Nursing the Nation: Building the Nurse Labor Force by Jean C. Whelan (review).

Abstract

Reviewed by: Nursing the Nation: Building the Nurse Labor Force by Jean C. Whelan Dominique Tobbell Jean C. Whelan. Nursing the Nation: Building the Nurse Labor Force. Critical Issues in Health and Medicine. New Brunswick, N.J.: Rutgers University Press, 2021. xiv + 222 pp. $29.95 (978-8135-8598-7). In Nursing the Nation, Jean Whelan describes and analyzes the history of the nursing labor market in the United States from 1890 through 1950, focusing on the working lives of professional nurses and the mechanisms by which nursing labor was distributed within the American health care system. Published posthumously, this book makes a much-needed contribution to the history of the American health care system and provides critical historical perspective on the perennial nursing shortages—and attendant crises—that have characterized the American health system throughout the twentieth and twenty-first centuries. Whelan’s analysis draws upon a wide range of primary sources, including the personal papers of nurses, the records of school of nursing alumnae associations and professional nursing associations, contemporaneous studies of the nurse workforce, the published nursing and hospital administration literature, and data from the U.S. Census and the U.S. Bureau of Labor Statistics. Superbly written and convincingly argued, Nursing the Nation makes three key interventions into the history [End Page 461] of American health care. First, Whelan argues that working nurses have had considerable agency and power in determining the conditions of their employment and the infrastructure of nursing care delivery. From the 1890s through 1950s, when hospitals relied on student nurses to deliver nursing care, private duty nursing served as the primary source of employment for graduate nurses. In this model, patients and physicians hired nurses to attend to patient’s nursing care needs, twenty-four hours a day for the duration of the patient’s illness. During these decades, private duty registries—agencies that systematically connected patients with nurses—“served as the main employment structure through which nurses found work” (p. 32). Some registries were physician or hospital controlled, but most important were those that were nurse operated (referred to as central registries). Central registries, Whelan shows, “allowed nurses to negotiate with hospitals over fees, working hours, employment conditions, and a miscellany of other factors relevant to their working lives” (p. 148). Registries that enrolled large numbers of nurses proved to be powerful advocates on behalf of working nurses because they brought to their negotiations the power of a critical mass of nurses (as well as the support of local physicians). Although they weren’t always successful in their negotiations, registries nevertheless proved “difficult for hospitals to ignore” (p. 104). The private duty registry system was thus a “nurse-run, woman-run business enterprise” that achieved a degree of success in delivering nursing services to the public (p. 149). To be sure, “the private duty/student system of care delivery was an inefficient, expensive, and poor distributor of nursing services” (p. 68), and Whelan’s second intervention is to locate the origins of ongoing problems in nurse supply in the early nurse labor market. During the Great Depression and World War II, for example, as nurse supply continually failed to meet the growing demand for nurses, nurse leaders, health care institutions, and policy-making organizations focused on increasing the supply of student nurses and creating new types of nurse workers through reform and expansion of nursing education. In so doing, they ignored the workforce issues that deterred women from remaining in (or even entering) the nursing profession, including discriminatory hiring practices, low wages, and poor working conditions. “Concentrating on the supply of nurses,” Whelan argues, “failed to solve the shortage issue and created significant tensions within the market” (p. 123). These tensions persisted even after the nurse workforce underwent a major restructuring after World War II, when staff nursing became the standard model for nursing care delivery, concomitant with the demise of central registries. Although the employment of a permanent hospital nursing staff solved many problems the private duty system had failed to address—such as, providing hospitals with a more reliable and controllable labor force—it created others by solidifying hospital’s “control over nurses’ conditions of work” (p. 147). “In...