Page images

from the Tri-Council of the exact money and how it would be allocated, with the different aspects of the nurse training, Nurse Education Act.

It includes increasing the professional nurse traineeship from the current level to $15 million, the advanced nurse education from $12.463 million to $13.7 million. All of these we have outlined in the information that we gave you.

Senator INOUYE. I thank you very much. We will do our best.
Dr. STRACHOTA. Thank you.


Senator INOUYE. The next witness represents the National Association of Pediatric Nurse Associates, Dr. Virginia Millonig. Did I pronounce it correctly?

Dr. MILLONIG. Yes, you did, very good.
Senator INOUYE. I just took a guess at it.

Dr. MILLONIG. Good job. Mr. Inouye, I too want to commend you for all of the support that you have provided for nursing over the years. You really have been a strong advocate for us and I really appreciate it and am honored to be able to have you in front of me to be able to really convey those thoughts. They certainly have been present for a long time within the nursing community and I am privileged to be able to let you know personally our thoughts on that.

As you know, Mr. Chairman, I am Virginia Millonig. I am a pediatric nurse practitioner. I am the immediate past president of the National Association of Pediatric Nurse Associates and Practitioners, and today I am going to be addressing the nurse practitioner funding component of the Nurse Education Act.

I also want you to know that, as long as our testimony has been presented for the record, I am just going to illustrate some of the highlights rather than addressing directly or reading from my


Let me first start out with, for some of the members who may not be familiar with what a pediatric nurse practitioner is, is that they are a registered nurse with advanced education in pediatrics, primarily within the area of ambulatory pediatrics.

For those of the committee who may not know what they do, they provide immunizations, assess growth and development, provide family counseling, health assessment, counseling in the area of drug and substance abuse, alcohol abuse, and nutrition. Because they do manage children all the way from birth to 21 years of age, therefore the substance abuse areas that they do get into.

In addition to that, they manage children with common acute illnesses, such as sore throats, earaches, the common cold, various maladies that young children do seem to get as they are going through their growth process. And then they manage common chronic stabilized illness, such as coronary heart disease, developmental disabilities, rheumatoid arthritis, and such.

As far as where are they located, well, they practice in community health centers, they practice in health departments, they are in many of the underserved areas, they are in physicians' offices, they are in HMO's. And yes, Senator, they even are in Hawaii.

As far as their education is concerned, most of the programs today are located in master's programs, and that is wherein the entire problem lies. Education is very expensive. The reason why is because there is a high faculty to student ratio.

You cannot take nurse practitioners, say 70 or 80 of them, and put them in a classroom, lecture to them, give them paper and pencil tests, graduate them, and put them out into the field to see your children and my children and treat them. They need a laboratory setting. They do need the theory and the paper and pencil tests, but they also need the very close educational process in the laboratory where they learn to diagnose, treat, and manage illness as well as wellness.

Also, when they are in their clinical component, and that also is very costly, they are in various settings where they apply the knowledge then that they have learned. This too cannot be done with 70 or 80 students. It has to be on a very small, say four students to one faculty. Thus it is very costly.

The evaluation process. Again, they have their theory examinations, but they also have their clinical examination. That requires faculty to observe how do they manage, diagnose, and treat illness and wellness, so that when they do graduate they are competent providers to take care of all of our children.

What is happening is that many of the universities cannot afford these programs. If they can, students then cannot enroll in them. because they do not have the moneys available in order to do that, because they are extremely costly.

My reason in being here today is to ask for and that you support the $18 million that we are requesting for nurse practitioner programs. We have, you know, more job openings for pediatric nurse practitioners than we can fill. Ask any program director throughout the country, of which there are about 44 now, the number of requests that they get for pediatric nurse practitioners to fill their positions and they cannot.

Another sad part about all of this, too, is that of those 44 programs there is only seven of them that are funded. I have personal colleagues today who have had three programs approved, but not funded, due to lack of moneys.

What I am asking you is we are looking at the preparation of the nurse practitioner, the pediatric nurse practitioner, in that they are providing the care for our children of today, their main thrust being disease prevention as they look at immunization status and a variety of other modalities, health promotion, and the maintenance of wellness, that we cannot afford not to have the support of our most valuable commodity, which are our children today.

We all know that healthy children beget healthy adults. We all are aspiring for healthy adults that are going to be healthy adults that are going to be productive to society and not drains on society. So again, we implore that you continue to support us, and also want you to know that we really appreciate all of the support that you have given in the past.


You know, you have supported the pediatric nurse practitioners since its inception about 25 years ago. As a result of that, there

have been hundreds of children who have been served by pediatric nurse practitioners, and I am sure these children are grateful to you. I know the PNP's are grateful to you, and I am grateful to you to have the opportunity to speak before you today.

Thank you.

[The statement follows:]


Mr. Chairman and distinguished Members of the Subcommittee. My name is Virginia Millonig, I am a pediatric nurse practitioner (PNP) and Immediate Past President of the National Association of Pediatric Nurse Associates and Practitioners (NAPNAP).

Today, I have the pleasure of representing the National Association of Pediatric Nurse Associates and Practitioners which represents over 3,200 PNP's in the country. My testimony today will address the funding needs of the nursing education programs specifically the nurse practitioner program and funding for research in child health programs.

PNP's provide basic health care and preventative services to children from birth through the age of 21. PNP's are critical links in the delivery of primary prevention services to children who traditionally have no other access to care. They staff wellbaby clinics, administer immunizations, conduct screening programs, and teach parenting skills, growth and development, and nutrition and safety. PNP's can independently manage a broad range of health care needs, including the management of colds, ear infections and other common childhood diseases. In addition, PNP's coordinate the management of many chronic illnesses and can deliver direct care to those children with stable chronic conditions. In essence their practice base extends the entire spectrum of care delivery for children. PNP's are found in community health centers, health maintenance organizations (HMO's), primary care centers private practices and hospitals throughout the U.S.

You can hardly pick up a newspaper without seeing something about the crisis in health care-and its most innocent victims-children. In fact, recent discussions by Congressional leaders have indicated that the health and welfare of the children in this nation will be one of the pivotal domestic programs of this decade. The health care problems of children are multifaceted ranging from access to health care, the availability of health care providers and health care delivery to medically underserved populations. The Congress has supported pediatric nurse practitioners since its inception. As a result, children in medical underserved areas have received health care that would have otherwise been unavailable to them. On behalf of these children, we thank you and your colleagues for your past support, and urge that you maintain and strengthen that support this year as you address the pressing problems of children in our society.

I am here today to ask for continued support and request that you fund the nurse practitioner program at $18 million in fiscal year 1992. In addition, we seek further emphasis, through report language on the funding of Pediatric Nurse Practitioner programs. Perhaps some background will provide insight with regard to this funding request.


A PNP is a registered nurse who has completed a formal education program. In other words, a PNP is an "advanced nurse" educated at higher level to perform more advanced services. The majority of all PNP education programs are at the Masters level. The program content includes courses in growth and development, family and cultural issues, pediatric physical and development assessment and the management of common childhood illnesses and problems, and a strong clinical component. After graduation, a PNP can obtain professional certification, which is a confirmation of professional competency.


NP programs are expensive. Many educational institutions and most state supported universities cannot support or afford to offer these programs because of the high costs associated with them. Most programs average 8-16 students per class. The costs are due mainly to the necessary faculty-student ratios and the number of faculty and hours such programs require.

Today there are 44 PNP education programs in the country. Unfortunately only 7 are receiving federal funding support through the Nurse Education Act funds. Most recently, 3 PNP education program applications were approved but notified they will go unfunded due to a lack of resources.

For the entire Nurse Practitioner and Nurse Midwife traineeship program the Division of Nursing expects that there will be about 14-18 unfunded but approved grant applications amounting to about a $2.7 million shortfall. Last year 13 grants for federally assisted educational programs were approved and unfunded.

We are appreciative of the increased funding Congress recommended for the nurse practitioner-nurse midwife program last year. According to Division of Nursing Staff, after reductions and expenses are taken out for "evaluations" and other expenses only about $13 million to $14.6 million will be realized for funding of grants. Because of these meritorious programs that are going unfunded, and which could make a critically important difference in the health care that is delivered to children in medically underserved areas, we urge Congress to provide a minimum of $18 million for the nurse practitioner-nurse midwife program.

Federal funding for these programs does help to make a difference. Without such support the number of PNPs will decline at a time when the needs are ever increasing. Low-birth weight babies, immunization problems, school screening programs, substance abuse and the feeding of children are but a few examples of problems in which PNP's can help resolve.


PNP's are needed, and their current numbers are unable to fill the requests for open positions in the health care provider community. PNP program education directors receive numerous requests for PNPs to work in a number of settings such as HMO's, schools, private practices and rural health settings and other primary care centers in medically undeserved areas. Unfortunately, we do not have enough bodies to fulfill the needs.

The profile on America's child health has improved in some areas over the past 40 years. But problems still exist. Injuries have now replaced infectious diseases as a great concern for the health of children. Motor vehicle accidents, drownings, falls, poisoning, fires and homicide still remain problems at the top of the list.

Other primary and preventable problems include homicide, suicide, child abuse and neglect, developmental problems and lead poisoning. Some infections, like influenza and respiratory illnesses, like asthma, remain major child health problems. childhood is the time to focus on human development. A good health plan for children helps to prevent bad health behaviors-i.e., drug abuse, smoking, alcohol and diet and establishes good healthy behavior.

PNP's are well prepared to focus on these kinds of issues, manage and deliver this kind of health care. PNP's are an integral part of the health care team and can be used more effectively to provide these services. This concept has been supported by numerous federal agencies and the federal government.

Throughout the last 25 years, PNP's have helped to make a difference. But, there are only about 6,000 of us available to provide care to our nation's children. Most recently, the GEMNAC report highlighted PNP's as a potential contributor in which PNP's could make to the delivery of child health care. The GEMNAC report also suggested "the balance of care (child care) is felt to be ideally provided by non-physician professionals while medical needs would be roughly 50 percent higher if no care was ever delegated." It also stated that there was a need for more mid-level providers and primary care nurse practitioners than are available.

PNP's provide access to health care. However nurses also need access to education programs in order to receive the proper education to go out and work.

Today, both of these issues are critical to address the acute problems which exist with this nations most precious resource, and hope for the future-its children.

We respectfully request your favorable consideration in funding the nurse practitioner traineeship program at $18 million in fiscal year 1991. Thank you again for the opportunity to present our views. I'd be happy to answer any questions you may have.

Senator INOUYE. Thank you very much. I appreciate your kind words.

Your testimony is very timely because this committee has been very supportive of pediatrics in general. Recently, as a result of studies that we conducted, we instituted a new program, pediatric

emergency medicine. We found that most of the emergency stations in hospitals and such did not cater to children.

Dr. MILLONIG. That is correct.

Senator INOUYE. And they looked upon children as little adults, and so the instrumentation there and medicine were all meant for adults. But now we, with the appropriation of funds, we are now setting up model stations throughout the United States, and it is beginning to grab hold.

Dr. MILLONIG. You certainly are to be commended for that, because what you say is absolute fact. Most emergency rooms, unless you go to a children's hospital emergency room or where they have residency programs in pediatrics, they are not equipped to deliver care to children.

Senator INOUYE. Well, we do our best. That is all I can say.
Dr. MILLONIG. Thank you very much.


Senator INOUYE. Our next witness is Dr. Robert J. Ruben, representing the American Academy of Otolaryngology Surgery. Thank you for waiting.

Dr. RUBEN. Thank you very much, Senator. I would like to just for a second leave my prepared remarks. I have been privileged for a number of times to be a witness in front of this committee and Mr. Natcher's committee, and I am forever awed, I think is probably the most correct word, of the time that you and your colleagues take to listen to all of us year in, year out, day in, day out, to absorb and to make impossible decisions.

Today has been a long day. It has been a great education for me. I realize there are other things going on, and I am even more, again, awed that you would be here and not at other ceremonies. It is a wonderful system to be part of. Quite sincerely, I have seen other parts of the world. We are very lucky.

Mr. Chairman, members of the committee, ladies and gentlemen, I am Dr. Robert J. Ruben, professor and chairman of the Department of Otolaryngology and professor of pediatrics at the Albert Einstein College of Medicine. I am here today as a representative of the American Academy of Otolaryngology and Head and Neck Surgery, the largest organization of otolaryngologists, head and neck surgeons in the world, with more than 9,200 members.

The National Institute on Deafness and Other Communication Disorders, NIDCD, has as its mission the responsibility to improve the health of individuals which results in economic and social wellbeing of society. The research carried out in the areas of hearing, voice, speech and language, which are just part of the mission of the NIDCD, result in the enhanced ability to communicate.

The optimization of personal communication is a critical factor for economic growth of the individual and the Nation in this era, which is called the communications society. Disabilities of communication, including hearing loss, voice, speech and language deficits, are major factors in the economic and social failure of individuals and societies.

« PreviousContinue »