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We are aware of the related need for maintaining and expanding our present supply of professional nurses and nursing aides. We do not believe, however, that Federal assistance can be as productive in the recruitment or training of these two categories of nursing personnel.

In the case of professional nurses, it is doubtful whether Federal assistance could add significantly to the energetic recruitment campaigns now being conducted by nursing and hospital associations. Enrollment figures for professional nursing schools indicate that the proportion of high-school graduates interested in nursing as a career has not varied significantly in the last decade. Therefore, except for recruitment programs for special emergency needs-such as the cadet nurse program in World War II-we should not rely on Federal recruitment programs or training inducements to increase the supply of professional nurses.

In the case of nursing aides, there is no evidence of any general shortage of recruits. Furthermore, since nursing aides are trained on the job, without preemployment schooling, no specialized training programs or facilities are necessary. The principal requirement is nurse personnel on the hospital staff qualified in on-the-job training techniques. Through the efforts of State vocational education agencies, supplemented by instructor training programs sponsored by national nursing organizations, very gratifying progress along these lines has been made in the last few years.

THE TRAINING OF PRACTICAL NURSES

With respect to practical nurses, however, the situation is considerably different. This difference results from a marked change in the qualifications and duties of the practical nurse that has come about in the last decade. In the past, the term "practical nurse" was commonly applied to an unlicensed group of workers-not clearly identifiable-with widely varying skills and experience. Today, largely as the result of laws enacted during the last decade, 46 States have established licensing requirements for practical nurses. These laws provide that, as of specified dates in the near future, new licenses will be issued only to applicants who meet statutory training requirements.

The typical training program for practical nurses covers a 1-year periodincluding 3 months of classroom and laboratory instruction and 9 months of supervised experience with patients in a hospital. The instructional staff of the school, composed principally of professional nurses, provides both the classroom teaching and the supervision of practice in the hospital.

These recent developments in the licensure and training of practical nurses have a twofold significance from the standpoint of the supply and utilization of nursing personnel.

First, the requirement of formal preparatory training as a basis for licensure enhances the value of the practical nurse as a member of the nursing team. Her basic training qualifies her to perform many skilled nursing services which would otherwise require the time of a professional nurse. Thus, an increase in the number of trained practical nurses offers great promise in relieving total shortages of nursing personnel.

Second, the very training requirement that adds to the competence of practical nurses is also the principal factor limiting increases in the supply of this type of nonprofessional nurse. From now on, increased supply can be achieved only through expanded training programs.

It is essential, therefore, that we review the capacity and limitations of our existing practical nurse training institutions and programs.

Some 400 training schools or programs are now in operation. About two-thirds of these are operated by public vocational education agencies, in cooperation with nearby public or private hospitals. In addition, there are some 150 practical nurse schools operated by other agencies-usually large hospitals.

The number of these schools or training programs may give a somewhat misleading impression of their total training capacity. In fact, these 400 programs combined graduated only about 7,000 students last year-an average of approximately 17 graduates per program.

These graduates are in great demand. Typically, there are 3 or 4 offers of employment for every graduate. There is a particular need for more trained practical nurses in chronic disease hospitals and nursing homes. In view of the increasing national need for such facilities-which we discussed with your committee in connection with last year's extension of the hospital survey and construction program-this particular demand for practical nurses is of nationwide significance.

Another limitation is the fact that training programs are not available in many parts of the country. For example, 1 State has no schools in operation, and 6 States have only 1 school.

This factor of distribution or location of training opportunities has a special significance in practical nurse training. Most of the students interested in such training are mature women, usually in their thirties, with family and other community ties. As a consequence, they are not a mobile group. They will enroll for training only when it can be obtained nearby. After their training is completed they usually accept employment in their home communities-often in the hospital where they obtain their supervised experience. To assure increased enrollment and an adequate distribution of trained personnel we must therefore give particular attention to the establishment of training programs in additional communities.

To summarize, Mr. Chairman, we have focused our proposal for increasing the nursing supply on the expansion of practical nurse training programs for the following reasons:

(1) The basic training of the practical nurse makes her the key nonprofessional worker-the one who can do most to release professional nurses for duties requir ing advanced skills.

(2) There is a general shortage of trained practical nurses.

(3) These shortages can be overcome only by expanding enrollment capacities and by establishing new training programs in communities which do not have them now.

Title III of S. 886 would establish a program designed to meet these needs for additional trained practical nurses.

PRINCIPAL PROVISIONS OF TITLE III

The program proposed in title III is essentially an extension-with new emphasis of the existing Federal-State program of vocational education.

It will require little new administrative structure, either in the Federal Government or in the States. Every State now has a vocational education agency with a staff skilled in the administration of training programs which combine preemployment instruction with supervised experience. Almost all of these State agencies have had some experience in the training of practical nurses.

The administration of the program by a single State agency assures the widest and most equitable distribution of training funds. It also offers assurance that the training will be of high quality and will be geared to State licensure requirements for practical nurses.

Specifically, title III would authorize a 5-year program of earmarked grants to the States for projects which would extend or improve their activities in the vocational training of practical nurses.

Appropriations of $2 million would be authorized for this purpose for the first year of the program, $3 million for the second year, and $4 million for each of the remaining 3 years. These grant funds would supplement any existing grant funds now being used by the States for the training of practical nurses.

Funds appropriated for such grants would be alloted among the States on the basis of their respective populations. The minimum grant to any State would be $7,500.

For the first 2 years of the program the matching provisions of title III would require at least 1 State dollar for every 3 Federal-grant dollars. For the remaining 3 years, dollar-for-dollar matching would be required—as in the existing vocational education grant programs. These matching provisions are designed to stimulate an immediate expansion of practical nurse training programs, and yet to assure sufficient State participation to provide a basis for later consolidation of this categorical program into the general State program.

State expenditures under the program would be made in accordance with an approved State plan. Most of the State plan conditions specified in section 303 are based upon provisions relating to existing programs. The only new feature is the requirement that "the individual supervising the functions of the State board under the plan shall be a registered nurse or shall have the consultative services of a registered professional nurse available to him ***" The number of these plan conditions has been kept to a minimum, and their terms will permit maximum flexibility in State operations.

The program would be administered at the Federal level by the Commissioner of Education. In practice, of course, there would be close cooperation between the Office of Education and the Public Health Service-both being constituent units of the Department of Health, Education, and Welfare.

We believe that this intensive emphasis on practical nurse training for the next 5 years will result in a substantial expansion of existing training programs and in a continuing increase in the supply of trained practical nurses. According to our best estimates, it should increase the number of graduates from public vocational training programs from the present level of 5,000 per year to approximately 15,000 per year by the end of the 5-year period. By that time, we believe that practical nurse training will be so well established and developed in all States that categorical aid may no longer be required.

I should now like to ask Mr. James H. Pearson, Director of the Division of Vocational Education in the Office of Education, to present some additional charts relating to the training and employment of practical nurses and showing how title III would help meet current shortages.

Mr. Pearson.

Third chart: Practical nurse training proposal

This chart summarizes the major provisions of title III of the proposed bill. The purpose is to extend and improve the practical nurse training program as developed on a limited basis by State boards for vocational education.

The bill proposes to make grants to the States on a matching basis, providing for 75 percent of the costs to be paid from Federal funds the first 2 years, and dollar for dollar matching the next 3. The bill proposes an appropriation of $2 million the first year, $3 million the second year, and $4 million for the next 3 successive years. This program would be operated in accord with the established pattern in vocational education.

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Fourth chart: Practical nurse employment

Practical nurses are employed in the occupational field for which specialized training was provided. Sixty percent of the practical nurses trained in the Vocational education program are employed in general hospitals, usually where they were trained; 10 percent are employed in homes; 6 percent are employed in chronic hospitals and nursing homes; 24 percent are employed in other places, for example, in doctors' offices, industrial plants, and other establishments.

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Fifth chart: Practical nurse training as a part of the vocational educational program

Vocational education programs as a Federal-State cooperative activity are developed as a result of funds made available under the provisions of the SmithHughes Act of 1917 and the George-Barden Act of 1946.

The training that is provided in the States is designed to fit persons for useful employment in four occupational fields: agriculture, distributive occupations, home economics, and trades and industry. It meets the needs of persons preparing for or already employed in occupations for which specialized training is essential. Also, the program is designed to meet occupational demands for trained workers.

Practical nursing is an example of specialized training that meets the needs of the worker and the occupation. In recognition of such a need, practical nurse training was initiated about 10 years ago as a part of the vocational education program. More specifically, it is a part of the trade and industrial education program. During the past decade much "know-how" with respect to administration, supervision, teacher training, and teaching in both the classroom and at the hospital has been developed. The program has been highly successful. However, because practical nurse training has had to compete for funds with established trade and industrial training programs, the growth of this comparatively new program has not kept pace with increasing demands.

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Sixth chart: A community gets a practical nurse program

A community gets a practical nurse training program by making a request for a program to the State board for vocational education-the board responsible for the Federal-State cooperative program of vocational education. The State board has a State plan which has been approved by the Commissioner of Education. The State has received funds for the program.

After the application is approved, the courses are organized and operated by the local school authorities. They receive funds to assist in meeting the costs of the program. Students complete the training program and become employed as practical nurses.

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