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Shaping nursing profession regulation through history – a systematic review

A. Stievano1 RN, MSN, PhD, R. Caruso2 RN, MSN, PhD , F. Pittella3 RN, MSN, F.A. Shaffer4 EdD, RN, FAAN, G. Rocco5 RN, MSN, PhD & J. Fairman6,7 RN, FAAN, PhD 1 Researcher, Centre of Excellence for Nursing Scholarship - Ipasvi Rome - Italy, 5 Director, Centre of Excellence for Nursing Scholarship, Ipasvi Rome, Italy, 2 Chief, 3 Director of Education, Health Professions Research and Development Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy, 4 President and Chief Executive Officer, CGFNS International, USA, 6 Chair, Department of Bio-behavioral Health Sciences, School of Nursing, University of Pennsylvania, USA, 7 Director Emeritus, Barbara Bates Center for the Study of the History of Nursing, Philadelphia, PA, USA

STIEVANO A., CARUSO R., PITTELLA F., SHAFFER F.A., ROCCO G. & FAIRMAN J. (2019)

Shaping nursing profession regulation through history – a systematic review. International Nursing Review 66, 17–29

Aim: The aim of this systematic review was to provide a critical synthesis of the factors that historically

shaped the advancements of nursing regulators worldwide.

Background: An in-depth examination of the different factors that moulded regulatory changes over time

is pivotal to comprehend current issues in nursing.

Introduction: In the light of global health scenarios, the researchers explored the factors that historically

influenced the socio-contextual circumstances upon which governments made regulatory changes.

Methods: A systematic search was performed on the following databases: PubMed, CINAHL, Scopus,

OpenGrey and ScienceDirect. The review included papers from January 2000 to October 2016 published in

English. The authors used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA) and an inductive thematic approach for synthesis.

Results: Two main themes were identified: factors underpinning current challenges and historical and

contextual triggers of regulation. The first theme was composed of three aspects: education, migration and

internationalization, and policy and regulation; the second theme consisted of four attributes: demographics,

economics, history of registration and wars, and historical changes in nursing practice.

Discussion: Factors that shaped nursing regulation were linked to changing demographics and economics,

education, history of nursing registration, shifting patterns of migration and internationalization, nursing

practice, policy and regulation and significant societal turns often prompted by wars.

Conclusion: A deeper understanding of the developments of the nursing regulatory institutions provides

the foundation for portable standards that can be applied across an array of jurisdictions to guarantee a

better public safety.

Correspondence address: Alessandro Stievano, Centre of Excellence for Nursing Scholarship, Viale Giulio Cesare 78 - 00192 - Rome - Italy; Tel: +39-0645437035; Fax: +39-

0645437034; E-mail: [email protected].

Funding

The study was supported by a grant from the Centre of Excellence for Nursing Scholarship – Ipasvi Rome – Italy (Research Grant number 1.17.06). Conflict of interest

No conflict of interest has been declared by the authors.

Literature Review

http://orcid.org/0000-0002-7736-6209

http://crossmark.crossref.org/dialog/?doi=10.1111%2Finr.12449&domain=pdf&date_stamp=2018-03-23

Implication for nursing and health policy: Understanding factors that socially, legislatively and politically

have influenced the development of regulatory bodies over time helps to mould local, national and

international policies that have a stronger impact on health worldwide. To achieve this, there must be

effective cooperation among systems of nursing regulations globally.

Keywords: Credentialing, Economics, Globalisation, History, Immigration, Nursing Legislation, Nursing Pol-

icy, Nursing Regulation, Registration, Systematic Reviews

Introduction Historian Catherine Choi notes ‘Without a doubt, healthcare

workers are on the move. In the new millennium, they are

moving across national borders in significant numbers, and

policy analysts and academics are taking note of the phe-

nomenon’ (Choy 2010, p. 13). So the professions, their regu-

latory bodies, and nations taking notice of nurses’ movement.

As scholars have noted, since the Second World War, the

migration of nurses across borders is tied to global eco-

nomics, particularly the integration of markets and the cross-

border movement of goods and services (Nelson 2013). The

migration of nurses affects the health of both the country

they leave and the nation they adopt, as the health of a coun-

try is a critical indicator of the nation’s stability.

The aim of this systematic review was to provide a critical

synthesis of existing manuscripts about the factors that histor-

ically shaped the advancements of nursing regulatory bodies

worldwide and to delineate future dynamics in the ever-chan-

ging agendas for regulatory authorities.

Background Nurse migration across national borders, for whatever reason,

has shaped global health by providing economic opportunities

to nurses and their families (e.g. through remittances back

home and influencing the price of nursing services). It has

also served to have an impact on health care, gender hierar-

chies, (e.g. the regulation of nurses has an impact on the sta-

tus of women in both host and native countries) and income

distribution as nurses move from culture to culture, from war

zones to more peaceful areas and from high distribution areas

to lower areas (Choy 2010, p. 14).

As nurses move across the globe, and into areas such as the

Gulf Countries and Europe (in addition to the traditional

destinations of Australia, Canada, Great Britain and the Uni-

ted States), many policymakers have raised questions about

the portability of the nursing credentials and skills across

national boundaries. How can one nation judge the quality

and safety of a nurse from another State when nurses are so

variably educated, regulated and disciplined without a com-

mon set of international standards? As Nelson has noted,

‘What is typically involved [in regulation] is the oversight of

curricula and accreditation of schools, the maintenance of the

defined, but typically with continued education and recency

of practice, along with relevant re-certification requirements

and other auditable dimensions to competency assessment)

and the management of misconduct’ (Nelson 2013, p. 86).

Very often discussions surrounding regulations occur without

context and understanding of how a nation’s regulations

shape the nursing profession’s education and practice, as well

as the health of particular nations.

Regulatory priorities encompass the belief that the public

should have access to providers who practise safely as defined

by education standards and competencies backed by interna-

tional or national boards and accrediting agencies.

Given the international interest in the area of regulation of

health professions and in the light of worldwide challenges

brought on by the complexities of the fluctuating nursing

and global health issues such as rising rates of chronic dis-

eases, and the (re)emergence of new epidemics (Benton &

Shaffer 2016), we believe it is time to examine how nursing

regulations developed and have been propagated to serve the

public and the profession. Nursing regulatory bodies and the

regulations they develop and apply should play a paramount

role in dealing with these challenges as their policies affect

workforce movement (Gwatkin 2017; Speakman et al. 2017),

sustainability of welfare in developing and developed coun-

tries (McKee et al. 2013), decision-making in national and

international health policies (Oliver et al. 2014) and relation-

ships between different global jurisdictions and countries

(Benton et al. 2015a).

Nursing regulatory bodies traditionally change in response

to many factors such as societal turns, national health priori-

ties and global economics. In increasingly forceful scenarios

of global movement, an updated and more nimble approach

is necessary to achieve goals expressed by the Global Strategy

on Human Resources for Health: Workforce 2030 vision

(WHO 2016). These goals are set to influence the policymak-

ers of World Health Organization member States accelerating

processes ‘Towards universal health coverage and the UN Sus-

tainable Development Goals by ensuring equitable access to

health workers within strengthened health systems’ (World

18 A. Stievano et al.

Health Organization 2016, p. 4). As the report and researchers

have stressed, modern regulatory bodies’ approach should

optimize access to contemporary quality services to all citizens

worldwide (Benton & Shaffer 2016). A better historical under-

standing of the factors that moulded the current nursing reg-

ulatory bodies over time could be useful to assess education

variations, market imbalances, cultural influences, and above

all, ways to fairly and equitably support an increasingly

mobile nursing workforce (Shaffer & To Dutka 2013). A his-

torical perspective can also help to acknowledge the need for

a modern role for nursing regulations to create portable stan-

dards and shared competencies that will apply across an array

of jurisdictions (Benton et al. 2015a).

As Gilman & Fairman (2014, p. 206) have written: ‘Regula-

tory development often exhibits a certain path dependency,

and existing rules may reflect the historical context of their

origins as much as contemporary assessments of patient care.

Neither history nor habit is much of a rationale, however,

much less an adequately substantiated rationale [for their

characteristics]’.

Most of the literature on nurse regulation has paid little

attention to the factors that have historically shaped the regu-

latory bodies due to procedural issues (i.e. complex bodies of

evidence, impossibility to set clear inclusion criteria for pri-

mary studies). Much of the research that exists is very recent

and underexplored (Benton et al. 2015a,b). But nursing regu-

lation has generated recent interest from policy reports such

as the Human Resources for Health: Workforce 2030 that rec-

ommends a guarantee of recognition of the nursing compe-

tencies across nursing jurisdictions to strengthen citizens’

protection and foster nursing transnational flows, ensuring

better public safety.

Methods

Design

A systematic review was performed according to the recom-

mendations of the Centre for Reviews and Dissemination

(CRD 2008) and to the ‘Preferred Reporting Items for Sys-

tematic Reviews and Meta-Analyses’ (PRISMA) statement and

flow chart. Then, the authors adopted a three-stage approach:

the free line-by-line coding of the findings of primary studies;

the grouping of these meaning units into connected areas to

create descriptive themes and the development of interpretive

themes (Greenhalgh et al. 2005). This approach considers the

main and common results of each included study and synthe-

sizes it according to the following three phases: (a) the recog-

nition of all the meaning units of the phenomena that have

been studied, (b) the connection of these meaning units in

descriptive themes and, (c) the rethinking of these descriptive

themes through a process of interpretive abduction (Green-

halgh et al. 2005). All those phases had to be iteratively

handled to ensure a robust analysis.

Search, selection and appraised outcomes

A systematic search was performed to identify the literature

related to factors which historically shaped the nursing regu-

latory bodies worldwide. Accordingly, the authors used the

PRISMA statement and flow chart to select studies for inclu-

sion and to provide a systematic search (Liberati et al. 2009).

The following computerized databases were searched:

PubMed, CINAHL, Scopus, OpenGrey and ScienceDirect. The

key terms used for search were as follows: ‘regulatory body’ OR

‘regulatory bodies’ OR ‘registration’ AND ‘nurse’ OR ‘nurs*’ ‘history’ OR ‘change’ OR ‘growth’ OR ‘progression’ OR ‘pro-

gression*’ OR ‘transformation’ OR ‘transformation*’. Searches for misspellings and MeSH terms were automatically added in

PubMed searches. Indeed, the authors followed up references

in papers or books, consulting experts in the field and hand-

searched two journals (i.e. International Nursing Review and

Journal of Nursing Regulation). The searches’ objectives were

aimed to explore the factors that historically shaped the

advancements of nursing regulatory bodies worldwide and to

delineate future dynamics in the ever-changing agendas for

these authorities. The inclusion criteria acknowledged papers

with different methodologies to better cover large bodies of evi-

dence, and they encompassed records: (a) published between

January 2000 and October 2016 to highlight the most recent

interest in the literature regarding the topic under scrutiny, (b)

written in English, (c) with abstract and (d), with full texts

focused on changes in nursing regulatory bodies worldwide. No

exclusion criteria were identified considering the study method,

but the authors applied the records quality appraisal as an

exclusion criteria in the eligibility phase (i.e. PRISMA flow

chart phase 3). The quality appraisal of eligible papers was per-

formed to ensure the quality of the included manuscripts, using

the Joanna Briggs Institute Qualitative Assessment and Review

Instrument (JBI-QARI). JBI-QARI is a useful instrument to

evaluate papers which have diverse methodologies.

Two authors (AS, RC) independently conducted the pro-

cess of including records. Consensus discussions solved

potential disagreements for each phase, which are shown in

Fig. 1. In the first phase (i.e. identification), the search

queries – which was developed for computerized databases – identified 222 records and other 101 records were identified

by following up the references and by hand-searching. In the

second phase (i.e. screening), the duplicates were removed

(n = 135) and 30 papers were excluded using time filters, and

Regulatory changes through history 19

then, other 115 papers were excluded reading titles and

abstracts because their focus did not meet the research aim.

In the third phase (i.e. eligibility), the 43 full texts were

retrieved, read and assessed using JBI-QARI by the indepen-

dent work of all authors. In this phase, the overall JBI-QARI

decision (i.e. include or exclude) was discussed within a con-

sensus meeting. The authors’ agreement concerned both the

inclusion and exclusion decisions. Twenty-nine manuscripts

were excluded because their overall foci were far from the

description of factors which shaped the nursing regulatory

bodies. Then, the Fleiss’ Kappa index was used to objectively

assess the degree of agreement among authors’ decision of

inclusion/exclusion for the last 14 papers. The consensus

meeting was considered concluded when the authors reached

a consensus with Fleiss’ Kappa index ≥0.70. Therefore, in the fourth phase (i.e. inclusion) were included all the 14 papers.

The whole flow diagram of the search and selection process is

shown in Fig. 1.

Data synthesis

Data from each included paper were synthesized using a stan-

dard format: authors, type of study, country, publication year,

purpose of the study, main findings (Table 1).

The papers included in the study were inductively content

analysed through a line-by-line coding to search for concepts

(Vaismoradi et al. 2013) to identify all the key codes of the

phenomena researched by two authors (RC, FP), and then,

the research team gave a narrative account and discussed con-

flicting results within and between studies. During this pro-

cess, the main codes were clustered in descriptive themes and

ultimately in two main interpretive themes (Table 2). In fact,

during 2 days of research retreats (with all authors) and

through Skype meetings, clusters were discussed, clarified and

reconceptualized into interpretive themes offering a new

understanding of the main factors that historically shaped the

advancements of nursing regulatory bodies worldwide (Tho-

mas & Harden 2008).

Fig. 1 Systematic review flow diagram.

20 A. Stievano et al.

T a b le

1 S u m m a ry

o f th e st u d ie s in cl u d ed

in th e re v ie w

A u th o r( s)

T yp e o f st u d y

C o u n tr y

P u b li ca ti o n

ye a r

P u rp o se

o f th e st u d y

M a in

fi n d in gs

B en to n D .C .,

G o n z� a le z- Ju ra d o

M .A ., B en ei t-

M o n te si n o s J. V .

(a )

D el p h i st u d y

In te rn at io n al

p er sp ec ti v e

2 0 1 3

T o g en er at e in te rn at io n al

co n se n su s o n a

co n te m p o ra ry

d efi n it io n o f p ro fe ss io n al

n u rs e re g u la ti o n

A se t o f 4 7 k ey

fe at u re s o f h ig h -p er fo rm

in g

re g u la to ry

b o d ie s w as

ag re ed . A lt h o u g h a

p re fe re n ce

fo r th e d el eg at ed

se lf -r eg u la to ry

m o d el

an d si n g le -b o ar d ad m in is tr at iv e ap p ro ac h

w as

ex p re ss ed , th e u n d er ly in g ra ti o n al e fo r su ch

a p re fe re n ce

w as

u n cl ea r

B en to n D .C .,

G o n z�a le z- Ju ra d o

M .A ., B en ei t-

M o n te si n o s J. V .

(b )

S y st em

at ic

R ev ie w

In te rn at io n al

p er sp ec ti v e

2 0 1 3

T o ex am

in e th e cu rr en t p o li cy

li te ra tu re

o n

p ri n ci p le -b as ed

re g u la ti o n an d co m p ar e

th is w it h th e se t o f p ri n ci p le s ad v o ca te d

b y th e IC N

A m ap p in g o f te rm

s b as ed

o n a d et ai le d

d es cr ip ti o n o f th e p ri n ci p le s u se d in

th e v ar io u s

re se ar ch

an d p o li cy

d o cu m en ts w as

g en er at ed .

T h is m ap p in g fo rm

ed th e b as is o f a cr it iq u e o f

th e cu rr en t IC N

p ri n ci p le s. A p ro fe ss io n al

se lf -

re g u la ti o n ad v o ca te d b y th e IC N

w as

id en ti fi ed

B en to n D .C .,

G o n z�a le z- Ju ra d o

M .A ., B en ei t-

M o n te si n o s J. V .

R ev ie w /

D o cu m en ta ry

an al y si s

In te rn at io n al

p er sp ec ti v e

2 0 1 4

T o id en ti fy

o p p o rt u n it ie s to

st re n g th en

p u b li c p ro te ct io n an d re d u ce

b ar ri er s to

fr ee d o m

o f m o v em

en t

P o te n ti al

re la ti o n sh ip s w er e id en ti fi ed

b et w ee n

fa ct o rs

su ch

as g eo g ra p h ic

re g io n , le g al

tr ad it io n s, ad m in is tr at iv e ap p ro ac h , re g u la to ry

m o d el

an d ec o n o m ic

st at u s an d th e n u m b er

an d ap p ro ac h es

u se d to

sp ec if y d efi n it io n s. A

m aj o r w ea k n es s in

th e p re ci si o n o f d efi n it io n s

w as

d is co v er ed

C u tc li ff e J. R ., B aj k ay

R ., F o rs te r S .,

S m al l R ., T ra v al e

R .

C as e st u d y

In te rn at io n al

p er sp ec ti v e

2 0 1 1

T o co n si d er

th e is su e o f n u rs in g re g u la ti o n

w it h in

th e co n te x ts

o f g lo b al iz at io n an d

p sy ch ia tr ic /m

en ta l h ea lt h n u rs in g . It

d ra w s at te n ti o n to

th e in cr ea si n g ly

m o b il e an d co n n ec te d in te rn at io n al

n u rs in g w o rk fo rc e an d th e ex is te n ce

o f

si g n ifi ca n t d is p ar it ie s b et w ee n co u n tr ie s

an d ev en

p ro v in ce s w it h in

co u n tr ie s

co n si d er in g th em

es su ch

as n u rs in g

p o li ci es

T h er e ar e si g n ifi ca n t d is p ar it ie s b et w ee n co u n tr ie s.

It is n ee d ed

an in te rn at io n al

o v er si g h t b o d y to

fa ce

w it h in te rn at io n al iz at io n . T h is ap p ro ac h

co u ld

ad d re ss

is su es

su ch

as in te rn at io n al

sh o rt ag e o f n u rs es

an d en fo rc e p ro fe ss io n al

re g u la ti o n

D u n ca n S ., T h o rn e S .,

R o d n ey

P .

C ri ti ca l p o li cy

an al y si s

In te rn at io n al

p er sp ec ti v e

2 0 1 5

T o d is cu ss

th e im

p ac t o f re ce n t re g u la to ry

tr en d s o n w h at

In te rn at io n al

C o u n ci l o f

N u rs es

co n si d er s n u rs in g ’s th re e p il la rs

(i .e . th e p ro fe ss io n o f n u rs in g , so ci o -

ec o n o m ic

w el fa re

o f n u rs es

an d n u rs e

re g u la ti o n )

T h em

es su rf ac in g fr o m

th is an al y si s in cl u d ed

re g u la to ry

d is co n ti n u it y , a ti g h te n in g o f

re g u la to ry

co n tr o l an d an

in cr ea si n g ly

m an ag er ia l g o v er n an ce

cu lt u re

Regulatory changes through history 21

T a b le

1 C o n ti n u ed

A u th o r( s)

T yp e o f st u d y

C o u n tr y

P u b li ca ti o n

ye a r

P u rp o se

o f th e st u d y

M a in

fi n d in gs

F ai rm

an J. A ., R o w e

J. W ., H as sm

il le r S .,

S h al al a D .

T h eo re ti ca l/

d is cu ss io n

U S A

2 0 1 1

T o d is cu ss

th e cr it ic al

fa ct o rs

li m it in g

n u rs e p ra ct it io n er s’ ca p ac it y to

p ra ct ic e

to th e fu ll ex te n t o f th ei r ed u ca ti o n ,

tr ai n in g an d co m p et en ce

ar e st at e- b as ed

re g u la to ry

b ar ri er s

T h is is a cr it ic al

ti m e to

su p p o rt

an ex p an d ed ,

st an d ar d iz ed

sc o p e o f p ra ct ic e fo r n u rs es .

E co n o m ic

fo rc es , d em

o g ra p h ic s, th e g ap

b et w ee n su p p ly

an d d em

an d , an d th e p ro m is ed

ex p an si o n o f ca re

n ec es si ta te

ch an g es

in p ri m ar y

ca re

d el iv er y . A g ro w in g sh o rt ag e o f p ri m ar y

ca re

p ro v id es

se em

s to

en su re

th at

n u rs es

w il l

u lt im

at el y b e re q u ir ed

to p ra ct ic e to

th ei r fu ll es t

ca p ac it y

F ea ly

M .G ., et

al .

R ev ie w /

D o cu m en ta ry

an al y si s

In te rn at io n al

p er sp ec ti v e

2 0 0 9

T o p ro v id e a sy n th es is o f li te ra tu re

o n

in te rn at io n al

p o li cy

co n ce rn in g

p ro fe ss io n al

re g u la ti o n in

n u rs in g an d

m id w if er y , w it h re fe re n ce

to ro u te s o f

en tr y in to

tr ai n in g an d p at h w ay s to

li ce n su re

M u lt ip le ro u te s o f en tr y in to

in it ia l tr ai n in g an d

m u lt ip le p at h w ay s to

li ce n su re

p o se

ch al le n g es ,

in te rm

s o f ac h ie v in g co m m o n ly

ag re ed

u n d er st an d in g s o f p ra ct ic e co m p et en ce . N u rs e

le ad er s n ee d to

co n si d er

th e p o te n ti al

fo r

co n si d er ab le

v ar ia ti o n in

co m p et en cy

re p er to ri es

am o n g n u rs es

tr ai n ed

in g en er ic

an d sp ec ia li st

in it ia l m o d el s

F re n ch

P .

H is to ri ca l

N ew

Z ea la n d

2 0 1 1

T o d is cu ss

th e n u rs in g re g is tr at io n h is to ry

in N ew

Z ea la n d

N u rs in g N ew

Z ea la n d re g is tr at io n is th e o ld es t

w o rl d w id e (1 9 0 1 ). It w as

d et er m in ed

b y a so ci al

re q u es t es p ec ia ll y b y th e m ed ic al

ar ea

au sp ic es .

O n ly

re ce n tl y (2 0 0 0 s)

n u rs in g is an

in d ep en d en t

d is ci p li n e an d p ro fe ss io n in

N ew

Z ea la n d

Jo n es

M .L .

H is to ri ca l

U K

2 0 1 2

T o co m m en t th e p at h th at

le d to

th e

re g is tr at io n o f n u rs es

in 1 9 1 9

R eg is tr at io n o f n u rs es

is th e fi rs t st ep

to sa fe g u ar d s

th e h ea lt h an d w el l- b ei n g o f th e p u b li c, th ro u g h

th e se tt in g o f st an d ar d s o f ed u ca ti o n , tr ai n in g ,

co n d u ct . H o w ev er , th e d eb at e re la te d to

re g is tr at io n is al iv e

S o in e A .

H is to ri ca l

In te rn at io n al

p er sp ec ti v e

2 0 1 0

T o d is cu ss

n u rs in g re fo rm

s u n ti l W o rl d

W ar

W it h th e F ir st W o rl d W ar

I, m an y st at es

re fo rm

n u rs in g w h er e st at e re g is tr at io n an d re g u la ti o n

re p re se n te d a m il es to n e to

p o la ri ze

n u rs in g

id en ti ty

w it h an

in te rn at io n al

p er sp ec ti v e

S o la n o D ., R af fe rt y

A .M

H is to ri ca l

U K

2 0 0 6

T o lo o k at

th e h is to ri ca l b ac k g ro u n d o f

o v er se as

n u rs e re cr u it m en t in

th e B ri ti sh

co n te x t

T h e re ce n t im

p le m en ta ti o n o f th e N u rs in g an d

M id w if er y C o u n ci l’ s O v er se as

N u rs e P ro g ra m

re g u la te

th e re g is tr at io n ro u te

fo r in te rn at io n al

n u rs e re cr u it s to

th e U K is sy m p to m at ic

o f

g ro w in g in te rn at io n al

n u rs e re cr u it s to

th e U K

an d in te rn at io n al

n u rs e m ig ra ti o n

22 A. Stievano et al.

Results Of the 14 included papers (Table 1), three were reviews, six

were historical papers illustrating the development of regula-

tory bodies in different countries, two were policy analysis

about the future trends of regulatory systems, one was a

paper illustrating a case study on nursing regulation, one was

a Delphi study on a contemporary definition of professional

nursing regulation and, one was a discussion paper. More-

over, the investigated settings were mainly cross-national. The

analysis of the included papers drove the identification of two

main themes:

• Factors underpinning current challenges;

• Historical and contextual triggers of regulation.

Theme 1: factors underpinning current challenges

This theme was formed by three subthemes: ‘education’, ‘mi-

gration & internationalization’ and ‘policy & regulation’

(Table 2).

Education

The identified papers highlighted how the history of licensure

has always been connected to education and to the routes of

entry into nursing (Fealy et al. 2009; Lloyd Jones 2012), often

standardizing credentialing through systems of licensing,

accreditation, certification (While 2014). Regulation and

equivalency of nursing education was a major historical issue,

and it still represents a current challenge. Education equiva-

lency supports migration as well as serving to indirectly

improve the nursing education standards of different nations.

Regulatory authorities play a pivotal role in developing safer

credentialing evaluation of professionals for the public safety,

and for more culturally specific standards that are popula-

tion-based. Country-specific standards in education were typi-

cally introduced with regulation (Lloyd Jones 2012). Although

many nations, such as those who were former British colonies

developed similar systems of nursing education, those outside

of the colonial orbit had different motivations and created

different outcomes (Nelson 2013; Salami & Nelson 2014).

Fealy et al. (2009) noted that in many countries, the nursing

profession is at the point where international policies (rather

than local or national policies) should guide regulations, or at

the least, serve as benchmarks for growing consistency. The

nursing workforce movement depends on this consistency

(Fealy et al. 2009).

Policy and regulation

Common threads and needs between policy and regulation

were highlighted throughout the included manuscripts, such

as the need for professional regulation and policies to beSh af fe r F . A ., T o

D u tk a J.

C ri ti ca l p o li cy

an al y si s

U S A

2 0 1 3

T o lo o k at

g lo b al

la b o u r m o b il it y as

lo g ic al

o u tg ro w th

o f th e g lo b al iz at io n o f

th e w o rl d ’s w o rk fo rc e

C h al le n g es

fo r In te rn at io n al

E d u ca te d N u rs es

b ri n g in to

fo cu s th e re g u la to ry

im p li ca ti o n s fo r

ju ri sd ic ti o n al

au th o ri ti es

in te rm

s o f cr ed en ti al s

ev al u at io n

W h il e A .

H is to ri ca l

U K

2 0 1 4

T o d is cu ss

th e W o rl d W ar

I fr o m

th e

p er sp ec ti v e o f th e d is tr ic t n u rs in g

T h e N u rs es ’ R eg is tr at io n A ct

en su re d th at

fu tu re

n u rs es

h ad

to m ee t a cr ed en ti al in g st an d ar d an d

p ro te ct ed

th e em

er g in g p ri v il eg es

to th o se

h o ld in g th e ti tl e as so ci at ed

w it h th e n ew

p ro fe ss io n ; b ei n g a st at e re g is tr at io n n u rs e

b ec am

e a p re re q u is it e fo r d is tr ic t n u rs e tr ai n in g

af te r th e A ct

W o n g F .K .Y .,

Z h ao

Y .

H is to ri ca l

C h in a

2 0 1 2

T o d es cr ib e th e d ev el o p m en t o f n u rs in g

ed u ca ti o n in

th e p as t, p re se n t an d fu tu re

in C h in a

N u rs in g ed u ca ti o n in

C h in a,

b o th

at th e

p re re g is tr at io n an d p o st -r eg is tr at io n le v el , p la y s

a k ey

ro le in

b u il d in g a st ro n g te am

o f n u rs es

to fu lfi l th e h ea lt h m is si o n o f th e co u n tr y .

E d u ca ti o n fo ll o w ed

a ra p id

ch an g in g p at h in

th e

la st h u n d re d y ea rs , u n ti l th e re ce n t p at ie n t-

ce n tr ed

ca re

ap p ro ac h

Regulatory changes through history 23

Table 2 Elements that influence nursing profession regulation through history. Summary of the analysis

- Nurse practitioner education can bridge the gap between primary care and care delivery (Fairman et al. 2011)

- Education paths should be studied to guide international policy (Fealy et al. 2009)

- Standards of education was introduced with regulation (Lloyd Jones 2012)

- Higher education supports a variety of nursing research directions (Wong & Zhao 2012)

- There is a need for consensus in identifying a set of regulatory body performance indicators to shape the international policy (Benton et al. 2013a)

- A principle-based approach to regulation should drive the international policy (Benton et al. 2013b)

- There is a need of an international policy to regulate the growing international nursing recruits (Solano & Rafferty 2007)

- Strategic themes coming from professional policies should be considered to renew and revitalize nursing social mandate (Duncan et al. 2015)

- Professional regulation and policies need to be flexible to accommodate changing patterns of healthcare delivery (Fearly et al. 2009)

- Literature indicates that internationalization issues need to be addressed (Cutcliffe et al. 2011)

- Transnational nurse migration highlight a tension between the professional agenda of nursing and responses to market pressures (Solano & Rafferty 2007)

- There is a need to develop tracks to reduce delays in transnational nursing movements (Benton et al. 2014)

- The regulation in Europe after the World War I contributed to polarize nursing identities (Soine 2010)

- This is a critical time to support an expanded, standardized scope of practice for nurses (Fairman et al. 2011)

- Reductions in cost associated with broadening nurse practitioners’ scope of practice can be seen elsewhere as well (Fairman et al. 2011)

- Migration is linked to international shortage of nurses and increased healthcare costs (Cutcliffe et al. 2011)

- World War I formed the context for the emergence of the 1919 Nurses’ Registration Act (While 2014)

- The fight for nurse registration started to take shape after the passing of the Medical Act in 1858 (Lloyd Jones 2012)

- With the introduction of registration in 1901, the relationship between nursing and medical profession was of unequal power/knowledge (French 2001)

- A new Nurse Act was introduced in 2008 to support the further development of nursing in China (Wong & Zhao 2012)

- Following the World War I, the attitude towards women changed in UK […]. These aspects had an influence on nursing professionalization (Lloyd Jones 2012)

- The gendered sense of professional unity lasted until World War I, after that, nursing followed a new path (Soine 2010)

- The Second World War dictated a change of policy in nursing (French 2001)

- The routes of entry into practice are interdependently connected with licensure and education (Fealy et al. 2009)

- Registration Act standardized credentials for practice (While 2014) - Standards of education safeguarded health and well-being of the public

(Lloyd Jones 2012) - The gap between supply and demand is a trigger for broadening

the nursing scope of practice (Fairman et al. 2011)

Education

History of registration and wars

Factors underpinning current challenges

CODES DESCRIPTIVE THEMES

INTERPRETIVE THEMES

Economics

Historical changes in nursing practice

Policy & regulation

Demographics

Migration & internationalization

Historical and contextual triggers of regulation

24 A. Stievano et al.

flexible to accommodate changing patterns of healthcare

delivery across clinical and geographic locations (Fealy et al.

2009) or the need of an international policy to regulate grow-

ing international nursing recruits (Solano & Rafferty 2007).

Interestingly, none of the studies directly addressed the con-

textual issues that might influence regulation, such as trade

and economic policies. The studies, in general, except for

Solano & Rafferty (2007), were acontextual and did not place

nursing regulation in the larger transnational societal context

of the movement of goods, services and workforce other than

nursing.

Benton et al. (2013a) address the need for consensus in

identifying a set of regulatory body performance indicators to

shape international policies and standard settings where a

principle-based approach to regulation should drive the inter-

national course of action. In this scenario, strategic strands of

action coming from professional policies should be consid-

ered to invigorate nursing’s social mandate (Duncan et al.

2015). This is a position that has been advocated for decades

without effective movement towards these common stan-

dards, although the International Council of Nurses has, since

1986, adopted principles for professional self-regulation.

These principles have been revised to reflect current issues in

2013 (Benton et al. 2013b).

Migration and internationalization

Nurses crossing borders can be traced across history but this

trend is on the increase due to a major interconnectedness

among markets. For this reason, Solano & Rafferty (2007) and

Benton et al. (2014) identify a priority to develop standardized

education tracks and an easier recognition of competencies to

reduce delays in transnational nursing movements and to foster

a better comparability in credentialing across different geogra-

phies. In this context, the transnational nurse migration high-

lights a tension between the professional agenda of nursing

regulations and responses to market pressures (Solano & Raf-

ferty 2007). Standardization of nursing education helps to raise

the education level of nurses across the globe while also creating

opportunity for migration and mobility. However, standardiza-

tion may also lead to ‘brain drain’ as nursing schools, in coun-

tries such as the Philippines and India, train progressively more

nurses, many of whom migrate, as the economic status of the

nursing profession in other countries increases (Salami & Nel-

son 2014).

Theme 2: historical and contextual triggers of regulation

This theme was shaped by four interwoven subthemes:

‘demographics’, ‘economics’, ‘history of registration and wars’

and ‘historical changes in nursing practice’ (Table 2).

Demographics

Demographic changes and changing social contexts have been

triggers for nursing workforce markets. For example, in the

last 25 years, an ageing population required sustainable orga-

nizational models (e.g. implementation of nurse practitioners)

to guarantee access to primary care (Fairman et al. 2011;

Riegel et al. 2012). In the contemporary context, demographic

trends should drive changes in primary care delivery that sup-

port liberalization of state regulations, allowing greater scope

of practice for nurse practitioners. This has begun to happen,

as more than ten states in the United States have expanded

scope of practice regulations since 2010, and more are consid-

ering expansion (Phillips 2016). By 2006, 23 countries for-

mally recognized the role of nurse practitioner, and more

countries each year are beginning to move towards recogni-

tion (Pulcini et al. 2010).

Economics

Along the economic framework, the reductions in cost associ-

ated with broadening nurse practitioners’ scope of practice

are widely demonstrated in many contexts (Fairman et al.

2011; Riegel et al. 2012). However, even as the role of nurse

practitioners is increasingly recognized, it still is underused

and undervalued worldwide (Riegel et al. 2012). Currently,

there is an international shortage of nurses in many countries,

which contributes to increased healthcare costs and which is

closely linked to the phenomena of nurses’ migration (Benton

et al. 2014; Cutcliffe et al. 2011). Economic conditions of

both the source and target countries, with the attraction of

better salaries and working conditions in the receiving

country, have been historically a pivotal pull for the mobility

of health professionals (Shaffer & To Dutka 2013). Economic

conditions have also shaped education and practice condi-

tions, leading to an influence on the production and work

output of nurses (Duncan et al. 2015). These conditions have

also led to predatory recruitment practices and poor working

conditions that could be improved through a better

regulation (World Health Organization 2016).

History of registration and wars

Historically, nursing has an extensive tradition of registration

that has been connected to regulation, and this binomial con-

ceptual couple has always been linked to the most important

societal events. After times of uncertainty or conflict, there is a

tendency to create more lasting frameworks for vital service

resources. For example, World War I formed the context for

the emergence of the 1919 Nurses’ Registration Act in the UK

(While 2014), even though the debate for nurse registration

started to take shape after the passing of the Medical Act in

Regulatory changes through history 25

1858 (Lloyd Jones 2012). During the turn of the century, nursing

leaders saw professionalization and registration as an ongoing

political campaign in many European and British colonial

countries. As an example, nurses were regulated and registered

in New Zealand (a British Commonwealth country) in 1901,

well before World War I and before the UK (Soine 2010).

The major societal turns, such as wars, led social changes

that encouraged nursing professionalism. For example, after

World War I, the social advancements of women were tangi-

ble in many countries, influencing in different ways nursing

professionalization (Lloyd Jones 2012). In general, the strong

gendered sense of professional cohesion lasted until the First

World War. After that, nursing professionalism and regula-

tion in Europe became a politicized endeavour (Soine 2010).

In this sense, World War II dictated a change in policy in

nursing, boosting important changes, such as the length of

training and the significance of respect of nurses in hospital

hierarchies (French 2001).

Historical changes in nursing practice

A strong link with changing global scenarios is represented by

historical changes in nursing practice. In fact, the breach

between supply and demand in both nursing and medicine has

always been a cause for broadening the nursing scope of prac-

tice for many years, at least in advanced countries (Fairman

et al. 2011). The need to broaden the scope of practice for

nurses, with the implementation of nurse practitioners, is sup-

ported in many contexts by higher ratings of patient satisfac-

tion and by the reduction in healthcare costs (Riegel et al.

2012). There has been some movement in enlarging practice

boundaries over the last three decades. For example, nowadays,

some states in the United States are allowed to ‘Opt of out’

physician supervision of nurse anaesthetists for Medicare

patients and by 2012, 17 states took this action (American

Association of Nurse Anesthetists 2016).

Discussion Currently, the lack of synthesis of evidence to support policy-

makers during the nursing regulatory legislation process is a

major problem with roots mainly linked to the inattention

paid to the factors shaping regulation through history (Ben-

ton et al. 2013a). For this reason, this study aimed to describe

those elements that underpinned and shaped nursing regula-

tion throughout the past and identified two main areas of

research: ‘factors underpinning current challenges’ and ‘his-

torical and contextual triggers of professionalism’.

The two themes summarize a number of issues supporting

the existing challenges for regulatory authorities. These issues

are mainly linked to changing demographics with an

increased ageing society above all in advanced countries and

economic forces that are critical push/pull factor for the

nurses’ cross-border movements. Also pivotal are variables

connected to education, history of registration, a greater

migration and internationalization, nursing practice, policy

and regulation and significant societal turns often prompted

by wars. All the elements mentioned have a strong mutual

relationship and have to be understood at both local and glo-

bal levels in our intertwined society.

In Europe, for instance, despite the reforms in nursing edu-

cation, after the beginning of the Bologna process in 1999,

there is still a strong need for harmonizing education across

different countries (Dobrowolska et al. 2015; Rautiainen &

Vallimies-Patom€aki 2016) and this is true for many regional

areas of the world. Even in the United States, there remain at

least three education pathways to registration (diploma, associ-

ate degree and baccalaureate degree). All three paths are regu-

lated through the same state regulations. Attempts to move to

an all baccalaureate-prepared nursing workforce, such as the

2011 National Academy Report, The Future of Nursing (Insti-

tute of Medicine 2011), have only slowly moved the needle.

Conversely, faculty shortages, costs and geography have an

impact on the education pathway students choose, with many

lower income and rural students in the United States choosing

associate degree programs through community colleges.

As demonstrated by the results of the review, the historical

connection between nursing regulatory authorities and nursing

registration has always been a central point in understanding

the main functions of regulators, as regulatory bodies institu-

tionalize nursing licensure to protect citizens by ensuring that

every registered nurse delivers a safe and competent health care

(Evans 2015; Gilman & Fairman 2014). Registration can be a

valid exercise of a state’s power and a way to exercise public

protection from people who could potentially deliver unprofes-

sional care and confuse the public through titles that are not

legally protected (e.g. the title of nurse or physician; Duncan

et al. 2015). A regulated licensure entry system signifies stan-

dardized education aimed to prepare nurses to work in differ-

ent environments in transnational contexts.

The findings of our work strongly emphasized the current

global healthcare contexts of transnational migration and

internationalization. The topic of migration has always

involved challenges and opportunities for the profession and

the society considering that nurses are one of the most

numerous professionals who move within and among coun-

tries (Jones & Sherwood 2014; Shaffer & To Dutka 2013).

Nurses’ migration is closely linked to nursing shortages,

where a decreased supply in some contexts cannot meet the

increased demand of ageing societies. Many countries lack

26 A. Stievano et al.

workforce policies that support a national supply, such as

reasonable staff ratios or outlawing mandatory overtime

(Cho et al. 2016; Griffiths et al. 2014).

Historically, policy and regulation have always been strictly

linked, and, today, even if, they are moving towards a com-

mon internationalization, boosted by common worldwide

issues, there is a strong need for a greater synergy among

them (ICN 2013). Currently, some policy initiatives (e.g.

Health Workforce 2030 from the Global Health Workforce

Alliance) provide opportunities for regulatory bodies to

shape and influence the rapidly changing policy landscape

(Benton et al. 2015b) and have the chance to have an impact

on the health of both patients and nurses. Studies should

also take into consideration the movement of goods and ser-

vices across the globe, which have an implication for policy

and regulation.

Considering nursing practice, the main dispute seems to

be related to the nurse practitioner role, which has been

gaining ground worldwide, as well as the need to set com-

mon standards at least in Westernized countries (Riegel

et al. 2012). The role of nurse practitioners should be rec-

ognized in more countries to provide essential services in

addition to other types of health providers (Carney 2016).

Many suggest nurse practitioner education should be linked

to the master’s level, but not all countries have or can

reach this goal due to lack of education facilities, political

opposition from physicians and societal structures that set

rigid boundaries around professions, producing diverse

educational requirements across the world (Heale & Rieck

Buckley 2015).

Limitations

This study has a number of limitations. Firstly, this review

was not intended to be a comprehensive review of studies

regarding regulation; the aim was to emphasize factors shap-

ing regulation through history, considering only studies since

2000. That choice obliged the researchers to restrict the land-

scape on the review question to the most recent perspectives.

Secondly, the included papers have diverse research questions

and methods; for this reason, it was challenging to find expla-

nations (i.e. common themes) from the included papers and

these themes did not follow a linear analytical pathway.

Implication for nursing and health policy Our findings could drive the implementation of studies aimed

to explore how the identified elements that shaped nursing

regulation are perceived from different stakeholders, provid-

ing a broader framework to examine the advancements of

regulators through main milestones. This review could also

support policymakers in understanding which factors shape

the current nursing regulatory bodies and the present chal-

lenges for them. Historical perspectives on nursing regulation

can help understand the past and how this knowledge can

shape thinking about new regulatory models that are best fit

for the digital society, to work more collaboratively to

exchange best practices and have common strategies to face

social/healthcare risks for the population. It is imperative that

nursing regulation is formulated to have international per-

spectives because the globalized environments call for reno-

vated networks of integration among the various regulators

worldwide.

Conclusion The first enactments and regulation of the nursing profession

in countries such as New Zealand, United Kingdom and the

USA date back more than a hundred years (Evans 2015;

French 2001; While 2014; Wong & Zhao 2012). New Zealand

did enact legislation, regulate and register nurses (1901) as

did a number of countries in those years. But, even if,

nursing regulation preceded the 20th century, countries

establish their own legislation based on their own healthcare

needs and politics.

Finally, like other historical fields of study, the presump-

tion is that ‘The nation defines what counts as history may

have had the effect of trivializing foreign-trained nurses. . .’

(Choy 2010, p. 14) and their difficulties getting credentialed

in the host countries. ‘The result of these gaps is the erro-

neous assumption that the international migration of foreign-

trained nurses is a recent phenomenon devoid of a substan-

tive past’ (Choy 2010, p. 14). As the past informs us, tensions

between the issues of a transient nurse workforce, and host

countries need to both protect citizens and fairly treat nurses,

have existed over time. Our present state of the mobility of

the global workforce has pushed the tension to the forefront

of global health.

Acknowledgements We wish to thank Arianna Magon, Greta Ghizzardi and Gian-

luca Conte for their critical reading of the manuscript and

their useful contribution in retrieving papers.

Author contributions Study design: AS, RC, JF

Data collection: AS, RC, FP, JF

Data analysis: AS, RC

Study supervision: AS, GR, FAS, JF

Manuscript writing: AS, RC, FP, GR, FAS, JF

Critical revisions for important intellectual content: AS, RC, JF

Regulatory changes through history 27

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Regulatory changes through history 29

http://www.who.int/hrh/resources/16059_Global_strategyWorkforce2030.pdf