NR 393 Week 3 Lillian Wald Biographical Analysis Example

Lillian Wald and the Question of Who Pays for Nursing at Home

Student Name

College of Nursing, Chamberlain University

NR 393: Nursing History

Instructor Name

Month Day, Year

Lillian Wald and the Question of Who Pays for Nursing at Home

The Figure and the Fight

Lillian Wald, a nurse working in New York City from the 1890s to the 1930s, is remembered as the founder of the Henry Street Settlement and as the person who named public health nursing. This paper focuses on a less celebrated question she took a side on, one that nursing still argues about: who should pay for nursing care delivered in people's homes. In Wald's time, visiting nursing was funded almost entirely by charity, which limited it to the poor and to whatever donors would support. Wald pursued a different answer, and the paper argues that her most consequential achievement was not the settlement itself but the financing arrangement she negotiated with a life insurance company, which made home nursing a service that could be bought on a large scale and, for the same reason, left it exposed when the buyer withdrew.

Background That Explains the Position

Wald trained at the New York Hospital school of nursing, graduating in 1891, and in 1893 began visiting sick families in tenements on the Lower East Side with a fellow nurse, Mary Brewster. The work grew into a nurses' settlement on Henry Street, supported by wealthy donors, where nurses lived in the neighborhood and visited families on request, charging a small fee to those who could pay and nothing to those who could not (Buhler-Wilkerson, 1993). Wald described this work in her own account, The House on Henry Street, as an effort to bring nursing to people in their homes rather than waiting for them to reach a hospital (Wald, 1915). Her biography matters here only because it explains why the funding question pressed on her: a service built on donations could grow only as fast as donations grew, and the need she saw on Henry Street was far larger than philanthropy could meet.

The Arrangement With Metropolitan Life

In 1909, Wald proposed to the Metropolitan Life Insurance Company that it pay for nursing visits to its industrial policyholders, working families who paid small weekly premiums for life insurance. Her argument was that nursing care would reduce deaths among policyholders and so save the company money on claims. The company agreed to a trial with Henry Street nurses in part of Manhattan and soon extended the program. It expanded rapidly, contracting with visiting nurse associations in many cities and employing its own nurses where no association existed, and for several decades it was one of the largest sources of funding for home nursing in the United States (Buhler-Wilkerson, 2001).

The arrangement changed what visiting nursing was. For the first time, nursing visits were paid for per visit by an organization that expected a measurable return, and visiting nurse associations began to keep careful records of visits and costs to satisfy the insurer. Home nursing became something that could be priced, counted and sold, which allowed it to reach far more families than charity could. That is the basis for the claim that the insurance partnership, more than the settlement, was Wald's decisive contribution to the structure of community nursing.

The Cost of the Arrangement

The same arrangement carried a vulnerability that the charity model did not. A service funded by an insurer continues only as long as the insurer finds it worthwhile. Buhler-Wilkerson (2001) describes how, as death rates from infectious disease fell and the company's policyholder population changed, Metropolitan Life came to see less return from nursing visits, and it ended the nursing service in the early 1950s. Visiting nurse associations that had come to depend on its payments lost a major source of income. The pattern, home nursing expanding when a large payer finds it worthwhile and contracting when the payer changes its calculation, has repeated since with public insurers.

A reader could reasonably deny the paper's claim. One could argue that Wald's most lasting achievement was the idea of public health nursing itself, or her role in founding the national public health nursing organization, or her part in the campaign for a federal children's bureau. Those contributions were real. The paper's position is that ideas and organizations spread only when someone pays for the work, and that Wald's willingness to make nursing a purchased service is what turned a neighborhood settlement into a national pattern of home nursing, with all the strengths and fragility of that model.

Why This Figure and This Question

Wald was chosen over other leaders of the same period because the funding question connects her era directly to the writer's own practice. The writer works as a home health nurse, and every visit she makes is authorized, counted and paid for under rules set by a large public insurer. Home health agencies today plan their staffing around what the payer will cover, document to satisfy the payer's requirements and close or shrink when payment rules change. The arrangement Wald made with a private insurer in 1909 is the earliest large-scale version of that relationship, and studying it offers a way to see the writer's daily documentation as the product of a historical choice rather than as a fixed feature of nursing.

The question also divided nurses in Wald's own time. Some visiting nurse leaders worried that working for an insurance company would make nurses employees of a business whose interest was profit rather than patients, and that nurses would be pressured to limit visits to what the company found worthwhile. Others argued, as Wald did, that the reach of the service mattered more than who paid for it. That disagreement is the ground on which the full paper will stand, because it shows that Wald's choice was a choice, made against real objections, and not simply the obvious next step.

Evidence Still to Locate

The full paper will need three kinds of evidence not yet examined in depth: the correspondence or reports documenting Wald's original proposal to the insurer, figures showing the size of the insurance nursing program at its peak, and accounts from visiting nurse associations of how the program's end affected them. The Henry Street Settlement records and the published histories of home care are the likely sources, and the paper will distinguish between documents from the period and later interpretations, since the insurer's own reports would naturally present the program favorably.

References

Buhler-Wilkerson, K. (1993). Bringing care to the people: Lillian Wald's legacy to public health nursing. American Journal of Public Health, 83(12), 1778-1786. https://doi.org/10.2105/AJPH.83.12.1778

Buhler-Wilkerson, K. (2001). No place like home: A history of nursing and home care in the United States. Johns Hopkins University Press.

Wald, L. D. (1915). The house on Henry Street. Henry Holt and Company.