Do RCN members really resent allocating the ICN just £1.80 per year from their subscriptions, asks Jane Salvage, Maura Buchanan, Christine Hancock, Pat Hughes, Tom Keighley, Shelagh Murphy, Anne Marie Rafferty and Jane Robinson
The Royal College of Nursing is on the cusp of a decision that could have profound effects on nursing worldwide. On 23 April, 539 members at an extraordinary general meeting voted for a resolution “to authorise RCN Council to withdraw the RCN from membership of the International Council of Nurses”.
Council now faces a momentous choice about whether and when to exercise its new power. Either way, the shock waves will electrify the forthcoming ICN 25th Quadrennial Congress, to be held in Australia on May 18-23. ICN delegates will be voting on a new fee structure, and choosing a new president – though the RCN will have no say, since it is suspended for withholding part of its ICN subscription.
While only 49 members voted against, the heated EGM debate revealed deeply held views, and much ignorance of what ICN actually does. At this critical juncture, our aim here is to explore the issues more thoroughly, and to suggest a constructive way forward. The authors are all longstanding RCN members with many years of nursing experience in the UK and overseas, including RCN fellows and former elected officials and staff members.
ICN, a federation of over 130 national nurses’ associations (NNAs), was founded by nurses from the UK, the US and Germany in 1899 - 17 years before the RCN. It has grown steadily, now represents many millions of nurses, and is the only organization that speaks for nurses from a truly global perspective.
ICN works to ensure quality nursing care for all and sound health policies globally. Its many activities include leadership development; shaping nursing policy; fighting for nurses’ socioeconomic welfare; improving nursing practice, regulation and education; and many projects in the field, from providing mobile libraries for nurses in 17 African countries to campaigning for positive practice environments.
It represents nursing at the annual World Health Assembly, and works with the World Health Organization, the International Labour Organization and other partners. This skilled work in the corridors of power is not always visible. Its leadership is all the more important at a time when nursing is losing ground globally. WHO leaders are presiding over a shameful decline in its nursing posts and influence, while global health is increasingly dominated by private philanthropists and multinational corporations.
ICN uses its unique role and pulling power to forge new alliances, attracting partnerships and sponsors to tackle major challenges like TB, HIV/AIDS, mental illness, and primary health care. It leads International Nurses’ Day to promote nursing in countries where the profession has little influence or visibility. Its role in leadership development has been formidable and it is sometimes a lone force in capacity-building for low income countries.
It has also done seminal work as a global resource for workforce management policy and mobilisation. All these initiatives and impacts demand working across a united front with United Nations agencies; no other body represents the interests of nurses so forcibly. Many major health problems, like the economic crisis and climate change, do not respect frontiers, and can only be solved collectively and globally.
Nurses around the world value their ICN membership in a way that may be surprising to UK nurses, who have so many different forms of support. Being part of an international organisation increases their influence at home, and provides a coordinated opportunity for richer countries to help others. They understand that the financial contributions made by big associations, such as the RCN, enable the ICN to do its work. And they appreciate that many ICN programmes would not happen without them.
We find it hard to envisage an ICN without the RCN. After Florence Nightingale British nursing continued to lead the way worldwide. It still influences nursing in many countries, and is hugely respected worldwide. Many countries base their nursing systems on the British model.
You could say that ICN is in the RCN’s DNA. Headquartered in London for many years, ICN boasts previous RCN presidents and general secretaries among its presidents and directors, most recently Christine Hancock. Its current chief executive officer, Scotsman David Benton, is an RCN Fellow. The RCN’s charter and charity objects require it to promote the art and science of nursing through international agencies. Much if not most of this has been achieved though ICN membership.
The push for reform
Why, then, would the RCN want to leave? It’s not as though ICN is a bloated organisation of fat cats – it’s actually a tiny organisation with a huge reach, trying to meet massive needs on a budget of less than £5m. It is by no means perfect, but the amount of work undertaken by its staff - less than 20 people -is awe-inspiring.
Like many other international organisations, though, it was founded in a different era and has found it hard to modernise. Its member associations need to agree how to improve its decision-making processes and membership model, and reform its fee structure, which places a heavy burden on around half a dozen of the wealthiest countries.
The RCN leadership has worked tirelessly to promote ICN reform, and we share the frustration at the slow pace. There have been years of patient effort behind the scenes. Like reforming the UN, WHO or the EU, it’s like reversing a juggernaut. The ICN, like the RCN, is a member organisation, and major changes must be agreed by its large, diverse member states.
The governance of multi-country international organisations is always problematic. Member states have to trade off the advantages of influence by having a seat at the table against the frustration of inertia, conflicts of interest, and cost. The RCN leaving the ICN would be like the UK saying that membership of the UN was too expensive and too cumbersome, and that it intended to give up its seat at the table.
What of the financial arguments, of which much has been made? It is the fluctuations in exchange rates of the pound and the Swiss franc - beyond the control of either RCN or ICN – that have increased the costs to the RCN in the past few years, rather than major changes in RCN membership numbers.
It’s a question of priorities. Yes, £624,000 in annual dues is a lot of money, though this will reduce in future. The RCN is a victim of its own success here, because with a per capita fee system, it looks a great deal when added up. To put it in perspective, international expenditure is an estimated 1-2 % of the RCN’s £84m budget, and ICN fees are 0.7%.
And yes, there are many competing demands on RCN resources. There is always more that could be done to support UK nurses as they fight for their jobs, for justice and for the survival of the NHS. But do RCN members really resent allocating ICN just £1.80 per year from their RCN subscription? And let’s not forget that the economic crisis affects all ICN members, especially those who are much poorer in the first place.
Reform is in the air at ICN. Its forthcoming vote on a new fee structure could give the RCN a 17% reduction in its dues. The election of a new president offers potential for fresh leadership. We can all see the difficulties of democracy in action in the international arena - but the responsible solution is to stay in the tent, continue to negotiate and shape the future together.
Why ICN still matters
We have offered some answers to the question, what does ICN do for us? But the other question is what the RCN, the world’s second biggest NNA, gives back to the global nursing community. As well as the cost, the value of ICN membership and the UK having a voice at global level should be considered. To paraphrase President John Kennedy, ask not what the ICN can do for you, ask what you can do to promote the art and science of nursing on the only truly global platform.
Nursing is a global profession, and the RCN reflects its wonderful diversity. Many people attending the EGM were born outside the UK, and many more have roots outside the UK. Many have worked overseas. The International Slavery Museum in Liverpool, near the Congress venue, is a powerful reminder of how Britain’s past and current prosperity - despite all, we are still a rich country - was built on conquest and exploitation of other peoples. And for decades we have reaped the benefits of recruiting skilled nurses from other countries to fill our own gaps.
This gives us a moral duty to extend the hand of friendship to nurses worldwide. And as everyone who has done international development work knows, our generosity is repaid many times over, and we learn and grow though the experience.
ICN is not “them” or “it”, it is us – just as the RCN is us, its members, and is what we make it. It’s integral to our legacy, our shared history, our institutional memory, and our humanitarian commitment. Indeed, at a time when the planet desperately needs our collective wisdom and energy, scaling up our international engagement – not retreating into isolation – is the only way forward.
A message to RCN Council
RCN Council should urgently lead a wide, informed debate to clarify whether the ICN is still the best vehicle for RCN international engagement. If it is not, we need to know what would replace it. There should be a full, open risk analysis of the impact of RCN withdrawal. Issues we should think about with enormous care include the damage to the reputation of the UK and the RCN, and our loss of influence in the global arena. There could be devastating political consequences that would be difficult to repair
. Fellow nurses in many countries will feel shocked and let down. The RCN might be perceived as selfish and arrogant.
Withdrawal from ICN is the last resort - the nuclear option - and we urge Council to use its power wisely and cautiously. There is no immediate reason to leave the ICN now, and everything still to play for. At least await the outcomes in Melbourne and the possibilities of fresh ICN leadership. Take a leaf from Trevor Clay’s book – when he was RCN general secretary, he proposed and funded an independent review of ICN. See Box 1 for further suggestions.
We take comfort from the words of Kath McCourt, chair of RCN Council, that “the RCN is fully committed to working with international partners on issues of common interest to nursing at home and abroad”. Whatever decisions are made about ICN, we need a lively, engaging, balanced debate on how to strengthen RCN engagement as a fully contributing member of the global nursing family, and how to increase UK nurses’ understanding of the value and importance of international engagement.
Box 1. Suggestions for further action
- Continue to work for change from inside ICN through constructive dialogue with ICN leaders.
- Seek impartial mediation between RCN and ICN to seek an amicable solution.
- Fund an independent review of ICN.
- Launch debate on how to strengthen RCN international engagement and promote the value and importance of international engagement to all UK nurses.
Jane Salvage, FRCN, independent nursing consultant; Maura Buchanan, director, Uganda-UK Health Alliance, and RCN Past President; Christine Hancock, director, C3, and former ICN president and RCN general secretary; Pat Hughes, consultant, C3, former chair of RCN Council and former ICN staff member; Tom Keighley, FRCN, management consultant; Shelagh Murphy, former RCN international secretary and past board member, ICN; Anne Marie Rafferty, FRCN, professor of nursing policy, King’s College London; Jane Robinson, FRCN, editor, International Nursing Review