the association is to elevate the standards of nursing education to insure effective nursing practice. I welcome the opportunity to appear here today on behalf of ANA to speak to H.R. 11241, the proposed Nurse Training Act of 1964, and to urge you to give the provisions of the bill your immediate and favorable consideration.

The legislation you are considering would authorize construction grants for schools of nursing; extension of the professional nurse traineeship program; a loan program for nursing students; project grants to develop new and improved methods of training and enable collegiate schools of nursing to strengthen, improve, and expand programs of nursing education; and a direct subsidy program to diploma schools of nursing.

There are over half a million registered nurses practicing today. However, an acute shortage exists that is both qualitative and quantitative. This has been caused in part by the rapid population increase, the growth and expansion of health facilities and advances in medical science.. It has been intensified by the delegation to registered nurses of many functions once performed only by physicians. For example, since the enactment of the Hospital Survey and Construction Act in 1946, 9,810 projects have been approved, representing a total of 290,000 general, mental, tuberculosis, and chronic disease hospital and nursing-home beds. In addition, 1,992 rehabilitation facilities, public health centers, diagnostic and treatment centers, and State public health laboratories have been constructed. With the exception of laboratories, nursing personnel are needed in all these facilities. The American Nurses' Association has always supported the intent and purposes of the Hospital Survey and Construction Act, but we are concerned that there are continuing appropriations for construction without an associated plan for staffing the facilities to insure effective and safe care. The Congress has passed bills for hospital and health facility construction with over $2 billion. We must have properly prepared persons to staff these new institutions.

There is a growing imbalance between professional nurses, on the one hand, and practical nurses and nurses' aids, on the other. Federal support of practical nurse education was increased and expanded with the enactment of the Health Amendments Act of 1956 and has further expanded under the Manpower Development and Training Act. The Area Redevelopment Act and the Manpower Development 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 a concomitant increase in the number of professional nurses to give the needed direction and supervision leads to deterioration in the quality of service. Professional nurses are responsible 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.

Now, I would like to speak briefly on each section of the bill. 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 adminis tration. It was due to expire June 30, 1964; section 821 of H.R. 11241 proposes its extension for 5 more years. It now includes a provision for training clinical specialists. During the first 6 years of this program, 9,029 nurses were awarded traineeships. Although this legisla tion 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.

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 knowledge in her subject area. There fore, 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 schools, have graduate degrees.

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 thereapeutic level of nursing care. Such administration and supervision is dependent upon familiarity with a body of knowl edge 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. There is also a shortage of personnel to fill positions in administration and supervision. A 1962 spot check 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.

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 specialist's 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. ANĂ 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. Ten thousand one hundred and eight-four nurses 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. We support the continuance of the short-term traineeship program if it does not infringe on the long-term program.

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 collegiate 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 graduating 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.

The Surgeon General's Consultant Group on Nursing has reconmended that the number of graduates from collegiate schools of nursing be doubled by 1970. Graduations presently total around 4,000 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.

The CHAIRMAN. Doctor, if I might interrupt you there, do you think with the passage of this legislation you can reach that 1970 goal?

Dr. DOUGLAS. The 1970 feasible goal, yes, sir; we hope so.
The CHAIRMAN. Do you think we can?

Dr. DOUGLAS. We hope so.

The CHAIRMAN. Good.

Dr. DOUGLAS. 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. 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 population 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 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; that is, 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 portion of the statement which I am omitting deals with the provisions of the original companion bill, S. 2529 and H.R. 10042, and our reasons for supporting the provisions which were deleted as the bill was considered in the House of Representatives. We believe these provisions are important and essential to providing well-prepared nurses in sufficient quantities to meet current and future needs.

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.

The ANA strongly supports H.R. 11241 in its present form and urges its immediate passage. We are confident with your understanding and support, Mr. Chairman, the bill will be acted upon promptly.