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Enrolled Nurse Education

• 1. Introduction
  • 1.1 Background
  • 1.2 The Enrolled Nurse
  • 1.3 Education of Enrolled Nurses
  • 1.4 Scope of practice and education issues
  • 1.5 The Enrolled Nurse workforce
  • 1.6 International models for second level nurse education
  • 1.7 Structure of this report

1 Introduction

1.1 Background

This report contains information on the education of Enrolled Nurses in Australia. The Monash University-ACER Centre for the Economics of Education and Training (CEET) was commissioned by the Department of Education, Training and Youth Affairs (DETYA) on behalf of the National Review of Nursing Education under the Evaluations and Investigation Programme (EIP) to produce this report. The purpose of the project is to provide research support for the National Review of Nursing Education.

This study examines the current arrangements for the education and training of Enrolled Nurses in Australia including programs offered by both public and private providers. It focuses on variation among the eight States and Territories. The recent introduction of traineeships for Enrolled Nursing is also examined. Additionally, this study reviews education pathways for Enrolled Nurses, articulation arrangements between Enrolled Nurse and Registered Nurse education programs, costs involved in the delivery of Enrolled Nurse education, and legislation impacting on educational delivery.

This chapter provides the context of the study. It discusses the role of the Enrolled Nurse, the evolution of the education and training of Enrolled Nurses and changes in the position of Enrolled Nurses within the nursing workforce. The ability of Enrolled Nurses to administer medication is identified as an important source of differences in Enrolled Nurse education between the States and Territories. The chapter also provides some international perspective through a discussion of recent changes in the education of similar occupations in Britain and New Zealand and a discussion of similar occupations in the United States. It concludes with a discussion of the structure of the report.

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1.2 The Enrolled Nurse

Australian States and Territories recognise two broad levels of nurse. These are known as Registered Nurse and Enrolled Nurse in all States and Territories, except Victoria. In Victoria, the 'Registered Nurse' is referred to as 'Registered Nurse, Division One', and the 'Enrolled Nurse', as 'Registered Nurse, Division Two'. The more widely used nomenclature of Registered Nurse and Enrolled Nurse will be used in this report.

According to the Royal College of Nursing, Australia, Enrolled Nurses deliver 'nursing care that is complementary to that delivered by registered nurses' (Royal College of Nursing, Australia 2000). Enrolled Nurses work primarily under the supervision and direction of Registered Nurses. The nurse registration authorities of the individual States and Territories regulate the practice of enrolled nurses through educational compliance mechanisms and regulatory standards. Additionally, the Australian Nursing Council Incorporated has developed standards for practice in its National Competency Standards for the Enrolled Nurse (ANCI 1990). The Council is currently conducting a study of the role and function of Enrolled Nurses that includes possible revision of these standards (ANCI 2000).

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1.3 Education of Enrolled Nurses

Traditionally, the education of Enrolled Nurses had been the responsibility of hospitals that offered training programs accredited by nurse registration authorities. The education of Enrolled Nurses gradually transferred to the Vocational Education and Training (VET) sector during the 1990s. The VET sector consists principally of government-funded Technical and Further Education (TAFE) institutes, although it includes some other organisations registered as training providers. At the time of the 1994 national review of nurse education, only Western Australia offered enrolled nurse education solely within the VET sector. Queensland and South Australia had some involvement of VET in the education of Enrolled Nurses. The education of Enrolled Nurses in Victoria remained hospital-based despite a recommendation by the Nursing Policy and Planning Unit of the Health Department of Victoria that it be transferred into the VET sector (Health Department Victoria 1991). In 1994 there was no Enrolled Nurse education offered in Tasmania, the Northern Territory or the Australian Capital Territory (Commonwealth of Australia 1994). By 1995, VET-based education for Enrolled Nursing became available in Victoria (Dunn, 1998) but this education has only been offered in Tasmania and the ACT since 1999 and 1997 respectively.

A report to the Federal Parliament in 1998 highlighted the variation in educational preparation of enrolled nurses. The report recommended changes that would lead to greater uniformity in the preparation of Enrolled Nurses across Australia (Commonwealth of Australia 1998).

Table 1.1 Course Enrolments in Enrolled Nurse Courses by State and Territory 1994-2000

Source: Unpublished data supplied by NCVER.

Note: Courses defined by ASCO code 341 1997-2000 and code 6603-11 before 1997.

Table 1.2 Course Commencements in Enrolled Nurse Courses by State and Territory 1997-2000

Source: Unpublished data supplied by NCVER.

Note: Courses defined by ASCO code 341.

Table 1.1 shows enrolments in Enrolled Nurse courses in the VET sector from 1994 to 2000. Much of the apparent increase in enrolments during this period has resulted from the transfer of Enrolled Nurse courses from hospitals to TAFE courses. For instance, enrolments in Victoria and Queensland are only included from 1997. More recently, coverage of VET enrolments was expanded to include private training providers. This expansion should have resulted in the inclusion of enrolments in private providers of Enrolled Nurse education in Victoria and Tasmania and a further apparent increase in enrolments.

Regardless, it seems that in recent years enrolments in Enrolled Nurse courses have increased substantially in New South Wales, Queensland and Western Australia. Given the relative population sizes of the States and Territories, Victoria appears to have higher rates of enrolment than other States.

Table 1.1 shows no enrolments in Tasmania and the Northern Territory for Enrolled Nurse courses. There is a problem with using the occupation code for Enrolled Nurses to identify Enrolled Nurse courses in the VET data collection (as was done in Table 1.1) because several courses offering Enrolled Nurse education in Tasmania and the Northern Territory are included in the present study. These courses have clearly not been allocated the appropriate occupation code. Indeed the data on which Table 1.1 is based include some students in non-award and Certificate III courses - courses that are clearly not Enrolled Nurse courses. Hence the values in Tables 1.1, 1.2 and 6.1 should be treated as indicative at best.

Enrolment numbers in time series can be misleading. Students can be counted in two or three years if the course exceeds 12 months or the student is enrolled part-time. Hence comparisons between States and Territories or over time may be confounded by differences among the States and Territories or changes over time in the duration of courses, in the mix of full and part time students and in the commencement dates of courses.

Table 1.2 shows commencements in Enrolled Nurse courses for 1997 to 2000 by State and Territory (earlier data are not available). Again commencements appear to have increased in recent years, particularly between 1998 and 1999. Indeed commencements in the years 1999 and 2000 increased by 25 per cent compared with the years 1997 and 1998. Much of this growth is due to the rapid increase in commencements in New South Wales. The absence of any commencements in Tasmania and the Northern Territory appears to be a problem with the data.

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1.4 Scope of practice and education issues

The scope of practice of Enrolled Nurses varies substantially between States and Territories. The major differences relate to the administration of medication. Each State and Territory has its own regulations governing the type of medication Enrolled Nurses are allowed to administer. These differences in turn influence the educational preparation for Enrolled Nurses.

Table 1.3 summarises the various practices for the administration of medication. In some States and Territories Enrolled Nurses give no medications, while in others the regulations are more liberal. The different practices effect the amount of pharmacology required by Enrolled Nurse course in the different jurisdictions. Such differences among courses then raise questions about the adequacy of the preparation of Enrolled Nurses if graduates move between States and Territories.

The legislation in South Australia is unclear about the permissible levels of administration of medicines by Enrolled Nurses. According to the Nurses Board of South Australia, the legislation has been interpreted to mean that Enrolled Nurses are able to administer all medications. The Enrolled Nurse, however, must be under the direct supervision of a Registered Nurse when administering Schedule eight medications.

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1.5 The Enrolled Nurse workforce

Analyses of the ABS Labour Force Surveys show there were 22 500 Enrolled Nurses employed in 2001 (Shah & Burke 2001, Table 1). Enrolled Nurses were 9.1 per cent of the 248 500 persons in nursing occupations (Directors of nursing, Nursing professionals, Enrolled nurses and Personal Care or Nursing Assistants) and 0.2 per cent of all employed persons.

Table 1.3 Enrolled Nurses and medication administration

Table 1.4 Employment of Nursing Workers and Enrolled Nurses and Change in Employment of Enrolled Nursing Workers by State and Territory, 1987-01

Original source: ABS Labour Force, adapted from Shah & Burke (2001)

Enrolled Nurses as a percentage of the total nursing workforce vary substantially across States. Table 1.4 shows that Enrolled Nurses are a higher percentage of the nursing workforce in South Australia, Queensland and Western Australia than in the other States.

In absolute terms, the number of Enrolled Nurses in employment has declined by 20.6 per cent in the period 1987-01 (or by 36.8 per cent from the peak employment level of 35 600 in 1989). Given the overall increase in employment of nursing workers during this period, Enrolled Nurses have also declined as a percentage of total nursing employment. Based on these trends, employment of Enrolled Nurses is projected to decline further to the year 2006.

Part of the decline in the early 1990s has been due to the significant restructuring of the nursing workforce in that period (AIHW 2001) The further decline in numbers during the late 1990s suggests that some degree of restructuring is continuing. Table 1.4 shows that the changes in the level of employment of Enrolled Nurses have not been consistent across the States and Territories. Despite the national decline in employment, the number of Enrolled Nurses employed in Queensland, South Australia and the ACT has increased.

It is difficult to identify the causes for the decline in Enrolled Nurse numbers. In Victoria, decreasing student numbers before 1992 and the closure of the largest school may have been contributing factors. Fewer programs are now being offered in rural areas of Victoria (Department of Human Services 2001). Rural areas have also been highlighted as problematic in South Australia, where recruitment and retention of Enrolled Nurses has been identified as an issue, whereas numbers are considered adequate in metropolitan areas (Rawinski, Brown & White 1999).

The apparent increase in student enrolments and commencements in Enrolled Nurse courses shown in Tables 1.1 and 1.2 respectively sits uneasily with the finding of declining number of Enrolled Nurses in the workforce. Some of the increase in student numbers is simply the result of courses have been transferred into the VET sector and the expansion of the statistical collection to include private training providers. In the most recent two year (1999-2000) there has, however, clearly been an increase in the preparation of Enrolled Nurses.

Increased potential entrants to the occupation, however, are only one aspect of the size of the workforce. They are likely to have a lagged effect on the size of the workforce. At the other end, practicing Enrolled Nurses may be leaving the occupation at a higher rate, either altogether or, as we discuss later, to become Registered Nurses.

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1.6 International models for second level nurse education

Second level nursing, predominantly in the form of Enrolled Nursing, has experienced a number of changes around the world in recent years. The United Kingdom and New Zealand in particular have recently introduced significant changes. This section provides an overview of the developments in those two countries, as well as an introduction to the role of the second level nurse (known as Licensed Practical Nurse or Licensed Vocational Nurse) in the United States.

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United Kingdom

Before 1989, Enrolled Nurse education in the United Kingdom involved a two year hospital training program (Francis & Humphreys 1999). With the introduction of Project 2000, the United Kingdom Central Council (UKCC) determined that there would be one level of nurse in the United Kingdom. Therefore, training for Enrolled Nurses ceased in the United Kingdom in 1992 (Webb 1999). Enrolled Nurses then had two options - either train to become a Registered Nurse through specially created conversion programs, or else to continue to practice as Enrolled Nurses (Francis & Humphreys 1999).

According to Francis and Humphreys (1999), the abolition of second level nurses has resulted in a gap in skills in the delivery of nursing care in the United Kingdom. The void left by discontinuing Enrolled Nurse education has resulted in the creation of a 'lesser-qualified, non-nurse helper, to aid the RN. Hence the Health Care Assistant (HCA) was introduced' (p.131), a person who provides patient care but is not a nurse. Francis and Humphreys (1999) express concern that these health workers may replace qualified nurses for patient care simply to reduce health costs.

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New Zealand

Within New Zealand there has also been a move to abolish Enrolled Nurse education. Consequently, Enrolled Nurse programs have not been conducted in New Zealand since 1993. The lack of trainees over the period has resulted in a gradual decline in numbers of practicing Enrolled Nurses (New Zealand Health Information Service 2001).

Unlike the United Kingdom, New Zealand is currently considering reinstating education programs for a second level of nurse. A project is being led by the Ministry of Health in New Zealand re-examining the role and developing competencies for the second level nurse. The title given to the second level nurse has not yet been determined. The decision is being deferred until the competencies have been developed (Ministry of Health 2001). Currently, some polytechnic institutes in New Zealand are considering offering courses for second level nurses from 2002 (Gerritsen 2001; O'Connor 2001).

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United States of America

A second level of nurse continues to exist in the United States health care system. Within that country, the second level nurse is referred to as a Licensed Practical Nurse (LPN) or as a Licensed Vocational Nurse (LVN). Individual State Boards regulate the practice of these nurses. Courses leading to preparation of second level nurses are undertaken at vocational schools and community colleges. According to the National Federation of Licensed Practical Nurses Inc. (2001), these courses range anywhere from seven months to twenty-four months duration. On completion, graduates may work in a range of areas across the health care system, including hospitals, aged care facilities and community environments.

The practice domain for Licensed Practical Nurses appears to be expanding. Opportunities exist for second level nurses in the United States to obtain advanced preparation in clinical skills such as intravenous therapy and dialysis and employment in areas including intensive care, coronary care and operating theatre (Hunt & James 1997). In addition, there are opportunities for Licensed Practical Nurses to articulate into Registered Nurse courses (Murdock, McMorrow, LaCoursiere & Scriven 2000).

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1.7 Structure of this report

This report focuses on the education and training of Enrolled Nurses. The next chapter summarises the legislative environment. Given that there is relatively little literature on Enrolled Nurses, this study is on newly collected data. Chapter three describes the two surveys used to collect that information. Chapters four to nine discuss the results of the survey of coordinates of courses leading to registration as an Enrolled nurse - respectively, the structure of the courses, the students, enrolment and selection procedures, employment and study outcomes, quality assurance, financial aspects, and opportunities for further education and training.

Chapter 10 presents the results of a briefer survey of admission officers of university courses leading to recognition as a Registered Nurse. The purpose of this survey was to examine the pathway from Enrolled Nurse to Registered Nurse.

Chapter 11 discusses some further inter-sectoral issues relating to nursing education.

The final section contains the conclusion.

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