We agree the questions posed are "urgent policy questions, with serious implications for nursing practice and resident outcomes." But we would also emphasize the costs to society. As stated in the article, "Our findings suggest a potentially greater risk of nursing home residents suffering avoidable adverse outcomes if nothing is done to improve RN staffing levels, and nursing homes and society incurring greater costs as a result of such outcomes." A separate article, 1 of which Randall J. Smout and I were coauthors, drew on the same research results in order to examine the economic consequences of various nurse staffing levels, finding that there would be a savings to society of nearly $3,200 per at-risk resident per year if RN direct care were increased from less than 10 minutes per resident per day to 30 to 40 minutes.

The authors remark that the numbers of residents and nursing homes reported in our research were small. However, alternative databases, such as administrative data sets, don't contain the level of detail about disease severity, timing (the time spent with residents, according to type of nursing staff, as well as the timing of outcomes such as hospitalizations and development of pressure ulcers, and the timing of various interventions), and interventions used that was available in our data. We agree that it's important to identify new data sets with sufficient detail to determine those RN activities that contribute to improved quality of care.

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