Saturday, 27 July 2019
It is 2018 and many young adults are choosing a career in nursing thus decreasing the severity of the predicted nursing shortage, yet a shortfall of 340,000 registered nurses (RNs) by 2020 is still projected (Auerbach, Buerhaus & Staiger, 2007). However, floating remains a major contributor to nurse dissatisfaction and turnover and will contribute significantly to the nursing shortage especially at the bedside. Therefore, it is important to proactively address factors that promote retention and reduce turnover to ensure that nurses remain at the bedside. So, what is the definition of floating? Floating is defined as assigning nurses who work in a specific unit to float to another unit that is short staffed (Klaus, Ekerdt & Gajewski, 2012). The reasons for the staffing issues are varied from sick call outs by the staff to increased acuity of the patients. So, if floating is a cause for so much distress among nurses, why does health care organizations float nurses and what is their rationale? To understand this concept, one must look at nursing education in the United States. Nurses are trained to be nurse generalists which is guided by the Essentials of Baccalaureate Education with the purpose of successfully passing the National Council Licensure Examination (NCLEX). The NCLEX is a standardized exam that each state board of nursing uses to determine whether a candidate is prepared for entry-level nursing practice [NCSBN]. Therefore, the expectation is that all graduating registered nurses can work anywhere, be assigned into any setting with the expectation that they are knowledgeable and will provide safe patient care (American Association of Colleges of Nursing [AACN], 2009). The definition of a nurse generalist brings the phrase “jack of all trades but a master of none” to mind. Put simply, a nurse generalist is having a little bit knowledge on a lot of things (pediatrics, obstetrics, psychiatry and medical-surgical) but not an expert in any field. However, nurses working at the bedside have a different opinion – while most nurses acknowledge that they graduate as a generalist, they tend to work in one specific area after being hired. Therefore, the question that arises is, when does the generalist nurse become a nurse specialist in their assigned area and is it fair to float the “specialist nurse?” A “nurse is a nurse,” approach does not set well with nurses who look to administration for support. The literature search revealed some opinions when referencing administrator’s response to floating as “we float because we have too and not because we want too,” or “they don’t care, they just need a warm body.” However, nurses acknowledge that floating is inevitable but emphasized that “acknowledgement does not mean acceptance” (American Nurse Association, [ANA] 2017). Floating is not a new concept as it has been routinely utilized to meet the demands of an organization since 1970s. It was considered cheaper than using agency nurses. Institution staff nurses are floated to areas of demand, sent home when census drop, and the staff have no options but to follow the floating protocol (ANA, 2017). The lack of a voice or lack of perceived administrative support leads to dissatisfaction, resentment of administrators, and ultimately turnover.
Purpose:
Balancing the staffing needs in a cost-effective manner while maintaining a high staff morale is a constant battle for administrators. The purpose was to perform a literature review and highlight the options available to administrators to implement floating with staff buy in and to avoid a nurse shortage crisis at the bedside.
Methods: A literature search was conducted in August 2018 to determine best practices and float policies in effect that can enhance nurse morale and reduce nurse dissatisfaction. The literature review utilized the terms floating, nurses, float pool, nursing satisfaction, nurse dissatisfaction, nurse retention and other related key words. Databases searched included the Cumulative Index to Nursing and Allied Health Literature [CINAHL], Full text from Ovid, and ProQuest Central. Databases and search engines were searched one at a time to reduce error or search limitation
Results:
Administrators can adopt a policy of support through implementation of simple measures. The research review recommends creating a unit specific cheat sheet. The cheat sheet should include the following information: the admissions/transfers or discharge procedures; guidelines to contacting the physician, pharmacist, dietary or respiratory therapist; a brief description of the routine such as vitals, electrocardiograph strips, assessments, equipment storage, and breaks. These can be saved and shared on the institution intranet and or available on every floor in a float policy binder [Crowell-Grimme & Garner, 2007). Units need to demonstrate support and welcome the float nurses. The nurses should be provided with a brief unit orientation and provided with the unit cheat sheet. All float nurses should be assigned a “buddy” which can assist in reducing the stress of floating. A “buddy” is a unit staff nurse that is assigned to the float nurse’s as a resource person. In addition, some recommend cross training of nurses especially if they are floated frequently. Another recommendation is the creation of a float pool. The float pool is a group of hospital employed nurses who opt to go anywhere in the hospital that needs to be staffed. Some have pools that either support the intensive care only and the rest of the hospital respectively. These nurses are promised flexibility with their schedule, earn a higher pay rate but must be adept at adjusting to different patients each day. The float nurses usually complain they are often given the difficult assignments. However, float pools have proved to be cost-effective for the institutions and if it is going to be implemented successfully, float nurse assignments need to be monitored (Lebanik, L. & Britt, S., 2015). Institutions pursuing magnet status or have adopted shared governance can use that platform for buy-in to make floating more palatable. Shared governance required true collaboration among the nurses, that nurses are committed partners in making policy, nurses are recognized and must recognize others for their value and nurse leaders must fully embrace this healthy work environment and strive to achieve this goal. The nurses will make up the committees that address staff concerns, make suggestions and then address concerns with administrators. Closed staffing was another option that was implemented but it also required buy-in. It is good for institutions that float intensive care nurses who don’t want to go to unfamiliar environments. Closed staffing requires that nurses are fully cover their units during high acuity, sick call outs and downgrade when census is low. This is not an option for nurses who don’t want to work more than their usual shifts. However, the staff nurses are actively involved and need to be mindful of the budget and the unit needs. It does lead to great collaboration by nurses rather than administrators and thus more favorable. Unfortunately for nurses, floating is not an option that is easily eliminated and that is due the variety of reasons it is used for. As providers of safe care, nurses can maintain a positive attitude, ask for a brief orientation, ask questions, and take your breaks so that they can give the best possible care (Gray-Bernhardt, 2016).
Conclusion:
The literature review revealed that research on floating issues has been explored since the 1980s and 1990s. Those studies have made several recommendations, but they were not always adopted or implemented by institutions. However, institutions that were hard-pressed especially by large turnovers utilized some of these recommendations, but the implementation remained sporadic among health care institutions. The current trend for bedside nursing creates a dire need and coupled with both an impending shortage and the desire for new graduates to pursue nurse practitioner roles, institutions must do all in their power to keep the nurses at the bedside by encouraging them to have a voice and implementing floating measures that work for their respective institutions. Therefore, implementations of small changes are crucial, and the eventual float pool or closed staffing option encouraged for long term management. Staff buy-in is key to success of any plan.