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Allison is a Registered Nurse of 25 years experience with a background in executive management, policy, project, professional advisory and governance within the health, community, education and indigenous sectors. She is the Principal Consultant with The Health Objective, a consultancy providing health education and training, policy and projects. Allison’s areas of expertise are in Nursing Law and Ethics; Professional Practice and Regulation; Scope of Practice Decision Making; Professional Documentation and Care Planning; Professional Supervision and Delegation; RN and EN Accountability; Safe Use of Medicines; Infection Control in Community Settings; Continence Management in Schools and Childcare; Leadership; Motivation and Project Management. Allison is a sought after public speaker on the national speaking circuit and is recognised as a vibrant and highly evaluated teacher who makes any topic interesting and engaging.

Friday, 16 September 2011

The role of the Enrolled Nurse in Australia - Understanding Scope of Practice (ENs Part 1)


Over the last decade or more focus has increased on more clearly examining and clarifying the enrolled nurse roll and scope of practice in Australia. Several key investigative reports have made specific recommendations in relation to the enrolled nurse scope of practice in particular, in relation to administration of medication, issues of supervision, delegation and accountability and the relationship between the enrolled nurse and unlicensed healthcare workers.

Implementation of the advanced enrolled nurse education curriculum has contributed greatly to the development of the enrolled nurse roll and provided much needed and sought after formal continuing education for enrolled nurses.

The scope of practice of nursing is recognised as varied and diverse, meeting the broad range of client needs across a variety of health care settings and dependent on; client profile, environment and setting in which nursing practice occurs, field of practice and organisational policy.

Nurses (including enrolled nurses) are increasingly taking on expanded roles and activities in order to comprehensively address client needs in a timely, safe and cost effective environment. At the same time, nurses are reclaiming roles that were previously within their responsibilities. Nurses are still expected to maintain the core aspects underpinning the philosophy of care and caring.

Nursing practice is moving toward broad, enabling scope of practice frameworks that support nurses to make decisions about and within the professions’ scope of practice.  The profession has moved away from over prescriptive policy and individual certification of tasks and activities.

Diverse research over the past decade has identified the need to further clarify the role of the enrolled nurse relating to accountability, delegation, supervision and education as enrolled nurses, registered nurses report that they are frequently confused about the scope of enrolled nurse practice particularly related to accountability, delegation and supervision. This confusion has often resulted in unnecessary barriers to enabling the enrolled nurse workforce to practice within their full scope of practice.


National Research Reports that Informed Change


The following four national reviews into the nursing workforce and education focused specific discussion and recommendations in relation to the enrolled nurse. Though now nearly a decade old, it is encouraging to note that many (if not most) of the recommendations have been/or are being implemented nationally, particularly in relation to enrolled nurse education, uniformity across states and now, medication management.

What is still largely necessary is the recognition, adoption, and full implementation of these policies into workplace practice. The barriers to this being achieved remain largely with workplace policy and education of registered and enrolled nurses about these changes.

A short summary of the nature and findings of these four key reports has been included to further provide background to the changes to enrolled nurse scope of practice.

The reports include;

1. National Review of Nursing Education – Our Duty of Care 2002[1]

2. Senate Committee Affairs Reference Committee Report on the Inquiry into Nursing The Patient Profession: Time for Action 2002[2]

3. An Examination of the Role and Function of the Enrolled Nurse and Revision of Competency Standards Australian Nursing Council 2002[3]

4. The Aged Care Enrolled Nurse Working Party A Report to the Minister for Aging 2003[4]


National Review of Nursing Education – Our Duty of Care 2002

Established by the Commonwealth Government in 2001 the Review examined the future nursing educational needs and provided advice on appropriate frameworks for educational policy and funding.

Our Duty of Care (2002) identified that there are a number of barriers to nursing development, many of which flow from the fragmentation arising from the different funding and policy responsibilities of the Australian, State and Territory Governments. It also concluded that to realise the potential of nurses (and midwives), the removal of these barriers would need to occur in a coordinated, national manner.

The Report identified that a new approach was needed to define and regulate scope of practice that would recognise the diversity of nurses and nursing work, and the variety of settings in which nursing occurs. This should be is characterised by its:
  
  • Responsiveness to change 
  • Flexibility of workforce structure and work organisation and
  • National approach to coverage 

The recommendations of the National Review of Nursing Education – Our Duty of Care 2002 identified 36 recommendations that encompassed such issues for the nursing and midwifery professions as recruitment and retention, skill mix and education requirements for the future. Several of the Recommendations had particular relevance in the development of an Enrolled Nurse Scope of Practice Framework.

Recommendation 4 - Nationally consistent scope of practice
To promote a professional scope of practice for nurses and greater consistency across Australia:

a) a national consistent framework should be developed to that allows all nurses to work within a professional scope of practice, including the administration of medication by enrolled nurses
b) to facilitate this development, all Commonwealth, State and Territory legislation and regulations that impact on nursing should be reviewed and reformed as required.

Recommendation 21 – Enrolled Nurse Competencies
To provide links to other training and to develop national consistency for the education and training of enrolled nurses;

a)   the Australian Nursing and Midwifery Council [ANMC] and Community Services and Health Training Australia should meet as a matter of urgency to ensure the [ANMC] competencies for enrolled nurses are incorporated into existing or new Australian National Training Authority sponsored training packages.
b)   in establishing the appropriate level of qualification, account should be taken of the training requirements for evolving models of care and changes in supervisory practice, including those related to medication administration and new enrolled nurse specialisations.

Recommendation 27 – Work organisation
Because the nursing workforce (including trained care assistants) contains arrange of experience and skills, and because it needs to adapt to an evolving care environment, work organisation throughout the health, aged and community care sectors should;

a)   constantly seek to achieve the most effective and efficient use of the total nursing workforce (including learning from best practice elsewhere)
b)   ensure that skills and expertise are matched to the work required in the particular workplace
c)    take account of the interrelationships with other health professionals
d)   ensure that nurses are encouraged to practise within their full professional capacity.


Senate Committee Affairs Reference Committee Report on the Inquiry into Nursing The Patient Profession: Time for Action 2002

The Senate Committee Affairs Reference Committee, “Report on the Inquiry into Nursing The Patient Profession: Time for Action” (2002) terms of reference identified;

a)   The shortage of nurses in Australia and the impact that this is having on the delivery of health and aged care services; and
b)   Opportunities to improve current arrangements for the education and training of nurses, encompassing enrolled, registered and postgraduate nurses.

Of its 85 recommendations, a number of recommendations related specifically to the role of the enrolled nurse. The Report Senate Committee made the following conclusion;

The Committee identified the need for national consistency in enrolled nurse education in relation to course structure, duration and content. The Committee recommended a national framework or guidelines for the education of enrolled nurses should be developed by the Australian Nursing and Midwifery Council], in conjunction with professional bodies, training providers, nurse regulatory bodies and unions. The Committee supported that educational preparation for enrolled nurses be, at a minimum, equivalent to Level IV of the Australian Qualifications Framework.

The Committee also saw that the variation between States in regards to the administration of medications by enrolled nurses needed to be addressed by the adoption of consistent legislation across all States.


Recommendation 25
That the Australian Nursing Council, in consultation with major stakeholders, develop a national framework for the education of enrolled nurses in relation to course structure, duration and content.

Recommendation 26
That State and Territory Governments develop nationally consistent legislation in relation to the administration of medications by Enrolled Nurses.(The Patient Profession: Time for Action p 86-87)
        
Further in relation to education

The Committee notes progress made in the development of articulation and recognition of prior learning between different levels of nursing. The Committee believes that formal articulation and recognition of prior learning should be further extended for enrolled nurses, unregulated healthcare workers and Aboriginal and Torres Strait Islander (ATSI) health workers.

Recommendation 22
That formal articulation arrangements and recognition of prior learning between enrolled nurse courses and registered nurse courses by universities and enrolled nurse education providers be further developed nationally.


An Examination of the Role and Function of the Enrolled Nurse and Revision of Competency Standards Australian Nursing Council 2002

This Study was commissioned by the Australian Nursing and Midwifery Council (ANMC) as the first national research into the role and function of the enrolled nurse. The project brief was to;
  • identify the generic role expected of enrolled nurses on entry to practice in Australia 
  • Revise the enrolled nurse competency standards to reflect the contemporary role and function of the enrolled nurse in Australia including articulation with the competency standards for the registered nurse 
  • Validate the revised competency standards
  • Identify, from the data collected on enrolled nurse practice, the issues concerning the ongoing and evolutionary development of the role, function, and educational preparation of enrolled nurses
  • Recommend the educational preparation required for enrolled nurses to achieve the validated and revised competency standards

The project was undertaken based on the underpinning assumptions that;
  • Enrolled nurses provide a valued contribution to Australian health care delivery 
  • The revision of the enrolled nurse competency standards was necessary for the regulation of nursing practice in Australia
  • Differences in state legislation would inform, and not drive, the nationally applicable outcomes of the project
  • Collaboration between the project team and nurse regulatory authorities was essential to the success of the project 
  • There would be wide consultation with and involvement of relevant stakeholders, including, enrolled and registered nurses, employers and consumers of nursing services, professional and industrial organisations, educational providers, health departments, and nurse regulatory authorities in all states and territories.

Of the 12 Recommendations made as a result of the study 3 recommendations relate most specifically to enrolled nurse scope of practice.

Recommendation 3
·       That the [ANMC] facilitate further research to clarify the scope of enrolled nursing practice.
Recommendation 4
·       That the [ANMC] facilitate research into nationally applicable decision-making frameworks
Recommendation 5
·       That the [ANMC] facilitate the development and dissemination of a nationally applicable statement about delegation and supervision in relation to nursing practice
Recommendation 5
·       That the [ANMC] require that educational preparation of enrolled nurses be at a minimum of Certificate IV level of the Australian Qualification Framework


The Aged Care Enrolled Nurse Working Party A Report to the Minister for Aging 2003

The Aged Care Enrolled Nurse Working Party was convened to investigate how an enhanced scope of practice for enrolled nurses (regarding the administration of medications by enrolled nurses) in aged care might be implemented on a national level and to ensure endorsement of this enhanced scope of practice by nursing regulatory authorities.

The then Minister for Aging the Hon Kevin Andrews, in response to ‘Our Duty of Care’ established the Aged Care Enrolled Nurse Working Party to report on:

What barriers exist in preparing enrolled nurses to administer medications;

How these barriers might be addressed nationally to ensure the endorsement of an enhanced scope of practice for enrolled nurses by relevant nursing regulatory authorities; and

What implications an enhanced scope of practice for enrolled nurses in the aged care sector will have on the broader health system.

Of the 13 Recommendations made by the Report 4 recommendations relate most specifically to enrolled nurse scope of practice.

Recommendation 2
·       The National Review of Nursing Education Implementation Taskforce coordinate a meeting of [ANMC] and State and Territory Nurse Regulatory Authorities to progress national consistency in relation to pre-enrolment enrolled nurse courses – specifically nomenclature and educational preparation that supports administration of Schedule 4 medications in the enrolled nurse  scope of practice should be addressed
Recommendation 3
·       The [ANMC] work with Nurse Regulatory Authorities to achieve nationally consistent definitions of direct and indirect supervision through the adoption of the [ANMC] proposed definitions in all jurisdictions
Recommendation 4
·       All Nurse Regulatory Authorities consider adopting a decision-making framework to provide guidance in regard to the delegation aspects of nursing care, and in particular, the administration of medications by enrolled nurses
Recommendation 5
·       Nurse Regulatory Authorities ensure courses leading to registration/enrolment include appropriate education/training on the rights and responsibilities of enrolled nurses in relation to scope of practice


In summary the recommendations across the reports were implementation of a nationally consistent

1.   decision-making framework should be developed to that allows all nurses to work within a professional scope of practice

2.   enrolled nurse education, allowing articulation and recognition of prior learning to degree based education and an advanced enrolled nurse program 

3.   enrolled nurse workforce and the enabling of enrolled nurses to work within their full scope of practice

4.   framework for enrolled nurses to be fully educated and enabled in administration of medications

5.   statements in relation to direct and indirect supervision and delegation


All of these recommendations in relation to expanding and enhancing the enrolled nurse role have been implemented.  The workplace adoption of policy and practice that enables enrolled nurses to work within their full scope of practice, including administration of medication, relies on employers, managers, policy makers and supervising registered nurses to fully understand the enrolled nurse scope of practice and decision making and to support this though appropriate supervision and delegation.  This requires further education in the workplace.

[1] Australian Government Department of Education, Science and Training , Archive www.dest.gov.au/archive/highered/nursing/pubs/duty_of_care
[2] Parliament of Australian Senate www.aph.gov.au/senate/committee/clac_ctte/completed_inquiries/2002-04/nursing/report
[3] National Library of Australia trove.nla.gov.au/work/16736415?selectedversion=NBD26828943
[4] Australian Government Department of Health and Aging www.health.gov.au/internet/main/publishing.nsf/Content/ageing-workforce-enfinal

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