Senator HILL. Miss Arnstein, we welcome you back before the committee. We will be glad to have you proceed in your own way.

Miss ARNSTEIN. Mr. Chairman, I have a statement which I would like to submit for the record and I will give you some highlights of that statement.

Senator HILL. All right. Proceed in your own way.

Miss ARNSTEIN. Thank you, Mr. Chairman. I will submit this

statement.

Senator HILL. It will be inserted in the record at this point. (The statement referred to follows:)

STATEMENT BY CHIEF, DIVISION OF NURSING, ON NURSING SERVICES, AND RESOURCES, PUBLIC HEALTH SERVICE

Mr. Chairman and members of the committee, funds appropriated for the nursing services and resources activity enable us to operate a program of planning and promotion for good nursing care for all the people who need to receive it through community health and medical services.

The 1962 increase in training funds appropriated by the Congress is being used to support training in rehabilitation nursing for about 500 nurses. A grant for several short courses to one collegiate nursing school enabled it to establish an entirely new program in rehabilitation nursing. The program holds great potential for the future training of much larger numbers of nurse leaders in this field of nursing. We will soon complete our negotiations with one institution and two universities on contracts for rehabilitation training for staff public health nurses to give direct care to patients.

Our greatest need still is to extend nursing care for the sick of all ages from the hospital to the home. Close to a third of the Nation's incorporated cities of 25,000 and over still lack home nursing services.

We continue to help the States and local health agencies develop the kind of home nursing programs needed by the communities they are to serve. Some entirely new community programs have been started with our assistance.

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Even before Public Law 87-395, the Community Health Services and Facilities Act of 1961, passed, we recognized that health departments would have to charge fees for home nursing service. The need for a new way to determine how much the services cost became urgent with the added stimulus of Public Law 87-395. Existing cost methods for nursing care had proved too diffcult for smaller agencies to use. Three months after Public Law 87-395 passed, the Division had developed a method which has already been tested and found valuable as a basis for setting fees for home nursing care. It is being published as a guide and is almost ready for a wide distribution to health departments across the country. A method to measure the effectiveness of public health nursing has resulted from a study and project only recently completed by the Division. Field tests conducted in six community nursing agencies and health departments showed that almost two-thirds of the patients' nursing needs had been met at the end of about 3 months under home nursing care. These tests also turned up a large number of illnesses and diseases which had not previously been detected or treated, to bear out anew the public health nurse's key role in casefinding. The method has been enthusiastically received by those who have used it for evaluation or for supervision. We plan to encourage wide use of this new tool through publication of a report and through consultation.

We have made a beginning in the study to determine more precisely what kinds and how much nursing care is being given to elderly ill. In 1963 we will follow through with a thorough study of care provided in hospitals, nursing homes, and outside facilities.

An experimental field center has long been needed for studies which cannot be carried out except in a "laboratory" setting or one which makes daily, close relationships possible with cooperating institutions and agencies. In 1962, we were able to make a small beginning on field center studies. For 1963, we are requesting an increase of $77,000 to enable us to start important studies and demonstrations of new methods of teaching more efficiently; and also a study to determine standards for quality of nursing care.

Nurse activity study methods developed by the Division continue to demonstrate their value in improving patient care. Use of these methods helps hospital administrators cope with problems arising from the still short supply of trained nursing personnel.

Three university hospitals in the South cooperated with the Division this year to conduct studies of nursing in their outpatient departments. This afforded us an opportunity to further develop this study method so that its use can be promoted on a wider scale.

Our study of inactive nurses has been expanded to include at least a dozen States. Each section of the country will be represented in this study to determine the present and future work potential we can expect from this reservoir of trained nurses. Progress also was made in 1962 on the study to determine characteristics and work patterns of the many thousands of nurses employed parttime by hospitals.

Our continuing analyses of nursing needs show very clearly that there is a need for stepped-up recruitment, for assistance to schools of nursing, and for assistance to students. The Surgeon General's Consultant Group on Nursing is considering all these needs, but the group has not yet made its recommendations for dealing with the problems. Meanwhile, even conservative estimates of the need for professional nurses are formidably high. Hospitals report about 23,000 professional nurse positions as vacant; we need more than twice that many public health nurses for preventive and therapeutic services in people's homes.

Close to 100 educational institutions now participate in the professional nurse traineeship program by using traineeship grant funds for awards to professional nurses for long-term training. In addition, the need for short-term training has been well demonstrated in the 211⁄2 years since we initiated this program. Short courses have been invaluable for nurse teachers and leaders who are unable to leave their jobs for the time needed to obtain long-term training. or for a full academic year. In the first 2 years of operation, grants were awarded for 192 short courses, and about 6,500 nurses took advantage of this opportunity to obtain additional instruction. A survey we made of participants in two such courses revealed that at least three-fourths of these nurses were away from their jobs for the the first time for training which lasted as long as 5 consecutive days. We are requesting an increase of $721,000 which will enable us to provide both long-term and short-term traineeships for an additional 1,700 nurses.

As

directed by the Congress, the traineeship program will be reevaluated in the summer of 1963, and the necessary planning will be done and data gathered this

year.

A more comprehensive approach to career development for nursing in the Public Health Service can no longer be delayed if we are to adequately meet our responsibilities to provide leadership in entirely new public health activities as well as in expansions of existing programs. As long as we cannot even cope with personnel losses due to attrition, we cannot hope to handle the intensified demands for highly trained and well-qualified public health nurses in community health and in environmental health. In order to meet increasing demands for nursing care in the home, we also should recruit and train some nurses for assignment to State and local programs to strengthen services. And arrangements such as contracts, need to be made to provide preparation for nurses for service in long-term illness, rehabilitation, and care of the elderly. An increase of $120,900 is requested for this purpose, and for a comprehensive analysis and evaluation of nurses supply and distribution, which has not been carried out in the Nation since 1951.

Mr. Chairman, I shall be glad to answer any questions you and the other committee members may have about this program or the budget request.

COMBINED NURSING SERVICES

Miss ARNSTEIN. This was the first full year of our new Division which combined the public health nursing activities and the nursing resources and hospital activities of the two former divisions. This has made possible a better planning of continuity of care between the hospital, the clinic, and the person who may be sick at home.

It has been an eventful year in other ways, too, in that we have embarked on the first broad national study of nursing which has been undertaken by the Surgeon General's consultant group, as you no doubt know. The chairman of the group is Dr. Alvin Eurich, who is vice president of the Fund for the Advancement of Education, and the group is expected to submit its recommendations to the Surgeon General by July of this year.

In the meanwhile, it is quite clear that the present program of the Division should be continued and that certain parts of it need to be expanded. This past year, along with many other Divisions in the Bureau, we have focused our attention on the extension of home health services and particularly on the programs of nursing care of the sick at home. We no longer call it bedside care, if you may notice, because we expect the patient to be up, in line with the latest medical practice. Senator HILL. You are carrying this forward in the spirit of the Community Health Services and Facilities Act?

LACK OF SERVICES IN SMALLER TOWNS

Miss ARNSTEIN. Yes, sir. We have made a study of a number of communities with a population of 25,000 and over to find out how many have nursing care services which traditionally have been supplied by Visiting Nurses Associations and which are supported by the Community Chest and other private funds. This type of association exists in all the large cities, in cities of over 1 million, but as we get to the smaller cities we find fewer and fewer have these services; and in the rural areas, except in about two States of New England, there are almost no such associations. We are therefore looking to the health departments in our smaller cities to expand their services to include care of the sick at home and this Community Health Services and

Facilities Act provides some help to them in doing this. We are beginning to see a growth in this function of the Health Department.

STATES INCREASING SERVICES IN COUNTIES

There are several States that have made an all-out effort, and have embarked on establishing these services in all of their counties. Most of the States are beginning in a smaller way and are trying to do it in two or three counties to start with in order to study what it means in terms of expense and personnel and so on before they try it on a statewide basis.

Senator HILL. How many States are carrying the program forward in all their counties?

Miss ARNSTEIN. No State yet has it in every county.

Senator HILL. What States have a program which looks as though, within a very short period of time, they will bring every county within the program?

STATES SHOWING MOST PROGRESS

Miss ARNSTEIN. Michigan is the closest to it. Colorado is starting a program of promotion, but is a long way from having it all over the State. There are several other States that are thinking in these terms. Florida already has it in some 7 counties and has plans for extending it to 26 additional counties. Now, this is about half of the State of Florida, a little over half. We do not have all the information on this, and it changes, actually from week to week. Each week we hear of a new place that is beginning such a service.

Senator HILL. But your information coming in each week shows progress; does it not?

Miss ARNSTEIN. Yes; it does. I have a little fact sheet that came in last week from the State of Colorado which the State is sending out to all of its local communities, giving them information. It is a very simple form, as you can see.

Senator HILL. I think we might put that in the record following your testimony.

Miss ARNSTEIN. Very well.

Senator HILL. It is a good example of a State trying to move forward; is that not right?

Miss ARNSTEIN. Yes sir, it is. I have here another leaflet. The cover shows a picture of an elderly woman who is sick at home and it says, "What is missing in this picture?" And on the inside of the leaflet they have the picture of a nurse taking care of this woman, showing that the nurse is what is missing.

RETRAINING OF NURSES AND RECRUIT TRAINING

Whenever these services are offered for the first time, it is necessary to retrain the nurses who are on the staff and also to train new recruits because our knowledge in the rehabilitation nursing field is so new that the person who graduated 5 years ago is not up to date. So we have, with the funds we received last year from the Congress helped to support three new training centers for public health nurses who are now on duty or being recruited to these counties in order to furnish these services.

Senator HILL. Where are they?

Miss ARNSTEIN. One is in California, one is in Florida, and one is in Massachusetts. We tried to distribute them around the country so that the nurses would not have far to travel in order to get to them. The increase in demand for this service of nursing care for the sick makes it important that our nursing services are used wisely, and we have developed a new method which has aroused a great deal of interest across the country. This is a method of assessing the results of public health nursing care, but this method has not yet been promoted across the country because we just finished the trials in six agencies.

SHORT RETRAINING PERIOD

In those agencies, it showed that approximately two-thirds of the patients' nursing needs were met within a 3-month period. It also showed that the nurse was a very important case finder. She suspected various conditions and referred the patients to physicians. They went to their physicians and the suspicions were confirmed in 22 of the 26 instances in one agency. I am just giving this as an example.

AGENCY FEE FOR NURSING CARE

The agencies who establish a nursing-care-of-the-sick program also establish a fee for nursing care of the sick. Many of these health departments have never charged fees before. They have to have some method for deciding what their fees should be. We have developed an easy cost method that they can use to determine the level of fees.

FIELD CENTER

We have established a field center, too. It is small but we anticipate that it will grow in years to come. This year we have been exploring possibilities with our own hospital in San Francisco for ways to improve patient care in the hospital. In the years to come we expect to work with agencies outside the hospital to find better methods than we now have to establish continuity of care.

AMOUNT REQUESTED

We are asking for an increase of $77,000 and eight positions for this activity next year.

The rapidly changing medical field which I referred to makes supervision and on-the-job training essential and our long-term traineeship program provides a thorough type of training for teachers, supervisors, and administrators.

We are asking for an increase of $400,000 this coming year both to increase the number of trainees and to meet the cost of rising tuitions. We are also requesting an increase of $300,000 to increase our shortterm traineeships which, as you know, are for the nurses who cannot leave their jobs for a full academic year but can go to workshops for 1 or 2 weeks.