NRS-451V Lecture 3 Applying Servant Leadership in Practice Introduction The idea of servant leadership may seem contradictory. Servants are thought of as meek and followers of those with great stature, while the term leader inspires images of those that come first and receive great honor. The focus this week will be on the characteristics of a servant leader, as well as how to operationalize those characteristics in one's life through personal mission, vision, and values. Characteristics of the Servant Leader Servant leadership differs from every other theory of leadership in its emphasis on leading through serving others and through the desire to hold others through leadership, rather than through the desire to hold power over others. Servant leadership supports the notion that enhancing growth in others produces a stronger organization through relationships. Greenleaf (1991) states the following: The servant-leader is a servant first... It begins with the natural feeling that one wants to serve... Then conscious choice brings on to aspire to lead... The best test, and difficult to administer, is: Do those served grow as persons? Do they, while being served, become healthier, wiser, freer, more autonomous, more likely themselves to become servants? And, what is the effect on the least privileged in society? Will they benefit or at least not be further deprived? (p. 7). In studying Greenleaf's materials, the following characteristics are of critical importance to the success of the servant leader: 1. Empathy: Servant leaders need to be able to recognize someone else's intentions, feelings, and pain. 2. Listening: To truly have empathy, one must be an active listener, listen to what is behind the words, reflect, and repeat back to the communicator what was heard. 3. Emotional Intelligence: This characteristic will be discussed later in the course. It is the ability to be keenly aware of human emotional reactions and patterns. 4. Foresight: Lessons from the past allow the leader to predict and steer an outcome and decision for the future. 5. Stewardship: Stewards serve the needs of others, build relationships, oversee the allocation and utilization of resources, and help others to grow. All of these build trust and promise for followers. An excellent analogy to servant leadership is the old anonymous saying, "Give a man a fish, and you have fed him for a day; teach a man to fish, and you have fed him for a lifetime." Servant Leadership Operationalized Hierarchical power structures are present in every health care organization. Some have chosen flatter structures, but there is still hierarchy inherent in the system. To truly get to servant leadership in a management model, practices must be redefined, structures must be realigned, the role of the employee must be reevaluated, and the human resource strategies must be built around the characteristics mentioned above. Management in this new structure involves taking the initiative and being responsible and accountable to those being served. It also requires that the manager support the decisions made by employees. Managers in this system should delegate authority for decision-making to those closest to the patient, but they cannot delegate or abdicate their responsibility for the outcomes. Allowing others to make mistakes encourages their growth and the progression of the organization. Examples of leaders range from Winston Churchill, Napoleon, or Hitler to Mother Theresa, Pope John Paul II, or even Oprah Winfrey. Although all leaders have power through the influence they have over others, some leaders are servants, and some are not. Power can be addicting, and it requires the leader to have intelligence, understanding, wisdom, magnetism, and confidence. Servant leaders possess these skills and derive their power from the desire others have to follow them. When examining the question of how to operationalize servant leadership, one must realize that attitude and behavior must reflect the desire to serve before others will follow. Blanchard, Hybels, & Hodges (1999, p. 172) describe this process as "aiming for the best interest of those I lead and gaining personal satisfaction from watching the growth of others." Secondly, a clear vision of the goal should be developed and then realized. Performance can be monitored through guidance, coaching, and praise. Next, servant leaders are more concerned with service than with recognition or wealth. They listen and show concern, empathy, and willingness to serve and reinforce it every day. Finally, servant leaders remove obstacles from the paths of others so that they can do their job. When people feel cared for, they are more likely to serve others themselves. Personal Mission, Vision, and Values Personal mission, vision, and values are closely tied to the topics discussed in the previous paragraphs. A mission statement is a declaration of why a person exists and what his or her purpose is in life. A vision statement is a declaration of what a person desires to be, and values are the foundations of ethics followed every day. Clearly identifying one's personal mission, vision, and values can lead to higher satisfaction with work and personal life by creating clarity around goals and facilitating decision-making that contributes to the overall sense of purpose and value in life. Knowing the personal leadership styles of individuals in a health care environment helps define where the strengths and deficiencies might be within a team. The focus for this week will be on personal leadership styles and how they affect and are affected by interpersonal communication, emotional intelligence, and integration into health care of leadership and management roles and functions. Leadership Styles Leadership is difficult to describe, yet it is critical to the success of health care organizations. History has taught people that there are many different leadership styles. Each leader has unique preferences and ways of behaving. Differences between leaders do not mean that one leader is good or bad, right or wrong, effective or ineffective. However, to increase effectiveness, leaders must be able to grow and develop those whom they are leading. Leaders must be flexible and adapt styles to meet the needs of the situation and the individuals involved. Goleman, (2003) asserts that leaders who have mastered four or more styles, especially authoritative, democratic, affiliative, and coaching styles, have the best chance of success in leading. Authoritative leaders mobilize people, are self-confident, and are strong in situations when change is required. Democratic leaders gain consensus through collaboration and are best in situations when buyin is needed. Affiliative leaders create harmony, build relationships, and are best in healing teams or motivating people. Coaching leaders develop people for the future through empathy and selfawareness. They are best in improving performance in the long run. Emotional Intelligence "In 1998, Daniel Goldman in partnership with the consulting firm of Hay/McBer, recognized that 90% of the difference separating the average and best leaders lies within their grasp of emotional intelligence" (Breen, n.d.). According to Breen (n.d.), "emotional intelligence describes an individual's ability to manage his or her self as well as other relationships effectively." It consists of four fundamental capabilities: self-awareness, self-management, social awareness, and social skill. Having these capabilities allows leaders to have a positive impact on the culture and climate of an organization. Leaders are able to adjust their style to get the best results. • Changing behavior and sustaining the change is extremely difficult. Emotional intelligence will help create faster, deeper, long-term change. Porter-O'Grady and Malloch (2002) describe the principles of emotional intelligence in the following ways: The individual members of an organization are interconnected and interrelated. • The individual members perceive their work as natural and a source of fulfillment and growth. • Creativity is inherent in the individual and in the collective wisdom of each team. • The individual members are motivated to contribute in meaningful ways to relevant goals and focus on self-esteem and self-actualization. • Leadership emerges from the combined active engagement of all members of the organization, not from the activities of a single individual. Although measuring the softer side of an organization is difficult, the absence of it is clearly felt in the culture. When leaders have strong emotional intelligence, the organization also has strong emotional intelligence. Conclusion Servant leaders are imperative to the success of health care organizations today: "A new moral principle is emerging which holds that the only authority deserving one's allegiance is that which is freely and knowingly granted by the led to the leader in response to, and in proportion to, the clearly evident servant stature of the leader" (Dye, 2000, p. 61). Leadership consists of many styles and types throughout the organization. After studying leadership types and styles, and emotional intelligence, it becomes clear that an understanding of relationships and the soft side of management is essential. Drucker (n.d.) states, "Management is doing things right; leadership is doing the right things." The possibilities and limitations of all leaders are within their control; they become the kind of leaders they choose to be. References Blanchard, K., Hybels, B., & Hodges, P. (1999). Leadership by the book: Tools to transform your workplace. New York: William Morrow and Company, Inc. Breen, A. (n.d.). Leadership: An introduction to fundamental concepts and styles. Case Western Reserve University. Drucker, P. (n.d.). Quotations by author. The Quotations Page. Dye, C. F. (2000). Leadership in healthcare: Values at the top. Chicago: Health Administration Press. Greenleaf, R. K. (1991). The servant as leader. Indianapolis: Robert K. Greenleaf Center. Goleman, D. (2000). Leadership that gets results. Harvard Business Review, 78(9). 78-90. Goleman, D. (2003). Leadership styles that get results. The Institute for Management Excellence. Porter-O'Grady, T., & Malloch, K. (2002). Quantum leadership: A textbook of new leadership. New York: Aspen. © 2013. Grand Canyon University. All Rights Reserved. Topic 3 DQ 1 You have an idea to improve patient care that you would like upper management to support and fund. What type of communication tool would you use to present your idea and why? Topic 3 DQ 2 What differentiates someone that is intrinsically motivated from someone that is extrinsically motivated? Give an example of how you would go about motivating an individual who is intrinsically motivated and one who is extrinsically motivated. What are the characteristics of a performancedriven team? Due Date: Jun 11, 2017 23:59:59 Max Points: 150 Details: In this assignment, you will select a program, quality improvement initiative, or other project from your place of employment. Assume you are presenting this program to the board for approval of funding. Write an executive summary (850-1,000 words) to present to the board, from which they will make their decision to fund your program or project. The summary should include: 1. 2. 3. 4. 5. The The The The The purpose of the program or project. target population or audience. benefits of the program or project cost or budget justification. basis upon which the program or project will be evaluated. Share your written proposal with your manager, supervisor or other colleague in a formal leadership position within a health care organization. Request their feedback using the following questions as prompts: 1. Do you believe the proposal would be approved if formally proposed? 2. What are some strengths and weaknesses of the proposal? Submit the written proposal along with the "Executive Summary Feedback Form." Prepare this assignment according to the APA guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required. This assignment uses a grading rubric. Instructors will be using the rubric to grade the assignment; therefore, students should review the rubric prior to beginning the assignment to become familiar with the assignment criteria and expectations for successful completion of the assignment. You are required to submit this assignment to Turnitin. Refer to the directions in the Student Success Center. Only Word documents can be submitted to Turnitin. NRS451V. ExecutiveSummaryFeedbackForm_2-24-24.doc Executive Summary 1 Unsatisfactory 0.00% 80.0 %Content 16.0 %Executive The purpose of the summary program or project addresses the is not provided. purpose of the program or project 2 Less than Satisfactory 75.00% 3 Satisfactory 79.00% The purpose of the program or project is incomplete, missing relevant information. The purpose of the program or project is provided and meets the basic criteria for the assignment as indicated in the assignment instructions. 16.0 %Executive The target summary population or addresses the audience is not target population addressed. or audience The target population or audience is incomplete, missing relevant information. The target population or audience is provided and meet the basic criteria for the assignment as indicated in the assignment instructions. 16.0 %Executive The benefits of the summary program or project addresses the are not provided. benefits of the program or project The benefits of the program or project are incomplete, missing relevant information. The benefits of the program or project are provided and meet the basic criteria for the assignment as indicated in the assignment instructions 16.0 %Executive The cost or budget summary justification is not addresses the provided. cost or budget justification The cost or budget justification is incomplete, missing relevant information. The cost or budget justification is provided and meets the basic criteria for the assignment as indicated in the assignment instructions. 4 Good 89.00% 5 Excellent 100.00% The purpose of the The purpose of the program or project program or project meets all criteria meets all criteria for for the the assignment, as assignment, as indicated in the indicated in the assignment assignment instructions, is instructions, and is provided in detail, provided in detail. and demonstrates higher level thinking by incorporating prior learning or reflective thought. The target The target population or population or audience meets all audience meets all criteria for the criteria for the assignment, as assignment, as indicated in the indicated in the assignment assignment instructions, and is instructions, and is provided in detail. provided in detail, while demonstrating higher level thinking by incorporating prior learning or reflective thought. The benefit of the The benefit of the program or project program or project meets all criteria meet all criteria for for the the assignment, as assignment, as indicated in the indicated in the assignment assignment instructions, and is instructions, and is provided in detail, provided in detail. while demonstrating higher level thinking by incorporating prior learning or reflective thought. The cost or budget The cost or budget justification issue justification issue meets all criteria meets all criteria for for the the assignment, as assignment, as indicated by the indicated in the assignment assignment instructions, and is instructions, and is provided in detail, provided in detail. while demonstrating higher level thinking by incorporating prior learning or reflective thought. 16.0 %Executive summary addresses the basis upon which the program or project will be evaluated The basis upon which the program or project will be evaluated is not provided. 15.0 %Organization and Effectiveness 5.0 %Thesis Paper lacks any Development and discernible overall Purpose purpose or organizing claim. 15.0 %Organization and Effectiveness 5.0 %Paragraph Paragraphs and Development and transitions Transitions consistently lack unity and coherence. No apparent connections between paragraphs are established. Transitions are inappropriate to purpose and scope. Organization is disjointed. 15.0 %Organization and Effectiveness 5.0 %Mechanics Surface errors are of Writing pervasive enough (includes that they impede spelling, communication of punctuation, meaning. grammar, Inappropriate word language use) choice and/or sentence construction are used. The basis upon which the program or project will be evaluated is incomplete, missing relevant information. The basis upon The basis upon which the which the program program or or project will be project will be evaluated is evaluated meets provided in detail. the basic criteria for the assignment as indicated in the assignment instructions. The basis, upon which the program or project will be evaluated as indicated by the assignment instructions, is provided in detail, while demonstrating higher level thinking by incorporating prior learning or reflective thought. Thesis and/or main claim are insufficiently developed and/or vague; purpose is not clear. Thesis and/or main claim are apparent and appropriate to purpose. Thesis and/or main Thesis and/or main claim are clear and claim are forecast the comprehensive; development of contained within the the paper. It is thesis is the essence descriptive and of the paper. Thesis reflective of the statement makes the arguments and purpose of the paper appropriate to the clear. purpose. Some paragraphs and transitions may lack logical progression of ideas, unity, coherence, and/or cohesiveness. Some degree of organization is evident. Paragraphs are generally competent, but ideas may show some inconsistency in organization and/or in their relationships to each other. A logical progression of ideas between paragraphs is apparent. Paragraphs exhibit a unity, coherence, and cohesiveness. Topic sentences and concluding remarks are appropriate to purpose. Frequent and repetitive mechanical errors distract the reader. Inconsistencies in language choice (register), sentence structure, and/or Some Prose is largely Writer is clearly in mechanical free of mechanical command of errors or typos errors, although a standard, written, are present, but few may be academic English. are not overly present. A variety distracting to of sentence the reader. structures and Correct sentence effective figures of structure and speech are used. audienceappropriate There is a sophisticated construction of paragraphs and transitions. Ideas progress and relate to each other. Paragraph and transition construction guide the reader. Paragraph structure is seamless. word choice are present. 5.0 %Format 2.0 %Paper Template is not Format (use of used appropriately appropriate style or documentation for the major format is rarely and assignment) followed correctly. Template is used, but some elements are missing or mistaken; lack of control with formatting is apparent. 3.0 %Research No reference page Reference page is Citations (In-text is included. No present. Citations citations for citations are used. are inconsistently paraphrasing and used. direct quotes, and reference page listing and formatting, as appropriate to assignment) 100 %Total Weightage language are used. Template is Template is fully All format elements used, and used; There are are correct. formatting is virtually no errors correct, in formatting although some style. minor errors may be present. Reference page is included and lists sources used in the paper. Sources are appropriately documented, although some errors may be present. Reference page is present and fully inclusive of all cited sources. Documentation is appropriate and GCU style is usually correct. In-text citations and a reference page are complete. The documentation of cited sources is free of error. CULTIVATING QUALITY By Gina Murphy, BSN, RN, Anissa Bernardo, LCSW, and Joanne Dalton, PhD, RN, PHCNS-BC Quiet at Night: Implementing a Nightingale Principle A quality improvement project uses noise reduction strategies to provide patients with a sound night’s sleep. T he ill effects of noise on patients and the importance of maintaining a quiet, restful environment have long been recognized by nurses, beginning with Florence Nightingale. In her seminal book, Notes on Nursing: What It Is, and What It Is Not, Nightingale cautioned: “Unnecessary noise, or noise that creates an expectation in the mind, is that which hurts a patient. . . . [It] is the most cruel absence of care which can be inflicted either on sick or well.”1 Many contemporary researchers and health experts have attested to the continued relevance of Nightingale’s nursing principles.2-5 And recent research has shown that not only is sleep critical to the physical functioning and emotional wellbeing of patients, but brief or fragmented sleep has negative effects on the immune system, the healing process, and general health.6, 7 The typical hospital environment, with alarms going off, equipment clanging, and the bustle of staff and visitors, is not conducive to sleep. Noise dosimeters and sound-level meters can be used to measure sound levels in A-weighted decibels or dB(A), a unit that corresponds to the loudness of sounds as perceived by the human ear. (The ear isn’t equally responsive to all frequencies; for example, it’s less responsive to low frequencies. The A-weighted scale corrects for this variable responsiveness to different frequency ranges.) Researchers have found that sound levels on critical care and general units can average more than 50 dB(A), with transient peaks from 80 dB(A) to more than 100 dB(A).8, 9 These levels far exceed noise guidelines for hospitals set by the Environmental Protection Agency (EPA) in the early 1970s,10 which called for limiting noise to 45 dB during the day; they also breach more recent recommendations by the World Health Organization (WHO), which suggest that average noise levels should not exceed 35 dB at any time in rooms where patients are resting or being treated or observed.11 To put these recommendations into context, conversational speech in a public space averages 60 dB; street traffic, 70 dB; and motorcycle noise, 100 dB.12 ajn@wolterskluwer.com At our hospital, Beth Israel Deaconess Medical Center (BIDMC), ensuring that patients have a safe and restful care environment has been a long-standing priority. BIDMC is a large academic medical center with a wide range of state-of-the-art services, rapid patient turnover, and high patient acuity. Patient feedback regarding the care environment is closely monitored by our patient satisfaction steering committee, using data from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The HCAHPS survey contains 32 questions about patients’ perceptions of their hospital experience, including one that asks, “During this hospital stay, how often was the area around your room quiet at night?”13 Patients answer these questions using a four-point scale that ranges from “never” to “always.” Since July 2007, the Centers for Medicare and Medicaid Services (CMS) have required acute care hospitals to administer the HCAHPS survey to a sample of discharged patients each month and report the results in order to receive their full cost reimbursements. The 2010 Patient Protection and Affordable Care Act requires the CMS to include the HCAHPS survey results in the calculation of incentive payments in the Value-Based Purchasing Program; this provision went into effect in October 2012.14 In 2011, our patient satisfaction steering committee, led by our chief nursing officer and senior vice president for patient care services, observed that only 48% of BIDMC patients who completed the HCAHPS survey said the area around their room was “always” quiet at night. The committee believed this finding represented an opportunity to improve patients’ perceptions of the “hospital environment,” an HCAHPS domain that includes nighttime quietness and cleanliness of patients’ rooms and bathrooms. Sufficient improvement would earn the hospital credit toward incentive payments from the CMS; therefore, improved performance in this area was identified as a priority goal for fiscal year 2012. To achieve the necessary improvement in the HCAHPS score, the committee set a target of 59% of patients responding AJN ▼ December 2013 ▼ Vol. 113, No. 12 43 CULTIVATING QUALITY Silent Hospitals Help Healing 9pm – 6am From , we ask all staff, patients and visitors to help us maintain a quiet healing environment: Hallway lights will dim. A hospital that promotes a quiet environment We will use flashlights to check on patients instead of turning on the overhead lights. promotes an environment of healing. At BIDMC we are taking steps to minimize noise We will put pagers on vibrate and avoid hallway conversations when possible. at night so that our patients can get the rest needed to heal. We will close the room door if it is safe and acceptable for the patient. Even with our efforts, there are some hospital noises that can not be avoided. Earplugs have been provided to all patients to help reduce some noise. If it is still too noisy, please let staff know, and we will do all we can to keep things as quiet as possible. “always” to the quiet-at-night survey item, an increase of 11 percentage points over the previous year’s score. The committee appointed a nurse manager (GM) and the hospital’s patient satisfaction improvement coordinator (AB) to co-lead the improvement effort. We agreed the best approach for effecting organization-wide change was to test a variety of noise reduction strategies on a pilot unit before using them on other units. We selected a 44-bed medical–surgical unit, Reisman 12 (GM’s unit), as the pilot unit; it’s one of the medical center’s largest medical–surgical units and specializes in the care of gynecology, urology, and joint-replacement surgery patients. Reisman 12 has a consistently high patient volume, a large staff, and many rooms close to a busy nurses’ station—conditions that we believed made it a good environment for testing noise reduction strategies. The unit was also among those that scored lowest on the quiet-at-night survey question: in the third quarter of 2011, only 45% of the unit’s 120 surveyed patients indicated that the area around their room was “always” quiet at night. In forming our improvement team, we purposely sought out individuals who represented a range of perspectives, knowledge, and experiences related to the care environment. In addition to recruiting several clinical nurses who worked on the pilot unit, we also asked the unit’s operations coordinator, an associate chief nurse, and an environmental services manager to join the team. PLANNING THE INTERVENTION Poster designed by Kristina Cicelova, Media Services, Beth Israel Deaconess Medical Center. 44 AJN ▼ December 2013 ▼ Vol. 113, No. 12 The improvement team’s early efforts focused on identifying noise reduction strategies described in the literature, engaging staff members in the initiative and obtaining ajnonline.com their input, and gathering additional data on the unit environment. Examining the noise reduction literature. Studies conducted in hospitals indicate that noises generated by nursing activities (conversations in the hallway and nurses’ station, for example) and devices in the care environment (such as overhead paging systems, equipment alarms, and call lights) are the loudest and most troubling noises for patients, preventing or interrupting nighttime sleep.9, 15, 16 A number of nursing studies have focused on identifying strategies for reducing noise at night. One, conducted in a surgical ICU, determined that reducing noise in the care environment—by closing patients’ doors, turning down the volume of vital sign monitors and telephones, responding to alarms within one minute, and changing the schedule of routine tests— significantly reduced sleep interruptions and improved sleep quality as reported by patients.15 In a quality improvement project conducted on a surgical thoracic care unit, nurses focused on reducing both environmental noise and noise made in carrying out nursing activities.9 The sleep promotion team educated staff members on the importance of sleep and asked them to talk quietly and use designated rooms to give report; patient doors were closed to block hallway noises; overhead pages were eliminated at night; and ancillary staff were asked to avoid using hallway phones at night, change supply delivery times, and alter radiology schedules. The interventions increased staff awareness of noise on the unit and yielded a decrease in overnight dB levels. In a third study, nurse researchers offered post–cardiac surgery patients 10 different relaxation and sleep promotion aids and found that, although patients most often chose pain medication to promote sleep, the second and third most frequently chosen interventions were aimed at reducing noise generated by nursing activities, such as asking nurses to speak more softly.16 In our review of the noise reduction literature, we found a seven step approach to improving the auditory environment in hospitals. Developed by Mazer, the approach complements the Plan–Do– Study–Act improvement cycle, which has been promoted by the Institute for Healthcare Improvement and used in many health care organizations’ quality improvement initiatives,17, 18 and includes the following steps4: 1. Get everyone involved. 2. Assess the sound environment. 3. Establish sound standards. 4. Establish equipment maintenance and purchasing standards. 5. Be the patient advocate: select patient-appropriate equipment. ajn@wolterskluwer.com Figure 1. The SoundEar Noise Warning Sign. The red light flashes and “WARNING” is displayed when noise levels reach or exceed the preset threshold. Photo courtesy of NoiseMeters, Inc. 6. Educate staff and model sound-sensitive behavior. 7. Measure results. Mazer’s approach and the research on reducing hospital noise provided a framework for developing our noise reduction strategy. In planning our work on the pilot unit, we decided to employ a quasiexperimental, preintervention–postintervention design, using HCAHPS survey data obtained before and after implementation of noise reduction strategies to evaluate the strategies’ effectiveness. Getting everyone involved. The improvement team realized that engaging the pilot unit’s nursing staff—clinical nurses, patient care technicians, and unit coordinators—would be essential for the success of what we decided to call the Quiet at Night initiative. Over a period of several weeks, we held a series of meetings with the night-shift nursing staff, in which we discussed the adverse consequences of too little sleep, the noise reduction strategies described in the literature, and the initiative’s goals; we also asked the staff to share ideas for reducing the noise level on the unit. Nurses and other staff members responded enthusiastically and offered many ideas to create a more restful environment for patients. Together, we selected 10 strategies for implementation as part of our noise reduction plan (see Table 1). The 10 strategies included interventions aimed at reducing environmental noise as well as the noise and stimuli generated by people. In addition to working with the nursing staff, we met with members of the hospital’s environmental AJN ▼ December 2013 ▼ Vol. 113, No. 12 45 CULTIVATING QUALITY Table 1. Ten Strategies for Reducing Noise at Night on the Pilot Unit 1. Identify an RN who can serve as a unit champion to facilitate communication between the improvement team and the unit’s nursing staff. 2. Close doors at night unless there’s a safety concern or clinical reason for not doing so. 3. On admission, supply earplugs and a bookmark explaining our goal of reducing noise at night. 4. Keep patients by themselves in semiprivate rooms during periods of low census. 5. Use mini-flashlights when performing overnight checks to avoid turning on overhead lights. 6. Perform 11 PM and 7 AM change-of-shift conversations in the break room, not in the hallway or nurses’ station. 7. Provide headphones (if a headphone jack is available) to patients who need the TV on at night. 8. Install beep-free keypads on all doors. 9. Pad the pneumatic tube system with thicker foam. 10. Institute “quiet hours” from 9 PM to 6 AM: U Dim lights at 9 PM. U Turn all pagers to vibrate. U Do not use overhead pages. U Avoid conversations in hallways. U Ensure that patients and visitors know when quiet hours are in effect, and encourage visitors to adhere to the restrictions or plan to head home. U Display posters explaining quiet hours at elevator banks on each side of the unit. services staff to explain the purpose of the initiative and to obtain their support and hear their ideas. We also recruited a permanent night-shift RN to serve as a unit champion, responsible for keeping the team informed about the progress of ongoing changes, helping staff incorporate the noise reduction strategies into the daily work flow, and explaining the initiative and strategies to nurses who floated to the unit. The champion would become a crucial link between the unit staff and the improvement team. Assessing the sound environment and establishing sound standards. Prior to implementing the noise reduction strategies on the unit, we used a programmable, handheld noise dosimeter (the NoisePro DL from Quest Technologies) to obtain noise-level readings in two 14-hour periods (from 6 pm to 8 am). The noise dosimeter allowed us to measure ambient noise levels (of more than two seconds in duration) and transient peaks (loud noises less than two seconds in duration), so that we could evaluate noise levels on the unit according to EPA and WHO recommendations. On the first night of data collection, the dosimeter was set up at the nurses’ station, across from patient rooms. The maximum ambient noise level measured in that 14-hour period was 79.6 dB(A)— equivalent to the sound of heavy truck traffic. We also obtained a peak reading equal to 102.4 dB(A)—as loud as a motorcycle or jackhammer.12 On the second night of data collection, the dosimeter was set up on 46 AJN ▼ December 2013 ▼ Vol. 113, No. 12 the opposite side of the nurses’ station, about 30 feet from the first location and across from a different set of patient rooms. The maximum ambient noise level on the second night was 86 dB(A), and the peak reading was 117.1 dB(A). On both nights, the maximum ambient levels were well above the EPA and WHO recommendations. While peak readings are usually disregarded when assessing average noise levels, they do serve to illustrate the extreme disruptions that can occur on patient units. In addition to confirming patient perceptions of noise at night, the readings increased staff awareness of the scope of the problem. The dosimeter readings also made us appreciate the value of providing staff with ongoing feedback about noise levels on the unit. Working with the facilities department, we identified a noise indicator we could install in the nurses’ station to alert staff whenever noise reached an undesirable level. We believed this would further heighten awareness of the noise problem and empower staff to take steps in real time to reduce noise. The noise indicator we selected, the SoundEar Noise Warning Sign (NoiseMeters Inc.), consists of three sets of lights in the shape of an ear and can be set at a predetermined threshold level (see Figure 1). When the noise level falls more than 5 dB below the undesirable threshold, green lights on the indicator light up. If the noise level is less than or equal to 5 dB below the threshold, yellow caution lights go ajnonline.com on; and if the noise level reaches or exceeds the threshold, red lights turn on and the word “WARNING” flashes on the indicator’s screen. Initially, we set the threshold at 45 dB; however, we quickly learned that the normal ambient noise level was already louder than the ideal according to established guidelines. While this is certainly an indication of a noisy care environment, we were also challenged by the physical limitations of the nursing unit: we wanted to mount the unit on the wall near the nurses’ station where it would be visible to nursing staff, but the only available location was within a few feet of a ceiling air-conditioning vent and the central telemetry monitoring station. This equipment routinely triggered the red lights and “WARNING” sign. Since the location of the noise indicator could not be changed without compromising its visibility, we opted to set the threshold at 55 dB. Although higher than desired, this allowed the indicator to serve as a better gauge of ambient noise. Our efforts to assess the sound environment also led us to review HCAHPS survey data for the pilot unit going back to 2009. Our review indicated an ongoing problem with noise levels: depending on the year and quarter, the proportion of patients reporting that the area around their room was “always” quiet ranged from 43% to 50%. Many patients also complained in writing about bright lights being turned on when they were trying to sleep, roommate noise, loud hallway conversations, and noise at the nurses’ station. This data further confirmed the importance of our efforts to reduce noise at night. IMPLEMENTING THE CHANGES By the beginning of June 2011, we were ready to implement the noise reduction strategies we’d chosen, which required working with the evening and night nursing teams and members of the environmental services and facilities departments to modify equipment, educate patients and families, and incorporate quietat-night interventions into the normal work routine. Establishing equipment standards and advocating for patient-appropriate equipment. A key area of preparation involved modifying environmental conditions and equipment to minimize noise and disruptions at night. This included checking and repairing all night-lights in the hallways and patient rooms so that overhead lights could remain off at night, silencing keypads on all doors, padding the pneumatic tube system with thicker foam, repairing door bumpers, and checking and repairing all heating, ventilation, and air-conditioning equipment in or near patients’ rooms. We also evaluated and, when possible, adjusted any patient care equipment that had the potential of adding to the noise level. Such equipment included the continuous oxygen saturation monitors; pneumatic compression boot machines; telemetry equipment; and iv, epidural, and patientcontrolled analgesia pumps. Percentage of Patients 80 60 60 43 47 45 Jan–Mar 2011 Apr–May 2011 40 20 0 Sep–Dec 2010 Before the pilot Jun–Aug 2011 After the pilot Figure 2. The percentage of patients on the pilot unit who responded “always” to the HCAHPS survey question, “During this hospital stay, how often was the area around your room quiet at night?” before and after the Quiet at Night initiative. HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems. ajn@wolterskluwer.com AJN ▼ December 2013 ▼ Vol. 113, No. 12 47 CULTIVATING QUALITY Percentage of Patients 54 52 51 50 50 49 49 48 Quiet at Night rolled out October 2011 46 44 0 Oct 2008–Sep 2009 Oct 2009–Sep 2010 Oct 2010–Sep 2011 Oct 2011–Sep 2012 Figure 3. The percentage of patients at Beth Israel Deaconess Medical Center who responded “always” to the HCAHPS survey question, “During this hospital stay, how often was the area around your room quiet at night?” in fiscal years 2009 through 2012. HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems. Educating staff, and modeling and implementing sound-sensitive behavior. The central element of the Quiet at Night initiative was the adoption of quiet hours, which required nurses and other staff to change many aspects of their work routine, including some that had been in place for decades. Our efforts to implement these changes were facilitated by education and planning sessions that we held with staff on the evening and night shifts, ongoing support provided by the nurse manager, and modeling and just-in-time education provided by the unit champion. Quiet hours began each evening at 9 pm, when the unit secretary dimmed the hallway lights and plugged in the noise indicator sign. For the rest of the night, overhead paging was suspended and staff relied on their individual pagers, set to vibrate, for communication. Nurses and patient care technicians used mini-flashlights rather than overhead lights to check on patients, attaching the flashlights to their ID badges for easy access. They kept patient doors closed whenever possible (when it didn’t jeopardize patient safety and was acceptable to the patient) and, census permitting, placed only one patient in each semiprivate room. When patients had to share a room, nurses coordinated their rounds to minimize interruptions. The nursing staff also paid prompt attention to bed alarms and took note of any noisy equipment, reporting it to the facilities department for repair. 48 AJN ▼ December 2013 ▼ Vol. 113, No. 12 To prepare patients and their families for the changes, we developed an explanatory poster and bookmark. We mounted the poster at the entrance to the unit to alert visitors, and asked environmental services staff to place a bookmark and earplugs on the bedside table when they readied a room for admission. Nurses discussed the Quiet at Night program with patients on admission and reminded them about quiet hours at the beginning of each evening shift. The nurse manager and other members of the leadership team reinforced the information shared by nurses during daily leadership rounds with patients. Over time, nurses identified additional ways to reduce sleep interruptions and noise at night. For example, nurses began working with patients to develop plans for overnight care, mapping out when they would obtain vital signs, administer pain medication, and complete other treatments. In addition to minimizing sleep interruptions, the nighttime plans let patients know what to expect and reassured them that their needs would be met, thus eliminating some of the anxiety that contributes to sleeplessness. RESULTS OF THE STRATEGIES We monitored the effects of the noise reduction strategies on the pilot unit by tracking patient ratings and comments about noise levels using the HCAHPS survey. Figure 2 presents HCAHPS data obtained before and after implementation of the Quiet at Night ajnonline.com strategies. In the three survey periods before implementation, 43% to 47% of patients said the area around their room was “always” quiet at night. In the survey period after implementation, the percentage of patients responding “always” increased to 60%. Favorable perceptions of the noise level on the unit were also reflected in patient comments. Sample comments included: “I appreciated the quiet at night”; “Earplugs were amazing! They helped keep me relaxed”; and, “Extremely quiet environment, especially at night.” The nursing staff also reported that the majority of patients liked the bookmark provided on admission and appreciated having earplugs, especially when a roommate snored. In unstructured discussions, unit staff members said they were satisfied with the interventions. Nurses especially liked the mini-flashlights that allowed them to safely check patients and equipment settings without turning on overhead lights. The staff also noted that turning the lights down at 9 pm prompted families to wrap up their visits more quickly, giving patients more time to rest. With the initiative under way on Reisman 12, we decided to expand our efforts to the rest of the medical center in October 2011. The Quiet at Night improvement team created a training tool kit for nurse managers and educators, who would be responsible for implementing changes on their units and training and supporting their staff. The tool kit consisted of a detailed work plan for rolling out the program, literature and education on the healing qualities of quiet environments, a supply of bookmarks, and two posters to be hung in areas visible to visitors; each unit also received its patient satisfaction data on the quietat-night survey item. As on the pilot unit, each unit identified a unit champion, who served as an on-site resource to staff. The facilities department also became involved, creating a schedule to address all maintenance interventions on each unit. We also purchased a second noise indicator and rotated the displays among the units (budget constraints prevented us from purchasing a device for every unit, and—while this conjecture was not tested—nurse managers and staff nurses believed that if the device remained on a given unit for too long, staff members would become accustomed to it and not react to warnings). The response to our dissemination efforts varied across units: some readily adopted the noise reduction interventions; others took time to consider how to best incorporate them into the unit’s work-flow and care processes. The varied pace and degrees of adoption in the early implementation period were reflected in the HCAHPS scores. While some units experienced no improvement in the percentage of patients who said the area around their room was “always” quiet at night, other units realized gains of between one and six percentage points. Overall, BIDMC experienced an average gain of two percentage points during the year the program rolled out, with the percentage of patients who said the area around their room was “always” quiet at night increasing from 49% to 51% (see Figure 3). 60 Percentage of Patients 58 56 56 54 52 52 51 50 48 46 44 43 42 40 0 Oct–Dec 2011 Jan–Mar 2012 Apr–Jun 2012 Jul–Sep 2012 Figure 4. The percentage of patients on the pilot unit who responded “always” to the HCAHPS survey question, “During this hospital stay, how often was the area around your room quiet at night?” in the four quarters following implementation of the Quiet at Night initiative. HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems. ajn@wolterskluwer.com AJN ▼ December 2013 ▼ Vol. 113, No. 12 49 CULTIVATING QUALITY Recently, unexpected feedback on the impact of our noise reduction efforts appeared in the local newspaper. The columnist, whose father had been a patient at the medical center, praised the Quiet at Night initiative, writing: “My father is of that certain age and condition where he is now a regular guest of hospitals. . . . [R]ecently while at Beth Israel Deaconess Medical Center he was struck. . . by something that didn’t occur. During the night, no one woke him up.”19 The columnist went on to point out the benefits of the Quiet at Night interventions and to urge other hospitals to consider adopting similar changes. DISCUSSION The Quiet at Night initiative illustrates how many small changes in care practices and environment can have a cumulative effect that promotes rest, sleep, and healing. While our work is ongoing, we believe a number of factors contributed to our initial success. Most critical is the involvement of all unit staff members, including clinical nurses, patient care technicians, and unit coordinators. With their firsthand knowledge of the unit environment and patient care requirements, these staff members were able to identify practices and equipment that contributed to disruptions, and develop interventions—such as mapping out a nighttime plan of care and coordinating visits to patients in semiprivate rooms—that minimized disturbances and aided their efforts to keep patients safe and comfortable. Also important was involving managers and staff from departments that interface with patients and the care environment, such as environmental services, facilities, and phlebotomy. Members of these departments offered many useful suggestions and were critical in addressing factors that contributed to the noise level. Small changes in care practices can have a cumulative effect. A key role was that of the unit champion. In addition to modeling good work habits, the unit champion provided on-site support to staff and ongoing feedback to the improvement team, allowing them to quickly address systems issues that required intervention. The support of senior leaders was also critical. In addition to ensuring that necessary resources were available, nurse leaders on the patient satisfaction committee and Quiet at Night work group (formed after the rollout and composed of pilot unit improvement team members, including 50 AJN ▼ December 2013 ▼ Vol. 113, No. 12 GM and AB, as well as individuals from other hospital units and departments) helped keep the institution’s attention focused on the issue, lending the effort credibility and engendering widespread interest. Patients and families uniformly welcomed the changes. We believed that, from a need-to-know and patient safety perspective, it was necessary to explain the initiative to patients, but the explanation itself may have been a confounding factor that contributed to the improvement in satisfaction scores. Nevertheless, we wanted to be sure that the whispered conversations among staff and their use of flashlights rather than overhead lights would not cause any undue anxiety or confusion among patients and family members. Challenges. Among the biggest challenges in our efforts to create and sustain a quiet, healing environment is sustaining the improvements in patient satisfaction. After our initial success with the start of the pilot project in June 2011, the percentage of patients on the pilot unit who responded “always” to the HCAHPS quiet-at-night survey question dipped below 60% (see Figure 4). We believe there are several factors that contributed to the variability in our scores. There was an increase in our hospital census during fiscal year 2012 that often made it impossible for us to place only one patient in a semiprivate room. Furthermore, our scores dropped steeply during the third quarter of 2012 when the pilot unit had to absorb patients from a unit that was closing and increase the use of float staff to accommodate the greater number of patients. Finally, it has become evident that the importance of leadership in sustaining gains cannot be undervalued. Ten months after the completion of the pilot program, the nurse manager of the pilot unit (GM) was asked to fill an interim nurse manager role on another unit. It is significant that this leadership change occurred before the Quiet at Night program was hardwired into the unit’s culture. The variability in the data underscores the vigilance and leadership focus that are required to sustain the initiative’s gains and ensure lasting change. In the midst of these larger changes on the unit, we have been using multiple strategies to keep everyone’s attention on the program. These include making quiet hours a regular topic in staff meetings, sharing patient satisfaction data and feedback on the unit environment as soon as they become available, and routinely engaging nurses in discussions about quiet-at-night interventions during rounds. Disseminating the interventions to other units has also proven to be a challenge. Our Quiet at Night work group meets monthly to review each unit’s HCAHPS scores and patients’ noise-related comments, ajnonline.com and it uses these data to drive next steps toward improvement. For example, as a result of themes identified through patient comments, the Quiet at Night work group recently began focusing on defining guidelines for visitors and helping staff have conversations with them about respecting efforts to maintain a quiet environment. While the work group’s efforts are important, nurse managers and educators continue to play a lead role at the unit level. When asked about the best approach for effecting lasting change, one nurse manager said, “It is never one thing.” She remarked on the importance of identifying unit champions, discussing the initiative and sharing patient satisfaction data at staff meetings, using the visual noise indicator as a reminder to staff, attending to alarms and other sources of noise, and encouraging nurses to have open conversations with patients and visitors regarding quiet hours so they’re not surprised by them. Key lessons learned through this initiative include the importance of involving all members of the team in the improvement effort, including the evening and nighttime nursing staff, as well as departments that provide support and services on the unit, and patients and family members who experience the changes firsthand. Also important is the recognition that there’s no single “magic fix” or solution to the problem; instead, success depends on maintaining a continuous focus on the work and keeping the effort in staff members’ awareness. In addition, we learned that committed and focused unit leadership that promotes and prioritizes the program makes a significant difference in sustaining results and long-term success. But perhaps the most important lesson is the critical role of nurses in ensuring that units remain quiet at night. By identifying factors that contribute to noise, advocating needed changes, and leading the development and implementation of interventions, nurses play a crucial role in creating an environment that promotes patient rest and well-being. The important role of nurses was perhaps best expressed by Nightingale, who shared the following observations in Notes on Nursing: “A good nurse will always make sure that no door or window in her patient’s room shall rattle or creak; that no blind or curtain shall, by any change of wind through an open window, be made to flap—especially will she be careful of all this before she leaves her patient for the night. If you wait till your patients tell you, or remind you of these things, where is the use of their having a nurse?”1 ▼ Keywords: decibel, environment, noise, noise reduction, patient satisfaction, quiet, quiet at night ajn@wolterskluwer.com Gina Murphy is a nurse manager at Beth Israel Deaconess Medical Center (BIDMC), Boston, where Anissa Bernardo is the patient satisfaction project manager. Joanne Dalton is a nurse scientist at BIDMC and an associate professor of nursing at Regis College, Weston, MA. Contact author: Gina Murphy, gamurphy@bidmc. harvard.edu. The authors have disclosed no potential conflicts of interest, financial or otherwise. REFERENCES 1. Nightingale F. Notes on nursing: what it is, and what it is not. New York: D. Appleton and Company;1860. 2. Attewell A. Florence Nightingale’s relevance to nurses. J Holist Nurs 1998;16(2):281-91. 3. Dossey BM. Florence Nightingale’s vision for health and healing. J Holist Nurs 2010;28(4):221-4. 4. Mazer SE. Nursing, noise, and norms: why Nightingale is still right. The C.A.R.E. Channel 2009. http://healinghealth. com/images/uploads/files/NursingNoiseNorms.pdf. 5. Selanders LC. The power of environmental adaptation. Florence Nightingale’s original theory for nursing practice. J Holist Nurs 1998;16(2):247-63; discussion, 264-6. 6. Redeker NS, et al. Sleep is related to physical function and emotional well-being after cardiac surgery. Nurs Res 2004; 53(3):154-62. 7. Redwine L, et al. Effects of sleep and sleep deprivation on interleukin-6, growth hormone, cortisol, and melatonin levels in humans. J Clin Endocrinol Metab 2000;85(10):3597-603. 8. Christensen M. Noise levels in a general intensive care unit: a descriptive study. Nurs Crit Care 2007;12(4):188-97. 9. Cmiel CA, et al. Noise control: a nursing team’s approach to sleep promotion. Am J Nurs 2004;104(2):40-8. 10. U.S. Environmental Protection Agency, Office of Noise Abatement and Control. Information on levels of environmental noise requisite to protect public health and welfare with an adequate margin of safety. Washington, DC; 1974 Mar. http:// www.fican.org/pdf/EPA_Noise_Levels_Safety_1974.pdf. 11. Berglund B, et al. Guidelines for community noise. Geneva, Switzerland: World Health Organization; 1999. http:// whqlibdoc.who.int/hq/1999/a68672.pdf. 12. Industrial Noise Control, Inc. Comparative examples of noise levels. 2010. http://www.industrialnoisecontrol.com/ comparative-noise-examples.htm. 13. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). HCAHPS survey: survey instructions. Baltimore, MD: Centers for Medicare and Medicaid Services; 2013 Mar. http://www.hcahpsonline.org/files/HCAHPS%20 V8.0%20Appendix%20A%20-%20HCAHPS%20Mail%20 Survey%20Materials%20(English)%20March%202013.pdf. 14. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). HCAHPS fact sheet (CAHPS hospital survey). Baltimore, MD: Centers for Medicare and Medicaid Services; 2013 Aug. http://www.hcahpsonline.org/files/ August%202013%20HCAHPS%20Fact%20Sheet2.pdf. 15. Li SY, et al. Efficacy of controlling night-time noise and activities to improve patients’ sleep quality in a surgical intensive care unit. J Clin Nurs 2011;20(3-4):396-407. 16. Spence J, et al. Nighttime noise issues that interrupt sleep after cardiac surgery. J Nurs Care Qual 2011;26(1):88-95. 17. Deming WE. Out of the crisis. Cambridge, MA: MIT Press;1986. 18. Langley GJ, et al. The improvement guide: a practical approach to enhancing organizational performance. 2nd ed. San Francisco: Jossey-Bass; 2009. 19. 1. Keane T. The quiet hospital. Boston Globe 2012 Jul 22. http://www.bostonglobe.com/opinion/2012/07/21/bostonhospital-program-strives-for-quiet-night/pIBE3tcJ5tcK2e W8HNVjRI/story.html. AJN ▼ December 2013 ▼ Vol. 113, No. 12 51 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units Crit Care. 2009; 13(2): 208. PMCID: PMC2689451 Published online 2009 Mar 9. doi: 10.1186/cc7154 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units Hui Xie, 1,2 Jian Kang,1 and Gary H Mills2 1 School of Architecture, University of Sheffield, Western Bank, Sheffield S10 2TN, UK 2 Sheffield Teaching Hospitals NHS Foundations Trust, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK Corresponding author. Hui Xie: h.xie@sheffield.ac.uk; Jian Kang: j.kang@sheffield.ac.uk; Gary H Mills: Gary.Mills@sth.nhs.uk Copyright © 2009 BioMed Central Ltd This article has been cited by other articles in PMC. Abstract Go to: Excessive noise is becoming a significant problem for intensive care units (ICUs). This paper first reviews the impact of noise on patients' sleep in ICUs. Five previous studies have demonstrated such impacts, whereas six other studies have shown other factors to be more important. Staff conversation and alarms are generally regarded as the most disturbing noises for patients' sleep in ICUs. Most research in this area has focused purely on noise level, but work has been very limited on the relationships between sleep quality and other acoustic parameters, including spectrum and reverberation time. Sound­absorbing treatment is a relatively effective noise reduction strategy, whereas sound masking appears to be the most effective technique for improving sleep. For future research, there should be close collaboration between medical researchers and acousticians. Introduction Go to: Noise, defined as unwanted sounds, could affect people both psychologically and physiologically [1], with reported negative effects including cardiovascular stimulation, hearing loss, increased gastric secretion, pituitary and adrenal gland stimulation, suppression of the immune response to infection, as well as female reproduction and fertility [2­7]. The World Health Organization (WHO) recommended that noise levels inside hospital wards should not exceed 30 dBA at night in terms of sleep disturbance [8]. Unfortunately, most case studies, especially the recent data, show that noise levels inside hospitals are much higher than the guideline values. Since the 1960s, the average noise levels inside hospitals have increased by an average of 0.38 dBA (day) and 0.42 dBA (night) per year [9]. The noise level in intensive care units (ICUs) ranges from 50 to 75 dBA, with the highest night peak level even reaching 103 dBA [10]. Sleep disturbance is thus a common problem for patients. Sleep is a complicated and active process. In terms of the measurement of eye movement, sleep is divided into two main types, namely rapid eye movement (REM) and non­rapid eye movement (NREM) sleep. Each type may have a distinct set of associated physiological, psychological and neurological functions. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 1/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units Numerous general studies have been carried out on the effects of noise on sleep [11­16]. However, many of them are not directly related to the influence of noise on patients' sleep in ICUs. Firstly, healthy subjects, rather than patients, were normally used in most existing studies. Secondly, road/rail/air traffic noise sources were considered, and their acoustic characteristics are rather different from those of the complicated, multiple and dynamic noise sources in ICUs. Thirdly, multiple factors, such as patients' discomfort, pain, as well as lighting and ventilation conditions, would definitely contribute to patients' inability to sleep. Therefore, the aim of this review paper is to answer the following questions. First, is noise the most disruptive factor to sleep for ICU patients, or is noise only responsible for a small percentage of the sleep disruption? Second, from the patients' point of view, what is the most disturbing noise source for their sleep? Besides the noise level, what are the effects of other room acoustic parameters, such as the noise spectrum and reverberation time (RT), on ICU patients' sleep quality? Third, how effective are the noise reduction strategies/interventions to decrease the sleep disturbance in ICUs? Methods Go to: The Cochrane Collaboration method was used for this review. An extensive literature search was conducted using the following electronic databases: MEDLINE (1966 to June 2008), CINAHL (1982 to June 2008), Scopus (1966 to June 2008), Cochrane Library (1991 to June 2008), and ISI Web of Knowledge (1900 to June 2008). The major medical subject heading (MeSH) and text words used in the search were: 'sleep', 'sleep disorder', 'sleep deprivation', 'noise' in conjunction with 'intensive care', 'intensive care unit' and 'critical care'. Related references of all identified papers displayed in the above databases were also scanned. To study the effectiveness of noise reduction strategies/interventions, additional search terms were used, including 'spectrum', 'reverberation time', 'sound masking' and 'acoustic absorber'. The searches were restricted to the research literature concerning the relationships between noise and patients' sleep during their hospital stay and published in full in the English language. Of the 167 papers found by the search strategy, 23 finally met the inclusion criteria. A number of methods have been applied in those studies, including polysomnography, observation, patient self­ assessment/questionnaire, and environmental noise recording. Some methods were effectively integrated by the investigators in order to enhance the accuracy and reliability of the research outcomes. Table 1 summarises the characteristics of the key studies. Table 1 Summary of the studies on the influence of noise upon intensive care unit patients' sleep Importance of noise on sleep disturbance Go to: Although it has been widely recognised that noise has negative effects upon the sleep of ICU patients, there are some disagreements in the literature on the importance of sleep disturbance from ICU noises, as can be seen in Table 1. Of the 11 selected previous original papers, 6 studies suggest that noise is responsible for only a small proportion of the overall arousals and awakenings from sleep, whilst 5 papers believe that noise is the most significant cause of sleep disturbance. Based on the SPSS statistic analysis, no significant differences were found between the two groups that argue whether or not noise is the major factor in sleep disturbance, in terms of sleep evaluation method, publication year, type of ICU, age of patients, number of patients and duration of stay. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 2/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units Jones and colleagues [17], according to their questionnaire outcome, indicated that the inability to lie comfortably was the most important factor in preventing patients' sleep, and then pain, noise and anxiety followed subsequently. A large­sample survey was conducted by Freedman and colleagues in 1999 [18] to investigate the ICU patient perception of sleep quality and etiology of sleep disruption. They further explained the patients' quick adaptability to ICU noise and noise's inability to cause awakenings as the two possible reasons for the low mean sleep­disruptive scores collected in their study. Meyer [19] also mentioned the same point that patients would gradually be conditioned to environmental noise in ICUs. After continuously monitoring the noise level and performing polysomnography over 24 hours, Freedman and colleagues in 2001 [20] concluded that only 17% of awakenings and 11.5% of arousals from sleep under mechanically ventilated conditions were due to the environmental noises. Frisk and Nordstrom [21] found the noise level rated by the patients to be low, which indicated that noise was not the major etiologic factor responsible for sleep disruption in ICUs. Pain was considered to be the commonest reason of disrupted sleep. According to Gabor and colleagues [22], loud noise accounted for 20.9% of the observed sleep disruption, while the cause of the majority of sleep disturbances under mechanically ventilated conditions remained unknown. According to Ugras and Oztekin [23], 57.6% of the patients indicated that being in a noisy environment was the second most frequently sleep disturbing factor, only after being kept immobile (63.6%). On the other hand, Hilton used polysomnography, continuous investigator observation over 24 hours and patient interviews to identify that most sleep disturbances of selected patients in the respiratory ICU were caused by noise [24]. Aaron and colleagues [25] confirmed a significant correlation with sound peaks over 80 dBA and electroencephalogram arousals from patients' sleep, as well as a significant difference between the number of arousals in quiet periods and that in very loud periods based on the number of noise peaks. In another study, although the sample size was small (nine subjects), the sleep observation together with the continuous recordings of noise and light level enabled Cureton­Lane and Fontaine to determine that noise was the strongest indicator of sleep state. The louder the noise was, the greater the awaking possibility of the children in the pediatric ICU [26]. Richardson and colleagues [27], after examining the impact of earplugs and eye masks on the critical care patients' sleep, found that 58.8% of the patients in the intervention group and 25% of the patients in the non­intervention group voted noise as the main factor of their sleep disturbance. Hweidi's [28] research supported that patients interpreted the unfamiliar and loud noises as the major cause preventing them from sleeping during their ICU stay. The impact of sleep disturbance on patients Go to: Sleep disturbance is a factor in the development of delirium, as well as producing specific effects on the respiratory, cardiovascular and immunological systems. Critical care patients are especially prone to delirium, as their normal circadian pattern of adrenocorticotropic hormone and melatonin levels is changed markedly by sepsis. Rather than there being a peak of adrenocorticotropic hormone at dawn and an elevation in melatonin levels during the period after midnight (peaking around 3 am), a flattening of this response is seen. This encourages a disturbance in sleep patterns leading to sleep during the day [29­31] and a reduction in sleep at night as well as general sleep fragmentation, with a reduction in both slow wave sleep and REM sleep. Hallucinations may occur during the transition from wakefulness into NREM sleep and from NREM sleep to wakefulness and are a major problem for critical care patients. Patients may also develop state dissociation disorders, which will appear as hallucinations or as REM sleep behavioural disorders. These episodes promote delusional memories, which in turn increase the likelihood of post­traumatic stress disorder. Drugs used in hospital may further aggravate the levels and appropriateness, as well as timing, of either wakefulness or sleep and, on withdrawal (for example opioids), may precipitate a rebound increase in https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 3/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units REM sleep, which in itself can precipitate nightmares, hypertension, tachycardia and hypoventilation. Noise will exaggerate these phenomena by triggering a transition from sleep towards wakefulness. All these factors increase the risk of delirium, which may occur in up to 70% or 80% of ICU patients [32,33]. Delirium increases length of stay, morbidity and even mortality [33]. Sleep disturbance may also disrupt immune function [34,35]. Two days of sleep deprivation has been shown to impair cell­mediated immune reactions as measured by lymphocyte production and adhesiveness [36] and to nullify the beneficial effect of immunisation in mice immunised against the influenza virus [37]. In humans, sleep deprivation increases IL1, IL2 [38], IL6 and tumour necrosis factor levels [39] and probably reduces natural killer cell activity [34,38,40]. Cardiovascularly, episodes of increased sympathetic activity may occur during noise disturbance. From a respiratory perspective, increases in REM sleep produce a reduction in ventilatory response to hypoxia and hypercapnia, particularly in the obese, men and those prone to apnoeas. This may also be a problem during weaning from mechanical ventilation [41] as well as a cause of respiratory deterioration towards the end of a critical illness, potentially increasing readmission rates to critical care. Acoustic characteristics Go to: Noise sources The major noise sources identified by the previous studies vary from ventilator noise, ventilator alarm, suctioning, heart monitor alarm, nebulizer, pulse oximeter tones and alarm, telephones ringing, air conditioning, television, radio, banging, rubbish bin or trolley noises, intercom, staff bleeps, talking (staff, nurses), visitors, fellow­patients, and general activities [42,43]. According to the occurrences in the literature, staff conversation (five papers) and alarm (four papers) seem to be the most disturbing noises for ICU patients' sleep. It is interesting to note that alarms are not usually perceived as helpful by the ICU staff [44]. Noise spectrum Sound spectrum, a plotted relationship between frequency and sound level, is important for sound perception [1], whereas in the existing studies the consideration of this facet is very limited. Busch­ Vishniac [45] and colleagues showed that the spectra at a pediatric ICU were flat over 63 Hz to 2 kHz, with higher sound levels at lower frequencies, and a gradual roll off above 2 kHz. Livera and colleagues [46] analysed the spectrum of equipment and activity noises in the neonatal ICU, showing that the noise was predominant in the range of 1 to 8 kHz. Ryherd and colleagues [47] provided detailed information concerning the noise characteristics in a neurological ICU, with the background noise measured in 1/3 octave bands, indicating that high frequency noise dominated in the case study. However, it is noted that none of the three papers studied the impact of noise spectrum on patients' sleep. Reverberation time RT is an important index to evaluate room acoustics. It is defined as the time taken for a sound to decay 60 dB after the source has stopped [1]. Blomkvist and colleagues [48] replaced the old sound reflecting ceiling tiles by the sound absorbing tiles in an intensive coronary care unit. The RT was markedly reduced by 0.4 s in the main working space and 0.5 s in a patient ward, which had a positive effect, including better general care quality and improved staff working efficiency. MacLeod and colleagues [49] installed the sound absorbing panels made of wrapped fibre­glass and antibacterial fabric on the ceiling and corridor walls in a hematological cancer unit. The reverberation dramatically dropped, and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 4/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units the excessively prolonged RT that had existed in the 800 Hz 1/3 octave band was eliminated. While only one of the above two studies was carried out in an ICU, the relationship between sleep disruption and RT was not analysed. Effectiveness of noise reduction strategies Go to: Although descriptive studies have defined and increased understanding of noise problems and serious sleep disturbance in ICUs, relatively few interventional studies have been carried out. Interventions that have manifested observable improvements in patients' sleep can be categorised into earplugs, behavioural modification, sound masking, and acoustic absorption. The effectiveness of these interventions is compared in Table 2. The average noise level reduction and sleep improvement of each intervention protocol are listed in Table 3. Table 2 Effectiveness of noise reduction strategies in intensive care units Table 3 Comparison of the effectiveness of noise reduction strategies in intensive care units Earplugs/earmuffs Three controlled clinical trials [27,50,51] claimed that ear­plugs or earmuffs generally have a positive effect on patients' sleep in hospitals. A study by Zahr and Raversay [50] involved the behavioural and physiological responses of 30 premature infants to noise reduction by earmuffs. When the infants wore the earmuffs, the noise level was significantly decreased by 7 to 12 dB, and their average oxygen saturation levels were higher and more stable than those of the infants without earmuffs. In Wallace and colleagues' pilot study [51], six healthy subjects were exposed to simulated ICU noise to evaluate the effect of earplugs on sleep measures. The use of earplugs was found to result in a significant increase in the REM sleep measured by polysomnography. Richardson and colleagues [27] undertook the first study to determine the combined impact of two interventions, earplug and eye mask, on the sleep experience of patients. Longer periods of sleep were successfully achieved for the patients of the intervention group at a very cost­effective price (£2.50 each). Behavioural modification Behavioural modification is a treatment approach, based on the principles of operant conditioning, that replaces un­desirable behaviours and reactions with more desirable ones through biofeedback and positive or negative reinforcement [52]. Two conditions are important for the selection of guidelines of behaviour modification: they must be easy to implement and they must not diminish the safety of the patients. Both noise and light are often the primary paired concerns of behaviour modification. A randomised trial was accomplished by Mann and colleagues [53] to test the effect of night and day on infants in a newborn nursery. Besides turning off the radio, lights and covering the windows with thick and dark curtains, the behaviour of the staff and visitors were changed by the researchers to avoid generating unnecessary noise. Infants from the intervention group slept longer and gained more weight than those from the control nursery. Kahn and colleagues [54] concluded that many of the noises causing sound peaks over 80 dBA were amenable to behaviour modification and that it was possible to reduce the noise levels in an ICU setting significantly through a comprehensive educational program of https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 5/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units behaviour modification towards all the ICU staff. Walder and colleagues [55] implemented five guidelines to significantly lower the noise level and the number of alarms of hemodynamic monitoring in the surgical ICU. Noise reduction strategies included cutting down the intensity of the alarm sound and talking, and switching off the phone, television and radio. A "quiet time" (2 to 4 am, 2 to 4 pm) protocol was carried out in Olson and colleagues' study [56] to promote sleep in a large sample size in neurocritical care units. The increase in sleep behaviour was associated with decreased sound and light levels achieved during the quiet time. Patients observed during the intervention period were 1.6 times more likely to be asleep during the quiet time than were patients observed during the control period (p < 0.001). Monsén and Edéll­Gustafsson [57] introduced non­disturbance periods during afternoon and night, and changed nursing and medical routines, which resulted in reduced sleep disturbance factors and partly reduced noise levels in the neonatal ICU. Sound masking The sound masking system is often used to increase speech privacy and to minimize distractions from other sounds. The system is being introduced to hospitals while patient confidentiality is becoming more of an issue where responsible handling of personal details forms an essential part of a data protection policy. Limited case studies have also shown that using the systems in hospital wards could improve patient satisfaction [58­60]. In Gragert's study [58] the masking signal was proved to be an effective intervention and should be considered a viable method of enhancing the sleep quality of patients in noisy ICU environments. Patients with sound masking intervention believed that they slept better and that it was quieter than in the control group. Williamson [59] investigated the influence of ocean sounds (white noise) on the night sleep pattern of postoperative coronary artery bypass graft patients after being transferred from an ICU. The group receiving ocean sounds reported higher scores in sleep depth, awakening, return to sleep, quality of sleep, and total sleep scores, indicating better sleep than the controlled group. The study by Stanchina and colleagues [60] suggested that white noise increased arousal thresholds in healthy individuals exposed to recorded ICU noise. The change in sound from baseline to peak, rather than the peak sound level, determined whether an arousal occurred. From Table 3 it can be seen that sound masking has the most significant effect in promoting ICU patients' sleep, producing an improvement of 42.7%. Acoustic absorbers Johnson [61] tested the effect of acoustic foams on the level of noise inside the incubator and examined neonatal response behaviours to changes in environmental noise. Acoustic foam pieces were placed in each of four corners of the incubator. The noise was reduced by 3.3 dBA inside the incubator. In a study by Blomkvist and colleagues [48], after the replacement of the ceiling tiles the noise level was reduced by 4 dB. Limitation of previous studies and directions for future work Go to: Previous studies, especially in medical sectors, have mainly been based on simple measurements of sound levels, whereas the influence of other room acoustic conditions, such as reverberation and reflection patterns, have not been paid enough attention. The sound level based approach has many limitations, even though different kinds of noise reduction protocols have been implemented and their effectiveness in improving patients' sleep has been demonstrated. Further research including other sound characteristics is required. Besides noise, many other factors – for instance, light, medication and pain – would all contribute to the disturbed sleep of ICU patients. Some arousals may even mistakenly be attributed to noise [62]. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 6/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units However, research on the relative influence and the combined effects of those factors has been limited and this should be pursued in the future. There has been very little research on the influences of acoustic conditions on healthcare staff. The patients are the centre of every hospital; however, the degree of staff satisfaction with the working environment directly affects working efficiency, enthusiasm and the quality of care provided. No study has been found to compare noise conditions in different types of ICUs, for example, respiratory ICU, pediatric ICU, neonatal ICU, cardiac ICU, medical ICU, surgical ICU, and neuro ICU. Conclusion Go to: Based on a number of original papers, the impact of noise on patients' sleep and the effectiveness of noise reduction strategies in ICUs have been reviewed. These have shown: noise is just one of a number of factors that may disrupt the sleep of patients on the ICU; staff conversation and alarms are generally regarded as the most disturbing noises for patients' sleep in ICUs; no research has been done on the relationships between ICU patients' sleep quality and the other room acoustic parameters besides sound level; and there are generally four interventions for sleep improvement, including earplugs, behavioural modification, sound masking, and acoustic absorption. Sound­absorbing treatment is a relatively effective noise reduction strategy, whereas sound masking appears to be the most effective technique for improving sleep. There are some limitations of the existing studies, including the lack of attention to other room acoustic conditions in addition to sound level, the combined effects of different sleep disturbing factors, and the effects of noise on staff. For future research, there should be close collaboration between medical researchers and acousticians to examine the different characteristics of sound. Abbreviations Go to: ICU: intensive care unit; IL: interleukin; NREM: non­rapid eye movement; REM: rapid eye movement; RT: reverberation time. Competing interests Go to: The authors declare that they have no competing interests. Notes Go to: See related commentary by Bosma and Ranieri, http://ccforum.com/content/13/3/151 References Go to: 1. Kang J. Urban Sound Environment. London: Taylor and Francis; 2006. 2. Snyder­Halpern R. The effect of critical care unit noise on patient sleep cycles. CCQ. 1985;4:41– 51. [PubMed] 3. Thomas KA, Martin PA. NICU sound environment and the potential problems for caregivers. J Perinatol. 2000;20(8 ptz):S94–S99. [PubMed] 4. Tomei F, Papaleo B, Baccolo TP, Persechino B, Spano G, Rosati MV. Noise and gastric secretion. Am J Ind Med. 1994;26:367–372. doi: 10.1002/ajim.4700260310. [PubMed] [Cross Ref] 5. Falk SA, Woods N. Hospital noise: levels and potential health hazards. New Engl J Med. 1973;289:774–781. [PubMed] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 7/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units 6. Wysocki A. The effect of intermittent noise exposure on wound healing. Adv Wound Care. 1996;9:35–39. [PubMed] 7. Nurminen T. Female noise exposure, shift work and reproduction. J Occup Environ Med. 1995;37:945–950. doi: 10.1097/00043764­199508000­00010. [PubMed] [Cross Ref] 8. Berglund B, Lindvall T, Schwela DH. Guidelines for Community Noise. Geneva: World Health Organization; 1999. 9. Busch­Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118:3629–3645. doi: 10.1121/1.2118327. [PubMed] [Cross Ref] 10. Al­Samsam RH, Cullen P. Sleep and adverse environmental factors in sedated mechanically ventilated pediatric intensive care patients. Pediatr Crit Care Med. 2005;6:562–567. doi: 10.1097/01.PCC.0000165561.40986.A6. [PubMed] [Cross Ref] 11. Saletu B, Grunberger J. Traffic noise­induced sleep disturbances and their correction by an anxiolytic sedative, OX­373. Neuropsychobiology. 1981;7:302–314. doi: 10.1159/000117865. [PubMed] [Cross Ref] 12. Cluydts R, De Roeck J, Cosyns P, LaCante P. Antagonizing the effects of experimentally induced sleep disturbance in healthy volunteers toy lormetazepam and zolpidem. J Clin Psychopharmacol. 1995;15:132–137. doi: 10.1097/00004714­199504000­00009. [PubMed] [Cross Ref] 13. Kawada T, Kiryu Y, Sasazawa Y, Suzuki S. Instantaneous change in transient shift of sleep stage in response to passing truck noise. Environ H Preventive Med. 1998;3:1–5. doi: 10.1007/BF02931231. [PMC free article] [PubMed] [Cross Ref] 14. Franssen EAM, Van Wiechen CMAG, Nagelkerke NJD, Lebret E. Aircraft noise around a large international airport and its impact on general health and medication use. Occup Environ Med. 2004;61:405–413. doi: 10.1136/oem.2002.005488. [PMC free article] [PubMed] [Cross Ref] 15. Basner M, Samel A, Isermann U. Aircraft noise effects on sleep: application of the results of a large polysomnographic field study. J Acoust Soc Am. 2006;119:2772–2784. doi: 10.1121/1.2184247. [PubMed] [Cross Ref] 16. Marks A, Griefahn B, Basner M. Event­related awakenings caused by nocturnal transportation noise. Noise Control Eng J. 2008;56:52–62. doi: 10.3397/1.2828211. [Cross Ref] 17. Jones J, Hoggart B, Withey J. What the patients say: A study of reactions to an intensive care unit. Intensive Care Med. 1979;5:89–92. doi: 10.1007/BF01686054. [PubMed] [Cross Ref] 18. Freedman NS, Kotzer N, Schwab RJ. Patient perception of sleep quality and etiology of sleep disruption in the intensive care unit. Am J Respir Crit Care. 1999;159:1155–1162. [PubMed] 19. Meyer TJ, Eveloff SE, Bauer MS, Schwartz WA, Hill NS, Millman RP. Adverse environmental conditions in the respiratory and medical ICU settings. Chest. 1994;105:1211–1216. doi: 10.1378/chest.105.4.1211. [PubMed] [Cross Ref] 20. Freedman NS, Gazendam J, Levan L, Pack AI, Schwab RJ. Abnormal sleep/wake cycles and the effect of environmental noise on sleep disruption in the intensive care unit. Am J Respir Crit Care. 2001;163:451–457. [PubMed] 21. Frisk U, Nordstrom G. Patients' sleep in an intensive care unit – patients' and nurses' perception. Intensive Crit Care Nurs. 2003;19:342–349. doi: 10.1016/S0964­3397(03)00076­4. [PubMed] [Cross Ref] 22. Gabor JY, Cooper AB, Crombach SA. Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. Am J Respir Crit Care. 2003;167:708–715. doi: 10.1164/rccm.2201090. [PubMed] [Cross Ref] 23. Ugras GA, Oztekin SD. Patient perception of environmental and nursing factors contributing to sleep disturbances in a neurosurgical intensive care unit. Tohoku J Exp Med. 2007;212:299–308. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 8/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units doi: 10.1620/tjem.212.299. [PubMed] [Cross Ref] 24. Hilton BA. Quantity and quality of patients sleep and sleep­disturbing factors in a respiratory intensive care unit. J Adv Nurs. 1976;1:453–468. doi: 10.1111/j.1365­2648.1976.tb00932.x. [PubMed] [Cross Ref] 25. Aaron JN, Carlisle CC, Carskadon MA. Environmental noise as a cause of sleep disruption in an intermediate respiratory care unit. Sleep. 1996;19:707–710. [PubMed] 26. Cureton­Lane RA, Fontaine DK. Sleep in the pediatric ICU: an empirical investigation. Am J Crit Care. 1997;6:56–63. [PubMed] 27. Richardson A, Allsop M, Coghill E, Turnock C. Earplugs and eye masks: do they improve critical care patients' sleep? Nurs Crit Care. 2007;12:278–286. doi: 10.1111/j.1478­ 5153.2007.00243.x. [PubMed] [Cross Ref] 28. Hweidi IM. Jordanian patients' perception of stressors in critical care units: a questionnaire survey. Int J Nurs Stud. 2007;44:227–235. doi: 10.1016/j.ijnurstu.2005.11.025. [PubMed] [Cross Ref] 29. Aurell J, Elmqvist D. Sleep in the surgical intensive care unit: continuous polygraphic recording of sleep in nine patients receiving postoperative care. Br Med J (Clin Res Ed) 1985;290:1029– 1032. doi: 10.1136/bmj.290.6474.1029. [PMC free article] [PubMed] [Cross Ref] 30. Gabor JY, Cooper AB, Crombach SA, Lee B, Kadikar N, Bettger HE, Hanly PJ. Contribution of the intensive care unit environment to sleep disruption in mechanically ventilated patients and healthy subjects. Am J Respir Crit Care. 2003;167:708–715. doi: 10.1164/rccm.2201090. [PubMed] [Cross Ref] 31. Cooper AB, Thornley KS, Young GB, Slutsky AS, Stewart TE, Hanly PJ. Sleep in critically ill patients requiring mechanical ventilation. Chest. 2000;117:809–818. doi: 10.1378/chest.117.3.809. [PubMed] [Cross Ref] 32. McNicoll L, Pisani MA, Zhang Y, Ely EW, Siegel MD, Inouye SK. Delirium in the intensive care unit: occurrence and clinical course in older patients. J Am Geriatr Soc. 2003;51:591–598. doi: 10.1034/j.1600­0579.2003.00201.x. [PubMed] [Cross Ref] 33. Ely EW, Shintani A, Truman B, Speroff T, Gordon SM, Harrell FE, Jr, Inouye SK, Bernard GR, Dittus RS. Delirium as a predictor of mortality in mechanically ventilated patients in the intensive care unit. JAMA. 2004;291:1753–1762. doi: 10.1001/jama.291.14.1753. [PubMed] [Cross Ref] 34. Dinges DF, Douglas SD, Zaugg L, Campbell DE, McMann JM, Whitehouse WG, Orne EC, Kapoor SC, Icaza E, Orne MT. Leukocytosis and natural killer cell function parallel neurobehavioral fatigue induced by 64 hours of sleep deprivation. J Clin Invest. 1994;93:1930– 1939. doi: 10.1172/JCI117184. [PMC free article] [PubMed] [Cross Ref] 35. Benca RM, Quintas J. Sleep and host defenses: a review. Sleep. 1997;20:1027–1037. [PubMed] 36. Palmblad J, Petrini B, Wasserman J, Akerstedt T. Lymphocyte and granulocyte reactions during sleep deprivation. Psychosom Med. 1979;41:273–278. [PubMed] 37. Brown R, Pang G, Husband AJ, King MG. Suppression of immunity to influenza virus infection in the respiratory tract following sleep disturbance. Reg Immunol. 1989;2:321–325. [PubMed] 38. Moldofsky H, Lue FA, Davidson JR, Gorczynski R. Effects of sleep deprivation on human immune functions. FASEB J. 1989;3:1972–1977. [PubMed] 39. Vgontzas AN, Zoumakis E, Bixler EO, Lin HM, Follett H, Kales A, Chrousos GP. Adverse effects of modest sleep restriction on sleepiness, performance, and inflammatory cytokines. J Clin Endocr Metab. 2004;89:2119–2126. doi: 10.1210/jc.2003­031562. [PubMed] [Cross Ref] 40. Boyum A, Wiik P, Gustavsson E, Veiby OP, Reseland J, Haugen AH, Opstad PK. The effect of strenuous exercise, calorie deficiency and sleep deprivation on white blood cells, plasma https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 9/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units immunoglobulins and cytokines. Scand J Immunol. 1996;43:228–235. doi: 10.1046/j.1365­ 3083.1996.d01­32.x. [PubMed] [Cross Ref] 41. Younes M. Apnea following mechanical ventilation may not be caused by neuromechanical influences. Am J Respir Crit Care. 2001;163:1298–1301. [PubMed] 42. Hansell HN. The behavioral effects of noise on man: the patient with "intensive care unit psychosis". Heart Lung. 1984;13:59–65. [PubMed] 43. MacKenzie DJ, Galbrun L. Noise levels and noise sources in acute care hospital wards. Build Serv Eng Res Technol. 2007;28:117–131. doi: 10.1177/0143624406074468. [Cross Ref] 44. Chambrin MC. Alarms in the intensive care unit: how can the number of false alarms be reduced. Crit Care. 2001;5:184–188. doi: 10.1186/cc1021. [PMC free article] [PubMed] [Cross Ref] 45. Busch­Vishniac IJ, West JE, Barnhill C, Hunter T, Orellana D, Chivukula R. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118:3629–3645. doi: 10.1121/1.2118327. [PubMed] [Cross Ref] 46. Livera MD, Priya B, Ramesh A, Suman Rao PN, Srilakshmi V, Nagapoornima M, Ramakrishnan AG, Dominic M. Spectral analysis of noise in the neonatal intensive care unit. Indian J Pediatr. 2008;75:217–222. doi: 10.1007/s12098­008­0048­z. [PubMed] [Cross Ref] 47. Ryherd EE, Persson Waye K, Ljungkvist L. Characterizing noise and perceived work environment in a neurological intensive care unit. J Acoust Soc Am. 2008;123:747–756. doi: 10.1121/1.2822661. [PubMed] [Cross Ref] 48. Blomkvist V, Eriksen CA, Theorell T. Acoustics and psychosocial environment in intensive coronary care. Occup Environ Med. 2005;62:e1. doi: 10.1136/oem.2004.017632. [PMC free article] [PubMed] [Cross Ref] 49. MacLeod M, Dunn J, Busch­Vishniac IJ, West JE, Reedy A. Quieting Weinberg 5C: A case study in hospital noise control. J Acoust Soc Am. 2007;121:3501–3508. doi: 10.1121/1.2723655. [PubMed] [Cross Ref] 50. Zahr LK, DE Traversay. Premature infant responses to noise reduction by earmuffs: effects on behavioral and physiologic measures. J Perinatol. 1995;15:448–455. [PubMed] 51. Wallace CJ, Robins J, Alvord LS, Walker JM. The effect of earplugs on sleep measures during exposure to simulated intensive care unit noise. Am J Crit Care. 1999;8:210–219. [PubMed] 52. Miltenberger RG. Behavior Modification: Principles and Procedures. Wadsworth/Thomson Learning; 2003. 53. Mann NP, Haddow R, Stokes L, Goodley S, Rutter N. Effect of night and day on preterm infants in a newborn nursery: randomised trial. Br Med J (Clin Res Ed) 1986;293:1265–1267. doi: 10.1136/bmj.293.6557.1265. [PMC free article] [PubMed] [Cross Ref] 54. Kahn DM, Cook TE, Carlisle CC, Nelson DL, Kramer NR, Millman RP. Identification and modification of environmental noise in an ICU setting. Chest. 1998;114:535–540. doi: 10.1378/chest.114.2.535. [PubMed] [Cross Ref] 55. Walder B, Francioli D, Meyer JJ. Effects of guidelines implementation in a surgical intensive care unit to control nighttime light and noise levels. Crit Care Med. 2000;28:2242–2247. doi: 10.1097/00003246­200007000­00010. [PubMed] [Cross Ref] 56. Olson DM, Borel CO, Laskowitz DT, Moore DT, McConnell ES. Quiet time: a nursing intervention to promote sleep in neurocritical care units. Am J Crit Care. 2001;10:74–78. [PubMed] 57. Monsén MG, Edéll­Gustafsson UM. Noise and sleep disturbance factors before and after implementation of a behavioural modification programme. Intensive Crit Care Nurs. 2005;21:208–219. doi: 10.1016/j.iccn.2004.12.002. [PubMed] [Cross Ref] 58. Gragert MD. PhD Thesis. The University of Texas at Austin; 1990. The use of a masking signal to enhance the sleep of men and women 65 years of age and older in the critical care https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 10/11 6/8/2017 Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units environment. 59. Williamson JW. The effects of ocean sounds on sleep after coronary artery bypass graft surgery. Am J Crit Care. 1992;1:91–97. [PubMed] 60. Stanchina ML, Abu­Hijleh M, Chaudhry BK. The influence of white noise on sleep in subjects exposed to ICU noise. Sleep Med. 2005;6:423–428. doi: 10.1016/j.sleep.2004.12.004. [PubMed] [Cross Ref] 61. Johnson AN. Neonatal response to control of noise inside the incubator. Pediatr Nurs. 2001;27:600–605. [PubMed] 62. Drouot X, Cabello B, d'Ortho MP, Brochard L. Sleep in the intensive care unit. Sleep Med Rev. 12:391–403. doi: 10.1016/j.smrv.2007.11.004. [PubMed] [Cross Ref] Articles from Critical Care are provided here courtesy of BioMed Central https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2689451/ 11/11 6/8/2017 Sleep - American Academy of Nursing Main Site Contact Us Sign in Sleep Don't Statement Click Here to download this page in PDF format. http://www.aannet.org/initiatives/choosing-wisely/sleep 1/11 6/8/2017 Sleep - American Academy of Nursing Main Site Don't wake the patient for routine care unless the patient’s condition or care specifically requires it. Rationale Sleep is a ‘periodic reversible state of cognitive and sensory disengagement from the external environment’ that is essential for rest, repair, well-being and survival. Normal sleep consists of 4-6 cycles of 90-100 minute periods with cycles of REM and nonREM sleep (Kamdar, Needham and Collop, 2012). Studies of normal subjects show sleep deprivation negatively affects ventilatory, circulatory, immunologic, hormonal and metabolic stability. Sleep deprivation also impacts a person’s ability to perform physical activities and affects cognitive function as evidenced by delirium, depression and other psychiatric impairments. Multiple environmental factors affect a hospitalized person’s ability for normal restorative sleep. These include noise, patient care activities including assessment, measuring vital signs, equipment adjustment, medication administration, phlebotomy, radiographs, bathing and lighting levels. Patient-related factors involve pain, response to medication and comorbid conditions. http://www.aannet.org/initiatives/choosing-wisely/sleep 2/11 6/8/2017 Sleep - American Academy of Nursing Main Site Among the recommendations to improve a hospitalized person’s ability to sleep are reduced noise and light, consolidation of patient care activities, and nonpharmacologic sleep aids, such as eyeshades, ear plugs, music and tailoring patient care interventions to meet patient needs. Other interventions include changing nighttime nursing routines and maintaining day-night cycles that support normal circadian rhythms. Background There is a perception among nurses that patient safety requires patient assessment and monitoring at predetermined intervals around the clock. This generally involves activities such as measuring vital signs, repositioning, use of infusion pump alarms that signal completion of infusions and use of pre-set monitoring alarms unrelated to specific patient needs. Prevalent practice tailors patient care to the needs of the nurse and institution — for example, bathing at night, early morning phlebotomy and radiographs, and maintaining environmental lighting at daytime levels to keep the clinical staff awak...
Purchase answer to see full attachment