NZNO writes to DHBs in support of enrolled nurses.

NZNO CHIEF executive Geoff Annals has written to all district health board (DHB) chief executives outlining a process to ensure enrolled nurses (ENs) practise safely within their scope of practice.

His letter is in response to the letter to DHBs from Director-General of Health Karen Poutasi and Nursing Council chief executive Marion Clark on DHBs' employment responsibilities in relation to ENs. (See Kai Tiaki Nursing New Zealand, September 2003, p9.) The letter stated ENs' scope of practice "significantly restricts the number of acute settings in which ENs are competent to practise". The ministry letter arose from the Health and Disability Commissioner Ron Paterson's inquiry into Southland DHB's mental health services. The inquiry looked at the quality of care Mark Burton received.

Annals' letter challenges the ministry views and states the issue of safety can only be determined in relation to specific situations and nurses, not through "bureacratic, blanket categorisation of workplace setting and nursing class". The process to determine what is safe and lawful practice for ENs was a matter of considered professional assessment, "not crude application of a formula", Annals said.

Considered professional assessment must assess four conditions: the knowledge, skill and experience of the EN; the knowledge, skill and experience of the registered nurse (RN) providing direction and supervision; the nursing care needs of the patients/clients, ie they have relatively stable and predictable health outcomes; and the setting in which care is delivered.

Only such professional assessment could determine whether EN practice was appropriate in any particular specialty, work type or setting. "So long as all the conditions of practice are met, EN practice may be safe and lawful in any specialty, work type or location," Annals' letter said.

Employers could expect nurses to act professionally and should not replace that professional autonomy with general guidelines, as suggested by the ministry. "Any attempt to apply guidelines for EN practice without a thorough consideration of the relevant factors by the nurses charged with the responsibility to make the professional assessment required, is likely to restrict patient access to appropriate care." It was also likely to create dissatisfaction among nurses who were prevented from exercising their professional responsibilities.

Professional evaluation

The "bureaucratic guidelines approach" suggested employers could obtain a list of activities ENs could undertake and suggested ENs could not work in acute settings. This was not so. "The activities ENs may undertake must be evaluated professionally and will vary according to relevant conditions. And the settings of EN practice will vary according to the relevant conditions and many ENs practise safely and appropriately in a range of acute settings, including operating theatres and acute medical wards," Annals said.

There were no generally applicable specific limits to the practice of ENs acting under appropriate direction and supervision.

Annals suggested DHBs review their nursing practice policies to ensure those policies were not imposing unnecessary restrictions on EN practice.

NZNO has received backing from Mark Burton's father Trevor in its support of ENs. In a letter to NZNO, he said while the report on his son's care in Southland was extremely critical of many health professionals, it did not criticise ENs. "The Burton tragedy was the result of individuals failing to perform to even minimum standards and it seems to me that the 'profession of enrolled nursing' emerged from the inquiry with reputation unblemished.

"There will doubtless be some ENs who should not be working with seriously ill psychiatric patients, the same as there will be some RNs and even doctors in that same category. However, a wholesale ban is ... an overeaction," Burton's letter said.

It was more a matter of needing clear job descriptions, each staff member fully understanding their responsibility and staff responsibilities being consistent with each individual's training. That had to be reinforced by adequate supervision, as well as providing checks and balances to ensure work was being performed properly.

Annals said Burton's support meant a great deal, as nurses judged their own worth on their value in patients' and families' eyes.

Meanwhile, a letter to ENs from national EN committee chair Robyn Hewlett and professional nursing adviser Faith Roberts encourages them to join their local EN section as now was a "tough time" for ENs. The letter includes a card with a list of issues and asks ENs to tick those they support. One issue is Nursing Council's policy that RNs sign off ENs' competencies, rather than ENs submitting portfolios for competence-based annual practising certificates. NZNO opposes this policy. These cards will be presented to Nursing Council.