“For us who nurse, our nursing is a thing, unless we make progress every year, every month, every week, take my word for it we are going back.” Florence Nightingale (Nash, 1914)

Florence Nightingale: Leader and Legacy

Known as both the “founder of modern nursing,” and “the lady with the lamp,” Florence Nightingale was a legend in her own time and continues to resonate on the nursing stage today. Every year on May 12 we celebrate her birthday as the culmination of National Nurses Week. The date is also International Nurses Day, as set forth by the International Council of Nurses (ICN) in 1965.

...Florence Nightingale was a legend in her own time and continues to resonate on the nursing stage today.This year, we mark the 200^th anniversary of Nightingale’s birth in 1820. She was born into an upper-class British family and came of age in the Victorian era. This was a period of massive change throughout the United Kingdom (UK), marked by technological and scientific advancements, population growth, and social reforms (Hamilton, 2015).

Nightingale was an independent, well-educated woman. She pursued a nursing career at a time when nursing was not considered a profession. An adventurous world traveler, she witnessed the United Kingdom’s imperial expansion, which peaked during the Crimean War (1853-1856). It was her work in this conflict that produced her most impressive achievement. It also earned her the moniker “The Lady with the Lamp” as she made rounds through the war barracks at night.

The British Government appointed her to lead a team of nurses to care for wounded soldiers on the front lines. Through written observations, numerical data, and critical review and analysis, she made the connection between the soldiers’ high rates of infection and unclean environments in medical facilities with high death rates. This early example of using evidence to inform policy and practice ultimately led to massive reforms in health, social, and workforce policies throughout Britain (Benton et. al, 2019; Hamilton, 2015). These changes directly influenced care and saved soldiers’ lives in subsequent military conflicts in the United States (US), including the Civil War, World War I and World War II.

Revered by the British public, Nightingale became a champion for modern nursing.Revered by the British public, Nightingale became a champion for modern nursing. She worked tirelessly to turn what was considered a somewhat lowly job into a respectable profession, opened the first modern nursing school in London, and established the framework for nursing education.

Like her lamp, her legend continues to shine across the world today. In part to mark the bicentennial of her birth, World Health Organization (WHO) Director, General Dr. Tedros Adhanom Ghebreyesus, after intensive advocacy efforts by the ICN and the Nursing Now Campaign, a program of the Burdett Trust for Nursing, declared 2020 the International Year of the Nurse and Midwife (WHO, 2019). Throughout the year, we celebrate not only Florence Nightingale’s remarkable contributions, but also countless other nurses who have played significant roles in the reform and globalization of the nursing profession. This article focuses specifically on how nurses in the United States have impacted the profession of nursing’s legacy through the formation, development, and leadership of the ICN. The authors of this article have worked with, and for, ICN and the WHO in high-level positions developing strategy and implementing change. They have extensive expertise in nursing practice, education, regulation, research, and consultation in low-, middle- and high-income countries.

Echoes of the Past, Collaborating Today and Tomorrow
ICN’s founders were active participants in the women’s emancipation movement.Benton et al. (2020) have recently noted that the current policy climate reflects broader issues that were addressed during the time of the birth of ICN. Today, as nurses seek to address the challenges of the sustainable development goals (SDGs), many issues relating to education, equality, and poverty need to be viewed through the lens of addressing the challenges that women face. ICN’s founders were active participants in the women’s emancipation movement. Indeed, the idea of creating an international organization for nurses began to evolve in the margins of the inaugural conference the International Council of Women (ICW), held in Washington, DC in 1888 (Quinn, 1989).

From the outset, American nurses played a major role in the efforts of ICN to develop and advance the nursing profession internationally.This is perhaps not so surprising as Benton and Ferguson (2017), in their study of the formation and sustainability of how nurses connect and collaborate worldwide, identified the importance of existing international meetings as a platform for the creation of professional networks. Indeed, the actual birth of ICN came proximal to the next ICW meeting in London in 1899, where the founding group included Lavinia Dock of the United States. As an assistant superintendent at John Hopkins School of Nursing, Dock was a pioneer in nursing education and a fervent women’s activist. She went on to become the inaugural honorary secretary of ICN alongside Ethel Bedford Fenwick of the UK, who was appointed the first ICN president. From the outset, American nurses played a major role in the efforts of ICN to develop and advance the nursing profession internationally. The following narrative provides a chronology of the major contributions.

Leadership

...six American nurse leaders have served as ICN president...American nurses have played a significant role in the leadership of ICN. They have served as elected presidents and board members, and appointed executive officers. Throughout ICN’s 121-year history, six American nurse leaders have served as ICN president, including Nina Gage who was elected from the Chinese Nurses Association.

Taylor was instrumental in securing ICN representative status at the United Nations.Effie Taylor, born in Canada, was educated as a nurse at John Hopkins; received her bachelor’s degree from Columbia; and spent her entire professional career in the United States. She served for 10 years as ICN president, the longest serving president of all time. Taylor was instrumental in securing ICN representative status at the United Nations (UN). Largely due to her efforts, the ICN gained special consultative status with the WHO and the UN Economic and Social Council in 1949.

Other American nurses elected ICN president included Anne Warburton-Goodrich, Agnes Ohlson, Dorothy Cornelius, and Margaretta Styles. All served standard terms of office.

In addition to presidential leadership, the United States has gifted numerous nurse leaders to serve on the ICN board of directors. Examples of some of these trailblazers include:

• Barbara Nichols, the first African American president of the American Nurses Association (ANA);
• Lucille Joel, celebrated scholar, ANA President, ICN’s first vice president, represented the ICN on the United Nations International Children’s Emergency Fund (UNICEF) and at the UN;
• William Holzemer, eminent researcher and academic; and
• Pamela Cipriano who is currently ICN’s first vice president and served as ANA President.

While all presidents and board members are volunteers, ICN also benefits from the wisdom and management skills of U.S. nurses who have held executive leadership positions, including Adele Herwitz and Constance Holleran.  

After completing their terms with ICN, they continued to contribute to domestic nursing and health policy...All of these leaders were active members of their national nursing association and frequently held leadership roles in the ANA. After completing their terms with ICN, they continued to contribute to domestic nursing and health policy, albeit from a much-expanded global perspective, benefiting both domestic and international nursing.

The Christiane Reiman Prize For Nursing Achievement
The Christiane Reimann Prize, which recognizes outstanding nursing achievement, is named for ICN’s first full-time executive secretary. Considered nursing’s most prestigious international recognition, it is often referred to as the Nobel Prize for Nursing. Since 1985, the prize has been given every four years to one or more registered nurses whose work has impacted the nursing profession for the greater good. Recipients are chosen for their contributions to one of ICN’s three pillars: Professional Practice, Socio-Economic Welfare, and Regulation. Ten nurses have received the honor, four of whom are from the United States.  

American Recipients of the Christiane Reimann Prize

• 1985: Virginia Henderson – Excellence in Professional Practice.
  Henderson was the first recipient of the award. She is lauded as the “world’s most beloved nurse,” and often compared to Florence Nightingale for her impact on national and international nursing communities. Henderson was a writer, clinician, and researcher who authored the landmark text, Basic Principles of Nursing Care.
• 1997: Dr. Hildegard Peplau – Excellence in Professional Practice.
  Peplau’s work revolutionized patient-nurse relationships and set the foundation for psychiatric-mental health nursing. She was also an innovator in graduate nursing education and research.
• 2005: Dr. Margretta Madden Styles – Regulation.
  Styles was a nurse scholar, known worldwide for her lifelong commitment to leadership in nursing education, regulation, and credentialing. She served as President of ICN from 1993 to 1997. Her achievements in the area of nurse credentialing led to the creation of Certified Nurses Day on March 19, her birthday.
• 2017: Dr. Linda Aiken – Socio-Economic Welfare.
  Aiken is an internationally recognized nurse researcher whose pioneering scholarship in nursing practice, policy, and work environments has led to improved patient care and outcomes. In particular, her research has shown that outcomes are better in healthcare organizations with optimal nurse staffing and a highly educated (BSN or above) nursing workforce.

The Power of Regular Convening

The British Journal of Nursing (BJN) (2009) noted that one of their former editors, Ethel Bedford Fenwick, the founding president of ICN, documented the value and power of regular ICN congresses. Each congress, the BJN (2009) contends, not only provides an opportunity for nurses from around the world to identify priorities and share experiences, but also to develop and set guidance for the advancement of the profession.

These have provided ideal opportunities for American nurses to meet their global peers...Over the years, the United States has hosted major ICN events in Buffalo, NY; Atlantic City, NJ; and Los Angeles, CA. These have provided ideal opportunities for American nurses to meet their global peers and discuss challenges of the day, as well as potential solutions. Smaller meetings of various working groups have been co-hosted by ANA to look, amongst other issues, at workforce and credentialing matters.

ICN offices have generally been located in Europe (London and Geneva). However, the headquarters did transfer to the United States during World War II, located first in New Haven, CT, and then in New York, NY. Because it was impossible to collect fees from nurses in war-torn Europe, it was the ANA that kept ICN afloat during these troubled times.

United States Funders For ICN Initiatives And Events

Over the years, ICN has received funding for important projects from a range of philanthropic sources. Three of the more prominent donors include the W.K. Kellogg Foundation (WKKF), the Rockefeller Foundation (RF), and the Carnegie Foundation (CF).

Advancing Nursing Leadership
Breakfast cereal entrepreneur Will Keith Kellogg was another strong supporter of nursing and global health. Through the WKKF, founded in 1930, he supported multiple initiatives to advance nursing leadership. Kellogg believed that strengthening leadership capacity would produce meaningful worldwide change.

From the mid-1990s to 2003, the WKKF funded the development and implementation of the ICN Leadership for Change^™ (LFC) program (https://www.icn.ch/what-we-do/projects/leadership-change-lfc), with the goal to strengthen leadership knowledge, skills, and abilities among nurses, and broaden the positive impact of nursing on health systems and society.

Specifically, WKKF funds have supported Phase 1 of the program, which included implementation across the Caribbean; Latin America; the South Pacific; and East, Central and Southern Africa (Ferguson et al., 2016). In 2002, WKKF funded an evaluation of the program, focusing on the impact and sustainability of outcomes.

To expand the reach and impact of the LFC program, ICN developed the LFC Training of Trainers (TOT) program, again with WKKF support. The LFC TOT program improves implementation of LFC by placing the responsibility for leadership training directly in the hands of stakeholder organizations at the regional or country level, which allows the opportunity to train more nurses and other healthcare providers.

Thanks to WKKF’s generous investment, LFC continues to thrive today and is currently participating in the Nightingale Challenge – a global initiative to inspire the next generation of nurses and every health employer in the world to provide leadership and development training for nurses and midwives in 2020, the International Year of the Nurse and the Midwife. The Nightingale Challenge hosted its first employee webinar in September: Voices from nurses in practice – ICN’s Leadership for Change (LFC)™ ( https://www.icn.ch/news/nightingale-challenge-inspires-next-generation-nurse-and-midwife-leaders-during-2020-year).

Supporting Nursing Education and Regulation
Established in 1913, the RF marked the origin of modern philanthropy. John D. Rockefeller, Sr., and other family members started it as a way to channel the family’s vast fortune to address underlying social problems in the United States. From the start, the RF was keen to enhance medical education, which led to an interest in supporting nursing education.

The Rockefellers believed that one could not advance without the other and considered nursing a good investment.The Rockefellers believed that one could not advance without the other and considered nursing a good investment. Among their earliest beneficiaries were the Yale School of Nursing in the United States and the University of Toronto’s nursing program in Canada. Ultimately, the RF would fund 53 nursing schools around the globe.

In 1947, ICN received a $5,000 grant from the RF to help nurses from Europe and Asia attend the Ninth Congress of Nurses in Atlantic City, NJ. Of the 6,700 nurses at the congress, 748 were from countries outside the United States, including India, the Netherlands, Palestine, Brazil, Mexico, Sweden, Finland, Norway, China, the Philippines, Great Britain, and Canada (Rockefeller Foundation, 2003).  

The RF has been a strong supporter of initiatives to improve the nursing profession and global health. These programs align with the foundation’s mission to “Promote the well-being of humanity throughout the world.” This in turn aligns with ICN’s mission to “Represent nursing worldwide, advance the nursing profession, promote the well-being of nurses, and advocate for health in all policies,” and its vision to ensure “the global community recognizes, supports, and invests in nurses and nursing to lead and deliver health for all.”

The CF was established in 1905 by American industrialist and leading philanthropist Andrew Carnegie. Today, the Foundation seeks to build a field around improvement science and networked improvement communities that solves important problems of educational practice.

Both the CF and the WKKF invested in nursing regulation by providing funds to disseminate findings from a global study on how the profession was regulated and how its regulation could be established or improved. This entailed convening workshops in Africa, Europe, Latin America, and the Caribbean and has been described by the former executive officer of ICN, Dame Sheila Quinn, as one of the most important projects ever undertaken by the council (Quinn, 1989).

Support From American Corporate Charitable Sources

In recent years, several ICN projects have benefited from corporate charitable support.In recent years, several ICN projects have benefited from corporate charitable support. Many of these contributions have been recognized with the ICN Partners in Development Award. In 2007, the year the award began, Merck & Company was honored for its introduction of mobile libraries in low- and middle-income countries to support the nursing contribution toward attainment of the MDGs.

In 2009, Elsevier was recognized for further support of the mobile library, ensuring its availability in Francophone African countries. Becton, Dickinson and Company (BD) was recognized in 2011 for supporting the development of the ICN Wellness Centres for Health Care Workers®.

Pfizer Incorporated received the award in 2013 for its support of several ICN initiatives, including the girl child project in four African countries. This unique program ensures that female children of nurses who pass away can continue their education. Pfizer also funded initiatives to address improved health and well-being and the reduction of non-communicable diseases.

In 2015, Eli Lilly and Company was awarded the Partners in Development Award for its long-term support of a global capacity-building program to address tuberculosis in countries with high rates of the disease. Most recently, Johnson & Johnson received the award for sponsoring implementation of the LFC program in China (2019).

Conclusion

These leaders have developed and implemented the science behind nursing care and evidence-based practices.The authors of this article highlighted the contributions of American nursing and its leaders to the evolution of the ICN, which has been actively pursuing excellence in nursing and healthcare for more than 120 years. These leaders have developed and implemented the science behind nursing care and evidence-based practices. As politically skilled networkers, they brokered their power and influence to ensure sustainable development and change around the globe. They built partnerships with public, private, philanthropic, and corporate entities, who in turn invested in nursing to bring value to the profession at home and abroad.

...investing in the nursing profession is critical to move society forward and realize meaningful change.As we engage in activities during the International Year of the Nurse and the Midwife, we salute those nurses whose diligence and commitment elevated the profession and paved the way for generations to come. This milestone year for nursing is a golden opportunity to not only put the spotlight on nurses’ invaluable work and contributions, but also to advocate for increased investments in the nursing and midwifery workforce. As savvy philanthropists John D. Rockefeller, Will Kellogg, Andrew Carnegie and a range of corporate leaders recognized, investing in the nursing profession is critical to move society forward and realize meaningful change. The global challenges we face today, including poverty, inequality, climate change, peace, and justice, rely on a strong and thriving nursing workforce. Investment in nurses and nursing will help us to address these challenges and meet the UN SDGs, the blueprint to achieve a better and more sustainable future for all.

Authors

Stephanie L. Ferguson, PhD, RN, FAAN
Email: drsferguson@stanford.edu

Dr. Ferguson has worked in 100+ nations as a technical advisor, consultant and facilitator for organizations such as the World Health Organization (WHO) and the International Council of Nurses (ICN). At ICN, based in Geneva, Switzerland, for 10+ years, Dr. Ferguson directed the ICN Leadership for Change Program™, the ICN-Burdett Global Nursing Leadership Institute™ and served as an ICN Consultant for Nursing and Health Policy. For WHO, for more than 20 years at the headquarters, and regional offices, Dr. Ferguson developed strategic plans and initiatives to strengthen and evaluate global healthcare delivery systems, population health outcomes, and nursing and other health professional education and leadership programs and services. She is the President and Chief Executive Officer of Stephanie L. Ferguson & Associates, LLC, and a faculty member at Stanford University in the Stanford in Washington Program. Dr. Ferguson is an active member of the American Nurses Association and an elected member of the American Academy of Nursing, the National Academy of Medicine and the National Academies of Practice.

David C. Benton, PhD, RN, FRCN, FAAN
Email: dbenton@ncsbn.org

Dr. Benton hails from North East Scotland. He completed his RN education at Highland College of Nursing and Midwifery in Inverness, specializing in both general and mental health practice. He undertook his MPhil degree studying the application of computer-assisted learning to post-basic psychiatric nurse education at the University of Abertay, and received a PhD Summa Cum Laude from the Complutense University of Madrid, Spain for his groundbreaking work on an international comparison of nursing legislation. Prior to his current position as Chief Executive Officer of the National Council of State Boards of Nursing, he worked for 10 years at the ICN based in Geneva, Switzerland. Dr. Benton is a prolific author and has published more than 200 papers on leadership, workforce, health policy, social network analysis, bibliometrics and regulation. He is a global expert in regulation and health and nursing policy and has advised governments around the world about both nursing legislation and wider health policy issues.