In addition to this statement on H.R. 11241, ANA is submitting a statement wholeheartedly supporting H.R. 11083, the Public Health Training Amendments of 1964.

I request that this statement be included in the record of the hearings.

The CHAIRMAN. It may be so included.

(The prepared statement of Dr. Douglas follows:)

PREPARED STATEMENT OF ANN M. DOUGLAS, R.N., PH. D., AMERICAN NURSES ASSOCIATION, ON H.R. 11083

I am Ann M. Douglas, dean of the School of Nursing, Georgetown University, Washington, D.C. I welcome this opportunity to present this statement on behalf of the American Nurses' Association to support H.R. 11083, the Graduate Public Health Training Amendments of 1964. I urge you to give this bill your prompt and favorable consideration.

The two major provisions of H. R. 11083 are to extend the public health traineeships program and to continue authorization for project grants to educational institutions providing public health training.

The public health traineeships would be extended for an additional 5 years under the provisions of the bill. These traineeships were originally established under the Health Amendments Act of 1956 to provide financial assistance to physicians, engineers, nurses, and other professional personnel undertaking graduate training in public health.

The number of persons preparing for public health positions declined 50 percent between 1947 and 1955, and it was the intent of Congress to reverse this trend and increase the number of adequately prepared public health specialists so urgently needed by State and local health agencies and by agencies of the Federal Government.

A total of 4,281 public health traineeships were awarded during the 7 years of the program; 58 percent of these went to professional personnel without previous public health experience, an indication of the impact the program had in recruiting individuals for training. Although the traineeships contributed to increasing the number of prepared public health personnel, the increase has not kept pace with the population growth nor with the demands made on public health agencies to add new programs to meet new needs.

Although nurses are the largest group of professional workers in public health and half of the public health traineeships were awarded to nurses preparing for public health staff positions, the need for more and better prepared nurses is acute A generally accepted minimum standard for public health work in a local area is one public health nurse to 5,000 population a figure which does not provide for care of the sick at home. At this level 43.000 qualified public health nurses would be needed in 1970. An additional 43,000 registered nurses would be needed if agencies provided a program for care of the sick at home. The present number of nurses employed in public health agencies is approximately 34,000 but of these only 36 percent are fully qualified for public health nursing practice.

Public health nurses carry increasing responsibilities. In addition to working with other disciplines to further community health and provide direct service to individuals and families in the home, school, clinic, and in industry, they must also train and supervise the large numbers of registered nurses, practical nurses, and nursing aids now being employed by public health agencies. As one means of insuring effective and safe community and individual health services we urge the Congress to act favorably on the extension of the public health traineeship program.

H.R. 11083 would continue authorization of project grants for an additional 4 years. It would strengthen the project grants program by expanding authorization to schools not presently eligible for grants such as schools of medicine, dentistry, social work, and pharmacy; increase the appropriation ceiling for the project grant program to $2.5 million for fiscal 1965, $4 million for fiscal 1966, $5 million for fiscal 1967, $7 million for fiscal 1968, and $9 million for fiscal 1969. Project grants to schools of public health and to schools of nursing and engi neering offering specialized public health training were first authorized in 1960. The purpose of these grants was to assist the schools in meeting the needs of public health programs. They have been used to enrich curriculums, strengthen train

"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.

"Facts About Nursing," 1962-63 edition, American Nurses Association.

ing programs, and develop improved methods of training. Fifty-seven grants have been awarded to schools of nursing. In addition, nurses have participated in projects in schools of public health.

The grants have established programs for preparing faculty for teaching in college and university schools of nursing, for identifying the contribution of nursing in the provision of comprehensive medical care services, for preparing at the post-master's level nurse practitioners and teachers in the fields of chronic illness and gerontology, and for studies of the most effective way to provide content and public health experience for students in baccalaureate programs in nursing.

We strongly support the continuation of the project grant awards in sufficient quantity and of such amounts that their purpose of improving education of public health personnel will be realized. Improving the preparation of practitioners results in improved health services.

The Public Health Training Amendments of 1964 fit in logically with legislation now under consideration, or already acted upon, by Congress. Such health legislation includes the Hill-Burton program, the Health Professions Educational Assistance Act, and the Nurse Training Act which you are considering today. In authorizing the public health traineeship program in 1956 and in 1959, Congress was instrumental in markedly increasing the number of qualified health personnel. Additional prepared workers are needed if public health agencies are to expand their programs to meet present and emerging health needs. We, therefore, again urge you to consider favorably the Public Health Training Amendments of 1964. On behalf of the American Nurses Association, may I thank the committee for the privilege of presenting our views on this legislation.

Dr. DOUGLAS. Thank you for the opportunity to present the views of the American Nurses Association.

The CHAIRMAN. Doctor, could you tell us the percent of high school graduates who enter nursing schools? Is this percentage increasing or decreasing? Do you know?

Dr. DOUGLAS. I can speak for our own school, Senator Hill, and I will tell you that this year the increase has been so overwhelming that where normally we accept a class of 70, we have accepted a class of 98 out of better than 350 applicants.

The CHAIRMAN. You had 350 applicants?

Dr. DOUGLAS. Yes, sir.

The CHAIRMAN. In other words, if you had places for them, you could have had 350 students; is that correct?

Dr. DOUGLAS. That is correct, sir.

The CHAIRMAN. Senator Javits, have you any questions?

Senator JAVITS. I just have one question which I came over to ask. Personally, I feel very strongly about the nursing profession and the need for attracting to it adequate core personnel and a core of the right kind. I am sure the ladies' presentations have made that very clear. I notice we are in something of a variance about the incentives, and the House apparently feels a little differently about it than we do here. I just wondered whether you regard the 50-percent forgiveness incentive as adequate or whether you are compromising because of the feeling of "well, that is about the best we can do"?

In other words, would you have any absolute recommendations to make to us in the best interest of the nursing profession, attracting students into nursing, and what is even more important, persuading them to continue in the profession after they have had their training, on an absolute basis rather than on the basis of "well, we are having a lot of trouble getting what we have got; we better try to keep them"? In other words, what would you give us as the optimum formula with respect to loans to induce students or for scholarships, to induce students to study nursing, students of the right type, and to continue thereafter for certainly 5 years and perhaps even more in the practice of nursing?

Dr. DOUGLAS. I think that I would certainly support the statement made by Dr. Price just prior to my speaking in which he suggests, I believe it was, a 60-percent forgiveness, with the understanding that for each year they spend in nursing in a public or nonprofit agency a certain amount would be forgiven.

I also would very strongly support his position on scholarships. and once again, I can speak only for my own school, and our concern with our own freshman class coming in this year. We have some students, sir, who are potential leaders in nursing who have taken out as many as three loans to get themselves through the first year of nursing. I think the need is very great.

Senator JAVITS. Well, so that you would consider Dr. Price's prescription to be the optimum and the American Nurses Association you believe favor that?

Miss THOMPSON. Yes. The original bill did include 60 percent forgiveness which we supported at that time, but we are willing to accept the 50 percent, and we do support H.R. 11241 as passed by the House.

Senator JAVITS. Would you also make a distinction for us, for the record, between private nonprofit enterprises like the normal voluntary hospital and the public enterprises, or public establishments to which you refer? Is there a distinction? Would you want to deny the forgiveness to the nurse who works, let us say, at Mount Sinai Hospital in New York?

Dr. DOUGLAS, No.

Miss THOMPSON. No. They all would be given the forgiveness. Senator JAVITS. All are classed the same. When you use the word

"public," you mean open to the public?

Dr. DOUGLAS. Yes.

Senator JAVITS. You do not mean the method of financing. You use public in the sense of open?

Miss THOMPSON. No, the method of financing.

Senator JAVITS, Thank you.

The CHAIRMAN. Doctor, thank you for your statement. We certainly want to thank you for it.

Thank you, Miss Thompson. We are certainly very much obliged to you. Thank you very much.

Now Dr. James T. Howell, American Hospital Association.

Doctor, I note you are assistant administrator of the Henry Ford Hospital in Detroit. Is that correct, sir?

STATEMENT OF DR. JAMES T. HOWELL, CHAIRMAN, COMMITTEE ON NURSING, AMERICAN HOSPITAL ASSOCIATION; ACCOMPANIED BY KENNETH WILLIAMSON, ASSOCIATE DIRECTOR, AMERICAN HOSPITAL ASSOCIATION

Dr. HOWELL. Yes, sir.

The CHAIRMAN. How many beds do you have in that hospital, sir? Dr. HOWELL. 1,100.

The CHAIRMAN. 1,100. That is one of the largest hospitals in the country, is it not?

Dr. HOWELL. In addition, we have a very large outpatient department, with nearly 3,000 outpatient visits per day.

The CHAIRMAN. 3,000 outpatient visits per day?

Dr. HOWELL. Six days a week.

The CHAIRMAN. And 1,100 beds in the hospital?

Dr. HOWELL. Yes, sir.

The CHAIRMAN. I had a friend who was in your hospital quite a number of years ago, and I know how enthusiastic he was about the hospital and about the treatment that he received. I am sure you have a very high level of service.

Dr. HOWELL. Thank you, sir. We hope that we do.

The CHAIRMAN. I am sure that is true, too.

Well, Doctor, we will be happy to have you proceed now in your

own way.

Dr. HOWELL. Mr. Chairman, I am Dr. James T. Howell, associate director of the Henry Ford Hospital, Detroit, Mich. I am also chairman of the Committee on Nursing of the American Hospital Association. I am accompanied today by Mr. Kenneth Williamson, associate director of the American Hospital Association.

We appear here today in behalf of the American Hospital Association. We wish to express our great appreciation to this committee for the opportunity of presenting our views on H.R. 11241 and particularly our appreciation for your concern with the urgent national problem of providing nursing services to the American people.

This committee has, over the years, participated in the development of a number of far-reaching programs which have contributed immeasurably to the health and welfare of the American people. Proposals to provide new and improved health facilities, proposals for expanding medical research, proposals to move ahead in meeting the urgent needs of the mentally ill and the mentally retarded, and proposals to provide increased numbers of well-trained physicians, dentists, and others are among the important Federal programs which have been initiated by this committee. Several of these programs may well be dependent, in large measure, for their success upon the actions taken by you in respect to this legislation you are now considering. The availability of greater numbers of well-trained and well-prepared professional nurses is a necessary requirement to future health progress.

There are three types of basic educational programs which prepare registered professional nurses. The 3-year diploma programs, of which there are 875, operated by hospital schools; the 2-year associate degree programs, of which there are 84, provided by junior colleges; and 176 4-year programs provided by colleges and universities. The latter also provide the advanced training to prepare nurses at the masters and doctorate levels. All three types of programs are needed.

The great majority of graduating nurses, approximately 84 percent of the total, graduate from the hospital diploma programs. These schools are preparing the general bedside nurses in greatest number. A portion of these graduates go on to take advanced training and to secure degrees in collegiate programs. About 90 percent of nurse educators who hold graduate academic degrees received their basic training in the 3-year programs provided by the hospital schools.

The 2-year associate degree programs are relatively new. They are increasing in number. Some of the junior college programs are sponsored by private groups. The great majority, I believe, are

sponsored by units of government. The 2-year nursing educational program has not yet been in effect a sufficient length of time for complete evaluation.

The hospitals of the Nation are the primary employers of professional nurses. For years we have seen a situation developing where the number of professional nurses available is insufficient to meet the needs of patients. In part, this growing shortage has been alleviated through the development of ancillary nursing per sonnel. These are the nurse aids and practical nurses.

We have been very pleased with the assistance the Federal Government has given to increase the number of practical nurses through the vocational educational system. Only a few years ago, 5 of every 1,000 girls of 17 years of age entered the field of practical nursing and today more than 17 out of each 1,000 enter practical nursing. The ducation of practical nurses has improved measurably and they are meeting critical needs throughout the entire health field. Approximately 18,000 practical nurses were graduated last year. The projected figure in order to meet the future needs is 20,000 graduates per year.

Nursing aids who receive their training in hospitals together with practical nurses are performing many duties and services previously performed by professional nurses. The realinement of duties and the use of ancillary nursing personnel have enabled hospitals in many areas to continue to function in spite of an increased shortage of professional nurses. We now see increasing evidence of the effects of an insufficient number of professional nurses, and the staffing ratios indicate too heavy a proprotion of ancillary nursing groups to insure sufficient quality of care. Many people in the field believe we have reached a danger point where patient care will begin to suffer unless the shortage of professional nurses is remedied.

As we all know, the whole area of chronic illness and the operation of greatly increased numbers of long-term care facilities such as nursing homes is before us. There are now about one-half million patients in nursing homes. There has been considerable concern as to the quality of care in nursing homes and other long-term care facilities.

Great effort is being directed toward raising the quality of care in these facilities. For these efforts to be successful, it is necessary that the nursing services in nursing homes be under the supervision of professional nurses. This in itself is going to require a great increase in the number of professional nurses which must be available.

As we trace the whole spectrum of medical advances and changes in health care, we constantly come face to face with the serious question as to whether the public will have available to them the benefits of all such advances unless we greatly increase the number and improve the educational programs of professional nurses.

Then, of course, there is the problem of the increase in our population and the demands of this increase which will have to be met. As a basic premise, nothing we anticipate in the health field can result in any decrease whatever in the number of professional nurses that will be needed. In fact, it is the opposite for which we need to plan. We are pleased that H.R. 11241 recognizes the important role of the collegiate schools of nursing. We are dependent upon the collegiate programs to provide improved and increased numbers of