Intensive and Critical Care Nursing (2014) 30, 204210

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ORIGINAL ARTICLE

Alarm setting for the critically ill patient: A

descriptive pilot survey of nurses
perceptions of current practice in an
Australian Regional Critical Care Unit
Martin Christensen a,, Andrew Dodds b, Josh Sauer b,
Nigel Watts b

a
School of Health & Human Science, Southern Cross University, Rie Range Road, Lismore, NSW 2480,
Australia
b
Intensive Care Unit, Lismore Base Hospital, Lismore, NSW 2480, Australia

Accepted 27 February 2014

KEYWORDS Summary
Aim: The aim of this survey was to assess registered nurses perceptions of alarm setting and
Alarm fatigue;
management in an Australian Regional Critical Care Unit.
Nuisance alarms;
Background: The setting and management of alarms within the critical care environment is
Alarm
one of the key responsibilities of the nurse in this area. However, with up to 99% of alarms
desensitisation;
potentially being false-positives it is easy for the nurse to become desensitised or fatigued by
False alarms
incessant alarms; in some cases up to 400 per patient per day. Inadvertently ignoring, silencing
or disabling alarms can have deleterious implications for the patient and nurse.
Method: A total population sample of 48 nursing staff from a 13 bedded ICU/HDU/CCU within
regional Australia were asked to participate. A 10 item open-ended and multiple choice ques-
tionnaire was distributed to determine their perceptions and attitudes of alarm setting and
management within this clinical area.
Results: Two key themes were identied from the open-ended questions: attitudes towards
inappropriate alarm settings and annoyance at delayed responses to alarms. A signicant num-
ber of respondents (93%) agreed that alarm fatigue can result in alarm desensitisation and the
disabling of alarms, whilst 81% suggested the key factors are those associated with false-positive
alarms and inappropriately set alarms.

Corresponding author. Tel.: +61 7 5316 7508.

E-mail addresses: martin.christensen@scu.edu.au, mchristensen64@me.com (M. Christensen).

http://dx.doi.org/10.1016/j.iccn.2014.02.003
0964-3397/ 2014 Published by Elsevier Ltd.
Alarm setting for the critically ill patient 205

Conclusion: This study contributes to what is known about alarm fatigue, setting and management
within a critical care environment. In addition it gives an insight as to what nurses within a
regional context consider the key factors which contribute to alarm fatigue. Clearly nursing
burnout and potential patient harm are important considerations for practice especially when
confronted with alarm fatigue and desensitisation. Therefore, promoting and maintaining an
environment of ongoing intra-professional communication and alarm surveillance are crucial in
alleviating these potential problems.
2014 Published by Elsevier Ltd.

Implications for Clinical Practice

The implications for practice are such that any further education around alarm setting and management whether
formally or informally are probably not warranted. However, identifying key factors that lead to alarm desensitisa-
tion/fatigue should be a priority because of the inherent risk to patient safety. Instead, practice could:
As part of its surveillance of adverse patient incidences, include a forum where adverse events have occurred that
were attributable to clinical alarms.
Provide ongoing education that focuses on identifying those behaviours that would be suggestive of alarm fatigue.
Creating an environment in which colleagues presenting and/or exhibiting behaviours conducive to alarm fatigue or
burnout feel supported.
In addition, nursing education teams reinforce the importance of alarm management as a part of safe patient
monitoring and meeting the requirements of competent professional practice as stipulated in the nursing code of
conduct.

Introduction
The intensive care unit (ICU) is notorious for exposing the
critically ill patient to unnecessary noise, and this noise is
strongly associated with signicant patient stress, the devel-
opment of ICU delirium and other problems. Noise levels
in ICU have been recorded in excess of 80 decibels (dBs),
mainly from mechanical alarms, which are similar to expo-
sure to a pneumatic drill in operation (Christensen, 2007).
However, exposure to this level of noise is relatively spo-
radic. Despite this, there have been a number of studies
which have identied the average noise level in the ICU
to be between 55 dB and 60 dB (Christensen, 2007; Cmiel
et al., 2004; Kahn et al., 1998; Kam et al., 1994) with
the lowest level being 48 dB produced by low frequency
background noise such as air-conditioning and a working
ventilator (Christensen, 1997). Apart from the noise that is
created by human interaction, which accounts for nearly
80% of the noise produced in the ICU, it is mechanical
alarms which are a cause for concern because of the inten-
sity and startling physiological effect that is often produced
(Christensen, 2007).
There appears to be no uniformity as to a standard alarm
sound and as such the critical care nurse must be able to
distinguish differing alarms and which ones to respond to
as a matter of urgency. However, there is a hierarchical
order to alarms and these alert the nurse to either life-
threatening conditions (a crisis alarm) or are advisory as in
the case of a syringe driver for example (Cvach et al., 2009;
Edworthy and Hellier, 2006). With a proliferation in the num-
ber of medical devices currently seen within a typical ICU
the threshold for responding appropriately can diminish over
time (Sendelebach, 2012). Referred to as alarm fatigue, the
ever increasing number and frequency of alarms can become
overwhelming, which can result in nurses delaying or even
failing to respond to or in some case disabling alarms (Solet
and Barauch, 2012). It has been suggested that responding
to alarms can take up to 35% of the nurses time, which
would otherwise be more productive providing patient care
(Bitan et al., 2004), or putting this into a different context:
responding to 150400 alarms per day per patient (Keller,
2012).
The causes of alarm fatigue can be multi-factorial;
however, the most signicant cause is false alarms.
False/positive alarms sometimes referred to as nuisance
alarms account for 7599% of all alarms encountered in
critical care environments (Atzema et al., 2006; Lawless,
1994; OCarroll, 1986). The most commonly reported false
alarm is the pulse oximeter alarm due to a poor trace
(Bitan et al., 2004; Graham and Cvach, 2010). Yet, despite
the sense of urgency in attending to alarms, a high per-
centage of patient injuries have occurred as a result of
alarm desensitisation, which often meant serious debilitat-
ing patient outcomes (Atzema et al., 2006; Wyckoff, 2009).
It can be readily agreed that faced with a signicant number
of alarms many of which are false, can lead nursing staff
to distrust alarms. Korniewicz et al.s (2008) national sur-
vey (n = 1327) on the effectiveness of clinical alarms found
that 78% of health care professionals distrusted the sounding
alarm and purposely disabled the monitoring device. More-
over, they found that when alarm management issues were
ranked in terms of importance, the most signicant were
the frequency and number of false alarms and inadequate
staff numbers responding to alarms as they occurred. This is
206 M. Christensen et al.

Table 1 Frequency of alarm setting and management content specic categories.

N = 48 %

Denition of a nuisance alarm

Alarm accuracy 15 32
Inappropriate alarm limits 13 27
Not attended to by Principal Nurse 12 25
Patient interference 5 10
Alarm setting practice
Individualised to Patient 30 64
Prescribed by Doctors 12 25
As per clinical practice guideline 5 11
The practice of silencing other nurses alarms
Principal nurse not present 14 30
Attending to other patient care 13 28
Patient not attended to by the Principal Nurse 9 19
Given permission 7 14
Inappropriate alarm limits 4 9
The practice of altering another nurses alarm limits
Inappropriate alarm limits 34 71
Patient not attended to by Principal Nurse 11 22
Patient condition changed 3 7
Informing colleagues of alarm limit change
Because of inappropriate alarm limits 13 27
Dont because of negative response 9 19
Because they are not responding to their alarms 7 15
Its part of being a team 7 15
Its the responsibility of RN in charge to inform the nurse responsible 6 12
Its not my responsibility its the primary nurses 6 12

worrying given the importance of monitoring patient phys-
iological parameters to adjust and gauge responsiveness to
therapy. However, there is a consensus that the number of
alarms including false alarms can be reduced through simple
measures such as adjusting alarms to meet patient parame-
ters or on-going education (Bell, 2008; Graham and Cvach,
2010; Korniewicz et al., 2008). Although this appears to
be straightforward, in practice this is not always the case
as competing demands placed on the nurse often force
them to prioritise care and forsake the alarm (Tanner,
2013).
A recent audit of patient experiences at this study site
identied that noise was a major disturbing factor for them
during their stay. Whilst the majority of individuals audited
did not describe specics noise sources, a small proportion
of patients had commented that staff conversations and
alarms played a signicant part in the noise levels that they
experienced. In addition, a signicant number of nurses
commented that prolonged alarm noise caused them consid-
erable irritation and disturbed patients, especially so in the
coronary care unit. Furthermore, New South Wales Health
have invested heavily on the Essentials of Care (Ministry of
Alarm setting for the critically ill patient
Health, 2013), an evaluative care framework similar to the
United Kingdoms Essence of Care (Department of Health,
2010). This Ministry of Health directive together with the
aforementioned anecdotal observations then served as a
justication for this study.
Method
Aim
The aim of this survey was assess registered nurses per-
ceptions of alarm setting and management in an Australian
Regional Critical Care Unit.
Design
A descriptive, survey design was used for this study.
Sample and setting
A total population sample of 48 critical care nurses from a 13
bedded CCU/ICU/HDU from an Australian Regional Critical
Care Unit were selected. A regional hospital in the Australian
context is akin to the United Kingdom model of district gen-
eral hospitals. This unit is able to provide care to level 2
HDU/CCU and 3 ICU patients, but patients requiring more
complex care such as those with acute neurological trauma
or requiring cardiac surgery are transferred to the closest
major metropolitan hospitals typically based in the state
capitals. Typical length of stay within the unit is 23 days
depending on the nature of the presenting condition. Nursing
staff in this unit are all trained to graduate certicate level
in intensive care nursing; most have Bachelors degrees and
a very small number have Masters degrees; none have doc-
toral qualications. Substantive demographic data was not
collated due to the small cohort size and the ease with which
participant statements could identify the respondent. The
study was conducted over a two-month period from January
2013 to March 2013.
Ethical considerations
Ethics approval for this study was granted by the local area
health district ethics committee. Approval was also sought
and granted from the Nurse Unit Manager. Consent to the
study was waived and based on return of the completed
questionnaire as an indication of the participants interest
in the study. Participants were informed that their answers
would be anonymous and no individual identiers would be
used.
Data collection
A self-administered 10-item questionnaire was developed
from the literature. The instrument consisted of multiple
choice questions (n = 2) (Sendelebach, 2012) together with
open-ended questions (n = 8) (Tanner, 2013; Wyckoff, 2009).
Question construction was based on observations made by
these authors where specic problems or issues were iden-
tied. The nal questionnaire was vetted by the study team
207
to ensure content validity prior to it being piloted in the unit.
The questions focused on issues about alarm fatigue and cur-
rent practices for managing alarms and their settings. The
participants were informed that they had the right to with-
draw from the study at any time and their questionnaire
would be removed from the nal analysis. The completed
questionnaires were kept in a locked ling cabinet. All elec-
tronic data were stored on a password protected computer
accessible only by the study team until the study ndings
are in print. Thereafter all material will be safely deleted.
Data analysis
The SPSS software for Windows, version 20 (SPSS, 2010)
was used to perform the data analysis. Descriptive statis-
tics were used to describe the frequency and percentages
of participant responses. In addition the open-ended ques-
tions were coded and analysed based upon the principles of
inductive content analysis to examine participant responses
in relation to those practices associated with alarm set-
ting and alarm management. These were open-coded based
on participant descriptions and formed into content spe-
cic categories. It was these categories that were analysed
quantitatively for frequency.
Results
Descriptive categories were derived from the participant
responses. Five descriptive themes were identied based on
the questionnaire and frequency of those responses: den-
ing a nuisance alarm, alarm setting practice, the practice
of silencing other nurses alarms, the practice of altering
another nurses alarm limits and informing colleagues of
alarm limit change (Table 1). Overall, the results provide
a mixed view of nurses perceptions of alarm management
in a regional ICU. Whilst most are able to identify the char-
acteristics of a nuisance alarm, many felt that it was the
responsibility of the primary nurse to set appropriate lim-
its and responded to alarms in a timely manner. However,
descriptively it can be seen that inappropriate alarm set-
ting gured high in the participants responses across all ve
themes (2771%) (Table 1). When asked what a frequent
nuisance alarm would be, 81% of respondents identied a
false positive or clinically irrelevant alarm as being the
key factor. When compared with dening a nuisance alarm,
interestingly, 57% of individuals suggested alarm accuracy
and inappropriate alarm setting were major contributing
factors. Within those themes the practice of silencing and
altering alarm limits, >50% of alarms were as a result of the
nurse being absent from the bed-space. This clearly sug-
gests that being present would, in all likelihood, reduce
the number of inappropriate alarms and provide more effec-
tive patient-centred alarm management. However, at times
when the primary nurse was not present, 48% of respondents
did not change the alarm limits because of actual and/or
perceived negative responses from the primary nurse, or
they felt it was not their responsibility to interfere. Com-
paring this with what effect alarm desensitisation can have
on an individuals practice, 93% agreed that desensitisation
can lead to decreased alarm reaction time and silencing or
disabling alarms inappropriately.
208
Two major themes emerged from this study which char-
acterised the registered nurses perceptions of alarm setting
and management in an ICU/CCU:
Experiences of inappropriate alarm setting.
Experiences of delayed response times to alarms.
Experiences of inappropriate alarm setting
The nurses in this study certainly had strong feelings about
the setting of inappropriate alarm limits. Many consid-
ered the amount of false alarms rectiable given the nurse
patient ratio within the unit. However, for some there was
the perception that a small number of nurses failed to see
the importance of appropriate alarm setting inasmuch that
some respondents felt that:
. . .having alarms can promote laziness and reduce vig-
ilance and make nursing staff feel that they can stay at
the nurses station and look after the patient remotely.
(R23)
This may be the case for those nurses who may have
become desensitised or attuned to the many different
alarms present. In which case they either failed to respond
or they felt did not need to respond depending on the type of
alarm. Others, however recognised that some nurses simply
might not know or fully comprehend the importance of alarm
setting, for example junior nursing staff new to the unit. Yet
there also appeared to be a sense of professional responsibil-
ity amongst some of those nurses who often felt compelled
to intervene when alarms were not being silenced. Once
having readjusted the alarms to what they thought was a
more realistic limit, some individuals then informed the pri-
mary nurse this is what they had done. In a small percentage
of cases there appeared to be little negotiating or discus-
sion as to what was safe or appropriate for the patient from
both parties. Instead the intervening nurses often took it
upon themselves to make a judgement call based on pre-
vious experiences or they felt they were in the right. The
primary nurse either accepted these changes or changed the
alarms parameters themselves in private.
Experiences of delayed response times to alarms
What appeared to be an insurmountable delay in responding
to alarms angered most nurses. The absence of the pri-
mary nurse from the bedside was a considerable annoyance.
However, this is explained especially in the HDU where the
primary nurse was attending to another patient or in the case
that someone was on a meal break. Yet, like the setting of
inappropriate alarms the sense of professional responsibility
was very evident in the participants responses who were
clearly disappointed by colleagues behaviour: behaviour
that some felt was not necessarily conducive to the profes-
sional image of a critical care nurse for example, chatting
at the desk (R02) or surng the internet checking sports where they were not familiar with the patient history or
scores (R12).
It was evident that alarm desensitisation was a common
occurrence within this unit. Individual nurses at the patient
bed-space were either completely unaware of the alarm or
assumed that whatever the cause was would rectify itself
M. Christensen et al.
in time or as a result of their intervention. However, when
addressing the problem of distracting and annoying levels
of noise within the clinical environment, some nurses felt
vulnerable from a certain nursing element who were con-
sidered too rude (R36) or scary (R27) or aggressive
verbally (R09) within the unit. In some cases individ-
uals felt very uncomfortable approaching these colleagues
because it could be received as [a] critical judgement of
[a] colleagues practice (R15) or some simply did not bother
because:
. . .some people are arrogant and think they know it all
and dont take to well constructive advice [so there is]
no point really. (R21)
Discussion
The aim of this survey was to determine the perceptions of
nursing staff working in a regional Australian ICU/CCU/HDU
around alarm setting and management. Much of the work
around alarm fatigue appears to be anecdotal (Sendelebach,
2012; Solet and Barauch, 2012; Tanner, 2013). What few
studies that have been undertaken reiterate what has been
established here that alarm setting and alarm man-
agement contributes signicantly to alarm fatigue in the
critical care environment (Korniewicz et al., 2008). This
study clearly identied that inappropriate alarm setting was
one of the major factors that caused individual annoyance
especially when relative inaction was witnessed in respon-
ding to the initial alarm. Clearly false-positive alarms are
inevitable in this clinical environment because of the ever
changing condition of the patient (Korniewicz et al., 2008),
for example a ventilated patient coughing will trigger a high
pressure alarm and the delusional patient removing moni-
toring devices. However, these are manageable in the right
context. It does become problematic when the intricacies of
monitoring prove to be challenging such as ST wave depres-
sion/elevation or cardiac ectopy monitoring (Atzema et al.,
2006). This therefore comes down to the skill of the nurse
in interpreting this information and setting alarms appropri-
ately.
Yet, from this study there appeared to be no clear consen-
sus as to what appropriate alarm limits were despite there
being a clinical practice guideline available on the unit.
Whilst many of the respondents set alarm limits individuali-
sed to their patient, there appeared to be no consistency as
to what these meant. For example when setting mean arte-
rial alarm limits, some individuals set these 20 mmHg above
and below the current reading or in the case a heart rate lim-
its these were often set 10 beats/minute above and below
the current rate. For others, it was either those set by the
medical team or what they themselves (the nurse) deemed
was within acceptable parameters; presumably based on
their level experience. Of course this did create problems
for other nurses responding to patient alarms especially
the current treatment plan. Clearly, inadvertently changing
alarms can expose the patient to harm particularly if the
primary nurse has not been made aware this has occurred
or indeed places little signicance on the information given
by the relieving nurse.
Alarm setting for the critically ill patient
Two key ndings from this study are worthy of discus-
sion; the time it took to respond to alarms within the unit
and nursing team dynamics. It is evident from the language
used in some of the participant responses that there are spe-
cic issues around perceived professional behaviour when it
came to alarm setting and management in this clinical set-
ting. The nature of the comments would rst suggest that
there is perhaps an element of incivility perpetuated by of the nurses station or had become so desensitised to the
a select few nurses within the unit to the point that oth-
ers felt concerned by their responses. There is however,
the perception that bullying and aggressive behaviour are
commonly misinterpreted as being the same thing. Casual
observations of nursing communication suggest that aggres-
sion is sometimes the over-riding behaviour that is witnessed
and experienced on this unit. Three possible reasons may
explain why some nurses felt distressed at the supposed
aggressive responses they encountered. First, some indi-
viduals whose alarms were not being attended to in an
appropriate time frame angered others who therefore felt
they had to intervene to ensure the patient was safe, or
at the very least reduce the level of noise the alarms cre-
ated. Second, the apparent self-protectionist behaviours in
which certain individuals viewed constructive feedback as
a personal attack, would often responded inappropriately or
aggressively to fellow colleagues. This suggests that to some
degree these individuals may have felt embarrassment at
having their nursing care come under close scrutiny, which
clearly was not the case. Last, the intensive care environ-
ment can be a source of stress for vulnerable nurses, so
much so that burnout and compassion fatigue may be a com-
mon occurrence for these individuals. Therefore, instead of
responding in a more emotionally intelligent fashion simply
lashed out aggressively. As a result this may have alien- for some individuals to work through specic issues, we are
ated these individuals to the point that some nurses may
not intervene on their behalf. What the root cause of this
phenomenon is likely to be however is difcult to pinpoint
and would be purely conjecture and perhaps grounds for
future work.
Whilst this study did not aim to directly measure response
times, Bitan et al. (2004) demonstrated this succinctly when
they measured nurse response times to specic alarms. On
average it took a nurse more than 30 seconds to respond
to a heart rate alarm compared with 15 seconds for a sat-
uration alarm. They concluded that the number of alarms
relates to the acuity of the patient and length of time
the nurse responds and initiates treatment. For example
the more critically ill the patient the closer attention is
paid by the nurse to the alarm. Whilst this unit does admit
level 3 patients the majority of those admitted tend to be
HDU or CCU patients whose length of stay in the unit is on
average 23 days. Given the nature of this clinical environ-
ment it would seem reasonable to expect nurses to respond
quickly and appropriately to all alarms, but when >75% of
alarms are false-positives (Atzema et al., 2006; Lawless,
1994; OCarroll, 1986) it is no wonder a sense of impor-
tance is not always forthcoming. Yet, judging by participant
responses there appeared to be a sense of complacency
amongst some nurses as to what alarm was important and
therefore responding to an alarm took longer than would
be normally tolerated. This of course encouraged an envi-
ronment of annoyance, the danger of which was to silence
an alarm without necessarily intervening. Of concern to the
209
respondents in this study were the reasons why nurses did
not respond appropriately. There was universal agreement
that nurses attending to another patient (an HDU patient
where the nurse/patient ratio is 1:2) or on a meal break
was seen as acceptable and part of the culture within the
unit. However there were a minority of nurses who, it would
appear, preferred to monitor their patient from the connes
alarms around them that they failed to respond altogether.
Limitations
This study would be difcult to generalise to like sized
regional ICU/HDU/CCUs because of patient and staff demo-
graphics as well as differing levels of acuity within this
clinical environment compared with others. The survey
questionnaire itself was gleaned from the literature and
whilst not statistically validated to support construct valid-
ity it did support content validity and as such it provided
information that was seen as important to address this issue.
It may be appropriate in the future to consider more con-
cise methods to ensure construct validity such as exploratory
factor analysis to identify decits and rene the question-
naire or indeed use mixed method approaches to incorporate
focus groups or individual interviews to explore the issues
identied here.
We also accept that the emotiveness that this topic raised
is a little concerning given the language and words individual
respondents used to describe current alarm management on
this unit. Whilst we did not provide a more detailed debrief
now conscious of the need to allow staff an outlet to express
concerns when conducting future studies of this type.
Conclusion
Desensitisation to alarms through inappropriate settings
is clearly worrying given the nature of alarm observa-
tions. Whilst many would agree that a more comprehensive
approach be made to alarm monitoring such as a buddy-
ing system or clinical rounds by the nurse in charge, the
overall responsibility for patient care and therefore patient
monitoring surely rests with the allocated nurse. In some
instances it may be technology-based solutions that may
well provide the answers, for example smart alarms that are
based on algorithms which cover more than one condition.
However, it would also seem that alarm management
is undertaken on an ad-hoc basis with individuals setting
alarms limits to what they considered appropriate based
on their knowledge of the patients condition and treat-
ment plan. Unfortunately, this is not always conveyed to
colleagues who might be relieving for meal breaks or res-
ponding to the alarm when the primary nurse is otherwise
engaged. Whilst education seems to be an important aspect
of understanding the monitoring system it is probably bene-
cial to include such forums as incident or adverse reporting
as a surveillance measure to identify patient events that
were attributable to clinical alarms.
210 M. Christensen et al.

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