December 2019 marks 100 years since the introduction of the Nurses' Registration Act and statutory nurse regulation in the UK. The commemoration of a century of nursing registration is a useful lens through which to view the advancement of nursing as a profession and the decades of struggle by nurses for eventual state registration.
Modern nursing is attributed to the influence of Florence Nightingale, who rose to fame during the Crimean War. Before this, nurses were often considered slovenly and incompetent, as depicted by Charles Dickens, whose nurse character Sairey Gamp in the novel Martin Chuzzlewit (first serialised in the 1840s) was to become representative of all that was bad with nursing. Indeed in 1887, in a mental health context, ‘lunatic attendants’ (who would later become ‘mental health nurses’) were referred to as the ‘unemployable of other professions’ (Norman and Ryrie, 2019).
Glasper and Charles-Edwards (2002a) pointed out that Dickens was a strong supporter of the medical fraternity and close friend of the paediatrician who founded the Hospital for Sick Children in Great Ormond Street, London. Furthermore, Rafferty (1995) believed that, in developing the character of Sairey Gamp, Dickens provided the ammunition that may have destabilised and undermined the embryonic female-led working class domiciliary nursing movement in favour of a medically dominated, more subservient nursing workforce.
Campaign for improved education
Before the Nightingale era, there was no national nursing curriculum or state examinations, and hospital nursing was undertaken by an ad hoc workforce including members of the ecclesiastical community.
Florence Nightingale was not actually a nurse and never undertook formal training, although she studied nursing in the context of its application to the care of the sick. Her role was administrative, and she noticed that nurses, given the right leadership, could change patient outcomes for the better. Her first appointment in 1853 was as Superintendent of the Institution of Sick Gentlewomen in Distressed Circumstances in Harley Street, London. In 1854, the Crimean War exposed the dreadful state of military health care, and Nightingale was asked by the war minister to lead a party of nurses to the hospital at Scutari on the Bosphorus near the frontline. She and her nurses arrived shortly before the disastrous battle of Balaclava and improved conditions for a huge number of casualties. In recognition of Nightingale's success, the government pledged to donate a fund worth £45 000 (equivalent to £5.5 million in 2019), which she used to develop the Nightingale Training School in the grounds of St Thomas' Hospital, London, in 1860. However, the medical establishment was unsupportive of Nightingale's aspirations to give nurses formal education and training, believing they needed only the simplest of instruction. In the years that followed, nurse training schools were developed in most hospitals across the country, but there was still no national curriculum and no standard length of programme (Baly, 1995).
The quest for state registration
The passing of the 1858 Medical Act provided statutory registration for doctors. Towards the end of the 19th century, senior nurses began to lobby for nurse registration, with entry to the profession being determined by public examinations and the protected title ‘nurse’ used only for those who were registered (Glasper and Charles Edwards, 2002a).
Nightingale was opposed to any form of nurse registration because she feared career barriers for working-class women with little formal education. Despite her opposition, the campaign continued, led by Ethel Bedford Fenwick, a former nursing sister and later the matron of St Bartholomew's Hospital, London. Bedford Fenwick founded the British Nurses' Association (BNA) in 1887 and the British Journal of Nursing in 1902, and used these to lobby for a nursing register. The College of Nursing (later the Royal College of Nursing (RCN)) was founded in 1916, and both organisations worked together to petition for statuary regulation of nurses (Baly, 1995). By contrast, ‘lunatic attendants’ who completed 2 years of training became registered with the Royal Medico-Psychological Society from 1890 (Carpenter, 2010).
On 23 December 1919, the Nurses' Bill received royal assent with a mandate to create a General Nursing Council (GNC) for England, Wales, Scotland and Northern Ireland. In addition to a general part of the register, a number of supplementary parts were created, including male nurses, mental nurses, fever nurses and sick children's nurses. Bedford Fenwick became the first nurse to register with the GNC when it was officially opened on 27 July 1921. The registration process was laborious, and by 1923, only 12 097 nurses had been noted on the register. The problems of capacity having haunted the regulatory bodies ever since (Glasper and Charles-Edwards, 2002b).
Overcoming shortages of nurses
The outbreak of wars in 1914 and 1939 created an unprecedented need for nurses, resulting in the development of the Voluntary Aid Detachment founded by the British Red Cross. These nursing assistants, mainly from middle-class families, provided nursing care for military personnel during the wars, and their simple training was provided by the British Red Cross Society, including bed-making and basic patient care and hygiene provision. Many undertook some aspects of nurse training during war time, and a coup for the Hospital for Sick Children in Great Ormond Street was enrolling Princess Mary as a probationer nurse in 1918. Although the Princess undertook some training as a children's nurse, she would have been unable to meet the stringent entry requirements expected by the fledgling GNC. Although the GNC ratified a 3-year training period, a national curriculum and state written and practical examinations, most nursing care was still being delivered by nursing assistants, many of whom would have undertaken various types of training before the creation of the council in 1919.
Following the establishment of the GNC, successive governments expressed concerns about the shortages of trained nurses. Hospitals had to rely on non-registered auxiliary nurses. Lord Horder's Nursing Reconstruction Committee, set up by the RCN in 1941, reported on the development of an assistant nurse to ease the pressure on the registered nurse workforce (RCN, 1942). The committee recommended that a new grade of assistant nurse should be enrolled on the GNC register and that pupil nurses should undergo a 2-year training programme. As a consequence, the responsibilities of the GNC were extended by the Nurses Act of 1943 to include a Roll for Assistant Nurses, renamed State Enrolled Nurses (SEN) by the Nurses (Amendment) Act 1961.
Project 2000
The RCN continued to raise concerns about the quality and nature of nurse training and was instrumental in lobbying for the Briggs Co-ordinating Committee, which was established in 1976 to devise a new statutory framework for nursing education (Ousey, 2011). This work resulted in the passing of the Nurses, Midwives and Health Visitors Act 1979, which came into force on 1 July 1983. The Act fundamentally changed the face of nursing by replacing the GNC with the United Kingdom Central Council (UKCC) and four national boards for Nursing, Midwifery and Health Visiting for each of the countries of the UK, which subsequently developed ‘Project 2000’.This educational initiative was launched in the late 1980s; it took nurse training into higher education and phased out enrolled nurse provision (Carpenter et al, 2012). The abolition of enrolled nurse training was controversial, and many senior nurses mourned its demise. Under the new scheme, student nurses became supernumerary to the nursing workforce, and the abandonment of enrolled nurse training necessitated the employment of greater numbers of auxiliary nurses to fill the void. New titles for these support workers began to emerge, with the healthcare assistant (HCA) dominating. However, although HCAs were now enabled to undertake National Vocational Qualifications as part of their support worker role, in reality, many found themselves unable to progress in their careers. Many of those same nurses who expressed anxiety about the decision to abandon enrolled nurse training now see the introduction of the nursing associate as an acknowledgement that this 1988 decision was flawed (Glasper, 2018).
Creation of the NMC
During the following decade, the complexities of the nursing profession began to change, and the UKCC and the national boards were superseded by the Nursing and Midwifery Council (NMC) in April 2002. Established by Parliament (the Nursing and Midwifery Order 2001) and with a UK-wide remit, the NMC remains the regulatory body for nursing, midwifery and health visiting. The NMC sets standards for the structure and nature of pre-registration nursing programmes and is responsible for developing standards of proficiency for pre-registration nursing education. In September 2010, the NMC produced new standards for pre-registration nursing education, replacing the old diploma level with that of degree preparation.
The nursing associate
The degree-level standards for nursing students were modified in 2018, but the abolition of the student nurse bursary in 2016 led to a major reduction in the number of nursing applicants, particularly mature entrants. This has become a particular concern for the RCN (2018), which has warned of severe workforce shortages within the nursing profession that could persist for many years. Since the enrolled nurse programmes ended, senior nurses have increasingly recognised that the clinical acumen gap between a registered nurse and an HCA is too great, resulting in skill mix challenges. Shields and Watson (2007) have been vociferous in highlighting the problems of using unqualified HCAs to replace registered nurses. However, Glasper (2013), in appraising Cavendish's review of HCA preparation, indicated that to improve patient care, the NHS should see HCAs as an important strategic resource. In October 2016, the government announced a range of strategies to address shortages in the NHS workforce, including an initiative by Health Education England (HEE) to fund training for nursing associates (HEE, 2016). This new role has been designed to bridge the gap between the existing cadre of HCAs and fully-qualified registered nurses to deliver hands-on care for patients.
In January 2019, the NMC was mandated by the government to open its register to nursing associates. Many are optimistic that this will fill the void left by the enrolled nurse, and after a century of nurse regulation, the primary mission of the regulator remains the same: to protect the public by preparing nurses and nursing associates who are fit for purpose.