Running head: ALARM FATIGUE

Technology in Nursing: Alarm Fatigue

Cameron Verkaik
Ferris State University

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Abstract

This paper examines alarm fatigue, a desensitizing to alarm sounds, which can affect nurses in
the healthcare setting. Advantages and disadvantages of current technologies are discussed to
present a rather complex issue. Applying alarm fatigue to both an environmental and
psychological theory promotes several informative perspectives. The assessment of the
healthcare environment in connection to technology and alarms is examined through various
study statistics, systems framework, policies, assumptions, and quality and safety issues. Using
root cause analysis, the problems surrounding alarm fatigue are outlined. The American Nurses
Association (ANA) Standards of Practice as well as the QSEN Institutes competencies are
reviewed and provide beneficial guidelines to review the implications and consequences to alarm
fatigue. Several strategies of implementation are discussed such as removing scope-of-barrier
practices, collaboration, lifelong learning and leadership and deciphering current alarm sounds.
These strategies have proven to lower the risk of alarm fatigue in several healthcare settings and
promote a safer patient environment.

Keywords: technology, alarm fatigue, nursing, informatics, safety, patient risk, healthcare,
environment

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Technology in Nursing: How Technology is Changing Healthcare

Technology is changing the world at warp speed and nowhere is this more evident than
in the health care setting (Huston, 2013, p. 1). This statement by Huston is one few would
argue. The world of technology seems to have no end in many professions, and medical
professionals are being bombarded with many technologies to create greater work efficiency,
more mature patient analysis, and safer healthcare environments. But are all technologies
advantageous? Technology has been described as both part of the problem and part of the
solution for safer health care, and some observers warned of the introduction of yet-to-be errors
after the adoption of new technologies (Powell-Cope, Nelson, Patterson, 2008, p. 1). Many of
these technologies that the health care environment has implemented have alarms, many times
multiple, with various sounds, warnings, and signals. Common sense would tell us these alarms
are beneficial to all involved, granting efficiency to the nurses supervision, yielding warning to
possible health threats for the patient, while putting the patients family at ease knowing their
loved one is being carefully monitored. Yet what if these alarms were actually creating an
opposite effect? Due to the constant barrage of noise, patient families may be feeling trapped in a
disruptive, anxiety-filled environment and clinicians may becoming desensitized or immune to
the sounds, overwhelmed by information, and suffering from a condition called alarm fatigue.
Alarm Fatigue
With nearly five thousand types of medical devices used by millions of health care
providers, alarm fatigue is a widespread issue that can affect any hospital with technology
(Powell-Cope, Nelson, Patterson, 2008). The more advanced and widespread the technology, the
more likely the clinicians in this setting suffer from some level of alarm fatigue. Technology
allows for greater efficiency and many times lower costs, yet needs to be balanced with the

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importance of human interaction, and not devalue the human element (Huston, 2013, p. 10).
Nursing professionals should be well informed of alarm fatigue so that they can evaluate their
own behavior and work environment, and also work towards possible solutions, in order to
minimize risks and give all patients the best care possible.
Theory
Alarm fatigue can be studied through multiple theoretical frameworks. This type of
analysis can lead to a greater understanding of the issue as well as develop deeper awareness and
education.
Florence Nightingale: Environmental Theory
Florence Nightingales environmental theory discusses the importance of environmental
conditions and the direct relation to patient outcome. Two of the ten canons of the environmental
theory relate to technology in nursing. First, observation is a key component to promoting a
healing environment for the patient (Environmental Theory, 2013). Now pulse oximetry allows
nurses to identify decreased oxygenation before clinical symptoms appear, and thus more
promptly diagnose and treat underlying causes (Powell-Cope, et al., 2008). Thus, many
technologies allow for close monitoring of patient status, complementing this component. The
second canon related to alarm fatigue discusses the importance of light and noise of the patients
environment (Environmental Theory, 2013). Excess alarms can affect the noise and light levels,
causing stress to both the patient and family members, which reduces their ability to cope with
their circumstance.
It is also important to remember that Florence Nightingale believed nursing to be both an
art and a science. The science comes in the use of technology to diagnose and treat patients
according to the data that is obtain. The art is concerned with how nurses interact with patients.

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Technology is here to stay and more incredible advances are arriving daily. We, as nurses, must
make certain that these technological wonders do not become more important than the human
beings we are caring for (Nash, 2014, p.12). We cannot allow technology to take over clinical
skills or personal interaction.
Abraham Maslow: Hierarchy of Needs Theory
Complementing Nightingales theory, psychologist Abraham Maslow believed that there
are basic needs that must be satisfied in humans before higher-order needs are met. One of these
basic foundational needs is safety, including security of environment (McLeod, 2007). Many
technologies have been implemented into health care due to their attractiveness of increased
safety and security. All individuals, whether patient or nurse, desire to feel they are in a secure
environment.
The advancement of technological alarms started out supporting this secure environment,
but is now creating danger to the patient.
For example, a 60-year-old man died in the intensive care unit of a hospital not
from the injury he suffered but from a system failure that resulted in delayed
response to an alarm signal that indicated significant changes in his condition.
Serious changes that included rapidly increasing heart rate and falling blood
oxygen levels. Staff responded only after one hour, when a critical alarm
condition signaled that the patient had stopped breathing. (Joint Commission,
2013).
The environment of each patient is directly correlated to their safety, as well as their overall
health improvement during their time in the health care setting.

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Assessment of the Healthcare Environment

Alarm fatigue is a complex issue that requires careful, on-going assessment of the
healthcare environment. Because technology is being introduced consistently, the healthcare
environments are also consistently changing, therefore healthcare organizations should be
regularly assessing their nursing staffs behavior when working alongside many alarms.
The Association for the Advancement of Medical Instrumentation, the Food and Drug
Administration, and the Joint Commission came to this conclusion during a 2012 summit
hearing:
Medical alarm systems are out of control. Every day, around the clock, hundreds
of auditory alarm signals sound for every patient, thousands of alarm signals
chime in every unit, tens of thousands of alarm signals blare throughout every
hospital. Clinicians are fatigued, confused and overloaded with sensory alerts or
left in the dark without actionable information from this cacophony of sounds
and signals. (Ferenc, 2012, p.1).
Systems Framework
Organization Policies
Due to its severity, the Joint Commission has announced alarm fatigue as a 2014 patient
safety goal. Between January 2009 and June 2012, there were ninety eight events of alarms
ignored due to sheer volume, with eighty of those resulting in death and thirteen resulting in loss
of function, as well as five unexpected additional care or extended stays (Nault & Sincox, 2014).
In order to complete the alarm fatigue safety goal, several phases are occurring. Phase one began
in January 2014, with hospitals being required to establish alarms as an organization priority and

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identify the most important alarms to manage based on their own internal situations. Phase two
will begin in January 2016 when hospitals will be expected to develop and implement specific
components of policies and procedures. Alarm system management education will also be
required of those in the organization (Joint Commission, 2013).
Resources
Boston Medical is facing the alarm fatigue problem head on by creating a task force
made up of nurses, physicians, and residents. After taking time to compile their alarm data
through frontline user input and nurse evaluations, they discovered 67% of the alarms came from
violations in heart rate default settings (McKinney & Maureen, 2014). These individuals were
asked to explain, in their opinions, why there were so many unanswered alarms, the obstacles to
alarms, and determine what the cause of the problem is. From the start, their focus was on
standardizing devices default settings across units. They adjusted heart rate monitors, while still
within clinically acceptable ranges, as well as changing heart rate alarm levels from warning to
crisis so they could not automatically reset. Boston Medicals clinical service manager of
cardiology, Deborah Whalen stated, Staff were used to warning alarms resetting so if they went
off, they often waited to see if they went away (McKinney et al., 2014, p. 2). Rather than
addressing the alarm and assessing the patient immediately, many nurses were experiencing
alarm fatigue. The task force did develop a process in which nurses have authority to raise or
drop certain heart-rate parameters in certain patient circumstances. In order to allow this change,
two registered nurses must review patient data together and agree to make the change. In
addition, nurse professionals are also required to have a thorough understanding of heart-rate
knowledge, scoring at least ninety percent on their exams. Audible cardiac alarms are now down

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eighty nine percent from nearly ninety thousand to roughly ten thousand over a six week starting
period (McKinney et al, 2014).
Assumptions
In the nursing profession, the patient is the highest priority. The patients safety, feelings,
and rights are the nurses main concern. The respectfulness of privacy is also a high priority, as
call lights are used to allow patients to call the nurse when needed. In the health care setting, the
element of team is encouraged, as the acuity of patients increases, the work of the nurse
increases and makes it hard to address every alarm. Nurses may assume others will respond to
the purpose of the alarm. In a system where teamwork and collaboration are in place, this nurse
may be able to depend on fellow staff to answer the alarm. However, assumptions should not be
made as this may put the patient in great danger if no one, in fact, responds.
Inference, Implications and Consequences
Consequences of Alarm Fatigue
The consequences of alarm fatigue can be very costly to any organization. Extended
hospital stay, injury, and even death can result. Such an instance occurred in 2007 when a 77 year
old who had been admitted to a cardiac unit passed away due to cardiac arrest after a low
battery alarm had gone unanswered for an extended period of time (Sendelbach & Funk, 2013).
This type of consequence is much more costly than the education and high exam standards that
could be implemented for all nurses.
Recommendations for Quality and Safety Improvements
Removing scope-of-barrier practices. All nurses and other health care providers must
be able to practice to the full extent of their education and training (Cipriano & Murphy, 2011,
p. 3). By removing scope-of-practice barriers, nurses will better be able to collect and analyze

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patient data as well as make informative decisions that can decrease the number of alarms being
used.
Collaboration. By encouraging collaboration in the nursing setting, teamwork will
become the norm and allow for responsible decision-making for all patient-related technology
decisions. More importantly, before making widespread initiatives, it is important to include
nurses in testing of new models of care and new technology. Selecting wrong equipment and
technology can be costly and expose the patient to errors (Powell-Cope, 2008, p.7).
Lifelong learning and leadership. Ensuring that nurses engage in lifelong learning will
promote technology in the healthcare setting. In turn, nurses will be better equipped to lead
change and advance health. Ideally, all nurses will be able to lead in technology, rather than only
technically competent staff members. If lifelong learning is occurring, all nurses will feel
competent to lead.
Alarm setting improvement. By setting alarms to have different tones, nurses can
anticipate the severity of the alarm. All of these warning systems depend on the ability of the
nurse to notice the warning, process the alarm and comprehend what is happening, and finally
take the appropriate action to decrease risk to the patient (Powell-Cope, 2008, p.6). For
example, when a code is called, the alarm that rings overhead is very distinct so that everyone is
informed of the patients status. Thus, nurses and other staff can act quickly on the situation and
decrease the risk and harm that may have otherwise occurred.
American Association of Critical-Care Nurses (AACN). The AACN has implemented
a practice alert to help nurses decrease the amount of alarms they may experience. The AACN
practice alert is focused on ECG monitoring as 80% to 99% are false alarms for of minimal
clinical significance. They include proper skin preparation for ECG placement, daily changes,

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individualized alarm settings including threshold settings for oxygen saturation, educating new
nurses on the proper use of the equipment, monitoring only patients who have clinical
indications for it, and establishing teams to address alarms issues and develop policies directly
related to them (AACN, 2013). Following these guidelines will help nurses troubleshoot alarm
issues as well as enhance the patients experience.
American Nurses Association (ANA) Standards
Standard 1: assessment. The registered nurse collects comprehensive data pertinent to the
healthcare consumers health and/or the situation (ANA, 2010, p.32). Today, nurses use many
different types of technology to determine the health status of the patient. These various
technologies can include IV pumps, telemetry monitoring, electronic medical records, and
barcode scanning. Both application and interpretation of data is necessary in order for clinicians
to make wise decisions. When determining which data is pertinent to the patients health, it is
also important to document in a timely and accurate manner. Rather than relying on technology,
the nurse should rely on their own assessment and consider technology a complementing tool.
Standard 5: implementation. The registered nurse utilizes technology to measure, record,
and retrieve healthcare consumer data, implement the nursing process, and enhance nursing
practice (ANA, 2010, p.38). Operating equipment effectively and efficiently protects the
patient from harm and allows the nurse to use only equipment that is necessary. Therefore,
feelings of anxiety are avoided for the patient and family that can arise from an overuse of
technology that includes many alarms.
Standard 8: education. The registered nurse attains knowledge and competence that
reflects current nursing practice (ANA, 2010, p.49). Continuing education allows the nurse to

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gain awareness of the issue of alarm fatigue as well as strategies to control it. If all nurses stay
current in their field, patients will be better cared for in a calmer, quieter environment.
Standard 9: evidence-based practice and research. The registered nurse integrates
evidence and research findings into practice (ANA, 2010, p.51). Nurses should find evidence
based on research that shows alarm fatigue is a serious issue that may cause harm to the patient,
therefore working to develop ways that alarms can be diminished is a priority that may require
re-training as well as various alarm settings for each individual patient.
Quality and Safety Education for Nurses (QSEN) Competencies
Patient centered care. The QSEN definition of patient centered care focuses on
including patients in all decisions and providing compassionate care that's based on a patient's
needs and values (Hunt, 2012, p.2). Applying this practice is crucial in maintaining a positive
relationship with the patient and patients family. By asking the patient how the alarms are
making them feel, a nurse can perform a more accurate assessment of the patients health and
improve the quality of environment.
Teamwork and collaboration. Teamwork and collaboration is define as
interdisciplinary collaboration and shared decision making among the healthcare team (Hunt,
2012, p.2). By collaborating with other nurses in regards to alarm parameters and settings, both
nurses and patients can feel secure that the correct decisions are being made.
Evidence-based practice (EBP). QSENs EBP focuses on the use of research and
evidence in the development of nursing practice (Hunt, 2012). Research has shown that alarm
fatigue is a serious issue that needs to be address. The American Association of Critical-Care
Nurses (AACN) has shown that the implementation of the practice alert has decreased the
number of alarms (AACN, 2013).

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Quality improvement. QSEN defines quality improvement as it relates to data

collection, evaluation, and improvement of patient outcomes (Hunt, 2012, p.2). It is important
to continue evaluating the healthcare setting through patient outcomes even after alarm
improvements are made. This type of data collection will provide necessary feedback for the
healthcare setting trying to make improvements.
Safety. The S of QSEN, safety, focuses on preventing harm to patients as it relates to the
Joint Commissions National Patient Safety Goals (Hunt, 2012). This education is the most
critical when applied to alarm fatigue. Nurses must prevent harm, and if technology is harming
patients, that technology needs to be re-evaluated or changed in some way.
Informatics. The QSEN definition of informatics relates to the utilization of
technology to promote safety and quality (Hunt, 2012, p.2). When using equipment properly,
the number of alarms does decrease. The idea that technology is harmful because of the alarm
fatigue effect must be balanced with the usefulness technology provides for all patients.
Conclusion
In conclusion technology will continue to be a prevalent and beneficial tool in many
healthcare settings. It is the responsibility of medical professionals to continue to gain awareness
of the disadvantages to technology as well. The value of technology hinges on how its used and
whether it helps or hinders care (Cipriano & Hamer, 2013, p. 2). Alarm fatigue is a consequence
to alarm technology that can affect anyone, and nurses must work to assess their own behavior as
well as their patients environment to stay on top of this issue. If nurses continue to keep patient
safety as a first priority, they will engage in lifelong learning that will benefit them for many
reasons and technology will continue to be a complementing tool to their medical knowledge and

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experience. Technology enables care and enhances safety by automating functions both simple
and complex. It doesnt replace nurses (Cipriano & Hamer, 2013, p. 2)
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