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ENs and RNs side by side

There is room for both these nursing workforces to perform their full scope of practice.

Enrolled nurses (ENs) play an integral role in the delivery of healthcare in our country, yet often appear to be the forgotten cousin when it comes to discussions around workforce issues.

It would be easy to dismiss the reasons around this perception as all about numbers – the EN workforce is less than a quarter of the size of the registered nurse workforce – but I believe there is more to this issue. Of particular note is what is often a lack of clarity around the EN’s scope of practice.

I’m sure most of us would appreciate that ENs and RNs share a common nursing philosophy and a commitment to high-quality care; however, the two workforces differ in a number of respects. It’s important to note that these differences relate to the level of responsibility and scope of practice, nothing to do with an individual’s ability. Here is the description of the role of enrolled nurse, as written by the Australian Nursing and Midwifery Council and adopted by the Nursing and Midwifery Board of Australia (NMBA):

“The enrolled nurse is an associate to the registered nurse who demonstrates competence in the provision of patient-centred care as specified by the registering authority’s licence to practise, educational preparation and context of care. Core as opposed to minimum enrolled nursing practice requires the enrolled nurse to work under the direction and supervision of the registered nurse as stipulated by the relevant nurse registering authority. At all times, the enrolled nurse retains responsibility for his/her actions and remains accountable in providing delegated nursing care.”

As many of us would be aware, NMBA is reviewing the Enrolled Nurse Competency Standards but this description of the EN seems self-explanatory –why then does there still seem to be some level of confusion around the EN role, and where does this confusion stem from?

One possible source of confusion is the preparation of undergraduate nursing students with respect to delegation, often to ENs with more experience. The relationship dynamic between the newly registered nurse and the experienced EN can be a sensitive issue. The 45–54 age group was identified as the largest amongst the Australian EN workforce, so the odds are that early career nurses will be, at times, overseeing ENs who have many more years of practice. When asked earlier this year, ‘What has been the hardest thing you’ve encountered when transitioning from student to RN?’, Renee Callender, ACN member and recently registered RN said, “The increased responsibility for my actions as a registered nurse compared with being a student nurse; having team members rely on my judgements and learning to delegate to very experienced nurses.” As nurses with the same shared goal – that of best nursing practice for those we care for – mutual respect and recognition of skill mix in relation to authorised scope of practice is essential.

In my opinion, confusion also originated from the variable EN educational requirements and responsibilities applied in each state, prior to the transition to national registration in 2010. Now, all Australian RNs, ENs and midwives must adhere to uniform National Registration Standards in order to practise in Australia. This nationally consistent approach has already lessened the confusion and sometimes entrenched attitudes around EN scope of practice. I believe this confusion will only continue to dissipate as time goes on; particularly as from July this year the minimum education qualification for ENs will be a diploma-level course.

One example of a health service ensuring that ENs are supported in their endeavours to work to their full scope of practice is a workshop program implemented at Repatriation General Hospital (RGH) in Adelaide. In an article in the The Hive titled, “An Educational Initiative to Expand The Enrolled Nurse Scope of Practice”, June Cox and Sean Prendergast write that the program facilitated “clarification around EN scope of practice issues and also served to alleviate concerns about the perceived erosion of the RN role by diploma-prepared ENs”.

The majority of workshop participants surveyed experienced a change in practice regarding the RNs’ confidence in delegating. Also, and of particular relevance to this article, ENs felt more encouraged and positive about their expanded role. As you would expect, challenges did present themselves during the workshops. A small number of RNs disagreed with the expansion of the EN scope of practice; concerns were expressed about the expansion of the EN role affecting RN jobs. It’s interesting to note the parallels of this argument to the opinions some medical practitioners expressed about nurse practitioners encroaching on their scope of practice.

The challenges RGH experienced are to be expected but should not be a deterrent to implementing strong frameworks to advise both ENs and RNs about the role ENs can play in the healthcare of patients.

For the nursing workforce – both RN and EN – to deliver the best of care, it is necessary that all members practise to the full scope for which they have been educated. Therefore, it is important that we all individually and collectively work to ensure that all nurses are enabled to perform to their full extent. Local policies and attitudes do affect the capacity of ENs, and at times RNs, to practise to full scope. Additional clarity and discussion around the role of ENs in today’s health system still needs to take place; however, initiatives such as those of RGH are encouraging and it is to be hoped that more programs will occur that endeavour to support the EN role, the RN role and the relationship between the two.

Adjunct professor Debra Thoms is CEO of the Australian College of Nursing.

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