Contemporary enrolled nursing practice: Opportunities and issues

Contemporary enrolled nursing practice: Opportunities and issues Terri Gibson, Marie Heartfield, University of South Australia Over the last decade, Australia, as with the rest of the developed world, has experienced a widespread labour market decline in the numbers of nurses in the health workforce. Concurrent with this nursing shortage, the second level nurse has, in many countries, ceased to be recognised as a legitimate nursing role. In Australia, recent research indicates that the enrolled nurse role, though contentious, is consolidating as a core component of the health care workforce. This paper reports on national research that examined the role and function of the enrolled nurse in Australia and reviewed the Australian Nursing Council Inc (ANCI) National Competency Standards for Enrolled Nurses. Specific issues related to the contemporary role and function of enrolled nurses, namely supervision, scope of practice and education, are also discussed. Key words: nursing role, competencies, enrolled nurse, supervision, scope of practice, nursing education Introduction Internationally, the perception that enrolled nurses often undertake similar roles to registered nurses without the same level of education (Brown 1994, Allan & McLafferty 1999) has, in some countries, underpinned moves to phase out enrolled nurse training and encourage enrolled nurses to convert to a registered nurse qualification (Department of Health 1999, Nursing Council of New Zealand 2000). In Australia, although a twotiered nursing structure continues to be endorsed, demarcation between the levels of nurse and the associated roles and responsibilities has been a significant and ongoing professional issue (Pearson et al 1992, Percival et al 1994, Owen 1995, Owens & Macarty 1999). Competency standards were introduced in the late 1980s as one strategy to address this issue. The development and maintenance of competency standards for nursing practice in Australia is facilitated through the Australian Nursing Council Inc (ANCI). These standards are endorsed by the state and territory nurse regulatory authorities and play a significant role in the regulation of nursing practice. In 2000, the ANCI, as part of its national involvement in nursing regulation, commissioned a project to examine the role and function of the enrolled nurse (EN) in Australia and review the National Competency Standards for Enrolled Nurses to ensure their relevance for contemporary and future nursing practice. This paper presents an overview of the project and reports on key issues emerging from the research that have implications for the future role of the enrolled nurse in Australian health care. Terri Gibson RN MNStd BN(Ed) DipAppSc(Nsg) FRCNA, Senior Lecturer, University of South Australia, School of Nursing & Midwifery Marie Heartfield PhD RN FRCNA, Senior Lecturer, University of South Australia, School of Nursing & Midwifery. Email: marie.heartfield@unisa.edu.au Project aims and objectives The project used a qualitative research design to revise the contemporary role, function, competencies, and educational preparation of enrolled nurses in Australia. The project team consulted with identified stakeholders 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; 22 Collegian Vol 10 No1 2003

Contemporary enrolled nursing practice: Opportunities and issues 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; and recommend the educational preparation required for enrolled nurses to achieve the validated and revised Competency Standards for the Enrolled Nurse (Gibson et al 2002). Research design The project aim and objectives were addressed through four interrelated phases of data generation and analysis, which included: Phase 1: Identification of the role of the enrolled nurse on entry to practice through literature review and critical incident interviews; Phase 2: Development of draft revised Competency Standards for the Enrolled Nurse following analysis of literature, interviews, workshops, open forums, teleconference and written submissions; Phase 3: Validation of the draft revised Competency Standards for the Enrolled Nurse against existing practice through direct observations of enrolled nurse practice; Phase 4: Determination of the educational requirements for enrolled nurse practice through analysis of relevant curriculum documents in relation to the revised Competency Standards for the Enrolled Nurse and consultation with relevant stakeholders (Gibson et al 2002). The range of research techniques used in the project have been demonstrated as valid for occupational analysis and the development of competencies (Gonczi et al 1990) and included empirical as well as reported data. The participants Registered and enrolled nurses and other key stakeholders including professional and industry bodies, regulatory authorities, consumers, employers of enrolled nurses and those involved in enrolled nurse education participated in the study. The sampling frameworks that guided the purposeful selection of participants from each state and territory were developed from national labour force data on the distribution of enrolled nurses in the Australian health workforce by geography and area of practice (Australian Institute of Health Welfare 1999, Gibson et al 2002). Consistent with the goal of purposeful sampling to ensure information rich cases (Miles & Huberman 1994, Sandelowski 1995), representation was sought from individuals in metropolitan, rural, regional and remote locations by virtue of their direct experience with enrolled nursing. The research phases Phase 1: Identification of the role of the enrolled nurse on entry to practice through literature review and critical incident interviews Semi-structured telephone interviews were conducted with enrolled nurses from a range of diverse practice areas in each state and territory (n=48). The enrolled nurses were asked to describe specific situations encountered and activities undertaken in their daily nursing practice. Data generated through the literature review and telephone interviews informed a series of national workshops, rural teleconferences and open forums conducted in Phase 2 of the project. Phase 2: Development of draft revised Competency Standards for the Enrolled Nurse following analysis of the literature, interviews, workshops, open forums, teleconference and written submissions Workshops in each state and territory (n=8) and a rural teleconference (n=1) targeted specific stakeholders to explore the role, function, competencies and education of enrolled nurses. Open public forums, advertised through the ANCI website, letters to Nurse Regulatory Authorities and the targeted workshop participants, were also held in each state and territory to enable interested people to comment on issues relevant to the project. A call for written submissions was also placed on the ANCI website, with letters sent to relevant national organisations, inviting their submission to the project. These data informed the development of a draft revised set of competency standards for enrolled nurses. Phase 3: Validation of the draft revised Competency Standards for the Enrolled Nurse against existing practice through direct observations of enrolled nurse practice Observations of enrolled nurse practice were undertaken in each state and territory to validate the draft revised competency standards (n=160). Each four-hour observation was followed by an interview with the observed enrolled nurse and in some cases with the RN with whom the EN was working. Ethical and administrative approval was gained from all venues prior to commencement of the observations and all ethical principles were adhered to in the conduct of the research. Registered nurses were trained to conduct the observations in a three-day program focused on observing, interviewing and recording data for research purposes. Pilot observations of enrolled nurses in practice settings, conducted as part of the training, were used to develop standardised tools for data collection to enhance reliability. In addition, through a process of reviewing, critiquing and discussing each pilot observation, the registered nurse observers developed a shared understanding of the observation and recording process which enhanced consistency in data collection. Written consent and demographic and education information were obtained from all participants prior to the commencement of each observation. Information was also recorded about the context of the observations including time of day, clients receiving care, nature of care provided and interaction with registered nurses and other team members. The draft competency standards were revised in accordance with this data. Phase 4: Determining the educational requirements for enrolled nurse practice through analysis of relevant curriculum documents in relation to the revised Competency Standards for the Enrolled Nurse and consultation with relevant stakeholders Following validation of the revised competency standards, Collegian Vol 10 No1 2003 23

copies of currently approved enrolled nurse curricula from at least one major enrolled nurse education provider in each state and territory were analysed to determine the fit of current educational preparation with the revised standards. Analysis of educational issues also took into account data generated in all phases of the research. Data analysis Data analysis included use of N-Vivo (N-Vivo 1999) qualitative research software for data management and some aspects of coding. Data transcripts were individually read by two of the chief investigators in the research team (Gibson et al 2002) to gain an overall sense of themes, practices and events or situations in relation to enrolled nurse role, function, competency and education. Phase 1 and 2 data sets were compared, interpreted and integrated with the N-Vivo coding and cross referenced with the draft competencies resulting in a revised set of Competency Standards for the Enrolled Nurse. Data from all phases nurses need to recognise that competency standards are only one of the resources necessary to guide decision-making about the scope of enrolled nurse practice. were also coded and synthesised to produce a thematic description of the current enrolled nurse role and function on entry to practice. Content analysis of enrolled nurse curricula produced an overview of course structure (including content, assessment and theoretical and clinical hours), graduate outcomes, entry requirements, recognition of prior learning as well as integration of the current enrolled nurse competency standards. Results and discussion Enrolled nurse role and function in Australia The results of this project suggest that the enrolled nurse, as an associate to the registered nurse, remains a flexible and integral member of contemporary Australian health care services. While the project team observed role diversity as a salient feature of enrolled nursing practice, core aspects of the enrolled nurse role were also clearly evident. Core features of the role include: working as a part of the health care team by assisting patients with activities of daily living; providing physical and psychological comfort and support; assisting with assessment; communicating and liaising with patients and their families, colleagues and other members of the health care team; assisting with planning and evaluating nursing care; undertaking specific nursing interventions; and maintaining a safe environment (Gibson et al 2002). Core enrolled nurse practice was characterised by a supervisory relationship with the registered nurse, the nature of which was determined by the relevant state and territory legislation, educational preparation and experience of the enrolled nurse, and the health care context. Anecdotal evidence of complex and high level functioning for the enrolled nurse from participants in phases 1 and 2 of the study was not supported by the observational data generated in phase 3 of the project. Operational knowledge of organisational context, policies and procedures was commonly perceived as evidence of enrolled nurses performing at a higher level of knowledge and skill than was actually the case. Emphasis on efficiency in the completion of visible nursing tasks suggests that though enrolled and registered nurses may, in many instances, be seen to be performing the same or similar activities, the accompanying cognitive and analytical processes are often quite different in accordance with the broader registered nurse educational preparation and role responsibility. Amid a strong sense of collegiality and discussion of associate roles between registered and enrolled nurse participants, one registered nurse cautioned that sanctioning a wider role for enrolled nurses risked reducing... the complexity of nursing skills to that of a lesser level of tasks, just so that enrolled nurses, who are nurses with different levels of education, therefore cheaper, might perform them (workshop participant). Despite this complexity and differences in registered and enrolled nurse roles and the potential for role confusion, this research indicates that the enrolled nurse retains considerable visibility as a direct nursing care provider, liaising with registered nurses and other health care professionals (Gibson et al 2002). Enrolled nurse competency standards The commissioning of the project by ANCI to revise the competency standards was supported by participants as necessary and timely due to the increasing fragmentation of the health system, use of unregulated health workers, nursing shortages, expanded nursing workloads and increasing numbers of enrolled nurses working in community and residential care sectors and general medical practices. The significance of these issues in shaping nursing practice meant that the inclusion of observations of actual enrolled nursing practice to validate the competency standards was viewed as a particular strength of the research design. Participants proposed that the revised enrolled nurse competency standards use the ANCI registered nurse competency domains of professional and ethical practice, critical thinking and analysis, management of care and enabling (Australian Nursing Council Inc 2001). It was argued that the same domains would signify the enrolled nurse as a core part of the nursing profession and assist differentiation between the roles of the registered and enrolled nurse, and the enrolled nurse and unregulated care worker. The ANCI registered nurse domains were therefore adopted with different descriptions of each domain, competency statements and cues to reflect the enrolled nurse role, function and educational preparation (Gibson et al 2002). 24 Collegian Vol 10 No1 2003

Contemporary enrolled nursing practice: Opportunities and issues A significant finding from the research was that nurses need to recognise that competency standards are only one of the resources necessary to guide decision-making about the scope of enrolled nurse practice. Decision-making about nursing practice requires consideration of a range of factors including the educational preparation and experience of the enrolled nurse, and context of care taking into account the particular needs of the individual patient/client, state and territory legislative requirements and organisational policy. An illustration of this can be seen in the role of the enrolled nurse in the administration of medications in that educational preparation, individual client need and the degree of involvement of enrolled nurses in this practice vary considerably between states and across practice settings. Whilst the revised competency standards do not preclude the administration of medications by enrolled nurses, decision-making about this practice issue cannot be resolved through interpretation of competency standards alone. The strength of the revised competency standards for enrolled nurses is that they are reflective of contemporary enrolled nurse practice without being prescriptive, thus accommodating the diversity of health care settings and nursing practice whilst providing a framework for safe and accountable nursing care. Education of enrolled nurses Significant debate related to enrolled nurse education centred on issues of national consistency, level and models of educational preparation, transition to practice, articulation with other programs, curriculum content and post-basic education (Gibson et al 2002). Analysis and interpretation of the current enrolled nurse role and function and revised competency standards indicates a strong correlation between the distinguishing features of a Certificate IV qualification as currently specified in the Australian Qualifications Framework (Australian Qualifications Framework Advisory Board to MCEETYA 1998) and the requirements of entry to practice for enrolled nurses. (see Table 1). Consistency in enrolled nurse educational preparation was seen as essential to effective implementation of national competency standards. However, considerable variation exists in the current educational preparation of enrolled nurses in Australia. Substantial debate occurred (and is yet to be resolved at national level) about whether enrolled nurses should be educated at Certificate IV or Diploma level. Currently enrolled nurses in all states and territories except Queensland are educated at Certificate IV level, Table 1: Distinguishing features of a Certificate IV qualification Demonstrate understanding of a broad knowledge base incorporating some theoretical concepts Apply solutions to a defined range of unpredictable problems Identify, analyse and evaluate information from a variety of sources Identify and apply skill and knowledge areas to a wide variety of contexts with depth in some areas Take responsibility for own outputs in relation to specified quality standards Take limited responsibility for the quantity and quality of the output of others (Australian Qualifications Framework Advisory Board to MCEETYA 1998) whilst initial EN preparation in Queensland is at Diploma level. The continuing education needs of enrolled nurses as highlighted in the project included the development of transition to practice support programs to maximise integration of enrolled nurses into the workforce, and ongoing education to facilitate career pathways for enrolled nurses other than conversion to a registered nurse. Supervision The supervision of enrolled nurses by registered nurses was a key issue that pervaded all aspects of the study. Definitions and interpretations of supervision vary between state and territory nurse regulatory authorities and according to the nature of the work delegated. For example, indirect supervision is defined by the Queensland Nursing Council (1998) as where the registered nurse is working in the same setting as the enrolled nurse and though accessible for consultation does not constantly observe the enrolled nurse s activities, while the Nurses Board of South Australia s definition of indirect supervision stipulates that in the absence of proximity, processes need to be established for the direction, guidance, support and monitoring of the enrolled nurse (Nurses Board of South Australia 1999). Further, the Tasmanian Nursing Board emphasises that where direct supervision of an enrolled nurse may not be required, the accountability for delegation remains with the registered nurse (Nurses Board of Tasmania 1997). Many registered and enrolled nurses in this study described a more liberal interpretation of supervision than the definitions of nurse regulatory authorities. In general, participants considered that formal delegation arrangements were unnecessary where the registered nurse knew the enrolled nurse. Registered nurse supervision of enrolled nurses was expressed as: An ideal not always achievable in reality in the current and emerging models of care delivery, staff shortages, and high patient acuity and turnover (workshop participant). While the legal requirement for enrolled nurses to work under the direct and/or indirect supervision of a registered nurse was acknowledged, some participants commented on the inevitability that enrolled nurses will assume increasing responsibility for team leadership roles which will include delegation and supervision of health care workers in aged care and community environments. A key issue related to supervision was the enrolled nurse s ability to act with relative autonomy, in a variety of contexts within nursing teams. Although it was acknowledged that registered nurses are responsible for providing direct or indirect supervision, this was seen as very much dependent on the skills and attributes of the enrolled nurse and the context of nursing care within which they were practicing. Whilst acknowledging that registered nurses remain accountable for delegation decisions, decision-making about enrolled nurse practice needs to legitimise enrolled nurse knowledge and experience by allowing for models of supervision that accommodate variations in supervision by a registered nurse. Such Collegian Vol 10 No1 2003 25

flexibility enables more effective use of enrolled nurses and reduces the frustration that many experience at not being able to use their knowledge and skills appropriately in the workplace. The argument for more flexible models of enrolled nurse supervision does not imply an expanded scope of enrolled nurse practice; rather, the aim is to enable enrolled nurses to practice to their fullest capability within the regulated scope of enrolled nurse practice, according to their level of education and experience, so as to facilitate safe, effective standards of nursing care. Scope of practice Discussion of the contexts in which supervision of enrolled nurses occurred, and in particular, the frustrations associated with making decisions about enrolled nurse scope of practice featured prominently in the research. Registered and enrolled nurse participants were often passionate in describing difficulties in making and implementing decisions about enrolled nurse competency in the contexts of acute nurse shortages and a perceived lack of support for both registered and enrolled nurses. As one participant noted: How is the enrolled nurse supposed to manage when they are [often] the ones with the specialist, in this case, mental health qualification, yet they are being supervised by a registered nurse who does not have the mental health care qualifications? (workshop participant). From another participant: How many times has an enrolled nurse been the only regular staff member on a floor with only a junior or agency registered nurse, this by default making them the senior person on the floor and in charge when there is no recognition that this is what is being expected (workshop participant). Hence a reasonable consensus developed between participants in the majority of states and territories about the need for resources to assist decision-making about scope of nursing practice. An illustration of the effectiveness of such resources was evident in the consistency with which registered and enrolled nurses in Queensland described how they made decisions about scope of nursing practice. Participants suggested that the education process associated with the implementation of a decision-making framework (Queensland Nursing Council 1998) by the Queensland Nursing Council had greatly assisted clarification of the roles and relationships between registered and enrolled nurses (Gibson et al 2002). Conclusion The type of work that enrolled nurses do is changing; and there is recognition that competence is not simply about the tasks that can be done, but also about the educational preparation and practice environment and how they shape enrolled nurse practice. This is reflected in the proposed changes to accommodate more flexible interpretations of supervision. Decision making about enrolled nurse practice is no longer the sole domain of the registered nurse, but requires consideration of a number of factors by both the enrolled and registered nurse. Whilst the registered nurse is accountable for delegation decisions, the enrolled nurse is accountable and responsible for his/her own practice and acceptance of delegated responsibilities. Although the enrolled nurse role has recently been affirmed as a core feature of contemporary health care delivery in Australia, this does not suggest that there is a role for enrolled nurses in all areas of health care service provision, or that the role should be expanded to enable working without the supervision of a registered nurse. However, it does indicate recognition that the composition of the Australian health workforce is evolving to meet the specific requirements of the Australian health care system. Issues related to enrolled nurse scope of practice, articulation between registered and enrolled nurse roles, and enrolled nurse educational preparation are far from resolved and require continued dialogue between the nursing profession, industrial and professional bodies, health service and educational providers and consumers to maximise the potential of enrolled nurses in the health workforce while ensuring quality standards of nursing care. References Allan I, McLafferty I 1999 Professional issues. The road to conversion for enrolled nurses: a literature review. British Journal of Nursing 8(6):356-60 Australian Institute of Health and Welfare 1999 Nursing labour force 1998. 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Australian Nursing Council Inc, Canberra Gonczi A, Hager P, Oliver L 1990 NOOSR research paper no 1: Establishing competency-based standards in the professions. AGPS, Canberra Miles M B, Huberman A M 1994 Qualitative data analysis: an expanded sourcebook. Sage, Thousand Oaks, CA Nurses Board of South Australia 1999 Personal communication Nurses Board of Tasmania 1997 Scope of nursing practice. Nursing Board of Tasmania, Sandy Bay, Tasmania Nursing Council of New Zealand 2000 The second level health worker of the future: a draft scope of practice and discussion paper to guide the development of program requirements. Nursing Council of New Zealand. Retrieved 16 October 2000 from the World Wide Web: http://www.nursingcouncil.org.nz/secondlevel.html N-Vivo 1.0 CDRom, Qualitative Solutions and Research Pty Ltd, April 1999, Bundurra Victoria Owen A 1995 Enrolled Nurses and the need for balance. Australian Nursing Journal 2(7):4 Owens J, Macarty M 1999 Enrolled Nurse practice in rural Australia. In: Education, training and support for Australian rural nurses. Association for Australian Rural Nurses Inc, Whyalla Pearson A, Hocking S, Mott S, Riggs A 1992 Skills mix in Australian nursing homes. Journal of Advanced Nursing 17:767-776 Percival E, Anderson M, Lawson D 1994 Assessing beginning level competencies: the first steps in continuing education. The Journal of Continuing Education 25(3): 139-142 Queensland Nursing Council 1998 Final report of the Scope of Nursing Practice Project: the development, refinement and validation of the Scope of Nursing Practice decision making framework, volumes 1 and 2. Queensland Nursing Council, Brisbane Sandelowski M 1995 Focus on qualitative methods. Qualitative analysis: what it is and how to begin. Research in Nursing and Health 18:371-375 26 Collegian Vol 10 No1 2003