). However, the results indicated a statistically significant decrease across the six points of measurement in sensitivity related to the I.V. infusion pump alarm (P = .006).
Paired t-tests were conducted to observe any significant before-and-after changes in sensitivity between tq1 and tq6 for each of the five survey items. For example, there was a statistically significant increase in sensitivity ratings relative to the fall and safety alarms (P = .003) and a statistically significant decrease in sensitivity to the I.V. infusion pump alarms (P = less than .001).
A series of independent sample t-tests assessed whether previous healthcare experience led to differences in how the participants responded to the five questions. No statistically significant differences were noted between those who had worked in healthcare settings and those who had not in tq1, tq2, tq3, and tq5 (P = less than .05). However, a statistically significant difference was observed during tq4. During this time, participants with previous healthcare experience were more sensitive to the bathroom call bell and fall and safety alarm than those without experience (P = .003, P = .001). However, those with previous healthcare experience were statistically less sensitive overall compared with those without previous healthcare experience (P = 0.12).
A multiple stepwise regression analysis assessed whether the documented alarm sensitivity during the first five points of data collection could predict the results for tq6. For questions related to call bells, bathroom call bells, and fall and safety alarms, the multiple stepwise regression analysis was not statistically significant. For I.V. infusion pump alarms, however, the results of tq1 and tq4 were statically significant and predicted 12.4% of the variability during tq6 (P = .003). Similarly, the results related to the question on telemetry alarms during tq1 were statically significant and could predict 4% of the variability in the responses during tq6 (P = .048). The regression analysis also revealed good reliability and internal consistency of the measurement tool.
|Reliability estimates are done on new measurement tools to test for consistency and dependability. As this tool was created by the authors, its reliability needed to be tested.
||Reliability estimates using Cronbach's alpha (n = 89), ranging from 0.5 to less than 1
||alpha = .862
||alpha = .755
||alpha = .563
||alpha = .524
||alpha = .673
||alpha = .688
This study demonstrated a decrease in sensitivity to I.V. infusion pump alarms and an increase in sensitivity to fall and safety alarms, the latter of which has been emphasized in the nursing curriculum. Additionally, nursing students noted a decrease in sensitivity the longer they were in the program. This suggests that more clinical exposure to and experience with alarms taught nursing students to ignore the alarms. However, increased exposure and experience did not offer students a strong familiarity with safety concerns related to patient alarms. Consequently, nursing students could affect patient safety in the hospital setting by ignoring or failing to respond to patient-care alarms.
Nursing students have limited clinical judgment skills to provide high-quality patient care. A solution-based process acknowledges this and individualizes education through practical application and experience. Performance-based simulated scenarios with clinical judgment reasoning represent one potential option to maximize nursing student responses and minimize patient safety issues. These scenarios provide opportunities to assess the nursing student's ability to recognize and respond to alarms.
In simulated nursing scenarios, the students identified an audio alarm and performed the expected response to that alarm. For example, when the bathroom alarm sounds, the expectation is that nursing students should stop what they are doing and respond. The simulated scenarios asked nursing student participants to respond to the situation and prioritize the next steps for patient care. Upon their arrival, they also addressed any potential fall or safety issues encountered, such as a patient on the floor. The debriefing process then included a review of the expectations and patient safety responsibilities for the specific alarms. Nursing students also reviewed the importance of urgency in response to specific alarms, as prolonged response times or ignoring alarms may negatively impact patient outcomes.
Patient safety related to alarms and the associated healthcare responsibilities may represent a vulnerable area for nursing students and should be emphasized in their curriculum. Recognizing the types of alarms, the causes of alarm fatigue and desensitization, and any associated patient safety issues is crucial and requires review. Similarly, assessment rubrics that list the steps and processes to follow when an alarm sounds would be beneficial for nursing students. (See Alarm recognition performance criteria.)
Limitations and implications
Alarm fatigue is one of many challenges facing nursing students in today's hospital environment. This study supports the need for programs to address alarm fatigue in these students. For example, potential alarm sounds could be reviewed as part of hourly nurse rounding. Further research should consider addressing the impact of previous or concurrent work experience, as well as any nursing school clinical experiences, on a nursing student's sensitivity to alarms.
The authors' research was limited by a small sample size that differed between periods of measurement and data collection points, with only one cohort followed throughout the study. Additional research with larger sample sizes and additional cohorts may also add to the generalizability to the findings.
Alarm fatigue is a well-documented phenomenon among practicing nurses, but little is known about its impact on nursing students. This study suggests that alarm fatigue may develop in nursing school. As such, nurse educators should provide evidence-based tools and strategies to increase awareness of alarm fatigue among their students. Additionally, performance-based solutions can identify core issues, individualize solutions, and increase awareness and response among nursing students to better prepare them for clinical practice and subsequently improve patient safety and quality of care.
Prioritizing alarm system safety
Between 2009 and 2012, The Joint Commission identified 98 alarm-related episodes most commonly attributed to clinician alarm fatigue. These resulted in 90 patient deaths. Additionally, 13 patients had permanent disabilities and 5 required unforeseen healthcare interventions and experienced an increased length of stay. As a result, The Joint Commission partnered with the Association for the Advancement of Medical Instrumentation and the FDA to establish national patient safety goals, which directed hospital organizations to prioritize “alarm system safety.”1
Nurses and other clinicians, nursing students, patients, and families are exposed to over 700 alarms per patient day.2 These noises may interfere with safe nursing practices and lead to alarm fatigue. Alarm fatigue occurs when the highly sensitive physiologic monitors that respond to subtle patient changes create “nuisance alarms” for healthcare staff.3 The present piece encourages students and readers to consider the default settings of a monitor in terms of what should be monitored, how patients can be monitored safely without unnecessary alarms, and what (if any) ongoing assessment may be needed. Specifically, the authors conducted one of the few research studies examining alarm fatigue in nursing students. The participants became significantly less sensitive to infusion-pump alarms. Similarly, those with prior experience in hospital settings were not only desensitized to infusion-pump alarms, but also to fall and safety alarms and bathroom call alarms.
An evidence-based tool kit presented by Philips and colleagues provides a resource for education on alarm safety and the use of the physiologic monitors.3 This can be adapted to individual units or larger organizations to ensure that the educational framework is a good fit and eventually reduce alarm fatigue by eliminating the unnecessary use and/or overuse of alarms while maintaining patient safety. It may also be an appropriate resource for the nursing faculty at the authors' institution to guide the development of simulation exercises throughout the nursing program and assess the students' use of physiologic monitors, knowledge of appropriate alarm parameters, and diligent responses to patient alarms.3
DONNA FELBER NEFF, PhD, RN, FNAP
Professor, University of Central Florida in Orlando, Fla., and coordinator of the Nursing Research department
Likert survey: Alarm fatigue sensitivity
The five-item survey was rated on a scale of 1 to 5, with 1 describing no sensitivity and 5 describing extreme sensitivity, and included the following questions:
- How sensitive do you feel when you hear a call bell ring?
- How sensitive do you feel when you hear a bathroom call bell ring?
- How sensitive do you feel when you hear a fall and safety alarm ring?
- How sensitive do you feel when you hear an I.V. infusion pump ring?
- How sensitive do you feel when you hear a telemetry alarm ring?
Key terms for statistical analysis10
Cronbach's alpha: measures reliability and evaluates the consistency and stability of scores over time; displayed as alpha.
Independent sample t-test: compares the means of two independent groups to measure whether they were significantly different.
Multiple stepwise regression analysis: assesses the strength of the relationship between the dependent variable and predictor variables.
Paired t-test: compares two sets of observations to evaluate the differences; in this case, alarm sensitivity over time.
P-value: evaluates the strength of the hypothesis; the smaller the number, the stronger the strength of the hypothesis.
Repeated-measure analysis of variance and generalized linear model analysis: measures the same measurement over time for each variable.
Alarm recognition performance criteria
Below is a faculty evaluation checklist to assess alarm responses in nursing students:
- recognized the alarm and location
- proceeded to the alarm room, demonstrating a sense of urgency
- identified any immediate patient safety concerns
- identified and silenced the alarm
- identified a solution to the alarm
- implemented and evaluated the solution to the alarm
- educated the patient on the alarm
- reengaged the alarm as needed.