Position Statement

Floating

The intent of this position statement is to reaffirm the nursing profession’s responsibility to monitor staffing effectiveness for the protection of the public from unsafe and ineffective nursing practice, especially during times of floating.

Position

It is the position of the New York State Nurses Association that:

Patients are entitled to safe, quality health care at all times, including during times of a staffing crisis and floating.
Registered Nurses (RNs) have an obligation to provide safe, competent, and ethical care to patients in all practice settings.
Adequate staffing (appropriate number, mix and competency of nursing staff) is critical to ensure quality patient care.
The nursing profession has an obligation to evaluate and monitor patient assignments to ensure the delivery of safe, quality care.
The state has a responsibility to hold healthcare employers accountable for the provision of appropriate and timely orientation and training for staff expected to float to unfamiliar units.
The optimum solution to emergency staffing, such as in a sudden fluctuation in census or unexpected increase in absenteeism, is the establishment of an internal pool of competent personnel whose credentials have been reviewed and who have been oriented to the facility’s units and current policies.
All professional nurses must continually assess their own knowledge, ability, and experience and access appropriate resources when needed.
RNs have the right and responsibility to express their concerns and protest an assignment if placed in a potentially unsafe practice situation.

Background

Floating to unfamiliar units is a common practice in many healthcare settings, especially in a climate of staffing shortages and fluctuating census. This practice poses concerns regarding patient safety and liability for both the professional nurse as well as the facility. According to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), “…inadequacy of orientation and training was identified as the most common root cause of more than half of all sentinel events reviewed” (2004, p. 5). JCAHO requires all accredited organizations to ensure that “…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).

Regardless of the setting, professional nurses must maintain clinical competence and must be held accountable for their nursing judgments and actions. The nursing profession requires “…a life-long learning commitment and willingness to update skills to competent current practice standards…. A lack of knowledge does not excuse the nurse from accountability and responsibility for patient safety and welfare” (Gardner, 1997, p. 55). Each nurse is responsible and accountable for their practice and should use professional judgment when determining competence. At no time should a nurse practice with negligence, incompetence, or perform tasks that he/she has no knowledge of or has not been educated to perform (§ 29.1, Regent’s Rules of Unprofessional Conduct).

Registered nurses must have the support of management at both the operational and executive level in order to competently meet the needs of a varying population of patients in a rapidly changing, technological environment. According to the American Nurses Association (ANA), healthcare facilities should have policies in place that reflect their value and commitment to the profession of nursing enabling nurses to practice in a manner consistent with their scope of practice. The ANA also recommends that facilities should have documented competencies for nursing staff for those activities that they have been authorized to perform, including temporary staff. In addition, there should be a systematic plan for the cross-training of staff expected to float to ensure competence (2005).

Although RNs are licensed generically and not by specialty areas of practice, the ANA recommends ‘shifting the nursing paradigm from an industrial model to a professional one’ that would allow for a more realistic focus on the complexity of nursing duties and levels of nurse competency that are needed to adequately provide quality patient care (ANA, 2005). No longer is a ‘nurse-is-a-nurse-is-a-nurse’ mentality acceptable in a technologically advanced and multifaceted healthcare system. Staffing determinations should be based on the intensity of care required by the patient population and the level of experience, competency, and mix of the staff available to provide care.

Recommendations

In order to facilitate safe, quality patient care by RNs who are adequately trained and competent to care for an assigned group of patients, and to ensure that the rights of RNs are upheld within their legal scope of practice, the New York State Nurses Association recommends that:

Floating of professional nurses to unfamiliar practice settings should be avoided as it poses potential risks for unsafe practice situations.
If floating is deemed necessary, it should only be permitted in emergent situations when inadequate staffing is unanticipated and could lead to unsafe practice situations.

The RN should:

assess his or her own competency and skill level and seek additional information as needed;
refuse to perform any task not permitted within his or her scope of practice;
inform the supervisor if given an assignment that involves knowledge or skills beyond his or her competency level;
explore alternatives, within reason, to gain the necessary information to perform required tasks (e.g., review unit specific policies and procedures, access other available references, confer with an experienced co-worker); and
utilize NYSNA’s Nurses’ Rights and Responsibilities booklet to guide decisions in unsafe practice situations.

The supervisor should:

make an informed decision when assigning patients based on the RN’s qualifications and competencies;
make necessary adjustments to assignments when the knowledge and skill necessary to perform certain tasks is outside an individual’s skill set; and
assign a regular staff member to the floated RN as a ‘consulting registered nurse’ to provide immediate guidance and support for practice issues specific to the unit’s patient population.

The healthcare facility should:

establish a consistent policy for addressing emergent staffing issues;
provide adequate orientation and training for RNs expected to float to unfamiliar practice settings;
monitor patient outcomes (e.g., pressure ulcers, falls, medication errors, infections, etc.) in relation to staffing levels and mix in order to evaluate the sufficiency of current staffing systems; and
monitor trends in nursing indicators (e.g., turnover, satisfaction, work-related illnesses and injury, overtime, etc.) to evaluate the quality of the nurse’s work life.

Reviewed/revised by NYSNA’s Council on Nursing Practice 06/02/06 and 12/01/06. Approved by the Board of Directors on 06/08/06 and 01/23/07.

Note: The use of the term “patient” anywhere in this document is intended to be generic and refers to the recipient of nursing care.

References

American Nurses Association. (2005). Utilization guide for the ANA “Principles for nurse staffing”. Silver Spring, MD: Author.

Gardner, S. L., & Hagedorn, M. E. (1997). Your practice and the law. Holding nurses accountable. AWHONN Lifelines, 1(1), 55-6.

Gobis, L. (2001). Workplace rights. The perils of floating. American Journal of Nursing, 101(9), 78.

Higginbotham, E. (2002). Advice of counsel. When you believe an assignment exceeds your expertise. RN, 65(6), 72, 74.

Iowa Board of Nursing. (2003). Iowa Board of Nursing position statement: nurses floating to other health care areas. Des Moines, IA: 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.

Kany, K. (2001). Workplace rights. Policy vs. reality. American Journal of Nursing, 101(5), 87.

Mustard, L. W. (2002). Perspectives. The paradigm shift in RN staffing in hospitals: corporate responsibility and institutional liability. Journal of Nursing Law, 8(2), 31-4.

New York State Nurses Association. (2005). NYSNA position statements. Nurses rights. Retrieved March 24, 2006, from http://www.nysna.org/programs/nai/practice/positions/positions41.htm.

New York State Nurses Association. (2005). NYSNA position statement. RN staffing effectiveness and nursing shortage. Latham, NY: Author.

New York State Nurses Association. (2005). Nurses’ rights & responsibilities. What to do in unsafe patient care situations. Latham, NY: Author.

Sullivan, G. H. (1995). Legally speaking. When assignments don’t match skills. RN, 58(4), 57-8, 60.

The University of the State of New York, the State Education Department, Office of the Professions. (2003). Nursing guide to practice. Albany, NY: Author.

For more information on nursing practice, contact NYSNA's Education, Practice and Research Program at 518.782.9400, ext. 282 or by e-mail.