By Professor Judith Ellis OBE
Ethel Gordon Fenwick is celebrated for leading the charge to bring in regulation of nurses through registration. She recognised that although it is powerful and motivating to see nursing as a true vocation, as expounded by Florence Nightingale, it was unrealistic to expect that without regulation all nurses would be educated to, and practice at, a comparable and acceptable level. She also appreciated that it was naïve to believe that there would never be a ‘bad egg’ within the nursing ranks who, for the safety of patients and the public, would need to be prevented from practising.
The Council for Healthcare Regulatory Excellence in 2010 clarified that registration and thus regulation requires that patients and the public can recognise health professional titles because they indicate competence and fitness to practise. There is a risk to patient safety and public protection when unqualified people pass themselves off as registered professionals’ and the misuse of a protected title ‘should lead to private or public prosecutions’(CHRE, 2010).
When making a case for nursing registration Ethel Gordon Fenwick and her associates gave midwifery and medicine as exemplars for the need for registration:
The Medical Act of 1858 had established the General Council of Medical Education and Registration of the United Kingdom but the earliest reference to medical regulation in the UK dates from 1421, when physicians petitioned parliament to ask that ‘nobody without appropriate qualifications be allowed to practice medicine’ saying that unqualified practitioners caused ‘great harm and slaughter of many men’ (Wikipedia 2019)! It is worth noting that the word ‘doctor’ by itself is not a protected title as it is an academic term rather than a professional title (for example, used by holders of a PhD) but CHRE (2010) state that for public safety anyone using a name or title that implies that she/he is registered under the provision of the Medical Act 1983 should be prosecuted.
Midwives were legally recognised as a specific profession in the Midwifery Act of 1902 with the midwifery roll opening in 1904 but it was acknowledged at that time that not all those attending women in labour had received appropriate training, with many attended by untrained local women or lay midwives. Therefore, a time scale was attached with all ‘bona fide’ midwives having to register by 1905. From that date those not on the register could no longer use the title midwife. This regulation for the safety of mothers was further controlled in 1910 when ‘bona fide’ midwives were prevented from legally attending births without being under the supervision of a physician or a certified midwife, who had undertaken recognised and regulated training. Step by step the safety of mothers and babies has continued to be assured through regulation and registration. The title midwife is protected.
When campaigning to introduce registration of nurses Ethel Gordon Fenwick and colleagues faced a far more complex situation. The word nurse is a name, a noun, but is also a verb widely used to describe caring for someone. In 1919 with the Nurse Registration Act every effort was made to protect the public by introducing State Registered Nurses and indeed Ethel Gordon Fenwick was SRN number 1. This effort to protect continues and in the Nursing and Midwifery Order 2001 it is clarified that it is an offence to misuse the protected title ‘registered nurse’ (Article 44 of the Nursing and Midwifery Order 2001)
The problem is that the title ‘nurse’ is not protected and can be used by anyone, which as the Nursing and Midwifery Council state ‘is confusing for patients and the public’ undermining public understanding of the role of a registered nurse (CHRE 2010).
As the NHS and Social Care workforce crisis extends the UK are seeing a plethora of new roles that have adopted in their title the word ‘nurse’. This is not to say that these individuals are not delivering a vital and often high-quality service but a person appearing in uniform and with ‘nurse’ on a name badge is fundamentally misleading the public and potentially putting the public and patients at risk. Unlike ‘registered nurses’ for a ‘nurse’ there is no consistent regulation of training received, and unfit or unsafe practice can only be addressed through individual employer based HR processes, with no system for preventing a dismissed ‘nurse’ seeking employment elsewhere unless their unacceptable practice has led to criminal prosecution.
There is no easy answer but perhaps we all need to pause and recognise again the importance of Ethel Gordon Fenwick’s legacy. When asked what we do rather than just saying ‘I am a nurse’ we all need to embrace the importance and indeed pride of being able to say we are ‘Registered Nurses’. Also, accepting all the research that tells us the positive impact on patient care and patient outcomes of being cared for by Registered Nurses (see the work of Professor Anne Marie Rafferty CBE), when influencing our politicians and managers we should insist that they address the registered nursing shortage not just a ‘nursing workforce shortage ’ (RCN 2019). The word ‘registered’ matters.
Professor Judith Ellis OBE is Chair for Tropical Health and Education Trust. She was former CEO of the RCPCH and former Interim Chair NMC.
CHRE February 2010 Protecting the public from unregistered practitioners: Tackling misuse of protected title. https://www.professionalstandards.org.uk/docs/default-source/publications/policy-advice/tackling-misuse-of-protected-title-2010.pdf?sfvrsn=d8c77f20_10
Medical Act 1858. www.legislation.gov.uk/ukpga/Vict/21-22/90/enacted
Medical Act 1983. www.legislation.gov.uk/ukpga/1983/54/contents
Midwifery Act 1902.
Nurse Registration Act 1919.
RCN (2019) Nursing Counts. RCN Bulletin; December, Pg 9.Wikipedia. History of medical regulation in the United Kingdom. https://en.wikipedia.org/wiki/History_of_medical_regulation_in_the_United_Kingdom (accessed December 12th 2019).