Overman, Kimberly RN; Hauver, Jeni BSN, RN; McKay, Jennifer MHA, BSN, RN; Aucoin, Julia DNS, RN-BC, CNE
Kimberly Overman, RN, is Staffing Department Clinical Nurse IV, Duke University Health System, Durham, North Carolina.
Jeni Hauver, BSN, RN, is Staffing Department Clinical Nurse IV, Duke University Health System, Durham, North Carolina.
Jennifer McKay, MHA, BSN, RN, is Clinical Operations Director, Duke University Health System, Durham, North Carolina.
Julia Aucoin, DNS, RN-BC, CNE, is Nurse Scientist, Duke University Health System, Durham, North Carolina.
There is no conflict of interest expressed by any author of this manuscript. This work was performed as part of regular job expectations for each of the authors, and the organization provides permission to print the information listed. Julia Aucoin is the authorized agent to provide permission for this information and the figure to be attached. As this was not a study, no human subjects protection was required.
ADDRESS FOR CORRESPONDENCE: Julia Aucoin, DNS, RN-BC, CNE, Duke University Health System, 2301 Erwin Road, Box 3543, Durham NC 27710 (e-mail: Julia.firstname.lastname@example.org).
Centralized float pools are a strategy used to address the need to provide safe, effective, and efficient care to a variable patient volume and provide staff for planned and unplanned needs through competency-based staffing. Meeting consistent expectations for performance, providing skills consistently, and maintaining a cohort of adaptive staff are requirements in maintaining a centralized float pool. Procedural areas may have similar processes but could vary in their departmental competencies, especially when applied to the expectations of float staff. This article describes a process by which competencies can be identified, developed, and confirmed for inclusion in the orientation plan and competency assessment plan for all float staff working in ambulatory and procedural areas. The purpose of this process was to create a clear pathway for orientation to better serve the needs of the departments using float staff services and provide documentation of those competencies completed in a more systematic manner.
Managing float staff competency has been a consistent area for attention to support patient care, with one of the earliest articles being written by staff from this institution (Shulby & Dawson, 1993) as well as other organizations (Bradley, 1998). Yet there has been little written about competencies required for float staff in the last 20 years. The focus has been primarily on cross-training and float policies. The needs of the float pool model in ambulatory care can be different from those in inpatient settings (Hemann & Davidson, 2012). Concern for patient safety and quality is always important and more difficult to address when the nursing staff is inconsistent. There is minimal literature to support effective models (Dziuba-Ellis, 2006). Staff often experience a sinking feeling when asked to support an area for which they feel unprepared (Brooke, 2010). Larson, Sendelbach, Missal, Fliss, and Gaillard (2012) found in their study of 217 shifts that float staff were often assigned patients with higher acuity, greater volume, and more patient flow than regular staff on the same unit. Although their findings were not statistically significant, the acuity was 13.98 for patients assigned to float staff as compared to 13.18 for regular staff. Additional differences were that patient volume were 12.7 (float) and 11.8 (regular) and patient flow were 15.13 (float) and 14.12 (regular). In all cases, higher numbers were associated with assignments to float staff. It is not known if this is intentional; however, it requires attention to setting and meeting expectations to retain float staff in their roles and maintain good patient care standards.
Nurses in the authors’ organization frequently verbalize feelings of concern that they are asked to care for more acute patients on a regular basis than the unit-based staff. In addition, because orientation was driven by the departments the nurses floated to, rather than centralized, inconsistencies in practice between areas they float increased the difficulty in satisfactorily completing orientations and the necessary documents. On occasion, a nurse joined the float pool and was then assigned to a previous work area, portraying a highly competent level while setting unrealistic expectations for another float nurse with less experience in that particular area.
ASSESSMENT OF PROBLEM
Orientation prior to this project included a centralized orientation to the hospital followed by orientation to individual units. Not all orientation documents followed the same format, and because the orientation was coordinated with a unit-based preceptor, these documents were inconsistently completed. In addition, there was no consideration for a float pool standard expectation regarding what skills were reasonable to attain. The nurses were often put in the position of being asked to perform a skill that only a specialized nurse on the unit would perform. For example, this might include a physician-assisted procedure. It was clear that standardizing the expectations common to all float pool nurses was needed. An additional challenge was to create a tool to document and track the competencies for each nurse for ease of scheduling assignments. Prior to the development of this process, there was no method for determining what skills were needed by each area, the current competency skill for each nurse, and expectations for length of orientation. For instance, if a procedural area required staff competent in conscious sedation and had an urgent staffing need, it was essential to identify a float nurse with that skill to assign and quickly orient. The tracking tool was designed to allow for an efficient way to keep unit requirements and staff nurse competency records in a spreadsheet format. When hiring into the float pool, anticipating the unit needs and matching these to appropriate skills were essential.
At initiation of the project, the float pool consisted of 132 Certified Nursing Assistants and 123 Registered Nurses, providing staffing across the health system to inpatient and outpatient departments. The RN float pool staff serves five specialties: Procedural and Ambulatory, Adult Critical Care, Adult Inpatient Medical/Surgical, Pediatric Critical Care, and Pediatrics Inpatient. Although there has been an orientation process, coordinated through the organization’s Clinical Education Department, it was more focused on the inpatient venues where skill sets are more consistent and easily transferable from unit to unit. The ambulatory and procedural venues require float staff who possess not only skill sets that have some commonalities but also skills that are specific to the area assigned. In the float pool procedural and ambulatory specialties, there are 24 RNs prepared to provide coverage to 26 clinical and procedural areas. These areas include outpatient clinics, imaging, cardiac diagnostics, vascular access, and surgical services. In just 14 months, the procedural nursing pool grew from 11 to 24 RNs because of planned growth and a need for increased staffing flexibility. Orientation was often duplicated when moving from one procedural area to another, causing delays in providing supplemental staff from the centralized float pool who were ready to function. With regards to those skills that were unique to specific areas, it was difficult to define what was expected of a float nurse and what and how to obtain the documentation when those specific skills were completed.
Although many inpatient nurses routinely float to other units, for ambulatory or procedural department-based staff, this is not the norm. Therefore, float nurses are assigned to a variety of units and departments for partial or entire shifts to provide coverage to meet patient flow. They provide support for staff turnover, vacations, leaves of absence, increased training needs related to new initiatives, and fluctuations in volume. Requests are made by department managers as openings in the staffing plan are identified. Once trained, nurses are often requested for consistent assignment in that area for an extended time. Float pool nurses can change venues within the shift or from day to day, or be assigned to a specific area for several weeks.
The RN job description for float staff is the same as permanently assigned clinical nurses with the added expectation of maintaining multiple competencies through online training modules, testing, and observed validation. Nurses should not be assigned to areas where they have not received orientation or showed competency. Annual performance appraisals are performed by float pool nurse managers; input is sought from the unit and department colleagues and leadership.
GOALS OF PROJECT
The primary goal of the project was to streamline and create a standardized process for orientation and subsequent competency assessment to the ambulatory and procedural settings. One desired outcome was to create a strategy that could identify and capture competencies that were common to these areas. The resulting document would reflect the competencies to serve as an organizing framework for making staffing decisions. A broader goal involved the continued improvement of patient safety through a focused approach to orientation and competency management. The challenge to patient safety was defining expectations for competencies of a float nurse versus the nurse permanently assigned to the procedural or ambulatory area. Whereas many float nurses required orientation to be able to perform skills, others would benefit from the use of a consistent competency assessment framework. Because of the complexity and dynamic nature of the procedural environment, the demand caused by unexpected staffing needs or increases in volume created delays in care or less than optimum provision of services. The effort to create documentation of core and specialty competencies for the procedural staff was intended to eliminate delays in treatment by providing a nurse who held the required competencies. For instance, some areas had a high volume of sedation cases that necessitated advanced life support, peripheral intravenous access, and moderate sedation skills. In this situation, providing a nurse that has yet to complete the institutional requirements would lengthen the procedure time and perhaps result in reducing the volume of patients that could be scheduled because of unavailable competent staff. Regarding work culture, the goal of finding the right fit for the nurse is paramount. It is essential for the float staff to be resourceful and flexible and have a positive attitude. The goal for the float pool leadership providing float staff is to create a positive work culture through educating both the float staff and the requesting unit about the appropriate use of this supplemental role. Staff must be team players and able to fulfill a variety of roles to assist with patient care and flow. Expectations for higher levels of care than can be safely delivered by the float nurse can cause frustration, animosity, and rejection. Misconceptions about what the float staff can and should do abound. For example, if a float nurse had previously been a full-time employee for a clinic and then became assigned as a float nurse, her skill set might be higher and create false expectations for all float staff who do not have the historical perspective and experience. If this area had not previously utilized float pool staff and used this experienced nurse as the barometer for future expectations, orientation and performance expectations would not be met.
As procedural services shift to outpatient settings, the acuity of the patients has simultaneously increased. Financial models have placed some clinics under the supervision of hospitals rather than remain independently functioning entities (Guidi, 2013). Because these absorbed clinics were not established under the umbrella of a hospital institution, the expectations for care delivery, policies, and procedures for staffing and scheduling are not always consistent with that of a health system.
The orientation packet was designed to define the float nurse role and allow managers of procedural and ambulatory departments to easily integrate the float staff into the staffing mix. By defining the expectations of the float nurse and creating tools to define the appropriate competency-based assignments, roles are clear, patient care is provided safely, and the ease of transitioning into the requesting unit is smooth.
STRATEGIES TO COMPLETE THE WORK PLAN
A plan was developed to collect and organize required competency information. The first step was to identify all the procedural and ambulatory settings that currently used float pool staff. As new requesting departments were added, they were included in the project. All existing competency documents were collected from staff files and through department leadership from our designated areas and float staff who are assigned there. This allowed for determining similar terms to express the same competency to limit duplication. A spreadsheet was created with the departments along the columns and the identified competencies along the rows. This project provided an opportunity to update contact information for all areas to include cost centers for payroll reimbursement and phone numbers for managers, educators, and nursing stations. This spreadsheet (see Table 1) was distributed to all the procedural and ambulatory settings that currently used float pool staff for marking the expectations for the area. An informal benefit of this step was that it allowed for reinforcement with the procedural managers the competencies that were reasonable for a float nurse to possess. All the individual spreadsheets were merged into one master document for the clinical education department to determine the competencies that should be completed within the 90-day probationary period by all float staff assigned to procedural and ambulatory areas. This created a competency-based orientation tool with shared expectations for competence regardless of area assigned. Additional competencies were scheduled for completion within the first year in the role; thus, immediate and developmental needs were addressed. The spreadsheet allowed for monitoring of the process to maintain alignment with the competency-based orientation tool and annual validation with managers about needs and expectations. The plan is summarized in Table 2. Nurses new to the float role can use this tool to self-assess their competencies and jointly plan the required orientation. The intent is that one sign off per competency covers all assigned areas and that repeated competency assessment is not required for the same competence in multiple settings.
Prior to the implementation of this project, float pool staff were oriented solely with area-based preceptors. It was proposed that having a portion of the orientation provided by a procedural float pool nurse would be beneficial. There are times when scheduled precepted shifts would turn into an actual staffing shift because of staffing needs, which created frustration and a sense of unbalance for the new float nurse. Having initial orientation shifts with float pool-based staff eliminated this practice. In addition, allowing the float pool preceptor to focus on skills validation for specific competencies, such as peripheral IVs and defibrillator use, allowed for a more timely completion of orientation and deceased the need to complete validation of some skills after the orientation period was complete.
The primary goal was to streamline and provide consistency to the orientation process for the ambulatory and procedural setting. This was initially achieved by six nurses completing orientation and staffing six areas. Complaints from assigned staff and requesting units have ceased as expectations were clarified and can be met. The additional goal of continued improvement of patient safety through a focused approach to orientation and competency management was met as evidenced by the significant decrease in the number of complaints and safety reports, with none being received related to competency or performance of the nursing staff, in the 6 months after implementation of the new competencies. Audits indicate that the orientation is being completed in the 90-day probationary period, and the interim audits show that staff continues to achieve those competencies needed for their role. Three new departments have joined the shared competency effort since the project was implemented. The 2013 work culture scores for float staff increased from the 2012 in the areas of communication, respect, accountability, teamwork, support, and satisfaction. This strategy was developed with the intent to apply it to other float pool clusters to provide for consistent expectations to support patient care. To sustain the progress made in improving the process, review of procedural nurses’ orientation is done weekly with the nurse manager and staff educator to ensure that the orientees are progressing in a positive manner. Rounding with new staff is done to obtain feedback and help with any perceived barriers to successful completion of orientation. Staff has formal meetings with the manager and/or staff educator at the 30-day, 60-day, and 90-day time frames to review progress and set ongoing goals for completion of competencies.
A serendipitous outcome of the project was that badge cards were created to list department cost center codes of all the procedural/ambulatory areas to facilitate easy access to the correct code for use when clocking in to various areas. The card also listed the primary contact phone number for each area. Although this did not directly impact care, it increased the accuracy of payroll and gave staff a quick reference to contact a clinical area.
Serving as a float nurse requires constant attention to meeting shared expectations and providing competent care to a variety of patients. This article described a plan for setting and implementing those shared expectations with positive outcomes for the organization. This work can be easily adopted by other facilities.
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