Question

It is important that an enrolled nurse has the skills and knowledge they need to do their work.

a) List three formal qualifications or training options that a new enrolled nurse may need to be able to start work in the nursing sector

Answer 1

Nurses and other health workers seeking employment in primary health care and general practice

settings may present with a range of qualifications, professional experience and scopes of practice.

Ensuring that the right person is selected for a specific position requires an understanding of roles,

responsibilities and accountabilities. The purpose of this resource is to demystify the hierarchy of

nursing roles, and to clarify terminology relating to the various titles, in particular focusing on

information relevant to the primary health and general practice settings.

In July 2012, Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers

joined Australia’s national registration and accreditation scheme. As many of these health

professionals work in primary health settings, information about the role of these workers is also

included in this resource.

The resource is intended to be used by health professionals, clerical staff and others working with

nurses and Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers

in primary health care settings.

Using the resource

The resource kit is set out as a series of fact sheets which explain the status of each nurse

classification, explains their accountabilities and responsibilities, provides links to primary and other

sources of useful information, and includes scenarios which assist in illustrating how the various

professionals may work in the primary health and general practice setting. A similar fact sheet

illustrates the roles and responsibilities of Aboriginal and Torres Strait Islander Health Practitioners

and Aboriginal Health Workers.

A diagrammatic representation of the relationships and dependencies which exist between nursing

roles is displayed in Figure 2. It is suggested that this could be displayed in poster form for staff in

general practices to familiarise themselves with the information. A similar diagram(Figure 2) explains

how contexts of practice will define the accountabilities, responsibilities and working relationships

for, Aboriginal and Torres Strait Islander Health Practitioners.

A word of caution

The resource is intended to clarify in general terms, the roles, responsibilities and accountabilities of

nurses and Aboriginal and Torres Strait Islander Health Practitioners and Aboriginal Health Workers.

When considering what individual skill sets or scopes of practice may be required for a specific

position, it is vital to ensure that the latest information is obtained from the relevant professional

National Board. Professional standards and requirements are constantly being updated, and may

impact on which health professional best meets the needs of the employer.Definition of nursing

The International Council of Nursing definition of nursing states that:

Nursing encompasses autonomous and collaborative care of individuals of all ages, families, groups

and communities, sick or well and in all settings. Nursing includes the promotion of health,

prevention of illness, and the care of ill, disabled and dying people. Advocacy, promotion of a safe

environment, research, participation in shaping health policy and in patient and health systems

management, and education are also key nursing roles 1

Regulation of nursing

In Australia, the Nursing and Midwifery Board of Australia regulates the nursing workforce under the

Health Practitioner Regulation National Law (2009) [The National Law]2

. Nurses are classified as

either registered nurses (RNs) or enrolled nurses (ENs). In addition, midwives are registered

separately to nursing. Nurse practitioners (NPs) are registered nurses who have been endorsed. The

endorsement of registration identifies registered nurses (and midwives) with additional

qualifications and specific expertise which meet the requirements of the relevant registration

standard.

‘Nurse practitioners are registered nurses who have been endorsed. The endorsement of registration

identifies registered nurses (and midwives) with additional qualifications and specific expertise which

meet the requirements of the relevant registration standard’3

These are protected titles, and it is an offence for anyone to make another person believe they are

registered under the Act unless they are registered in the profession. This is known as ‘holding out’.

Nursing is also defined through a range of professional standards including separate competency

standards for the enrolled nurse, registered nurse and nurse practitioner, and the code of conduct

and code of ethics for nurses in Australia4

. Additionally, there are various guidelines which assist

nurses to practice safely, to identify their scopes of practice and to meet their continuing

professional development requirements.

Following the introduction of national registration in 2010, some previous state categories of

registration have been abolished, and potential employers should be aware that some nurses may

have notations on their registration which limit their practice to a specific specialty. Currently these

notations are: solely qualified in the area of mental health nursing; solely qualified in the area of

paediatric nursing, or solely qualified in the area of disability nursing.What is a registered nurse?

The registered nurse demonstrates competence in the provision of nursing care as specified

by registration requirements, National Board standards and codes, educational preparation,

relevant legislation and context of care (ANMC 2006)5

.

A registered nurse (RN) must have successfully completed an approved Bachelor degree (or, where

relevant, an approved post graduate qualification). The minimum duration of the course of study

must be equivalent to six semesters of full time study. A newly qualified (or ‘entry to practice’)

registered nurse is expected to be able to practise independently and to take responsibility and

accountability for the care they provide. They are also expected to take responsibility for the

delegation of care to enrolled nurses (ENs)and other health care workers. Delegation by the RN

includes taking into consideration the education, level of training and individual scope of practice of

the EN or other health care worker, and the context of care.

Registered nurses working in clinical settings are educated to assess, plan, implement and evaluate

nursing care provided to patients and clients across age, cultural and social spectrums. Their work

may be undertaken independently or more commonly in collaboration with individuals and the

multidisciplinary health care team in order to achieve goals and health outcomes.

An individual RN’s scope of practice is determined by a number of factors, such as their level of

education, seniority, time in a specific role or specialty, and individual competence levels. The scope

of practice of an individual RN is likely to be more specific that the scope of the profession.

The role of a registered nurse in primary health care and/or general practice

settings

‘Registered nurses in general practice have a responsibility to seek out and engage in

ongoing education and professional development to maintain the competencies that are

specific to nursing in general practice settings.’ (ANF 2005)6

Competency standards for nurses in general practice7

describe the specialist skills and attributes

which a nurse working in the general practice setting should be able to demonstrate after a

reasonable period of time working in the general practice setting. Many of these skills and attributes

are also relevant in primary health settings such as clinics and schools. Information provided by the

Australian Practice Nurses Association8

identifies that nurses working in primary health care and

general practice are likely to participate in:� health promotion

� illness prevention

� midwifery, antenatal and postnatal care

� treatment and care of sick people

� rehabilitation and palliation

� community development

� population and public health

� education, quality improvement and research

� policy development and advocacy

Whilst these roles are not specific to registered nurses, the RN will practice within his/her scope,

which is likely to include providing leadership within the relevant health care setting and delegating,

where appropriate, to others.

Specialist or generalist?

There is some debate about whether nurses working in primary health/general practice settings

should be considered ‘specialists’ or ‘generalists’ (ie. capable of providing a broad range of clinical

interventions). The Coalition of National Nursing Organisations define specialist practice as following

and building on a base of generalist practice and focussed…. ‘on a specific area of nursing. It is

directed towards a defined population or a defined activity and is reflective of depth of knowledge

and relevant skills’

9

. The debate may be of significance for employers seeking to employ an RN for a

specific role in a practice, such as diabetes education or immunisation. Position descriptions and

selection criteria should clearly articulate the requirements of the position.

Accountabilities

� An RN is accountable for the care and/or actions which he or she provides.

� An RN is accountable for the decision to delegate care to another health professional such as

an EN. However, the delegatee is responsible for accepting the delegation, and for the

actions they may take as a result of that delegation. (See Fact Sheet 3 – The Enrolled Nurse).

� RNs are accountable for making professional judgements about when an activity is beyond

their own capacity or scope of practice and for initiating consultation with, or referral to,

other members of the health care team

‘As regulated health professionals, RNs are responsible and accountable for their own

practice, and as such are not ‘supervised’ nor do they provide care ‘for and on behalf of’ any

other health care professional. [In the general practice setting] nurses provide care in

collaboration with general practitioners and other health care providers, focusing on

positive outcomes for all peopleScenarios/examples

There is no such thing as a ‘typical’ RN working in the primary health or general practice setting, but

the following indicates innovative roles for RNs:

1. The Murrumbidgee Medicare Local has employed a Parkinson’s Disease Nurse who works

alongside staff in the Murrumbidgee Local Health District in NSW in delivering a Parkinson’s Disease

Clinic as well as supporting people in the community with Parkinson’s disease and their carers.11.

2. A practice nurse with an interest in chronic disease management can contribute to the care of

patients in the practice by:

� Assessing patients’ health needs and ability to manage self­care

� Collect data and map patients’ current care and status

� Prepare care plans in consultation with the GP and patient, and arrange new referrals as

required

� Collaborating with the GP and with other health professionals involved in the patients' care,

collecting and collating information from referral appointments and incorporating

information into patients' care/review care plan

� Reassessing and/or reviewing the patients to measure outcomes, offering support including

CDM, and presenting reports to the GP

� Asthma care: monitoring, education, health maintenance and planning

� Diabetes care: monitoring, education, health maintenance, and planning

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