Debunking the myth of unsafe enrolled nurse practice: the myth of public safety issues around enrolled nurse practice persists while the profession ignores issues of genuine concern.

Why does the myth of unsafe enrolled nurse (EN) practice persist? Why do so many senior nurses allude to this myth? It may be because they genuinely believe it, or have heard it cited so often they have come to accept it as fact. Or it may be part of a concerted effort to remove the second-level nurse from the regulated nursing workforce. Without these supposed EN safety issues, there is no legitimate basis for their removal.

NZNO's complaint against the Nursing Council's decision on the title for second-level nurses trained after 2000 was heard by Parliament's Regulations Review Committee (RRC) last month. (1) At the hearing, Nursing Council chief executive Marion Clark alluded to public safety "problems and issues raised, and the Burton case was a key one" (2) around EN practice. This was the investigation by the Health and Disability Commissioner (HDC), Ron Paterson, into the care Mark Burton received from Southland District Health Board (DHB) before he was discharged, against his family's wishes, and subsequently killed his mother. (2) NZNO rebutted Clark's claim by stating that "even a reasonably superficial examination of the facts (of this and other HDC cases) would show the primary problem was not with the practice of enrolled nurses." (2)

The continuation of the myth of unsafe EN practice prompted me to explore the HDC's website. I reviewed all the HDC cases from 1996-2007 classified as involving "nurse" or "nurses" There are 18 investigations under this classification. These have led to findings of 52 breaches involving 39 registered nurses (RNs) working as staff nurses, district nurses, practice nurses, charge nurses, nurse managers etc. (3) No EN has been found in breach of the Code of Health and Disability Rights (the Code), although ENs were investigated in the course of two investigations. Not yet lodged on the HDC website is the recently reported Capital and Coast DHB Case where one of two nurses found in breach was an EN. This works out at around four RNs per annum or a rate of 1:1000, an acceptably low rate giving no concern for a fundamental problem with the safety of RNs. Let's compare this with ENs. If ENs breached the Code at the same rate as RNs, given the EN workforce is around one tenth that of RNs, we would expect one breach every two or three years, or three to five to date. The EN rate is therefore even less than that of RNs. Where is the public safety problem requiring change in scope and title? Where is the argument for removal from acute settings?

The HDC investigation into the Southland case found the EN concerned did not breach the Code. In fact, expert advice given to the HDC was that the EN involved "provided sound care within her level of training and qualification". (2) But the HDC investigation did find a number of deficiencies within the nursing profession. (2) Rather than focusing on those failings, an enormous amount of time and energy has been focused on ENs as if EN practice explained the nursing failures.

The truth is we have failed to act on the real issues and scapegoated ENs. It is time we dealt with the real issues. They are outlined in 11 of the 51 recommendations made by the HDC to Southland DHB. (2) From these recommendations we must ask ourselves:

* What steps will we take to ensure nursing services are under the direction and authority of nurses, so the public can be assured that nursing standards of practice, including professional development and clinical audit, are maintained?

* What will we do to ensure individual nurses are supported in making fundamental decisions about their professional practice?

* Does the current education of RNs adequately prepare them to practise in mental health?

* How will the profession ensure there are sufficient experienced and skilled mental health nurses willing to work in mental health?

* How will we ensure we will not continue to fail practitioners by leaving ENs to practise without adequate professional support?

Some of these questions have been addressed by the recommendations of the NZNO/DHBs' Safe Staffing and Healthy Workplaces Committee of Inquiry. Otherwise, all we have seen to date is a denial of responsibility by our profession.

'Must do better'

We must do much better than the 2003 letter to DHBs from the Ministry of Health and Nursing Council advising that ENs should not work in acute mental health units and to review their employment in other acute areas. That letter created endless confusion and many ENs were removed from acute settings because of it. NZNO sought clarification on the role of ENs in acute care but this just led to further confusion. (4) We now have a situation where the role of ENs in acute care remains unclear; where the myth of unsafe EN practice is publicly perpetuated; where there is disagreement over the title for the second-level nurse; and the real deficiencies, as highlighted in the HDC report, are ignored. I am determined NZNO will take a lead in addressing deficiencies identified in the HDC report. We must come up with answers to the questions posed by the HDC. And, in so doing, ensure the public's respect for and trust in our profession continues to be justified.

References

(1) NZNO's complaint against Nursing Council heard. Kai Tiaki Nursing New Zealand; 13: 4, 8. Welington: NZNO.

(2) Regulations Review Committee. (2007) Transcript of the Complaint regarding Notice of Scopes of Practice and Related Qualifications prescribed by the Nursing Council of New Zealand. Wellington: Regulations Review Committee.

(3) Southland District Health Mental Health Services Feb-March 2001. A report by the Health and Disability Commissioner. http://www.hdc.org.nz/files/hds/publications/other_southlandreport. Retrieved 05/ 05/07.

(4)The Office of the Health and Disability Commissioner. http://www.hdc.org.nz/complaints/opinions/occupations Retrieved 05/05/07.

(5) Ministry and Council fail to agree on ENs. Kai Tiaki Nursing New Zealand; 13: 1, 7. Wellington: NZNO.

By NZNO chief executive Geoff Annals