Today in the chart

Operation Nightingale: Villains & Victims

At a time when the profession is grappling with diversifying its workforce, Operation Nightingale means we all lose

Credit: U.S. Department of Health and Human Services Office of Inspector General

Following the September 11 terrorist attacks, a 2001 Gallup survey of trusted professionals gave top billing to firefighters. In the two years before that, and for the 21 years following, nursing has been ranked as the most trusted profession. The public believes standards for honesty and ethics are higher in nursing than in any other profession. Nurses are thought to have higher honesty standards than judges and higher ethical standards than clergy (Brennan, 2023).  

Fifteen days after the publication of the 2023 Gallup poll indicating the high esteem nurses are held in, the Department of Justice issued a press release, Fraudulent Nursing Diploma Scheme Leads to Federal Charges Against 25 Defendants (DOJ, 2023). The press release described an illegal licensing scheme in which fraudulent nursing school diplomas and transcripts had been sold. These documents permitted the purchasers to sit for the NCLEX and obtain nursing licenses. The US Attorney for the Southern District of Florida, Markenzy Lapointe, noted that “Not only is this a public safety concern, (sic) it also tarnishes the reputation of nurses who actually complete the demanding clinical and course work required to obtain their professional licenses and employment” (USDOJ, 2023). Similarly, the special agent in charge, Omar Pérez Aybar, made a brief press statement in which he noted that the enforcement action was to protect the public and the integrity of the nursing profession itself (HHS-OIG, 2023).

Agent Aybar also noted that “Operation Nightingale” was an appropriate name for this DOJ enforcement action (because, you know, Florence was the saint who set the ethical standards for the nursing profession). For the moment, we will ignore that the relentless identification of nursing with Florence Nightingale perpetuates the “angel of mercy” narrative and continues to keep nursing from being taken seriously as a profession. Nightingale’s veneration perpetuates whiteness in nursing and the exclusion of women of color in teaching our history.  

By solely focusing on the “lady with the lamp,” we avoid studies of other nursing pioneers like Mary Seacole, Ann Bradford Stokes, Lucy Higgs Nichols, Mary Eliza Mahoney, Suzie King Taylor, Namahyoke Sockum Curtis, Jessie Sleet Scales, Adah Belle Samuels Thoms, Martha Minerva Franklin, Frances Reed Elliott Davis, Mabel Keaton Staupers, Aileen Bertha Cole Stewart, Estelle Massey Riddle Osborne, or any of the other women of color in nursing whose lifetimes intersected with Nightingale’s. We don’t teach nursing students that before Isabelle Baumfree became Sojourner Truth and before Araminta Ross became Harriet Tubman, they were both nurses.  

Nursing today requires a university education, but we will ignore that Florence Nightingale opposed higher education for women (Morris, 2023). Nursing requires assertive patient advocacy, so we will also ignore Nightingale’s belief that nursing education should be based on obedience rather than autonomy (DiGregorio, 2023). Nursing education involves substantial study of science and an understanding of disease etiology and transmission, so we will ignore Florence Nightingale’s belief that Australian tropical disease morbidity and mortality was a consequence of the “uncivilized” and “half-civilized” nature of native tribes (Nightingale, 1863, p.8).   

Most ironically, we will ignore that the vast majority of the nurses from these predatory schools are from the Caribbean and Africa. Florence Nightingale was a colonialist who played a political role in genocide under British rule and supported the forced migration of Māori tribes in New Zealand (Brookes, 2020). So, by all means, let us name an operation involving people of color after a white supremacist. But we will ignore all this and look at the scheme. 

“Operation Nightingale” seems simple, right? People bought false diplomas, then sat for the NCLEX, got licensed, and now practice without an actual nursing education. They must be stopped because they are criminals who can injure patients. They knew what they were doing was wrong and obtained nursing employment with unwitting healthcare providers. Let’s revoke those licenses, get them out of the workplace, and categorize them as fraudsters. Then we will all be safe, and the nursing profession will be protected. 

But it is not that simple. Certainly, some people knowingly purchased fraudulent documents. They need to be taken out of the game. But that is not the whole story. Most of the nurses who attended these schools are not criminals or fraudsters. They are victims. The nursing schools at issue aggressively marketed to women of color – particularly single mothers (Roberson, 2022). They held themselves out as programs that would qualify its graduates to sit for the NCLEX and become licensed as Registered Nurses. They did not tell their applicants or their students that, although the Florida nursing board had approved the programs, they were not accredited, or their accreditation was on probation. The students believed they were paying tuition to a valid program. They spent money not only on tuition and student loan debt but also on flights and hotels to Florida for “clinicals” – again, in approved programs. 

For a Florida nursing school to maintain accreditation, its graduate NCLEX passing rate cannot be any lower than 10% below the national passing rate (Florida Senate, 2011). While the national passing rate was 86%, Florida just made the cut-off with a 76% passing rate. Some of these predatory schools had pass rates below 50%. The schools blocked some students from graduating to falsely inflate their passing rates. When the programs faced the risk of termination, they created “new” programs to buy time for meeting compliance requirements. The” new” programs were the same programs, just renamed. The students were not told of the real reason for the name change. Nor were they told that identical programs had been closed. So the students continued paying tuition, attending classes, and flying in and out of Florida to complete these programs. 

The students who graduated from these programs believed they had attended nursing school. They had no reason to believe the schools were lying to them or that the board of nursing would approve an inadequate program. They received authorization to test for the NCLEX. They had no reason to believe Pearson Vue would authorize testing for graduates of fraudulent schools. They passed the NCLEX and were issued licenses. They had no reason to believe a nursing board would issue a license to a graduate of a fraudulent school. They obtained employment as nurses and have been working for years as nurses. Some have gone on to obtain advanced degrees. During this time, there have been zero reported incidents of patient harm.

Now, they are told their education was fraudulent; they are criminals; they must surrender their licenses; and are not nurses. They must cease practicing, leave their jobs, lose their income and health insurance, and, if in the US on a work visa, be deported. The nursing boards and Pearson Vue dropped the ball. They allowed these nurses to attend these programs, sit for the NCLEX, and obtain licenses. The criminals who ran these schools made millions of dollars by duping their students. They are being prosecuted, and any recovered money will go to the US Government. But it is their graduates who are paying the price. They have been labeled criminals, have had their reputations and careers destroyed, are paying legal fees, and must incur even more expenses to return to school if they are to stay in nursing.  

 The nursing profession and the public are also victims. Many of these nurses will leave nursing. Nurses of color will leave nursing. At a time when the profession is grappling with diversifying its workforce, Operation Nightingale means we all lose.

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