Expansion of educational programs for nursing in colleges and universities is impossible without immediate and substantial Federal aid.

Another very serious deterrent to expanding and improving nursing education and to improving standards of practice is the serious shortage of qualified teachers, administrators, and supervisors. We are very pleased that a 5-year extension of the traineeships providing for nurses preparing for such positions which was established under the Health Amendments Act of 1956 was approved by Congress recently. Part of this program includes traineeships for public health personnel, including nurses.

If we are to come near to meeting the present demands for nursing, let alone prepare for the future, the public must support nursing education at least to the same extent that it supports education for other essential professional services. There must also be increasing appropriations of public funds for research in nursing. All of the profession's efforts to improve nursing practice and to foster proper utilization of nursing skills depend upon enlarging our knowledge of the scientific bases of patient care, and upon our ability to experiment in finding ways to best utilize the skills of the various categories of nursing personnel.

Many programs of the ANA are directed toward improvement of patient care through improvement of the distribution of nurses to that care. Our work on defining functions and setting standards of practice, our efforts to advance nursing education, and the utilization of nursing skills, are all conducted in the light of the major health problems of the Nation, including the problems of the aged.

The ANA works closely with the National Federation of Licensed Practical Nurses in its efforts to improve practical nursing and increase the number of licensed practical nurses. The trained practical nurse plays an important part in nursing services for the aged where she can perform many of the simple acts of care, and thus relieve the professional nurse for those functions which require her judgment and skill.

A major concern of our State nurses associations is the continuing improvement of licensure designed to protect the public from unsafe practices in nursing through the establishment of minimum legal requirements for nursing practice. In recent years, the profession has had to work hard to maintain such protection for the public and the qualified nurse. State legislatures should move with great care when they are asked to lower the legal standards of nursing. Rather than lowering the standards for nursing, State governments should move to raise the standards of the institutions in which patients are cared for. Much needs to be

done, especially to improve the regulation of so-called nursing homes.

Nursing is the largest and most complex of the health professions and its services are vital to the prevention and treatment of disease and injury in any age group. Our special concern for the problems of the aged is manifest in all that is done to improve nursing service for the public.

In addition to its own programs and activities, the ANA works with other organizations and with government agencies when opportunities arise for joint effort in the health care of the aged.

On behalf of the American Nurses' Association, I would like to thank the committee for this opportunity to appear and present our views on this subject. The American Nurses' Association will be pleased to assist this committee in any way possible.

Senator MCNAMARA. You may proceed in your own manner.

Miss THOMPSON. Mr. Chairman and members of the subcommittee, I am Julia Thompson, the Washington representative of the American Nurses' Association, and we welcome this opportunity to present and discuss with you the problems of the aged and the aging which come within the scope of the association's activities.

We realize, of course, that the subject of your inquiry includes many social and economic problems. One of the major ones, we believe, is that of the health care for the aged and it is to certain aspects of this problem that we will confine our comments.

It is generally agreed that the health problems of persons 65 years of age and over are serious ones, since it is the long-term and chronic diseases to which this group is most subject. The increasing number of aged persons in our population and the facts that persons of this

age usually are less able to pay the costs of such illness, of course, add to our concern with this problem.

The American Nurses' Association believes that this committee would find it worthwhile to study the possibilities and needs for the expansion, improvement, and extension of methods of providing health care to aged persons in their homes as a partial solution of their needs. We realize, of course, that there is a need for more hospital facilities, but we believe that more hospital beds alone are not a solution for the health problems of persons 65 or older.

Another area which must receive attention in our efforts to provide adequate health care for this group is the very serious situation now existing in many so-called nursing homes. A marked improvement in standards of care must be made if these facilities are to serve their purpose in meeting needs of our aged population for nursing care.

At the present time there is no classification system which establishes the kind of care which is to be given in the home, and the cares extend from custodial to skilled nursing care. When skilled nursing care or nursing care is offered, then there should be a professional nurse in this nursing home. But we find that many of them they operate without any personnel who have any background in nursing. Public health nursing agencies are finding that more and more of their visits to patients are made to aged persons with long-term illnesses. We mention this not only because it indicates a need for such service, but to point out that the only method of providing such service, by and large today, is through visiting nurse services, which exist mainly in the large urban areas. Small urban centers and rural areas have few facilities for the care of patients at home. In a few instances such service is supplied by local health departments, and there is evidence of a trend in this direction although we cannot support this statistically. We do know that in 1957 there were 807 local nonofficial public health agencies in this country. Local nonofficial agencies usually are visiting nurse services which are not supported by public funds. There were also 97 local combination agencies. These are local health departments which usually include a visiting nurse service.

In reports of a number of visiting nurse associations we find that a large number of nursing visits are made to patients in the older age brackets.

For instance, in 1958, in Detroit, they reported that 16.4 of its patients were 65 years of age or over. The Visiting Nurse Service of Rochester and Monroe County, N.Y., has studied the age range of their patients and found that in 1950, 34 percent were over 65, an increasing number in 1954, and in 1958, 44 percent of these patients were over 65, and these patients received 52.7 percent of the total visits made. The VNA of New York reported that in 1958, 25 percent of their patients were 65 or older and this group received 50 percent of the visits.

Then I would like to quote a paragraph from the 1958 annual report of the Chicago VNA, which I think very succinctly summarizes the problem. I quote:

Our records reflect an ever-changing health picture in the community. The senior citizen is receiving most of the nursing care; 71,822 visits were made to patients over 65 years of age. This is 38 percent of our total visits. Fifty-seven 47461-59

percent of our visits went to patients over 45 years of age. Most of these are patients who have some form of crippling disease which requires long-term nursing care. In addition to the physical problem, these people have many social, nutritional, and emotional needs. The problems of this group of the population are partially the result of the change in attitudes and institutional patterns of society. Formerly the aged formed an integral part of the family organization. Today more and more older people live apart from families-often alone. Alteration in family living conditions and shrinkage in family living quarters have left no place for the aged.

A number of studies have been done on various ways of providing nursing care to patients. Some have been on the extension of hospital care, the rearrangement of hospital services and facilities into units providing care for patients depending on the type of nursing needed, and the financing of home-care nursing visits as a part of hospital insurance.

We have not listed these studies here but we will be glad to furnish the names of some of them for the committee if they would so desire. Senator MCNAMARA. We would appreciate it, if you will.

Miss THOMPSON. All of these studies contribute to our information and should provide some guidance in the extension of home-service care which would reduce the number of patients in institutions.

Community services would have to be created and organized in many areas and adapted to the local situations to bring home-care services to more people. Such things as the needs, population, and finances should be considered. Such an effort would probably require participation of local, State, and Federal Governments, as well as voluntary cooperation.

The ANA believes that nursing service should be an integral part of any prepaid medical care plan whether under governmental or voluntary auspices. We now have a committee at work on guiding principles for the inclusion of nursing benefits in such plans. The inclusion of both private duty and public health nursing service as a benefit of health care plans would do much to make home nursing care more readily available to the aged.

In one study that was done in New York by the Associated Hospital group, in several selected hospitals, it was found much less expensive to provide prepaid nursing care in the home under Blue Cross insurance than it was to pay for the care in the hospital.

Since visiting nurse services provide nursing care free in many cases and visits to aged patients appear to be increasing, payment through insurance coverage would help extend such service which is limited by the present income of these agencies.

The ANA recently testified before the House Ways and Means Committee in favor of providing health insurance coverage to OASDI beneficiaries. We filed a copy of that statement with the letter which we wrote to the committee. This position was taken by the ANA house of delegates at its June 1958 convention.

The most frequent and important service provided by home-care programs is bedside nursing and the attendant health care teaching, which is a major part of such nursing. Other important services should also be included, such as homemaker services, social casework, occupational and physical therapy, and nutrition. Home-care programs benefit all groups in the population, but they are particularly suited to meeting many of the health-care needs of the aged. Along with the suggestion that this committee study the need for increasing and expanding care in the home goes the full realization that today

personnel shortages in the health professions, particularly nursing, make this almost impossible.

There has been a great deal of emphasis on the need for building additional hospital and nursing-home facilities. There are several Federal-grant programs to provide financial assistance in this area. However, we believe not enough attention has been paid to the need for personnel to staff such facilities. Additional buildings and beds without qualified health personnel are useless.

On the next page we summarize some of the things that we believe can be and should be done in terms of providing health care for persons in any kind of facility or in their home.

At the present time bills are now pending before both Houses of Congress which will assist in meeting these needs, particularly for

nurses.

In addition to that we are very pleased that the Congress has seen fit to extend the traineeship program for another 5 years and just this last week the Senate has now approved the financing of these programs, and we hope that the House will concur in your recommendation.

If we are to come near to meeting the present demands for nursing, let alone prepare for the future, the public must support nursing education at least to the same extent that it supports education for other essential professional services. There must also be increasing appropriations of public funds for research in nursing.

So that we may be able to provide studies which will help us to best utilize the skills of various categories of nursing personnel.

Many programs of the ANA are directed toward improvement of patient care through improvement of the contribution of nurses to that care. Our work on defining functions and setting standards of practice, our efforts to advance nursing education and the utilization of nursing skills, are all conducted in the light of the major health problems of the Nation, including the problems of the aged.

The ANA works closely with the National Federation of Licensed Practical Nurses in its efforts to improve practical nursing and increase the number of licensed practical nurses. The trained practical nurse plays an important part in nursing services for the aged where she can perform many of the simple acts of care. We are helping them to understand their roles so that they may relieve the professional nurse for those functions which require her professional judgment and skill.

A major concern of our State nurses associations is the continuing improvement of licensure designed to protect the public from unsafe practices in nursing through the establishment of minimum legal requirements for nursing practices.

In recent years, the profession has had to work hard to maintain what we had aready attained, and we will have to continue to work to maintain our standards that we have. State legislatures should be very careful when they are asked to lower legal standards of nursing. Rather than lowering the standards for nursing, they should raise the standards of the institutions in which patients are cared for. Much needs to be done, especially to regulate the so-called nursing homes. We have had instances in several States this last year where there have been attempts to amend nursing practice acts, so that persons working in nursing homes would be eligible to continue to work in these homes. At the present time they are not because they do not

qualify under the licensing laws for nursing homes; now under the nursing practice acts.

Nursing is the largest and most complex profession, and its services are vital to the prevention and treatment of disease and injury in any age group. Our special concern for the problems of the aged is manifest in all that is done to improve nursing service for the public.

In addition to its own programs and activities, the ANA works with other organizations and with Government agencies when opportunities arise for joint effort in the health care of the aged.

On behalf of the American Nurses' Association, I would like to thank the committee for this opportunity to appear and present our views on this subject.

The American Nurses' Association will be pleased to assist this committee in any way possible.

And I will try to answer any questions that you have.
Senator MCNAMARA. Thank you, Miss Thompson.

You mention on page 2 a very serious situation in many so-called nursing homes. Do you have any quick description of what a nursing home should consist of by way of facilities and staff?

Miss THOMPSON. It would depend a great deal on how they are classified, whether they are to give purely custodial care to the person who has no place to live and needs someone to look at their physical and nutritional needs, or whether this home is established to give the kind of care which we would call skilled care.

There are, I believe, 15 States that have now some very limited description of the kinds of persons who should be working or the qualifications of the persons who should be working in these homes. A great deal needs to be done in clarifying the types of homes and deciding the qualities of the personnel that should be employed in order to carry out the functions of that home.

Senator MCNAMARA. We agree it is hard to generalize.

Miss THOMPSON. That is correct.

Senator MCNAMARA. Senator Clark, have you any comments or questions?

Senator CLARK. No questions.

Senator MCNAMARA. Senator Randolph ?

Senator RANDOLPH. No, Mr. Chairman, except to compliment Miss Thompson on her realization that those in the nursing profession are alert, qualified, and most cognizant of the problem of the need for improved nursing qualifications.

I think you have quite a challenge and I know you will help us in this special field.

Miss THOMPSON. We will do our best.

Senator MCNAMARA. Thanks very much. Your testimony has been very helpful.

Miss THOMPSON. Thank you.

STATEMENT OF RT. REV. MSGR. JOHN O'GRADY, SECRETARY, NATIONAL CONFERENCE OF CATHOLIC CHARITIES

Senator MCNAMARA. Now, our last witness today is from the National Conference of Catholic Charities, Msgr. John O'Grady.

Monsignor O'Grady, we are sorry that the hour is so late. I see that you have a comparatively short statement and we will ask you to proceed in your own manner.