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  “Where Did All the Nurse Go?”: Mid-Twentieth Century Nurse Shortages, Causes, Solutions, and Continuing Problems

Jean C. Whelan, PhD, RN 

 

In the mid-1930s, reports of an emerging nurse shortage began surfacing throughout the United States. Many in the health-care field greeted news of this shortage with surprise. After all, the country was still suffering from the financial devastation of the Great Depression. Unemployment rates for registered nurses had climbed dramatically during the early years of the depression, and hospitals found it relatively easy to secure nurses, who were always in plentiful supply. It seemed almost unbelievable that nurses would become scarce. Yet, by 1936, many hospitals were reporting severe shortages of nurses. [1] Astonished by the speed and intensity with which the shortage appeared, hospital administrators wondered, “Where did all the nurses go?”

This mid-twentieth-century shortage, which lasted into the World War II years and beyond to the 1960s, was one of the first in a series of nurse shortages that plagued the U.S. health-care system over the next five decades. The story of this shortage illustrates the characteristic ways in which nurse shortages have developed and the classic solutions that have been used to address them. Each nurse shortage is unique, a function of the particular social, economic, technological, and cultural context in which it occurs. At the same time, however, nurse shortages tended to demonstrate remarkable similarities, both in the reasons for which they occurred and in the strategies selected to address them. 

Health care and nursing leaders used a trio of strategies to deal with this mid-twentieth century shortage of nurses.  The first was to increase the supply of nurses by increasing the number of students admitted to nursing schools. The second was to increase the use of less educated and trained personnel either to substitute for or to extend the work of professional nurses. The third was to shorten the educational period for nurses to produce not just more nurses, but nurses in a faster manner.

As periodic nurse shortages persisted into the century’s later decades, health care policies continued to promote these methods. The three strategies in and of themselves continued to be very successful at what they intended to do. The number of nurses in the U.S. labor force increased substantially during the twentieth century as did the variety of nurse assistive personnel employed in health care. Yet, at the same time, the country also failed to avoid repeated nurse shortages. This suggests we question strategies that prove successful in their goals but disappoint in the long-term. Exploring alternative tactics that received less attention in the past might provide better solutions to nurse shortages.

The Beginning of the Shortage

Nurse shortages are complex phenomenon the result of many interacting factors. Most nurse shortages occurring in the twentieth century were demand-driven shortages related to increased utilization of registered nurses. This is exactly what happened in the mid-1930s, when several technological, economic, and health care-related events combined to increase the demand for registered nurses and to lay the groundwork for a shortage.

During the 1930s, increased hospital use, changes in hospital construction, more technologically complex patient care requirements, and a reduction in the working hours for nurses all necessitated an increased number of nurses to deliver bedside care. [2] By mid-decade, reports of a shortage of nurses, described as most severe in the acute-care hospital sector, began appearing in various parts of the country and increased throughout the later years of the decade. [3] Unaccustomed to dealing with nurse shortages, hospital administrators reacted slowly to the situation. Some blamed nurses themselves for creating the shortage by failing to live up to the ideals of their profession and refusing to work. [4] By the time the United States entered World War II, signs that the country faced a critical problem were too obvious to ignore. 

Wartime Nursing Needs 

At the time of the U.S. entry into the war the immediate need was for nurses to serve in the armed forces. Contemporary inventories of registered nurse supply indicated that a sufficient number of active and eligible nurses were present in the workforce to meet military needs. [5] By war’s end, over 77,000 nurses, joined the military services. But removing what was then about 25 percent of the nurse population for the war effort severely compromised the nursing needs of the civilian population. [6] 

A proactive response was required. Adopting practices used in the past to deal with shortages, hospitals directed their efforts at expanding the nurse educational system as the primary means of maintaining adequate nurse services. The nurse educational system in place in the United States in the 1940s was the traditional apprenticeship type of training in which hospital-based schools of nursing took in students, teaching them the rudiments of the profession while at the same time using them to deliver the majority of patient care. A vast number of hospitals in the country, approximately 1,300, operated schools of nursing and depended heavily on students for bedside nursing care. Hospitals hoped to alleviate the shortage of nurses by merely admitting more students.

This time, however, the strategy posed a considerable challenge for the hospitals. The traditional population of nursing students: young, white females with a secondary school education, was exactly the same group heavily recruited by war-related industries. For those eager to help the war effort immediately, the three years required before a young woman graduated from nursing school was a disincentive. Further, discrepancies between working conditions for nurses, such as low salaries, long hours, and requirements that nurses live within hospital grounds, and working conditions for other occupations made nursing a less attractive field for young people to consider.

The Government Steps In

In the early years of the war, the federal government provided a small amount of money to subsidize some nurse education activities. When the programs supported by these funds proved ineffective at increasing the number of student nurses, Congress enacted a more extensive federal nurse education program. The 1943 Bolton Act created the Cadet Nurse Corps, a program that ran through to 1948. The act provided $160 million for nurse education funding and financial support for nursing students, a much larger amount of federal money for both students and hospitals than had previously been allocated. Students enrolled in the program received a free education as well as a monthly stipend and uniforms. The intent of the Cadet Nurse Corps was specifically to maintain nursing services to hospitalized patients by increasing the number of students within nursing education programs. Students were not required to serve in the military. Including a requirement that participating schools reduce the length of the educational period raised expectations for meeting the goals of the program, which was to produce more nurses, quickly. Over 160,000 students took part in the Cadet Nurse Corps that was considered contemporarily a huge success. After the war, estimates were that in hospitals associated with a school of nursing, students provided about 80 percent of the in-hospital patient care delivered during the war years. [7] 

 

Licensed Practical Nurses and Other Assistive Nurse Personnel

A second tactic employed during the war years was to increase the use of licensed practical nurses and nurse aides as nursing assistive personnel in civilian hospitals. Licensed practical nurses, or LPNs, were nurses educated in short programs—generally about a year in length—who carried out basic nursing care under the supervision of a registered nurse. The licensed practical nurse movement began in the late 1930s and became more formalized during the 1940s. Many in the health-care field, believed that the availability of a group of less highly educated nursing personnel would solve many problems, and they greeted the entry of LPNs into hospital care with enthusiasm. The short training programs for LPNs, appealed to hospital administrators who wanted more nurses fast. The lower cost associated with educating LPNs added to their attractiveness. Since educational requirements for admission to LPN schools was less stringent than that of registered nurse programs, some believed LPN programs would attract a wider population of students and add substantial numbers to the nurse workforce. [8] 

Nurses aides were another group of workers heavily relied upon during World War II. The use of some type of nurse assistive personnel, such as ward maids, nurse aides, and orderlies, was common practice in early-twentieth century hospitals. During the war the use of nurses aides—both those who worked in a voluntary capacity and those who were regular hospital employees—increased dramatically. Hospital administrators found nurse aides particularly appealing to employ because of their low costs and flexibility. Nurse aides received training enabling them to be moved around the hospital as needed and assigned to a variety of functions. The training period was short; from as little as a few hours up to six weeks. Because nurse aides were unlicensed, hospitals felt free to use them as they saw best. [9] Although intended to extend the work of nurses by serving in an assistive capacity, both LPNs and nurse aides were frequently, and often inappropriately, used as nurse substitutes. [10] 

The Post-World War II Shortage

Once the war was over, health care and nursing leaders, expected that nurses released from the military would resume their prewar jobs and that the nurse shortage would cease. This did not happen. In fact, not only did the shortage continue, but it also increased in severity. For a number of reasons, nurses who had served in the military failed to return to their former positions, and hospitals spent much of the late 1940s engaged in a continual battle to staff nurse-poor hospitals. 

At the same time, as nurses seemed to be shunning hospital work, postwar nurse demand skyrocketed. Increased hospital utilization rates, a trend evident from the late 1930s, continued. In the four-year period between 1946 and 1952, hospital admission rates rose 26 percent. The 1946 Hill-Burton Act, a federal act that funded hospital construction, increased and expanded hospital facilities considerably. Moreover, as was typical with previous nurse shortages, the escalating technological needs of patients and further reductions in the working hours of nurses also fueled a greater demand for professional nurse services.   

Complicating the situation was a slowdown in the number of new entrants into the profession. During the war, admissions to schools of nursing climbed, the result of the Cadet Nurse Corps program. But once, federal monies for nurse education ran out, less incentive and support existed for both hospitals and the profession to attract large numbers into the profession. Enrollments in schools of nursing fell from a high of 129,000 in 1946 to a low of 99,000 in 1949. [11]

Efforts to deal with the post-war shortage followed familiar patterns set in the early 1940s. Student recruitment programs flourished and widespread use of assistive personnel increased. Indeed, a redefinition of the primary role of the registered nurse in patient care evolved. Registered nurses, formerly seen as the main providers of patient care, were instead viewed as a scarce resource better utilized as supervisors of other lesser trained personnel who actually carried out the majority of bedside care. Estimates of the proportion of patient care provided by professional nurses declined from over 70 percent in 1941 to only 30 or 40 percent in 1951.  

Concern over the depth of the nurse shortage stimulated the U.S. Department of Labor, to conduct a study examining its causes. This 1947 investigation, entitled the “Economic Status of the Registered Professional Nurse,” confirmed a rising demand for nurses at the same time the profession was experiencing a loss of practicing nurses and declining student enrollments. Findings of the study indicated that there were insufficient economic incentives either to attract a large number of new recruits or to keep experienced nurses in the profession. Nurses identified the lack of retirement pensions, a low rate of pay, and limited opportunities for promotion as sources of major dissatisfaction with their jobs. One nurse who took part in the study forcefully described the economic situation facing nurses: “As it stands today nursing offers only enough to cover the bare essentials of living with no chance to save for the future or for emergencies. It is obvious that a nurse cannot live on the gratitude of patients; she must have sufficient income.” [12] The study concluded that poor working conditions, such as low salaries and long hours for nurses affected workforce participation at two points. The first was at the entry level, discouraging young women from choosing nursing as a career. The second was within the workplace where the employment conditions deterred many from continuing to work once they married. [13]

The idea that nursing was a difficult job with few financial rewards was hardly breaking news. Studies completed on nursing in 1923, 1928, and 1936 had repeatedly documented the poor working conditions and inadequate compensatory schemes under which most nurses were employed. [14] Given the consistent findings of the 1947 investigation, it seemed obvious that efforts to improve employment conditions for nurses would lessen the shortage. This presented a logical course of action. And key among those improvements was higher wages. 

Hospitals however did not follow this logic. Instead, relying on familiar tactics, hospitals continued to put their efforts into recruiting new students into nurse education programs. To deal with the immediate problem of care delivery, they continued wide-scale use of assistive personnel.

Not surprisingly, the shortage persisted. In fact nurse shortage conditions existed well into the 1960s. At that point the federal government again took action, passing the 1964 Nurse Training Act intended to increase the supply of nurses by providing significant funding for nurse education. [15] A noticeable rise in the number of nurses followed. While it is tempting to connect larger numbres of nurses in the workforce to the effects of the Nurse Training Act, it is also presumptuous. Several analysts have attributed the increase in working nurses not to an increase in the number of nurses, but rather to rising wage rates for nurses. In the late 1960s, hospitals, reaping the financial benefits of the passage of the Medicare and Medicaid legislation, began offering nurses better salaries. Taking advantage of this chance to improve their economic situation more nurses joined or rejoined the workforce 

Back to the Future. What Does This Mean for Today?

Today, the American health care system confronts once more a nurse shortage, one predicted to increase in severity over the next twenty years, raising the question, “Why does the United States never have enough nurses?” Well in fact, the U.S. has a very large population of registered nurses. Since 1900, the number of registered nurses has increased from a mere 12,000 nurses to around 3 million today, of which almost 2.6 million are actively working. [16] Given the size of this workforce, perhaps the problem rests in having too much demand, rather than too little supply. Perhaps the demand for nurses required to maintain the highly technological, complex American health care system has grown beyond the nursing workforce’s ability to meet that demand. Framing the issue from the demand point of view is enticing, but it fails to help us the current shortage. Given the historical record and future projections about the health care needs of the twenty first century population, it is unlikely that demand for nurses will lessen.

Where do we go from here?

Contemporary efforts aimed at alleviating the contemporary nurse shortage center as they did in the past on adding new recruits to the profession by enlarging the student body. And, this will probably be successful. Recent reports indicate that admissions to U.S. nursing programs are on the upswing. Historically, the nursing profession has proven very adept at producing more nurses. There is little reason to think the profession will not be able increase its numbers in the future. 

But, adding more nurses may be an insufficient solution. And it is doubtful that the other strategies that hospitals have traditionally relied upon will offer much help. The urge to speed up the nurse educational process is hard to resist. Shorter nurse education programs are extremely popular in the United States. Graduates of short education programs, such as two-year community college programs, account for slightly over 50 percent of the U.S. nurse population today. And, in the last twenty years, the percentage of nurses whose highest degree is a two-year associate degree has increased. Yet, recent research demonstrating that in hospitals that have a higher percentage of nurses educated in longer, four-year baccalaureate programs have better patient outcomes raises serious questions regarding the wisdom of emphasizing shorter training courses. Likewise, increasing the use of assistive personnel is no longer a viable option given the very medically complex dimensions of patient care today.  

What’s left? We may need to revisit the points made by the 1947 U.S. Department of Labor study and examine the economic status of registered nurses. Nurses have made dramatic gains in improving their working conditions in the last few decades; yet, the current nurse shortage indicates that we may have reached the position where compensation and opportunity are not high enough to maintain a stable and sufficient workforce. History is good for providing us with a sense of what has worked and not worked in the past. In this case we also have an example of an approach seldom tried. We need to attend to the economic issues facing the profession, issues that both historically and currently trouble us.  Economists note that when a labor market demonstrates a shortage of workers, the typical response of the market is to experience a rise in wages in an effort to draw more people into the occupation. By insuring that nurses’ wage rates respond to normal labor market principles, we may begin to put a dent into the nurse shortage problem. Nursing has always been a satisfying ennobling career that provides numerous intangible benefits. Remembering that nurses need to receive equally satisfying concrete rewards may provide us with a more lasting solution to our nurse shortage dilemmas.

References

[1] “Nursing at Recent Hospital Conventions,” American Journal of Nursing 36 ( 1936): 1156-1162; Stella Goostray, “Supply, Demand, and Standards,” American Journal of Nursing 41 ( 1941): 745; “The Nursing Situation in New York State,” Trained Nurse And Hospital Review 96 ( 1935): 253.

[2] Marilyn Flood, “The Troubling Expedient: General Staff  Nursing in United States Hospitals in the 1930s, A Means To Institutional, Educational and Personal Ends” (Ph.D. diss., University of California, Berkeley, 1981). 

[3] Robin Buerki, “President’s Address,” Trained Nurse and Hospital Review, 38 (1936): 302-3.

[4] “Nursing Problems Receive Special Emphasis at Hospital Meetings,” Trained Nurse And Hospital Review, 97 (1936): 478;”‘Ties That Bind,” Trained Nurse And Hospital Review, 99 ( 1037): 404; “1,200—Nurses Imported For N.Y.C. 8-Hour Day,” The Modern Hospital, 49 (July, 1937): 104.

 [5] Pearl McIver, “Registered Nurses in the U.S.A.,” American Journal of Nursing 42 (1942): 769-73.

[6] Mary Roberts, American Nursing: History and Interpretation (New York: Macmillan Co., 1954). 

[7] Roberts, American Nursing, 383-393.

[8] Jean C. Whelan, “Too Many, Too Few: The Supply, Demand, and Distribution of Private Duty Nurses, 1910-1965” (PhD. diss, University of Pennsylvania, 2000): 324-348.

[9] “Nursing Situation Takes Spotlight at A.H.A. Midwinter Conference,” Modern Hospital 70 (March, 1948): 130; Florence Hyde, “What Are The States Doing About Licensing of Practical Nursing,” Hospitals 70 (September,1950): 73, 76-84.

[10] William White, “Mandatory Licensure of Registered Nurses: Introduction and Impact” in Simon Rottenberg, ed., Occupational Licensure and Regulation (Washington: American Enterprise Institute for Public Policy Research, 1980), 53-54, 57-58.

[11] Joan E. Lynaugh and Barbara L. Bush, American Nursing From Hospitals to Health Systems, (Malden, MA.: Blackwell Publishers, 1996), 1-25.

[12] United States Department of Labor, The Economic Status of Registered Professional Nurses 1946-1947 (Washington, D.C.: Bureau of Labor Statistics, 1947): 37

[13] United States Department of Labor, The Economic Status of Registered Professional Nurses 1946-1947.

[14] Josephine Goldmark, Nursing and Nursing Education in the United States  (New York: The Macmillan Co., 1923); May Ayres Burgess, ed., Nurses, Patients, and Pocketbook (New York: Committee on the Grading of Nursing Schools, 1928); American Nurses Association, Study of Incomes, Salaries, and Employment Conditions Affecting Nurses. (New York: American Nurses Association, 1938).

[15] Lynaugh and Brush, American Nursing.

[16] The Registered Nurse Population Findings from the 2008 National Sample Survey of Registered Nurses, (Rockville, MD: US Department of Health and Human Services Health Resources and Service Administration, 2010).

 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.