Float Nursing on the Rise

Every hospital has stories of nurses who thrive by floating. More than likely, they have chosen to be part of the hospital’s float pool. Yet, for floor nurses who must take float assignments when their unit’s census is low or to fill staffing shortages across the hospital due to absences, vacancies, or high-acuity levels, floating can be a major source of job dissatisfaction. In the past decade, hospitals across the country have revamped their float policies to give nurses greater autonomy and agency in deciding whether or not to float. 

Risi Bello, RN, has been a float nurse at MedStar Washington Hospital Center in Washington, DC, for 12 years, and for the most part, loves it. The flexible schedule, the variety of clinical experiences, and the constant exposure to new patients and coworkers are what attracted Bello, 49, to floating in the first place. She’s only required to work a total of 48 hours over a six-week period, which she can work in either 8- or 12-hour shifts. Although two of her shifts have to fall on major holidays each year, the schedule has given Bello, a married mom of six, a work-life balance she might not have achieved had she been a floor nurse.

And watching Bello work on two different floors during separate shifts in late December, it was clear that she was comfortable wherever she went in the 926-bed hospital. She confidently cared for four patients she had met only hours before, knew where to access the floor’s medication and supplies, and updated patient records on a hand-held mobile device.

“You get to meet the best people in the hospital,” says Bello, a native of Nigeria. “It’s socially engaging and you learn a lot because you’re not stuck with a particular set of diagnoses.”

Tools for Success

In an essay published last year in MedSurg Nursing, Katie J. Bates, MSN, RN, reflects on recent research gauging nurses’ attitudes towards floating as well as her own experiences with it early in her career. Recent graduates and experienced nurses alike can feel “alone, anxious, and even incompetent when floated to other units,” if they haven’t received proper orientation, she wrote in her piece, “Floating as a Reality: Helping Nursing Staff Keep Their Heads Above Water.”

Nurses who float to unfamiliar units can get stuck either with less challenging patients or with the most difficult cases to give staff nurses a break. They may feel less productive as their time is spent searching for supplies or seeking help from nurses on the unit. These scenarios make the floating nurse feel “undervalued and expendable,” and patient care may suffer as a result, explains Bates, a critical care staff nurse at Good Samaritan Hospital in Puyallup, Washington.

Bates recommends creating tip sheets, informational packets, or pocket guides for float nurses that contain specific information about subspecialties. For example, “an orthopedic tip sheet may describe hip precautions for postoperative patients,” she wrote. Bates also suggests having a dedicated resource nurse in each unit who doesn’t take her own patients, but is there to assist nurses who float to the unit. Finally, Bates says the unit’s charge nurse should check in with the float nurse periodically to ensure she is comfortable with her patient load and responsibilities.

Bates acknowledges that budgetary constraints may preclude efforts to implement these changes. Yet additional resources and staff support are critical to turning floating into a positive experience, she argues.

Float Pools or Resource Nurse Teams 

In response to dissatisfaction floor nurses have expressed about mandatory floating, several hospitals have developed dedicated teams of full-time float nurses. At MedStar Washington Hospital Center, the float pool is composed of 91 nurses who are mostly full-time floaters, says Rosemarie Paradis, RN, MS, NEA-BC, CENP, FACHE, the hospital’s vice president of nursing excellence. Additionally, the pool is also staffed by nurses from other hospitals who want to pick up shifts on their off days.

Over time, the float pool has attracted new employees, with 20 nurses being added to the float pool in the past two years, according to Dennis Hoban, the hospital’s senior director of recruitment services. Float pool nurses, Paradis says, are expected to improve their skills and maintain their competencies just as floor nurses are.

While the hospital relies on the float pool first to cover deficiencies in staffing, occasionally staff nurses are called upon to float outside their home units. “As has been our normal practice, nurses float to areas that are similar to their own…and where they have the competency to work,” says Paradis.

In 2006, University of Utah Health Care’s University Hospital in Salt Lake City transformed its resource nursing unit—what the hospital calls its float pool—from an underutilized tool into a highly valued asset. Until that point, the nurses in the unit had been perceived as fill-ins and denied opportunities to take on challenging assignments and complex patients. Now, the 45 nurses in the unit are sought after by other units because the 654-bed hospital decided to invest in training them, explains Karen Nye, BSN, RN, the resource nurse manager.

“We have a timeline of expectations,” says Nye. “We make sure they have training opportunities within a certain date of their hire, and we make sure they adhere to that timeline.”

Now, resource nurses can earn advanced certificates in the ER, ICU, burn, and neurology units. The hospital’s AirMed medical transport team relies heavily on resource nurses since its work requires flexibility and versatility, says Nye. Most recently, a new cardiovascular ICU opened with the assistance of Nye’s resource nurses.

Since there is greater trust and utilization of resource nurses across the hospital, Nye preschedules them in units at risk of paying out too much overtime to staff nurses. The result has been a significant cost savings for the hospital. In five ICUs that accepted pre-scheduled resource nurses in 2010, there was a 62% reduction in overtime hours over a ten-month period, according to a 2011 nursing report published by the health system.

More Options for Staff Nurses who Float

Other hospitals have done away with mandatory floating by floor nurses altogether to boost employee morale and reduce turnover. In 2005, Aultman Hospital in Canton, Ohio, eliminated mandatory floating in response to frustration nurses expressed at being floated from their home units on days when patient volume or acuity was low.

The 808-bed hospital replaced its old float policy with a “Willing to Walk” program, which gives floor nurses the right to decline an offer to float without negative consequences, according to Eileen Good, MSN, MBA, RN, Aultman’s senior vice president for clinical advocacy and business development. Good oversaw the development of the program when she was the hospital’s chief nursing officer.

A floor nurse who declines to float to other units can either take time off without pay or use benefit time. Giving nurses choices and greater autonomy helped Aultman earn Magnet recognition from the American Nurses Credentialing Center in 2006.

Before Good proposed the “Willing to Walk” program, Aultman had developed specialty float pools of nurses trained to work in similar units across the hospital. Good noticed that only a few floor nurses were being floated each day because units were taking advantage of the specialty float pools, composed of 40 to 50 nurses. The rates of floor nurses required to float had decreased significantly. “If we could improve this process with float teams, then why couldn’t we just eliminate [mandatory floating]?” she asks.

As a result of these changes, Aultman reduced its turnover rate from 8.3% in 2007 to 4.3% in 2010. The hospital is in the process of reapplying for Magnet designation, says Good.

While Mercy Hospital, a 175-bed facility in Portland, Maine, hasn’t eliminated floating, it created a tiered system of compensation directly tied to the floating nurse’s competency level in 2007. The new policy was aimed at easing ill will on both sides of the float divide: nurses who floated felt unwelcomed and out of their depth when working in unfamiliar territory, while floor nurses resented the fact that float nurses were getting paid a higher daily rate regardless of their skill level.

Aside from compensation issues, there were also no clear expectations of float nurses or the units that received them, explains Scott Edgecomb, RN, RRT, CCRN, clinical nurse lead in the hospital’s critical care unit. “The expectation was that they would function at a pretty high level when they arrived,” says Edgecomb, a member of a retention and recruitment council that developed the policy. Yet, no structure had been put in place to ensure float nurses received adequate training.

The new policy created four distinct levels of competency for nurses who float, with Level One functioning as little more than “helping hands” on the receiving unit all the way to Level Four, demonstrating the highest level of competency and an ability to take complex cases on specialty floors. Now each level is compensated differently, replacing the across-the-board pay differential float nurses received before.

Edgecomb says the new float policy creates greater incentives for nurses to develop their skills, and that nurses who float now are most likely functioning at a Level Three or Four. Floating is no longer looked upon with dread, but as an opportunity to earn more and develop competencies in specialized units. And the recruitment and retention council has sought to mentor nurses who are proactively seeking floating assignments that expand their skill set.

“People were stepping forward and saying they were interested in assuming those higher level roles,” he says.

Floating as New Nurse Orientation 

Advocate Christ Medical Center in Oak Lawn, Illinois, has developed a new program that aims to introduce new nursing graduates to their professions through floating. The program aims to solve two problems: the high number of seasoned float pool nurses who were leaving the pool to take positions as floor nurses and the inability of new nursing graduates in the area—south of Chicago— to find jobs, explains Kristen Brown, MSN, BA, RN, CPN, the hospital’s professional nurse educator and nurse residency coordinator.

Growing out of Brown’s practicum requirements for her master’s degree, the program is starting small but could change the way the 695-bed hospital recruits its nursing staff. In 2013, the program’s pilot year, six nursing graduates were hired from over 100 applicants, and Brown plans to hire at least two more rounds this year.

Nurses in the new graduate float program receive a 12-week orientation and participate in a 12-month nursing residency program, where they receive training with content specialists and have a chance to interact with their peers. Once they start to float, they are sent to specific zones within the hospital—medical-surgical units, orthopedics, surgical trauma, and women’s surgery—where clinical coaches work with them one-on-one over a three-month period.

Brown says the program will enable the hospital to rebuild its float pool with clinically competent nurses. By moving away from hiring to a specific vacancy and capturing strong candidates early in their careers, the hospital can fill vacancies as they occur. It also gave new graduates a chance to learn about the health system and specialties they may want to explore in the future.

“This could be the way new nurses are hired here, potentially,” Brown says. “If you have high quality candidates, you don’t have to worry about finding a spot for them. You’ve got a continuous pipeline of individuals coming in.”

Archana Pyati lives in Silver Spring, Maryland, and writes frequently on health and science topics.