I agree with your Editorial, "How Many Patients Are Too Many?" (October 2003), except for your last point. Not all hospitals are resorting to poor staffing levels. I am the director of nursing at a small community hospital, and our CEO could not be more supportive of the nurses and our staffing needs.

The problem is with Medi-care, Medicaid, and third-party payers. It seems that every month the federal government informs us of yet another service for which we will not be paid. Patients are being denied routine and preventive care; yet we have to care for them once they become seriously ill. This puts a terrible burden on our hospitals. Many physicians have left the state because of tort reform and the cost of insurance. I've been a nurse for more than 40 years, and this is the worst mess I've ever seen.

The question is, "How long should nurses and patients wait for the federal government to do the right thing?"

Sharon Eddy, MSN, RN

Natchez, MS

For some time I've been discussing the staffing strategies described in your Editorial to my employer. I continue to be told these cannot work, despite the fact that I know there is a strong link between nurse-to-patient ratios and the nursing shortage. In fact, I can only conclude, after reading Lynn Schnautz's Viewpoint, "Our Own Worst Enemies," (November 2003) that nurses' negative feelings about their profession are at least partly due to inadequate staffing.

Your Editorial has encouraged me to answer the call for more appropriate staffing levels. Please tell me how I can help.

Crystel Farina, RN

Denton, MD

Christopher Donnellan, associate director of Government Relations at the ANA, responds: The Quality Nurse Care Act of 2004 (HR 3656), introduced this past December, complements the Senate's version, the Registered Nurse Safe Staffing Act of 2003 (S 991), introduced last May. Both bills mandate the development of staffing systems in hospitals that require the input of direct-care RNs and provide whistle-blower protections for nurses who speak out about patient safety. The ANA has worked closely with congressional staff to develop and introduce these bills, which incorporate the ANA's Principles of Nurse Staffing. The legislation is gathering cosponsors in Congress, the first step toward passage.

To help make a difference, log on to and register as a user at the ANA's Political Power site (http://www.anapoliticalpower.org). You'll be able to track legislation, contact members of Congress, learn how your representatives voted on nursing issues, become involved in grassroots political activities, and add your voice to those of thousands of RNs nationwide who have joined the ANA's Nurses Strategic Action Team (N-STAT), a grassroots network for nurses. Also, don't miss opportunities to educate the media and the general public on the need for safe staffing legislation by writing letters to your local newspapers. For writing tips and other suggestions for securing media coverage, go to the ANA's RN=Real News site (http://www.nursingworld.org/rnrealnews) and click on "Nurses' Toolkit."

Hospitals stand to gain greater profits if they can get away with employing fewer nurses (and other qualified staff) while still charging the same amount for patient services. A certain amount of money is charged to the patient per bed per day for the nursing services he receives while hospitalized. Essentially, the nurse is part of the room-kind of like a piece of furniture. The hospital will charge the same fee, regardless of how many nurses care for the patient.

We need to warn patients about the understaffing problems in our hospitals. I would even advise that they hire a private duty nurse.

Lawyers, accountants, and corporate executives-not health care professionals-run hospitals these days. Corporations care little for their employees or their customers, and many believe they can lower the hospital's overhead costs and increase profits by using fewer nurses.

Richard M. Knox, RN

Gainesville, FL

Diana J. Mason, editor-in-chief, responds: A recent study by Michael McCue and colleagues shows that although operating costs are greater when hospitals increase RN staffing levels, this doesn't result in a statistically significant decrease in profits (J Health Care Finance 2003; 29[4]54-76). Yet the researchers found that hospitals that added more administrative and operational support staff had greater operating expenses and lower profits.