Ci e his a icle: Sanz-Segu a, R., Manchado Pé ez, E., Özcan, E. (2019) ‘Ala m Compliance in Heal hca e: Design
Conside a ions o Ac ionable Ala ms (In In ensi e Ca e Uni s)’, in P oceedings o he 22nd In e na ional Con e ence on
Enginee ing Design (ICED19), Del , The Ne he lands, 5-8 Augus 2019. DOI:10.1017/dsi.2019.88
ICED19
INTERNATIONAL CONFERENCE ON ENGINEERING DESIGN, ICED19
5-8 AUGUST 2019, DELFT, THE NETHERLANDS
ICED19
ALARM COMPLIANCE IN HEALTHCARE: DESIGN
CONSIDERATIONS FOR ACTIONABLE ALARMS (IN
INTENSIVE CARE UNITS)
Sanz-Segu a, Rosana (1); Manchado Pé ez, Edua do (1); Özcan, Eli (2)
1: School o Enginee ing and A chi ec u e. Uni e si y o Za agoza; 2: Facul y o Indus ial Design
Enginee ing Del Uni e si y o Technology. Depa men o In ensi e Ca e E asmus Medical Cen e
ABSTRACT
In ensi e ca e uni s a e echnologically ad anced en i onmen s ha a e designed o sa egua d he pa ien
while hei i als a e s abilized o u he ea men . Audible and isual ala ms a e pa o he heal hca e
ecology. Howe e , hese ala ms a e so many ha clinicians su e om a synd ome called ‘ala m
a igue’ and o en do no comply wi h he ask ala m is con eying. Measu ing compliance wi h ules in
he wo kspace and de e mining he success o a sys em belongs o he ield o e gonomics and is based
on da a collec ed h ough ask obse a ions and sco ing. In his pape , we will explo e compliance wi h
c i ical ala ms by no only om hei po en ial success o ailu e pe spec i e bu also om he
pe spec i es o he clinician capaci y, needs, and mo i a ions o comply wi h ala ms in c i ical
en i onmen s. We will inally, e lec on u he possible design s a egies o inc ease compliance in
c i ical ca e ha a e beyond ollowing ules pe se bu h ough in insic mo i a ion.
Keywo ds: Compliance, Design p ac ice, Decision making, Audible ala ms, Design enginee ing
Con ac :
Sanz-Segu a, Rosana
Uni e si y o Za agoza
Design and Manu ac u ing Enginee ing
Spain
[email p o ec ed]
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1 INTRODUCTION
In ensi e ca e uni s a e echnologically ad anced en i onmen s ha a e designed o sa egua d he
pa ien while hei i als a e s abilized o u he ea men . Audible and isual ala ms a e pa o he
heal hca e ecology. E e y elec onic de ice ( anging om pa ien moni o o in usion pumps o bed
hea e s) has ala ms inco po a ed ha signal a echnical o bodily mal unc ion. These ala ms a e pa o
he medical p o ocol designa ed by policy make s, in e na ional s anda ds o ice, medical ins i u ions,
and manu ac u e s, and a e oo ed in complex sys em design ha equi es clinician ac ion (Edwo hy,
2013). Howe e , audible ala ms a e so many ha clinicians su e om a synd ome called ‘ala m
a igue’ and o en do no comply wi h he ask ala m is con eying (K is ensen, Edwo hy and Özcan,
2017).
Sa e compliance beha iou is desc ibed as beha iou which do no iola e policy, o ganiza ion
secu i y ules and p ocedu es such as aking secu i y p ecau ions and epo ing any secu i y inciden s
exis in an o ganiza ion sys em (Humaidi and Balak ishnan, 2015). Measu ing compliance wi h ules
in he wo kspace and de e mining he success o a sys em belongs o he ield o e gonomics and is
based on da a collec ed h ough ask obse a ions and sco ing. Compliance is a e m equen ly used in
medicine (as a synonymous o adhe ence o capaci ance) o measu e o explain he deg ee o which a
pa ien co ec ly ollows medical ad ice. A he same ime, i also e e s o he use o medical de ice
o he esponse o heal hca e p ocedu es (De Gees and Saba é, 2003). Compliance, when applied o
c i ical medical ala ms e e s o imely ac ing on he message he ala m con eys. Howe e , he
phenomenon ‘ala m a igue’ obse ed in in ensi e ca e uni s indica es ha clinicians’ non-compliance
wi h ala ms is a speci ic issue and can ha e se ious li e- h ea ening o long- e m consequences on he
pa ien sa e y and wellbeing.
In his pape , we will explo e compliance wi h c i ical ala ms by no only om hei po en ial success
o ailu e pe spec i e (e gonomics measu es and in o ma ion heo y) bu also om he pe spec i es o
he clinician capaci y, needs, and mo i a ions o comply wi h ala ms in c i ical en i onmen s (e.g.,
beha iou change, pe suasi e model, app aisal heo y). We will inally, e lec on u he possible
design s a egies o inc ease compliance in c i ical ca e ha a e beyond ollowing ules pe se bu
h ough in insic mo i a ion.
2 WHAT IS COMPLIANCE IN HEALTHCARE
While compliance in o he indus ies can h ea en mission sa e y and ha e inancial isks, compliance
in heal hca e comes wi h e en highe s akes: i clinicians ail o ollow he p ope p ocedu e, hey can
end up inju ing a pa ien o ano he s a membe (Powe DMS, 2017). Acco ding o Manzey (2014),
“compliance e e s o he ex en ope a o s espond o a gi en ala m in acco dance wi h he ala m, i.e.
by ini ia ing all ac ions necessa y in case o a c i ical e en o mal unc ion. Con e sely, eliance e e s
o he ex en o which ope a o s e ain om any ac ion unless he ala m goes o ”. Compliance in
medical ca e in hospi als can co e a wide a ie y o p ac ices and be a ec ed by a ious ac o s. In
his pa icula con ex , nu ses a e he i s o espond o he pa ien ’s needs, supe ise he moni o ing
o hei cons an s, esponsible o keeping ope a ions unning smoo hly and make su e ha adequa e
p ocedu es a e ollowed and expec a ions a e unde s ood. Clinical ala ms a e one o he main channels
o communica e a wa ning e en o which nu ses ha e he obliga ion o espond o, in o de o
gua an ee pa ien sa e y (IEC 60601-1-8). A he same ime, a al inciden s ela ed o ala ms a e well
documen ed in he li e a u e. In he pe iod 2005-2008, US Food and D ug Adminis a ion ecei ed 566
epo s o ala m- ela ed pa ien dea hs (Join Commission, 2013). Mo eo e , lack o compliance
induces excessi e numbe o ala ms asking o a en ion e en ually c ea ing a chao ic en i onmen .
Pa ien sleep dep i a ion, s ess and a igue can be a po en ially impo an ac o s in he pa hogenesis
o ICU deli ium, which in u n is highly associa ed wi h inc eased pa ien mo ali y and mo bidi y.
Thus, non-compliance can ha e bo h di ec and indi ec consequences h ea ening pa ien sa e y as
well as well-being.
I medical ala ms a e designed o b ing nu ses o ac ion, hey can also be conside ed as s esso s o
s imuli ha e oke an emo ional episode o ac ion. F om Hancock´s pe spec i e on s ess, ala m
compliance can also be conside ed as a same in e ac i e p ocess wi h h ee ace s (Hancock, 2008).
Fi s , he physiological in e nal esponse o a c i ical e en , isible o in isible o he es o
indi iduals; second, he psychological e alua ion o app aisal o he e en , and he consequen
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esponse o ask demand in unc ion o men al wo kload, which may lead o ca e abou he ask o
e use i ; and hi d, how he esponse is a ec ed by a change in he en i onmen . As i was iden i ied
by Hancock and Wa m (1989), “ he beha iou in esponse o a ask is i sel di ec ly e lec i e o he
s ess le el expe ienced” and consequen ly, he deg ee o (non)compliance o he mission
pe o mance. Clinicians expe iencing ala m a igue may also be su e ing om lack o s imuli ha
b ing hem o ac ion. The easons o such non-ac ion and he lack o compliance will be explain in he
ollowing pa ag aphs.
3 WHY THERE IS NON-COMPLIANCE IN HEALTHCARE
A signi ican numbe o acciden s a e caused by human e o s due o he non-compliance wi h
p ocedu es such as igno ing impo an ac ions o ge ing con used by messages. The mos common
symp om o non-compliance in c i ical heal hca e en i onmen s is he ala m a igue. He e, we s a e
ha he e m “non-compliance” means ha clinicians ail o ollow he di ec ions due o conscious o
unconscious beha iou o (in) olun a y igno ance o ins uc ions, o he de imen o a bene icial
expe ience o he o ganiza ion o communi y (see also K is ensen, Edwo hy, Özcan, 2017).
Bu , why is he e non-compliance in he in ensi e ca e p ac i ione s? The e a e se e al schools o
s udies (i.e., e gonomics, beha iou al s udies, ala m managemen ) ha gi e insigh s o explain why
nu ses o en ail o ollow he p ocedu es. F om hese s udies and in-si u obse a ions i is de i ed ha
no all ala ms ha a nu se hea s a e medically ac ionable, which causes an inapp op ia e esponse o
he wa ning e en and induces disin e es and a lack o compliance. In ensi e Ca e Uni s (ICUs) a e a
complex heal hca e en i onmen ha in ol e mul iple use s, egula o y equi emen s, o e lapping
c i ical e en s and la ge amoun s o da a o be p ocessed. The e o e, in such a c i ical con ex , audible
ala ms a e he main medical ale s o wa n clinicians o po en ial haza d e en s. The use o ala m
sounds o p e en pa ien s om dying o being se iously ha med is an in eg al pa o mode n ca e in
hospi als. Ala ms a e undamen ally designed o be a c ucial wo k ool o clinicians. I onically, he
excessi e amoun o all hese ala ms c ea e a s ess ul sound en i onmen . Clinicians hea mul i ude o
ala ms a he ICU, some o hem come om hei own pa ien s, o he s om hei colleagues. As a
consequence, pa ien s’ men al and physical heal h as well as clinicians’ compliance a e h ea ened
(C i ical Ala ms Lab, 2018). O he aspec s as he loca ion o he sys em uni layou o he loo plan
also a ec s nu ses´ wo kload and explains why he e is non-compliance in c i ical ca e.
Ala m compliance ela e o ala m managemen by he o ganiza ion and is measu ed by he lack o
ac ion on ala ms. Howe e , non-compliance canno be a ibu ed solely o e gonomic ac o s. The e
a e also ci cums an ial issues and con ex - ela ed a i udes and p ac ices, caused by en i onmen ,
social and o ganiza ional ac o s. Sowan (2015) concluded ha “clinicians” a i udes and p ac ices
ela ed o clinical ala ms a e key in designing con ex ually sensi i e quali y ini ia i es o igh ala m
a igue and he e o e, an addi ional app oach o conside in imp o ing compliance. These ac o s,
among o he s, a e he le el o s ess ole ance, nu ses expe ience le el o aining, he sensi i i y o
sound and he ala m nuisance deg ee, o he le el o in ui ion (Humaidi, 2015; Pa k, 2003). Thus,
compliance can be desc ibed om di e en app oaches: om an e gonomic discipline, as adhe ing o
equi emen s, s anda ds, laws o egula ions ha ela e o ala m managemen in o de o gua an ee he
pa ien sa e y, based on human ac o s p inciples and p e ious expec ed alues conside a ions
(Meye s, 2004; Phansalka , 2014); and/o om a pe suasi e model, o help and mo i a e people o
adop beha iou and/o change a i udes owa ds a mo e desi able ou come in c i ical ca e. The la e is
mo e likely o be adop ed by nu ses han he manda o y app oach, due o i s mo e human-cen ed
na u e.
3.1 Con ex - ela ed ac o s inducing non-compliance
Acco ding o Hancock (2008, 1989), u he p og ess o p edic someone’s esponse in a speci ic
s ess ul c i ical si ua ion lies in wo ac o s. The i s one is ela ed wi h a global issue abou he
complexi y wi h in e ac ions and i s e ec s associa ed wi h wo kload and a igue; he second one is
he con ex - ela ed issue whe e, due o he indi idual di e ences, a s anda dized esponse canno be
expec ed. This ecological app oach (Gibson, 1979) is con i med wi h in ensi e ca e p ac i ione s and
explains why non-compliance is happening. Thus, he pe sonal app aisal p ocesses o he a ailable
esou ces and he ex e nal e en s ha a ec asks demanding can be summa ized in he ollowing
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speci ic ac o s obse ed in-si u in he daily li e in in ensi e ca e uni s du ing he decision-making
p ocess.
3.1.1 Pa ien -induced ala ms
Ce ain ala ms a e caused by a mo emen he pa ien make, o when pa ien s a e being ea ed and
equipmen is handled by nu ses o doc o s. F equen ly pa ien s induced an ala m asking o a en ion
o simply, hey sneeze o cough which igge s an unnecessa y ala m. In such cases he ala m does no
ep esen wha is eally happening o he pa ien .
3.1.2 Senso -induced echnical ala ms
Senso s ha a e used o moni o pa ien s may ge disconnec ed o may mal unc ion. Examples a e he
oxygen sa u a ion senso on he pa ien ’s inge ha is disconnec ed o senso s coming o du ing
pa ien hygiene p ocess and an ala m goes o . Though i is impo an o know ha all senso s wo k,
ala ms also occu when nu ses know he senso has come o du ing ea men .
3.1.3 Nu ses’ indi idual needs and p e e ences o ala m se ing
Nu ses can in luence he numbe o ala ms hey hea by changing he bounda ies a which he medical
de ice igge s an ala m o a ce ain alue. Howe e , nu ses may se limi s oo na ow ha esul s in a
non-ac ionable ala m. An ala m ha should usually be associa ed wi h a p oblem wi h o example one
o he pa ien ’s i als, can now ac ually mean a pa ien is esponding as expec ed o medica ion. Each
nu se has hei own app oach o hese se ings; ha is, a pe sonal p e e ence in ala m managemen and
se e al easons o why hey migh choose one o e he o he . Thus, he ala ms and he a en ion hey
ask o he nu se do no ake in o accoun how much in o ma ion a nu se al eady has o need.
3.1.4 Incomple e in o ma ion om pa ien moni o
The pa ien moni o signals an ala m based on a ange o i als ha a e measu ed. Since each o hese
alues has a se o bounda ies, he ala m will o en go o when jus one o hese alues exceeds he
limi . The nu se howe e , needs mo e nuanced in o ma ion abou he combina ion o se e al alues o
be able o judge he u gency o he p oblem. The esul is ha mos o he ala ms he moni o p oduces
a e swi ched o because hey do no equi e ac ion.
3.1.5 C y-wol e ec
Non-ac ionable ala ms lead o desensi iza ion o ala ms, meaning ha clinicians s op hea ing he
ala ms o he ala ms lose hei meaning as clinicians epea edly expe ience he ala ms as alse ala ms.
C y-wol e ec may esul in missed a al ala ms.
“Whe he o no a s esso is expe ienced as discom o ing is in luenced by a a ie y o pe sonal and
con ex ual ac o s including capaci ies, skills and abili ies, cons ain s, esou ces, and no ms
(Mechanic, 1978)”. In o de o imp o e ala m compliance by clinicians, i is necessa y o s udy he
a ie y o pe sonal and con ex ual ac o s ha a ec hei esponses and ac ions in c i ical
en i onmen s. Conside ing ha s ic p o ocols and adi ional p ocedu es ail o help clinicians o
eac a all o in a imely ashion. Because o his, al e na i e app oaches a e need o con ince
clinicians ha he ala m is ue and needs ac ion.
4 HOW TO IMPROVE COMPLIANCE IN CRITICAL CARE
While non-compliance needs o be esol ed in a mul i-s akeholde se ing beyond ‘ala m managemen ’
wi h p ocedu es and p o ocols, in his pape we ocus on he ‘ala m use ’ wi h hei capaci y and
willingness o espond. A s a ing poin o unde s and he human esponse in c i ical si ua ions is he
s udy o decision-making p ocesses, a ailable beha iou al models and psychological heo ies ha
e alua e pe cep ion and emo ional eac ion o a speci ic e en . Thus, a mul idisciplina y inqui y mus
be conside ed in o de o ob ain design p inciples ha guide ala m managemen in e ms o
compliance. Some o he heo ies o be conside ed as pa o his mul idisciplina y app oach a e shown
in Table 1 and also de ailed u he .
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Table 1. Mul idisciplina y app oaches o ala m compliance analysis
Model
Main con en
Some e e ence au ho s
Pe suasi e models
A ec use beha iou s
o a i udes by means
o p o iding
knowledge
(O ji, 2016)
(Nakajima, 2011)
(Oinas-Kukkonen, 2009)
Beha iou al models
and heo ies o
change
A ec use esponse
by means o speci ic
ac o s (mo i a ion,
abili y and igge s)
(Fogg, 2002)
(P ochaska, 1997)
App aisal heo y
A ec use esponse
by means o
an icipa ing hei
esponse unde s ess,
emo ional in luence
ha can a ec hei
decision-making
p ocesses
(Sche e , 1999)
(Laza us,1989)
Communica ion
models
A ec use esponse
by means o p o iding
p ope and p ecise
unde s anding o he
message ela ed o
each ala m
(Ma hews, 2015)
(Kelle mann, 1992)
(Shannon and Wea e , 1949)
4.1 Pe suasi e models
Pe suasi e models pe aining o compu ing echnology and in e ac i e sys ems a e a cu en and
eme ging end o heal h p omo ion and p e en ion (O ji, 2016) bu also o p edic ing use
accep ance and o change use beha iou s o a i udes (Oinas-Kukkonen, 2009). S udies in he ields o
a s o psychology p opose challenging and isiona y app oaches de ining design p inciples and
guidelines ha suppo beha iou change h ough he use /ope a o ´s cu en beha iou o a i ude
(Fogg, 2002). Some o he bes p ac ices a e based on p o iding use s wi h eedback ( hei own
beha iou al mi o ) and sui able suppo o achie e signi ican beha iou change ega ding hei
choices and ac ions (Nakajima, 2011); imp o ing in e ac i i y o he in o ma ion sys ems o a be e
communica ion (Ma hews, 2015); o encou aging ope a o s by an enhanced sys em h ough p omp s,
sugges ions and eminde s in o de o mo i a e o engage use s o pa icula beha iou (Oinas-
Kukkonen, 2009). In con as wi h hese app oaches, audi o y ala ms ca y oo li le in o ma ion; in
he absence o a meaning ul message, nu ses ely on a men al map o hei pa ien and use his o hei
own in e p e a ion and o p io i ize ala m u gency on hei own.
4.2 Beha iou al models and heo ies o change
These a e di e en a emp s, and also complemen a y o each o he , in o de o unde s and speci ic
beha iou s by iden i ying he unde lying ac o s and how esponse beha iou s can change
espec i ely. The ans heo e ical model o beha iou change (TTM) is based on a empo al
dimension, in eg a ing p ocesses and p inciples o change h ough s ages, and om di e en
in e en ions o change a use ’s undesi able beha iou (P ochaska, 1997). The Fogg Beha iou Model
(FBM) de ised o in e ac ion design sugges s beha iou as a esul o h ee di e en ac o s:
mo i a ion, abili y and igge s (Fogg, 2009). I he cogni i e load is oo high due o o e lapping asks,
i is mo e di icul o ocus on ala ms and he abili y o pe o m he ask dec eases. T igge s can be
applied as eminde s in clinical ala ms explo ing al e na i e modali y channels. Undesi ed clinical
beha iou can be sol ed unde s anding enables and ba ie s pe cei ed by nu ses. P ospec i e design
p ojec s as Ca eTunes by Koen Boge s o he Silen ICU by Eli Özcan, among o he s (see C i ical
ala ms Lab p ojec s) p opose design oppo uni ies ha could lead o a beha iou al change wi hin he
ICU. They a e based on al e na i e solu ions such as musical s eaming moni o ing o ala m
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communica ion emo ing sounds. They a e di e en mo i a o s o conduc mo e pleasan and quie e
c i ical ca e en i onmen s ha gua an ee ala m compliance.
4.3 App aisal heo y
The app aisal heo y is he e alua ion, om he ield o psychology, o he pe sonal signi icance and
meaning o an objec o si ua ion (Sche e , 1999), and he emo ional eac ion o a speci ic e en . I
desc ibes he psychological s eps o how ‘s esso s’, -in his case “ala ms”-, would possibly esul in
coping beha iou and eapp aisal. As an ex ension o his heo y, Richa d Laza us (1989) de eloped
he ansac ional model o s ess and coping. I desc ibes how s imuli can be pe cei ed by people.
Depending on a pe son’s app aisal o he s esso and hei a ailable esou ces o espond, hey can
expe ience s ess. The model p oposes consecu i e s ages ha desc ibe a decision making p ocess.
Pe cep ion il e s age is explained in a clinical en i onmen wi h lo s o s esso s, whe e human il e
is a su i al mechanism. Nu ses a e ex emely sensi i e o ala ms and il e ing happens bo h
consciously and unconsciously, being o some people ha de o il e han o o he s. The p ima y
eac ion ha a nu se has when an ala m sounds is o app aise he si ua ion acco ding o he c i icali y
o he e en and hus es ablish he le el o dange . I an ala m is pe cei ed as a alse ala m and no
a en ion is equi ed, he e is an oppo uni y o emo e ha ala m and become he s esso in o a
di e en design solu ion o communica e he e en . P ocess-o ien ed models o app aisal heo y a e
oo ed in he idea ha i is impo an o speci y he cogni i e p inciples and ope a ions unde lying
hese app aisal modes bu also o de ine en i onmen al ac o s ha acili a e o inhibi ac ion.
4.4 Communica ion models
A ansac ional model, in e ms o communica ion, e e s o a bidi ec ional in e ac ion, om one
pe son o sys em o ano he and back. In addi ion o he models men ioned p e iously, an
unde s anding o wha happens du ing he in o ma ion p ocessing is equi ed, in o de o imp o e he
p edisposi ion o ala m p ocessing and o keep nu ses in he loop. The e is s ill a li le known abou
he co ela ion be ween he in o ma ion (sys em e en s o messages o communica e), he cues
ollowed o guide medical design ecommenda ions and he decisions eached by nu ses in he con ex
o clinical p ac ice. In his sense, communica ion models a e also use ul o agmen he ala m
communica ion p ocess in di e en s ages and an icipa e he esponse o nu ses and desi ed decisions
in he la e s age (Shannon and Wea e , 1949; Kelle mann, 1992). Thus, oge he wi h mo e ecen ly
a ailable pe suasi e and beha iou models and heo ies o change, communica ion models can be
aken as a s a ing poin o de ine mo e success ul ac ionable ala m design p inciples.
5 CONCLUSIONS
The aim o his con ibu ion is o p esen a wide pe spec i e in ala m managemen in heal hca e
scena ios, in o de o explain clinicians´ non-compliance beha iou . In o de o add ess his, we
p esen a mul idisciplina y app oach based no only in e gonomics, bu also in he combina ion o
s udies abou decision-making p ocesses, exis ing pe suasi e and beha iou al models and
psychological heo ies. These al e na i e app oaches help clinicians o adop a mo e desi able
beha iou and mo i a ing a i udes wi h c i ical ala ms.
This pape ocuses on he ‘ala m use ’ wi h a human-cen ed app oach in o de o p o ide knowledge
o designe s and all he s akeholde s in ol ed in ala m compliance (de ice manu ac u es, medical
ins i u ions and clinicians, o policy make s). F om his s udy, hose disciplines can ob ain new
insigh s in o designing be e ala ms, unde s anding he wo k en i onmen in which clinicians in
gene al, and in ensi e ca e p ac i ione s in pa icula , ope a e in o de o: eo ganise he loo plan
layou , manage he in o ma ion sys em, o o de elop new design s a egies ha inc ease compliance,
no based only on he manda o y na u e bu also in human-cen ed app oaches wi h mo i a ion as an
unde lying challenge. F om cu en knowledge and in-si u obse a ions in se e al c i ical ca e a eas, i
highligh s he need o be awa e o he emo ions and beha iou esponses in a deepe way and om an
indi idual di e se app aisal, conside ing he human ac o s ha make ICU a complex scena io.
The li e a u e collec ed p o ides insigh s in o u u e inno a i e solu ions o ake as e e ence in o de
o inc ease compliance in such a posi i e way ha clinicians wan o espond o ala ms. The
pe suasi e app oach ga he s design p inciples use ul in a clinical ala m con ex such as an emo ional
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and meaning ul impac in engaging in beha iou al change (e.g., he use o al e na i e senso y o
cogni i e pa hways, such as musical o a is ic languages, can be he solu ion o es o e a peace ul
en i onmen o pa ien s o eco e in an in ensi e ca e uni ). Al e na i e modali ies o use
in e ac ion, om passi e moni o ing beha iou h ough sma de ices o a slow echnology philosophy
implemen use -sensi i e sys ems ha can sense he people p esen in a pa ien oom, adap ing hei
communica ion sys ems o he di e en needs o who use hem. Reducing p e-emp i e ala ms using
a i icial in elligence o il e ing ue ala ms; allowing a sys em o nu ses o become p oac i e, a he
han eac i e; o he need o keep nu ses in o a eedback loop a e o he posi i e ends o conside o
ala m compliance.
T adi ional esea ch in li e a u e in p ocesses ela ed o decision-making sugges a linea p ocessing
ha is simple and au onomous, whe eas he eali y in medical p ac ice is abou o ganiza ional
ela ionships and complex p ocesses ha equi e a ull ci cle o ac ions wi h emo ional, con ex ual
and pe sonal cha ac e is ics a ec ing ask pe o mance. Howe e , heal hca e and ICUs a e no he
only c i ical a ea ha equi es an imp o emen in compliance wi h ala ms. Eme gency si ua ions,
mission con ol ooms, ai c a s cockpi s o au onomous d i ing a e dynamic sys ems and all equi e
e y o en ime-c i ical esponses (Sousa e al., 2016; Baldwin & Lewis, 2014; Heyd a, Jansen & Van
Egmond, 2014; G aham, 1999; So kin, 1988; Pa e son, 1982). The aim o any ala m design
amewo k o igh non-compliance in c i ical con ex s, should be o p o ide he bes e idence abou
he managemen o a c i ical e en in o ming ope a o s (nu ses), and e.g. pa ien s whe e possible,
abou op ions ha a e a ailable, oge he wi h hei isks and bene i s (Hancock, 2005). The esponse
o a nu se is highly con ex - ela ed; a c i ical en i onmen go e ned by mul i ude o audi o y (and
isual) wa nings, no p io i ized, di icul o dis inguish and ha cause he ecu ing ala m a igue.
As an al e na i e o adi ional linea models, we a e cu en ly de eloping a ci cula amewo k o
nu se-cen ed compliance owa ds audible ala ms. This con ibu ion is one o he s a ing poin s o
en ich he en i e ecology o he ala m communica ion p ocess in c i ical ca e. Fu u e di ec ions a e
aimed a illing he gap in he las s age o he communica ion p ocess and gi e designe s he ools o
design new s a egies du ing he ala m design p ocess, om a nu se-cen ed app oach and in he
sea ch o a mo e desi able ou come in c i ical ca e. Thus, we will eel success ul when we close loop
by mo i a ing nu ses o comply wi h an audible ala m ha is eliable, con ex - ele an , and is
seamlessly embedded in he complex echnological a chi ec u e o in ensi e ca e uni s.
ACKNOWLEDGEMENTS
We would like o hank he ha dwo king clinicians a E asmus Medical Cen e Ro e dam (NL),
Hospi al Qui ón Za agoza and Hospi al HLA Mon pellie Za agoza (SP) o p o iding us wi h
oppo uni ies o discussions and in e iews on he opic o ala m a igue. We also hank he
esea che s a C i ical Ala ms Lab (TU Del , NL) o hei inspi a ional wo k on designing agains
ala m a igue.
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