Workflow, Turbulence, and Cognitive Complexity

This chapter’s primary focus is on system characteristics within the Quality Health Outcomes Model (QHOM), particularly workflow and turbulence. The idea of workflow originated in the manufacturing industry as managers sought to improve efficiency by removing bottlenecks to smooth out processes. Flow is reflected in smooth, continuous movement. Workflow in healthcare, however, is rarely smooth. Instead, it is turbulent, like the irregular motion characterized by the up- and downwind currents experienced in an airplane. For nurses, the idea of workflow is an oxymoron because the “flow” of work is irregular, not smooth. Instead, nurses’ work is typified by turbulence. Sources of turbulence for nurses include interruptions, handoffs, and patient turnover. Also, the use of workarounds may be a sign of turbulence. The system characteristics of poor flow and high turbulence tend to increase the cognitive complexity of nurses’ work. Cognitive complexity derives mainly from the invisible work of nursing. Cognitive workload, or mental effort, and cognitive stacking, or juggling numerous shifting priorities within a turbulent setting, escalate the cognitive complexity of nurses’ work. Together, poor workflow, high turbulence, and high cognitive complexity can contribute to work stress and cognitive failure, thereby adversely affecting patient safety and quality care.