Many hospitals are experiencing increased noise levels due to technology, alarms, equipment, and voices. Quietness at night is one determinant of patient satisfaction that influences hospital reimbursement. Today, hospital workload pressures are equally as demanding at night as they are during the day, which makes it difficult to keep the unit quiet enough for patients to sleep. The World Health Organization recommends that sound levels be kept at 30 decibels (dB) or less in patient rooms, but hospital noises have been measured as high as 67 dB in the ICU.1
Studies link sleep deprivation with delirium, which can increase mortality.2 The importance of sleep has been well documented and is necessary for clear thinking, a healthy immune system, and general health.3 Sleep deprivation is linked to decreased immunity, impaired metabolism, decreased pain tolerance, and increased falls.4 In the hospital, cortical arousal, which disturbs sleep, can be caused by pain, nursing interventions, and noise.3 According to Florence Nightingale's seminal work, Notes on Nursing, “Unnecessary noise, then, is the most cruel absence of care which can be inflicted on the sick or well.”5
A 30-bed medical telemetry unit in a Southern California community hospital responded to the challenge of improving the unit environment for patients by reducing noise levels at night with a nurse-led evidence-based Quietness Program. The initiative, which began in April 2015, successfully raised Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores related to patients' satisfaction with quietness on the unit and sustained these higher scores.
Quietness at night and the opportunity to experience restful sleep are key measures of patient and family satisfaction and directly relate to the HCAHPS survey question “During this hospital stay, how often was the area around your room quiet at night?”6
Clinical nurses on the medical telemetry unit reviewed the unit's preintervention HCAHPS scores and realized the scores did not reflect the healing environment that staff strived to provide. Patient satisfaction scores for this HCAHPS survey question were below the 50th percentile for the first quarter of 2015.
The initial Quietness Program development included gathering a small group of staff champions dedicated to creating a healing environment. The group started by reviewing the literature and surveying the staff. In response to the survey question, “What causes noise?” staff members listed the generator check at 0500 hours, the floor cleaning equipment, the tube system, fire alarms, and food carts. Group members also surveyed patients on the most common source of noise that disturbed their sleep. Patient responses included beeping infusion pumps, visitors, hallway noise, air conditioners, and staff voices. A clear gap in perspective emerged.
After interviewing patients and staff, researching current evidence-based practices, evaluating possible solutions, and discussing barriers to quietness with staff members, the quietness champions developed an action plan. The plan included a comprehensive evidence-based Quietness Program with unit-specific interventions, an implementation timeline, and staff education.
The Quietness Program incorporates many strategies to reduce noise and promote auditory comfort. Patients are provided with ultra-soft earplugs, satin eye masks, and their choice of lavender, peppermint, or sweet orange essential oils aromatherapy on request and at the discretion of the clinical nurse based on their current health condition.7 Aromatherapy is administered by putting a few drops of essential oil on a cotton ball in a medicine cup placed near the bedside. The facility instituted a hospital-wide reduction of I.V. lines inserted into the antecubital veins to prevent potentially irritating line-occluded alarms in the infusion pumps. A soothing nightly reflection and blessing is announced over the hospital-wide announcement system at 2000 hours to remind staff, patients, and visitors that the day has come to an end and it is time to sleep. Squeaky hinges and noisy wheels have been fixed or replaced.
Afternoon (1400 to 1500) and evening (2200 to 0500) quiet times were chosen based on the unit flow and patient-care activities. Immediately prior to quiet times, staff offer patients holistic interventions including aromatherapy, Healing Touch, massage, eye masks, ultra-soft earplugs, warm blankets, and snacks. Healing Touch is an energy therapy that promotes wellness and relaxation. Several of the nurses on the authors' medical telemetry unit are students of the Healing Touch accredited certification program.8 During quiet times, the lights are dimmed and many doors are closed in the unit hallways and patient rooms. Soothing music is played at the nurse station to set the tone and act as a reminder to all who enter the unit. All staff were educated by the quietness champion clinical nurses who created the program via one-on-one and small-group trainings. Specific quiet time interventions for each staff member were outlined and distributed on reminder cards throughout the unit. Some physicians adjusted their schedules to avoid seeing patients during quiet time; and if a patient was visited during quiet time their quiet time was extended. Quiet time signage was placed at unit entrances, on the outside of the door to each patient's room, and inside each patient's room. This increased awareness for patients, visitors, and staff that quietness is a commitment. Badge pulls that stated “I am committed to quietness” were given to each staff member. Many clinical nurses and unlicensed assistive personnel volunteered to join with the original three Quietness Champions to help raise awareness and role model expected behaviors. The unit manager partnered with ancillary departments to decrease noise and interruptions during quiet times.
During leadership rounding, the manager or charge nurse asks each patient if any staff members were particularly helpful in creating a quiet, healing environment. The staff members mentioned by the patients received a raffle ticket thanking them for their efforts. A weekly raffle was held as a means of recognition and provides an incentive for staff. The highly valuable prizes are the winning staff member's choice of a “get-out-of-floating” pass or a “freeze-my-schedule” pass.
After implementing the Quietness Program in April 2015 (Quarter 2), the unit's HCAHPS scores related to quietness consistently improved above the 50th percentile for eight consecutive quarters beginning in the second quarter of 2015 through the first quarter of 2017. Notably, two quarters were above the 75th percentile. (See HCAHPS quiet score—CY2015 to 1st quarter CY2017.)
The improved patient experience reflected the value of the highly engaged nursing team's implementation of an evidence-based practice project. The medical telemetry unit achieved its goals of bringing more awareness to the importance of maintaining a quiet, healing environment for patients and improving the unit's quietness scores. This opportunity to improve the patient experience regarding quietness has empowered and encouraged the medical telemetry clinical staff to continue to make a difference for patients and families. Staff also expressed satisfaction with quiet times, as they had a chance to complete charting and found the environment relaxing.
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