Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes
Vivian Dinh
Dixie State University

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes
It has been another busy weekend for the Thoracic Intensive Care Unit with shortage of
staffs, and full load of patients. Being a new nurse, Kristy was quite anxious to find out that it is
her turn to float today for the first time due to the low census on her unit. After she finished
getting report from the previous shift nurse, she went in to perform an assessment on her patient,
and realized that the patient chest tube chamber has been tipped over on the floor. Kristy came
from a Neurological Intensive Care Unit and as a new nurse; she has not been dealing with many
chest tubes during her clinical experience. After she was done with her assessment, and make
sure the chest tube chamber is secure on the floor. She went out to look for help, and find no one
available on the floor. Kristy felt frustrated about not knowing what to do to be able to get an
accurate output on her chest tube chamber since the fluid in the chamber has been distributed
throughout the entire column. Does this scenario sounds familiar?
As nurses, working in a hospital base, often time we get floated to a different unit to help
out with the shortage of staff issue. This is a way to help out the hospital to balance their staff,
and fulfilling needs where there is a shortage. Although the practice of floating is usually viewed
as an efficient, cost effective strategy for responding to workload and unplanned staffing
changes, it can negatively affect overall job satisfaction, staff turnover, and the quality of patient
care (Nicholls, Duplaga, & Meyer, 1996). Often time, the nurses may feel disoriented when
floating to a different unit because they are taking out of their comfort zone, they may not get
proper orientation to the unit, they do not know where things are, they may be assigned with a
difficult assignment to give the unit nurse a break, and they are lacking of resources buddy like a
charge nurse or an experienced nurse on the floor to help them with questions about the specific
unit routine and procedures. The three aspects of a nursing assignment structure that appear to

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

most severely affect patient safety are floating, nurse understaffing and shift working
(Davidhizar, Dowd & Brownson, 1998). Communication between team members including the
charge nurse and the float nurse also play an important part in keeping the patient safe and ensure
quality of care. Effective communication is essential among individuals and groups within the
hospital, and between the hospital and external parties. Poor communication often contributes to
adverse events and can compromise safety and quality of care, treatment, and services. Effective
communication is timely, accurate, and usable by the audience (Division of standards and survey
methods, 2009). In the Neurological Critical Care Unit, there are specific routine neurological
exams that the nurses perform every one to two hours on the patients to be able to catch any
neurological changes as soon as they can to be able to intervene. It is quite important for us to be
consistent with the exam because with the brain, time is valuable. Recently, we have been
running into problem from having float nurses forget to perform neurological exam as order per
MD, medication errors, as well as float nurses not happy with their assignment. Therefore, it has
been our manager goal to minimize these problems to provide safer care for the patients, and
increase the float nurses satisfaction by the end of year. This project is implementing base on the
Relationship Based Care (RBC) on resources driven. A resource driven practice is one which
maximizes all available resources-staff, time, equipment, systems, budget-in the interest of
achieving desired outcomes and safeguarding patient care (Koloroutis, 2004, p. 19). Along with
this project, the Relationship Based Care method of measuring the outcomes is also utilizing to
monitor the progress monthly by checking the patient satisfaction score like HCAPPs scores, as
well as reviewing survey that was given out to the float nurses. Gathering data for outcomes
measures would make sure that the plan of change is working effective in increasing patient
safety care and increase the float nurses satisfaction.

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

In reviewing the problems with floating with the nurses in our units as well as the other
nurses from other unit that float to our unit. From the nurses point of view, there are issues like
not getting proper orientation, taking time to look for materials and ask for door codes, do not
know which physician to call, not familiar with the unit specific routine, protocol, and
procedures. When floating to a different unit, the nurses hesitated to ask question because it may
make them look incompetent. Also, without appropriate resources provide to the float nurses
like a buddy, they might not be able to complete simple tasks by themselves for example double
check medications like insulin or heparin drip, wasting narcotic medications, turning the patient
every two hours, toileting patients, and many mores. Therefore, it puts the patients at risk for
problems like unsafe procedures, fall, and medication errors. On the other side, there were
nurses that believe that floating actually keep their skill sharp, enhanced their critical thinking
skills, and be able to gain new skills from the experiences. Being in the critical care
environment, it is more critical as nurses have to follow specific routines, protocols, guidelines,
and procedures to be able to provide quality and safe care for our patient population. In the
neurological critical care unit, we have large amount of different type patients with strokes, brain
tumor, seizures, and many mores. Therefore, we have a specific routine neurological
examination that we perform on our patient every two hours or more often depend on the
physician order. It is quite important for us to perform this neurological examination strictly to
be able to catch any neurological decline or changes as a sign of increased swelling or bleeding
in the brain as soon as possible. When we can catch these sign early, well be able to get a quick
head CT, and intervene accordingly. In certain type of strokes patient, the physician goal was to
keep a higher concentration of sodium in the patient body to help with the amount of swelling in
the patient brain. Therefore, it is important to check the patient electrolyte according to the

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

physician order, and replace it according to plan. We also have patients that come in with a large
amount of blood in their brain, that cause severe swelling required the neurological surgeon to
put an EVD (external ventricular drain) in their ventricle to drain the excess blood in a chamber
to help with the swelling. These patients are on strict bed rest and require close monitor to make
sure the EVD is working properly, and that they do not over drain their cerebral spinal fluid with
movement. We also monitor their ICP (intracranial pressure) to make sure that it is within the
range. Because of our unit specific procedures and protocol, it is important for us to make sure
that the float nurse aware of our routine and expectation. From interviewing the float nurses,
they voiced that they did not get an orientation to the unit most of the time, not having proper
resources like an experienced nurse from the unit, and wasting a lot of time looking for materials
being in the unfamiliar place.
The final solution to the problems based on the majority of nurses voiced that they did
not get an appropriate orientation to the unit as well as the resources that they need to be able to
provide safe and quality care for the patient. With the unit manager approval, the float nurses
orientation sheet was enhanced by adding a cheat sheet along with it that the float nurses can clip
on to their clipboard with important information including the resources person like the charge
nurse, healthcare coordinator (HUC), critical care tech (CCT), experience nurses as buddy, the
pharmacist, and the physician. The cheat sheet also including information like the location of the
medication room, clean utility room, crash cart, emergency equipment, emergency evacuation
plan, and door codes. There is also important unit specific information on the cheat sheet
included the shift routines as well as specific procedures and/or protocol. Including in the
orientation package, there is also a survey that will be given to the float nurses where it will ask
for their valuable feedback on the floating experience to be able to improve the plan. Along with

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

the changed to the orientation information, the charge nurses also involve in the progress as well.
According to Bates (2013) the charge nurses should be involved in making decisions about
patient assignments based on the float nurses level of experience. This is key in improving
satisfaction for the nurses floating to the unit.
The new changes to the orientation process have a positive support from the nurses on the
unit. It was definitely a team effort of working together to make the float nurses feel welcome
and comfortable being part of the team. Good teamwork is fundamental to achieving positive
results. Teamwork begins with overcoming assumptions one may have about another's roles.
Communication is essential to ensuring successful outcomes (Gonzales & Rodman, 2010). The
assigned experienced nurses have been working together with the CCT to be available as the
float nurses resources buddy. The float nurses was able to get help in no time knowing who
their resources buddy were, and be able to call them for questions and concerns using the
hospital vocera system. The charge nurses was frustrated a little at the beginning about having to
oriented the float nurses around the unit which is time consuming. It was also the charge nurses
job to coordinate with the HUC to make sure that the float nurses receive the orientation sheet
along with the cheat sheet and survey. However, the charge nurses was able find a perfect
routine by including the float nurses in the unit huddle happen at the beginning of each shift, then
taking them for their orientation tour of the unit after the huddle, then giving them the orientation
package which include the fill out cheat sheet, and the survey in it. The charge nurses also make
sure to treat the float nurses as a guest on the unit by checking on them from time to time
throughout the shift to make sure that theyre getting the help they needed.
Within a month of starting the routine, the unit audited report showed a reduction in
medication errors related to the float nurses. Although the patient satisfaction score in November

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

has not been improving very much; however, the float nurses feedbacks from the surveys has
mostly been positive with great comments and suggestions.
Working under the hospital systems, nurses must understand that they were hired to work
for a corporation not just a particular unit in the hospitals. Therefore, floating is not an option
when the hospital is facing issues like shortage of staff, because it is unsafe, and can definitely
increase the rate of patient with complications and fatalities unnecessary. It is understandable
that most nurses view floating away from their unit as a negative experience due to unfamiliar
environment and lacking resources. According to Kane-Urrabazo (2006), preparing your staff to
successfully float to another unit in times of need is a small price to pay in comparison to the
incurred costs of unnecessary infections, injuries, and patient deaths that frequently coincide with
understaffing. For example, a 24 years old female who came in to the hospital for a surgical
procedure to remove a tumor on her pituitary gland in her brain was being transferred to the
Neurological Critical Care Unit after surgery for overnight observation. Due to the shortage of
staffing, the patient was assigned to the nurse floating from a different unit because she was
considered the most stable and low acuity. The patient remained stable for the first part of the
shift until midnight when the patient urine output increased dramatically over one liter in two
hours and the patient start getting really thirsty and constantly asking to have her jug of water
refill. The float nurse did not understand why the patient urine output increase along with being
thirsty constantly, therefore he was able to contact the charge nurse via vocera system by looking
up her name on the cheat sheet to ask for advice before calling the physician about it. The
charge nurse was able to explain to the float nurse that this condition is called diabetes insipidus
and is quite common with patient that has their pituitary tumor remove. Its happening usually
when the pituitary glands do not produce enough vasopressin hormones in the brain that control

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

the water balance in the body. From lacking vasopressin, the kidney will not be able to hold on
to water and therefore causing patient to have symptom like increased thirst as well putting out
great amount of urine output. The charge nurse then walked the float nurse through the chart to
look up for the contact information on the specialist endocrinologist that was assigned to the
patient. The float nurse was able to get in contact with the endocrinologist in no time to get
specific order like checking the patient specific gravity, electrolyte and giving the patient
appropriate medication to be able to get the condition under control. The patient urine output has
been decrease since the intervention took place, and she was able to be transfer to the regular
floor in the morning. This example showed that with appropriate orientation, utilizing teamwork
strategies with the help from having resources like the charge nurse, along with communication
has helped the float nurses provide safe and quality care for the patient. Teamwork is a key
component of many professions; when employees feel as if they are part of a unit, relevant
outcomes are improved. Nurses report enhanced job satisfaction and patient care outcomes are
met (Ward, 2013).
In the end, floating may not become an option any time soon due to the amount of short
staffs that the hospital has to deal with on a daily basis. However, creating solution to make the
floating experiences more positive will promise to increase satisfaction for the staffs, and
improve patient satisfaction as well as safety care. Relationship Based Care model has provided
great guide for nurses to work together as a team, and utilize available resources to be able to
provide optimal care for the patient. Along with the teamwork, having resources like appropriate
orientation process provided for the float nurses from other unit has proved to provide more
positive experience in a short amount of time. It will be interesting to see the impact of this

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

process in improvement of the patient satisfaction scores as an outcome measurement by the end
of the year.

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

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References
Bates, K. J. (2013). Floating as a reality: helping nursing staff keep their heads above
water.Medsurg Nursing, 22(3), 197-199.
Davidhizar, R., Dowd, S. B., & Brownson, K. (1998). An equitable nursing assignment
structure. Nursing Management (Springhouse), 29(4), 33-36. doi:10.1097/00006247199804000-00010
Deck, M. L. (2010). Nursing professional development: stories, tips, and techniques. Journal
for Nurses in Staff Development, 26(6), 284-287. Retrieved from
http://www.nursingcenter.com/static?pageid=1130711
Division of standards and survey methods. (2009). The Joint Commission standards supporting
the provision of culturally and linguistically appropriate services. Retrieved from Joint
Commission website:
http://www.jointcommission.org/assets/1/6/2009_CLASRelatedStandardsHAP.pdf
Gonzales, C. M., & Rotman, S. (2010). Effective strategies can reduce turnover rates, improve
group cohesion and nurse satisfaction. Advance healthcare network for nurses. Retrieved
from http://nursing.advanceweb.com/Article/Building-Blocks-of-Teamwork.aspx
Nicholls, D. J., Duplaga, E. A., & Meyer, L. M. (1996). Nurses' attitudes about floating.Nursing
Management, 27(1), 56-58.
Ward, J. (2013, January 14). The importance of teamwork in nursing. Retrieved December 1,
2015, from http://www.nursetogether.com/the-importance-of-teamwork-in-nursing

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes
Float Nurses Survey
1. Where is your home unit?

2. Have you float to the unit before?

o Yes
o No
3. Were you provided an orientation tour?
o Yes
o No
4. Did you receive an orientation package?
o Yes
o No
5. Did the charge nurse introduced his/herself to you?
o Yes
o No
6. Did you have an assigned buddy?
o Yes
o No
7. Did the assignment given to you appropriate to your skill level?
o Yes
o No

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Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

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Please rate your experience of floating to the unit as follow

1. Strongly disagree 2. Disagree 3. Neutral 4. Somewhat agree 5. Strongly agree

The team members from the unit has been a great resources to you
1

The team members has been helping you with your assignment throughout the shift
1

You receive a throughout orientation tour to the unit

1

Overall, your floating experience to the unit was great

1

Thank you for your help floating to our unit today and your effort for filling out this survey.
Your feedbacks and suggestions are valuable to us to improve your experiences and satisfaction
when floating to our unit.

Enhance Orientation for Positive Floating Experience and Improve Patient Care Outcomes

NCCU Float Nurse Quick Tips

Charge Nurse
HUC
Tech
Buddy
Physician
Pharmacist
Clean Utility Code
Neurological Check Routine

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