A special effort is required to attract talented high school graduates into baccalaureate programs in nursing. Advances in medicine and in technology, the explosion of knowledge in related fields, dictates that nurses master an increasing body of knowledge and also develop the intellectual ability to make the necessary application in nursing care.

The professional nurse today must possess technical skills unheard of a few years ago. A high degree of intellectual and technical skill is required and must be utilized by her in every area of practice, whereever patients need nursing care.

Baccalaureate programs are designed to provide a broad background in the biological, physical, behavorial, and social sciences to enable their graduates to make sound judgments in giving, planning, and directing nursing care; to interpret and demonstrate care; to help patients and families identify and meet their health needs and to work with others in their communities in planning and carrying out health programs. They are prepared, without need for further formal education, to advance to positions requiring beginning administrative skills. They have the foundations for continuing professional development and for graduate study in nursing.

Section 822 of H.R. 10042 provides for scholarships for highly qualified high school graduates attending collegiate schools of nursing. Early and favorable congressional action in this matter is necessary to increase the number of nurses with baccalaureate degrees.

Families are often unable to meet the full cost of collegiate nursing education. Repeatedly, we hear from deans of collegiate schools and from nursing students of the need for scholarship assistance.

A study in 1963 by the National League for Nursing for the Division of Nursing, U.S. Public Health Service of total charges, exclusive of room and board, to students in 138 baccalaureate programs showed an average charge of $2,805. The range of charges in the middle 50 percent of the programs was $1,425 to $3,775. Student nurses have the additional expense of uniforms, special shoes, and are frequently responsible for travel costs to and from their affiliations away from the campus.

Because of the nature of the nursing education programs, they have less opportunity than other students to earn money to help pay some of the cost of their education. Although the number of scholarships provided for in H.R. 10042 is small in terms of the need, they would be a means of attracting some college-bound students and focusing attention on the academic nature of professional nursing.

We believe also that the loan provisions in section 824 of this bill will have an impact on the enrollment in schools of nursing. Students in baccalaureate and associate degree programs are now eligible for loans under the National Defense Education Act of 1958. In 1962, about 800 nursing students, out of over 26,000 enrolled in these programs, had loans. High priority in granting loans has not been given students of nursing and their work in nursing does not make them eligible for the forgiveness provisions of the act.

This committee is aware that nurses' salaries are generally low. Newly licensed nurses usually practice in beginning staff positions in hospitals and other agencies. According to the Bureau of Labor Statistics, average weekly earnings for general duty nurses in 1963 ranged from $74 to $98.50. Entrance salaries for these positions in

a number of hospitals in 3 of the 15 cities surveyed were as low as $55 a week. These 15 areas represent the most highly populated areas in the country.

In a study made by the American Nurses' Association in November 1962, it was found that general duty nurses' salaries averaged about 24 percent more in cities with 500,000 or more population than in those of less than 10,000 population. When salaries are so low, repaying a loan can be difficult. We would therefore believe the forgiveness provision in H.R. 10042 is most important and one that could very well foster sustained employment in nursing.

It has been my own personal experience in my State that an administered plan through the Medical Care Commission for medical students, dental students, and nursing students, very few of these loans have been utilized by students in nursing. It has been very effective for the medical students and the dental students.

I think probably the reasons for this is that first nurses are primarily women, and I think a young woman has great reluctance to obligate herself for a long-term financial commitment which she knows may interfere with her own future plans. She hesitates to ask her husband to undertake this kind of obligations. Secondly, she knows her earning capacity, once she graduates, is so low it makes it extremely difficult to repay this loan.

This has not been effective in our State and they have changed the provision from loans to scholarships because they realize that this was not effective in increasing the number of nurses needed in the State.

We would also like to call your attention to the fact that nearly 9,000 registered nurses, graduates of associate degree and diploma programs, are studying for a baccalaureate degree. In 1962, 5,262 were enrolled on a part-time basis. This practice is uneconomical in terms of time, money, and effort but persists because on their salaries, nurses cannot save enough to undertake full-time study and there is very little financial assistance available to them. Before they earn their baccalaureate degree, many will have spent 6 or 7 years in part-time study.

The American Nurses' Association agrees with the recommendation of the Consultant Group on Nursing that for a limited period Federal funds be provided for traineeships for graduates of diploma and associated degree programs for up to 2 years of full-time study toward a baccalaureate degree. This would help registered nurses secure more rapidly the level of education their positions call for today and enhance the quality of patient care.

In relation to the planning grants, we are very much in accord with the provision for planning grants in section 805 of H.R. 10042. Comprehensive and careful planning is vital when a program of the kind proposed in this legislation is undertaken. The grants would encourage a State or region to survey its resources to determine needs and whether emphasis should be placed on new schools or expanding of existing schools.

Not to plan could result in an unwise use of public funds and an indiscriminate mushrooming of facilities for teaching nursing that could only lower the quality of nursing education and nursing service. When programs in nursing education are instituted more is required than a building. Qualified faculty is essential and there must be ade

quate clinical facilities and community agencies for laboratory experience. We hope the committee will agree that the provision for planning grants is a wise inclusion in this bill and will give it favorable consideration.

In section 806 of H.R. 10042, a 5-year program of project grants is proposed. The object of this proposal is to stimulate new and improved methods of nurse training and recruitment, to improve utilization of nursing personnel, and to enable schools to strengthen, improve, and expand their programs of nursing education.

While we believe the scholarship and loan provisions in the bill will help increase enrollment, other ways must be found to attract larger numbers of talented high school graduates into nursing. During a 5-year period, 1955-60, the number of girls entering colleges and universities increased 50 percent. In this same period, admissions to schools of nursing increased 5 percent. Nursing needs to be interpreted as an intellectually challenging and satisfying profession. Too often only inadequate and misleading information about nursing is available. New materials specifically directed to those who are in a position to influence young people in the choice of career need to be developed.

Considerable experimentation with methods that promote better teaching and better use of teaching personnel has been going on in the field of education. These methods need to be more widely incorporated into the teaching of nursing. The project grants offer the opportunity to schools to improve their methods and thereby enhance the quality of instruction.

Of concern is the matter of whether present professional nursing personnel are being utilized to their full potential or whether their energies are being expended on tasks that are within the competence of less highly trained people. The Division of Nursing of the U.S. Public Health Service has done studies and developed a methodology that can be used by institutions and agencies that seek to improve utilization of all nursing personnel. Availability of project grants would encourage hospitals and health agencies to experiment with staffing patterns to see how they might most effectively utilize nursing personnel in their own situations.

Since the project grants would support a movement toward improving the quality of nursing education and nursing services and recruitment into the profession of well-qualified young people, we support this provision.

The American Nurses' Association believes that certain safeguards are essential to insure the best use of the Federal funds that H.R. 10042 would make available. It is most important that only schools of nursing accredited by a recognized national accrediting body be eligible to receive funds for construction, apply for project grants, and establish and operate loan funds. These are the schools that have met standards set by the National League for Nursing, the recognized accrediting body for schools of nursing. There will be instances where evidence can be given that a nonaccredited program will meet accreditation standards within a reasonable time. In cases of this kind, we recommend consultation with the accrediting agency before assistánce is extended.

In the past, the Congress has demonstrated its awareness and concern for nursing education. During World War II when the need for nurses was especially acute, legislation was enacted to establish the U.S. Cadet Nurse Corps. This 5-year program enabled schools of nursing to increase their enrollment and resulted in 41,000 graduations in 1947, the largest number of students ever graduated fro basic professional schools in one year. This program also helped graduate nurses secure additional preparation.

Assistance available after World War II under Public Law 346, the G.I. bill, significantly increased the number of nurses undertaking additional study in colleges and universities. In 1956 and in 1959, Congress approved the professional nurse traineeship program, designed to prepare nurses for positions in teaching, supervision, and administration. The Public Health traineeships have also assisted nurses preparing for the field of public health.

The problem of insuring adequate nursing service now and in the future is a critical one. There is overwhelming evidence it can be solved only with substantial Federal aid. Immediate action is needed to reverse the progressive dilution of nursing services. We believe that delay will have grave consequences for the future health care of the American people.

May I thank the committee for this opportunity to present the views of the American Nurses' Association on this legislation.

We would be happy to answer any questions that you may like to direct either to me or to Miss Thompson or to Miss Connor. Thank you, Mr. Chairman.

Mr. ROBERTS. Thank you, Mrs. Dolan. I compliment you on a very fine statement.

Certainly the statements you make on page 6 enlighten us on the traineeship program expansion on which you speak there about clinical specializations. This is one section that has not been as well stressed upon and set out in some of the other statements. I think you have done a very excellent service in setting it out.

I had frankly hoped that your group might go along with some of the other witnesses with reference to construction of facilities, so it seems to me that in the budgetary situation in which we find ourselves that we would have to have a tremendous demand before we go ahead and add additional law providing for construction of facilities until we see what is going to be done under H.R. 12.

We know that under the other acts as you pointed out and other witnesses have pointed out there has been a tremendous amount of construction. Whether the emphasis has been misplaced or not is something I have to look into and perhaps have some more information.

I have the feeling that you still put the emphasis on the need for faculty and personnel ahead of the need for new construction; is that correct?

Mrs. DOLAN. Well, we believe that the need for faculty is acute, but we also believe that we cannot produce this faculty unless we have the teaching facilities to prepare them.

Now, I have information that already 52 collegiate schools of nursing have applied for construction funds under public law, the former H.R. 12. Now, if nursing has low priority and they are competing

with medical schools, dental schools, schools of osteopathy, et cetera, then I think it is logical that many of these requests will have very great difficulty in getting approved.

We do believe that we do need to place emphasis on the preparation of teachers, but teachers can only be prepared in collegiate schools and these schools must be expanded in order to increase their enrollments to meet the need. We say we have to double. We hope that we would have, I think it is 25,000, by 1970.

Mr. ROBERTS. Well, I realize that you are going into these other competitive areas.

It seems to me that if we were to get out the assistance to professional nurses and students, we were able to get that part of the bill out, we would still have some time to review or look into the existent construction both on the private field and in the Federal field-Federal-State field, I should say-and perhaps even have this subcommittee look at some of the situations over the various part of the country.

There is always a timelag between the passage of the bill, of course, until they start doing something with the provisions.

In the main, I think we have covered the subject quite well and I am very grateful to the committee.

Any questions, Mr. Pickle?

Mr. PICKLE. Just a short question.

In your own State, do you have a scholarship program underway and a loan program, also?

Mrs. DOLAN. Yes, we have. It was first established as a loan program and the State legislature appropriated funds to the medical care commission. This was to provide loan funds for medical students, dental students, and nursing students, in order to try to recruit people into the rural areas. They had a rural area commitment.

But after a number of years of experience with this, it was not meeting the need for nurses because nurses were unable to take advantage of the loans because of their low economic position.

Last year, the legislature changed it to a scholarship program for nurses. It is still a loan program for dentists and physicians but the amount is very small.

Mr. PICKLE. Is the scholarship program successful?
Mrs. DOLAN. The scholarship program is.

Mr. PICKLE. Did you ask your legislature to change the loan program and insert a forgiveness clause in there? Was that ever

considered?

Mrs. DOLAN. With a forgiveness clause?

Mr. PICKLE. Yes.

Mrs. DOLAN. It has a forgiveness clause only up to 50 percent if the nurses worked in a mental institution or in an area of less than 2,500 population.

Mr. PICKLE. Now, your original program and the loan program did have a forgiveness clause in it up to 50 percent; is that correct? They were not successful?

Mrs. DOLAN. If they worked in an area or in a town with less than 2,500 population. Now, this, itself, is a deterrent because as the nurse knows when she enters a school of nursing she must work for 4 years in a community with less than 2,500 population.