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Nurses floating to different specialized areas Essay Abstract: Floating is a staffing strategy that is seen as a solution to the general problem of nursing shortage. Floating involves utilizing nurses to work in different specialized units. Floating has its advantages in that it gives nurses an opportunity for overall professional development and relieves them from additional responsibilities such as delegating and staffing. Float nurses stick to patient care. However, as they have to work in units for which they are not sufficiently educated or trained, they find themselves inadequate in providing quality patient care. Moreover, it affects their overall sense of connectedness with their patients, their peers, and their specialty department. Thus, floating of nurses is considered by many as a threat to both nurses and patients. However, more recently, it has been found that the float nurse can be trained to meet varied needs of specialized units. This is made all the more easier when the float nurse undergoes training for a cluster of closely related specialty units. Resource teams are float pools where specialty of the nurse is recognized and training is provided as per needs by the management. Introduction: Nursing shortage is one of the major issues facing the healthcare sector of the United States. This is attributed mainly due to lack of enthusiasm amongst the youngsters today for pursuing nursing as a career option and secondly due to the rising population. To counter the increasing demands of nursing, the concept of floating has been introduced in many hospitals and clinical settings. Floating is a very recent phenomenon in nursing introduced mainly due to problems such as staffing shortages and fluctuating census (Dziuba-Ellis, 2006). Nurses are in general trained to work in particular specialties. But working in different specialized units requires them to undergo cross-training. This causes stress to the nurses and they lose their efficiency and confidence of attending to critically ill patients in specialized departments. In fact, when nurses are floated to different specialized units, both the nurses and the patients suffer. While the nurses find themselves inadequately trained to work in certain specialized units, patients face the danger of negligent or faulty treatment. Suitable analysis of issues involved in floating of nurses to different specialized units shows that this is highly risky both from the viewpoint of nurses and the viewpoint of patients. This problem is particularly relevant in today’s context as the concept of having a float pool of nurses is touted as a solution to the overwhelming national problem of nursing shortage. This paper focuses on the issue of floating of nurses to various specialized units in the United States – the reasons for floating, impact of such floating on nurses, impact of floating on patients and how to adapt this concept to the situation of nursing shortage. This paper will not cover alternate solutions to nursing shortage. The floating of professional nurses to unfamiliar practice settings should be avoided as it leads to unsafe practice situations and if at all floating is found to be totally essential, it must be ensured that it is allowed only in emergency situations when an increased demand for nurses with general basic skills is expected. Literature Review: The research report titled Nursing Resource Team: An Innovative Approach to Staffing by Baumann et al (June 2005) contrasts the traditional float pools with resource teams and after detailed analysis of the case study of the Nursing Resource Team at Hamilton Health Sciences from September 2002 until June 2004, concludes that resource teams as an innovative staffing strategy creates opportunities for full-time work, and provide nurses with opportunities for professional development. According to Baumann et al, floating is not a new practice. Nursing shortages that existed between 1974 and 1979 lead to innovative staffing solutions and floating was one of them. However, floating came to be known as resource team in 1981 when the term was first used in an article to describe the creation and organization of a float pool (Baumann et al, 2005). Earlier, float pools or resource teams were used across Canada and the US to save expenditure, counter the shortage of nurses, fluctuations in patient census, acuity, volume, and care demands. Baumann et al point out that use of float pools/resource teams is often viewed as a staffing strategy – one that facilitates flexible manipulation of staff. Today, float pools are more of a recruitment and retention strategy and this is proved by a study conducted by Crimlisk (Crimlisk et al, 2002). Contrary to this finding, however, experts in Canada suggest float staff do not serve retention purposes. According to Baumann et al, the NRT approach is different from the float pool in that it recognizes nursing expertise. In the case of float pools, a nurse is regarded as a generic worked who is able to work with different patient groups and utilize many skill sets. Further, the literature indicates that float nurses may be deployed as either assistive or replacement staff. According to a study by organizational development specialist Suzanne C. Luongo, titled â€Å"Connectedness as a Motivator for Nurse Retention at the Bedside† (2004). It has been found that floating is a disruption to connectedness to patients and families, connectedness to peers and connectedness to administration of the institution. This study was based on group interviews of staff nurses who have been at the bedside for a minimum of 5 years and have received high evaluations. While the first study focused on defining the concept of floating and explaining how it is applied in the nursing context, the second study raises the warning that float nurses may not enjoy their job because the job takes away the connection that a nurse needs to develop with the patients, the peers, and to the administration. When nurses are shifted through various specialized units, they cannot follow up on patients continuously; they cannot form stable friendships among other nurses and will not form any attachment to any specialized unit (Luongo, 2004). Crimlisk et al (2002) in their study titled â€Å"New graduate RNs in a float pool: An inner-city hospital experience† focus on the view of nurse managers and nurse educators that fresh graduate RNs cannot be included in a float pool. They prefer to have experienced nurses with multiple skills. However, the authors say that new graduate RNs are highly motivated, ready-to-learn, educationally prepared and intellectually stimulated though they do not have much clinical experience. The authors present a program for training new graduate RNs to practice nursing in a float pool. It has been proved that the program resulted in a 96% retention rate Boston Medical Center Nursing Division (Crimlisk et al, 2002). Moreover, the program offered the medical surgical units a strong clinical support float nurse, nursing managers a staffing solution in times of need, and the new graduate RN a broad range of clinical experiences making them more valuable members of the healthcare team. According to Crimlisk et al, this training model can be replicated in other institutions. Thus, this study gives a positive approach to the inevitable staffing solution of having a float pool of nurses. Crimlisk concludes that fresh graduate nurses who do not have the experience needed to become a float nurse should be trained specially to become more flexible and versatile (Crimlisk et al, 2002). Thus, this study holds that floating of nurses to specialized departments does not necessarily need only experienced nurses. With training, even newly graduated RNs can handle various specialized services in nursing. The article titled Full-Time or Part-Time Work in Nursing: Preferences, Tradeoffs and choices by Jennifer Blythe et al (2005), reviews historical trends in full-time and part time work in the general workforce and among nurses in particular. The study was conducted at three teaching hospitals in Ontario with more than 400 beds and included 10 focus groups of RNs and RPNs. Fourteen additional interviews were conducted with hospital administrators who were knowledgeable about nursing work arrangements. According to this paper human resources managers in all hospitals agreed that investment in full time staff saved â€Å"costs, provided better coverage, higher commitment, lower turnover and more continuity of car and more stable relationships in nursing and multidisciplinary teams† (Blythe et al, 2005). To increase full time jobs, the paper reports that one hospital offered a float pool of full time nurses in critical care, maternal-child and medical surgical areas. This float pool was part of a training strategy to help novice nurses to progress from medical surgical settings to specialist areas with shortages. However, it was found that these floating jobs appealed only to nurses with particular needs. The first study indicated that float nurses could be absorbed as assistive or replacement staff. According to the second study float nurses suffer due to lack of connectedness whereas the third study showed that float nurses could be trained to acquire new skills. But despite such training and absorption, this study takes a neutral stand that only some nurses can enjoy the experiences that come through float jobs depending on their needs. While the lack of connectedness and lack of training are cited to be discouraging factors in floating nurses, this study brings in a third angle – that of needs of nurses. Only nurses with particular needs would like floating to different specialized units. According to the study by Hugonnet et al (2004) titled â€Å"Nursing resources: a major determinant of nosocomial infection? † there is growing concern that changes in nurse workforce and hospital-restructuring interventions negatively impact on patient outcomes. The review focuses on the association between understaffing and health-care-associated infections. Previous studies have shown that overcrowding, understaffing or a misbalance between workload and resources are important determinants of nosocomial infections and cross-transmission of microorganisms. Importantly, not only the number of staff but also the level of their training affects outcomes. The evidence that cost-driven downsizing and changes in staffing patterns causes harm to patients cannot be ignored, and should not be considered as an inevitable outcome (Hugonnet et al, 2004). The fact that ‘level of training’ affects outcomes is a major finding as float nurses often suffer from inadequate skills. In this study it has been found that such inadequacy can lead to nosocomial infections and cross-transmission of microorganisms (Hugonnet, 2004). Thus it is indirectly implied that floating of nurses can lead to such infections and cross transmission of microorganisms. This study brings out a scientific drawback in the floating of nurses – one that could be detrimental physically to both nurses and the patients. This finding is further strengthened by the finding of Stone et al (2004) who point out that nursing shortage is managed by many health care facilities by expanded use of nonpermanent staff, such as float pool and agency nurses. Overwork and fatigue among these nurses have been associated with medication errors and falls, increased deaths, and spread of infection among patients and health care workers (Stone et al, 2004). Issue Analysis: RNs at many health care institutions have traditionally been required to float to other units as a solution to the issue of staffing shortage. Staffing practices, like floating, cross-training and the use of larger float pools are highly debated with focus on quality patient care and less stressful environment at work for nurses. Studies show that nurses naturally want to use the expertise theyve gained over the years on their own specialized units. But if they must work in a different area, or even if they choose to work on different units, they want the appropriate orientation to provide competent, safe care. According to Christine Kane-Urrabazo, MSN, RN, in Said another way: our obligation to float, floating is a viable solution to the issue of nursing shortage. She says that the though floating is opposed on the basis of many arguments, they are not justifiable when weighted against the consequences of not floating (Kane-Urrabazo, 2006). The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), requires all accredited organizations to ensure that â€Å"†¦all staff providing patient care and services on behalf of the organization are properly oriented to their jobs and the work environment before providing care, treatment, and services† (JCAHO, 2004, p. 5). This means, regardless of the settings, it is important for professional nurses to maintain clinical competence. According to the American Nurses Association (ANA, 2005), it is recommended that there should be a systematic plan for the cross-training of staff expected to float to ensure competence (2005). â€Å"The Psychological Stresses of Intensive Care Unit Nursing† by Hay and Oken focuses on floating in the ICU that provides complex nursing care (1972). The float nurse in the ICU is exposed to traumatic events such as death and dying, posing threats of object loss and personal failure. The nurse in the ICU needs to be familiar in handling many kinds of complex technical equipments and make correct measurements. The nurse in the ICU should be capable of making observations about her patients condition, to interpret subtle changes and use judgment to take appropriate action. Moreover, the nurse must maintain detailed records. Because of this and the nature of her tasks, temporarily floating in nurses from elsewhere when staff is short can be dangerous when the specialized unit concerned is the ICU (Hay and Oken, 1972). Kelly Herbig, RN-OCN, Rockford Memorial Hospital, Rockford, in her article titled â€Å"The highs of floating† in Nursing Spectrum says that she enjoys a lot of benefits as a float nurse. She points out that as a float nurse, she needs to focus only on patient care and need not deal with issues of staffing, delegating, and other charge-nurse responsibilities. Kelly Herbig says: â€Å"Floating to different departments and units affords me the chance to meet and work with a wide variety of staff and physicians†¦.. Talking to them about their experiences and viewpoints has helped me broaden my own views and given me a new perspective on nursing† (Herbig, 2004). Best of all she says that as a float staff, she is often viewed positively as â€Å"the help, the relief, the answer to the problem of short staffing†. On the contrary we have the case of Jackie. Badzek et al (1998) in her research article titled Administrative ethics and confidentiality privacy issues cites the case of Jackie. As a float nurse, Jackie found her work very stressful. She had to rotate between many units and patients. Each day she worked on a different unit with different co-workers. She developed few friendships or collegial relationships. She was often dispensing medications and treatments she found unfamiliar. When she attempted to ask questions, she found she approached gruff busy attending doctors and young uninformed house staff. Feeling trapped, Jackie began to divert narcotics (Badzek et al, 1998). This case highlights the plight of the float nurse without specific training and also offers a glimpse to the stress levels of an untrained float nurse. Many states have laws that indicate that it’s considered negligent or unprofessional for a nurse to offer or perform services for which she is not qualified by education, training, or experience. Therefore, accepting floating assignments for which the nurse is not qualified can jeopardize his or her career. There can be lawsuits and also disciplinary action by the state board of nursing. Disciplinary action can include license limitation, suspension, or revocation, and possibly mandatory continuing education (Gobis, 2001). In the study titled â€Å"When terror is routine: how Israeli nurses cope with multi-casualty terror†, authors Riba and Reches report on the case of Israeli nurses working in hospitals and looking after emergency care in times of terror attacks (Riba and Reches, 2002). Based on qualitative analysis of the data collected from focus group discussions involving 60 nurses and analysis of problems faced by them, the authors make a few recommendations in the context of floating. Riba and Riches recommend that post-basic courses in emergency medicine and trauma should be expanded to include emergency room logistics, stress management techniques, and debriefing strategies. Moreover, for nurses floating into emergency care from other departments, they suggest that an annual workshop should be held that includes drills for emergency care. They also suggest that the ER charge nurse should be provided training in leadership and group dynamics. Thus we find that the training that should be insisted for float nurses should be related to the specialized units for which they are chosen to work. This finding is also in accordance with the conclusion of the research report titled Nursing Resource Team: An Innovative Approach to Staffing by Baumann et al (June 2005). Indicators that can be used to measure success of these specially trained staff would be based on measuring retention in clinical settings where such trained float personnel are used. Susan Trossman, RN in her article titled â€Å"Staffing smart: A difficult proposition† says that cross-training to several units will make a nurse end up being an expert at little things and lose in-depth specialty advantage. Kim Armstrong, RNC, has worked at Tacoma General Hospital in Washington for 20 years. She agrees that cross-training gives RNs a greater range of skills. But, she says, It also dilutes skills. She clearly points out that floating nurses to various units and making them accept assignments for which they are educationally unprepared are putting their patients and their livelihood at risk. A nurse at the Elms College hearing illustrates this point. I was recently floated to Hematology/Oncology unit and had 8 patients. Six patients were on research protocols, each with 6 to 10 medications that I had to deliver. I didnt know any of these drugs. Many nurses do not even know their deficits (Nursing Report, 2001). In this context, it must be noted that there is a direct relationship to the skill of nurses and the number of nurses to patient outcomes (Nursing Report, 2001). All the above arguments indicate to only one clear solution. In a country that is facing nursing shortage, it would be unreasonable to say that floating should be totally banned. As numerous studies have shown, what is needed is adequate training of staff for various specialties. This argument is further stressed by Ruth Shumaker, RN, CNOR, and president of the Association of Operating Room Nurses, Inc. : The valuable nurse in the next millennium is the one who can do more who has the knowledge base to function as a specialist but also as a generalist working in multiple areas† (Trossman, 1999). Recommendations: While it is understood that float nurses need special training and education, one should remember that such skills imparted through short term programs tend to be forgotten if not used constantly. Hence they need regular scheduled workshops. Some recommendations to remember while choosing to have a float pool of nurses are (NYSNA, 2005): †¢ Nurses should not be floated to unfamiliar practice settings. †¢ If floating is deemed necessary, it should only be permitted in emergency situations that call for general nursing care. †¢ The RN should be able to self-evaluate and ask for further knowledge or training as her job needs. She should be granted the right to refuse assignments for which she is neither qualified nor trained. †¢ The charge nurse/supervisor should take the responsibility of allotting a particular float nurse to a particular specialized unit. If possible, she should assign a regular staff member of the specialized unit to guide and instruct the new float nurse. †¢ The healthcare facility should be able to perform needs assessment on a continuous process and provide inter department training as per needs. By monitoring trends in nursing indicators such as turnover, satisfaction, work-related illnesses and injury, overtime, etc. , they should also evaluate and maintain the quality of the nurse’s work life. Conclusion: Further research should be conducted as to the type of skills a float nurse is expected to perform in her various specialized units. It has been proved that resource teams that are an improvised float pool are ideal to counter the problem of nursing shortage. In resource teams, nurses work in their area of clinical expertise and preference, developing â€Å"in-depth knowledge of particular clinical populations. † Sometimes, nurses may be assigned as generalists and specialists from the float pool or resource team. It has been found that training is better possible when nurses are assigned to clinical clusters with certain patient populations. Examples of clustered units include critical care and emergency departments, adult medical-surgical, and pediatrics. However, nurses may also be sent to areas such as medical-surgical for which it is assumed only generic skills are required. The following general points should be remembered while implementing float pool nursing as a staffing strategy: Innovations should be introduced in a phased manner; it is important to have consistent leadership during the implementation phase; Orientation and interpretative sessions must be planned and roles of float nurses should be charted in detail; Evaluation should be done on a continual basis. With respect to the float pool of nurses, it must be ensured that their number is large enough so that there is no overtime. Care should be taken to ensure that clinical clusters include relatively narrow and related skill sets and areas of expertise. To make floating of nurses to different specialty units, a viable solution to the problems of nursing shortage and quality care, it is important that the top management, the nurse in charge and the float nurse all work in synchronization towards providing respect and support for development of float nurses as specialists with patient-specific expertise and experience. When individual nurses are deployed only to those areas for which they possess the requisite skills, there is mutual benefit for the nurses as well as for the patients to whom they offer their valuable services. Bibliography: American Nurses Association (2005). Utilization guide for the ANA â€Å"Principles for nurse staffing†. Silver Spring, MD: Author Joint Commission on Accreditation of Healthcare Organizations. (2004). Systems analysis. Ensure that your float staff and contracted staff are providing safe care. Joint Commission Perspectives on Patient Safety, 4(7), 5-6. New York State Nurses Association. (2005). NYSNA position statements, RN staffing effectiveness and nursing shortage. Latham, NY: Author. http://www. nysna. org/programs/nai/practice/positions/floating. htm Kane-Urrabazo, Christine (2006). Said Another Way: Our Obligation to Float. Nursing Forum. Volume 41, Issue 2, Page 95. April 2006. http://www. blackwell-synergy. com/doi/abs/10. 1111/j. 1744-6198. 2006. 00043. x Luongo et al (2004). Connectedness as a Motivator for Nurse Retention at the Bedside. July 24, 2004. Nurse Retention. http://stti. confex. com/stti/inrc15/techprogram/paper_17745. htm Hugonnet et al (2004). Nursing resources: a major determinant of nosocomial infection? Current Opinion in Infectious Diseases. 17(4):329-333, August 2004. Copyright Lippincott Williams Wilkins, Inc. http://www. co-infectiousdiseases. com/pt/re/coinfdis/abstract. 00001432-200408000-00009. htm;jsessionid=FDkbKKGyZ54nPbDSzyJwhhhBs1b8hS866nCYvc8Lxqp2qV1zHRp5! 2082300909! -949856145! 8091! -1 Crimlisk et al (2002). 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