I work on a busy medsurg-oncology floor on midnights and am wondering how other hospitals deal with the accuity related to demented, detoxing, and confused patients. On my floor midnights generally has 6 or 7 patients to start and generally get atleast one if not 2 admits nightly. Our patients range from chemo to ETOH detox to pneumonia to you name it. Over the last 4 months, we have been transitioning to a staffing by accuity model which focuses on a Braden scale score and "nurse input" regarding how heavy the patient is. Factors such as wound care, tubes in and out, telemetry, etc are left to the nurse to add in. We on midnights are having a hard time getting the management to recognize how big of a factor sundowners, agitation, dementia, detoxing behaviors, etc increase a patient's accuity rating. They tend to minimize the patient who is climbing out of bed from the minute you come on or screaming at the top of their lungs. Does your facility get how much this impacts a patient load and adjust accuity accordingly or is it like this everywhere?