Concept of Alarm Fatigue in Intensive Care Units

Concept Analysis

Concepts analysis is a process of studying the basic elements of a concept or idea (McEwen & Willis, 2014). Concepts analysis helps to advance concept transparency. To describe the concept, a concept is a theoretical idea (Honan, et a.,2015). A concept can be defined as a word which conveys in-depth understanding, and a value among individuals within the same discipline (McEwen & Willis, 2014). Concepts analysis should be performed when certain concepts need to be studied in detail and need more clarifications, or improvement is needed in nursing practice (Jenkins & Warren, 2012).

Concept of Alarm Fatigue

Alarm fatigue is an overexposure of alarms that causes an individual to become de-sensitized to them decreasing their reaction time and efficiency in responding to alarms (Bonafide, et al., 2014). Frequent alarms can cause anxiety and difficult sleeping in patient, while staff become desensitized. Nurses begin to silence or are blinded by the abundance of sounds on the unit. This can have a negative impact on patient safety. There are a lot of noises and different disturbing sounds in the hospitals nowadays. These sounds can be either derived from the humans or by the different machines. As we advance in the medical field so are the new technologies and life-saving machines.

These advanced machines have highly sensitive alarm signals creating a lot of noise in the hospitals. Due to highly developed lifesaving medical equipment’s and growing number of critical patients in the hospitals, the alarm sounds are growing immensely leading a problem of alarm fatigue for nurses and other healthcare team members. Alarm fatigue can be defined as a clinician getting desensitization to the various numbers of alarms as a result the alarm will be missed or deactivated (Solet & Barach, 2012). Alarm fatigue is considered one of the biggest concerns of patient safety in the healthcare’s industry, due to the fact that it causes distraction among the nurses towards the critical environment which they are working on and restricts the nurses to perform their patient centered care to these critical patients.

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As per the joint commission article published in 2016, joint commissions reported 98 sentinels’ events related to alarm fatigue; among these 80 were death cases, 13 patient’s had loss of function permanently and 5 patients were disabled to some extent (Rayo & Moffatt-Bruce, 2016). Regarding theses incidences the biggest culprit were the false alarm, alarm malfunction, improper alarm setting and alarm misuse subsidizing as a contributing factor for alarm fatigue (Solet & Barach, 2012). As per the article by Rayo & Moffatt-Bruce (2016), 85 % to 99 % of the alarms heard in the hospital does not require any interventions but do cause a lot distraction and takes tremendous time away from nurses which can be utilize providing quality care to the patient.

There are various reasons for the false alarm signals, but the common reasons mentioned in the article by Rayo & Moffatt-Bruce (2016) are improper settings of the alarm, wrong alignment of the sensor, vague parameters setting, improper prepping of the skin prior to the application of the sensor, and lack of training regarding machines and alarms. These multitude of alarms ringing every second can result in clinician getting desensitization to the clinical alarms leading to the alarm fatigue. Too much alarm can cause “cry wolf “effect in the clinical settings and a lot of alarms which might be sentinel will either be missed or deactivated. Even though alarm fatigue is considered the biggest problem in healthcare settings now a days, there are not a lot research done on this concept. A well-constructed, and in detail research is needed in the concept of alarm fatigue. Well-defined, clear, concise and in detail evidence-based practice research is much needed on the concept of alarm fatigue. Thus, the focus of this paper will be on concept analysis of alarm fatigue.

Method

This paper is based on the method of Walker and Avant eight steps of concept analysis. The eight steps of concept analysis by Walker and Avant (2011) are: Select a concept, determine the purpose of analysis, identify all the uses of the concept, determine the defining attributes, recognize the model case, find the alternate cases, pinpoint the antecedents and consequences, and define the empirical referents. This method by walker and Avant was chosen for this paper because it is simple, easy to understand and yet provide all the necessary guidelines for an effective research.

Data Sources

A credible, peer-reviewed and published journal articles and literatures search was conducted to support this concept analysis. Various articles from the online library in CINAHL databases, joint commission websites, and various legitimate web of science databases were utilized and researched for the concept analysis of alarm fatigue. This search was not limited to only nursing literature, so the research was conducted on the multidisciplinary aspects of healthcare and its effects from alarm fatigue to the nurses and the patients.

Utilizing Walker and Avant Eight Steps of Concept Analysis for Alarm Fatigue

Concept Selection

First and foremost, the important part of any research is to select the concept. Concept selection should be within the scope of practice, it should be something related to our work environment or the task that we do on a daily basis (Jenkins & Warren, 2012). As described by walker and Avant, selecting a concept is the very first and important step of any concept analysis paper. This paper is focused on the concept analysis on the alarm fatigue concept. As mentioned above, alarm fatigue is immense concern in health care settings nowadays which seems to be growing in the numbers. Thus, this paper is focused on the concept of alarm fatigue.

Purpose of the Analysis

The second step of the Walker and Avant (2011) is the purpose of the analysis. The concept selection should be something that the author will be able to explain the purpose of the research and analysis. In this second step, the author should be able to mention why it is important for the author to do the concept analysis on this particular concept (Jenkins & Warren, 2012). The main purpose of the concept analysis in this paper is to elucidate the importance of the concept of alarm fatigue. There are not a lot of research on the concept of alarm fatigue, so to subsidize more into evidence-based research, alarm fatigue has been chosen to be the concept for this paper.

Identify All the Uses of the Concept

Identifying all the uses of the concept is the third step in the research process by Walker and Avant (2011), it is recognizing many uses of concept in various different articles and journals. By doing through studying, the author has identified the possible uses of the concept. By conducting the literature review and supporting articles analysis, the author was able to provide the evidence-based foundation for the analysis. To better understand the concept of alarm fatigue, these two words were separated, and definition was searched out individually.

Two word “alarm” and “fatigue” were studied individually in different dictionaries. Also, the term “Alarm Fatigue” was researched individually. Alarm fatigue concept was explored in various settings and multidisciplinary teams in health care sector regarding the patient safety and the noise pollution in the hospitals. Alarm: As per Cambridge dictionary, alarm is defined as, “sudden anxiety and fear especially that something very bad or dangerous might happen” (2013a).

As per the Merriam-Webster dictionary alarm is described as, “a device that makes a sound as a warning of signal” (2013a). Fatigue: According to the Merriam-Webster dictionary fatigue is described as, “the state of being very tired” (2013a). As per the Cambridge dictionary fatigue is defined as, “the condition of being extremely exhausted” (2013b). Alarm Fatigue: Alarm fatigue is the process of getting continuous exposure to the alarms that causes an individual to become desensitized to them decreasing their reaction time and efficiency in responding to alarms (Sendelbach & Funk, 2013). Frequent alarms can cause patient anxiety and difficulty sleeping, while staff become desensitized towards it. Nurses begin to silence or are blinded by the abundance of sounds on the unit.

Defining Attributes

Defining attributes is the fourth process in the concept analysis process. Attributes can be defined as a characteristic of the concept which emerges continuously in various articles and research and are highly linked to the concept enlightening in-depth concept into it (Honan, et a.,2015). The author has defined the attributes by conducting several similar literature analyses. There are three attributes that incorporates into the concept of alarm fatigue and theses are:

• Continuous exposure to the environment with immense and recurrent situations
• Less interest and less incentive in surroundings
• Reduced competence for mental and physical work

Recognize the Model Case

Recognizing the model case is the fifth step in the concept analysis process regarding the alarm fatigue. In this step, the model case will be recognized. The model case provides the reader with various example defining the attributes of the concept which were provided in borderline, contrary, invented and illegitimate case by the author (Jenkins & Warren, 2012). For an instance, a middle-aged man was admitted in the cardiac unit with end stage renal disease, hypertension, and diabetes with slightly elevated troponin T showing no sign of ischemia at the time of admission. Patient was placed on the cardiac monitor. Later on, that night the patient cardiac monitor was alarming constantly showing atrial fibrillation, the nurse who was attending was Tina who constantly check the patient diligently.

Nurse Tina also called the other nurse to verify the EKG rhythm and called the hospitalist who was the attending physician for the night. As per the hospitalist there was no significant issues with the patient and the EKG rhythm. It was believed to be the malfunction of the cardiac monitor which was alarming continuously. At around four am, another nurse saw some changes on the rhythm on the monitor for the same patient and went to tell the primary nurse Tina. The EKG rhythm was showing the ventricle fibrillation that time. Nurse Tina stated to the coworker that the cardiac monitor has some malfunction issues and asked the coworker to disregard the alarm. Nurse Tina started working on the charting and disregards the alarm.

Suddenly after thirty minutes the alarm just went to an asystole and every single nurse on the unit rushed to the patient room. This particular example exemplifies the three serious attributes of alarm fatigue which was mentioned earlier. The cardiac nurse was at a work environment with repeated and constant beeping of the alarms. Like mentioned above it was like “cry wolf” situation and finally came to the point where the nurse did not respond to alarm and ignores it until it went to asystole. It clearly shows that the nurse was desensitized to the alarms and disregards it.

Identify Alternate Cases

Identifying the alternate cases is the sixth step in concept analysis of alarm fatigue. In this step, the author has to provide various cases defining the attributes of the concept like borderline, contrary, invented and illegitimate case to support the concept (Sendelbach & Funk, 2013). As per (Honan, et a.,2015), a borderline case contains some of the attributes but not all of them. On the other hand, a contrary case is a case which does not include any attributes described in a concept. Enclosed below are the examples of the borderline and contrary cases.

Borderline Case: The cardiac unit was very busy getting mostly overdoses patient. It was one of those night where the hospital was full of patients. Even when we discharged someone there will be another patient waiting for admission. It was back to back admission in short amount of time. Everyone on the unit really worked hard and did a great teamwork. Nurses were tired but were able to manage patient flow and their needs. This examples only demonstrate the two of three attributing factors mentioned above. For an instance, it was highly crowded unit with frequent admission and discharges. Frequent admission and discharged caused nurses to get frustrated and tired demonstrating the second attribute of alarm fatigue. Even though the staff were very tired, but their capabilities was not reduced. Instead the nurses were able to work together and provide patient centered care for this busy unit. In this example the nurses did not demonstrate the lessened capabilities to provide patient centered care thus the attributes of reduction in the nurse’s capabilities was not demonstrated.

Contrary Case: Nurse Tina is a critical care float nurse and she likes to work on a different unit with high acuity. She enjoys the flight or fight response and the adrenaline rush working on these high acuity units. Multiple alarm sounds do not bother her, and she does not get distracted by all these sounds. She does not get super tired working on this high acuity critical units, does not get bothered by frequent admissions, does not get bothered by the multiple alarms going off at the same time in a constant way, and does not seem to have lessened capabilities. She seems to be always prepared for any type of situation and excited to work on these environments. On this example of nurse Tina, none of the three attributes of alarm fatigue were present. Nurse Tina was exposed to high acuity unit, with multiple alarms alarming at the same time, frequent admission with repeated stressful environment but she seems to be enjoying what she does and is highly motivated which is contrary to the three attributes of the concept of the alarm fatigue.

Identification of Antecedents and Consequences

This seventh step of concept analysis is the identification of antecedents and consequences. Antecedents are the incidents that must occur before the indication of the concept, and consequences are the results which happens after the concept. Identification of antecedents and consequences can enlighten the variables towards the concept. The antecedents of alarm fatigues are:

• Healthcare professional participation
• Continuous exposure to the environment with similar incentives
• The capabilities to evaluate manners in subjective way

The consequences of alarm fatigue are:

• Reduced capabilities towards the alarms and environment
• Alarms missed or deactivated that might lead to sentinel events
• Vague insight of the importance of alarms

Defining Empirical Referents

The last step of the concept analysis of alarm fatigue is defining empirical referents. This last step is defined as the classes or categories of actual phenomena which by presence demonstrate the occurrence of the concept itself. As per Walker and Avant (2011), empirical referents are the actual phenomena which establishes a presence of concept on the actual settings. Empirical referents are very important since it helps to measure and implies the concept (Solet & Barach, 2012). The articles and journals on alarm fatigue suggest empirical referents to the concepts. Some of the empirical referents to the alarm fatigue are as listed below:

• Bonafide, C. P., Zander, M., Graham, C. S., Weirich Paine, C. M., Rock, W., Rich, A., & Keren, R. (2014). Video methods for evaluating psychologic monitor alarms and alarm responses. Biomedical Instrumentation & Technology, 48(3), 220-230. doi:10.2345/0899-8205-48.3.220
• Honan, L., Funk, M., Maynard, M., Fahs, D., Clark, J.T., & David, Y. (2015). Nurses perspectives on clinical alarms. American Journal of Critical Care, 24(5), 387-395 9p. doi: 10.4037/ajcc2015552
• Solet, J.M., & Barach, P.R. (2012). Managing alarm fatigue in cardiac care. Progress in Pediatric Cardiology, 33 (The Future of Pediatric and Congenital Cardiac Care (Part 2), 85-90.doi: 10.1016/j.ppedcard.2011.12.014

Conclusion

The focused of this paper was to deliver the concept of alarm fatigue in clearer and in concise way. Alarm fatigue is a huge concern in healthcare industry now a days. A multidisciplinary approach and a well-established plans and policies are needed in order to handle the alarm fatigue. To provide a holistic patient centered care to the patient, multidisciplinary health care teams have to come together and make plans, policies, and strategies regarding the alarm fatigue.

A more in-depth research is needed regarding the alarm fatigue to recognize more variables and tackle the alarm fatigue. Nurse are crucial towards patient centered care and the healthcare teams. Nurse are the ones who deals with this phenomenon on daily basis. The environment where the nurses works, the different variables that can contribute to the false alarms, and false alarm settings has to be studied in more detail to better handle the alarm fatigue. A more advanced evidence-based practice research is much needed in this concept of alarm fatigue.

References

1. Bonafide, C. P., Zander, M., Graham, C. S., Weirich Paine, C. M., Rock, W., Rich, A., & Keren, R. (2014). Video methods for evaluating psychologic monitor alarms and alarm responses. Biomedical Instrumentation & Technology, 48(3), 220-230. doi:10.2345/0899-8205-48.3.220
2. Cambridge Advanced Learner’s Dictionary & Thesaurus. (2013a). Retrieved from http://dictionary.cambridge.org/us/dictionary/american-english/alarm_1?q=alarm
3. Cambridge Advanced Learner’s Dictionary & Thesaurus. (2013b). Retrieved from http://dictionary.cambridge.org/us/dictionary/american-english/fatigue?q=fatigue
4. Honan, L., Funk, M., Maynard, M., Fahs, D., Clark, J.T., & David, Y. (2015). Nurses perspectives on clinical alarms. American Journal of Critical Care, 24(5), 387-395 9p. doi:10.4037/ajcc2015552
5. Jenkins, B., & Warren, N. A. (2012). Concept Analysis. Critical Care Nursing Quarterly,35(4), 388-395. doi:10.1097/cnq.0b013e318268fe09
6. Merriam-Webster. (2013a). Retrieved from http://www.merriam-webster.com/dictionary/alarm
7. Merriam-Webster. (2013b). Retrieved from http://www.merriam-webster.com/thesaurus/alarm
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9. Rayo, M. F., & Moffatt-Bruce, S. D. (2016). Diagnosing and Treating “Alarm Fatigue”: Pragmatic and Evidence-Based Approaches Needed. The Joint Commission Journal on Quality and Patient Safety,42(7), 291-292. doi:10.1016/s1553-7250(16)42039-8
10. Sendelbach, S., & Funk, M. (2013). Alarm Fatigue. AACN Advanced Critical Care,24, 4th ser., 378-386. Retrieved October 2, 2018, from https://www.nursingcenter.com/pdfjournal
11. Solet, J.M., & Barach, P.R. (2012). Managing alarm fatigue in cardiac care. Progress in Pediatric Cardiology, 33(The Future of Pediatric and Congenital Cardiac Care (Part 2), 85-90. doi: 10.1016/j.ppedcard.2011.12.014
12. Walker, L.O., & Avant, K.C. (2011). Concept analysis. In L.O. Walker & K.C. Avant (Eds.), Strategies for theory construction in nursing (5th ed., pp. 157-179). Upper Saddle River, NJ: Pearson Prentice Hall.