State Registration of Trained Nurses
State Registration of Trained Nurses
About the Author: William Henry Welch (1850–1934), a pathologist and bacteriologist, helped raise the level of medical instruction in the United States. After pursuing medical studies in Germany, he returned to the U.S. to organize the first teaching laboratory for pathology at Bellevue Hospital. The first professor appointed to the new Johns Hopkins University Medical School in 1884, he helped institute new admission standards for medical students that included a bachelor's degree with appropriate courses in the sciences. In 1903, at the time of this speech, Welch was president of the Maryland Board of Health and dean of the medical faculty at Johns Hopkins. He would later serve as the president of the American Medical Association and as the president of the National Academy of Sciences. The discoverer of the bacillus causing gas gangrene, he is also responsible for helping to spread knowledge of bacteria among medical scientists.
The nursing profession's quest for status as a health care profession began in the late nineteenth century with the formation of the American Nurses' Association (ANA). The organization aimed to raise the standards of nursing, initially by pushing for state registration of nurses that would mandate standardization of training. In 1903, William Henry Welch spoke to the newly formed Maryland state chapter of the ANA about state registration of nurses.
Nursing in the twentieth century was a woman's profession. Along with careers in teaching, libraries, and social work, nursing provided personal satisfaction and met the criteria for women's work. A nursing career drew on years of socialization and a consciousness bred to serve. Women who took up nursing could assume a social role consistent with the home. Nurses remained subordinate to (mostly male) doctors, served others, and had limited possibilities for advancement. This pattern of subservience and female submissiveness led to an undervaluing of the contributions of nurses.
To develop nursing as a profession, the ANA had to attach it in the public mind with competence in a distinguished field. ANA members believed that registration would force schools of nursing to improve the quality of training offered to students. Some of these schools were barely worthy of being called educational establishments. Typically attached to a hospital in this era, too many of these schools simply existed to provide inexpensive, menial labor for the hospital. As an indication of the lack of status of nursing, one Kansas hospital expected its nurses to provide patient care and mow the hospital lawn.
Determined to make the public view of nursing as a worthy partner to medicine, the ANA pushed for state registration. It had long been a requirement that medical practitioners meet certain fixed educational standards and become licensed. It seemed logical to many in the health care professions to expect nurses to also adhere to fixed standards.
… I hope, therefore, that in this state you will aim to secure such standards as are equal to the best. If that is not possible, get what you can, but, if possible, set up a standard that will be recognized not only here but in all the states of the country, so that a nurse who is a registered nurse in the state of Maryland shall by that very fact be recognized as qualified to practice her profession in any state of the union. I do not know that you will encounter the question that we have in the medical profession, that is, the great problem of reciprocity between the different states, but it is a matter for you to consider. The underlying difficulty has been just what I have stated, that the qualifications have been so little uniform in the different states that as a result a physician who has passed his examination and has been perhaps for a number of years practicing in a given state finds great difficulty in changing his residence and engaging in practice in another state; he may no longer be able to pass the requisite examination….
You are only endeavoring to secure for your profession what has already been secured for other professions. You are not therefore asking for anything that is novel, that is experimental, or the application of any new principles of legislation whatever. The conditions differ little as regards nurses than as regards physicians, or pharmacists, or dentists, or lawyers, all of whose professions are amply protected now by the law. It is not for the present and doubtless it will never be considered judicious to prescribe that those who do not meet your qualifications shall be hindered from the practice of nursing. Judge Harlan has explained, that is not contemplated. It is clear that such a purpose would encounter an overwhelming opposition. You ask for nothing of the kind. Everyone is permitted to practice the art of nursing. You simply ask that some definite meaning shall be attached to the term trained and registered nurse, that meaning implying that those qualified to register have had a certain definite training. Now if all training schools in the country had high standards of education, similar periods of study and equal facilities or giving practical training, it might be questioned whether there was any urgent necessity for this registration of nurses. In the earlier days very likely such a need did not exist, but now the very fact that this movement has arisen and obtained in these three or four years since it began such momentum indicates that there is need for making clear in what the qualifications of a trained nurse really should consist.
The art of nursing, as Judge Harlan has stated, is a profession that is of the highest rank. It is one eminently fitted for women, it is one that requires a long period of training, one that requires special qualifications in the way of education on the part of the nurse, and I may say that I consider, although I am not a practitioner of medicine, that there is no improvement in modern medicine which outranks in importance, in its value in the prevention and cure of disease, the introduction of the system of trained nurses. One can put one's finger on great discoveries in medicine, the relation of bacteria, we will say, to the causation of disease, which is of the greatest interest in the progress of medicine, but so far as the treatment of disease is concerned the applications of the system of trained nursing counts for as much, if not more than any scientific discovery in medicine. So important is it that it is the main factor in the treatment and management of a number of the important and prevalent diseases. The benefits, therefore, which will come from the passage of this law in a measure are to you as a body of trained nurses, but in larger measure to the medical profession and in still larger measure to the whole community, to the general public. Therefore it seems to me that all the enlightened forces of society should be interested in the furtherance of this great movement on your part.
The first registration laws for nurses adopted in the U.S. were permissive laws. People who satisfied the legal standards were permitted to register and use the title, "Registered Nurse." However, students who failed the licensure examination were merely referred to as graduate nurses and they continued to work as professional nurses. State nurse practice acts typically defined professional nursing as the performance for compensation of professional services requiring the application of scientific knowledge and nursing skills in the care of the sick. Unqualified nurses who did not claim to be registered nurses did not break the law. By 1923, all of the states had nursing licensure laws but these laws meant little in practice.
Nursing schools were able to avoid meeting the legal guidelines set down in the permissive licensure laws. Where schools lacked the resources to upgrade their programs, they often chose to forego the legal requirements. As registration was not mandatory, this decision had no serious consequences for hospitals, since they could hire the graduates of their own schools of nursing rather than the more expensive registered nurses. Hospital management justified their support of low entrance requirements for the profession of nursing on the grounds that it was in the public interest to have many nurses.
Following the 1923 Rockefeller Foundation survey of nurse education and the 1926–1934 Grading of Nursing Schools study, legislators in various states began to consider revising nursing licensure laws. The new legislation aimed to safeguard the health of the public from incompetent members of a health care team and aid nurses by establishing a fair field of competition. In 1938, New York became the first state to require licenses of all who nursed for hire. The dramatic and sudden increase in the nurse supply occasioned by World War II (1941–1945) forced the suspension of the law and it did not come into full effect until 1949. Other states followed the example of New York with licensure becoming standard in the 1950s.
Along with licensure and education requirements, today's nurses are bound to specific standards of practice that are law within each state. The nursing profession also contains several licenses and levels of practice, according to established educational requirements. Practical or vocational nurses provide direct patient care, registered nurses provide patient assessment, deliver specialized and direct care, and fill supervisory and administrative roles. Advanced practice nurses make diagnoses, deliver specialized care, and have limited authority to prescribe medications.
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