Wednesday, 05 October 2022


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Let’s reappropriate silence in hospital units: a bisensory article

Important note! Before you start reading this article, you must activate the play text of the audio file. This is the only way to have the bisensory experience foretold. To avoid being hated by anyone next to you, I suggest you wear earphones or just seclude yourself for 2 minutes (time needed to read the complete article). I know you’re wondering and the answer is “yes”. This article only gains a different meaning if, while reading, the audio is not stopped.

I’ve been working for a few years in highly specialized cardiology and pulmonary rehabilitation department, where the vital signs of the most critical patients are often monitored 24 hours a day. And you know, with the monitors there aren’t just waves and parameters, but also sounds and alarms of all types. So many sounds, one more irritating than the other, of different volumes, that sometimes signal your important things and sometimes (in most cases) artefacts. An unwritten law affirms that the volume of the alarm is directly proportional to the importance (hypothetical) of the episode that it is signalling. Adding a bit of imagination, and taking our cue from Murphy’s law, we could elaborate on two corollaries: ” more frequent is the alarm, less are the probabilities that the episode is relevant” and “more the volume of a specific alarm is high, higher are the probabilities that it sounds that very alarm”. In a department similar to mine, in addition to these “vital” sounds, there are the various infusion pumps, equipped with a fine sound, but at the same time particularly penetrating to those close to them, i.e. the patients. And then, there are the routine sounds and the sounds of transition. Health workers who grind, slam, open, close, move, drop, tear, break, talk and why not, sometimes scream.

Suffering the performance of this orchestra of forgotten instruments and arrhythmic musicians is the patient. The noises that develop in the various departments cannot all be attributable to the technological innovation of our instruments. The noise-related disorder is as old as human beings. For example, in the Babylonian flood myth, Enlil (Lord of the Storm), annoyed by the noise created by mankind, which prevented him from sleeping, decides to exterminate the entire human race with a flood. A little more than a century ago, however, it was our colleague Florence Nightingale who defined unnecessary noise (noise, from the Latin for nausea) as “the cruellest absence of care that can be inflicted on both the sick and the healthy”. The intuitions of Florence, who went down in history not only for her work on infectious diseases, later proved to be correct. Noise is not only disturbing the peace of patients or problems related to altered hearing but, following numerous researches, it is also associated with several disorders and pathologies: for example, it has been demonstrated that it slows down wound healing1, promotes higher blood pressure2,3, alters heart function4, causes psychological disorders such as minor depression or anxiety disorder5,6 and promotes insomnia7,8. In addition, noise increases the level of distraction for healthcare workers, who, working on a priority basis, have to stop what they are doing and focus on alerting: again, there are numerous studies that associate noise with a high probability of error9. The Joint Commission on Accreditation of Healthcare Organizations claims that noise is a potential risk factor related to medical and nursing errors, stating that “ambient sound levels shouldn’t exceed a specific level that would prevent caregivers from understanding each other”. An article in the Journal of the Association of Operating Room Nurses (November 2003) reported an incident where an anesthesiologist, in an operating room where the music was very loud, misunderstood the surgeon’s instructions regarding the levels of heparin to be infused. Faced with this evidence, it’s the same World Health Organization established that the sound level of bedrooms should be around 40 dB (maximum 35 dB at night, which is equivalent to a loud whisper) for a good quality of sleep in healthy people. In most cases, this doesn’t happen inwards with a high intensity of care, with negative effects not only for the operators but especially for the patients, who at that stage of hospitalization are highly likely to develop psychotic disorders. And specifically, as far as patients are concerned, I’m referring to the critical ones, who can’t interact properly, express their disappointment, get out of bed, unplug and, in the worst-case scenario, throw the monitor out of the window (as you probably want to do now with your cell phone or computer). They are the ones who should be protected the most by healthcare providers, who experience the unit for a limited amount of time during the day. In this regard, a few weeks ago, on the advice of a colleague, I read in one go the book “What do goldfish dream of?” by anesthesiologist Marco Venturino, which deals with the drama of a dying patient “parked in the ICU”, locked up in the metaphorical aquarium of his bed. An aquarium, unfortunately for him, without that acoustic barrier that guaranteed superheroes with super-hearing to take a break: water. With a great narrative ability, the author touches profoundly on the tragedy of a patient immobilized by a marked destiny: he cannot speak, he cannot gesture, he cannot sign. Mr Tunensi, “the Number 7”, the Red Fish, can only listen, listen and listen. He doesn’t have a choice. At times he can no longer even follow the flow of his thoughts, constantly disturbed by the monotonous noise of the monitors and everything around him. Often health workers, maybe because of routine or the spirit of adaptation, become accustomed to these noises and lose the sensitivity necessary to empathize with the patient and cancel in some way the disturbance. Screaming, for example when the patient has a hearing loss, creates a loud noise, resulting in discomfort, and often leads to misunderstandings with other patients. Sometimes, when you get home, with the same workload, you feel more tired on noisy days than on quieter ones. This is mental fatigue, which manifests itself in most cases with a headache. Paying more attention to noise means providing better care, significantly improving outcomes on many fronts. In some countries, like Finland, silence is particularly sponsored and sells quite well in the tourism field. A week of meditation, immersed in Nordic nature, costs hundreds of euros. With the same logic, driven by scientific evidence and simple common sense, as nurses, operators always present in hospitals, we must attempt to regain possession of silence in the wards, often perceived as a delicate quality, like a porcelain vase, and, where necessary, be vigilant and guarantors of quiet in the rooms.

Now that you have probably arrived at the end of this article, (I hope) still listening to the audio I have suggested, ignoring some understandable difficulty in concentrating, how long do you think you would resist, immobile in your hospital bed, if this monotonous, loud and irritating sound marked every minute of your life?

Hamilton Dollaku works as a nurse practitioner at IRCCS Don Carlo Gnocchi in Florence in the highly specialized cardiac and respiratory rehabilitation unit.


  1. Wysocki AB. The effect of intermittent noise exposure on wound healing. Advances in Wound Care : the Journal for Prevention and Healing. 1996 Jan-Feb;9(1):35-39.
  2. Wu TN , Ko YC , Chang PY : A study of noise exposure and blood pressure in shipyard workers. Am J Ind Med 12:431-438, 1987.
  3. Stansfeld SA, Matheson MP. Noise pollution: non-auditory effects on health. Br Med Bull. 2003; 68: 243-57.
  4. Villa A. , Andreini GC , Merluzzi F. , et al: Relationship between cardiac functions and environmental noise in a group of car engine testers. Med Lav 71:397-405, 1980.
  5. Stansfeld S, Gallacher J, Babisch W, Shipley M. Road traffic noise and psychiatric disorder: prospective findings from the Caerphilly Study. BMJ. 1996 Aug 3; 313(7052): 266-7.
  6. Tarnopolsky LJ, MacDougall JD, Atkinson SA, Tarnopolsky MA, Sutton JR. Gender differences in substrate for endurance exercise. J. Appl Physiol. 1990 Jan; 68(1): 302-8.
  7. Vallet M, Mouret J. Sleep disturbance due to transportation noise: ear plugs vs oral drugs. Experientia. 1984 May 15; 40(5): 429-37.
  8. Hume K. Sleep disturbance due to noise: current issues and future research. Noise Health. 2010 Apr-Jun; 12(47): 70-6.
  9. Penney, P. J., & Earl, C. E. (2004). Occupational noise and effects on blood pressure: Exploring the relationship of hypertension and noise exposure in workers. AAOHN Journal 52(11), 476-80.

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