tor of Nurses." I arrived-and may I never outgrow my innocence--eager to help the hospital improve its nursing service. I had been there only about a week when the night supervisor telephoned me at home. The hour was 2 in the morning. She sounded angry and desperate. "The lung case on the surgical floor is worse, we've just admitted a heart case, and we have two mothers in labor. The place is a madhouse." I said I'd be right down.

I arrived to find that five trained nurses would have been welcome on the surgical floor alone. In charge of it was a 23-year-old registered nurse, a pretty girl who did night duty once a week, while she went to college by day to earn her bachelor's degree in nursing. Her help consisted of two nurse's aids-one dragooned from another floor-"nonprofessionals," unlicensed, forbidden by this State's laws and by hospital accreditation standards to do anything for a patient of even a remotely medical nature, not even hand out a pill. On this floor were 24 patients. Five were postoperative that day from major surgery. All five were receiving intravenous infusions, and three were being given oxygen as well. All were supposed to be having frequent blood-pressure readings, as often as every 10 minutes. Two were just fighting their way upward from anesthesia, and by every medical and humane standard, they needed someone beside them, a reassuring voice, a sedative, the moment they opened their eyes on a groggy, pain-filled world.

Besides the critical five, two other patients were also receiving infusions, each flat on his back with a hollow needle lodged precisely and perilously within a vein. One small move, the vein wall could be punctured and the infusion would drip into tissue. For the patient lying helpless under that dripping bottle, it is a painful, frightening experience. His light should be answered fast.

Finally, the most serious of the postoperative cases, a young man who had had lung surgery, had his doctor working over him frantically. The doctor was giving him glucose and oxygen. He wanted to give him whole blood, as well. He wanted to give him a stimulant. And he wanted to change his dressing. The doctor was so angry that he could only glare mercilessly at the frightened, useless nurse's aid who stood in the doorway. "Tell the nurse to get in here. Tell her I need caffeine. Tell her to bring the emergency tray."

All this was on the head of Miss White, my 23-year-old registered nurse. Being a decent, intelligent, idealistic girl-just the kind the nursing profession wants-she felt every bit of it. When she met me, to give me the hastiest possible briefing, she was near tears. "Miss Aynes," she said wildly, "you just can't do nursing this way."

She was right; you just can't.

Tearing the nurse apart are two conflicting pressures that have developed since World War II and that continue unabated in the face of nursing's high dropout rate. One comes from the doctors, who are in even shorter supply than nurses. They have every incentive, humane as well as economic, to see as many patients per day as they can. Doctors are now handling as many as several hundred patients a week by the expedient of handing over to nurses some routine medical procedures they once jealously guarded.

The other comes from hospital administrators-relatively new figures on the `hospital scene-whose job, without mincing words, is to control costs. The two forces, medical and administrative, must necessarily jockey for power, and which wins out, and to what degree, varies greatly from hospital to hospital. But something of the administrators' victory is indicated in a major report on nursing issued by the U.S. Surgeon General's office in 1963. It also tells us who is nursing patients. "In some hospitals the use of auxiliary workers has reached such extreme proportions that nursing aids give as much as 80 percent of the direct nursing services." The national average is 70 percent. "Auxiliary workers" are cheaper than trained nurses. The report adds the findings of another study that “highest patient satisfaction was achieved when professional nurses gave at least 50 percent of the direct care."

Miss White that night did not even question the fact that she was being paid a small fixed salary to perform the highly technical medical chores of half a dozen doctors, who had written their orders, walked off the floor, and would collect the fees. She was too young to know that, 25 years ago, it wa unheard of for a mere nurse even to take a blood pressure. Today, the nurse not only does this harmless chore, she does far more fateful injections, infusions, and catheterizations. She administers oxygen. Life-giving and death-dealing drugs arrive by her hand. A recent article in a nursing journal listed 19 facts that a good nurse should know about a specific drug and a specific patient at the moment of their coming together-and then pointed out that in the past 10 years,

over 4,000 new drugs and dosage forms have poured into our pharmacies. More recently, blood transfusions are becoming a routine part of a nurse's duties. And make no mistake about it, in this day of hustling people out of hospital beds and home, those still in the hospital need all these critical services and more. This development of the nurse into a semimedical backup for the doctor is a perfectly welcome one among the women of spirit who make up the ranks of nursing. Ideally, she should be far better paid for this office than she is. The median income for physicians in this country is now close to $25,000 a year; the median staff nurse's salary is less than $4,000. Hospital patients now pay extremely high medical fees in return for the actual amount of minutes doctors spend with them, as well as extremely high hospital fees. Somewhere in these fees there should be a more appropriate share for all the various nurses who do most of the work. However, nursing has always had other rewards besides dollars. The fact that it is now a more technical profession-and even a more dangerous profession-than it used to be is not the main difficulty.

But nurses cannot do the physically impossible. Most hospitals—and I declare this flatly-operate on a shoestring: shoestring budgets and shoestring nursing staffs. Across the country, the hospital administrator, counting his dimes, feels justified in rationing his professional nurses like gold. Miss White's official staff for the night was one aid-based on the common assumption that night staffs can be reduced. Yet life ebbs lowest at dawn, and every night nurse has had harrowing emergencies. Only 2 other graduate nurses were on duty that night in the entire 75-bed hospital. One was on the medical floor, dealing, among other things, with the newly admitted heart patient. The other was the night supervisor who had called me. She couldn't come and help out, because she was the only professional person available to the maternity and pediatric wards, the delivery room, and the emergency room.

There is no room in such staffing for emergencies. Yet a hospital lives from emergency to emergency. Rarely have I known a hospital staff to fail to rally around, often miraculously, when death comes near a bed. Yet this can be done only at the cost of less vital things: the 4 o'clock round of treatments and medications, the personal notice of a newly admitted patient, the individually prescribed care for the less ill medical and surgical cases. The nurse is already troubled enough by the fact that she has no time for the giving of comfort and the making of trained observations that are her subtler tasks. When she is really busy, the massive routines of the hospital floor-meal hours and visiting hours, water pitchers, bedpans, and back rubs-stagger on in the hands of aids, without her supervision. And much, much too often, she must send aids to do things they have no business doing. And there is all the room in the world here for the most ghastly mistakes.

Hospital nursing staffs are now a ramshackle hierarchy, with the professional nurses at the top in a definite minority. About 367,000 registered nurses now serve in hospitals, about a third of them in supervisory or administrative positions. (Only 10 percent of all nurses have the collegiate nursing degrees that those officially concerned feel should go with such supervisory jobs.) Many of the others are anesthetists, operating-room nurses, and clinical specialists. Thus only half our hospital nurses may be functioning as general-duty nurses. Underneath them in rank are the licensed practical nurses, 127,000 of thema relatively small group, but catching up in numbers to the general-duty R.N.'s. The L.P.N.'s as they are called, have taken on a protective coloring; they have blended so well that to the naked eye they are indistinguishable from the trained nurse. Practical-nursing schools now offer caps and pins to their graduates, and most hospitals allow them to wear white. This is a jealously guarded right among the L.P.N.'s and a sore point among nurses. It is considered impolite of a head nurse to inquire of her new assistant on the floor just which kind of school she graduated from. If she can't tell, certainly the patients can't.

Licensed practical nurses need not have graduated from high school (although about two-thirds of the younger school-trained group have), and at best they have had only about a year of formal training. They are intended by most State laws and hospital regulations to work only under the supervision of a trained nurse or a physician and to do only certain types of things for patients. In practice, many thousands of devoted L.P.N.'s have acquired the wisdom of years of experience and are lifesavers not only to patients but to doctors and

nurses.

Yet no one should regard without qualms the growing use of L.P.N.'s as fully qualified nurses. Everyone behind the scenes in hospitals knows that they do things they are not trained to do. And so we have the patient who must lie at

the mercy of the woman in white jabbing at his arm with a needle because she cannot find the vein, haphazard sterilization techniques, well-meant mistakes. Practical nursing attracts many thousands of enormously capable women, but standards are not high enough to weed out the incompetent.

Below the L.P.N.'s come the aids, orderlies, attendants, and others, who now outnumber trained nurses by a comfortable margin. Over 400,000 of them staff hospitals. They are nonprofessionals in every way. They need meet no educational qualifications, no standards of training; anyone who will take the job can have it. Their on-job training varies enormously, but the aid who turns up at your bedside is almost sure to be raw material, for their annual turnover is 70 percent.

Aids are in use in the most alarming places. They man the central supply room, where supplies are sterilized and aseptic techniques are essential. I uncovered an aid once whose custom was to turn off the sterilizers before the water was adequately sterile, because she didn't like the popping sounds. They keep vigil at night in pediatric wards tucked away in basements, the nearest registered nurse upstairs and half a floor away. Nothing serious on the ward, of course only an infant in a croupette, two older children with pneumonia, and a post-tonsillectomy who is still throwing up. They are in full force on maternity floors-where, after all, the patients aren't really ill. Aids have administered anesthesia in delivery rooms when the attending physician could raise no one else, and they have delivered many, many babies.

They are even turning up in operating rooms. One of the more calamitous events of my stay at Miss Smith's hospital was the administration's effort to train an aid as an operating-room technician; often, she was the only person scrubbed to assist the surgeon. Within a 2-week period, three surgical patients had to be returned for the repair of disastrously sloppy surgery. I do not mean to generalize from this one hospital, which, since it was run for private profit, was more shameless about cutting corners than most. But hospitals, by and large, are so poor that no one should underestimate their incentive to save money, either. There are more cases of that old operating-room joke, the lost sponge, than the public suspects.

A nurse in a supervisory role quickly learns that most aids find it easier and more face-saving to struggle along, pretending a competence they don't have, than to ask for help. She has no choice but to use them-there is too much to be done yet I have known aids so ill-trained that they presented bed pans backward (too often, the patients haven't known the difference either), with disastrous results. The answers to such questions as "Did you remember to patch the rubber gloves?" and "Have you ever given an injection?" are not always reliable. I remember the time an orderly assured me he knew how to give an enema. When he came back, he said with awe, "Say, that could be dangerous, couldn't it?" Alarmed by unimaginable possibilities in this most nondangerous procedure, I asked him to show me what he was talking about. We went to the utility room together; there was the equipment, with the plastic insertion tip missing, nothing at the end of the tubing but a broken glass connector with an ugly, jagged edge. Fortunately, he had used plenty of vaseline and the damage to the patient turned out to be minimal. But it was a rare aid who went to her head nurse and asked uncertainly, "Have I measured Mrs. Brown's penicillin right?" She had measured four times too much.

Hospital aids have proved themselves indispensable members of the hospital team. They perform a hundred tasks that are of priceless value to the patient, save the time of the higher paid nurse, and yet require no great skill or training. But their services should be limited to match their training-in fact, as well as by law and regulation. Hospital administrators need to review their hopeful belief that if they fill their staffs with low-cost personnel, the patients will. somehow, be nursed.

The nursing shortage has been studied again and again by professional groups-without avail so far. One of the most important studies of last year, the Surgeon General's report, prepared by a distinguished consultant group on nursing, warns that we cannot possibly hope to have the desirable number of nurses by 1970 and offers dubious grounds for hope that we will reach even the minimum number it suggests as next best. But perhaps yet more studies are needed: Would some of the half million R.N.'s who aren't working come back to fill the "vacancies" on hospital nursing staffs if administrators offered them reasonable pay and working conditions? Could the deficiencies of a staff unduly loaded with nonprofessionals be hiking hospital costs?

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There was a comfortable pool of nonworking registered nurses in the community of Miss White's hospital; but the administration preferred not to hire them. It is doubtful if they would have come for the rates of pay and working conditions offered. The hospital that has earned a good reputation among nurses usually has no difficulties in filling its staff. And just how much money is being saved when a worried director of nurses with an insufficient professional staff keeps issuing calls to the administrator for more help and yet more helpand the administrator keeps supplying the wrong kind? Many, many directors, untrained in administration, cannot themselves put their fingers on just what is wrong with their staffs. With all these orderlies and aids, things should go better. Yet things stumble and bumble along; administrator, nurses, and aids feel harried—and the patients lie helpless, puzzled, outraged, wondering why no one answers the light.

Finally, one more thing wrong with nursing was an element in that scene on the surgical floor at 2 o'clock in the morning. Miss White, a graduate of a 3year hospital school of nursing, would be out of circulation, except for occasional part-time work, for 3 or more years while she pursued her college bachelor's degree in nursing. Our system of educating nurses is an ornate, gingerbread structure, with a turret here and a wing there, with all the stairways left out. No other profession-not even teaching-is in more demonstrably appalling shape.

This is not an attack on our schools of nursing—nursing has as many superior ones (and as many inferior ones) as most professions. It is a plea for a sensible structure, with stairs, so that a young girl can proceed through various levels in an orderly manner, acquire her extra training at the least time and cost, and stop at the most suitable level.

Consider the present structure. Most of our nurses come from 3-year hospital schools; 10 percent come from 4-year college or university programs. Yet both types take the same State examination and end with the same catchall title: registered nurse. Both programs emphasize bedside care. Their graduates are then tumbled out into the real world of hospital practice. They find themselves almost instantly head nurses or higher, largely removed from bedside care and needing supervisory, administrative, clerical, and teaching skills, in which they have not been trained. Nursing organizations are very aware of these new increased duties of nurses. There is a great deal of official pressure on all nurses to go on to an ever-higher education. Yet if an ambitious, hospitaltrained nurse wishes to further her career with college training, she finds that her hospital experience counts for almost nothing in the way of college credits. She must stop in her tracks, go backward, and perhaps start out as a sophomore, at a painful cost of time and money.

Now let's look, not upward from the hospital-trained R.N., but downward. All nursing schools, including hospital schools, prefer to fish for their recruits among the top half of high school graduates competing for the same outstanding girls as industry and teaching. After these girls become nurses, who in the hospital hierarchy is beneath them? We plummet quite a way down to the practical nurses, who have, typically, 1 year of training, usually in a vocational course administered by a public school system. But practical nurses are a minority. When we look down to the aids, unlicensed, unstandardized by any governing body, and often uneducated, we really zoom downward.

The gap between the professional nurse and her aid is too great. It is, on the face of it, unreasonable. The professional nursing organizations, interested in promoting their members upward, are doing nothing to promote prestige for the person who is actually at the bedside. Yet a training program to create just such a figure, operating somewhere between the R.N. and the L.P.N., offers all kinds of tempting possibilities. Some junior colleges have already had some success in turning out a 2-year-trained registered nurse-a little short in clinical experience, to be sure. A 2-year hospital program might also be developed-short in theory, perhaps, but strong in clinical practice. Such a program should come within the shelter of professional concern, with professional standards and a professional diploma of some kind. It would draw on the entire high school graduating class and offer credits to qualified practical nurses who wish to advance to professional status. It would draw, in effect, on all the good-hearted girls with a vision of nursing as it used to be whose touch with the ill may be excellent, but who have no particular interest in or aptitude for the thankless role of top sergeant. It doesn't matter what their title might be: "registered bedside nurse" or whatever. The important point is to reinstate professional standards and eithics to the direct care of patients in bed.

Of course, all those stairways need to be built. The 2-year bedside nurse should be well prepared clinically; the 3-year nurse shoud begin to specialize, including the specialty of administration if she wishes, a specialization that may be furthered with a 4th year on a college campus and carried on to the master's -degree.

But the broad professional base of nursing should be the army of young women whose day-to-day skills have so much to do with patient cheer and patient recovery. The public still believes that the nurse at the bedside-not the nursing director with the master's degree-is the heart of nursing.

Mr. HEMPHILL. Now without calling attention to the personality involved, because I have not been given that permission, I would like to read from a letter written to me and keep the name anonymous, because giving you the name would not add anything to the testimony in the record. This lady, who is a great Christian lady in addition to being a fine nurse, writes to me and I quote:

There are people who have from 1 to 2 years, 10 months' nurse's training who as classified would be named an aid. They did not attend our present NLP School of Nursing. They are doing a great job, but these people are given the task of administering injections.

I go on to quote:

(1) What would happen if these people were allowed to be licensed (by practicing so many years, or by a test of some sort); (2) if these people had their salary base raised to compete with industry, public health nurses, Army, Navy nurses, etc., what would happen; (3) if these people had their pension benefits, sick leave, and so on?

To me, Mr. Chairman and members of the committee, it seems futile. for us to vote here for the brick and mortar, for the improvements, which program I heartily endorse today and will endorse as a member of the committee, if we are not going to have the personnel. I am delighted that this subcommittee, as part of my committee, has taken on the task of doing something about it. We could have no greater purpose, in my opinion.

I don't know how it is in Alabama or Minnesota, but I do know how it is in South Carolina, and I assume it is like other places. Numbers and numbers of people who are in the fading years of life are in the hospitals and in the nursing homes. These people, as citizens, have given to us who are a new generation with the responsibilities of this country, a great country and a great purpose; they served their time as citizens, either as business people or professional people or, in the greatest of all, the noblest of all tasks. They need the care and attention, and one of the difficulties is getting the nursing care; not that there are not fine people who are volunteering, but we have a shortage. We have it because we don't pay them enough, because we have never given them the salutation that their noble cause deserves.

I can think of nothing finer than someone giving their life to this great profession of service. So, Mr. Chairman, with some emotion and considerable gratitude, I endorse the legislation and hope to give it my full and untiring support. I will answer any questions you may wish to ask.

Mr. ROBERTS. I express not only my personal feelings but also the feelings of the gentleman from Minnesota in saying, first of all, how much we appreciate your appearance on this very important legislation and how much we appreciate the wonderful service you rendered to this committee during your stay in Congress. And I read with a great deal of regret the statement the other day in the rollcall that you