Turbulence and Turmoil in Nursing

While neither measured nor acknowledged, turbulence in the workplace monopolizes nurses' time and has serious consequences for nurses and patients.

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Turbulence and Turmoil in Nursing

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.

(Image credit 1)

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.2 Most 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.

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Nurse Beth

About Nurse Beth, MSN

Career Columnist / Author

Hi! Nice to meet you! I especially love helping new nurses. I am currently a nurse writer with a background in Staff Development, Telemetry and ICU.

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Specializes in NICU, PICU, Transport, L&D, Hospice.

It sounds like turbulence is a new descriptor for bare bones hospital staffing.  

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Noise can also add to this turbulence and actually impact our health

https://news.umich.edu/nurses-exposed-to-high-levels-of-noise-experience-more-health-problems-stress/

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Specializes in NICU, PICU, Transport, L&D, Hospice.
Wuzzie said:

Noise can also add to this turbulence and actually impact our health

https://news.umich.edu/nurses-exposed-to-high-levels-of-noise-experience-more-health-problems-stress/

Certainly.  Working in healthcare can be very unhealthy. 

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This article really resonates. Thanks for understanding. 

Over my nursing career, I have noticed a decline in the staffing of ancillary staff.

Orderlies and candy stripers were before my time, but I remember having way more CNA support, stock clerks, more available patient transport and free charge. When we went to computer charting, the higher management decided that we didn't need unit secretaries anymore, the CNAs could do both jobs. The nurses would do the rest. When the phone rang all the time, our new manager hired some unit secretaries again. 

Another factor that contributes to turbulence: open visitation.

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Specializes in Tele, ICU, Staff Development.
RNperdiem said:

This article really resonates. Thanks for understanding. 

Over my nursing career, I have noticed a decline in the staffing of ancillary staff.

Orderlies and candy stripers were before my time, but I remember having way more CNA support, stock clerks, more available patient transport and free charge. When we went to computer charting, the higher management decided that we didn't need unit secretaries anymore, the CNAs could do both jobs. The nurses would do the rest. When the phone rang all the time, our new manager hired some unit secretaries again. 

Another factor that contributes to turbulence: open visitation.

Thank you! Open visitation may be good for patients but it does add to the chaos. 

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Specializes in Psych/Ortho-neuro rehab.

I can't think of any personality who should enter nursing. If you care about your patients, you're screwed. If you don't care, what's the point? I don't know of one female nurse who has not cried on the job. Staffing ratios/acuity standards are a joke. 

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Specializes in NICU, PICU, Transport, L&D, Hospice.
Elodea Tiaga said:

I can't think of any personality who should enter nursing. If you care about your patients, you're screwed. If you don't care, what's the point? I don't know of one female nurse who has not cried on the job. Staffing ratios/acuity standards are a joke. 

https://wwmt.com/news/local/michigan-nurses-survey-quit-working-conditions-work-career-study-state-licensed-christopher-friese-results

Are you in Michigan?  

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Specializes in NICU.

Wait the turbulence is only going to get worse.Hold onto your hats,..see tik toc on how a certain hospital posted floating will be everyone everywhere and take a Full assignment.They have really lost their marbles.LD to cardiac ,ER to nicu,maternal child to LD.I recall those days before union organizing,cutting out floating post partum to detox/psch.,I got floated to LD,doc wanted me to assist in epidural placement,got yelled at by doc for informing him I was a float from unrelated floor.When revolution magazine came out with that floating pic of a nurse with a gun held to her head...well mgmt was aghast...but it spoke the truth.With unions help designated float teams were created and staffed by those who knowing wanted to work different areas,yet even they ..never had a full upper level critical patient.Sad to see nurse abuse getting worse...

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Specializes in NICU.
RNperdiem said:

Another factor that contributes to turbulence: open visitation.

100%

worse thing that could happen,never a moment of downtime,not even to fart,those video cams on the poor sick patients ,families that don't respect the patients condition,sleep,routine etc.rudeness galore..

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Specializes in Critical Care.

Your article and all the comments are so true.  The alarms were my Achilles heel,  constant and unpredictable.  I couldn't take the stress anymore of all of the above, especially unsafe working conditions created by corporate's cost cutting of support staff, increased patient ratios and refusal to have working equipment, even enough tele monitors.  What I didn't realize it was contributing to my own health problems, beyond just migraines, but uncontrolled HTN, weight gain, elevated HgbA1C, elevated liver enzymes and I don't drink at all; so basically metabolic syndrome from uncontrolled stress over the years in hospital nursing.  The good news is I've lost 30 pounds since early retirement, my BP is WNL, all my labs are WNL now.  I'm basically stress free, happy and content.  I didn't lose it thru diet or exercise either, other than I took topamax to quit my pepsi addiction but I had already lost 15 pounds before that.   Topamax is for seizures, but is used off label for migraines and also now for weight loss, but it will break a soda addiction because it will make it taste bizarre, thick and gross.

I didn't take the effect of stress seriously enough on my health or I would have left bedside sooner given the untenable working conditions.  My advice is take your health seriously, don't ignore workplace stress, be ready and willing to quit and find a better job.  The irony is back in 2002 they were trying to make my hospital Magnet status and demanded we all make a resume and a career binder of our achievements.  I probably should have taken the hint and moved on back then for greener pastures.  Oh well, I can pass on this good info to the younger generation to have your own resume, binder of nursing achievements, and networking to help you find a better job.  

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Specializes in Critical Care.

So the alarms started becoming exponentially more frequent and troublesome in 2002 because that year our manager decided we didn't need tele monitor techs anymore and instead added tele alarms at the station and in the halls and eventually to our phones.  When I questioned the safety of this to the risk manager I was told it was fine and maybe I should look for a different job! 

Probably should have listened and the resume and career binder were a mandatory part of the clinical ladder that they were instituting to improve pay but then they refused to give us a raise for the work!  They said we would be grandfathered in as a level II after we jumped thru the hoops but without the 4% raise!  If we wanted a raise we would have to jump thru more hoops to be a Level III or IV later, only the new grads would get the 4% raise. 

And by the way, they reserved the right to demote you and take your pay raise away in the future if you were a III or IV; and they did just that to several nurses, didn't matter if a person was dealing with a dying family member or personal problem.   They had a committee with one staff RN and the rest were the CNO and other management and management was bragging about their 300,000 plus houses one minute and the next voted to demote an ER nurse her pay!  I'm happy to report two of these managers who became subsequent CNO's one after the other only to be fired abruptly and lead out by security and it took them about a year to get another job!  I tracked their careers thru Linked In.  One of them had to move to a rural town 200 miles away.  I wonder if she sold her McMansion or not?  Also, shortly after that hospital was taken over by Ascension which is notorious for laying off management and if you have any chance of staying on it's like musical chairs and reapply for your job and see if you still have it and how many are left after the dust settles.  If you do still have it you will be doing the work of many more people than before and might wish you were let go.  Maybe it depends on if she still had a mortgage to pay off.  Who knows!  All I can say is it seems like Karma came a calling!

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