Mr. WILLIAMSON. Yes.

Mr. BROTZMAN. Thank you very much.

I have no further questions.

Mr. ROBERTS. Thank you, Mr. Brotzman.

We appreciate very much your appearance and thank you for your

statements.

Dr. HOWELL. Thank you, Mr. Chairman.

Mr. ROBERTS. I call next Mrs. Margaret B. Dolan, president, American Nurses Association, Inc.

STATEMENT OF MRS. MARGARET B. DOLAN, PRESIDENT, AMERICAN NURSES' ASSOCIATION, INC.; ACCOMPANIED BY MISS HELEN CONNOR, DIRECTOR OF THE LEGISLATIVE PROGRAM; AND MISS JULIA THOMPSON, DIRECTOR OF THE WASHINGTON OFFICE

Mrs. DOLAN. Mr. Chairman, I am Margaret B. Dolan, professor of public health nursing, School of Public Health, University of North Carolina.

I am president of the American Nurses' Association, the national professional organization of registered nurses.

I have with me Miss Helen Connor who is director of the legislative program for the American Nurses' Association, and Miss Julia Thompson who is director of the Washington office of our professional association.

Our ultimate purpose is to secure for the people of this country the best possible nursing care, and one commitment of the association is to elevate the standards of nursing education to insure effective nursing practice.

I welcome the opportunity to appear here today on behalf of ANA to support H.R. 10042, the proposed Nurse Training Act of 1964, and to urge you to give provisions of the bill your early and favorable consideration.

The legislation you are considering would authorize construction grants for schools of nursing; planning grants to determine need and where emphasis should be placed; an extension of the professional nurse traineeship program; a scholarship and loan program for nursing students; project grants to develop new and improved methods of training and recruitment, to improve utilization of nursing personnel and to enable schools of nursing to strengthen, improve, and expand programs of nursing education.

There are over half a million registered nurses practicing today. However, an acute shortage exists that is both qualitative and quantitative. This has been caused in part by the rapid population increase, the growth and expansion of health facilities and advances in medical science. It has been intensified by the delegation to registered nurses of many functions once performed only by physicians.

For example, since the enactment of the Hospital Survey and Construction Act in 1946, 9,810 projects have been approved, representing a total of 290,000 general, mental, tuberculosis, and chronic disease hospital and nursing home beds. In addition, 1,992 rehabilitation facilities, public health centers, diagnostic and treatment centers, and State public health laboratories have been constructed. With the

exception of laboratories, nursing personnel are needed in all these facilities.

The American Nurses' Association has always supported the intent and purposes of the Hospital Survey and Construction Act but we are concerned that there are continuing appropriations for construction without an associated plan for staffing the facilities to insure effective and safe care.

There is a growing imbalance between professional nurses on the one hand and practical nurses and nurses' aids on the other. Federal support of practical nurse education was increased and expanded with the enactment of the Health Amendments Act of 1956 and has further expanded under the Manpower Development and Training Act.

The Area Redevelopment Act and Manpower Development and Training Act have also stimulated the setting up of many programs for the training of nurses' aids. Increasing the number of these personnel without a concomitant increase in the number of professional nurses to give the needed direction and supervision leads to deterioration in the quality of service. Professional nurses are responsible for planning the total nursing care of patients. It is urgent that their number be increased and that their preparation be improved.

When the Surgeon General's Consultant Group on Nursing reported in 1963, it estimated that to meet the needs of the Nation in 1970 for safe, therapeutically effective, and efficient nursing service, there should be 850,000 professional nurses, including 200,000 holding baccalaureate degrees and 100,000 with graduate degrees.

Realistically, considering the potential supply of students and the potential capacity of schools of nursing, this total could not be met by 1970. The Consultant Group then set as a feasible goal for 1970, 660,000 professional nurses including 120,000 with academic degrees, 25,000 of whom would have advanced degrees. Presently, 11,500 nurses have advanced degrees and 43,500 have baccalaureate degrees. This is about half of the feasible goal set for 1960 plus. This is a little more than just one-third of the feasible goal for 1970.

The professional nurse traineeship program established under the Health Amendments Act of 1956 provided financial assistance to nurses preparing for positions in teaching, supervision, and administration. It is due to expire June 30, 1964; section 821 of H.R. 10042 proposes its extension for 5 more years. During the first years of the program established in 1936, 9,029 nurses were awarded traineeships. Although this legislation increased the number of nurses with graduate degrees, the need is still great. Taking into account that the Surgeon General's Consultant Group on Nursing considered 100,000 nurses holding advanced degrees the ideal, the ANA sees the Group's feasible goal of 25,000 by 1970 as the very minimum required for adequate health services.

The responsibilities of those who serve in positions in teaching, supervision, and administration in nursing are such as to require advanced preparation at least at the master's level. Sound programs of nursing education cannot be developed without qualified teachers. Quality nursing service cannot be provided for the people of this country unless we have sufficient numbers of well-prepared supervisors and administrators. The continuing shortages are both quantitative and qualitative and will not be resolved without Federal assistance to nurses seeking advanced preparation.

In all nursing education programs, the faculty should hold graduate degrees. It is at this level of study that the prospective teacher learns about methods of teaching, testing and evaluating, and acquires the necessary clinical and scientific knowledge in her subject area. Therefore, it is startling to consider the preparation of those presently teaching in all types of schools of nursing. Only 38 percent of current fulltime faculty members in senior and junior colleges, in hospitals and in practical nursing schools, have graduate degrees.

In your testimony, you have the figures showing the distribution of the faculty and preparation of faculty in collegiate schools and practical nursing schools.

Our present dilemma and the often heard criticism of inadequate nursing care is directly related to insufficient supply and inadequately prepared nurse teachers. Obviously, it is impossible for our schools to prepare nurses to give the quality of nursing care society needs and expects when such a large number who are in the position to mold future practitioners have no education beyond basic nursing preparation. This can be compared to a high school graduate teaching high school mathematics or science courses.

In addition to our concerns about the quality of faculty in schools of nursing, we face the further problem of shortage of personnel to fill these positions. There are 1,740 vacancies in full-time budgeted faculty positions in all schools preparing nursing practitioners. Therefore, we urge immediate congressional action to extend the traineeship program so that the preparation of nurse teachers can continue without interruption.

The quality of nursing practice is improved or deterred by the organizational framework in which the nurse practitioner functions. Effective nursing service administration and supervision fosters a safe, efficient, and therapeutic level of nursing care. Such administration and supervision is dependent upon familiarity with a body of knowledge based on sound principles that can be applied in nursing service situations.

I will skip the statement there because it refers to the figures on the bottom of the page. In the interest of time, I will leave that to your

reference.

There is also a shortage of personnel to fill positions in administration and supervision. A 1962 spot check of non-Federal general hospitals shows that 13.4 percent of full-time budgeted positions for directors and assistant directors and 15 percent of supervisory positions

are vacant.

If we are to raise the level of education of nurses functioning in the critical areas of supervision and administration and fill the vacancies which still persist, it is imperative that the Congress continue the professional nurse traineeship program it initiated in 1956.

H.R. 10042 (sec. 821 (a)) also provides that the traineeship program be expanded to include financial grants for assistance to nurses seeking preparation as clinical specialists. The nurse clinician is a master practitioner. She may, for example, be a nurse midwife, a psychiatric nurse, the expert in cardiopulmonary nursing, or in the care of the chronically ill. To become such a practitioner in so broad a field as nursing requires concentrated study at the graduate level in the selected area. Once prepared, this nurse uses her specialist's com

petence in providing direct care to patients needing expert nursing. She collaborates with the physician in planning and providing patient care to patients needing expert nursing, and works with and teaches other nursing personnel during the provision of nursing care and treatment. She may teach in schools of nursing and in programs of continuing education. She conducts and participates in clinical research. Highly qualified expert nurses to practice in specialized areas of nursing offer an opportunity to improve the quality of care. At the present time, there are no Federal funds available for the training of nurse clinicians except in the field of psychiatric nursing. ANA strongly supports expansion of the traineeship program to increase the number of specialized clinical practitioners.

When the professional nurse traineeship program was extended in 1959, provision was made for awarding short-term traineeships to nurses unable to engage in full-time study. Ten thousand one hundred and eighty-four nurses benefited under this part of the program. While we do not consider that the short-term program is a substitute for the educational experience obtained through full-time study it has, considering its limitations, met a need.

With over 47,000 nurses engaged in teaching, supervision, and administration without the minimum preparation required, a variety of programs are needed to supplement their basic education. We support the continuance of the short-term traineeship program if it does not infringe on the long-term program and believe Federal funds for courses should go only to institutions and agencies conducting high quality programs.

To achieve the goal of 25,000 nurses with advanced degrees and to double the number holding baccalaureate degrees by 1970 requires assistance to basic collegiate nursing education programs along with the assistance to graduate education offered through the traineeship program. The baccalaureate degree is becoming a requirement for an increasing number of positions in nursing. Also, it is from the pool of nurses graduated from baccalaureate programs that future teachers, supervisors, and administrators will come.

To accommodate increasing numbers of students, collegiate schools of nursing must expand their facilities. When this committee was considering the health professions educational assistance bill in 1962 and 1963, it received considerable information from the collegiate schools about the need for additional classrooms, laboratories, libraries, and offices.

As colleges and universities undertake building expansion programs they tend to give priority to the overall service rather than to the needs of smaller professional schools unless these schools can secure special funds to help defray costs. This observation is true in both the private nonprofit school and in the publicly supported college.

Congress has already recognized the need in the Health Education Assistance Act. Nursing is included in this act but it is my understanding that if this current legislation under consideration is passed. nursing would be deleted from that program. It is my understanding that nursing has been given low priority for funds for construction under the particular act.

Therefore, we think it is imperative that legislation be provided to give assistance for the expansion of collegiate facilities as well as developing new schools at collegiate level.

Moreover, the cost of a nursing education program to the college or university is greater than many other types of programs. One laboratory for the nursing student is the clinical setting-hospital, public health agency clinic-and in these settings her laboratory experiences are with human beings. Because the welfare of patients cannot be jeopardized, a higher ratio of teachers to pupils is required. Because of this, more funds must be allocated for faculty salaries in the nursing department or school than in many other divisions of the educational institution.

The Surgeon General's Consultant Group on Nursing has recommended that the number of graduates from collegiate schools of nursing be doubled by 1970. Graduations presently total around 4,000 a year. With present facilities, accredited schools can accommodate an increase in enrollment of only 11 percent, or approximately 2,400 students.

Therefore, I think you can see the urgent need for increasing the facilities available to collegiate programs.

Even if this increase were realized, there would need to be an additional 3,500 admissions to baccalaureate programs to reach the 1970 feasible goal.

H.R. 10042 in section 801 (A) (1) authorizes $35 million for construction of facilities for collegiate schools of nursing. The American Nurses' Association believes this assistance to schools would help them increase their enrollment and any expansion of the educational facility would be a step toward reaching the feasible goal set up by the Consultant Group on Nursing.

However, the Congress should recognize that only 10 percent of nurses practicing today hold baccalaureate degrees. The potential increase in enrollments made possible with added facilities will raise this to only 18 percent. We cite this to underscore the serious situation that exists and the tremendous task ahead if the real need is to be met. The need will not be met without sustained and generous support from the Federal Government.

Very little public or private financial assistance is available to nursing students in basic programs. A recent survey conducted by the ANA shows that in only 13 States have the legislatures appropriated funds for scholarships for nursing students. The total appropriated in these 13 States is less than $1 million. Also, the awards are generally small and not realistic in terms of the cost of nursing education. In only two States is the upper limit $1,000; in the others, the range is from $100 to $600 a year.

The Committee on Careers of the National League for Nursing maintains a list of sources of scholarship aid throughout the country but does not have information on the total funds available. However, it has evidence of need and demand. For example, the 1959-62 national foundation scholarship program made available a total of 407 awards. Of these, 5,269 were fully qualified for admission to the schools and yet fewer than 8 percent could get assistance from this source.