Sunday May 26th 2019

On less familiar ground

Strategies aim to reduce random floating, improve the experience

Having to float can fill even the most highly experienced nurse with a sense of dread. And despite its link to nurse dissatisfaction, floating continues to be a staffing practice in health care facilities throughout the land.

There are, however, potential strategies that can help nurses cope with getting pulled outside their regular units, as well as approaches that hospitals can employ to reduce or eliminate staff from needing to float.

A stressful situation

Polly Willis, MSN, RN-BC, PCCN, a staff nurse on an interventional cardiology unit at Emory University Hospital Midtown, estimates that she floats about once a month or less, usually to one of the med-surg units.

“While I might be floated to an oncology unit, I would not be assigned to a patient who needs chemotherapy, because I do not have that competency,” said Willis, a nurse for 38 years and a Georgia Nurses Association (GNA) member. “Instead, I’d be assigned to care for patients with other medical needs.”

And floating to an OB-newborn nursing unit also is unlikely, given that the last time she worked there was in 1973.

Yet despite her rich experience, Willis said, “I find it quite stressful when I float for a number of reasons. I’m least worried about the care I’m going to render, because I’ve been a nurse for so long and, as an RN, I use the same assessment and other nursing skills that I’d use on my unit. But I don’t really know the staff, or the physicians or the routines. And I miss the teamwork and just knowing everyone and their capabilities [as I do] on my unit.”

Willis’s feelings are quite common, say nurses who’ve studied the issue of floating.

“Nurses who float do have anxiety, especially because today there are so many specialty units with different patient populations,” said Kristin Davies, MSN, RN, a clinical educator at Grand View Hospital and a Pennsylvania State Nurses Association member. “They often have chosen their specialty unit, because they like working with that patient population. On their own units, nurses know their typical patients, where the supplies and other resources are, and who the go-to people are.

“The unknown is their highest concern.”

Added Eileen Good, MSN, MBA, RN, NEA-BC, “Nurses being pulled from their area of clinical specialty cannot be expected to demonstrate the same competence as nurses who are working within their area of clinical specialty and certification.  And certification in a clinical specialty is important to the delivery of quality patient care.”

Now the senior vice president of Clinical Advocacy and Business Development at Aultman Hospital, a Magnet®-designated facility in Canton, OH, Good began looking at alternatives to floating around 2005 while serving as chief nursing officer.

“If you really stop and look at how often it happens in a week or a month and that it’s a source of dissatisfaction [among nurses], leaders in health care need to recognize

floating as a problem,” said Good, an Ohio Nurses Association member. “We need to develop a better way to make sure the right staff are on the right unit.”

The Aultman approach

To address variability in staffing and hospital census, Good and her nursing team created a “Willing to Walk” program and a “no-pull rule,” which began in 2005 and gives nurses more autonomy in scheduling and work assignments.

When the need arises, only nurses who have expressed a preference to float — or are “willing to walk” to another unit — are asked. They are pulled solely to similar units, such as one med-surg unit to another, or to units in which they have demonstrated competence. They also can refuse to float that day without any consequences.

During low-census days, nurses who prefer not to float can take time off without pay, use benefit time, or decide to work another unit that day if the need exists.

Like other hospitals, Aultman had a traditional float pool for many years.

“But we didn’t believe it was developed enough to respond to our clinical needs,” said Good, who can still recall the discomfort of being pulled from the ER to inpatient units.

So around the same time as the no-pull rule began, Good helped to create several specialty float pools, including critical care, med-surg, post-acute care, and women and children. For example, per diem float pool nurses who are trained in critical care only float within critical care areas. Nursing leaders dip into this pool when no staff nurses agree to leave their home units.

To help retain float nurses, they have certain perks, such as potentially being on call, but not scheduled, to work holidays. They also are eligible for Aultman’s nurse recognition programs, Good said.

“We really like to acknowledge them, because float nurses are an important part of who we are,” she added.

To further ensure coverage, the facility created some “sister” units, allowing nurses to work between the same two units, such as the critical care unit and the cardiovascular surgical intensive care unit. And nurses who work part time can commit to working one extra shift over either four or eight weeks, and are paid a higher wage. The extra shift is scheduled, so nurses can plan around that day.

“Floating is a big staffing issue that takes a broad approach, including hiring more experienced nurses who might want to try floating between units,” Good said.

Since instituting the no-pull and other staffing strategies, Aultman is enjoying high nurse satisfaction rates, and their turnover rates have decreased house-wide.  Good has written about these floating policy changes in a May 2011 article in the Journal of Nursing Administration.

What may work, or not

Davies notes that finding strategies to prevent routine floating that meet everyone’s needs and are cost-effective can be challenging. Float pools, the creation of sister units and orienting new staff to several units are common practices, but can have variable results. For example, nurses who are oriented to several units when first hired most likely will not recall the special skills or processes needed on a specific unit when floated there many months later, according to Davies.

Then there is another option. Tiffany V. Banks, MBA/HSA, BSN, RN, NEA-BC, transplant unit director at Emory University Hospital and a GNA member, said that her hospital recently replaced its float pool with an enterprise staffing system, which functions like an internal agency. Nurses are paid at a higher wage, but do not receive benefits.

But because there are currently not enough enterprise nurses to fill in when there are numerous call-ins or other absences, regular staff nurses continue to periodically float between sister, or like, units, she said.

Banks, who routinely makes staffing decisions for her unit and others within the Surgical Division, added that Emory uses a synergy model in which assignments must align with nurses’ skill level and patients’ acuity and needs. Nurses also must meet certain competencies to float to other units.

That said, she acknowledged that nurses who float to her unit can be very intimidated by the complex care of transplant patients. So Banks and her nurse colleagues have developed some strategies to make nurses who are floated to their unit have a positive experience.

Among those approaches are: a personal welcome by Banks and the shift manager; an orientation to unit-specific processes, such as the twice-a-shift huddles; an assigned buddy who serves as the floated nurse’s resource person; and a pocket guide on common meds and other clinical information specific to transplant patients.

“We also will not give a nurse who is floated fresh transplant patients, but, for example, those who are more stable but having blood sugar issues,” Banks said.

“When nurses are floated to our unit, we can’t change what’s happening in the patients’ rooms — that they are working with a less familiar type of patient. But we can change what’s happening in the hallways and the break room so people feel welcomed. We want them to feel they are a part of the team.”

Those positive strategies are echoed by Davies, who has written a CE article about balancing floating and other staffing practices with fiscal responsibilities and quality care.

“It should be a rule that nurses who are floated are considered guests on that unit — and that message should come from the manager on down,” Davies said. Further, nurses should be able to say when they don’t feel competent to take care of a particular patient or be floated to a certain unit without any repercussions, she said.

“There are certain jobs where you can just put a ‘body’ someplace and everything is fine,” Davies said. “But that’s not the case in nursing. Also, units must be able to be staffed up to certain levels, which also is a top-down strategy.”

Willis added that nurses on the home unit must think about the experience level of the person whose turn it is to float.

“Floating is difficult, but safe patient care is the goal for all of us who are nurses,” Willis said. “There are times when a more experienced nurse should float out of turn instead of a nurse who recently completed orientation.”

In the moment

As for personal strategies, Davies said that nurses — even the most accomplished — sometimes psych themselves out. They truly must remember their competency and take advantage of any unit-specific tools available to floated staff, she said.

Willis advises nurses to simply acknowledge that the day will be somewhat more stressful. And she suggests making the unfamiliar, more familiar. For example, Willis immediately arranges the various lists and settings on the unit-supplied phone the way she likes it; she gets the lay of the land; and introduces herself to the charge nurse.

“I will need his or her help at some point,” Willis said. Additionally, she lets physicians and patients know that, although the unit is not her usual one, she is certified and a very competent provider of care.

As an experienced nurse who has worked at other facilities, Willis believes that most nursing units are trying to do the right thing by creating a better experience for nurses who’ve been pulled to their unit.

Said Willis, “No one wants the reputation that your unit treats floated staff poorly.”

— Susan Trossman is the senior reporter for The American Nurse.

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