I can and appreciate the frustration. It’s unfortunate that your experience with the acuity system appears to be so disastrous. I agree with your assessment that the bedside nurse should have input in the development of an acuity system, the head Nurse or Team Leader and of course it should be in the purview of the nursing administration, not the bean counters. Unfortunately, far too often nursing administration is often perceived to be on the side of the “administration”, and out of touch with the realities of the floor nurse. Back in the day — when I did a lot of consulting, one of the first questions I would ask the nurses was for them to name their CNO, and more often then not they didn’t know the name or would comment that this person never made rounds or could barely remember the last time they even had a conversation with their CNO. I wrote about this in my column “Put out a A.P.B on your D.O.N”.

California’s ratio law is very much cookie-cutter nursing, simply treating patients as “numbers” and RNs as “robots” in the scheme. It even designates breaks in such a way that nurses often have no say when they actually would like to or need to take a break. It is a very rigid formula – but this doesn’t mean that some nurses haven’t learned to manipulate it (and I mean nurses, not administration). I had an experience not long after the implementation of the law where the nurses were re-categorizing oncology patients so they could adjust the patient to nurse ratio, the actions were being lead by one of their lead nurses and before you assume this must have been a non-union hospital, it wasn’t. This was a C.N.A. represented hospital and the RN doing the manipulation was a C.N.A. member. In another case (which made the papers) a patient died in the now closed King/Drew Medical Center. The nurse that day had one high acuity patient, she was given another equally high acuity patient but had to also do all the intake of this new admission. She made her superiors aware that the assignment was inappropriate, but this fell on deaf ears and they were within the mandate “safe nurse/patient ratio”. The nurses at this hospital were represented by the S.E.I.U. The nurse was fired.


If you read enough of my articles I think you’ll find a strong underlying current that good, competent and strong management (specifically nursing management) could go a long way to ameliorating many of the issues confronting RNs today. The other piece of the puzzle is an empowered and informed nursing staff. Some nurses tried to solve this issue through unionization and others have achieved this by other means. In California there has been a lot of decertification attempts the past several years, some have been successful, others have not and some have been too close to call. One that comes to mind was in Southern California where the union had to agree to a concession of an open shop (most nurse union represented hospitals are closed shops out here) in order to gain enough votes to stay union represented, and I hear that this year the nurses have filed decertification papers once again. I think what I find interesting in most of these recent attempts is that they have all been nurse driven, with those nurse getting no support from management but building strong networks among their nursing team mates.


Please feel free to keep in contact I always like “talking nurse shop” with other nurses and it sounds as though the Tennessee nurses are facing some professional challenges. It sounds like you may have been bitten by the “activist” bug, and I hope you’ve had the chance to walk the hall of your legislature and speak with various legislators and policy makers. I have always found this an invigorating experience.