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Nurs Admin Q
Vol. 34, No. 4, pp. 327–333
Copyright  c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

The Effects of Hospital Noise

Denise B. Choiniere, MS, RN

Noise is an environmental stressor that is known to have physiological and psychological effects.
The body responds to noise in the same way it responds to stress and overtime can impair health.
Research clearly shows that hospital noise levels exceed noise level recommendations and has the
potential to increase complications in patients. What is less known is the effect hospital noise
has on nurses. The purpose of this article is to discuss hospital noise and its effects on patients
and nurses. Because nurses spend more time in hospitals over the course of their career, they
experience most of the burden from excessive occupational noise levels. Nurses must advocate
not only for a healthy work environment but also for a healing environment, for themselves as well
as for their patients. Key words: hospital, noise, nursing, stress

BACKGROUND AND SIGNIFICANCE disturbing sleep, and triggering hormones,

The word “noise” is derived from the Latin
word “nausea,” meaning seasickness.1 Noise
is among the most insidious and underrec-
ognized pollutants today. Unwanted sound
from road traffic, jet planes, jet skis, garbage
trucks, construction equipment, manufac-
turing processes, lawn mowers, and leaf
blowers negatively affect human health and
well-being.2 In 1979, the US Environmental
Protection Agency’s (EPA’s) Office on Noise
Abatement and Control released a document
highlighting the health concerns related to
noise. They noted that noise can produce se-
rious physical and psychological stress and no
one is immune to stress. Although individu-
als can adjust to noise by ignoring it, the ear
never stops receiving noise and the body still
responds to it, even during sleep.3-5
In 1954, it was observed that the noise lev-
els of daily living had increased 1 dB (A) per
year over the previous 25 years.6 According
to the World Health Organization (WHO), un-
wanted noise is causing hearing impairments,
Author Affiliation: Facilities and Patient Care
Services Department, University of Maryland
Medical Center, Baltimore.
Correspondence: Denise B. Choiniere, MS, RN, Uni-
versity of Maryland Medical Center, 22 S Greene St,
Baltimore, MD 21201 (dchoiniere@umm.edu).
which could affect the cardiovascular system,
the immune system, and the metabolism.2
The body responds to noise in much
the same way as it responds to stress,3,6-8
which, over time, can impair health. Ad-
verse health effects related to noise, noted
in the literature, include hearing loss,3,9,10
cardiovascular disturbances,3,7,8,11,12 sleep
disturbances,3,7,8-10,13-15 and impaired wound
healing.7,10,13 Psychosocial effects of exces-
sive noise include miscommunication3,6,8,16
and increased annoyance.3,6,7,10,16
Noise also affects unborn children when
mothers are exposed to industrial and en-
vironmental noise.5,17 Pregnant women ex-
posed to excessive noise have been shown
to have an increased risk of preterm birth
and give birth to infants with decreased birth
weight.17 Children exposed to high noise lev-
els may experience learning difficulties and
suffer poor health.5 Stansfeld and colleagues18
found that a long-term environmental stres-
sor, such as aircraft noise, could impair cog-
nitive development in children, specifically
reading comprehension. Occupational noise
is noise that is encountered in the work place
and therefore falls under the responsibility
of the employer and the individual.19 Strong
evidence shows that occupational noise is
a risk factor for adverse health outcomes.19
The hospital is one such work setting where
noise levels exceed WHO and EPA noise level
327

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NAQ3404-11 August 26, 2010 20:11 Char Count= 0
328 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2010
recommendations.7,8,10,20,21 Excessive hospi-
tal noise levels place patients and hospital
staff at risk to develop the adverse health ef-
fects related to noise.
MEASURING NOISE LEVELS
There are several ways to measure noise
levels. For the purposes of hospital noise, rel-
evant measures of noise are related to sound
levels. The relative loudness of sound is mea-
sured in decibels. However, individuals are
not equally sensitive to sounds of different fre-
quencies than one of equal loudness. There-
fore, a sensitivity factor is used that rates
sound pressure levels at different frequencies
in a way comparable with that of the human
ear, this is referred to as A-weighting. The bio-
physical quantity A-weighted sound pressure
level (L) is expressed as dB (A) and is referred
to as a sound level.2
HOSPITAL NOISE
Florence Nightingale believed that unnec-
essary noise is the most cruel absence of
care, which can be inflicted either on sick
or on well.22 Excessive hospital noise caused
by alarms, beepers, intercoms, and conver-
sation has been identified in the literature
as a stressor.8,20,21 The EPA recommends
that hospital sound levels should not exceed
45 dB (A),4 whereas the WHO recommends
that hospital sounds levels should not exceed
30 dB (A) and peaks should be less than
40 dB (A).2,23 These recommendations, how-
ever, have been exceeded in all reports of hos-
pital noise.7,8,10,20,21 A typical intensive care
unit (ICU) averages sound levels at 55 to 70 dB
(A), with pagers being recorded at 84 dB (A)
and monitor alarms recorded at 79 dB (A).8 To
put the sound levels into perspective, the A-
weighted decibels of a vacuum cleaner is 70,
a lawn mower 90 dB (A), and conversations
typically 55 dB (A).8
CONCEPTUAL FRAMEWORKS
Noise can stimulate the pituitary gland
and the sympathetic nervous system, which
Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
produces endocrine and sympathetic effects
commonly seen in response to a stressful
situation.7 Stress theories have been used to
explain the negative reaction individuals have
in response to their environment that are as-
sociated with negative health outcomes.20
Han Selye is regarded as one of the orig-
inators of stress theory. He defines stress
as “the nonspecific response of the body
to any demand” and a stressor as anything
that produces stress.24(p472) Although broad,
Selye’s general adaptation syndrome is consis-
tent with more recent theories.
Karasek and Theorell’s demand-control
model is similar to Selye’s stress theory and
predicts that a certain degree of stress is ben-
eficial whereas too much stress can result in
pathology. In jobs situations with high de-
mands and low control, such as nursing, it
is predicted that there will be an increase
in physiological and psychological stress, and
possibly disease.25 The theory of allostasis is
another theory that helps to predict the nega-
tive effect of stress. According to this theory,
physiological changes, such as pH, tempera-
ture, and glucose and oxygen levels, occur to
maintain homeostasis, or balance.26 Accord-
ing to McEwen and Lasley,27 the allostatic re-
sponse can become allostatic load when it is
activated too frequently, such as when a per-
son is subjected to repeated, unrelieved, or
unremitting stress. They believe that a healthy
stress response in the healthiest individual
has the potential to cause damage if activated
again and again over an extended period of
time.
OCCUPATIONAL STRESS
The National Institute for Occupational
Safety and Health defines occupational stress
as “the harmful physical and emotional re-
sponses that occur when the requirements
of the job do not match the capabilities, re-
sources, or needs of the worker.”28(p1) Health
care workers are known to suffer from occu-
pational stress often due to high expectations
coupled with insufficient, time, skills, and/or
social support at work.29 Nursing in particular
NAQ3404-11 August 26, 2010 20:11 Char Count= 0
is often regarded as a stressful occupation be-
cause of not only the nature of the work of car-
ing for the sick but also the features of nurse’s
work environments are stressor.
NOISE-INDUCED STRESS
Noise is often defined as unwanted sound3 ;
however, it is also recognized as an envi-
ronmental pollutant, which causes workplace
disruption and has implications for chronic
mental and physical health.8 Noise that is
considered unpredictable and not able to
be controlled is perceived as more stressful
than continuous noise.21 According to Topf
and Dillon,21 human effects that are associ-
ated with noise-induced stress include a de-
crease in sustained attention, rapid detection,
multiple single tasks, and incidental memory.
Noise-induced stress also has a negative effect
on sensitivity to others and is linked to ex-
treme and premature judgments.21 Topf and
Dillon21 also showed that noise-induced stress
is positively related to burnout in critical care
nurses.
LITERATURE REVIEW
Sound levels in hospital
Hospitals were once quiet environments.6,7
This is not quite the case today. In 1960,
the average daytime hospital sound level was
57 dB (A) and nighttime noise was 42 dB
(A). In 2005, the average daytime sound lev-
els were recorded at 72 dB (A) and night-
time noise averaged 60 dB (A).30 Researchers
have concluded that all hospitals, regardless
of their size, type of patients they care for, at
all times of day, every day of the week, ex-
ceed recommended noise levels put forth by
the EPA and the WHO.30
Advances in the complexity of patient care
and the technology being used for that care
contribute to hospitals becoming noisier en-
vironments. However, human activities, such
as talking, are often identified as the most
frequent source of noise.8,14,30 According to
Christensen,7 the majority of research done
Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Hospital Noise 329
on hospital noise has been conducted in ICUs
and has shown that ICUs tend to be where
noise pollution is the most excessive. Average
ICU sound levels range from 55 to 70 dB (A),
with peak sound levels recorded from 100 to
120 dB (A).8
Effects of noise on patients
Noisy environments have adverse health
implications on patients who are undergoing
the healing process and recovery. Research
has indicated that there is a positive correla-
tion between hospital noise and physiological
responses experienced by patients,7 the most
significant being an increased risk of hyper-
tension and ischemic heart disease.7,11,12,30,31
Uncontrollable noise triggers the human
stress response, activating the sympathetic
nervous system to release epinephrine and
norepinephrine, which constrict blood ves-
sels and elevates blood pressure and heart
rate.7,32 Excessive noise levels also stimulate
the production of adrenocorticotropic hor-
mone and the release of adrenaline and nora-
drenaline, similar to the endocrine response
that occurs in response to a stressful event.7
Adrenocorticotropic hormone activation re-
sults in the release of cortisol by the adrenal
cortex, which promotes the accumulation
of body fat and formation of atherosclerotic
plaques in the coronary arteries,7,26 placing
individuals at a higher risk for developing
heart disease. Adrenaline and noradrenaline
increase blood glucose by inhibiting the se-
cretion of insulin and inhibiting the uptake of
glucose.7,26 In addition, cortisol, adrenaline,
and noradrenaline delay wound healing.7,10 El-
evated serum cortisol and adrenaline levels
have been associated with noise levels mea-
sured at 85 dB (A),7 which is common in the
ICU setting.7
Sound levels greater than 50 dB (A) cause
sleep disturbances in hospital patients.8 Re-
search has shown a positive correlation be-
tween ICU noise levels and ICU delirium re-
lated to sleep deprivation.7,13 ICU delirium
is portrayed by patients as changes in be-
havior, delusions, paranoia, slurred speech,
NAQ3404-11 August 26, 2010 20:11 Char Count= 0
330 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2010
irritability, and disorientation.7,15 Sleep depri-
vation has also been shown to have a neg-
ative effect on the immune system.13,15 It
is during sleep that protein synthesis and
cell division occur, which are necessary for
the human body to heal and recover.13,15
Topf and Thompson15 also note that with-
out adequate sleep, patient recovery may be
negatively affected, and according to Morri-
son and colleagues,10 sleep deprivation in-
creases length of hospital stay. Excessive
noise has also been positively associated with
the increased sedation requirements for ICU
patients.8 Patients who were sedated with
propofol prior to surgery required more med-
ication to reach adequate sedation in nois-
ier environments.33 The implications of in-
creased sedation include an increase in the
incidence of patient complications, such as
ventilator-acquired pneumonia, and extended
requirements for mechanical ventilation.34
Effects of noise on nurses
Although there has been an extensive
amount of research done on the effects of hos-
pital noise on patients, less has been done to
determine the negative effects noise has on
nurses.10,21 Anecdotal evidence suggests that
nurses are not aware of the physiological ef-
fects noise has on them.7 Thus, nurses are not
identifying noise as a potential health risk of
their own. Research has shown that people
adapt to noisy work environments by becom-
ing less interpersonally engaged, less caring,
and less reflective.6 In addition, those work-
ing in noisy environments are more likely to
use noncommunicative styles of interaction,
are more impulsive, and have increased ag-
gression and annoyance.6,10,16
Nurses are exposed to the same noises
as patients, so the impact on nurses must
also be considered. The typical nurse is bom-
barded daily with the sounds of telephones,
pagers, call lights, alarms, and conversations.
Although mechanical instruments are identi-
fied by nurses as the contributor of noise,
research has shown that the elevated noise
level is mainly due to staff conversations.7,14
Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Elevated noise levels can affect communi-
cation between health care providers and
patients, which increases the risk of er-
rors due to miscommunication and impaired
concentration.8 There is also a potential for
delayed recognition and response to alarms in
noisy environments,8 which has implications
for compromising patient safety.
Morrison and colleagues10 were the first re-
searchers to measure hospital noise and cor-
relate it with a nursing stress questionnaire,
salivary amylase, and heart rate. A positive cor-
relation was found between increased noise
levels and increased stress levels, heart rate,
and annoyance rating. Interestingly, however,
the results for salivary amylase did not show
a significant correlation with noise levels. De-
spite the small sample size of 11 nurses, their
findings indicate that noise is a significant con-
tributor to increased heart rate, stress, and an-
noyance among nurses, indicating the need
for further research to be done with regard to
the effects of hospital noise on nurses.10
Topf and Dillon21 found that prolonged
exposure to noise, results in noise-induced
stress, which was a predictor of burnout in
critical care nurses. Burnout is described as
emotional exhaustion, depersonalization, and
decreased personal accomplishment.21
Blomkvist and colleagues16 replaced tradi-
tional ceiling tiles with sound-absorbing tiles
and found that the staff working in the unit
with the sound-absorbing tiles experienced
reduced demands and less pressure/strain and
felt less irritable than the staff who did not
have sound-absorbing ceiling tiles in their
unit. Their study concludes that improved
acoustic conditions in hospitals can reduce
risk of conflicts and errors through the re-
duced noise load.16 In a hematology oncology
unit at a tertiary hospital, patients complained
about the noise in the unit, specifically noise
resulting from the alarms, intercom call, and
conversations. Rashva and colleagues35 mea-
sured the noise levels on the unit, and they
were found to be 70 dB (A). Noise reduc-
tion panels were installed on walls and ceiling
of work areas and follow-up noise level mea-
surements dropped 15 dB (A). There was a
NAQ3404-11 August 26, 2010 20:11 Char Count= 0
decreased perception of noise in the unit by
patients and staff, thus decreasing the risks for
errors and stress on staff.35
IMPLICATIONS FOR NURSING PRACTICE
Fifty percent of hospital sound peaks are di-
rectly attributable to human behavior; there-
fore, there are multiple opportunities to re-
duce noise levels in ICUs through behavior
modification.8,9 Patients identify staff conver-
sations to be the most disturbing noise in
the unit,8 so nurses need to become more
cognizant of their conversations and identify
ways to decrease the noise level. For example,
during change of shift, patient doors could be
closed and reports can be given in a confer-
ence room.
Kahn and colleagues9 identified exactly
what caused excessive noise levels in ICUs
and found that many of the sound peaks
greater than 80 dB (A) could be mitigated
through behavior modification. Forty-nine
percent of the noise levels greater than 80 dB
(A) were attributed to conversations and the
television.9 Behavior modification programs
consist of a comprehensive educational pro-
gram for all staff members and include in-
formation about noise pollution, its effects
on patients and staff and identify the types
of noise that are amenable to human be-
havior and therefore modifiable.9 Suggestions
for behavior modification included turning
off large central televisions, placing beepers
on vibration mode, decreasing intercom use,
and allowing only 2 visitors at a time in the
patient room. Following the educational pro-
gram, peak sound levels attributed to hu-
man behavior decreased from 6:00 AM to
12:00 AM.9 However, the researchers did not
address the long-term effectiveness of their
intervention.
The University of Maryland Medical Cen-
ter cardiac ICU implemented a quiet hour
to combat the noise in its 15-bed unit. Af-
ter a complete review of unit activities con-
tributing to elevated noise levels, a designated
quiet hour was adopted daily from 2:00 PM to
Copyright © 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Hospital Noise 331
3:00 PM.36 During that time, visitors were
asked to leave to allow the patients to rest, pa-
tient doors were closed, lights were dimmed,
alarm volumes were lowered, intercom was
not permitted, and no nonemergent proce-
dures were performed.36 Deliveries into the
unit, such as pharmacy, linen, supplies, and
dietary, were coordinated to not occur during
this time unless emergent.
Hospitals are beginning to install TalkLights
to help units maintain a calm environment.
TalkLights look like traffic signals. When noise
levels are acceptable, the light is green, and
as noise levels increase, the TalkLight begins
to flash yellow and then changes to red when
noise levels exceed limits.37 TalkLights are be-
ing used in conjunction with wireless tele-
phone and paging systems that reduce the
need for overhead pagers.
Physicians and nurses must be educated
about the dramatic effects their own talking
can have on patient outcomes.13,14 Additional
behavior modification strategies that can re-
duce ICU noise include decreasing telephone
ring volume and adjusting patient alarms spe-
cific to each individual patient’s requirements
rather than using default alarm settings. In 1
study, it was found that 75% of alarms were
found to be spurious, with only 3% of the
sounds indicating true risk to the patient.6
Nurses can also begin partnering with hos-
pital architects and advocating for improved
building design to decrease noise. Building de-
signs that improve the sound acoustics in hos-
pitals include decentralized nurses stations,
reducing the number of right angles, which
elicit more sound vibrations, sound-absorbing
ceiling tiles and wall coverings, soft flooring,
and single patient rooms.38
CONCLUSION
The research clearly shows that hospitals
are noisy work environments that may cre-
ate increased risks for patients and nurses.
Over the course of their career, nurses spend
more time in hospitals than patients and, as
a result, experience most of the burden from
NAQ3404-11 August 26, 2010 20:11 Char Count= 0
332 NURSING ADMINISTRATION QUARTERLY/OCTOBER–DECEMBER 2010
excessive occupational noise. The body re-
sponds to noise in the same way it responds
to a stressful situation3,6-8 ; therefore, individu-
als exposed to excessive noise are at a higher
risk to develop adverse health effects.
Hospital noise levels clearly exceed
recommendations put forth by the EPA
and the WHO and has implications for
chronic mental and physical health.8 Ex-
cessive noise increase risks to patients
through cardiovascular disturbances,3,7,8,11,12
miscommunication,3,6,8,16 increased length
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Hospital Noise 333
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