receive training under these two measures is that of auxiliary hospital workers provided in Senate bill 929. The inclusion of these workers in this program is not only important to the hospitals, but also to over 20 millions of patients in hospitals each year.

I should like to point out that hospitals

Chairman HILL. Might I interrupt you there, Doctor. If it will not disturb you, I wish you would in just one sentence, perhaps, summarize the auxiliary hospital workers that you feel we need today.

Dr. WILSON. There are such people as nurse aides, nurse attendants, orderlies, technicians, dietary aids, and people of that category, Senator Hill.

Chairman HILL. Even medical librarians?

Dr. WILSON. Medical librarians.

Chairman HILL. Thank you, sir.

Dr. WILSON. I should like to say that hospitals have usually paid a stipend to practical-nurse students during their clinical training period so that the overall cost of their training to them should be moderate. To the extent that both measures will help to increase the supply of practical nurses they have identified a very substantail health need and are presenting an effective and desirable method of meeting such need. Both are action programs. Both attempt to meet these needs now. While all society benefits from the services provided by nurses-hospitals are bearing most of the cost of nurse training. This should not necessarily be the case. The very considerable costs involved in organizing hospital training programs is worthy of thoughtful consideration. Salaries of directors, supervisors, teachers, teacher-trainers, together with the costs of administration, equipment, supplies, and the like are very substantial. These factors have definite applications on the costs that patients must pay for hospital care. Despite the fact that nursing education is a direct charge on hospitals and adds to the hospital costs which have meant higher costs to the patients, there are many users of the nursing services who bear little, if any, of the costs related to their training and education.

Section 203 (c) of Senate bill 929 makes possible payments to public or nonprofit hospitals exempt from income tax under the provision of the Internal Revenue Code of 1954 for the purpose of meeting costs incurred by them in providing supervised training in hospitals for practical nurses or auxiliary hospital personnel trainees. This provision gives recognition to the trend toward increasing emphasis on in-service training programs for practical nurses and auxiliary hospital workers. This provision is also important since it will pay the costs incurred by hospitals for providing opportunities to practical nurses or auxiliary hospital personnel for their supervised training in hospitals.

Senator LEHMAN. May I ask a question, Doctor?

Dr. WILSON. Yes, Senator Lehman.

Senator LEHMAN. I know, of course, many of the great hospitals of the country operate nurses' training schools. Do many of them operate schools or classes for auxiliary hospital workers, for training?

Dr. WILSON. Most of them are training on-the-job programs at present, Senator.

Senator LEHMAN. On the job?

Dr. WILSON. Yes. In providing for an immediate attack on the problems in this area, this provision will also benefit hospital patients by making more workers available. There is no such comparable provision in Senate bill 886.

Under the provisions of these respective measures by which Federal funds are allocated to the States, the formula contained in Senate. bill 929, section 204, in our opinion, more equitably distributes funds than does the equivalent provision of Senate bill 886. The former is more closely related to the financial ability of the States to raise money and consequently to existing unmet health needs. Moreover, in this same section of Senate bill 929, as contrasted with the comparable provision of Senate bill 886 providing for starting partial Federal and State contributions, the initial impetus given to such program by a 100-percent Federal contribution will cause it to be started immediately. In so doing it should sooner develop additional health personnel to help meet pressing health needs. We believe that the facts and circumstances underlying demands for health services which can be met by more workers of the categories contemplated by these bills warrants an initial 100-percent contribution to speed the start of this program. There is not the same uncertainty of an immediate start to a program under Senate bill 886 with a lesser initial Federal contribution, since the States will have to raise the necessary matching funds, and the legislatures of many of the States may not be in session at the time such legislation would have been enacted.

Senate bill 929 also provides travel funds for students. There is no comparable provision in Senate bill 886. Since most practicalnurse students are mature women who have difficulty in financing their living costs during their training period, the provision in the former measure, at very little additional cost, should prove most helpful.

One additional distinction that exists between these two measures, upon which I shall comment, is that Senate bill 929 makes provision for an advisory council at the State level composed of 6 to 10 persons with a representative from the professional nurses, practical nurses, physicians, educators, hospital administrators, and consumers. This meaure, however, leaves it discretionary with the Commissioner of Education whether or not he should appoint an advisory council at the Federal level.

We believe that in this instance it is appropriate to vest such discretion in the Commissioner.

For the reasons that I have advanced in this statement, the American Hospital Association, while it supports both Senate bill 929 and title 3 of Senate bill 886, it believes that Senate bill 929 will more completely meet the problems in this important area of health care.

However, there is an amendment I should like to suggest to section 201 (b) of Senate bill 929 which defines the term "auxiliary hospital personnel." Such amendment would read as follows

Senator LEHMAN. What section is that?

Dr. WILSON. 201 (b) of 929:

The term "auxiliary hospital personnel" means persons working in hospitals under the general supervision and direction of graduate nurses and heads of departments and services.

End of definition.

By amending this provision in the manner I have suggested, it would make for greater flexibility in the administration of the program proposal in this legislation.

The State directors of vocational education would have greater latitude in developing programs for those workers for which there is the greatest need. -Specificity, I feel, may cause undue emphasis on the development of plans to cover all categories of workers mentioned, even though the demands for specific categories will not be equal. Thank you, sir.

(The prepared statement of Dr. Lucius R. Wilson follows:)

STATEMENT OF LUCIUS R. WILSON, M. D., CHAIRMAN, COUNCIL ON GOVERNMENT RELATIONS, AMERICAN HOSPITAL ASSOCIATION

The American Hospital Association welcomes the opportunity of presenting its views on S. 929 and title III of S. 886, which are receiving the attention and consideration of your committee. These measures, in the main, seek to cope with many complex and diffuse problems confronting the nursing profession and the hospitals of this Nation. It is to the specific proposals embodied in these measures that we address this statement.

Today in the United States there are approximately 800,000 professional nurses. Of these about 390,000 are actively engaged in the practice of their profession. Some 84,000 occupy key positions in the sense that they are the teachers of the many thousands of persons studying nursing and practical nursing, as well as the administrators and supervisors of nearly three-quarters of a million persons working in the Nation's hospitals and health agencies.

Hospital service is the primary field of nursing activity, with hospitals employing about 231,000 nurses: private duty, 74,000; physicians' offices, 35,200; public health, 25,300; industry, 14,000; school of nursing, 8,200; other, 1,900.

In 1953 it was estimated that there were in excess of 350,000 auxiliary workers in hopsitals, and perhaps approximately another 100,000 engaged elsewhere in other health service activities. Of these about 54,000 practical nurses were working in hospitals. In addition some 6,000 practical nursing students were receiving in-service training in hospitals.

Nurses are still in short supply. Demand is still outrunning the increasing supply. In recent years the major national nursing organizations have completed surveys showing very substantial shortages in almost every city and rural area. Hospital wards have been closed for lack of nurses to staff beds. Inability to get nurses has forced mental and tuberculosis hospitals to operate shorthanded. Additional numbers are needed by public health units and industrial health programs. Almost every conceivable health service actively requiring the services of nurses has unfilled vacancies.

Nurses, unfortunately, like other health personnel, are not distributed geographically in relation to the population. For example, in 1951, for each 100,000 people, the State of Connecticut had 4 times as many nurses as Arkansas. That same year in Massachusetts there was 1 graduate general duty nurse for each 3 patients in nongovernmental general hospitals; Oklahoma had 1 for every 8. Since 1951, close to 29,000 nurses have graduated annually from the schools of nursing. However, creditable estimates indicate that our health needs now require increases of 50,000 graduates annually. Increments related to our growth in population will also be needed with each succeeding year. Enrollment data from these schools indicate that their total number of graduates will not increase materially for another 5 years. This is brought about by the following circumstance: a larger proportion of girls between the ages of 17 and 19 are entering nursing than ever before (the proportion is higher than at any time except for the years 1943-45). But, because of the low birthrate in the depression years, the number of girls entering nursing school each year is not appreciably, if at all, greater. Thus, while there has been an appreciable improvement in the supply of nurses since the pre-World War II period when approximately 22,000 nurses were being graduated annually, in 1960 the ratio of nurses to the total population will most probably be much the same as it is today.

Social and economic factors also tend to offset gains made by increasing the total number of nurses actively engaged in their profession and the increasing number of annual graduates. Nurses now enjoy much shorter hours. A few

years ago graduate nurses working in hospitals averaged about 50 hours a week. Today the average workweek is about 40 hours and the trend in almost all labor fields is for even shorter workweeks.

With the tremendous advances which have been made by medical science in the last few decades, the complexity of developing high quality medical care has substantially increased. Teamwork has become more important, more of a necessity. Out of the recognized need for centering patient care the concept of a nursing team developed about 1948. By this concept a number of persons working as a group under the supervision of a professional nurse meet a variety of patient needs. As head of the team the professional nurse assigns duties to the other members commensurate with their abilities and the patients' requirements for

care.

Both patients and hospitals have benefited tremendously from the development and use of this nursing team concept. Patients have had many of their health needs not requiring the highly skilled services of professional nurses met by other members of the team. Hospitals have found that they can operate more efficiently and effectively with the coordinated and precision work of team action. Today practical nurses are a very vital part of this nursing team. While their early courses emphasized training for duty in homes, practical nurses are now being increasingly used by hospitals. In 1953, as we have previously mentioned, some 54,000 of them were working in hospitals. To a very considerable degree they have appreciably helped in meeting patients' demands for services. They have been instrumental in helping to bridge over the gap of such pressing health needs as those arising from the demands for more professional nurses.

Other categories of auxiliary hospital personnel are also important to and part of the nursing team. Recognition of the value of their services is obtained from the fact that such workers are being increasingly employed by hospitals. To the degree that they relieve nurses from duties not requiring their highly skilled training, these workers are helping to relieve nursing shortages.

The American Hospital Association, representing 5,300 of the Nation's hospitals and serving approximately 20 million patients a year, is vitally interested in the health of the American people. Our membership includes general hospitals, long-term hospitals, clinics, diagnostic, and other health-care facilities. In each of these, nurses are an integral part of the team that has proven necessary to provide the high quality health care that is the due of all American citizens. We have learned throughout the growth and development of our organization that the quality of hospital care rendered patients is directly related to the availability of adequate numbers of well trained personnel.

No organization within the United States is any more concerned with the problems confronting hospitals in caring for patients and with the urgent necessity of attracting more of our able young women into the nursing profession than is the American Hospital Association. It is with this background of deep, earnest interest that the American Hospital Association presents to you its views on the legislative measures before you.

I shall not, however, discuss all the provisions in both of these measures but will confine my testimony to those which I think are most pertinent to and have the greatest impact upon the hospitals of this Nation.

The American Hospital Association supports S. 929 and title III of S. 886. We believe in the philosophy underlying these measures. They recognize the principle that the role of the Federal Government should be to stimulate and encourage the building up of necessary health resources, not to control them. This should hold true whether such resources are physical facilities as in the Hospital Survey and Construction Act, or in programs for training more health personnel, as proposed in this legislation.

These measures deal with vocational education. Such programs are not untried and untested. They evolved from the fundamental idea that vocational education is a matter of national interest and essential to the national welfare. Experience has demonstrated time and again their value. Since 1917, with the passage of the Smith-Hughes Act, State and local public school systems with Federal funds matched with State or local funds, have conducted vocational education programs. Both measures make additional Federal funds available for such programs. S. 929, however, earmarks them for training of practical nurses and auxiliary hospital personnel and inservice training for directors, teachers, and supervisors. S. 886 for practical nurses, teachers, teacher-trainers, directors, and supervisors. The material difference of eligible persons who may receive training under these two measures is that of aux

iliary hospital workers provided in S. 929. The inclusion of these workers in this program is not only important to the hospitals, but also to over 20 million patients in hospitals each year.

I should like to point out that hospitals have usually paid a stipend to practical-nurse students during their clinical training period so that the overall cost of their training to them should be moderate. To the extent that both measures will help to increase the supply of practical nurses they have identified a very substantial health need and are presenting an effective and desirable method of meeting such need. Both are action programs. Both attempt to meet these needs now. While all society benefits from the services provided by nurses, hospitals are bearing most of the cost of nurse training. This should not necessarily be the case. The very considerable costs involved in organizing hospital training programs is worthy of thoughtful consideration. Salaries of directors, supervisors, teachers, teacher-trainers, together with the costs of administration, equipment, supplies, and the like are very substantial. These factors have definite implications on the costs that patients must pay for hospital care. Despite the fact that nursing education is a direct charge on hospitals and adds to hospital costs which have meant higher costs to patients, there are many users of the nursing services who bear little if any of the costs related to their training and education.

Section 203 (c) of S. 929 makes possible payments to public or nonprofit hospitals exempt from income tax under the provision of the Internal Revenue Code of 1954 for the purpose of meeting costs incurred by them in providing supervised training in hospitals for practical nurses or auxiliary hospital personnel trainees. This provision gives recognition to the trend toward increasing emphasis on inservice training programs for practical nurses and auxiliary hospital workers. This provision is also important since it will pay the costs incurred by hospitals for providing opportunities to practical nurses or auxiliary hospital personnel for their supervised training in hospitals. In providing for an immediate attack on the problems in this area, this provision will also benefit hospital patients by making more workers available. There is no such comparable provision in S. 886.

Under the provisions of these respective measures by which Federal funds are allotted to the States, the formula contained in S. 929, section 204, in our opinion, more equitably distributes funds than does the equivalent provision of S. 886. The former is more closely related to the financial ability of the States to raise money and consequently to existing unmet health needs. Moreover, in this same section of S. 929, as contrasted with the comparable provision of S. 886 providing for starting partial Federal and State contributions, the initial impetus given to such program by a 100-percent Federal contribution will cause it to be started immediately. In so doing it should sooner develop additional health personnel to help meet pressing health needs. We believe that the facts and circumstances underlying demands for health services which can be met by more workers of the categories contemplated by these bills warrant an initial 100percent contribution to speed the start of this program. There is not the same certainty of an immediate start to a program under S. 886 with a lesser initial Federal contribution, since the States will have to raise the necessary matching funds, and the legislators of many of the States may not be in session at the time such legislation would have been enacted.

S. 929 also provides travel funds for students. There is no comparable provision in S. 886. Since most practical-nurse students are mature women who have difficulty in financing their living costs during their training period, the provision in the former measure, at very little additional cost, should prove most helpful.

One additional distinction that exists between these two measures, upon which I shall comment, is that S. 929 makes provision for an advisory council at the State level composed of 6 to 10 persons with a representative from the professional nurses, practical nurses, physicians, educators, hospital administrators, and consumers. This measure, however, leaves it discretionary with the Commisioner of Education whether or not he should appoint an advisory council at the Federal level.

We believe that in this instance it is appropriate to vest such discretion in the Commissioner. Vocational education has had a relatively long and successful administration in this office. As a consequence, we see no cogent or compelling reasons to change its current method of operation. We would leave this provision as it is, permitting the Commisioner, if he chooses, to use an advisory council at the Federal level for the purposes contemplated in this measure.