It is Thursday afternoon and in my medical intensive care unit there are twelve critically ill patients. I am one of six nurses scheduled for duty that day. Normally we would have a 2:1 ratio, a nurse for every two patients. However, like most days, this is not a normal day. Difficult decisions will need to be made. 

Three patients are fighting kidney failure and septic infection, which means they need someone to constantly manage the highly technical equipment that keeps them alive, monitor vital signs and, every hour, write extensive documentation. A stroke patient needs nurses to perform assessments every 15 minutes to make sure they do not start to hemorrhage and deteriorate quickly. A fifth patient, in the midst of a mental health crisis while detoxing from opioids, requires physical and medical restraint. 

Caring for a patient means far more than attending to medical concerns. Nurses must also manage timely documentation and the needs of the unit, as well as communicate with other departments, social workers and other support systems. It also means working with patient’s families. Imagine one nurse working with more than one of these critically ill patients. Would you want your family member to receive care from a clinical provider stretched to their max capacity? When choices need to be made about how to best allocate and assign nurses, do you want people who are not working at the bedside to make unilateral decisions that determine the safety and care of your loved ones?

Basing nurse staffing decisions on the specific needs of the patient, acuity, is a proven way to achieve better patient outcomes, this is particularly true related to mortality in hospitals. Inadequate and inappropriate staffing has been directly linked to several of the clinical errors I have witnessed: medication errors, wound treatments, critical care delays, patient falls, poor communication with families and patients. 

I’ve worked critical care and trauma for nearly ten years. I’ve witnessed firsthand the high risks institutions often inadvertently take in regards to patient care, and the devastating consequences.  However, we can better mitigate human error through acknowledgment of real-world situations that occur daily in health care institutions. Of all healthcare providers, nurses spend the greatest amount of time in direct patient care and have invaluable understanding of who should provide that care. 

Bedside nurses must drive conversations around nurse staffing, and that only happens when they have a seat at the decision-making table. Their insight is critical, and improves patient care by ensuring that institutions treat people the way that nurses see them, on an individual basis, not as mere numbers in an economic system. Nurses believe our patients deserve individual, competent, safe healthcare and this bill supports that philosophy. Making staffing decisions based on acuity is not only about assessing the level of care for the patient, it also takes into account the skill set and specialized abilities of the nurse. 

Thursdays, or any day, in my ICU are often not normal. We have to make decisions about how to handle patients with profound needs and this means the need for acuity-driven nursing care, and direct care nurse-driven staffing choices, is critical. Our patients are not mere numbers! We must base our care on the actual clinical acuity. This is a matter of life and death. 


Casey Ketchum, BSN, CCRN