“Deep experience is never peaceful”: Raising awareness of noise sources in the ICU
Darbyshire JL1, Greig PR1, Jeffs EL1, Barrett C2, Edmonds P3, Young JD1,2, Hinton L4
1 Nuffield Department of Clinical Neurosciences, University of Oxford | 2 Adult Intensive Care Unit, Oxford University Hospitals NHS Trust | 3 Patient | 4 Nuffield Department of Primary Health Care, University of Oxford
Background: The World Health Organisation recommends that noise levels in hospital should not exceed 35dB, with a maximum of 40dB overnight1. Several studies have shown that hospitals routinely exceed this limit, and that levels in intensive care units are comparable with the dining room of a busy restaurant2. The hospital is not only a working environment, but must be a living space for patients. Attempting to sleep in a disruptive environment is difficult, and high background noise is likely to contribute to abnormal sleep. Disrupted sleep is common in the intensive care unit (ICU)3, and may be associated with ICU-acquired delirium4 which contributes to increased length of stay, and more health problems after patients return home5.
Methods: Accelerated Experience-Based Co-Design6. Members from the local patient forum, staff from ICU, and the research team agreed noise reduction strategy.
Alarms management policy
Encourage day/night routine
Bespoke noise visualisation
Noise awareness training
Developing teaching methods: Teaching was developed with the assistance of a medical educationalist. Learning materials were designed to cater for learners with VARK-preferences (figure 1), and varying learning styles (figure 2).The teaching materials were designed to increase staff understanding of the patient experience of noise. The intent was to enable staff to reflect on their experience with a view to motivating changes in practice, per Kolb’s learning cycle (figure 2).
The syllabus for the teaching intervention was collaboratively designed by subject experts and an educationalist. Materials were piloted and refined over two iterations based upon candidate feedback.
Rollout of teaching: Teaching is delivered in two formats. The first was designed as an immersive learning experience, based in the workplace. The second comprises a short online e-learning package to be completed at the learner’s convenience.
Immersive learning: participants are asked to lie in an ICU bed while a 3D-audio recording of a simulated ICU environment is played back to them via stereo headphones. Participants wear glasses that replicate impaired vision, and simulated care activities such as re-positioning and equipment checking are carried out on and around the participant. The experience lasts for approximately 5 minutes per participant.
E-learning: delivered online using a commercial content-hosting platform. Materials cover the theory of sound measurement, WHO guidelines, and methods of noise-control. Multimedia content, including patient interviews, are included. Self-assessment questionnaires are included throughout the package, with feedback on answers.
Results: Data were collected both quantitatively and qualitatively. Most participants to date have been ICU nurses (table 1), and all participants described the experience as useful. All suggested that they would alter their practice after the experience (figure 4).
Qualitative responses: After completing the immersive experience staff are presented with a list of words generated from patients’ own descriptions of their ICU experience and asked to choose those that most reflect their simulated experience. Most staff found the experience ‘uncomfortable’ or even ‘frightening’ (table 2).
Conclusion: We believe it is important that staff understand the effect that their interventions can have on their patients, and experiential learning can be a powerful tool to achieve this.
It is encouraging that 100% of staff found the experience useful (even those that reported feeling uncomfortable), and that all members of staff reported that they would make changes to their practice in light of the teaching.
The involvement of medical educationalists is important to ensure that teaching is robustly designed and pedagogically sound.
1. Berglund B Guidelines for community noise WHO; 1999
2. Darbyshire JL, An investigation of sound levels on ICU Crit Care. 2013; 17(5): R187
3. Elliott R, The quality and duration of sleep in the ICU setting Int J Nurs Stud. 2011; 48(3): 384-400
4. Aaron JN Environmental noise as a cause of sleep disruption Sleep. 1996; 19(9): 707-10
5. Salluh JI, Delirium epidemiology in critical care Crit Care. 2010; 14(6): R210
6. Locock L Testing AEBCD J Health Serv Deliv Res. 2014; 2(4)
7. Fleming N VARK®: a guide to learning styles www.vark-learn.com [accessed 21/11/2016]
8. Kolb DA, Experiential learning Prentice Hall; 1984
9. Honey P, Using Your Learning Styles Peter Honey Publications; 1986