On good authority, much of this apprehension is unfounded. According to Dr. Mountin,' there never has been a true surplus of nurses. He estimates that approximately 485,600 full-time graduate nurses will be needed to serve the country's probable postwar population of 138 million; and that by the end of 1946, after allowing for withdrawals, probably not more than 300,000 nurses will be engaged in active practice. In spite of the war-acceleratted program of nursing education, the number of available nurses will thus fall far short of the estimated need.

When the war ends, doubtless many nurses overseas will remain abroad and help in the postwar rehabilitation programs of foreign public health departments. A greatly increased demand for public health nurses is anticipated in this country also. The public health field will, therefore, afford jobs for a large number of nurses-perhaps twice as many as are now engaged in this type of work.2 "A better and wider distribution of graduate nurses" is anticipated in other fields of service. Also, private duty nursing in hospitals will probably be replaced to a great extent by general staff nursing service. "We may expect for the registered nurse greater economic security than in the past.'

Another widening field for nurses, as well as service to the public, is in fulltime employment of nurses with prepayment organizations furnishing hospital and medical care. Hospitalization plans in general are increasing their benefits to members and will, perhaps, include special nursing care in hospitals. Prepayment medical care organizations which have employed visiting nurses speak highly of the value of their services. It seems probable that had it not been for the wartime shortage of nurses, many more of these organizations would have utilized their services.

The nursing profession has had a long-standing interest in prepayment medical care plans--both as prospective members of such plans and as workers in the health field. As far back as 1917, American Nurses Association committees were studying health insurance and its possible effect upon the profession. In 1936, the American Nurses Association and the National Organization for Public Health Nursing united their activities in this field and formed the joint committee of the American Nurses Association and National Organization for Public Health Nursing to study health insurance and its implications for nurses. 1941, this joint committee made a detailed study of health-insurance plans, with special emphasis on provisions for special duty nursing. The general conclusions of the study were summarized as follows:

In

"Routine nursing service by the general staff in a hospital is the usual nursing care at present provided to subscribers of prepayment plans for medical care and hospitalization. Services of special private duty nurses in the hospitals are provided by a few associations if the physiican in charge of a patient deems such service necessary."

In the same year, a statement on health insurance prepared by the joint committee and approved by the boards of directors of the American Nurses Association and the National Organization of Public Health Nursing declared that nursing service was a necessary part of any comprehensive medical-care program.

Two years later, the joint committee pointed out that a plan including special nursing care might be set up on a sound actuarial basis, but that the necessary additional cost might prevent general acceptance of such service. In the committee's opinion, a war period might not be the most propitious time to attempt an experiment including special nursing care, but nurses should familiarize themselves with the plans providing care for the sick.

CURRENT EXPERIMENTATION

Today the nursing organizations are more interested in action than in continued study. The Joint Committee of the American Nurses Association and National Organization Public Health Nursing on prepayment plans for health services has replaced the joint committee to study health insurance and its implications for nursing. Principles of a suggested program in which nursing

1 Mountin, Joseph W.: Suggestions to Nurses on Postwar Adjustments, American Journal of Nursing, vol. 44, p. 321 (April), 1944.

2 Bryan, Leah Blaisdell: Problems in Public Health Nursing Education, Public Health Nursing, vol. 36. p. 448 (September), 1944.

Folendorf, Gertrude R.: What of Nursing in 1950?, Modern Hospitals, vol. 61, p. 67 (September), 1943.

services may be added to existing health or hospital or medical insurance plats have been approved. The program would provide all types of nursing service when it is most needed; that is, special private nursing service in the hospital or in the home for a serious condition or for illness requiring continuous nursing care and a visiting nurse service in the home for a condition or illness requiring part-time skilled nursing care. The services proposed for inclusion in the contract are as follows for each individual covered: A maximum of 12 visits of 1 hour each in the home by a visiting nurse, and 9 periods of 8 hours each of special private duty nursing service in the hospital or home. The organization would pay $1.25 for each visit by a visiting nurse, and $5 for each 8-hour period of special private duty service. The total expense of these two services should not exceed $60 per year for each individual. The cost of such service is estimated at approximately 40 cents a month for each individual subscriber and 90 cents a month for each family.

Some consideration is being given to the suggestion that the subscribers pay for the first nursing visit in the home and for the first three periods of special nursing service, after which the organization would pay the cost up to the $6 maximum. It is recognized that some procedure must be established to limit the prenaid nursing service to the medical requirements rather than the wish of the patient.

SURVEY OF PREPAYMENT MEDICAL CARE ORGANIZATIONS

A recent report indicates the services provided and the medical personnel affiliated with more than 200 prepayment medical care plans in the United States and a few in Canada. The following paragraphs summarize data cotained in this report and in the agreements between the organizations and their subscribers, with particular reference to the number of nurses associated with prepayment organizations, types of nursing services provided, persons eligitie for care, and the influence of hospital ownership and the provision of care to workmen's compensation cases on the type of nursing service furnished.

About 3,300 000 persons were eligible for medical care under the 214 plas surveyed in the United States during the spring and summer of 1943 (table 1). More than half the plans are associated with industry, and their membership accounts for almost half the total. Although a few of the industrial plans are financed entirely by the employer, about half are financed jointly by the employer and employee and, in nearly half, the entire cost is borne by the employees. The other types of plans which have a substantial membership are medical society plans and private group clinics.

NURSES ASSOCIATED WITH THE ORGANIZATIONS

In 1943, more than 2,000 full-time registered graduate nurses were emel, vod by 117 of the 214 organizations included in the study. Some of the 2.000 pres gave care in hospitals owned by the organization, a few gave visiting nure service, but in general the duties of these nurses corresponded to those of nures employed by physicians in private practice. In addition to the 2,000 nurses e ployed full time, there were many who provided special nursing service for the medical care organizations when the need arose From the information ava> able, it is impossible to estimate the equivalent full-time nursing service for nished by this group; 13 organizations which provided special nursing ser❤ employed no full-time nurses, while a few organizations called upon certa nurses so frequently that the services of these nurses were equivalent to p time employment; other organizations used the nurses' registries and did not call certain nurses exclusively.

A striking difference among plans appears in the extent to which nures are members of the staff. Almost all private group clinics and all industria' pts financed entirely by employer have staff nurses.

Randall, Marian G.: Nursing in Health Service Jlans, Public Health Nursing, val “ p. 314 (Julv), 1944. Prepayment Medical Care Organizations, Social Security Barl Bureau of Research and Statistics, Memorandum No. 55, ed. 2, June 1944. AvailaNoe from the Government Printing Office, 30 cents each.

5 Klem, Margaret C.

TABLE 1.-Number of persons eligible for medical care in prepayment medical care organizations, number of such organizations, number and percent employing nurses, and number of nurses employed, by type of organization

! Industrial plans are those organized within an industrial establishment, whether initiated by the employers, the employees, or joint employer-employee action. Medical society plans are those organized by State of county medical societies on a State-wide or county basis. Private group clinics are organizations owned and managed by one or more physicians who as a rule do not also engage in private practice. Consumer-sponsored plans are organized by subscribers with services provided by salaried medical personnelGovernmental plans are, as a rule, compulsory plans established for the employees of specified governmental units.

21 organization also employs 1 part-time nurse. 'Employs 8 part-time nurses.

In plans financed entirely by employers the medical care given is of two types: (1) first aid, general health supervision, and care for industrial accidents or injuries, and (2) medical care for nonindustrial cases limited in some plans to the employees and in others extended to their dependents also. In some plans financed jointly by the employer and employee, and in some financed entirely by the employee, care to industrial and nonindustrial cases is provided by the same medical staff. A variety of financial arrangements exists through which the employer pays for the care given to industrial cases. The nurses employed by industry to give only first aid, general health supervision, or care to industrial accidents and injuries are not included in the 1,471 nurses associated with industrial plans (table 1). No industrial organization was included in the study unless medical care was provided for nonindustrial accidents, injuries, and illnesses. Almost all of the 1,471 nurses represented in the study are included in the 13,805 nurses estimated to be employed by industry, but some whose duties are in no way connected with industrial cases are not represented in the estimate.

Medical society plans, as a rule, have no nurses associated with them since, in most instances, medical service is provided by physicians in individual practice. In only two instances do medical society plans employ nurses; one of these plans, in the State of Washington, employs eight part-time nurses to work in first-aid rooms during the canning season; the other, in California, provides care to residents of war-housing projects. In this second plan, part of the medical service is provided through clinics in housing projects.

Regional differences.-In which section of the country are nurses most likely to find employment in prepayment medical care organizations? Plans in the Pacific region included in the survey employed more than half the nurses associated with prepayment medical care organizations; the membership in this

Nursing Needs and Nursing Resources, American Journal of Nursing, vol. 44, pp. 10441045 (November), 1944.

region accounted for slightly less than one-third of the total. The east north central region, which had about 25 percent of the total membership, report the second largest number of nurses, 12 percent of the total. The midde A ́lantic region, with one-tenth of the total membership, accounted for less th one-twentieth of the employed nurses. New England reported less than 1 pr cent of the nurses and less than 1 percent of the total membership. The p centage of nurses employed by prepayment organizations in the other regis was from 4 to 8 percent of the total.

The region in which the largest number of nurses were employed (the Pacif also accounted for the largest proportion of members and of physicians associat with prepayment medical care organizations; in the other eight census reg there was no exact correlation between membership and the number of physicals and nurses associated with prepayment plans.

Nurses employed in relation to membership.-During a year a nurse employee' by a prepayment medical care organization may come in contact with about 1.2 › persons if all persons eligible for care come to the office, clinic, or hospital dur the period. In spite of the fact that some of the nurses employed by the organ zations give care only in the office or clinic and others do visiting or specia! d5'; nursing, there is a fairly consistent ratio between the number of nurses emp'ogand the number of persons eligible for care.8

In industrial plans financed entirely by the employer a nurse is employed fr every 1,237 persons eligible for care. Among plans in which the employees J." the entire cost of the medical program, more nurses are employed in relation membership-1 for each 760 persons to be served. The other type of plan in wh. : the policies are determined by members, namely, consumer-sponsored plans (exɛ -sive of those financed in part by the Department of Agriculture) also employ relatively large number of nurses, 1 for each 857 persons eligible for care. T following table indicates the average number of persons per nurse in var... types of organizations:

Consumer sponsored (excluding plans financed by Department of Agriculture).

1.

1.17

SPECIAL DUTY AND VISITING NURSE SERVICE

Special information on the provision or exclusion of special duty and value nurse service was obtained from the cooperating organizations. As Indrected table 2, prepayment plans differ widely in their policies toward the provis such services. Of the 214 plans studied, 81 reported that they furnished spe. or visiting nurse service, or both. Special nursing, usually limited to care hospital, is available to members of 50 organizations; visiting nurse servs available to members of 43.

Most industrial organizations financed entirely by the employer provide special or visiting nurse service, or both; 10 of the total of 13 such organizat provided visiting nurse service; 6 provided special duty service. Among the T in which the employees bear the entire cost of the medical program, the~ * types of service are less common; of the 47 plans of this type, only 17 r. either visiting nurse or special duty service (or both) available to their mer but, as will be shown later, these 17 had 69 percent of the total membership employee-financed plans. Among the 53 organizations financed jointly by employer and the employee, 19 provided special duty, visiting nurse care, or b = types of service; 13 plans provided special duty service and 8 visiting nurse serv

Klem, Margaret C.: Voluntary Medical Insurance Plans, Their Extent and Limitată ** Medical Care, vol. 4 (November), 1944.

Some organizations, which give care to persons not belonging to the plan as well as " members, have been excluded from this particular analysis.

TABLE 2.--Number of prepayment medical care organnizations providing special and visiting nurse service, by type of organization and type of nursing service provided

1 Special nursing and visiting nurse service provided to approximately 40,000 persons covered in 1 contract with an organization having a total membership of 80,000; the other 40,000 were eligible for special nursing service only.

Of the 24 private group clinics studied, one-third reported the provision of special duty service. No plans of this type provided visiting nurse care.

The plans developed by the War Food Administration and cooperating agencies for seasonal farm workers, domestic and foreign, recruited, transported, housed, or placed by these agencies, all provided visiting nurse service but no special duty service.

PERSONS ELIGIBLE FOR PREPAID SPECIAL AND VISITING NURSE SERVICE

The membership of the prepayment medical care organizations which provide special or visiting nurse service gives an indication of the extent to which these services are available on a prepayment basis. One-half of the membership of prepayment organizations is entitled to receive either special nursing service or visiting nursing service, or both. More than one-third of the 3,300,000 persons eligible for medical care in prepayment organizations could get special duty nursing either in the hospital or in the home upon the recommendation of the attending physician or the association's medical director. Six of every 10 persons belonging to plans financed entirely by employees and 7 of 10 belonging to plans financed jointly by the employer and employee, were entitled to such service through their prepayment plan. In plans financed solely by employers, slightly more than 1 out of 10 members could get special nursing service. In the medical society plans of Washington and Oregon, three-fourths of the membership was entitled to special nursing care under the prepayment contract. Except for private group clinics, in which about one-third of the subscribers and their dependents could get special nursing service, the other organizations, as a rule, made no provision for such care. It is of interest that the 1,200,000 persons who could receive special duty nursing under the prepayment plan were all members of plans providing relatively complete medical care.

The visiting nurse has not been used to any great extent by prepayment medical care organizations. In all, only 610,000, or about 18 percent of the members of all types of plans, can get visiting nurse care under their prepayment contracts. This group is made up almost entirely of persons belonging to governmental plans

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