The primary drivers of care, those who care for residents daily, are essential people at a nursing care facility: (1) Registered nurses (RNs). RNs are usually the unit managers and/or supervisor. They graduate from a state accredited nursing program and have been licensed by the state Board of Nursing. They were the units’ managers and the ones responsible for the residents’ care plans, and the ones that do the assessment in case of fall or any other type of injury. They also were the ones to start and manage IVs and administer any medication by vein. (2) Licensed practical nurses (LPNs), were originally educated and trained to work as bedside nurses in hospitals and are working now in nursing homes, rehabilitation centers, physicians’ offices, schools, and clinics. Becoming a licensed practical/vocational nurse requires the completion of a formal training program plus supervised clinical instruction. They all have high school diplomas or its equivalent and have graduated from a program with a license granted by the state Board of Nursing. Their main task is to administer medication, take vital signs, but they are also required to respond to the various alarms in the unit. LPNs work under the close supervision of registered nurses. (3) Certified nurse assistants (CNAs). They all completed a training program at a state-approved facility. They provide most of the direct care and assist residents with their daily activities such as toileting, shower, change clothes, transportation, mealtime, etc.
Organizational policies and standards are also important to keep residents safe. According to the nursing homes administrators, all the staff working on the unit are required to respond to every alarm, such as bed and chair exit alarms, and must respond to the call lights within 5 minutes. It was observed that LPNs often ignore call light notifications, in many cases walking past residents in need. It was also observed that it takes more than 5 minutes to respond to a call nurse light; in some cases, these responses can take up to 20 minutes. In many cases, the staff enter the resident’s room to ask about their needs and ask them to wait and forget to come back, in which case the residents must use the call light again (see the process section of the results). Many complaints were observed regarding the long response time, and in one of the nursing homes, the administration was studying the option of upgrading the call light system to a new one where they can monitor the response times of the staff to show the residents’ families that the response time is within the acceptable range in a way to try to reduce the number of complaints.
Communication across the staff working in the same unit is important for the safety of residents. However, there is no system for the staff to communicate in the same unit or between the staff in different units. If one CNA was busy with one resident, and another resident needed help, the CNA could not leave one resident to assist another resident. In addition, CNAs in some cases cannot provide care to residents without having two people involved (ex. Using lifting machine). With the lack of communication system, it is often difficult for the CNAs to find help; they run across the unit to find an available CAN or LPN. This can cause a delay in assisting the residents and might lead to an adverse event. Communication going vertically in the hierarchy is also important. CNAs have reported limited communication with the nurses on the unit due to their high workload
Between two shifts, there is a 30-minute overlap. The second shift, for example, starts at 2:45 p.m., whereas the first shift ends at 3:15 p.m. During this overlap, staff members are supposed to hand off reports (CNAs to CNAs, LPNs to LPNs) and do rounding. Rounding is a means of transferring information to the staff coming on shift and giving them updates regarding the residents’ current healthcare plan. Rounding usually takes place during the overlap between shifts. Staff members are supposed to check safety mechanisms during rounding and report any changes in a resident’s condition- such as changes that might require immediate attention and response to call lights from these residents. However, the checklist is not always followed. Normally only two to three people go on rounds because others may be busy with tasks such as charting, and in some cases, CNAs tend to underestimate the importance of rounding and not do it. A lack of direct communication between the two shifts was observed, which might result in the lack of feedback regarding the residents’ conditions.
Residents’ rooms are divided into sections and certain rooms are assigned to teams. This assignment remains unchanged for the whole month to ensure the consistency of service provided to residents. Each CNA oversees 8 to 13 residents and each LPN oversees 9 to 14 residents. There are three shifts per day with eight hours each. Day shifts have higher level of staffing than evening and night shifts.
When an alarm goes off, whether it is a call light, chair pad alarm, or a bed pad alarm, everyone should respond, including the housekeepers. There might be multiple staff members responding to an alarm until the resident is being assisted by the assigned team. Staff members communicate primarily in person. For example, two staff members may go to the same room to attend an alarm where they may also discuss another ongoing alarm and notify each other about their plans to deal with it.
The timing of the alarms also includes problems. When the alarm goes off, the patients may have already fallen (1, 18). Even if the staff are notified on time, they may not be able to address the resident’s needs on time. For example, if they were occupied with someone else, they cannot leave that resident unless all necessary actions and procedures guaranteeing the resident’s safety have been performed. This issue is more significant in the morning. Most residents wake up between 6:45 a.m. and 7:45 a.m. Numerous alarms can go off simultaneously when they all try to get out of bed or begin moving at the same time. The staff members race from one room to another. They rely on their experience and try to start with residents who cannot walk or stand by themselves. However, more than one resident need assistance from a CNA. Once, during our observation, CNAs asked the observers to watch residents several times because they could not leave another resident and no staff member was able to help. The noise from so many alarms can also confuse the staff, and noise produced from the auditory systems is almost constant. This causes discomfort for both residents and staff members. Staff can also develop alarm fatigue due to too many non-urgent call lights (24, 26). This leads to nursing staff to assume that residents do not need urgent help. This can cause them to ignore the alarms. While using a pager can reduce the noise and display the room number, nursing home staff members are constantly busy providing service for residents, which makes it difficult for them to grab the pager to see the room number.
Nursing homes are often understaffed, and nurses’ stations may not always be occupied. As nursing staff are always on the move in order to care for residents, this makes using a centralized monitoring system difficult. Due to the tight schedule and understaffing, while the CNAs are working with residents, they may not be able to provide time for rounding as planned. As a result, residents with risks may not be checked as often as prescribed. Can must either stay late after the shift is over to enter updates to the electronic health record (EHR) system or to use their breaks and become exhausted after unable to take a break during their shifts.
Additionally, a single staff member may be assigned to multiple residents at the same time, this can be particularly stressful when more than one resident need attention, such as instances whereby more than one resident must be transported. While working on their own, these logistical hurdles can create chaotic moments for both the nursing home staff and their residents. Further details are included in the summary of observations in Table 1.
Tools and Technologies
Three different call light systems were observed. Included in each system were nurse station consoles which triggered an alarm to indicate a call light. All systems have lights placed above the residents’ doors, and the lights come in two colors: white and either red or orange. These lights help in locating the senior using the call light. The white light indicates that the resident is asking for assistance from the bedroom, while the red or orange light indicates that the resident is asking for assistance from the bathroom.
The first call light system did not display the room number; instead, it only triggers an auditory alarm that is also broadcasted over speakers throughout the units. The auditory alarm uses a series of “beeping” at two levels of speed: slow beeping indicates that the call is coming from the bedroom, and fast beeping indicates that the call is coming from the bathroom. At the ceiling above the nurse station, there is a group of 4 lights which indicates 4 different areas in the unit. These lights turn on in response to a call light. The staff must locate the area first and then locate the resident by identifying the lights above the doors. If the lights for multiple areas are on, then the staff must check the lights above the doors in those areas.
The second call light system also used at nurses’ station console. The console was could display the room number to help the CNA easily locate the room, however it could only display one room number at a time. If a new alarm was triggered, it would “cover” or override the previous room number. In this system, the only auditory warning triggered is at the nurses’ stations. If the staff is working down the hallway or inside the residents’ rooms, they could not hear the alarm. Further, there are no sound differences between a call bell in the bedroom and a call bell in the bathroom the bathroom, with the latter often reflecting more urgent needs. In one of the nursing homes, it was observed that the console was muted in one unit and was covered with a file in another unit.
The third call light observed was a pager-based system that displays the room numbers in addition to a “beeping” sound. In this system, there is also a nurse station console that can display the room number and trigger an auditory alarm. However, the system can display only one room number at a time. In case of more than one alarm, the console will keep switching between the room numbers; it will display each room number for approximately 5 seconds before switching to display the next room number. The staff must cancel the alarm from inside the resident’s room and from the pager. See table 2.
Call light systems include both visual and auditory alarms. However, auditory alarms are not directional as they are broadcast through loudspeakers located at multiple spots in the hallway or only broadcasted at the nurse station area.
Usability Issues of Call Light Systems
There are many usability issues in the current employed call light systems. First, the staff is often unable to find a stopping place in there, in order to contribute to monitoring the central display of the call light. Some systems could only handle one alarm at a time. If an alarm was triggered by two or more residents, room numbers would not display until the first one was resolved, or the system would display the newest alarm and cover the previous one. In both cases, the nursing home staff have no access to feedback information about the number of alarms in the unit, if the alarms were resolved, and whether the residents were properly assisted. Not distinguishing between the alarms from bedrooms and the alarms from bathrooms (which often reflects more urgent needs) is another usability issue. In addition to reporting to the nurse station to receive notification, the staff must also look down the hall to distinguish the alarms by using the lights above the residents’ room doors.
Further, the nursing home staff are working inside the resident’s room most of the time. As a result, they lack access to hear the alarm when the systems trigger them from the nurse station. Additionally, systems that broadcast alarms using loudspeakers as well as other alarms in the unit constantly adjust the noise level in nursing home to a high pitch. While this is not desirable for the nursing home staff, it is even worse for the residents, the response time to call lights is long since the nurse station is not staffed most of the time. Using a pager can reduce the noise and display the room number, but the nursing home staff is always busy providing service for residents, and they cannot grab the pager to see the room number. Many staff members mute their pagers or leave them at the nurse station. Further, the auditory sound is not directional and thus is unhelpful for locating the resident’s alarm. CNAs tend to locate the room by looking at lights on the top of the doors, which can also be challenging at times due to the layout. The timing of the alarms also causes problems. Usually, when the alarm goes off, the patient may have already fallen. For example, a resident who tries to stand up but is unable to support him- or herself may lean forward and fall.
Broken parts were also a main usability issue impeding the systems. In some units, there were many broken and non-working lights. When a resident pushed the call light button, the auditory sound would be triggered, but the light might not have worked. In some cases, because the systems were very old, the lights would turn on, but no auditory alarm would be heard. See the summary of usability issues in Table 2.
The unit layouts for the facilities observed in the present study were L- or T-shaped with one nurse station. Residents who have high risks/more critical conditions stay in the rooms closest to the nurse station.
The auditory alarms are active for most of the day. This can be obnoxious to live-in residents, as it often disrupts their rest and distracts them from their activities. The study finds that this ultimately works against the nursing homes goal of creating a comfortable environment.
The floor layout and other aspects of the physical environment are poorly designed, making it difficult for the staff to know where an alarm (e.g., a call bell) is signaling danger. The auditory alarms were broadcasted without any directional information. The door lights did not always work, and beams and doorframes blocked certain alarms from being seen, requiring staff to walk to the middle of the hallway. In most nursing homes, CNAs tend to locate the room by looking at lights on the top of the doors, so CNAs must walk to the middle of the hallway to be able to see the lights.
Having many auditory notifications in nursing homes, such as bed mats, chair mats, call light systems, and the Wander Gard system, makes nursing home environments noisy and uncomfortable for many residents to live in. During our observations, many residents complained about constantly hearing the notifications and alarms throughout the day. Consequently, the staff members sometimes had to mute the call light system in some units, which posed challenges for notifying and responding to a call light. The impact of this noisy environment is not confined to residents but also reaches and affects the staff’s performance. See the summary of observation in table 1.
Call Light System
Task analysis methodology was used to analyze the task of being notified and responding to the call light system, as well as the actions the staff took to finish the task.
The results show that the highest response time was before dinner, and this was true in both units. ANOVA analysis results showed that the unit type had no significant effect on overall response time (p = 0.856). However, timing has a significant effect on the overall response time (p = 0.014), while the interaction between the unit type and the time interval had no significant effect on the response time (p = 0.874). In later analysis, the response time data in both units were combined due to there being no significant difference between them.
The average response time to a call light in both units was 9 minutes, these responses we’re the longest before dinner time. Response to call lights in the morning were also long, around 50% of the time, CNAs responded after 5 minutes, which exceeded the administration’s expectations/standards (Figure 1).
The staff did not use all the features in the system due to usability issues because the console was muted in the south unit. CNAs had to look at and track the lights all of the time. More than 16% of the time, CNAs forgot to cancel the alarm after they responded in this unit because there was no auditory alarm. This could cause a redundancy of work if another nurse noticed the light and responded to the same resident. More than 80% of the time, CNAs were notified by the light. All the cases when CNAs were notified by the display or console took place when they were near the nurse’s station area where they could hear and see the display. In many cases, due to broken parts in the system, CNAs were notified by the residents (Figure 2). After pushing the button for assistance, if no one responded to them, residents tended to stand and attempt to help themselves or to go the room door to lookout and shout angrily for a nurse’s attention. In more than 10% of call lights, CNAs responded and asked the resident to wait until they were done with someone else. Around 3% of the time, they forgot to come back to assist the first resident, see Figure 3.