Chapter 29. Turbulence 

Bonnie M. Jennings 

Background 

The health care environment was once regarded as safe and secure1 for patients and staff. 

Turmoil and change have pervaded the U.S. health care system since the 1980s, contributing to a 

state of chaos and instability.1 Today’s health care work environment can therefore be 

characterized as turbulent—it is in a state of unrest, disturbance, agitation, or commotion.2 

There are many sources of turbulence in 21st century health care. They can be grouped into 

five categories: 

• Hectic conditions in hospitals; 

• The rapid growth of large health care corporations, which has altered organizational 

structures and dynamics; 

• Constantly changing health policies, such as those related to insurance—what is covered, 

what is paid for out-of-pocket, how Medicare Part D really works; 

• World events that have placed new demands on health care workers, such as concerns 

related to bioterrorism; and 

• An aging population that is seeking care for chronic conditions from a health care system 

designed for acute care. 

Although turbulence from all of these categories works to create challenges for health care 

workers, it is turbulence on hospital units that has the most immediate effect on the nurses’ work 

environment. Staff nurses are striving to meet complex patient needs that require rapid 

decisionmaking, despite there being fewer resources and more interruptions and distractions. 

The focus of this review is predominantly on studies that explored turbulence at the level of 

the patient care unit. Although publications were located that addressed turbulence in health care, 

no systematic conceptualizations were found delineating or describing the features of turbulence. 

Moreover, there were indications of slippage between the terms turbulence and uncertainty. 

Nevertheless, turbulence seems to capture key components of the dynamic and complex work 

environment that add to the challenge of providing quality care and keeping patients safe. 

Research Evidence 

Perhaps because turbulence remains to be clarified conceptually, a number of studies relied 

on qualitative methods. Although these investigations do not meet the criteria for inclusion 

according to most evidence hierarchies, they provide a rich description of turbulence. The 11 

qualitative studies that were identified through database searches examined the work environment 

from the perspective of various health care personnel—Registered Nurses (RNs),3–11 physicians,12

and physical therapists.13 

Although these studies varied in the rigor of their analytic approaches, five themes appeared 

across them. In general, turbulence was viewed as a loss of control6, 11, 13 due to simultaneous 

demands; new, difficult, or unfamiliar work; heavy patient loads; and excessive responsibility.6

Staff experienced the loss of control as a sense of chaos that infiltrated both their professional 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

and personal lives.13 As the environment became more turbulent, noise escalated.3, 6 Problems 

with equipment and supplies (e.g., malfunctioning, missing, calling for cumbersome processes to 

acquire) were also addressed as elements of turbulence.3, 5, 11 Aspects of workload, particularly 

variability associated with patient turnover—due to admissions, discharges, and transfers—were 

mentioned as well.4, 7, 11, 13 

Turbulence and Communication: The Qualitative Evidence 

The dominant discovery from qualitative investigations concerned how turbulence altered 

various aspects of communication, leading to breakdowns, distractions, interruptions, loss of 

information during handoffs,3-6, 8-10 and impaired decisionmaking.3, 4, 10, 12 Although these studies 

did not always explore patient outcomes, they offer initial evidence to suggest that turbulence 

may upset certain aspects of communication, thereby compromising patient safety. 

Findings from three qualitative investigations can be used to illustrate how turbulence might 

contribute to heavy communication loads and interruptions. In the first study,5

 eight experienced 

acute care nurses were observed and interviewed. The investigators in this study coined the term 

“stacking” to characterize a care management strategy in which nurses kept track of patient care 

that remained to be done. Evidence of cognitive stacking was also found in the second study,10

where both ethnography and human factors engineering techniques were used to analyze the 

work of seven RNs on medical and surgical units. Based on 43 hours of observation, the 

investigators found that, on average, nurses had a cognitive load of 11 activities; the maximum 

load averaged 16. These numbers become highly meaningful when viewed in relation to a classic 

paper from psychology that identified seven, plus or minus two, informational concepts as the 

limit for information processing.14 The cognitive stacking experienced by these medical-surgical 

nurses often exceeded seven. 

In the third study,9 communication related to nurse call systems was studied in two hospitals. 

Data were gathered from 41 nurses through observations and focus groups. The call systems 

were viewed by RNs as a source of unnecessary interruptions: 70 percent of the patient calls in 

one hospital and 80 percent in the other were for issues that did not require the skills of an RN. 

Interruptions were also common in the previously mentioned study of medical-surgical RNs, 

comprising an average of 7 percent of their work time.10 Forty-seven percent of the interruptions 

happened during patient-related interventions, with 22 percent of these occurring in the 

medication room during medication preparation. 

Turbulence and Medication Errors 

The likely connection between turbulence and medication errors was also found in interview 

data from eight novice RNs who recounted their experiences with near-miss (n = 2 cases) or 

adverse events (n = 6 cases).4

 All six adverse events and one of the near misses were related to 

medication administration. Factors in the environment that may have contributed to these errors 

included a sense of time pressure, inadequate handoffs, impaired decisionmaking, or awkward 

workflow patterns—all of which could pertain to turbulence. 

 The quantitative studies can be categorized according to three ideas: medication errors, 

patient turnover, and communication. Medication errors were explored in three studies that 

examined features of turbulence.15-17 In one study,15 the investigators discovered that the work 

environment was more likely to be hectic and staff were more likely to be distracted in the 30 

2
Turbulence 

minutes preceding medical errors, 91 percent of which related to medication administration. In 

another study,16 two protocols were designed to reduce distractions during medication 

administration. Although there were fewer distractions with one protocol (64 distractions) than 

the other (180 distractions), both protocols were effective in minimizing disruptions as compared 

to the control group (484 distractions). The differences among the three groups were statistically 

significant (P = .0001). Interruptions were the most common source of distractions across all 

three groups. Finally, in an intervention study designed to reduce patient transfers between 

coronary care and step-down units,17 the medication errors index was reduced by 70 percent. 

Transfers were characterized as a “hiccup” in care delivery that could allow error to be 

introduced. Moreover, transfers take time that could be better spent in caring for patients (see 

Table 1). 

Patient Turnover 

The second grouping of quantitative studies considered census and staffing variability or 

patient turnover related to admissions, discharges, and transfers, as well as observation 

patients.17-23 The census variability from patient turnover demonstrates the need to replace 

midnight census as an indicator of patient volume; it also contributes to turbulence in the 

environment. The previously mentioned intervention study,17 for example, reduced patient 

turnover from transfers by 90 percent through using acuity-adaptable rooms for coronary patients. 

The importance of patient turnover is further illustrated in work by Houser,24 who used 

structural equation modeling to assess features of the complex work environment on patient 

outcomes. Although workload, measured by length of stay and midnight census, demonstrated a 

negative relationship with patient outcomes, it was not a statistically significant predictor of 

outcomes. Adding patient turnover to the workload measure may have yielded different findings. 

Patient turnover was used in combination with other variables in an additional two studies. 

The first19 illustrates the slippage between turbulence and uncertainty. The investigators 

measured objective uncertainty—at times referred to as environmental turbulence—using patient 

turnover divided by midnight census. Although objective uncertainty was predictive of emotional 

exhaustion (P < 0.01) among staff nurses, the relationship was negative. The investigators 

suggest this unexpected finding may reflect that patient census variability possibly mediates the 

emotional effects of environmental turbulence because of the relief offered by occasional 

decreases in patient turnover. 

In the second study,21 path analysis was used to test a model to predict environmental and 

personal characteristics affecting nurse performance. Similar to objective uncertainty, the 

measure of turbulence included patient turnover. Although turbulence did not demonstrate direct 

effects on nursing performance, it did have a direct negative relationship with interpersonal 

relations and communication skills that was statistically significant (p < 0.01). These findings 

begin to illustrate that more turbulent environments may exert undesirable effects on 

communication with patients, families, and other staff. 

Turbulence and Communication: The Quantitative Evidence 

Turbulence and communication were explored in other studies as well. Communication 

mechanisms were examined at one academic health science center based on three types of unit 

level practice environments—complex, unpredictable and rapidly changing, or stable.25 Patient 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

care communication mechanisms used by the RNs were similar regardless of the degree of 

stability in the practice environment. The investigators suggested that quality could be better 

sustained if nurses learned to adjust their communication according to demands in the practice 

setting. 

Communication was quantified and described in two studies. In observing eight emergency 

department (ED) nurses and physicians for about 20 hours across all shifts, 831 distinct 

communication events were identified.26 On average, each of the eight clinicians spent 89 

percent of their time communicating; they experienced 42 communication events per hour. 

Interruptions characterized one-third of the communication events, with each clinician 

experiencing an average of 15 interruptions per hour. 

In the second study,27 communication patterns were evaluated between the operating room 

(OR) charge nurses and other OR staff members at four hospitals—two university and two 

community. The OR suites ranged in size from 4 to 18 rooms. Observations and a data collection 

tool were completed on 17 nonconsecutive days, for a total of 2,074 communication episodes 

observed over about 100 hours. Communication episodes per hour ranged from 32 to 74, with 

more communication episodes associated with the larger OR suites. Charge nurses most often 

communicated with OR nurses (39 percent). The most common purpose of communication 

related to equipment coordination. Most communication occurred face-to-face (69 percent), with 

only 7 percent of the exchanges occurring via intercom. The duration of the communication 

ranged from 10 seconds to 10 minutes, with a mean of 40 seconds and a median of 20 seconds. 

Despite the overall brevity of most communication, the investigators did not assess interruptions. 

The findings from this collection of qualitative and quantitative investigations have strong 

implications for practice (see Table 1). Turbulence can be said to emanate from two major 

sources—workload and communication. Reducing workload and improving communication, 

with particular attention to minimizing interruptions, could have dramatic effects on stabilizing 

the practice setting. 

Table 1: Summary of Research Evidence Related to Turbulence—Key Findings Center on 

Communication and Workload Issues

Communication • Breakdowns 

• Distractions 

• Interruptions 

• Inadequate handoffs (e.g., loss of information) 

• Impaired decisionmaking 

• Overload of information (cognitive stacking) 

• Noise 

• Interpersonal relations 

Workload • Excessive responsibility 

• Heavy patient loads 

• Patient turnover (admissions, discharges, transfers) 

• Simultaneous demands 

• New, difficult, unfamiliar work 

• Time pressure 

• Equipment and supply issues 

4
Turbulence 

Evidence-Based Practice Implications 

Common sense suggests that turbulence could interfere with care delivery in several ways. 

However, the practice implications related to turbulence are only beginning to surface. There is a 

paucity of studies examining turbulence, fewer still that include patient outcomes, and only three 

that met criteria for inclusion in the evidence table (see Evidence Table). Even these studies must 

be considered with caution. None of the studies, for example, was designed to allow causality to 

be inferred.17 

However, messages that can be used in practice can be constructed by combining the 

findings from studies in the evidence table with those using qualitative methods and the 

quantitative investigations that did not focus on patient outcomes. First, it appears that mitigating 

turbulence has a positive return in regard to patient safety. In particular, efforts to reduce 

environmental turbulence may be a major remedy for reducing medication errors. Second, 

intriguing and potentially fruitful areas for future exploration include cognitive stacking and 

cognitive shifts, interruptions and other distractions such as noise, and the overall effect of 

turbulence on communication in general. Finally, features of workload, such as patient turnover 

and time pressure, are also important avenues for future investigations. Data indicate that each of 

these elements is connected to patient safety in important ways. 

Needed: A Conceptual Framework 

Turbulence is an emerging concept that appears to have important ramifications for patient 

safety. Empirical work is limited, however, by the absence of a model that specifies the 

components of turbulence. Developing and testing a theoretical model of turbulence would 

therefore make an important contribution to guiding future research. Exploring similarities and 

differences between turbulence and uncertainty would also advance conceptual and theoretical 

clarity. Additional qualitative work may be required to achieve this goal. 

Although common sense suggests that chaos is not compatible with patient safety, the 

understanding based on research findings is limited. Findings from a few studies are beginning to 

indicate there is a connection between environmental turbulence and medication errors.4, 10, 15-17

The relationship of turbulence to other clinical outcomes and patient safety indicators remains to 

be illuminated. More rigorous designs would facilitate a better understanding of the effects of 

turbulence on patient outcomes. Instrument development would also make a contribution, if a 

psychometrically sound measure of turbulence could be developed once there is greater 

conceptual clarity. 

Concurrently, although some individuals may regard intervention studies as a bit premature, 

evidence is accumulating in support of the belief that features of workload and communication 

have undesirable effects on patient safety. A challenge to researchers, therefore, is to design 

easy-to-introduce ways to reduce environmental turbulence. Questions and avenues of pursuit 

might include establishing a metric of a safe patient load, developing an intervention to mitigate 

the undesirable effects of patient turnover, introducing ways to minimize interruptions, 

developing processes and procedures to improve handoffs, and determining how to reduce 

cognitive overload. 

Additional possibilities include working with architects and engineers to construct patient 

care units for the future. These units would take into consideration the needs of both patients and 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

staff. The overall goal would be to reduce turbulence for the purpose of creating a safer, more 

secure environment for both patients and staff. 

Lastly, there is currently a gap in examining turbulence in long-term care, outpatient settings, 

and the home. Along with advancing the understanding of turbulence in each of these care 

settings, it would be useful to explore turbulence across the care continuum as it applies to 

patient safety and quality care. 

Conclusion 

Turbulence is a concept that appropriately characterizes contemporary conditions 

surrounding nurses’ work. Because this concept is more recent in its application to health care, 

the literature about it in relation to quality care and patient safety is sparser. Nevertheless, as 

indicated in Table 1, ideas related to turbulence cluster nicely within two themes—

communication and workload. Focusing efforts on improving communication and managing 

workload could offer much needed help to the practicing nurse who is often found working in a 

highly turbulent environment. 

Search Strategy 

Literature for this review was identified with the help of a reference librarian. Both 

MEDLINE® and CINAHL® databases were searched from 1995 to 2005 with the goal of being 

as inclusive as possible. The search terms were slightly different for each database because of 

differences in MeSH® headings. The terms included: turbulence, work interruptions, attention/or 

distractions, uncertainty, variability, unpredictability, workload or work overload, loss of control, 

and work environment. Citations were limited to research reports published in the English 

language. 

 The MEDLINE search identified 158 possible citations and the CINAHL search identified 

1,324 possible citations. The abstracts for each of the 1,482 studies were reviewed. Based upon 

information in the abstracts, all but 119 publications were eliminated from consideration. 

Reasons for excluding papers were that they were not related to nurses in particular, health care 

staff in general, quality, or patient safety. For example, some studies identified initially pertained 

to memory assessments, environmental factors related to racial disparities, statistical tests, and 

studies of particular patient populations. The remaining 119 articles were reviewed in their 

entirety, 94 of which were eliminated from further consideration because they were not pertinent 

to turbulence per se (i.e., they were related to other concepts such as stress or leadership), or 

because they were simply short reports lacking in details. 

Acknowledgments 

Tremendous gratitude is expressed to the staff of the Armed Forces Medical Library, Falls 

Church, VA, for their considerable support of this work. They conducted the database searches 

and assisted in acquiring numerous papers considered in this review. 

6
Turbulence 

Author Affiliation 

Bonnie M. Jennings, D.N.Sc., R.N., F.A.A.N., Colonel, U.S. Army (Retired), and Health 

Care Consultant. E-mail: bmjennings@cox.net. 

References 

1. American Hospital Association Commission on 

Workforce for Hospitals and Health Systems. In our 

hands. How hospital leaders can build a thriving 

workforce. Chicago, IL: American Hospital 

Association; 2002. 

2. Merriam-Webster. Online dictionary. Available at 

http://www.m-w.com/. Accessed March 26, 2006. 

3. Beaudoin LE, Edgar L. Hassles: Their importance to 

nurses’ quality of work life. Nurs Econ 2003;21(3): 

106-13. 

4. Ebright PR, Urden L, Patterson E, et al. Themes 

surrounding novice nurse near-miss and adverseevent situations. J Nurs Adm 2004;34(11):531-8. 

5. Ebright PR, Patterson ES, Chalko BA, et al. 

Understanding the complexity of registered nurse 

work in acute care settings. J Nurs Adm 

2003;33(12):630-8. 

6. Gaudine AP. What do nurses mean by workload and 

work overload? Can J Nurs Leadersh 2000;13(2):22-

7. 

7. Geddes N, Salyer J, Mark BA. Nursing in the 

nineties. Managing the uncertainty. J Nurs Adm 

1999;29(5):40-8. 

8. Hedberg B, Larsson US. Environmental elements 

affecting the decision-making process in nursing 

practice. J Clin Nurs 2004;13:316-24. 

9. Miller ET, Deets C, Miller RV. Nurse call systems: 

Impact on nursing performance. J Nurs Care Qual 

1997;11(3):36-43. 

10. Potter P, Sledge J, Wolf L, et al. Understanding the 

cognitive work of nursing in the acute care 

environment. J Nurs Adm 2005;35(7/8):327-35. 

11. Tillman HJ, Salyer J, Corely MC, et al. 

Environmental turbulence staff nurse perspectives. J 

Nurs Adm 1997;27(11):15-22. 

12. Griffiths F, Green E, Tsouroufli M. The nature of 

medical evidence and its inherent uncertainty for the 

clinical consultation: Qualitative study. Brit Med J 

2005;330(Mar 5):511-5. 

13. Blau R, Bolus S, Carolan T, et al. The experience of 

providing physical therapy in a changing health care 

environment. Physical Therapy 2002;82(7):648-57. 

14. Miller GA. The magical number seven, plus or minus 

two: Some limits on our capacity for processing 

information. Psych Rev 1956;63:81-97. 

15. Grayson D, Boxerman S, Potter P, et al. Do transient 

working conditions trigger medical errors? In: 

Henrikson K, Battles JB, Marks ES, et al., eds. 

Advances in patient safety: From research to 

implementation. Vol 1, Research findings. Rockville, 

MD: Agency for Healthcare Research & Quality; 

2005. p. 53-64. AHRQ Publication 05-0021-1. 

16. Pape TM. Applying airline safety practices to 

medication administration. MEDSURG Nurs 

2003;12(2):77-93. 

17. Hendrich AL, Fay J, Sorrels AK. Effects of acuityadaptable rooms on flow of patients and delivery of 

care. Am J Crit Care 2004;13(1):35-45. 

18. Budreau G, Balakrishnan R, Titler M, et al. 

Caregiver-patient ratio: Capturing census and staffing 

variability. Nurs Econ 1999;17(6):317-24. 

19. Garrett DK, McDaniel AM. A new look at nurse 

burnout. The effects of environmental uncertainty 

and social climate. J Nurs Adm 2001;31(2):91-6. 

20. Jacobson AK, Seltzer JE, Dam EJ. New methodology 

for analyzing fluctuating unit activity. Nurs Econ 

1999;17(1):55-9. 

21. Salyer J. Environmental turbulence. Impact on nurse 

performance. J Nurs Adm 1995;25(4):12-20. 

22. Volpatti C, Leathley M, Walley KR, et al. Timeweighted nursing demand is a better predictor than 

midnight census of nursing supply in an intensive 

care unit. J Crit Care 2000;15(4):147-50. 

7
Patient Safety and Quality: An Evidence-Based Handbook for Nurses 

23. Wagner C, Budreau G, Everett LQ. Analyzing 

fluctuating unit census for timely staffing 

intervention. Nurs Econ 2005;23(2):85-90. 

26. Spencer R, Coiera E, Logan P. Variation in 

communication loads on clinical staff in the 

Emergency Department. Annals Emerg Med 

2004;44(3):268-73. 

24. Houser J. A model for evaluating the context of 

nursing care delivery. J Nurs Adm 2003;33(1):39-47. 27. Moss J, Xiao Y. Improving operating room 

coordination. Communication pattern assessment. J 

25. Allred CA, Arford PH, Michel Y. Coordination as a Nurs Adm 2004;34(2):93-9. 

critical element of managed care. J Nurs Adm 

1995;25(12):21-8. 

8
Evidence Table 

Source 

Safety Issue Related to Clinical Practice

Design Type

Study Design, Study Outcome Measure(s)

Study Setting & Study Population 

Study Intervention Key Finding(s

Grayson 200515

Work conditions 

Case control Patient outcomes 

(Level 4), medical errors (medication and procedural) (Level 1) 

11 acute care hospitals, 112 of 300 nursing personnel (RNs, licensed practice nurses, nursing assistants, patient care technicians) involved in a recent medical error that resulted in minimal or no harm to the patient. 

None per se: working conditions were described at 3 points in time and attributes of the work environment were explored to determine the prevalence of potential triggers for errors. 

Preliminary reinterviews indrelated to medParticipants whectic working minutes prior tto the rest of th1.3-5.4) and m(OR = 4.1; 95% 

Hendrich 200417

Patient transfers 

Pretest, post-test Design: Level 3, 

Patient outcomes, sentinel events (medication errors and falls) (Level 1), patient satisfaction and financial outcomes 

Two, 28 bed floors in an acute care hospital, Patient transfers. 

Acuity-adaptable rooms to provide progressive and critical care in the same setting. 

During the two coronary care more than 200 month; after thwere introduce90%, the medireduced by 70from an annuapatient dissatis

9
10

Source Safety Issue Related to Clinical Practice Design Type Study Design, Study Outcome Measure(s) Study Setting & Study Population Study Intervention Key Finding(sPape 200316 Distractions Non-randomized trial Design: Quasi- experimental. The dependent variable was the number of distractions experienced by the nurse A medical-surgical unit with an average patient census of 30, in a 520-bed acute care hospital, Nurses (n = 24)— 46% (n = 11) licensed practical nurses, 17% (n = 4) of the RNs had BSNs Two protocols were tested. Both provided the nurses checklists to guide their medication procedures. In addition, for the focused protocol, staff members were asked not to interrupt the nurse during medication administration. For the Medsafe protocol, in addition to the checklist and staff instructions, the nurses wore a special vest when administering medications. The control group received their medications under usual conditions. Each group (control, focused, Medsafe) was tested for 8 cycles yielding 24 high-volume medication cycles (the unit of analysis started with the beginning of medication administration and ended when the administered medications were 

documented). 

The control grdistractions (

M 

180 distraction(M = 22.5; SD 

with the Meds4.5). Statisticawere found beeach of the probetween the tw

indicating that when protocolthe control grodistractions ocprotocol. Acrocommon distrapersonnel (n = 

followed by heothers (n = 215a less frequent 

1.42).