In clinical settings, an alarm is defined as a signal for notifying caregivers when a patient is in a potentially hazardous situation requiring immediate assistance.1 Clinical alarms promote patient safety by alerting clinicians when there is an indication or change in a condition that requires a response. At certain time points, alarm-capable medical equipment has been widely used for patient care;2 a patient might be connected to one or multiple alarming devices, including a cardiac monitor, ventilator, or medication pump.3 The use of clinical alarms, which promote patient safety by alerting potentially hazardous situations, is steadily increasing. However, repeated false alarms may lead to desensitization of staff to alarms, which presents potential hazards to patients and reduces their trust in alarms. In 2013, the Joint Commission issued a sentinel event alert for 98 reported alarm-related events, 80 of which resulted in death. While multiple contributing factors were identified for each event, alarm fatigue was the most common contributing factor.4 Alarm fatigue from frequent, false, or unnecessary sounding causes inappropriate or wrong behavior by the nurses. Previous research indicates that more than half of nurses believe that frequent false alarms reduce trust in alarms, leading nurses to inappropriately disable alarms.5 According to the life cycle of alarms,6 it refers to the process which begins with alarm generation to dispose of the patient's condition, and then eliminate the alarm. An alarm life cycle includes four important links: alarm generation, alarm transmission, alarm recognition, and alarm response. Nurses, as major operators of medical equipment, should be informed of proper alarm-related behaviors to ensure patient safety. According to the alarm life cycle, the alarm-related behaviors of nurses mainly refer to the behaviors of nurses in alarm setting, alarm notification, alarm recognition, and alarm response of medical equipment in clinical work, especially in the use of medical equipment, as well as learning alarm-related knowledge, acquiring the skills through training, alarm management, and so on.7
One study has reported that too many false alarms can disrupt daily nursing duties and foster distrust.8 In this study, 150–350 alarms per day for patients (80%–90%) were non-actionable. In general, false alarms cause high levels of frustration, aggression, and misconduct,9 and clinical nurses become susceptible to the consequences of “wolf coming,” which ultimately leaves the patients in jeopardy.
In the United States, the Emergency Care Research Institute has listed alarms among the top three Health Technology Hazards for several consecutive years.10 In China, item nine of the Patient Safety Goals of the China Hospital Association (2019/2020 Edition) is strengthening medical equipment safety and alarm management, which highlights the importance of clinical alarm management. However, few studies have analyzed the alarm-related behaviors of nurses and the related influencing factors, which can provide rationales for clinic alarm management.
A cross-sectional survey was conducted.
The behavior of nurses regarding clinical alarms was measured through a self-made questionnaire11: questionnaire of nurses’ clinical alarm-related knowledge, attitude, and behavior (NCAKAB). The questionnaire was based on the KAP model, We developed an item pool based on “the life cycle of an alarm” theory, literature reviews, and in-depth interviews. Then a two-round of expert consultation was conducted using the Delphi process and 450 clinical nurses were surveyed. The final questionnaire consisted of 40 items (total score = 152) and 3 dimensions: knowledge dimensions with 12 items, attitude dimensions with 11 items, behavior dimensions with 17 items. For knowledge dimensions (total score = 12), which are multiple choice, 1 point is calculated for each correct answer. For the attitude dimensions (total score = 17) and behavior dimensions (total score = 85), the answer options are set according to Likert's five-level scoring method. According to the degree of approval (strongly disagree = 1, disagree = 2, general = 3, agree = 4, strongly agree = 5) and the frequency of behavior (never do like this = 1, normally don’t do like this = 2, occasionally do like this = 3, often do like this = 4, always do like this = 5), and there are some reverse entries. Higher scores indicate better performance of the nurses.
The
To determine the number of participants required, we used previously published data and formulas.12 The pre-survey resulted in a standard deviation (SD) of 13.02 with an allowable error of 0.6,
In June 2018, we recruited 2400 nurses from 10 different hospitals (total: 9600 nurses) One grade-3 general hospital and one grade-2 general hospital in the east, west, south, north, and middle regions of Hunan province, China were selected respectively. Thus, the 10 hospitals were selected to conduct the sampling method. A multi-stage cluster random sampling method was used and one nurse was selected randomly from every four nurses in each interval.
Registered nurses who enrolled in the study met the following criteria: (1) practicing at a clinical department; (2) nursing stint > 1 year; c) registered status; (3) provided informed consent. The exclusion criteria included refresher nurses and those working at non-clinical nursing units. It took 6–10 min for each respondent to complete the questionnaire.
The study protocol was executed by three graduate students of the Nursing College and five nurses with master's degrees. Data were collected by mobile phone with a customized electronic data collection form.
Software SPSS18.0 was utilized for statistical analyses. Statistical descriptions of measurement data were expressed as mean ± SD. The inter-group comparison was made by
A total of 2368 completed responses (98.66% response rate) were obtained from 2400 participants. Most participants (97.4%,
The highest scores for alarm behavior came from nurses in ICU, followed by anesthesia, surgery, internal medicine, emergency, and pediatrics (
Nurses in the group aged 46 or above had the highest alarm behavior scores, while those in the 26–30-year-old group scored the lowest. The longer the nursing stint (working years of nurses), the higher the alarm behavior scores (
The alarm behavior scores of nurses in the third-level hospitals were higher than that of nurses in the second-level hospitals (
There were no statistical differences in the scores for alarm behavior of nurses based on gender, educational background, marital status, whether or not they have children, administrative position, organizational attributes, or whether they have experienced adverse events related to clinical alarm in the past 2 years, as shown in Table 1.
Clinical alarm behavior scores and demographic data of surveyed nurses (
Items | Constituent ratio (%) | Alarm settings | Alarm notifications | Alarm recognitions | Alarm responses | Alarm learning | Total behavior score | ||
---|---|---|---|---|---|---|---|---|---|
Score | Comparison | ||||||||
Male | 62 | 2.6 | 20.06 ±4.26 | 5.94 ±2.25 | 7.98 ±1.80 | 27.05 ±4.09* | 4.00 ±0.83 | 65.03 ±8.40 | |
Female | 2306 | 97.4 | 19.22 ±3.87 | 6.26 ±1.83 | 7.62 ±1.67 | 28.02 ±3.62 | 4.02 ±0.85 | 65.15 ±7.94 | |
20–25 | 623 | 26.3 | 19.29 ±4.08 | 6.10 ±1.90* | 7.50 ±1.75 | 27.83 ±3.76* | 3.99 ±0.89* | 64.70 ±8.35 | |
26–30 | 1043 | 44.1 | 19.01 ±3.94 | 6.26 ±1.84 | 7.66 ±1.66 | 27.76 ±3.62 | 3.97 ±0.87 | 64.66 ±8.05 | |
31–35 | 360 | 15.2 | 19.41 ±3.58 | 6.47 ±1.76 | 7.70 ±1.63 | 28.11 ±3.57 | 4.06 ±0.81 | 65.75 ±7.32 | |
36–40 | 188 | 7.9 | 19.53 ±3.64 | 6.36 ±1.89 | 7.73 ±1.61 | 28.97 ±3.41 | 4.20 ±0.75 | 66.79 ±7.59 | |
41–45 | 112 | 4.7 | 19.68 ±3.52 | 6.10 ±1.70 | 7.65 ±1.79 | 29.00 ±3.38 | 4.21 ±0.71 | 66.63 ±7.17 | |
46–55 | 42 | 1.8 | 20.38 ±3.46 | 6.45 ±1.69 | 7.88 ±1.44 | 28.26 ±3.60 | 4.26 ±0.83 | 67.24 ±5.99 | |
≤5 | 1044 | 44.1 | 19.23 ±4.05* | 6.09 ±1.84* | 7.57 ±1.67 | 27.80 ±3.63* | 4.01 ±0.87* | 64.70 ±8.05 | |
6–10 | 755 | 31.9 | 19.00 ±3.83 | 6.37 ±1.86 | 7.65 ±1.71 | 27.83 ±3.72 | 3.95 ±0.89 | 64.81 ±8.23 | |
≤11 | 569 | 24.0 | 19.59 ±3.60 | 6.40 ±1.79 | 7.71 ±1.66 | 28.57 ±3.49 | 4.14 ±0.77 | 66.41 ±7.22 | |
Class III | 1582 | 66.8 | 19.52 ±3.78* | 6.25 ±1.88 | 7.70 ±1.66* | 27.95 ±3.63 | 4.03 ±0.85 | 65.45 ±7.93 | |
Class II | 786 | 33.2 | 18.69 ±4.02 | 6.26 ±1.77 | 7.49 ±1.70 | 28.08 ±3.66 | 4.01 ±0.87 | 64.52 ±7.96 | |
Yes | 1777 | 75.0 | 19.39 ±3.88* | 6.26 ± 1.87 | 7.71 ±1.66* | 27.97 ± 3.69 | 4.03 ±0.85 | 65.36 ±8.06 | |
No | 591 | 25.0 | 18.80 ± 3.84 | 6.23 ±1.76 | 7.40 ±1.71 | 28.07 ±3.48 | 3.99 ±0.86 | 64.50 ±7.57 | |
Nurse | 595 | 25.1 | 19.23 ± 4.13 | 6.16 ± 1.91 | 7.46 ± 1.79* | 27.99 ± 3.77* | 4.00 ± 0.89* | 64.85 ± 8.40 | |
Nurse practitioner | 1186 | 50.1 | 19.12 ± 3.90 | 6.31 ± 1.84 | 7.66 ± 1.65 | 27.75 ± 3.64 | 3.98 ± 0.87 | 64.82 ± 8.06 | |
Nurse-in-charge | 507 | 21.4 | 19.55 ± 3.58 | 6.26 ± 1.79 | 7.77 ± 1.62 | 28.57 ± 3.49 | 4.13 ± 0.78 | 66.28 ± 7.17 | |
Associate director nurse and above | 80 | 3.4 | 19.15 ± 3.50 | 6.09 ± 1.59 | 7.56 ± 1.57 | 27.96 ± 3.20 | 4.19 ± 0.71 | 64.95 ± 6.80 | |
Secondary/tertiary schools | 615 | 26.0 | 19.18 ±3.99 | 6.30 ±1.85 | 7.53 ±1.69 | 27.98 ±3.61 | 4.03 ±0.87 | 65.01 ±8.05 | |
Undergraduate | 1678 | 70.9 | 19.26 ±3.85 | 6.25 ±1.85 | 7.67 ±1.67 | 28.00 ±3.65 | 4.01 ±0.85 | 65.20 ±7.92 | |
Master's and above | 75 | 3.2 | 19.29 ±3.70 | 5.99 ±1.59 | 7.60 ±1.68 | 28.00 ±3.60 | 4.17 ±0.80 | 65.05 ±7.89 | |
Married | 1456 | 61.5 | 19.26 ±3.79 | 6.28 ±1.83 | 7.66 ±1.68 | 28.05 ±3.63 | 4.04 ±0.84 | 65.29 ±7.84 | |
Unmarried | 889 | 37.5 | 19.23 ±4.04 | 6.19 ±1.88 | 7.60 ±1.67 | 27.90 ±3.65 | 3.99 ±0.88 | 64.92 ±8.15 | |
Divorced | 23 | 1.0 | 18.43 ±3.54 | 6.74 ±1.48 | 7.09 ±1.54 | 28.00 ±3.78 | 4.04 ±0.83 | 64.30 ±7.22 | |
Have child | 1253 | 52.9 | 19.29 ±3.75 | 6.30 ±1.83 | 7.67 ±1.68 | 28.09 ±3.60 | 4.06 ±0.82* | 65.42 ±7.74 | |
Not have child | 1115 | 47.1 | 19.19 ±4.02 | 6.20 ±1.85 | 7.59 ±1.68 | 27.88 ±3.68 | 3.98 ±0.88 | 64.84 ±8.16 | |
Nurse | 2165 | 91.4 | 19.23 ±3.92 | 6.27 ±1.86 | 7.65 ±1.68 | 27.96 ±3.66 | 4.01 ±0.86* | 65.13 ±8.02 | |
Head nurse and above | 203 | 8.6 | 19.26 ±3.43 | 6.10 ±1.63 | 7.49 ±1.71 | 28.32 ±3.37 | 4.14 ±0.75 | 65.31 ±7.10 | |
Formal | 1241 | 52.4 | 19.38 ±3.77 | 6.26 ±1.82 | 7.70 ±1.64 | 28.03 ±3.64 | 4.04 ±0.83 | 65.41 ±7.65 | |
Contracting system | 1049 | 44.3 | 19.07 ±4.02 | 6.25 ±1.87 | 7.55 ±1.73 | 27.93 ±3.66 | 4.00 ±0.88 | 64.79 ±8.33 | |
Temporary employment | 78 | 3.3 | 19.46 ±3.58 | 6.12 ±1.89 | 7.68 ±1.57 | 28.31 ±3.34 | 4.09 ±0.72 | 65.65 ±7.20 | |
ICU | 294 | 12.4 | 20.41 ±3.47** | 6.62 ±2.11** | 8.34 ±1.33** | 28.43 ±3.35** | 4.11 ±0.78** | 67.90 ±7.40 | |
Surgery | 835 | 35.3 | 19.08 ±3.97 | 6.17 ±1.82 | 7.44 ±1.80 | 27.70 ±3.91 | 3.99 ±0.90 | 64.38 ±8.43 | |
Internal medicine | 700 | 29.5 | 19.10 ±3.87 | 6.08 ±1.74 | 7.55 ±1.67 | 27.94 ±3.49 | 4.04 ±0.83 | 64.72 ±7.72 | |
Pediatrics | 196 | 8.3 | 18.69 ±3.92 | 6.35 ± 1.87 | 7.49 ± 1.56 | 28.08 ± 3.83 | 3.91 ± 0.82 | 64.52 ± 7.85 | |
Emergency medicine | 132 | 5.6 | 19.28 ± 3.71 | 6.13 ± 1.63 | 7.57 ± 1.47 | 27.67 ± 3.12 | 4.11 ± 0.77 | 64.76 ± 6.77 | |
Anesthesia | 104 | 4.4 | 19.28 ± 4.20 | 7.02 ± 1.81 | 7.81 ± 1.46 | 28.84 ± 3.27 | 3.98 ± 0.89 | 66.92 ± 7.41 | |
Others | 107 | 4.5 | 19.13 ± 3.68 | 6.33 ± 1.83 | 7.81 ± 1.74 | 28.87 ± 3.48 | 4.07 ± 0.86 | 66.21 ± 7.11 |
ICU, intensive care unit.
The majority of nurses (73.9%,
General demographic data of surveyed nurses (
Items | Frequency ( |
Constituent ratio (%) |
---|---|---|
Yes | 1751 | 73.9 |
No | 617 | 26.1 |
Yes | 1095 | 46.2 |
No | 1273 | 53.8 |
Yes | 1877 | 79.3 |
No | 491 | 20.7 |
Willing | 2226 | 94.0 |
Not sure | 24 | 1.0 |
Not willing | 118 | 5.0 |
Yes | 165 | 7.0 |
No | 2203 | 93.0 |
The average score for the NCAKAB was 121.82 ± 5.24 (full score = 155), and the major influencing factors included age, title, educational background, department, whether nurses have received alarm-related training, willingness to participate in alarm-related training, whether or not departments have improved alarm management over the last three years, and whether or not departments have formulated norms for alarm managements.
The average score for clinical alarm knowledge (NCAK) was 7.43 ± 2.56 (full score = 12), and on average 61.9% of questions were answered correctly Nurses scored highest on questions related to knowledge of alarm signal (average score of 0.83 (full score = 1)1 and scoring rate of 83%) and lowest for questions related to knowledge of alarm classification (average score of 0.63 (full score = 2) and scoring rate of 31.5%).
The average score for alarm attitudes (NCAA) was 49.25 ± 5.21 (out of 55). ICU nurses scored higher than nurses from other departments; 41 to 45-year-old nurses scored the highest on alarm attitude, and 20 to 25-year-old nurses scored the lowest. The statement that received the highest score was “Minimizing false alarms lowers alarm load of nurses and improves alarm response rate” (average score of 4.62 out of 5). The statement that received the lowest score was “Proper handling of alarms affects the inpatient satisfaction of medical services” (average score of 4.20 out of 5).
The average score for NCAB was 65.14 ± 7.95 (out of 85). The dimensions for alarm-related behavior, from high to low scores, were alarm learning (4.02 ± 0.85, out of 5), alarm response (27.99 ± 3.64, out of 35), alarm setting (19.24 ± 3.88, out of 25), alarm recognition (7.63 ± 1.68, out of 10) and alarm notification (6.25 ± 1.84, out of 10), as shown in Table 1.
Upon receiving an alarm signal, 49.2% (
For frequent false or interfering alarms, 33.1% (
Clinical alarm-related behavior scores of nurses (
Behavior items | Never do like this ( |
Not normally do like this ( |
Occasionally do like this ( |
Often do like this ( |
Always do like this ( |
Number | Minimum | Maximum | Mean ± SD |
---|---|---|---|---|---|---|---|---|---|
Dimension 1: alarm settings | 5 | 5 | 25 | 19.24 ± 3.88 | |||||
1. When using alarming devices, adjusting alarm-related settings. | 18 (0.8) | 87 (3.7) | 490 (20.7) | 952 (40.2) | 821 (34.7) | 1 | 1 | 5 | 4.04 ± 0.88 |
2. Setting personalized alarm thresholds according to patient condition. | 40 (1.7) | 198 (8.4) | 583 (24.6) | 887 (37.5) | 660 (27.9) | 1 | 1 | 5 | 3.81 ± 0.99 |
3. With the changes of patient conditions, adjusting alarm settings. | 78 (3.3) | 288 (12.2) | 444 (18.8) | 826 (34.9) | 732 (30.9) | 1 | 1 | 5 | 3.78 ± 1.11 |
4. While rotating shifts, checking alarm settings. | 39 (1.6) | 204 (8.6) | 490 (20.7) | 793 (32.5) | 842 (35.6) | 1 | 1 | 5 | 3.93 ± 1.03 |
5. Adjusting alarm volume according to the environment and time of ward. | 73 (3.1) | 291 (12.3) | 587 (24.8) | 792 (33.4) | 625 (26.4) | 1 | 1 | 5 | 3.68 ± 1.09 |
Dimension 2: alarm notifications | 2 | 2 | 10 | 6.25 ± 1.84 | |||||
1. You will be alerted to alarm by patient or escort. | 361 (15.2) | 545 (23.0) | 723 (30.5) | 537 (22.7) | 202 (8.5) | 1 | 1 | 5 | 2.86 ± 1.18 |
2. Missing alarm because you can’t hear it. | 133 (5.6) | 195 (8.2) | 962 (40.6) | 769 (32.5) | 309 (13.0) | 1 | 1 | 5 | 3.39 ± 1.00 |
Dimension 3: alarm recognitions | 2 | 2 | 10 | 7.63 ± 1.68 | |||||
1. You can accurately identify the alarm-triggering device according to alarm signal. | 35 (1.5) | 121 (5.1) | 460 (19.4) | 1148 (48.5) | 604 (25.5) | 1 | 1 | 5 | 3.91 ± 0.88 |
2. According to different alarm signals, identifying different levels of alarm | 68 (2.9) | 218 (9.2) | 555 (23.4) | 1001 (42.3) | 526 (22.2) | 1 | 1 | 5 | 3.72 ± 1.00 |
Dimension 4: alarm responses | 7 | 15 | 35 | 27.99 ± 3.64 | |||||
1. Responding to all alarms generated in the responsible area. | 21 (0.9) | 91 (3.8) | 307 (13.0) | 1024 (43.2) | 925 (39.1) | 1 | 1 | 5 | 4.16 ± 0.85 |
2. Upon receiving an alarm signal, responding immediately. | 9 (0.4) | 30 (1.3) | 153 (6.5) | 1011 (42.7) | 1165 (49.2) | 1 | 1 | 5 | 4.39 ± 0.70 |
3. When multiple alarms occur simultaneously, you order the responses according to the priority level of alarms. | 15 (0.6) | 69 (2.9) | 226 (9.5) | 934 (39.4) | 1124 (47.5) | 1 | 1 | 5 | 4.30 ± 0.81 |
4. Correctly handling various events leading to alarms. | 15 (0.6) | 37 (1.6) | 286 (12.1) | 1264 (47.5) | 766 (32.3) | 1 | 1 | 5 | 4.15 ± 0.74 |
5. You will not respond to alarms that you believe are false or interfere with. | 186 (7.9) | 355 (15.0) | 640 (27.0) | 867 (36.6) | 320 (13.5) | 1 | 1 | 5 | 3.33 ± 1.12 |
6. For frequent false or interfering alarms, turning off/muting alarm. | 166 (7.0) | 308 (13.0) | 673 (28.4) | 784 (33.1) | 437 (18.5) | 1 | 1 | 5 | 3.43 ± 1.14 |
7. For alarms that you cannot handle, actively seeking the assistance of other colleagues. | 11 (0.5) | 41 (1.7) | 317 (13.4) | 1018 (43.0) | 981 (41.4) | 1 | 1 | 5 | 4.23 ± 0.78 |
Dimension 5: alarm learning | 1 | 1 | 5 | 4.02 ± 0.85 | |||||
Actively seeking ways of acquiring alarm-related knowledge. | 11 (0.5) | 78 (3.3) | 533 (22.5) | 971 (41.0) | 775 (32.7) | 1 | 1 | 5 | 4.02 ± 0.85 |
Total behavior score | 17 | 33 | 85 | 65.14 ± 7.95 |
The nurses’ total alarm behavior score was positively correlated with the total alarm knowledge score (
Factors that influence nurses’ clinical alarm behavior.
Factors | Variable name | Assignment statement |
---|---|---|
Age (age) | X1 | |
X1.1 | 20–25: Yes = 1, no = 0 (reference) | |
X1.2 | 26–30: Yes = 1, no = 0 | |
X1.3 | 31–35: Yes = 1, no = 0 | |
X1.4 | 36–40: Yes = 1, no = 0 | |
X1.5 | 36–40: Yes = 1, no = 0 | |
X1.6 | 41–45: Yes = 1, no = 0 | |
X1.7 | Over 46: Yes = 1, no = 0 | |
Hospital level | X2 | Level 3 hospitals = 1 |
Department | X3 | Level 2 hospitals = 2 |
X3.1 | ICU: Yes = 1, no = 0 (control) | |
X3.2 | Surgery: Yes = 1, no = 0 | |
X3.3 | Internal medicine: yes = 1, no = 0 | |
X3.4 | Pediatrics: yes = 1, no = 0 | |
X3.5 | Emergency anesthesia surgery department: yes = 1, no = 0 | |
X3.6 | Others: is = 1, no = 0 | |
Title | X4 | |
X4.1 | Nurse: Yes = 1, no = 0 (control) | |
X4.2 | Nurse: Yes = 1, no = 0 | |
X4.3 | Nurse in charge: yes = 1, no = 0 | |
X4.4 | Deputy director nurse and above: yes = 1, no = 0 | |
Education | X5 | |
X5.1 | Secondary or tertiary school: yes = 1, no = 0 (control) | |
X5.2 | Undergraduate=: yes = 1, no = 0 | |
X5.3 | Master's degree or above: yes = 1, no = 0 | |
Have you received alarm-related education and training? | X6 | Yes = 1, no = 0 (control) |
Are you willing to take part in alarm-related training? | X7 | Willingness = 1, unwillingness = 0 (control) |
Has the department implemented the alarm management improvement project in the past 3 years? | X8 | Yes = 1, No = 0 (control) |
Does the department or hospital in which it is located formulate relevant systems or norms for alarm management? | X9 | |
Have received alarm-related training or not. | X10 | |
Willing to attend alarm-related training or not (from willing to unwilling) | X11 | Yes = 1, no = 0 (control) |
Have experienced alarm-related adverse events over the last 2 years or not | X12 | |
Have used auxiliary technology to improve alarm management? | X13 | |
Department or hospital have an alarm management system or not. | X14 | |
Alarm knowledge score | X15 | |
Alarm attitude score | X16 | |
Alarm behavior score | Y |
Multivariate linear regression analysis of alarm behaviors and related.
Items | Non-standardization coefficient | 95%confidence interval of B | |||||
---|---|---|---|---|---|---|---|
Lower bound | Upperbound | ||||||
1. Age | 0.000 | 0.083 | 0.000 | 0.003 | 0.997 | −0.163 | 0.164 |
2. Hospital level (control = tertiary hospital) | −0.165 | 0.320 | −0.010 | −0.517 | 0.605 | −0.793 | 0.462 |
2.1 Affiliated Hospital of University (control = yes) | 0.005 | 0.350 | 0.000 | 0.016 | 0.988 | −0.681 | 0.692 |
3. Surgery Department (control = ICU) | −2.960 | 0.457 | −0.178 | −6.477 | 0.000 | −3.856 | −2.064 |
4. Internal Medicine Department (control = ICU) | −2.637 | 0.455 | −0.151 | −5.794 | 0.000 | −3.529 | −1.744 |
5. Pediatrics Department (control = ICU) | −2.298 | 0.615 | −0.080 | −3.739 | 0.000 | −3.504 | −1.093 |
6. Emergency Department (control = ICU) | −2.237 | 0.678 | −0.065 | −3.299 | 0.001 | −3.567 | −0.908 |
7. Anesthesia operating Department (control = ICU) | −1.667 | 0.746 | −0.043 | −2.235 | 0.026 | −3.130 | −0.204 |
8. Other department (control = ICU) | −1.047 | 0.749 | −0.027 | −1.398 | 0.162 | −2.515 | 0.421 |
9. Professional title (from low to high) | −0.627 | 0.296 | −0.061 | −2.120 | 0.034 | −1.208 | −0.047 |
10. Education level (from low to high) | 0.005 | 0.350 | 0.000 | 0.016 | 0.988 | −0.681 | 0.692 |
11. Working seniority | 0.130 | 0.072 | 0.111 | 1.812 | 0.070 | −0.011 | 0.271 |
12. Have received alarm-related training or not (control = have) | −1.546 | 0.353 | −0.079 | −4.384 | 0.000 | −2.238 | −0.855 |
13. Willing to attend alarm-related training or not (from willing to unwilling) | 0.292 | 0.309 | 0.016 | 0.944 | 0.345 | −0.314 | 0.897 |
14. In 3 years, have the alarm management improvement project or not (control = yes) | −1.503 | 0.351 | −0.083 | −4.280 | 0.000 | −2.192 | −0.815 |
15. Have used auxiliary technology to improve alarm management? (control = yes) | 0.417 | 0.291 | 0.026 | 1.431 | 0.152 | −0.154 | 0.989 |
16. Department or hospital have alarm management system or not.(control = have) | −1.617 | 0.372 | −0.087 | −4.352 | 0.000 | −2.346 | −0.889 |
17. Total alarm knowledge Score | 0.282 | 0.055 | 0.091 | 5.128 | 0.000 | 0.174 | 0.390 |
18. Total Alarm attitude Score | 0.478 | 0.027 | 0.313 | 17.551 | 0.000 | 0.425 | 0.532 |
ICU, intensive care unit.
Alarm learning behaviors in the study mean seeking ways of acquiring alarm-related knowledge. Alarm learning scored highest for all NCAB items; 41.0% (
Alarm response behaviors refer to how to handle an alarm once the nurse is informed of it, in the study. As for frequent false or interfering alarms, 33.1% (
In this study, 41.4% (
Alarm setting refers to adjusting the alarm thresholds, the priority of the alarm according to the patient's situation when using the alarm device, and adjusting the alarm volume according to the ward environment and time. In this study, when using alarming devices, 34.7% (
Alarm recognition behaviors refer to identifying accurately the alarm trigger device and alarm priority according to the alarm signal once the nurse is informed of it, and the recipient of the alarm understands the meaning of the alarm and can predict what changes in the patient's condition may occur.in the study. When asked if they could accurately identify the alarm-triggering device according to the alarm signal, 48.5% (
Alarm notification means that once an alarm is generated, the nurse can be notified in time, as mentioned in the study. Only 13.0% (
In this study, we showed that significant differences in alarm behavior scores of nurses are due to factors such as age, nursing stint, professional title, department, hospital level, alarm knowledge level, and alarm attitude level.
Nurses 46 years of age and older scored highest for alarm behavior, which may be explained by the eagerness for professional knowledge learning and rich experience with proper handling of alarm-related events. The low scores for alarm-related behavior in the 20–30 years age group were probably due to insufficient professional knowledge, inadequate equipment-related know-how, shorter working experiences, and less safety awareness of patients.
The longer the working years of nurses, the higher the alarm behavior scores. Nurses-in-charge scored the highest for alarm behavior, likely related to their long working life, rich working experiences, and higher levels of self-confidence. Senior nurses scored high for alarm-related knowledge and attitude yet low for behavior. Senior nurses generally have abundant clinical experiences, meticulous handling of safety issues, and comprehensive, specialized knowledge and skills. However, with little practical experience in alarm management, the low scores for behavior may be due to weaker risk awareness, and a reduced ability to predict risks.
ICU nurses scored highest for behavior, followed by anesthesia and surgical nurses; these findings are in agreement with a previous study in which nurses who worked in ICUs performed better in relation to clinical alarms than those working in other wards. As physiologic monitoring is most common in ICUs, alarm fatigue in the ICU setting has been well studied.25 We hypothesize that there are better clinical alarm management initiatives in the ICU than in other departments.
Compared to second-level hospitals, the alarm behavior scores of nurses in the third-level hospitals were higher. The behavior scores of nurses at hospitals affiliated with colleges or universities were higher than for nurses at non-affiliated hospitals. This may be explained in part by the fact that critical patients at third-level hospitals are relatively complex and more patients may require monitoring equipment, thus providing these nurses with richer clinical alarm experiences.
Higher scores for alarm attitude or alarm knowledge were positively correlated with higher scores for alarm-related behavior. The theoretical model of knowledge, belief, and action26 divide change in human behavior into three interrelated processes: acquiring knowledge, generating beliefs, and forming behaviors. Knowledge is the basis of change; faith indicates behavioral tendency, and the premise of changing behavior is to change beliefs and attitudes. To change behaviors, we must have knowledge and information as the basis and correct beliefs and positive attitudes as the driving forces. In this study, nurses with high alarm knowledge scores had high attitude and behavior scores, which corroborates the view of Lorenz,8 who suggests reducing alarm fatigue through training and using personalized patient-related alarm restrictions.
For nurses who have received alarm-related education and training, the alarm knowledge and behavior scores were positively correlated, (On the other side, those who have not received the clinical alarmrelated education and training (control = yes) (
There were statistical differences in alarm-related behavior scores depending upon the use of auxiliary technology such as central monitoring stations for improving alarm management or formulation of alarm management-related systems or norms. Nurses who had used auxiliary technology to improve the management of alarms scored higher for alarm-related behaviors than those who had not used the technology. Similarly, nurses who worked at departments or hospitals with alarm management-related systems or norms scored higher than those who did not have such systems in place. Although critically ill patients are concentrated in ICUs at hospitals, there are still no authoritative medical equipment alarm management processes or parameter setting guides for ICUs.28 In our study, if no improvement project for alarm management had been implemented over the last 3 years (control = yes) (
There were no statistically significant differences in the scores for alarm behavior of nurses whether or not they had experienced adverse events related to clinical alarms in the past 2 years. Although 7% (
In the present study, there were no statistically significant differences in the scores for alarm behavior among nurses regardless of gender, educational background, marital status, administrative position, organizational attribute, or whether they have children. In our study, highly educated nurses scored higher for alarm-related knowledge and attitude, but lower for alarm behavior. However, some researchers have shown no differences in alarm-related knowledge among nurses with different educational backgrounds.30 The lack of statistically significant differences in scores for alarm-related behavior for nurses with varying educational backgrounds may indicate a dearth of teaching content about clinical alarm management in nursing schools in China and warrants further exploration.
This study regarding alarm-related clinical behavior of nurses demonstrates that the best alarm behavior of nurses was alarm learning, followed by alarm response, alarm setting, alarm recognition, and alarm notification behavior. The major factors that influenced alarm-related behavior included age, professional title, departments, nursing stint, hospital level, alarm-related training, willingness to participate in alarm-related training, whether or not departments have improved alarm management over the last 3 years, and whether or not departments have formulated norms for alarm management. Nurses with higher scores for clinical alarms knowledge and attitude had higher scores for alarm-related behavior. The results from this suggest clinical alarm management and education are urgently needed. Additionally, specialized clinical policies and procedures for alarm behavior management according to the level of nurses’ clinical behaviors and influencing factors should also be considered. New directions and strategies for patient safety management at modern hospitals should include recognition of the importance of alarms formulation of alarm-related systems and norms, and strengthening drills for medical staff.
Although the sample size of Hunan province s relatively large, the study provided a representative inspiration for the current situation and influencing factors of clinical alarm behavior of nurses. However, it is still necessary to investigate in other provinces to make a more in-depth study on the nurse's clinical alarm-related behavior and its influencing factors.