Private Duty Nursing
As in colonial times, in nineteenth century America if you were sick the last place you wanted to be cared for was in what passed for a hospital. Sick family members were cared for by a family member, usually female, in the home. Families who could afford to do so hired a nurse to care for the sick family member in order to relieve the family of much of the responsibility of 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 [i] While the women who hired out as nurses did not have formal training in a school of nursing some had gained experience and knowledge caring for family members who were ill others gained their knowledge working with the family physician to care for his patients at their home and others gained their knowledge while caring for wounded in the Civil War .
1873 Graduate Nurses Arrive on the Scene
In 1873, Linda Richards, the first ‘Trained Nurse” graduated from the New England Hospital for Women and Children. In the same year, three hospitals opened nurse training schools based on the Nightingale model. - Bellevue in New York,– Connecticut Training School for Nurses and the Dispensary in New Haven Ct and Massachusetts General, in Boston. As hospitals realized the value of having a nursing school with students – unpaid or paid a small stipend - providing care –and the value of having a ‘trained’ graduate nurses working as either private-duty nurses or as Supervisors or Head Nurses instructing the students, other hospitals started their own nursing schools.
Graduates of hospital schools of nursing in the late nineteenth century had two main career opportunities either working in the home of a patient as a private-duty nurse or a position in a hospital as a superintendent or a head nurse. The majority of graduates nurses chose private duty. Private-dusty nurses were employed by the patient or their family to provide care 24 hour 7 days per weeks for the length of the patient’s illness. Asa Private-Duty Nurse, she was considered an independent practitioner of the art of nursing.[i]
Employment Concerns of Private-Duty Nurses
The Private-Duty nurse as an independent practitioner had to let people know she was available – in essence she had to market her services. While new physicians could hang out their shingle in front of their office; the nurse did not have an office and needed to ‘get the word out' . Nurses could find patients through word of mouth by letting the neighbors know, announcements in her church as well as visiting physician offices or pharmacies and leaving their cards. After making the rounds, she had to go back to her home and wait to be contacted.
Registries or Directories were established early schools of nursing as a service to help graduate nurses find patients and to assist physicians looking for graduate nurse to care for their patients. In 1879 the Mayor of New York urged the graduating class of New York City Hospitals first class to set up a central registry in New York where members of the public could find graduate nurses. Adelaide Mabie organized The New York Agency for Trained Nurses, however this effort was not successful and the Agency was turned over to the Philomena Society, considered the first organization of graduate nurses in the United States.[i]
Consider the difficulties in contacting the nurse or with the nurse responding to a request. "Runners' -messengers, usually young boys were paid to delver messages. Today, we can call – or text --on our mobile phone . This wasn’t possible in 1873. While the telephone had been invented, it was nothing like what we now have available.
1877 saw the development experimental Telephone Exchange in Boston.
Role and Function Private Duty Nurse
The early volumes of the American Journal of Nursing included articles to assist the Private-Duty nurse in her career. As the nurse ‘s place of work – and also where she lived while caring for her patient - -was in a private home, she was expected to bring with her whatever equipment and supplies that might be needed in the care of her patient as well as personal supplest and clothing she would require.
Hay,[i] states that the “ outfit of the nurse on private duty is a subject “requiring no inconsiderable planning and thinking”. See Figure 1 for a detailed list of what the nurse needed to bring for the average case lasting 3 to 4 days, including the cost of the items needed.
Hay concludes by stating that “all will contribute to the nurse’s self-confidence, to her efficiency, and so to her success. But it is her tact and energy, her ingenuity and her resourcefulness, and these only, that will most often, clear up her difficulties.
And it is through the possession of these gifts that the trained nurse will prove equal to all demands, whatever her equipment may be.”.
Nursing in the Home
The private-duty nurse being responsible for 24 hour care 7 days a week, moved in to the home of the patient; she ate, slept and provided all required nursing are for the patient. This included carrying out physician’s orders for medications and treatments; observing the patient , maintaining a record of the patient’s condition and notifying the physician of any changes in condition.[i] The nurse had “abundant opportunity to know their patients and their families because severe illnesses , such as typhoid, required a long convalescence.
The private-duty nurse’s relationship within the household was unclear; she was a professional when interacting with her patient and family over nursing matters but her relationship with the servants was blurred. The nurse was expected to perform necessary housekeeping tasks related to the patient or her needs but where were the boundaries. Relationships were tricky; there was a difference in social class; the nurse usually came from a working class background as the household servants did; the patient and the families were from a higher social class than her own. Did she eat with the servants, family or by herself? The patients linen and garments were laundered with the families laundry – were the nurse included? Isabel Hampton Robb “captured the uncertainty of the private-duty nurse in the patient’s household writing that the private-duty nurse was “neither for the drawing room nor the kitchen.”
Keeping Current - Resources
There were two main nursing journals available to assist the private-duty nurse to keep current One was The Trained Nurse and Hospital Review the other was the American Journal of Nursing.
Economics of Private-Duty Nursing
Rates charged by nurses varied over time. In the 1880s and 90s, salaries were $15 per week this was gradually increased; 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.[i] Private-Duty nursing was expensive so the patient or their family had to have sufficient financial resources . This limited the number of people who could afford professional nursing services and also limited the nurse’s earnings. While a nurse could increase income by increasing fees to keep pace with the cost of living, the family in order to decrease their expenses, could hire a ‘nurse’ with no formal training but with years of experience. The needs of individual patients also dictated the type of nurse hired. As the patient improved, there was less need for the skill of a trained nurse. In these convalescent cases and those with chronic conditions, , where all that was needed was a companion-homemaker the family looked for an untrained nurse.
Private duty nursing tended to be ‘seasonal’ work with increased need for their services in winter and decreased demand in the warmer weather. Reverby suggests that this decrease might be partly due to the wealthy leaving the city during the summer months.[i]
Between cases the private-duty nurse was without income so she needed to conserve expenses . Maintaining an apartment or a room in a Boarding House was not economical; since when she had a case it included what was termed maintenance - food and shelter. Between cases if f she had family and was able to return home, she returned home otherwise she sought a Boarding House or roomed with friends. Nurses found a variety of means for sustaining themselves until a case came along. Some went home to their families while others found work in public health nursing, operating a reset home or selling surgical equipment.[ii]
Reverby pointed out “the irrationality of the complicated the employment situation. In an attempt to provide nurses (and to make a profit in their deployment) registries sponsored by medical societies and commercial agencies, as well as by hospitals and nursing alumni groups, began to spring up.”[iii] Since registries usually established the wage rates for trained and untrained nurses, there arose multiple registries with differing standards leading to confusion among both the public and the nurses regarding which registry to contact.
In the mid-1890s ,the nursing schools were graduating more nurses resulting in an oversupply of private-duty graduate nurses in the cities this, along with the continued competition of less expensive untrained nurses , led to increased difficulty finding work . The problem was compounded by the depression of 1893-4 which limited the demand for nurses to the those wealthy families who could afford the more expensive graduate nurse.
There had always been an undercurrent of discontent with the registries; many nurses felt they were unfairly treated by the registries but were afraid to complain. Concerned that registries owned and operated by physician’s groups and commercial agencies were controlling distribution and profiting while nurses were struggling, some nurses began to advocate for nurse controlled and officially sponsored agencies. As Reverby points out “there was no guarantee that a nurse controlled agency would provide more work.”[iv]
In the late 1890s and early 1900’s a combination of events decreased the need for 24/7 private care in the home . First were changes in medicine, more complex surgery and nursing care that a patient could now receive only in the hospital. Secondly, as these medical advances were made, there was a decrease in debilitating sickness. Third, other opportunities started to open up for trained nurses which offered better pay and increased security. However the new graduate was advised that every nurse should have some private duty experience.