to encourage still greater expansion to make more facilities available for education. I want to thank you very much, because I hope this can move us still further in that direction.

I have no questions, Mr. Chairman. I wish to thank Miss Schwier for a very fine statement.

Miss SCHWIER. Thank you.

Mr. O'BRIEN. If the committee will bear with me, a New York State Committee on Medical Education, appointed by the Governor, made a comprehensive evaluation of health personnel needs and methods for meeting future needs. Their report, submitted in June 1963, contains a chapter on the "Need for Nurses." The prominence and stature of the members serving on this committee should certainly add prestige and credence to their report. The members were Dr. Thomas Parran, a former Surgeon General of the United States and commissioner of the New York State Department of Health; Dr. William R. Willard, vice president for the Medical Center of the University of Kentucky and a member of the Surgeon General's Consultant Group on Nursing; and Mr. Malcolm Muir, chairman of the board and editor of Newsweek magazine. Dr. Lester J. Evans, now assistant to the vice president for the education of the health professions at the University of Illinois, served as executive director of the committee.

Unless there is objection, I would like to insert in the record of the hearings the chapter relating to nursing, pages 26 through 33, a portion relating to financial aid for nursing students, page 48; and paragraph (b) on page 51.

Mr. NELSEN. No objection.

Mr. O'Brien. Hearing no objection, it is so ordered. (The information referred at follows:)

THE NEED FOR NURSES

When Florence Nightingale swept into the pesthole called a hospital at Scutari in 1854, the first thing she did was sanitize it to combat the infections that were taking more lives than volleying Russian cannon. Then she began her nightly rounds through the 4-mile rows of beds, with a smile and a word for each shattered survivor of Balaklava. "The lady with the lamp," the troops called her devotedly, and their morale rose as surely as their temperatures fell.

So, ever since, has the profession that Miss Nightingale founded given integrated balance and continuity to the basic elements of good medicine-fighting disease through the physical and biological sciences, and cheering patients through simplified application of the behavioral and social sciences. By 1900, nursing had become so respected a part of medicine that the wry "Mr. Dooley" observed that it didn't matter much whether you called a faith healer or a doctor-"if ye had a good nurse." But if good nurses were important in 1900, they are essential in today's far more complex medical practice. And the changing patterns of patient care and of society, itself, are challenging the adequacy of their educational facilities, their services, and their numbers.

THE BACKGROUND

The rapidly growing demand for nursing services, due in part to increased utilization of hospitals, has affected the fundamental role of the nurse. Even though the number of actively employed registered nurses has been on the rise, the increase has not been sufficient to satisfy the new and expanding needs of patients within (or without) the hospital.

The function of the nurse has been modified in response to these changes. Where once she was a housekeeper and general assistant to the physician, today she is directly or indirectly engaged as a vital member of the health team in multiple and varying tasks often requiring highly sophisticated skills. She is responsible as a bedside nurse for the care and comfort of the patient while at

the same time, she undertakes more and more tasks formerly performed by the physician. Paradoxically, as the patients needs, both technical and psychological, have become more apparent, the professional nurse who is prepared to meet these needs finds herself increasingly removed from the bedside for supervisory and administrative duties. Her patient-care role then falls to the less-trained practical nurse, aid, and attendant. Although the aim of today's patient care should be integration and continuity of services, the nursing care of hospital patients becomes increasingly disjointed and intermittent.

Outside the general hospital, the need for highly skilled nurses is growing apace. More and more, the chronically ill and the aged need professional care in clinics, old-age and nursing homes, rehabilitation centers, and their own homes; likewise, public health, schools, and industry are calling for more nurses.

The growth in demand for nursing services has been coincident in recent years with a general shrinkage in the working hours of nurses toward the national standard of the 40-hour week. This trend, while eminently just and desirable, inevitably aggravates already existent shortages.

SHORTAGES OF NURSING PERSONNEL

It is generally agreed that there is now an acute shortage of nurses in New York State. Recent surveys by the State education department indicate that in hospitals about 33 percent of positions for general duty professional nurses are unfilled. In a few of these hospitals, as much as 80 percent of the direct nursing care of the patients is given by practical nurses and nurses aids rather than by registered nurses. In the municipal hospitals of New York City, 60 percent of the budgeted positions for registered nurses are vacant. Public health agencies, nursing homes, and mental hospitals are urgently in need of trained professional nurses. Patients and their families, physicians, and hospital administrators express dissatisfaction with the amount and quality of nursing service available in hospitals.

This situation exists even though the number of active registered nurses has increased by 40 percent in New York State since 1950, from approximately 50,000, or 337 per 100,000 population, to approximately 70,000, or 416 per 100,000 population (see app. I, table I, p. 93).

Current shortages have resulted in various adjustments to the situation. To cope with the pressure, nurses have incorporated into their organization within hospitals and health agencies persons with less training-the practical nurse, the nurse's aid, and other auxiliary personnel. While this practice has eased some immediate pressures, it has resulted in an insufficiency of professional nurses to supervise the nonprofessional personnel involved. There is a desperate need for nurses with leadership qualifications, not only to supervise, but to administer and to teach. There is, additionally, a growing need for clinical specialists in nursing in such fields as psychiatry, surgery, obstetrics, and pediatrics.

NURSING EDUCATION IN NEW YORK STATE

In New York State today there are three basic kinds of educational programs designed to supply the demand for professional nurses. Through any of the three a student may qualify for the State licensing examination and become a registered nurse. Generally, graduation from high school is a prerequisite for admission. The total includes:

(1) Nineteen baccalaureate programs, requiring 4 years of college work and leading to bachelor of science degrees.

(2) Eight associate degree programs, 2-year courses conducted under the auspices of junior or community colleges. In New York State the vast majority of these programs are taught in community colleges within the State university system.

(3) Ninety-four diploma school programs, usually 3 years in length, conducted under the auspices of hospitals.

Beyond these undergraduate programs (which graduate approximately 3,500 a year from a total enrollment of about 12.000), 11 universities in the State offer graduate studies in nursing toward masters' degrees and 2 toward doctorates. These programs, in which approximately 1,000 students are now enrolled, part time or full time, are of vital importance in the training of nurse administrators, clinical specialists, researchers, and faculty of nursing schools. They should

2 See app. I, table III, p. 94.

receive every encouragement to develop new programs of patient care, teaching, and continuing education.

At the other end of the training range are 48 practical nurse programs, which require 1 year of training. They are commonly conducted by local boards of education, often with Federal subsidy, as part of their vocational training programs. Some are operated by hospitals. High school graduation is not usually required for admission to these schools. Their present total enrollment is 2,303. (Nurses' aids and other auxiliary personnel receive on-the-job training and require no formal education.)

CAUSES FOR CONCERN

While this inventory of nurse-training resources is numerically impressive, there is solid evidence that it will not prove adequate either quantitatively or qualitatively in the next decade. Among major causes for concern are these:

(1) Nonaccredited status of many nursing programs: While all programs must be approved by the State education department, the National League for Nursing conducts a voluntary acceditation program with somewhat higher standards. Although nurse educators are generally agreed that accreditation by the league is desirable, only half of the State's programs have qualified for it.

(2) Quality and availability of faculty: The availability of faculty is a sig nificant problem in the development of nursing schools, and in the expansion and improvement of quality of existing schools. While the State education department reports approximately 94 percent of faculty positions filled in New York nursing schools, the educational background of the aggregate faculty is weak by accepted academic standards. For example, only 41 percent of nursing faculty members have a master's degree (or higher)-the desirable minimum acceptable standard for faculty appointment.

(3) Inadequacy of expansion plans: A study by the education department in 1957 (updated in 1961) concluded that the number of places for entering students in nursing programs should be doubled by 1970, from approximately 5,000 to 10,000. But expansion plans for that period, reported by the schools involved, provided for an increase to only 6,400 entering places. In short, while the projected need for increased first-year capacity was about 100 percent, the planned increase was only 27 percent.

(4) Declining attractiveness of nursing as a career: Another factor complicating the problems ahead is the declining interest of high school graduates in nursing as a career in New York State. There was an absolute increase in enrollment in nursing programs of only 4 percent between 1957 and 1960, while enrollment in other post-high-school educational programs was increasing 17 percent-a clear indication that the appeal of nursing as a career is losing ground relatively. This conclusion is supported by the declining ratio of nursing freshmen per 100 female high school graduates--down from 7.3 in 1957 to 6.4 in 1960. A related problem is the high attrition rate (about 34 percent) among nursing students, largely due to marriage or economic considerations.

All of these factors will require prompt attention and early remedial action by the State, if the nursing profession in New York is to keep abreast of the burgeoning demands upon it. Certainly increased financial aid to students is indicated to help meet the economic factor.

GOALS FOR NEW YORK STATE

In the committee's judgment, based upon population projections and the increasing nurse population ratio demanded by modern society and medical practice, New York State should set as its goal the provision of 500 active nurses per 100,000 population by 1970 (a goal for 1980 will require additional, interim study). This figure compares with a present ratio of 416 per 100,000, and requires a total of 94,000 nurses, or 24,000 more than are currently employed, an increase of 34 percent. To reach this goal it will be necessary, because of student attrition and retirement of nurses, to double the State's present entering class capacity. If existing schools expand sufficiently to account for half of the additional students needed by 1970, then the committee calculates that 40 new schools or programs with an average enrollment of 60 students per freshman class will be needed before 1970 to meet the goal.

See app. I, table II, p. 93.

Because of the large number and varied types of schools involved, it is not possible at this time to designate specific institutions for expansion. Considering nurse training generally, however, the committee attaches first importance to the baccalaureate schools. The development of such schools is essential if the nursing profession is to be supplied adequately with practitioners of the broad background in the social, behavioral, and physical sciences that is eminently desirable in the bedside nurse, and vital to the supervising and teaching nurse. They are the schools most heavily depended upon to supply leadership in the profession.

It follows that those few nurse training programs offering master's and doctor's degrees to selected, highly qualified students should be nurtured and enlarged. It is here that sorely needed faculty members, administrators, and researchers in nursing and patient care can be provided.

The committee's enthusiasm for baccalaureate and advanced degree programs in no way diminishes its interest in the associate degree programs in community colleges. These are the fastest growing programs in the State and should be given every encouragement, because, they, too, meet the major criterion that education for the health professions should be provided in an educational rather than a service environment.

Diploma schools of nursing, as appendix I, table III (p. 94) clearly indicates, now produce the overwhelming majority of nurses in the State, and any realistic appraisal must accept this situation as certain to continue for many years. Therefore, the committee would encourage strengthening of existing diploma schools of high quality, of which there are many, but it would withhold support from small unaccredited programs. Where they cannot be improved, perhaps through consolidation, such programs should be eliminated.

In addition to more professional nurses, the State will require, in the committee's judgment, a total of nearly 38,000 practical nurses, an increase of 50 percent, plus an increase in the number of nurse's aids and auxiliary personnel (see app. I, table II, p. 93). These totals reflect the conviction of leaders in nursing that about half of direct nursing service to patients should be provided by professional nurses, 20 percent by licensed practical nurses, and 30 percent by nurses' aids and auxiliaries. Because programs for practical nurses, generously supported by Federal funds, are proliferating at a rate adequate to meet the goal, they should not require material State assistance. The problem here is one of careful quality control of curriculums, faculties, and standards for graduation.

RECOMMENDATIONS

As steps essential to the attainment of the goals set forth in this chapter, the committee recommends:

(1) A State program to encourage increased enrollment and maximum utilization of facilities in accredited schools of professional nursing, particularly those offering bachelor's or higher degrees. (For details see ch. 10, p. 55.)

(2) Initiation of baccalaureate programs in nursing at both the upstate and downstate medical centers; and establishment of associate degree programs in each new community college of the State university system which can provide adequate clinical training.

(3) Vigorous State support for patient care and education research in nursing. The proposed Council on Health Profession Education (see ch. 13, beginning on p. 73) should be authorized to plan and initiate experimental projects for study of the various roles of nurses looking toward the development of a system of nursing education equipped to meet the needs in the broad spectrum of comprehensive medical service.

(4) The development of opportunities for continuing education for the professional nurse. Such programs should be included in an overall statewide program of continuing education for all the health professions. (See ch. 12, beginning on p. 68.)

(5) Financial aid to students in nursing. Details of the committee's proposals are discussed in chapter 9, beginning on page 46.

NURSES

A survey of 871 nursing programs throughout the country made in 1960 by the National League of Nursing reported median costs to students for 4 years of baccalaureate training came to $3,250. Data on associate degree and diploma programs indicated costs of $500.

In New York State, tuition for baccalaureate and graduate programs of nursing ranges from $600 to $1,200 annually. Tuition charges for students in community college programs in the State university is $300 per year.

While these costs are small compared to those of medical and dental education, so are the ultimate income expectancies. And the costs alone bar many good prospects from becoming nurses. The recently published Surgeon General's report on nursing reveals that in a recent sample survey "almost half of all degree programs reported that most of their students needed full or partial financial help. Approximately 25 percent of the diploma programs stated that students needed some financial assistance. The need for financial assistance probably will be even greater among increased numbers of students whom we hope to attract into nursing. Of 1,200 students who were accepted by diploma schools in 1960 but did not enroll, 33 percent gave lack of financial assistance as the reason." (b) Nursing.-Awards, varying with need, up to the following totals, which take into account differences in tuition cost for the several programs; master's degree program $1,500; baccalaureate degree, full tuition, not to exceed $1,500; associate degree, $300; diploma, $300. Like medical and dental students, nursing students would require certification by the board of regents that they had shown promise of successful completion of their chosen courses. In baccalaureate programs, students would qualify in the college year in which they become bona fide nursing majors.

Mr. O'BRIEN. Our next witness is Miss Sylvia Peabody, executive director, Visiting Nurse Association, Detroit, Mich., representing the American Public Health Association.

STATEMENT OF MISS SYLVIA PEABODY, EXECUTIVE DIRECTOR, VISITING NURSE ASSOCIATION, DETROIT, MICH., REPRESENTING THE AMERICAN PUBLIC HEALTH ASSOCIATION

Miss PEABODY. My name is Sylvia R. Peabody. I am the executive director of the Visiting Nurse Association of Detroit. In addition to my nursing education, I have a master's degree in public health nursing supervision and administration. I have been employed in public health nursing for the past 20 years in both official and voluntary agencies. For the past 10 years, I have worked with the Detroit Visiting Nurse Association.

Today I appear before you as the representative of the American Public Health Association. I am proud to represent the world's largest association of public health workers, with over 14,000 membersand 25,000 additional members of affiliated State public health associations. At present I am serving as secretary of the public health nursing section of APHA and as a member of the APHA program area committee on chronic disease and rehabilitation. I have been a member of the American Public Health Association since 1951 and was elected a fellow in 1961. The public health nursing section has 1,665 members, a large majority of whom are employed in administrative and consultant capacities in both voluntary and official agencies, or in teaching positions in schools of public health and collegiate schools of nursing. They have the experience and competence to consider the needs for and the effects of the legislation proposed.

The American Public Health Association wishes to support this bill, because the need for more and better prepared nurses for employment in public health agencies is critical. The APHA believes the provisions of this bill will help to correct the serious situation of shortage for all nursing positions, including public health nursing. There are many new demands and challenges for public health nursing in