notes on nursing rosemary bender

Running head: NOTES ON NURSING NOISE 1

Notes on Nursing

Noise

Rosemary T. Bender

De Sales University

NOTES ON NURSING NOISE 2

Abstract

The concept of noise in Florence Nightingale’s book Notes on Nursing (1859) will be

discussed in this paper. The fast pace of todays’ clinical care setting creates an environment

of noise and turbulence which raises concerns about the potential for this environment to

compromise patient health recovery and wellbeing. Noise has the potential to impair

hearing, cause irritability, confusion and sleep deprivation. It has been suggested that noise

can increase the need for analgesia, prolong wound healing and ultimately delay recovery

from surgery. The adverse effects of noise have been identified in staff as well.

Environmental noise has been positively linked to both headaches and burnout in nurses and

other direct care staff. Five nursing research articles were reviewed that address the concept

of noise and propose multifaceted environmental measures. A multi- centered non-

randomised parallel group trial, a prospective cohort study, a quasi-experimental intervention

with randomization, a single, non-randomized trial and a single, descriptive, qualitative study

will be discussed. More research is needed to validate these environmental studies. Florence

Nightingale was the first nurse on record to stress the importance of creating the optimum

healing environment. Nursing today is uniquely positioned to actualize her vision by

participating in evidence-based research.


Notes on Nursing: Noise in Health Care and the Impact on the Healing Environment

Noise is a significant feature of the contemporary hospital environment. It is

measured on a sound level meter which records the pressure of sound on a logarithmic scale

in units called decibels (dB). A whisper is about 20 dB, normal conversation is about 50 dB

and rush hour traffic is about 90 dBs. The Environmental Protection Agency recommends

that hospital noise levels not exceed 45 dBs during the day and 35 dBs at night (EPA, 1974).

Recent research has found hospital sound levels have risen to 72 dB during daytime hours

and to 60 dB at night (Busch-Vishniac, et al., 2005; Gardner , Collins, Osborne, Henderson

& Eastwood, 2009). Noise levels recorded in various clinical settings produce negative

effects on patient satisfaction as well as outcomes. Problems such as sleep disturbance,

heightened stress response, headaches, prolonged wound healing and increased sensitivity to

pain are well documented. The stress and health effects of hospital noise on patients and

nurses have been the focus of the majority of research to date.

Florence Nightingale suggested that careful control of the hospital environment

should be a major concern for nursing. She particularly warns against unnecessary noise and

sudden noise as she begins to address the importance of ensuring a patients’ sleep

architecture (Nightingale, 1859). Noise is a significant barrier to sleep and sleep has been

shown to be therapeutic for health, healing and overall recovery (Gardner et al., 2009).

Understanding the role of noise in the sleep efficacy of ill patients can help nurses identify

sources of noise and initiate sleep improvement protocols. Not surprisingly, three of the four

journals reviewed incorporate interventions specifically targeting sleep or scheduled quiet

time. There appears to be more than ample evidence to justify continued nursing research

focused on noise reduction and a holistic incorporation of environmental enhancements


which will aid in the recovery process. If this were done it would improve the working

environment for nurses as well as the quality of care and outcomes for patients. A literature

review of four studies was done in this paper that explores the impact of noise on the

optimum healing environment.

Anecdotally, as the author I was drawn to this concept for two reasons. Initially, my

interest in noise stemmed from having a hearing impairment and undergoing a mastoidectomy

and tympanoplasty at University of Pennsylvania in 2009. More importantly, while reading

Nightingale’s chapter on Noise I was fascinated by her writings on what sound like therapeutic

communication, speech and empathy under the headings of ‘hurry’ and ‘how to visit the sick and

not hurt them’. I have begun a literature search on this topic and am developing my Review of

Literature assignment based on this concept.

Body

A multi-centered non-randomised parallel group trial study by Gardner et al. (2009)

evaluated a scheduled quiet time intervention in an acute care setting. The effect of a scheduled

quiet time on noise levels, inpatients’ rest and sleep behavior, and wellbeing were measured.

Professionals’ satisfaction, organizational functioning and impact on visitors were tracked as

well. Research was conducted on the acute orthopaedic wards of two urban hospitals in

Brisbane, Australia over a 5 month period. The study received ethical clearance from local

ethics committees and the Queensland University of Technology Human Research Ethics

Committee. This study was funded by a competitive grant from Queensland Nursing Council.

299 participants were recruited over the 5 month data collection period, 6 withdrew consent

during the course of the study. The experimental group had 137 participants and the control

group had 156 at the completion of the study. The four main variables were noise levels,


afternoon sleep, overall sleepiness, and health status during the first week following discharge.

Data for noise level, sleep status, sleepiness and wellbeing were collected using previously

validated instruments. The results of the Gardner et al. (2009) study confirmed the majority of

their hypotheses. This included that a scheduled quiet time intervention on an acute hospital

ward made a significant difference to noise level and patient sleep status during the quiet time

period. Significant positive correlations were identified in that as noise levels decreased more

patients were sleeping. Findings did not support the hypotheses that a quiet time would result in

improved overall sleep status or improved health outcome. Funding limitations impacted the

data collection and estimated sample size fell short. Limited response rates at discharge and

follow up also impacted the confirmation of these two hypotheses. The second aim of the study

was to investigate the impact of a quiet time intervention on patient and visitor satisfaction and

on ward operational issues and nursing, medical and allied health work patterns. Survey

responses confirmed a well-accepted intervention with positive outcomes. This reader agrees

with the limitations of the study identified by Gardner et al. (2009) which were reduced sample

size and low response rates. The low response rates for discharge and follow up questionnaires

prevented the study from testing hypotheses 3 and 4 concerning improvements to overall sleep

status and health outcomes.

Lower, Bonsack, and Guion (2002) are nurses at Johns Hopkins Hospital who pooled

their clinical experiences, conducted a literature review and developed an environment of healing

in their neuroscience critical care unit and neurovascular intensive care unit. They designated the

period between 2 to 4 p.m. as Quiet Time in the two ICU’s. These hours were selected as they

are one of the two natural lows in the body’s circadian rhythm, a time when the body is most

vulnerable and needs protecting ( Lower, Bonsack & Guion, 2002). Noise control was their


initial goal and they gathered data by purchasing a decibel meter and measuring noise levels in

various areas. Measures were then implemented to reduce overall unit noise level. Creative

signs were posted as a visual cue for all who entered the units and the visitors’ pamphlet was

updated to explain Quiet Time rationale and purpose. This reader was impressed by their

development of an Attentive Caring Time team. Each team consists of an RN, a clinical

associate and a support associate. The ACT team goes to work a 2 p.m. explaining the purpose

and process of Quiet Time to each patient and follows a set protocol which includes positioning,

lowering lights, patient selected relaxation music, massage, prn pain meds, prn prayer or spiritual

intervention, doors closed with do not disturb signage posted. As this was not a pure research

study, the only data collected were patient and family satisfaction scores which were markedly

improved from a low of 50% to 88.9% , significantly higher than the rest of the hospital.

Anecdotally, staff has found they benefit as well with time to catch up on charting and enjoying

the relaxing music playing in the hallways. The study has also allowed them to deploy a staff

member routinely to the visitors lounge during Quiet Time to minister to families’ needs,

offering support to families facing a crisis alone in a large hospital. To encourage physician

support poster boards have been developed with available research studies. As a result of this

unit based study, Lower, Bonsack and Guion have begun formulating plans for further research.

Identified goals are to demonstrate that Quiet Time can decrease use of pain medications,

decrease length of stay, increase patient and family satisfaction scores, and improve cognitive

responses in the neuroscience population they serve.

Scotto, McClusky, Spillan and Kimmel (2009) performed a quasi-experimental

intervention study with random assignment of subjects to determine the effects of earplug use on

the subjective experience of sleep for patients in critical care. The authors conducted a literature


review and identified that most interventions to address noise in critical care have been targeted

at reducing environmental noise. Their belief that it is difficult to adequately enforce quiet time

protocols in critical care led them to the position of protecting patients from the negative effects

of noise on an individual basis with earplugs. The study received approval from their Health

System IRB. Strong inclusion and exclusion criteria were applied. Informed consent included

participants agreeing to forgo use of ‘as needed’ sedating or sleep medications during the study

in an effort to prevent confounding results of the earplug intervention. An eight item visual

analogue instrument, the Verran-Snyder-Halpern Sleep Scale was selected and administered to

the 88 randomly assigned participants completing the one night study. T- tests were performed

to identify differences in means between intervention and control groups for sleep scale items

and total sleep score. Not surprisingly, the intervention group identified falling asleep easier and

experiencing less waking and tossing and turning. Sleeping more deeply, for longer periods and

awaking more refreshed were also confirmed by the group with earplugs. The authors identify

the smaller sample size as a limitation. This reader doesn’t find the sample of 88 down from 100

following drop outs that restrictive. However, I wondered if the brief duration of the study (only

one night) might be a limitation. A major strength of this study I believe may be realized in the

promotion of unmedicated sleep improving patients’ health and nursing’s ability to identify

changing status and provide more timely interventions.

Margaret Topf (2000) provides an interesting commentary proposing an expanded

version of the environmental stress model. Conceptual relationships between ambient stressors,

ambient stress and health are explored. The contention that hospital sounds are ambient stressors

is well supported. Research results on the stress and health effects of hospital noise on patients

and nurses are incorporated to provide support for the model. A three part intervention,


enhancement of person-environment compatibility is well detailed. Personal variables believed

to mediate the impact of environmental stress on health such as personality, culture and

perceived social support are thoughtfully examined. Topf (2000) wisely recommends the need

for additional studies in this area as no studies were found that linked greater life event stress (a

personal variable) with greater hospital noise stress. Topf believes nurses are well positioned to

engage as environmental activists based on our involvement in design and redesign teams

involving hospital administration, architects, state agencies, etc. Such teams collaborate and

recommend equipment to abate noise pollution. Topf advises that the nursing process can be the

vehicle for carrying out an environmental activist role citing that during the assessment phase the

nurse might assess the decibel level at the head of a CCU bed with a sound level meter and

compare this to EPA standards. Future recommendations include operationalizing and testing

EP-EC using laboratory simulation in addition to clinical studies. As a reader of this

commentary and study I struggled to understand all of the concepts she was presenting.

However, I do feel it represents a valuable contribution to the body of research available on the

topic of noise or environmental stress in the health care setting.

Conclusions

The authors of the research articles reviewed looked at interventions to minimize the

exposure to unnecessary noise for patients/study participants under their care. All of the literature

reviewed supports the therapeutic benefit of rest and sleep on health recovery. Since the time of

Florence Nightingale the hospital has been recognized as an environment for healing and health

recovery. Also, nurses have been the health care workers principally accountable for creating and

managing a therapeutic environment in hospitals. Policies and practices related to hospital care

have changed over time. One policy that may need to be revisited is unrestricted visiting hours

which emerged in response to patients’ rights issues at the time. Patients today are more acute,


treatments are more invasive, and technology is integral to care in every setting. Acutely ill

patients have increased physiological demands for recovery from illness and maintenance of

well-being. Quiet time with restrictions to visitors and treatments as well as earplugs may

actually be considered a therapeutic nursing intervention or nurse initiated strategy in the sense

of the environmental activist role which Topf proposed in her commentary. This author would

like to propose an area for future study. In our present fast paced, technology driven society we

may need to examine the impact of personal communication devises on recovery from illness

and maintenance of well-being. Laptops, I-Pads, PDA’s, Blackberry’s etc. allow us real time

updates on any topic we desire. However, the preoccupation with this virtual access, coupled

with the sensory bombardment associated with these items likely exerts a negative impact on the

healthcare environment and the patient care outcomes we are able to achieve.


References

Busch-Vishniac, I.J., West, J.E., Barnhill, C., Hunter, T., Orelanna, D., & Chivukula, R. (2005).

Noise levels in Johns Hopkins Hospital, Journal of Acoustical Society of America 118,

3629-3645.

Gardner, G., Collins, C., Osborne, S., Henderson, A., & Eastwood, M. (2009). Creating a

therapeutic environment: a non-randomised controlled trial of a quiet time

intervention for patients in acute care. International Journal of Nursing Studies, 46(6), 778-

786.

Johnson, P. & Thornhill, L. (2006). Noise reduction in the hospital setting. Journal of Nursing

Care Quality, 21(4), 295-297.

Lower, J., Bonsack, C., & Guion, J. (2002). Combining high tech and high touch. Nursing

2002, 32(8), 32cc1-32cc6.

Nightingale, F. (1859). Notes on Nursing: what it is and what it is not. Reprinted by Lippincott,

Philadelphia, 1992.

Scotto, C., McClusky, C., Spillan, S., & Kimmel, J. (2009). Earplugs improve patients’

subjective experience of sleep in critical care. Nursing in Critical Care, 14(4), 180-184.

Topf, M. (2000). Hospital noise pollution: an environmental stress model to guide research and

clinical interventions. Journal of Advanced Nursing, 31(3), 520-528.


U. S. Environmental Protection Agency (1974). Information on Levels of Environmental Noise

Requisite to Protect Public Health and Welfare with an Adequate Margin of Safety,

Publication number 550-9-74-004. Government Printing Office, Washington D.C

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