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In Reply: These letters raise concerns about the appropriateness of our analysis. Our article follows a long tradition in health services research that asks whether differences in health care resources are associated with variation in patient outcomes. Hospitals in which nurses cared for fewer patients and in which a greater proportion of nurses had baccalaureate degrees had lower rates of mortality and failure to rescue.

Using a sample of more than 232 000 patients in 168 hospitals, we estimated the effects of nurse workload and educational mix simultaneously, after controlling for more than 130 patient, hospital, and physician characteristics including hospital size, teaching status, technology, and surgeon board certification. Nurse education was significantly associated with patient outcomes after controlling for these factors and for nurse workload and experience.

We measured nurse experience using average years of experience in nursing, at the current hospital, on current units, and estimating the proportion of . . . [Full Text of this Article]

Linda H. Aiken, PhD, RN
laiken@nursing.upenn.edu

Sean P. Clarke, PhD, RN; Robyn B. Cheung, PhD, RN; Douglas M. Sloane, PhD
School of Nursing

Jeffrey H. Silber, MD, PhD
School of Medicine
University of Pennsylvania
Philadelphia

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