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To the Editor: There are several limitations in the data of Dr Aiken and colleagues.¹ First, while the response rate of 52% may compare favorably with rates seen in other voluntary surveys of health professionals, and the "sample of nurses also closely resembles those participating in the National Sample Survey of Registered Nurses," the sample may be less representative of nurses working in hospitals. Nurses who work in hospitals differ from nurses who work in other settings.² Second, the number of responses from some hospitals is low. While for 80% of the hospitals 20 or more nurses provided responses, there were 50 responses from fewer than half the hospitals. This could introduce response bias. Third, the failure to weight nurses' responses by the type of unit or shift on which they work can introduce measurement errors in the average patient-to-nurse ratio used as the independent variable. A hospital with a . . . [Full Text of this Article]

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