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Noise at Night on Inpatient Units: What It Costs Patients and What Nurses Can Change

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College of Nursing, Chamberlain University

NR 351: Foundational Concepts for the Practicing RN

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Month Day, Year

Noise at Night on Inpatient Units: What It Costs Patients and What Nurses Can Change

Hospitals are loud places at night, and they have become louder over time. In a study of noise at a large academic medical center, Busch-Vishniac et al. (2005) measured sound levels across patient care areas and found that average levels exceeded the World Health Organization's recommendations for hospital patient rooms in every location measured, both during the day and at night. They also reported that average nighttime noise levels in hospitals had risen steadily over the previous decades. The World Health Organization's guidelines for community noise recommend that sound levels in hospital patient rooms stay low at night, with an average guideline value of 30 decibels and a maximum of 40 decibels for single noise events (Berglund et al., 1999). Most inpatient units come nowhere near those values.

Noise matters because it disrupts sleep, and sleep matters for recovery. Patients in intensive care units, where noise is often highest, report noise as one of the most disturbing features of their stay, and studies reviewed by Xie et al. (2009) link noise to fragmented sleep, raised heart rate and blood pressure, and patient distress. Sleep disruption is also associated with delirium in older patients, although the relationship is complicated by illness, medications and other factors. The effects are not limited to patients. Staff working in noisy environments report more fatigue and difficulty concentrating, and noise can mask alarms and conversations that need to be heard.

Sources of Noise

Much of the noise on an inpatient unit at night comes from sources that staff control. Alarms from monitors, infusion pumps and bed exit systems are among the loudest and most frequent, and many of them are not clinically actionable. Conversations at nurses' stations and in hallways, overhead paging, telephones, carts, doors and ice machines add to the background. Xie et al. (2009) note that in intensive care units, a large share of peak noise events comes from staff activity and equipment rather than from patients. This matters because it means that noise is not simply an unavoidable feature of hospital care; it is partly a result of how units are organized and how staff behave.

Some noise cannot be avoided. Alarms that signal real deterioration must be heard, and emergencies bring noise with them. The goal is not silence but the removal of noise that serves no purpose at the hours when patients most need to sleep.

Strategies Nurses Can Use

Several strategies are within the reach of nursing staff and require little or no equipment. Quiet time protocols set a period, often from 2300 to 0500, during which lights are dimmed, doors are closed where safe, overhead paging stops and nonurgent tasks are clustered or rescheduled. Alarm management reduces the number of nonactionable alarms by setting patient-specific limits and removing monitoring that is no longer needed. Staff education about the effect of voices at the station, and simple changes such as moving shift report away from patient rooms or lowering phone ringer volume, reduce background noise. Patients can also be offered earplugs and eye masks, which Xie et al. (2009) describe as a low-cost option that some patients find helpful.

The evidence for these strategies varies. Some quiet time programs have reported lower measured noise levels and better patient-reported sleep, but many were before-and-after studies on single units, which cannot rule out other explanations. A unit adopting these strategies should measure noise and patient-reported sleep before and after the change rather than assume that the strategies worked.

Measuring Noise on a Unit

A unit that wants to reduce noise needs a baseline, and measuring noise is simpler than many nurses assume. Sound level meters that record average and peak decibel levels over time are inexpensive, and a meter placed at the nurses' station and another in an empty patient room for a week of nights gives a picture of when noise peaks and what the typical level is. The two numbers that matter most are the average level across the night and the number of peak events above a set threshold, since patients are woken more often by sudden loud events than by a steady background. Staff can add a simple log of what was happening during peaks, which usually points to a handful of causes such as the 0400 laboratory draw, the linen cart or a particular alarm.

Patients' own reports are the other half of the baseline. A short question on the unit's existing discharge survey, asking how often noise kept the patient awake, costs nothing to add and measures what matters to patients directly. Measured noise and reported sleep often move together but not always, and tracking both keeps a unit from declaring success when the meter improves but patients still sleep poorly.

Barriers to Quieter Nights

Quiet nights compete with other goals. Night shift is when many units draw laboratory specimens, give scheduled medications and complete admissions from the emergency department, and each of these brings light, voices and movement into patient rooms. Reducing noise may mean moving some tasks to other hours, which affects laboratory schedules, pharmacy delivery times and physician rounding, none of which nursing controls alone. Staff may also resist quiet time protocols if they feel that they restrict communication at the station or slow down work at a busy hour. For these reasons, noise reduction works best when it is treated as a unit-wide change agreed with the departments whose routines affect the night, rather than as a request that nurses simply speak more quietly.

Conclusion

Nighttime noise is a patient safety and comfort problem that nurses can partly address. The evidence shows that hospital noise routinely exceeds recommended levels (Busch-Vishniac et al., 2005) and that it disrupts patients' sleep (Xie et al., 2009). Nurses control many of its sources, including conversations, alarms and the timing of care. Units that want quieter nights should begin by measuring their own noise and asking patients how they slept, and then choose from strategies that fit their setting. The recommended limits published by the World Health Organization (Berglund et al., 1999) offer a clear, if ambitious, target. Progress toward that target is best judged over months rather than weeks, since a single quiet week may reflect a low census rather than a change in practice.

References

Berglund, B., Lindvall, T., & Schwela, D. H. (Eds.). (1999). Guidelines for community noise. World Health Organization.

Busch-Vishniac, I. J., West, J. E., Barnhill, C., Hunter, T., Orellana, D., & Chivukula, R. (2005). Noise levels in Johns Hopkins Hospital. The Journal of the Acoustical Society of America, 118(6), 3629-3645. https://doi.org/10.1121/1.2118327

Xie, H., Kang, J., & Mills, G. H. (2009). Clinical review: The impact of noise on patients' sleep and the effectiveness of noise reduction strategies in intensive care units. Critical Care, 13(2), Article 208. https://doi.org/10.1186/cc7154