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Are enrolled nurses finally on the comeback trail? Is enrolled nurses' day in the sun about to arrive?


Enrolled nurses (ENs) are a dogged bunch. Despite a recent history that has seen their training stopped, then reinstated at a lowlier level, local policies which excluded them from acute areas, no unified support from the profession, their roles frequently usurped by unregulated health care assistants (HCAs) and employment problems, they have survived. And they may now be beginning to stake a more permanent claim in the nursing workforce landscape.

After a long NZNO-led campaign, the recommendation by the Ministry of Health-convened nursing advisory committee in 2008 that second-level regulated nurses were the key second-level clinical support for registered nurses (RNs) was a turning point. The subsequent introduction of an extended scope of practice, an 18-month diploma at level five on the New Zealand Qualifications framework and a competency framework, provided the springboard for an expansion of the EN workforce. Is that expansion real or a chimera?

Despite Ministerial support for Ens--at the beginning of his first term Tony Ryall proclaimed ENs would play a greater role in the health workforce--Health Workforce New Zealand (HWNZ) has no national nursing workforce plan to cement the place of the second-level nurse in the nursing workforce. The Minister did not respond to Kai Tiaki Nursing New Zealand's questions about the lack of a strategic plan for or whether it should be an HWNZ priority. But he said as the number of trained ENs grew, "these nurses will be a key part of the future delivery of health services, alongside registered nurses and nurse practitioners. The big challenge currently is the much lower turnover rates in the nursing workforce."

The Ministry of Health, with input from NZNO, is putting the final touches on an EN fact sheet which will make plain to DHB and aged-care employers the extended scope of practice and how ENs can contribute to the health care team. NZNO's associate professional services manager Hilary Graham-Smith says there's very good work underway in the ministry to support the EN workforce.

Some directors of nursing (DoNs) are fulsome in their support; others lukewarm. A workshop on employment at the 2012 NZNO EN section conference revealed a range of DHB practices: some are employing into acute care, others aren't; some have development pathways for ENs, some have no professional support structures; some aren't employing ENs at all, while others are replacing them with HCAs. A paper to NZNO's board of directors last year said NZNO's 2011 employment survey revealed an EN workforce becoming increasingly demoralised with the lack of any plan for implementation of the new scope of practice. The paper contained a raft of recommendations on how to ensure the most effective use of ENs, including a national workforce plan, using ENs to their full extent of their scope in all practice areas, and funding and professional support.

A shift in attitude

Graham-Smith says there's been a big shift in attitudes towards ENs since the paper was written. "It's probably due to a range of reasons but it's fantastic that it's happening."

The education institutes offering the diploma are, unsurprisingly, confident about its robustness and the role of ENs in the future workforce.

In August, 2858 ENs held current practising certificates and 2108 had transitioned to the new scope. Graduates from the first diploma courses are now in the workforce. A survey conducted by Nurse Educators in the Tertiary Sector in July showed the employment rate of diploma graduates was 56 per cent, comparable to the 57 per cent DHB employment rate for graduates looking for jobs next year.

Executive DoN at Canterbury District Health Board (CDHB) Mary Gordon has been a long-time champion of ENs. Her support is predicated on ENs' training and regulation, both planks of nursing professionalism, and the stability of the EN workforce. There's a pragmatic reason too. "Looking to the future, there's certainly going to be a nursing workforce issue. If an all-RN workforce is not sustainable, who is going to provide the second-level? If I have a choice between a non-regulated vs a regulated and trained workforce, from a risk management perspective, I'm going to go the regulated way."

More than a decade ago the DHB made its support for ENs clear. "That support continues. We have kickbacks from time to time, with some charge nurses stating they won't have ENs in their wards, but you work with that," Gordon said. She is clear ENs are not "mini RNs" but a distinct workforce group. She's also clear that taking observations and monitoring patients are nursing responsibilities, not HCA ones.

The CDHB has changed all its policies to align with the extended scope of EN practice. "In the long term, if we are pushing RNs to the edge of their scope, then something has to be taken away. I'd prefer to give those responsibilities to a workforce that has a prescribed nursing training and understands the philosophy of nursing. And the change of scope means they can work in multi-disciplinary teams."

She believes it would be useful to have a national nursing workforce plan. "There's no one answer, but the key for me is how to ensure a sustainable workforce."

With 360 ENs at the DHB and few aged under 50, it is going to be a slow process replacing the current cohort. Gordon says there've been no new ENs for some years now. "Our benchmark is experienced ENs and we can't expect new ENs to have 30 years' experience from day one."

Nurse Maude DoN Sheree East has employed five graduates from the first diploma to a new aged-care service providing intensive home-based support to people who fit the criteria for hospital-level care. "We needed a high skill mix for the service. These people are receiving hospital-level care so need an educated, regulated, qualified workforce caring for them. That's why we decided to employ the ENs."

Boundares around nursing work clear

The service, Total Care, was established in the wake of the February 2011 earthquake which saw Christchurch lose 600 aged-care beds. There are now two teams operating, each with RNs, ENs and HCAs. 'The boundaries are very clear between nursing work and that of the HCAs. It's working very well. I'm very happy with the skill mix and there is very good outcome data," East said.

Counties Manukau DHB (CMDHB) DoN Denise Kivell is another EN advocate. She is confident of ENs' place in the future nursing workforce. Planning for the next financial year includes looking at the make up of the health care team. "We definitely support the education programme and the role. We have 86 ENs employed at CMDHB and have employed graduates from the diploma course, including into mental health and maternity. The others are spread throughout the DHB."

Auckland DHB employs 66 ENs, of whom 75 per cent have transitioned to the new scope. Executive DoN Margaret Dotchin said the ENs were "valued members of our health care team". The board supports EN students with clinical placements but has not employed any diploma graduates. "The current level of nursing turnover is generally lower than in previous years so there are limited opportunities at this point in time for newly qualified ENs to secure employment. The board's policies do not preclude the employment of ENs to appropriate clinical areas."

The board would continue to examine the skill mix required to care for different populations and patient groups. "ADHB believes ENs are a valuable asset to the health workforce," she said.

Educators are upbeat about the diploma and the employment rates of graduates. Programme leader at Southern Institute of Technology Lucy Prinsloo said the first cohort finished in July 2012, with 25 of the 26 graduates securing work, 14 in Southland. Four have got work in Australia, two in Christchurch and three in Dunedin. "It is very heartening. Once a few ENs are working in acute care, there'll be a snowball effect. People will realise what they can do and the demand for ENs will increase," Prinsloo said. The Southern DHB supported ENs.

She believes the diploma provides a very solid foundation for second-level nursing. "Working under the direction and delegation of RNs and in the extended scope of practice means they do a lot more and take a significant burden off RNs," she said. Twenty-one EN students began SIT's second diploma course in October, with many more applicants than places.

Of the 14 students who completed the first diploma through the Universal College of Learning's (UCOL) Whanganui campus in August, nine have jobs with a range of providers and five are still looking for work. Programme leader Lesley Bayliss said she'd been concerned about how many would get positions but is encouraged by the figures. The second cohort of students started at the end of September. Originally an EN, Bayliss is delighted to witness an EN comeback. "I've travelled the EN, RN, masters path and really believe there is a need for a regulated, second-level nurse."

Forty students will begin the EN diploma at Christchurch Polytechnic Institute of Technology (CPIT) in March 2013. Applications had not closed and numbers had exceeded 40, according to academic manager Lisa McKay. "This reinforces ENs as a valid choice for the health sector."

Of the 19 who graduated from the first diploma in July 2012, 14 had jobs and the other five were not looking for EN work. "We're very pleased. ENs are extremely well supported across the DHB."

The diploma entitles CPIT bachelor of nursing students to six months off the degree.

Interest in Manukau Institute of Technology's (MIT) diploma is "excessive", according to programme leader Sandra Wilkinson. "We had an awful lot of applications for the second programme which began in July and the level of continuing interest is high. We'd love to be able to respond to that need but we can't because of future employment. Two schools up here are offering the programme [the other is UNITEC] and it's hard for us, as some DHBs don't employ ENs."

MIT has an agreement with stakeholders that it will only accept as many students as there are clinical placements for. That has meant 22 students in the July intake.

"There are always challenges and each region will be different. But there is certainly more awareness of how ENs can be used now. We value having the programme and don't want to flood the market. It's a balancing act. If graduates can't get employment, they can't keep their practising certificates," Wilkinson said.

Long-time EN campaigner Robyn Hewlett is feeling more hopeful. "The employment figures for diploma graduates are better than I thought they would be. There's been no mass exodus to Australia. I'm pleased to hear some are being employed into acute areas and mental health."

Acknowledging the employment environment is difficult across the health sector right now, Hewlett is confident the predicted nursing shortage, expected within a matter of years, will boost ENs' prospects.

Another committed EN supporter, NZNO professional nursing adviser Suzanne Rolls, says change at policy level can take some time to influence change at practice level. But she believes that shift is now happening. "We are pleased to see some changes in attitudes to EN employment, but we want more and we won't be dropping our focus on it."

The extended EN scope is still bedding in, the EN diploma is still in its infancy and the health sector is currently cash strapped. Against that background, EN graduates' employment rates are comparable to that of 2012 new RN graduates. With the continued support of influential DoNs, the diploma proving a robust qualification, graduates proving sound second-level nurses, ongoing work at the ministry, employers realising the potential of ENs, and the predicted nursing shortage, the expansion of the EN workforce may, indeed, prove to be real and long lasting.

By co-editor Teresa O'Connor

Puawai Thompson, an NZNO delegate in the plastics department at Hutt Hospital, takes Shirley Webb's temperature. Thompson has transitioned to the extended scope of practice and is one of three ENs in the department.
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Title Annotation:NEWS FOCUS
Author:O'Connor, Teresa
Publication:Kai Tiaki: Nursing New Zealand
Geographic Code:8NEWZ
Date:Dec 1, 2012
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