Major Highlights in NC Laws Related to Nursing Practice

Major Highlights in NC Laws Related to Nursing Practice
     In the United States, nursing is governed by state laws and regulations. Nursing is regulated because it is one of the health professions that pose risk of harm to the public if practiced by someone who is unprepared and incompetent.          When the first meeting of the North Carolina Nurse Association was called to order in 1902, the most important item on the groups’ agenda was the creation of legislation setting standards for nursing education and practice.  For over one hundred years, through legislative advocacy, NC nurses have advanced both professional interests and altruistic ideals. North Carolina nurses have taken pioneering stands and with determination, accomplished much.    Major legislative accomplishments achieved by NCNA and the nurses of North Carolina are:
March 2, 1903 NC becomes the first state to pass legislation regarding nursing. The law established a Board of Nurse Examiners of Trained Nurses to examine and issue certificates to new nurses and determined criteria  for those already practicing nursing (a diploma from a “reputable” training school for nurses, OR a certificate of attendance for at least 2 years at a “reputable” training school OR a certificate signed by at least 3 registered physicians stating that the applicant has practiced nursing competently for at least 2 years) who wished to have their names placed in the Registry of Graduate Nurses found in each county’s Clerk of Courts office. Having one’s name in the county Registry ensured the public that the nurse had achieved a high level of education and competency in the practice of nursing. This law did NOT define nursing practice, nor have penalties for those practicing nursing unless they used the title Registered Nurse without being registered in at least one county in the state.  This Board was composed of two physicians and three nurses appointed by their respective professional associations.  Over the years the roles and responsibilities of the NC Board of Nursing have evolved according to the needs of the citizens of North carolina, the needs of the profession and the states political climate. The NC Board of Nursing continues to promote laws and regulations that strengthen the standards for safe nursing care as well as educational standards to obtain and maintain a license to practice nursing in NC. Once a license is issued, the Board continues by monitoring licensees' compliance to state laws and takes action against the licenses of those nurses who have exhibited unsafe nursing practice.

1919 – State funds are used to hire 6 full time nurses to travel across the state to inspect and provide services to elementary school children regardless of race.

1925 Public Law 87 created a Joint Commission on Standardization of Nursing Education to set minimum classroom and clinical standards for schools of nursing. A joint commission on standardization of nursing education consisting of 3 members appointed by the NCSNA (NC State Nurses Association as it was then called) and 3 members from the NC State Hospital Association was established.  The Standardization Board set minimum standards for nursing programs to receive accreditation.  A nursing school inspectress was hired by the Board and visited each school in the state annually to ensure standrds were being met.

1928 – The Model County Midwife Regulations become law.  These regulations set education and practice standards for lay midwives including the provision that they must take an annual class about sepsis, hygiene and cleanliness taught by Registered Nurses or physicians.
1947 – The NC Nurse Practice Act was amended to include standards for the education, practice and licensure of the new role of Licensed Practical Nurse. The NC Nurse Practice Act was amended to include the education and licensure of Licensed Practical Nurses in NC.   The Board of Nursing was enlarged to include 3 LPNs to advise and act on all issues related to practical nursing. An Education Director was hired and funded out of LPN licensing fees to work with the newly created LPN programs. The same legislation established a central state registry to take the place of county registries. The NC Board of Nursing was charged with maintaining the statewide registry. All RNs were required to renew their licenses annually at a fee of $1.00.  
1953 – The NC Nurse Practice Act was amended to include a definition of nursing for the first time.  It read :“A person is engaged in the practice of professional nursing when such person for compensation or personal profit performs any professional service requiring the application of principles of the biological, physical or social sciences and nursing skills in the care of the sick, in the prevention of disease  or in the conservation of health, such as responsible supervision of a patient requiring skill in observation of symptoms and reactions and the accurate recording of the  facts, the carrying out of treatments and medications as prescribed by a licensed physician and the application of such nursing procedures as involve understanding of cause and effect in order to safeguard life and health of a patient or other …”.  The law explicitly reserved the titles graduate nurse, trained nurse, registered nurse and professional nurse for those people who passed the licensing examination given by the NC Board of Nursing.  The law explicitly reserved the titles graduate nurse, trained nurse, registered nurse and professional nurse for those people who passed the licensing examination given by the NC Board of Nursing.

The law also mandated that the licensing examination would only cover anatomy, physiology, nutrition, bacteriology, obstetrical nursing, medical nursing, surgical nursing, nursing of children, ethics of nursing and the theory of psychiatric nursing. Applicants taking the nursing examination had to be at least 20 years old, be of good moral character, have good physical and mental health, be a high school graduate or its equivalent and have graduated from an accredited school of nursing. Licenses could be revoked for fraud or deceit in obtaining a license, committing a felony or crime of moral turpitude, gross immorality, dishonesty, negligence, habitual drunkenness or addiction or being mentally incompetent.
The 1953 Nurse Practice Act also delineated standards for nursing schools. They were required to have a connection with a general hospital of 50 beds or more, provide 1,000 hours of classroom instruction (see Table below), provide 2,285 hours of clinical instruction, have a library of at least 100 recent edition books, adequate classroom, laboratory and other suitable instructional facilities to effectively carry out the program and a sufficient number of faculty with educational qualifications and experiences to effectively teach and supervise students.
The NC Board of Nurse Registration and Nursing Education (as it was now called) consisted of nine members all appointed by the governor. These nine members were 5 Registered Nurses, 2 physicians with experience in teaching nurses, and 2 representatives of hospitals operating nursing schools. Three Licensed Practical Nurses , appointed by the governor were to participate in Board activities related to LPN practice.
Table 1 – Courses and Hours as mandated by the 1953 Nurse Practice Act
Anatomy and Physiology
History of Nursing
Nursing Arts
Nutrition/Diet therapy
Obstetrical Nursing
Nursing – General Medical
Nursing – General Surgical
OR Technique
Nursing –Medical Specialty
Nursing Surgical Specialty
Pediatric Nursing
Psychiatric Nursing (theory only)
1963 – State funds are allocated for educating nurses in advanced practice (nurse anesthetists). Recognizing the need for many more nurse anesthetists to practice in the state, the General Assembly made scholarships available for Registered Nurses to attend nurse anesthetist programs. It was the first time state funds were used for education for advanced practice nurses.
1965 – NCNA wins a major victory when licensure becomes MANDATORY to practice nursing in NC.
In this session of the General Assembly the Nurse Practice Act underwent major revisions.   For the first time, the state declared it was illegal to practice nursing without a license. A Registered Nurse was defined as a person to whom the NC Board of Nursing has issued a certificate as a Registered Nurse. The practice of nursing was redefined as “ A unique service provided for persons who are ill, injured, experiencing alterations in normal health processes, assisting in the ministering to, assisting of and the sustained vigilant and continuous care of those acutely or chronically ill, and the supervision of patients during convalescence, restoration, rehabilitation and the promotion of health.”
1973 1973 – Nurse Practitioners role and practice are defined and Nurse Practitioners are authorized to practice in NC. The legislature changed the Nurse Practice Act and the Medical Practice Act to allow for the new role of Nurse Practitioner. The state funded NP programs at 9 educational institutions across the state (Fayetteville Technical Institute, UNC-CH, UNC-C, ECU, CPCC, WPCC, WCU, UNC-G and the forerunner to Wake Technical Institute).
1975 – Nurse Practitioners gained the legal right to prescribe, compound and dispense medications.

1981 – NC nurses win the right to elect nurse members of the NC Board of Nursing. The Board is to be composed of nurses elected by nurses in NC and public representatives.
1983 – The state legislature authorized the practice of certified nurse midwives in NC.
1987- Due to a severe nursing shortage in the state, the legislature appropriated over $500,000 for nursing scholarships and created a Nursing Study Commission to explore issues related to nursing education, recruitment, retention and salaries. Over the next few years as the Nursing Study Commission reported on its findings, the legislature created the NC Center for Nursing and appropriated over $1,000,000 for innovations in nursing education, recruitment and retention efforts by schools of nursing and health care agencies.
1997 - The state legislature gave the North Carolina Board of Nursing the right to join the Nurse Licensure Compact. NC joins the Nurse Licensure Compact states allowing nurses reciprocity to practice in other Compact states without having to retake the NCLEX. This interstate compact is the basis for the mutual recognition model of nursing regulation among states whose legislatures have enacted the compact.

1999 – NCNA wins a major victory when NC General Statute 90-171.43 is passed prohibiting anyone from using the word “Nurse” in their title unless they are a currently licensed RN or LPN with the NC Board of Nursing.
2001 – The Nurse Practice Act was again revised with new definition  of nursing as a “dynamic discipline which includes the assessing, caring, counseling, teaching, referring and implementing of prescribed treatment in the maintenance of health, prevention and management of illness, injury, disability or the achievement of a dignified death. It is ministering to, assisting, and sustained, vigilant, and continuous care of those acutely or chronically ill; supervising patients during convalescence and rehabilitation; the supportive and restorative care given to maintain the optimum health level of individuals, groups, and communities; the supervision, teaching, and evaluation of those who perform or are preparing to perform these functions; and the administration of nursing programs and nursing services” was enacted.
The scope of practice of Registered Nurses and Licensed Practical Nurses were delineated as:
The “practice of nursing by a registered nurse” consists of the following ten
  • a. Assessing the patient's physical and mental health including the patient's
  • reaction to illnesses and treatment regimens.
  • b. Recording and reporting the results of the nursing assessment.
  • c. Planning, initiating, delivering, and evaluating appropriate nursing acts.
  • d. Teaching, assigning, delegating to or supervising other personnel in
  • implementing the treatment regimen.
  • e. Collaborating with other health care providers in determining the
  • appropriate health care for a patient but, subject to the provisions of
  • G.S. 90-18.2, not prescribing a medical treatment regimen or making
  • a medical diagnosis, except under supervision of a licensed physician.
  • f. Implementing the treatment and pharmaceutical regimen prescribed by
  • any person authorized by State law to prescribe the regimen.
  • g. Providing teaching and counseling about the patient's health.
  • h. Reporting and recording the plan for care, nursing care given, and the
  • patient's response to that care.
  • i. Supervising, teaching, and evaluating those who perform or are preparing
  • to perform nursing functions and administering nursing programs and
  • nursing services.
  • j. Providing for the maintenance of safe and effective nursing care, whether
  • rendered directly or indirectly.
The “practice of nursing by a licensed practical nurse” consists of
the following seven components:
  • a. Participating in the assessment of the patient's physical and mental
  • health, including the patient's reaction to illnesses and treatment
  • regimens.
  • b. Recording and reporting the results of the nursing assessment.
  • c. Participating in implementing the health care plan developed by the
  • registered nurse and/or prescribed by any person authorized by State
  • law to prescribe such a plan, by performing tasks assigned or delegated
  • by and performed under the supervision or under orders or directions of
  • a registered nurse, physician licensed to practice medicine, dentist, or
  • other person authorized by State law to provide the supervision.
  • d. Assigning or delegating nursing interventions to other qualified
  • personnel under the supervision of the registered nurse.
  • e. Participating in the teaching and counseling of patients as assigned by a
  • registered nurse, physician, or other qualified professional licensed to
  • practice in North Carolina.
  • f. Reporting and recording the nursing care rendered and the patient's
  • response to that care.
  • g. Maintaining safe and effective nursing care, whether rendered directly or
  • indirectly.
2005The General Assembly passed G.S. § 90-171.23 (b) (20), mandating all nurses in NC to demonstrate continuing competency to the NC Board of Nursing in order to renew their licenses.
The NC General Assembly has the authority to define the scope of nursing practice, legislate the standards for schools of nursing, designate the qualifications for applicants taking licensing examinations including the PN examination, the NCLEX and advanced practice certifications. and determine what, if any, criteria are necessary for nurses to maintain their license. These decisions are made in a political environment with pressure from many groups including nurses, physicians, hospital administrators and the general public. Being an active part of professional nursing associations is one way for nurses to ensure our voices and priorities become law.