Noise-Nightingale minisode #4

Michelle: Well, welcome back to the Nightingale series. And this is minisode number four, Noise, when Florence tells us the negative effects of noise on patient recovery, and then she shares even stronger opinions on patient visitation. And I'm sure there's a lot of nurses that also share her strong opinion, so we'll get into that. Florence's sarcastic humor will also make a reappearance. So let's have some fun. You're listening to the Conversing Nurse podcast. I'm Michelle, your host. And this is where together, we explore the nursing profession, one conversation at a time. Florence starts off by saying, "unnecessary noise or noise that creates an expectation in the mind is that which hurts a patient." She's saying it's not necessarily the volume of the noise, but more the noise itself. For example, when you're trying to sleep or you're sick, is it the white noise of a distant lawn mower or is it someone whispering that's going to annoy you more? Well, Florence says it's definitely the whisper. I mean, it couldn't be the lawnmower because gasoline-powered lawn mowers hadn't been invented yet, right? She also says that the patient's sleep quality is severely affected if he is awakened during the first sleep, which she describes as the first few minutes after he falls asleep. And if he is awakened after a few hours instead of a few minutes, he's much more likely to fall asleep again. She says if you're a healthy person and you sleep during the day, as in take a nap, it's going to affect your sleep at night, maybe you won't sleep as well. But she says the reverse is true for the sick person who naps, they sleep better at night. "Generally, the more the sick sleep, the better they will be able to sleep." And of course, it makes perfect sense that the sick need more sleep because their bodies are trying to repair themselves after surgery or they're fighting an infection. So not a surprise. Now, Florence seems quite perturbed about noise in hospitals, such as people talking in the room or right outside the door. And I can relate to this, as I'm sure every nurse can. As a NICU nurse, it was very disconcerting to see parents at the bedside with their extremely premature infant, who was ventilated and sedated, just talking away with little regard. Meanwhile, the baby is tachycardic, tachypneic, and desatting, basically showing all the signs of overstimulation. And in the parent's defense, they are most likely not aware of the pathophysiology behind the immature brain, right? They need education and reminders and more education before they finally understand how noise is affecting their infant. In today's hospitals, noise comes from many sources monitor alarms, people talking, environmental services, cleaning equipment being pushed in the hallways, portable radiographs clicking, IV pumps, telephones and doorbells ringing. I mean, any of these things alone would annoy me, but all of them together just become this cacophony of chaos. It's not good for patients. Remember HCAHPS? That stands for Hospital Consumer Assessment of Health Care Providers and Systems. The surveys that our patients get when they leave? Well, they report that noise continues to be a problem for patients and it results in more confusion, more restraints being used, more pain medicine being given, and more calls to the nurse. Noise is also harmful to healthcare providers. I mean, the detriments of alarm fatigue have been known for years. I remember myself coming home from twelve-hour shifts and first thing asking my husband please turn the TV volume down, which wasn't really high in the first place, but everything sounded so incredibly loud. Florence goes on in the next few paragraphs to talk about what she titles as "noise of the female dress." And it's about to get hilarious. Florence describes in detail how the nurse should move about in the room. Remember, this is the 1850s, and women, including nurses, wore dresses with crinolines. A crinoline was a wooden or wire cage wrapped in some sort of fabric that women wore under their dress. So, think Cinderella or Scarlet O'Hara. The Victorians had a thing for making women look like they had very small waists and very large hips. I mean, I'm paraphrasing here, but Florence talks about being a nurse with the type of dress they had to wear while caring for patients. And she describes it as brushing and rustling against everything and says, "the fidget of silk and crinoline, the rattling of keys, the creaking shoes will do a patient more harm than all the medicines in the world will do him good. Her skirts, if they do not throw down some piece of furniture, will at least brush against every article in the room as she moves." And then a footnote, which is pretty humorous until I looked into exactly what she was referring to, and then it's a little more gruesome than funny. But here's how she describes it, "fortunate it is if her skirts do not catch fire and if the nurse does not give herself up a sacrifice together with her patient to be burnt in her own petticoats. I wish the Registrar General would tell us the exact number of deaths by burning occasioned by this absurd and hideous custom." She also describes how when the nurse bends over, the crinoline flares up in the back, which results in basically mooning her patient. Nice picture, thanks Florence. But in all seriousness, I found several articles that estimate that during a ten-year period between the late 1850s and the late 1860s in England, about 3000 women were killed in crinoline-related fires. And these were just the fires. There were also accidents where the skirts would balloon up over the woman's head, maybe by wind, causing them to fall because they couldn't see, and the massive skirts getting caught in carriage doors which resulted in being dragged to death. I mean, this was a public health threat if Florence ever saw one, and thankfully, crinolines finally met their demise in the late 1890s. The last reference Florence makes about noise is to music, and she says "not all music is soothing."  Amen to that, Florence. I mean, musical preferences are highly individual. She cites two different types of music and how they affect the patient. Music that is continuous in nature, which she describes as wind instruments, stringed instruments, and the human voice. Those are beneficial to the patient, whereas the piano, which has no continuous sound, has the reverse effect. I was a developmental specialist in the NICU for about twelve years, and during a long period of time, we were in an open-bay NICU. It was on a regular basis that nurses would play music while they were charting, et cetera. And when I say playing music, it would be like having iHeart radio playing in the background of a busy NICU with sick and premature infants. And I was aware of the developmental research on the growing premature baby's brains and how noise affects them. And what I learned from that is that a radio playing in the NICU is just more noise in an already overly noisy place. Yes, it's music, but we weren't playing the type of music that would be beneficial to sick or growing preemies. Some of the studies that I looked at said the most beneficial music was actually live music, such as someone playing a guitar and singing. So for about a year, we had arranged for a guitarist to come in and play and sing for the babies, which the nurses really enjoyed and I can hope the babies got some benefit as well. Florence gives advice to nurses and visitors, which is still pertinent today for nurses. "Take all the supplies you need in the room to avoid leaving and returning." And today, thankfully, many of our hospital rooms are stocked with supplies so that we can do just that. Have everything where we need it when we need it. She says, "don't hurry when you're with your patient. Always sit down when speaking to him. Never make your patient repeat a message or a request. It exhausts him. Never talk to your patient from behind, from the door, or from a far distance." Florence says these things are not fancy, meaning they're common sense actions. And I would agree they may be beneficial for patients, but I'm not convinced that they can be regularly employed. Still, we should try. Florence talks about how visitors can be respectful of patients and suggests things like, "never make a patient stand for an extended period. Never surprise a patient, if at all possible. Don't lie on or shake the patient's bed. Don't share bad news. Enter and exit the room quickly, but not in a rush." In a later chapter, Florence speaks of visitors, both lay and medical, that give advice that contradicts their current treatment. And I think we've all been witness to this, which is extremely frustrating. Aunt Bea is visiting the patient, and she's telling him, "you don't need antibiotics to heal this abscessed wound. You just need to rub some honey on it." Next thing you know, your patient is asking the dietary aid for those "little honey packets". Well, that's it for the fourth minisode, very interesting stuff, Florence, thank you. Join me for the fifth minisode variety. It's the spice of life, apparently. And Florence will tell us why our patients need it. Thank you and see you soon.