TABLE I.-Utilization of general hospitals by persons of age 65 and over, and persons of all ages-Comparative data from various surveys and

insurance plans

FACILITIES REQUIRED TO PROVIDE COMPREHENSIVE HOSPITAL SERVICES

A hospital which provides comprehensive service offers to inpatients and outpatients, examination, diagnostic, and therapeutic services in the fields of anesthesiology, dentistry, dermatology, and syphilology, internal medicine, neurology, neurological surgery, obstetrics and gynecology, ophthalmology, orthopedic surgery, otorhinolaryngology, pathology, pediatrics, physical medicine, plastic surgery, preventime medicine and public health, proctology, psychiatry, radiology, surgery, urology, general practice and communicable disease.

To provide these services the following facilities must be available: Outpatient department; radiological department, both diagnostic and therapeutic, superficial and deep, and radioisotopes; laboratory, in addition to routine laboratory services, tissue examination, autopsy and morgue facilities, basal metabolism, electrocardiography, electroencephalography, blood banks; physical therapy, including heliotherapy, hydrotherapy, electrotherapy, massage and therapeutic exercise; pharmacy; operating suite; delivery room suite; anesthesia service; oxygen service; central sterilizing and supply. In addition, facilities are available for medical records, medical library, nutritional services, medical social service and health education services. Also, the conventional administration services, i. e., audit, fiscal, purchase and supply, storage, maintenance or other similar housekeeping functions would be required. An institution offering comprehensive hospital service usually has associated with it an educational program for student nurses, practical nurses and aides; dietitians, student medical record librarians, ancillary technicans, as well as an educational program for undergraduate and post graduate medical students.

[Public Health Reports 68: 933-939 (October 1953)]

DISTRIBUTION OF HOSPITAL NURSING SERVICES

1 By Helen G. Tibbitts, M. A‚1

The need for more nurses in hospitals is a familiar problem. As a result, sometimes hospital beds have been closed, but more often the available nursing services have been spread more thinly over the existing patient load. The American Hospital Association reports that at the end of 1951, nearly 14,000 hospital beds were closed for lack of personnel and that job vacancies existed for 22,486 graduate nurses (1), 10 percent of the total number already employed in hospitals. These data, collected by the American Hospital Association, cannot be used to show the amount of nursing care patients are receiving, but data from the 1951 American Medical Association's census of registered hospitals can be used for this purpose, and so round out the picture.

The American Medical Association has made available to the Public Health Service unpublished data on patient census and nursing personnel, which show the geographic locations and hospital types in which those patients are concentrated who are receiving less care than the nursing profession's standards recommend. Such standards have been set forth for three distinct types of hospitals: general and allied special, nervous and mental, and tuberculosis. For general and tuberculosis hospitals the standards are in terms of hours of care per patient-day, and for mental hospitals they are in terms of a nurse-patient ratio. While the nursing profession recognizes that these standards are not based on adequate data, they are the only guidelines available at this time. standards are in fairly general use pending the results of studies now underway or contemplated.

The

Nurse-patient ratios have been computed for each type of hospital from data supplied by the American Medical Association. The nursing personnel included in thes ratios are limited to nurses available to give direct care to patients. General duty nurses are the only professional nurses included. The nonprofessional personnel include practical nurses, attendants, nurses' aides, and orderlies. The care given by student nurses is excluded from the nurse-patient ratios developed from the American Medical Association data. The personnel counts are as of

1 Mrs. Tibbitts was statistical analyst with the Division of Nursing Resources at the time this study was made. She is now with the Health Resources staff of the Office of Defense Mobilization.

a particular day in October 1951, while the number of patients was counted as the daily average patient census for the most recent 12-month period for which data were available at that time. An adjustment is made for part-time general duty nurses so that personnel counts would be on a full-time basis. No adjustments are made for care given by private duty nurses, and to offset this, no adjustments are made for newborn census.

The ratios computed from the data for hospitals registered by the American Medical Association have been converted by a very simple process into estimates of average hours of care received by patients: For hospitals whose nurses work an average of 44 hours a week and 48 weeks a year, the average hours of care per patient-day is one-seventeenth of the number of nursing personnel per 100 patients. For hospitals that average a 40-hour week, the average hours of care is one-nineteenth of the ratio. For example:

Figure 1. Estimated daily hours of total nursing care per patient in nongovernmental general hospitals, 1951.

In States where nurses work 40 hours a week, each nurse works 1,920 hours per year (40×48). The number of patient-days per year is the product of 365 multiplied by the daily average patient census. If we let R stand for the number of nursing personnel per 100 patients, C stand for the average hours of care per patient-day, NP for the total number of nursing personnel, and DAPC for the daily average patient census, the following relationships can be stated:

Data are shown in this report in terms that make them comparable to professional standards for nursing service for each of the three types of hospitals. Comparisons are made between the staffing of Federal hospitals, other governmental hospitals (includes those administered by the Bureau of Indian Affairs),

and nongovernmental hospitals for each of the three types of service. Where figures are quoted in terms of hours of care given, they are based on the assumption that nurses in Federal hospitals work a 40-hour week and that nurses in other hospitals average a 44-hour week.

GENERAL AND ALLIED SPECIAL HOSPITALS

The variations in hours of nursing care per patient-day available in hospitals under different types of control and the number of patients affected are as follows:

This picture of the situation in general hospitals shows that patients in Federal hospitals and those in other governmental hospitals are receiving not more, but actually less, nursing care than are patients in nongovernmental hospitals. The average length of stay of patients in Federal hospitals is about three times as long as in nongovernmental hospitals. Long-term patients usually need less nursing care than short-term patients. However, obstetrical cases make up about one-fifth of the admissions to nongovernmental hospitals and only one-fifteenth of the admissions to Federal hospitals, and such cases are characterized by shorter than average stay and less than average acuity. Furthermore, in Public Health Service hospitals (data are not at hand for other Federal hospitals), the median length of stay is only about one-half the average stay; and of the 80 Figure 2. Estimated daily hours of professional nursing care per patient in nongovernmental general hospitals, 1951.

percent of patients who are discharged in less than 1 month the average stay is considerably less than one-half the average stay of all patients.

If an adjustment were made for the care given by student nurses, the difference between the amounts of nursing care available to patients in govern

mental hospitals of both types and those in nongovernmental hospitals would be more pronounced.

Information from other sources indicates that on a national basis studentnurse care averages about 0.5 hour per day for each patient in general hospitals, and that 86 percent of it is concentrated in the nongovernmental hospitals. The breakdown of these figures follows:

State surveys made by the Division of Nursing Resources, Public Health Service, corroborated by evidence from the 1950 list of State approved schools of nursing, indicate that a student nurse gives care to patients 0.4 as many hours as a graduate nurse employed on a full-time basis by the hospital. This means that the 102,500 students enrolled on January 1, 1951, were spending as many hours giving care to patients as 41,000 full-time nurses employed by the hospitals, or 86,592,000 hours a year, based on average personnel policies in nongovernmental hospitals. The 509,446 patients in general and allied special hospitals received 185,947,790 days of care in the year, or .47 hours per patient day from student

nurses.

The concentration of student care in nongovernmental hospitals can be inferred by the control of the hospitals operating the schools in which the students are enrolled. Of the 97,903 students reported in Facts About Nursing to have been enrolled in schools of nursing January 1, 1950, 13,561 were enrolled in schools operated by Federal, State, city, county, or city-county hospitals. The control of the hospitals with schools was determined from the list of hospitals registered by the American Medical Association, and their enrollments from the 1950 list of State Approved Schools of Nursing.

A conservative estimate is that patients in nongovernmental hospitals probably average 0.4 hour of care daily by student nurses, which brings the total hours of care they are receiving up to 4 a day, about one-half of it being professional.

The average staffing of nongovernmental hospitals, computed by totaling personnel and patients in this entire group of hospitals, appears to meet the standards set by the nursing profession in 1948 with respect to total hours of nursing care although not in number of professional nursing hours. A study published by the National League of Nursing Education in that year indicated that each patient should have 3.5 hours of care per day, with 2.4 of these hours provided by professional nurses (2).

A more recent study indicates that under specified conditions of assignment and supervision professional care may be sufficient if it is one-third of the total (3), and another shows that patients on active medical and surgical service required 3.9 hours of care (4). A definitive study is needed now to relate amounts of nursing service to the demands of modern medical practice, but in the last analysis each hospital has, and will continue to have, different requirements.

The staffing ratios presented here are average for large groups of hospitals; and hence, as would be expected, many hospitals in any group will have ratios lower than the group average. The extent to which nongovernmental hospitals fail to meet the standards of the nursing profession for general hospitals is sketched in briefly following the discussion of geographic variations.

NERVOUS AND MENTAL HOSPITALS

Patients are distributed among the three classes of nervous and mental hospitals in inverse relationship to the amounts of nursing care available:

In contrast to the situation in general hospitals, patients in Federal mental hospitals are receiving considerably more care than patients in other governmental hospitals. It remains true that patients in nongovernmental mental hospitals are receiving the most care.