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Secretary HOBBY. Senator Hill, I certainly would not comment on the $30 million because, as you well remember, the detailed report we sent to you I think both last year and this year, research organizations, universities and otherwise were called upon to say what they needed. Of course, the figure, as you recall very well, was a figure far in excess of the $30 million that is in this bill.

Chairman HILL. I think you have applications on file now, do you not, for at least $150 million?

Secretary HOBBY. I do not know whether we have that many applications.

Chairman HILL. At least $150 million.

Secretary HOBBY. It was the result of a survey, as I recall, Senator Hill. It was $150 million or $155 million. Whether they are applicants, I do not know. I would have to ask Dr. Scheele.

Dr. SCHEELE. They are mostly indications that they would like to build and could use this amount of money. There are some in the form of applications. I do not know the breakdown between the two types.

Chairman HILL. If the opportunity were given they would be asking for these funds.

We had some very, very interesting testimony here a couple of weeks ago. We had, I think, some of the outstanding research men in cancer and mental health and heart and multiple sclerosis; in fact, we held some of our hearings out at the National Institute of Health. Surely, those men who are in this work, devoting their lives to it, made very compelling cases for the need, not only for funds such as they are getting today which we might call the maintenance and operation funds, but also for the need for some aid for physical facilities. They give some very graphic and challenging illustrations of particular instances where there was very great need today. Secretary HOBBY. I am sure that you had competent witnesses. In commenting upon this bill, we tried to comment as objectively as we could. I would not say to you or to anyone-I do not think anyone around this table would-that more money could not be used for research construction. It gets always to be a problem of where you put it. And my sympathy goes out to the Appropriations Committee this year as to how you allocate it.

Chairman HILL. Speaking of the Appropriations Committee, I happen to be a member, as you know. After all, you make the authorization and then the Appropriations Committee determines each year and the particular facts and circumstances of the year as to what the appropriations shall be. Is that not true?

Secretary HOBBY. Yes, sir. I never quite understood. Maybe this is a good time for me to find out. Is the authorization always a target, a limit, Senator? And then each year you come back with what the Appropriations Committee allocates for that year? Is that the ceiling or below?

Chairman HILL. The authorization would be a ceiling, insofar as the Appropriations Committee is concerned. That is, they could not make an appropriation larger than the authorization. If they did, such an appropriation would be subject to a point of order, and if the point of order was made the entire appropriation would go out of the bill. But anywhere under this ceiling the Appropriations Committee has the authority to bring in an item. The thing that I am tre

mendously interested in is the testimony before this committee by so many of these outstanding men and women that shows there is the need for some aid for physical facilities for research.

Secretary HOBBY. Mr. Chairman, may I ask both of you and of the Surgeon General a question?

It was our belief, and I believe that we said that the bill added little to the authority that the Surgeon General already has to make grants. Is that true?

Dr. SCHEELE. That is correct. We do have authority in the present statute to make grants for construction. As the committee knows, we did make such grants over a 2-year period for cancer and heart-research facilities. So we could make grants now if we had funds to make them with.

Chairman HILL. You could make the grants now?

Dr. SCHEELE. That is right. There are some differences, however, in the approach in this bill and in our present authority.

Our present authority would authorize appropriations on a categorical basis-cancer, heart, and other diseases in other words, to the disease categories. In your proposal this is lumped so that it is for facilities for health research into the crippling and killing diseases. Chairman HILL. And carries such provisions as matching?

Dr. SCHEELE. We do not have matching now.

Secretary HOBBY. The law does not now require matching.

Dr. SCHEELE. S. 849 limits the authority of the Surgeon General to make a final decision in that it places the final determination in the Council. It limits the Surgeon General.

Chairman HILL. I notice that Mr. Perkins is looking at his watch. You advised us this morning that you had a very important engagement this afternoon.

Secretary HOBBY. I could not be sorrier.

Chairman HILL. We are sorry, too. Let me ask just one other question.

Do you not think that the environment, atmosphere and physical facilities in which a man works contribute a lot, particularly from the standpoint of bringing young men into this research work? As we know, there is mightly little compensation in research work.

Secretary HOBBY. I would just to have to say, as a generalized statement, that I think that physical environment contributes greatly to recruiting any person to any profession.

Chairman HILL. That would apply to research as well as anything else, is that right and correct?

Secretary HOBBY. Yes.

Chairman HILL. Are there any further questions? That is, questions of a special nature.

Senator BENDER. I have a couple of special questions.

Is it not a fact that section 433 (a) gives you authority for construction in addition to cancer and heart, without any additional authorization?

Dr. SCHEELE. Yes, sir; that is correct.

Senator BENDER. And merely to reemphasize your testimony. Section 405 of the Public Health Service Act states that appropriations to carry out the purposes of title IV of the Public Health Service Act, the National Cancer Institute title shall be available for the acquisi

tion of land or the erection of buildings only if so specified. It seems to me that that language is specific authority for construction grants for cancer research purposes, provided that the relating appropriations act making funds available specifically states that they may be used for the acquisition of land for the erection of buildings. Is that a correct impression?

Dr. SCHEELE. Yes, sir; that is correct. As a matter of fact, you recall to my mind, as you read that, the fact that our present authority also includes the giving of grants for the acquisition of land, whereas the new proposal does not include land.

Chairman HILL. We deeply appreciate your being with us.
Secretary HOBBY. I appreciate this very much. Thank you.

Chairman HILL. Dr. Scheele, I want to ask one other question. I was not sure that I got your answer. The bill that we are now considering provides for the matching of these funds and provides other provisions that you do not now have in the law, is that not true? Dr. SCHEELE. That is correct.

Chairman HILL. In other words, what you really have in the law now, as I recall, is just one phrase, put in parentheses?

Dr. SCHEELE. Yes.

Chairman HILL. Whereas in line with the thinking of the Senate Appropriations Committee, the bill that we are now considering spells out these procedures and provides for matching and things of that kind, is that not true?

Dr. SCHEELE. Yes, sir; that is true.

(The statement of the Department of Health, Education, and Welfare in its entirety follows:)

STATEMENT BY OVETA CULP HOBBY, SECRETARY OF HEALTH, EDUCATION, AND WELFARE, IN SUPPORT OF TITLE III OF S. 886

Mr. Chairman and members of the committee, the two practical nurse training proposals under consideration by your committee today, S. 929 and title III of S. 886, are similar in their objectives and approach. They differ, however, in a number of particulars.

Our prepared statement is confined to the objectives and provisions of title III of S. 886, which embodies one of the President's recommendations for legislation to alleviate shortages of health personnel. We will, however, indicate briefly the relationship between this proposal and a related nurse training proposal contained in title IV of the bill.

Our report on S. 929, which has already been submitted to your committee, summarizes the views of our Department on this alternative proposal.

INCREASING DEMAND FOR NURSING SERVICES

The need for more nursing personnel is serious. Shortages of hospital staff nurses are particularly acute. In a recent survey covering two-thirds of the Nation's 7,000 hospitals, the American Hospital Association found there were 23,000 vacancies for professional staff nurses. In addition, there are shortages of nursing personnel in clinics, doctors' offices, industrial plants, and public health agencies.

The present imbalance between supply and demand is due primarily to the remarkable increases in demands for nursing services that have developed during the last two decades. There are three principal factors responsible for this increasing demand.

The first is the changes that are taking place in the size and composition of our population. Our total population is increasing at an accelerated rate. This in itself increases the demand for nursing services. Furthermore, the acceleration in birth rates and the increasing proportion of persons in the older age groups have enlarged the two groups with the greatest need for nursing care-the very young and the aged.

Second, all groups in the population are making increased demands on the services of hospitals and other health facilities. This is due partly to the growth and extension of these facilities and partly to increased utilization by our people of the skills and facilities of modern medicine.

The third factor affecting the demand for nursing services is the spectacular advance in medical knowledge. As such knowledge expands and new therapeutic techniques are developed, the responsibilitis of both the doctor and the nurse become more complex. The nurse is now a far more important member of the medical team than she ever was before. As a result of these developments, more nursing services are required per patient.

All these factors affecting demand represent continuing trends. There is every reason to believe that these trends will be accelerated in the future.

SUPPLY OF NURSING PERSONNEL

While some progress is being made, the supply of nursing personnel has not kept pace with the rapid growth in demand for nursing services.

Our supply of nursing personnel is composed of two general categories: first, professional nurses and, second, nonprofessional nursing personnel-which includes both practical nurses and nursing aides.

Professional nurses, who are also known as registered nurses, constitute the central core of skilled nursing personnel. Their professional preparation consists of at least 3 years of training, including both academic studies and practice in a hospital. They are the staff nurses in hospitals, clinics, and public health agencies. They are also the principal providers of private nursing care both in the hospital and in private homes. From their ranks are selected the supervisors and administrators of nursing services, as well as the instructional staffs of nursing schools.

At the present time there are about 390,000 professional nurses active in all fields. The total number of active professional nurses is greater today than it ever has been, and the number of graduates from nursing schools is steadily increasing. These increases, however, are barely keeping pace with population growth; they are not adequate to meet the growing per capita demand for nursing services.

Practical nurses are the most highly skilled group in the nonprofessional nurse category. Their training now generally covers a year of preparatory schooling and experience. They can therefore relieve hospital staff nurses of many duties. They are also employed to care for patients in chronic disease hospitals, in nursing homes, and in private homes when the patient's condition does not require professional nursing skills.

There are now more than 100,000 licensed practical nurses, and their number has been steadily increasing. Several factors, however, limit the increase in supply of this type of nonprofessional nursing personnel. I shall discuss these factors in some detail later in my statement.

Nursing aides are usually recruited directly into hospital service without preparatory training. They receive brief training on the job by the professional nursing staff. Because of their limited training they are usually employed only in hospitals and nursing homes where adequate supervision can be provided.

The total number of nursing aides has increased greatly in recent years. About 260,000 are now employed in hospitals. This is the only category of nursing personnel in which the supply appears to be reasonably adequate.

I should now like to ask Mrs. Lucile Leone, Chief Nurse Officer of the Public Health Service, to illustrate some of these points relating to supply and demand in nursing services.

Mrs. Leone.

First chart: Nursing personnel in general hospitals, 1954

This chart shows one large portion of the Nation's nursing personnel-those employed in our 5,000 general hospitals and their distribution among types of jobs. It does not include nursing personnel in chronic disease hospitals, nursing homes, and other fields of employment.

There are 392,000 nursing personnel in general hospitals-201,000 professional nurses and 191,000 nonprofessional nursing personnel.

The professional nurses are in four kinds of jobs: 8,000 are administrators of the entire nursing service in a hospital; 19,000 are supervisors in charge of nursing service in one department of a hospital--the surgical department, the obstetrics department, etc.; 31,000 are head nurses in charge of one ward of a

hospital with from 20 to 50 patients; 143,000 are staff nurses who care for patients on those wards.

The 191,000 nonprofessional nursing personnel are divided into 41,000 practical nurses who assist the professional staff in the care of patients and 150,000 nursing aides who perform simpler tasks.

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Second chart: Demand for nursing services has doubled

The second chart explains some of the reasons for growth in demands for nursing services.

In 1930, 6,321,861 people were admitted to general hospitals. This amounted to 5 per each 100 of our population.

In 1954, 18,692,812 people, or 11 per 100 population, were admitted to general hospitals. This does not mean that more people were sick last year but that more people used health facilities.

In 1954, the average patient stayed in the hospital for a shorter average period of time than in 1930. This fact in itself means increased demand for service, since most patients remained in the hospital only for the acute phases of their illness, and were quickly followed by others who were acutely ill.

In 1930, medical and health practices required 1 professional nurse for each 6 patients; in 1954, 2 for each 6. Actually, more than 2 nurses were needed for these 6 patients, but their positions were vacant. The advance in medical science has increased the per capita demand for nursing service.

Three factors then increase demands: the growing population, the increased utilization of hospitals and other health facilities, and the advance in medical and therapeutic techniques which require more nurses per patient.

In view of existing shortages and of increasing demands for nursing services, it is apparent that action is needed along two general lines: First, we must increase the total number of nursing personnel; second, we must utilize all available nursing personnel more effectively.

APPROACHES TO INCREASING THE NURSE SUPPLY

Title III is directed toward increasing the supply of nursing personnel through the training of additional practical nurses. We believe that this approach offers the greatest promise of immediate and long-term results. We also believe it is the approach through which the Federal Government can most effectively participate.

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