Florence Nightingale, aided by the resourceful Mrs Sarah Wardroper, the matron of St Thomas's Hospital London, established the first modern secular training school for nurses in 1860. This was soon to be adopted throughout the UK and worldwide. However, despite the success of the Nightingale approach to nurse education and its dissemination to other hospitals, there remained significant variation in both its quality and the length of training offered.
Modern concepts such as the preliminary training school and the block system of study were subsequently introduced by some Nightingale school graduates (disciples) elsewhere, but their adoption was not universal. And, although Nightingale and other emulators developed local hospital registers of nurses they had trained, there remained no national and transparent state-wide register of nurses.
Background
Florence Nightingale undoubtedly was the matriarch of the emerging nursing profession in the early years following the establishment of the Nightingale school of nursing in 1860. By this time, nursing was becoming a respectable profession and a vocation for women.
The success of Nightingale's educational reforms launched the development of a cadre of well-educated senior nurses, whose ambitions for the profession in some cases diverged from of Nightingale's. The reforms led to heated discussions and debates about how the profession should be regulated, starting a nurse-led crusade to demand state registration. Although this aspiration was popular, not all the movers and shakers of the emerging profession agreed.
The Medical Act of 1858 established state registration for doctors, and by the 1880s many of the Nightingale-type trained nurses wanted to emulate this for nurses. The warring factions fell into two camps, with one campaigning for state registration and the other—including Nightingale—wanting to preserve the status quo. The quest by nurses wanting state registration was also linked to the fight for universal suffrage.
This complex state of affairs was to hinder the quest for state registration for many years. The war between 19th century nurses was fought over the competing values of confirmation of training through the award of a hospital certificate and that of a national state examination. The introduction of state registration would distinguish between those who had completed the new style of training and those who had only undergone minimal training. The old-style nurses were naturally fearful of being unable to join this proposed register. The anti-registrationists were committed to retaining nurse training primarily as a vocation under the jurisdiction of hospitals and their associated training schools, while the pro-registrationists were promoting a nursing profession governed by self-regulation.
The protagonists
The anti-state registrationists
First, let us consider those who opposed registration: they consisted of nurses and others who wanted to preserve local hospital-set examinations and local registers of those who had successfully passed. The group was composed of a number of factions, but was principally and actively led and supported behind the scenes by Nightingale herself. Despite her waning influence, she remained a formidable force who was able to impede the registration movement up until her death in 1910.
Nightingale was not a supporter of women's rights and was concerned that a state examination, which concentrated primarily on factual knowledge, might fail to capture the personal qualities she believed were essential for a nurse. In addition, some matrons and doctors of hospitals outside London were fearful that setting higher standards for nurses, coupled with registration fees, might result in a shortfall of recruits. If state registration were to be bestowed only on nurses who had trained under the newer system, then it is easy to understand the apprehension of those who hadn't had this training, who would be disenfranchised by not being allowed to call themselves nurses post state-registration. The anti-registrationists were soon aided and abetted by Henry Burdett, a Victorian philanthropist with a great interest in health care who had founded the Hospitals' Association in 1884.
The Hospitals' Association's primary objective was to facilitate dialogue among senior health officials, including matrons, on optimum hospital management. Burdett also launched a weekly journal entitled The Hospital, which became his personal platform for lobbying for causes, not least of which was in supporting the view of the establishment that a register for nurses would be disadvantageous.
The Nursing Mirror was at first the nursing section of The Hospital, but it became a stand-alone journal in 1899 and was used as a vehicle to support the anti-registration voice. The Hospitals' Association had discussed nurse registration in 1886 and had proposed a universal 1-year training scheme. Burdett had wanted some type of nurse registration, but his attempt to advance this idea in 1887 fell short of the expectations of many matrons who were part of the Hospitals' Association. As a consequence, the matrons showed their disapproval of his initiative by resigning from the organisation, infuriating Burdett.
One of the strongest supporters of Nightingale's opposition to state registration was the matron of the London Hospital, Eva Charlotte Ellis Luckes. After completing her nurse training at the Westminster Hospital in 1878, she became a night sister at the London Hospital, before being appointed lady superintendent of the Manchester Children's Hospital in Pendlebury. Subsequently, at the age of only 24 years, Luckes applied for the position of matron at the London Hospital, where she had begun her career. Several of the appointments committee thought her ‘too young and too pretty’, and some readers may remember matron Eva Luckes from the BBC historical drama Casualty 1909, where her character was played by Cherie Lunghi.
Luckes was a friend of Nightingale, who was her mentor, and both women shared the view that centralised nurse registration was folly. After a House of Lords enquiry criticised Luckes' management of nurses at the London Hospital, Nightingale lent Luckes her support. However, despite the criticism, the enquiry supported Luckes. Not surprisingly, after being exonerated, Luckes developed a reputation for maintaining her opposition to statutory nurse registration.
The pro-state registrationists
Luckes and Nightingale believed that the essential qualities of a good nurse should not become subordinate to theory and examinations. However, one woman who was to champion pro-registrations disagreed. This was Ethel Gordon Manson, later Gordon Fenwick. Gordon Fenwick, who had trained in Nottingham and Manchester, rapidly progressed in her career, becoming matron of the prestigious St Bartholomew's Hospital in London aged just 24 years.
She became convinced of the need to extend the period of training and that state registration for nurses was a way to consolidate the emerging profession. Like many matrons of the time, Gordon Fenwick had joined Burdett's Hospitals' Association but when, in 1887, the Hospitals' Association established a non-statutory voluntary register, many matrons, including Gordon Fenwick, felt this was a bridge too little and resigned.
She and Bedford Fenwick, whom she had married the same year, were political activists and they soon formed a rival organisation, the British Nurses' Association (BNA). They invited many senior nurses to join the BNA, which had the specific aim of campaigning for nursing to be governed through an Act of Parliament. However, the BNA had limited success and failed to secure parliamentary support for full registration of nurses.
The Fenwicks, angered at their failure, sought other ways to achieve their goal. Gordon Fenwick helped establish the International Council of Nurses (ICN), but her linking of state registration for nurses with women's suffrage only served to confuse the issue. To give greater clarity to her goal Gordon Fenwick then acquired ownership of the journal Nursing Record in 1893, which she used in her capacity as editor to pursue the fight for state registration. In 1903, she changed the name of the journal to the British Journal of Nursing, which continues to promote the work of nurses today.
Gordon Fenwick was not alone in the fight for registration. One of her strongest allies was Catherine Jane Wood, matron of the Hospital for Sick Children Great Ormond Street, London. Wood had helped found the BNA and was an ardent supporter of the cause of registration.
However, the fight for registration proved a long one, lasting some 30 years after Gordon Fenwick's formal launch of the initiative in 1899. Luckes, supported by Nightingale and indirectly by Burdett, managed to slow the process down, but after the passing of the Midwives Act 1902 full nurse registration was at last on the horizon. Nightingale died in 1910 and Luckes in early 1919, neither surviving to see full state registration. Despite the waning influence of these formidable anti-registrationists, there remained much disquiet as to the intention of the register of nurses, with fierce debate among pro-registrationists generating much heat but throwing little light on the subject.
Within the now Royal British Nursing Association, internal disagreement was fuelled by counter proposals of the Matrons' Council for Great Britain and Ireland, and the leader of the new College of Nursing, Sarah Swift (forerunner of today's Royal College of Nursing), who attempted to seek support for different Parliamentary Acts to introduce state registration.
Swift had trained as a nurse at the Dundee Royal Infirmary and, after further training, was appointed assistant matron at Guy's Hospital in London, before becoming matron in 1901. In 1916, during the First World War, she was instrumental in founding the College of Nursing. In line with the other pro-registrationists, Swift recognised that nurse training needed to be aligned with state registration. Swift was also quick to recognise the benefits that a dedicated college of nursing would bring, and she made many astute political alliances to help in the quest for state registration. The college then, as now, was called the College of Nursing.
Progress towards achieving state registration for nurses was delayed by the First World War, but consensus among the warring factions was finally achieved in 1919 when the Nurses' Bill received royal assent with a mandate to create a General Nursing Council for England and Wales, Scotland and Northern Ireland. Unsurprisingly, and for historical record, Gordon Fenwick at the age of 64 was entered on the nursing register as Nurse Number 1 in 1921.
Conclusion
There can be no doubt that Florence Nightingale was the instigator of modern secular nurse training, which ultimately paved the way for full state registration. Regardless of the various intrigues of those nurses who followed Nightingale in the decades after the launch of the first school of nursing, all of them—were they alive today—would look back in amazement at how successful the profession has been since the passing of the Nurses Registration Act 1919.