An Analysis of Past Florence Nightingale Medal Recipients: Insights Into Exceptional Nurses and the Evolution of Nursing.

AIM: To examine past Florence Nightingale Medal recipients' parallels with the evolving nature of the nursing field as a whole.
DESIGN: Descriptive research.
METHOD: The professional and demographic characteristics of 1,449 Florence Nightingale Medal recipients between 1920 and 2015 were analyzed to develop a high-level overview of the award recipient characteristics. RESULT: Medal recipients were primarily female (98.07%), with 36% being Specialist nurses. Awards were mainly conferred for aid work (30.4%) in the context of war or armed conflict followed by Nursing education (17.2%) and disaster aid (14.9%). The majority of recipients were affiliated with the Red Cross and the majority of recipients were those conducting Red Cross duties.
CONCLUSION: Our results offer statistical validation for the dedication of these exceptional individuals, while also highlighting overall parallels with the ongoing development of the nursing field as it expands to better deliver culturally-sensitive care and to overcome outdated stereotypes that would otherwise constrain innovation.

Understanding the historical evolution of each profession’s education can be helpful when developing solutions to advance future education and improve patient care (Christine Nathe, 2017). Nursing has documented roots during the height of the Roman Empire in 300 A.D but realistically has been around since the beginning of time. The Roman Catholic church was an early advocate in the utilization of nurses to care for others, but there were a variety of advocates throughout the ages. Florence Nightingale opened the first documented nursing school in London in 1860. Nursing education later moved to the U.S. in the late 1800s (Oliver, 2018). Initially, nurses were educated in nursing schools, so that students could focus on learning theory as opposed to providing care with little emphasis on the scientific knowledge of health care. This began with Nightingale’s influence since she knew how difficult it was to train providers who lacked the scientific knowledge to care for patients. Nightingale realized the importance of an educated health provider and presented a paper in 1893 that argued for an educated workforce with standards of practice as opposed to one in which nurses served as apprentices (preceptorship) in hospitals (Dumrose, 2012).

A medal was established in 1907 to commemorate the distinguished career of Florence Nightingale, the founder of modern nursing. Henry Dunant created the International Red Cross, which was inspired by Nightingale's contributions during the Crimean war. In accordance with the recommendations of the Eighth International Conference of the Red Cross in London (1907) and the resolution of the Ninth International Conference in Washington (1921), this medal was created in honor of Florence Nightingale's contributions to improve care for the injured. National Red Cross Societies donate money to a fund, the proceeds of which are used to support the award of the Florence Nightingale Medal to qualified male or female nurses and volunteer care workers that are active members and/or long-term assistants at a National Red Cross, Red Crescent, or an affiliated medical care facility (International Committee of the Red Cross [ICRC], 2003). This medal was first awarded in 1920, and has been awarded every two years or more frequently on some occasions (Wang et al., 2018). As of 2015, the award has been given to a total of 1,449 nurses from 97 different countries. As the medal is intended to be used to identify and honor distinguished nurses who have pioneered important and urgently needed work in underserved or hazardous environments, these recipients are known for their exemplary service and dedication to nursing and patient care. The medal in particular aims to recognize leading nurses who are notable for their courage and compassion exhibited when delivering nursing care in disaster or conflict zones, and their pioneering and innovative spirit exemplified in the fields of public health and nursing education.

This core spirit of the medal embodies the values of humanity, charity, bravery, and selfless dedication to identifying those nurses that have made and continue to make essential contributions to the world, much as did Nightingale herself as a pioneer dedicated to patient care and innovative nursing reform. Historically, this medal was largely used to recognize nurses for their dedication to war zones and other humanitarian aid scenarios. While such recognition is important, there has been some discussion over whether a shift in nursing focus to more broadly encompass other key values is important. A recent piece published in the American Journal of Critical Care in 2010 entitled “Nightingale is Not the Best Role Model for Today’s Nurses” (Brunton, 2010) emphasizes the limitations of the so-called “Nightingale spirit” as a nursing model, while Chinese researchers further suggest that this model may be too constraining to adequately meet with modern nursing needs (Duan, 2009). The winners’ contributions to public health in recent years have become more prominent. For example, in 2003, as many as 10 nurses in China won awards for fighting SARS (Gu & Cm, 2003), and also many others won awards for Ebola, leprosy, and AIDS, etc. The role of nurses in public health is increasingly apparent, especially in the global outbreak of 2019-nCoV in 2020, nurses around the world have made great contributions. In addition, the nurses represented by the winners have also made many innovative contributions in nursing education and other fields (Lee Kkotme, 2015). Moreover, tomorrow, as today, nurses will work with individuals, families, and communities to identify and address barriers to health by focusing their interactions on the evolving nature of what is meaningful in terms of health (Pharris & Endo, 2007). In the present study we have summarized basic information regarding all winners from 1920 to 2015, to better understand who the Florence Nightingale Medal recipients are and how trends in award conferral have shifted over time.

Methods and Materials

Participants and Materials

All the subjects included in this study were 1,449 winners of the Florence Nightingale Medal between 1920 and 2015. Information collected from the archives of the ICRC archives related to these winners was collected and used for downstream analyses.

Data Collection Procedures

We first contacted a professional translation agency to translate the original ICRC award archives into our local language for better ease of analysis. Two independent researchers then classified all items within this dataset according to the categories of information to which they pertained, including gender, working-age, nationality, the nursing field of contribution, service institution, and professional positions held. Any discrepancies between the two researchers were resolved through discussion and considering inter-rater reliability to reach a final decision. Data were imported into Microsoft Excel, which was used for downstream analyses and summary statistics. Several awards were selected as sample size, the number of awards in different fields of nursing was selected as dependent variables, and periods were regarded as independent variables.

Results

Medal Recipient Nationalities

Using the archived information regarding past Florence Nightingale Medal recipients (1920–2015) available from the ICRC, we were able to compile a range of demographic and professional information regarding these individuals. We began by assessing the number of winners from each country, with those from the top 20 most frequently represented countries being shown in Table 1. Among the top 10 countries with the most medal recipients, the majority participated in either the First World War or the Second World War.

Table 1.

List of Number of Awards and Winners from the Top 20 Countries (1920–2015).

Number	Nationality	Total Awards	Total Winnersa
1	Japan	44	107
2	Poland	30	101
3	France	34	89
4	United States of America	35	73
5	China	17	73
6	Germany	30	60
7	South Korea	30	55
8	Hungary	23	52
9	Australia	32	51
10	Russia	15	51
11	Italy	25	48
12	United Kingdom	35	47
13	Denmark	20	37
14	Thailand	19	37
15	Philippines	17	30
16	India	18	30
17	Former Yugoslaviab	18	30
18	Greece	22	28
19	Canada	22	27
20	New Zealand	24	27

aThe award is shared by more than one individual in most cases.

bSocialist Federal Republic of Yugoslavia (1945–1992).

Gender and Working-Age of Medal Recipients

The majority of medal winners (1,420/1,449) were women, while just under 2% were men (Table 2). This dramatic difference in the ratio of females to males among winners is likely related to overall nursing profession demographics. The percentage of award recipients who were given the award either after retiring or who were posthumously recognized was 11%. This low percentage is mainly due to the early regulations stated that medals must be personally awarded by the state leaders or the Chairman of the Central Committee of the Red Cross, and the International Committee of the Red Cross considered that the founder of this Medal focused on living nurses. Secondly, the ICRC did not require all countries to include sacrificial nurses among the recommended persons in the lists before the 1st award. The trend is now changed because of the current changes in regulations of the Florence Nightingale Medal that were passed in 1991 in Budapest, stating that “The Medal may be awarded posthumously if the prospective recipient has fallen during active service” (Wang et al., 2018).

Table 2.

Gender and working age of the winners.a

	Male	Female	Retirement	Death
Number	28/1,449	1,421/1,449	126/1,449	37/1,449
Percent (%)	1.93	98.07	8.7	2.55

aAs it was not possible to determine the age of every winner, this study used retirement or death as a correlate for working age.

Recipient Nursing Categories

By far the largest proportion of medal recipients were general registered nurses (Figure 1). Of note, 36% of recipients were specialized nurses, indicating the dedication of many past winners in areas of conflict and disaster relief.

Figure 1.

Nurse Types of the Winners. Notes: If one person had two or more nursing licenses, only one category was used for analysis purposes.

Recipient Contribution Fields

Next, we classified the fields of contribution for which medal recipients were recognized. As this information was derived from the presentations of winners, statistics were not available for all winners and were limited to those whose’ details included the relevant information. The most common field for which recipients were recognized was their service in the context of war or armed conflict (29.1%), followed by public health (17.9%), Nursing Education (16.5%), and public disaster relief (14.3%). Fewer medals were awarded for academic research (1.1%), although such prizes were conferred to select recipients. The largest number of winners awarded the medal for their contributions during war or conflict were conferred the medal prior to 1955 (68%), whereas in more recent years a growing number of recipients were awarded the medal for their contributions to nursing education (54.3%), disaster aid (46.9%), and public health (74.3%) (Table 3). This is because contributions during wartime or in response to disasters were preferentially recognized by the ICRC at times closer to the event in question, with other contributions being receiving further recognition during other periods (Wang et al., 2018).

Table 3.

Contribution field of Florence Nightingale Medal recipients over time.

	1920–1929	1931–1939	1947–1955	1997–2005	2007–2015	Totala
Aid in War and Conflict Situations	75 (64.7%)	93 (83.0%)	123 (62.8%)	72 (42.6%)	59 (33.7%)	422 (29.1%)
Nursing Education	23 (19.8%)	23 (20.5%)	53 (27.0%)	45 (26.6%)	95 (54.3%)	239 (16.5%)
Hospital Management	25 (21.5%)	21 (18.8%)	38 (19.4%)	1 (0.6%)	0 (0%)	85 (5.9%)
Disaster Aid	15 (12.9%)	21 (18.8%)	50 (25.5%)	39 (23.1%)	82 (46.9%)	207 (14.3%)
Public Health	15 (12.9%)	30 (26.8%)	19 (9.7%)	65 (38.5%)	130 (74.3%)	259 (17.9%)
Nursing Academic Research	1 (0.9%)	0 (0%)	0 (0%)	15 (8.9%)	0 (0%)	16 (1.1%)
Pioneering Work	0 (0%)	2 (1.8%)	3 (1.5%)	4 (2.4%)	1 (0.6%)	10 (0.7%)
Other	8 (6.9%)	18 (16.1%)	68 (34.7%)	48 (28.4%)	7 (4.0%)	149 (10.3%)

aTotal winners counted in this table is 768. The winner’s contributions are always more than one field in most cases.

Although we were unable to determine the contribution areas of all past award recipients due to a lack of data, we were able to observe trends in these contribution areas over time that offer insight into changing trends in the field of nursing as a whole.

Recipient Service Institutions

We next sought to classify the service institutions of medal recipients (Figure 2). Because there was no reference to the service agencies of some winners, our analyses refer only to winners whose service institution was identified. These results indicate that the Red Cross and its subordinate institutions have had more medal recipients than have any other institutions, followed by military hospitals and general hospitals. The lowest number of award recipients to date were from research institutions.

Figure 2.

Distribution of the Winners According to Service Institution.

Professional Duties of Medal Recipients

When we surveyed the professional responsibilities of award recipients, we found that there were roughly equal numbers of recipients who did and did not hold a position at the time of award conferral. Relative to those individuals who were serving as nurses in a medical institution as a head nurse, nursing director, or other related position, the number who were serving in the Red Cross was far greater, consistent with the key nonpartisan role of the Red Cross in nursing development.

Discussion

The Status of Male Nurses Has Improved in Nursing

Prior to the foundation of modern nursing through the work of Florence Nightingale in 1860, nurses were primarily nuns or untrained women engaging in care efforts. Even after the development of a more formalized nursing care structure, the vast majority of nurses remained women, with any male nurses being discriminated against owing to the perceived femininity of the nursing career path in a patriarchal society (Andrist et al., 2006). As the feminist movement gained steam, women increasingly entered into previously male-dominated career paths, leading to some reciprocal entry of males into historically female-dominated careers such as nursing. In 1971, The American Assembly for Men in Nursing was founded (O’Lynn & Tranbarger, 2006). In 1991, the ICRC delegation officially allowed male nurses to participate in the Florence Nightingale Medal award for the first time. Prior to this rule amendment, only women could receive the Nightingale Medal. Thus, this underscores the more widespread international acceptance of male nurses in recent years while highlighting the persistent gender imbalance in the nursing profession, which is not beneficial to the development of the profession as a whole. Male nurses have been increasingly considered for this prestigious award even though they still make up just under 2% of all-time medal recipients (Table 2). As of the year 2000, male nurses accounted for 5.4% of all registered nurses in the United States (Trossman, 2003), increasing in 2004 to 5.7% (Anthony, 2006). Research suggests that policies promoting gender equality affect nursing professionalization (Virginia et al., 2019). However, a recent survey of current Chinese college students found that prejudice still exists against male nurses, indirectly influencing many students to choose other professions or to be less satisfied with their career choice (Feng et al., 2016). There are thus still major hurdles to overcoming the gender-specific stereotypes of the nursing career path in order to fully accommodate all who are interested in this profession. There may be a few reasons why the total number of male Florence Nightingale Medal recipients has lagged behind the overall percentage of male nurses. For one, many medal recipients are later in their careers, and thus the more recent trend of increasing numbers of male nurses may not yet have reached those nurses at the average age and career stage of medal recipients. Alternatively, male nurses may be more likely to choose to work in settings or for organizations that are less frequently associated with the conferral of this award. More studies will be needed to parse these possibilities, but the increasing prominence of male award recipients will likely help overcome gender-related bias in the nursing field by providing prominent male nurse role models to those interested in pursuing a nursing career.

The Evolution of Nursing and Changing Trends in Nursing Specialties and Fields of Contribution

Changes in the frequencies of different nursing specialties among award recipients over time reflect the evolutionary history of nursing. For example, nun nurses with a religious affiliation are included among medal recipients, with Florence Nightingale having sought to change the nursing field based on their efforts to ensure that it was a respectable career for gentlewomen (Nelson and Gordon, 2004). Over time, nurses from increasingly diverse specialties have been awarded this medal, including visiting nurses, anesthesia nurses, and public health nurses, reflecting the continued expansion and extension of the scope of care (Figure 1). Pioneers in public health nursing have helped to develop scientific approaches to data collection and analysis, allowing for more robust studies based on a nursing science framework (Earl, 2009).

The diversification of nursing contribution areas also reflects this evolution of nursing. Our analyses confirmed that the majority of medal recipients hailed from countries that were participants in the two World Wars (Table 1)—a finding that was likely because these countries were especially prominent on the international stage in the 20th and 21st centuries, and because this medal was most often awarded for service in a war or armed conflict. The frequency of award conferral to those nurses who served either in conflict settings or provided disaster and aid relief was true cross-culturally. However, trends in the contribution areas of award recipients (Table 3) suggest that as the incidence of major international conflict has declined, so too has the number of awards conferred for service during war or conflict. In contrast, and the number of winners recognized for their contributions to the fields of nursing education, disaster relief, and public health has continued to rise over time.

When the Florence Nightingale Medal was originally conceived by the ICRC, it largely sought to focus on the dedication of individual nurses in settings of conflict. Only in more recent decades have the criteria for award conferral broadened to incorporate other important nursing ideals such as innovation in public health and nursing education settings. This shift in the focus of the ICRC is important, as there has been some criticism that the original dedication-focused scope of the medal was insufficient to encapsulate the key values of modern nursing, particularly in cross-cultural contexts where new issues have arisen in need of innovative and compassionate nursing solutions (Duan, 2009). While our analysis found that the majority of medal recipients at present are still those who have been recognized for their important service in conflict or disaster relief settings, we were able to detect an increasing number of winners recognized for their work in academic research indicating an overall shift in the culture surrounding this award.

The Red Cross and Nursing Science Promote One Another

Those serving in the Red Cross and its affiliates accounted for the highest number of medal recipients (Figure 2), and except for medical institutions, the greatest number of winners held positions in the Red Cross (Figure 3). This is consistent with the vital and central role which the Red Cross has played in the development of modern nursing. The international nonpartisan acclaim of this organization and its devotion to caring for those in need of humanitarian aid has lent credibility and esteem to the nursing profession as a whole, and it is thus no surprise that so many winners of this medal, which has historically been awarded largely for nursing in war zones and other settings where the Red Cross is prominent, are affiliated with this organization.

Figure 3.

Professional Duties of Medal Recipients. Notes: Several winners were omitted from this analysis, as the awards in 1957 and 1959 had little information regarding the winners, and the relevant information was lacking for 12 of the winners in 1920 and 2 of the winners in 2013.

We found that many of the winners graduated from nursing schools founded by the Red Cross. Due to a lack of original data availability, however, we were not able to fully compile these data. However, they still offered insight into the fact that the Red Cross further serves as a platform that provides essential training and education to nurses, driving nursing development and promoting modern innovations in nursing education which further embody the spirit embodied by the Florence Nightingale Medal.

Limitations

There are certain limitations to the analytical techniques used in this study that warrant consideration when interpreting our results. For one, the original award announcement materials were used to learn about medal recipients, and these materials were published in a variety of languages depending upon the nationality of the winner. As a consequence, there were some differences in terms of the information available regarding each awardee. Similarly, the titles and administrative levels into which nurses are classified are not consistent across cultures and institutions, and thus some of the comparisons drawn in that respect may be susceptible to contextual biases. This study is also of a limited subset of exceptional nurses and thus does not give direct insight into the field of nursing as a whole. Despite these limitations, we feel that these results do provide unique and valuable insights into those nurses at the forefront of the field and that our findings may have relevance to broader nursing trends.

Conclusions

As of 2015, there have been a total of 45 award ceremonies covering an award period of 100 years. Its regulations have also been revised several times. Through our overview of past Florence Nightingale Medal recipients, we have been able to identify certain key trends that are consistent with broader shifts in the focus of the nursing field as a whole. For one, the eligibility of male nurses for medal consideration parallels the increasing acceptance of males in this historically female-dominated profession. Additionally, while originally established to recognize exceptional dedication in settings of conflict or humanitarian need, this medal has been increasingly awarded for other innovative work to individuals at academic and other institutions not associated with urgent combat or disaster aid, seeking to broaden award criteria in order to foster and recognize nursing innovation. These shifts highlight the fact that recipients are making significant and innovative contributions to nursing development while exhibiting substantial dedication to nursing and patients, thus embodying the core mission of nursing as a profession.

We believe that consistent with recent commentary and an overall shift in the ICRC criteria for awarding the medal, the Florence Nightingale Medal should be awarded not only for dedication to humanitarian efforts but also for innovation in the nursing field. While dedication to those in need is an essential facet of the nursing profession that should always be held in high regard, there is a vital need for the development of novel public health and nursing education solutions to ensure that future generations of professionals are equipped to handle evolving global challenges. By placing equal value on dedication and innovation, the Florence Nightingale Medal can truly serve to encapsulate the innovative nature of its namesake for generations to come.

In addition, if the ICRC were to consider awarding the medal to more external candidates, it would greatly increase the number of prestigious nurses eligible for the award and would enable to medal to play a more prominent role in the evolution of nursing.