As nurses, we’re familiar with eight-, 12- and even 24-hour shifts, but our profession has developed another unpleasant permutation that not all of us have yet encountered: split-shift floating.

Split-shift floating means that a nurse starts his or her shift in one unit and then at some point during the shift is moved to a different unit. Shift-splitting is most often done with registry or traveling nurses, although it occasionally happens to staff nurses as well.

Thankfully, shift-splitting is relatively rare, but it can be a sign that something is seriously wrong with the way a hospital manages its nursing staff.

Why It Happens
I know that a lot of readers have strong prejudices against registry nurses, but there’s no denying that they are a fact of life in many hospitals. In a perfect world, there would be no need for registry nurses, but in a perfect world, no staff nurse would ever call in sick, have to leave in mid-shift due to an emergency or quit at an inopportune time. Unfortunately, in the real world, those things happen all the time and when they do, many hospitals turn to registry nurses (also called travel nurses or just “travelers”) to pick up the slack, particularly in states like California that mandate minimum nurse/patient ratios

Registry nurses typically work through a staffing agency that contracts with the hospital to provide temporary nursing services. Because hospitals aren’t usually in a strong bargaining position in these negotiations, travel nurses are often hired on “pay or play” contracts, meaning the hospital is obliged to pay for a predetermined number of hours or shifts regardless of how many hours the traveler actually works.

That’s why when the patient census drops, staff nurses sometimes find themselves sent home while the registry nurse stays — the hospital is on the hook for the traveler’s time whether he or she is working or not! For the same reason, travelers may sometimes find themselves shifted from one unit to another during a single shift to make up nursing shortages in different areas of the hospital.

Where It Goes Wrong
Floating nurses from unit to unit on different shifts is not itself a bad thing and there are occasions where shift-splitting is unavoidable, albeit far from ideal. However, if they become commonplace,  “Houston, we have a problem.”

Splitting shifts can have very negative consequences for the hospital and patients as well as the nurses. Having to change units during a shift can lead to a whole assortment of errors ranging from incomplete charting to missed or late medication. Worse, if something does go wrong, other nurses may have to step in to fix it, taking time away from their other duties and potentially compounding the bigger problem.

Behind the Eight-Ball
To illustrate the disruptive nature of shift-splitting, here’s a recent night in the life of a travel nurse named Charlene, who has given me permission to share her story with you.

Charlene was scheduled to spend the first half of her eight-hour shift, from 19:00 to 23:00, in Unit A and the remainder of the shift in Unit B. Here’s a small sampling of her duties during her four hours in Unit A: One patient presented with glucose of over 400 with no order for a sliding scale, had a wound V.A.C. to address ulcers on one foot and needed a leg ulcer dressing change at hours of sleep.

Charlene managed to track down the physician and get an order to administer a stat dose of 15 units of NovoLog while caring for three other patients, one of whom presented with a persistent fever and prompted Charlene to seek a doctor’s order for straight catherization for urine culture and sensitivity.

Charlene managed to accomplish and document all these tasks and at 23:05 was ready to brief the nurse assigned to relieve her. Five minutes later, while giving that report, she got a call from the assistant nurse manager of Unit B demanding to know why she wasn’t there yet!

This is a common dilemma for nurses working a split shift: If they don’t take the time to make a full report to their relief, patients’ continuity of care is likely to suffer, but taking that time almost certainly means being late to the next unit and being chewed out by the manager there. Charlene aptly describes the whole situation as being “behind the eight-ball.”

Dirty Curtains
Obviously, this is not good or sound nursing practice. Unfortunately, nurses in that position don’t have much recourse. When Charlene spoke up, she was given a dressing down and warned, “When you’re in someone’s home, you don’t tell them that their curtains are dirty.” A travel nurse who complains too much about a hospital’s practices is likely to be rewarded with a “do not send” note in her agency file.

Staff nurses may not fare any better. How many of us have been (or seen colleagues) reprimanded or otherwise punished for pointing out an unsound or unsafe practice? Such punishments send a message to the rest of the team that they should keep their mouths shut or share a similar fate.

A Better Way
During my various tenures as a director of nursing, one of the first things I always tried to put in place was an in-house pool of floater nurses. This pool wasn’t simply plucked arbitrarily out of the nursing staff; it was a group of talented and adventurous nurses who had been carefully recruited and, most importantly, had volunteered for this unique and challenging assignment.

Building those pools took work (each nurse had to be a generalist with the right personality and the ability and desire to take on a diverse and ever-changing array of duties), but it allowed our leadership to respond to each unit’s day-to-day staffing needs with nurses who were up to the task — without needing to rely on travelers or shift-splitting.

The point is not that hospitals should  never float nurses between units or hire registry nurses, but it is vital that the nursing chain of command not allow short-term solutions to become routine practice. Responding to an occasional emergency is one thing, but regular shift-splitting or constantly relying on travelers rather than addressing ongoing staffing issues will just mean higher costs and more mistakes.

It’s also crucial for nurse managers to create a climate where the staff is not afraid to offer constructive criticism. At the same time, nurses must have the courage to speak up when they see an unsafe situation and not throw each other under the bus just to make it through the workday.

If more nurses made it clear that we as a profession won’t stand for unsafe nursing practices like shift-splitting (and won’t stand for colleagues being capriciously or unfairly punished for a valid complaint), it will make our hospitals safer, saner environments for nurses and patients alike.

~Geneviève M. Clavreul, RN, PhD

From The Floor

Working Nurse Magazine