Nurses and Role Confusion

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.