1 From Hospital Service in the United States, J. A. M. A., vol. 127, p. 782 (Mar. 31), 1945.

In 1943 the number of State-accredited schools in Massachusetts was 64.11 Four of these schools were operated by institutions for psychiatric patients, 1 by a children's hospital, and of the remaining 59, 58 were conducted by general hospitals, and 1, Simmons College School of Nursing, secured pediatric experience for its students in the children's hospital just noted. Fifty-one of the fifty-eight schools connected with general hospitals reported their daily average pediatric patients. Five of the seven schools which did not report sent all of their students on affiliation for pediatric experience; it is highly probable that their home hospitals had no pediatric service. Since pediatric experience was given both in the home hospital and by affiliation in one of the other two nonreporting schools, it doubtless had very limited facilities in the home hospital.

The total daily average number of patients on the pediatric service in the home hospitals of the reporting schools in Massachusetts was 888. From the facts given in the preceding paragraph, it would appear that this figure is approximately correct for the home hospitals of all of the schools. Of these 888 patients, 417 are in three hospitals-the Children's, the Boston City, and the Massachusetts General; and 471 are distributed in the remaining 56 general hospitals a daily average of eight pediatre patients per hospital. As a matter of fact, eight of the reporting places had no pediatric facilities, and in another 20 the number was less than 12. Obviously, many of the schools in Massachusetts must look elsewhere than in their home hospitals for pediatric nursing practice. How many do?

Of the 64 schools, 33 reported that all pediatric experience is given through affiliation, and 9 that pediatric nursing is provided partly in the home hospital and partly in the affiliating institutions. Two others indicated pediatric experence as an affiliation elective. Before discussing both present and potential sources of affiliation, it is worthwhile to relate pediatric experience to clinical facilities in the home hospitals, both in schools having affiliation and in schools which do not.

In Massachusetts affiliations for pediatric experience and the daily average children census do not consistently show relationship. One school with an average census of 17 pediatric patients reported pediatric affiliation for all its students; another with the same census did not report affiliation for any students.

11 A List of Schools of Nursing Meeting Minimum Requirements Set by Law and Board Rules in the Various States and Territories, op. cit., p. 13.

It is, of course, possible that the scope of experience in the school which had an affiliation was so limited that an affiliation had been established to supplement the experience in the home hospital. Two other schools with an average census of 9 and 7 children respectively have no pediatric affiliation. A school which reported a daily average of 3 pediatric patients indicated that experience is given both in the home hospital and through affiliation. It is difficult to see how a pediatric service of 3 patients would fit into a planned clinical instruction program when the pediatric experience is given in two separate institutions.

In the 1943 inventory of schools the names of the institutions with which the schools had affiliations were not secured. Usually the school will seek needed experience in its own State when that experience is available through an already established affiliation. Six hospitals offered pediatric affiliation varying from 6 to 17 weeks in Massachusetts in 1943. Five of the hospitals conducted their own schools of nursing offering a basic program. The sixth hospital, the Boston Floating, offered an affiliating course only. From the standpoint of clinical facilities in Massachusetts, but 38 patients were added through the Boston Floating Hospital affiliation to the 888 in the home hospitals.

Of the five hopsitals conducting schools of nursing offering a basic program, one had a daily average of 14 pediatric patients, another 15, and another 20. The school with a daily average of 14 pediatric patients bad a total student enrollment of 55; the school with a daily average of 15 patients, a student enrollment of 81; and the school with 20 patients, 20 students. These enrollment figures do not include affiliating students from other schools. Pertinent questions are: (1) How large should a pediatric service be before an institution accepts students for affiliation? (2) How many affiliating students can a school receive and maintain a balance between the educational needs of its own students and the needs of students received from other schools?

Insofar as a statistical analysis can go, the situation concerning the pediatric facilities utilized for student experience in Massachusetts in 1943 resolves itself in the following facts: 44 of the 64 schools in the State secured pediatric experience through affiliation. Six institutions offered affiliating experience. Of these six, five conducted their own schools. Of the five, one was the Children's Hospital and had a daily average of 236 patients; another the Boston City Hospital, had a daily average of 146 patients. The daily average census in each of the other three was 20 patients or less. Since these three places had their own schools, they could not receive any considerable number of students from other schools without crowding the service and limiting and jeopardizing the educational experience of their own students or the experience of students from other schools or both. What could Massachusetts do to add to its pediatric clinical facilities within the State?

Information collected by the league from the State boards of nurse examiners in October 1945, preparatory to assembling facts for the 1946 list of schools meeting minimum State requirements, provides evidence that Massachusetts has taken specific steps since 1943 to increase its clinical opportunities in the nursing care of children. Three new institutions were reported as accredited by the State board for affiliation in 1945 that were not so reported in 1943; the House of the Good Samaritan in Boston and the Sharon Sanatorium in Sharon where children with cardiac conditions are cared for, and Shriners Hospital for Crippled Children in Springfield. The combined daily average number of patients for these three places is 124. The extent to which the new facilities add to the necessary pactice field for the 44 schools requiring pediatric affiliation is not known. It can be assumed that the scope of the experience would be somewhat enriched. There are still, however, resources to be explored in Massachusetts.

The table shows that Massachusetts has 3,061 beds for children, with an approximate daily average census of 2,124 pediatric patients." At the present time it would appear that about 1,050 of that number provide nursing experience for students. There still remains a potential pediatric field of more than 1,000 children,

Five children's institutions which have not so far been utilized for student nurses are listed in Massachusetts in the March 31, 1945, Hospital Service number of the Journal of the American Medical Association. Two of these are children's orthopedic hospitals, the New England Peabody Home for Crippled Children in Newton and the Sol-e-Mar Orthopedic Hospital for Children in South Dartmouth. The other three listed are the Hospital Cottages for Children in Baldwinsville, 12 Percent occupancy in children's hospitals given as 69.4 percent. See Hospital Service in the United States, op cit., p. 779.

the North Shore Babies Hospital in Salem, and the Convalescent Home for Children in Wellesley. The combined daily census of these five places is 275. Approximately another 400 children, not utilized for pediatric experience, are in tuberculosis institutions: 352 in sanatoriums, 7 in departments of hospitals, and 52 in preventoriums.13

When all of the children accounted for in Massachusetts hospitals not now used for pediatric nursing experience are added to the children in hospitals at present providing a pediatric practice field, the sum is approximately 1,725. This leaves about 400 patients in some hospitals somewhere not at present accounted for. These children are doubtless in hospitals where they cannot be identified through the available national statistics. It is possible that State records would help in locating these places.

Summarizing the statistical analysis of the pediatric facilities in Massachusetts as they relate to the State-accredited schools of nursing in that State, there were 64 State-accredited schools of nursing on January 1, 1943. Forty-four of these schools secured pediatric affiliations for their students. Since schools usually establish affiliations with in-State institutions, it is reasonable to assume that the majority of these schools send their students for pediatric experience to a Massachusetts institution. The total pediatric facilities, both those in home hospitals and those in affiliating institutions, totaled 926 patients.

That the State recognized the need for expansion of pediatric facilities is evident by the fact that three new affiliating pediatric centers have been established since 1943, providing for an additional 124 patients. This brings the total children in Massachusetts now being used for pediatric experience to 1,050. There still remain 1,074. Of this number, 275 have been accounted for in hospitals caring exclusively for children and 400 in tuberculosis institutions. The remaining 400 are in all probability in an unclassified group of hospitals. In closing, it is desired to point out:

1. That Massachusetts was selected to illustrate how a State might proceed in the devlopment of its pediatric practice field because it was necessary to select some State for purposes of illustration. The State selected might have been almost any one of the other 47.

2. That although the statistical data used in the analysis were gathered in 1938, 1943, and 1944, it is probable that the situation then would not differ appreciably from that existing now.

3. That this article deals only with hospital facilities in the care of children, and that other resources, such as nursery schools, should be explored when developing the pediatric field in any State.

4. That this analysis considers the statistical aspects only of the potential clinical facilities in the care of sick and convalescent children, and that a second and equally important step is to determine the suitability of the institutions as educational practice fields.

5. That President Truman's proposals and the recommendations of the National Commission for Children in Wartime place a new emphasis on the fundamental importance of the essential practice fields in preparing professional nurses for their responsibilities in the child-health program of the Nation.

EXHIBIT 2

EXCERPTS FROM THE STATEMENT OF THE NATIONAL NURSING COUNCIL ON BASIC POLICY IN REGARD TO FEDERAL AID TO NURSING EDUCATION, JANUARY 21, 1946

1

Nursing is a profession essential to the health and well-being of citizens of the United States, yet the burden of the education of nurses has traditionally been left largely to private institutions. For the most part, young women who wished to become nurses have paid their tuition partly in cash but chiefly in service to the hospital while their schooling was in progress. War pressures

18 Tuberculosis Facilities in the United States, J. A. M. A., vol. 114, table 27, p. 780 (March 2) 1940. (In 1940 the Sharon Sanatorium was classified as a tuberculosis institution; in 1945 as a hospital for the care of children with cardiac conditions.)

1 Member organizations of the National Nursing Council are: American Nurses' Association, National League of Nursing Education, National Organization for Public Health Nursing, Association of Collegiate Schools of Nursing, National Association of Colored Graduate Nurses, American Red Cross Nursing Service, Council of Federal Nursing Services, International Council of Nurses, Division of Nursing, U. S. Public Health Service, American Hospital Association, National Association for Practical Nurse Education, American Medical Association, Nursing Unit, U. S. Children's Bureau, American Association of Industrial Nurses.

for unprecedented numbers of nurses brought about establishment of the Division of Nurse Education in the United States Public Health Service with its extensive scholarship aid both for basic and advanced nursing education and formation of the United States Cadet Nurse Corps. Public Law 74 under which the United States Cadet Nurse Corps is administered is a war measure. The aid it affords will cease when students admitted before October 15, 1945, have completed their

courses.

Sweeping changes are needed in many schools of nursing to make of them genuine educational institutions.

Scholarships

Scholarships should be arranged so far as possible directly between the educational institution and the student who should meet requirements of the institution. Such scholarships should be arranged:

1. For qualified students in basic professional nursing education in schools which meet criteria set by appropriate national professional nursing organizations. 2. For qualified students in advanced programs in universities and colleges where programs and courses meet creteria set by appropriate national professional nursing organizations.

3. For qualified students in practical nurse education in schools which meet criteria set by approprite national nursing organizations.

Grants

Grants should be made:

1. To universities and colleges for development of advanced programs in nursing education which meet criteria set by appropriate national professional nursing organizations. It is especially important that facilities be developed in certain clinical fields such as tuberculosis, pediatric, and psychiatric nursing including mental hygiene and also for administrative, supervisory, and teaching positions in educational institutions and nursing services.

2. To schools of basic professional nursing education only if selection of schools is based on criteria set by appropriate national professional nursing rganizations. 3. To schools of practical nurse education only if selection of schools is based on criteria set by appropriate national nursing organizations.

4. For research and experimentation in nursing as it relates to education of professional and practical nurses, carried on either by a Government agency administering the Federal-aid program or by allocation of funds to national professional nursing organizations and to educational institutions.

5. To make possible the assignment of Federal nursing education personnel for furtherance of studies and demonstrations and educational program development. 6. For promotion of nursing education in geographic areas where there is special need and local funds are limited; these special grants to be distributed at the discretion of the Federal administering agency to educational institutions and agencies which meet criteria set by appropriate professional national nursing organizations.

Advisory committee

In the administration of all these programs it is believed that an advisory committee should be formed with representatives recommended by the appropriate professional nursing organizations.

EXHIBIT 32

COUNCIL OF SOCIAL AGENCIES, Philadelphia 7, Pa., June 25, 1946.

Hon. CLAUDE PEPPER,

United States Senate, Washington, D. C.

DEAR SENATOR PEPPER: We herewith present our view of the proposed legislation, Maternity and Child Welfare Act of 1945 (S. 1318).

1. We agree with the principle that better medical services and wider distribution of them are necessary to ultimate improvement in infant and maternal welfare.

2. We disagree that the bill as now constructed will result in such improvement for the following reasons:

(a) There is an inadequate supply of well-trained medical personnel to provide care for the entire population.

(b) Distribution of medical services as they exist will not improve the quality of medical care. It is indeed likely that the poor quality medical care, rather than the better, would be disseminated.

(c) Population at large also requires much more education as to what may be considered adequate health practices. Public education must precede legislation in this respect.

(d) Compulsory insurance would create huge sums of money for which there are inadequate means of effective use.

(e) Insufficient authority is placed in the hands of medical personnel who are familiar with the needs in medical education and stable progress.

(f) There is no differentiation between the patient who is able to pay for services in toto, the patient who can pay in part, and the patient who can pay nothing.

(g) There are inadequate provisions for improvement of hospital facilities, health centers, and medical schools.

3. We would favor legislation which would:

(a) Through State agency channels provide funds for medical care of the indigent.

(b) Provide direct aid to hospitals and cooperate with well-managed hospital clinics so that the cost of medical care in such institutions could be materially reduced.

(c) Provide direct aid to health centers which should be placed in strategic geographic areas.

(d) Provide direct aid to medical schools for the improvement of their teaching facilities-possibly the most important consideration in any long-range view of this problem; with the result that

(1) Better teachers can devote more time to instruction.

(2) Improved physical facilities, e. g., laboratories, hospitals, cooperating clinics, and health centers may be provided.

(3) Postgraduate educational opportunities increased.

(e) Setting up of medical districts in which the teaching institutions or larger hospitals would act as the hub of wider spread high-grade medical practice. In such areas residents in postgraduate training would act as one of the principal links between the peripheral medical units and the central teaching institution. 4. We suggest that legislation which is designed for the improvement of the medical care of infants and children be limited for the time being to obvious needs and that any policy of changing legislation be deferred at least until the completion of the survey of child-health service now being conducted under the joint auspices of the American Academy of Pediatrics, the United States Public Health Service, and the Children's Bureau.

5. Finally, we suggest that greater strides in the improvement of the state of health of infants and children, as well as women, can be achieved by measures designed to improve housing and sanitary conditions and nutrition, than by the effort to spread more widely (and incidentally more thinly) inadequately trained and inadequately manned health services.

United States Senate, Washington, D. C.

MY DEAR MR. PEPPER: I am in receipt of your letter of October 24 relative to comment on bill S. 1318 which you have introduced in an effort to improve maternal and child health.

It is evident that procedures which have been in vogue for a long time have not been generally effective-an ineffectiveness that is spotlighted by the appalling draft findings and the resulting physical deficiency corrections necessary to raising an adequate military force. It is equally evident that measures must be introduced to strengthen the health of our youth-a distinct contribution to a permanent national security.