Chapter 29. Turbulence

The health care environment was once regarded as safe and secure 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. Today’s health care work environment can therefore be characterized as turbulent—it is in a state of unrest, disturbance, agitation, or commotion. 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.