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Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No. 1 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 1

Noise Pollution in the Operating Room: Student Registered Nurse Anesthetist Education: 
Reduction Strategies and Tools
Tyler Davis-Sandfoss, DNP, CRNA
Rachel Smith-Steinert, DNP, CRNA
Affiliation:
University of Cincinnati

Funding/Conflict of Interest Disclosure: 
None

KEYWORDS:  Anesthesia; noise; noise pollution; operating room; occupational safety

Abstract
Noise pollution in the operating room (OR) poses a safety concern to both patients and providers. Sound levels often 
exceed recommended standards set forth by the National Institute for Occupational Safety and Health (NIOSH) 
and the Occupational Safety and Health Administration (OSHA). The purpose of this project was to examine current 
evidence and implement education for student registered nurse anesthetists (SRNAs) regarding noise pollution in the 
OR. A pre-test and post-test methodology was utilized to assess the efficacy of the education module. Results generated 
from the education module illustrated a knowledge deficient in SRNAs pertaining to noise reduction, cognitive demand, 
and attention allocation during the delivery of an anesthetic in the OR. Average post-test scores were found to have a 
statistically higher average compared to the average pre-test scores (p < 0.001).  Noise pollution has been shown to be 
a complex, multifactorial problem. Emphasis should be placed on sustaining and integrating noise reduction education 
into curriculum schemas of nurse anesthesia programs.

AEJ



BACKGROUND
Noise pollution in the operating room (OR) poses a significant 
threat to both patients and OR staff during the intraoperative 
period. Evidence shows that operating room noise levels 
often exceed the standards set by the National Institute for 
Occupational Safety and Health (NIOSH) and the Occupational 
Safety and Health Administration (OSHA). 1, 2, 3 Katz and 
Englemann highlight the magnitude of noise levels, suggesting 
levels in the OR are greater than those generated from lawn 
mowers or passing trucks on a major highway. 4, 5 Currently, 
OSHA suggests limiting exposure to 95 decibels in four hours 
compared to NIOSH suggesting exposure limits of 95 decibels 
to one hour. 1 Routine exposure to noise pollution can predispose 
OR staff to increased chances of hearing loss, cardiovascular 
disease, cognitive stress, and hinders one’s ability to provide clear 
communication with other team members. 6, 11 
The purpose of this project was to construct and evaluate a 
noise pollution education module for student registered nurse 
anesthetists (SRNAs) with the goals of knowledge attainment 
and personal reflection pertaining to current practices. Future 
ramifications of this project could have an impact on improving 
overall patient outcomes and provider safety. Operating room 
staff work in a fast paced, high acuity, stressful environment. 
During the intra-operative time period, care providers must 
remain vigilant, as their work requires critical thinking and a 
tremendous amount of responsibility. Noise pollution presents a 
serious challenge in this setting. Interdisciplinary collaboration 
to achieve decreased noise levels and improve patient outcomes is 
essential. 
Investigation of current evidence identified initiatives such 
as the National Institute for Occupational Safety and Health 
(NIOSH) standards set forth in conjunction with the Centers 
for Disease Control (CDC). 8 The CDC asserts, “The mission 
of the NIOSH Hearing Loss Prevention Program is to provide 
national and world leadership to reduce the prevalence of 
occupational hearing loss.” 8 Emphasis on noise pollution and 
provider distraction has also been examined by the Anesthesia 
Patient Safety Foundation (APSF) recommending elimination 
of unnecessary clinical distractions, modulating unavoidable 
distractions, minimizing avoidable distractions, and reducing 
environmental noise.” 9,10 Multiple sources of noise exist during 
perioperative care. Staff behaviors, clinical practices, and OR 
traffic in and out of the operating suite contribute to noise 
pollution. Patient monitors and associated alarms, as well as 
surgical and anesthesia equipment, all contribute to a significant 
increase in noise pollution. 1, 3, 5 A loud environment not only 
creates an occupational hazard or distraction but can negatively 
affect care delivery which may ultimately result in patient harm. 
In addition to affecting staff performance, exposure to high 
noise levels can be harmful to patients by triggering physiologic 
changes like tachycardia, hypertension, oxygen desaturation, and 
laryngospasm. 6, 7 

METHODS 
Literature Search
PubMed, CINAHL and Scopus databases were searched 
using key words: noise, noise pollution, operating room, anesthesia, 

occupational safety. Systematic reviews, randomized and non-
randomized controlled trials, cohort studies, case studies, 
qualitative studies, and expert opinions were all considered. A 
total of 117 articles were retrieved, of which thirty-seven were 
included for review.
Educational intervention 

This SRNA education module was constructed with 
consideration of the Joint Commission’s 2018 National 
Hospital Patient Safety goals. Institutional review board (IRB) 
approval was deemed exempt for non-human subjects from 
the academic medical center. An in-depth analysis of current 
initiatives in the United States of America were reviewed to 
establish the need for this quality improvement project. The 
CDC Hearing loss prevention program, the Joint Commission’s 
2017 Hospital Patient Safety goals and the Anesthesia Patient 
Safety Foundation (APSF) conference reviewing Distractions 
in the Anesthesia Work Environment, were utilized to establish 
project need and construct the education module. 8, 9, 10 The noise 
pollution education content was not in the basic curriculum or 
nurse anesthesia traineeship programs evaluated. Furthermore, 
regulatory bodies have mandated institutions to protect 
employees from occupational hazards and that employees 
understand what occupational hazards pose a threat to their 
health. 
Student recruitment was elicited via email and participation was 
voluntary. Forty students participated in two education modules 
and lectures focusing on noise pollution. The education module 
for SRNAs on noise pollution was constructed to provide learners 
with a comprehensive summary of noise pollution, factors 
contributing to excessive noise, and the effects of noise pollution 
on patients and providers in the OR. 
An oral presentation was utilized to provide learners information 
on the characteristics of sound waves and how that leads to the 
production of noise. The primary sources of noise from monitors, 
alarms, equipment, and staff behavior were reviewed. 1, 4 Several 
tools and strategies to ameliorate noise pollution were provided 
including the use of noise measuring phone applications for 
reference sound levels and how to facilitate interdisciplinary 
huddles to address noise pollution. Actions to eliminate or 
minimizing unnecessary noise like music and suction were 
discussed. 
Evaluation Method
A pre-test and post-test methodology was utilized to assess 
effectiveness of the educational content delivery (Figure 1). Ten 
minutes were allotted to complete a pre-test, fifteen minutes 
for delivery of educational content, and ten minutes for post-
test completion. Students were provided an open forum session 
following delivery and completion of the education module to 
ask more detailed questions or express concerns regarding the 
content. Scores were analyzed using a t-test for paired data. 
RESULTS
The aim of this quality improvement education project was 
to assess SRNA awareness of noise pollution in the operating 
room and the associated consequences. The null hypothesis 
stated: There will not be a statistically significant difference between 

Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No. 1 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 2



pre-test scores and post-test scores. The pre-tests and post-tests 
included 8 multiple-choice questions and two open-response 
questions (Figure 1). Answers to questions were marked as 
correct or incorrect. The mean average pre-test score was 60% 
compared to the mean average post-test mean score of 90%. A 
2-tailed t-test for paired data was completed and revealed the 
observed difference (30%) was statistically significant (p<0.001).  
Assumptions for the t-test for paired data included continuous, 
interval/ratio level data and normality of data distribution. 
After analyzing data generated from the t-test demonstrating 
a statistically significant difference (30%) between the average 
pre-test scores and the average post-test scores, the decision was 
made to reject the null hypothesis. Results generated from the 
education module illustrated a knowledge deficient pertaining to 
noise pollution, cognitive demand, and attention allocation when 
providing anesthesia. The education module appeared effective in 
shedding light on noise pollution in the OR- a true knowledge 
deficit of SRNAs. 
The open forum discussion section revealed that over half the 
students were, “not concerned with noise” (N=29). Four stated 
they were, “sometimes concerned,” and seven stated they “were 
concerned.” However, 100% of students would change future 
practice after completing the education modules.
DISCUSSION
Noise pollution in the operating room has been an overlooked, 
but significant environmental and occupational hazard for both 
patients and providers. There has been a large body of evidence 
to support that sound levels in the operating room often exceed 
safe levels 1, 2, 3, 13 Special attention should be given to the 
current initiatives in place that acknowledge noise pollution 
as a significant threat. This project aim was to disseminate the 
current body of knowledge pertaining to noise pollution and 
provide suggestions to decrease or eliminate noise. Even if 
the findings had not been statistically significant, there was a 
profound argument that this project was clinically important in 
that interdisciplinary practice changes may yielded improved 
outcomes.  
Van Pelt stated, “distractions in the perioperative work environment 
can adversely affect vigilance, situational awareness, and the ability 
to respond promptly to changes in the patient’s condition and pose a 
risk to patient safety.” 10 One may assert that in order to achieve 
a system wide culture change, early delivery of formal education 
pertaining to environmental and occupational hazards should be 

employed. This initiative could improve patient safety and patient 
and provider satisfaction. 
LIMITATIONS 
The main limitation for this project was a small convenience 
sample from one nurse anesthesia program for the educational 
content delivered. Future projects should expand educational 
content to other OR professionals (eg, anesthesia providers, OR 
staff ). Furthermore, this quality improvement project was limited 
by the time constraint allotted for implementation. Students 
completed the pre-test, education module, and post-test in one 
session. Follow-up six months post-education would be beneficial 
to assess retention. A follow-up survey would assist in collection 
of data regarding practice changes have and any other perceived 
beneficial changes.
CONCLUSION
Excessive noise in the operating room poses a significant threat 
to both patients and providers. Noise pollution strains an 
anesthesia providers’ cognitive ability to function and challenges 
attention allocation. Interdisciplinary teams should be formed 
to identify, implement, and evaluate processes to decrease noise 
pollution in the operating room. It is imperative that ongoing 
assessment of interventions be conducted to ensure progress and 
augmentation of a therapeutic environment. Although several 
national initiatives are in place to reduce noise, it is imperative 
the knowledge pertaining to noise reduction is disseminated, and 
effective interventions implemented to protect both providers and 
patients. 

About the Authors

Tyler Davis-Sandfoss DNP, CRNA currently practices at Ann 
& Robert H. Lurie Children’s Hospital of Chicago with special 
interests in pediatric anesthesia and occupational safety for 
clinicians. Rachel Smith-Steinert DNP, CRNA is the Assistant 
Program Director at the University of Cincinnati Nurse 
Anesthesia program and currently practices at the University 
of Cincinnati Medical Center with special interests in nurse 
anesthesia education, grant writing, and collaboration with 
international schools of nursing.  The authors currently are 
involved in ongoing quality improvement efforts addressing noise 
pollution and reduction in the operating room. 

Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No. 1 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 3



REFERENCES
1. Fritsch MH, Chacko CE, Patterson EB. Operating room sound level hazards for patients and physicians. Otol Neurotol. 

2010;31:715-721. 
2. Hogan LJ, Harvey RL. Creating a culture of safety by reducing noise levels in the OR. AORN J. 2015;102(4):410.e1-410.e7. 

doi:10.1016/j.aorn.08.005
3. McNeer RR, Bennett CL, Dudaryk R. Intraoperative noise increases perceived task load and fatigue in anesthesiology residents: 

a simulation-based study. Anesth Analg. 2016;122:512-525. 
4. Katz JD. Noise in the operating room. Anesthesiology. 2014;121:894-898. 
5. Engelmann CR, Neis JP, Kirschbaum C, Grote G, Ure BM. A noise-reduction program in a pediatric operation theatre 

is associated with surgeon’s benefits and a reduced rate of complications: a prospective controlled clinical trial. Ann Surg. 
2014;259:1025-1033. 

6. Kerns E, Masterson EA, Themann CL, Calvert GM. Cardiovascular conditions, hearing difficulty, and occupational noise 
exposure within US industries and occupations. Am J Ind Med. 2018;61:477-491. 

7. Antonucci, R, Annalisa P, and Vassilios F. The infant incubator in the neonatal intensive care unit: unresolved issues and future 
developments, Journal of Perinatal Medicine. 2009;37(6): 587-598. doi:10.1515/JPM.2009.109

8. CDC - NIOSH Program Portfolio: Hearing Loss Prevention: Program Description. CDC website. https://www.cdc.gov/niosh/
programs/hlp/description.html. Published 2018. Accessed September 1, 2018.

9. 2018 Hospital National Patient Safety Goals. The Joint Commission website. https://www.jointcommission.org/assets/1/6/2018_
HAP_NPSG_goals_final.pdf. Published 2018. Accessed September 1, 2018.

10. van Pelt M, Weinger MB. Distractions in the anesthesia work environment: Impact on patient safety. Anesth Analg. 
2017;125(1):347-350. doi:10.1213/ANE.0000000000002139 

11. Ginsberg SH, Pantin E, Kraidin J, Solina A, Panjwani S, Yang G. Noise levels in modern operating rooms during surgery. J 
Cardiothorac Vasc Anesth. 2013;27:528-530. 

12. Kulkarni E, Abdallah Y, Hanseman D, & Krishnan, D. How much noise is an oral and maxillofacial surgeon exposed to? Journal 
of Oral and Maxillofacial Surgery. 2018; 76(7): 1400-1403.

Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No. 1 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 4



Figure 1. Educational Module Pre/Post Test

1. What is the average noise level in the operating room?
a. 40 decibels
b. 65 decibels
c. 75 decibels
d. 85 decibels
e. 100 decibels

2. What organization regulates occupational noise 
exposure limits?

a. National Institute of Occupational Health and 
Safety (NIOSH)

b. American College of Surgeons
c. State Associations (eg, Ohio State Health 

Association)
d. American Association of Nurse Anesthetist

3. What is the maximum amount of noise exposure 
suggested by the above-mentioned regulatory body in an 
8-hour period?

a. 65 decibels
b. 75 decibels
c. 85 decibels
d. 95 decibels
e. 105 decibels

4. During noisy procedures, such as neurosurgical, 
orthopedic surgery, etc., what is the average noise level 
40% of the time?

a. 85 decibels
b. 90 decibels
c. 100 decibels
d. 110 decibels

5. Please list one organization that has established a task 
force or has been proactive in attempting to educate OR 
staff on noise pollution.

a. ______________________________________
________________________________

6. Please list 3 variables that can be most easily 
manipulated to decrease noise pollution.

a. ______________________________________
________________________________

b. ______________________________________
________________________________  

c. ______________________________________
________________________________ 

7. Please list 3 complications for patients associated with 
noise pollution in the operating room.

a. ______________________________________
________________________________

b. ______________________________________
________________________________  

c. ______________________________________
________________________________ 

8. Please list 3 complications associated with noise 
pollution for providers.

a. ______________________________________
________________________________

b. ______________________________________
________________________________  

c. ______________________________________
________________________________ 

Educated Hand Publishing LLC 
“The Science Behind the Art” 
Volume 8 - No. 1 2020 

 Anesthesia eJournal - Online
ISSN 2333-2611

Page 5


