Research for Practice
Staffing Patterns of Scheduled Unit
Staff Nurses vs. Float Pool Nurses:
A Pilot Study
Nicole Larson, Sue Sendelbach, Bernita Missal, Jeff Fliss, and Philippe Gaillard
he health care environment
is evolving and organizations
are working to adapt to the
changing needs of their patients.
One area on which many hospitals
are focusing is the creation and use
of flexible resources. Flexible resources such as float pool nurses help
hospital leaders staff units effectively
while also allowing adjustment to
the changing needs of the patient
population. Additionally, as hospitals face continuing economic and
regulatory restraints, nursing leaders
are being challenged to maintain
safe nurse-to-patient ratios, decrease
patient length of stay, and manage
increasing patient acuity. Dougan,
Lanigan, and Szalapski (1991) found
that unlike staffing agencies, with
variable staffing by nurses who do
not work specifically for the organization, float pool nurses are more
autonomous and reliable due to
their training and familiarity with
the organization. This approach has
contributed to improved patient
care. Therefore, the more that nurses
are cross-trained and competent to
work in various areas within the hospital, the easier and safer it is to provide quality care to patients as it is
needed (Strzalka & Havens, 1996).
Gosztyla and Fowler (1998) and
Cavouras (2002) found flexible
resources, such as float pool nurses,
can benefit health care organizations. However, evidence indicates
hospitals with float pools have
decreased from 87% to 71%
(Cavouras, 2002; Gosztyla & Fowler,
1998). Anecdotal reports from float
pool nurses at Abbott Northwestern
Hospital (ANW) suggested that float
pool nurses receive more difficult
patient assignments than regularly
scheduled unit staff nurses. This per-
T
In this study, the differences in patient assignments between float
pool nurses versus scheduled unit staff nurses were examined.
Although there was a tendency for float pool nurses to receive more
difficult patient assignments, this was not statistically significant
(at alpha=0.05).
ception increased staff dissatisfaction
and potentially discouraged nurses
from joining a float team.
Literature Review
Online databases were used to
search for float pool related articles
published between 1990-2007. Databases used were CINAHL, PubMed,
and Ovid. Search terms included
float pool, nurse resource team, nurse
staffing equality, floating, staffing acuity, and nurse staffing. The literature
review revealed no published quantitative studies related to the differences in difficulty of patient assignments for float pool nurses versus
unit staff nurses.
Several authors (DziubaEllis, 2006;
Vandankumar & Warner, 1976)
identified float pool nurses as a
group of nurses who accommodate
unit staffing in response to variability in patient care needs. The first
published literature on floating was
the work of Connor (as cited in
McHugh, 1997), who found measuring patient census alone would not
balance registered nurse (RN) workload. Instead, Connor developed a
method for looking at workload and
patient acuity together, in which
floating and controlled variable staffing
were created to help control costs
and provide sufficient caregivers
(DziubaEllis, 2006; McHugh, 1997).
Since Connor’s original work, float
pools, more recently known as
resource teams (DziubaEllis, 2006),
have become an invaluable part of
the nursing workforce within a hospital.
In addition to providing patient
care, float pool RNs also may offer
other benefits. For example, because
the float pool nurse would be the first
to float between units during times of
low patient census, scheduled staff
may experience increased satisfaction. In a survey of 76,000 nurses, the
American Nurses Association (ANA,
Nicole Larson, MA, RN, is Patient Care Supervisor, St. Francis Regional Medical Center,
Shakopee, MN.
Sue Sendelbach, PhD, RN, CCNS, is Clinical Nurse Researcher, Abbott Northwestern Hospital,
Minneapolis, MN.
Bernita Missal, PhD, RN, is Associate Professor of Nursing, Bethel University, St. Paul, MN.
Jeff Fliss, RN, is Patient Care Manager, Float Pool, Abbott Northwestern Hospital, Minneapolis,
MN.
Philippe Gaillard, PhD, is Research Associate, Office of Clinical and Translational Science,
University of Minnesota, Minneapolis, MN.
Acknowledgment: The authors acknowledge the generous support of the Minnesota Nurses
Association Foundation for funding this study.
January-February 2012 • Vol. 21/No. 1
27
Research for Practice
2005a) found approximately 29%
were experiencing increased floating
between units. Nurses have described
negative feelings about floating,
ranging from unfamiliarity with the
float unit to concerns about competence in providing care (Banks,
Hardy, & Meskimen, 1999; Nicholls,
Duplaga, & Meyer, 1996). Floating
also can be a source of stress for nurses (Nicholls et al., 1996). One survey
revealed 73% of nurses disliked floating between units (Ornstein, 1992). A
survey by Centra Health sought to
determine strategies for staff retention; results indicated floating
between units dissatisfied nurses
(Bethune, Burnette, Cavouras, &
Wolf, 2004). Consequently, Centra
Health put closed staffing in place
and created a float pool team that
maintained competency in several
areas.
Additional benefits to having a
hospital float pool include cost savings. For example, an approach used
when hospitals are understaffed is to
hire outside agency nurses. Agency
nurses cost ANW approximately
$71.00 per hour per nurse. In contrast, the average ANW nurse salary
is $38.00 per hour (H. Kapaun, personal communication, January 8,
2010). Therefore, it is in the hospital’s financial best interest to avoid
using agency nurses if possible.
Despite the patient and staff benefits the float pool nurse provides,
anecdotal reports suggest pool nurses receive the most difficult patient
assignments and are treated poorly
and with little consideration (Kidner,
1999; Nicholls et al., 1996; Roberts,
2004). This often dissuades nurses
from joining a float pool team. In
addition, the usual benefits given to
float pool nurses, such as salary,
choice of schedule, or choice of shift
(DziubaEllis, 2006), are now the
same for unit staff nurses (Cavouras,
2002).
In spite of these negative aspects
associated with floating, nurses who
choose to work in float pools like the
variety of experiences, including
exposure to new advances in nursing
and medicine (C. Graham & C.
Sebold, personal communication,
December 3, 2011). Nurses also find
working in the float pool allows for
28
independence, gives them the
opportunity to work with a variety
of people, and makes them more
marketable (Gosztyla & Fowler,
1998). In fact, according to Altimier
and Sanders (1999), three hospitals
in Ohio joined forces to create crosstrained nurses who would float
between two facilities in Cincinnati.
At the completion of their crosstraining program, nurse leaders
found the program helped with
staffing, decreased nurses’ perceived
stress, created unity across the hospitals, and developed more flexible,
competent, and marketable nurses.
Patients also benefit from float
pools. The relationship between
staffing ratios and quality of patient
care has been demonstrated in the
literature (Needleman, Buerhaus,
Mattke, Stewart, & Zelevinsky, 2002).
Without properly cross-trained float
pool nurses, nursing units may not
have enough nurses on a given shift
to provide safe patient care. Float
pool nurses can fill any variance in
staffing on a unit and can ensure
enough staff are available to care for
patients adequately and safely.
Even though qualitative evidence
published in the literature (Kidner,
1999; Nicholls et al., 1996) supports
the belief float pool nurses receive
the most difficult assignments, there
are no published quantitative studies
to support this. Because there is very
little published literature on the difficulty of patient assignments given
to float pool nurses, the purpose of
this study was to determine any differences in patient assignments
between float pool nurses and scheduled unit staff patient assignments.
The null hypothesis was as follows:
There is no difference in patient
assignments between float pool
nurses’ and scheduled unit staff
nurses in a hospital setting. This
study was part of the float pool’s initiatives to increase job satisfaction
and employee engagement.
Methods
Setting and Sample
This comparative study was performed in medical-surgical, cardiovascular, neurology, and orthopedic
inpatient units at a large, quaternary
care hospital in the Midwest. The
hospital is stratified in “communities” of service that include cardiovascular (ICU 16 beds; CCU 16 beds;
three progressive care units of 22
beds each), medical-surgical (general
40 beds; renal 34 beds; oncology 34
beds; GU/GYN 40 beds), neurology
ICU (27 beds), neurology (46 beds),
spine (40 beds), and orthopedics
(two units with 20 beds each).
At the study hospital, medicalsurgical units are staffed at a ratio of
one nurse to four patients on a day
or evening shift, and one nurse to
five or six patients on a night shift.
The intensive care units are staffed at
a ratio of one nurse to every one
or two patients. The current care
delivery model incorporates an allRN staff with assistive personnel
assigned to the RNs.
Inclusion criteria were the medical-surgical, orthopedic, neurology,
and cardiovascular inpatient care
units. Many of the specialty units
within the hospital are considered
closed staffed, meaning the float
pool does not consistently work in
those areas. The closed staffing units
were not included in this study.
Exclusion criteria were women’s
care, mental health, emergency
department, and outpatient care
units.
Procedure
After obtaining approval from the
hospital’s institutional review board,
researchers randomly selected three
8-hour shifts (7:00 a.m.-3:00 p.m.,
3:00-11:30 p.m., and 11:00 p.m.7:30 a.m.) and two 12-hour shifts
(7:00 a.m.-7:30 p.m. and 7:00 p.m.7:30 a.m.) occurring November 1December 13, 2007 (excluding
Thanksgiving week). The staffing
office was utilized to determine to
which units float pool nurses were
assigned. One of two research assistants (RAs) rounded on units that
had float pool nurses working on
them during the selected shifts.
Rounding consisted of stopping by
each unit to obtain the staffing
sheets for the shift. The RAs were
both RNs who worked in the float
pool. Using the tracking tool developed for this study (see Figure 1), the
January-February 2012 • Vol. 21/No. 1
Staffing Patterns of Scheduled Unit Staff Nurses vs. Float Pool Nurses: A Pilot Study
FIGURE 1.
Data Collection Tool
Patient
Care Unit
Float
RN
Unit
RN
Assistive
Personnel
Difficulty = Acuity + Flow + Volume
Difficulty Total score
RAs collected data about the patient
care assignments of float pool nurses
and unit staff nurses for the shift
from the patient assignment sheet.
Occasionally, conversations occurred
between the RA and the charge
nurse of participating units in order
to verify or clarify any questions
from the RA. The RA did not speak
with the individual nurses.
Data Collection Tool
At the time of data collection, not
all patient care units in the hospital
were using the same acuity system
developed for the organization (see
Figure 2). Because of this, a consistent
data collection tool needed to be created. By using this tool, researchers
could compare data from multiple
units more accurately. The data collection tool was developed specifically
for the purposes of this study (see
Figure 1) and was used to assign a
composite level of difficulty to each
patient assignment. The composite
level of assignment difficulty was represented with three dependent variables: patient volume, patient flow,
and acuity of patient condition.
Patient volume was defined as the
total number of patients for whom a
nurse provided care during the
worked shift. Patient flow was defined
as the number of admissions, discharges, transfers, or surgical patients
for whom a nurse cared during the
shift. The patient acuity rating was utilized on units that were using the acuity tool developed for the hospital (see
Figure 2). When data on all the variables were collected, they were added.
Assignment difficulty could range
Acuity - Each
patient rated
1-5
Flow - 1 point
for each
admission,
discharge,
transfer, or
surgical patient
Volume number of
patients
cared for
throughout
the shift
from 2 to 24, with a higher number
indicating a more difficult patient
care assignment. For example, if a
nurse started with four patients, the
volume would be four. If the nurse
had one patient discharge and then
received a surgical patient, the flow
would be two. If the acuity was 16,
the difficulty score would be 22 (4
[volume] + 2 [flow] + 16 [acuity]).
Float staff were RNs from the float
pool (approximately 142 RNs) as
opposed to unit RNs floating
between units. Unit RNs were those
RNs who were assigned to the
patient care unit where they were
working. Additional data were collected, such as any assistive personnel working on each unit. Assistive
personnel included certified nursing
assistants, operation coordinators,
and operations technicians. Operations coordinators and operation
technicians are assistive personnel
who are specially trained to perform
phlebotomy and obtain ECGs.
Finally, a space on the data collection form titled “other” allowed for
qualitative comments from the
charge nurse. “Other” included
patient characteristics that RNs
informally identified as making the
patient more complex. All patient
assignments were covered with an
opaque piece of paper to maintain
confidentiality of information.
Statistical Analysis
Descriptive statistics were used to
describe trends, patterns, and factors
of patient assignment of float and
unit nurses. The independent vari-
January-February 2012 • Vol. 21/No. 1
Nursing
assistants
Operations
technicians
Operations
coordinators
Other
Qualitative
comments by
charge nurses
such as:
Total care
Confused
Isolation
Fall risk
able was the nurse group: float vs.
non-float. Three t-tests were used to
test the null hypothesis that there is
no difference in patient assignments
between float pool nurses and scheduled unit staff nurses in a hospital
setting. The tests of significance were
non-directional and conducted at
the 95% confidence level. Because
the assumption of homogeneity of
variance was not met, the
Satterthwaite method was used to
compute standard errors. The SAS
9.1 for Windows software package
was used for the computations.
Results
Patient assignments from 217
shifts were analyzed and, although
there was a tendency for float pool
nurses to receive more difficult patient
assignments compared to unit staff
nurses, this was not statistically significant (p=0.05) (see Figure 3). The top
three factors that influenced patient
difficulty included patient confusion,
fall risk, and isolation.
The mean acuity for float pool
nurses was 13.92, while the mean
acuity for unit staff nurses was 13.18,
a 0.73 difference (p=0.47). Higher
numbers meant higher acuity. The
mean of patient flow was 15.13
(float pool nurses) and 14.12 (unit
staff nurses), a 1.01 difference
(p=0.38). Although float pool nurses
on average handled more admissions, discharges, transfers, and surgical patients during a shift than unit
staff nurses, the difference was not
significant statistically. Finally, in
terms of patient volume, the mean
29
Research for Practice
FIGURE 2.
Acuity – Levels of Patient Care: Acuity Level Definitions Were Created by Representation from the
Minnesota Nurses Association and Selected Clinical Nurse Managers at the Study Hospital
Level 1
The patient is able to participate in care decisions and assume self-care/activity independently. The patient is able to
understand instructions and have effective strategies/skills for adapting to illness and hospitalization. Patient has a
strong support system. The patient is responsive to interventions and is predictably advancing in his or her plan of
care/care path. Assessment occurs once per shift and care coordination requirements are low.
Level 2
The patient is alert and oriented and has an identified support system. The plan of care is identified and clear. The
patient can participate in care and understands the plan of care and teaching. Patient can communicate effectively
and requires minimal assistance or supervision in activities of daily living (ADL) with or without limitations. The patient
is at low safety or complications risk. There is a predictable and decreasing need for assessment and intervention.
The patient is motivated, meeting goals, and on projected pathway or outcome.
Level 3
The patient is alert, oriented, and able to participate in his or her plan of care. This patient may experience confusion or forgetfulness, but is cooperative and responds to reminders and reinforcement. ADLs are performed with
assistance. The patient/family has ongoing educational needs, requiring repetition and reinforcement. Psychosocial
needs are continually addressed to reduce fear and anxiety during hospitalization. The patient is at moderate safety and complication risk, requiring ongoing assessment and interventions to manage present problems and prevent
others. The patient is advancing in the plan of care through frequent interventions, and vigilance is needed to maintain progression and prevent complications.
Level 4
The patient is complex, challenging, and usually requires a longer length of stay than expected. The patient requires
stamina, persistence, and a high level of communication and coordination from the nurse and other disciplines. The
patient has multiple problems, complex social needs, and variances from the frequent modifications to plan of care.
She or he is nurse-dependent for ADLs. The patient and/or family have high educational needs. They exhibit high levels of anxiety, often expressed by multiple questions, and need for contact with staff. Care coordination with other
disciplines is complex and ongoing. Patient is at a high safety risk and risk for complications. This patient may be
confused, suicidal, or experiencing withdrawal. Patient requires complex procedures and protocols. Pain, nausea,
nutrition, fluid and electrolyte imbalances, and skin integrity are not well controlled and are difficult to manage.
Level 5
The patient is in crisis and dependent on continual care by a nurse or a team of caregivers for ongoing life support.
The patient requires continuous assessment, adjustment, and use of multiple interventions and technology to
achieve physiologic stability. The family requires continuing information, support, and care to manage their responses to the patient’s condition. Care coordination is complex and urgent.
Adapted from Minnesota Nurses Association, 2007. Reprinted with permission.
30
FIGURE 3.
Patient Assignment of Float Pool RNs and Unit Staff RNs:
Patient Acuity, Flow, and Volume
2
Level of total difficulty as
measured by patient acuity,
flow, and volume
for float pool nurses was 12.7 and
the mean for unit staff nurses was
11.8, a difference of 0.90 (p=0.41). In
summary, although there was a
trend toward float pool nurses providing care for more acute patients,
having more patient movement during the shift, and greater number of
patients, the differences were not statistically significant.
The “other” category comprises
patient characteristics that contribute to the complexity of care for
a patient, making it more difficult
for the nurse to provide care.
Frequently, this includes patient
characteristics that affect safety and
infection control. In the “other” category (see Figure 4), confusion
(n=65) was the most frequent factor
identified by nurses, followed by fall
risk (n=46) and isolation (n=45).
1
1
5
0
Acuity
Flow
■ Float Pool
■ Unit Staff
January-February 2012 • Vol. 21/No. 1
Volume
Staffing Patterns of Scheduled Unit Staff Nurses vs. Float Pool Nurses: A Pilot Study
Number of Patient Shifts
FIGURE 4.
Other Category Qualitative Data Used to Describe Patient Characteristics/Factors Contributing to
Complexity of Patient Care
80
60
40
20
0
Confusion
Fall/Risk
Isolation
Infection
Total
Split
Assignment
Patient
Anxiety
Identified Conditions
Discussion
Although results of this study
were not statistically significant for
measures of patient acuity, patient
flow, and patient volume, there was
a trend toward more difficult assignments for float pool nurses (see
Figure 3). Because this is the first
known published study on differences in staffing patterns between
float pool nurses and unit staff nurses, no data are available to compare
the results.
As identified in the literature
(Cavouras, 2002), this trend has dissuaded some inpatient nurses from
transferring to the float pool and
may be the reason many nurses have
left the float pool. Concern over consistency and equality of patient care
assignments have been brought to
the attention of the float pool manager. Presenting this study’s data to
the nursing leadership teams has led
to changes in charge nurse orientation and support of a house-wide
acuity system. Also, data collection
and response to staff concerns have
led to increased float pool recruitment, retention, and employee
engagement based on the belief float
pool nurses will be supported in their
work.
One surprising trend noted when
analyzing the data was the frequency
of the “other” qualitative data nurses
used to describe patient characteristics
or factors that added to the complexity of care (see Figure 4). In greater than
60 of the 217 shifts analyzed, float
pool nurses cared for patients with
confusion. Characteristics such as
confusion may add to the complexity
of care of patients. Recognizing this
information may provide opportunities for recommendations of quality
improvement projects related to
patient care (Sendelbach, Guthrie, &
Schoenfelder, 2009).
Isolation was noted in the “other”
category and was cited frequently as a
factor contributing to a difficult
patient care assignment. Methicillinresistant Staphylococcus aureus (MRSA)
rates are increasing steadily. In 1974,
2% of S. aureus infections in an
intensive care setting were caused by
MRSA. In 1995, that number increased to 22%, and in 2004 reached
64% (Centers for Disease Control
and Prevention, 2007). Klevens and
colleagues (2007) found MRSA infections were associated with greater
lengths of stay, higher patient mortality, and increased costs. An
increase in MRSA means more time
gowning and gloving for inpatient
nurses, more money spent on isolation precautions for an organization,
and increasing challenges in the
management of patient care.
Patients at risk for falls also were
identified in the “other” category.
Affected patients pose challenges to
nurses, resulting in an increase in
assignment difficulty. Patient falls
have been associated with understaffing or poor nursing care; patient
harm can occur (ANA, 2005b), leading to increased lengths of stay and
health complications. This informa-
January-February 2012 • Vol. 21/No. 1
tion, along with the Joint Commission’s National Patient Safety
Goals related to patient safety and
infections (Joint Commission,
2009), has led to hospital-wide initiatives to reduce the number of
patient falls and decrease the nosocomial infection rate.
Study Limitations
The medical-surgical and critical
care results were analyzed together,
affecting the measurement of patient flow and patient volume in
data collection. For example, data
showed over half the float pool nurses had only one patient during a
shift and had no admissions or discharges (see Figure 5). Because most
critical care assignments involve
only one patient, this is likely reflective of a critical care assignment versus an accurate representation of a
typical medical-surgical assignment.
All the shifts also were analyzed
together. The volume of patients and
patient flow varies from shift to shift.
A day shift medical-surgical nurse
may have three to five patients,
including new admissions, while a
night medical-surgical nurse may
have six patients with no patient
flow. By analyzing all shift data
together, the researchers may not
have represented accurately the
measure of patient flow difference
between medical-surgical and critical
care units.
Two RAs were used to collect data
for this research study. The tool was
31
Research for Practice
FIGURE 5.
Staffing Patterns and Total Volume of Patients per RN
6
Frequency
5
4
3
2
1
0
1
2
3
4
5
6
Number of Patients
created by the RAs and informal conversations were held regarding how
data were to be collected. However,
prior to starting the data collection,
no test of inter-rater reliability was
conducted. This was a limitation of
the study.
Recommendations
In future studies, a larger sample
size would be beneficial. Patient
assignments from 217 shifts were
analyzed for this study. Also, results
from the medical-surgical units and
critical care units should be analyzed
separately in order to compare similar patient care units with similar
staffing patterns. Of the 217 shifts,
54 (25%) reported assignments in
which the nurse cared for only one
patient. These numbers suggested a
critical care assignment which, when
combined with the medical-surgical
data, create a less-accurate average
patient volume. Also, each shift (day,
evening, night) should be analyzed
independently because staffing and
patient flow vary from shift to shift.
Of the 217 shifts, 152 reported a
patient flow of one, meaning only
one admission, discharge, transfer,
or surgical. Again, these data are
more representative of critical care
than medical-surgical assignments.
These two patient care communities
thus should be analyzed separately.
32
Conclusion
Although results of this study
were not statistically significant, a
trend was shown of float pool nurses receiving more difficult assignments. As hospitals and other health
care organizations adjust and adapt
their practices to remain viable in
the changing health care environment, flexible resources such as float
pools will be paramount to their
success. Addressing and monitoring
the equality of patient care assignments of float pool nurses versus
unit staff nurses may increase float
pool recruitment and retention and
assist health care organizations to
adapt to changes in health care
demand.
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Staffing Patterns
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