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Allison is a registered nurse and senior health policy adviser with some 25 years experience. Prior to launching CPD Nurse Escapes, Allison worked as a private consultant for a diverse range of clients in the government and non-government, health, community and education sectors. Allison has an extensive background in regulation, governance and professional practice and applies this in education, policy development and project management. Allison was the Principal Advisor, Professional Practice at the Nursing & Midwifery Board of South Australia, for 10 years where she was responsible for developing nursing and midwifery policy and standards and advising and educating nurses and midwives on professional practice issues.

Saturday, 17 September 2011

Scope of Practice of Enrolled Nurses is Unclear (ENs Part 2)

If I had a dollar for every time I have been asked to explain the distinction between the registered and the enrolled nurse role I would not have to work again for the rest of my life! How can we not be clear about this important relationship given our accountability and responsibility to work within regulatory, legislative and policy requirements that so specifically require us to understand it? And how can we still not understand a two professional roles and a professional relationship which has existed for decades?  So many decisions are by nurses, nurse managers and policy makes, based on a complete lack of understanding of the nature of this relationship.

If nurses, both registered and enrolled, more clearly understand the nature of accountability, supervision and delegation, many of the artificial barriers to enabling enrolled nurses to practice within their full scope of practice would be eradicated.

The core enrolled nurse practice is characterised by a supervisory relationship with the registered nurse, the nature of which is determined according to the relevant legislation, their educational preparation and experience, and the health care context.

The literature consistently agrees that the scope of practice of the enrolled nurse is unclear and often misinterpreted and misunderstood in the practice setting. The predominant causative factors of this role confusion are identified as being the varied and differing approaches to scope of practice and the different culture and ‘shared knowledge’ in an organisation. This role confusion and inconsistencies in practice are a source of frustration and concern to enrolled nurses and registered nurses alike. 

Registered nurses and enrolled nurses commonly talk to me about their concerns about their lack of understanding of the distinction between the registered nurse and enrolled nurse roles.  Nurses identify that pressures (frequently due to registered nurse shortages) to expand the role of the enrolled nurse are resulting in greater blurring of the lines between the two levels of nurses and that this blurring is creating more confusion than ever before. Registered nurses may respond to this by being cautious when delegating tasks or responsibilities as a means of protecting their role and accountability.

Enrolled nurses frequently comment express to me their frustration that their scope of practice is often determined by the registered nurse they work with rather than the enrolled nurses’ level of competence or experience. Responsibilities and functions delegated to the enrolled nurse may change from workplace to workplace, ward to ward, or shift to shift. Enrolled nurses also reported to the National Review of Nursing Education that their scope of practice differed not only between jurisdictions but between employment settings and between clinical areas.

Registered nurses may be reluctant to delegate tasks to enrolled nurses for fear of greater accountability. Registered nurses anecdotally use the rationale ‘if I am accountable for everything I may as well do it myself’ and a misinterpretation of that accountability results in many registered nurses being reluctant to delegate tasks to enrolled nurses even if the enrolled nurse is competent. 

Enrolled nurses are increasingly seeking to expand roles and to work within their full scope of practice and level of competence but meet but may be restricted by organisational policy or culture. Many enrolled nurses have experienced the erosion of their role and are frustrated at loosing skills and recognition of functions that were previously part of their role. With the ever shrinking health dollar, and government cutbacks of nursing positions, clarity of the enrolled nurse role has never been so important or necessary.

Clarification of professional accountability supervision and delegation will assist to remove many of these artificial barriers to enrolled nurse practice and reassure registered nurses when making decisions about delegation.

The enrolled nurse has an important and unique role as part of an appropriate staff skill mix. Enrolled nurses provide an additional level of qualified nursing support in the provision of nursing care to clients with some level of health instability. This includes recognition of normal and abnormal function in assessment, intervention and evaluation of clients’ health and functional status. 

Enrolled nurses have, by virtue of their education, training and regulation, the appropriate level of skill, knowledge and expertise to effectively assess and report changes in health and functional status to the registered nurse in a timely and informed manner.

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