The relationship between ENs and RNs

There is a long history of difficulty in the managing of role, titles and job practice between registered and second level nursing. A frequently raised example is the difficulty in managing the relationship between an experienced EN and a new graduate RN. The literature reviewed in Dixon (1996), notes that increased stress resulting from supervision difficulties is experienced in mixed RN and EN staffing situations.

The requirement for the EN to be supervised by a RN or a medical practitioner is seen as the main cause of the difficult relationship. The College does not support the NZNO’s proposal to remove the supervision requirement. In practice this would mean groups such as the frail elderly, the chronically ill, and those requiring rehabilitation from an accident could be placed in the sole care of personnel who would have a limited and essentially superficial training. The College’s view is that those people in less acute settings who are receiving care, need and should have a primary care relationship with a registered nurse. There is considerable variation in the actual supervision arrangements for ENs and this is, in the College’s view, an area of risk to patient safety.

There is a history of issues around inappropriate utilisation of ENs, either curtailing their practice, or asking them to work outside their level of competency. If a second level health assistant is to be introduced a clear relationship between them and RNs needs to be established based on knowledge of what the training of that assistant includes, and realistic expectations as to their skills and abilities are understood.

The work by the College of Nurses of Ontario in producing guidelines and decision guides for nurses working with second level nurses and unregulated care providers provides a useful example of how this issue could be progressed. Dixon’s (1996) work supports the view that differentiation between levels of nurse must be based on clinical judgement rather than on task performance. Within New Zealand work has also been done by the College and the NZNO on separate guidelines.