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The standard approved by the American Psychiatric Association in 1945 for staffing mental hospitals called for 4 professional nurses per 100 patients, and 25 nonprofessional nursing personnel (5). The great majority of mental patients in the hospitals operated by States and other local governments thus is receiving less than one-tenth the professional nurse care and only two-fifths of the total amount of care considered essential.

While on the face of it, the average staffing ratios of nongovernmental mental hospitals appear to meet the standards quoted, it must be realized that these hospitals generally are undertaking intensive therapy for a much larger proportion of their patients than the State mental hospitals for which the standards were designed. The American Psychiatric Association has since developed a more discriminating set of standards, but they can be used only in a situation in which something is known of the condition of the patients in addition to their total number (6).

TUBERCULOSIS HOSPITALS

The patient with tuberculosis receives the most care in a Federal hospital, and the least care if he is in a nongovernmental hospital:

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On the basis of standards of the Tuberculosis Advisory Nursing Service, even the better staffed Federal tuberculosis hospitals are short of professional nurses (7). These standards are based upon the regimen prescribed for patients, that is, whether the patient is on strict bed rest, bed rest, or is semiambulant, or ambulant. To obtain a single figure from these four standards so that comparison could be made with existing staffing practices, the nursing requirement of patients in each category was weighted by the probable proportion of all patients in the category. The weighted average nursing requirements of tuberculosis patients amounts to a total of 1.8 hours of care per day, .9 hour of which should be professional nurse care.

GEOGRAPHIC VARIATIONS

All of the figures cited so far have been national averages. It is reasonable enough to use national averages when discussing Federal hospitals since their centralized administration means that there is relatively little local variation in staffing ratios.

What justification is there, however, for computing a single ratio by combining data for 48 States from Arkansas to Maine and from Georgia to California? A comparison of the ratios for nongovernmental general hospitals across the country suggests part of the answer (8). Figure 1 shows some geographic variations in the ratios of total nursing personnel to patients. The ratios have been grouped into four classes for mapping purposes. The States with the lowest ratios have fewer than 55 nursing personnel of all types available to care for each 100 patients. This means that in these States if nurses work 44 hours per week, patients can receive an average of less than 3.2 hours of care per day. Patients in the next higher States can receive 3.2 to 3.7 hours; in the next to the highest group of States they can receive 3.8 to 4 hours, and in the highest States, 4.1 hours or more are available.

Figure 2 shows similar variations in graduate professional nurse to patient ratios. In the States with the lowest ratios, fewer than 22 graduate professional nurses care for each 100 patients. That is, patients in these States can average less than 1.3 hours professional nurse care each day. Patients in the next group of States can average 1.3 to 1.9 hours professional nurse care daily, in the next higher group, 2.0 to 2.5 hours, and in the most privileged States they can average 2.6 hours or more.

TABLE 1.-Average hours of nursing care by all types of nursing personnel, except student nurses, per patient-day and distribution of hospitals according to actual hours provided: nongovernmental general hospitals in 8 States

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TABLE 2.—Average hours of care by graduate nurses per patient-day, and distribution of hospitals according to actual hours provided: nongovernmental general hospitals in 8 States

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It cannot be inferred that a State whose average nurse-patient ratios provide for amounts of care that meet professional standards has all the nurses it needs in its hospitals. Nurses are not distributed among all hospitals in proportion to the number of their patients, and no assumption is made that this should be so (tables 1 and 2). Admittedly, the patients in some hospitals need more care while those in other hospitals may need less, depending upon the conditions for which they are being treated, the nature of the treatment, and the hospital's program.

The safest assumption probably would be that the patients in any general hospital need at least the amount of care that would be equivalent to the nursing profession's 1948 standard for total hours of care and Bredenberg's standard for hours of professional nurse care. The corollary of this assumption is that hospitals providing more hours of care than this do so either because of the kind of care their patients need, out-of-date facilities for care, awkward administrative procedures, educational programs for student nurses or medical students, or for a variety of other possible reasons. Thus, in Nebraska, although the State average meets professional standards for total hours of care, at least 12 hospitals could be considered inadequately staffed.

Differences in the extent to which student nurses give patient care show up in table 3. Table 4, when compared with table 1, shows how including the care given by students in the total hours affects the picture of the amount of care patients are receiving.

TABLE 3.-Nongovernmental general hospitals with schools of nursing distributed according to hours of care provided per patient-day by student nurses in 8 States

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1 Only 1 hospital operates a school of nursing, and to avoid disclosing confidential information, data are not shown.

TABLE 4.—Hospitals distributed according to total hours of care provided per patient-day, including care given by student nurses: nongovernmental general hospitals in 8 States

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1. The ratio of nursing personnel to patients in the entire group of nongovernmental hospitals in the country is sufficient to provide an average of 3.6 hours of care, 1.6 hours of this being professional. Nevertheless, numerous hospitals in every State need more of both categories of nurses even where statewide ratios are at the national average. Only in the Pacific coast States and in Nevada, Wyoming, and Florida do patients in general hospitals appear to be receiving an average amount of both professional and nonprofessional nursing care that is up to minimum professional standards. In the New England States the average amount of professional nursing care appears to be sufficient, but hospitals in this area perhaps should employ more nonprofessional nursing personnel. In all of the remaining States there appear to be too few graduate nurses in the general hospitals.

2. All general hospitals under government control of any sort appear to be short of both professional and nonprofessional nursing personnel, although the longer average length of stay in Federal hospitals modifies the picture to some extent. 3. In the mental hospital field, only those under nongovernmental auspices come close to meeting the staffing standards of the nursing profession, and these hospitals care for only 17,000 of the 698,000 patients in this kind of institution.

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4. Tuberculosis hospitals in all three classes appear to be grossly understaffed with respect to both professional and nonprofessional nurses.

REFERENCES

(1) Statistical guides. In Administrators Guide Issue, part 2. Hospitals 26: 1-31 (June 1952).

(2) American Nurses Association: Facts about nursing. New York, 1952.

(2) National League of Nursing Education: A study of nursing service in one children's and 21 general hospitals. New York, 1949.

(3) Bredenberg, Viola: Nursing service research. Philadelphia, J. B. Lippincott Company, 1951, 170 pp.

(4) Wright, Marion J.: Meeting the need for nursing personnel. In Administrators Guide Issue, part 1. Hospitals 26: 49-51, 76-78 (June 1952).

(5) Standards for psychiatric hospitals and out-patient clinics. Am. J. Psychiat. 102: 164-269 (1945).

(6) American Psychiatric Association: Standards for psychiatric hospitals and clinics. Washington, D. C., 1951. (7) Tuberculosis Advisory Nursing Service of the National League for Nursing: Cues to staffing tuberculosis units in hospitals. New York, National Tuberculosis Association, 1952, 28 pp.

(8) Tibbitts, Helen G., and Levine, Eugene: Health manpower source book. Part 2. Nursing personnel. Washington, D. C., U. S. Government Printing Office, 1953, 88 pp. (8) National League of Nursing Education: State approved schools of nursing. New

York, 1950.

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APPENDIX B

Characteristics of 6 comprehensive medical care plans in the United States

See footnote at end of table, p. 2535.

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