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relate patient outcomes with any particular nurse(s) in this study.
1. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of
hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623.
In a hospital categorized as having a high proportion of bacca-laureate-prepared nurses, it could well have been the RN with To the Editor: Dr Aiken and colleagues1 presented the effects
an associate degree who took care of the patients who survived of different levels of nurses’ education on the outcomes for sur- or who were rescued. Another important consideration is that gical patients. To put this in perspective, however, the Institute hospitals with low numbers of baccalaureate-prepared nurses were of Medicine reports that numerous studies have led to the con- smaller, rural facilities with fewer financial, educational, and tech- clusion that “the burden of harm conveyed by the collective im- nological resources than hospitals with larger numbers of bac- pact of all our health care quality problems is staggering.”2,3 calaureate-prepared nurses. These are important variables that Nurses are major contributors to quality health care. The in- undoubtedly affect patient care and outcomes.
creased visibility of nursing’s vital contribution to patients’ well- In our roles as administrators and faculty in a community being highlights the need for all health professionals to learn college, we continue to see the contributions that our associ- more about their colleagues and create and maximize effec- ate degree nursing students and graduates create daily in a mul- tive health care teams. Health care settings and patient popu- titude of health care settings. We are concerned that these con- lations are extremely complex, and many quality problems ex- tributions were minimized by the unsupported conclusions of ist because of system problems. There are no simple answers to the challenges faced in providing health care. Browbeating Carol Comeau, RN, MSN
health professionals, including nurses, is not the answer.
Mary Crook, RN, MSN
The Institute of Medicine4 reported that clinical education Crook_Mary@sac.edu
across the disciplines has not kept pace with or been respon- Rosemarie Hirsch, RN, MSN
sive to shifting patient demographics, changing health system Santa Ana College
Santa Ana, Calif
expectations, evolving practice requirements and staffing ar-rangements, new information, a focus on improving quality, 1. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of
or new technologies. The larger issue is not whether to imme- hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623.
diately put public funds into specific types of programs. Rather,the question is how health professionals in education and prac- To the Editor: Dr Aiken and colleagues1 discounted the effect
tice can fund and reform clinical education at a time of short- of surgeons’ qualifications and overall hospital quality on pa- age of key professionals and budget shortfalls.
tient mortality. The authors stated that “the strong and signifi- The nursing community supports the need for advanced edu- cant decrease in mortality associated with having a board- cation and lifelong learning. Significant funding is required to certified surgeon as operating physician is largely explained by enhance the quality of all types of nursing education pro- the tendency of patients with board-certified surgeons to be grams, particularly now during an unprecedented shortage in treated at hospitals with other characteristics associated with nursing education and practice, a crisis situation that is antici- better outcomes.” Although hospitals with more board- pated to last for many years. Therefore, the challenges in nurs- certified surgeons also had more nurses with baccalaureate de- ing and health care must be faced and solutions must be ad- grees, the authors did not examine these “other characteris- tics” to explain the much smaller difference in patient mortalityassociated with nurses’ educational background.
Ruth D. Corcoran, EdD, RN
Furthermore, the study was a secondary analysis of data that rcocor@nln.org
Joyce P. Murray, EdD, RN
were collected to look at workload, not educational background, National League for Nursing
as the independent variable. The authors then grouped the nurses New York, NY
into 2 education levels depending on whether they had a BSN orhigher academic degree. There are several additional gradations 1. Aiken LH, Clarke SP, Cheung RB, Sloane DM, Silber JH. Educational levels of
hospital nurses and surgical patient mortality. JAMA. 2003;290:1617-1623.
of nursing degrees, however, and the authors should have exam- 2. Board of Health Care Services, Institute of Medicine. Health Professions Edu-
ined these separately. In any event, the results of a retrospective cation: A Bridge to Quality. Washington, DC: Institute of Medicine; 2003:2.
3. Chassin MR, Galvin RW, and the National Roundtable on Health Care Quality.
study should be used only to suggest areas for further research; The urgent need to improve health care quality. JAMA. 1998;280:1000-1005.
no conclusions should be drawn from such an analysis.
4. Committee on Quality of Health Care in America, Institute of Medicine. Cross-
ing the Quality Chasm: A New Health System for the 21st Century. Washington,
Finally, the authors stated that a random sample of nurses were surveyed, not just those who care for surgical patients. It is likelythat, on average, nurses who work in different areas have differ- In Reply: These letters raise concerns about the appropriate-
ent educational backgrounds. Nurses who work with surgical pa- ness of our analysis. Our article follows a long tradition in health tients are the only nurses whose educational background could services research that asks whether differences in health care possibly have any impact on clinical outcomes in this setting.
resources are associated with variation in patient outcomes. Hos- George R. Boggs, PhD
pitals in which nurses cared for fewer patients and in which a American Association of Community Colleges
greater proportion of nurses had baccalaureate degrees had lower Washington, DC
rates of mortality and failure to rescue.
1322 JAMA, March 17, 2004—Vol 291, No. 11 (Reprinted)
2004 American Medical Association. All rights reserved.
Using a sample of more than 232 000 patients in 168 hos- the authors’ methods. First, the dosage was not determined, pitals, we estimated the effects of nurse workload and educa- nor did the authors measure lipophilic phenol or hydrophilic tional mix simultaneously, after controlling for more than 130 polysaccharide fractions. The lack of standardization calls into patient, hospital, and physician characteristics including hos- question the relevance of the outcomes compared with other pital size, teaching status, technology, and surgeon board cer- commercially available standardized echinacea preparations.2 tification. Nurse education was significantly associated with pa- Furthermore, fractions derived from whole echinacea (roots, tient outcomes after controlling for these factors and for nurse seeds, leaves, and flowers) represent a broader spectrum of po- tentially bioactive compounds and biological activity.3,4 We measured nurse experience using average years of ex- The placebo group used significantly more vitamins and/or perience in nursing, at the current hospital, on current units, mineral supplements than the echinacea group. There is evi- and estimating the proportion of nurses in each hospital with dence that vitamins and minerals may be therapeutic for URIs.5 less than 1 year and less than 5 years of experience and those Although the specific vitamin and mineral dosages were not with more than 10 years. In response to Ms Atkins and col- identified, the potential effect of these supplements contrib- leagues and Dr Broome, none of these measures was found to uting to the recovery and severity of URI is unknown and may have significant effects on patient outcomes after controlling have confounded the results in the placebo group.
for other factors. Nurse experience was correlated only mod- Echinacea has been hypothesized to be more effective when estly with nurse education, thus reducing concerns about col- used to support the body’s immune response at the first sign linearity that Ms Burger raises. Others concur that experience of a URI, and not after 2 or more symptoms have been estab- cannot be equated with expertise,1 and in our analysis experi- lished.6 The limited benefit noted in efficacy may be due to the ence does not account for the effect of education.
late timing of administration; however, the authors did note a We agree with Ms Comeau and colleagues that often mul- significantly lower URI recurrence rate in the group treated with tiple nurses in different hospital units care for each surgical pa- echinacea compared with the placebo group. This may indi- tient. Thus, our models were estimated by deriving workload cate the need for more timely intervention with echinacea than and education measures from all hospital staff nurses. When measures were derived from only medical and surgical nurses, Linda Kim, ND
the effect of education on mortality was still significant.
l.kim@scnm.edu
In response to Dr Boggs, the relative proportions of nurses Southwest College Research Institute
holding diplomas or associate degrees did not affect the pa- Tempe, Ariz
tient outcomes studied and the 2 categories were collapsed.
Debra Wollner, PhD
Fewer than 2% of staff nurses had graduate degrees and there Paul Anderson, ND
was no difference in the education effect when nurses with Debra Brammer, ND
graduate degrees were excluded. The small number of nurses Southwest College of Naturopathic Medicine & Health Sciences
Tempe
with graduate degrees did not explain the lower mortality as-sociated with higher proportions of nurses with BSN degrees.
1. Taylor JA, Weber W, Standish L, et al. Efficacy and safety of echinacea in treat-
Linda H. Aiken, PhD, RN
ing upper respiratory tract infections in children: a randomized controlled trial. JAMA.
2003;290:2824-2830.
laiken@nursing.upenn.edu
2. Dorsch W. Clinical application of extracts of Echinacea purpurea or Echinacea
Sean P. Clarke, PhD, RN
pallida: critical evaluation of controlled clinical studies. Z Arztl Fortbild ( Jena). 1996; Robyn B. Cheung, PhD, RN
Douglas M. Sloane, PhD
3. Bauer R, Wagner H. Echinacea species as potential immunostimulatory drugs.
Econ Med Plant Res. 1991;5:253-321.
School of Nursing
4. Perry NB, van Klink JW, Burgess EJ, Parmenter GA. Alkamide levels in Echina-
Jeffrey H. Silber, MD, PhD
cea purpurea: a rapid analytical method revealing differences among roots, rhi- School of Medicine
zomes, stems, leaves and flowers. Planta Med. 1997;63:58-62.
5. Jaber R. Respiratory and allergic diseases from upper respiratory tract infection
University of Pennsylvania
to asthma. Primary Care. 2002;29:231-261.
Philadelphia
6. Henneicke-von Zepelin H, Hentschel C, Schnitker J, Kohnen R, Kohler G, Wusten-
berg P. Efficacy and safety of a fixed combination phytomedicine in the treatment
1. Benner P, Tanner CA, Chesla CA. Expertise in Nursing Practice. New York, NY:
of the common cold (acute viral respiratory tract infection): results of a random- ized, double-blind, placebo-controlled, multicentre study. Curr Med Res Opin. 1999;15:214-227.
The letter from Drs Corcoran and Murray was shown to Dr Aiken and colleagues,who chose not to respond.—ED.
To the Editor: Dr Taylor and colleagues1 did not provide any
information about the chemical content of the echinacea they
Echinacea for Treating Colds in Children
administered. The main pharmacological substances with im-munostimulant activity in experimental2,3 and clinical stud- To the Editor: Dr Taylor and colleagues1 concluded that a non-
ies4 are purified polysaccharides that can be extracted only in standardized dose of Echinacea purpurea did not decrease the small quantity from pressed E purpurea. Their extraction gen- severity or duration of upper respiratory tract infections (URIs) erally requires a solvent and not simple pressing of the fresh in children 2 to 11 years old. We have several concerns about plant because they are a primary structural constituent of the 2004 American Medical Association. All rights reserved.
(Reprinted) JAMA, March 17, 2004—Vol 291, No. 11 1323

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