Effectiveness of a noise control program in a neonatal intensive care unit

Abstracts

OBJETIVOS: Avaliar a eficácia de um programa para redução do nível de ruído na Unidade de Terapia Intensiva Neonatal do Hospital Universitário de Santa Maria (UTIN/HUSM). MÉTODOS: O estudo foi realizado na UTIN/HUSM, em Santa Maria, Rio Grande do Sul. A primeira etapa constou de contatos verbais informais com todos os profissionais que atuam no local durante os turnos da manhã, tarde e noite. Também foram distribuídos folhetos e afixados cartazes apontando a nocividade do ruído para o neonato e para os profissionais e ainda mudanças comportamentais capazes de levar à redução do ruído neste ambiente. As sugestões foram: evitar falar em volume elevado, manusear cuidadosamente as portinholas das incubadoras e manter os aparelhos de celular no modo silencioso. Após um mês foram aplicados questionários para avaliar as mudanças comportamentais ocorridas neste período. RESULTADOS. Após o desenvolvimento do programa a maioria dos profissionais caracterizou o ruído da UTIN/ HUSM como moderado. Verificou-se que 71,4% dos profissionais admitem que seus comportamentos geram ruído. A totalidade dos profissionais referiu acreditar na possibilidade de reduzir o ruído da UTIN/ HUSM e para isso sugeriram falar mais baixo, responder rapidamente aos alarmes e cuidado ao manipular os móveis, medidas que foram adotadas por todos eles. CONCLUSÃO: O programa para redução do ruído desenvolvido na UTIN/ HUSM obteve êxito na medida em que os profissionais passaram a ter cuidado para que seu comportamento não gerasse ruído desnecessário.

Efeitos do ruído; Monitoramento do ruído; Recém-nascido; Unidades de terapia intensiva neonatal

ORIGINAL ARTICLE

^IPostgraduate Program (MSc Level) in Human Communication Disorders, Universidade Federal de Santa Maria - UFSM - Santa Maria (RS), Brazil

^IIHearing Disorders Society - APADA; Serviço Social da Indústria - SESI - Santa Rosa (RS), Brazil

^IIIDepartment of Speech and Language Therapy, Universidade Federal de Santa Maria - UFSM - Santa Maria (RS), Brazil

Corresponding author

ABSTRACT

PURPOSE: To evaluate the effectiveness of a noise control program in the Neonatal Intensive Care Unit of the Hospital Universitário Santa Maria (NICU-HUSM) in Santa Maria, Rio Grande do Sul, Brazil.

METHODS: NICU-HUSM professionals were initially contacted through informal interviews during the morning, afternoon and night shifts. Leaflets were delivered and posters were installed to raise awareness of the harmful effects of noise on neonates and professionals and to suggest behavioral changes to reduce noise levels. The suggestions included avoiding loud talking, careful handling of the incubator doors and keeping mobile phones on silent mode. One month later, questionnaires were used to assess behavioral changes since the first contact.

RESULTS: Most of the professionals rated the NICU-HUSM noise level as moderate. Overall, 71.4% of the respondents acknowledged that their behaviors were noisy. The entire sample reported believing that the unit noise levels could be reduced by speaking lower, reacting more quickly to alarms and handling furniture more carefully. The NICU professionals reported adopting these behaviors.

CONCLUSION: This noise control program was considered successful because the professionals became aware of the level of noise and adopted behavioral changes to avoid generating unnecessary noise.

Keywords: Noise effects; Noise monitoring; Infant, newborn; Intensive care units, neonatal

INTRODUCTION

The treatment of high-risk neonates admitted to neonatal intensive care units (NICU) requires a quiet environment in addition to capable professionals and appropriate equipment. However, noise levels in hospitals, including in NICUs, are reported to be above acceptable levels. The Brazilian Technical Rules Association rule number 10152/1987⁽¹⁾ establishes hospital noise levels of 35 and 45 dB as desirable and acceptable, respectively.

However, at the NICU of the Hospital Universitário Santa Maria (HUSM) as in many other Brazilian NICUs, the measured noise is above the acceptable level. In Brazil, Aurélio⁽²⁾ measured the noise levels in the NICU-HUSM, which ranged from 43.3 to 114.9 dB(A) (mean 60 to 65 dB). These levels are excessive according to Brazilian and international rules. Other NICU studies have shown similar noise levels as in the study conducted in Novo Hamburgo (Rio Grande do Sul, Brazil) in which levels between 48.3 and 82.6 dB(A) were found.⁽³⁾

Noise in NICUs results from different sources, including equipment, such as heart monitors, ventilators, oxymeters, infusion pumps, aspiration systems and incubators.^(3,4) Medical, nursing and other professional teams' conversations and parental visits are also directly related to increased noise levels.^(3,5,6) Some noisy professional behaviors can be prevented, such as talking, using mobile phones, radios or televisions and careless handling of furniture and equipment.^(4,7,8)

Daily exposure to high noise levels may cause physiological and behavioral changes, affecting newborns' recovery process. Likewise, professionals may be affected, and their performance levels may be reduced.

Newborns exposed to noise may have high blood pressure, increased heart rate, hearing loss,⁽⁹⁾ apnea, bradycardia, hypoxia, sleeping disorders and consequent fatigue, agitation, crying and irritability. In addition, noise may affect weight gain by increasing oxygen consumption and heart rate, thereby leading to increased use of energy.⁽¹⁰⁾

Healthcare professionals working in NICUs may have arterial hypertension, sleep and mood disorders, hearing loss, irritability, stress and fatigue, which may affect their working performance.^(4,8)

Educational programs aimed at this population are believed to contribute to noise control through behavioral changes. First steps to achieving a healthier environment include increasing awareness of the effects of noise on neonates and healthcare professionals, identifying behaviors that cause unnecessary noise and understanding how to change these behaviors.

Based on the observation of excessive NICU-HUSM noise levels,⁽²⁾ a noise control program was developed and proposed for this NICU. The aim of this article was to assess the effectiveness of a noise control program at the Neonatal Intensive Care Unit of Hospital Universitário Santa Maria, in Santa Maria, Rio Grande do Sul, Brazil.

METHODS

This study was conducted in the Neonatal Intensive Care Unit of the Hospital Universitário Santa Maria in Santa Maria, Rio Grande do Sul, Brazil between July 2009 and September 2009; this study was carried over from the study by Aurélio⁽²⁾ that was developed in this unit.

During the first phase, leaflets were distributed and posters were installed to educate healthcare professionals about the harmful effects of noise on neonates (Figure 1). This information compared the NICU-HUSM noise levels with daily noise levels (Figure 2) and provided strategies for noise control. Two speech and language therapist students, appropriately supervised by a responsible professor, gave informational lectures to the morning, afternoon and night shift personnel. Approximately 40 healthcare professionals took part in this phase and were educated about the effects of noise on neonates and on healthcare professionals' hearing and overall health, the current sources of noise and possible behavioral changes to ensure a healthier environment.

One month after the first phase, questionnaires (^{Appendix 1}) containing open and closed questions were completed by the NICU-HUSM healthcare professionals to identify noise-related behavioral changes. The questionnaire included questions related to noise sources, noise impact on neonates, healthcare professionals and parents, possible noise-related behavioral changes and the identification of concerns the healthcare professionals had developed since the previous contact.

All 28 healthcare professionals participating in this phase had completed this questionnaire in the previous study.⁽²⁾ The responses to both studies were compared except for the responses regarding changes related to noise control.

The questionnaire data were inserted into shift tables and were statistically analyzed using the chi-square test.

This study is part of a research project, titled Noise in a Neonatal Intensive Care Unit, which was approved by the institution's ethics committee under the number 0158.0.243.000-07.

RESULTS

Questionnaires were delivered to 40 healthcare professionals; 28 completed questionnaires were returned by 8 nurses, 16 nursing technicians, 2 physicians and 2 physiotherapists.

When the responses were compared to those of the previous study,⁽²⁾ statistically significant differences were found only for the questions related to NICU-HUSM noise intensity and sources (Table 1). Overall, the noise intensity was rated as moderate (Figure 3).

Overall, healthcare professionals believe that there is a predominance of noise from equipment and healthcare professionals in the NICU-HUSM (Table 2); 71.5% of the healthcare professionals admitted that their own behavior generated noise. However, the difference between this percentage and the previous study⁽²⁾ was not statistically significant (Table 1). According to the healthcare professionals, most of the noise came from talking. No statistically significant difference was found between the healthcare professionals' identified noise sources and the behaviors acknowledged to cause noise (Table 3).

All of the professionals stated that they believed that the noise level could be reduced. The main suggestions for reducing noise levels are shown in Table 4. There was a statistically significant difference between the suggestions for noise control and behaviors adopted after the lectures (Table 4).

After receiving information, the most common behavioral change reported by healthcare professionals was talking more quietly (Table 5). All healthcare professionals reported at least 2 behavioral changes.

Regarding the harmful effects of noise exposure, all healthcare professionals acknowledged that noise could harm neonates, indicating as the main injuries irritability (21.4%), shortened sleeping time (21.4%), hearing impairment (14.2%), stress (14.2%), nervous system disorders (10.7%) and neuropsychomotor development disorders (10.7%). The responses regarding possible harmful effects for healthcare professionals included stress (50%), irritability (28.5%), hearing loss (28.5%) and headache (14.2%). Harmful effects for parents included stress (39.2%), hearing loss (28.5%) and irritability (17.8%).

DISCUSSION

After the lectures, 60.7% of the healthcare professionals working at the NICU-HUSM rated the environmental noise level as moderate (Figure 3). In a previous trial involving this same NICU,⁽²⁾ 60.4% of respondents considered the noise level to be intense.⁽²⁾ This change in noise perception was statistically significant (p=0.374), showing that at least some of the healthcare professionals adhered to the noise control program.

The main source of noise identified by healthcare professionals was a combination of equipment and healthcare professionals' behavior (35.7%) (Table 2), which was a finding in agreement with the literature.⁽⁴⁾ Alarms, air conditioning, handling objects, dragging chairs, slamming doors and talking were reported as the main sources of noise pollution.⁽¹¹⁾ In contrast, in other studies, only equipment was reported to be responsible for the excessive noise.^(1,8)

Most of the healthcare professionals (71.4%) acknowledged that their own behavior was a source of noise. In the previous study,⁽²⁾ only 67.5% acknowledged their part in the sources of noise. Conversations (46.4%) and speaking loudly (25%) were the most frequently mentioned behaviors as observed in other studies.^(4,12)

After the lectures, NICU-HUSM healthcare professionals acknowledged that their behavior was a significant part of the noise (Table 1). In contrast, in the study by Aurélio,⁽²⁾ healthcare professionals pointed to equipment as the major source of noise.

Statistically significant differences were found between the healthcare professionals' responses about the major sources of noise at the NICU-HUSM (p=0.0055). This finding suggests that healthcare professionals became aware of their contribution to the noise in their workplace. Some studies point to awareness as the main means of controlling the noise level in NICUs.^{(8,9,11,14,15)}

All respondents acknowledged that noise is harmful to neonates with most respondents mentioning irritability and shortened sleeping time. According to the literature, excessive neonatal exposure to noise can cause sleeping cycle disorders,^(4,7,8,9,11) immediate vital sign changes⁽⁵⁾ and hearing loss.^(4,7,11,13)

All respondents acknowledged that the noise in their workplace could harm their own health, predominantly through stress, which was mentioned by 50% of the subjects. In the previous study,⁽²⁾ the main reported effects resulting from noise were stress, irritability, fatigue and headache, which could impact the professionals' job performance and, consequently, harm their patients.^(4,8)

All NICU-HUSM healthcare professionals believed that it was possible to control the noise level. In the previous study, 97.67% of the healthcare professionals believed that reducing noise levels was possible.⁽²⁾ Based on their awareness of the harmful effects of noise for their patients and for themselves, healthcare professionals changed their noisy behaviors and improved the acoustic environment.

Based on the information provided, the number of professionals who stated that they had changed their behavior was higher than the number of healthcare professionals who suggested these changes; this difference was statistically significant (Table 4). In addition to talking more quietly, being careful not to slam incubator doors and promptly attending to alarms, the professionals reported being more careful when closing hampers. These results demonstrate the effectiveness of the program and healthcare professionals' commitment to improving the acoustic environment of their workplace.

Speaking loudly was reported by 23 respondents to be a source of noise generation (Table 3). After the educational program, 78.5% of the respondents began speaking more quietly (Table 4). In other studies, lowering of voices in NICU rooms was suggested as a possible method of noise control.^(9,14,15)

All healthcare professionals reported that they had changed at least 2 noise-generating behaviors. Other solutions identified by this group included keeping radios and televisions off and covering hamper lids to prevent noise.

Based on their awareness of the harmful effects of noise for their patients and for themselves, healthcare professionals changed their behaviors, rendering the NICU environment quieter. Accordingly, educational programs for NICU professionals are one way to control environmental noise.^{(8,9,11,14,15)}

Long-term evaluations show that behavioral changes are not as effective as interventions involving the physical environment. However, because these measures are not financially feasible for most NICUs, reminders can consistently motivate healthcare professionals to maintain acoustically healthier workplaces.⁽⁹⁾ Therefore, we suggest that this issue should be periodically addressed with the healthcare team.

CONCLUSION

The NICU-HUSM noise control program was considered to be successful because healthcare professionals took greater care to prevent their professional behavior from causing unnecessary noise.

REFERENCES

• ¹
  Associação Brasileira de Normas Técnicas - ABNT. NBR 10152. Níveis de ruído para conforto acústico. Rio de Janeiro: ABNT; 1987.
• 2. Aurélio FS. Ruído em unidade de terapia intensiva neonatal [dissertação]. Santa Maria: Centro de Ciências da Saúde da Universidade Federal de Santa Maria; 2009.
• 3. Saraiva CAS. Fatores físicos-ambientais e organizacionais em uma unidade de terapia intensiva neonatal: implicações para a saúde do recém-nascido [dissertação]. Porto Alegre: Escola de Engenharia da Universidade Federal do Rio Grande do Sul; 2004. 103f.
• 4. Kakehashi TY, Pinheiro EM, Pizzarro G, Guilherme A. Nível de ruído em unidade de terapia intensiva neonatal. Acta Paul Enferm. 2007;20(4):404-9.
• 5. Elander G, Hellström G. Reduction of noise levels in intensive care units for infants: evaluation of an intervention program. Heart Lung. 1995;24(5):376-9.
• 6. Zahr LK, Balian S. Responses of premature infants to routine nursing interventions and noise in the NICU. Nurs Res. 1995;44(3):179-85.
• 7. Rodarte MDO, Scochi CGS, Leite AM, Fujinaga CI, Zamberlan NE, Castral TC. O ruído gerado durante a manipulação das incubadoras: implicações para o cuidado de enfermagem. Rev Latinoam Enferm. 2005;13(1):79-85.
• 8. Carvalho WB, Pedreira MLG, Aguiar MAL. Nível de ruídos em uma unidade de cuidados intensivos pediátricos. J Pediatr (Rio J). 2005;81(6):495-8.
• 9. Darcy AE, Hancock LE, Ware EJ. A descriptive study of noise in the neonatal intensive care unit. Ambient levels and perceptions of contributing factors. Adv Neonatal Care. 2008;8(3):165-75. Republished in Adv Neonatal Care. 2008;8(5 Suppl):S16-26.
• 10. Tamez RN, Silva MJP. Impacto do ambiente da UTI neonatal no desenvolvimento neuromotor. In: Tamez RN, Silva MJP. Enfermagem na UTI neonatal: assistência ao recém-nascido de alto risco. Rio de Janeiro: Guanabara Koogan; 1999.
• 11. Otenio MH, Cremer E, Claro EMT. Intensidade de ruído em hospital de 222 leitos na 18Ş Regional de Saúde - PR. Rev Bras Otorrinolaringol. 2007;73(2):245-50.
• 12. Menon D, Martins AP, Dyniewicz AM. Condições de conforto do paciente internado em UTI neonatal. Cad Esc Saude Enferm. 2008;(1):1-15.
• 13. Pimentel-Souza F. Efeitos da poluição sonora no sono e na saúde em geral - Ênfase urbana [citado 2008 Ago 8]. Disponível em: http://saci.org.br/index.php?modulo=akemi¶metro=519
• 14. Krueger C, Wall S, Parker L, Nealis R. Elevated sound levels within a busy NICU. Neonatal Netw. 2005;24(6):33-7.
• 15. Lamego DTC, Deslandes SF, Moreira MEL. Desafios para a humanização do cuidado em uma unidade de terapia intensiva neonatal cirúrgica. Ciênc Saúde Coletiva. 2005;10(3):669-75.

Appendix 1

Effectiveness of a noise control program in a neonatal intensive care unit

Tainara Milbradt Weich^I; Ana Cláudia Ourique^II; Tania Maria Tochetto^III; Cacineli Marion de Franceschi^I

Publication Dates

• Publication in this collection
  24 Oct 2011
• Date of issue
  Sept 2011

History

• Accepted
  10 Aug 2011
• Received
  24 May 2011