Miss DENSFORD. That is right.

Senator DONNELL. I quote:

The expansion of health insurance plans

There was no mention in either this resolution or any other resolulution of your House of Delegates of compulsory nursing service or compulsory health insurance? That is right, is it not?

Miss DENSFORD. There was no action taken regarding any specific type of legislation.

Senator DONNELL. And particularly no action taken either affirmng or to the contrary with respect to compulsory health insurance? I am right, am I not, in that?

Miss DENSFORD. Neither compulsory nor voluntary. Neither for nor against.

Senator DONNELL. Neither for nor against compulsory insurance? Miss DENSFORD. That is right.

Senator DONNELL. Now, Miss Densford, today under our prevailing practice, if a person becomes ill, who is the person that decides on nursing service, whether or not it should be given, and the extent of that nursing service; does the doctor ordinarily make that decision? Miss DENSFORD. In most instances.

Senator DONNELL. In most instances. Yes, ma'am.

Now, I observe in this bill, S. 1606, at page 58, paragraph 210 (b), it s provided that

The Surgeon General, having regard for the adequacy of available personnel, may, after consultation with the Advisory Council and with the approval of the Administrator, determine for any calendar year or part thereof that general iental, special dental, or home-nursing benefit shall have such restricted content is the Surgeon General may determine

o that under this bill, instead of the local physician, the physician at home, determining it, the decision rests with the Surgeon General. You are familiar with that provision, are you not?

Miss DENSFORD. Yes.

Senator DONNELL. And then I call your attention further on the ame page to this language, quoting at lines 21 and following:

With respect to home-nursing benefit, restriction of content may be effected by imitation of the service to part-time care on an hourly or visit basis, by limitation of the types of cases for which such benefit shall be available, by limitation of he maximum amount of service per case, or otherwise, as may be practical and ecessary. Any restriction on the content of general dental, special dental, or ome-nursing benefit shall be reduced or withdrawn as rapidly as the Surgeon eneral finds practical.

I call your attention, Miss Densford, to the fact that as distinuished from our present-day practice, where in large part the physiian attending the patient decides the content of nursing services o be rendered, this act would undertake to vest that authority, under he provision I have read, in the Surgeon General of the United States. You are familiar with this provision, are you not?

Miss DENSFORD. I have read the bill and I am familiar with it. Senator DONNELL. Yes, ma'am. Let me ask you this: Under this ill as pointed out earlier in my questioning to you, while it is proided in 203 (a) that the Surgeon General shall perform the duties mposed upon him by the act, it is distinctly stated that it shall be under the supervision and direction of the Federal Security Adinistrator."

I want to ask for your personal opinion, if you are willing to ge it: Do you regard it as advisable that in the first place such extensive powers as I have indicated with respect to nursing benefits shall: transferred from the attending physician up to the Surgeon Gener. or his deputy, and in the second place, if it is advisable that it te vested in him, or if it seems most practical to do that, is it advisank. in your judgment, that he shall, in turn, in the administration a:: determination of those questions as to what home-nursing benefit sh. . be given, shall be under the supervision and direction of a man w.. does not have to be a physician; namely, the Federal Security Administrator?

Do you regard that as advisable?

Miss DENSFORD. Mr. Chairman, the Senator has posed some very pertinent questions. It rather seems to me, however, if it meets wit your approval, that one can hardly express a personal opinion regar:ing those. The association which I represent, and that is the occasion for my being here

Senator DONNELL. Yes, ma'am.

Miss DENSFORD. Has not taken action either in favor of su policy or in opposition to it.

Senator DONNELL. I see.

Yes.

Miss DENSFORD. And it would not seem that I could officially speas Senator DONNELL. That is all right, Miss Densford; I can app ciate your position on that matter. That is all, Miss Densford.

Senator PEPPER. Miss Densford, Senator Donnell has called y attention, on page 58 of the pending bill, to the authority of the A. ministrator to limit in a practical way the quantity and volume home nursing service. Now, you realize that the effect of that is guage is a matter of interpretation. But you understand that : two provisions are set into the context of a bill, which is trying make medical, dental to a degree, and nursing care as fully as it " be provided, available to as many people in the United States as psible, and that there is a limit to the number of nurses who are ava able for home services, and if you had a limited number of nurses a you had nursing care by some kind of financial arrangement avs able to everyone who needed it, that it might be necessary for t Administrator to limit, according to some general principles, aft consultation with his advisory council, to limit the number of nu-serving in the home to certain kinds of cases, certain types of pati maybe certain sorts of illness, maybe have certain general limitats of time. You can understand why the law would give authority to Administrator to impose such practical limitations as that, can i

not?

Miss DENSFORD. The comments are pertinent also to this situat Senator PEPPER. Very well.

Miss DENSFORD. And the bill and our consideration of it by t American Nurses Association.

Senator PEPPER. I quite understand your desire to confine y testimony as the house of delegates did, to a statement that there need for greater medical care than the people are now getting, a a need for more home nursing service than the people are now g ting, and you are leaving it up to such as the Senators here and oth Members of Congress to determine the manner in which that med care shall be provided. Is that not correct?

Miss DENSFORD. At present.

Senator PEPPER. Do you recall that during the years 1932 and 1938 there were many nursing schools in the country closed down because of unemployment among nurses in practice.

Miss DENSFORD. Mr. Chairman, there would be many factors that would contribute to that situation, and as I have said, the president of the National League of Nursing Education, which is concerned primarily with the education of nurses and with the development of schools and the guidance of program of preparation, both for graduate nurses and undergraduates, will appear before you, and I would believe that you might prefer having an answer to the questions having to do with the educational program come from her.

Senator PEPPER. Very well. Are you aware of the fact that of all the private plans that are in effect now by the voluntary method to give insurance coverage, that of the people who are covered by these voluntary insurance plans, only 44.2 percent are eligible to receive home-nursing service?

Miss DENSFORD. I had not known the exact percentage. I am glad to have that figure. Thank you.

Senator PEPPER. Thank you so much.

Senator DONNELL. Pardon me. By your response to Senator Pepper's question as to leaving it up to the Congress to determine the method of extension of nursing care, I take it you are not expressing an opinion either for or against compulsory health insurance. Am I right in that?

Miss DENSFORD. That is right; either in favor of or opposed to. Senator PEPPER. There is one other set of figures I would like to call your attention to, which this committee disclosed in connection with an examination of the Fair Labor Standards Act: that of the people in all communities of the country, of the people who are on relief, only 1.2 percent of them received private nursing care, and 11.8 received any visiting nursing care at all.

In the income group of less than $1,000, 2.9 percent received any private nursing care, and 6 percent receiving visiting nursing care. Between $1,000 and $2,000, 3.9 percent received private nursing care, 6 percent received visiting nursing care.

Between $2,000 and $3,000 annual income, 6.4 percent private nursing care, and 4.6 percent visiting nursing care.

From $3,000 to $4,000 annual income, 9.2 percent received private nursing care, and 3.3 percent received visiting nursing care.

Of $5,000 or more, 16.6 percent received private nursing care, and 2.7 percent received visiting nursing care.

Now, they tend to indicate that at the present time and under the present system that people who get nursing care, especially private nursing care, which I consider of the more desirable character, that it is the people with the higher income that get the private nursing care rather than the people in the lower income group.

Miss DENSFORD. There is a correlation between the care and the provisions.

Senator PEPPER. All right. Thank you so much.

Senator DONNELL. May I ask you, Senator Pepper, to read into the record, please, the date at which these statistics you read applied and existed.

Senator PEPPER (reading):

Source: Britten, R. H., Collins, S. D., and Fitzgerald, J. S., United Sa Public Health Service, Public Health Reports, Washington, D. C., volume 2 No. 11, March 15, 1940, pages 444-470. (Based on data from the National Heat Survey 1935-36.)

Senator DONNELL. I wanted to make it clear that that was 1935data on which these figures were based.

Senator PEPPER. Yes. That is correct.

Miss DENSFORD. Mr. Chairman, I wonder if I might have the priv lege of submitting the figures for which you asked and have the included in your report.

Senator PEPPER. We would be very pleased to have them. Thank you.

(The figures and information referred to are as follows:)

STATEMENT OF RUTH SLEEPER, PRESIDENT, NATIONAL LEAGUE OF NURSING EDUCATION ON S. 1606 BEFORE THE SENATE COMMITTEE ON EDUCATION AND LABJE

In principle the concerns of the National League of Nursing Education are the expressed in S. 1606-the promotion of health, the prevention of disease, and the proper care of all persons of all ages when ill. In actual functioning the Nation. League of Nursing Education is a nursing education for nursing service associa tion. Its major activities have included:

1. Development and promotion of standards for all types of nursing eduation.

2. Operation of a program of accreditation for undergraduate professiona schools of nursing.

3. Operation of a testing service for nursing education and nursing serves counseling.

4. Promotion of a consultation service on all phases of nursing education 5. Studies related to nursing education and nursing service.

The National League of Nursing Education has 8,950 members with representa tion in 47 States, District of Columbia, Alaska, Hawaii, and Puerto Rico.

It is desired to make clear the specific interests of the organization I represent in the legislation proposed in S. 16C6. These interests are concerned with t technical and educational aspects of the bill as they relate to the training ! qualified nursing personnel. The National League of Nursing Education therm fore asks the privilege of presenting, in relation to such training, certain facsi fundamental importance in the administration of a national-health program as outlined in S. 1606 in the event that this bill becomes law.

There are, at present, approximately 1,300 State-accredited professional sebe's of nursing in 47 States and the District of Columbia. In relatively few States a training in either tuberculosis nursing or venereal disease nursing required! recommended in order to take the State licensing examinations to practice as ! registered professional nurse. Twenty-two percent only (286) of the 1.300 seb»»** offer tuberculosis nursing experience. This means that of the appror" 32,000 students who will be graduated from schoo's of nursing in 1943, only ab ** 7,000 will have had any experience in the nursing care of tuberculous patients The number of professional nurses needed in tuberculosis hospitals and str toria in order to provide a good quality of nursing care was recently estimated 2 14,500. Although an approximate 7.000 nurses who have had tuberculosis tra ing will be graduated during 1946, it cannot be expected that even half of them will enter the hospital tuberculosis field.

The discrepancy between tuberculosis nursing needs and the number of nurses who have had instruction and training in that field is due to a multiplicity of causes. A major cause is the lack of the proper facilities, instructional and phys cal, which are essential to teach good tuberculosis nursing and to safeguard students' health.

1 Unnublished studv, National League of Nursing Education, 1946.

Estimate made (March 1946) by Department of Studies, National League of Nursin Education, and Esta McNett, Assistant Director, Nurse Specialist in Tuberculosis Narsing Division, Veterans' Administration, Washington, D. C.

Less specific information is available on the needs and resources for venereal disease nursing. It is safe to say that the number of nurses who have had training in the care of venereal-disease patients will be considerably smaller than the number who have had training in tuberculosis nursing.

In maternity nursing and nursing of children every professional graduate nurse will have had some kind of training, since such training is a requirement for admission to the State licensing examinations. But unfortunately in many Stateaccredited schools of nursing, both the maternity experience and the experience in the care of children are too narrow in scope to prepare nurses to fulfill the nursing responsibilities contained in S. 1606. Specifically, in a large number of schools, the training in maternity nursing is limited to the hospitalization period of mothers and does not include prenatal nursing or post partum nursing after the mother leaves the hospital, which are important health services in the maternity cycle. Evidence in support of this statement is the fact that 48 percent, or 624, of the 1,300 schools report that their students receive outpatient experience, the field which large provides prenatal and post partum experience."

The limitations of the training for the care of children are not unlike those of the training for maternity nursing. In too many undergraduate schools the nursing of children is narrowed to the hospitalization period. As indicated in the preceding paragraph, only 48 percent of the schools provide outpatient experience, and it is in the outpatient clinics where students have the opportunity to participate in well-baby and preschool clinics. Only two-fifths of the schools give their students training in acute communicable disease nursing, an important phase in the preparation for the care of children. The number of schools which provide experience in the nursing care of either premature infants or crippled children is not known. It is probable that the number is small for both services. A sound training in the nursing of children should provide for an understanding of their emotional, mental, and spiritual needs as well as the knowledge and skills required for their physical care during illness.

The reason for the inadequate professional undergraduate training in many schools of nursing is deep rooted. Fundamentally, it is economic. There are relatively few schools of nursing controlled by educational institutions (less than 50). The remaining 1,250 are hospital-owned schools. As such, they provide service for the hospital, and in providing this service, it is by no means always possible to prepare the student for the broad nursing functions which are implicit in the national-health program of S. 1606. Student service and its economic relationship to the hospital are discussed in exhibit 1.

Professional graduate nurses, realizing the inadequacies of their undergraduate nursing education, have sought and are seeking to enlarge and enrich it by postgraduate nursing work. But the programs which provide special kinds of clinical training for graduate nurses are exceedingly limited, one reason being the lack of qualified instructional personnel and another the lack of proper field facilities. Moreover, the expense of operating these programs is prohibitive without financial aid from sources outside the institution.

The picture I have presented to you on nursing education, both undergraduate and graduate, reveals the major weaknesses of the system. There are undergraduate schools of nursing operated on a high educational level, but they are too few. More programs soundly conceived are needed for graduate nurses.

The estimated 14,500 professional nurses needed to staff tuberculosis hospitals and sanatoria in the United States include 2.189 for supervisory positions (p. 1). In December 1945, similar data were compiled for maternity nursing and nursing in the care of children. It was estimated that approximately 7,000 professional nurses are needed to instruct students in maternity nursing and to supervise the care of maternity patients; that 3,500 professional nurses are needed for teaching and supervising the nursing care of children. There are indications that the shortages that were reported in supervisory and teaching positions during the war are continuing-though exactly how the supply of personnel, in numbers and in quality, d'ffers from the needs is not known and is difficult to ascertain.

During the school year 1945-46, enrollment of professional graduate nurses reported for advanced or supplementary work in clinical nursing specialties was as follows: In tuberculosis nursing, 5 institutions reported an enrollment of 36 students; in venereal-disease nursing, 1 institution reported 7 students; in ma

3 Ninonblished study. National League of Nursing Education. 1946.

* Estimates made (December 1945) by department of studies. National League of Nursing Education, collaborating with the Nursing Unit, Children's Bureau, U. S. Department of Labor, Washington, D. C.