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Quality improvement: creating a float pool specialty within a new graduate residency.

Staffing shortages, fluctuating census, and straining hospital budgets currently drive the need for unit-based registered nurses (RNs) to care for patients outside their primary clinical unit (Bates, 2013). Having unit RNs float to areas of care outside their specialty practice may result in high levels of stress and decreased work satisfaction (Bates, 2013; Duffy, 2011). In response, and as part of a strategic staffing initiative, more acute care hospitals are using internal float pools to address staffing needs.

Depending on the geographic location, the new graduate nurse (GN) may experience difficulty getting his or her first job. According to Staiger, Auerbach, and Buerhaus (2012), since the most recent economic downturn in 2007, more RNs who were considering a career change or retirement are staying in the profession. As a result, the number of available positions for the GN has decreased sharply. For example, the California Board of Registered Nursing's biennial survey reported only 64.4% of new graduates in 2011-2012 were employed within a year of graduation (Spetz, Keane, Chu, & Blash, 2013).

Leaders in acute care hospitals are considering staffing needs and GN availability when determining staffing options. While the float pool has been reserved historically for experienced RNs, the availability of GNs as float pool staff is being considered. The challenge for the healthcare organization is in creating a new graduate residency that meets unique challenges of a float pool position. In this article, authors describe how one California hospital used a quality improvement process with GNs to support their employment in the float pool.

Literature Review

CINAHL, PUBMED, and the Virginia Henderson International Nursing Library were searched for 2010-2015 for relevant articles. The literature search used the terms floating combined with nursing and new graduate nurse. The searches were not limited by study design or language of publication. Further studies were identified by examining reference lists of all included articles as well as searching relevant websites. Several articles were located on unit-based floating as well as the use of internal or centralized float pools. No published articles were found on GN residencies and float pools.

The literature review identified common themes related to unit-based floating, such as decreased work satisfaction and increased perceived stress for those who float from their units. Clinical nurses reported feeling "alone, anxious, and even incompetent" when accepting a float assignment for which they were not prepared adequately (Bates, 2013, p. 197). When floating was not done with needed education and support, staff RNs consistently described it as an extremely difficult, anxiety-provoking experience (Bates, 2013; Larson, Sendelbach, Missal, Fliss, & Caillard, 2012). Eventually, job dissatisfaction and retention issues surfaced, creating a cycle that perpetuated floating (Duffy, 2011).

In contrast, a centralized float pool provides a staffing solution and organizational cost savings, and proactively addresses understaffing. Instead of using outside agency nurses at premium hourly rates, hospitals tap qualified internal employees from the float pool (Larson et al., 2012). In a best-case scenario, internal float pools develop competent personnel by offering additional knowledge and skill development needed to work within the intricacies of each clinical unit (Good & Bishop, 2011; Roach, Tremblay, & Carter, 2011).

Many float pool RNs thrive on challenges of floating and recognize floating as an opportunity (Linzer, Tilley, & Williamson, 2011). Independence and appreciation for the opportunity to work with multiple staff in varied settings are characteristics of a successful float pool RN (Larson et al., 2012). Supportive peer relationships represent an additional benefit to centralized floating because fellow RNs appreciate the reduction in unit-based floating secondary to internal float pools. Duffy (2011) studied 314 RNs in an organization where 44% reported dissatisfaction when floating and 86% reported a hospital-wide RN float pool improved their job satisfaction. Preparedness, extra opportunity, independence, and amplified organizational socialization each demonstrate specific advantages for becoming a float pool RN (Cita, 2010; Lebanik & Britt, 2015).

Improvement Needs/ Group Oversight

White Memorial Medical Center (WMMC), a 353-bed, not-for-profit, faith-based teaching hospital in Los Angeles, CA, is part of Adventist Health. Members of the RN float pool at WMMC fully appreciate the critical role they play in securing patient safety regardless of the setting. They expect to maintain clinical competence and assume account ability for nursing judgments and actions in every area they practice. As full-time float pool RNs, they need to maintain flexibility, competency, and efficiency for each patient in the care area in which they practice.

WMMC collaborates with the Versant RN Residency program to onboard GNs to the organization during a 1-year residency program. The residency transitions GNs into many specialty areas. However, prior to this project, the float pool had not been one of these areas. WMMC also had more GN applicants than available clinical positions. In response, the centralized float pool collaborated with the Residency Manager to create a process to hire GNs into the pool. Because the concept was unfamiliar to GNs and organizational leaders, examination and refinement of the existing residency processes were essential.

The structure for the flagship float pool cohort assigned GNs to one clinical unit during the 18-week residency immersion period, with the intention of floating to other areas after immersion. September 2012 marked the inaugural WMMC float pool residency when four GNs were hired. During their 18 weeks, residents acclimated to their assigned clinical units. They were so well received and socialized that three of the four GNs asked to remain on the initial orientation units, defeating the purpose of the float pool. Primary rationale for leaving the float pool included lack of opportunity to float during orientation, ignorance with float unit protocols, and concerns over poor acceptance in the clinical float units. Anecdotally, GNs from the cohort reported correspondence from seasoned staff about drawbacks of floating, highlighting improper training and experience, lack of a home unit, instability, and insufficient security as crucial for new nurses. After review of the initial float pool cohort outcomes, especially considering high attrition for RNs in the first float pool residency, leaders identified a need to redesign the float pool.

As part of the RN residency at WMMC, GNs have the opportunity and tools to focus on the importance of early engagement in quality improvement (QI) during professional mentoring sessions. WMMC leaders support this initiative and, according to WMMC's Residency Manager, believe the GN's "fresh perspective provides insight and ambition for initiating quality improvement in the workplace" 0. Desmond, personal communication, January 10, 2014). During the GN residency the mentoring component provides a venue in a mentor circle format for residents to describe and discuss organizational QI projects. This creates a platform for sharing perceptions about QI and how past projects have had an organizational impact. The goal is for GNs to recognize the potential effect they may have in identifying a current practice issue and collaboratively working with the healthcare team to initiate the QI process to address it.

To understand improvement needs, participants conducted a focus group identifying specific areas for improvement and reinforced the direction of the project (see Table 1). They then agreed on the following goals for the project: revise the current floating orientation process so the GN would be assigned to a float pool nurse instead of a unit, and create a resource to facilitate transition into varied units for GNs and experienced float pool RNs.

Continuous Quality Model

The QI team included the Residency Manager, the Versant Performance and Outcomes Manager (POM), and nine GN float pool participants. During discussions to identify the best way of addressing the residency float pool problem, team members agreed to use the Plan-Do-Study-Act (PDSA) cycle to guide and standardize changes and monitor progress. The PDSA model was chosen because it was proven successful for specific problems and settings (Taylor et al., 2014) and was a familiar process to GNs and organizational staff.

During the planning phase, current float pool practices were reviewed and problems identified. Supporting data were selected from a metrics list that best aligned with objectives of the project. The QI team also met during this time to identify corrective actions to support program objectives. During the do phase, these actions were implemented. Participants then studied effects of the changes over time. Finally, team members determined changes would be permanent with outcomes monitored over time (act).

Quality Indicator and Data Collection

Versant Residency metrics predict turnover by asking residents if they intend to leave the organization in the next year. The tool uses a 6-point scale (1=not at all, 6=1 surely do). The Work Satisfaction Scale includes general items that address the work environment. The 5-point scale for item responses ranges from strongly agree (1) to strongly disagree (5). Higher scores indicate higher levels of satisfaction with work. The Work Satisfaction Scale total score as well as the pay and professional status subscales are significant predictors of turnover intention. Metrics are completed at the beginning of the residency, the end of the residency year, and annually for 5 years. These tools have been employed since 1999 with over 15,000 nurse residents and have been validated well over time. Program evaluation in the form of a satisfaction survey, completed at the end of the residency, also contributed to the revision of the float pool residency.

Evaluation and Action Plan

WMMC's Residency Manager has close contact with each resident and maintains responsibility for program implementation and oversight. Working in collaboration with the Versant POM, and using residency metrics and survey data along with focus group responses, the manager addresses the gaps identified between current practices and program goals.

The first revision in the residency was to assign GNs to nurses in the float pool instead of a specific unit. Using this approach, the GN learns how to work in multiple units from the beginning of the residency. Float nurse preceptors receive needed education to ensure they have the knowledge and skills to precept a GN successfully and the support needed for the task. The focus for the GN was unchanged: to validate competencies at the point of care.

Initial steps in creating a resource for all float nurses included assigning GNs to a specific unit for information collection on the identified topics. This entailed communicating with managers, charge nurses, and nurse educators regarding practices and protocols specific to their unit. Compilation of the information was completed and checked for accuracy, organization, and formatting. Once validated, subsequent decisions included how to distribute the information and make it accessible. A specific page on WMMC's intranet was deemed the best way to connect the float pool staff in an online hub. This provided float pool RNs with an intranet home, up-to-date information, and the ability to exchange information. Additionally, the web page provided unit information, announcements, staff meetings, discussion boards, and upcoming educational activities. Within a few months of conception, float pool residents launched the float pool page nicknamed The Hive. The page includes links to each unit in the hospital. Users find pertinent data for each hospital unit for a successful float experience. To maintain security, viewing information on The Hive is by invitation only.

Results and Limitations

The program was redesigned and The Hive intranet support was available for the March 2013 cohort.


In March 2013, 46 GNs were hired into the residency. Of these, eight (17%) were hired for the float pool specialty. The Hive hosted 51 members at that time, including float RNs, unit managers, and nurse educators. Participant comments were positive and residency evaluations indicated The Hive provided an interactive format. A limitation of the project was the number of float pool participants during the cohort.


The March 2013 float pool (n=8) had 62% float pool retention at 12 months after residency completion, with three RNs leaving the float pool. Two of them took full-time positions within the hospital system and one left to take a position closer to home. This compares with the overall residency retention rate at WMMC of 98% for the same time period (N=46). The retention rate for the float pool has improved, with some nurses leaving when they are recruited into full-time positions within the organization.

Work Satisfaction

Work satisfaction scores remained high for all residents during the cohort. Participants reported 80% satisfaction compared with 75% satisfaction from the Versant National Database. A limitation of using this metric was that participants were not separated by clinical unit and float pool.

Anecdotal evidence from work satisfaction comments noted float pool residents appreciated the guidance and support of organizational leaders to make changes to the float pool structure and improve outcomes. This support also empowered GNs as they advocated for the float pool through involvement in different projects and organizational initiatives.

During the year following this QI project, three GNs joined WMMC's Shared Governance Council and created the Float Unit-Based Council. With these councils, each clinical unit may change policies and practices directly affecting the patient care area. The GN float pool team also shared its QI story by presenting "Float Pool Resource Guide: A Web-Based Resource Tool for Newly Hired Float Pool Personnel" at the 9th Annual Versant Client Conference to an audience of more than 200 participants and at the Association of California Nurse Leaders 36th Annual Conference in February 2014.

Nursing Implications

Review of the literature surrounding floating consistently notes dissatisfaction when the expectation is staff RNs float from their home units (Good & Bishop, 2011). Recommendations for practice include creating a centralized float pool staffed by well-educated, engaged RNs who appreciate the challenges and benefits of working in a float pool and who are encouraged to provide input into the function of the unit and the floating process (Good & Bishop, 2011; Linzer et al., 2011). For WMMC, the key was to use a quality improvement process with strong leadership support that addressed onboarding and practice concerns for new graduate RNs and experienced staff in the float pool.

For this project, nurses working in the float pool recognized potential areas of concern but the challenge was to provide them with a voice in the remedy and redesign of the residency. This encompassed review and revision of the onboarding process using problem identification, organizational support, and available technology.


Floating is an economic necessity for hospitals to ensure safe staffing in a constantly changing care environment (Good & Bishop, 2011; Kroning, 2014). The flexibility offered by a float pool helps support the financial viability of hospitals while ensuring safe staffing is maintained at the point of care. Concurrently, retention of float pool RNs ensures the success of this strategic staffing resource. Also, work satisfaction is an important predictor of a nurse's intention to remain in his or her current position (Hairr, Salisbury, Johannsson, & Redfern-Vance, 2014). Making the floating experience a positive one should be a consideration for all hospital leaders when designing the float pool experience.

A successful floating experience remains the mutual responsibility of all stakeholders. Moving from a unit-centric to organization-centric way of thinking is needed to support work satisfaction and retention for the float nurse. Focusing on the complexity of nursing duties, providing needed support and resources, and recognizing higher levels of nurse competence required for float RNs to work with multiple patient populations are crucial for sustaining a float pool.


Bates, K.J. (2013). Floating as a reality: Helping nursing staff keep their heads above water. MEDSURG Nursing, 22(3), 197-199.

Cita, B. (2010). Top ten tips for fearless floating. Nursing2015, 40(2), 57-58.

Duffy, M.E. (2011). Effects of a house wide hospital registered nurse float pool on nurse job satisfaction. Highland Heights, KY: Northern Kentucky University.

Good, E., & Bishop, P. (2011). Willing to walk: A creative strategy to minimize stress related to floating. Journal of Nursing Administration, 41(5), 231-234.

Hairr, D.C., Salisbury, H., Johannsson, M., & Redfern-Vance, N. (2014). Nurse staffing and the relationship to job satisfaction and retention. Nursing Economics, 32(3), 142-147.

Kroning, M. (2014). The domino effect: Staffing for "what is" versus "what if." Nursing Management, 45(2), 53-55.

Larson, N., Sendelbach, S., Missal, B., Fliss, J. & Caillard, P. (2012). Staffing patterns of scheduled unit staff nurses vs. float pool nurses: A pilot study. MEDSURG Nursing, 21(1), 27-39.

Linzer, R, Tilley, A.M., & Williamson, M.V. (2011). What floats a float nurse's boat? Creative Nursing, 17(3), 130-138.

Lebanik, L., & Britt, S. (2015). Float pool nurses come to the rescue. Nursing 2015, 45(3), 50-53.

Roach, J.A., Tremblay, L.M., & Carter, J. (2011). Hope floats: An orthopaedic tip sheet for float pool nurses. Orthopaedic Nursing, 30(3), 208-212.

Spetz, J., Keane, D., Chu, L., & Blash, L. (2013). California Board of Registered Nursing 2012 Survey of Registered Nurses. Retrieved from http://www.rn.

Staiger, D.O., Auerbach, D.I., & Buerhaus, P.I. (2012). Registered nurse labor supply and the recession--are we in a bubble? New England Journal of Medicine, 366(16), 1463-1465.

Taylor, M.J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J.E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23, 290-298.

Jean Shinners, PhD, RN-BC, is Executive Director, Versant Center for the Advancement of Nursing, St. Petersburg, FL.

John Aldrich N. Alejandro, BSN, RN, PHN, is Float Pool Staff Nurse, White Memorial Medical Center, Los Angeles, CA; and FNP student, UC Irvine University, Irvine, CA.

Vanessa Frigillana, BSN, RN, PHN, is Float Pool Staff Nurse, White Memorial Medical Center, Los Angeles, CA.

Juliann Desmond, M.Ed, BSN, RN, is RN Residency Coordinator, White Memorial Medical Center, Los Angeles, CA.

Ronda LaVigne, MHA, BSN, RN, NE-BC, is Director, Performance and Outcomes, Versant Center for the Advancement of Nursing, St. Petersburg, FL.

Unit Specifics

* Unit leadership
* Unit-based protocols
* Variations in assessment
* Key codes for room access
* Variations in the admission and discharge process
* Times and days of interdisciplinary care rounds
* Certified nursing assistant duties
* RN Patient ratios
* Unit-focused HCAHPS categories
* Friendly suggestions from unit RNs to float personnel

Note: HCAHPS = Hospital Consumer Assessment of Healthcare Providers
and Systems
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Title Annotation:CNE SERIES: Continuous Quality Improvement
Author:Shinners, Jean; Alejandro, John Aldrich N.; Frigillana, Vanessa; Desmond, Juliann; LaVigne, Ronda
Publication:MedSurg Nursing
Article Type:Report
Date:Mar 1, 2016
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