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As nursing celebrates 100 years since becoming a registered profession this month, Nursing Times has spoken to nurses about what it means to them as well as exploring how it might look in the future.
Before Pam Hibbs was accepted onto the nursing register in 1957 she had to get through a rigorous interview with the General Nursing Council.
“It will be a really big thing for me when my name gets on the register”
Now aged 84, she remembers the occasion vividly. “You felt you were going to this interview to make sure you were a fit and proper person to be a nurse,” said Ms Hibbs. “It was very formal and they asked lots of questions trying to work out what sort of person I was.”
Gaining her registration meant “an enormous amount”, explained Ms Hibbs, who went on to work in the profession for more than 50 years including as chief nurse and general manager at Barts Health Trust.
The system is somewhat different today but for newly qualified nurses registration remains a watershed moment.
Holly Veness, who finished her training this summer and hopes to start her first nursing job in the New Year, is about to apply for her PIN. “It will be a really big thing for me when my name gets on the register,” she said.
“Throughout your training you are constantly told ‘when you get your PIN’ – you’re working towards that significant moment when it all pays off and you think ‘I’ve done it – I’m at that standard’.”
Kate Forsyth, who obtained her PIN this summer and now works in a special care baby unit, agreed joining the nursing register is a landmark moment in any nurse’s career.
“It was a bit terrifying at first because it seemed to happen so quickly,” she said. “It was such a relief at the same time, like all the hard work had been worth it to get to this point where I can be an official band 5 staff nurse.”
“What registration forces you to do – which is great – is always think about your actions”
For her, registration underpins everything she does. “What registration forces you to do – which is great – is always think about your actions when you’re out in practice.
“You are always thinking: Are my actions justified? Is it safe? Is this in the best interests of the patient? I would never want to do anything to jeopardise my PIN and risk no longer being able to do the job I love.”
This month, the nursing community will mark the centenary of legislation being passed in 1919 that ushered in UK nurse registration.
For the past year, retired nurse and lecturer Alison O’Donnell, chair of Royal College of Nursing’s History of Nursing Forum, has delved into the RCN archives in Edinburgh to research the history of registration.
What struck her most was the sheer determination of the women who fought for more than 30 years to see the Nurses’ Registration Act passed on 23 December 1919.
However, she suspects many nurses today are unaware of the background, including the fierce rows within the profession about the benefits of registration and the canny campaigning and political machinations that won the day.
Nevertheless, she believes registration continues to be “a real game-changer in terms of how they think about themselves”.
She recently left the register and noted that she “thought long and hard about it”. “It felt very odd not re-registering,” she said. “It felt like – not quite a bereavement – but certainly a bit of a loss.”
The latest available figures from the Nursing and Midwifery Council show that, as of March this year, there were nearly 700,000 nurses and midwives on its register.
“The existence of the register demonstrates the profession’s maturity”
Many like Christine Hallett, professor of nursing history at the University of Huddersfield, would argue the core principles of registration and regulation are the same today as they were in 1919.
“There is a myth that nurse registration and professionalisation is all about status,” she said. “This does a disservice to our hard-working, altruistic, caring professional nurses.
The existence of the register demonstrates the profession’s maturity and willingness to hold itself to account. Its main purpose has always been to secure and guarantee patient safety.”
Nevertheless, being a registered professional does help nurses hold their own. “It is a professional kite mark and gives weight to my role,” according to Amanda McGough, quality and governance lead at Butterwick Hospice Care in the North East, who said this was the case when working with “other healthcare professionals, managers, commissioners and patients”.
Elizabeth Tysoe is president of the St Bartholomew’s League of Nurses and works for the General Medical Council as one of the regulator’s employer liaison advisers.
It is the first job she has done where she has not needed to be a registered nurse but her professional registration is “always in the back of my mind” and comes to the fore whenever she is made aware of potential misconduct by nurses in the course of her work.
“The Code of Conduct is very important to people. I think about it as a kind of plimsoll line”
Anne Marie Rafferty
Her registration and the nursing Code of Conduct also provided a vital framework when she worked for Her Majesty’s Inspectorate of Prisons as head of health inspection.
“When I was being pushed in the prison service – Couldn’t you just do that? – the answer was ‘No because you are now putting my registration on the line’.”
While registration may not be something nurses consciously reflect on day to day, it often moves to the fore when they are faced with problems.
“You hear people in debates about safe staffing saying things like ‘I am putting my PIN on the line’ because the Code of Conduct is very important to people,” said Anne Marie Rafferty, professor of nursing policy at King’s College London and RCN president.
“It may not be something they recite before they go on shift every day but I think it is implicitly embedded in the psyche and DNA of every practising nurse. Because there are so many pressures now that seem to throw up the Code of Conduct almost as a kind of conscience. I think about it as a kind of plimsoll line, a line in the sand.”
Over the years, the registration and regulation of nurses and midwives has continued to evolve, not least since the advent of revalidation in April 2016.
“Before then a lot of the emphasis was on your initial qualification and registering. Revalidation is all about continuing professional development and ensuring people are supported throughout their career so that was a major change for us,” said Emma Broadbent, director of registration and revalidation at the Nursing and Midwifery Council.
Taking into account views that the regulator could still do more to support nurses and midwives once they join the register, the NMC has strived to make the process of registration faster and more streamlined, including for overseas nurses hoping to work in the UK, according to Ms Broadbent.
The NMC has also recently updated standards of education for both nurses and midwives and embarked on a major revamp of its fitness to practise processes, in a bid to move away from an adversarial system to one that is fairer for all.
While the NMC’s core duty continues to be protecting the public, key themes proposed for a new five-year strategy due to be launched in April 2020 include strengthening its relationship with the professions it regulates.
Research shows many people mainly associate the body with FtP when it only really applies to a very small number of nurses and midwives, explained Ms Broadbent.
She accepts the body needs to “work harder” to explain its role and how it spends nurses and midwives’ registration fees. “That is absolutely where we have got to move so people really understand our role,” she said.
So, how might registration and regulation of nurses and midwives change in the future? The NMC has just embarked on a major review of post-registration standards and also promised to look at the regulation of advanced nursing practice.
Regulation of advanced practice is something Professor Rafferty would very much like to see, as she believes it would help stabilise the career structure for nurses.
“At the moment we have a very precarious structure, because we have too few people at the top and we’re asking a huge amount of our senior leaders to support all those myriads of people below them,” she said.
While some want the UK to follow other countries in regulating advanced practice, others do not pointed out Ms Broadbent. “There is a difference of views and we need to listen to that and think about it and also think about what the practicalities would be if we were to do it,” she said.
At the other end of the scale, many nurses feel anyone who provides direct care to patients ought to be regulated. At the start of this year the NMC opened its register to nurse associates. Long before the role was created there were calls for the regulation of healthcare assistants.
As a student nurse, Ms Forsyth worked on the bank as a healthcare assistant and, as a result, knows “firsthand what they do”.
“Throughout my training, I thought it was so weird that they aren’t registered and held accountable to standards or values like nurses are,” she said.
Ms Tysoe believes more professionals will be registered in the future because of growing public awareness of the need for accountability in the wake of high profile care scandals. People are keen to know “not just what someone’s qualifications are but who they are registered with”, she said.
Whether or not to extend regulation to other roles is a matter for government and not regulators to decide, explained Ms Broadbent.
However, she acknowledged one of the key challenges for the regulator is keeping pace with “the complex world that is healthcare and how fast it is changing” including diverging policies in the four UK nations.
“One of the big things for us is to stay plugged in with those changes and the huge variety of settings nurses work in,” she said.
Ethel Gordon Fenwick and the campaign to make nursing a registered profession
A name that has become synonymous with the introduction of the nurse register is Ethel Gordon Fenwick, who campaigned tirelessly for it with her supporters for over 30 years, writes James Shepherd.
She was born in 1857 in Elgin in Scotland and moved to Nottinghamshire in 1860. She began her nursing career in 1878 when she was aged 21 at the Nottingham Children’s Hospital, before continuing her training for a further year at the Manchester Royal Infirmary.
Having completed her training, Ms Gordon Fenwick moved to London where she worked in several hospitals before being appointed matron at St Bartholomew’s Hospital in 1881 at the age of 24.
Six years later, she stopped nursing following her marriage and focused entirely on her political campaign for the introduction of a nurses’ register. She believed a register would allow nurses to develop a professional identity, improve patient care and protect nurses from being exploited via low pay and poor working conditions.
Serious discussions regarding the formation of a nurses’ register first began in 1887 at a meeting held by the Hospitals Association (HA), which consisted of a group of hospitals.
Ms Gordon Fenwick disagreed with the HA due to their support for a non-compulsory register and formed a breakaway group that became the British Nurses’ Association to campaign for the introduction of a compulsory nurses’ register.
Ms Gordon Fenwick was a formidable campaigner and frequently clashed with those who were against registration. They were often members of hospital authorities, which feared state registered nurses would be more costly than non-registered hospital workers. They were also concerned about the level of independence and autonomy it would grant hospital nurses.
But opponents of the move to registration also included senior nurses such as Eva Luckes, matron at The London Hospital, and even Florence Nightingale herself.
The campaign for registration was also fraught with infighting and conflict, because different societies and campaign groups fought for different kinds of nursing registration.
The period had seen various disputes emerging between doctors and nurses over the position of the nurse in the hospital hierarchy. This opposition, combined with the infighting, was the main reason for the length of the campaign for registration.
The first two bills which sought to introduce a register were presented to parliament in 1903 and 1904, but both were unsuccessful, as were several more attempts over the following decade. It was a bill introduced to parliament by the then health minister, Dr Christopher Addison, which was ultimately passed in December 1919.
The register opened two years after the act came into being, with Ms Gordon Fenwick the first to sign it in 1921, becoming the first state registered nurse.
Alongside her commitments to UK nursing, Ms Gordon Fenwick also campaigned on the international stage to improve standards of nursing. In 1899 she was instrumental in the founding of the International Council of Nurses and served as its first president until 1904.
She sympathised with the non-militant arm of the suffragette movement and in 1910 was elected President of the Society of Women Journalists. She died on 13 March 1947.
Timeline: the road to regulation
1874 – President of the General Medical Council, Dr Henry Acland, suggested the introduction of a nurses’ register in his foreword to Handbook for Ward Sisters by Florence Lee
1887 – The Hospitals’ Association held a meeting to discuss a register for nurses. A breakaway group formed after the meeting due to disagreements over the style of the register. The association advocated a non-compulsory register
1887 – The new breakaway group held its first meeting on 21 November at the London home of Ethel Gordon Fenwick
1887 – The British Nurses’ Association was formed, gaining a royal charter in 1893. It opened a register in 1889 but it was not legally binding and nurses had no obligation to join it
1889 – The British Medical Association passed a resolution calling for the opening of a nurse register
1894 – Ethel Gordon Fenwick formed the Matrons’ Council of Great Britain with her supporters to continue the campaign for mandatory registration
1902 – The Society for the State Registration of Trained Nurses was established
1903-04 – Both the Royal British Nurses’ Association and the Society for the State Registration of Trained Nurses presented bills to parliament on the introduction of a nurses register, but both failed
1905 – A House of Commons select committee was set up to debate nurse registration and concluded in favour of the introduction of the State Registration of nurses
1905-10 – Several bills for registration are presented to parliament during this period but are all blocked by ‘anti-registrationists’
1910 – Ethel Gordon Fenwick united seven organisations, including the Royal British Nurses’ Association, Matrons’ Council and Irish Nurses’ Association, to form the Central Committee for the State Registration of Nurses
1919 – Both the central committee and the Royal College of Nursing presented bills to parliament but were asked to withdraw them. Instead, the government itself presented a bill on 6 November, which was passed as the Nurses’ Registration Act on 23 December
1920 – The first General Nursing Council for England and Wales was appointed, with similar councils established for Scotland and Ireland. They agreed standard requirements to be admitted to the register: aspiring nurses had to be aged over 21, able to give three references of good character, and able to demonstrate they had at least one year’s training and two years’ subsequent practice. The council also decided on disciplinary procedures
1921 – The Nursing Register opened in September. Ethel Gordon Fenwick was the first to sign the register, becoming ‘state registered nurse number one’
Winner of NMC’s badge contest revealed
A nurse who left the Philippines to land her dream job in England has been announced as the winner of a competition to design a commemorative badge for the centenary of the nursing register.
“This country and the community have welcomed me with open arms and this is my way of saying thank you”
Karen May Mojica
Judges singled out the submission from Karen May Mojica, works in the critical care unit at the Lister Hospital in Stevenage, out of more than 100 entries from across the profession.
In partnership with Nursing Times, the competition was held by the Nursing and Midwifery Council as part of its “Always Caring, Always Nursing” initiative to celebrate 100 years of regulation.
Ms Mojica’s design features two hands, an ECG rhythm and a heart in the centre to portray the invaluable skills and expert knowledge – together with the relentless care and compassion – that nurses demonstrate day in, day out.
The 29-year-old was inspired to enter the contest by Ethel Gordon Fenwick, who was the driving force behind creating a professional register of nurses.
She said: “Ethel gave her entire life trying to establish regulation and I wanted to do something in return. This country and the community have welcomed me with open arms and this is my way of saying thank you.”
On behalf of the four UK chief nursing officers, England’s CNO Ruth May announced the winning badge entry at a special event on 25 November. The NMC brought together over 200 frontline nurses and key partners to officially mark the centenary, which falls on 23 December 2019.
Andrea Sutcliffe, NMC chief executive and registrar, said: “We had some truly amazing entries… but sadly, we could only pick one. Karen’s design represents a tangible, lasting legacy that professionals on our register can wear with pride.”
Exhibition shows registration’s journey
The Royal College of Nursing has opened a new exhibition to showcase the history of the journey from the Nurses Registration Act 1919 through to the modern day.
The exhibition explores the arguments around the official registration of nurses and features archived letters and documents from the RCN and loaned collections.
It will remain open at RCN headquarters in Cavendish Square, London, until 20 March 2020 before it will be relocated to Scotland for another six months.