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Nursing Licensure, Legislation and Nurse Practice Acts
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Nursing Licensure

The status of women in society is inextricably tied to the development of nursing as a profession.  The development of nursing licensure laws closely follows the advancement of women’s roles in the struggle for suffrage and women’s increased visibility related to war time service. This project will explore these parallels.

Credentials, registration and licensure
 A nursing license is a credential granted by an individual state.  Most states require that healthcare practitioners with direct patient contact be licensed.  Each individual state has the sole authority to license health care practitioners in their jurisdiction.  A license confers a legal property right to the holder.  Consequently, the license can not be taken away from the practitioner without due process.  Legally speaking due process includes the right to a hearing and access to the courts in a proceeding to remove a legal right.

A license differs from certification or registration.  Registration requires a practitioner only register their intent to practice within a jurisdiction.  Registration does not restrict the use of the professional title; consequently an unregistered practitioner can use the title.

Certification is a credential provided by an organization rather than the state and is usually granted after an applicant has completed an approved course of study and passed and examination.  Certification does not confer the same legal rights to the holder as does a license.  Some states use the term certified and registered interchangeably.

Isabel Hampton Robb nurse 1920s Civil War Nurses Public Health Nurses Nurses needed poster
Isabel Hampton Robb Nurse with soldier 1920's Civil War Nurses with officers Nurse in Red Cross camp Nurses needed for the war WWII


History of Nursing Licensure
Prior to the Nightingale era, no credentials were available to nurses.  The first true nursing credential was a certificate of completion issued to nursing graduates.  In the late 19th century, nursing education varied widely in quality and length.  Programs varied from 6 weeks to 3 years and included as little education as on the job training to extensive apprenticeships.  Nursing leaders became united in the belief that a more uniform education and credentialing system was necessary so that nursing was seen as accountable to the general public. A uniform credentialing process would allow the public to gage the individual qualifications of each nurse.

In 1893, several nursing leaders arranged to meet at the Columbian Exposition in Chicago, Illinois to discuss these important issues affecting nursing practice.   In 1896, this group became the procurer to the American Nursing Association (the Nurses’ Associated Alumnae of the United States and Canada). One of their primary aims was to promote nursing licensure.  The first proposed laws advocated permissive licensure of nurses.  The situation was so dire in the late 19th century that the first president of the American Nurses Association, Isabel Hampton Robb, lamented that
"In the absence of educational and professional standards, I am sadly forced to admit that the term 'trained nurse' means anything, everything and next to nothing.” 
In an era when women had not yet won the right to vote, nursing was committed to obtaining recognition through licensure.

Doughboys and Nurses German Nurses Public Health Nurse nurse bandaging arm African American nurse
Doughboys and Nurses WWI Graduates of the German Nursing School in Chicago Public Health Nurse

Nurse Bandages a child's arm c1930

African American Nurse assistant 1944

Permissive Nursing Licensure
The concept of permissive licensure does not require that all practitioners have a license to practice nursing.  Permissive licensure allowed nurses who met certain standards to use the title, registered nurse. Requirements included graduating from a nursing school that met predetermined standards and passing a comprehensive examination. 

Permissive licensure allowed nurses to choose whether or not to obtain the additional registered nurse credential. Permissive licensure provided the public with protection by establishing a way for the public to identify a qualified practitioner.  Permissive licensure did not protect the title “nurse”.  Any one could call themselves a nurse, however in order to be called a “registered nurse” the practitioner had to complete the requirements determined by the state.

North Carolina passed the first permissive licensure legislation in 1903. Prior to 1903, anyone could call themselves a nurse and practice nursing. By 1923, all 48 states had permissive licensure legislation.  Women did not receive the right to vote until 1920 which means nursing organizations were lobbing legislators for permissive licensure laws in a time when most nurses could not vote.  The magnitude of their accomplishment becomes more apparent when one realizes that without the promise of the votes of constituent nurses in the legislator’s home district, most law makers were uninterested in helping nursing leaders pass licensure laws.

Permissive licensure was the first step toward professional autonomy but nursing leaders continued to pursue mandatory licensure as a requirement for nursing practice.  After permissive licensure statutes were enacted, most nursing school graduates sought and received licenses to use the title “Registered Nurse.” The majority of the nurses practicing who were not licensed were either nursing school graduates who failed the licensing examination or foreign educated nurses.  The permissive licensure system continued to allow anyone to call themselves a nurse and practice nursing as long as they didn’t use the title “Registered Nurse.” 

Red Cross Nurse Columbian Exposition 1893 Are You a Star Spangled Girl poster Uncle Sam and Nurse Student Nurses Needed
Red Cross Nurse Columbian Exposition 1893 Are You a Star Spangled Girl? If She is good enough for war, sheis good enough for the vote. Student Nurses Wanted


Mandatory Nursing Licensure
One of the goals of permissive licensure was to protect the public by empowering them to distinguish between highly qualified registered nurses and less qualified unlicensed nurses.  This aim began to be frustrated as the public began to assume that all nurses were registered nurses.  Since most nursing school graduates received a license to practice as a registered nurse, the public became less vigilant about asking for proof of licensure.  Since most nurses were employed as private duty nurses in individual homes and hired by private citizens, the aim to protect the public became a significant one.

 New York enacted the first mandatory licensure legislation for nurses in 1947.  The law was originally passed in 1935 but enforcement was delayed due to the shortage of nurses during World War II.  Today all 50 states and territories of the United States require that nurses be licensed in their practice state.  The terms registered nurse and licensed practical (vocational) nurse are now legally protected titles.  No one can call themselves a nurse without passing a licensing examination and meeting the requirements set by each individual state. 

An interesting footnote to nursing licensure is that Florence Nightingale did not support licensure for nurses.  She felt that only continuing education could ensure the competence of nurses not an examination taken once upon entry into nursing practice.

View Digital Story of Licensure

Timeline of Nursing Licensure
1867 – Licensure for nurses first considered in England
1893 – Nursing leaders organized a meeting at the Colombian Exposition in Chicago to discuss issues effecting nursing including licensure
1896 - American Society of Superintendents of Training Schools for Nurses organized and supported licensure in the United States
1901 – New Zealand is the first country to require licensure of nurses
1903 – North Carolina becomes the first state in the US to enact permissive licensure for nurses followed by New Jersey, New York and Virginia
1915 – ANA drafted its first model nurse practice act
1923- All 48 states have enacted permissive licensure laws
1935 – New York passes first mandatory licensure law in US (enactment delayed due to WWII)
1946 – 10 states include definition of nursing in their licensing laws
1947 – New York becomes first state to enact mandatory licensure law


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