The next two questions, regarding the nurse-to-patient ratio and the acuity of other patients who share the same nurse, will identify how much attention the patient is going to get. Nurses measure acuity in terms of how much assistance a person needs in carrying out activities of daily living, such as eating, toileting, and personal hygiene, and how much skilled nursing time is needed to provide medical treatments and medications. There are actually five levels in standard measurements of acuity that determine how many patients a nurse can reasonably handle, assuming all the patients are at the same level. The fact that on a typical floor nurses usually have a mixture of all levels complicates this calculation. Additionally, over the past two decades, patients have been surviving longer on life support, and their doctors are moving them out of the intensive care units onto regular floors. Thus you will find a larger of percentage of artificially ventilated people on the regular floors. This formerly unacceptable practice has become a standard.
At any rate, it is difficult to determine with any precision what an acceptable nurse-to-patient ratio should be because acuity can change drastically from one moment to the next. Nonetheless, in areas where nursing shortages are acute, the dangerous levels become obvious.
To simplify the discussion of acuity, I shall identify three general levels: high, medium, and low. High acuity would identify someone who is ventilator dependent with intravenous lines, drainage tubes, and/or catheters and who may require heart monitoring by telemetry or may have an open wound. Moreover, anyone who needs total care for activities of daily living (ADLs) falls in this category.
Medium acuity defines a person who has all or some of the lines and tubes of the high-acuity patient but is not life-support dependent and does not need the heart monitor. A patient with open wounds is also included. These folks would need partial assistance with ADLs.
Finally, low acuity pertains to those who are ambulatory and independent with ADLs. They only need minimal supervision, provision of medication and treatments, and teaching.
Staffing levels in New York, Florida, Ohio, California, Texas, and South Carolina, to name a few states, are becoming dangerously low. It is common to find a floor with forty patients relying on three nurses where the acuity mix is 20 percent high, 60 percent medium, and 20 percent low. One would also find five or six life-support dependent individuals among the high-acuity group. This is dangerous, unacceptable, and commonplace. The irony is that through this threatening nursing shortage there is no shortage of nurses. There is only a shortage of nurses willing to work in hospitals. Considering their plight, this revelation should not astonish or astound anyone. Nurses work with their minds, their hearts, and their backs. They are accountable to a slew of bosses, regulators, doctors, patients, and family members in being required to anticipate and provide the needs of patients. The workload is often cruel, and there is the added pleasure of forced overtime turning an eight-hour shift into sixteen. At the end of the day, they have to worry about lawyers dragging them into court as defendants or nonparty witnesses.
Generally speaking, these shortages have been running in cycles, since more than half the workforce are married women providing secondary family incomes. During prosperous times with less general unemployment, nurses leave the workforce in droves. During recessions with high unemployment, some nurses tend to come back. The difference now is that the baby boomers are getting older with no replacements, so the available human pool is shrinking. This, coupled with the fact that we baby boomers are also going to load up the hospitals as patients in the coming years, makes the future safety of hospital services look bleak with half the nurses and twice the number of patients.
There are both short- and long-term solutions to these perils. The short-term resolution requires family participation. If your loved one is on a floor with three nurses, two nursing assistants, and forty-eight patients with the acuity mix as described previously, you have two choices. You can complain to the supervisor, or you can volunteer to participate in the care of the person for whom you are concerned. If you complain, the supervisor is likely to respond with, "I'm only a supervisor. I am not a magician." In reality, nursing supervisors spend most of their time finding nurses to work for the next shift because the prescheduled staffing levels are appallingly dangerous.
Thus if you volunteer, you will make a huge difference in keeping the patient out of harm's way. In tandem, the hospital management must do away with strict enforcement of visiting hours for family members who want to conduct a round-the-clock vigil to provide one-to-one care. Certainly, we have a right to expect full and safe service for the enormous amounts of money we pay for hospital coverage. However, the immediate concern is the safety of our family and close friends.
In the long term, on the other hand, solutions are possible but more difficult. The relief of some of the endemic problems facing nurses in hospitals requires a willingness on the part of hospital executives to acknowledge that such problems exist. Then they need to look at options like nursing program scholarships and recruitment of foreign nurses. Regarding the latter, we need some changes in federal immigration law to streamline the process of granting work visas to registered nurses from certain English-speaking countries. There also has to be a more equitable distribution of the corporate revenue of hospitals. The chief executive who makes half a million dollars per year with a cadre of executives each drawing six-figure incomes cannot justify saying that the hospital is unable to pay recruitment fees and expenses to bring nurses in from other areas. At the risk of earning the wrath and ire of hospital executives, I feel strongly that there should be a shift of some of the cash from executives' pockets to the cost of hiring and retaining more nurses.