When the Business of Nursing Was the Nursing Business

The Private Duty Registry System, 1900-1940

Jean C. Whelan, PhD, RN

Online J Issues Nurs. 2012;17(2) 

Abstract and Introduction

Abstract

In the initial decades of the 20 ^th century, most nurses worked in the private sector as private duty nurses dependent on their own resources for securing and obtaining employment with individual patients. To organize and systematize the ways in which nurses sought jobs, a structure of private duty registries, agencies which connected nurses with patients, was established via professional nurse associations. This article describes the origins of the private duty nurse labor market as the main employment field for early nurses and ways in which the private duty registry system connected nurses and patients. The impact of professional nurses associations and two registries, (New York and Chicago) illustrates how the business of nursing was carried out, including registry formation, operation, and administration. Private duty nurses are compelling examples of a previous generation of nurse entrepreneurs. The discussion identifies problems and challenges of private nursing practice via registries, including the decline and legacy of this innovative nurse role. The story of early 20 ^th century nurse owned and operated registries provides an early and critical historical illustration of the realization of nurse power, entrepreneurship, and control over professional practice that we still learn from today.

Introduction

For members of the class of 2012 graduating from schools of nursing across the country, obtaining a position as a registered nurse (RN) is a fairly straightforward exercise. Numerous advertisements appear in newspapers and professional journals, beckoning nurses to seek employment; job fairs are routinely held attracting new recruits; hospitals visit schools hoping to entice senior students to their institutions; the internet provides vital information on websites describing employment opportunities, and if a new nurse is not attracted to a position through one of these means, direct contact with an employing institution can often result in the offer of a job.
Most 2012 graduates will likely find positions in institutional or other health care facilities. The latest RN Population Sample Survey estimated that in 2008, 62.2 % of nurses were employed by hospitals (U.S. Department of Health and Human Services, 2010). Upon acceptance of a position, the nurse will be informed as to the salary offered, the benefits included, and the expected work schedule. The nurse will most likely work 8 to 12 hours a day, approximately 40 hours a week, and will enjoy scheduled days off.
For earlier generations of nurses, the employment situation was considerably more complex. A graduate of the class of 1912, for example, put in considerably more hours of work per week than nurses of today and rarely worked as a salaried hospital employee. Most early 20 ^th century nurses were independent contractors, working for and receiving pay from private patients who required nursing care when ill. These nurses, known as private duty nurses, worked for short temporary periods of time caring for an individual patient 7 days a week, 24 hours a day for the duration of the patient's illness. Studies of the early 20 ^th century nurse labor market estimated that approximately 80 percent of practicing nurses worked as private duty nurses, making it by far the largest nurse labor field employing nurses (Committee for the Study of Nursing Education, 1923).
The role of private duty nursing is inherently interesting to those investigating the historical underpinnings and evolution of the American nurse workforce, for it offers a glimpse into a little acknowledged aspect of early professional nursing practice, that of nurse entrepreneurship. The independent nature of private duty practice meant that nurses were responsible for seeking out patient cases and determining when, for whom, and how often they wanted to work. Further, the private duty field offered professional nursing an opportunity to build an infrastructure designed to deliver modern nursing services to the public. This infrastructure was composed of private duty registries, or agencies which connected nurses with patients and patients with nurses. A critical element of the registry system was professional private duty registries. Those registries were nurse owned, nurse operated, and for the most part nurse funded by and for nurses, and represented the main means through which nursing services were delivered to the American public for much of the first half of the 20 ^th century. The establishment and operation of a nurse registry system was a significant accomplishment of the profession and one which depended not just on their nursing knowledge, but also required expert business skills not typically associated with nurses.
This article presents an overview of the private duty system as it existed in the first four decades of the 20 ^th century focusing specifically on the professional private duty registry system and highlighting how nurses established a system of agencies which distributed nurses to the public with control vested in nurses themselves. The establishment of nurse registries took place as a deliberate action on the part of nurses who realized the potential for power over their work. Private duty nursing serves not just an exemplar of the original occupational role for nurses; it also illustrates a compelling example of a time when the business of nursing was truly the nursing business.

Origins of the Private Duty Nurse Labor Market

Understanding the prominence of the private duty system for earlier generations of nurses requires first considering how nurses sought employment in the United States once professional schools of nursing opened in the latter half of the 19th century. The establishment of professional schools of nursing, often referred to as nurse training schools, began in earnest in the late 19 ^th century coinciding with a simultaneous growth of hospitals and fueled by late 19 ^th century advances in medical science. The formulation of the germ theory of disease; the introduction of antiseptic and aseptic techniques; better and safer surgical procedures; and increased knowledge of the body's reaction to disease states all contributed to the rise and solidification of scientific medicine.
Changes in medical therapeutics revolutionized the delivery of health services and also changed the way and the place in which patients received sick care (Rosenberg, 1987; Rosner, 1982; Stevens, 1999; Vogel, 1980). Traditionally, most Americans received sick care at home delivered by family, generally female caregivers (Reverby, 1987). However, by the mid-19 ^th century, newer therapeutics demanded skills beyond those possessed by the average family member. Modern caregivers needed to be able to deliver increasingly complex treatments, to observe treatments effects with a discerning eye, to identify complications, and to take actions when things went awry. They needed to possess the ability to read and write; perform mathematical calculations; enlist critical observation skills; and act quickly in emergencies. It was to educate a group of caregivers in the intricacies of these activities that schools of nursing were established (D'Antonio, 2010, Lynaugh, 1989).
Schools of nursing began appearing in the United States in the latter half of the 19 ^th century attracting predominantly, but not exclusively, young, white, female students who received education in the techniques of care demanded by new, scientifically based therapeutics. The success and growth of these schools has been well recorded by others (D'Antonio, 2010, Lynaugh, 1989; Roberts, 1954). By 1904, there were over 800 schools of nursing operating in the United States, with about 10,000 practitioners of nursing (Department of Commerce and Labor, 1905).
The success of these schools, and they were extremely successful, led to a peculiar paradox. Graduation from a school of nursing offered the chance to join a respectable occupation and the promise of steady employment. Yet, students who survived the rigors of their educational years found that few job opportunities existed for them upon graduation (Reverby, 1987).
For the most part, turn of the century hospitals did not hire graduate nurses. Because student nurses, as part of their training, provided the majority of patient care in hospitals affiliated with schools of nursing, employed positions for nurses to work in a staff position existed in only very limited numbers. Hospitals found the use of cheaper, more easily controlled student workers as staff preferable to one composed of nurse graduates.
In the absence of hospital-based jobs, graduates of nurse training programs sought work in the private duty market. A private market for nursing services pre-dated the establishment of professional schools of nursing. Untrained individuals, some of whom functioned as highly competent nurses, and others who were less skilled, often hired out when family with sick relatives required outside help during times of illness (Reverby, 1987). As more and more graduates of training schools entered the workplace, they too joined this market for nurse services, offering what they considered to be a superior commodity—the services of a professional nurse well versed in the techniques and methods of modern medicine.
Private duty nurses were directly employed by a patient or the patient's family. Nurses accepted cases and typically remained with the patient to provide care for the duration of an illness. In the late 19 ^th century, nurses generally provided care to patients in their own homes on a 24 hour, 7 day a week basis. As patients increasingly sought out hospital care, it was to the hospital that private duty nurses moved. Despite the change in setting, the work arrangement remained the same. Whether the nurse delivered care in the home or the hospital, it was the patient who assumed full responsibility for payment of nurse services and it was the individual nurse who assumed the entire care of the patient (Whelan, 2000).

Connecting Nurses and Patients

Early Nurse Entrepreneurs

As the number of schools of nursing increased, word of the competence of trained nurses for sickness care spread, and demand for private duty services rose. Nurses recognized the potential for nurses to take a prominent role in the private duty system and wholeheartedly took on the task of setting up the mechanisms for which both patients would have access to a nurse and nurses could secure jobs. Chronicles of private duty nursing in the late 19 ^th century indicate that enterprising nurses often performed the equivalent of hanging out a shingle by sending notification to physicians and patients that they were available to take patient cases (Feeny, 1904; Scovil, 1901). This word of mouth method worked well in rural or low population areas, but for those nurses living in large cities, as most nurses did, the difficulty of advertising availability for work presented a major problem. The profession recognized early on that a systematic method of hiring nurses was required. Nurses needed reliability in obtaining cases and patients and physicians needed an easy means of hiring nurses as well as verifying the capabilities of the nurse.
The main means through which nurses found patient cases was through a private duty registry. A registry was an agency, similar to an employment bureau, which received requests from patients for nurses and responded by sending out a nurse. By the turn of the century many hospitals operated private duty registries. These hospital-based registries, often administered by the alumnae association of the hospital nursing school, listed nurses who were available for private duty. Persons who wanted a nurse contacted the registry which then sent out a suitable candidate (Best, 1932).

Types of Registries

Hospital-based registries customarily did not place nurses who graduated from another school, and as nurses tended to move about from one location to another, many who relocated to a new area found it difficult to find cases. Hospital-based registries also served mainly local geographic areas, so that patients who either resided some distance from a hospital or patients in hospitals without a school of nursing experienced more difficulty in obtaining nurses. In the last decades of the 19 ^th century, nurses began to favor the concept of centralizing private duty nurse services within a locality leading to the growth of what were called central registries (Best, 1932; Feeny, 1904; Thornton, 1901).
Central registries were intended to place nurses who did not belong to a local hospital-based registry and served as a source of nurses for patients over large geographic areas. The benefits of a central registry extended not only to nurses, but to others involved in sickness care. For example, physicians or families who required a nurse for a patient needed an easy way to arrange for nursing services. One call to a central registry accomplished that goal. The registry was responsible for checking the credentials of the nurses enrolled on it, relieving the physician or family of that task. And presumably, a central registry serving an entire city would receive a greater volume of patient requests for nurses thus ensuring steady employment opportunities for those on the registry (Dock, 1906; Peterson, 1911; Philpottts, 1904; Roberts, 1954).
As the popularity of setting up central registries grew, some in nursing envisioned that these agencies should aim to provide services beyond that of placing nurses with patients. Advocates encouraged nurses to set up registries that provided a range of services for nurses including meals, recreation, and educational opportunities and not just serve as an employment bureau. Income from such services would add to the profits of the registry, ensuring a more stable financial base to support the business. Others saw registries as the major connecting point between all employment opportunities and nurses. For example, a registry might be useful to hospitals and other health related agencies looking to fill an open position. Some believed a nurse registry should offer a variety of services to patients, such as selling sick room supplies and equipment and special diets (Dietrich, 1924a; 1924b; Mellinchampe, 1916; Rutley, 1915).
These aims were quite lofty, and while some central registries did branch out and provide services beyond nurse placement, most registries found that connecting nurses with patients was a complicated business requiring total attention from those administering the agency. The majority of registries focused on nurse placement with patients as the prime objective of the registry.

Role of Nurses in Registry Administration

Key to the concept of a central registry was the role of nurses in the administration of the agency. By the turn of the century, the idea that central registries should be nurse owned, nurse operated, and nurse controlled became popular among organized nursing (Foster, 1909; Roberts, 1954; Whelan, 2000). This was indeed a powerful idea. Within hospitals, it was physicians or hospital superintendents who held the positions of influence. While nurses were not completely without power (early hospital superintendents were often nurses themselves), for the most part the needs of the nursing service remained subsumed within the needs of the hospital. A registry run by nurses, so the theory went, held the potential to put nursing needs first, placing the professional stamp on the work in a way in which professional nurses wanted. Numerous articles in professional journals and presentations to professional groups by early nurse leaders, such as Isabel Hampton Robb and Lavinia Dock, testified to the benefits for nurses of running their own registries (Dock, 1897; Editor, 1908; Foster, 1909; Philpotts, 1904; Robb, 1897). As American Journal of Nursing editor Mary Roberts (1954) noted in her landmark history of American nursing:

The potential efficiency of a central service appealed to spacious thinkers like Mrs. Robb and Miss Dock. It was frequently discussed at meetings of both of the professional organizations. They were opposed to the control of the placement of private duty nurses by the medical societies because they had little or no interest in the standardization and upgrading of nursing (p.120-121).

To achieve such a wide array of goals was no small task. Leaders believed that nurse run central registries connected to a local professional nurse association would result in meeting objectives in an easier manner. An already organized nurse association offered a structure in which to readily establish a registry. Fortunately for nurses, a plethora of nurse associations existed in the early 20 ^th century in which to sponsor the establishment of central registries.

Professional Nurse Associations and Private Duty Registries

Development of Professional Nurse Associations

Nurses began organizing professional associations in the last decade of the 19 ^th century. The American Society of Superintendents of Training Schools for Nurses, later the National League for Nursing, organized in 1893 and focused on nursing educational issues. In 1896, the forerunner of the American Nurses Association (ANA), the Nurses Associated Alumnae of the United States and Canada formed, dedicated to issues concerning nurses graduated from schools of nursing (Flanagan, 1976). The formation of these two bodies, national in scope, encouraged the growth of numerous smaller associations on state and local levels, many of which were the foundational units of the current state and district nurse associations making up the present ANA. Discussion of the complex manner in which professional nursing organized is beyond the scope of this article, yet, critical to note is that there existed by the turn of the 20 ^th century an increasing number of professional nurse groups, such as local city and county nurse associations, capable of setting up nurse registries. A number of these associations readily jumped into the registry business.

Nurse Association Sponsored Registries

Professional nurse journals in the initial years of the 20 ^th century reported enthusiastically on the establishment of local nurse association sponsored central registries (Editor, 1909). Numbers vary on how many professional private duty registries existed at any given time. In 1915, a Special Registry Committee of the ANA located 40 central registries (Report of Special Registry Committee, 1915). Nine years later, a 1924 ANA survey found 75 registries (Official Registries, 1926). By then the terminology used to identify such registries switched from central registry to official registry indicating their status as a professional association-sanctioned agency. In the post-World War II era, registries operated by professional groups were more commonly referred to as professional private duty registries or simply professional registries, a term which will be used in the remainder of this article. The number of professional registries continued to increase over the first half of the 20 ^th century. By 1950, there were approximately 164 professional nurse registries (Roberts, 1954).

Registry Formation, Operation, and Administration

Forming and Funding A Registry

Examination of how professional registries formed, operated, and administered sheds light on how nurses organized the distribution of nurses to the public and the skills required to launch a nursing business. In setting up any business, the initial ingredient required is funds necessary to get the operation up and running. For most professional association registries, the group sponsoring the registry either supplied their own funds or asked for support from others. For example, in 1910, the New York County Registered Nurses Association, forerunner of the present New York Counties Registered Nurses Association, District 13, New York State Nurses Association, embarked on an ambitious project known as the Central Registry. Startup funds for the registry came from the sale of bonds by the association to its members as well as contributions from local school of nursing alumnae associations (Committee on Registry, 1909). Three years later, Chicago nurses followed a similar pattern when in 1913 a local association, which later became District I of the Illinois Nurses Association, established the Central Directory (Dunwiddie, 1937). In the Chicago case, local alumnae associations and individual nurses contributed close to $4000, a significant sum of money for the time, to organize the registry (Dunwiddie, 1937, p. 163-165).

Continued Operation

Once the registry opened, income generated from nurse members, called registrants, provided operating capital. Typically, a nurse applied for membership on the registry by submitting her credentials. Registries specified rules and procedures regarding who was eligible for membership and the qualifications required. In the case of a professional registry for instance, not only graduation from a school of nursing and licensure as a registered nurse, but also membership in the ANA might be requisite. Once accepted as a registrant, the nurse paid a yearly membership fee. As membership fees were the main, and in most cases the only, source of registry income, building up a significant membership was essential to registry survival. Success for both the Chicago and the New York registries in their early years was attributed to satisfactory, in some cases even high, membership levels.

Administrative Oversight by Nurses

Control and oversight of registry business was vested in the body organizing the registry, oftentimes delegated to a committee or governing board. Yet, as in any business, the most crucial component in ensuring a successful operation rested in the hands of the administrator responsible for day to day running of the registry. Registry administrators, often called head registrars, were charged with assuring that nurses were sent out to patients in a competent and speedy manner; that the business of the registry increased; and that the financial situation remained either profitable or at minimum, stable. The registrar also monitored the treatment accorded nurses enrolled on the registry, assured that nurses received assignments to patients in an appropriate and fair manner and dealt with problems which inevitably arose. Additionally, there existed the myriad tasks and duties associated with any business. For example, in New York City, nurse registries came under the law licensing employment bureaus, adding a further layer of red tape to the registry operations. The New York nurses hired Pauline Dolliver, considered an ideal individual to administer the new Central Registry. A graduate of and former superintendent of nurses of the prominent Massachusetts General Hospital, Dolliver was a respected nurse leader whose reputation promised to add prestige to the new registry (Minutes, governing board, 1910).
Head registrars, often hired to work on a seven day, 24 hour basis with minimal relief, faced an arduous job and sometimes did not measure up to expectations. This happened in the case of Dolliver who left the New York registry after a short, four year tenure. Dolliver, hired in anticipation that her expertise would grow registry business, proved disappointing at running the enterprise and despite urgings of the governing board to promote the registry, was unsuccessful in making it a thriving venture. Her replacement was Irene Yokum, a graduate of the New York City Hospital Training School and a local nurse, familiar with the New York nurse job market. Yokum proved to be an able administrator. Popular with nurse registrants, Yokum successfully guided the registry through several years of increasing business. In 1928, however, the registry governing board embarked on a re-organization and expansion of registry services which resulted in Yokum's resignation in 1929. Following this, the registry underwent a period of instability when administrators came and went with some frequency and the registry was unable to attract a strong leader. The lack of stable leadership, coupled with a deteriorating financial situation caused by the onset of the Great Depression and declining nurse membership, caused the registry to close in 1932 (Whelan, 2000).
The example of the New York Central Registry highlights the challenges nurses faced running a business. The New York group, offering a service which they deemed reliable at providing competent nurses, at competitive rates, to a population in need of nurses, was convinced of the value of their services. And, for most of the years it operated the Central Registry, which also received strong support from New York City physicians, held a reputation as a well-managed agency on which patients and physicians could depend. Yet, despite good intentions, the prevailing business environment and some ill-considered decisions, such as the attempt to expand the registry during the worst financial down-turn experienced by the country, resulted in premature closure of the registry.
The registry situation in Chicago stood in stark contrast to that of New York. Like their counterparts in New York, Chicago nurses received strong support from nurses, physicians, and hospitals throughout the city in setting up the Central Directory. They also turned to an administrator with stellar credentials to lead the new registry. Lucy Van Frank was a nurse with background and experience in business, two fields considered a winning combination for running a registry. Van Frank, who directed the Chicago registry for almost 30 years, received credit for establishing it as a major source of nursing services in the Chicago area. Van Frank became a national expert on registry matters, often writing and speaking on the subject (News About Nursing, 1943). The registry, which later became known as the Nurses Professional Registry (NPR), proved to be highly successful and operated for 67 years.
Van Frank's success in running the registry was aided in part by a large membership which showed steady increases in the years preceding the Great Depression and insured stable finances (Annual Report Club and Registry, 1926). Yet, as in New York, the onset of the Depression challenged both the registry and private duty nurses to develop survival techniques which would see them through the lean years. The Depression witnessed calls for private duty nurses, always heavily dependent on patients able to afford out of pocket expenses for nursing care, to plummet. As nurses' obtained fewer cases, incomes dropped and many decided to leave the registry leading to lower registry profits.
Registry management instituted a variety of measures designed to help it and the nurses survive the financial devastation. The registry began a loan fund for nurses in dire financial straits (Unemployment and Relief, 1933). A Nurses Exchange, where nurses could sell handmade articles, helped some nurses raise small amounts of cash (Annual Report, First Disrict, 1933). Changes to registry rules relaxed on-call policies enabling nurses to return to their home towns and reduce living expenses (Registry, 1933). And, most importantly, the registry encouraged hospitals to hire private duty nurses on a per diem basis, opening up an additional field of work (Minutes, annual meeting, 1933). The growth, survival and success of the Chicago registry, which closed in 1980 amid major changes in health care re-imbursement, highlights important elements required by nursing businesses; strong, competent leadership, adaptability in the face of conflict, and a dependable financial base.

Conclusion: The Decline and Legacy of Registries

The New York and Chicago examples of nurse owned and operated registries presented in this article are only two illustrations of a model of nurse entrepreneurship replicated across the country in the first half of the 20 ^th century. The main mission of professional registries was to supply nurses to the sick public and this they did admirably, often serving as a major distribution point for nurses in a community. By mid-20 ^th century, private duty itself entered into a slow descent in popularity as an occupational choice for nurses. In 1949, in a complete reversal of earlier proportions, only about 20 percent of nurses identified as private duty nurses (American Nurses Association, 1951). This percentage further declined as the century progressed and nurses increasingly sought employed positions in institutions, as they continue to do today. The need for registries waned with the decrease in the number of nurses in the field. Fewer and fewer nurse owned and operated businesses to connect nurses and patients were required and the professional private duty registry business became an anachronism.
Historians traditionally emphasize the 1930s as pivotal in the transition of nurses from private duty to employee status (Flood, 1981; Lynaugh, 1989; Reverby, 1983; Roberts, 1954). Yet, other research indicates that the timing of and the reasons for the demise of private duty nursing is later than and different from previous estimates. Whelan (2005; 2000) found heightened demand for private duty nurses beginning in the late 1930s when hospitals initiated the use of private duty nurses as temporary staff nurses, and continuing well beyond the World War II years. 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.
The legacy of private duty registries represents a mixed bag and should not be over romanticized. The examples of the New York and Chicago group illustrate both successes and failures. Other issues also mar the legacy of professional registries. For example, African American nurses were routinely barred from membership on registries until the mid-20 ^th century; a failing that few in the registry business acknowledged. In New York City, African American private duty nurses were forced to set up their own professional registry separate from that of white nurses (Thoms, 1929).
Despite such failings, the registry system did offer nurses a potential vehicle in which to set up the parameters for independent practice. Further, the private duty nurse market represents a tantalizing subject in which to look at the ways through which nurses found employment and operated their own businesses. Noteworthy also is the resemblance of private duty registries to today's temporary nurse employment agencies. Contemporary hospitals often rely on the use of short-term nurses, in the form of either agency or "traveling nurses" mimicking a practice hospitals engaged in during the mid-20th century when private duty nurses from nurse-run private duty registries were hired on a per diem basis to staff acute care institutions (Klarman, 1963; Whelan, 2005). While not a completely analogous situation (temporary nurse employment companies tend to be corporate entities rather than local nurse-run agencies), the market for temporary nurses remains an enduring one in the American health care system. Finally, the story of nurse owned and operated registries provides an early and critical historical illustration of the realization of nurse power, entrepreneurship, and control over professional practice roles.

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Acknowledgements

Funding for this research was received from the National Institute of Health, National Library of Medicine Scholarly Work in Biomedicine and Health Grant, 1 G13 LM008400.
Online J Issues Nurs. 2012;17(2) © 2012  American Nurses Association