For more than a century the Royal College of Nursing (RCN) has endeavoured to steer the profession of nursing in the UK, and not always through calm waters. When the RCN was founded in 1916 the landscape of nursing was very different from that of today, without even statutory state registration, which did not occur until December 2019. It was the former matron of Guy's Hospital in London, Dame Sarah Ann Swift (1854-1937), who first suggested forming an organisation for nurses similar to the colleges of physicians and surgeons (Pearce, 2016) The primary aims of the college at the outset were to:
It is against this backdrop that the RCN is consulting on the benefits to nursing of re-joining the International Council of Nurses (ICN), which it left in 2013.
Background
ICN (https://www.icn.ch) is a federation of more than 130 national nurses' associations representing the more than 27 million nurses worldwide. Its primary mission is to represent nursing worldwide, advance the nursing profession, promote the wellbeing of nurses, and advocate for health in all policies.
Founded in 1899, ICN remains the world's first and widest-reaching international organisation for nurses. Less well known is that ICN was created and launched by Ethel Gordon Fenwick, or ‘Mrs Bedford Fenwick’, the architect of nurse registration in the UK. Her aspirations for nursing also ran parallel to her support for universal suffrage for women and when in 1899 the International Council of Women met in London, she seized the moment to use the strength of the Matrons Council to promote the concept of what was to become ICN. The inaugural meeting of ICN was held in London in 1900, and the very first ICN congress meeting the following year in Buffalo, NY, with Fenwick the president (Lynaugh, 1999). In her first stirring address as president she encouraged her audience to secure the honour and interests of the nursing profession and in addition promised that ICN would be augmented through the efforts of individual country nursing organisations She envisaged that her own British Nursing Association, formed in 1887 and later to become the Royal British Nursing Association (RBNA) in 1892, would be the nursing organisation to represent the UK within ICN. However, the influence of the RBNA became less important after the passing of the Nurses Registration Act in 1919 and it was actually the College of Nursing, later to become the RCN, that went on to become the major organisation with a seat on ICN.
Today, ICN is operated by nurses and provides international leadership to ensure high-quality nursing care for all citizens in many countries and helps in the development of robust worldwide healthcare policies. In recognition of the contribution of its first president ICN promotes the advancement of nursing knowledge and the importance of strong links with national, regional and international nursing and non-nursing organisations. ICN works with specialised agencies within the United Nations but especially the World Health Organization (WHO).
Given these noble aspirations, why did the British contingent, under the auspices of the RCN, resign from ICN? The RCN left ICN when the decision to continue in membership was put to a vote at the 2013 Annual General Meeting. The decision was made due to concerns about ICN, including its strategy, operational effectiveness and membership model. In 2013, the full cost of membership subscription for the RCN was £614 470, based on the size of its own membership. As of January 2013, the membership was 416 077 and it is important in context to recognise that the RCN's financial contribution had risen dramatically in line with increases in its membership. Hence, as of 2013, the RCN was funding 16% of ICN's overall fee income and it was believed by the membership that this was not sustainable in the long term The vote followed lengthy negotiations to try to secure changes to the membership fee structure, among others, and the vote in favour of leaving passed at 91.7%.
Currently the RCN has a membership of about 450 000 registered nurses, midwives, nursing support workers and nursing students. It is important to stress that the RCN is not the only nursing union organisation in the UK, with a significant proportion of healthcare members of UNISON being part of the nursing family. According to UNISON (2016) there are more than 40 000 healthcare assistants and clinical support workers in the UK. Since 2001 healthcare support workers have been eligible to join the RCN and in context it should be remembered that it is a college of nursing, not of nurses! Clearly, since that date the membership of the RCN has continued to expand and as the financial contribution of nursing organisations to ICN is based on a per capita payment, the RCN prior to its withdrawal was contributing a significant amount to ICN's total budget. As that amount increased over the years in line with a growth in the overall RCN membership, many began to question if ICN membership remained good value for money. There is no individual membership to ICN because nurses who are part of their national nurses' association are automatically part of ICN (ICN, 2020). Although UNISON has no direct link with ICN this public services union does have formal associations with others throughout the world.
What remains unclear, however, is what percentage of ICN members are actually nurses and not simply individuals who contribute to nursing care delivery. The title ‘nurse’ is not a legally protected title in the UK, as it is in other countries such as most of the US, in New Zealand and Australia. The title ‘registered nurse’ is, however, protected in UK law. Despite this, ‘nurse’ is currently a default term of reference to describe a person involved in the delivery of patient care in hospitals and other healthcare settings. Up until 2013 the RCN was mandated to contribute to ICN's global budget on a member-by-member basis irrespective of the status of that membership, and following years of negotiation with ICN to reduce the annual fee, the college made the decision to withdraw from the organisation.
However, since leaving ICN many influential members of the college have openly expressed concerns and fears that UK nurses are being marginalised in key global discussions about the profession and that this will become exacerbated unless formal links with ICN are restored. Readers will be aware that 2020 was designated by the World Health Assembly as the International Year of the Nurse and Midwife. In recognition of these concerns at the May 2019 RCN congress in Liverpool, the following agenda item was proposed and subsequently debated.
‘That this meeting of Congress debates whether the RCN would be more influential for nursing and health globally if we re-joined the International Council of Nurses (ICN).’
The mission to lobby for a re-joining of ICN has been led by a group of 100 influential RCN members from a campaign group called ‘We Are Global Nurses’ (https://www.weareglobalnurses.co.uk) who in October 2017 signed a letter to the Chair of RCN Council calling for the RCN to re-join ICN. This group of senior members believe that re-joining ICN will help bolster the reputation of the RCN globally, helping it to become more strategically political and professionally influential for nursing within the UK, and further afield.
On launching the International Year of the Nurse and Midwife in 2020, the Director General of WHO, Dr Tedros Adhanom Ghebreyesus, said
‘Nurses are essential to increasing access to quality and affordable healthcare around the world.’
The quest to re-join ICN has also been strengthened by ‘Nursing Now’, which is a programme of the Burdett Trust for Nursing sponsored by the Royal National Pension Fund for Nurses, and has been working directly with the WHO to promote global nursing hegemony (https://www.nursingnow.org). On a historical note, readers will remember that the Victorian philanthropist Sir Henry Burdett, who founded the Royal National Pension Fund, was an antagonist of Fenwick and opposed her campaign for statutory state registration for nurses (Glasper, 2020)
‘Nursing Now’ was launched in 2018 with a specific aim of raising the profile of global nursing, making it more pivotal to the development of healthcare policy and to empower nurses to utilise their skills, education and training to their maximum capacity. Undoubtedly the whole landscape of global nursing has changed significantly since the RCN left ICN in 2013. As the world is struggling to cope with the impact of the COVID-19 pandemic, it is now realised that nurses around the world are pivotal in the fight against the virus, demanding a seamless strategy which unites all. In addition, as the UK begins Brexit, other issues that impact on nursing within the UK, such as the social status of nurses, will need to be reconciled with what happens in other countries. Although the RCN still liaises with a number of similar international bodies, fears are being expressed that UK nurses could be left out of key strategic global discussions about the profession that are scheduled to take place in the near future unless more formal links are restored, ie a re-joining of ICN.
In light of the congress debate and the actions of ‘Nursing Now’ and ‘We Are Global Nurses’ the RCN International Committee and RCN Council have agreed to consult members as to whether views in relation to ICN have changed. The consultation will take place from 30 October until the end of November 2020 in advance of a decision at the RCN AGM in 2021. All members of the RCN are eligible to participate and can access the survey via the RCN website.