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Improving the Patient Experience: Reducing Avoidable Noise at Night.

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Abstract and Figures

The perennial problem of disruptive night time noise in acute care hospital wards has been highlighted through successive national NHS Patient Experience surveys, with approximately 30% of patients reporting that they were disturbed by night-time noise. However, this finding does little to identify the nature, frequency or severity of night-time noise, and therefore there is little opportunity to develop targeted solutions to address avoidable night-time noise. The overall aim of this project was to investigate and reduce avoidable disruptive night-time noise.
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Improving the Patient Experience:
Reducing Avoidable Noise at Night
Service Development Project
Funded by NHS Scotland Better Together Innovation Fund
Final Report
January 2013 (DRAFT V1)
Authors:
Dr Kay Currie, Glasgow Caledonian University
Ms Annie Ruddy, Project Nurse, NHS Greater Glasgow & Clyde
Mr Toby Mohammed, Head of Practice Development (Acute Services), NHS Greater
Glasgow & Clyde
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Contents
Summary .............................................................................................................................. 4
Project objectives and data collection methods ................................................................. 4
1. Background ....................................................................................................................... 9
2. Project aims, objectives, and principle activities .............................................................. 10
2.1 Project objectives and data collection methods ......................................................... 10
2.2 Project Activity Plan ................................................................................................... 11
3.0 Methods ........................................................................................................................ 12
3.1 Design ....................................................................................................................... 12
3.2 Selection of pilot sites ................................................................................................ 13
3.3 Recruitment of participants ........................................................................................ 13
3.3.1 Recruitment for patient interviews ....................................................................... 13
3.3.2 Recruitment for in-patient surveys ....................................................................... 14
3.3.3 Recruitment for staff consultation and focus groups ............................................ 14
3.3.4 Recruitment for Senior Staff Focus Groups ......................................................... 14
3.3.5 Recruitment for Service User Focus Group ......................................................... 15
3.4 Ethical approval ......................................................................................................... 15
4.0 Pre intervention data analysis and results ..................................................................... 15
4.1 Stage 1: Patient interviews ........................................................................................ 15
4.2 Stage2: Pre-intervention in-patient survey ................................................................. 17
4.2.1 Response to in-patient survey ............................................................................. 17
4.2.2 Cause, frequency and severity of night-time noise disturbance: .......................... 18
4.2.3 Type, frequency and severity of noise due to ‘EQUIPMENT’ factors ................... 19
4.2.4 Type, frequency and severity of noise due of to ‘OTHER PATIENTS’ ................. 21
4.2.5 Type, frequency and severity of noise due of ‘STAFF’ factors ............................. 22
4.2.6 Type, frequency and severity of noise due to ‘ENVIRONMENTAL’ factors .......... 24
4.2.7 Summary of factors causing disruptive night time noise ...................................... 26
5.0 Stage 3: Generating potential solutions ......................................................................... 27
5.1 Service user focus group ........................................................................................... 28
5.2 Clinical staff consultation ........................................................................................... 29
5.3 Senior staff focus group ............................................................................................. 29
6.0 Stage 4: Noise reduction interventions .......................................................................... 31
6.1 Ward protocol ............................................................................................................ 31
6.2 Practice development sessions ................................................................................. 32
6.3 Medium to longer term actions ................................................................................... 34
6.3.1 Facilities management ........................................................................................ 34
6.3.2 Repair and maintenance of equipment ................................................................ 35
6.3.3 Procurement ....................................................................................................... 35
6.3.4 Commissioning ................................................................................................... 36
3
6.3.5 Multidisciplinary issues ........................................................................................ 36
6.3.6 Patient information: Mobile phone and lap top use; earplugs .............................. 37
7.0 Evaluation of the pilot ward protocol .............................................................................. 37
7.1 Stage 4: Staff feasibility opinion survey ..................................................................... 37
7.1.1 Nurse hand-over reminder of protocol ................................................................. 38
7.1.2 Keeping conversations low and appropriate ........................................................ 39
7.1.3 Turn off the main lights at 22.30 hours ................................................................ 39
7.1.4 Keep lights as low as possible............................................................................. 40
7.1.5 Use bedside lights instead of main lights ............................................................. 40
7.1.6 Use lamps/nightlight at the nursing stations ........................................................ 41
7.1.7 Reduce the volume of telephones ....................................................................... 42
7.1.8 Reduce the volume of the patient nurse call system (night time setting) .............. 42
7.1.9 Avoid noise created when using doors, drawers and bins ................................... 43
7.1.10 Ask patients to turn off mobile phones etc. ........................................................ 43
7.2 Stage 5: Comparison of pre and post intervention in patient survey results ............... 44
7.2.1 Cause, frequency and severity of night-time noise disturbance: .......................... 45
7.2.2 Type of noise due to ‘EQUIPMENT’ factors ......................................................... 45
7.2.3 Type of noise due to ‘OTHER PATIENTS’........................................................... 46
7.2.4 Type of noise due of ‘STAFF’ factors .................................................................. 48
7.2.5 Type of noise due to ‘ENVIRONMENTAL’ factors ............................................... 48
7.3 Summary of changes in Top Ten factors causing disruptive night time noise ............ 49
8.0 Limitations ..................................................................................................................... 50
9.0 Conclusions .................................................................................................................. 51
10 Recommendations ......................................................................................................... 51
10.1 Summary of key Recommendations: ....................................................................... 51
10.2 Proposed action points ............................................................................................ 52
Appendix 1: In-patient interview schedule ........................................................................ 55
Appendix 2: In-patient survey tool .................................................................................... 58
Appendix 3: Nominal group technique instructions .......................................................... 63
Appendix 4: Staff survey tool ........................................................................................... 64
Appendix 5: Ward pilot protocol ....................................................................................... 66
Appendix 6: Pilot site layout and facilities ........................................................................ 67
Appendix 7: NHS Research Ethics waiver letter .............................................................. 68
Appendix 8: School of Health & Life Science Ethics Committee Approval ....................... 69
Appendix 9: Suggested Solutions from Staff Consultation Sessions ................................ 70
Appendix 10: General feedback comments from Senior staff Focus Group ..................... 74
Appendix 11: Senior Charge Nurse Focus Group Ranking .............................................. 76
Appendix 12: Patient awareness of electronic equipment use poster .............................. 79
Appendix 13: Steering Group membership ...................................................................... 80
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Summary
The perennial problem of disruptive night time noise in acute care hospital wards has been
highlighted through successive national NHS Patient Experience surveys, with
approximately 30% of patients reporting that they were disturbed by night-time noise.
However, this finding does little to identify the nature, frequency of severity of night-time
noise, and therefore there is little opportunity to develop targeted solutions to address
avoidable night-time noise. The overall aim of this project was to investigate and reduce
avoidable disruptive night-time noise.
Project objectives and data collection methods
Table 1: Project objectives and associated data collection methods
Project objective
Data collection method
Stage 1: To identify potential sources of
disruptive night-time noise from the
patients’ perspective.
To generate ‘patient stories’ of the impact
of disruptive night-time noise on their care
experience.
Face to face semi-structured interviews
with patients, generating qualitative data
regarding their experience of disruptive
night-time noise.
Stage 2: To quantify disruptive night-time
noise from the patients’ perspective.
Drawing on the initial patient interview
data, pre-intervention survey of in-
patients within the pilot sites to generate
descriptive quantitative data regarding the
various sources of night-time noise.
Stage 3: To generate potential solutions
for noise reduction from the perspective of
service users and the multi-disciplinary
workforce.
Facilitated group discussions with service
users and members of the multi-
disciplinary workforce, using the Nominal
Group Technique.
Stage 4: To use the PDSA (Plan, Do,
Study, Act) cycle to test feasibility of noise
reduction solutions.
To develop and implement a protocol to
reduce disruptive night-time noise within
the pilot sites.
Practice development intervention phase.
Stage 5: To assess acceptability and
feasibility of the protocol from the
perspective of the multi-disciplinary
workforce.
Staff survey.
Stage 6: To evaluate post-intervention
night-time noise from the patients’
perspective.
Post-intervention in-patient survey.
5
A key principle within the project was to involve stakeholders in order to ensure the patient
voice was represented, that clinical staff were involved in identifying and testing potential
solutions, and senior staff were committed to supporting the project. Sixteen pilot sites from
across five clinical directorates and eight hospital sites were nominated by Heads of Nursing.
NRES approval waiver was provided and approval granted from the School of Health & Life
Sciences Ethics Committee at Glasgow Caledonian University.
Summary of findings:
Stage 1: Categories of disruptive night-time noise identified via patient interviews
Thirty nine face-to-face interviews were conducted across the pilot sites. Twenty three
discrete noise producing factors were identified by patient interviews; these were groups into
four categories: noises made by staff; noises from equipment; noises made by other patients
and noises from the environment. However, several patients reported being satisfied with
night-time noise levels indicating that staff made efforts to promote a peaceful environment.
Interestingly, patient disturbance caused by lights being put on appeared to cause significant
night-time disruption and issues related to lights were therefore included in subsequent
project stages.
Stage 2:
144 useable questionnaires were returned from 16 pilot clinical areas. Overall, 68.1% (n=98)
respondents indicated that they had been disturbed by one or more type of noise at night.
Table XXX: Rank order categories of night-time noise causing disturbance
Category of noise
Number of respondents
Equipment
79
Other patients
55
Staff
47
Environment
47
In general, the frequency of disturbance from all categories of noise was reported as being
low (less than 3 times per night) and the severity of disturbance was similarly reported as
being low. In addition, open comments from patients indicated a realistic expectation of
some noise at night as staff went about their duties.
A rank ordered table of the ‘Top Ten’ reported noise producing factors was created to enable
comparison with post-intervention surveys after the implementation of the ward protocol.
6
Stage 3:
Stakeholder groups of service users and pilot area clinical staff were involved in generating
potential solutions to avoidable night-time noise. These ideas were then ranked ordered in
terms of usefulness and practicality by a group of Senior Staff using the Nominal Group
Technique. The outcome of these consultations was the development of a range of noise
reduction interventions and recommendations:
A ward based protocol to be used at nursing shift handovers, highlighting key actions
staff should take to reduce avoidable night-time noise (implemented for a 7 week
period prior to evaluation)
A patient information poster raising patient awareness of potential noise caused by
mobile phones and other electronic equipment, requesting patients to be considerate
of others.
Recognition of the opportunity afforded during the commissioning of new hospital
building to integrate noise risk assessment and reduction during the commissioning
process.
Identification of issues related to facilities management and equipment maintenance
that have been referred to Facilities managers.
Medium term actions to be introduced within a multi-disciplinary context e.g. footwear
use; hospital at night services; dementia champions; patient information leaflets.
Stage 4: Staff feasibility survey
Eighty-eight staff from across the 16 pilot sites responded to a survey seeking their opinion
regarding the effectiveness of each of the interventions in the ward protocol and whether or
not they would recommend roll-out of each of these actions across all hospital sites. Overall,
evaluation was positive, and whilst the strength of opinion was variable, no intervention was
felt to be ‘not effective’’ and the majority of respondents would recommend roll-out of the
protocol to all areas, with the proviso that it should be tailored to meet the needs of the
individual area and that there was not a ‘one-size-fits-all’ solution.
Stage 5: Post intervention in-patient survey
Repeat of the in-patient survey across the 16 pilot sites was conducted 7 weeks after the
introduction of the ward protocol. Comparison of pre and post-intervention survey findings
showed promising early signs of improvement in those factors which ward nurses have most
control over, namely response to patient buzzers, nurses talking or laughing loudly, ward
telephones ringing. Unfortunately, disturbance from lights was not greatly improved, despite
7
this featuring strongly in the ward protocol, although feedback in the staff feasibility survey
indicated that dimmer lights were frequently not available or were broken. Disturbance from
noisy commode or trolley wheels and ‘clicky heels’ from footwear (generally of medical staff)
persisted, and unfortunately disturbance from other patients in terms of snoring (particularly
problematic), confused, agitated or aggressive patients increased. Details are shown in the
table below.
‘Top Ten’ Noise disturbance factor:
Post-
intervention
(n=142)
Trend
Patient Buzzers (call for nurse button)
24.6%
(n=35)
Patient Infusion Alarms (pumps that give
medicines)
27.4%
(n=39)
=
Staff talking or laughing (personal
conversations)
15.5%
(n=22)
Ward telephones ringing
19.0%
(n=27)
Wheels from trolleys or commodes being
moved
27.5%
(n=39)
Other patients snoring
23.2%
(n=33)
Lights being kept on late or going on through
night
(not noise but caused sleep disturbance)
16.9%
(n=24)
Noise from staff banging doors, drawers, or
bin lids
17.5%
(n=25)
=
Disturbance from confused or agitated
patients
19.0%
(n=27)
Footsteps or footwear (all staff)
13.4%
(n=19)
Conclusions:
This pilot study has provided clear evidence of the type of noises that disturb patients at
night-time; many of these are avoidable and the introduction of a simple ward protocol has
shown encouraging early results. However, further medium and longer term actions are
required in relation to facilities management, equipment maintenance, procurement and
actions required by staff who work between clinical areas e.g. medical staff.
8
It is also important to note that many patients reported their appreciation of the considerable
efforts that some staff made to ensure patients were not disturbed and their general
understanding of the inevitability of some disruption in a clinical environment.
Evaluation of the feasibility of the ward protocol was positive and it is important that the
momentum generated by the project is sustained and extended; on-going senior
management support for roll-out of the ward protocol and commitment to follow-up action in
line with the comprehensive project recommendations is needed.
Key Recommendations:
1. That the pilot ward protocol should be rolled out across all hospital sites, and
promoted as a simple tool to reinforce positive attitudes and actions to avoid
disruptive night time noise.
2. That consideration be given to the most effective means of providing on-going
support for this initiative
3. That audit of the patient experience of the ‘Top Ten’ noise disturbance factors should
be integrated within the regular Senior Charge Nurse Better Together Patient
Experience survey.
4. That the issues raised in section 6.3 related to medium and longer term actions by
facilities management, equipment maintenance, procurement, commissioning, multi-
disciplinary team and patient information production be taken forward via the Better
Together Steering Group.
The following diagram presents an overview of areas for action:
Action Plans
Practice
Development
Protocol
Noise
Champions
Equipment
Infusion
Alarms
Wheeled
Equipment
Audit
SCN
questionnaire
Better
Together
Survey
Principles &
Care Plans
Dementia
Patients
Brain Injury
Patients
Substance
Misuse
Learning
Disability
Facilities
Estates
New Build
Projects
MD
Workforce
Patient
Information
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1. Background
As part of its commitment to improving the quality of the in-patient experience of care, Health
Improvement Scotland commissioned a national survey, the ‘Better Together Patient
Experience Survey (BTPES) to be conducted within each NHS Board
(www.bettertogetherscotland.com/inpatientsurvey).
In common with other NHS Boards, night-time noise disruption was one of the NHS Greater
Glasgow and Clyde (NHSGG&C) BTPES ‘low-lights’ reported in 2010 i.e. over 30% of
respondents indicated they were disturbed by night-time noise. Whilst NHSGG&C have
committed to tackling this issue, there was recognition that currently there is not sufficient
information about the nature of night-time noise to guide action. In addition, we believed that
imaginative solutions could be generated by involving staff and service-users in a service
development pilot project. As a consequence, NHSGG&C in collaboration with Glasgow
Caledonian University sought and were awarded funding from the Scottish Government
Department of Health ‘Better Together Innovation Fund’ to initiate a project to investigate
and reduce disruptive night time noise.
This project fits with the quality ambition to deliver person centred services by tackling a key
problem area, thus improving the quality of patient experience and care. Identifying and
managing avoidable noise in the care environment is intended to improve the quality of sleep
and rest patients are able to achieve, which should also impact positively on their ability to
recover from illness and influence health outcomes
10
2. Project aims, objectives, and principle activities
The overall project aim was to investigate and reduce avoidable disruptive night-time noise.
2.1 Project objectives and data collection methods
Table 1: Project objectives and associated data collection methods
Project objective
Data collection method
Stage 1: To identify potential sources of
disruptive night-time noise from the
patients’ perspective.
To generate ‘patient stories’ of the impact
of disruptive night-time noise on their care
experience.
Face to face semi-structured interviews
(appendix 1) with patients, generating
qualitative data regarding their experience
of disruptive night-time noise.
Stage 2: To quantify disruptive night-time
noise from the patients’ perspective.
Drawing on the initial patient interview
data, pre-intervention survey (appendix 2)
of in-patients within the pilot sites to
generate descriptive quantitative data
regarding the various sources of night-
time noise.
Stage 3: To generate potential solutions
for noise reduction from the perspective of
service users and the multi-disciplinary
workforce.
Facilitated group discussions with service
users and members of the multi-
disciplinary workforce, using the Nominal
Group Technique (appendix 3).
Stage 4: To use the PDSA (Plan, Do,
Study, Act) cycle to test feasibility of noise
reduction solutions.
To develop and implement a protocol to
reduce disruptive night-time noise within
the pilot sites.
Practice development intervention phase.
Stage 5: To assess acceptability and
feasibility of the protocol from the
perspective of the multi-disciplinary
workforce.
Staff survey (appendix 4).
Stage 6: To evaluate post-intervention
night-time noise from the patients
perspective.
Post-intervention in-patient survey
(appendix 2).
11
2.2 Project Activity Plan
The project commenced in March 2012 and extended to December 2012.
Table 2: Project time-frame and associated activity
Time frame
Activity
March 2012
Project Preparation
April 2012
Conduct patient interviews in pilot sites
Transcribe and analyse patient interviews
Develop pre-intervention in-patient survey questionnaire
May 2012
Data collection and analysis of pre-intervention in-patient survey
Staff consultations and Patient Panel Focus Group to generate potential
solutions to night-time noise identified via survey results
June 2012
Focus group (Nominal Group Technique) with Senior Charge Nurses
from pilot sites / Infection Control Nurse / Facilities manager, to generate
potential solutions to night-time noise identified via survey results
July 2012
Analysis of staff consultations and focus group outcomes to inform
development of Pilot Protocol
Aug/Sept 2012
Implementation of Pilot Protocol from 10
th
August- 28
th
September 2012
i.e. 7 week pilot phase (protocol maintained within pilot sites and future
roll-out planned beyond project timeframe)
Oct 2012
Post-intervention in-patient survey
Staff feasibility and acceptability survey
Nov/Dec 2012
Post-intervention survey analysis and final report
The work plan was undertaken by a Band 6 Project Nurse seconded to Practice
Development Unit (Annie Ruddy), with Project Management led by Toby Aslam Mohammed
(Practice Development Lead, NHS GGC) and evaluation design and supervision led by Dr
Kay Currie (Reader, Department of Health and Community Sciences, Glasgow Caledonian
University).
Noise Monitoring
The original proposal included the use of noise monitors to measure the levels of noise in
the pilot areas pre and post interventions. However, the data software was not compatible
with Microsoft Excel and therefore could not be migrated for analysis; obtaining noise
monitoring data was therefore excluded from the project. The two noise monitors which had
already been procured were used in the practice development sessions and three clinical
areas used them for raising noise awareness within their staff.
12
3.0 Methods
3.1 Design
A mixed methods pre and post intervention service evaluation design was adopted within a
staged approach.
Stage 1 involved face to face semi-structured interviews (appendix 1) with patients,
generating qualitative data regarding their experience of disruptive night-time noise. Noise
factors were identified and used to construct the framework for an in-patient survey tool.
Stage 2 was a pre-intervention in-patient survey (appendix 2) which sought to quantify the
nature, frequency and severity of various potential noise factors as identified via patient
interviews, as well as whether patients reported disturbance to staff; how satisfied they were
with staff response to their concern; and any suggestions to reduce night-time noise.
The survey questionnaire was sent to the Community Engagement Manager and to the
Quality Department of NHS Greater Glasgow and Clyde to ensure it met with requirements
on the use of plain English language and font size. It was also reviewed by members of the
Patient Panel for face validity; however, due to time constraints, the questionnaire was not
piloted with patients prior to distribution. This led to a few inconsistencies in responses which
had not been anticipated e.g. patients reporting being disturbed by a night-time noise factor
but not answering questions related to frequency or severity of disturbance, or conversely
not reporting a night-time noise factor but answering the related frequency or severity
questions later on in the questionnaire.
Stage 3 incorporated staff consultation and focus groups using the Nominal Group
Technique (appendix 3) with Senior Staff and, separately, service users, to generate and
prioritise potential solutions for noise reduction from the perspective of service users and the
multi-disciplinary workforce. Nominated participants were sent out a list of the identified
noise factors of noise in advance of the meeting in order that they could give thought to
potential solutions for avoidable night time noise.
Stage 4 developed and tested a protocol (appendix 5) intervention to be implemented for a
period of 7 weeks within each of the pilot sites.
Stage 5 used a structured staff survey (appendix 4) to explore the acceptability and
feasibility of each element of the intervention protocol, also seeking staff recommendations
for future use.
13
Stage 6 was a post-intervention in-patient survey, using the same data collection tool, to
identify any change in measures of nature, severity and frequency of night-time noise
3.2 Selection of pilot sites
The NHSGG&C Nurse Director for the Acute Services Division authorised access for the
project and Heads of Nursing from each Directorate were asked to consider the results of
the BTPES in their own areas and then nominate clinical pilot areas. Seventeen pilot sites
were originally identified; however, one was closed due to an infection outbreak over the
early project period and was withdrawn from the project and the patient group in another was
deemed to be clinically unsuitable for project involvement and a different site was
subsequently identified. Pilot areas were distributed across 8 separate hospital sites, within 5
acute services divisions, as indicated in Table 3.
Table 3: Distribution of pilot sites across Acute Services Directorates
Directorate
Number of
pilot sites
Surgery and anaesthetics
5
Regional services (cancer; spinal
injuries; nephrology )
3
Emergency Care & Medical Services
5
Rehabilitation & Assessment
2
Women & Children (gynaecology)
1
Total
16
The wards varied from modern bay layout to older style Nightingale wards. Variation in
design also led to differences in patient nurse-call systems, availability of volume reducing
telephones, and dimmer switches on bedside lights as indicated in appendix 6.
3.3 Recruitment of participants
3.3.1 Recruitment for patient interviews
Senior Charge Nurses from each of the pilot sites were asked to display a patient poster to
provide information to patients if they wished to self-select for interview. Patients who were
interested in participation were given written information about the project via a participant
information sheet. The Nurse in Charge was responsible for assessing patient’s suitability to
participate in face-to-face structured interviews with the project nurse; this took into account
the patient’s clinical condition, ability to communicate, and ability to make an informed choice
with written consent.
14
Dates and times for patient interviews were scheduled in advance in April 2012. The project
nurse met with potential patient participants and discussed the contents of the information
sheet before confirming agreement to participate and obtaining written consent. Patient
interviews were conducted in quiet areas to ensure confidentiality and were digitally
recorded and transcribed by the project nurse.
The interviews lasted up to thirty minutes, based on a semi structured questionnaire. Thirty
nine face-to-face interviews were conducted across the pilot sites, including the site which
was later withdrawn from the project; this interview data was excluded from analysis leaving
38 usable interview transcripts.
3.3.2 Recruitment for in-patient surveys
As with patient interviews, a recruitment poster was displayed in each pilot site and the
Nurse in Charge was asked to bring the study to the attention of patients who they assessed
as potentially suitable participants. Participant information was attached to the questionnaire
and consent was assumed by completion and return. The survey questionnaires were
delivered to the 16 pilot sites with a box to place the sealed responses. These were left for a
period of approximately one week and collected by the project nurse.
3.3.3 Recruitment for staff consultation and focus groups
Two staff focus groups were initially proposed, however difficulties with releasing staff from
clinical areas and difficulties travelling to proposed meeting sites meant that this strategy
was not feasible. Instead, we offered discussion / consultation sessions facilitated by the
project nurse within each of the hospitals/ward areas that had pilot sites. A total of 17 clinical
staff from 5 hospital sites were involved in these discussions.
3.3.4 Recruitment for Senior Staff Focus Groups
Senior Charge Nurses from each of the pilot sites were invited to take part in focus group
discussions; in addition, a representative from Infection Control and Facilities Management
was sought to ensure their perspectives were integrated into data collection. There were
nine focus group participants comprising of 6 Senior Charge Nurses, 1 Practice
Development Nurse, 1 Infection Control Nurse, and 1 Facilities manager.
15
3.3.5 Recruitment for Service User Focus Group
A letter was sent out to members of the Patient Panel for NHS Greater Glasgow and Clyde,
inviting them to participate in a service user focus group; five individuals responded and
participated on the day.
3.4 Ethical approval
An outline project proposal was discussed with the West of Scotland NHS Research Ethics
Service Co-ordinator; it was agreed that the project met the criteria for service evaluation
and therefore NRES review was not required and a waiver letter (WoS Asb 773) was
provided (Appendix 7).
In order to uphold the ethical principles of autonomy, beneficence and non-maleficence only
adults who were able to provide informed consent for participation were involved. Written
information was provided in advance to all participants, assuring them of their right to refuse
to participate and the ways in which their confidentiality would be protected. Patient
treatment and care was paramount in all aspects of the project and patient selection for
interviews and questionnaire completion was guided by the clinical judgement of the nurse in
charge.
Identification numbers have been used in the study report to identify participants and clinical
areas and no personal identifiable information was gathered. All data was handled, stored,
analysed and destroyed (as appropriate) in accordance with the Data Protection Act and
University policies. Anonymity could not be guaranteed for staff and service users who
participated in group discussions; however, ground rules on confidentiality were established
at the beginning of each small group discussion.
Review and approval of all participant information and written consent documents was
provided by the Glasgow Caledonian University School of Health & Life Sciences Ethics
Committee (Ethics Application ID B22/44) (Appendix 8).
4.0 Pre intervention data analysis and results
4.1 Stage 1: Patient interviews
Patient interviews were tape recorded and fully transcribed. Transcriptions were then
subjected to content analysis to identify a comprehensive list of factors which caused
disruptive night time noise; there was no attempt to quantify the occurrence of various night-
time noise factors from the in-patient interviews. Twenty three discrete factors were
16
highlighted, these were groups into four categories; noises made by staff; noises from
equipment; noises made by other patients and noises from the environment (see table 4)
Table 4: Categories of disruptive night-time noise identified via patient interviews
Type of noise due to ‘staff’ factors
Staff talking or laughing (personal conversations)
Footsteps or footwear (all staff)
Staff eating in ward area
Noise from staff banging doors, drawers, or bin lids
Staff playing radio or TV
Type of noise due to ‘EQUIPMENT’ factors
Wheels from trolleys or commodes being moved
Ward telephones ringing
Staff pagers or bleeps
Patient Buzzers (call for nurse button)
Patient Infusion Alarms (pumps that give medicines)
Type of noise due to ‘ENVIRONMENTAL’ factors
Lights being kept on late or going on through night (not noise but
caused sleep disturbance)
Bedside curtains being pulled ‘swished’
Medicine rounds late at night
Apron dispensers (on walls)
Any noise from outside the hospital e.g. building works, bins being
emptied early in morning, Seagulls, Traffic noise
Type of noise due to ‘OTHER PATIENTS’
Patients being admitted or beds moved through the night
Patients playing radio or TV
Other patients snoring
Other patient talking loudly
Disturbance from aggressive patients
Disturbance from intoxicated or drunk patients
Mobile phones text messages and conversations
Disturbance from confused or agitated patients
Any other noise from other patients
However, it is also important to note that some patients reported a positive night-time
experience, indicating that staff made efforts to promote a peaceful environment, for
example;
It was all very, a very low toned voice when they were talking. No high heels
clicking or anything like that, you know. All very, just respectful I think that people
were sleeping, and they’re aware of that…. I think the way the staff acted on Ward X
I felt that, you know, they done everything they could to keep the noise levels
down…. And thats I think all you can expect when you’re in hospital because at the
end of the day, as I said, there is other people in the room, and they need to be cared
for. And sometimes people are sick during then night. So I just think you need to
expect a bit of noise. (Interview 1)
And
17
Because this ward is very quiet. You hardly hear a sound on this ward. Even the
staff. You wouldn’t even know they were there during the night. The only reason I
know they’re there is because my door is left open. (Interview 4)
4.2 Stage2: Pre-intervention in-patient survey
4.2.1 Response to in-patient survey
The findings from the in-patient interviews were used to construct a framework for the in-
patient survey tool. The resultant self-completion questionnaire asked patients to;
Tick any noise factor within the four categories (noise from staff; equipment;
environment; other patients) that they had experienced at night
Identify the average frequency of occurrence for each of the four noise categories
i.e. Once or twice a night; 3-10 times a night; Over 10 times a night
Rate (on a scale of 1-10) how disruptive this type of noise was (where 1=not at all
and 10=severely disrupted sleep)
Whether they had reported that category of night-time noise to staff
Rate on a scale of 1-5 how satisfied they were with staff response to their concerns
about night-time noise
Give any suggestions to reduce each category of night-time noise
As noted above there was evidence of some inconsistency in patient response to the
questionnaire, however, all data was coded into an excel work-sheet and imported into
SPSS for quantitative statistical analysis. Qualitative responses were extracted and thematic
analysis conducted
A total of 144 useable questionnaires were returned from 16 pilot clinical areas across 8
hospital sites within NHS Greater Glasgow & Clyde; the number of respondents from each
pilot area varied, depending on the number of patients per ward and the clinical condition of
patients during the collection period. Respondents had variable length of stay; Range 1 - 341
nights, Median (due to outlying values) = 5 nights. Given the variation in ward size,
admission / discharge rates, and clinical condition of in-patients, a response rate could not
be calculated; however we believe the survey is broadly representative of the in-patient
experience across the pilot areas.
18
Table 5 Sample size per site:
Hospital site
n
%
A
33
22.9
B
27
18.8
C
23
16.0
D
18
12.5
E
12
8.3
F
12
8.3
G
10
6.9
H
9
6.3
Total
144
100%
Table 6 Sample size per clinical directorate:
Directorate
n
%
Surgery and anaesthetics
39
27.0%
Regional services
(cancer; spinal injuries;
nephrology )
36
25.0%
Emergency Care &
Medical Services
34
23.6%
Rehabilitation &
Assessment
20
14.0%
Women & Children
15
10.4%
Total
144
100%
4.2.2 Cause, frequency and severity of night-time noise disturbance:
Respondents were asked to indicate against a list of previously identified factors what types
of noise had caused disturbance at night.
Overall, 68.1% (n=98) respondents indicated that they had been disturbed by one or more
type of noise at night.
More specifically, types of noise were categorised as due to ‘staff’; ‘equipment’;
environment’; or ‘other patients’. Respondents could indicate more than one category of
noise; hence the data in the following table is greater than the number of respondents and
represents a rank order of categories of noise disturbance.
19
Table 7: Rank order categories of night-time noise causing disturbance
Category of noise
Number of respondents
Equipment
79
Other patients
55
Staff
47
Environment
47
Patients were then asked to indicate the frequency and severity of disturbance from each
category of noise;
[N.B. there are some inconsistency in the following data as some respondents identified a
specific noise factor but did not answer frequency or severity questions; conversely, some
respondents did not identify a specific noise factor but rated frequency or severity within that
category (generally rating both at lowest scores); all data provided was included in analysis,
irrespective of inconsistent response].
4.2.3 Type, frequency and severity of noise due to ‘EQUIPMENT’ factors
54.9% (n=79) of respondents indicated they had been disturbed by at least one or
more form of ‘EQUIPMENT’ noise, as detailed below;
Table 8: Rank order of disturbance due to ‘EQUIPMENT’ factors
Type of noise due to ‘EQUIPMENT’ factors
Frequency
Patient Buzzers (call for nurse button)
27.8% (n=40)
Patient Infusion Alarms (pumps that give medicines)
26.4% (n=38)
Ward telephones ringing
22.9% (n=33)
Wheels from trolleys or commodes being moved
20.8% (n=30)
Staff pagers or bleeps
4.9% (n=7)
When asked ‘How often did ‘noises equipment made’ happen during an average night?
36.8% (n=53) indicated once or twice a night
11.8% (n=17) indicated 3-10 times a night
2.1% (n=3) indicated over 10 times a night
When asked ‘On a scale of 1 10 (where 1=not at all and 10=severely disrupted my sleep)
how disruptive was noise due to equipment for you?
33.3% (n=48) indicated a severity score of 1-3
20
13.2% (n=19) indicated a severity score of 4-7
2.7% (n=4) indicated a severity score of 8-10
A moderate, significant positive correlation was found between the frequency and severity of
noise disruption caused by equipment (Spearman’s Rho=0.613, p<0.01), indicating that
patients who were disturbed more frequently by noise from equipment tended to perceive
the disruption caused as more severe.
6.3% (n=9) respondents indicated they had reported ‘noise from equipment’ to nursing staff
or Senior Charge Nurse; of those, 4.9% (n=7) were satisfied with the response received,
0.7% (n=1) were less than satisfied.
Suggestions to reduce disturbance from ‘‘noises from equipment’ included
Infusions pumps/alarms, and patient buzzers e.g.
‘Patient buzzers and infusion alarms should be responded to as soon as possible,
and not left to disturb fellow patients especially infusion alarms.’ (patient 120)
Wheeled equipment, particularly maintenance e.g.
‘Increase maintenance to wheeled equipment i.e. oil or grease wheels, condemn or
replace/repair faulty/ damaged wheels. (patient 121)
‘Bins’, (although this was not included in this category in the questionnaire).
‘Soft closing bins lids everywhere.’ I was next to bins.’ (patient 55)
Also, some comments indicated not being disturbed by the noises from equipment they
heard.
‘I would never complain or comment on noises from equipment as this is essential to
the well-being of my fellow patients.’ (patient 77)
‘This is part of necessary treatments. Largely any disturbance has been intrinsic to
my treatment.’ (patient 87)
Other comments about ‘noises from equipment’ included;
‘Pumps on through night dispensing food are noisy. In HDU monitors are constantly
malfunctioning.’ (patient 61)
‘Again, unavoidable.’ (patient 63)
21
4.2.4 Type, frequency and severity of noise due of to ‘OTHER PATIENTS’
38.2% (n=55) of respondents indicated they had been disturbed by at least one or more
form of noise from ‘other patients’, as detailed below;
Table 9: Rank order of disturbance due to ‘OTHER PATIENTS’ factors
Type of noise due to ‘OTHER PATIENTS
Frequency
Other patients snoring
18.1% (n=26)
Disturbance from confused or agitated patients
12.5% (n=18)
Patients being admitted or beds moved through the night
8.3% (n=12)
Disturbance from aggressive patients
8.3% (n=12)
Patients playing radio or TV
6.9% (n=10)
Other patient talking loudly
6.9% (n=10)
Mobile phones text messages and conversations
4.2% (n=6)
Disturbance from intoxicated or drunk patients
3.5% (n=5)
Door alarms being set off
2.1% (n=3)
Patient shouting
1.4% (n=2)
Patient being sick
1.4% (n=2)
Patient going to the toilet during the night
1.4% (n=2)
Patient buzzing for assistance’
0.7% (n=1)
When asked ‘How often did ‘noises from other patients’ happen during an average night?
24.3% (n=35) indicated once or twice a night
12.5% (n=18) indicated 3-10 times a night
1.4% (n=2) indicated over 10 times a night
When asked ‘On a scale of 1 10 (where 1=not at all and 10=severely disrupted my sleep)
how disruptive was noise from other patients for you?
25% (n=36) indicated a severity score of 1-3
9.7% (n=14) indicated a severity score of 4-7
4.2% (n=6) indicated a severity score of 8-10
A moderate, significant positive correlation was found between the frequency and severity of
noise disruption caused by other patients (Spearman’s Rho=0.511, p<0.01), indicating that
patients who were disturbed more frequently by noise from other patients tended to perceive
the disruption caused as more severe.
22
7.6% (n=11) respondents indicated they had reported noise from ‘other patients’ to nursing
staff or Senior Charge Nurse; of those, 7% (n=10) were satisfied with the response received,
0.7% (n=1) were less than satisfied.
Suggestions to reduce disturbance from ‘‘noises from other patients’ included:
Ward layout and availability of single rooms e.g.
‘Hospitals should have more rooms so that very disturbed or very ill patients can
occupy. Nurses try to keep noise down but sometimes it’s impossible.’ (patient 53)
‘More single rooms in wards!’ (patient 35)
‘Vigilance by staff when patient noises become disturbing should be enough to keep
noise within reasonable limits. As the wards are open plan a patient has to expect
some noise will occur.’ (patient 79)
Other suggestions:
‘Awareness to all patients that not all patients like to sit up and talk and hold a hearty
conversation. Notice’s requesting noise levels and disturbance be kept to a minimum
at appropriate times.’ (patient 49)
‘Mobiles should be off after a certain time. If a patient is confused or agitated they
should be spoken to and explained how disruptive they are being and hopefully
calmed down.’ (patient 92)
‘Giving patients some sort of ear plugs.’ (patient 5)
Other comments:
I have not experienced noise at night on the ward, only from an abusive patient but
this is only temporary.’ (patient 51)
‘Not a problem.’ (patient 116)
‘Unavoidable.’ (patient 89)
4.2.5 Type, frequency and severity of noise due of ‘STAFF’ factors
32.6% (n=47) of respondents indicated they had been disturbed by at least one or
more form of ‘STAFF’ noise, as detailed below;
23
Table 10: Rank order of disturbance due to ‘STAFF’ factors
Type of noise due to ‘STAFF’ factors
Frequency
Staff talking or laughing (personal conversations)
23.6% (n=34)
Noise from staff banging doors, drawers, or bin lids
17.4% (n=25)
Footsteps or footwear (all staff)
10.4% (n=15)
Staff playing radio or TV
2.1% (n=3)
Staff eating in ward area
0.7% (n=1)
When asked ‘How often did ‘noises staff made’ happen during an average night?
31.9% (n=46) indicated once or twice a night
9.7% (n=14) indicated 3-10 times a night
2.1% (n=3) indicated over 10 times a night
When asked ‘On a scale of 1 10 (where 1=not at all and 10=severely disrupted my sleep)
how disruptive was this type of noise for you?
29.9% (n=43) indicated a severity score of 1-3
12.5% (n=18) indicated a severity score of 4-7
2.7% (n=4) indicated a severity score of 8-10
A moderate, significant positive correlation was found between the frequency and severity of
noise disruption caused by staff (Spearman’s Rho=0.551, p<0.01), indicating that patients
who were disturbed more frequently by noise caused by staff tended to perceive the
disruption caused as more severe.
Only 4.2% (n=6) respondents indicated they had reported ‘noise from staff’ to nursing staff or
Senior Charge Nurse; of those, 2.1% (n=3) were satisfied with the response received, 1.4%
(n=2) were less than satisfied.
Suggestions to reduce disturbance from ‘noises staff made included:
To ask staff to reduce the volume of their voices at night:
‘Ask staff to keep voice down when having conversations during the night as I felt as
if this went on all night, although I realise things are amplified during the middle of the
night.’ (patient 34)
‘Talk quieter at night and realise its not the same as a day shift and working around
patients who are trying to sleep.’ (patient 39)
‘Suggest staff made aware of how disturbing this can be, and that care should be
made/taken to ensure voice is cut to minimum.’ (patient 120)
24
Mechanisms such as doors and bins and maintenance.
‘Soft closing bins lids everywhere.’ (patient 55)
‘In ward (x) the doors are on a slow release mechanism which doesn’t work as
they end by banging each other. Even putting a cloth which reached from one side
of the door to the other would soften the closure.’ (patient 56)
‘Have a programmed maintenance schedule in place for oiling doors, wheels on
trolleys, and medicine cabinet hinges.’ (patient 49)
Nurses station to be enclosed and any confidential discussion be within enclosed
area.’ (patient 49)
Some comments indicated noise from staff was unavoidable;
‘Difficult for staff to do this as they care for the patients.’ (patient 58)
‘Virtually impossible. (patient 81)
Other comments about ‘noises staff made’ included;
Positive responses, not experiencing noise, or having in expecting noise within a
hospital environment (and therefore not disturbed by it).
‘Found staff friendly, professional and did not notice them as being noisy’ (patient 18)
‘The staff were quiet during the night any time I was awake’ (patient 5)
‘Staff noise has been zero.’ (patient 123)
‘Staff in my experience are trying to do a job of work which cannot help but create
noise day or night’ (patient 18)
‘Out with their control, especially when dealing with very ill or disturbed patients.’
(patient 53)
4.2.6 Type, frequency and severity of noise due to ‘ENVIRONMENTAL’ factors
32.6% (n=47) of respondents indicated they had been disturbed by at least one or
more form of ‘ENVIRONMENTAL’ noise, as detailed below;
25
Table 11: Rank order of disturbance due to ‘ENVIRONMENTAL’ factors
Type of noise due to ‘ENVIRONMENTAL’ factors
Frequency
Lights being kept on late or going on through night (not noise
but caused sleep disturbance)
18.1% (n=26)
Any noise from outside the hospital e.g. building works, bins
being emptied early in morning, Seagulls (Gartnavel)
9.7% (n=14)
Medicine rounds late at night
8.3% (n=12)
Bedside curtains being pulled ‘swished’
4.9% (n=7)
Traffic noise
3.5% (n=5)
Apron dispensers (on walls)
0.7% (n=1)
When asked ‘How often did noises from the environment’ happen during an average
night?
34% (n=49) indicated once or twice a night
8.3% (n=12) indicated 3-10 times a night
2.1% (n=3) indicated over 10 times a night
When asked ‘On a scale of 1 10 (where 1=not at all and 10=severely disrupted my sleep)
how disruptive was environmental noise for you?
29.9% (n=48) indicated a severity score of 1-3
13.9% (n=20) indicated a severity score of 4-7
4.1% (n=6) indicated a severity score of 8-10
A moderate, significant positive correlation was found between the frequency and severity of
noise disruption caused by environmental noise (Spearman’s Rho=0.656, p<0.01), indicating
that patients who were disturbed more frequently by environmental noise tended to perceive
the disruption caused as more severe.
Only 2.8% (n=4) respondents indicated they had reported ‘environmental noise’ to nursing
staff or Senior Charge Nurse; of those, 2.1% (n=3) were satisfied with the response
received, 0.7% (n=1) were less than satisfied.
Suggestions to reduce disturbance from ‘environmental noise’ included:
‘There really needs to be sound proofing around the console’ (patient 33)
‘Speed limit on road. At certain times noise is really bad, even with windows closed.’
(patient 53)
‘Unavoidable. Constant traffic on dual carriageway.’ (patient 89)
‘Other patient had fallen asleep with bed light on. Nurses could check to see if all are
turned off if not in use.’ (patient 100)
26
‘Reducing use of lights during the night by explaining to patients how disruptive this
can be i.e. use of lights at night should only be when absolutely necessary.’ (patient
120)
‘Guidance given by nursing staff to visitors, impact of noise disruption during the
night visiting seriously ill relatives, and volume of visiting groups i.e. numerous
visitors at the same time.’ (patient 121)
Other comments about ‘environmental noise’ included:
Outside noise is just something you have to live with.’ (patient 5)
‘Fit PIR lights in areas that are only used minimal’ (patient 120)
‘Did not experience noise in the environment’
‘Three months in isolation and feel the ward is just as good, don’t hear any noise
from staff or equipment. When open windows hears a lot of traffic.
Some patients added general comments. These were mainly positive statements on their
experience, and praising the hospital ward and staff.
‘Staff considerate at all times.’
‘The ward was very quiet.’
‘I think the staff do a wonderful job with limited resources, and under difficult
circumstances. I would never fault them, they are dedicated group of people, to
whom I owe a debt of gratitude.’
‘The staff are all great and do as they are supposed to. Thank you.’
‘This ward is probably one of the east likely to be affected e.g. nature of
illness/clients etc.’
‘I never heard any noise.’
‘The hospital is a pleasure to be in. Lovely nurses, lovely meals. Very well-
mannered staff.’
Heating and patient alarms only problem’
4.2.7 Summary of factors causing disruptive night time noise
Table 12 below presents the ‘Top Ten’ frequency ranking of noise disturbance factors
identified by the pre-intervention survey. Table 13 identifies less frequently reported noise
disturbance factors. Taken together these two tables represent a summary of the types of
noises which cause noise disturbance at night, and their reported frequency.
27
Table 12 rank order table of ‘Top Ten Factors’
Noise disturbance factor:
Frequency
Patient Buzzers (call for nurse button)
27.8% (n=40)
Patient Infusion Alarms (pumps that give medicines)
26.4% (n=38)
Staff talking or laughing (personal conversations)
23.6% (n=34)
Ward telephones ringing
22.9% (n=33)
Wheels from trolleys or commodes being moved
20.8% (n=30)
Other patients snoring
18.1% (n=26)
Lights being kept on late or going on through night (not noise but
caused sleep disturbance)
18.1% (n=26)
Noise from staff banging doors, drawers, or bin lids
17.4% (n=25)
Disturbance from confused or agitated patients
12.5% (n=18)
Footsteps or footwear (all staff)
10.4% (n=15)
Table 13 Rank order table of ‘other factors’ causing disruptive night time noise (n>5)
Noise disturbance factor:
Frequency
Any noise from outside the hospital e.g. building works, bins being
emptied early in morning, Seagulls (Gartnavel)
9.7% (n=14)
Patients being admitted or beds moved through the night
8.3% (n=12)
Disturbance from aggressive patients
8.3% (n=12)
Medicine rounds late at night
8.3% (n=12)
Patients playing radio or TV
6.9% (n=10)
Other patient talking loudly
6.9% (n=10)
Staff pagers or bleeps
4.9% (n=7)
Bedside curtains being pulled ‘swished’
4.9% (n=7)
Mobile phones text messages and conversations
4.2% (n=6)
Disturbance from intoxicated or drunk patients
3.5% (n=5)
5.0 Stage 3: Generating potential solutions
Stages 1 & 2 of the project identified and quantified factors which cause night-time noise
from the perspective of in-patients; stage 3 involved service users, ward staff and senior
managers in discussion of these factors and generating potential solutions which could be
developed into a ward based protocol to be tested as part of the projects PDSA cycle. Using
the PDSA cycle enabled the changes to be recommended in the protocol to be tested within
the pilot sites before wholesale implementation across the Acute Services Division, thus
giving stakeholders the opportunity to see if the proposed changes would work.
Contributions from all three groups were integrated into a final protocol which was
28
implemented within the 16 pilot sites over a seven week period, prior to post-intervention
evaluation, and further medium to long term action plans were developed for further
consideration by relevant parties (see section 6.3).
5.1 Service user focus group
Volunteers for the service user focus group were sent details of the factors identified by
patients as causing disruptive night-time noise in advance of the meeting and were asked to
give some thought to potential solutions which could be discussed by the group. Following
facilitated discussion, the group agreed the statements presented in Table 14 as being the
most important considerations to promote rest and sleep: these statements are not rank
ordered however they represent general consensus of opinion and have been grouped into
themes of ideas related to professional practice; communicating with patients; and providing
information for patients.
Table 14: Service User Group statements of care to promote sleep and rest
Professional Practice
Promoting rest and sleep at night is a duty of care
Strong Leadership from Senior Charge Nurses taking forward this work, so patients
know who to complain to.
Named ‘go to’ person who will champion the work on rest and sleep and take it
forward in their clinical areas
Training for staff e.g. Awareness raising on attitudes, behaviour, respect, dignity,
courtesy, and promoting within ward/clinical areas (staff don’t have to go ‘out’ for
training sessions).
Training in the universities (nurse training) on attitudes, behaviour, respect, dignity,
courtesy
Ensure a sustainable protocol/guideline fit for purpose and revisited frequently (audit)
Use common sense and awareness
Communicating with patients
Recognise the different needs of different groups of patients (e.g. age)
Ask every patient directly as part of the nursing care ‘are you getting enough rest and
sleep?’ (Do not make assumptions)
Include sleep and rest as integral part of care plan for patients, and plan interventions
accordingly
29
Communicating with patients when something is happening on the ward that is
disruptive or disturbing
Communicating with patients to reassure and explain when there has been
disturbance
Promote open arena between patients and staff to have dialogue on what disturbs
them at night.
Listen and respond to what patients say
Providing information for patients
Literature on our position that ‘NHS GGC promotes rest and sleep’: ‘Collaborative
Relationship’ (this is what we do, this is what we would like you to do)
Rest and sleep icons/interactive feedback on NHS GGC Website
Less graphs and charts at the entrance of clinical areas, and clear language
statements that ‘we are an area that promotes rest and sleep’, and how to complain
of any disturbance. Clear, concise, user friendly
5.2 Clinical staff consultation
It was initially planned to hold focus groups for clinical staff from the pilot sites to review the
results of the in-patient survey and generate potential solutions for the identified noise
factors. Unfortunately, due to reported difficulties in releasing staff during working hours,
recruitment for these focus groups was poor and instead the project nurse arranged more
conveniently timed meetings with available staff at each of the pilot hospital sites; seventeen
individuals participated in these discussions and a range of potential solutions were
generated (see appendix 9).
5.3 Senior staff focus group
Relevant senior staff, including Senior Charge Nurses from the pilot sites, a practice
development nurse, an infection control nurse and a representative from facilities
management participated in a focus group discussion, which used the Nominal Group
Technique (see appendix 3) to discuss and then score the potential nose solutions
generated by clinical staff consultation, in terms of usefulness and importance, thus creating
a rank ordered list of potential noise solutions.
Several relevant issues were raised during general discussion: the group wanted to convey
the importance of ‘context’ i.e. different areas of practice, different types of wards, building
etc., that in terms of ‘solutions’ meant that one size does not necessarily fit all. There were
some concerns about a ‘policy’ that could not be realistically implemented across all areas in
30
all ways. There was also consensus that the project offered a tremendous opportunity to get
the right information about causes and possible reduction of disruptive night time noise to
the right people, including facilities management and maintenance as well as informing the
new build at Southern General Hospital in terms of design, layout and equipment. For
example consideration should be given to:
Ensuring all doors, cupboards drawers, etc. are noise reducing in all areas, and not
just clinical areas.
Consider where sluice areas and suchlike are in relation to clinical/patient areas.
Have all soft closure quiet bins
Planners and builders to ask from input from clinicians in order to plan for noise
reduction rather than ‘fix’ e.g. light disturbances from non-clinical areas
Additional general feedback comments are included at appendix 10
Senior staff were then asked to use the 10 ‘sticky stars’ they had been given to score the
potential noise solution in each category; participants could allocate their stars in whichever
way they felt reflected their weighting of the importance of each solution. A full list of rank
order scores is provided in appendix 11; however table 15 below illustrates the top three
ranking solutions in each noise category.
Table 15: top three ranking solutions in each noise category.
Noise
Category
Noise solution
score
Equipment
No unnecessary night time ‘routines’ that would cause movement
and noise
15
Condemn and replace equipment that does not meet standards
for noise reduction
14
Reduce volume of telephones at night
9
Other patients
Mobile phone use: Produce patient literature and signage
indicating that we are a hospital that promotes rest and sleep,
including guidelines for mobile phone use.
37
Adhere to guidelines on bed management/movement after 8 pm
12
Holistic assessment/admission processes of patients to try and
ensure patient routine is reflective of routine at home as far as
possible to avoid increased agitation and confusion
5
31
Staff
Promote awareness of volume of voice, being professional and
appropriate at all times in the workplace
31
Replace/Override ‘Alert’ call buttons for entrance to wards where
they exist
12
All staff should adhere to health and safety/infection control
policies and guidelines on flat, lace up fully covered soft shoes
that protect the feet i.e. no noisy heeled shoes by male or female
staff (all staff including medics)
10
Environment
Use dimmer lights were possible
*acknowledging the need for dimmer option to be adequate to
facilitate safe task being undertaken and distribute light over
clinical area
12
No routine emptying of waste and laundry skips during the night
or early morning in hospital grounds, e .g. Gartnavel lorry bins
during night skips are dragged and lorries make bleeping noise
12
Hospital deliveries at appropriate times (e.g. supplies and linen
cages) and not during sleep and rest hours
9
6.0 Stage 4: Noise reduction interventions
On review of the rank ordered potential noise solutions, developed by involvement of service
users, clinical staff and senior staff as described above, it was determined that there were
some interventions that could be implemented in the short term via a ward based protocol,
covering many of the top ten factors of noise disturbance identified in the survey; however,
there were also intermediate and longer term action plans required.
6.1 Ward protocol
It was agreed via the project Steering Group that to maximise benefit from short term
interventions, the initial pilot protocol would focus on increasing staff awareness and where
possible reducing noise from patient buzzer systems and telephones, although it was
recognised that there were some pilot areas that did not have phones and buzzers where
the volume can be reduced. A draft protocol was developed and circulated to Senior Charge
Nurses in the pilot sites for consultation within ward areas; the agreed protocol content was
as follows:
32
Our aim is to promote rest and sleep for our patients by creating an environment which aims
to eliminate avoidable noise or disruption at night
This protocol is to be used at each nursing shift handover:
Be aware of keeping our conversations low and appropriate.
Turn off main overhead lights at 22.30 hours.
Keep lights as low as possible
Use bedside lights instead of main lights. *
Use lamp/nightlight at the nurse’s station.
Reduce the volume of telephones if they have this facility.
Reduce volume of patient nurse call system (night time setting).
Be mindful of noise that can be created when using doors, drawers, and bins *
Ask patients to turn off mobile phones and other equipment or reduce to silent as part
of the night time settling down period e.g. during medicine rounds.
(*Report broken bedside lights as soon as possible via online system)
The protocol statements were laminated and intended for use specifically during nursing shift
handovers. A series of practice development workshops was delivered to ‘noise reduction
champions’ from each pilot site, to discuss and support implementation of the pilot protocol.
6.2 Practice development sessions
Link nurse ‘Noise reduction Champions’ were able to be recruited from ten of the pilot areas.
Practice development teaching materials were developed, and link nurses were invited to a
two hour session, facilitative by the project nurse using the ‘train the trainer’ approach. The
sessions involved a mix of discussion and activities, including reflecting on the pilot protocol
and other ways they could work constructively with their colleagues to reduce avoidable
night time noise. Other resources included some of the qualitative comments from the Pre-
Intervention In-Patient questionnaires and extracts from the patient transcriptions to ensure
the patient voice was visible in the initiative. The detail of protocol implementation was
discussed, particularly around using the handover time to night staff, and emphasising the
aim of promoting rest and sleep for patients. Teaching materials were also sent out by email
to Senior Charge Nurses to distribute and discuss within their own clinical areas.
Clinical staff were encouraged to view the protocol as a dynamic document that each area
could use and adapt to their specific clinical area. As part of the engagement process, the
project nurse emphasised that noise reduction initiatives would not end with the pilot project,
but would be built into future work, processes and audit; the pilot was intended to provide an
33
evidence base around the change processes and clinical areas were encouraged to take
ownership of implementation and on-going support for the initiative.
There was a variable level of engagement across the pilot site areas in planning the
implementation of the protocol, possibly due to some resistance in some areas and time
constraints in terms of release of ward staff and also the project work plan.
Feedback from group discussion at the practice development sessions was largely
constructive, however a range of perceived barriers were identified;
Sometimes staff talk at night to ‘keep themselves awake’. It’s difficult to create a
tranquil atmosphere as that can also make you sleepy.
Geography of the ward e.g. one ward houses the female staff toilets that staff from
other wards on the floor come through to use. This can cause additional noise in
some clinical areas.
Raising staff awareness and the change process may take time, beyond the project
timeframe.
Lights. There is the potential for the protocol to cause tension because staff will put
off the lights when the nurse in charge is still trying to do her drug round not
working together. Link nurses were asked to reflect on this and how to create a team
effort.
Link nurses are not the ‘go to’ person, but are the bridge to build on the awareness
and change; noise reduction is ‘everyone’s responsibility’
Nurse-call buzzers. Some areas don’t have a system where volume can be reduced.
Phantom buzzers are also an issue. There is a cultural challenge of some staff not
answering buzzers that are not ‘their patients’ or it’s not ‘their turn’ to answer. This
can create tensions, but also impact on noise for patients if not answered speedily. A
suggestion was to add to the protocol to answer buzzers as quickly as possible.
Patients: some patients don’t want the ward to ‘settle’ down at a specific time and
wish to continue to watch TV, use laptops etc.
There are still too many patient transfers after 10pm that create noise and impact on
the rest of the routine for the evening/night in settling the ward environment.
34
It is recognised that the implementation period for the ward protocol was brief (7 weeks) and
that a longer time frame with on-going support would be necessary to maximised benefit.
However, as a short term piloting applying the Plan; Do; Study; Act process, implementation
provided insight into potential mechanisms (as well as barriers) to reduction of disruptive
night time noise.
6.3 Medium to longer term actions
From the project work undertaken with patients, service users, and members of staff a
multidisciplinary and cross function approach to reducing noise at night is necessary to
ensure a collaborative framework that can contribute to improved service and experiences
for patients. Patients experience noise at night due a variety of factors, including noises
within and out with the ward environment; some are particular to specific hospital sites.
However, whilst short term actions within the ward area were addressed via the pilot ward
protocol, other medium to longer term actions, out-with the scope of this project, are
required, involving facilities management, equipment maintenance, procurement,
commissioning, multidisciplinary issues (e.g. link with dementia champions, medical staff,
hospital at night staff), and the Acute Services Quality Department in relation to patient
information.
6.3.1 Facilities management
The following points are pertinent to facilities management;
Reconsideration of the routine emptying/collection of waste and laundry skips during
the night at Gartnavel General Hospital. Currently skips are dragged and the lorries
make a noise (particularly when reversing) which is disruptive to patients. Gartnavel
General Hospital also experience significant problems with seagulls.
Hospital deliveries, e.g. supplies and linen cages are being delivered very early in the
morning, contributing to noise. This was reported in relation to Gartnavel General
Hospital and Beatson Oncology Unit.
Cleaning of hospital corridors and other routine cleaning outside the hospital ward
was reported to contribute to noise at night.
Certain clinical areas there are ‘secure doors’ with doorbell noise that does not have
any volume control. Within the pilot sites this specifically included Beatson B5.
These make a noise when visitors require entrance. There are also movement
35
sensitive doors at Philipshill in Southern General Hospital at one particular end of the
clinical area, which disturbs patients. These also contribute to staff stress due to
noise exposure.
Corridor Sensor Lights: These are activated by movement and can disturb patients
sleep and rest. During the project one area reported their shared corridor lights with
another ward, which meant they could put lights out, but they could be put on by
another ward. The Senior Charge Nurse reported that she would like the opportunity
for refurbishment to include her staff being able to control their own ward
environment (lights).
It was felt that it may be beneficial to include signs outside of hospital buildings that
used to exist e.g. ‘Quiet Please. Hospital’. It was perceived that these used to be
commonplace, particularly where hospitals are located in busy areas, but that in
recent years these were no longer in place.
These issues have been reported to Facilities management in a separate paper and should
be followed up in future audits of patient experience of disruptive night time noise.
6.3.2 Repair and maintenance of equipment
The following points reflect feedback relating to noise from equipment;
Noise is experienced from all forms of wheeled equipment, including trolleys and
commodes. The solutions include regular maintenance, as this falls out with the remit
of clinical nursing duties. It was proposed that a regular maintenance and repair
schedule would be beneficial. It is essential that requests for repair of equipment are
dealt with speedily. Senior Charge Nurses fed back that reported faulty equipment
can take up to several weeks to be repaired.
Patient bedside lights. Lights were reported as a disturbing factor by patients. These
do not always work, resulting in staff having to use overhead lighting unnecessarily.
Patient’s curtains require regular maintenance, as they contribute to noise when
pulled.
6.3.3 Procurement
Senior charge nurses reported some issues related to procurement difficulties;
Patient’s identified noise from bin lids, and it was noted that there was a variation in
36
clinical areas on the amount of soft top bins. A recommendation would be replacing
all noise producing bins with bins that have quiet mechanisms for closure
Senior Charge Nurses cannot always order the equipment that is necessary to help
reduce noise e.g. soft closure bins due to financial constraints.
Consideration should be given to whether certain items of equipment were fit for
purpose/cost effective in the longer term e.g. apron dispensers on walls (these make
a lot of noise)
6.3.4 Commissioning
It is recommended that a risk assessment for night time noise is undertaken when
undertaking planning and commissioning of products and services, including New Build
Projects. Members of the Senior Charge Nurse Focus Group felt that the new hospital
buildings underway at Southern General Hospital offered an ideal opportunity to utilise the
projects findings to ensure where possible noise reducing equipment, fixtures and fittings
should be installed. An example of learning offered was from the Beatson Oncology Unit,
which is a fairly new build. The secure doors for ward entrances have ‘doorbell’ alerts where
the volume cannot be controlled. Neighbouring wards ‘doorbells’ can also be heard, which
results in continued and consistent noise disturbance. Similarly the ‘deliveries’ area is
beneath ward areas, which means that patients can be disturbed.
Additionally, current noise caused by doors, drawers or bin lids banging might be able to be
addressed during the commissioning of new facilities.
6.3.5 Multidisciplinary issues
Any initiative to reduce avoidable night time noise should include all members of the
multidisciplinary workforce, including clinicians. In particular, patients’ highlighted noisy
footwear, specifically that worn by medical staff, being a factor contributing to noise.
The use of a ‘walkie-talkie’ system by Hospital at Night practitioners in some areas seemed
problematic; following the identification of this issue the Hospital at Night Coordinator for
Glasgow Hospitals was going to implement a trial ‘earpiece’ for the hospital at night support
workers for a couple of the areas (results awaited).
Although not significant and generally tolerated by patients, disturbance from confused and
agitated patients was identified as challenging; this issue is to be referred to the Acute
Services Dementia Group to be integrated into the Dementia Strategy.
37
6.3.6 Patient information: Mobile phone and lap top use; earplugs
The project identified variation in interpretation and implementation of the mobile phones
policy across the pilot sites. Some areas applied a ‘no use’ policy. Despite this patients use
phones and electronic equipment, which are a potential source of noise and disturbance to
other patients. However, results from the pre- interventions in-patient questionnaire showed
4.2% (n=6), patients experienced noise from mobile phone use (from the 144 questionnaire
responses). This is consistent with findings in existing literature on reducing noise in clinical
areas that staff are more troubled by mobile phone and electronic equipment use, than
patients.
Attempts to enforce a ‘no use’ policy for mobile phone use were not working. There was also
variation in the visible signs being displayed, with some areas not having any signs. A
‘different’ approach was discussed to pilot a sign that ‘invited’ patients to consider the impact
of their use of equipment on others. Senior Charge Nurses from the pilot sites were invited to
comment on the design of the poster and from those who responded they were positive in
trying out a poster that did not have a ‘red cross/do not use’ type of sign. NHS Greater
Glasgow and Clyde Medical Illustration were invited to design a sign to be used in the pilot,
and these were procured for the pilot sites who wished to use them (appendix 12). (Job
Number 254703)
Further use of signage or patient information leaflets related to the use of mobile phones and
lap tops should be considered.
In addition, several patients suggested that ear plugs be distributed, particularly when e.g. a
neighbouring patient snores loudly. It may be helpful to incorporate this suggestion in patient
pre-admission information.
7.0 Evaluation of the pilot ward protocol
The impact of the short term pilot protocol intervention was evaluated via two mechanisms;
Stage 4 staff feasibility opinion survey and Stage 5 post intervention in-patient survey, using
the same survey tools as pre-intervention to enable comparison.
7.1 Stage 4: Staff feasibility opinion survey
A post interventions staff survey tool was developed (appendix 4) and distributed following
implementation of the pilot protocol to assess feasibility of the protocol from the perspective
38
of clinical staff within the pilot sites; there were 88 responses received from across the 16
pilot project sites. (N.B. Not all respondents answered each question; % rates are given as
% of the 88 returned questionnaires)
In relation to each of the 10 items on the ward based protocol staff were asked
Please tick (√) if you were personally involved in implementing this intervention
On a scale of 1 5 (where 1= not effective and 5 = very effective) how effective do
you think this intervention has been?
Would you recommend implementing this intervention across NHS GGC? (State Yes
or No) Please explain your response
Do you have any further comments of suggestions related to this intervention?
The following sections present staff views in relation to each protocol intervention.
7.1.1 Nurse hand-over reminder of protocol
56% (n=49) of respondents were personally involved during handovers in being reminded of
the aim to promote rest and sleep.
Views on the effectiveness of this intervention were reasonably evenly spread:
1n=18, 2n=12, i.e. tend toward not effective =30
3n=23
4n=9 5n=11 i.e. tend toward effective =20
A slight majority (53%, n=47; 15 missing responses) would recommend implementing this
intervention across NHS GGC.
Additional comments included:
Could put reminder on safety brief?
‘Needs to be adapted to suit area
Noise comes from patients, ill, dementia, confused, aggressive. How do you manage this !
Nurse’s station not conducive for this to happen.’
Staff should not require to be reminded of this.
However, also;
Not been done.’
Not being handed over.
39
7.1.2 Keeping conversations low and appropriate
89% (n=79) of respondents were personally involved in being aware of the need to keep
staff conversations low and appropriate.
Views on the effectiveness of this intervention generally tended to be positive:
1n=5, 2n=12 i.e. tend toward not effective =17
3n=21
4n=17 5n=28 i.e. tend toward effective =45
A majority (77%, n=68; 13 missing responses) would recommend implementing this
intervention across NHS GGC.
Comments or suggestions related to this intervention included:
‘Education on noise levels some people don’t know how loud they are.’
‘All staff need reminded to do this at times.’
Night staff already do this.
‘Keeping conversations low isn’t always possible due to noise from patients and relatives.’
‘We dont have a quiet environment to hand over due to interruptions from patients and
relatives.’
7.1.3 Turn off the main lights at 22.30 hours
68% (n=61) of respondents were personally involved in off the main lights at 22.30 hours
where possible.
Views on the effectiveness of this intervention were reasonably evenly spread although
tending towards being positive:
1n=18, 2n=7 i.e. tend toward not effective =25
3n=13
4n=6 5n=22 i.e. tend toward effective =28
Views tended to be positive (51% (n=45) positive; 31% (n=27); negative 16 missing
responses) regarding whether they would recommend implementing this intervention across
NHS GGC.
40
Comments or suggestions related to this intervention included:
Too early for a busy ward,
Not always possible depending on ward activity
Not always practical for lights out at 22.30
There are 6 staff for 34 patients therefore you wouldn’t be able to turn lights off at that
time due to volume of work.
Only way to achieve this is to treble the amount of staff on duty
Due to having only 2 staff nurses to do medications it is not always possible to turn lights
down.
We aim to do this. Not always possible due to workload and patients needs
7.1.4 Keep lights as low as possible
85.4% (n=76) of respondents were personally involved in keeping lights as low as possible.
Views on the effectiveness of this intervention were highly positive:
1n=1, 2n=6, i.e. tend toward not effective =7
3n=14
4n=13 5n=37 i.e. tend toward effective =50
A majority (74%, n=65; 19 missing responses) would recommend implementing this
intervention across NHS GGC.
Comments or suggestions related to this intervention included:
Not always possible i.e. checking skin, putting people to bed late etc
If night lights work!
Not always possible to dim lights.
The lights need to be low enough to promote sleep but our patients also need lights left on
as they become confused/disorientated.
We need lights at times due to patient agitation/poor eyesight.
We always attempt to do this.
7.1.5 Use bedside lights instead of main lights
84% (n=75) of respondents were personally involved in using bedside lights instead of main
lights.
41
Views on the effectiveness of this intervention were highly positive:
1n=2, 2n=4, i.e. tend toward not effective =6
3n=11
4n=10 5n=43 i.e. tend toward effective =53
A majority (78%, n=69; 14 missing responses) would recommend implementing this
intervention across NHS GGC.
Comments or suggestions related to this intervention included:
Lights don’t work
If lights were working
If this was in wards, and corridor lights stayed on then staff may benefit too.
If possible
Need main lights on for safe administration of medication.
We don’t want to use main lights but some bedside lights are not working, although we have
reported long time ago.
This is always suggested and used.
7.1.6 Use lamps/nightlight at the nursing stations
78% (n=69) of respondents were personally involved in using lamps/nightlights at the
nursing stations.
Views on the effectiveness of this intervention were largely positive:
1n=6, 2n=4, i.e. tend toward not effective =10
3n=6
4n=9 5n=39 i.e. tend toward effective =48
A majority (72%, n=63; 19 missing responses) would recommend implementing this
intervention across NHS GGC.
Comments or suggestions related to this intervention included:
Too dark
Desktop night light is not available
I feel my eyes get sore in the dark
Inadequate lighting.
42
7.1.7 Reduce the volume of telephones
65% (n=58) of respondents were personally involved reducing the volume of telephones.
Views on the effectiveness of this intervention tended towards being positive:
1n=11, 2n=9, i.e. tend toward not effective =20
3n=8
4n=11 5n=21 i.e. tend toward effective =32
A majority (65%, n=57; 21 missing responses) would recommend implementing this
intervention across NHS GGC.
Comments or suggestions related to this intervention included:
Not possible on our ward phones
Telephone has this facility but not always used.
It’s not possible as the telephone is used to page the doctor and night coordinator.
Lower volumes and flashing light on phone.
Difficulty due to single rooms and telephone can’t be heard when volume is reduced.
We don’t have any facility for this.
7.1.8 Reduce the volume of the patient nurse call system (night time setting)
66% (n=59) of respondents were personally involved reducing the patient nurse call system.
Views on the effectiveness of this intervention were largely positive:
1n=10, 2n=5, i.e. tend toward not effective =15
3n=7
4n=14 5n=27 i.e. tend toward effective =41
A majority (62%, n=55; 23 missing responses) would recommend implementing this
intervention across NHS GGC.
Comments or suggestions related to this intervention included:
Emergency it’s not appropriate as cannot be heard
Need to have it so you can hear if in a patient room
Not used.
It’s set to low tone.
Sometimes we cannot hear because we have two separate wards.
Tend to ask patients to call for a nurse in W small area and usually works well. Saves
setting off a buzzer that even on low wakes everyone.
43
7.1.9 Avoid noise created when using doors, drawers and bins
86% (n=77) of respondents were personally involved in avoiding noise created when using
doors, drawers and bins.
Views on the effectiveness of this intervention were largely positive:
1n=5, 2n=8 i.e. tend toward not effective =13
3n=17
4n=14 5n=29 i.e. tend toward effective =43
A majority (72%, n=63; 20 missing responses) would recommend implementing this
intervention across NHS GGC.
Comments or suggestions related to this intervention included:
Sometimes difficult to avoid
More slow closing bins are needed
Nurses are aware of what wakes people and do our best to keep noise to a minimum.
Can be hard as bins, doors etc are used often on a busy shift.
Patients do comment on this therefore we are trying to amend our practice.
7.1.10 Ask patients to turn off mobile phones etc.
78% (n=69) of respondents were personally involved asking patients to turn off mobile
phones and other equipment or reduce to silent as part of the night time settling down
period.
Views on the effectiveness of this intervention tended towards being positive:
1n=9, 2n=11 i.e. tend toward not effective =20
3n=11
4n=12 5n=26 i.e. tend toward effective =38
A majority (69%, n=61; 19 missing responses) would recommend implementing this
intervention across NHS GGC.
Comments or suggestions related to this intervention included:
Patients not compliant
10.30 pm too early for TV to be off
Can only be advised
This is a good idea
44
Patients sometimes will not comply
Patients usually non-compliant
Has all round benefit for all patients.
Patients not keen on doing this.
Most patients/clients would be offended and would not comply.
Patients should be told not to use mobile phones.
Perhaps a leaflet produced to state what is acceptable in a ward setting.
Advise people they need to turn off or reduce volume
7.2 Stage 5: Comparison of pre and post intervention in patient survey results
Tables 16 and 17 below demonstrate sample sizes for the pre and post intervention in-
patient surveys; these were the same in all but one pilot site, which returned two less
questionnaires post-intervention.
Table 16 Sample size per site:
Hospital
site
Pre ‘n
Pre %
Post ‘n’
Post %
A
33
22.9%
33
23.2%
B
27
18.8%
25
17.6%
C
23
16.0%
23
16.2%
D
18
12.5%
18
12.7%
E
12
8.3%
12
8.5%
F
12
8.3%
12
8.5%
G
10
6.9%
10
7.0%
H
9
6.3%
9
6.3%
Total
144
100%
142
100%
Table 17 Sample size per clinical directorate:
Directorate
Pre ‘n
Pre %
Post ‘n’
Post %
Surgery and
anaesthetics
39
27.0%
39
27.5%
Regional services
(cancer; spinal injuries;
nephrology )
36
25.0%
34
23.9%
Emergency Care &
Medical Services
34
23.6%
34
23.9%
Rehabilitation &
Assessment
20
14.0%
20
14.1%
Women & Children
15
10.4%
15
10.6%
Total
144
100%
142
100%
45
7.2.1 Cause, frequency and severity of night-time noise disturbance:
As before, respondents were asked to indicated whether they had been disturbed by one or
more broad category of noise; table 18 indicates the number of patients pre and post
intervention who indicated they were disturbed by each category
Table 18: Rank order categories of night-time noise causing disturbance
Category of noise
Pre ‘n’
Post ‘n’
Trend
Equipment
54.9% (n=79)
48.6% (n=69)
Improved
Other patients
38.2% (n=55)
48.6% (n=69)
Worse
Staff
32.6% (n=47)
29.6% (n=42)
Improved
Environment
32.6% (n=47)
33.1% (n=47)
Same
The numbers involve were too small to demonstrate statistically significant changes,
however, it can be seen that the trend showed improvement in disruptive noise caused by
equipment and staff (factors most likely to be controllable by staff), no change in noise
caused by environmental factors, but increased reporting of noise caused by other patients,
which remains a challenge for ward staff to address.
Detail of changes in each component noise factors within the identified categories is
presented below; given the acknowledged inconsistency in some patient responses in that
they did not report being disturbed by a specific category or factor, yet went on to give a low
frequency or severity of disruption score, frequency and severity scores are not reported
below as these were consistently low and there was little change in rates from pre-
intervention data. Similarly, post-intervention data showed only one or two patients reported
noise disruption to staff and numbers are too small for satisfaction levels of staff response to
be meaningful.
7.2.2 Type of noise due to ‘EQUIPMENT’ factors
Overall, disturbance caused by at least one or more form of ‘EQUIPMENT’ noise improved
slightly from 54.9% (n=79) to 48.6% (n=69), although individual elements varied as detailed
below;
46
Table 19: Rank order of disturbance due to ‘EQUIPMENT’ factors
Type of noise due to ‘EQUIPMENT’ factors
Pre
Post
Patient Buzzers (call for nurse button)
27.8% (n=40)
24.6% (n=35)
Patient Infusion Alarms (pumps that give medicines)
26.4% (n=38)
27.4% (n=39)
Ward telephones ringing
22.9% (n=33)
19.0% (n=27)
Wheels from trolleys or commodes being moved
20.8% (n=30)
27.5% (n=39)
Staff pagers or bleeps
4.9% (n=7)
5.6% (n=8)
Notably, those aspects more readily controlled by nursing staff i.e. patient buzzers and ward
telephones, reduced most, whereas other equipment noise such as infusion alarms or noise
from wheels stayed the same or got worse.
Nineteen patients provided additional comments related to noises from equipment; the
majority (n=10) recognised that alarm sounds from technical equipment was largely
unavoidable, for example;
There’s not much you can do as machines go off for a reason (patient 118)
Cannot see solution as IV and SAT monitors must alarm (patient 141)
I didn’t really mind as you would expect this in a hospital and it is essential; so it
didn’t really bother me (patient 32)
I feel that any noises from equipment is necessary to the well-being and safety of
patients (patient 142)
I would suggest this would be impossible as a busy ward with patients who have
different health conditions. There must be some noise. Staff were very good and
very attentive. (patient 105)
The only new additional suggestion to reduce disturbance from ‘noises from equipment’
was for “The option for patients to have or be offered earplugs.” (patient 31).
7.2.3 Type of noise due to ‘OTHER PATIENTS’
In general, reported disturbance from noise made by other patients worsened, with an
increase from 38.2% (n=55) to 48.6% (n=69) in almost all elements, as detailed below;
47
Table 20: Rank order of disturbance due to ‘OTHER PATIENTS’ factors
Type of noise due to ‘OTHER PATIENTS
Pre
Post
Trend
Other patients snoring
18.1% (n=26)
23.2% (n=33)
Disturbance from confused or agitated
patients
12.5% (n=18)
19.0% (n=27)
Patients being admitted or beds moved
through the night
8.3% (n=12)
14.8% (n=21)
Disturbance from aggressive patients
8.3% (n=12)
13.4% (n=19)
Patients playing radio or TV
6.9% (n=10)
6.3% (n=9)
=
Other patient talking loudly
6.9% (n=10)
16.2% (n=23)
Mobile phones text messages and
conversations
4.2% (n=6)
6.3% (n=9)
Disturbance from intoxicated or drunk
patients
3.5% (n=5)
4.9% (n=7)
Door alarms being set off
2.1% (n=3)
0.7% (n=1)
Patient shouting
1.4% (n=2)
0.7% (n=1)
=
Patient being sick
1.4% (n=2)
0%
Patient going to the toilet during the night
1.4% (n=2)
0%
Seventeen patients provided additional comments regarding noises from other patients; the
majority recognising that disturbance was largely unintentional although other patients
snoring seemed most problematic, as illustrated below;
The only problem encountered was other patient snoring. One of the nurses noticed
this when dealing with my drip and very kindly brought in some earplugs for me on
the following night. (patient 142)
I found the snoring of the other patients really annoying, making it difficult for me to
fall asleep. I ended up with very little sleep. (patient 32)
Snoring is the worst problem with patients making noises.(patient 39)
Once again, the suggestion regarding issuing earplugs was made by another patient;
Perhaps having earplugs available or asking patients who snore to identify
themselves when checking in and have a separate ward. I know this sounds drastic
but when you are sick and cant’ sleep for people snoring it’s no fun. (patient 32)
48
7.2.4 Type of noise due of ‘STAFF’ factors
Reported disruptive noise caused by staff fell slightly from 32.6% (n=47) to 29.6% (n=42),
encouragingly the largest reduction being in staff talking or laughing loudly, as detailed
below;
Table 21: Rank order of disturbance due to ‘STAFF’ factors
Type of noise due to ‘STAFF’ factors
Pre
Post
Trend
Staff talking or laughing (personal
conversations)
23.6% (n=34)
15.5% (n=22)
Noise from staff banging doors, drawers, or
bin lids
17.4% (n=25)
17.4% (n=25)
=
Footsteps or footwear (all staff)
10.4% (n=15)
13.4% (n=19)
Staff playing radio or TV
2.1% (n=3)
0.7% (n=1)
Staff eating in ward area
0.7% (n=1)
2.1% (n=3)
Nineteen patients provided additional comments related to noises staff made; the majority
(n=17) indicated that patients believed staff did their best to reduce noise but that some was
inevitable as they went about their work, for example
Staff made noises are unavoidable. The hospital ward is their working
environment. (patient 1)
Any noises made through necessity were kept to a minimum. (patient 17)
how are they meant to carry out work on a ward without making noises, i.e.
attending to patients, drips finishing etc! (patient 103)
Only two comments regarding unnecessary noise were provided, as shown below;
With myself, footwear is an issue and that especially refers to doctors! (patient 103)
The swishing noises of the plastic aprons was very disruptive. (patient 31)
No new suggestions to reduce disturbance from ‘noises for staffwere made.
7.2.5 Type of noise due to ‘ENVIRONMENTAL’ factors
Disturbance from noise in the environment showed little change overall, with 32.6% (n=47)
pre-intervention and 33.1% post intervention; however, there was some variation in
49
individual elements as detailed below. Disappointingly, there was little improvement in
disruption caused by lights being kept or put on, as this was a specific aspect of the ward
protocol intervention. Similarly, disturbance from late medicine rounds showed little change
and disturbance from curtains being ‘swished’ and from apron dispensers increased.
Table 22: Rank order of disturbance due to ‘ENVIRONMENTAL’ factors
Type of noise due to ‘ENVIRONMENTAL’
factors
Pre
Post
Trend
Lights being kept on late or going on
through night (not noise but caused sleep
disturbance)
18.1% (n=26)
16.9% (n=24)
Any noise from outside the hospital e.g.
building works, bins being emptied early in
morning, Seagulls (Gartnavel)
9.7% (n=14)
6.3% (n=9)
Medicine rounds late at night
8.3% (n=12)
9.8% (n=14)
Bedside curtains being pulled ‘swished’
4.9% (n=7)
11.9% (n=17)
Traffic noise
3.5% (n=5)
1.4% (n=2)
Apron dispensers (on walls)
0.7% (n=1)
4.2% (n=6)
Six patients provided additional comments regarding noise from the environment, generally
acknowledging some noise is inevitable; no new additional suggestions to reduce noise were
made beyond stay taking care to try to minimise disturbance.
7.3 Summary of changes in Top Ten factors causing disruptive night time noise
Comparison of pre and post-intervention survey findings showed promising early signs of
improvement in those ‘Top Ten’ noise disturbance factors which ward nurses have most
control over, namely response to patient buzzers, nurses talking or laughing loudly, ward
telephones ringing. Unfortunately, disturbance from lights was not greatly improved, despite
this featuring strongly in the ward protocol, although feedback in the staff feasibility survey
indicated that dimmer lights were frequently not available or were broken. Disturbance from
noisy commode or trolley wheels and ‘clicky heels’ from footwear (generally of medical staff)
persisted, and unfortunately disturbance from other patients in terms of snoring (particularly
problematic), confused, agitated or aggressive patients increased. Details are shown in
table 23 below.
50
Table 23: Comparison of pre and post intervention ‘Top Ten’ noise disturbance
factors
‘Top Ten’ Noise disturbance factor:
Post-
intervention
(n=142)
Trend
Patient Buzzers (call for nurse button)
24.6%
(n=35)
Patient Infusion Alarms (pumps that give
medicines)
27.4%
(n=39)
=
Staff talking or laughing (personal
conversations)
15.5%
(n=22)
Ward telephones ringing
19.0%
(n=27)
Wheels from trolleys or commodes being
moved
27.5%
(n=39)
Other patients snoring
23.2%
(n=33)
Lights being kept on late or going on through
night
(not noise but caused sleep disturbance)
16.9%
(n=24)
Noise from staff banging doors, drawers, or
bin lids
17.5%
(n=25)
=
Disturbance from confused or agitated
patients
19.0%
(n=27)
Footsteps or footwear (all staff)
13.4%
(n=19)
8.0 Limitations
Whilst the in-patient questionnaire was sent to the Community Engagement Manager and to
the Quality Department of NHS Greater Glasgow and Clyde to ensure it met with
requirements on the use of plain English language and font size. Due to time constraints the
in-patient questionnaire was only piloted via the Patient Panel. When survey tools were
analysed it became apparent that there were some inconsistencies which had not been
anticipated e.g. patients reporting a factor of noise but not answering questions related to
frequency or severity of that noise factor, or not reporting a factor of noise but subsequently
answering the related questions; thus the reliability of the tool could have been strengthened
by more robust piloting. All data was included for analysis, even when related questions had
an inconsistent response.
51
The implementation period for the pilot protocol was brief, only seven weeks, and it is
acknowledged that a longer time frame is required to reliably indicate changes in practice
that would influence night-time noise disruption. In addition, the relative numbers of patients
who reported disturbance from any noise factor was too small to power statistical
comparisons pre and post intervention. Thus the data can only be considered preliminary,
although showing some encouraging trends, and on-going support for implementation with
follow-up audit is required.
9.0 Conclusions
This pilot study has provided clear evidence of the type of noises that disturb patients at
night-time; many of these are avoidable and the introduction of a simple ward protocol has
shown encouraging early results. However, further medium and longer term actions are
required in relation to facilities management, equipment maintenance, procurement and
actions required by staff who work between clinical areas e.g. medical staff.
It is also important to note that many patients reported their appreciation of the considerable
efforts that some staff made to ensure patients were not disturbed and their general
understanding of the inevitability of some disruption in a clinical environment.
Evaluation of the feasibility of the ward protocol was positive and it is important that the
momentum generated by the project is sustained and extended; on-going senior
management support for roll-out of the ward protocol and commitment to follow-up action in
line with the comprehensive project recommendations is needed.
10 Recommendations
10.1 Summary of key Recommendations:
1. That the pilot ward protocol should be rolled out across all hospital sites, and
promoted as a simple tool to reinforce positive attitudes and actions to avoid
disruptive night time noise.
2. That consideration be given to the most effective means of providing on-going
support for this initiative
3. That audit of the patient experience of the ‘Top Ten’ noise disturbance factors should
be integrated within the regular Senior Charge Nurse Better Together Patient
Experience survey.
52
4. That the issues raised in section 6.3 related to medium and longer term actions by
facilities management, equipment maintenance, procurement, commissioning, multi-
disciplinary team and patient information production be taken forward via the Better
Together Steering Group.
10.2 Proposed action points
The following diagram presents an overview of areas for future action;
Suggested actions for future work:
Practice Development
Develop the current protocol with recommendations for implementation across NHS
Greater Glasgow and Clyde Acute Services Division.
Link nurses will continue to be ‘noise champions’ for their own area, but build on the work
of the project to embed avoidable night time noise as a standard for excellent clinical
practice.
Action Plans
Practice
Development
Protocol
Noise
Champions
Equipment
Infusion Alarms
Wheeled
Equipment
Audit
SCN
questionnaire
Better Together
Survey
Principles &
Care Plans
Dementia
Patients
Brain Injury
Patients
Substance
Misuse
Learning
Disability
Facilities
Estates
New Build
Projects
MD
Workforce
Patient
Information
53
Equipment
Infusion Alarms: Work to be carried forward by Clinical Risk Manager and Lead on IV
Infusion Training to identify if training needs analysis, and undertake clinical risk
assessment.
Noisy Wheeled Equipment: Feedback and recommendations to Procurement
Departments to include risk assessment for equipment ordered.
Noisy Wheeled Equipment: Feedback and recommendations to Facilities for regular
repair and maintenance, including responding to repair requests.
Audit on Noise at Night
Senior Charge Nurse Questionnaire: Adapt question on noise to include more detailed
factors of noise to continue audit.
Better Together Survey: The next survey is not until 2014. Results from 2011 survey
showed that there was little difference in the experience of noise by patients.
Other Patients
Adapt Patient Information Leaflets to include advice to bring in ear plugs/eye masks in
2013.
Review mobile phones and electronic equipment policies to ensure consistency across
NHS Greater Glasgow and Clyde, to include a stand-alone leaflet.
Display notices to patients including statements that their area is promoting rest and
sleep, and how they are achieving this inviting feedback from patients. (e.g. see version
used by NHS Tayside)
(ii)Patients affected by dementia, acquired brain injury, substance misuse, learning
disability and mental health issues : Link with Dementia Nurse Consultant, and other
lead clinicians in multidisciplinary workforce (Addictions, Learning Disability, Mental
Health) to consider principals and care planning for these patient groups.
54
Multidisciplinary Workforce
Staff Footwear :
Discuss with medical Director to take forward actions for medical staff to adhere to
standards of dress including wearing of appropriate footwear. This should be included in
the induction of all new doctors for NHS Greater Glasgow and Clyde.
Feedback and notices to all directorate leads to remind staff of the appropriateness of soft
footwear in clinical areas to avoid noise .
Facilities
Deliveries : It is recommended that timing of deliveries to hospitals be reconsidered to
ensure patients are not disturbed. Findings of the project in feedback paper to be
disseminated to the appropriate leads.
Estates : It is recommended that estates respond appropriately to requests for fixing
equipment, including lights. Findings of the project in feedback paper to be disseminated
to the appropriate leads.
New Build Projects :
It is recommended that risk assessments for noise are undertaken for all equipment,
fixtures and fittings to include clinical and non-clinical equipment. This is to apply to new
equipment and whether existing equipment can be migrated across to the new buildings
on the site of Southern General Hospital (including the new children’s hospital). This is to
include where planned security doors, with consultation with Senior Charge Nurses.
It is recommended that the report and recommendations for the noise at night project be
fed back to the Project Team for the new build at Southern General Hospital.
55
Appendix 1: In-patient interview schedule
Improving the Patient Experience
Reducing Noise at Night
Service Development Project
Patient Interview Form
Interviews to be recorded for detail.
Introduction
Interviewer to explain :
The purpose of the project, and how we hope to respond to what patients have to say
on their experience of noise at night
Go over the participant information sheet. Discuss consent
How long the interview will last
How the information provided by the patient will be used and the anonymity
arrangements that will apply
Interviewer to explain how the voice recorder will work. Patient may ask to stop the
interview at any time
Obtain written consent
Interviewer to make clear to the patient that there are no right or wrong answers and to
thanks patient for their input to NHS Greater Glasgow and Clyde study.
Interviewer to ask the patient if they have any questions at this stage
Interviewer to confirm each of the following before proceeding with the study questions :
Consent Y/N
1. You understand the purpose and have
had the chance to ask questions.
2. You understand that your participation is
voluntary and that you are free to withdraw at
any time, without giving a reason.
3. You agree for the interview to be voice
recorded.
4. You agree to the use of anonymised
quotes from this interview in the study project
reports relating to this project only.
Background Information
Ward:
Beds per Area:
Hospital:
Division:
Date of Admission:
Length of Stay at time of
interview:
56
Interview Begin Recording
State Participant Interview Number:
(Number to be recorded on voice recorder)
State Date and Time of Interview (Detail to be recorded on voice recorder):
State Ward, Directorate, and Hospital: (Detail to be recorded on voice recorder):
Thank you for agreeing to take part, and I hope you feel comfortable to be open in what has
happened to you in hospital. First of all I would like to find out about your hospital stay
generally and how it has been for you?
I would like to hear about what kinds of noise you experienced during the
night?………………
Examples are:
(Offer these if patient requires an example), but do not lead the patient)
Telephones Ringing
Patient Buzzers
Movement of beds, trolleys or carts
Staff talking on the telephone
Conversations between patients and staff
Conversations between staff
Other Patients Calling Out
Other patients making other kinds of noise
Mobile phones making noise
Doors Banging
Bin lids
Noise of shoes on the floor/
People walking about
Television
Monitoring equipment (pumps/infusions)
Noise from outside
Anything else?
57
You mentioned …………………………………………………………………………………….....
……………………………………………………………………………………….………………
…………………………………………………………………………………………………………
Did these types of noises disturb your sleep/rest?
Could you tell me more about that, and how it made you feel?
I am interested in finding out whether you reported your concerns to staff, and the ways in
which they responded to your concerns?
What did you say?
What did they do?
Did these things help in any way?
In general, what do you feel about the noise in the ward at night time?
Do you have any suggestions on how noise can be reduced or minimised at night to help
patients get more rest and sleep?
Have you had any previous stays in hospital? If so, was this experience similar or different
and in what ways?
Is there anything else you would like to say or add that we have not already covered?
58
Appendix 2: In-patient survey tool
Improving Patient Experience
Reducing Noise at Night Service Development Project
In-Patient Survey
We would like to invite you to take part in our survey of night-time noise in our hospital
wards.
You do not have to take part and your participation is entirely voluntary and will not affect
your treatment in any way. The survey is completely confidential; the form does not ask any
personal information about you or your clinical condition.
The survey may take around 10 minutes to complete. If you decide you would like to take
part then please answer the questions in the next few pages.
Once you have finished answering the questions, please put the form into the attached
envelope, seal the envelope, and place in the collection box at the nurses station or ask a
member of staff to place your envelope in the box for you.
The results of this survey wil be used with other information to help us put systems in place
to reduce avoidable night time noise and disturbance.
If you have any questions or concerns about any aspect of this project please do not hesitate
to contact me on 0141 201 5530 or email annie.ruddy@ggc.scot.nhs.uk
If you wish to make a complaint about any aspect of this project, you can do this through the
NHS complaints procedure.
Thank you.
Annie Ruddy
Project Nurse
Practice Development
4
th
Floor, Old Outpatients Building
Victoria Infirmary
Langside Road, Glasgow
This questionnaire will ask you questions on your experience of Night-time noise and
disturbance*
* Night time means between the hours of 10 pm 7 am *
59
Q1A Name of Ward
Q1B Name of Hospital
Q2. How many nights have your been in hospital during this stay
Q3. Please put a tick (√) if you have not been disturbed by noise at night
I was not disturbed by noise at night
Q4. Please put a tick () against any items on this list that you have experienced at night
during your hospital stay.
4a Noises staff made that disturbed you:
Staff talking or laughing (personal conversations)
Footsteps or footwear (all staff)
Staff eating in ward area
Noise from staff banging doors, drawers, or bin lids
Staff playing radio or TV
4b Noises from equipment that disturbed you
Wheels from trolleys or commodes being moved
Ward telephones ringing
Staff pagers or bleeps
Patient Buzzers (call for nurse button)
Patient Infusion Alarms (pumps that give medicines)
4c Noises in the environment that disturbed you
Lights being kept on late or going on through night
Bedside curtains being pulled ‘swished’
Medicine rounds late at night
Apron dispensers (on walls)
Any noise from outside the hospital e.g. building works, bins being emptied
4d Noises other patients made that disturbed you:
Patients being admitted or beds moved through the night
Patients playing radio or TV
Other patients snoring
Other patient talking loudly
Disturbance from aggressive patients
Disturbance from intoxicated or drunk patients
Mobile phones text messages and conversations
Disturbance from confused or agitated patients
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Thinking about different types of ‘noises staff made that disturbed you’:
Q5. How often did ‘noises staff madehappen during an average night?
Once or twice a night
3-10 times a night
Over 10 times a night
Q6. On a scale of 1 10 (where 1=not at all and 10=severely disrupted my sleep) how
disruptive was this type of noise for you? (Please tick ()).
1
2
3
4
5
6
7
8
9
10
Q7. Did you report ‘noises staff made’ to the Nursing Staff or Senior
Charge Nurse? Please tick ()
Yes
No
Q8. If you ticked ‘yes’ how would you rate the way staff responded to your concerns?
Please tick ()
Less than
satisfactory
Satisfactory
Good
Very Good
Excellent
Q9. Do you have any suggestions to reduce disturbance from ‘noises staff made’?
Q10. Do you have any other comments you would like to make about ‘noises staff made?