Alarm fatigue in nurses working in intensive care units: A multicenter study

Abstract

BACKGROUND:

Technological progress improves health care efficiency, quality, safety, and cost, supporting clinical activity in various scenarios, such as Intensive Care Unit (ICU). A timely response to alarms from monitors and other ICU electromedical devices is therefore crucial. The number of false alarms tend to desensitize care providers increasing the risk of experiencing alarm fatigue and, at times, lead to severe consequences for patients.

OBJECTIVES:

To assess the psychometric properties of the Italian version of the Alarm Fatigue Questionnaire and to explore the phenomenon of alarm fatigue among nurses working in intensive care settings.

METHODS:

The CVI-I was calculated to evaluate the validity of the content of the tool. Construct validity was investigated through exploratory factor analysis. Cronbach’s alpha coefficient (α) was used to examine the internal consistency of the scale and Spearman’s rho coefficient to test for stability.

We designed a multicentre cross-sectional survey. A convenience sample of nurses from 4 Major Italian hospitals was recruited. The nurses completed the Italian version of the Alarm Fatigue Questionnaire.

RESULTS:

The content validity index CVI-S of the scale (CVI-S) was 91.11%; Cronbach’s alpha coefficient was 0.71. The Italian version of the tool explained 67.18%of the overall variance. 396 nurses were enrolled (79.84%). The overall level of alarm fatigue was Me = 29 [22;30]. 42.17%of the sample reported prior experience with alarm fatigue incidents.

CONCLUSIONS:

The extension of alarm fatigue requires the adoption of a preventive intervention plan. The Italian version of the Alarm Fatigue Questionnaire shows promising psychometric properties.

Keywords

Alarm fatigue intensive care unit nurses patient safety

1 Introduction

Patient safety is fundamental to delivering quality essential health services. Indeed, there is a clear consensus that quality health services across the world should be effective, safe and people-centred [1]. For this reasons, research and scientific development are increasingly being supported by the continuous technological progress. It allows the use of different equipment and devices to support clinical activities, particularly useful in the intensive care unit (ICU). In fact, in this area, patients are clinically unstable and often unable to effectively communicate, needing a constant monitoring able to recognize the slightest change in clinical conditions and to promptly alert the personnel with visual and acoustic alarms [2].

To ensure patient safety, a nurses promptly response to the alarms is crucial as it promotes the rapid recognition of dangerous situations [2]. Surprisingly, despite the aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care, the increasing use of the above-mentioned devices can be a risk factor for patient safety [3 –5]. In fact, the literature reports up to 300 alarms per bed each day, 72%to 99%of which are false alarms [5 –10]. This occurs because alarms are setting to avoid missing of any important event, however they are not very specific resulting in high rate of “false alarms” potentially dangerous because it increases the workload of the staff - reacting to alarms constitutes 35%of the working time of a nurse in an ICU [11]. Moreover, the sensory overburden caused by an excessive amount of alarms may lead to delayed reactions or to ignoring potential danger [5 , 12].

Nurses spend most of their time caring patients, continuously monitoring their condition, and are particularly exposed to so-called alarm fatigue (AF) [13], which is defined as an excessive exposure to the stimulus generated by the monitoring unit [14]. AF consists of desensitization to the alarm and the consequent delay in the response of the health worker. Moreover, it brings to the adoption of dangerous behaviors such as lowering the volume, adjusting the alarm settings outside safe and appropriate limits for the patient, ignoring or even disabling the alarm signals [15 –19]. It is evident how each of these actions, together with malfunction, misuse, or inappropriate alarm setting of the monitoring devices, can be harmful to the patient and may result in serious consequences for patient safety [5, 6]. Proper management of alarm devices is increasingly being studied. In 2016, the Joint Commission (JCAHO) included it among the international goals for patient safety [20]. The framework presented by the JCAHO suggests the fundamental importance of implementing a multidimensional pathway aimed at contracting the risk for patients and increasing the safety of the services provided [7 , 21]. The first step in this effort should be oriented toward understanding the nature and the extent of the phenomenon of AF in nurses. The Alarm Fatigue Questionnaire was developed with the aim of define this phenomenon. It was validated by Torabizadeh in 2017 [22], showing a high reliability. Considering that there is currently no Italian version of this instrument, the aim of the study was to evaluate the psychometric properties of the Alarm Fatigue Questionnaire and to evaluate the phenomenon of AF in nurses working in different Italian intensive care settings.

2 Methods

2.1 Design and setting

A cross-sectional multicentre study was developed by administration of a paper questionnaire. The Alarm Fatigue Questionnaire was independently translated into Italian by two nurses, one of which has certified knowledge of the English language (level C2). The Italian version obtained was then back-translated into English by an English teacher and definitely approved by the original author. The questionnaire consisted of a demographic and professional curriculum section and a validated scale to assess the level of AF in nurses [22]. Nurses with at least 12 months of experience in ICU, working in four major hospitals in Milan, Italy, were involved in the study. Nurses are asked to quantify the frequency of any of the behaviours regarding alarm management described in the scale. The total score of the questionnaire ranges from 0 (lowest impact of fatigue) to 52 (highest impact of fatigue).

Table 1
EFA of the Italian version of the Alarm Fatigue Questionnaire

Item Factor 1 Factor 2

1. I adjust alarm settings based on patient condition 0.671

2. I turn off alarms at the beginning of each shift 0.770

3. In general, I hear a certain amount of noise on the ward 0.672

4. I believe that much of the noise in the ward is due to alarms from monitoring equipment 0.801

5. I pay more attention to alarms on certain shifts 0.599

6. On some shifts the heavy workload in the department prevents me from responding quickly to alarms 0.821

7. When alarms go off repeatedly, I become indifferent to them 0.745

8. The sound of the alarm makes me nervous 0.690

9. I react differently if the alarm identifies a higher (high volume and/or red color) or lower priority (low volume and/or yellow/green color) 0.813

10. When I’m angry and nervous, I’m more bothered by alarm sounds 0.817

11. When alarms go off repeatedly and continuously, I lose patience 0.660

12. Alarm sounds prevent me from focusing on my professional activities 0.631

13. During visiting hours, I pay less attention to equipment alarms 0.753

Item	Factor 1	Factor 2
1. I adjust alarm settings based on patient condition	0.671
2. I turn off alarms at the beginning of each shift		0.770
3. In general, I hear a certain amount of noise on the ward		0.672
4. I believe that much of the noise in the ward is due to alarms from monitoring equipment		0.801
5. I pay more attention to alarms on certain shifts	0.599
6. On some shifts the heavy workload in the department prevents me from responding quickly to alarms	0.821
7. When alarms go off repeatedly, I become indifferent to them	0.745
8. The sound of the alarm makes me nervous	0.690
9. I react differently if the alarm identifies a higher (high volume and/or red color) or lower priority (low volume and/or yellow/green color)	0.813
10. When I’m angry and nervous, I’m more bothered by alarm sounds	0.817
11. When alarms go off repeatedly and continuously, I lose patience	0.660
12. Alarm sounds prevent me from focusing on my professional activities	0.631
13. During visiting hours, I pay less attention to equipment alarms	0.753

Face and content validity were assessed by submitting the scale to six nurses with more than 5 years working experience in critical care. They were asked for their opinion on the level of understanding and clarity of the statements that made up the instrument and the formulation of a judgment regarding the relevance of each item (on a four-point Likert scale). Based on the answers provided, the content validity of each statement (CVI-I) and of the questionnaire (CVI-S) (23) were calculated. The tool was completed by adding a final part aimed at collecting sociodemographic data such as age, gender, and professional qualifications of participants and work experience as measured by the number of years they had worked in the critical care area. The study was approved by the directors of every hospital involved in the study. We complied with the rules of the local Ethical committee, which at the time of data collection did not require approval for studies on this topic and this type of data. A written informed consent was collected for each participant.

2.2 Statistical analysis

Normally distributed data are indicated as mean±SD, while median and interquartile range are used to report non-normally distributed variables. Internal consistency was assessed by measuring Cronbach’s Alpha coefficient. Pearson’s r coefficient was used to evaluate test-retest stability (assessed by comparing data of 80 nurses at the baseline and after 5 days).

Exploratory factor analysis (EFA) was conducted. The factors were extracted through the method of principal components, and rotated with the Promax algorithm. Kaiser-Meyer-Olkin’s (KMO) measure of sample adequacy and Bartlett’s test of sphericity were conducted prior to extracting the factors. The factor loadings were retained according to Stevens’ criterion.

The Kolmogorov-Smirnov test was used for normality checking. The significance level was set at 5%for all calculations. The analyses were conducted with SAS University Edition for MacOS-X (Cary, NC, USA). The different scores of AF in different clinical settings was assessed by using the non-parametric Mann-Whitney test.

3 Results

The instrument showed excellent content validity (CVI-S = 91.11%). According to the panel of experts, the scale proved to be clear and quick to be completed. Cronbach’s alpha was 0.71. No significant differences were found in the scores of 80 nurses recorded in the two moments (p = 0.76).

Bartlett’s test of sphericity (p < 0.01) Kaiser-Meyer-Olkin’s measure (0.778) confirmed the acceptability of the results for conducting EFA. The unrotated factor pattern showed the presence of two factors, according to the original version of the scale, which was also confirmed with non-orthogonal Promax rotation. The Italian version of the Alarm Fatigue Questionnaire explained 67.18%of the overall variance (Table 1).

A total of 396 nurses were enrolled in the study (response rate 79.84%). Table 2 shows the intensive care areas involved.

Table 2
Breakdown of the sample in the different intensive areas

Operating unit n Unit response rate % %

Emergency room 86 78.18 21.72

Resuscitation 80 76.19 20.20

Cardiac intensive care unit (CICU) 86 77.48 21.72

Emergency medicine 49 81.67 12.37

Neonatal pathology 15 88.23 3.79

Cardiac surgery 22 81.48 5.56

Neonatal intensive care 28 87.5 7.07

Pediatric resuscitation 30 88.24 7.58

Total 396 100.00 100.00

Operating unit	n	Unit response rate %	%
Emergency room	86	78.18	21.72
Resuscitation	80	76.19	20.20
Cardiac intensive care unit (CICU)	86	77.48	21.72
Emergency medicine	49	81.67	12.37
Neonatal pathology	15	88.23	3.79
Cardiac surgery	22	81.48	5.56
Neonatal intensive care	28	87.5	7.07
Pediatric resuscitation	30	88.24	7.58
Total	396	100.00	100.00

The main participant characteristics are showed in Table 3. 238 subjects were female (60.10%) and 158 (39.90%) were male. The most represented age group was 41–50 years (n = 136, 34.34%) (Table 3). The median overall working experience was 14 years [7;24] (Me = 8.5 years [3;16] in ICU). 42.17%(n = 167) of the sample reported having experienced AF-related patient safety incidents in their career; of these 81 (48.50%) had direct experience.

Table 3

Socio-demographic data of the sample

		n	Percent (%)
Gender	M	158	39.90
	F	238	60.10
Age	21–30	76	19.19
	31–40	118	29.80
	41–50	136	34.34
	>50	66	16.67
Alarm fatigue incidents	Yes	167	42.17
	NO	227	57.32
	Yes, personal	81
	Yes, indirect	88

The overall level of AF was Me = 29 [22;30]. The level of AF increased significantly between the working experience in ICU (p < .0001) while no significant differences regarding gender (p = 0.109), unit (p = 0.203), age (p = 0.092) and overall working experience (p = 0.083) were detected. Table 4 shows the number of subjects with a median score≥3 for each item on the scale representing a fatigue alarm condition. Scores obtained were also compared according to experiences of adverse events that were experienced during clinical practice and related, in nurses’ perception, to AF. Table 5 reports the 4 items of the Alarm Fatigue Questionnaire that showed significant differences.

Table 4

Relationship between behaviors assumed and experiences of alarm fatigue incidents

Item	Alarm fatigue	No alarm fatigue
	Me≥3	Me < 3
1. I adjust alarm settings based on patient condition	338	58
2. I turn off alarms at the beginning of each shift	363	33
3. In general, I hear a certain amount of noise on the ward	158	238
4. I believe that much of the noise in the ward is due to alarms from monitoring equipment	147	249
5. I pay more attention to alarms on certain shifts	193	203
6. On some shifts the heavy workload in the department prevents me from responding quickly to alarms	139	257
7. When alarms go off repeatedly, I become indifferent to them	303	93
8. The sound of the alarm makes me nervous	171	225
9. I react differently if the alarm identifies a higher (high volume and/or red color) or lower priority (low volume and/or yellow/green color)	96	300
10. When I’m angry and nervous, I’m more bothered by alarm sounds	184	212
11. When alarms go off repeatedly and continuously, I lose patience	213	183
12. Alarm sounds prevent me from focusing on my professional activities	210	186
13. During visiting hours, I pay less attention to equipment alarms	345	51

Table 5

Adverse events related to alarm fatigue

Item	Adverse events	Alarm fatigue	No alarm fatigue	p
		Me≥3	Me < 3
2. I turn off alarms at the beginning of each shift	No	214	12	0.001
	Yes	149	21
7. When alarms go off repeatedly, I become indifferent to them	No	168	58	0.030
	Yes	105	65
11. When alarms go off repeatedly and continuously, I lose patience	No	132	94	0.027
	Yes	81	89
12. Alarm sounds prevent me from focusing on my professional activities	No	130	96	0.014
	Yes	80	90

4 Discussion

AF is an emerging problem in the ICU, as well as in all settings that make extensive use of equipment and electro-medical devices equipped with acoustic alarm systems. Underestimation of this phenomenon, as well as a lack of its knowledge, may lead to serious consequences, especially regarding patient safety [5, 6]. Nurses are highly exposed to the alarms, and therefore fatigue can be a stressful aspect of their profession. It is mandatory to improve the knowledge and the understanding of this phenomenon among nurses, which was the aim of this paper.

This study has shown that the Italian version of the “Alarm Fatigue Questionnaire” is valid and reliable and therefore able to support using the complex assessment of the phenomenon in the Italian setting.

The overall level of fatigue in our sample can be defined as medium-high, with a median value of 29. This finding is similar to other studies supporting the hypothesis that it is a natural human behavioral response to alarm signals which often prove to be false and misleading [25]. AF may significantly impact on nursing care leading to incorrect behaviours in the management alarms, such as silencing, deactivation or not responding [15 –18]. Prolonged daily exposure to many alert systems can significantly lower the levels of attention of operators, raising the levels of stress. The word “fatigue” emphasizes a phenomenon that can potentially lead to a real state of exhaustion. The alarm-fatigue behaviors manifested by the majority of the sample were “I adjust alarm settings based on patient condition” (Item 1), “I turn off alarms at the beginning of each shift” (Item 2), “When alarms go off repeatedly, I become indifferent to them” (Item 7) and “During visiting hours, I pay less attention to equipment alarms” (Item 13). These results showed the adoption of incorrect behaviors (item 1 and 2) and the negative attitude of nurses (item 7 and 13), which can significantly affect the clinical practice and patient safety. The study by Lewandowska et al. [24] suggests that nurses with a greater knowledge and more years of experience in the critical care area should show more comfort in setting alarms, and the level of noise during their shifts is lower. However, the results of our study show that long-time experience is associated with higher levels of AF, suggesting how the experience is not a protective factor. In fact, almost 50%of the nurses reported having experienced of adverse events potentially associated with AF during their career. We found a relationship between these experiences and some AF behaviors of the questionnaire, in particular Items 2 (“I turn off alarms at the beginning of each shift”), item 7 (When alarms go off repeatedly, I become indifferent to them”), item 11 (“When alarms go off repeatedly and continuously, I lose patience”) and item 12 (“Alarm sounds prevent me from focusing on my professional activities”). This finding is not surprising and highlights behaviors and attitudes frequently experienced by nurses in the ICU that can increase the risk of error. Our study enrolled nurses in four hospitals in Milan, who represent just a small part of the Italian nursing population. It would be interesting to continue the study on larger samples. The high response rate (79.84%) is a point of strength and reveals interest in this topic. It could be useful to conduct a survey in other hospitals in our country, to obtain a wider picture of nursing nurses’ view of the problem which can also affect the psychological well-being of the individual practitioner and expose them to the risk of experiencing other issues as moral distress and burnout. [26, 27]. It could be also interesting to assess the nursing students’ perceptions at the end of their internship experience in ICU to verify whether the problem is perceived as early as during academic training.

5 Conclusion

The Italian version of the Alarm Fatigue Questionnaire is quick and easy to fill out, with promising psychometric properties. Validation should be completed with confirmatory factor analysis and other appropriate statistical tests (e.g. concurrent validity). This study provides a first overview of the phenomenon in the Italian setting. To date there are no other studies in Italy that have specifically investigated nursing AF, and no other tools validated to this purpose. Alarms are unavoidable in ICU and our results, in line with the literature indicate that nurses feel overburdened with an excessive number of tasks and a continuous wave of clinical alarms. Therefore, it is necessary to promptly introduce effective strategies of alarm management. In the future, it is well worth focusing on assessing the level of AF. This would help to ensure patient safety as well nursing well-being.

Conflict of interest

The authors have no conflict of interest.

Funding

The study did not receive funding.

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