Many hospitals have fluctuations in patient volumes that require staffing adjustments. Mercy Hospital in Portland, Maine, is no exception — we were struggling with challenges such as decreased employee satisfaction with the current low-census staffing allocation process. There was a reluctance among staff to float to other units contrasted by and the hospitals growing need to improve staff flexibility. Senior leaders responded by endorsing a staff-driven initiative to create an effective float policy and an equitable low census policy.
A team approach
Committed staff nurses from 12 different practice areas formed the Low Census/Float Policy Team. The goal was to create an equitable and effective method of responding to changes in staffing needs. The question that needed an answer was, “How do we deal with census fluctuations to support a healthy work environment for our staff and ensure quality patient care at the bedside?”
The first priorities were to develop a process to identify and optimize staffing resources during times of low census and to create a supportive and flexible float policy.
Revising the float policy
The original float policy gave our clinical advisors and managers the authority to float staff and determine the level of responsibility the nurse would take. Consideration was given to each nurse’s competency but assignments were not consistently aligned with skills and credentials. Nurses assigned to float did not consistently have a positive experience. Additionally, nurses who floated were compensated with a flat rate floating differential irrespective of skill level or level of assumed responsibility. The float policy was revised to reflect a tiered system with compensation linked specifically to availability, competency, and the level of support needed on the unit.
To improve staff satisfaction, the policy required the lead RN on the accepting unit and the floating nurse to collaboratively determine appropriate patient assignments. Float staff are expected to be welcomed to the accepting unit and be introduced to colleagues. All efforts are made to provide float staff with the level of support they need to have a positive experience.
The revised float policy was approved in September 2007 and uses four distinct levels of floating:
- Level I functions strictly as “helping hands” and performs core tasks that do not require additional training.
- Level II includes meeting a core minimum competency set for the particular unit and ability to take a partial patient load with a co-assigned RN.
- Level III signifies the ability to function independently with a full patient load in non-specialty areas and must have met all competencies for that unit.
- Level IV is for those individuals who float to a specialty unit, function independently and have met all required competencies.
Implementation of the revised policy has eased staff resentment of nurses who were being compensated at higher rates of pay when they were unable to function independently. In addition, it provides financial incentive to encourage staff to increase their competency level.
To assess the success of the revised float policy we conducted a staff survey for each float experience. The results have demonstrated success in providing positive floating experiences in a supportive environment. And, significant reduction in costs associated with float differentials have been realized — an unanticipated hospital benefit.
The need to improve staff flexibility comes to the forefront at times when it is most needed yet providing the opportunity to cross train remains a barrier as hospitals strive to maintain financial viability. Administrative support is an integral component in allowing time for successful training and education of nurses to respond to needs outside their home unit. At Mercy Hospital every option is being considered to strengthen our nursing staff and improve flexibility in all practice areas.
Response to low census
To address the hospital response to low census, the team developed a low census day (LCD) policy that clearly delineates the order of staff reduction and has additional limitations on the time regular staff are asked to take off if work is not available. This protects staff paid time off (PTO), which ensures time will be available for illness or vacations and promotes a healthy work life balance. Staff members use low census opportunities to work on many projects, including education, quality initiatives and policy revisions. When bedside nurses are involved in improving the clinical practice environment they can be empowered to succeed, which promotes organizational success. Ultimately this work improves the organization’s ability to provide quality patient care.
Changes pay off
Implementations of the revised float and LCD policies have increased staff satisfaction. Unit lead nurses are now engaged in staffing decisions at census/bed placement meetings. These interactions support relationships between units and have built a more cohesive healthcare team. Coordinating the use of float pool staff and balancing staffing between units has been a team effort. Interaction between units is necessary for team building and encourages professionalism and often empathy. Knowing what is happening on other units is an important part of the process.
Developing a workforce that can flex based on demand is necessary for providing consistent quality care and sustaining a healthy workforce. A team approach can help resolve floating and low-census staffing issues while supporting the staff.
Scott Edgecomb is the clinical nurse lead in the critical care unit, and Dorothy Dyer is Chair, Recruitment & Retention Council; both work at Mercy Hospital in Portland, Maine.
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