Professional graduate nurses, realizing the inadequacies of their undergraduate nursing education in the care of children and maternity patients, have sought and are seeking to enlarge and enrich it by postgraduate nursing work. But the programs which provide special kinds of clinical training for graduate nurses are exceedingly limited, one reason being the lack of qualified instructional personnel, and another the lack of proper field facilities. Moreover, the expense of operating these programs is prohibitive without financial aid from sources outside the institution.

During the school year 1945-46, enrollment of professional graduate nurses reported for advanced or supplementary work in maternity nursing was 152 students in 13 institutions; in nursing in the care of children, 144 students in 13 institutions. It was recently estimated that approximately 7,000 professional nurses are needed to instruct students in maternity nursing and to supervise the care of maternity patients; that 3,500 professional nurses are needed for teaching and supervising the nursing care of children. There are indications that the shortages that were reported in supervisory and teaching positions during the war are continuing-though exactly how the supply of personnel, in numbers and in quality, differs from the needs is not known and is difficult to ascertain.

With your permission, I should now like to discuss methods for strengthening professional nursing standards in order that nursing may function most effectively in the administration of the proposed Maternal and Child Welfare Act. These methods involve the development and expansion of nursing education programs by the use of grant-in-aid funds for special educational research projects and scholarships, and by the utilization of national nursing organizations, educational and nursing service institutions, and agencies for these several purposes. Fundamental to the improvement in the training of students, both undergraduate and graduate, in maternity nursing and the nursing care of children are the extension and development of clinical practice fields and the securing of qualified administrative, instructional,and supervisory personnel.

Since the bill under consideration provides for the training of additional nursing personnel in order that such personnel be available for the more extensive health services for mothers and children, as proposed in the bill, the special studies which should be carried on are listed below. Some work has already been begun on all of these projects by the national professional nursing organizations; more should and would be done were the necessary funds available.

1. Survey of clinical facilities for maternity patients and children to determine their suitability as practice fields for training both undergraduate and graduate nursng personnel.

2. Curriculum studies related to the training of undergraduate nurses in the care of mothers and children and especially to the training designed for graduate nurses.

3. Intensive and comprehensive studies of nursing service for mothers and children, both as related to quality and quantity of nursing care.

4. Surveys basic to estimating the number of graduate nurses needed for maternity and child nursing in hospitals and other institutions, clinics, public health agencies, and nursing education programs-such surveys to be made in terms of different types of personnel.

Throughout the proposed Maternal and Child Welfare Act, reference is made to standards for training personnel. Such standards, we believe, should be secured direct from the appropriate professional nursing education organizations. If these organizations do not have the standards that are indicated, then it is urgently important that grants-in-aid be made to the appropriate professional organizations as well as to the appropriate educational institutions and nursing service agencies-Government and voluntary-in order that the necessary investigations may be undertaken.

The National League of Nursing Education believes that all scholarships should be arranged, insofar as possible, directly between the educational institution and the student who should meet the requirements of the institution."

Estimates made (December 1945) by department of studies, National League of Nursing Education, collaborating with the Nursing Unit, Children's Bureau, U. S. Department of Labor, Washington, D. C.

Find the Children! Prepared by the department of studies, National League of Nursing Education, collaborating with Ruth G. Taylor, Director of the Nursing Unit, Children's Bureau, U. S. Department of Labor, American Journal of Nursing, February 1946. See exhibit 1.

This principle has been approved by the National Nursing Council.

See exhibit 2.

In order to meet current as well as future Nation-wide service demands for qualified nursing personnel in maternal and child care, it is essential that in these fields:

1. Grants-in-aid be provided to selected institutions to improve clinical courses in undergraduate nursing education.

2. Grants-in-aid be provided to improve, expand, and develop new programs for graduate nurses who are preparing to become teachers or administrators in schools of nursing and administrators or supervisors of nursing services.

The league also believes that, in general, all grants-in-aid for special research projects in nursing education and nursing service to national professional organizations, educational institutions, and nursing service agencies should be granted through direct allocation to the institution or agency concerned and not through a State health department."

Since nurses are essential in large numbers to the operation of the provisions of the proposed Maternal and Child Welfare Act, it would be most important that:

1. Appropriate nurse representation be included in every proposed advisory council-Federal, State, and local.

2. Such nurses be proposed by the appropriate national, State, or local professional organizations.

3. Preparation of these nurses be such that each can interpret the needs for nursing service and nursing education, both undergraduate and graduate, in their respective fields.

4. Nursing regulations in the specific fields be safeguarded by providing that each nurse representative on a council have the advice and support of an advisory technical committee composed of nurses.

In conclusion, may I say again that the National League of Nursing Education is deeply concerned with the implications for nursing, both as they relate to the care given to mothers and children and the preparation of qualified nurses to give this care, should the bill under discussion become law.

EXHIBIT NO. 1

[Reprinted for the Children's Bureau, United States Department of Labor, from the American Journal of Nursing, vol. 46, No. 2, February 1946]

FIND THE CHILDREN

Prepared by the Department of Studies, National League of Nursing Education, collaborating with Ruth G. Taylor, Director of the Nursing Unit, Children's Bureau, United States Department of Labor

The movement for the conservation and promotion of child health and welfare has made long strides since the beginning of the century. Witness President Truman's recent message to Congress proposing a five-point national health program.

"Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health.

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"We should resolve now that the health of this Nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the Nations.'

Calling attention to the fact that 40,000,000 persons in the United States live in communities which still lack full-time public health services, the President called for expansion of existing cooperative health programs between the Federal and State Governments with the help of increased Federal funds. Expansion is especially important to prevent disease and to provide services for mothers and children.

Some of President Truman's proposals, especially those regarding the expansion of services for mothers and children and training of professional personnel, 6 This principle has been approved by the National Nursing Council. See exhibit 2.

1 Official White House press release. The complete text of the President's message may be found in H. Doc. 380, dated November 19, 1945, obtainable from the Superintendent of Documents, Washington 25, D. C.

embody the recommendations made by the National Commission on Children in Wartime in its recently issued report, Building the Future for Children and Youth. These recommendations represent the results of a year's intensive study of the services the country now offers its children. They point to a course of action which would, if followed for the next 10 years, insure to all children and youth the kind of care and protection they need and deserve.

As background information against which to study both President Truman's proposals and any legislative action that may take place, and also because of their importance in connection with our immediate problem of adequate training facilities for pediatric nursing, some of the Commission's proposals for expansion of maternal and child health services and training of professional personnel are here quoted.

"Nothing short of a Nation-wide effort supported by adequate Federal and State funds will make it possible to assure access to proper health services and medical care for all mothers in. childbirth, for all newborn infants, and for children during the preschool and school years and throughout adolescence. The combined efforts of State and local agencies, professional groups involved in rendering service, and citizens' groups will be needed to develop the program.

"As a Nation we have the knowledge and skills to do the job, but we have not made available adequate resources to train personnel, to provide equipment and facilities, and to place personnel where they are needed.

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"Federal legislative action is required now through extension of existing Federal-State grants-in-aid programs to enable State health agencies (1) to meet immediate needs of mothers and children and prepare for the postwar period and (2) to provide for progressive expansion after the war of the total broad program of maternal and child-health and crippled children's services until each State is able to assure the availability of these services to all mothers and children within the State.

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"In the expansion of health and medical services for mothers and children, provision must be made for constant improvement in the quality of care so that as soon as possible there will be available to all the best care we know how to give. This will require :

"1. Qualification standards for administrative and clinical personnel and for institutional services, and minimum requirements for care established by Federal and State agencies.

"2. Opportunity for graduate and postgraduate training for all personnel needed to administer the program or provide care.

"Quality of care implies that fullest consideration be given to the needs of each mother or child and that all community resources be mobilized for this purpose.

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"There is need for great expansion of training programs for all types of workers engaged in maternal and child-health programs:

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"5. Pediatric nurses must also be trained in large numbers to provide supervisory and teaching staff for children's services in hospitals, including nurseries for new-born infants, convalescent homes, and clinics, and to act as specialized consultants in public nursing services. Training in the mental health of children should be included.

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"6. Other types of well-trained personnel, such as public-health nurses are now increasingly needed as the maternal and child-health and crippled children's programs expand. Such personnel will be required in even larger numbers as further extension takes place.

"Postgraduate training for all types of personnel, including administrators, must therefore be a basic part of an expanding maternal and child-health program.

"Immediate attention should be given to the following:

2 The National Commission on Children in Wartime, appointed in 1942 and reappointed in 1944 by Katharine F. Lenroot, Chief, Children's Bureau, of the U. S. Department of Labor. includes authorities in the professional fields concerned with child health, welfare, and education; leaders of the national organizations that work directly with and for children and representatives of labor and government. The report of the Commission may be secured from the U. S. Department of Labor, Children's Bureau, Washington 25, D. C.

"2. *

Postgraduate training should be given nurses and other profes

sional workers in the maternity and pediatric fields.

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"4. Postgraduate training for pediatricians and other physicians, and for nurses and other professional workers in the mental hygiene of childhood, including opportunities for clinic and field experience over considerable periods of time, must be made possible.

To the nursing profession the President's proposals and the recommendations of the Commission literally sound a call to arms. They reemphasize the role of the professional nurse in a maternal and child-health program and they place a new emphasis on the importance, in preparation for this role, of training and experience in the field.

The responsibility that the nurse shall have been adequately prepared to deal effectively with maternal and child health and the social conditions which affect the welfare of mothers and children is the direct responsibility of those who have a share in planning the nursing education program. One basically important factor in this program is the essential clinical field providing "opportunities for clinic and field experience over considerable periods of time."

Of the facilities lacking in schools of nursing in the so-called four "basic services," the pediatric are the most common. While the discussion that follows considers the pediatric clinical facilities in hospitals only, other community resources, such as nursery schools, should be explored in the development of any pediatric nursing field."

A study of the clinical facilities on the four basic services in the home hospital was made in 1943. This study disclosed that there were no pediatric patients in 163 of the 1,047 reporting hospitals and that in another 790 the fewest patients were on the pediatric service. As the size of the hospital increased, the daily average census of children generally increased, but not until the hospitals reached the size of 150 patients is it reasonable to expect a satisfactory pediatric field assuming that a daily average of 12 patients provides adequate learning opportunities in the care of sick children. Since 63 percent of the state-accredited schools in 1943 were connected with hospitals having fewer than 150 patients, the great majority of schools should seek a pediatric practice field outside the home hospital on the premise that the minimum number of patients needed for satisfactory learning opportunities is 12.

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Some 600 schools or 46 percent of the total schools reported that they had pediatric affiliations in 1943. A large number of these schools send their students for pediatric nursing to other schools which offer the basic program and are more favored by being connected with larger hospitals having sizable pediatric services. But from the foregoing analysis it would appear that the schools connected with the larger hospitals cannot accommodate all of the students from the schools connected with the smaller hospitals having very few pediatric patients or none at all. Another source for securing a pediatric practice field is the institution which does not conduct a basic program but offers affiliations only. There are 22 such institutions. In these places the total daily average number of patients is 1,900.

Although this discussion deals primarily with the needs of the pediatric practice field for student nurses, it is important to bear in mind also the needs for graduate nurses. Some graduate nurses who have had a limited pediatric course in their basic program may wish to enroll in the supplemental type of postgraduate course in order to strengthen their undergraduate work. In practically all of the supplemental courses at present offered, the experience is given in the same hospitals where student nurses have their basic pediatric practice.

Other graduate nurses may wish to prepare themselves as teachers, supervisors, or consultants in the pediatric nursing field. The recognition of the need of clinical specialists in pedriatic nursing to fill these positions has led to the recent development of several advanced pediatric nursing programs placing considerable emphasis on clinical practice. As health programs for children are extended and

3 Expansion of Pediatric Facilities, Bulletin No. 9, Nursing Education in Wartime, May 4, 1944, New York National League of Nursing Education.

4 Clinical Facilities in the Hospital as a Whole and on the Four Basic Services, Am. J. Nursing, vol. 44, pp. 779-783 (August) 1944.

5 Based upon data from A List of Schools of Nursing Meeting Minimum Requirements Set by Law and Board Rules in the Various States and Territories, New York, National League of Nursing Education, 1943.

Hospital Service in the United States, vol. 127, J. A. M. A. (March 31) 1945, and unpublished data.

improved, there will be increasing demand for more resources for advanced education in this field and, therefore, a corresponding demand for more clinical facilities for teaching advanced students.'

In the 1945 issue of Hospital Service in the United States, hospital facilities for children are listed by States. Twenty-nine hundred and thirty-one hospitals are reported as having 61,262 beds, with a daily average census of 42,516 patients. Some of these beds are in children's hospitals, but the number is relatively small-4,459 in 44 hospitals. The great majority of beds are in general hospitals-36,462. The remainder are distributed in nervous and mental, tuberculosis, and orthopedic hospitals, and in an unclassified group of institutions."

In the December 7, 1935, and the March 2, 1940, issues of the Journal of the American Medical Association, special reports were published concerning tuberculosis facilities in the United States. The 1940 report gives data for the year 1938. Here are some of the figures from that report:

In the United States as a whole the daily average number of children in all tuberculosis institutions was 6,838. Most of these children (5,382) were in sanatoriums, "institutions operating exclusively for the treatment of tubercu losis"; the next largest number (890) in preventoriums, "separate units for tuberculosis contacts or children with the first infection type of disease"; and the smallest number (566) in departments, "a hospital service devoted in part to tuberculosis care." Practically every State has institutions for the care of children with tuberculosis, since all but four reported either daily average census or beds for tuberculosis pediatric patients. The number of beds actually specified per State ranges all the way from 16 to 1,981; the daily average patients from 11 to 1,167. At the present time the extent to which the pediatric field in tuberculosis sanatoriums, departments of hospitals, and preventoriums is utilized for the education of nursing students is not known.

The 1,300 hospitals connected with schools of nursing offering the basic program have an estimated daily average of 12,100 children.10 As stated previously, 1,900 children are cared for daily in the 22 institutions offering affiliating courses only. The clinical facilities utilized as pediatric practice fields for student nurses consist of an approximate daily average of 14,000 patients, whereas the daily average number of children in all the hospitals all over the country is more than 42,000.

Where are the other 28,000? Why are the institutions which care for them not used as affiliating centers? It is the professional responsibility of those directly concerned with nursing education-heads of schools, State boards of nurse examiners, State league officials-to find these children and to determine whether or not the hospitals caring for them are proper places or can be made proper places for carrying on educational programs.

Since the recognition of professional schools of nursing meeting minimum requirements set by law is a power delegated to the State, the search for pediatric facilities, begins rightly in the separate States. There are two basic sources of information which provide the data for a preliminary analysis and for locating the pediatric facilities State by State. These are (1) the reports of hospital statistics by the council on medical education and hospitals of the American Medical Association entitled "Hospital Service in the United States," published annually in March; and (2) A List of Schools of Nursing Meeting Minimum Requirements Set by Law and board rules published by the National League of Nursing Education. To illustrate how these sources may be used, an analysis is made of the pediatric facilities, both those that are at present utilized and those that have potential utilization, in the State of Massachusetts.

Courses in Clinical Nursing for Graduate Nurses. Prepared by a Special Committee on Postgraduate Clinical Nursing Courses, New York, National League of Nursing Education, 1945. Percent occupancy in children's hospitals given as 69.4 percent. See Hospital Service in the United States, op. cit., p. 782.

• Ibid.

10 Based upon data from Clinical Facilities in the Hospital as a Whole and on the Four Basic Services, op. cit., p. 5.