Turbulence Can Add to Your Workload Woes and Impact Patient Care

By | 2022-10-11T10:59:48-04:00 February 2nd, 2021|4 Comments

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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About the Author:

Lisette Hilton
Lisette Hilton, president of Words Come Alive, has been a freelance health reporter for more than 25 years and loves her job.


  1. Avatar
    Will Keller, LPN February 7, 2021 at 8:10 am - Reply

    I’m no longer in nursing, but my wife is a CT tech — whose post-work complaints echo VERY CLOSELY your several incisive and very accurate points on turbulence, in its many forms!
    Well written, well presented, thank you!

  2. Avatar
    Lois Bull February 7, 2021 at 10:53 am - Reply

    Truly I spend a lot of time looking for dressing supplies even something simple to do a finger stick. And then admission or a fall adds 2 hours to my workload. I think I could work smarter by coming in early and anticipating all the needs for the day. but it is really difficult at best.

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    Jodi Henline February 7, 2021 at 10:58 am - Reply

    Having worked as a Circulator in the OR for most of my 20yrs as a Registered Nurse, I understand turbulence on a deep level. Finally there is a definition for the interruptions throughout our day that definitely negatively impacts not only our patients, but our ability to care for them in a safe manner. Chasing after equipment, not having the correct medications available, electronic charting, lack of communication on the part of the surgeon, anesthesiologist, or SDS/PACU, or dealing with patient interruptions all contribute to great amounts of turbulence in the OR. My blood pressure started to rise while reading this great article. I’m just grateful someone finally put a word to the interruptions. Turbulence definitely affects the way we care for our patients.

  4. Avatar
    Kim September 6, 2021 at 2:46 pm - Reply

    I work on a small inpatient hospice unit and in addition to charging the unit I also take a full load of patients. We don’t have a unit clerk so answering the phone also automatically becomes my responsibility. I supervise an LVN and a CNA so I often have to be very involved in their assignments. My nurse manager can not understand why there are days that I have to stay late or ask for help. I have been trying to describe the concept of nursing turbulence to her for years. I am so appreciative that this concept is being looked at and that I now have a tangible way to make the point that I literally can not be in more than one place at a time.

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