1. Welton, John M. PhD, RN, FAAN

Article Content

One of the more enduring traditions in nursing is to set staffing based on the midnight census. One of the main flaws of this approach is the underlying assumption that any point in the day, ostensibly midnight, can predict nursing care needs for patients in hospitals for the rest of the shift or following day. This may have worked 50 years ago when care was much simpler and patients were much more stable. In the fast and furious 21st century version of healthcare, the nursing component in acute care is very dynamic and subject to a myriad of patient and unit level conditions that can vary from moment to moment.

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Another important factor to consider is the acuity of each patient and the overall acuity mix in an inpatient unit. This ties to the overall demand and need for nursing care, as well as the patient care burden for each nurse within a shift assignment. Patients are "sicker" today because hospital lengths of stay are shorter and care is compressed and more intense. For example, patients newly admitted to a hospital require more care, are at a higher risk for clinical instability in the 1st few hours of admission, and may require more frequent assessments, treatments, or care coordination if the patients need further tests or procedures. How do nurse managers and charge nurses approach assigning nurses to patients? Too little nursing care can result in poor clinical outcomes, and too much nursing care can result in higher costs. Frequent measurement of patient acuity is needed for both nurse staffing and nurse-to-patient assignments to keep up with the real-time needs of inpatient care.


In this issue of the Journal, Dr Amy Garcia1 provides findings from a study that used nursing acuity measures linked to patient care outcomes. The key finding from 28 739 nursing assessments for 405 patients with heart failure treated at a single hospital showed wide variety in the acuity and associated needs for nursing care. Overall, acuity decreased from admission scores and then increased at discharge. Garcia also found that patients who had longer lengths of stay had higher nursing acuity scores on admission and throughout hospitalization. These clinical indicators can be used to develop new predictive models to identify at-risk patients and make adjustments for staffing and assignment.


The acuity system was based on a standardized nursing language, Nursing Outcome Classification (NOC), and linked to nurse assessment and other relevant clinical data and reported frequently during the shift.2 Systems such as the one used in the study provide timely information about the patient condition and overall acuity mix in an inpatient unit to aid in decision-making. One key benefit to this data-rich approach is the elimination of the burden for nurses to collect additional data to support nurse staffing and assignments. The NOC scores were directly linked to nurses' assessments and other clinical data.


The findings of this study demonstrate that nursing care can be measured at the individual patient level and can identify each nurse caring for each patient to optimize staffing and assignments. Future systems can use these data to develop data-driven approaches to staffing and assignment and can also be used to develop new predictive models to identify patient risk and measure nursing care performance in a near-real-time manner. Perhaps, it is time to retire the midnight census.




1. Garcia A. Variability in acuity in acute care. J Nurs Adm. 2017;47(10). [Context Link]


2. Birmingham SE, Nell K, Abe N. Determining Staffing Needs Based on Patient Outcomes Versus Nursing Interventions. In: Cowen PS, Moorhead S, eds. Current Issues in Nursing. 8th ed. St. Louis, MO: Mosby; 2010:391-404. [Context Link]