Nursing is among the many professions regulated by state-based practice acts. The emergence of these acts is historically important because they parallel the development and growth of the nursing profession.
Prior to 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 first hospital in North America, Our Lady of Solitude, was established by the Spanish in 1597 in St. Augustine, Florida. More than two centuries later medical training in the United States was still largely through apprenticeships. In the 1800s, folk medicine, homeopathy, herbal medicine, and midwifery predominated. Midwives, mostly African American women, provided much of the medical care, particularly maternity care, in impoverished and isolated rural communities throughout the South (Florida Memory, n.d.).
Around the time of the American Civil War (1861–1865), there were only about 150 hospitals in the United States. 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 first professional nurse training school in the world at St. Thomas’ Hospital in London, with the first class starting on July 9, 1860.
Circa 1850–1855. Public domain.
The Civil War had a profound effect on the development of the nursing and medical professions and in many ways laid the foundation for modern nursing (Egenes, 2009). The hundreds of thousands of casualties created a need for caregivers and tens of thousands of women offered their services, mostly on a volunteer basis. In 1861, responding to the strong opposition to female volunteers, Dorothea Dix (1802–1887) organized a march on Washington demanding that women be allowed to treat Union soldiers. She was quickly put in charge of nurses assigned to the U.S. Army.
Dix initially required nurses to be over 30 years of age, “plain looking” and without curls, and forbade them to wear anything except brown or black clothing without ornaments, jewelry, or hoops. The age requirement was soon dropped as the number of wounded soldiers began to overwhelm the medical system. It is estimated that 3,000 nurses served in the Civil War (Egenes, 2009), although as many as 30,000 women worked as volunteers.
The sacrifices made by nurses and other female volunteers during the war succeeded in changing public opinion about women working in healthcare. In 1868, just 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).
Nurse with wounded men after the Battle of Nashville, 1864. Public domain.
Just five years later, in 1873, the first educational programs for nurses in the United States were established in New York, Massachusetts, and Connecticut. Teaching techniques were largely based on the Nightingale Method, although there were some differences, particularly in hospital oversight of the nursing students. This period—from 1873 to 1893—is considered by some to be a “pioneering period” of nursing education (Stewart, 1935). The new nursing schools were so popular and successful that soon every hospital wanted a school of nursing.
In the late 1800s, women’s organizations began organizing to improve working conditions for nurses by encouraging nursing licensure (then referred to as “nursing registration”). The development of licensure and standards of practice was seen as a way to ensure public safety and improve working conditions for nurses. As the nineteenth century drew to a close, nurses themselves, along with many women’s organization, lobbied for nurse registration as well the development of standards for nursing education and establishment of nurse practice acts.
Both support for and opposition against regulation of nursing practice was strong. Although a vocal proponent for improvements in education and working conditions, an aging Florence Nightingale was famously opposed to nurse registration. Nightingale stated in 1890,
The tendency is now to make a formula of nursing, a sort of literary expression. Now, no living thing can less lend itself to a formula than nursing. It cannot be tested by public examinations, though it may be tested by current supervision. (Goodnow, 1916)
As the twentieth century dawned, intense political lobbying led to the establishment of nursing registration as well as the development of the first state-based nursing practice acts. The New York State Nurses Association, formed in 1901, led the charge, working to gain legal status for nurses. The preliminary political work was spearheaded by a handful of women, most notably Isabel Hampton Robb, Sophia Palmer, Sylveen Nye, and members of the New York Federation of Women’s Clubs, which a few years earlier had passed a resolution urging the formation in New York State of a Nursing Board of Examiners chosen by a state society of nurses. They argued that nursing education should be included in the list of professions supervised by the New York State Board of Regents.
Pioneers of Nursing
In 1902 a group of women from 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, “The day is coming when trained nurses will be required to possess a college education before being admitted to training” (Willis et al., n.d.).
In 1903 North Carolina passed the first registration law for nurses and, along with this, the first nurse practice act. 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.).
The Ohio State Nurses Association was formed in 1904. Ohio enacted its first nursing practice act in 1915 by creating a Nurses Examining Committee (NEC) under the jurisdiction of the state medical board. In 1941 the NEC separated from the state medical board and became an autonomous state nursing board.
Since these humble beginnings in the early twentieth century, nurse practice acts have been revised, updated, and modernized. Gone are rules related to moral character, marriage restrictions, pregnancy, and age limits. Added are updated definitions of professional nursing, educational requirements, regulations for licensed practical nurses, nurse practitioners, nurse midwives, clinical nurse specialists, and certified nurse anesthetists. Computerized licensure databases have been developed, as have rules related to continuing nursing education, chemical dependency, delegation, and criminal background checks, among other additions.
Now, each state and territory of the United States has a law called the Nurse Practice Act (NPA) that is enforced by each state’s nursing board. Nurses are required to understand and comply with the laws and related rules of their own NPA in order to maintain their licenses (NCSBN, 2017).
In general, nurse practice acts describe:
The Ohio Nurse Practice Act (NPA), established in 1915, sets guidelines for nurses who practice in the State of Ohio. It is codified in Chapter 4723 of the Ohio Revised Code (ORC). Nineteen chapters within the Ohio Administrative Code (OAC) fill out the ORC with additional rules regarding nursing practice.
An amendment to the Ohio Nurse Practice Act [Chapter 4723, Ohio Revised Code (ORC)] authorizes certified nurse practitioners, clinical nurse specialists, and registered nurses, under specific circumstances, to determine and pronounce death. The new law, Section 4723.36, ORC, which became effective March 22, 2013, authorizes certified nurse practitioners, clinical nurse specialists, and registered nurses to determine and pronounce death if an individual’s respiratory and circulatory functions are not being artificially sustained, and certain other circumstances exist (Ohio BON, 2017a).
Ohio nurses and others covered by the nurse practice act are responsible for understanding the laws and rules that govern and define their scope of practice. To determine if a procedure or activity is within a nurse’s scope of practice, see the Decision Making Model available on the BON website. The most up-to-date version of rules pertaining to scope of practice is also available on the Ohio Board of Nursing website.
As licensed nurses take an ever larger role in the delivery of healthcare, complaints against nurses have increased. The National Council of State Boards of Nursing reported that 1,015 licensed nurses in Ohio received a disciplinary action during 2012. Of those, 284 were placed on probation, 87 had their licenses revoked, and 400 had their licenses suspended (NCSBN, 2013).