Turbulence and Turmoil in Nursing

Nurse Beth, MSN

Look around the floor any day, and you'll likely see one or two frantic nurses. At one time or another, we've all been that desperate nurse, or maybe we've been the deceptively outwardly calm but inwardly frantic nurse who's drowning.

Why do nurses' days spin out of control? When do they spin out of control? And what is the tipping point?

Despite not being acknowledged or measured as a working concept, turbulence is regularly experienced by nurses.

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Model nurses work within context

Turbulence Defined

Jennings defined turbulence as the "disorder and turmoil that characterizes contemporary hospital environments" and "loss of control due to simultaneous demands" (p.1442).² Turbulence has been likened to a waterfall's uncontrollable force and rush, leading to the familiar declaration of "I'm drowning."

Causes of turbulence include:

new, complex, or unfamiliar work (think floating).
heavy patient loads.
excessive responsibility.
malfunctioning, missing, broken equipment and supplies.
patient churn due to admissions, discharges, and transfers.
complex communication problems.
duplication of work (typical in EHR systems).²

Existing Workload Measurements

Can chaos be measured?

Current workload measures are based on linear work and time and motion studies that originated in factories. Metrics include patient acuity and static measurements such as midnight census (heads in beds).

These measures do not capture turbulence even while turbulence monopolizes nurses' time.³

Nursing Work is Not Linear

Physical therapists, dieticians, and speech pathologists typically work with one patient at a time. Surgeons perform surgery on one patient at a time. Car mechanics work on one car at a time.

Even cashiers check customers out one at a time.

By contrast, a nurse juggles several patients and multiple competing priorities at a time. Nurses' work is compared to playing numerous chess games simultaneously.³

Nurses' work is not linear, predictable, static, or sequential. It is cyclic, unpredictable, and cognitively complex. As patients' conditions change, critical decisions must be made immediately.

A nurse's work is characterized by interruptions, the majority of which do not require the skills of a nurse.

A Simple Task

Time and motion studies fail miserably at capturing nurses' work.

Syndey needs a Hoyer lift to weigh her patient with C-diff. Time and motion studies indicate this task is relatively simple and accordingly is allotted about 20 minutes (estimation).

Syndey starts by searching for the Hoyer lift.

She calls her charge nurse, who answers after the third call and says the lift is on the 3rd floor. The charge nurse doesn't offer to get it. Syndey takes the stairs three flights down to the 3rd floor and doesn't find it in the eastside hallway nook where it should be. Maybe she heard wrong. She walks the length of the floor to the westside hallway nook, and it's not there, either.

She needs to figure out who to ask or call. Finally, she asks a nursing assistant who says she thinks it was taken to the Stepdown unit (SDU). Sydney calls the SDU secretary, who asks the charge nurse, who says she can come up and get it.

Sydney gets the massive piece of equipment and steers it out of SDU, down the hall, and towards the elevators. One of the elevators is not working, so it's a long wait. Finally, Sydney returns to the patient's room with the lift and uses the spreader handle to maneuver the base legs under the bed.

The certified nursing assistant (CNA) that was going to help Sydney is now busy in another room, so Sydney starts by herself. She was counting on the CNA's experience using the lift as Sydney has not used it by herself and can't recall the information-overloaded demonstration from Orientation six months ago.

She tries to remember how to zero it out...is it with a pull sheet? Without a pull sheet? And should she change it to read out in kgs and not lbs?

Together they log roll the patient and position the sling underneath the patient. They thread the S links through the sling attachment holes. While the lift hydraulically raises the patient in the air, Sydney realizes that the urine catheter bag is full (she should have emptied it!) and that the oxygen tubing will not reach. She asks her CNA to run and grab an oxygen extension tubing quickly.

Meanwhile, Sydney's phone rings, and she glances down. It's the provider she's been trying to get ahold of all morning. The battery light flashes, but Sydney remembers this is the phone with the loose battery cover; it needs to be held tightly to make the connection. Sydney makes a mental note to tape it together later.

With one hand on the Hoyer sling and one hand holding the phone, Sydney takes an order for a pain med for another patient and commits "hydrocodone 5 mg 2 every 4 hours PRN moderate pain" to memory, knowing she should ask the provider to enter it herself, but she is so grateful to get the order finally and so hesitant to be assertive that she doesn't.

The patient's IV keeps alarming loudly, reading occlusion, but the IV pump is on the other side of the bed. Sydney asks her patient, "Can you straighten your arm, please?"

Her CNA returns with the extension tubing, and just then, Sydney recognizes an undeniably distinctive odor wafting from the Hoyer sling. She and her CNA look at each other. Oh, no....you get the idea.

(Note: Each time in and out of the patient room required time-consuming donning and doffing of personal protective equipment (PPE), as the patient is in contact isolation for C-diff).

There are very few simple tasks.

Interruptions, Delays, Workarounds

According to Jennings, interruptions are the most common form of turbulence.²Most interruptions are unnecessary. However, interruptions completely redirect the nurse, causing thought diversion and cognitive shifts.³

Not only are nurses unprotected from continuous interruptions, but they are responsible for a plethora of non-nursing tasks.

Non-nursing Tasks

Nurses perform a tremendous number of non-nursing tasks to get the job done. Many tasks involve following up on others' work, such as chasing missing medications or tracking personal belongings.

These unplanned tasks, or "hassles," are not measured because they are not officially nursing tasks yet add to the turbulence.⁴

Examples include:

cleaning an IV pump to have one ready for your admission coming up the elevator.
going to another floor to grab supplies/calling for supplies.
ordering stock supplies.
scheduling tests and procedures.
taking a patient out to the curb for discharge because transport is backed up.
finding a bucket for a commode.
taking multiple unnecessary phone calls.

Consequences

Turbulence is more closely associated with the risk to patient safety than is workload and has a statistically significant and direct negative relationship on communication and interpersonal coworker relations.⁴

Turbulence increases nurses' stress and cognitive work and decreases nurses' sense of well-being.²

Conclusion

Actions to address turbulence include:

teaching students and nurses strategies to manage turbulence.
attending to longstanding issues with supplies and equipment.
identifying ways to reduce cognitive overload.
hiring support staff to manage non-nursing tasks.
developing ways to minimize interruptions.
developing technology platforms with nurse input.
suggesting investigations to advance understanding of how turbulence influences—nurses and to devise effective interventions.
developing organizational policies to address turbulence.
establishing metrics for safe patient loads. ^2,5

Further research into turbulence is essential to quantify nurses' workload and ensure patient safety.

References/Resources

1 Hawkins SF, Morse JM. Untenable Expectations: Nurses' Work in the Context of Medication Administration, Error, and the Organization. Glob Qual Nurs Res. 2022 Nov 13;9:23333936221131779. doi: 10.1177/23333936221131779. PMID: 36387044; PMCID: PMC9663611.

2 Jennings BM. Turbulence. In: Hughes RG, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 29.

3 Browne, J., & Braden, C. J. (2020). Nursing turbulence in critical care: Relationships with nursing workload and patient safety. American Journal of Critical Care, 29(3), 182-191.

4 Beaudoin, L. E., & Edgar, L. (2003). Hassles: their importance to nurses' quality of work life. Nursing Economics, 21(3), 106.

5 Jennings BM, Baernholdt M, Hopkinson SG. Exploring the turbulent nature of nurses' workflow. Nurs Outlook. 2022 May-Jun;70(3):440-450. doi: 10.1016/j.outlook.2022.01.002. Epub 2022 Feb 25. PMID: 35221055.