Before 1900 no state had a nurse practice act and nurses were neither registered nor licensed. The vast majority of working nurses had no formal education and most worked in unregulated, crowded workplaces or as private nurses in homecare settings.
The Civil War (1861–1865) had a profound effect on the development of the nursing and medical professions and in many ways laid the foundation for modern nursing in the United States. Around the time of the war there were only about 150 hospitals in the United States, and there were no formal schools of nursing, no nursing credentials, and no “trained” nurses (Egenes, 2009). In England, Florence Nightingale had only just succeeded in establishing the world’s first professional nurse training school at St. Thomas’s Hospital in London; the first class launched on July 9, 1860.
The hundreds of thousands of casualties during the Civil War created a need for caregivers and tens of thousands of women offered their services, mostly on a volunteer basis. In the beginning, nurse volunteers were inexperienced, untrained, and disorganized. The situation changed quickly as the volunteer nurses gained experience and training. When the war ended, the sacrifices made by nurses and other female volunteers succeeded in changing public opinion about women working in healthcare. In 1868, only three years after the end of the Civil War, Samuel Gross, president of the American Medical Association, strongly endorsed the formation of training schools for nurses (Egenes, 2009).
Just five years later, in 1873, the first educational programs for nurses in the United States were established in New York, Massachusetts, and Connecticut. Writing in 1935, Registered Nurse Isabel Stewart noted that “The immediate problem was not to build a finished educational structure, but to clear the ground, to provide decent conditions for both patients and nurses, and to lay the foundations of an adequate nursing service” (Stewart, 1935). The new nursing schools were so popular and successful that soon every hospital wanted a school of nursing.
The emergence of germ theory in the late 1800s was another event that had a profound effect on medicine. As medical doctors expanded their education and training, nurses also recognized the need for more comprehensive training. Thus began a period of significant increase in the number of nursing schools throughout the United States, and shortly thereafter the fight for nursing licensure (then referred to as “nursing registration”). As the nineteenth century drew to a close, nurses themselves, along with many women’s organizations and their leaders, lobbied for nurse registration, the development of standards for nursing education, and establishment of nurse practice acts.
The First Registrations and Practice Acts
In 1902 members of the newly formed New York Nurses Association met at the Rochester City Hospital to discuss the establishment of the nation’s first nurse practice act. In attendance was an elderly and frail Susan B. Anthony, who urged the attendees to remember the influence and power of their work. Anthony predicted in a speech to the group that “The day is coming when trained nurses will be required to possess a college education before being admitted to training” (Willis et al., 2011).
Just one year later, in 1903, North Carolina passed the first “permissive” registration law for nurses. Permissive licensure allowed nurses who met certain standards (such as graduating from a nursing school and passing a comprehensive exam) to work as a nurse but did not allow the use of the title “registered nurse.”
In addition to a registration law for nurses, North Carolina became the first state to pass a nurse practice act, signed into law by the governor on March 2, 1903, it read in part:
At meetings it shall be their duty to examine all applicants for license as registered nurse, of good moral character, in the elements of anatomy and physiology, in medical, surgical, obstetrical and practical nursing, invalid cookery and household hygiene, and if on such examination they be found competent, to grant each applicant a license authorizing her or him to register, as hereinafter provided, and to use the title ‘Registered Nurse’ signified by the letters R.N. The said Board of Examiners may in its discretion, issue license without examination to such applicants as shall furnish evidence of competency entirely satisfactory to them. Each applicant before receiving license, shall pay a fee of $5.00 which shall be used for defraying the expenses of the Board. (NCNH, 2015)
New York, New Jersey, and Virginia succeeded in passing nurse registration laws by the end of 1903 and by 1921, 48 states, the District of Columbia, and the Territory of Hawaii had enacted laws that regulated the practice of professional nursing (Egenes, n.d.). Mandatory licensure laws for nurses were not passed by the states until the late 1940s (Egenes, n.d.). The terms Registered Nurse and Licensed Practical Nurse (vocational) are now legally protected titles in all states.
Nursing in Texas
[This section taken from Tschirch & Crowder, 2010.]
In Texas, as elsewhere in the United States, care of the ill or injured and assistance in childbirth were part of the traditional and expected role of women. On the Texas frontier, settlements were often few and far between, as were physicians. Accidents, however, were not uncommon, and the hot Texas climate often contributed to outbreaks of disease (Tschirch & Crowder, 2010).
From the early 1820s there are records of Texas women nursing others through illness, injuries, and childbirth. The challenges of the frontier and the sometimes daunting climate meant they received a lot of practice even though there was no formal recognition or training for their work (Tschirch & Crowder, 2010).
The first groups in Texas to make an important impact on nursing outside of the home were lay nurses from Catholic congregations of women. In 1866 three sisters from the Incarnate Word Convent in Lyons, France, came to Galveston and opened St. Mary’s Infirmary. The following year Galveston was struck with a devastating yellow fever epidemic and more than a thousand people were treated in and out of the hospital. After the Civil War, in 1869, several sisters left to open a hospital in San Antonio. In later years others would be opened in Beaumont, Texarkana, Fort Worth, and Amarillo, and all would open schools of nursing (Tschirch & Crowder, 2010).
In 1890 the first formal school of nursing in Texas was established at John Sealy Hospital in Galveston, just 17 years after the first ones in the East. In 1896 the school became a regular department of the University of Texas Medical Branch. Nursing schools were financially dependent for many years on hospitals or medical schools (Tschirch & Crowder, 2010).
Nurses cared for patients in hospital wards and operating rooms and assisted at home surgeries. They were concerned with understanding and providing effective treatments for their patients. Nurses also had responsibility for equipment and supplies in an era without plastics and disposable products (Tschirch & Crowder, 2010).
Hospitals were mainly staffed by student nurses who were supervised by a head nurse and the head of the nursing school. Until the Great Depression most graduate nurses worked in private-duty settings. Some also worked as visiting nurses or in occupational medicine. Hospitals did not begin to hire more graduate nurses until the late 1930s and especially after World War II (Tschirch & Crowder, 2010).
The First Nurses Association in Texas
With nursing registration and nurse practice acts becoming law in several states, nurses saw the need for professional organizations to represent their needs. In Texas as elsewhere, employment difficulties and the lack of educational and practice standards motivated trained nurses to organize and push for improvements. In 1907 nineteen nurses met in Fort Worth to form the association that would rename itself the Texas Nurses Association (TNA) in 1964, but was first called the Graduate Nurses’ Association of Texas. One year later it became the Texas Graduate Nurses Association (TGNA) and it petitioned to join the forerunner of the American Nurses Association.
The TGNA helped influence the Texas legislature to pass a nurse registration and practice law in March 1909. The law did not provide any mechanism for inspecting or accrediting nursing schools so the TGNA undertook to study the means to improve standards in these schools. Finally, in 1923, a law was passed that provided an educational secretary to visit nursing schools annually and prepare a written report (Brown, 2010; BON, 2013).
The Texas Nurses Association is today the oldest and largest nursing association in the state. It is a membership-based professional association of licensed nurses who volunteer their time to the organization. They represent all parts of nursing from administration to practice in a wide variety of settings, but they share the common purpose of “advancing excellence in nursing” (TNA, n.d.).
The Texas Nursing Practice Act
The original Nursing Practice Act (NPA) was passed in March 1909, and has been revised and updated many times since, reflecting changes in healthcare and nursing practice (BON, 2013).
The NPA created the Board of Nurse Examiners, now known as the Board of Nursing (BON), and it met immediately to establish standards, but was not originally given authority over nursing education. It also had other weaknesses in that it only applied to individuals using the title Registered Nurse, it did not define “professional nursing,” and it did not specify educational requirements for nurse licensure (BON, 2013).
In 1923 the Board was given authority over nursing education, and in 1925 all Texas statutes were re-codified and the professional nursing laws were incorporated in Vernon’s Civil Statutes. Over the years changes were made to the Board’s responsibilities and to nursing licensure and education. In 1999, the NPA was codified as Chapter 301 of the Texas Occupations Code (discussed in detail in the next section). Today, the Texas Board of Nursing (BON) is responsible for licensing, regulating, and monitoring the status of approximately 260,000 licensed Registered Nurses and 98,000 Licensed Vocational Nurses. The BON approves 114 nursing education programs for registered nurses and 98 programs for licensed vocational nurses (BON, 2013).Back Next