Curing the Noise Epidemic in Hospitals
By Susan E. Mazer, MA
Note: This article originally appeared in the Fall 2004 issue of the Jackson Organization's e-newsletter.
When we think of places where we want to rest and recuperate from illness or medical treatment, most of us visualize places that are quiet, peaceful, and serene. This is a stark contrast to the typical hospital, where sounds of beepers, alarms, machines, telephones, voices, and more are part of the "normal" environment. The epidemic of noise in hospitals - one of the biggest complaints of patients -- is something that can no longer be ignored.
Why do patients complain about noise? Next to the requisite hospital annoyances and discomfort, noise is experienced as unnecessary neglect serving no good purpose. It disturbs patients' sleep, increases their anxiety, and puts into question basic consideration on the part of the hospital in general. The increased noise-induced stress is contagious, impacting the attendant family member who eventually winds up at the nurses' station complaining about a variety of issues, each worsened by extraneous noise.
Sudden noises, such as a dropped tray or slammed door, cause a "startle reflex" in patients, resulting in physiological responses such as facial grimacing, muscular flexion, increased blood pressure, higher respiratory rate, increased heart rate, and vaso-constriction. Patients exposed to continuous extraneous noise can also experience altered memory, increased agitation, less tolerance for pain, feelings of isolation, and sleep deprivation.
These symptoms are not just unique to patients, either. Staff members who work in noisy environments for long shifts, day in and day out, have similar stress-induced experiences. JCAHO mentions noise as a potential risk factor related to medical and nursing errors.
Because noise affects patient outcomes and privacy, it has both clinical and regulatory implications. The auditory environment plays a big role in the confidentiality compliance that HIPAA now requires. In pure fact, absolute auditory confidentiality does not exist anywhere because hearing acuity is uncontrollable and immeasurable. Adults, whose hearing is impaired most of the time, hear words and inflections and translate them into whole stories with varying degrees of accuracy. In the hospital setting, nurses and physicians appropriately exchange critical information at the right time and in what is now labeled as the wrong place. While HIPAA uses a standard of "reasonableness" regarding auditory privacy, obviously there is nothing reasonable about unnecessary noise.
Patient Dissatisfaction & Noise
While patient satisfaction surveys have consistently shown that noise receives the lowest ratings and always reduces overall ratings, patient dissatisfaction with the auditory environment is just as bad. Because hospital noise is neither isolated nor singular in its impact, it is off the hospital's "radar screen" because it is everywhere and nowhere. Whatever might disturb a patient is worsened by environmental and unnecessary noise. Recent studies on qualitative sleep levels confirm the direct relationship with the environment, stating the noise is the number one irritant. However, there is an argument to be made that a hospital whose environment appears to be what is expected, i.e. appropriately quiet, is more likely to deliver better care.
Annoyance is a response, not an auditory quality. Few people, if any, respond to noise in any other way. Further, a study published in the The Journal of Otolaryngology (Abel, S.M. 1990) found that victims of noise assume that they are unimportant or not cared about by those making the noise and, further, that the noise itself has no useful purpose or value.
Creating a Healing Environment
What can be done to reduce noise and improve the hospital auditory environment? The first step is to make a commitment to create a total healing environment for patients and staff. A "healing environment" requires both a physical setting conducive to recovery in all aspects and an organizational culture that supports patients and families through the stresses imposed by illness, hospitalization, medical visits, the process of healing, and sometimes, bereavement.
To assess the sound environment accurately, it is important to accept as fact that there is no "zero" in the scale between acceptable and unacceptable. Because of the nature of a healthcare crisis, the environment of care is either appropriate to the goals and objectives of patients and providers, or it is contrary. Therefore, the question becomes, "What is heard? What am I listening to? Is it helping or hurting? Is it public or private information? Does it accurately represent our standards of patient care?"
Enhancing the sound environment with music is a viable option if used appropriately. As shown in other industries, foreground music can mask other irrelevant sounds and maintain an appropriate noise floor. In hospital settings, music combined with images of nature have been shown to reduce the amount of requested pain medication and/or improve its analgesic effect. In addition, when used appropriately, music acts as an effective audio-anxiolytic, improving restfulness and the quality of sleep, and inducing relaxation.
Equipment Policies
Regardless of where the patient is, equipment dominates the hospital experience. The heavily orchestrated environment includes multiple monitors, beepers, buzzers, paging, telephones, carts, wheel chairs and gurneys, hospital beds that are electric, pillow speakers and nurse call systems, IV poles that role on tiled floors, doors that close abrubtly , and carts that squeak, All of this prior to one word being spoken or one person walking past the patient's room.
To minimize potential negative impact of hospital noise, standards or goals must be set to establish appropriate sound levels, including recommendations for modifying/maintaining/purchasing equipment. In addition, repair and maintenance policies should be reviewed to respond to a higher quality of functionality that includes quieter operation. Auditory impact query needs to be part of every remodel, construction, piece of equipment, and staff event.
For patients who need them, checking and adjusting monitors to avoid unnecessary alarms will undoubtedly reduce unnecessary noise exposure and distraction. Similarly, evaluating the patient's capacity to manage auditory stimuli will help improve the environment. Judiciously using barriers, such as doors and curtains, to provide both visual and auditory protection will begin the process of controlling sounds that resonate from one area to another.
Another important step is staff education and new employee orientation to make staff aware of where they are and their accountability for maintaining an appropriate sound environment. While mandating staff behavior has long been known to be the least effective method of managing noise, behavioral standards should nevertheless be modeled and extended organizationally. No different than dress codes and mandatory practices for infection control, sound control must be taken seriously. This includes standards governing private or confidential discussions that take place in public areas, use and methods of paging, and use of cell phones, nurse call systems, and the telephone.
Finally, it'is important to measure and notice the noise intervention on a continuous basis. Using both quantitative and qualitative measures-- decibel levels and patient satisfaction surveys -- a comparative analysis can be made to determine how far you have come and which aspects of the sound environment have yet to reach the established goals.
Patient perceptions of care are evidence-based, with the environment of care providing the bulk of relevant information. Within the environment, what is heard is the most prominent and accessible evidence of clinical standards, as well as patient care. Thus, leaving to chance the sounds heard by patients and families is risky. While there are effective steps that can shift an out-of-control environment into one that is therapeutic, the first one is to take active responsibility.
