The authors present strong evidence that the daily amount of RN direct care time greatly affects the quality of outcomes among nursing home residents. About 91% of the facilities in this small study provided less than 30 minutes of RN direct care to residents, resulting in disastrous and possibly preventable outcomes (among the 1,196 residents receiving less than 30 minutes of care, there were 376 pressure ulcers, 247 urinary tract infections, 326 patients with weight loss, and 426 who experienced a decrease in the ability to perform activities of daily living). The 180 residents living in the seven nursing homes that provided between 30 and 40 minutes of RN care enjoyed strikingly better outcomes.

These data were collected in 1996 and 1997 for the National Pressure Ulcer Long-Term Care Study Database. "Addressing the Dramatic Decline in RN Staffing in Nursing Homes" (Nursing Counts, September 2005) reported that from 1999 to 2003 the number of RN staff in nursing homes decreased by 25%. It's time to investigate what the few homes with adequate staff are doing differently. How are decisions made? How are the available dollars used? How stable is the staff? And how much more money is needed in the Medicaid program to increase RN staffing to an acceptable level? These are urgent policy questions, with serious implications for nursing practice and resident outcomes.

Finally, the numbers of residents and nursing homes were small in this study. The authors wisely used available data to investigate staffing and outcomes. Might there be other data sets already available that could be used to build on this excellent work?

Mathy Mezey, EdD, RN, FAAN

Diane Carter, MSN, RN

Susan Reinhard, PhD, RN, FAAN

Robin Remsburg, PhD, APRN, BC

The Coalition of Geriatric Nursing Organizations