Enrolled nurse standards for practice

Professional Codes & Guidelines

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Introduction

The Enrolled nurse standards for practice are the core practice standards that provide the framework for assessing enrolled nurse (EN) practice. They communicate to the general public the standards that can be expected from ENs and can be used in a number of ways including:

development of nursing curricula by education providers
assessment of students and new graduates
to assess nurses educated overseas seeking to work in Australia, and
to assess ENs returning to work after breaks in service.

In addition, they may also be used by the Nursing and Midwifery Board of Australia (NMBA) and relevant tribunals or courts to assess professional conduct or matters relating to notifications.

The Enrolled nurse standards for practice replace the National competency standards for the enrolled nurse (2002).

These contemporary standards reflect the role of the EN within the health environment. The standards for practice remain broad and principle-based so that they are sufficiently dynamic for practising nurses to use as a benchmark to assess competence to practise in a range of settings.

The EN works with the registered nurse (RN) as part of the health care team and demonstrates competence in the provision of person-centred care. Core practice generally requires the EN to work under the direct or indirect supervision of the RN. At all times, the EN retains responsibility for his/her actions and remains accountable in providing delegated nursing care. The need for the EN to have a named and accessible RN at all times and in all contexts of care for support and guidance is critical to patient safety.

Although the scope of practice for each EN will vary according to context and education, the EN has a responsibility for ongoing self and professional development to maintain their knowledge base through life-long learning, and continue to demonstrate the types of core nursing activities that an EN would be expected to undertake on entry to practice. Therefore the core standards in this document are the minimum standards that are applicable across diverse practice settings and health care populations for both beginning and experienced ENs. They are based on the Diploma of Nursing being the education standard.

ENs engage in analytical thinking; use information and/or evidence; and skilfully and empathetically communicate with all involved in the provision of care, including the person receiving care and their family and community, and health professional colleagues.

The EN standards are clinically focused and they reflect the ENs capability to:

provide direct and indirect care
engage in reflective and analytical practice, and
demonstrate professional and collaborative practice. ENs, where appropriate, educate and support other (unregulated) health care workers (however titled) related to the provision of care.

ENs collaborate and consult with health care recipients, their families and community as well as RNs and other health professionals, to plan, implement and evaluate integrated care that optimises outcomes for recipients and the systems of care. They are responsible for the delegated care they provide and self-monitor their work.

How to use these standards

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The EN standards for practice are intended to be easily accessible to a variety of groups, including ENs, governments, regulatory agencies, educators, health care professionals and the community. It should be noted that the ‘indicators’ (refer to glossary) written below the statements are indicative of EN behaviours, they are not intended to be exhaustive. Rather, they are examples of activities that demonstrate the specific standard.

The standards should be read in conjunction with the following relevant documentation, including, but not limited to:

They should also be read in conjunction with the attached glossary, which describes the way in which key terms are used in the standards.

There are three domains, namely:

professional and collaborative practice
provision of care, and
reflective and analytical practice.

The indicators are expressed through knowledge (capabilities)¹, skills², and attitudes³ inherent within these clinically focused domains. All are variable according to the context of practice.

¹Knowledge (capabilities) refers to information and the understanding of that information to guide practice.
²Skills refers to technical procedures and competencies
²Attitudes refers to ways for thinking and behaving

Domains

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Professional and collaborative practice

The professional and collaborative practice domain relates to the legal, ethical and professional foundations from which all competent ENs respond to their environment. The domain reflects the responsibilities of the EN to maintain currency and to demonstrate best practice. The standards are:

functions in accordance with the law, policies and procedures affecting EN practice
practises nursing in a way that ensures the rights, confidentiality, dignity and respect of people are upheld, and
accepts accountability and responsibility for own actions.

Provision of care

The provision of care domain relates to the intrinsic care of individuals or groups entrusted to the EN. It encompasses all aspects of care from assessment to engaging in care, and includes health education and evaluation of outcomes. The standards are:

interprets information from a range of sources in order to contribute to planning appropriate care
collaborates with the RN, the person receiving care and the healthcare team when developing plans of care
provides skilled and timely care to people receiving care and others whilst promoting their independence and involvement in care decision–making, and
communicates and uses documentation to inform and report care.

Reflective and analytical practice

The reflective and analytical practice domain relates to the ability of the EN to reflect on evidence-based practice and ensure currency of essential knowledge and skills, to care for the personal, physical and psychological needs of themselves and others. The standards are:

provides nursing care that is informed by research evidence
practises within safety and quality improvement guidelines and standards, and
engages in ongoing development of self as a professional.

Enrolled nurse standards for practice

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Standard 1: Functions in accordance with the law, policies and procedures affecting EN practice

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Indicators:

1.1	Demonstrates knowledge and understanding of commonwealth, state and /or territory legislation and common law pertinent to nursing practice.
1.2	Fulfils the duty of care in the undertaking of EN practice.
1.3	Demonstrates knowledge of and implications for the NMBA standards, codes and guidelines, workplace policies and procedural guidelines applicable to enrolled nursing practice.
1.4	Provides nursing care according to the agreed plan of care, professional standards, workplace policies and procedural guidelines.
1.5	Identifies and clarifies EN responsibilities for aspects of delegated care working in collaboration with the RN and multidisciplinary health care team.
1.6	Recognises own limitations in practice and competence and seeks guidance from the RN and help as necessary.
1.7	Refrains from undertaking activities where competence has not been demonstrated and appropriate education, training and experience has not been undertaken.
1.8	Acts to ensure safe outcomes for others by recognising the need to protect people and reporting the risk of potential for harm.
1.9	When incidents of unsafe practice occur, reports immediately to the RN and other persons in authority and, where appropriate, explores ways to prevent recurrence.
1.10	Liaises and negotiates with the RN and other appropriate personnel to ensure that needs and rights of people in receipt of care are addressed and upheld.

Standard 2: Practises nursing in a way that ensures the rights, confidentiality, dignity and respect of people are upheld

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Indicators:

2.1	Places the people receiving care at the centre of care and supports them to make informed choices.
2.2	Practises in accordance with the NMBA standards codes and guidelines.
2.3	Demonstrates respect for others to whom care is provided regardless of ethnicity, culture, religion, age, gender, sexual preference, physical or mental state, differing values and beliefs.
2.4	Practises culturally safe care for (i) Aboriginal and Torres Strait Islander peoples; and (ii) people from all other cultures.
2.5	Forms therapeutic relationships with people receiving care and others recognising professional boundaries.
2.6	Maintains equitable care when addressing people’s differing values and beliefs.
2.7	Ensures privacy, dignity and confidentiality when providing care.
2.8	Clarifies with the RN and relevant members of the multi-disciplinary healthcare team when interventions or treatments appear unclear or inappropriate.
2.9	Reports incidents of unethical behaviour immediately to the person in authority and, where appropriate, explores ways to prevent recurrence.
2.10	Acknowledges and accommodates, wherever possible, preferences of people receiving nursing care.

Standard 3: Accepts accountability and responsibility for own actions

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Indicators:

3.1	Practises within the EN scope of practice relevant to the context of practice, legislation, own educational preparation and experience.
3.2	Demonstrates responsibility and accountability for nursing care provided.
3.3	Recognises the RN as the person responsible to assist EN decision-making and provision of nursing care.
3.4	Collaborates with the RN to ensure delegated responsibilities are commensurate with own scope of practice.
3.5	Clarifies own role and responsibilities with supervising RN in the context of the healthcare setting within which they practice.
3.6	Consults with the RN and other members of the multidisciplinary healthcare team to facilitate the provision of accurate information, and enable informed decisions by others.
3.7	Provides care within scope of practice as part of multidisciplinary healthcare team, and with supervision of a RN.
3.8	Provides support and supervision to assistants in nursing (however titled) and to others providing care, such as EN students, to ensure care is provided as outlined within the plan of care and according to institutional policies, protocols and guidelines.
3.9	Promotes the safety of self and others in all aspects of nursing practice.

Standard 4: Interprets information from a range of sources in order to contribute to planning appropriate care

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Indicators:

4.1	Uses a range of skills and data gathering techniques including observation, interview, physical examination and measurement.
4.2	Accurately collects, interprets, utilises, monitors and reports information regarding the health and functional status of people receiving care to achieve identified health and care outcomes.
4.3	Develops, monitors and maintains a plan of care in collaboration with the RN, multidisciplinary team and others.
4.4	Uses health care technology appropriately according to workplace guidelines.

⁴Where an enrolled nurse is working in maternity services setting it is expected that they will be supervised by a midwife.

Standard 5: Collaborates with the RN, the person receiving care and the healthcare team when developing plans of care

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Indicators:

5.1	Develops and promotes positive professional working relationships with members of the multi-disciplinary team.
5.2	Collaborates with members of the multi-disciplinary healthcare team in the provision of nursing care.
5.3	Contributes to the development of care plans in conjunction with the multidisciplinary healthcare team, the person receiving care and appropriate others.
5.4	Manages and prioritises workload in accordance with people’s care plans.
5.5	Clarifies orders for nursing care with the RN when unclear.
5.6	Contributes to and collaborates in decision-making through participation in multidisciplinary healthcare team meetings and case conferences.

⁵Appropriate others include those in direct association with the person receiving care (with his/her consent) such as family, unpaid and paid carers, volunteers and clergy.

Standard 6: Provides skilled and timely care to people whilst promoting their independence and involvement in care decision–making

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Indicators:

6.1	Provides care to people who are unable to meet their own physical and/or mental health needs.
6.2	Participates with the RN in evaluation of the person’s progress toward expected out¬comes and the reformulation of plans of care.
6.3	Promotes active engagement and the independence of people receiving care within the health care setting by involving them as active participants in care, where appropriate.
6.4	Demonstrates currency and competency in the safe use of healthcare technology.
6.5	Exercises time management and workload prioritization.
6.6	Recognises when the physical or mental health of a person receiving care is deteriorating, reports, documents and seeks appropriate assistance.

Standard 7: Communicates and uses documentation to inform and report care

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Indicators:

7.1	Collects data, reviews and documents the health and functional status of the person receiving care accurately and clearly.
7.2	Interprets and reports the health and functional status of people receiving care to the RN and appropriate members of the multidisciplinary healthcare team as soon as practicable
7.3	Uses a variety of communication methods to engage appropriately with others and documents accordingly.
7.4	Prepares and delivers written and verbal care reports such as clinical handover, as a part of the multidisciplinary healthcare team.
7.5	Provides accurate and appropriate information to enable informed decision making by others.

Standard 8: Provides nursing care that is informed by research evidence

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Indicators:

8.1	Refers to the RN to guide decision-making.
8.2	Seeks additional knowledge/information when presented with unfamiliar situations.
8.3	Incorporates evidence for best practice as guided by the RN or other appropriate health professionals.
8.4	Uses problem-solving incorporating logic, analysis and a sound argument when planning and providing care.
8.5	Demonstrates analytical skills through accessing and evaluating healthcare information and quality improvement activities.
8.6	Consults with the RN and other relevant health professionals and resources to improve current practice.

Standard 9: Practises within safety and quality improvement guidelines and standards

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Indicators:

9.1	Participates in quality improvement programs and accreditation standards activities as relevant to the context of practice.
9.2	Within the multi-disciplinary team, contributes and consults in analysing risk and implementing strategies to minimise risk.
9.3	Reports and documents safety breaches and hazards according to legislative requirements and institutional policies and procedures.
9.4	Practises safely within legislative requirements, safety policies, protocols and guidelines.

Standard 10: Engages in ongoing development of self as a professional

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Indicators:

10.1	Uses EN standards for practice to assess own performance.
10.2	Recognises the need for, and participates in, continuing professional and skills development in accordance with the NMBA’s Continuous professional development registration standard.
10.3	Identifies learning needs through critical reflection and consideration of evidence-based practice in consultation with the RNs and the multidisciplinary healthcare team.
10.4	Contributes to and supports the professional development of others.
10.5	Uses professional supports and resources such as clinical supervision that facilitate professional development and personal wellbeing.
10.6	Promotes a positive professional image.

Glossary

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Accountability/accountable: Nurses and midwives must be prepared to answer to others, such as people in receipt of healthcare, their nursing and midwifery regulatory authority, employers and the public for their decisions, actions, behaviours and the responsibilities that are inherent in their roles. Accountability cannot be delegated. The registered nurse or midwife who delegates an activity to another person is accountable, not only for their delegation decision, but also for monitoring the standard of performance of the activity by the other person, and for evaluating the outcomes of the delegation. However, they are not accountable for the performance of the delegated activity.

Best practice: A technique, method, process, activity or incentive which has been proven by evidence to be most effective in providing a certain outcome.

Core practice: The day-to-day or regular activities or policies of a health service provider that fundamentally guide the service as a whole.

Decision-making framework: The NMBA expects all nurses and midwives to practise within the relevant standards for practice and decision-making frameworks.

Delegation/delegate: A delegation relationship exists when one member of the health care team delegates aspects of care, which they are competent to perform and which they would normally perform themselves, to another member of the health care team from a different discipline, or to a less experienced member of the same discipline. Delegations are made to meet people’s needs and to ensure access to health care services — that is, the right person is available at the right time to provide the right service to a person. The delegator retains accountability for the decision to delegate and for monitoring outcomes.

Duty of care/standard of care: A responsibility or relationship recognised in law. For example, it may exist between health professionals and their clients. Associated with this duty is an expectation that the health professional will behave or act in a particular way. This is called the standard of care, which requires that a person act toward others and the public with watchfulness, attention, caution and the prudence that would be made by a reasonable person in those circumstances. If a person's actions do not meet this standard of care, whereby they fall below the acceptable standards, any damages resulting may be pursued in a lawsuit for negligence.

Enrolled nurse (EN, Division 2): A person with appropriate educational preparation and competence for practice, who is registered under the Health Practitioner Regulation National Law.

Evidence-based practice: Assessing and making judgements to translate the best available evidence, which includes the most current, valid, and available research findings and the individuality of situations and personal preferences as the basis for practice decisions.

Indicators: Key generic examples of competent performance. They are neither comprehensive nor exhaustive. They assist the assessor when using their professional judgement in assessing nursing practice. They further assist curriculum development.

Midwife/midwifery practice: A midwife is a person with appropriate educational preparation and competence for practice who is registered by the NMBA. This term includes endorsed midwives for the purposes of this document. The NMBA has endorsed the ICM definition of a midwife (that includes the statement below on scope of practice) and applied it to the Australian context.

The International Confederation of Midwives (ICM) defines a midwife as follows:

A midwife is a person who has successfully completed a midwifery education programme that is duly recognised in the country where it is located and that is based on the ICM essential competencies for basic midwifery practice and the framework of the ICM global standards for midwifery education; who has acquired the requisite qualifications to be registered and/or legally licensed to practise midwifery and use the title ‘midwife’; and who demonstrates competency in the practice of midwifery.

Scope of practice⁶

The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures. The midwife has an important task in health counselling and education, not only for the woman, but also within the family and the community. This work should involve antenatal education and preparation for parenthood and may extend to women’s health, sexual or reproductive health and child care.

A midwife may practise in any setting including the home, community, hospitals, clinics or health units (ICM international definition of the midwife 2012).

Nursing and Midwifery Board of Australia (NMBA): The national body responsible for the regulation of nurses and midwives in Australia.

Person/people: Refers to those individuals who have entered into a relationship with an enrolled nurse. Person/people encompass patients, clients, consumers and families that fall within the enrolled nurse scope and context of practice.

Person-centred practice: A collaborative and respectful partnership built on mutual trust and understanding. Each person is treated as an individual with the aim of respecting people’s ownership of their health information, rights and preferences while protecting their dignity and empowering choice. Person-centred practice recognises the role of family and community with respect to cultural and religious diversity.

Plan of care: Outlines the care to be provided to an individual/ family/ community and includes the nursing component. It is a set of actions the nurse will implement to resolve/ support nursing diagnoses identified by nursing assessment. The creation of the plan is an intermediate stage of the nursing process. It guides in the ongoing provision of nursing care and assists in the evaluation of that care.

Professional boundaries: Refers to the clear separation that should exist between professional conduct aimed at meeting the health needs of people, and behaviour which serves a nurse’s own personal views, feelings and relationships that are not relevant to the professional relationship.

Quality: Refers to characteristics and grades with respect to excellence.

Refer/referral: Referral is the transfer of primary health care responsibility to another qualified health service provider/health professional. However, the nurse or midwife referring the person for care by another professional or service may need to continue to provide their professional services collaboratively in this period.

Registered nurse (RN, Division 1): A person who has completed the prescribed educational preparation, demonstrated competence to practise, and is registered under the Health Practitioner Regulation National Law as a registered nurse in Australia. For the purposes of this document the term also includes nurse practitioners.

Risk assessment/risk management: An effective risk management system is one incorporating strategies to:

identify risks/hazards
assess the likelihood of the risks occurring and the severity of the consequences if the risks do occur, and
prevent the occurrence of the risks, or minimise their impact.

Scope of practice: Is that in which nurses are educated, competent to perform and permitted by law. The actual scope of practice of individual practitioners is influenced by the settings in which they practise, the health needs of people, the level of competence and confidence of the nurse and the policy requirements of the service provider.

Standards for practice: Set the expectations of enrolled nurse practice. They inform the education standards for enrolled nurses; the regulation of nurses and determination of nurses’ fitness for practice; and guide consumers, employers and other stakeholders on what to reasonably expect from an enrolled nurse regardless of the area of nursing practice or years of nursing experience. They replace the previous National competency standards for the enrolled nurse.

Supervision/supervise: Supervision can be either direct or indirect:

Direct supervision is when the supervisor is actually present and personally observes, works with, guides and directs the person who is being supervised.
Indirect supervision is when the supervisor works in the same facility or organisation as the supervised person, but does not constantly observe their activities. The supervisor must be available for reasonable access. What is reasonable will depend on the context, the needs of the person receiving care and the needs of the person who is being supervised.

For the purpose of this document, supervision includes access, in all contexts of care, at all times, either directly or indirectly to professional and clinically focused supervision to a named and accessible registered nurse for support and guidance of the practice of an enrolled nurse.

⁶Scope of practice forms a part of the ICM definition of a midwife.