INTENT

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 when floating is used by management as a means to effectuate staffing levels.

POSITION

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

• Patients are entitled to safe, quality health care at all times, and staffing levels that support the immediate availability of an RN at all times to meet their needs
• Employers are responsible for maximizing appropriate staffing levels so that in times of a staffing crisis, the usual and customary need for floating will not be required
• Registered Nurses (RNs) have an obligation to provide safe, competent, and ethical care to patients in all practice settings coupled with the right to be supported by the employer with appropriate staffing levels;

• Adequate staffing (appropriate number, mix, skill level, and competency of nursing staff) is critical to ensure the right of every patient to quality care
• The nursing profession has an obligation to evaluate and monitor patient assignments to ensure the provision and delivery of safe, quality care.
• The state has a responsibility to hold healthcare employers accountable for the provision of appropriate staffing levels;
• The state has a responsibility to hold healthcare employers accountable for the provision of appropriate orientation and training of staff who are floated to other specialty nursing units. 

• The optimum solution to emergency staffing, such as in a sudden and unanticipated fluctuation in census or unexpected increase in absenteeism, is the establishment of an internal pool of competent personnel whose credentials have been evaluated and who have been oriented and trained to the facility’s units, supplies, equipment, and current policies;

• All professional nurses must continually assess their own knowledge, ability, skill, and experience and access appropriate resources when needed.

• RNs have the right and responsibility to express their concerns and protest an assignment in writing if placed in a potentially unsafe practice situation without fear of retribution.

BACKGROUND

Researchers have identified adequate staffing as one of the most important variables to influence patient outcomes, including mortality, nosocomial infections and patient complaints (Bitanga, 2018).

Floating to unfamiliar specialty nursing units is a common practice by employers in many healthcare settings, especially during times of otherwise anticipated staffing shortages and fluctuating census.  This practice poses grave concerns regarding patient safety and potential liability for both the professional nurse as well as the facility.  According to the Joint Commission (JC), “…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). JC 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” (JC, 2004, p. 5). 

Regardless of the setting, professional nurses must maintain clinical competence and are 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 populations 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 that enable nurses to practice in a manner consistent with their scope and standards of practice. The ANA also recommends that facilities maintain documented competencies for nursing staff, including temporary staff, for those activities that they have been authorized to perform.  In addition, there should be a systematic plan for the cross-training of staff expected to float to ensure competence in times of unanticipated emergencies (2005). 

Although RNs are licensed generically and not by specialty areas of practice, nurses, state, and national nurses associations recommend ‘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 the ‘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 expertise, skill, experience, competency, and mix of the staff available to provide care.

A registered nurse receiving an assignment that in her/his professional judgment places the patient(s) at risk has an obligation under law and ethics to take action. In acting in the interest of the patient, the nurse is required to notify the administrator on duty to whom she/he is reporting to and who has the authority to make staffing decisions.

The NYS Nurse Practice Act, the Code of Ethics for Nurses, and the mandates under the NYS Board of Regents Rules related to Unprofessional Conduct hold the nurse responsible and accountable to her/his patients for the quality of the nursing care provided. However, the responsibility and accountability for the overall level of care ultimately resides with the hospital/agency, including all hospital and nursing administration staff.

Protest of Assignment forms are used when nurses are expected to assume responsibilities and accountabilities that exceed their experience and educational preparation and/or the volume of care is more than the nurse can, in her/his professional judgment, safely administer. Protest of Assignment forms are also used when the nurse has been given an assignment that is beyond the legal scope of nursing practice under the NYS Nurse Practice Act. 

For any single situation, multiple forms may be completed if there are multiple nurses who feel care is compromised. More frequently, however, due to time constraints, multiple nurses will file one form objecting to the conditions under which the nurse(s) must practice.  This singular form, then, represents multiple nurses’ levels of analysis of the patient care situation.

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 and standards 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.
• Floating of nurses should only be used in otherwise unanticipated, emergent situations and when the otherwise adequate level of staffing 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, in writing and exercise his/her right to file a Protest of Assignment, without fear of reprisal;
• 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 bookletto guide decisions in unsafe practice situations.

The supervisor should:

• Routinely assign appropriate levels of competent staff on every unit and on every shift to cover for routine, known, and anticipated fluctuations in staffing numbers, patient acuity, and patient census;
• Make an informed decision when assigning patients based on the RN’s qualifications, skills, experience, 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
• When floating is implemented in unanticipated emergency situations, assign a proficient, regularly scheduled staff member to the floated RN to act as a mentor to the floated RN;
• When floating is implemented to supplement staffing in emergency situations, reduce the patient assignment of both the mentor and the floated RN.

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 Expanded 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.
Reviewed/revised March 8, 2018

REFERENCES

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

Bitanga, M. E. (2018). What Are The Effects Of Floating to Nurses and Patient Care. RN Journal. Retrieved March 8, 2018 from http://rn-journal.com/journal-of-nursing/effects-of-floating-to-nurses-and-patient-care.

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