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Clarity needed on regulatory issues: while the profession debates regulatory issues, the unregulated health workforce continues to expand.

The Health Practitioners Competence Assurance (HPCA) Act was passed in 2003 and enacted in 2004. Its principle purpose is to protect the public by providing mechanisms to ensure health professional are competent to practise. (1)

As a result of the Act, regulatory authorities had to develop scopes of practice and competence requirements for practitioners. The Nursing Council developed four scopes of practice, with the enrolled nurse (EN) scope undergoing the most significant change. Three years on, confusion over scopes of practice stiff reigns.

Confusion also reigns over the employment of ENs in acute settings. The February 2007 issue of Kai Tiaki Nursing New Zealand reported on the confusion created when two different letters regarding ENs' employment in acute settings were released to directors of nursing. (2)

In the March issue of Kai Tiaki New Zealand, the chief executive of the Nursing Council, Marion Clark, responded to the February story, stating the Council strongly supported a fully regulated workforce, was actively promulgating a second-level workforce and shared NZNO's concerns about the expanding unregulated workforce. (3)

Confusion and inconsistency

Nurses' scopes of practice were gazetted in September 2004. Enrolled nurses and nurse assistants (NAs) have two different scopes of practice but the same competency requirements. This is confusing and inconsistent, as nurse practitioners and registered nurses (RN) have two different scopes of practice and different competencies.

In a Nursing Council letter to directors of nursing in January, (4) the Council refers to its document Guidelines on Direction and Supervision. On the Nursing Council website, the only paper I found relating to direction and supervision was dated December 1999. (5) While the primary content of this paper may still be relevant, it was written when the Nurses Act, 1977, was in force and thus does not reflect current legislation.

The direction and supervision document creates further confusion by referring to ENs' old scope of practice which states: "Enrolled nurses practise nursing under the direction and supervision of a registered nurse or midwife to implement nursing for people who have relatively (my highlighting) stable and predictable health outcomes, to maintain and safeguard comfort and dignity, and to promote health and safety." (5)

The new scope of practice, introduced following the enactment of the HPCA Act, omits the word relatively. The current EN scope of practice is narrower than the NA scope of practice.

Since September 2004, no nurse can be registered under the EN scope of practice. Thus ENs from overseas must be registered under the NA scope of practice. These ENs are individually assessed for registration and may have conditions placed on their practice, or they may be assessed as able to practise in all settings, including acute areas. I know of one district health board which is considering whether to transfer its ENs to the NA scope of practice, with no conditions on their practice, as a way of maintaining them in the workforce and ensuring greater flexibility in the use of ENs in the workforce. The DHB is prepared to support ENs in any way to ensure they remain in the workforce. As the profession debates these regulatory issues, high acuity patients are being nursed in their own homes and in some hospitals by unregulated caregivers. In the aged-care sector, patients also have complex needs. In many cases, these patients are also being cared for by unregulated caregivers who have very little education or training. In some instances, NAs working in rest-homes are being managed by unregulated staff because there is not an RN on duty at all the times. From an employer's perspective, unregulated caregivers may be easier to employ than ENs or NAs, because the employer, rather than the Nursing Council, determines the unregulated caregivers' scope of practice and the tasks they can perform.

Unregulated caregivers are also concerned about the complexity of tasks they undertake and the difficult decisions they are required to make. NZNO is receiving an increasing number of calls from employers seeking legal clarification on what caregivers can do, and from caregivers who do not want to act on their employers' instructions because of the complexity of the care they are expected to undertake and for which they do not have the appropriate knowledge. There have been a number of Health and Disability Commissioner and Coroners' cases highlighting these issues.

Registered nurses are accountable for their own practice and for the practice of ENs and NAs. Working with an unregulated caregiver, the RN carries even more responsibility. With increasing public scrutiny of health professionals, nurses are starting to question this situation. In some aged-care sites, one RN may oversee as many as 60 patients. The safe staffing unit being established within District Health Board New Zealand is very timely but what protections and support exist for the rest of the health sector?

With the international shortage of nurses and an aging workforce, the nursing profession here needs to make some decisions on regulation of the workforce quickly. While the profession continues the debate and seeks clarification on regulation, more unregulated workers are being employed. The question for the profession is: are we acting in patients' best interests by allowing a burgeoning unregulated workforce? If there is a genuine desire for a fully regulated workforce, then the nursing profession must work together to achieve clarity and consensus on regulation for the benefit of the nursing workforce, those cared for and the public.


(1) Health Practitioners Competence Assurance Act 2003. Wellington: The New Zealand Government.

(2) Ministry and Council fail to agree on ENs. Kai Tiaki Nursing New Zealand; 13: 1, p7. Wellington: NZNO.

(3) Nursing Council wants fully regulated nursing workforce. Kai Tiaki Nursing New Zealand; 13: 2, p7. Wellington: NZNO.

(4) Clark, M. (2007) Employment of enrolled nurses within acute settings. Letter to directors of nursing, January 29, 2007. Wellington: Nursing Council.

(5) Nursing Council of New Zealand. Direction and Supervision. Retrieved 30/4/07.

By professional nursing adviser Margaret Cain
COPYRIGHT 2007 New Zealand Nurses' Organisation
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Author:Cain, Margaret
Publication:Kai Tiaki: Nursing New Zealand
Date:May 1, 2007
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