The problem with floating ER Nurses

apocatastasis · Oct 23, 2011

I think it would be hard to go from oncology or short stay to ER or visa-versa, but an ICU or cardiac nurse should be able to cross train and float and ER go to those units.

Cross-training is ok if the nurse feels compelled to do so, but a lot of ICU nurses have no desire to work ER and vice-versa, and I don't think that's an issue that should be forced. I'm an ICU nurse who now works ER (which I dislike and do it only for the schedule flexibility while in school). They're very different skill sets and mindsets.

As far as floating to the floor, I would never, as an ICU or ER nurse, agree to work for a facility that had me do anything on the floor other than task. Likewise, when we pull ICU and floor nurses to work ER, we never give them actual assignments, they just float and task.

momof3lv · Oct 23, 2011

Wow you mean there are nurses that dont have to float? When I worked in the hospital we floated all the time. No cross training really given. I worked general peds so when we floated to PICU, Hemoc or NICU we were suppose to be given less acute patients and feeder and growers in NICU. Didnt always happen but it was a nice thought. When I worked in the ER, er nurses usually didnt float because they usually staff for what they need and you were there even if it was slow, or busy as hell. But occasinally we did float, with the instructions that if hell broke loose we would be called back to the ER.

wooh, BSN, RN · Oct 23, 2011

I'm confused as to the problem. Are ED nurses floating because the ED is overstaffed and/or because somewhere else is understaffed?

crabalot · Oct 23, 2011

To highlandlass-I did contact the ENA and they don't have a position on ER NUrses who float. Thanx for the advice anyway. To those who asked, there is a perception our ER is fat while the rest of the hospital is lean as far as staffing. While that may or may not be true at the beginning of the shift, we will be full by noon. The problem is we are floated to areas with notoriously low staffing, then they refuse to let us return if the excrement strikes the blades of the rotary wind device. Sometimes we are used as sitters for psych 1:1 patients, or our Techs are used for the same which leaves us strapped. One day on the other rotation they floated all but three Nurses which left one Nurse for Triage (no Tech), one for patient care (we have 26 beds), and the Charge Nurse manned the phones and Telemetry. Any given day we could have 5 or 6 psych pts on 1:1 waiting on a bed either here or transferring out, 20 patients not eligible for Urgent Care, and 5 Nurses available for care. If they already floated our Techs (usually 4), we have to use Nurses for 1:1 in the ER. This is a normal day! My position is the ER can change from calm to tornado in one hour and we need to be ready for just that. Management is now offering orientation to the floors so we will lose if we refuse to float there. We feel that management sees us as a float pool instead of creating a float pool for that reason. We call in sick to keep others from floating. The burnout rate is accelerating. We have a useless union. I wonder if showing evidence supporting our position will effect change. Maybe if anyone knows court cases where low ER staffing resulted in bad patient outcomes :confused: . Or reports of med errors, adverse events, etc R/T poor ER staffing where an ER Nurse had to answer to their License Board?

crabalot · Oct 23, 2011

To momof3lv- our hospital is one of many in a national chain. In our division, we are the only ER who floats. One person said there are only 3 in the entire chain who floats ER Nurses! We did not float until this past year so this is a new thing for us. We went to the ER for the nature of the beast as well as not having to float! To Msn10- I know of a rural hospital where the ER Doc becomes the Attending if admitted and Nurses rotate all over the place. They knew this when they hired on, so this is no surprise. If it was a matter of sharing the float wealth with the rest of the hospital, we could probably adapt and get over it. We are the whipping post kids for the entire hospital for floating, and maybe we get help on out of 14 days. Whatever.

Larry77, RN · Oct 23, 2011

In all the ED's I've been involved with this was not common practice. I knew of some who still worked in the dept's they came from for OT but were not floated from the ED. We are not census staffed like other dept's so we do not call off RN's but if we are having a slow day we do send volunteers home early...occasionally involuntarily on a rotation basis per our contract.

Personally I think by being trained in multiple dept's it makes you less proficient, in a sense spreading your knowledge too thin. How can you be a master at any practice if you are an apprentice in many?

crabalot · Oct 23, 2011

Thanx Larry77. That's what we all are familiar with. It may be that something has to happen(God forbid) to get this point accross. For the record, I don't really care if I float as a matter of principle. I did that alot on med-surg/tele and in the units. The ER is a different animal. 'nuff said.

Esme12, ASN, BSN, RN · Oct 23, 2011

It's a dilemma. I think there are so few papers or studies because historically it just isn't done. The nature of the emergency department makes it difficult to adapt to floor nursing, and visa versa. Due to the many requirements and nature of the department the paper work is very different. So volunteer cancel/on call is usually the answer.

ED nurses historically have no training on floor paper work and EMAR/MAR's. Even when a nurse transfered in from with in the facility it remains difficult to re-acclimate to the floor and has long been considered too expensive to try to maintain competencies in areas that aren't used by ED nurses as well as being mindful of the liabilities involved with missed meds and labs of routine nature that are not routine to the ED staff......the need to float when the ED is in a "lull" is historically intermittent at best and the chance of being recalled to the department causing a hardship on the floor so much as the consideration of floating has not been explored nor maintained.

Most Emergency Department remain "closed" unit much like LDRP, Cath Lab/Radiology and the OR due to the uniqueness in the requirements of the positions that to maintain the competencies (IV's, ACLS, PALS, TNCC, ENPC, telemetry, and meds to be given by critical care nurses only... as well as casts, crutch walking, and gait training ) of those that float in have proven to be cost prohibitive. (I'd remind your manager/administration of this).

To maintain with in JACHO requirements competency must be proven and maintained. The requirements for the "usual staff" competencies is applicable to the float nurse as well, and to attempt the obtain such competencies and maintain them has proven to be cost prohibitive so those department has remained historically "closed" no floats in, no floats out....... except in those rare instances that someone will "help out" transporting, IV starting, EKG taking, or taking care of the floor boarders.

I have seen, on a strictly volunteer basis, the cross training of "like units" of those nurses who wish to experience the high liability and adrenaline of the ED but have done so, as I said, on a strictly volunteer basis. Those nurses usually already have ACLS and are capable in the event of a mass casualty or patient in cardiac arrest. The floating of the ED nurses is an expensive option to a CNA or patient care attendant as the nurses salary is twice that of the non licensed personnel. That coupled with the liability of having to leave a 1:1 SI unattended, however brief, due to an emergency in the ED and the 1:1 elopes or, God forbid, carries out their desire to die can lead to very expensive litigation to the facility.

Hospitals need to reveal their staffing patterns to JACHO and are accountable if they are not truthful or followed for whatever reason.....Maybe a complaint to the JACHO about slipping standards of care may help you. (and can be made anonymous) But be mindful in making waves and getting your head above the radar may make you a target because you didn't conform and made waves so be prepared for that.......What is your manager doing? She should know how to make this argument.

I hope this helps for your arguement, but the papers are non existant because it just didn't occur before.....maybe it will now... :crying2:

Altra, BSN, RN · Oct 24, 2011

One day on the other rotation they floated all but three Nurses which left one Nurse for Triage (no Tech), one for patient care (we have 26 beds), and the Charge Nurse manned the phones and Telemetry.

I have no words for this.

Totally unacceptable ... and I'm sorry you're going through this.

msn10 · Oct 24, 2011

One day on the other rotation they floated all but three Nurses which left one Nurse for Triage (no Tech), one for patient care (we have 26 beds), and the Charge Nurse manned the phones and Telemetry.

Well that is just crazy. That is not a floating issue, it is a staffing issue. Instead of trying to find floating protocols/research, it sounds as if you could just focus on safe ER staffing levels. ENA should have a lot of info on that.

Some articles that might help - You will need CINAHL to access, I cannot post them online because they are copy written through my university - I am not doing APA format, just copy and pasting them for you.

Impact of nurse staffing level on emergency department market share. (2007).

Hwang J; Chang H; Health Care Management Review, 2007 Jul-Sep; 32 (3): 245-52 (journal article - research, tables/charts) ISSN: 0361-6274 PMID: 17666995

Subjects: Emergency Nursing; Emergency Service; Patient Safety; Personnel Staffing and Scheduling

Using queueing theory to increase the effectiveness of emergency department provider staffing. Green LV; Soares J; Giglio JF; Green RA; Academic Emergency Medicine, 2006 Jan; 13 (1): 61-8 (journal article - research, tables/charts) ISSN: 1069-6563 PMID: 16365329

The relationships between emergency department staffing and clinical outcomes of the acute myocardial infarction patient.Detail Only Available

(includes abstract); Oster CAH; University of Colorado Health Sciences Center, 2002; Ph.D. (244 p) (doctoral dissertation - research) ISBN: 978-0-493-59716-4 (This one is old but it is a really good dissertation)

a comparison of in-hospital mortality risk conferred by high hospital occupancy, differences in nurse staffing levels, weekend admission, and seasonal influenza.Detail Only Available

(includes abstract); Schilling PL; Campbell DA Jr; Englesbe MJ; Davis MM; Medical Care, 2010 Mar; 48 (3): 224-32 (journal article - research) ISSN: 0025-7079 PMID: 20168260

Nurses' perception of nursing workforce and its impact on the managerial outcomes in emergency departments. Hu Y; Chen J; Chiu H; Shen H; Chang W; Journal of Clinical Nursing, 2010 Jun; 19 (11-12): 1645-53 (journal article - research, tables/charts) ISSN: 0962-1067 PMID: 20384667

This is a start. Give these titles to your hospital librarian if you have one, otherwise, I am sure there is some nursing student floating around who can get them for you, maybe even your old alma matter.

Let me know if you need more.

wooh, BSN, RN · Oct 24, 2011

I have to question, one nurse for patient care (we have 26 beds),how many of those beds were in use at the time? And what's the protocol for getting staff back to the ED if those beds start to fill?

Because THAT is where you're going to have fight your battle. Management is jumping on the model of staffing based on current patient levels at the moment, re-evaluating hourly, every couple hours, whatever. They don't care what MIGHT happen. Which we as actual practicing patient care nurses KNOW is what really mucks up the crap staffing for us. They care what IS happening at the moment, and feel no need to pay for people to be on site "just in case."

turnforthenurse, MSN, NP · Oct 24, 2011

Where I work, I never see the ER nurses get floated. They have a different charting system down there and therefore do not have access to the same charting system we utilize on the floors...hence why they don't float. On the flipside, nurses from my unit frequently get floated to the ER if my unit is overstaffed, but of course we do not have 100% access to their charting. We are able to chart through a different way, but that doesn't work the same when ER nurses get floated. I hope that makes sense.