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Workforce Issues

One of the most perplexing and long-term problems facing the U.S. health care system is the shortage of registered professional nurses available to meet demand for their services. Since the beginning of professional nursing in the United States, hospitals and other health care facilities have attempted to balance the need for an abundance of nurses to care for the ill and at the same time maintain the ability to pay for them.

Significant workplace problems appeared soon after the professionalization of nursing. A peculiar system, established in the late nineteenth century, in which hospital operated training schools provided patient care, combined nurse education with nurse employment in the same body of workers. In 1900, approximately 600 hospital-based schools of nursing existed in the United States using what has been labeled an apprenticeship type of learning (Lynaugh, 1989; Roberts, 1954). Students worked in the hospital learning the nursing procedures that particular institutions provided for their patients. In return for their education and a small stipend, student nurses delivered most of the patient care (Reverby, 1987). Bereft of any formal teaching staff, the students generally used a self-taught, practical method of learning. By using student labor, hospitals came to rely on an inexpensive and transitory workforce. Indeed, the students graduated and left their schools to find employment within three years. As hospitals did not hire their own graduates, the majority of nurses, roughly 80 percent in 1920, sought work in the private duty sector (Goldmark, 1923/1984). Private duty nursing meant direct employment of an individual nurse by a patient when sick. Nurses were hired by patients who assumed full responsibility for paying the nurses. Hospitalized patients unable to afford private nursing services were left to care delivered by students.

Nurse and patient, Jewish Hospital, Philadelphia, PA, c. 1930Nurse and patient, Jewish Hospital, Philadelphia, PA, c. 1930The private duty system suffered from a number of problems. Scarcity of cases, logistical difficulties, and financial
impediments limiting care to only those able to afford private nurses plagued the system. Private nursing services represented a considerable financial burden for sick individuals, and yet nurses fees proved inadequate to provide most nurses with an acceptable yearly income (Burgess, 1928/1984; Goldmark, 1923/1984; Committee on the Costs of Medical Care, 1932/1970). Even as nursing schools continued to graduate large numbers into the system, difficulties with distribution and placement of nurses with patients who truly needed nursing care continued (Burgess, 1928/1984; Falk, Rufus Rorem, & Ring, 1933). Debate raged over whether there was a surplus or a shortage of nurses.

During the 1930s several technological, economic, and health care related events transpired which caused health care analysts to question the adequacy of the student/private duty method of care for hospitalized patients. Technological changes created complex care requirements necessitating practitioners more expert than students. Middle class patients, unable to afford private duty nurses, expected hospitals to provide personalized care. Private and semi-private rooms replaced multiple bed wards, adding to the need for nurses. Efforts to institute efficient, rational methods of work assignment resulted in hospitals dividing the work between graduates, students, and nurses aides. Private duty nursing was increasingly viewed by health care leaders as an inefficient use of nursing resources (Falk et al., 1933; Flood, 1981; Reverby, 1983).

By the end of the Great Depression, the shift to staff nursing jobs was reflected in the precipitous decrease in the number of nurses employed in private duty. Staff nursing is the occupational field in which hospitals hire nurses in institutional positions for delivery of patient care. By 1941, institutional nurses, often referred to as general staff nurses, constituted 47 percent of active registered nurses; private duty nurses accounted for 27 percent (McIver, 1942). The conversion of nurses from independent contractors to employees was not smooth. Nurses resisted the move into hospital positions (Flood, 1981; Reverby, 1983), and hospitals long accustomed to receiving low cost nursing service via students had difficulty accepting graduate nurses as full-fledged employees (Reverby, 1981).

Contemporary historians have emphasized the 1930s as pivotal in the transition of nurses from private duty to employee Nurse and physician, Philadelphia General Hospital, Philadelphia, PA, c. 1925Nurse and physician, Philadelphia General Hospital, Philadelphia, PA, c. 1925status (Flood, 1981; Lynaugh, 1989; Reverby, 1983; Roberts, 1954). Yet, more recent research indicates that the timing of and the reasons for the demise of private duty nursing is later than and different from previously estimated. For instance, Whelan found that heightened demand for private duty nurses began in the late 1930s when hospitals initiated using private duty nurses as temporary staff nurses, and continued well beyond the World War II years (2000). The inability of the private duty market to meet that demand led to changes in the ways hospitals staffed their nursing departments. Hospitals increasingly sought to hire registered nurses in staff nurse positions, rejecting the traditional private system of nursing care in favor of institutionally controlled, industrial model nursing services. Yet, the abysmal working conditions existing in most hospitals in the post-World War II era failed to induce nurses to either enter or remain for long in the job market. Reluctant to address nurses concerns regarding poor working conditions, hospitals relied increasingly on hiring nurse substitutes and calling for greater numbers of new recruits into the profession.

The use of nurse substitutes for delivery of care received a boost in the mid-1940s when the movement to license a second level of nurses gained momentum. Passage of state nurse practice acts allowing for a licensed practical nurse (LPN) Nursing assistant preparing beds for patients, Frederick Douglass Hospital, Philadelphia, PA c. 1945Nursing assistant preparing beds for patients, Frederick Douglass Hospital, Philadelphia, PA c. 1945category settled some of the controversy surrounding non-professional caregivers and offered hospitals a new type of nurse worker to employ. Still, as hospitals found that hiring LPNs failed to solve nurse shortage dilemmas, they resorted to extensive use of a third level nurse worker, the unlicensed assistive personnel (UAP), also known as a nurse aide. The resulting three level hierarchical system of nursing care delivery, composed of a registered nurse, a LPN and a UAP nursing aide became the norm in acute care hospitals changing further the role of professional nurses in patient care delivery. Staff nurses, responsible for delivering care to their own individual patients, also assumed accountability for a plethora of nurse workers assigned under them. Private duty nurses felt threatened by LPNs, who they were convinced, would be used by hospitals to deliver the close personnel service for which they were well known. Hospitals failed to stem the persistent dissatisfaction felt by nurses by either allaying nurses’ fears or offering more support for an increasingly more complex job. Meanwhile nurse shortages continued into the 1960s and beyond.

Today, most hospitals continue to use some combination of the three-tiered system of nurse caregivers established in the mid-twentieth century for patient care delivery: registered nurses, licensed practical nurses and nurse assistants. However, late twentieth century technological advances have increased the complexity of hospitalized care, ensuring that the bulk of direct patient care is delivered by registered nurses. This of course has increased demand for registered nurses, a demand that continues to outpace supply. Furthermore, vast improvements in salaries and working conditions has raised significantly the cost of professional nursing care. Early twenty-first century hospitals find themselves faced with the same dilemma posed for their late nineteenth century predecessors: how to supply an adequate number of nurses to their patients at an affordable price. As the country enters into a new phase in health care delivery resulting from the passage of the 2010 Affordable Care Act answers to nursing care problems remain unresolved. Predictions of how nursing care will be supplied to the exploding patient population now able to access care are speculative. However, what is clear is that these patients deserve, and in many cases demand, an adequate number of nurses skilled at delivery of cutting-edge care.


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Committee on the Costs of Medical Care. (1970). Medical care for the American people. (Reprint ed.). Washington D.C.Department of Health Education and Welfare. (Original published by University of Chicago Press, Chicago, 1932).

Falk, I.S., Rufus Rorem, C., & Ring, R. (1933). The Costs of Medical Care. Chicago: University of Chicago Press.

Flood, M. (1981). The troubling expedient: general staff nursing in United States hospitals in the 1930s, a means to institutional, educational, and personnel ends. Dissertation Abstracts International, 42 (12), 4744B. (UMI No. 8211927).

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Reverby, S. (1983). ‘Something besides waiting”: The politics of private duty reform in the depression. In E. C. Lagerman (Ed.), Nursing history, new perspectives, new possibilities (pp. 133-156). New York: Teachers College Press.

Reverby, S. (1981). Re-forming the hospital nurse: The management of American nursing. In P. Conrad & R. Kern (Eds.), The sociology of health and illness, critical perspectives (pp. 220-233). New York: St. Martin’s Press.

Roberts, M. (1954). American nursing, history and interpretation. New York: MacMillan Co.

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).

Jean C. Whelan is Adjunct Assistant Professor of Nursing, University of Pennsylvania School of Nursing.