The history of nursing care in the early 20th century in the United States has taken on new significance as the nation grapples with what to do about our worsening health. By the 1920s, Lillian Wald's model of care—nurses working side by side with social workers at the intersection of medicine and society—had gained such prominence that it was an essential component of the health care system. Over subsequent decades, however, a confluence of historic forces marginalized this model of nursing care. Today, people are recognizing that medical cures alone, although important in the 20th century, will not address the soaring rates of chronic diseases; the epidemic of diseases of despair, such as substance abuse; or the growing challenges of health equity.
THE WALD MODEL OF NURSING AND ITS MARGINALIZATION
In the early 20th century, nurse Lillian Wald founded the Henry Street Settlement, which sent trained nurses to care for the sick in their homes. The organization mobilized a wide array of resources and established partnerships with a variety of community organizations that included donations of medicine, food, bedding, and cab fares.1 They arranged loans and housing subsidies, and they sought out and paid for others to clean, cook, and provide childcare. They organized community campaigns to clean roofs, disinfect houses, and clean up trash. They organized job-training classes and educated the community through individual instruction, as well as classes for mothers and a kindergarten for children. They also advocated for “upstream” policy reforms in the areas of industrial workplace conditions, education, recreation, and housing.
In a major step toward institutionalizing this approach to nursing care and making it financially sustainable, in 1909 Wald convinced the Metropolitan Life Insurance Company that it should cover nursing care as a means of reducing death rates among its members.2 By 1916, visiting nurse services were available to more than 90% of Metropolitan policyholders (10.5 million) across 2,000 U.S. and Canadian cities. It became the first national insurance for home-based care.
Building on the success of this model, and following women's suffrage in 1920, the women's movement's attention turned to expanding nursing care. In 1921, they had a major victory with the passage of the Sheppard–Towner Act, the first federally funded health care program in the United States. The field of preventive health care at that time remained largely outside the scope of physicians’ private practice, allowing women to consolidate their leadership. The aim was to build on the visiting nurse services model to reduce infant and maternal mortality through prevention and health promotion. The program sent public health nurses into homes to teach better health practices and established a network of free nurse-staffed clinics. Nurses referred sick patients to physicians, but sought to maintain a rigid separation between public clinics and private medical practices in order to avoid antagonizing the medical profession.
While the visiting nurse associations continue to do extraordinary work to this day, a number of historic forces conspired to constrain the reach of this early model. First, following the 1910 publication of the Flexner Report, medicine had been gathering force as an autonomous and dominant profession. As described by Paul Starr and others before him, central to this professionalization was the establishment of economic control.3, 4 Starr argued that “the advancement of science [cannot] explain the comparative and historical variations in the position of the professions…. Knowledge must be transformed into authority, and authority into market power, before the gains from scientific advances can be privately appropriated by a profession.” Physicians (primarily white and male) constructed an economic monopoly by establishing clear professional boundaries, including the enactment of state practice acts, which aimed to exclude alternative branches of health care, or medical “sects,” and to reduce nurses’ autonomy.
By 1929, the medical profession had mounted a campaign against the maternal–child programs of the Sheppard–Towner Act that ultimately led to its repeal and reallocation of funds in accord with the American Medical Association's priorities. Until then, medicine had restricted its activities to patients with diseases. Suddenly, general practitioners saw the growth of public clinics staffed by nurses as representing a lost opportunity for expansion. They declared preventive screening and health promotion as part of their private domain.5
Forces from within the nursing profession also weakened the Wald model. When Wald retired in 1933, she chose a social worker to head the Henry Street Settlement and a nurse to lead nursing services. A power struggle between the two wings of the organization subsequently ensued, leading to their split into two separate entities, with each claiming the other was imposing on its area of professional expertise.5 During her tenure, Wald's unique leadership style was undoubtedly able to transform interprofessional tension into a creative and flexible approach to health. She was unafraid to embrace the intersection of nursing and social care, and, as is often the case, it was precisely at this intersection where creativity in finding solutions to the intractable social problems of the time was most able to flourish.
Market forces also conspired against the model. Buhler-Wilkerson posits that the reduction in the prevalence of tuberculosis may have lessened the return on investment on nursing for Metropolitan Life Insurance.2 Rothman, however, argued that the greatest blow to this holistic model of nursing care was the emergence of prepaid health insurance in the 1940s.5 When Metropolitan Life Insurance terminated its contracts with nurses, it argued that nurses’ services should be covered by private health insurance. However, few of the new health plans included nurse home visits in their benefits, and it was only through the New York City Department of Health and Welfare that some of the independent nursing services were able to continue.
As public health nursing lost ground in the United States, hospitals were emerging as a major market force. Over the following decades, nurses’ work reverted to a version of the support role they had provided to physicians in hospitals before their professionalization. Hospitals’ rise in prominence also challenged physicians, who wanted to maintain autonomy from the hospital without losing their connection to it; physicians needed to use hospitals and laboratories without being employees.4 In this context, Starr argues, physicians recognized the need for “competent and loyal assistants” to work in their absence. Women, whom they hoped would not challenge the authority or economic position of the physician, would fill these auxiliary roles.4
In 1946 the federal government provided massive aid for the construction of new hospitals via the Hill–Burton Act, further centralizing health care. With this expansion of hospitals came a seemingly insatiable demand for more hospital nurses, a process that further redirected the history of nursing.
With the passage of Medicare in the mid-1960s, the role of physicians in society was enhanced, particularly with regard to their economic dominance.6 The contradictions inherent in physicians’ professional identity between the impetus to assert an economic monopoly, on the one hand, and the “high-minded duties” of the profession on the other, had, until then, restrained physicians from raising their fees beyond the reach of the poor, with fees varying according to ability to pay. Beginning in 1966, however, physician incomes rose dramatically, largely as a result of Medicare, given that there was now guaranteed payment for services. Indeed, President Lyndon Johnson agreed to allow physicians to set their prices as a means of offsetting their original opposition to Medicare.
Further widening of the gap between physicians and nurses developed during that period as a result of the increase in the use of specialized procedures that unlinked reimbursement from the clock, and the emergence of pharmaceutical companies’ practice of “spending freely to win physician favor.”6
Even as the power of the medical profession grew in the 1960s and ’70s, it was also a time of social unrest and the “second wave” of feminism. The women's health movement of the period was focused not just on improving access to care, but reforming care models as well, and, as in the period surrounding suffrage, nurses played a prominent role in conversations about how best to meet population health needs. With the publication of Our Bodies, Ourselves, originally titled Women and Their Bodies, the women's movement called for a demedicalization of women's reproductive health; more female providers; empowerment of patients, families, and communities to promote their own reproductive health; and novel care settings, such as peer support groups.5
Although many of the freestanding nurse programs that emerged in the 1960s and ’70s have survived over time, they have not changed our mainstream market-driven health care system. For example, by 2016 there were just 153 nurse-led clinics, despite abundant evidence that they provide cost-effective care.7 Among the constraints they face are restrictive state scope-of-practice laws, which in some states still require expensive physician supervision. Perhaps even more important, many of these clinics have experienced financial challenges because they were funded by short-term start-up grants from foundations. Federal funding has often eluded nurse-led clinics that grew out of schools of nursing, since in order to qualify they must establish a community board and give up the schools’ control.
THE EPIDEMIOLOGY OF THE 21ST CENTURY
Almost 20 years into the 21st century, the country is faced with a new set of health challenges that are markedly different from those faced in the last century. With unemployment in the United States currently below 4% and economic expansion increasing the demand for a larger technical workforce, there is growing concern about the high proportion of adults who remain outside the workforce as a result of poor health.8
This appears to be a uniquely American malaise. Other developed nations outperform the United States in health rankings, despite spending far less on health care.9 And the gap seems to be growing. The Centers for Disease Control and Prevention announced for the second year in a row that life expectancy in the United States has fallen, a trend driven in large part by suicides, drug overdoses, obesity, and chronic diseases. A new Lancet paper simulates the trend in life expectancy; whereas the United States expected to fall from 43rd place in 2016 to 64th in 2040 among 195 nations, China is predicted to rise to 39th place.10, 11
The term “diseases of despair” has been used to describe many of the conditions that are crippling our workforce.12, 13 These are health conditions rooted in social determinants, rather than germs or genes, and include substance abuse, mental health, obesity-related conditions, asthma, maternal mortality, and low birth weight. Maternal mortality, for example, has long been viewed as an outcome measure related to access to care and is often a measure of health inequity. In the United States, maternal mortality is now three times as high among black women as among white women,14 and epidemiologists have shown that high-income black mothers with access to high-quality care are more at risk than their uninsured poor white counterparts.15, 16 The emerging hypothesis is that it is the continued effects of racism over time (weathering) that place these mothers at risk.17
Other indicators of social inequity include declining high secondary school graduation rates, black men's high rates of incarceration and their risk of being killed in confrontations with police, childhood and adult trauma, and social isolation. Case and Deaton argue that factors such as the declines in employment, income, marriage, education, and health together have caused a “cumulative disadvantage” that results in a downward spiral, with fewer opportunities, lower income, increased social isolation, and a sense of helplessness.13
A recent study by the U.S. Department of Defense reveals the magnitude of the challenge. In 2017, the National Defense Authorization Act authorized the addition of another 25,000 troops on top of existing accession requirements.18 However, Spoehr and Handy demonstrated how difficult this will be.19 Among 17-to-24-year-olds eligible for recruitment, 59% were not qualified because of a health condition (obesity, substance abuse, mental health problems, and asthma). Additional disqualifiers included criminal records (10%) and a lack of high school diploma or GED (25%). The report concludes that just 29% of this age group were eligible for recruitment.
These new epidemiological challenges are resistant to the dominant medical model of care, and there is growing recognition that, without upstream solutions to the health crisis, as a nation we will continue the downward spiral. Employers in particular are concerned that economic growth will be hampered if there is no strategy for bringing people back into the workforce. Faced with the recruitment challenges described above, the military is exploring ways to invest in communities, with a special focus on childhood nutrition and physical activity.19
Cross-country comparisons by Bradley and colleagues suggest that social spending and coordination of social services with health care improve outcomes and reduce health inequities.20 There is also abundant evidence in the United States that investments in the social determinants of health can arrest these declines in specific at-risk groups.21
A CONFLUENCE OF OPPORTUNITIES
Although the new epidemiology is grim, there are reasons for optimism. First, the Robert Wood Johnson Foundation (RWJF) is motivating changes around the country with a new focus on a “culture of health” and promotion of models that are oriented toward cross-sector collaboration.
One important resource the RWJF has supported is the County Health Rankings model (see Figure 1). The framework uses evidence to show that clinical care is responsible for contributing to only about 20% of health outcomes. The work is setting the stage for new conversations about ways to address diseases of despair and improve health equity.
Second, since the 2000s, there has been growing bipartisan interest in moving away from the fee-for-service (FFS) payment model toward value-based payment. Observers believe this payment reform is encouraging health plans and providers to expand their services to include the social determinants of health. Historically, FFS drove patients to physicians and hospitals, rather than keeping them healthy at home and in their communities, as the Wald model of nursing had.
A third factor that could help enhance the financial viability of Wald-like models is the expanded oversight of tax-exempt hospitals’ community benefit spending, including required community health needs assessments. These assessments could help focus hospital investments on communities and help to align government, hospital, and community resources.22
Fourth, advancements in health information technologies have the potential to help speed this transformation by facilitating the decentralization of health services and enhancing patient engagement. Big data allows organizations to segment populations by risk and tailor wraparound programs for the most vulnerable. Technology may also help return some of medical diagnostic and therapeutic decisions to patients and families.
Finally, changes in the physician workforce may portend change. In the 20th century, most physicians owned their own practices, but that began to change as the century came to a close. As of 2016, more than half of physicians were employed by organizations.23 Some have argued that these changes in employment status carry with them a reduction in physicians’ autonomy and decision-making authority, as well as the power of their profession.4, 6 Equally significant is the trend of increased female participation in medicine, with the number of women enrolling in U.S. medical schools exceeding the number of men.24 Whether this change is related to the decline in physician autonomy is an open question.6 These changes could alter the relationship between nursing and medicine, re-introducing opportunities for collaboration that were stifled during a period of history in which nurses were viewed by physicians as merely support staff.
NURSING MODELS ACROSS THE CONTINUUM OF CARE
As these new developments unfold, nurses’ roles in some health care systems and independent settings are already beginning to change. Several studies describe how alternative payment programs are “activating” nurses in the context of new roles and new jobs.25-31
Examples of cost-effective innovations that either are led by or include nurses are being documented across a broad swath of health care and community-based settings. County Health Rankings and Roadmaps lists 159 interventions at the highest level of evidence, “scientifically supported.”21 Of these, 35 (about 22%) explicitly include nurses or are nurse led. The breakdown by domains (with some having more than one focus area) shows 10 nurse models focused on health behaviors, 16 on clinical care innovations, 10 on social and economic factors, and three on the physical environment.
The American Academy of Nursing Edge Runners initiative has documented 57 innovative nurse-led programs.32 Martsolf and colleagues found that the majority of these programs were focused on increasing access to care for rural and underserved populations and included wellness and community outreach, navigation and advocacy assistance, chronic disease management, and culturally appropriate approaches to outreach and care.33
It is important to note that these innovations span a broad range of settings, including schools, homes, and community settings, but they can also be found in hospital-based settings. One example of this is a project led by nurses at Rush University Medical Center (Janice Phillips, PhD, RN, CENP, FAAN, e-mail communication, March 1, 2019). Nurses developed and implemented a social determinants screening tool, which they use in their daily nursing assessments. The assessments quickly revealed food insecurities, transportation, and housing as priorities. Nurses began to work with external community partners to build solutions. For example, they designed the Rush Surplus Project, which repackages unused food from hospitals and restaurants and delivers it to families in need. They also provide a month's worth of food to patients identified as experiencing food insecurity before they are discharged. Nine hospitals, universities, and organizations across the country have adopted the model to date.
At a system level, the Southwestern Vermont Health Care's Accountable Community of Health provides an interesting example of how a variety of new programs that expand nurses’ and other health professions’ roles can be combined.34 Guided by a community board that meets monthly, their programs include transitional care nursing; community care teams; Interventions to Reduce Acute Care Transfers (INTERACT); certified diabetes nurse educators; integrated social work; a home safety initiative; medication management and education; ED-embedded physical therapists who initiate treatment planning before discharge; and Maternal Transitions of Care, a pilot program aimed at improving outcomes in infants whose mothers have a substance use disorder.
In summary, there is growing recognition that the old model of centralized health services organized around the idea of medical cures may have worked in the 20th century but is insufficient today. As care begins to decentralize, returning to homes and communities, it is much more difficult to ignore the social, economic, and physical conditions of health, and collaborating with other sectors to resolve these kinds of problems becomes more feasible. In this context, nurses have a historic opportunity to reclaim and expand their original vision of nursing practice. This vision, specifically at the beginning of the 20th century and again in the 1960s, has been grounded in a holistic focus on patients in the context of their full psychosocial well-being as members of families, workplaces, and communities.
To keep the momentum going, nurses will need to take the lead not only in engaging their own educational institutions and accrediting and regulatory bodies, but also in helping their employers and policymakers understand the changes that are needed in nurses’ roles and relationships with other professions. Among the critical next steps will be identifying a set of core functions that nurses can carry out in most, if not all, workplace settings. Drawing on Wald's model, there are at least four core functions that could serve as an organizing framework for change.
The first, which is at the core of Wald's model, is the idea that nurses must establish the trust of patients, their families, and communities. This requires demonstrating support and compassion, rather than adopting the traditional professional stance of holding a monopoly on technical knowledge. Second, Wald's approach requires that nurses conduct a comprehensive evaluation of patients that goes beyond health and includes an assessment of family and community context. Third, nurses must work to develop partnerships, not just with health care providers, but also with other social and economic organizations. This involves embracing the intersection of medicine and society, rather than being concerned about establishing professional boundaries with rigid scopes of practice. Wald's nurses worked intimately with social workers, as well as with other actors inside and outside of the health care sector. Last, Wald's model requires that nurses extend their focus to include upstream, collective solutions that help to address power asymmetries in society.
Although, to varying degrees, nursing schools today prepare students for these functions, most nursing jobs do not expect, or even allow, nurses to carry out this kind of work. Schools must, therefore, also prepare nurses to proactively pursue these functions once they graduate by arguing in favor of this evolved role in their workplaces and working to develop regulatory and payment policies that support it.
Wald's world is not the world we face today, but many of her ideas merit reconsideration as nursing refashions itself in the context of new epidemiological challenges in the 21st century. In the last 100 years, historical forces marginalized the Wald model while hospital and physician-centric models expanded. Opting not to replicate the medical model of professionalism and working to build an alternative professional pathway may not always be comfortable. But if nurses reposition themselves at the intersection of medicine and society, they will have an opportunity, and a responsibility, to engage in the kind of creative social solutions championed by Lillian Wald at the start of the last century.