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Department: PATIENT SAFETY

Addressing floating and patient safety

O'Connor, Karen BSN, RN; Dugan, Jamie L. RN

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doi: 10.1097/01.NURSE.0000511820.95903.78
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FLOATING IS A FORM of resource sharing often used by healthcare institutions to remedy staffing shortages. For nurses, being sent to work on another unit where patient needs are different than those usually encountered in their home unit can evoke stress, anxiety, and frustration. Working with an unfamiliar patient population can ultimately threaten patient safety.1 Interventions may be within the nurse's scope of practice, but not within his or her acquired skill set.

Floating is a cost-effective means of addressing fluctuating patient census. Floating can be used instead of using agency staffing or calling in nurses to work at an overtime rate.2 But floating nurses to unfamiliar units can also put patients and healthcare organizations at risk.3 This article describes why floating may be needed, why it can be risky, and what strategies healthcare organizations can implement to improve patient safety, such as using a dedicated float pool to reduce risks.

Pros and cons of floating

Some nurses find that floating to units other than their own is a positive experience because they get a chance to experience a diverse patient population and other specialties while building knowledge and skills. But even for nurses who enjoy the experience, the potential negative effects of floating to an unfamiliar unit must be carefully considered in terms of patient safety and outcomes.1

When even highly competent, experienced nurses are asked to float to an unfamiliar unit, their anxiety and uncertainty may be communicated to patients nonverbally.3 In an unfamiliar setting, even a simple task such as gathering supplies may become time-consuming, taking focus away from the patient and conveying disorganization. This directly affects face-to-face contact with the patient, which can in turn compromise quality nursing interventions and care.3

Nurses who lack unit-specific knowledge may not be able to answer patient questions or address patient concerns effectively, which also compromises their credibility and reflects poorly on the hospital.2,4 Even finding the correct person to ask can be difficult for the float nurse. If patients pick up on the nurse's struggle to adapt to an unfamiliar situation, they may feel unsafe, undermining the nurse–patient relationship. Prioritizing becomes a challenge and the nurse may become consumed with concern about making mistakes.3

According to Hendren, frequent floating can lead to staff dissatisfaction and compromise patient safety because a dissatisfied employee may not deliver the same quality of care as a satisfied one.1

National organizations weigh in

The Registered Nurse Safe Staffing Act of 2015, supported by the American Nurses Association (ANA), holds hospitals accountable for preventing nurses from working in units for which they lack adequate experience, education, and training, particularly specialty units.5 Furthermore, according to the ANA position statement, “Registered nurses have the professional right to accept, reject, or object in writing to any patient assignment that puts patients or themselves at serious risk for harm.”6

The Joint Commission's position statement 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.7 The Joint Commission also states, “Assigned employees should only be floated to areas of comparable clinical diagnoses and acuities.”7

Improving perceptions and outcomes

Although nurses may perceive floating negatively, it's often a necessity. Nursing and systems leadership can take steps to promote optimal outcomes when floating is used. Plans need to be put in place to ease anxiety and promote nursing confidence in providing patient care when floating is required. This may include steps such as creating a staff-development program that addresses common skill sets needed in specialty units for nurses in a designated float pool.

Organizations should consider providing nurses with the option of participating in cross-training rather than being part of a generalized staff floating approach. Establishing a dedicated float pool (a group of nurses with no home unit who are hired to work exclusively on a variety of units) can help hospitals meet this standard and minimize involuntary floating. Personnel hired specifically to be in a float pool are often more assertive, have more diverse experience, and may be more autonomous and reliable due to their prior training and experience.4 Cross-training nurses can reduce anxiety related to floating, making it easier to provide better quality care for patients.4

The experience level of nurses being asked or required to float should also be considered. New graduate nurses shouldn't be expected to float because this puts patients at increased risk.3 These nurses may already be anxious because they're new to clinical practice and are still familiarizing themselves with organizational policies and protocols.

Tips at the unit level

Charge nurses in the unit set the tone for float nurses. A clear resource plan should be in place when nurses float to unfamiliar units. For example, the charge nurse should orient the float nurse to the unit, partner the float nurse with another experienced nurse as a resource, and provide verbal and written information on the unit's policies, procedures, and clinical practices.8

Preparing a tip sheet for float nurses with unit-specific information is also helpful.3 Tip sheets should include information such as the location of equipment, healthcare team contact numbers, shift routines, specific required unit documentation, safety procedures, and unit-specific protocols. Besides helping float nurses feel more confident and less anxious, this information engenders a sense of belonging in the healthcare system.9

Systems-level interventions

Nurses and employers share accountability for patient safety.10 On a systems level, interventions could include developing a floating policy, which includes a list of patient-care expectations a float nurse could reasonably be expected to provide. Creating a hospital-wide organizational system that's followed by each nursing unit can help nurses quickly locate supplies and common equipment when floating to an unfamiliar unit.

Incorporating guidelines and strategies to facilitate a successful shift for the nurse and patient are in the best interests of the healthcare organization.10 Perhaps most important, regular feedback from float nurses should be expected and encouraged to ensure continuing success. Unit charge nurses and nurse managers can use feedback to improve future float nurses' experiences in their unit. Positive constructive feedback provided to the float nurse strengthens subsequent floating experiences.3

Floating in the future

Because the need for floating will never disappear, strategies to keep patients safe need to be put in place. Continued improvements in floating procedures, including who's chosen to float, how nurses float, and their experiences, will have a positive impact on both nursing satisfaction and patient safety.

REFERENCES

1. Hendren R. 5 reasons nurses want to leave your hospital. 2011. www.healthleadersmedia.com/nurse-leaders/5-reasons-nurses-want-leave-your-hospital.
2. Good E, Bishop P. Willing to walk: a creative strategy to minimize stress related to floating. J Nurs Adm. 2011;41(5):231–234.
3. Bates KJ. Floating as a reality: helping nursing staff keep their heads above water. Medsurg Nurs. 2013;22(3):197–199.
4. Larson N, Sendelbach S, Missal B, Fliss J, Gaillard P. Staffing patterns of scheduled unit staff nurses vs. float pool nurses: a pilot study. Medsurg Nurs. 2012;21(1):27–39.
5. American Nurses Association. ANA commends introduction of the Registered Nurse Safe Staffing Act. 2015. www.nursingworld.org.
6. American Nurses Association. Patient safety: rights of registered nurses when considering a patient assignment. 2009. http://nursingworld.org/rnrightsps.
7. Staffing Medical USA. The Joint Commission policy statement. http://staffingmedical.com/Forms/Joint%20Commission%20Policy%20Statement.pdf.
8. Trossman S. On less familiar ground: strategies aim to reduce random floating, improve the experience. Am Nurse. 2014;46(1):7. www.theamericannurse.org.
9. Groff Paris L, Terhaar M. Using Maslow's pyramid and the National Database of Nursing Quality Indicators to attain a healthier work environment. Online J Issues Nurs. 2010. www.nursingworld.org.
10. Edgecomb S, Dyer D. From our readers...Creative staffing solutions for floating and low census. Am Nurse Today. 2011;(6):2. https://www.americannursetoday.com.
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