nurse education was increased and expanded with the enactment of the Health Amendments Act of 1956 and has further expanded under the Manpower Develop ment and Training Act. The Area Redevelopment Act and Manpower Develop ment and Training Act have also stimulated the setting up of many programs for the training of nurses' aids. Increasing the number of these personnel without concomitant increase in the number of professional nurses to give the needed direction and supervision leads to deterioration in the quality of service. Profes sional nurses are responsibile for planning the total nursing care of patients. It is urgent that their number be increased and that their preparation be improved. When the Surgeon General's Consultant Group on Nursing reported in 1963 it estimated that to meet the needs of the Nation in 1970 for safe, therapeutically effective and efficient nursing service there should be 850,000 professional nurses, including 200,000 holding baccalaureate degrees and 100,000 with graduate degrees. Realistically, considering the potential supply of students and the potential capacity of schools of nursing, this total need could not be met by 1970. The Consultant Group then set as a feasible goal for 1970, 680,000 professional nurses including 120,000 with academic degrees, 25,000 of whom would have advanced degrees. Presently, 11,500 nurses have advanced degrees and 43,500 have baccalaureate degrees.3

EXTENSION AND EXPANSION OF THE PROFESSIONAL NURSE TRAINEESHIP PROGRAM

The professional nurse traineeship program established under the Health Amendments Act of 1956 provided financial assistance to nurses preparing for positions in teaching, supervision, and administration. It was due to expire June 30, 1964; section 821 of H.R. 11241 proposes its extension for 5 more years. During the first 6 years of this program, 9,029 nurses were awarded traineeships. Although this legislation increased the number of nurses with graduate degrees, the need is still great. Taking into account that the Surgeon General's Consultant Group on Nursing considered 100,000 nurses holding advanced degrees the ideal, the ANA sees the group's feasible goal of 25,000 by 1970 as the minimum required for adequate health services. The authorization ceilings which appear in H.R. 11241, we believe are adequate for the present.

The responsibilities of those who serve in positions in teaching, supervision, and administration in nursing are such as to require advanced preparation st least at the master's level. Sound programs of nursing education cannot be developed without qualified teachers. Quality nursing service cannot be provided for the people of this country unless we have sufficient numbers of well-prepared supervisors and administrators. The continuing shortages are both quantitative and qualitative and will not be resolved without Federal assistance to nurses seeking advanced preparation.

In all nursing education programs the faculty should hold graduate degrees. It is at this level of study that the prospective teacher learns about methods of teaching, testing, and evaluating, and acquires the necessary clinical and scientific knowlege in her subject area. Therefore, it is startling to consider the preparation of those presently teaching in all types of schools of nursing. Only 38 percent of current full-time faculty members in senior and junior colleges, in hospitals, and in practical nursing schoools. have graduate degrees.

Our present dilemna and the often-heard criticism of inadequate nursing care is directly related to insufficient supply and inadequately prepared nurse teachers. Obviously it is impossible for our schools to prepare nurses to give the quality of nursing care society needs and expects when such a large number who are in the

"Toward Quality in Nursing." Report of the Surgeon General's Consultant Group on Nursing, U.S. Department of Health, Education, and Welfare, Public Health Service, 1963. Ibid.

"Functions, Standards, and Qualifications for Practice for Educational Administrators and Teachers,” 1963; "Functions, Standards, and Qualifications for Practice of Nursing Service Administrators," 1956, American Nurses' Association.

"Facts About Nursing," 1962-63 edition.

position to mold future practitioners have no education beyond basic nursing preparation. This can be compared to a high school graduate teaching high school mathematics.

In addition to our concerns about the quality of faculty in schools of nursing, we face the further problem of shortage of personnel to fill these positions. There are 1,740 vacancies in full-time budgeted faculty positions in all schools preparing nursing practitioners." Therefore, we urge immediate congressional action to extend the traineeship program so that the preparation of nurse teachers can continue without interruption.

The quality of nursing practice is improved or deterred by the organizational framework in which the nurse practitioner functions. Effective nursing service administration and supervision fosters a safe, efficient, and therapeutic level of nursing care. Such administration and supervision is dependent upon familiarity with a body of knowledge based on sound principles that can be applied in nursing service situations. To be expert requires the thorough study that is possible only at the graduate level. Basic programs prepare practitioners for beginning positions in nursing and not for administration. At this time, the educational attainment of persons holding positions as supervisors and administrators in nursing services has by no means reached the level the profession deems desirable as will be seen from the following data collected for all hospitals and related institutions. 7 [In percent]

There is also a shortage of personnel to fill positions in administration and supervision. A 1962 spotcheck of non-Federal general hospitals shows that 13.4 percent of full-time budgeted positions for directors and assistant directors and 15 percent of supervisory positions are vacant.8

If we are to raise the level of education of nurses functioning in the critical areas of supervision and administration and fill the vacancies which still persist, it is imperative that the Congress continue the professional nurse traineeship program it initiated in 1956.

H.R. 11241 section 821 also provides that the traineeship program be expanded to include financial grants for assistance to nurses seeking preparation as clinical specialists. The nurse clinician is a master practitioner. She may, for example, be a nurse midwife, a psychiatric nurse, the expert in cardiopulmonary nursing or in the care of the chronically ill. To become such a practitioner in so broad a field as nursing requires concentrated study at the graduate level in the selected area. Once prepared this nurse uses her specialists' competence in providing direct care to patients needing expert nursing. She collaborates with the physician in planning and providing patient care and works with and teaches other nursing personnel during the provision of nursing care and treatment. She may teach in schools of nursing and in programs of continuing education. She conducts and participates in clinical research. Highly qualified expert nurses to practice in specialized areas of nursing offer an opportunity to improve the quality of care. At the present time, there are no Federal funds available for the training of nurse clinicians except in the field of psychiatric nursing. ANA strongly supports expansion of the traineeship program to increase the number of specialized clinical practitioners.

When the professional nurse traineeship program was extended in 1959, provision was made for awarding short-term traineeships to nurses unable to engage in full-time study. There were 10,184 nurses who benefited under this part of the program. While we do not consider that the short-term program is a substitute for the educational experience obtained through full-time study it has, considering its limitations, met a need. With over 47,000 nurses engaged in teaching, supervision and administration without the minimum preparation required, a variety of programs are needed to supplement their basic education. We support

the continuance of the short-term traineeship program if it does not infringe on

• Ibid. 7 Ibid.

"Spotcheck of Current Hospital Nursing Employment Conditions," New York, American Nurses' Association (November 1962).

the long-term program and believe Federal funds for courses should go only to institutions and agencies conducting high quality programs.

GRANTS FOR CONSTRUCTION OF FACILITIES

To achieve the goal of 25,000 nurses with advanced degrees and to double the number holding baccalaureate degrees by 1970 requires assistance to basic colleg ate nursing education programs along with the assistance to graduate education offered through the traineeship program. The baccalaureate degree is becoming a requirement for an increasing number of positions in nursing. Also, it is from the pool of nurses graduates from baccalaureate programs that future teachers, supervisors, and administrators will come.

To accommodate increasing numbers of students, collegiate schools of nursing must expand their facilities. When this committee was considering the health professions educational assistance bill in 1962 and 1963, it received considerable information from the collegiate schools about the need for additional classrooms. laboratories, libraries, and offices. As colleges and universities undertake building expansion programs they tend to give priority to the overall services rather than to the needs of smaller professional schools unless these schools can secure special funds to help defray costs. This observation is true in both the private nonprofit school and in the publicly supported college.

Moreover, the cost of a nursing education program to the college or university is greater than many other types of programs. One laboratory for the nursing student is the clinical setting-hospital, public health agency, clinic-and in these settings her laboratory experiences are with human beings. Because the welfare of patients cannot be jeopardized, a higher ratio of teachers to pupils is required. Some authorities in nursing education recommend a 1:8 teacherstudent ratio during most of the clinical experience, with 1:4 ratio desirable in some situations such as the delivery room. Because of this, more funds must be allocated for faculty salaries in the nursing department or school than in many other divisions of the educational institution.

The Surgeon General's Consultant Group on Nursing has recommended that the number of graduates from collegiate schools of nursing be doubled by 1970. Graduations presently total around 4,000 a year. With present facilities, accredited schools can accommodate an increase in enrollment of only 11 percent, or approximately 2,400 students. Even if this increase were realized there would need to be an additional 3,500 admissions to baccalaureate programs to reach the 1970 feasible goal.9

H.R. 11241 in section 801 (a) (1) authorizes $35 million for construction of facilities for collegiate schools of nursing. The American Nurses' Association believes this assistance to schools would help them increase their enrollment and any expansion of the educational facility would be a step toward reaching the feasible goal set up by the Consultant Group on Nursing. However, the Congress should recognize that only 10 percent of nurses practicing today hold baccalaureate degrees. The potential increase in enrollments made possible with added facilities will raise this to only 18 percent. We cite this to underscore the serious situation that exists and the tremendous task ahead if the real need is to be met. The need will not be met without sustained and generous support from the Federal Government.

We believe also that the loan provisions in section 822 of this bill will have an impact on the enrollment in schools of nursing. Students in baccalaureate and associate degree programs are now eligible for loans under the National Defense Education Act of 1958. In 1962, about 800 nursing students, out of over 26,000 enrolled in these programs, had loans. High priority in granting loans has not been given students of nursing and their work in nursing does not make them eligible for the forgiveness provisions of the act. This committee is aware that nurses' salaries are generally low. Newly licensed nurses usually practice in beginning staff positions in hospitals and other agencies. According to the Bureau of Labor Statistics, average weekly earnings for general duty nurses in 1963 ranged from $74 to $98.50. Entrance salaries for these positions in a number of hospitals in 3 of the 15 cities surveyed were as low as $55 a week. These 15 areas represent the most highly populated areas in the country. In a study made by the American Nurses' Association in November 1962, it was found that general duty nurses' salaries averaged about 24 percent more in cities with 500,000 or more than in those of less than 10,000 population. When salaries are so low, repaying a loan can be difficult. We would therefore believe the "Toward Quality in Nursing."

forgiveness provision in H.R. 11241 is most important and one that could very well foster sustained employment in nursing.

We would also like to call your attention to the fact that nearly 9,000 registered nurses, graduates of associate degree and diploma programs, are studying for a baccalaureate degree. In 1962, 5,262 were enrolled on a part-time basis. This practice is uneconomical in terms of time, money and effort but persists because on their salaries, nurses cannot save enough to undertake full-time study and there is very little financial assistance available to them. Before they earn their baccalaureate degree, many will have spent 6 or 7 years in part-time study. The American Nurses' Association agrees with the recommendation of the Consultant Group on Nursing that for a limited period Federal funds be provided for traineeships for graduates of diploma and associate degree programs for up to 2 years of full-time study toward a baccalaureate degree. This would help registered nurses secure more rapidly the level of education their positions call for today and enhance the quality of patient care.

Section 805(a) (b) authorizes $17 million for project grants to collegiate and associate degree schools of nursing to strengthen, improve, or expand programs to teach and train nurses. Considerable experimentation with methods that promote better teaching and better use of teaching personnel has been going on in the field of education. These methods need to be more widely incorporated into the teaching of nursing. The project grants offer the opportunity to schools to improve their methods and thereby enhance the quality of instruction. Since the project grants would support a movement toward improving the quality of nursing education, we support this provision.

Section 806 (a) (b) provides $41 million over a 5-year period in order to prevent further attrition and promote the development of public and nonprofit private diploma schools of nursing. We believe funds allocated to diploma schools of nursing should be based on the same requirements that the collegiate and associate degree schools must meet in order to receive grants; i.e., to contribute to the "general improvement in the teaching and training of nurses." Increased enrollment should not be considered as the sole criterion for Federal assistance.

Assistance is needed to expand and improve nursing education. However, we believe this should be done through a system of grants for specific purposes. In the interest of insuring the best use of public funds, all schools applying for grants should be required to submit projects of high quality that give assurance the educational program will be improved.

The omission of scholarship aid for students entering collegiate schools of nursing was a great disappointment. Very little public or private financial assistance is available to nursing students in basic programs. A recent survey conducted by the ANA shows that in only 13 States have the legislatures appropriated funds for scholarships for nursing students. The total appropriated in these 13 States is less than $1 million. Also, the awards are generally small and not realistic in terms of the cost of nursing education. In only two States is the upper limit $1,000; in the others, the range is from $100 to $600 a year.

The Committee on Careers of the National League for Nursing maintains a list of sources of scholarship aid throughout the country, but does not have information on the total funds available. However, it has evidence of need and demand. For example, the 1959-62 national foundation scholarship program made available a total of 407 awards to students entering accredited collegiate schools of nursing. What is significant is that 8,249 applied for the 407 awards. Of these, 5,269 were fully qualified for admission to the schools, and yet fewer than 8 percent could get assistance from this source.

A special effort is required to attract talented high school graduates into baccalaureate programs in nursing. Advances in medicine and in technology, the explosion of knowledge in related fields, dictates that nurses master an increasing body of knowledge and also develop the intellectual ability to make the necessary application in nursing care. The professional nurse today must possess technical skills unheard of a few years ago. A high degree of intellectual and technical skill is required and must be utilized by her in every area of practice, wherever patients need nursing care. Programs within the university complex, where there are qualified instructional personnel in related fields to augment the instruction in nursing, make possible the acquisition of the required body of knowledge and the development of the necessary skills.

Baccalaureate programs are designed to provide a broad background in the biological, physical, behavioral, and social sciences to enable their graduates to make sound judgments in giving, planning and directing nursing care; to interpret and demonstrate care; to help patients and families identify and meet their

health needs and to work with others in their communities in planning and carrying out health programs. They are prepared, without need for further formal education, to advance to positions requiring beginning administrative skills They have the foundations for continuing professional development and for graduate study in nursing.

Families are often unable to meet the full cost of collegiate nursing education. Repeatedly we hear from deans of collegiate schools and from nursing students of the need for scholarship assistance. A study in 1963 by the National League for Nursing for the Division of Nursing, USPHS, of total charges exclusive of room and board to students in 138 baccalaureate programs showed an average charge of $2,805. The range of charges in the middle 50 percent of the programs was $1,425 to $3,775. Student nurses have the additional expense of uniforms, special shoes and are frequently responsible for travel costs to and from their affiliations away from the campus. Because of the nature of the nursing education programs, they have less opportunity than other students to earn money to help pay some of the cost of their education. Although the number of scholarships provided for in H.R. 10042, the original bill, is small in terms of the need, they would be a means of attracting some college-bound students and focusing attention on the academic nature of professional nursing.

We regret that the provision for planning grants in section 805 of H.R. 10042 was deleted. Comprehensive and careful planning is vital when a program of the kind proposed in this legislation is undertaken. The grants would encourage a State or region to survey its resources to determine needs and to determine whether emphasis should be placed on new schools or expansion of existing schools. Not to plan could result in an unwise use of public funds and an indiscriminate mushrooming of facilities for teaching nursing that could only lower the quality of nursing education and nursing service. When programs in nursing education are instituted, more is required than a building. Qualified faculty is essential and there must be adequate clinical facilities and community agencies for laboratory experience. A report, "Study on Cost of Nursing Education," part I, "Cost of Basic Diploma Programs," 10 reveals that the larger schools are less costly to operate. As the size increases, the cost per student declines.

The American Nurses' Association believes that certain safeguards are essential to insure the best use of the Federal funds that H.R. 11241 would make available. It is most important that only schools of nursing accredited by a recognized national accrediting body be eligible to receive funds for construction, apply for project grants and establish and operate loan funds. These are the schools that

have met standards set by the National League for Nursing, the recognized accrediting body for schools of nursing. There will be instances where evidence can be given that a nonaccredited program will meet accreditation standards within a reasonable time. In cases of this kind we recommend consultation with the accrediting agency before assistance is extended.

In the past, the Congress has demonstrated its awareness and concern for nursing education. During World War II when the need for nurses was especially acute, legislation was enacted to establish the U.S. Cadet Nurse Corps. This 5-year program enabled schools of nursing to increase their enrollment and resulted in 41,000 graduations in 1947, the largest number of students ever graduated from basic professional schools in 1 year. This program also helped graduate nurses secure additional preparation. Assistance available after World War II under Public Law 346, the GI bill, significantly increased the number of nurses undertaking additional study in colleges and universities. In 1956 and in 1959, Congress approved the professional nurse traineeship program, designed to prepare nurses for positions in teaching, supervision, and administration. The public health traineeships have also assisted nurses preparing for the field of public health.

The problem of insuring adequate nursing service now and in the future is a critical one. There is overwhelming evidence it can be solved only with substantial Federal aid. Immediate action is needed to reverse the progressive dilution of nursing services. We believe that delay will have grave consequences for the future health care of the American people.

May I thank the committee for this opportunity to present the views of the American Nurses' Association on this legislation.

Dr. DOUGLAS. Our ultimate purpose is to secure for the people of this country the best possible nursing care, and one commitment of

10 "Study on Cost of Nursing Education," pt. I, "Cost of Basic Diploma Programs," p. 26.