Defining the daily demands on critical care nurses by workload alone doesn't take into account inevitable interruptions, called turbulence, that impact nurses' time and patient outcomes, according to a nurse-led study published in the American Journal of Critical Care.
Nursing turbulence, such as looking for equipment or resolving missing medications, is routine for nurses in all care environments. Linda Bell, MSN, RN, wrote in an accompanying commentary published in the same AJCC issue that navigating these interruptions and distractions can derail even experienced nurses. "Currently, acuity systems neither identify nor capture this work or its impact. However, these activities have a considerable impact on nursing workload and patient safety," Bell wrote. Using survey responses from American Association of Critical-Care Nurses members, study authors Jennifer Browne, PhD, RN-BC, CCRN, and Carrie Jo Braden, PhD, RN, did a 2-phase study to explore the concept of turbulence, create a preliminary measure, and propose a conceptual definition of turbulence.
Nurses' Work is Ill-Defined
The authors' earlier research revealed there wasn't a consistent definition of workload in nursing, according to study author Jennifer Browne, PhD, RN-BC, CCRN, Assistant Professor in the School of Nursing and Health Professions at the University of the Incarnate Word, San Antonio, Texas. "In some cases, we found that workload science was poorly done," Browne said. "For example, a 2011 literature review explored 30 workload studies of which 26 contained no definition of workload!" The authors found potential flaws in underlying assumptions about ICU workload, including an observational study, which revealed that patients needing ICU care require more nursing care hours, yet mechanically-ventilated patients might actually need fewer care hours than those who are self-ventilating, according to Browne.
"We also found numerous activities performed by nurses that are not described in any workload definitions or attributes," she said.
The authors defined workload in the AJCC study as the amount of work -- including physical, emotional and cognitive -- that a nurse is required to perform in a defined period of time. They used two simple measures: nurse/patient ratio and the degree of workload nurses experienced, whether it was light, moderate, or heavy, according to Browne.
Defining Turbulence
Turbulence is also known as environmental turbulence, work-fluency, complexity, and environmental uncertainty. According to Browne, it involves internal and external factors and can be described as an ineffective buffering of any disruptive force that may intrude on nurses' ability to do their jobs.
"Turbulence came to our attention during early phases of our pilot, when nurses were observed to be performing activities not described by workload measures," Browne said. "Nurses were spending a great deal of time searching for equipment, acquiring missing medication, double and triple documenting, being interrupted for non-essential reasons, and managing incomplete and missing communications."
Staffing and workload models don't generally consider turbulence, she said. Based on their findings, the authors defined turbulence as the degree to which a nurse's attention to tasks is diluted or redirected by thought diversions, resource inadequacy, communication breakdowns, and/or interpersonal relationships.
Turbulence as Nurses Experience It
Many of today's workload measures don't capture the complexity and variability involved in nursing care. "For example, transfusing one unit of packed cells may seem straightforward enough, but negotiating the order, obtaining appropriate consent, transporting the blood product, and any additional 'hidden work,' such as technology obstacles and verification processes, can greatly add to the RN's workload," Browne said. The researchers found that indeed turbulence is an unexplored concept, it adds to workload, and can negatively impact patient safety. Turbulence included interruptions, distractions, loss of information, and lack of secretarial support, equipment and supply issues. And, as turbulence increased, so did workload.
"While most contemporary studies associate patient safety risk with elevated workload, our study revealed that turbulence was most strongly correlated with patient safety risk," Browne said. "The weakest association was found between workload and patient safety risk."
The authors included four processes and 12 items in their proposed turbulence measure. Under the process of thought diversion, they included distractions, interruptions, and noise. Under the process of inadequate resources are absence of secretary, equipment/supply issues, staff leaving unit, and administrative demands. Under the process of communication breakdown are communication breakdowns, information overload, and loss of information. Under the process of interpersonal relationships are preceptor responsibility and interpersonal distractions. The authors included technology as a fifth process to consider, including the items of inadequate training, data loss, and delayed response time. One nurse described the organizational problem of a severe lack of training in using a technology. Another nurse described first trying several ways to enter an insulin drip order, eventually figuring out that it wasn't under insulin, diabetes, etc., but under glycemic control. The nurse unsuccessfully called the pharmacy and asked a pharmacist on the unit before figuring it out by trial and error.
Putting the Information to Practice
While nursing workload focused on patient acuity is difficult to change, turbulence items often are amenable to change, according to Browne.
Bell suggested, among other things, that nurses communicate turbulence issues, identify process issues that consistently impact care, and work collaboratively to address issues and test implemented changes.
"This was an exploratory study, and so more research is needed to better understand turbulence and its effect on nurses, quality care, and patient safety. This study has confirmed, however, that there are elements of nursing activities not identified in workload measures that might have a profound influence on patient care," Browne said. "Further research is also needed because the majority of our study respondents were expert ICU nurses. Turbulence might have different characteristics with nurses who have less experience or who work in other areas of acute care."
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