I have talked
about this topic frequently but it never fails to surprise me how many nurses
express their concerns and confusion about the difference between the
registered and the enrolled nurse roll.
Just recently, when running workshops for nurses on this topic, a
registered nurse became quite angry and defensive when I raised the issues of
enhancing and expanding enrolled nurse scope of practice. She argued that if
enrolled nurses are able to perform more clinical procedures then they will
start to take over registered nurse rolls and their jobs! She was unable to
understand or clarify in her own mind, the distinction between the roles as
anything other than clinical tasks. Unfortunately, this is not an uncommonly
held view. Equally, many enrolled nurses misunderstand the distinction and
argue that if they perform the same procedures as the registered nurse, then
the only difference between them is the salary level!
Why are so many
nurses confused about the different between the two roles and why do they
define it in such linear and simplistic terms as merely a distinction of tasks?
Nursing is a profession – a complex, evidence based profession, which requires
nurses to use their professional knowledge, skills and experience to make
professional assessment and judgment about client care and nursing
intervention. Nursing is more than the mindless performance of routine tasks.
Perhaps it is
because nursing is the only health profession with to distinct tiers. Perhaps because
these two tiers are tied together by different levels of accountability and
responsibility? Perhaps like all co-dependent relationships, they are a little
bit dysfunctional!
It
is the responsibility related to coordinating care and the knowledge and skills
utilised by the nurse in determining and providing the care that distinguishes
the nurse – not the task itself.
We need to be clear that the distinction between the two levels is
accountability for autonomous decision-making and accountability for
supervision and delegation – NOT competence. Enrolled nurses are not less
competent than registered nurses – both registered and enrolled nurses must be
competent in their practice.
Therefore is a registered nurse can become competent to perform a
complex procedure…so can an enrolled nurse!
The difference between them when performing the procedure is
the level of assessment and decision-making they have in determining ongoing
care. A registered nurse can therefore delegate the procedure without
delegating the decision-making.
I see two views
of thinking about scope of practice. The first I call the Horizon View of Scope
of Practice. It is a horizontal thinking that sees the enrolled nurse only
being able to perform a small, fixed range of clinical procedures that
encompass routine aspects of nursing care for clients with stable, predictable
health status.
This view of scope of practice is self-limiting, it promotes RN
only and EN only tasks and creates an artificial barrier. It’s an ad hoc approach,
determined by the culture of the workplace and the RNs concerns about their
accountability for delegation. It lacks sound rationale for the cut off point.
It fails to utilize the full capacity of the enrolled nurse in the workforce
and has registered nurses taking on ever increasing workloads and potentially
spreading them so thin that client care may be compromised.
The second view I
call the Summit View of Scope of Practice. It is a vertical thinking that
recognizes that both registered and enrolled nurses can develop competence in a
range of procedures which are not limited by an arbitrary line on the horizon
but in response to client and population needs. Delegation of procedures/tasks
to the enrolled nurse is based on an assessment of competence and an
understanding of the scope and limits of practice. The registered nurse
delegates procedures to the enrolled nurse but retains decision-making in all
aspect of client care and intervention. Both levels of nurses understand and
recognize their level of accountability in this process.
This view of scope of
practice is enabling, flexible and responds to trends in client care needs. It
recognizes parallel competence and differentiates the two tiers based on
accountability. It also recognizes the scope of practice from novice to expert
in both registered and enrolled nurse roles. It ensures both levels of nurses are utilised to their full
capacity and enables enrolled nurses to undertake a broad range of procedures
whilst freeing up the registered nurse to meet their additional
responsibilities and duties. It also recognizes and promotes the professional
relationship between the the levels of nursing.
Nursing comprises
63% of the health practitioner workforce in Australia. Yet nurses are working
harder and spreading themselves more unevenly than ever before. We must the
uniqueness of our two-tiered profession and ensure that both registered and
enrolled nurses are supported to provide the best care they can within their
full scope of practice.
