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Journal of Nursing

What Are The Effects Of Floating to Nurses And Patient Care

Marina E. Bitanga BSB, RN, CCRN [email protected]

You come prepared and ready to work in your permanent unit but when you are about to accept your assignment, you were told you need to float to a different area to fill in their short staffing. Why me? Is it my turn to float already? You lost the smile in your face, go in the charge nurse office and ask to see the float book. Most departments keep a float book to keep track of the nurse’s schedule to float. While some nurses do not have a problem floating, most staff nurses do not feel comfortable working outside their home unit.

ABSTRACT



There is a struggle within the healthcare regarding nursing staffing [6]. The experts identified this as one of the most important variables to influence patient outcomes, including mortality, nosocomial infections and patient complaints [6]. Hospitals are challenged daily to ensure each unit has enough qualified nurses per shift [6]. Adequate staffing is important in achieving good patient outcomes, safety, and satisfaction [10].

A unit’s schedule is done usually to cover adequate staffing on the shift for which it needs [10]. But inadequate schedule occurs when staff call off sick or floating to a different unit, or there is a fluctuation in patient’s flow, admissions, and discharges [10].

INTRODUCTION

Floating is a form of resource most healthcare institutions use to cover the shortage in staffing in other areas [2]. While the unit where the nurse is going to float will be happy to have an extra nurse to lower their work load, the permanent unit of the nurse who floated most of the time work and adjust with one less nurse.

Resistance to working a shift in a non-home unit can develop when a staff floats whether it is because you have the least seniority, it is your turn to float or the manager choose to send the nurse to another unit [9]. There are times when a more experienced nurse should float out of turn instead of a nurse who recently completed orientation [5].

Nurses want what is best for the patient [7] and their safety is their priority [7]. But how safe will it be for a patient when the unit does not have adequate staffing and the floating staff member is not familiar with the unit’s protocols for patient care [7]?

Floating influences aspects of leadership in a healthcare organization such as scheduling, staffing, etc. [13]. It is a factor that can affect nurse’s retention, job satisfaction and recruitment [13]. Increase turnover may result when staff are dissatisfied with the healthcare institution they work for [13].

Floating is a motivation for low morale, disengagement, perceived lack of organization support, and intent to have organization managers require staff to float routinely [13]. Floating represents a constant source of disagreement between management and staff [13] causing nurse’s dissatisfaction in the workplace [13].

Managers must control staff allocation in their units, avoid using contract personnel, and prevent paying staff overtime [13]. Staff nurses look up to administration for support [13] who in turn has the responsibility to maintain cost containment measures secondary to reimbursement controversies affecting health care institutions [13].

This article will explore how nurses feel about floating and the effects on them, what the staff can do to make floating less stressful and how management can help the staff on floating to prevent increase in turnover rates due to staff dissatisfaction.

WHAT IS FLOATING?



Also known as pulling, floating is defined as “the reassignment of staff from one nursing unit to another based upon the patient census and acuities” [6].

This is considered by hospitals a positive solution of saving money through resource utilization [6]. It continues to be a staffing practice in health care facilities throughout the land [5]. Floating is difficult and has always been a problem for nurses but safe patient care is always the goal [5]. Floating is a reality that often cannot be avoided, particularly in the hospital setting [7].

Short staffing leads to care not being done causing patients and families feel unsafe and dissatisfied with the staff and nursing management [2]. There is no quality of care and safety is compromised [2].
The Nurse Manager makes sure that there is adequate staffing in each shift [2] but you cannot avoid staff calling in sick or change in census [7] leaving your unit short staff. It has been a challenge to make sure that each unit has enough qualified nurses to work each shift everyday [6].

WHAT ARE THE EFFECTS OF FLOATING TO NURSES?



Dissatisfaction of registered nurses regarding floating may cause turnover and there will be a need to hire new registered nurses whose education and orientation will costs thousands of dollars (Jones, 2008) [5].

Floating may cause anxiety [2], stress [5], overwhelming [1], scary [2], draining [1], dissatisfaction [12], disruptive [12], and feeling of frustration [1] even to a very experienced and skillful nurse to be pulled to work on a unit outside her/ his comfort zone. This might be caused by discomfort from unfamiliarity related to diverse patient population, staff, unit, and the processes [6] to a work on a different department. Working in unfamiliar area makes nurses uneasy by not knowing what to expect. Yes, they know how to take care of the patients but without proper orientation to the unit/ area one will be floating is not easy [2]. Whenever staff members are sent to float to an unfamiliar unit, it is expected that at least they will be able to perform the basic assessment and skills [6].

Floating to unfamiliar area may become time consuming looking and gathering supplies needed leading to less patient care and feeling of disorganization [2] thereby compromising quality of nursing care and intervention [2]. The nurse might not be able to answer any questions patients have and may not be able to effectively address their concerns and this will question the nurse’s credibility [2] and again dissatisfaction with the management and hospital [2]. The lack of familiarity of the unit and the emotions of the floating nurse can often be relayed to fellow staff members, health care providers, as well as to the patients and their families through verbal and nonverbal communication [6].

One challenge the float nurse encounter is prioritizing and concerns of making mistakes [2] Registered nurses are usually responsible to provide safe and competent nursing care [3]. As a nurse, you will be responsible for your own actions and will be the one to face disciplinary action by the State Board of Nursing if you are not competent to perform the assignment given to you [4].

Floating has the advantage of giving nurses the experience of working with diverse patient population and other specialties, see how other units function and chance to meet and work with other nurses while building knowledge and skills [2].

The experience of floating depends largely on the receiving unit whether the staff will be grateful for having another nurse and give her/ him patient assignment that is less challenging [12] resulting in less anxiety and stress for the floating nurse. At times the float nurse arrives late in the unit and be assigned the worst patients with highest acuity [12] including admissions resulting in frustration and tension [12]. This must be brought to the attention of the management team because a float nurse frustrated and not satisfied with the workload given to her/ him will not be productive in delivering the quality care the patient deserves. The patients and families will not be satisfied with the care and will think the nurse is not competent to work in that unit.

Following are Tips to Help You Survive Floating [Rowell, 2016] [1]:

(1) Ask what is expected on that specific unit since different floors/ units have different way of charting, rounding, policy, etc. Know the unit [1].
(2) Introduce yourself, be friendly even though you may encounter people that are intimidating [1].
(3) Always offer help. Remember nursing is a team work even though you are not working in your own floor [1].
(4) Have a positive attitude. The floor/ unit will be happy to have you to reduce their patient work load [1].

If you encounter any problem in the floor you are floating, there is a Charge Nurse you can ask for help if needed. Some units have a resource nurse as well. It is better to ask if you are not sure of what to do rather than making mistakes that would jeopardize the patient care.

What Should the Registered Do When She / He Was to Float?

Before accepting patient assignment when floating to a different unit, make sure you have the necessary knowledge, judgement, skills, and ability to provide the required patient care [3]. The nurse should not accept any patient care assignment he/ she is not competent to deliver the care but instead accept limited assignment of nursing care duties you can utilize your current competence [3]. Remember that the department you are floating will be glad to have you to help them decrease their patient work load. You will be responsible for your own actions and will be the one to face disciplinary action by a State Board of Nursing if you are not competent to perform the assignment delegated to you [4]. Talk to the Charge Nurse of the unit you are floating if you refuse the assignment being given to you and discuss the reason of your refusal. Let him/ her know that you are there to help but they should give you patient assignments that you are competent and comfortable to handle. The Charge Nurse of your permanent unit may be able to help you as well in talking to the unit you are floating If they insist for you to take the assignment. You may seek the help of the Nursing Supervisor. You can write an incident report to cover yourself.

According to American Nurses Association (ANA), “Registered Nurses must have the professional right to accept, reject, or object in writing to any assignment that puts patients or themselves at serious risk for harm [2].” The Joint Commission on floating clearly states that when an employee is asked to float to a different unit, that unit must be similar to his or her own and that the nurse must demonstrate competencies specific to that unit [2]. Furthermore, the assigned employees should be floated to areas of comparable clinical diagnoses and acuities [2].

Buppert, in an article in Medscape, said that a nurse can refuse to accept an assignment under certain circumstances including lack of sufficient orientation, inadequate staffing for patient acuity, inappropriate skill mix, and when an assignment poses a serious threat to the health and safety of the patient [7]. Buppert cautioned nurses against first accepting patient assignment and then refusing it [7], because this could be considered patient abandonment [7].

Some nurses would rather miss being paid than floating to a different unit [8]. But depending on the institution where you work, you would not know if you are floating or not until you arrive to your unit to work your regular shift. There are times nurses sign up for overtime that comes up on certain days to cover the short staffing on that day [8]. When the day comes when nurses sign up for extra shift, there is a need to float a nurse to a different unit to cover the short staffing on that unit. If it is your turn to float even you only signed up overtime to help your unit, you will have to go where the manager tells you to float. This makes lot of nurses angry and dissatisfied with the system and not sign up anymore for extra shifts [8].

Role of the Management Team:

Finding strategies to prevent routine floating that meet everyone’s needs and are cost-effective can be challenging [5].

The nursing administrators, supervisors, and managers have a crucial responsibility to assure appropriate and competent nursing care to patients/ clients [3]. They are required to see to it that patient care is assigned to clinically competent Registered Nurses [3]. The staff member needs to demonstrate the appropriate knowledge and skills necessary to take care of the particular patient populations [6]. The Nurse Managers, Chief Nursing Officer, as well as the risk management must consider instituting a good orientation program [4] and listen to the needs of the nurses regarding floating policy [4]. RNs expecting to float in between Intensive Care Units (ICU) must have a competency validated as well as the Medical-Surgical nurses to float in same area [4]

WHAT STRATEGIES AND TOOLS CAN THE MANAGEMENT IMPLEMENT REGARDING FLOATING?



1. Orientation Program

Instituting a good orientation program where the staff is expected to float will help ease the anxiety, stress, and dissatisfaction of the nurses when time comes for them to float [4].

2. Competency

Validating nurse’s competency to take care of the diverse patient population of the units the nurse is expected to float will help assure that best care will be delivered to the patients [6]. Before floating to a unit, the staff member needs to demonstrate the appropriate knowledge and skills necessary to care for a diverse patient population [6]. Competency is the knowledge, skills, ability and behavior that a person possesses to perform tasks correctly and skillfully [6]. This is an ongoing education to maintain skills and knowledge [6].

3. Self-directed floating [9]

The staff choose to request open shifts outside home unit [9]. Research found that an increased autonomy that results from self-directed floating can reduce turnover and decrease staff burnout [9]. It is one strategy that allows the staff to have an instrumental role in decisions that impact the organization and the patients they care for [9]. The staff who wants to float must be available to the other units they are qualified to work [9]. The floating staff must have the feeling that they are welcome to the department they are floating [9]. Nice experience will make them come back to float again [9].

4. Cluster-unit Structure [11]

Organizations successfully created the “clusters of two to three similar units also called as sister units [11].” The nurse float across the unit within their established cluster [11]. This develops staff satisfaction and less stressful [11]. They become more accustomed working with the same staff [11] and they get familiar with their routines and the diverse patient population the unit provides care [11].
This also requires less training work for nurses to work in different settings [11].

5.. “Mostly cluster” strategy [11]

This is where majority of Registered Nurses float only across two to three similar units providing flexibility needed on daily basis [11].

6. Super float groups [11]

Registered Nurses who are nominated as excellent caregivers are eligible to participate and they receive special cross-training [11]. Super float pools are compensated extra dollar per hour by the organization they are working for [11].

7. Willing to Walk and “No-Pull Rule” [12]

In “willing to walk program, nurses who are “willing to walk” from their home unit to another, indicate their preference for floating, either with in like nursing units or to other areas which they have demonstrated competency on an annual basis [12]. When the census is low, the nurses who elect not to float have the option to take time off [12].

8. Validation [6]

Cross-training will help ease the anxiety of the staff and make sure competent employees are sent to the appropriate unit [6]. The staff will be trained and oriented to the unit as well as the processes, people, layout and patient population [6]. Cross-training of staff can improve quality patient care by better assigning staff to meet patient census [6]. The disadvantage of cross-training nurse for another unit is when they never work in that unit which makes them forget what they trained for or most of the protocols will be changed [6].

9. Float Tools [6]

This provide an outline of the nursing care guidelines for the typical patients found in different units [6]. The standardized, instructive tool was to be provided to the float nurses on arrival to the unit that could be used as a reference before and during the shift [6]. This will save time and frustration for the float nurses on trying to get their simple and important unit-specific questions answered,

CONCLUSION



Floating nurses outside the home unit is a cause of dissatisfaction that leads to high turnover rates [12]. It is a staffing strategy that involves sending a nurse from his/ her home unit to a unit that needs staff [12]. Floating is cost- effective means of staffing by using nurses already available and to avoid calling nurses to work overtime or using agency nurses [12]. Unfamiliarity is the most common problem encountered by the float nurse causing stress, anxiety and frustration [12]. The staff relies on the management to develop strategies and tools to help them make floating to a different unit less frustrating and stressful.

Providing quality patient care is the top priority. The float nurse must be able to provide care to the diverse patient population, must be familiar with the routines and processes of the unit, and oriented where to look for the supplies and medication room so they do not spend more time looking for supplies and less time taking care of the patients.

REFERENCES



1. Rowell K. Helpful-tips-to-help-you-survive-floating-to-another-unit/. July 13, 2016. www.yourheartismine.net.
2. O’Connor K, Dugan LJ. Addressing floating and patient safety. RN Nursing February 2017-Vol 47-Issue2-page 57-58 doi:10.1097/01. NURSE.0000511820.95903-78. Journals.lww.com>Home>Current>Issue.
3. RN responsibility when floating to new patient care unit or assigned to new population. www.rn.ca.gov/pdfs/regulations/npr-b-21-pdf
4. Nurse.com. Do registered nurses have to float to areas where they have not been … December 11, 2013. https://www.nurse.com/.../do registered nurses-have-to-float-to-units-where-they-have-not-been-tra...
5. American Nurse Association. The American nurse. On less familiar ground. August 31, 2017. www. the americannurse.org/2017/08/31-less-familiar-ground/
6. Davies K. Advance healthcare networks for nurses. Float assignments. Nursing.advanceweb com/continuing-education/CE-Articles/Float.Assignment.aspx
7. Brown T. Nurses are talking about: floating and rapid response duty. Medscape Sunday September 17, 2017. www.medscape.com/viewarticle/867786
8. Lisa RN. Float or flight? Mighty Nurse. May 28, 2013. http://www.mightynurse.com/ask-a-nurse-forums/topic/float-or-flight/
9. Pledger R. Healthcare in the know blog. What’s causing the change in nurse’s attitudes about floating? December 15, 2015. http://www.apihealthcare.com/blog/healthcare-trends/from-resisting-to requesting-what-
10. Mensik J. What every nurse should know about staffing. February 2014 Vol. 9 No. 2. https://www.americannursetoday.com/what-every-nurse-should-know-about-staffing/
11. Member asks: What is the best strategy for floating fixed nurses across different units? September 14, 2012. https://www.advisory.com/daily-briefing/2012/09/14member-asks
12. Good E, Bishop P. Willing to walk: a creative strategy to minimize stress related to floating. JONA: Journal of Nursing Administration. May 2011, volume: 41 Number 5, page 231 – 234. http://www.nursingcenter.com/journalarticle?Article_ID=1161969
13. Lafontant M. Exploring nurse’s feelings on floating: a phenomenological study. http:hdl.handle.net/10755/621367

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