The Nurse Practice Act
100 Years Ago, The Nurses Of Rochester Changed The World Of Nursing
In the beginning
Abraham Lincoln said in his Gettysburg Address, "The world will little note nor long remember what we say here but can not forget what they did here." Thus it is with history, events that in their day had a major impact on history become gray and forgotten with time. So it is with nursing history. Little is remembered of the part Rochester, New York and its leading hospitals of the time Rochester City Hospital -- today's Rochester General Hospital and Rochester Homeopathic Hospital -- The Genesee Hospital, played in the professionalization and reform of nursing. Rochester had been the center of nursing reform since the late 1800's. Rochester's leading nurses helped form the New York State Nurses' Association, the first such organization in the country, and the first regional organization, today's Genesee Valley Nurses Association. It was the home of the American Journal of Nursing for its first twenty years. The title Registered Nurse, "R.N." derived from the nurse registration act of 1903. These all happened here, in Rochester New York.
The New York State Nurses Association (Eva Allerton and Sylveen Nye). The purpose of the organization was to secure legislation that would allow a legal credentialing mechanism for nursing practice and thus protect graduate nurses.
In 1899, Sophia Palmer and Eva Allerton presented papers before the New York State Federation of Women's Clubs. In her paper, Miss Palmer said "The greatest need in the nursing profession today is a law that shall place training schools for nurses under the supervision of the University of the State of New York." Such a law would require every training school to bring its standard up to a given point" Miss Nye writing in the Buffalo-based Trained Nurse, made a similar argument for the professionalization of nurses.
During this period New York had 15,000 untrained nurses and about 2,500 formally trained nurses. Their training consisted of anywhere from six months to three years in a formal hospital setting. There was little control over the quality or content of nursing education at this time. But that was about to change.
The momentous meeting of October 21, 1902
At the regular quarterly meeting of the Association held October 21, 1902 in Rochester, New York, the Nurse Practice Act came to the forefront. The main object of the meeting was to secure a law, which would "establish a uniform and definite basis for the practice of nursing." The American Journal of Nursing of November 1902 relates the beginnings of this meeting held in the Assembly Room of the Isabella Graham Hart Nurse's Home at the Rochester City Hospital. Over one hundred trained nurses from Rochester and across the state attended. In attendance were Rochester General), Dr. William S. Ely, President of the Academy of Medicine of Rochester and a member of the State Board of Medical Examiners. State Senator William Armstrong was not in attendance but had guaranteed his support and sponsorship of the bill.
The American Journal of Nursing described the events of the meeting:
Miss Susan B. Anthony was the first speaker to be introduced, and although now in exceedingly frail health, Miss Anthony's interest in the discussions was so great that she remained in her seat on the platform through both the morning and afternoon sessions, an honor the memory of which those present will always cherish.
Miss Anthony gave an account of the evolution of the nursing profession. She explained that when she first took up the cause of women's rights, the trained nurse was unknown. She went on to describe the struggle of the first women physicians to get their degrees. She also pointed out the influence that the woman nurse exerts in the family. She referred to the great power of women's organizations and emphasized the point that where the graduate nurses had the right to vote, they could obtain their desire much more easily. She closed her address with an earnest appeal to the nurses to remember the power and the influence of their work, and to improve it. At the close of her address Miss Nye of Buffalo, "moved that a rising vote of thanks be given Miss Anthony for her words of advice and encouragement."
The remainder of the morning was devoted to the regular routine of committee reports and other business. Miss Mary Keith, Superintendent of Rochester City Hospital, supplied a luncheon served by the staff of house physicians and the head nurses of the hospital. Mrs. Arthur Robinson, president of the Board of Lady Managers, and Mrs. Henry Danforth served coffee in the memorial hall near the Tiffany Stained Glass window; other guests were distributed throughout the assembly rooms. "The Nurses' Home is well adapted for meetings of this kind, as, in addition to the large assembly room, which seats over a hundred people, there are several small reception rooms adjoining."
At the afternoon session two other prominent Rochesterians spoke in the opening of the session. The first, Dr. William S. Ely, stated that, "It was in this very room two or three years earlier that I argued to the nurses here the necessity for legislation that you now desire". He spoke from the physician's viewpoint and told how his profession had labored under the same difficulties years ago which now confronted the trained nurse. He strongly favored the nurse's position and thought that the medical profession would lend them "every assistance."
Also speaking on behalf of the proposed legislation was the Rev. Thomas Hendrick, a member of the State Board of Regents and later the first American Catholic Bishop in the Philippines. Father Hendrick spoke from the standpoint of the Regents and the public, impressing upon those present that the Board of Regents does not make the laws, but it simply executes them. "The Regents are simply trustees of the state. They are the officers of the university." Rev. Hendrick went on to give many examples how the Regents function in the role of oversight of professional licensure.
Following the Reverend's comments, Susan B. Anthony again addressed the assembly. She prophesied that "the day is coming when trained nurses will be required to possess a college education before being admitted to training."
Miss Palmer spoke on the actions taking place across the country to require higher education for nursing applicants. Dr. Ely outlined a program at the Mechanics' Institute (RIT) consisting of a cooperative effort on the part of the city's four nurse training schools to teach such classes as "Invalid Cooking" and German to be able to communicate with immigrants.
Next the report of Miss Allerton's committee on Legislation was taken up. The original bill as submitted to the assemblage had "Trained Nurse" in place of "Registered Nurse." This was the main area of disagreement: what the newly certified nurses should be called. A number of views were put forth that these nurses should be referred to as "Trained Nurse," "Nurse," "Registered Graduate Nurse," or "Registered Nurse". The debate was reproduced in full in the American Journal of Nursing for December 1902:
In the discussion which followed, to which ample time was given, and which was conducted with moderation and toleration, Miss Allerton, chairman of the Legislative Committee, with her associate Miss Damer, stood strongly for the term "Trained Nurse," urging in support of their arguments that the public were accustomed to that title, and it would take many years to educate the masses of the people to discriminate in favor of a new title the meaning of which they did not understand.
Miss Nye, of Buffalo, objected to all of the titles which had been proposed, stating that she believed the title should be simply "nurse;" that a woman should have the right to use that title or she should not have it; that there should be no qualifying or half-way measures, and she held that by adopting any one of the other titles, which must necessarily be misleading in its significance, we are creating difficulties for the future. Miss Nye spoke ably and forcibly in support of her opinions.
Miss Sophia Palmer, in expressing her preference for "Registered Nurse," quoted a letter received by the secretary from Miss Waterman of the Brooklyn Methodist Episcopal Hospital, saying that in the term "Registered Nurse" would be implied training and graduation from a school endorsed by the Regents, because by no other methods would a nurse be permitted to use that title. The visiting members, of whom there were over a hundred present, were given the privilege of taking part in the discussion on the title.
In a blocking move by Miss Enright of New York, and seconded by Miss Nye a motion was made to send a letter to the other state associations for their opinion on the title before the bill was submitted to the legislature. A reporter for the Rochester Democrat and Chronicle witnessed the ensuing discussion. Miss Enright felt that action should not be taken hastily in a matter so momentous that will have an effect on future nurses. It should not be settled by so small a body whose views may not be in tune with the majority of New York nurses. This suggestion was strongly opposed and if adopted would postpone legislation for another year.
Miss Nye again "spoke strongly for the term "nurse" declaring she could not see in all the arguments that had been advanced why that did not cover the whole ground. She wanted to know if a doctor wasn't a doctor, or a lawyer a lawyer, or a preacher a preacher without a qualifying term?" Miss Palmer responded "that the title M.D. guaranteed registration "(a doctor) could not hang out his sign with M.D. until he had been registered by the state." She equated the title R.N. with the respect shown a Doctor with his M.D. "No woman is debarred from nursing because she is not a graduated registered nurse, nor do they (NYSNA) wish to wage any war against such women. The only point was that the public should understand the difference between the two classes, the woman who had spent years in preparation and had passed the examinations, etc., of the registered nurse, and the woman who was nursing without any or little training."
Miss Enright insisted upon a vote on her motion in which it was roundly defeated. Miss Damer of Buffalo, emphasized the fact that all the state associations were undecided as to the title and that they were looking to the New York Nurses to make the decision. She then moved that the term "Registered Nurse" be incorporated in the act; Miss Frick from Rochester seconded the motion and it was approved by a vote of thirty-seven to two. The other sections of the bill were adopted as read. But getting this through the legislature and accepted by the nurses was just the beginning.
Read the text of the Armstrong Bill
Out of an attendance of one hundred and fifty only thirty-nine present were eligible to vote. The bulk of these were from Rochester. The "out of town faction" was a vocal group headed by Sylveen Nye. They were determined to reverse the decisions of the meeting. Meeting after the conference, the dissidents adopted the following resolution:
Whereas, The New York State Nurses' Association, at its last two meetings, did adopt a constitution and by laws which must result to the disadvantage of the nursing profession and which defeats the object for which said association was organized, and which as we believe, against the wishes and judgment of a majority of the nurses of New York state: and,
Whereas, We desire a state organization of nurses for the nurses and not an organization of nurses for the purpose of advancing the personal interests of a few, and believing that no legislation can be obtained unless the cooperation of all nurses and of the medical profession is secured; and,
Whereas, the said New York State Nurses' Association admits to membership only graduates of general hospitals, and hospitals for the insane, and we believe that such action is not Christian-like and is unwise, and we believe that nurses from all schools connected with reputable hospitals should be recognized until such time as the nursing and medical professions shall elevate the standard by securing legislation, gradually introducing such changes as will provide for hospitals a general training for pupils, and we believe that a few women have no moral or legal right to discriminate against the recognition of such nurses as are recognized by the laws of the state of New York and its medical profession; therefore,
Be it resolved, That the Buffalo Nurses Association deplores and disapproves the action of the New York State Nurses Association; and be it further
Resolved, That it is the sense of this association not to affiliate with the New York State Nurses' Association in its present form; and, be it further
Resolved, That a copy of these resolutions be sent to the nursing journals for publication.
Sylveen Nye and the Buffalo contingent returned home where they drew up an alternate nurse practice bill that was submitted by Nye's brother Assemblyman Olin Nye. His bill reached the floor of the Assembly days after the Armstrong Act. In order to make both bills agree the Nye bill was significantly altered to agree in all facets with Rochester's contribution. Miss Nye felt that too many persons who were then functioning competently as nurses within the state would be disenfranchised by the certification of others. Her concern was not easily dispelled and what came to be called the "Armstrong Bill" was a political target of hers in later years.
Modifications to the Original
In May of 1903 the American Journal of Nursing reported that "The Armstrong Bill passed the Assembly April 20 with a majority of 109 to 12." The Nye bill was then introduced in an attempt to change some particulars of the Armstrong Bill. The Armstrong Bill's proponents retaliated by amending the Nye Bill until it was identical to and agreed in all respects with the Armstrong Bill. The combined bill, as had been originally produced at the October 1902 meeting in Rochester, was taken to the governor for signature and enactment into law.
One of the first problems encountered after the Armstrong Bill became State law was that while the law had noble intentions, it did not provide guidance on how to implement all the changes it had proposed. A major disagreement regarded curriculums to be taught at State certified schools. As one editorial writer of the time put it: "The Board (of Regents nurse examiners) was called upon to define, for the first time in nursing history, what should constitute a general training." While it had been generally agreed that the training should include instruction in medical, surgical, gynecological and obstetrical areas as well as in the nursing of children and cooking, the levels of that instruction had not been defined.
What had been the basis for this law and its implementation was the idea that these standards were for the least developed schools of instruction. "...The requirements of the NYS law as it is now in operation, seem, possible, very meager; but it must be borne in mind that such a reform as the registration of training-schools under the Regents now contemplated calls only for the minimum of education which shall be recognized. The higher grade schools will go on broadening and developing, and the lower grade schools with a uniform, minimum standard made compulsory, will gradually be brought up to the standards of the advanced schools."
Many of the nurses who attempted to register under the "grand-mother" clause were turned down because their training school did not meet the basic criteria established by the act. Miss Palmer wrote in 1905 in the AJN:
The most important feature about the New York Law is that the training school from which a nurse has graduated must conform today to the standards approved by the Regents before the graduate, no matter of how many years ago, can be registered. Schools from every state in the Union can register. Many schools that could not conform when the law was passed have improved their course to conform to the NYS requirements. In this way the New York law is improving the standard of education for nurses all over the United States. Nurses who have applied for registration and have been refused because their schools are not registered are naturally very much disturbed ... (they should) investigate the training that the school is now giving its pupils. A training school that cannot conform to the simple requirements of the Regents, is, for these days, a pretty poor school.
By July 1905, topics of dissent had appeared in the nursing registration act. In particular, the specifics of nursing education needed to be more precisely spelled out for statewide implementation. Miss Sophia F. Palmer, as President of the New York Nurse Board of Examiners wrote:
Subjects of State Examination-- Training schools for nurses registered by the Regents shall provide both practical and theoretical instruction in the following branches of nursing:
(1) medical nursing (including materia medica)
(2) surgical nursing, with operative technique including gynecological
(3) obstetrical nursing (each pupil to have no more than six cases)
(4) nursing of sick children
(5) diet cooking for the sick, including
(a) 12 lessons in cooking at a good technical school or with a competent diet teacher
(b) food values, and feeding in special cases to be taught in classes, not by lectures
(6) a thorough course in theoretical instruction in contagious nursing where practical experience is impossible. Training schools for male nurses shall provide instruction in genitourinary branches in place of obstetrical and gynecological nursing.
After Jan. 1, 1906, all registered training schools for nurses must require the completion of one year of a high school course subsequent to an eight-year grammar school course, or the equivalent. ... Preliminary training. Training schools should teach their probationers before placing them at the bedside of patients:
(a) the various methods of making and changing the bed, with and without the patient;
(b) The temperature of baths and the simple methods of administering them;
(c) The use and the dangers of the hot-water bag;
(d) The principles of sweeping and dusting;
(e) the setting of trays, etc.
Another area of concern for many of the nurses was the lack of physician representation on the examining board. This was contrary to practice in many training schools; however it was felt that as the board of examiners was for nurses, the physician had no place on it. Additionally there were three physicians on the Board of Regents.
Eventually, the term used by the Rochester nurses won out. Henceforward all trained and certified nurses inside New York State and almost everywhere else would be known as Registered Nurses.
The Nurse Practice Act would continue to draw criticism from doctors, politicians and disgruntled nurses.
The first license was finally issued in 1904 to Ida Jane Anderson class of 1902 from the Rochester Homeopathic Hospital. The act took its toll when Eva Allerton died in part from the strain of the years of intense campaigning to pass the bill and make it a viable entity in the professionalization of nursing.
They say that the first one hundred years are the hardest. What remains after the first century is a piece of cake. In a few weeks, a major component of our healthcare system will be celebrating a century of service.
Unlike Zeus and Athena, the profession of nursing did not spring full borne from the head of Florence Nightingale. Like all difficult deliveries, having this newborn took time, superb prenatal care and a solid delivery system. In October 1902, a movement, which had been debated for decades, finally took root here in Rochester. For the first time "Registered" nurses were recognized as a separate and distinct branch of medical service. Conditions were established for their training and cultivation, and those who did not qualify were directed along the road towards that professional certification.
Imagine the odds stacked against these women. They demanded a bill that would give an entire class of women instant professional status on a par with doctors (who were overwhelmingly men). They demanded that the state sanction their proposed status change, codify it and then leave it entirely up to the women as to how those changes would be implemented. To complicate matters, this new group could not support the parties in power, as American women’s right to vote, the 19th Amendment, would not be ratified until 1920.
Credits and Sources
- Dave Willis
- Philip G. Maples
- Kathleen Britton
Layout and Web Design:
Special Thanks To:
- New York State Nurses Association for the linkage to the history portion of their web site.
- Susan B. Anthony House for linkage to the Susan B. Anthony Biography portion of their web site.
- NYS Senator James S. Alesi's Office for their research assistance.
- Teresa K. Lehr for editorial comment.
- Catholic Diocese of Rochester for Bishop Hendrick's picture.
- The major part of the script was taken from the American Journal of Nursing, October, 1902, November 1902, December 1902, March, 1903, May 1903, June 1903, July 1907
- Text of "New York Bill", American Journal of Nursing January, 1907, pp276-278
- The Hospital Review, Rochester City Hospital, Rochester, NY, May, 1901.
- Democrat and Chronicle October 14, 1902 and October 22, 1902
- Julie M. Pavri, Honoring our Past: Building our Future, A History of the New York State Nurses Association, NYSNA, Q Publishing, Franklin, Virginia, 2000, pp 23-27.