Quantitative Critique Directions and Criteria
Overview: The ability to critically appraise research reports is imperative for all nurses. To effectively adopt this practice, a nurse must learn how to use a critical appraisal instrument that is designed to assist individuals with research report appraisal. In your Melnyk & Fineout-Overholt (2019) chapter 5 and specifically see page 126 Box 5.1 for the General Appraisal Overview (GAO) Elements and Questions for Critical Appraisal of Quantitative Studies. You will use this outline to form a critical appraisal of a quantitative research article.
West Chester University of Pennsylvania
College of Health Sciences, Department of Nursing
NSG 313 Nursing Research
Quantitative Critique Directions and Criteria
Overview: The ability to critically appraise research reports is imperative for all nurses. To
effectively adopt this practice, a nurse must learn how to use a critical appraisal instrument that
is designed to assist individuals with research report appraisal. In your Melnyk & FineoutOverholt (2019) chapter 5 and specifically see page 126 Box 5.1 for the General Appraisal
Overview (GAO) Elements and Questions for Critical Appraisal of Quantitative Studies. You
will use this outline to form a critical appraisal of a quantitative research article.
Article Selection: Your professor will provide the article for this critique.
Writing Recommendations:
You will gain an understanding of quantitative studies through the required readings and online
lectures.
Grade: This paper is 10% of your total NSG 313 grade.
Length: There should be sufficient information to respond to each section of the critical
appraisal guidelines in an essay form. No maximum length is required. Points will be deducted
for yes/no or incomplete answers. You are expected to explain the answers in a complete but
succinct manner using appropriate grammar and spelling (i.e. complete sentences). You are
expected to cite references and develop a reference list.
Format: Title page, critical appraisal, and reference pages. Section headers should be included
in your paper and correspond to the critical appraisal guidelines in Table 18.1. You do not need
to include an abstract. APA format for citations and references is required. Please address the
prompts in essay format, meaning you are writing an essay and addressing each question in the
critical appraisal guidelines. Do not just answer the questions like a worksheet.
Submission Requirements: This project has been set up to be placed in the dropbox on the
required date.
Quantitative Grading Rubric:
Below are the sections found in Box 5.1 on page 126 (Melnyk & Fineout-Overholt (2019). Each
section has several questions that need careful consideration. However, not all questions may be
applicable to your selected article. State this in your essay, do not omit questions just because
they are not pertinent to your article. Points are assigned to each section and earned by
answering the questions in a clear and comprehensive manner. Points are awarded to each
section in the critical appraisal guidelines and total 85 points. An additional 15 points are
assigned for proper grammar, spelling and APA format. Please be sure to spell check!
Box 5.1 General Appraisal Overview (GAO) Elements and Questions for Critical Appraisal of
Quantitative Studies
PICOT Question
Overview of the study
• Why was the study done (purpose)?
• What was the study design?
• Was appropriate ethics review reported?
General Description of the Study
Research Question of Hypothesis
Sampling
• What was the sampling technique?
• What was the sample size?
• What were the sample characteristics?
Major Variables Studied
• What are the major variables, independent, and dependent
• Are the measurements of major variables valid and reliable?
• How were the data analyzed? Were the statistics used appropriate?
• Were there any untoward events during the conduct of the study?
• How do the results fit with previous research in the area?
• What does this research mean for clinical practice?
Conclusion
Intensive & Critical Care Nursing xxx (2018) xxx–xxx
Contents lists available at ScienceDirect
Intensive & Critical Care Nursing
journal homepage: www.elsevier.com/iccn
Research article
Critical care nurses’ knowledge of alarm fatigue and practices towards
alarms: A multicentre study
Siobhán Casey a,⇑, Gloria Avalos b, Maura Dowling c
a
Intensive Care Unit, Galway University Hospital, Galway, Ireland
School of Medicine, Medical Informatics and Medical Education, National University of Ireland, Galway, Ireland
c
School of Nursing and Midwifery, National University of Ireland, Galway, University Road, Galway, Ireland
b
a r t i c l e
i n f o
Article history:
Accepted 7 May 2018
Available online xxxx
Keywords:
Alarm fatigue
Alarm management
Clinical alarms
Patient safety
a b s t r a c t
Objectives: To determine critical care nurses’ knowledge of alarm fatigue and practices toward
alarms in critical care settings.
Research methodology/design: A cross-sectional survey using an adaptation of The Health Technology
Foundation Clinical Alarms Survey.
Setting: A sample of critical care nurses (n = 250) from 10 departments across six hospitals in Ireland.
Results: A response rate of 66% (n = 166) was achieved. All hospital sites reported patient adverse events
related to clinical alarms. The majority of nurses (52%, n = 86) did not know or were unsure, how to prevent alarm fatigue. Most nurses (90%, n = 148) agreed that non-actionable alarms occurred frequently,
disrupted patient care (91%, n = 145) and reduced trust in alarms prompting nurses to sometimes disable
alarms (81%, n = 132). Nurses claiming to know how to prevent alarm fatigue stated they customised
patient alarm parameters frequently (p = 0.037). Frequent false alarms causing reduced attention or
response to alarms ranked the number one obstacle to effective alarm management; this was followed
by inadequate staff to respond to alarms. Only 31% (n = 50) believed that alarm management policies
and procedures were used effectively.
Conclusion: Alarm fatigue has the potential for serious consequences for patient safety and answering
numerous alarms drains nursing resources.
Ó 2018 Elsevier Ltd. All rights reserved.
Implications for clinical practice
Non-actionable alarms continue to burden nurses despite customising patient alarm parameters. Research regarding effective alarm
reduction strategies must be prioritised
The findings suggest that the majority of nurses are unaware of current evidence-based approaches to attenuate alarm fatigue.
Education and training regarding all aspects of alarm management should be ongoing for critical care nurses
Alarm management practices need to be evaluated locally and governed by evidence based policies and procedures to protect patient
safety
Introduction
Medical devices rely on auditory alarms to alert clinicians to
deviations from a predetermined normal status in either equipment or patient. This ensures safeguarding against harm (American
⇑ Corresponding author.
E-mail addresses: siobhan.casey@outlook.ie (S. Casey), Gloria.avalos@nuigalway.
ie (G. Avalos), Maura.dowling@nuigalway.ie (M. Dowling).
College of Clinical Engineering Healthcare Technology Foundation
[ACCE HTF], 2007). However, healthcare technology advances have
resulted in the exponential growth of medical device auditory
alarm sounds (Borowski et al., 2011).
Nurses have become overwhelmed by the sheer volume of
alarms leading to alarm apathy (Sendelbach and Funk, 2013). The
number of alarms has exploded to as many as 171 alarms per monitored bed per day (Graham and Cvach, 2010) and the majority are
estimated to be false or in-actionable (Siebig et al., 2010). The tech-
https://doi.org/10.1016/j.iccn.2018.05.004
0964-3397/Ó 2018 Elsevier Ltd. All rights reserved.
Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004
2
S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
nology that has been designed to save lives has therefore been
accused of becoming the ‘problem’ (Emergency Care Research
Institute (ECRI), 2014a,b). This viewpoint is supported by records
associating clinical alarms with patient deaths. For instance,
Cvach (2012) reviewed the Manufacturer and User Facility Device
Experience (MAUDE) database kept by the Federal Drug Administration (FDA) for four months in 2010 finding 73 deaths related
to alarms, of which 33 were attributed to physiological monitors.
In addition, a search of the MAUDE database discovered 216 deaths
related to physiologic monitor alarms, and while alarms sounded
in 73 cases, they were not attended due to being silenced, volumes
lowered or other reasons (Keller, 2012). Moreover, it is claimed
that the actual death rate related to clinical alarms may be ten
times higher than declared (The Association for the Advancement
of Medical Instrumentation [AAMI], 2011). It is therefore not surprising that up until 2016 the United States (US) patient safety
research organisation (ECRI) has positioned alarm hazards as number one, or two, of the annual ‘Top 10 Health Technology Hazards’
list since it was first devised in 2007. Additionally, alarm management was designated a National Patient Safety Goal in 2014, 2015
and 2016.
Researchers have only recently explored the phenomenon of
alarm fatigue (Alsaad et al., 2017; Bonafide et al., 2014; Cho
et al., 2016; Deb and Claudio, 2015; Funk et al., 2016; Funk et al.,
2014; Gazarian et al., 2015; Honan et al., 2015; Joshi et al., 2017;
Ruppel et al., 2018; Varpio et al., 2012). Most of this research emanates from North America. This could partly be explained by different nurse-patient ratios and single occupancy rooms employed in
the United States (US) compared to elsewhere, rendering the phenomenon more apparent.
querying nurses’ familiarity with the term alarm fatigue, whether
they knew what caused alarm fatigue, and how to prevent alarm
fatigue. An additional question (Q19) gathered information on
the extent to which the practice of customising alarms to patients
occurs in practice.
The HFT survey has previously been used to survey healthcare
professionals nationally throughout the US in 2005–2006, 2011,
and 2016 (Korniewicz et al., 2008: Funk et al., 2014; Ruppel
et al., 2018), and also in several other studies to evaluate nurses’
perception of alarms (Baird, 2015; Cho et al., 2016; Deb and
Claudio, 2015; Sowen at al., 2015; Petersen and Costanzo., 2017;
Turmell et al., 2017).
The adapted instrument was pretested among nine critical care
nurses and issues with the layout of the survey’s nine-point scale
were highlighted and subsequently re-organised. A reliability analysis of the adapted instrument generated a Cronbach’s Alpha of
0.73.
Ethical considerations
Ethical approval was granted for sites A and B on December 3rd,
2015, site D on January 11th, site C on January 14th, site F on January 16th and site E on March 11th, 2016. Participant confidentiality and anonymity were maintained throughout the study.
Setting
This study aimed to determine critical care nurses’ knowledge
of alarm fatigue and their attitudes, perceptions, and practices
towards clinical alarms. A cross-sectional survey design was used.
Nurses working at six hospitals in the West of Ireland were surveyed; All were teaching hospitals with university affiliation
(Table 1). Five were Model 3 hospitals, which have intensive care
facilities on site and emergency departments open 24/7. Site A
had Model 4 status as it was the regional tertiary referral centre.
Site A was the only hospital with a post anaesthetic care unit
(PACU). Nurses at this hospital rotated between the ICU, PACU
and high dependency unit, (HDU), therefore, it was deemed appropriate to include PACU in the study despite the short-term nature
of this patient population. The small number of PACU nurses 2.87%
(n = 8) was not anticipated to affect the data.
Instrument
Participant selection
The Health Technology Foundation (HFT) 2011 Clinical Alarms
Survey (CAS) (Funk et al., 2014) was used. This instrument consists
of four main sections. The first section seeks demographic information including type of hospital and critical care department. The
second section consists of general statements about clinical alarms
and asks respondents to rate their level of agreement with the
statements on a five-point Likert scale (Strongly agree to Strongly
disagree). The third section presents a list of nine obstacles to
effective clinical alarm management and asks respondents to rank
them on a scale of one (most important) to nine (least important).
The final section is an open question requesting views on what is
needed to improve clinical alarm recognition and response.
Permission was granted from the Health Technology Foundation (HTF) to use the instrument and to make adaptations as necessary. For instance, question 21 was omitted as it pertained to
telemetry which is utilised in only two of the study settings. Questions 23 and 30 on the HFT questionnaire were also omitted as they
pertained to alarm communication systems and central monitor
watchers which are not utilised throughout the study settings.
The time frame for question 20, which queried adverse events
related to clinical alarms, was changed from ‘two’ to ‘five’ years
to capture whether nurses were knowledgeable about confirmed
alarm-related deaths occurring in an intensive care unit (ICU) in
Ireland (Geraghty, 2015). Three knowledge questions were added
Non-probability consecutive convenience sampling was used.
Excluding 12 nurses from the single private hospital in the study,
the total population included 266 public sector nurses representing 19% of the total public sector critical care staff across Ireland.
Excluding non-clinical nurses reduced the target population to
250.
Methodology
Research design
Data collection
The two-page paper instrument was distributed by the first
author in person to each site. Data was collected over a onemonth period from mid-February to mid-March 2016. A tray of
study questionnaires was positioned beside the sealed survey collection box. Respondents were asked to take a survey and return
the completed survey to the collection box. Coloured A3 posters
were hung in the staff rooms of each site to advertise the study.
A champion was recruited for each site to promote the study.
The first author collected the sealed box at the end of the data collection period.
Data analysis
Collected data were entered INTO IBM SPSS version 22 for
descriptive and statistical analysis. Descriptive statistics were
Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004
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S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
Table 1
Description of Study Sites.
Site
A
B
C
D
E
F
Sample
Population
N = 250 (%)
Response
N = 166 (%)
Hospital
Model
Capacity
Description
106 (45%)
29 (10%)
34 (11%)
43 (14%)
12 (7%)
26 (13%)
75 (71%)
16 (55%)
19 (56%)
23 (53%)
12 (100%)
21 (81%)
Model 4
Model 3
Model 3
Model 3
Model 3 (JCI accredited)
Model 3
708 Bed
Regional Referral
Centre:ICU x11,CTICU
up to 5, PACU x 4, HDU
x6
26
220 Bed
Combined Unit:ICU x 2,
HDU x 3,CCU x 3.Telemetry
monitoring for 6 hospital
beds.
8
332 Bed
Combined Unit:
ICU/HDU/CCU x 8,
variable
dependency.
8
326 Bed
ICU x 5,
HDU, 4
126 Bed
Combined Unit:ICU & HDU x 8.
Telemetry monitoring for 4x CCU
beds on a separate floor and 12
Hospital beds.
8
359 Bed
Combined Unit:
ICU/HDU/CCU x 5
variable
dependency.
5
Critical Care
Beds
reported as frequency and percentage (%) for categorical data and
median and interquartile range (IQR) for skewed data. The level
of significance was based on an alpha value of 0.05.
The combined number of those who strongly agreed or agreed
with the Likert items 1–19 in the instrument were ranked from
the highest agreement (1) to the lowest agreement (19). The nonparametric Mann-Whitney U (U) test was applied for skewed continuous data and compared participants’ responses to questions 1–
19 with the three knowledge questions related to alarm fatigue (i.e.
are you familiar with the term alarm fatigue, do you know what
causes it and how do you prevent it?).” The chi-square test (v2)
explored the relationship between the question, ‘do you know
how to prevent alarm fatigue?’ and participant demographics and
responses to questions 1–22.
Site A was characteristically different to the other five sites;
hence Site A data were compared to the merged data of the other
sites to identify the site’s influence on the overall findings.
Findings
Sample and response rate
A response rate of 66% (n = 166) was achieved across the six
hospital sites (Table 1). A high proportion of the respondents were
female (89%, n = 146), while 12% (n = 19) were male. The majority
were staff nurses, (93%, n = 154), while 7% (n = 11) were clinical
nurse managers (CNMs).
The majority of respondents (66%, n = 108) were educated to
postgraduate (Higher diploma or Diploma) level, and of these,
11% (n = 17) held a master’s degree. Twenty-seven percent (n =
45) of respondents held a degree and 7% (n = 11) held a preregistration certificate in general nursing. Almost two-thirds of
the participants (62%, n = 98) had 11 years or more critical care
experience.
Knowledge of alarm fatigue
Most nurses (88%, n = 146) stated they were familiar with the
term alarm fatigue. Similarly, 84% (n = 138) stated they knew what
caused alarm fatigue. However, when their knowledge level was
explored further, 52% (n = 86), did not know, or were uncertain
how to prevent alarm fatigue.
Among 79 nurses who knew how to prevent alarm fatigue, significantly more were from Site A (58%, n = 46 vs 42%, n = 33), v2 (2)
=14.4, p = 0.001. However, despite initiatives to address alarm fatigue at Site A, 39%, (n = 29) of respondents from Site A did not know
or were unsure how to prevent alarm fatigue.
9
There was no association between nurses’ knowledge of how to
prevent alarm fatigue and years of experience (v2 (1 3 0) = 131.8,
p = 0.439), educational level (v2 (8) = 9.156, p = 0.329), overseas
experience (v2 (12) = 19.780, p = 0.071), gender (v2 (2) = 0.081, p
= 0.960), department (v2 (6) = 8.078, p = 0.232), or job title (v2
(2) = 0.268, p = 0.874). Nurses did not possess greater knowledge
of alarm fatigue prevention if they had worked in a Joint (International) Commission Hospital (v2(4) = 4.262, p = 0.372). The Joint
Commission (JC) is responsible for accrediting 21,000 healthcare
organisations in the US, and The Joint Commission International
(JCI) accredits over 100 hospitals worldwide. The JC is one of the
organisations at the forefront of efforts to increase awareness of
alarm fatigue and has incorporated alarm management into their
accreditation standards.
Nurses who were familiar with the term alarm fatigue agreed
that non-actionable nuisance alarms occurred frequently (Q3),
(U = 783, p = 0.005) and that alarms in their area were adequate
to alert staff of actual or potential changes in a patient’s condition,
(Q8) (U = 727, p = 0.024). Nurses who knew what caused AF agreed
that non-actionable/nuisance alarms occurred frequently (Q3)
(U = 824, p = 0.019). Nurses familiar with how to prevent AF agreed
that alarm management practices within their area incorporated
best available evidence to prevent patient adverse events (Q18)
(U = 1045, p = 0.038) (Table 2).
Alarms Recognition, settings and checks
Customising patient alarm parameters at the beginning of a
shift and adjusting them throughout the day (Q19) ranked 4th
highest agreement level (88%, n = 145) and was significantly
related to nurses’ knowledge of preventing alarm fatigue (92%,
n = 72 vs. 8% n = 60) v2 (4) = 10.2, p = 0.037.
The 2nd lowest level of agreement (30.9%, n = 50) was that
properly setting alarm parameters and alerts is overly complex in
existing devices (Q6), while difficulty setting alarms properly (Q1 in
the 1–9 scale) was ranked 8th as an obstacle to effective alarm
management (Table 3).
A low percentage of nurses 36% (n = 59) agreed that alarms frequently could not be heard or were missed (Q9). However, 62%
(n = 102) felt that environmental background noise had interfered
with alarm recognition (Q12), while 50% (n = 82) agreed that, when
a number of devices were alarming, there was confusion determining which device was alarming (Q13). There was almost unanimous agreement among the 166 nurses in this study (99%, n =
164) that alarms should indicate alarm priority (Q1) (Table 3).
Within the nine-point scale ranking issues inhibiting effective
alarm management, difficulty understanding alarm priority (Q4)
Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004
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S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
Table 2
Alarm Fatigue Knowledge vs Perception of Alarms
Mean Rank
Median
IQR (25th-75th)
p-value
Q3. Non-actionable/nuisance alarms occurfrequently
Are you familiar with the term alarm fatigue?
Yes (n = 144)
No (n = 14)
78
95
1
1
0(1–1)
1(1–2)
0.005*
0(1–1)
1(1–2)
0.024*
Q8. The alarms in my area are adequate to alert staff of potential or actual changes in a patient’s condition
Are you familiar with the term alarm fatigue?
Yes (n = 142)
77
1
No (n = 14)
97
1.5
Q3. Non-actionable/nuisance alarms occur frequently
Do you know what causes Alarm Fatigue?
Yes (n = 136)
74
1
No (n = 15)
89
1
0 (1–1)
1 (1–2)
Q.18. Alarm management practices within my area incorporate best available evidence to prevent patient adverse events
Do you know how to prevent alarm fatigue?
Yes (n = 77)
52
1
No (n = 35)
65
2
0.019*
1 (1–2)
2 (1–3)
0.038*
Table 3
Survey items on adapted HTF questionnaire and respondents’ ranking.
Likert Questions (Total % (n) for those who Strongly Agree or Agree with the Statements)
Total N = 166
% (n)
Rank
1.
2.
3.
4.
5.
99%
88%
90%
91%
81%
1
5
2
3
7
Alarm sounds and/or visual displays should differentiate the priority of alarm.
Alarm sounds and/or visual displays should be distinct based on the parameter (e.g. heart rate) or source (device type).
Non-actionable/Nuisance alarms occur frequently.
Non-actionable/Nuisance alarms disrupt patient care.
Non-actionable/Nuisance alarms reduce trust in alarms and cause caregivers to turn alarms off at times other than setup or procedural
events.
6. Properly setting alarm parameters and alerts is overly complex in existing devices.
7. Newer monitoring systems (less than three years old) have solved most of the problems we experienced with clinical alarms.
8. The alarms in my area are adequate to alert staff of potential or actual changes in a patient’s condition.
9. There have been frequent incidences where alarms could not be heard or were missed.
10. Clinical staff are sensitive to alarms and respond quickly.
11. The medical devices used in my area all have distinct outputs (i.e. sounds, repetition rates, visual displays, etc.) that allow users to identify
the source of the alarm.
12. When a number of devices with alarms are used with a patient, it can be confusing to determine which device is in alarm.
13. Environmental background noise has interfered with alarm recognition.
14. Smart alarms (e.g. where multiple parameters, rate of change of parameters, and signal quality, are automatically assessed in their entirety)
would be effective for reducing false alarms.
15. Smart alarms (e.g. where multiple parameters, rate of change of parameters, and signal quality are automatically assessed in their entirety)
would be effective to use for improving clinical response to important patient alarms.
16. There is a requirement in my institution to document that the alarms are set and appropriate for each patient.
17. Clinical policies and procedures regarding alarm management are effectively used in my facility.
18. Alarm management practices within my area incorporate best available evidence to prevent patient adverse events.
19. I always customise patient alarm parameters at the beginning of a shift and adjust accordingly throughout the day.
20. Has your hospital experience adverse patient events in the last five years related to clinical alarms?
21. Has your hospital instituted new technological solutions to improve clinical alarm safety?
22. Has your area developed clinical alarm improvement initiatives over the past two years?
Education, training and improvement initiatives
New technology had been instituted to improve clinical alarm
safety in their area according to 47% (n = 76) of respondents (Q21).
This was significantly related to nurses’ knowledge of alarm fatigue
30.9% (50)
18% (29)
78% (126)
36% (59)
76% (123)
77% (125)
17
19
8
16
10
9
50% (82)
62% (102)
72% (117)
14
13
11
71% (105)
12
82% (134)
30.8% (50)
48% (77)
89% (145)
6
18
15
4
Yes
No
Unsure
54% (88)
46.6% (52)
50.3% (81)
21.5% (35)
31.9% (52)
33.5% (54)
24.5% (40)
21.5% (35)
16.1% (26)
Ranking statements on issues which inhibit effective management of clinical alarms (Most important = 1 to Least important = 9)
Q1 Difficulty in setting alarms properly.
Q2 Difficulty in hearing alarms when they occur.
Q3 Difficulty in identifying the source of an alarm.
Q4 Difficulty in understanding the priority of an alarm.
Q5 Frequent false alarms, which lead to reduced attention or response to alarms when they occur.
Q6 Inadequate staff to respond to alarms as they occur.
Q7 Over reliance on alarms to call attention to patient problems.
Q8 Noise competition from non-clinical alarms and pages.
Q9 Lack of training on alarm systems.
was ranked 4th, while difficulty hearing alarms when they occur
(Q2) was ranked 5th and difficulty identifying the source of an
alarm (Q3) was ranked 6th.
(164)
(143)
(148)
(145)
(132)
Mean Rank
4.14
3.80
3.81
3.69
2.43
2.66
3.40
4.31
3.86
Rank
8
5
6
4
1
2
3
9
7
prevention (58%, n = 45 vs. 42%, n = 33), v2 (4) = 15.3, p = 0.004. Half
of the sample (50%, n = 81) stated that their area had instituted clinical alarm improvement initiatives in the preceding two years (Q22).
This was significantly related to nurses’ knowledge of alarm fatigue
prevention (61% n = 47 vs. 39% n = 33), v2 (4) = 12.9, p = 0.011.
Nurses believed smart alarm technology, which uses multiple
parameters in alarm algorithms, would be effective at reducing
false alarms (72%, n = 117) (Q14), and would improve clinical
response to important alarms (71%, n = 115) (Q15). This was
Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004
S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
significantly related to knowledge of alarm fatigue prevention
(70%, n = 54 vs. 30%, n = 23), v2 (4) = 10.81 p = 0.029. The item
achieving the lowest agreement level (18%, n = 29) ranking 19th,
stated that newer monitors had solved most problems experienced
with clinical alarms (Q7). This was significantly related to alarm
fatigue prevention knowledge (24%, n = 19 vs. 24%, n = 59),
v2 (4) = 11.40, p = 0.022.
Too many false alarms
The second, third, and seventh highest level of agreement in
order, was that nuisance alarms are frequent (Q3) (90%, n = 148),
disruptive to patient care (Q4) (91%, n = 145), and reduced trust
in alarms causing nurses to disable alarms (Q5) (81%, n = 132).
The frequency of false alarms causing a subsequent reduced attention and response to alarms was ranked the number one obstacle
to effective alarm management (1–9 Scale).
Staffing
Nurses agreed (76% n = 123) that clinical staff were sensitive to
alarms and responded quickly (Q10). However, nurses ranked
‘inadequate staff to respond to alarms as they occur’ in 2nd place
(Q6, 1–9 scale) while over-reliance on alarms to alert staff to
patient problems was ranked 3rd (Q7, 1–9 scale).
Alarm related patient adverse events
Just over half of participants (54%, n = 88) had knowledge of
adverse patient events related to clinical alarms (Q20). Significantly more nurses from Site A (95%, n = 71) were aware of previous adverse events when compared to other sites (19%, n = 17),
v2 (2) = 93, p 0.001.
Although not statistically significant, (v2 (2) = 4.559, p = 0.102),
among the 71 nurses from Site A who confirmed their hospital had
experienced adverse patient events related to clinical alarms, 37%
(n = 26) did not know or were unsure how to prevent alarm
fatigue.
Discussion
To our knowledge, only one other European study (Joshi et al.,
2017) reports on critical care nurses’ practices toward alarms. The
findings of this study suggest that more education on prevention
of alarm related adverse events is needed across all hospital sites.
International literature suggests that practitioners are often unaware of the intricacies of monitors (ACCE, 2007; Borowski et al.,
2011; Harris et al., 2011) and tend to underestimate their knowledge
deficits (ACCE, 2007). Even experienced nurses need ongoing education regarding medical devices (AACN, 2013; Cvach et al., 2013).
The level of agreement for the Likert scale questions (Table 3)
are similar to those reported by ICU nurses isolated from HTF surveys conducted in the US (Korniewicz et al., 2008; Funk et al.,
2014), and Cho et al’s (2015) study in South Korea. The vast majority of ICU nurses from these aforementioned studies responded
that alarms should indicate alarm priority. Frequent false alarms
causing a subsequent reduced attention or response to alarms
was ranked number one across all samples. Difficulty understanding the priority of an alarm was ranked in the top four across all
studies. Inadequate staff to respond to alarms was ranked number
two in our study and number three in the Korean study (Cho et al.,
2015) and number six among the HTF ICU nurses (Korniewicz
et al., 2008; Funk et al., 2014).
This study demonstrates that nurses perceive alarm fatigue
from high alarm load, frequent inactionable alarms, alarm flood
and poor alarm design which feature commonly in Irish critical
5
care departments. Respondents agreed unanimously that alarm
sounds or visual displays should indicate alarm priority. However,
alarm alerts which do not match the criticality of the situation are
well documented in the literature (Mondor and Finley, 2003;
Momtahan et al., 2007; Schmid et al., 2013). Often they are difficult
to localise or discriminate their level of urgency or priority
(Edworthy and Helier, 2005). Matching alarm priority to the clinical situation is recommended by ECRI (2015). However, alarm
alerts which do not match the criticality of the situation continues
to be an issue (Edworthy, 2013).
Alarm loads from physiological monitors at site A had been
reported as 30,000 per week between ICU and HDU (17 beds)
(Geraghty, 2015). This equals approximately one alarm every
20 s from the monitor alone which is classified as an alarm flood.
Alarm flood is defined by the American National Standards
Institute/International Society of Automation ANSI/ISA 18.2 as
‘‘10 or more annunciated alarms in any 10 min period per operator”.
Alarm floods are classified as extremely hazardous and undesirable
by other high-risk industries.
In this study, most nurses felt that non-actionable alarms
occurred frequently and that they disrupted patient care. Although
it is known that most alarms are non-actionable, Paine et al. (2016)
conclude that there appears to be a relationship between alarm
exposure and response time that could be caused by alarm fatigue.
However, it is not known which interventions are the most effective in reducing the number of unnecessary alarms safely (Paine
et al., 2016).
This study and others (Cho et al., 2015; Korniewicz et al., 2008;
Funk et al., 2014) report that the majority of nurses agreed that
alarms are being disabled due to trust erosion in the alarm system.
Moreover, this study provides evidence that adverse events related
to clinical alarms are occurring, as all sites studied reported patient
adverse events related to clinical alarms. However, given that
alarm fatigue is a complex, multifactorial problem, examination
of associated sentinel events requires a broad outlook defining circumstances that contribute to its development.
Limitations
The study was confined to the West of Ireland limiting generalisability of findings. Furthermore, site A is distinctly different from
the other sites, as it is significantly larger and is the only model 4
hospital in the region. Moreover, the adoption of recommended
ECRI alarm management practices within critical care departments
is unique to this site. Additionally, two alarm-related deaths had
occurred in the department at Site A within the previous five years,
hence the heightened awareness of nurses working at this Site
likely influenced the results. Also, the first author worked in Centre
A, and although attempts were made to prevent introduction bias,
this may have influenced the results.
The HFT survey assesses nurses’ perceived views of alarm management in their area rather than the actual occurrence of alarm
fatigue in clinicians. Moreover, the psychometric properties of
the HTF instrument have not been rigorously tested or evaluated,
however, Torabizadeh et al. (2016) report good internal homogeneity and retest methods for their new tool which measures
alarm fatigue.
Conclusion
The full extent of alarm fatigue has not been properly considered outside the US. In this study, nurses perceive that the antecedents of alarm fatigue are prevalent in West of Ireland critical care
areas. Nurses reported a knowledge deficit regarding alarm fatigue
prevention despite reports of adverse patient events from all sites.
Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004
6
S. Casey et al. / Intensive & Critical Care Nursing xxx (2018) xxx–xxx
Alarm fatigue has profound consequences for patient safety with
the worst-case scenario resulting in death or serious patient harm.
An environment of excessive alarms is conducive to error. Moreover, the burden of responding to numerous non-actionable alarms
drains nursing resources.
Future research should focus on identifying levels of alarm fatigue among critical care nurses and evaluating education and training approaches to manage alarm fatigue.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
The primary author is a practicing staff nurse at one of the study
sites included in the research. The authors whose names are listed
immediately below certify that they have NO affiliations with or
involvement in any organisation or entity with any financial interest
(such as honoraria; educational grants; participation in speakers’
bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patentlicensing arrangements), or non-financial interest (such as personal
or professional relationships, affiliations, knowledge or beliefs) in
the subject matter or materials discussed in this manuscript.
Author names: Siobhán Casey, Gloria Avalos, Maura Dowling.
Acknowledgements
Dr. David S Evans – Senior Research Officer, Department of Public Health Merlin Park Hospital Galway (Statistics support).
Dr. Kristopher Fennie PhD, Florida International University,
Miami Florida,
Dr. Marjorie Funk, RN, PhD, Yale University School of Nursing
(HTF Clinical Alarms 2011, 2006, Survey Data).
Kim HwaSoon PhD, RN, Professor, Department of Nursing, Inha
University Incheon, Korea (Data for Ok Min Cho et al., 2016 Clinical
Alarms Survey South Korea doi: 10.4258/hir.2016.22.1.46.
Dr. R.L. Wears M.D, Ph.D., M.S Professor of Emergency Medicine,
University of Florida. Special Interest; Patient Safety (Patient Safety
advice).
References
Alsaad, A.A., Alman, C.R., Thompson, K.M., Park, S.H., Monteau, R.E., Maniaci, M.J.,
2017. A multidisciplinary approach to reducing alarm fatigue and cost through
appropriate use of cardiac telemetry. Postgrad. Med. J. 93 (1101), 430–435.
https://doi.org/10.1136/postgradmedj-2016-134764.
American Association of Critical-Care Nurses (AACN) Strategies for managing alarm
fatigue: an evidence-based approach for understanding and managing alarm
fatigue in the acute and critical care environment. nti ActionPak. [online] 2013
Available:
http://www.aacn.org/wd/practice/docs/practicealerts/alarmmanagement-practice-alert.pdf [Accessed: August 10th, 2016].
American College of Clinical Engineering (AACE), 2007. Health Technology
Foundation, Clinical Alarm Task Force. Impact of clinical alarms on patient
safety: a report from the American College of Clinical Engineering Healthcare
Technology Foundation. J. Clin. Eng. 32 (1), 22–33.
American National Standards Institute/ International Society of Automation (ANSI/
ISA) ANSI/ISA 18.2 – 2009 Management of Alarm Systems for the Process
Industries. 2009; www.ISA.org.
Association for the Advancement of Medical Instrumentation (AAMI). Clinical
alarms: 2011 summit [online] 2011. Available: http://kami.camp9.org/
Resources/Pictures/2011%20Alarms%20Summit%20Report.pdf [Accessed April
29th, 2018].
Baird, K.M., 2015. Examining the Problem of Alarm Fatigue: An Analysis of Intensive
Care Nurse’s Attitudes Related to Clinical Alarm Management. University of
California Davis. Unpublished Master’s Thesis.
Bonafide, C.P., Zander, M., Graham, C.S., Weirich Paine, C.M., Rock, W., Rich, A.,
Roberts, K.E., Fortino, M., Nadkarni, V.M., Lin, R., Keren, R., 2014. Video methods
for evaluating physiologic monitor alarms and alarm responses. Biomed.
Instrum. Technol. 48 (3), 220–230.
Borowski, M., Görges, M., Fried, R., Such, O., Wrede, C., Imhoff, M., 2011. Medical
device alarms. Biomedizinische Technik (Berlin) 56 (2), 73–83.
Cho, O.M., Kim, H., Lee, Y.W., Cho, I., 2016. Clinical alarms in intensive care units:
perceived obstacles of alarm management and alarm fatigue in nurses.
Healthcare Inform. Res. 22 (1), 46–53.
Cvach, M., 2012. Monitor alarm fatigue: an integrative review. Biomed. Instrum.
Technol. 46 (4), 268–277.
Cvach, M., Currie, A., Sapirstein, A., Doyle, P.A., Pronovost, P., 2013. Managing
clinical alarms: using data to drive change. Nurs Manage. 44 (11 Safety
Solutions), 8–12.
Deb, S., Claudio, D., 2015. Alarm fatigue and its influence on staff performance. IIE
Trans. Healthcare Syst. Eng. 5 (3), 183–196.
Emergency Care Research Institute (ECRI). ECRI Institute Top 10 Health Technology
Hazards Report for 2014 [online] Available: https://www.ecri.org/Resources/
Whitepapers_and_reports/2014_Top_10_Hazards_Executive_Brief.pdf
[Accessed April 29th, 2018].
Emergency Care Research Institute (ECRI) Alarm Safety Handbook: Strategies, Tools,
and Guidance 2014. ECRI Institute Plymouth Meeting: Pennsylvania [online]
Available:
https://public.vtoxford.org/wp-content/uploads/2015/01/ECRI_
AlarmSafetyHandbook [Accessed April 29th, 2018].
Emergency Care Research Institute (ECRI) The top 10 health technology hazards for
2015, ECRI Institute [online] Available: https://www.ecri.org/Documents/
White_papers/Top_10_2015.pdf [Accessed April 29th, 2018].
Edworthy, J., 2013. Alarms are still a problem! Anaesthesia 68 (8), 791–794.
Edworthy, J., Hellier, E., 2005. Fewer but better auditory alarms will improve patient
safety. Quality Safety Health Care 14 (3), 212–215.
Funk, M., Clark, J.T., Bauld, T.J., Ott, J.C., Coss, P., 2014. Attitudes and practices related
to clinical alarms. Am. J. Crit. Care 23 (3), e9–e18.
Funk, M., Ruppel, H., Blake, N., Phillips, J., 2016. Research: use of monitor watchers
in hospitals: characteristics, training, and practices. Biomed. Instrum. Technol.
50 (6), 428–438.
Gazarian, P.K., Carrier, N., Cohen, R., Schram, H., Shiromani, S., 2015. A description of
nurses’ decision-making in managing electrocardiographic monitor alarms. J.
Clin. Nurs. 24 (1–2), 151–159.
Geraghty, D. 2015. Woman Died in Hospital after Alarm Not Heard. Connacht
Tribune. Dec 22 [online] Available: http://connachttribune.ie/woman-died-inhospital-after-alarm-not-heard-200/ [Accessed April 29th,2018].
Graham, K.C., Cvach, M., 2010. Monitor alarm fatigue: standardizing use of
physiological monitors and decreasing nuisance alarms. Am. J. Crit. Care 19
(1), 28–34.
Harris, R.M., Manavizadeh, J., McPherson, D.J., Smith, L., 2011. Do you hear bells?
The increasing problem of alarm fatigue. Philadelphia Nurse. 66 (1), 10–13.
Honan, L., Funk, M., Maynard, M., Fahs, D., Clark, J.T., Yadin, D., 2015. Nurses’
Perspectives on Clinical Alarms. Am. J. Crit. Care 24 (5), 387–395.
Joshi, R., Mortel, H.V., Feijs, L., Andriessen, P., Pul, V.C., 2017. The heuristics of nurse
responsiveness to critical patient monitor and ventilator alarms in a private
room neonatal intensive care unit. PLoS One 12 (10), e0184567.
Keller, J.P., 2012. Clinical alarm hazards: a ‘‘top ten” health technology safety
concern. J. Electrocardiol. 45 (6), 588–591.
Korniewicz, D.M., Clark, T., David, Y., 2008. A national online survey on the
effectiveness of clinical alarms. Am. J. Crit. Care 17 (1), 36–41.
Mondor, T.A., Finley, G.A., 2003. The perceived urgency of auditory warning alarms
used in the hospital operating room is inappropriate. Can. J. Anesthesia 50 (3),
221–228.
Momtahan, K., Hétu, R., Tansley, B., 2007. Audibility and identification of auditory
alarms in the operating room and intensive care unit. Ergonomics 36 (10),
1159–1176.
Paine, C.W., Goel, V.V., Ely, E., Stave, C.D., Stemler, S., Zander, M., Bonafide, C.P.,
2016. Systematic review of physiologic monitor alarm characteristics and
pragmatic interventions to reduce alarm frequency. J. Hospital Med. 11 (2),
136–144.
Petersen, E.M., Costanzo, C.L., 2017. Assessment of clinical alarms influencing
nurses’ perceptions of alarm fatigue. Dimensions Crit. Care Nurs. 36 (1), 36–44.
Ruppel, H., Funk, M., Clark, J.T., Gieras, I., David, Y., Bauld, T.J., Coss, P., Holland, M.L.,
2018. Attitudes and practices related to clinical alarms: a follow-up survey.
AJCC Am. J. Crit. Care 27 (2), 114–123.
Schmid, F., Goepfert, M.S., Reuter, D.A., 2013. Patient monitoring alarms in the ICU
and in the operating room. Crit. Care 17 (2), 216.
Sendelbach, S., Funk, M., 2013. Alarm fatigue: a patient safety concern. AACN Adv.
Crit. Care 24 (4), 378–386.
Siebig, S., Kuhls, S., Imhoff, M., Gather, U., Schölmerich, J., Wrede, C.E., 2010.
Intensive care unit alarms-how many do we need? Crit. Care Med. 38 (2), 451–
456.
Sowen, A., Tarriela, A.F., Gomez, T.M., Reed, C.C., Rapp, K.M., 2015. Nurses’
perceptions and practices toward clinical alarms in a transplant cardiac
intensive care unit: exploring key issues leading to alarm fatigue; JMIR. Hum.
Factors 2 (1), e3.
Torabizadeh, C., Yousefinya, A., Zand, F., Rakhshan, M., Fararooei, M., 2016. A nurses’
alarm fatigue questionnaire: development and psychometric properties. J. Clin.
Monit. Comp. 31 (6), 1305–1312.
Turmell, J.W., Coke, L., Catinella, R., Hosford, T., Majeski, A., 2017. Alarm fatigue: use
of an evidence-based alarm management strategy. J. Nurs. Care Qual. 32 (1), 47–
54.
Varpio, L., Kuziemsky, C., MacDonald, C., King, W.J., 2012. The helpful or hindering
effects of in-hospital patient monitor alarms on nurses: a qualitative analysis.
Comp. Inform. Nurs. 30 (4), 210–217.
Please cite this article in press as: Casey, S., et al. Critical care nurses’ knowledge of alarm fatigue and practices towards alarms: A multicentre study. Intensive & Critical Care Nursing (2018), https://doi.org/10.1016/j.iccn.2018.05.004
Running header: QUANTITATIVE ANALYSIS
Quantitative Analysis Workplace Violence
RN-BSN Student
West Chester University of Pennsylvania
2
Quantitative Analysis
Background
The background states the rate of assault is higher for healthcare workers than other
industries. Gates (2011) states, “There is little evidence available regarding the effectiveness of
interventions” (p. 304). The research question is to develop and test intervention to reduce
violence against ED workers. There is no hypothesis stated. There is no prediction of outcome.
The goal of the study is to identify the victims, perpetrators, circumstances surrounding violence,
and interventions to prevent or control violence. The study is not organized into theoretical
framework. The research question can be supported.
Workplace violence is dependent variable. Frequency of violence related to independent
variables gender, age, job title, patient population, and hospital location. Feelings of safety is the
independent variable related to dependent variables of job satisfaction and overturn. Many
research works have been sited to support the occurrence of violence in the workplace. The
research questions have specific relationships outlined and can be supported. The application for
the research is to develop and study an intervention to reduce violence in emergency
departments.
Review of Literature
The study uses four key words. The study is using the conceptual framework within the
behavioral theory discipline. Research literature is solely used as primary source. The gap in
knowledge is the minimal availability of evidence for interventions in workplace violence.
Specified limitations are participants were not randomly selected and the information submitted
was recall of memory. The literature was organized. The conclusion summarized the research
3
Quantitative Analysis
study. The conclusion states, “The worker need to document the violent occurrences and
collaborate with leadership to reduce violence” (Gates, 2011).
Method
Internal external validity
Controls for threats to internal validity such as history and maturation were not
addressed. The survey was performed once. Every participant used the same survey, and every
survey used was filled out entirely. The method used to select the sample was proportional
recruitment strategy, convenience and assigned by hospital affiliation. Social desirability and
recall bias were not of concern. The Hawthorne Effect not valid because the survey was returned
by mail. The study was a cross sectional design. The study has no intervention. Threats to
validity weaken degree of correlation because the measure of the study is less effective.
Research design
The type of design is cross sectional developmental. The design is appropriate because
there is no control group, the independent variables are not manipulated. The study is non
experimental because the researcher looks to test relationships and differences among variables.
The design flow has appropriate connection.
Sampling
The type of sampling is nonprobability using inclusion criterion and convenience. The
study used proportional recruitment strategy. The size is appropriate, because more resources
would be needed to survey all workers. The sample was selected on a first come basis. Inclusion
criterion was based on the staff experiencing violence. The collection strategy was appropriate
Quantitative Analysis
4
for the design. The sample reflects the proposed population. The study needed a minimum of 160
participants, 213 were used to meet adequate sample deemed by power analysis. The findings
can be applicable to support the need for de-escalation training of staff.
Legal-Ethical Issues
The subject surveys were accompanied with informed consent stated in the data
collection and processing section (Gates, 2011 p.306). Institutional review board and hospital
approvals were obtained before beginning the study listed in methods (Gates, 2011 p.305).
Data collection
Rationale was given to include a variety of settings representative of most emergency
departments in the United States. There were no observations preformed or interviews. The
instrument was a survey using Likert Scale. The operational definitions were provided and
consistent with the study concept. The study appropriately used self-reporting methods. Social
desirability can be a bias, recall may not be accurate/bias. Existing definitions of violence and
surveys were used. Data sets came exclusively from current study. Fidelity was maintained by
use of computerized questionnaire.
Reliability and validity
Gates (2011) states, “the instruments demonstrated good face and content validity, and
the internal reliabilities for the safety scale and confidence scale were high in previous studies”
for the safety scale alpha > 0.75 and 0.95 for the confidence scale (p. 306). The instrument
validity is high thus reliable. The reliability is not negatively affected. Threats to validity
presented were: participants were first come, low number of participants at each site can cause
skewed results. Threats to reliability were recall of events may be less accurate. Reliability is the
Quantitative Analysis
5
measure of consistency. The correlation indicates: people scoring low on the confidence scale
should be nervous when dealing with aggressive patients. Validity measures accuracy the degree
of correlation between two measures show strength or weakness. The strengths and weakness of
the survey were not presented.
Data Analysis
The descriptive statistics used categorical data to define and summarize the information
with graphs. Inferential statistics were not presented. The tables available are supplemental and
economizes the text. The tables have precise headings and were summarized in the text. The
tables identified the correlation of variables related to workplace violence. Testing supported the
research question.
Conclusions, Implications, Recommendations
The results were presented objectively. The information was lengthy but is presented
sequentially. Theoretical framework was not addressed in the study. Limitations were stated but
the researcher was not passionate to make modifications. The researcher was satisfied to observe
correlations in variables consequently, suggestions were not made for future studies. The
relevance to clinical practice is the need for accurate reporting and de-escalation training for
healthcare workers. Generalizations made within were staff across the United States are at risk
for workplace violence. The study is part of a larger effort to develop and test interventions for
future study.
Applicability to Nursing Practice
Findings of the study applied to practice will improve workplace violence. Benefits are a
reduction in absenteeism, injury, job dissatisfaction, and loss of employees. Risks involved are
Quantitative Analysis
6
the learning curve to implement de-escalation technique and the cost of training the workers in
de-escalation technique. The strength of the study outweighs the weakness. The quality, strength
and consistency of evidence are suitable. Both interventions are feasible because implementation
outweigh the negative results. The findings are generalizable because violence is a wide concept
and healthcare is a stressful field. Clinical settings that can replicate the presence of workplace
violence are geriatrics, psychiatry, pediatrics, acute care and home care.
7
Quantitative Analysis
Reference
Gates, D., Gillespie, G., Kowalenko, T., Succop, P., Sanker, M., Farra, S., (2011). Occupational
and demographic factors associated with violence in the emergency department.
Advanced Emergency Nursing Journal, 33, 303-313. doi:10.1097/TME.0b013e31823
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