Multiple global studies suggest that quality patient care is directly impacted by healthcare work environments and safe nurse staffing levels.1 Academic medical centers provide highly complex, tertiary care in an environment where teaching and research also prevail. Specialized nursing care and management of such high-acuity patients require constant attention and adjustments to maintain quality outcomes, safety, and cost-effective staffing solutions. Staffing deficiencies are often precipitated by fluctuations in patient census and acuity, staff illness, vacations, leaves of absence, and turnover.2,3 That's why it's imperative for nurse managers to monitor and correlate inadequate staffing levels with poor patient outcomes and identify strategies that can increase efficiency, competency, and productivity to resolve staffing deficits without compromising patient safety.
This article describes one organization's investment and yearlong effort to build a cohesive, highly skilled, and cost-effective float pool team at a large, urban academic medical center.
Why float pools?
Incorporation of “float pools” to supplement staffing variations was first conceptualized in 1981 and is now broadly accepted as a permanent solution to meet fluctuating staffing needs across various specialties, clinical settings, and patient populations.4 However, an organization's perception of value and intrinsic variation may exist regarding the capacity, productivity, utilization, skill mix, and level of staff engagement within a float pool.3-5 In order for hospitals to ensure safe staffing in an often unpredictable and dynamic acute care environment, a high-functioning float pool team is considered an economic necessity.6 When empowered to practice to their maximum potential, float pools make the most effective use of staff by providing flexibility in meeting staffing and scheduling demands while simultaneously decreasing costs associated with contract labor, overtime, and incentive pay.2,3 Several authors attest that hospitals utilizing float pools within their overall staffing management plan typically save 2% to 5% of total nursing labor costs.7,8
Most organizations recognize that effective management, engagement, job satisfaction, and retention are key indicators for cost-efficient, outcomes-driven, and highly motivated teams. The float pool is no exception. Float pools can save a significant amount of money for organizations when justifiable resources are allocated and float team members coached to practice to their full potential. Otherwise, turnover, staffing shortages, and poor outcomes will expunge all anticipated cost savings.
The need for strategic redesign
In this academic medical center, before onboarding a dedicated nurse manager in early 2017, five different nurse managers oversaw the float pool team between 2014 and 2017. This led to a culture of distrust, coupled with negative perceptions and inconsistent expectations, resulting in float pool team disengagement and high turnover rates. Organizational spending related to staffing shortages and subsequent use of contract labor and overtime were unsustainable.
In response, senior leaders decided to mitigate these excessive costs by investing resources to increase float pool capacity. Typically, this strategy alone would be an effective approach to meeting daily variations in acuity and staffing needs while significantly decreasing payroll expenses. However, if concurrent strategies hadn't been undertaken to increase staff engagement and decrease turnover, costly expenditures would persist.
In 2017, a comprehensive assessment of team dynamics within the float pool was initiated. Data from a commercially available tool were used to evaluate each employee's engagement level. Further, internal metrics reflecting turnover rates and operational costs were derived from the human resources and finance departments. Findings revealed an inadequate and inefficient department suffering from a lack of consistent and effective management, high turnover rates, little to no sense of team or community, a lack of role clarity, and a general sense of feeling undervalued and overworked.
Nursing turnover can cost up to $80,000 per nurse. With a float pool turnover rate of 40% in 2016, organizational costs exceeded $1 million.9 Additionally, expenses associated with contract labor approached $30 million, and approximately $12 million was spent on overtime and incentive pay. With a bill of $50 million attributed to staffing inefficiencies and clear disengagement of staff, nursing and other hospital executives decided to add 50 nursing float pool positions and recruit a dedicated, full-time nurse manager to ease staffing burdens and enhance team dynamics.
Using a systems-thinking approach, the new nurse manager subsequently implemented multiple leadership strategies to improve nurse engagement, job satisfaction, and retention in the float pool. A systems approach impacts cause and effect, in which solutions to complex problems are accomplished through collaborative efforts while addressing factors at the organizational level.10 This process, which emphasizes understanding the fundamental interdependencies and interrelationships among nursing, the nursing work environment, and organizational goals, can be applied to individuals, teams, and organizations. A plan for intentional redesign of the float pool incorporated a multifaceted, evidence-based, systems-level change management initiative that spanned across 7 ICUs and 10 subspecialty telemetry units.11
This redesign approach to improve retention rates aimed to support, empower, and engage float pool nurses by recognizing the value of shared governance and team development. For 1 year, the newly hired nurse manager reinforced the float pool's positive effect on work culture, team dynamics, and patient satisfaction while monitoring financial outcomes and fulfilling staffing needs.
In 2017, an employee survey was offered to 55 float pool staff members, including unlicensed assistive personnel and monitor technicians, with a 62% response rate. An analysis of baseline data revealed that 54% of the float pool felt they weren't involved in decisions made about their work and 45% stated they didn't receive adequate recognition for a job well done. Seventy percent of nurses hospital-wide indicated that they didn't have an adequate number of unit-based staff to provide safe patient care.
Work engagement is defined as a positive, fulfilling, work-related state of mind characterized by vigor, dedication, and passion for work.12 Engaged nurses are typically more optimistic and hold a positive attitude toward the organization and its values.13 Nursing engagement is a predictor of job satisfaction and turnover, and its presence in the workplace is foundational to creating high-performing organizations.14 The Institute for Healthcare Improvement's (IHI) recent white paper, “IHI Framework for Improving Joy in Work,” links greater employee satisfaction to safer, more efficient patient care and highlights the key role of nurse leaders in creating an environment that fosters an engaged team, resulting in more positive patient experiences, fewer medical errors, increased productivity, reduced turnover, and improved financial performance.14 The formula for nurse leaders is quite simple—improving nurse engagement will lead to better organizational performance.15
To achieve work engagement in the float pool, the nurse manager formulated strategic and intentional actions to create a sense of community through implementation of a shared leadership model, daily staff rounding (visibility), personalized awards and recognition, and float pool specific professional development opportunities. (See Tips for creating a sense of community.)
The shared governance model encourages collaboration among nurses and leaders when determining internal policies that guide nursing clinical practice and quality of care.12 Systems-thinking competencies reinforce the significant role of nurses in safety and quality improvement efforts.11 It's imperative that nurse leaders encourage clinical nurses to assert an active approach in solving problems at the point of care and identify work unit inefficiencies and operational failures.11 Shared governance is based on the premise that nurses should have access to information, resources, and growth opportunities by involvement in the decisions that affect their work.
Float pool nurses are in a unique position to observe practices across multiple units or microsystems. This facilitates learning and sharing of best practices from one unit to the next, providing a distinctive perspective of viewing the organization as a whole.16 One study confirmed the importance of shared governance in the float pool by providing evidence of increased certification rates, clinical ladder advancement, feelings of empowerment, and nursing satisfaction scores following implementation.16
Float pool nurses have an essential role in delivering safe patient care across all units; therefore, initiating a unit practice council specifically for the float pool utilizing the shared governance model is crucial for creating a team of highly engaged and motivated nurses. One example of a project unique to the float pool is comparing documentation practices on each unit and then applying best practices for standardization across all units, capitalizing on float pool staff members' vast exposure to improve and replicate best practices.
Hospital-wide committee involvement is also embedded in the shared governance model and provides a clear route for communicating important updates, policy changes, product rollouts, and more. Each unit sends a representative (often a member of the unit practice council) to monthly committee meetings with the intention of gathering and sharing information with the team. Adopting this concept has been extremely helpful for the float pool team because it provides a mechanism for staff members to keep abreast of upcoming practice changes. Further, it addresses their initial complaints of feeling “out of the loop and disconnected” from other nursing units.
Creating a sense of community
Float pool team members don't have a primary work unit in the traditional sense, which tends to make them feel like outsiders.16 In many instances, local and regional awards, practice initiatives, staff recognition, friendly competitions, and opportunities for professional growth are unit-based, and this reality can inadvertently isolate float pool nurses. Due to the nature and schedule of their work, float pool nurses are often perceived as temporary staff (travelers or agency nurses) rather than members of a cohesive team. Creating consistency within an inconsistent environment is critical to achieve a sense of community within the float pool.
Recommendations include highlighting opportunities for professional growth that are available to float pool nurses, such as climbing the clinical ladder or attaining national certification. It's also important for managers to provide regular opportunities for knowledge-sharing and congregating or communicating as a team entity, such as holding monthly staff meetings, providing monthly (or quarterly) newsletters, and creating social or volunteering activities for team building outside of work.
Nurses work in a complex environment and endure challenging workloads every day.11 Float pool nurses experience the same complexities and challenges while managing the additional expectation that they seamlessly mirror the specialized skill sets of unit-based staff.
Daily staff rounding
Manager visibility is also crucial for float pool teams. Daily rounding with staff provides a tangible level of support that can be rare even for those assigned to one unit. Asking staff members each day, “Is there anything you need?” decreases some of the anxiety that float pool nurses experience and instills a sense of belonging and consistency in an otherwise inconsistent work environment. The nurses reported feeling “special” on the days when their manager visited his or her assigned unit to check in. Of all the leadership strategies utilized in this redesign project, daily staff rounding was the most important intervention to engage staff and increase job satisfaction.
Float pool nurses need to feel valued; taking time to visit each nurse provides a personal and professional connection. These check-in visits also afford the nurse manager a chance to assess various work environments and create mutually respectful relationships with staff members and leaders who work alongside float pool nurses.
Nurse administrators need to acknowledge the float pool as a specialty unit and include these nurses in activities, initiatives, and recognition as if they were core staff on a nursing unit. Recognition is a tangible success factor for engagement and retention that can be expressed in many different forms. Employees should feel important, needed, and essential to the department. Leaders should never take this fact for granted because genuine affirmation is vital to retention.9 Tapping into an individual's expertise and gaining knowledge from his or her vast experiences not only gives float team members the sense that they're valued, but it can also help improve nursing practice and quality of care across the organization.
Recognition for float pool staff can also include a peer appointed or manager selected “employee of the month.” Alternating between these two options is helpful because this status recognizes a job well done for those who receive compliments from patients or families, and whose practice style and contributions may not be well known to other float pool staff members. One practice within this medical center involves a survey that asks employees to define their preferences for rewards and recognition. Items include, “I prefer to be recognized privately for a job well done” and “I prefer to be recognized publicly.” The questionnaire also asks employees where they like to shop and dine. This offers nurse managers a variety of options to personalize gift cards or monetary rewards.
Moving from assignment to assignment, float pool nurses can serve as exemplars of best practices, their roles routinely and humbly making a difference throughout the hospital.8 Encouraging float pool nurses to work toward achieving clinical ladder recognition is also a key component of engagement and job satisfaction. An assumption made by several nurses was that ample opportunities to achieve clinical ladder points in the float pool didn't exist. Providing the team with information on hospital-wide committees and other opportunities to participate as a subject matter expert, clinical champion, or skills validator is an effective way to raise awareness about professional development activities that may not be commonly available for float pool nurses.
In 18 months, the float pool expanded from 16 to 63 nurses, with additional nurses projected to be hired in the upcoming year due to planned growth and the requisite need for additional staffing flexibility. Increasing the number of nurses in the float pool saves money through decreased utilization of contract labor and less reliance on overtime and incentive pay for census fluctuations. By the end of this project, the number of travelers had decreased by 67%, saving an estimated $10 million.
Actual cost savings are difficult to determine due to dynamic internal variables, such as wage increases and/or fluctuations in acuity and/or census, which can drive costs in either direction based on staffing needs and subsequent use of contract nurses (registry). Continuous prospective analyses are required to monitor and recalculate expenses and savings related to the organization's investment in the float pool and clinical, operational, human resources, and financial outcomes. Although saving money is important for the organization's bottom line, there's substantial evidence that work engagement, job satisfaction, and retention in the float pool are also fundamental to maximize cost savings and deliver uncompromised, safe, high-quality care.14,17
Implementation of the shared leadership model, strategies for creating a sense of community, increased manager visibility, and greater staff recognition have resulted in frequent and positive feedback from both current and newly hired float pool nurses. These nurses now report feeling personally supported and empowered to improve patient care on their assigned units throughout the organization. Retention rates in early 2018 reached 96%, with only 4% of nurses leaving the float pool as compared with the 40% turnover rate in 2016.
These results have demonstrated the necessity of investing in the float pool—financially, professionally, and personally. Additional data to measure success factors in the float pool will be available following integration of a new organization-wide engagement survey. This survey will measure staff satisfaction, engagement levels, intent to stay or leave the float pool, and perception of unit staffing and resource levels, as well as opinions on leadership visibility and support. The resulting data will be pivotal in measuring the organizational impact of the intentional leadership strategies needed to better support the float team.
Implications for nurse managers
In order for float pool nurses to hold themselves accountable for their individual professional practices, nurse managers must first model this behavior by exhibiting a responsive, appreciative style and cultivating a culture of continuous learning and improvement.14,17 Increasing the number of float pool nurses will eliminate the need for contract labor and overtime while significantly improving patient safety and outcomes.16 The cost savings resulting from expanding the float pool must also be aligned with investments to maximize and sustain organizational outcomes. Investing in the engagement and job satisfaction of float pool nurses not only provides a strategic solution to address staffing variances, but also improves retention, nurse satisfaction, and, most important, the quality of teamwork and patient care.
In a recent Nursing Management survey evaluating nurse leader wellness, the issue of “staffing adequately and safely” was ranked as the third-highest stressor among 14 choices.18 The development of a strategic and systems-based approach for investing in the float pool provides a safer staffing model. After 1 year, the float pool transitioned from a fragmented, unorganized group of nurses into an engaged team that's relied upon by nursing units to provide competent, compassionate care regardless of the patient population. Although certain interventions described in this article are geared toward float pools, leaders from different settings may also benefit.
Recognizing and nurturing the talent of an indispensable float pool offers nurse managers a sound clinical, interpersonal, and cost-effective solution to solve staffing challenges.13 Engaging and retaining a cohesive float pool team of well-respected, highly skilled, motivated, and caring nurses should be a top priority. By keeping the float pool team “above water,” healthcare leaders will realize the significant value of optimizing both human and fiscal resources in their organizations.
Tips for creating a sense of community
- Engage in daily rounds with staff on assigned units.
- Introduce fellow float pool staff members on the same unit.
- Conduct biweekly check-ins with charge nurses and nurse managers of each unit.
- Maintain an effective rapport between the float pool manager and unit-specific managers.
- Hold monthly team meetings, including introduction of new staff, updates, and a round table discussion.
- Recognize staff members for a job well done utilizing a team-based forum (monthly newsletter).
- Engage in ongoing collaboration with staffing coordinators to optimize continuity and preference (if feasible).
- Listen and respond to employees' emotional and learning needs and preferences.
- Create social and team-building events in and out of the work setting.
- Provide staff members with opportunities to mentor or precept incoming float pool nurses.
Head to www.nursingmanagement.com to read the results of the Nursing Management Wellness Survey.
The State of Nurse Leader Wellness: Results of the Nursing Management Wellness Survey