3. Accredited diploma programs are less costly than not-accredited diploma program The cost of nursing education programs varies inversely with the size of studen enrollment. A study of costs of nursing education conducted by the Research inc Studies Service of the National League for Nursing and published in 1964 provide dramatic evidence relating to cost, size of enrollment, and accreditation stats i the 126 diploma schools that participated in the study. The larger the progra the lower the annual cost per student and the greater the likelihood that the program is accredited.

1

Cost, enrollment, and accreditation status of 126 diploma programs included in National League for Nursing cost study

The numbers of associate and baccalaureate degree programs that participated in the cost study were toe small to provide comparable data.

4. Accredited programs have better prepared faculty

The educational preparation of the faculty teaching in accredited programs is better (as evidenced by the highest earned degrees) than that of faculty teaching in nonaccredited programs.

A. Highest earned credential of full-time nurse faculty employed in 195 accredited and not-accredited baccalaureate and higher degree programs as of Jan. 1, 1964

B. Highest earned credential of full-time nurse faculty employed in 82 accredited and not-accredited associate degree programs as of Jan. 1, 1964

C. Highest earned credential of full-time nurse faculty employed in 801 accredited and not-accredited diploma programs as of Jan. 1, 1964

5. A higher proportion of graduates from accredited programs enter nursing practice A higher proportion of the graduates from accredited programs than from nonaccredited programs pass State board examinations and are licensed to practice as registered nurses. It is only the graduates who are licensed and practice as registered nurses who swell the ranks of nurses to provide nursing service. Number of candidates and percent failing State Board examinations 1961-62

Nationwide it is usually accepted that the passing score on State board examinations is 350. For the years 1961-62, there were 31,409 candidates who took these examinations. While 4 percent of the graduates of accredited baccalaureate programs failed to pass these examinations at a first trial, 7 percent of the graduates of nonaccredited programs failed. For diploma programs 12 percent of the graduates of accredited and 22 percent from nonaccredited programs failed to pass. From the associate degree programs 6 percent of the graduates of accredited and 21 percent of the graduates of nonaccredited programs failed to pass these examinations to become registered for the practice of nursing.

Not only was there a greater proportion of failures from nonaccredited programs but the average scores on each of the five areas tested (medical, surgical, obstetric, pediatric, and psychiatric nursing) were lower for students from nonaccredited programs than for those from accredited programs.

The foregoing statement has presented characteristics of accredited and nonaccredited nursing programs that would substantiate the desirability of granting Federal funds to those schools that have national accreditation and to newly established programs that have reasonable assurance of meeting national standards. The designation of the National League for Nursing as the accrediting body recognized by the Commissioner of Education is warranted since the record of programs accredited by the NLN has demonstrated their ability to attract, maintain, and graduate the largest numbers of students; to recruit and retain qualified faculty; and to provide educational programs of good quality at lesser cost. Since it can be demonstrated that goodness of program is also associated with an increased number of qualified graduates, it is obvious that the public's money will reap the greatest dividends when it is invested in the students attending nationally accredited programs and in the schools conducting such programs.

Data in this statement have been obtained through questionnaire surveys of nursing education programs by the Research and Studies Service of the National League for Nursing.

Dr. BOYLE. I think I would just like to submit that statement and have it appear in the record, and then use this time to answer whatever questions you might have.

The CHAIRMAN. I am sure you have the answer to one question because I have asked it before and you are prepared.

Dr. BOYLE. Just informally, may I also say there are not many States like Alabama that can speak of the record of accredited programs that you have. You have a right to be concerned about our other States.

Now, let us go back to those 441 not accredited.

The CHAIRMAN. Yes, that is what we want to do.

Dr. BOYLE. I think we are most fortunate in having a program that can take care of the public. The schools are not all in the same category. Fifty-four of those are baccalaureate programs. One hundred of them are associate degree, and two hundred and eightyseven are diploma schools of nursing.

In the work at the league, the accrediting is governed by the same policies, but handled under three different departments. Last year the diploma department alone processed 129 for

The CHAIRMAN. You mean, you took final action on them when you say "processed"?

Dr. BOYLE. Final action was taken on 129 programs and they had to do it a little differently than before. Two boards of review were set up and met at the same time. The boards meet twice a year, and it is possible for the other departments to do the same thing.

Within a year's time the backlog could be handled as far as the league is concerned; whether those 441 would be ready for accreditation would be another question. But, were they ready, we could make accreditation possible.

The visits are made by people who are the peers of the schools being inspected. The boards of review are made up by peers for the diploma schools from other diploma schools, for collegiate from other collegiate schools, and for associate degree from other collegiate schools.

So their work pressures are not what they might seem, in that we have very responsible people in the schools responding to urgent need. We are delighted that you raised the question about accreditation. We now have a procedure in operation that would make it possible to give reasonable assurance that these programs can be accredited. The CHAIRMAN. So you think if they are ready they could be processed?

Dr. BOYLE. Those schools could be handled by the existing program within the year's time.

The CHAIRMAN. Within a year's time?

Dr. BOYLE. This is not a major problem. It is a heavy workload, but it can be done.

The CHAIRMAN. You think it could be done within the year's time?
Dr. BOYLE. Yes, if these schools brought in the information.
The Chairman. Senator Yarborough?

Senator YARBOROUGH. Referring to nonaccredited schools, looking at the records here I notice that a higher percentage of those failed than the accredited schools. Is there any discrimination against the graduates from the nonaccredited schools as contrasted with the accredited schools when they go before the State board? Do they get the same examination, the same exact treatment that a graduate of an accredited school would have?

Dr. BOYLE. Thank you for your question. The same examination is used throughout the country. It is administered by each State

board, and the passing score is set up by each State board. It is scored automatically at headquarters and the results are sent back to the States with no differential in treatment.

Senator YARBOROUGH. Is this a written or oral examination, or is it a practical examination?

Dr. BOYLE. These are written, objective-type examinations, covering each of the clinical areas of nursing.

Senator YARBOROUGH. You have a somewhat similar problem in law, in that you have people taking the bar exams who are graduates of law schools approved by the American Association of Law Schools, others taking the exams at the same time who are graduates of law schools not approved by the American Association of Law Schools, and a third type who studied in law offices. There are three categories in most States who take the bar examination, but it is one examination. So in these, it is your opinion that there is no discrimination in taking the exam between the graduate of an accredited school and a nonaccredited school?

Dr. BOYLE. That is right, because each of the schools is approved by the board in each State and may participate in the national accreditation program.

Senator YARBOROUGH. I mean in each State, does the State permit the taking of the examination only by graduates from nursing schools approved by that State authority?

Dr. BOYLE. Every nursing school must be approved by a State authority.

Senator YARBOROUGH. Regarding these are nonaccredited schools, the ones approved by the State authority, not meeting national accreditation standards. You do not feel that their work is up to standards set by your program; is that right?

Dr. BOYLE. The State boards set up minimal standards. The job for accreditation of NLN is nationwide voluntarily and has higher standards.

Senator YARBOROUGH. So your program is to raise the level of instruction in all the schools and to achieve excellence?

Dr. BOYLE. To work toward a nationwide standard of excellence. Senator YARBOROUGH. Some registered nurses have told me that the student nurses and practical nurses help out in combating the great shortage of nurses, but I have heard some adverse criticism of that by registered nurses in my State. They tell me that practical nurses and practical nursing programs, detract from what is required and what is done by the registered nurse.

They say that the practical nurses are not trained, but people confuse them with professional nurses and hire practical nurses where only a professional nurse should be employed. Do you have any comments on that?

Dr. BOYLE. The public is confused about our many types of nursing personnel. We need the practical nurses who are the graduates of the good schools.

Part of the confusion has been in our not using them as adequately as we might. They are essential.

Senator YARBOROUGH. Of course, they are needed particularly in nursing homes; are they not? There is a great demand there for practical nurses where you cannot furnish enough registered nurses.

Dr. BOYLE. They are needed in hospitals of all kinds, not just in the nursing homes. They are essential to us to help extend what the professional nurses are doing in caring for patients.

Senator YARBOROUGH. It is essential to have practical nurses supplementary aid?

Dr. BOYLE. It is very essential. It is an area in which we want a much quality as possible.

Senator YARBOROUGH. Now, does your National League for Nurs ing undertake any accreditation of standards for practical nurses, is yours limited to the professional nurses only?

Dr. BOYLE. The criteria for accreditation of practical nursing have been developed. The program will be in operation within this next year.

Senator YARBOROUGH. Is it a new program?

Dr. BOYLE. It is a new program of accreditation for the National League for Nursing.

Senator YARBOROUGH. To raise the standards of knowledge and skills of the practical nurses?

Dr. BOYLE. And to assure that nationwide there are minimum standards for the practical nurse that makes her a safe practitioner. Senator YARBOROUGH. Thank you. Thank you, Mr. Chairman. The CHAIRMAN. Senator Pell? Senator PELL. No questions.

The CHAIRMAN. Very well, Doctor. We want to thank you very much for your testimony. You answered some questions we were very anxious to have answered. We certainly appreciate it very, very much.

Dr. BOYLE. Thank you.

The CHAIRMAN. Thank you.

If there are no further witnesses, the committee will stand in recess. At this point we will insert in the records letters and statements from witnesses who were unable to appear.

(The material referred to above follows:)

PREPARED STATEMENT OF THE AMERICAN PUBLIC HEALTH ASSOCIATION ON H.R.

11241

The American Public Health Association appreciates this opportunity to support passage of legislation to increase the supply of professional nurse personnel in our Nation. Although our primary interest is in the supply of adequately trained public health nurses, it is realized that unless the aggregate of professionally trained nurses is increased all specialties of nursing will suffer proportionately. There are many new demands and challenges for public health nursing in the developing of new programs of all kinds in communities throughout our Nation. The need to provide nursing care in outpatient clinic facilities and to the sick at home becomes ever more important. We believe it important to point out that while there has been an increase in training, particularly of practical nurses and of some of the other personnel essential to the nursing program, that without an adequate number of professionally trained nurses the quality of care given to patients whether in hospitals, in clinics, or at home will necessarily deteriorate. The key to good nursing care is the presence of adequately trained and supervised personnel. In this case, it is imperative that support for collegiate training programs be kept strong and increased if possible because the supervisors and instructors for all nurse training programs comes from this source.

In addition, new programs and innovations in medical care bring new challenges. Special projects for the aging, nurse services to housing projects, new programs in mental retardation, and others are bringing their challenges to our supply of well trained nurse personnel. There is simply no question as to the need for more nurses for all positions in hospitals and out of hospitals; and the sooner this severe problem is attacked, the better are our chances to cope with it.