Supervision – Enrolled Nurses

What has your experience been?

Supervision is an element of the code of practice of the profession. The prevailing principle is that you have a duty to supervise – this is a broad obligation to the training nurse as well as to the community.

The GP can observe but not supervise an EN. This is according to the regulatory requirements of the EN’s training. Nursing and general practice are two different professions which adhere to separate regulations.

The EN must be supervised directly or indirectly by an RN. Indirect supervision is when the RN is easily contactable but does not directly observe the activities of the EN. The RN may be offsite but must be available for regular, direct communication with the EN. The absence of proximity requires robust processes to be in place for the direction, guidance, support and monitoring of the EN’s activities. While an EN is responsible for their actions, the RN is accountable.

As such, you may be the supervising RN even if you are not on the premises. Or you may have a nurse in another practice working at the same time as the EN in your practice, however, this supervising nurse would need an understanding of the capabilities of the EN they are supervising.

When the EN is carrying out tasks under supervision of a nurse, the task must come under the scope of practice of the supervisor to ensure those tasks are carried out safely. If you are not able to perform a certain task, how can you supervise the EN to perform that task? Do you have competencies in the field to intervene if the EN is about to cause harm? As an RN you are required to determine the EN’s scope of practice.

If you are uncomfortable that the EN is working without supervision of an RN you should make this clear to your employer. It is also useful to have a written record of the arrangement.

APNA recommends that EN’s work under direct RN supervision, but acknowledges in some circumstances this may be the only option. The practice must ensure that patient safety is not compromised and the medico-legal risk of the practice is not increased.

  • What are your thoughts about this information?
  • Have you felt pressure, or have you been put in a situation that you have not felt comfortable about?
  •  Do you have any advice for nurses on how to facilitate EN supervision requirements?

What you had to say…

 

15 thoughts on “Supervision – Enrolled Nurses

  1. I imagine that the role of supervisor is frequently compromised as many practices have limited supervisory arrangements in place. The onus is on the RN to be confident that the EN is working within their scope of practice, very difficult if the supervisory arrangement is for telephone contact when required.
    It would also be difficult for the EN as the only nurse on the premises (if that is the practice arrangement) to refuse to perform a task when requested by the GP even if it outside of the nurse scope of practice.
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  2. I agree with your statement and have been in this position. I cannot get the PM to understand that an EN is not the same as an RN. The onus of support direct and non-direct supervision are beyond some peoples thinking and the phrase..”oh the GP will supervise” drives me to distraction.
    I know an EN who will do anything for the GP even though it is not in her scope of practice insisting that if anything untoward happens she will be backed by them. I have printed out the scope of practice and other legal documents to explain their, her and my position and the problems they could come across and I have also provided phone numbers and website articles and explanatory documents for the EN, GP and PM but it makes no difference. What else can I do?
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  3. Hi Michelle and Fiona, welcome to the forum and thanks for your input.

    Apart from any discussion about competencies and scope of practice it is clearly stated within the RACGP Practice Standards 4th edition that all staff working within the practice must work within their scope of practice, and it would also be a significant factor in the clinical governance of the practice:
    http://www.racgp.org.au/your-practice/standards/standards4thedition/

    Do you think a reference to the standards would be useful as well as to the scope of practice?
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    1. Hi Cheryl,
      I think the standards and competencies are the basis of the framework and not referring to them would be a mistake.
      As for Fiona’s comments I think we could advocate for her and support her but she really needs to be helped by the ANMF or similar.

      It sounds much like my practice where management, although really nice people, have no clue as to the legalities of employing RN’s vs EN’s.

      Fiona is in a very sad place here as she is being made to be responsible for not only maintaining her standards of practice but the En’s. Also I think that non-support attitude from her manager and comments about “lording” her qualifications tantamount to bullying.

      I was in the same position except every time our EN did something out of her scope of practice I talked to her about it and then documented it as a ‘near miss episode’ as per accreditation. Nothing changed until she got sick of my “nagging” and resigned to go back into the hospital system where she could ‘do as she liked without being nagged’.

      So roll on the framework along with the review of the standards of practice…it is a beginning!
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  4. Not wanting to take away from the fact that obviously some individuals have had some bad experiences, I feel that EN’s are really being given a bad rap.
    I am an EN, working as a practice nurse for 5 years, my supervisor has many, many more years experience in practice nursing.
    I believe and my supervisor would vouch for me, that I work within my scope of practice at all times.

    Why do we not hear good news stories about EN’s in private practice? I feel it is almost a form of bullying, when I constantly hear of EN’s being put down.

    The training for EN’s these days has stepped up considerably from what it once was, since the diploma has replaced the previous cert IV.
    I am not wanting to take away from degree training, or saying the supervisory provisions should not be what they are, but posts such as what I read above and things I hear so often, we EN’s are often made to feel like we are seen as a lower class citizen.
    I think its unfair to imply that we are acting in a dangerous manner, when the majority of us are in fact working well within our scope.
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  5. I totally agree with you Tracy. I am also an EN of the old school training.

    We have many skills and often have felt the bullying tactics.
    I always update my education and its more then just doing my quota of 20 CPD points.

    I do not worked outside of my scope of practice although I have been asked to. When I have explained I am not able or trained in this area I have always met with no issues from the GP’s. I will also do competency training to allow me to do what is asked if the training is available.

    It is always good to have back up of an RN but sometimes it is just not practical to have them on site everyday, therefore any issues I’ve had I have always managed to be able to contact an RN for advise at the time.

    Most EN’s do work within their scope of practice and I think the answer is Team work!
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  6. Hi all, well I am an EN. I get annoyed at times when I hear RN’s criticise EN’s. There are very good EN’s out there and very bad ones as well . I have the wonderful support of the 3 RN’s that I work with in our Practise, as well as the doctors. I have never been asked to work out of my scope. I do feel we do not get a fair go with a lot of things. I find a lot of the education is aimed at post grad nurses, nothing much is around for us. I have a love of wounds, diabetes, and geriatric nursing, and CD Managment , and i am well respected with our patients who have asked for me by name to attend to their needs when they are in the clinic. While we are to have supervision, direct or indirect, it is up to each nurse to follow her conscious as each nurse knows her role. RN’s have to let go at times. lets work together for the love of our profession.
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  7. Welcome Tracy, Denise and Katrina.

    I wonder if there remains some confusion about the competencies and roles we have in the real world of primary health care nursing.

    There are amazing nurses with varying qualifications and skills who are working for the best outcome for our clients, and within their scope of practice.

    The mention of team work by Denise reminded me of a resource developed by AMLA (now defunct). The resource was called teamwork in primary care, a guide to roles, responsibilities and accountabilities. I will add this to our resources section for those who may not be aware of it.

    If you are aware of any guidelines and reputable resources that might be of use please consider adding them to this section of the forum.
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  8. The area of EN supervision is a very complex one as this discussion has identified. An area that I have always found difficult is how does an RN supervise an EN without first being able to assess competence?

    As an RN I am uncomfortable with this responsibility as often it is after the fact the RN is informed of issues and thus the culture of general practice can leave the RN open to disciplinary processes.

    I agree there are general practices with limited understanding of supervisory responsibilities and I think looking at the practice insurance policy can sometimes help facilitate the discussion.

    While I don’t have the answer to this professional issue I do wonder if each nurse is responsible to ensure they work within their scope of practice why do RNs have to supervise ENs and is indirect supervision really supervision or is it mentoring?

    Cheers

    Ros
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  9. I think you have some good points there Ros, however I don’t think the issues of supervision without being able to assess competence is entirely limited to practice nursing.
    I worked in aged care prior to my current role, in which EN’s were required to perform tasks for which they had training, that the ‘supervising RN’ had not.

    My understanding of the scope of practice has always been that as an individual nurse we have to be competent to complete a task and be responsible for our own actions, EN or RN.
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  10. Interesting discussion, to reiterate I would agree there is no doubt confusion about the competencies and roles we have in the real world of primary health care nursing.
    As a RN & RM working in GP who has recently employed x2 EN’s there is a great deal to consider, which has not been brought to my attention by my PM so now I will be chasing . I imagine I will have to look at my PI or would this come under practice insurance – I am now accountable.
    What I must say Nursing and Midwifery / RN/RM EN /mother craft nurse have we not moved away form being Task orientated.
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  11. Hi Everyone,

    I would like to add a different slant to this discussion. I see the situation of RN’s being asked to supervise ENs off site as similar to NP’s asking GP’s to work in collaboration with them when they work in a different location. If nurses wish to enter into these sort of collaborative arrangements in the future then it would seem unfair not to extend similar consideration to EN’s. We cannot know the extent of the EN’s scope of practice nor their competence unless we become familiar with their training and experience. Most of all we need to develop trust not just between EN’s and RN’s but RN’s and GP’s. How can this be achieved? Joint education sessions, communication and written policies that describe the extent of the role and when a referral to RN or GP is required may be a start. I know it is scary being asked to supervise someone when they are off site but has anyone actually been harmed by this practice or come under the scrutiny of the board?
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  12. Hi
    The ANMF are finalising the EN Professional standards, and we (APNA & ANMF) are finalising the Professional Standards for Nurses working in General Practice. The new standards will be more user friendly and there will be lots of education opportunities rolled out across Australia. I understand both of these Standards will be complete by end of 2014, with a roll out early 2015.
    This will provide employers with more information on the medico-legal aspects of Professional nursing practice.
    Exciting times!
    Kathy Godwin
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  13. Hi Kathy and welcome to the forum.

    Good news all round that the Professional Standards are being reviewed and soon to be made available in a more user friendly version. Many of the enquiries to APNA are about employment, scope of practice and supervision.

    This blog has generated a lot of discussion and food for thought about how we work together currently and in the future.

    The discussion has been moved here.
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