Private Duty Nursing
Jean C. Whelan, PhD, RN
When hospitalized, most Americans expect they will receive nursing care from a registered professional nurse paid for and supplied by the hospital. This assumption is correct. Twenty-first century American hospitals employ large staffs of registered nurses (RNs) who meet specific educational, professional, and legal requirements. This, however, was not always the case. In the late-nineteenth and early twentieth centuries, hospitals did not employ a regular nursing staff but rather used a system of care delivery called private duty nursing. This essay explores this system.
What Was Private Duty Nursing?
Private duty nursing was the employment of nurses by individual patients for the delivery of care. Patients hired their own nurse, who cared for them either in their homes or in the hospital. Patients paid the nurse for her services with cash, based on a predetermined fee. The nurse, generally employed for the duration of an illness, cared for only one patient at a time. In essence, the private duty nurse delivered highly individualized care to paying patients for as long as a patient needed and could pay for the nurse's services.
Why a Private System of Nursing Care Delivery?
The private duty nurse system replicated and continued patterns of nursing care delivery established earlier in the nineteenth century. When illness struck nineteenth century American households, it was typical for families that could afford to do so, to hire a nurse to care for the sick family member. Employing a nurse relieved patients' families of much of the responsibility of what was often a very burdensome and time-consuming duty: observing the patient, carrying out treatments, and being available at all times. Prior to the availability of trained nurses, many families employed individuals who hired out as nurses, much as people hired their own domestic staff or even their own physicians. Founders of the professional schools of nursing established in the late nineteenth century envisioned that their graduates would follow the tradition of delivering private home care. In fact, a major purpose of the early schools of nursing was to prepare students to enter the private nursing market both as a means of spreading the benefits of professionally trained nurses, which the proponents of training schools believed to be increasingly essential to patient care, and of providing a respectable and remunerative occupation for young women.
Why didn’t hospitals just hire trained nurses?
Late-nineteenth and early-twentieth century hospitals displayed great reluctance to hire graduates of the early nurse training programs. As more and more hospital affiliated schools of nursing opened up throughout the country and it became common to use student nurses to deliver care on the wards of hospitals, institutions recognized the benefits of exploiting a student-centered nursing care system. Student nurses were much cheaper than nurses already graduated, costing the hospital only the funds required to house and feed them and to provide them with a small stipend during their training period. Students were also easier to control than older graduate nurses and could be utilized in any way the hospital deemed necessary. Hospitals frequently assigned student nurses not only to patient care but also to non-nursing jobs within the institution. And, hospital administrators also felt reassured that even though the population of students changed every two to three years as students graduated, the number of students available to be used as staff remained relatively stable. Moreover, if a hospital needed more nurses, they could simply admit more students.
Some hospitals did hire graduates of their nurse training programs, but the number of trained nurses employed by hospitals was small and was usually limited to the brightest students, thought ready to take on such supervisory positions as head nurse once they graduated. The majority of nurses, once they received their diplomas, entered the private-duty market.
What Was the Private Duty System Like?
A nurse who became a private duty nurse first needed to publicize her availability for work. In areas with small populations, this might be as simple as just letting her neighbors or the local doctor or druggist know that she was ready for work—the equivalent of “hanging out a shingle.” In large towns and cities, a more complicated system developed, which involved setting up a private-duty-nurse infrastructure designed to connect patients with nurses and nurses with patients.
The primary element of this infrastructure was the private duty registry. Private duty registries were agencies that served as third parties bringing patients and nurses together in time of need. A nurse signed up, or “registered with” a registry, indicating the times she was available for work and the types of patients she would accept. Patients requiring a nurse would notify the registry, which in turn sent out an appropriate nurse to the patient.
Several types of private duty registries existed including commercial agencies, which placed nurses with patients for a profit and operated in major cities throughout the United States, and physician run nurse registries, which benefited local medical societies. Hospitals however operated the most common type of registry. Hospitals that ran nurse training programs found it convenient to operate a private duty registry from which they could send out graduates of their schools to nurse home-bound patients or to assign nurses to patients within the hospital who desired the personal care provided by a private nurse or whose medical condition required close monitoring and observation.
In hospitals that operated a school of nursing, the school’s alumnae association sometimes controlled the hospital’s registry. The alumnae of the school held a stake in seeing that the registry worked to the nurses’ advantage as it was the registry that set the rules and regulations of private duty nurses’ work. Registries controlled or had tremendous input into important employment matters such as the fees nurses charged, the numbers of hours nurses worked, and the ways by which nurses were selected for patient cases. In many cases, the alumnae excluded graduates of other schools from their lists of available nurses. Because a registry played such a critical role in organizing nurses’ work, groups of nurses in some areas banded together to own and operate registries. Nurse-owned registries, many of which were operated by professional nurses associations, flourished in the early decades of the twentieth century in large cities throughout the country and provided nurses with a significant amount of control over their day-to-day working conditions.
What Did Private Duty Nurses Do?
Private duty nurses took care of only one patient or "case" at a time, providing complete care to the patient. In the early years of private duty, when most patients were cared for at home, the nurse traveled to the patient’s house and moved in for the duration of the illness. The nurse was responsible for care on a twenty-four-hour, seven-day-a-week basis. She slept in the home, carried out patient treatments and physician’s orders, and delivered all required aspects of nursing care. As more and more patients began to use hospitals in the early twentieth century, private duty nurses followed them there. Initially, nurses following the traditional custom of private duty, moved into the hospital with their patients, often sleeping in the same room as the patient, and delivering care around the clock. However, providing sleeping arrangements for private duty nurses in the hospital created numerous problems and hospitals viewed with disfavor the twenty-four-hour workday. By the 1920s, many private duty nurses substituted twelve-hour shifts in place of long, tedious twenty-four-hour ones. This provided the nurse with more rest time, but it raised the cost of nursing care to patients considerably, as patients who desired or needed twenty-four-hour care had to hire two nurses in place of one.
What Was the Cost of Private Duty Care?
Rates charged by nurses varied over time. Around the turn of the century, nurses in large cities charged approximately $25 a week for round-the-clock care. In small towns and rural areas the rates were lower. Rates increased over the course of the first three decades of the twentieth century, with typical fees for private duty nurses in large cities averaging about $6–$7 per twelve-hour shift by the end of the 1920s. Once the Great Depression began and wages across the country plummeted, nurses' fees dropped precipitously. Additionally, fewer patients had the financial resources to pay for private nursing care, so nurses received fewer requests for their services.
Private duty nursing fees were problematic on several counts. The expense of private nursing care restricted nurses only to patients with considerable financial resources, particularly if the illness was of long duration. This reduced the number of people actually receiving professional nursing. The amount of money a nurse could earn was also limited. Since they cared for only one patient at a time, the only way nurses could increase their earning was to either raise their fees or take on more cases. Significant tensions developed between nurses who wanted incomes that kept up with the cost of living and other interested groups who believed nurses' fees should be low enough to keep the costs of illness down and allow more patients to hire private duty nurses.
What Were the Advantages and Disadvantages of Private Duty Nursing?
Private duty has been portrayed as both an arduous, at times demeaning, occupation with few financial rewards and as an independent nursing practice well liked by those who practiced it. In the early days of private duty, when most nurses cared for patients in their homes, the private duty nurse occupied a position somewhere between a domestic servant and a trained technician. Nurses often complained of unbearable treatment from families who expected them not only to provide nursing care but also to do household labor. In addition, the episodic nature of the work failed to offer nurses job stability or reliable incomes.
Private duty nurses were theoretically free to work when they wanted and under conditions of their choosing, an aspect of the job many nurses found appealing. In addition, they could accept or refuse patients based on their own preferences. However, nurses were pressured by registries and hospitals, which needed to provide nurses to all patients, to limit personal preferences concerning the type of patient they would take or the hours work. Moreover, while some nurses who may not have needed or wanted full-time employment, benefited from the intermittent aspects of the job, others suffered financially when patients were in short supply. For some nurses, private duty was a flexible job that fit into their lifestyle; for others it was a poor substitute for full-time, dependable employment.
What Happened to Private Duty Nursing?
By the end of the Great Depression, private duty nurses faced significant challenges. As the economy stabilized and the build-up to World War II led to monetary gains for millions of American workers, nurses were left behind financially. During the Depression, nurses unable to maintain a living in the shrinking market for private duty sought out jobs in hospitals. Hospitals recognizing the desperation of nurses for work and experiencing their own fiscal difficulties frequently employed nurses as general duty nurses, the equivalent of today’s staff nurses, often at very low salaries. In many cases, hospitals did not offer nurses full time jobs, but rather employed them temporarily in per diem positions, which were positions designated for only specific time periods, sometimes as short as a day. In this way, hospitals kept their costs down by not assuming the responsibilities of a regular full-time staff yet receiving the benefits of an adequate number of nurses as patient needs required. Nurses expressed much dissatisfaction with this system, and many remained committed to the private duty field.
Events worked against a resurgence of private duty after the Great Depression. As more and more nurses gained experience working as general duty nurses, working on hospital staffs became more normative. Several changes in the ways in which hospitals employed nurses made hospital employment appealing to newly graduated nurses. For example, beginning in the late 1930s many hospitals reduced the nurses' work periods from twelve to eight hours. In addition, requirements that employed nurses live within the hospital grounds were gradually relaxed. As working conditions in hospitals began to resemble those found in other industries, working as a staff nurse became increasingly more attractive for nurses. And, many nurses welcomed assignment to several, rather than one, patient as providing more interest and variety in their work.
Hospitals also developed a new view of the value of private duty nursing. In the early decades of the century, hospitals could count on a number of patients hiring private duty nurses thus relieving the hospital of the burden of caring for all their patients and reduced their nursing budgets. During the 1940s, however, hospitals viewed private duty nursing with less favor. Severe shortages of nurses plagued American hospitals in the post-World War II era. Hospitals, which now relied on professional nurses for modern patient care, coveted all nurses for their own institutional needs. The one-to-one nurse-patient ratio typical of private duty was seen as wasteful of precious professional nurse resources. Staff nurses, assigned to many more patients than private duty nurses, offered hospitals an easy means of stretching scarce nursing resources. The independence displayed by private duty nurses who could pick and choose when they wanted to work and for which patients they wanted to care threatened hospitals' control over nursing practice, a practice that hospitals increasingly wanted to dominate.
By the 1950s, private duty nursing was in a steep decline, and few new nurses chose private duty practice. However, the need for the close personal care delivered by private duty nurses did not disappear. Hospitals began developing alternative arrangements, such as intensive care units, for those patients requiring constant observation. This did not replace the private duty system, but it did mimic the one nurse–one patient ideal, at least for critically ill patients. Later, in the 1970s, nurses initiated nursing care delivery schemes such as primary nursing—the assigning of a specific nurse to each patient for overall coordination of care —which attempted to replicate the close nurse-patient relationship found in private duty nursing.
What is the Status of Private Duty Today?
Although the term private duty nurse seems almost an anachronism today, the tradition of hiring a nurse for close monitoring and personal care of the sick continues. In many hospitals, a patient or family member may request a private duty nurse. Hospital insurance plans often cover the services of a nurse when required. There are several reasons patients may employ their own nurses. Publicity concerning nurse shortages often motivates patients to hire a nurse who they know will be always available for their needs. In some cases, family members feel more secure knowing that a nurse is watching over their hospitalized loved ones.
Nursing care patterns used in caring for severely ill individuals at home replicate private duty nursing in many respects. Many patients who receive such high-technology treatments as ventilator care in their own homes require the service of a professional nurse on an individual basis. In many cases, nurses are in the home providing constant twenty-four-hour care. These nurses, called home health care nurses, are sent to the home via a professional home-care agency or nurse supplemental staffing bureau and may not consider themselves private duty nurses per se. Yet, they do in fact provide the direct, close, personal, one-to-one nurse-patient relationship that characterized private duty nursing care. They personify the modern equivalent of private duty nursing.
Even physicians have gotten into the act of private care. There currently exists a small but growing movement called “boutique medical practices” in which physicians contract with small numbers of patients to be available at all times for delivery of medical services. Patients wealthy enough to hire such physicians find the personal care delivered beneficial, efficient, convenient, and comforting.
Private duty nursing was the major means through which American patients able to afford it received professional nursing care in the first half of the twentieth century. Alternative versions of it exist today in a variety of health care settings. While the expense of private duty nursing limits its use to cases for which either insurance reimbursement covers its cost or to patients with the financial resources to pay for it, the benefit of having close personnel nursing care remains the ideal which many prefer in making their nursing care arrangements.
Reverby, S. (1987). Ordered to care. The dilemma of American nursing. Cambridge: Cambridge University Press.
Whelan, J. (2000). Too many, too few, the supply, demand, and distribution of private duty nurses, 1910-1965. (Doctoral dissertation, University of Pennsylvania, 2000). Dissertation Abstracts International, 61, (03), 1332. (UMI No. 9965594).
Whelan, JC (2004). ‘A necessity in the nursing world’: The Chicago nurses professional registry, 1913-1950. Nursing History Review, 13, 49-75
Jean C. Whelan is Adjunct Assistant Professor of Nursing, University of Pennsylvania School of Nursing and Assistant Director of the Barbara Bates Center for the Study of the History of Nursing.