Nursing history explains why US nursing looks the way it does today: why nurses are licensed by states, why education moved from hospital schools to universities, why public health nursing grew out of settlement houses, and why professional organizations set ethics codes and standards. Exam questions usually test who did what, and why it mattered.

Profession — an occupation with a specialized body of knowledge, formal education in higher-education settings, a code of ethics, self-regulation and licensure, autonomy in its own practice, and a service orientation. Nursing's history is largely the story of meeting these criteria.

Periods in brief

Florence Nightingale (1820–1910)

• Led nurses caring for British soldiers in the Crimean War (from 1854); improved sanitation and reduced deaths
• Wrote Notes on Nursing (1859); her ideas are the basis of the environmental theory — ventilation, light, warmth, cleanliness, quiet, nutrition, and observation help the body heal
• Used statistics and graphic displays (the polar-area diagram) to argue for reform — an early form of evidence-based advocacy
• Opened the Nightingale Training School at St Thomas' Hospital, London (1860) — the model for secular nurse training worldwide
• Views often tested: nursing is a calling ("vocation"), nursing care is for the sick person rather than the disease (holistic care), health promotion and prevention matter, and nurses should be of good character. She opposed state registration of nurses, believing character could not be tested by examination.

Early US leaders

Milestones in US regulation and education

• 1903 — North Carolina passed the first nurse registration law; New Jersey, New York, and Virginia followed the same year. These early laws protected the title "registered nurse"; later laws defined and restricted the practice itself.
• 1923 Goldmark Report — recommended moving nursing education into universities
• 1943 Cadet Nurse Corps — federal funding to train nurses during World War II
• 1952 — associate degree nursing programs began (Mildred Montag's model, 2-year community college programs)
• 1964 Nurse Training Act — federal support for nursing education
• 1965 — Medicare and Medicaid created; demand for hospital and home care grew
• 1978 — the National Council of State Boards of Nursing (NCSBN) formed; it develops the national licensure examinations used by state boards
• 1994 — first hospital designated under the Magnet Recognition Program (University of Washington Medical Center)
• 2010 — Institute of Medicine report "The Future of Nursing" recommended 80% of RNs hold a BSN by 2020, nurses practice to the full extent of their education, and lifelong learning
• 2021 — National Academies report "The Future of Nursing 2020–2030" focused on health equity, social determinants of health, and nurse well-being
• 2023 — NCSBN's redesigned "Next Generation" licensure examination (April 2023) began measuring clinical judgment with new item types

Professional organizations — know the purpose, not only the name.

Accreditation vs. certification vs. licensure — a common exam trap:

• Licensure — granted by a state board of nursing; mandatory to practice; sets minimum competence
• Certification — granted by a professional/specialty body; usually voluntary; shows specialty expertise
• Accreditation — granted to programs or institutions, not individuals (ACEN, CCNE, CNEA for schools; The Joint Commission and other bodies for hospitals)

• Understand the profession's roots in advocacy — Nightingale, Wald, and Sanger are models of nurses changing systems, not only caring for individuals
• Join and participate in professional organizations; they create the standards used in courts and regulation
• Maintain licensure and pursue certification and lifelong learning
• Advance education (BSN and graduate study) in line with national workforce recommendations
• Advocate for equity in the workforce — the exclusion of Black nurses from many early organizations and schools led to the National Association of Colored Graduate Nurses (1908), which dissolved into the ANA in 1951 after integration

• The shift from title-protection laws (1903) to practice acts is why today only licensed persons may practice nursing; each state's Nurse Practice Act is law, whereas ANA standards and codes are professional (not statutory) guidance that courts may use to define the standard of care
• The Code of Ethics for Nurses (first adopted by the ANA in 1950; current revision 2025) is the profession's ethical framework (Topic 2)
• The Nightingale Pledge (1893) is historical and not a legal or current ethical standard
• Professional organizations cannot license or discipline; only state boards can

Case 1. A student says, "The ANA can take away a nurse's license for unethical conduct." Correct response: only the state board of nursing can discipline a license. The ANA sets ethical and practice standards; a board may consider them. Why: licensure is a state legal function.

Case 2. A nurse wants to show expertise in critical care. Correct action: pursue specialty certification from a certifying body. Why: certification is voluntary recognition of specialty knowledge; licensure only establishes entry-level competence.

Case 3. A community health nurse organizes home visits and school health services for immigrant families in a crowded urban area. Link: this continues Lillian Wald's Henry Street model of public health nursing — care where people live, addressing social conditions.

Case 4. A hospital wants external recognition that its nursing environment attracts and keeps nurses and produces good outcomes. Correct program: ANCC Magnet Recognition Program.

• Confusing ANA (professional association, code and standards) with NCSBN (regulators, licensure examination, compact) and state boards (legal authority)
• Confusing the two AACNs: American Association of Colleges of Nursing (education) vs. American Association of Critical-Care Nurses (specialty)
• Thinking Nightingale supported registration — she opposed it
• Attributing the American Red Cross to Nightingale — Clara Barton founded it; Nightingale's work inspired the international Red Cross movement founded by Henry Dunant
• Thinking accreditation applies to individual nurses — it applies to programs and organizations
• Placing the first US registration law in New York — North Carolina (1903) was first
• Assuming Magnet is a legal requirement — it is voluntary recognition

• Nightingale: Crimean War, environmental theory, Notes on Nursing (1859), statistics, St Thomas' school (1860), opposed registration
• Lillian Wald: Henry Street Settlement (1893), "public health nurse"
• Clara Barton: American Red Cross (1881); Mary Mahoney: first African American trained nurse (1879)
• Mary Breckinridge: Frontier Nursing Service (1925), nurse-midwifery; Loretta Ford: first NP program (1965)
• 1903 North Carolina: first nurse registration law
• ANA: Code of Ethics and scope and standards; ANCC: certification and Magnet; NCSBN: licensure examinations and the compact; state boards: license and discipline
• Licensure = state, mandatory; certification = professional, voluntary; accreditation = programs and institutions
• IOM 2010: 80% BSN by 2020; NASEM 2021: health equity
• ICN (founded 1899; headquartered in Geneva) represents national nursing associations worldwide