RESEARCH

Alarms in the ICU: A study investigating how ICU nurses

respond to clinical alarms for patient safety in a selected
hospital in KwaZulu-Natal Province, South Africa
A Ramlaul, MSc; G Chironda, PhD; OrcID 0000-0003-1361-1495; P Brysiewicz, PhD; OrcID 0000-0001-6258-1603

School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa

Corresponding author: G Chironda (gerrychironda@yahoo.co.uk)

Background. Advances in technology have facilitated the implementation of improved alarm management systems in the healthcare sector. There
is a need to identify challenges encountered by intensive care unit (ICU) nurses with clinical alarm management systems in South Africa (SA) to
ensure utilisation of these technological resources for patient safety.
Objective. To investigate how intensive care nurses respond to clinical alarms for patient safety in a selected hospital in KwaZulu-Natal Province, SA.
Methods. A descriptive, non-experimental research design using the census sampling strategy was used to invite 120 nurses from four ICUs to
complete an adapted, structured questionnaire. Descriptive statistics were used to analyse the data.
Results. We had 91 respondents who completed the questionnaires (response rate of 75.8%). The majority of the respondents (85.7%) strongly
knew the purpose of clinical alarms and 45.1% strongly felt confident about adjusting and monitoring the clinical alarms. More than half of the
nurses (53.8 %) agreed to the existence of nuisance alarms that disrupted patient care (46.7%) and contributed to lack of responses (52.7%). While
76.9% strongly agreed with alarm sounds and displays to differentiate the priority of the alarms, 75.8% strongly agreed to the existence of proper
documentation on setting alarms that are appropriate for each patient. The most frequent barriers were difficulty in setting alarms properly
(51.6%) and lack of training on alarm systems (47.8%).
Conclusion. The complexity in setting the alarms, limited training and existence of false alarms was evident. Alarm-specific training is required to
keep intensive care nurses updated with changes in technology to ensure patient safety.
Keywords. clinical alarms, patient safety, intensive care nurses, intensive care unit.

South Afr J Crit Care 2021:37(1):57-62. https://doi.org/10.7196/SAJCC.2021.v37i2.469

Contributions of the study. The findings of this present study highlighted the importance of understanding the alarm management system within
the ICU environment of the healthcare sector in SA. Technological improvements, specialised trainings and clear clinical policies for alarm
management are essential to improve patient safety.

Nurses working in an intensive care unit (ICU) are dependent on clinical alarms.[10] These alarms are expected to make the nurses’ work
various medical devices to assist with patient monitoring, care and easier but their associated hazards have been reported as being among
safety.[1] There is an escalation in the number and type of innovative the top ten  health technological hazards encountered in the ICUs for
medical devices used in the ICU for patient care.[2] The alarm systems several years.[4,11]
of these medical devices (invasive and non-invasive) remain important The increasing use of clinical alarm systems in the ICU setting leads
components of the ICU environment as they alert nurses to the changing to the concept of alarm fatigue. Alarm fatigue occurs when clinicians are
physiological parameters of the patient.[3,4] Increased dependence on exposed to a high occurrence of alarms, resulting in a failure to recognise
these devices is standard practice as they warn of abnormalities in vital and respond to true alarms that require bedside clinical intervention.[12]
signs and deteriorating patient condition that may not be visible.[5] Alarm fatigue is an important clinical problem and delayed responses
Visual access to physiological data, waveform configurations and may impair patient care,[13] leading to patient deterioration and possible
false alarms are crucial determinants in timely responses of intensive patient mortality in the ICU setting.[2] Funk et  al.[14] highlighted the
care nurses to bedside alarm investigations.[6] Hence, the effectiveness ability of nurses to respond to the alarming limits as they are aware that
of alarm systems in an ICU is dependent on direct involvement of most of them are non-actionable or false. Unfortunately, most nurses are
nurses in setting the monitors and responding to the alarming limits unsure of how they could prevent alarm fatigue.[15] Studies carried out in
appropriately.[7] Currently, the availability of the ideal one-to-one nurse Ireland[15] and South Korea[16] revealed the occurrence of false alarms as
patient ratio is not a realistic expectation due to the increasing prevalence reported by 63.8% and 90% of nurses, respectively.
of nurse attrition and an inexperienced workforce.[8] Modern ICUs In the South African (SA) ICU setting, nurses are responsible for
are equipped with clinical alarms that are technologically advanced in monitoring the patient’s devices and alarms, hence there is a need
order to assist nurses;[9] however, nurses need to correctly interpret the for training and orientation to improve the nurse’s knowledge.[11,14]

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Understanding of the clinical alarms among ICU nurses is vital to The questionnaire comprised of three sections. Section A requested
guide the effective management and development of alarm system demographic data and section B (21 items) contained alarm-related
hospital policies that may further reduce false alarms and alarm fatigue. information aligned to the components of the Shepherd’s System Risk
However, this area remains relatively unexplored and there is scarcity Model.[17] The respondents were asked to respond using a 5-point Likert
of literature on the response of nurses to clinical alarms in the ICU scale: strongly agree, agree, neutral, disagree and strongly disagree.
setting in SA. Section C consisted of nine items related to the challenges or barriers to
the management of clinical alarms. The respondents were asked to rank
Methods the statements from 1 (most important) to 9 (least important).
Study design
A descriptive, non-experimental research design was used, and data Validity and reliability
were collected using a self-administered questionnaire. The conceptual We utilised two tools, the alarm fatigue questionnaire and the clinical
framework guiding this present study is the Shepherd’s System Risk alarms survey.[2,19] Alignment of the objectives of the study to the
Model,[17] which analyses device-related adverse events by considering questionnaire items was done, enhancing the content validity of the
components surrounding the situation and the persons that interact current tool. Pre-testing of the questionnaire was done with five
with these systems and devices. These components include device RNS working in the ICUs of the research setting. No problems were
(human factors design), patient (passive causes), operator (education highlighted, and no changes were made to the tool. Their data were not
and training, diverted attention) and environment (internal). included in the present analysis. The established reliability of both of the
questionnaires prior to them being combined was not highlighted by
Study setting the researchers of the previous tools. However, the reliability coefficient
The present study was conducted in a private hospital in Durban, analysis, which was the internal consistency of the newly combined
KwaZulu-Natal Province, SA. The hospital has three adult and one structured tool for the study, was 0.71. This indicated that the tool was
neonatal ICU. ICU 1 has 26 beds and manages cardiac patients such as an acceptable measure of the variables under study.[20]
those with myocardial infarction, post-catherisation, as well as cardiac
patients undergoing procedures and needing advanced levels of care. Data collection process
ICU 2 has 25 beds and receives predominantly surgical cases that are Data were collected in October 2015 over a 2-week period. After
elective or planned surgical cases that require advanced levels of care obtaining ethical approval and permission from hospital management,
and also receives trauma cases. Patients in ICU 3 (9 beds) are mostly AR made appointments with the unit managers of the respective ICUs
elective surgical cases for brain and cardiac surgery. Patients in ICU 4 in order to explain the objective of the present study and asked for access
(24 beds) are newborns and premature babies that require additional to the intensive care nurses. The distribution of the questionnaires was
advanced levels of care. done on duty time as per agreement with hospital management. The
respondents were given two envelopes; the first contained a detailed
Population, sample and sampling information sheet with details of the objective of the study and the
The target population was all registered and enrolled nurses (either consent form. A second envelope contained the questionnaire. The
permanent or sessional staff) working in any of the four ICUs in the respondents were asked if they agreed to participate in the study and
hospital. The South African Nursing Council regulations[18] identifies a if so, to then sign the consent form. They were asked to complete the
registered nurse (RN) as a practitioner who is qualified and competent questionnaire at their convenience, and this was then returned to the
to independently practise comprehensive nursing and midwifery, and unit manager in a sealed envelope. AR collected these sealed envelopes
is capable of assuming responsibility and accountability for such from the unit managers on a daily basis.
practice. An enrolled nurse (EN) carries out nursing care under the
direct or indirect supervision or direction of a RN. Sessional refers Data analysis
to non-permanent staff working through nursing agencies. These Data were cleaned, coded and entered into the SPSS software, version 23
registered and enrolled bedside nurses were directly involved in setting (IBM Corp., USA) for analysis. Descriptive statistics in the form of
and managing alarm limits for their allocated patients. Using a census frequencies and percentages were used to analyse the data. Cross-
sampling strategy, all of the 120 RNs and ENs working in the ICU units tabulations were carried out between the nursing categories and training
were targeted. on clinical alarm monitoring system and functionality.
The inclusion criteria were: (i) registered and enrolled nurses who
worked at least 1 month in the ICU at the study hospital; (ii) ICU and Ethical considerations
non-ICU trained nurses; and (iii) sessional nurses meeting the criteria Ethical approval was obtained from the University of KwaZulu-Natal
and working during the data collection period. Ethics Committee (ref. no. HSS/0714/015M) and the hospital research
committee. Confidentiality and anonymity of the respondents’ responses
Research tool were maintained, and they were informed that they could withdraw
A self-administered questionnaire was developed by the research team, from the study at any time. An information sheet explaining the nature
incorporating the alarm fatigue questionnaire and the clinical alarms of the research and the rights of the respondents was provided to ensure
survey.[2,19] Approval to use these two questionnaires was obtained from informed consent was obtained prior to participating in the study.
their developers. Items in these questionnaires deemed not applicable A signed consent form was completed and was collected separately from
to the SA context, namely questions related to other country-specific the completed questionnaires received to ensure that no participant
organisations for patient safety and communication systems such as could be linked to their completed questionnaire, thus ensuring their
pagers, were excluded. anonymity.

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Results orientation plus training, 75.8% indicated that and training), the majority of the respondents
We distributed 120 questionnaires to nurses they found this to be adequate. (85.7%; n=78) strongly agreed that they knew
and received 91 responses, resulting in a Table 2 reveals information on clinical alarms the purpose of the clinical alarms, and 45.1%
response rate of 75.8%. against the nursing categories. More than a third (n=41) strongly agreed they felt confident in
of the respondents (38.5) were permanent RNs adjusting and monitoring the alarm parameters.
Demographic data who were non-ICU trained and had orientation In terms of the component device (human factors
Table 1 shows the demographic characteristics only on the alarm monitoring system. The design), the majority of the respondents (76.9%;
of the study respondents. Almost a third of number of respondents who received both n=70) strongly agreed that alarm sounds and/or
the respondents (32%) were from ICU 1, 24% orientation and training were predominantly visual displays should differentiate the priority
from ICU 4, and ICU 2 and 3 each accounted low for all of the nursing categories except for of the alarms, 61.5% (n=56) strongly agreed that
for 22% of the respondents. Most of the unit managers. None of the sessional RNs or the alarm sounds and/or visual displays needed
respondents were permanent non-ICU trained ENs had received orientation and training. to be distinct based on the parameter or source
RNs (40.7%). Overall, 60.4% of respondents of the alarm, and 59.3% (n=54) strongly agreed
had 7 years or more of nursing experience. The Alarm-related information that multiple senses needed to be impacted
majority (72.5%) had only received orientation Table 3 shows alarm-related information which by the alarms. Concerning the parameter
regarding the alarm monitoring system and its is highlighted according to the components patient (passive causes), more than half of
functionality and 11% trained further. Among of the Shepherd’s System Risk Model.[17] the respondents (53.8%; n=49) supported the
respondents who received orientation or Regarding the component of operator (education existence of nuisance alarms which disrupted
patient care (46.7%; n=42), contributed to lack
Table 1. Demographic characteristics of the respondents (N=91) of responses (52.7%; n=48) and reduced trust in
Variable n (%) alarms (35.6%; n=32).
Distribution of ICU nurses For the parameter operator (diverted
ICU 1 29 (31.8) attention), 56% (n=51) disagreed that they
ICU 2 20 (22.0) were overwhelmed by the number of alarms,
ICU 3 20 (22.0)
60.4% (n=55) disagreed that alarms could not
ICU 4 22 (24.2)
be heard and were thus missed, and 59.3%
Nursing category
(n=54) disagreed with the statement that they
Permanent RN ICU trained 25 (27.5)
got confused with the sources of the alarms.
Permanent RN non-ICU trained 37 (40.6)
Permanent EN 12 (13.2) With respect to the environmental (internal)
Unit managers 3 (3.3) parameter, 51.6% (n=47) strongly agreed that
Sessional RN ICU trained 2 (2.2) the alarms were adequate, while 75.8% (n=69)
Sessional RN non-ICU trained 4 (4.4) agreed that they were sensitive and responsive to
Sessional EN 8 (8.8) alarms. The majority of the respondents (73.6%;
Years of experience of respondents n=67) agreed to the existence of a requirement
0 - 3 years 21 (23.0) in their institutions to document the setting of
4-6 15 (16.5) appropriate alarms for each patient.
7 - 11 25 (27.5)
≥12 30 (33.0)
Barriers to management of
Training received on alarm monitoring system and its functionality
No training and orientation received 15 (16.5)
clinical alarms
Table 4 identifies barriers to the management
Orientation only 66 (72.5)
Training received after orientation 10 (11.0) of clinical alarms. The highest ranked barriers
Adequacy of training and orientation received were difficulty in setting alarms properly
Yes 69 (75.8) (51.6%; n=47), lack of training on the alarm
No 22 (24.2) systems (47.8%; n=43), and difficulty in
ICU = intensive care unit; RN = registered nurse; EN = enrolled nurse. hearing alarms, identifying the source of an
alarm and understanding the priority of an
alarm ranked at the same level (46.2%; n=42).
Table 2. Cross-tabulation of clinical alarms training and nursing categories (N=91)
Orientation, Orientation and No training and Discussion
Nursing category n (%) training, n (%) orientation, n (%) The operators of the clinical alarms on the
Permanent RN ICU trained 21 (23.1) 4 (4.4) 0
equipment in the ICU environment were
Permanent RN non-ICU trained 35 (38.5) 1 (1.1) 1 (1.1)
predominately the ICU nurses who were either
Permanent EN 4 (4.4) 2 (2.2) 6 (6.6)
registered ICU trained, or non-ICU trained and
Unit managers 0 3 (3.3) 0
Sessional RN ICU trained 0 0 2 (2.2) enrolled nurses. The present study revealed a
Sessional RN non-ICU trained 0 0 4 (4.4) greater number of nurses who worked in the
Sessional EN 6 (6.6) 0 2 (2.2) ICU were non-ICU trained. Similar findings
were reported by Meng’anyi et al.,[3] who found
RN = registered nurse; EN = enrolled nurse; ICU = intensive care unit. that a majority of nurses working in the ICU
were non-ICU trained.

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Table 3. Alarm-related information (N=91)

Strongly agree, Agree, Neutral, Disagree, Strongly disagreed, Missing data,
Questionnaire item n (%) n (%) n (%) n (%) n (%) n (%)
Operator (education and training)
The purpose of clinical alarms is to alert staff 78 (85.7) 10 (11.0) 0 0 2 (2.2) 1 (1.1)
of an existing or potentially hazardous patient
condition
I feel confident in adjusting and monitoring 41 (45.1) 33 (36.3) 4 (4.4) 7 (7.7) 3 (3.3) 3 (3.3)
alarm parameters in order to reduce nuisance/
false alarms
Properly setting alarm parameters and alerts is 5 (5.5) 26 (28.6) 10 (11.0) 32 (35.2) 15 (16.5) 3 (3.3)
overly complex on existing devices
Device (human factors design)
Alarm sounds and/or visual displays should 69 (75.8) 17 (18.7) 3 (3.3) 0 1 (1.1) 1 (1.1)
differentiate the priority of alarm
Alarm sounds and/or visual displays should be 56 (61.5) 26 (28.6) 4 (4.4) 2 (2.2) 1 (1.1) 2 (2.2)
distinct based on the parameter or source (e.g.
device)
Alarms should impact multiple senses (audible, 54 (59.3) 28 (30.8) 4 (4.4) 0 2 (2.2) 3 (3.3)
visual, proprioceptive, etc.)
The medical equipment used on my unit/floor 33 (36.3) 48 (52.7) 6 (6.6) 1 (1.1) 1 (1.1) 2 (2.2)
has distinct outputs (sounds, repetition rates,
visual displays, etc.) that allow differentiation of
the source of the alarm
Patient (passive causes)
Nuisance alarms contribute to lack of responses 15 (16.5) 48 (52.7) 9 (9.9) 12 (13.2) 7 (7.7) 0
by many nurses
Nuisance alarms disrupt patient care 12 (13.2) 42 (46.2) 15 (16.5) 10 (11.0) 11 (12.1) 1 (1.1)
Nuisance alarms occur frequently 5 (5.5) 49 (53.8) 11 (12.1) 13 (14.3) 8 (8.8) 5 (5.5)
Nuisance alarms reduce trust in alarms and 18 (19.8) 32 (35.2) 15 (16.5) 16 (17.6) 9 (9.9) 1 (1.1)
cause caregivers to turn alarms off at times other
than setup or procedural events
Operator (diverted attention)
I feel overwhelmed by the number of alarms on 5 (5.5) 14 (15.4) 17 (18.7) 51 (56.0) 3 (3.3) 1 (1.1)
the unit
Clinical alarms are a significant contributor to 3 (3.3) 8 (8.8) 20 (22.0) 37 (40.7) 20 (22.0) 3 (3.3)
my stress level
There have been frequent instances where alarms 5 (5.5) 10 (11) 6 (6.6) 55 (60.4) 14 (15.4) 1 (1.1)
could not be heard and were missed
When a number of devices with alarms are used 5 (5.5) 12 (13.2) 6 (6.6) 54 (59.3) 13 (14.3) 1 (1.1)
with a patient, it can be confusing to determine
which device is in alarm mode
Have you experienced alarm fatigue in the past 6 (6.6) 22 (24.2) 18 (19.8) 28 (30.8) 15 (16.5) 2 (2.2)
6 months?
Environment (internal)
The alarms used on my floor/area of the hospital 47 (51.6) 39 (42.9) 1 (1.1) 1 (1.1) 1 (1.1) 2 (2.2)
are adequate to alert staff of potential or actual
changes in a patient’s condition
There is a requirement in your institution 69 (75.8) 11 (12.1) 3 (3.3) 5 (5.5) 3 (3.3) 0
to document that the alarms are set and are
appropriate for each patient
The staff is sensitive to alarms and respond 36 (39.6) 33 (36.3) 9 (9.9) 10 (11.0) 0 3 (3.3)
quickly
Policies and procedures exist within the facility 10 (11.0) 67 (73.6) 7 (7.7) 2 (2.2) 2 (2.2) 3 (3.3)
to regulate alarms and they are followed
Environmental background noise has interfered 3 (3.3) 13 (14.3) 10 (11.0) 57 (62.6) 6 (6.6) 2 (2.2)
with alarm recognition

Despite the years of experience of the majority of the nurses (7 years ICU nurses had received orientation to the new surroundings of clinical
and over), the number of ICU nurses who received both education and alarms at the time, they were new employees in ICU, the minority (11%)
orientation on alarm management was low. While the majority of the received training on knowledge and skills of managing the clinical

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Table 4. Barriers to effective management of clinical alarms (N=91)

1 9
Most Least No
important 2 3 4 5 6 7 8 important response
Questionnaire item n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%)
Operator priority ranked statements
Difficulty in setting 47 (51.6) 6 (6.6) 8 (8.8) 3 (3.3) 10 (11.0) 3 (3.3) 2 (2.2) 2 (2.2) 10 (11.0) 0
alarms properly
Lack of training on 43 (47.3) 7 (7.7) 4 (4.4) 6 (6.6) 7 (7.7) 5 (5.5) 3 (3.3) 5 (5.5) 10 (11.0) 1 (1.1)
alarm systems
Difficulty in hearing 42 (46.2) 7 (7.7) 4 (4.4) 8 (8.8) 6 (6.6) 3 (3.3) 4 (4.4) 5 (5.5) 11 (12.1) 1 (1.1)
alarms when they occur
Difficulty in identifying 42 (46.2) 8 (8.8) 5 (5.5) 3 (3.3) 10 (11.0) 1 (1.1) 2 (2.2) 5 (5.5) 13 (14.3) 2 (2.2)
the source of an alarm
Difficulty in 42 (46.2) 16 (17.6) 4 (4.4) 3 (3.3) 7 (7.7) 1 (1.1) 0 4 (4.4) 12 (13.2) 2 (2.2)
understanding the
priority of an alarm
Over-reliance on 38 (41.8) 11 (12.1) 5 (5.5) 7 (7.7) 6 (6.6) 5 (5.5) 8 (8.8) 6 (6.6 ) 4 (4.4) 1 (1.1)
alarms to call attention
to patient problems –
operator
Frequent false alarms, 33 (36.3) 10 (11.0) 6 (6.6) 9 (9.9) 9 (9.9) 5 (5.5) 2 (2.2) 6 (6.6) 10 (11.0) 1 (1.1)
which lead to reduced
attention or response
to alarms when
they occur
Inadequate staff to 32 (35.2) 8 (8.8) 8 (8.8) 11 (12.1) 6 (6.6) 8 (8.8) 3 (3.3) 3 (3.3) 10 (11.0) 2 (2.2)
respond to alarms as
they occur
Noise competition 25 (27.5) 11 (12.1) 8 (8.8) 4 (4.4) 8 (8.8) 4 (4.4) 2 (2.2) 11 (12.1) 14 (15.4) 4 (4.4)
from non-clinical
alarms and pages –
environment

alarms. This is almost similar to the findings by Aysha and Ahmed,[21] increased frequency of false alarms did predispose the nursing staff to
who reported that none of the nurses had received training before the alarm fatigue[24] and consequently negative clinical consequences for
implementation of the clinical alarm nursing intervention program. patient safety and care.[25] Bell[26] also confirmed that due to the many
Overall, the majority of the nurses did not receive any form of training potential alarms that one could be exposed to from the various medical
on alarm management systems; however, a study in by Mirhafez et al.[22] equipment, the risk of desensitisation to the alarming limits was high
in Iran revealed that nurses needed such training. Wyckoff[7] also agreed and could cause a patient safety concern.
with the need for further training coupled with simulation training Human factors design always comes into play when looking to
regarding better alarm usage. improve human performance with regards to the use of equipment.[27]
A significant number of nurses in the present study indicated that they
Alarm-related information understood the need for differentiating between the priority alarms
Although the operator education and training on clinical alarm based on the parameters and their impacts on multiple senses, thus
management was low, a greater number of nurses indicated that agreeing with the findings of Cho et  al.[16] The role of human factors
they understood the purpose of clinical alarms, thus agreeing with is coupled with the environmental space and the staff was well aware
the findings of Cho et  al.[16] Nevertheless, operator alarm-related of the existing policies for alarm management systems available within
information on distracted attention indicated that the staff did not their ICU environments. However, these policies could be reinforced
feel overwhelmed and were responsive to the alarming limits, thus to address staff that were not confident with alarm management.
making it an unnecessary area of concern in the present study. However, Bell[26] indicated that the development of a hospital or unit policy on
Baillargeon[23] highlighted delayed responses to alarm limits occurring appropriate parameters was implemented specifically to meet patients’
due to an overwhelming number of alarms sounding at the same time. clinical needs.
Passive patient causes in the form of clinically non-actionable alarms,
also known as nuisance alarms, were highlighted in the present study. Barriers to the management of clinical alarms
Although the ICU nurses in the present study did have an understanding The present study highlighted difficulties in setting alarms properly
of their roles and expectations with regard to alarm management, and lack of training on alarm systems as the top two challenges. This
the frequency of the nuisance alarms was acknowledged as a cause contrasted with the findings of Funk et al.,[14] Casey et al.[15] and Mirhafez
for delays in their responses to these alarming limits. This concurred et al.,[22] who identified that frequent false alarms caused reduced attention
with the findings of Casey et  al.,[15] where most nurses agreed to the and inadequate numbers of staff to respond to alarms as the most common
existence of non-actionable alarms, which disrupted patient care. The barrier to the management of clinical alarms. Although 11% of the ICU

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of alarm fatigue. Dimens Crit  Care  Nurs 2017;36(1):36-44. https://doi.org/10.1097/
DCC.0000000000000220
Due to technological advancements in the healthcare sector, nursing
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education and training should incorporate devices and alarm Care 2014; 23(3):e9-e18. https://doi.org/10.4037/ajcc2014315
15. Casey S, Avalos G, Dowling M. Critical care nurses’ knowledge of alarm fatigue and practices
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interpreted the data. AR, GC and PB drafted and critically revised the
manuscript. All the authors approved the final manuscript for publication.
Funding. None.
Conflicts of interest. None. Accepted 12 May 2021.

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