Each year, thousands of newly graduated nurses join the Spanish healthcare system with enthusiasm and a strong commitment.1,2 However, their transition into clinical practice often takes place under precarious and suboptimal conditions that fall far short of ensuring safe care delivery: short-term contracts offered at short notice, frequent rotations between services, unfamiliar clinical units or settings, multitude of protocols which they must assimilate within little time, and a complete lack of induction process or supernumerary status, mentoring, and clinical supervision.3,4 In a context characterized by chronic staffing shortages, employing nurses as float staff has emerged as a favourite organizational strategy to meet fluctuating care demands.5 Yet, this business approach entails significant risks, not only for patients and healthcare professionals, but ultimately health systems.
The study by Durán-Luque and colleagues rigorously addresses this phenomenon from a dual perspective, the safety of patients and healthcare workers.6 The authors propose an innovative yet pragmatic solution, an Integration Checklist, self-administered by float nurses, to facilitate safe and effective adaptation to new clinical environments. This proposal is a paradigm shift. In the absence of standardized onboarding programs, which should naturally be the optimal goal, authors advocate for a proactive approach that enables nurses to seek out essential information before initiating care.
This is not merely a clinical or operational problem—the roots of the nursing workforce imbalance are structural. Nursing professionals represent nearly half of the global healthcare workforce, with the global nursing shortage declared a global health emergency by the WHO.2 In Spain, the 2024 Ministry of Health Report on nursing workforce needs highlighted the longstanding but still growing gap between nursing human capital supply and demand, exacerbated by precarious employment conditions, underinvestment in training, high rates of temporary contracts, and a lack of generational replacement.4 Consequently, healthcare systems are forced to increasingly rely on temporary staff, including float nurses, to fill gaps caused by absences or to support overwhelmed units.
Despite the increasing use of float nurses, the evidence regarding their impact on patient safety remains inconclusive.7 Research findings are heterogeneous, in part due to inconsistent definitions and methodological limitations.8 Nonetheless, a recurring theme in the literature is the high prevalence of stress, anxiety, and job dissatisfaction among float nurses, along with their potential to become ‘second victims’, that is, professionals adversely affected by system-level failures that compromise their ability to provide safe care.9
Several critical barriers affecting float nurses have been identified, including the lack of unit-specific training, absence of structured onboarding, unfamiliarity with the physical layouts and clinical workflows, and insufficient support from host teams. A tragic example of the potential outcomes of this ‘perfect storm’ is the case of baby Ryan in Spain,10 who died whilst admitted at a leading hospital following a medication error where their enteral nutrition was mistakenly administered intravenously. While the incident was attributed to a human error, the underlying causes were undoubtedly organizational: the absence of an orientation to the ward and role, lacking supervision and support, and the delegation of clinical tasks without a proper assessment of competence. This case highlighted the fragility of onboarding mechanisms, if any, and the systemic risk of assigning nurses to care in unfamiliar environments without preparation.
Unlike physicians, who are legally restricted to practicing within their certified specialty, nurses are often expected to be universally adaptable, regardless of the complexity or idiosyncrasies of a given care environment. Such assumption conflicts with the technical, emotional, and organizational demands of high-quality, person-centred care. According to the Spanish Ministry of Health report, over 30% of initial nursing contracts were temporary or interim, with many nurses required to work in up to five different units within a single month, often without prior notice.4
As suggested, the risk posed by this status quo is not only clinical but also systemic. Durán-Luque et al. propose to flip the traditional model.6 Recognizing the impossibility of providing homogeneous and consistent orientation across all clinical settings, they advocate for equipping float nurses with a structured tool that would allow them to proactively gather critical information about the units they are sent to. This approach enhances nurses’ decision-making capacity, supports autonomy and agency, and promotes a culture of safety, without replacing the institutional responsibility, aiming to mitigate risk in urgent or unplanned staffing scenarios.
The authors outline a set of feasible and scalable interventions: pre-employment competency assessments, mentorship programs, information technology system training, and unit-specific onboarding plans. Central to their proposal is the Integration Checklist, organized into three key domains: administrative aspects, unit organization, and clinical care considerations. The Checklist's self-directed format also facilitates integration into diverse clinical contexts and nursing curricula.
The question, however, is not whether nurses can realistically complete the checklist at the start of their shift—but whether it is safe to expect them to begin working without it. The routine and comprehensive use of this tool would identify structural deficits and gaps within units, and enable tailored onboarding protocols and safety practices.
The WHO and the OECD both emphasize that patient safety cannot be assured without the safety and well-being of healthcare professionals.3,11 Providing float nurses with the tools and structure they need to integrate safety is essential to preventing clinical errors, minimizing emotional burden, and improving staff retention.
Investing in targeted, evidence-based strategies to mitigate risks associated with floating is not simply advisable—it is an ethical and organizational imperative. In a healthcare landscape where workforce shortages are likely to remain a persistent challenge, protecting those who currently care for others is the first step toward protecting those who are being cared for.
