What enrolled nurses can or cannot do should be guided by the scope of practice, not manager preference, cost or risk aversion, says a Canadian nurse leader.

Dianne Martin, chief executive officer of the Registered Practical Nurses Association of Ontario, has been studying the enrolled nurse (EN)/practical nurse (PN) and equivalent roles in six countries around the world and shared her findings to date at this year’s Enrolled Nurse Section conference.

One of her key findings was that while the registered nurse (RN) scope was diverse around the world the EN/PN scope was “wildly” diverse internationally, including qualifications ranging from six months to three years. Most of the controversial negative research about second level nursing scopes had historically come from the United States, where the PN scope was actually very similar to the healthcare assistant role, and where RN training programmes can range from two years to four years.

Martin, who holds registration as both an RPN and RN in her home province of Ontario, says one of the common themes around the world was that there was universal and longstanding confusion over the second level scope. But this confusion was less in countries where there were strong accredited training programmes and where the nursing scopes were educated early on about each other’s roles.

“Two countries did it best – New Zealand and Australia – which are head and shoulders above the rest of world in knowledge and understanding of each other’s role/scope,” says Martin. “You see yourselves as one profession. I wish I could say that was true globally.”

Enrolled nurses at the conference were proud of the praise but also agreed with Enrolled Nurse Section Chair Leonie Metcalfe that work still needed to be done to change some of the attitudes and myths in Kiwi nursing leadership about what role ENs can play in nursing models of care.

“It is easy to say enrolled nurses can’t and it is harder for them to say enrolled nurses can,” says Metcalfe.

Reasons in common

Martin says after looking at EN/PN roles in three states in the USA, New Zealand, Australia, Finland, Belgium and England she found the common reasons for boosting or reintroducing the role were shortages of RNs, increasing costs and the increasing needs of the ageing population.

Her study led to a number of recommendations including that organisations should use the EN scope of practice to guide decision-making on the role and not rigid in-house policies, manager’s preferences or cost.

“Cost is going to be a driver in health care for everything but do not let cost change your scope of practice,” advises Martin. Nor should ENs be used to address an RN shortage unless it was appropriate for an EN to take on the role, she says. Decisions should also be based on risk management not risk aversion, and not on the belief that having an RN at every bedside “will somehow create this great care”.

The conference was told that there had only been 1,052 new EN graduates in New Zealand since re-training enrolled nurses began early in the millennium – not enough to replace ENs retiring in the ageing workforce. The current 18-month diploma was not launched until 2011, by which time EN numbers had fallen to around 3,000 and have continued to fall and by 2017 were down to 2,648.

Backlash a challenge

Martin says in Ontario the RPN workforce was actually increasing, was a very young workforce, and was facing a backlash from the ageing and not-growing RN workforce who saw RPNs as taking their jobs.

“And the biggest problem we have in Ontario is that we have an RN group who are not only not working to full scope of practice, in my opinion, they don’t know what their full scope of practice is. So they end up bunching up in the middle with the RPNs.”

She says Ontario RNs with a four-year degree should be developing care plans for the sickest, most unpredictable patients to develop a safety net for that patient – “You are not going to just take the vitals, write them down and hope the doctor will see them and react to them… you are going to make high-level, difficult, complex decisions every day” – while the RPN/EN is going to be working with patients with more predictable outcomes and who are moving along an expected path of care.

“And they are going to do it equally well but just with a different group of patients.”

Martin says her research is continuing this year, when she plans to work with some of England’s first nursing associate graduates (their EN equivalent) and alongside PNs in Finland, where they greatly outnumber their RN equivalents.


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