Page 3, section 802: This section provides that only schools of nursing with accredited programs are eligible for construction grants. Though we are thoroughly in favor of increasingly higher standards of education in schools of nursing, we believe that limiting eligibility to accredited schools is an unwise provision. At the present time, approximately 564 hospital schools of nursing are accredited by the National League for Nursing, a private accrediting agency, and 310 schools are not so accredited.

We seriously question that the Federal Government should appear to establish Federal standards for educational institutions or that the Federal Government should appear to impose standards which exceed those required by State governments. We recommend that the bill be amended to provide that any public or private, nonprofit school of nursing providing a program of nursing education approved by an appropriate State authority is eligible.

On page 5, the bill provides that the Surgeon General secure the advice of the National Advisory Council on Nurse Training in approving or disapproving applications for construction projects. This appears to be in lieu of there being a single State authority, and the bill does not require that there be an overall State plan submitted to the Surgeon General for his approval.

We believe a preferred approach is that set forth in the Hospital Survey and Construction Act where the overall needs of the States are assessed by a State agency and a plan submitted to the Surgeon General for his approval. The Surgeon General is required to approve any individual project in compliance with the State plan and without reference to the Federal Advisory Council. We question that the existing provisions in the bill referring to local or other planning groups responsible for determining needs is an adequate substitute for an overall coordinated State plan. Further, we believe that the authority and responsibility for administering the program should be vested in the States. We would recommend that there be an initial allotment to the States for the preparation of an overall State plan. Page 6, section 803: Grants for the construction of new schools and for changes in the facilities of existing schools which would result in a major expansion of training capacity may go as high as 662% percent of the cost of construction. A second provision in the case of any other grant would allow a maximum of 50 percent Federal matching. We believe this second provision would only apply to the replacement of or the modernization of existing schools of nursing where no major increase in enrollment is provided. It is likely that this second provision would apply, for the most part, to schools of nursing operated by hospitals; and, therefore, it singles out such schools for a lesser entitlement to Federal funds.

Page 8, section 805: The purposes enumerated and for which grants are to be made appear to us to be indefinite, and we believe omit entirely what should be the major purpose of such planning grants and that is the development of a total State plan for the construction or modernization of educational facilities for nurses to be submitted to the Surgeon General. It is our belief that the existing provisions could result in a very hit-or-miss and uncoordinated approach to the provision of facilities.

Page 9, section 806: This section provides for planning and demonstration grants to strengthen, improve, and expand programs of nurse training. Increased research in these areas and particularly in respect to improving the utilization of nursing personnel is greatly needed and we support this provision wholeheartedly. However, we do question the amount of the proposed appropriation in relation to the effective use of the funds. We would recommend that the bill be amended to provide $3.8 million for the first year and a maximum of $7.5 to $10 million in succeding years.

At this point, Mr. Chairman, with your permission, we would like to introduce a suggested new provision: "Assistance to educational institutions for the training of professional nurses."

Two major sources of Federal assistance are required if we are to meet the needs of the public for nursing services. This bill proposes to assist in meeting only one of these needs and that is to provide financial aid to young people who wish to enter schools of nursing. The second and equally urgent need is for Federal financial participation in underwriting the direct cost incurred by the nursing schools in the provision of education. It is well recognized that tuition and fees are not sufficient to meet the costs of education in any institution of higher learning. The tuition assistance provided for in this legislation is appreciably less than the cost of providing the education.

The overwhelming majority of nurses receive their education in the diploma schools. There are approximately 124,000 students enroled in all three types of schools. Of these students, 95,278 are in hospital diploma programs. Therefore, if the needs of the people for nursing services are to be met, the problems of these schools in providing the education must be given immediate consideration. Student tuition in hospital schools has been relatively modest through the years. Most schools have gradually increased the tuition and today tuition and fees run from a low of $200 to a high of $1,800, with a median of $826 for the 3-year course. Students provide little service to offset the increased cost of the education. Therefore, the primary expense of educating nurses is borne by the hospital patients. This cost is an appreciable factor in the increasingly high cost of hospital care and in the decreasing number of diploma schools. A study recently completed by the National League for Nursing of 126 hospital schools indicated the total cost to the school per student per year ranges from $2,100 to $2,700. The median value of student services for a student per year is $600.

Mr. NELSEN. Would the gentleman yield at that point?

Dr. HOWELL. Yes.

Mr. NELSEN. If some provision were made so that this tuition problem and expense problem to the hospital were met, do you feel that more of the hospitals would be available to work out this program for education?

Dr. HOWELL. We do, sir.

Mr. NELSEN. Do you think it would almost meet the need if arrangements can be made?

Dr. HOWELL. I do not believe our answer could be stated as simply as a yes, because I think the problem is too complex. The need for the development of more and more faculty is one of the most important parts of the problem of our nursing shortage today.

Mr. NELSEN. In other words, you do feel that one of the problems that a hospital is faced with is the fact that actually it is a costly program for them. The student is not of great help to the hospital, it almost becomes a burden, and therefore the hospital needs some additional income to take care of the costs involved in training the student; is that right?

Dr. HOWELL. Yes; this we believe.

Mr. NELSEN. You do feel that if some of the funds that might be going to bricks and mortar in this bill, if some more were directed to the existing hospitals, more facilities would be available that are already bricks and mortar; is that true?

Dr. HOWELL. Yes, sir.

Mr. NELSEN. Thank you.

Dr. HOWELL. As public questioning of hospital costs has increased, expenditures for essential educational pursuits conducted in hospitals become more difficult to justify. Boards of trustees in many hospitals have a growing sense of apprehension as to their ability to continue to perform this essential service of nurse education. A good many schools of nursing have already ceased operation. In fact, 205 schools providing training for students ceased operation between the years of 1951 and 1962. We hear continually of additional schools that are likely to close because of the increased fiscal pressures.

Mr. ROBERTS. Dr. Howell, I hate to interrupt your statement, but you know we are faced with a quorum call on the floor. I am endeavoring to get permission to resume hearings at 1:30. I think the chances are good that we will be back at 1:30. If not, we will have to resume here tomorrow morning.

So we will stand in recess until 1:30 p. m. today or 10 a.m. tomorrow. (Whereupon, at 12:10 p.m., the hearing recessed to reconvene at 10 a.m., April 10, 1964.)

NURSE TRAINING ACT OF 1964

FRIDAY, APRIL 10, 1964

HOUSE OF REPRESENTATIVES,

SUBCOMMITTEE ON PUBLIC HEALTH AND SAFETY,

OF THE COMMITTEE ON INTERSTATE AND FOREIGN COMMERCE,

Washington, D.C.

The subcommittee met at 10 a.m., pursuant to recess, in room 1334, Longworth Building, Hon. Kenneth A. Roberts (chairman of the subcommittee) presiding.

Mr. ROBERTS. The subcommittee will come to order.

Yesterday we heard from Dr. James T. Howell who represents the American Hospital Association. I believe you know where you were in your statement, please proceed.

STATEMENT OF DR. JAMES T. HOWELL, ASSOCIATE DIRECTOR, HENRY FORD HOSPITAL, DETROIT, MICH.; ACCOMPANIED BY MISS RUTH SLEEPER, DIRECTOR, SCHOOL OF NURSING AND DIRECTOR OF NURSING SCIENCES, MASSACHUSETTS GENERAL HOSPITAL, BOSTON, MASS.; AND KENNETH WILLIAMSON, ASSOCIATE DIRECTOR, AMERICAN HOSPITAL ASSOCIATION-Resumed Dr. HOWELL. Mr. Chairman and members of the subcommittee, we thank you for the opportunity of continuing our presentation. For orientation, we are on page 13, beginning with the first paragraph.

Of the more than 7,000 hospitals in the country, only 875 operate schools of nursing. These schools bear the brunt of educating nurses needed by the thousands of other hospitals. They also provide the nurses for industry; they provide for the needs of the Federal Government, and all other levels of Government.

It is not difficult to understand the concern of the trustees in these hospitals to justify the burdens which their patients must carry in order to perform this public service. It seems to us to make very little sense to provide programs for new schools and for additional building unless we have first taken steps which will strengthen and improve and keep in operation the existing schools. We cannot emphasize too strongly that the existing schools of nursing in hospitals are not likely to continue indefinitely in the future unless they have a full measure of assistance in meeting the pressing financial obligations of their educational programs.

Therefore, we recommend that H.R. 10042 be amended and a new section be added to this bill providing for direct financial assistance to the schools. Such assistance should be provided on a matching

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