History of Nursing in Iowa
(click here for printable pdf file)
On March 12, 1907 the Iowa Legislature took the first step toward ensuring that individuals providing nursing care to the citizens of Iowa were qualified to do so by passing a law that required education and licensure by examination. Prior to 1907, hospitals set their own educational standards as a condition of employment. There was no entity to prohibit an individual from claiming to be a nurse.
Nurse Practice Act
The intent of Iowa’s first Nurse Practice Act was to separate qualified nurses from individuals who were not adequately prepared to provide nursing care. The first law set an educational standard. It mandated a five member “board of nurse examiners” to construct and administer an examination.
The 1907 Code of Iowa required an applicant to be 23 years of age and of “good moral character.” The latter requirement remained in the law until 1964. Proof was supplied in the form of personal references, preferably from clergymen and teachers. The Code provided for refusal to grant a certificate and revocation of a certificate. Revocation could result from the “use of false or fraudulent means of obtaining a license,” or “immoral or unprofessional or dishonorable conduct, or willful violation of the rules and regulations of the State Board of Health.”
The law identified that a person who practiced nursing without a license was guilty of a misdemeanor and could be fined up to $100 or imprisoned in a county jail for up to 30 days.
There was no definition of the practice of nursing in the first Nurse Practice Act. The first legal definition of nursing is found in the 1938 Code of Iowa and identifies that “any person shall be deemed to be engaged in the practice of nursing who practices nursing as a graduate or registered nurse, or publicly professes to be a graduate or registered nurse and to assume the duties incident to such a profession.”
Licensure by Examination
In 1908, the licensing exam was comprised of 50 essay questions divided into five sections, at least one of which was completed orally. There were 10 questions on “diseases of men” taken by male candidates only. The exam was required by law to include “elementary hygiene, anatomy, physiology, materia medica, dietetics, and also practical nursing, medical and surgical nursing, obstetrics, nursing of children and the rules and regulations of the state board of health relating to infectious diseases and quarantine and such other subjects as the examining board may require from time to time.” The oldest examination on file was given in 1917.
The first license issued by examination was number 696 because 695 nurses had been licensed by waiver on the basis of previous experience or education. All seven testers who sat for the examination in 1908 passed. Six months later, 50 individuals took the exam and Iowa recorded its first failure.
The examination was comprised of essay questions until 1935 when a Board-constructed, multiple choice exam of 500 questions was initiated. This type of exam was utilized until the first national State Board Test Pool Exam (SBTPE) was administered in 1946. By 1949, most states had adopted the SBTPE as a consistent national standard.
LPN licensure was mandated in 1949, and never required a Board-constructed examination in Iowa. Between 1949 and 1951, LPNs could obtain licensure by waiver without the required education of one year but all LPN applicants were required to pass a national examination.
State boards converted from the SBTPE to the National Council Licensure Examination (NCLEX) in 1982. After 1988, examination results were reported as Pass/Fail. Two RN examinations and two LPN examinations were held in Des Moines each year until April 1, 1994 when the National Council of State Boards of Nursing converted to a computerized adaptive testing methodology (CAT) that allowed candidates to self-schedule the NCLEX examinations at board-approved centers of their choice. With implementation of computerized adaptive testing, temporary licensure of new graduates prior to receipt of a license was terminated.
From 1994 until October 2002, the National Council of State Boards of Nursing, Inc., contracted with Educational Testing Services (ETS) and The Chauncey Group International based in Princeton, NJ, to serve as the national test service. Testing was administered in Thomson (Sylvan) Prometric Centers. On October 1, 2002 the National Computer Services (NCS Pearson) became the national test service for the National Council of State Boards of Nursing, Inc., and testing was conducted in Pearson Professional Centers nation-wide. Communication with the boards became Web-based and conducted in real time, and candidates could apply for the examination via the Internet, telephone or mail. Licensure status was made available by the Iowa Board of Nursing via telephone and Internet.
Iowa Board of Nursing
The Iowa Board of Nursing was created as a separate entity from the Board of Health in 1935. It was a five member board, consisting solely of licensed nurses actively engaged in practice. In 1976, the board gained hearing powers, formerly retained by the Office of the Attorney General, and two consumer members were added. The legislature mandated gender balance in 1988 to ensure equal representation on all state licensure boards. Following voluntary closure of the last hospital-based diploma program for registered nurses in July 1999, board representation specific to this level of nursing education was replaced by representation from a registered nurse engaged in the practice of nursing.
The Board’s power is exercised primarily through the promulgation and enforcement of the Administrative Code, a set of rules written by the Board and designed to implement the law.
In 1908, applicants were required to be graduates of training schools which were in good standing with the Board of Health and included two years of instruction in general hospital practice. After July 1, 1910 no training school could be approved unless it was attached to a general hospital and had at least a three year course of study. In 1915, a requirement for one year of high school was instituted. This was increased to a two-year requirement in 1926 and to a four-year requirement in 1930.
In 1915, there were only 10 schools in the United States that reported full-time paid instructors. Curricula were designed by each Director of Nursing, with physicians often teaching anatomy and physiology. Two years later, and 10 years after mandatory licensure in Iowa, a standard curriculum was developed by the National League of Nursing Education. Adherence to that curriculum was voluntary until 1939. In 1927, a Division of Nursing Education was set up in the Iowa Department of Health to review records of applicants and inspect training schools. This Division was separate from the Board of Nurse Examiners. The two were united with the creation of the Board of Nursing in 1935. The Iowa Board of Nursing retained authority for approval of all formal nursing education programs. Four years later, the National League for Nursing (NLN) became the national voluntary accrediting body for nursing schools. In 1998, NLN established a separate Accrediting Commission (NLNAC) for all levels of nursing education, and the American Association of Colleges of Nursing established a Commission on Collegiate Nursing Education (CCNE) to address voluntary accreditation of programs at the baccalaureate and higher degree levels.
According to Goodnow’s History of Nursing, a prominent faction of policy makers as late as 1930 opposed higher education for nurses, on the grounds that “the average nurse did not need it, that women with less education did satisfactory work, and that intellectual women often made poor nurses.” The U.S. Census Bureau classified nurses as semi-professional in 1930 and raised them to professional status in 1940.
Iowa law required three years of training for Registered Nurses until 1964. At that time, the Board decreased the requirement to two years to accommodate Associate Degree programs. Administrative rules permitting the use of clinical nurse preceptors were implemented in 1994. The last hospital-based diploma program in Iowa closed in 1999. By 2002, there was one doctoral program, five post-master’s programs, five master’s programs, 13 baccalaureate programs, 26 associate degree and 28 practical nursing programs. Most associate degree and practical nursing programs were located within the 15 Iowa community college districts and the curricula were based on a ladder concept allowing graduates of the first year to apply for LPN licensure by examination. The first professional master’s degree program leading to initial licensure as a registered nurse was approved for implementation in 2003 at the University of Iowa. Curriculum delivery methods in the nursing programs included a variety of Internet and Iowa Communications Network (ICN) courses.
The Iowa Articulation Plan for Nursing Education was implemented in 1990. The Plan provided four options through which graduates of associate degree and practical nursing programs could progress to the baccalaureate level with minimal repetition of course content. The options included direct transfer of Iowa graduates, standardized testing, three Articulation Courses and course credit through escrow. A Validation Committee identified competencies and curriculum content, and validated the sending and receiving institutions in Iowa.
In 1978, the legislature passed a law which made continuing education a prerequisite for license renewal. The initial requirement was 15 contact hours annually. This was extrapolated to 45 contact hours when the licensure cycle was expanded in 1980 to every three years by birth month.
In 2001, the requirement was reduced to 12 contact hours per year, or 36 contact hours every three years.
Advanced Practice Nursing
In 1978, the law permitted registration of Advanced Registered Nurse Practitioners (ARNP). Following extensive study, rules for ARNP education and practice became effective in 1983.
In 1908, the $5 examination fee and the $1 nursing certificate fee were placed in a special nurses’ fund. The fund covered the costs of conducting the exam, including compensation for all members of the examining committee, except for the Secretary of the Board of Health who received no compensation. In 1921, compensation was denied the physicians on the examining committee and all fees collected were relegated to the state’s general fund.
With the creation of the Iowa Board of Nursing in 1935, fees were placed in a Nurses’ Fund to be used by the board to “elevate the standards of schools of nursing, and to promote the educational and professional standards of nurses.” Excess funds were turned over to the general fund at the end of each fiscal year. Since 1975, the Board has been required to deposit all fees into the state’s general fund and pay expenses through appropriations from the fund. Appropriations are designated by law to cover the elevation of the standards of the schools and the promotion of educational and professional standards of nurses in Iowa.
Legislation was passed in 2003, which allows the board to retain 90% of any increase to licensure fees. These funds supplement the amount appropriated from the general fund.
Nurse Licensure Compact
Through legislation signed into law on March 16, 2000, Iowa became the ninth state to join the multi-state licensure compact agreement. Implemented July 1, 2000, the compact allows active registered and licensed practical nurses with a primary residence in a compact state, to practice nursing in any other compact state.