Enrolled Nurse Supervision and Standards of Practice Changes

APNA often gets a number of enquiries around supervision (specifically for Enrolled Nurses) and standards of practice. Below is a brief update around Standards of Practice and supervision.
As you may know, the Nursing and Midwifery Board of Australia (NMBA) recently updated Registered and Enrolled Nurses standards of practice. To practice in Australia, you must meet the NMBA’s professional standards. The revised standards can be found here.
They focused strongly on supervision of Enrolled Nurses. Below is a summary of supervision requirements for Enrolled Nurses.

Supervision of Enrolled Nurses by a Registered Nurse is a requirement of the Enrolled Nurse Standards for Practice.

  • Supervision by a person other than a Registered Nurse is not consistent with the professional standards of the profession and may contravene requirements. Professional supervision relates to the quality and safety of care and is provided by a member of the same profession.
  • A general practitioner or other Doctor, may have management responsibilities, but a member of the nursing profession, namely a Registered Nurse, must undertake professional supervision of an Enrolled Nurse. It is the obligation of the employing general practice to ensure that appropriate supervisory arrangements are in place.
  • Supervision and delegation of work to an Enrolled Nurse can be direct or indirect, and will vary depending on the abilities, education, qualifications, scope of practice, experience of the Enrolled Nurse, and contextual factors such as the geographical setting and size of the practice. Click here to read more around context of practice.

What does supervision of enrolled nurses mean?

Supervision of enrolled nurses by registered nurses can be direct or indirect depending on: the competence of the enrolled nurse for the scope of nursing practice; the condition of the person receiving nursing care; and the context in which the care is given. At all times, the enrolled nurse remains accountable for their own actions and is responsible to the registered nurse for all delegated functions

Direct and Indirect Supervision

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.

The employer must ensure that supervisory arrangements are in place. Registered Nurses should be aware of their legal responsibility in regard to supervision of Enrolled Nurses.

Another arrangement for indirect supervision of an Enrolled Nurse may occur in a general practice that has multiple sites. The Registered Nurse provides indirect supervision for Enrolled Nurses employed in that practice. In this type of situation the Registered Nurse may move between clinics giving supervision to an Enrolled Nurse/s. This model is particularly applicable to practices located in rural or remote settings, or multiple sites where geographical distances make direct supervision impractical. Registered Nurses should be aware of their legal responsibility in regard to supervision of Enrolled Nurses.

Some of the nurse regulatory authorities have produced policy statements and guidelines for delegation to and supervision of enrolled nurses and these must be considered by employers of enrolled nurses. The Australian Nursing and Midwifery Council has guidelines on delegation and supervision.

There are also decision making frameworks to assist registered nurses and enrolled nurses make decisions about the way that nursing work is delegated to enrolled nurses. Click here to view these and read more.

Report highlights failure in primary health care

The Grattan Institute, a public policy ‘think tank’, has just published a report entitled ‘Chronic failure in primary care’ (see here). It is disappointing there is little reference to nurses in the report but that aside, it does give a good insight into the problems (and some possible solutions) in Australian primary health care.

Some highlights of the report are as follows:

  • Ineffective management of heart disease, asthma, diabetes and other chronic diseases costs the Australian health system more than $320 million a year in avoidable hospital admissions.
  • Only a quarter of the nearly one million Australians diagnosed with type 2 diabetes get the monitoring and treatment recommended for their condition.
  • Each year there are more than a quarter of a million admissions to hospital for health problems that potentially could have been prevented. Yet each year the government spends at least $1 billion on planning, coordinating and reviewing chronic disease management and encouraging good practice in primary care.
  • Three quarters of Australians over the age of 65 have at least one chronic condition that puts them at risk of serious complications and premature death. Social, economic and environmental changes are the best way to prevent these diseases, but there are much better outcomes where good quality primary care services are in place.
  • The focus must move away from GP fee-for-service payments for one-off visits; a broader payment for integrated treatment would help to focus care on patients and long-term outcomes.
  • PHNs should be given more responsibility for local primary care services. The evidence shows that a consistent, coordinated approach to specific diseases helps primary care more effectively prevent and manage chronic conditions. In regional areas, clear targets and well-designed incentives for disease prevention are vital.
  • There needs to be a focus on more flexible services, which might include greater use of nurses and allied health staff for assessment, planning, coordination, review and support of people with chronic disease.
  • Practice and incentive payments are not working.

Do you agree there are fundamental problems with our primary health care system? Are there any easy, or even achievable, solutions? We would love to know what you think.

Removal of healthy kids check from MBS

From 1 November 2015, Medicare benefits for the pre-school healthy kids check (including the nurse item #10986) will no longer be available. See here for the MBS notification.

The Australian Government has cited a lack of evidence around the current system providing a higher quality service and the increased annual cost of delivering pre-school health checks as factors behind its decision to remove the healthy kids check MBS items.

The four year old health check remains a recommended child health assessment, which can still be undertaken in general practice settings using time and complexity based MBS items #23, #36, #44 (and the Aboriginal and Torres Strait Islander health assessment item #715). The health checks can also be undertaken by State and Territory funded infant health clinics, where available.

With these changes in mind there is debate around whether the rebates for these consults accurately reflect the work required to undertake a comprehensive childhood health assessment or support the non face-to-face work undertaken outside of the consultation.

  • Do you believe there will be a change in your health assessment rates for children in your area as a result of the Government’s decision?

Leave a comment: log in with your APNA member number and password, or register your account if you are not a member of APNA.

Nurse clinics: Collaboration and connectedness

Earlier this month the RACGP published their position on independent nurse-led clinics in primary health care. Many of the points made in this policy are compelling, including that to ensure whole-patient care and to avoid fragmentation of care, nursing services should be provided in a comprehensive and integrated primary health care setting wherever possible.

Over the next three years APNA will continue work initiating and supporting nurse clinics through the demonstration model to provide blueprints for the innovative delivery of clinical care by nurses in primary health care. The projects focus on developing nurse clinics in primary care in collaboration with primary health care nurses, the general practice or healthcare team, consumers and peak health organisations to address evidence-based, locally identified health needs.

  • What do you think of the RACGP’s position?
  • Are you interested in establishing a nurse clinic in primary health care to address your population health needs?
  • Have you found there to be barriers to operating a nurse clinic?
  • Have you worked out a successful nurse clinic model you’d like to share?

Leave a comment: log in with your APNA member number and password, or register your account if you are not a member of APNA.

Mental health of young people

On 7 August 2015, the Minister for Health, the Hon Sussan Ley MP, released The Mental Health of Children and Adolescents, a report on the second Australian Child and Adolescent Survey of Mental Health and Wellbeing. The report, described as the largest ever national survey of youth mental health of its kind in Australian history, follows on from the first national survey of the mental health of children and adolescent which was undertaken 17 years ago.

Some key highlights of the report are set out below:

  • One in seven children and young people experienced a mental disorder in the previous 12 months – the equivalent of 560,000 young Australians
  • Attention deficit hyperactivity disorder (ADHD) was the most common mental disorder in children and adolescents
  • Just over one third (35%) of 4-17 year-olds with a mental disorder had seen a general practitioner in the past 12 months
  • Schools provided services to 40.2% of the children and adolescents with mental disorders who attended them, and 5.6% had seen a school nurse
  • Around one in 10 12-17 year-olds (10.9%) reported having ever self-harmed
  • Females aged 16-17 years had the highest rates of self-harm, with 16.8% having harmed themselves in the previous 12 months
  • About one in thirteen (7.5%) 12-17 year olds had seriously considered attempting suicide in the previous 12 months.

While some of the information contained in the report is concerning, there are a number of positives, such as the large increase in the number of young people seeking help.

What is your experience of dealing with young people with mental health issues? Do you think there are adequate processes in place to identify mental disorders and provide the care and support needed?

On your behalf

On the 8th of July our President, Karen Booth and CEO, Alexis Hunt attended by invitation the MBS Review Stakeholder Forum in Canberra with a number of key industry leaders.

This forum is one of the three key initiatives currently being undertaken by the Department of Health to work collaboratively with health professionals to deliver a healthier Medicare. These priorities include the Medicare Benefits Schedule (MBS) Review Taskforce led by Professor Bruce Robinson, Dean of the Sydney Medical School, University of Sydney. The MBS Review Taskforce has been tasked with considering how services can be aligned with contemporary clinical evidence and improve health outcomes for patients.

The Primary Health Care Advisory Group (PHCAG), led by former AMA president and practising GP, Dr Steve Hambleton, will investigate options to provide; better care for people with complex and chronic illness; innovative care and funding models; better recognition and treatment of mental health conditions; and greater connection between primary health care and hospital care. Karen Booth has a lead role as a member of this group.

The third component of the Federal Government’s vision is a review of Medicare compliance rules and benchmarks, and will work with clinical leaders, medical organisations and patient representatives. The use of new techniques such as analytics and behavioural economics will provide more information to clinicians to enable them to better manage appropriate practices. As well, more information will be available to patients about fees charged by health professionals so they can make informed choices about their healthcare.

Some of the key outcomes of the MBS Review Stakeholder Forum included roundtable discussions on what major shifts will be required as part of the recommendations to the Review. The group identified a number of barriers to success which included a level of scepticism on the purpose and goals, financial implications of major changes, evidence or rather the lack thereof on more effective methodologies, inertia, workload and data availability. Some of the recommendations for overcoming these barriers as identified by participants included developing a clear case for change, high levels of consultation, robust commercial modelling, effective communication, connected systems and a well considered and designed implementation strategy.

We will provide updated information as we continue to work closely with these groups and forums.

We always want to hear from you on these matters and acknowledge you are the experts working in the field and have direct contact with patients and communities. We encourage you to provide us with your thoughts and feedback at every step of this journey so we can actively advocate on your behalf.

6 July 2015

Dear members, friends and colleagues,

APNA has achieved a significant win on behalf of our members, showing great recognition for the work you do for communities around Australia. APNA has been granted a contract to deliver the Nursing in Primary Health Care Program to 2018.

In making the announcement on Friday, the Government has focused on the outcomes of this program on people living in rural and remote areas, through the support of nurses in their communities.

The program will centre on enhanced nurse knowledge, skills and capabilities in chronic disease prevention and management, and in supporting healthy ageing in the community. The aim is to increase the contribution primary health care nurses can make to care for the chronically ill and elderly, delivering better and more cost-effective patient care, and reducing the burden on hospitals and the aged care system.

It will also be achieved through workforce sustainability. The program will focus on workforce recruitment and retention, to ensure Australia has an adequate supply of primary health care nurses to meet demand, and that general practice and other employers are supported to employ nurses and optimise their use. Our workforce sustainability program will be enhanced by the development of a transition to practice pilot to encourage new graduates to primary health care. Patients will benefit from good access to cost-effective care, and support for coordination delivered, as the Minister describes, by “having nurses in the right place at the right time”.

Effective primary health care can help keep people well and out of hospital and aged care. The challenge we face right now is to ensure our primary health care system can meet the challenges of ever-increasing demand, whilst maintaining affordability and quality.

Thrilled as we are, heads are already down and planning is underway. We look forward to sharing this journey with you.

Kind regards,


Where is the nurse?

You might have seen an ad on peak time TV over the last week demonstrating a GP’s lifelong relationship with a family. It is the first of several to be rolled out as part of a community awareness campaign investment by the RACGP.

Who can help the warm and fuzzy feeling you get as the generational cycles progress and child becomes adult?

I congratulate our GP colleagues on celebrating their profession but the campaign, naturally given it is funded and driven by the RACGP, is singularly GP-centric and has elicited a mixed bag of responses. It does portray a nice, somewhat sanitised story, but for me it is an unfortunate lost opportunity to acknowledge the collaborative, multidisciplinary approach to general practice. Where is the nurse? Where is the whole team that makes up contemporary general practice that the health of multicultural Australia is so dependent on today?

For me what this campaign does identify is the pursuit of ongoing, quality professional learning across one’s career and the importance of a professional body supporting that career development.

The emphasis, ‘The good GP never stops learning’, can and should be parallel to the team working alongside them.

Nurses’ and midwives’ thirst and desire for lifelong learning is not new and has been part of our make-up since before Florence was a girl. In fact all the members of the wondrous multidisciplinary team that is general practice today are on a continuum of learning supported by their respective professional bodies.

APNA offers enough online learning to complete years of a nurse’s CPD requirement, and much of it free to members. Education is a paramount offering for APNA members. To ensure you as APNA members benefit from our stringency and dedication to the highest quality education for nurses to achieve lifelong learning APNA partners with peak bodies and experts and gathers the most current information to develop and update our online education.

For me APNA’s education offering is just the icing on the cake, not why I joined APNA. I joined to be part of a collective with the same mindset and purpose of supporting, learning and developing a profession I love and am very proud of. To be a small part of an organisation run for and by nurses, for me this is the is the true benefit in contributing to APNA as the peak body for nurses working in primary health care.

APNA exists to support its members and develop their profession, and for that reason alone. That’s why you should be an APNA member. That is why all GPs should be proud of their nurse colleagues and wholly support their ongoing membership of APNA.


So, what do you think of the ad?

Message from Julianne: An international perspective on primary health care nursing

Hello APNA family!

I am filling in for Karen Booth who is taking a well-earned break.
APNA staff, Board and I’m sure delegates, are still riding the post Brave to Bold conference wave of euphoria. As Conference Chair I want to take this opportunity to thank the Conference Committee and the team who drove the conference. Well done, you are all amazing and now on to planning 2016 in Melbourne. For those of you who joined us, well done and congratulations for making the conference such a success.

Following on from our highly successful conference we took some of our international keynote speakers, Dr Sheila Tlou (Botswana), Dr Mary Moller (USA), Professor Sue Cross (UK) and Deb Davies (NZ), to Canberra to present at an APNA forum on Monday 18 May. In line with APNA’s ongoing determination to highlight and showcase the importance of primary health care nursing on both the national and the international stage, and to share this wealth of experience and knowledge outside our island home.

The forum – An international perspective on primary health care nursing: A cost and care effective force for change – was held just down from Capital Hill in Old Parliament House. The event was an opportunity to engage with nurses, health organisations and government on some of the key national and international issues affecting primary health nursing. The keynote presentations were very well received and picking up on the energy from the conference, we had a lively panel discussion which rounded off the morning. In case you missed it, the presentations from the event are available on APNA’s website.

Kind Regards,

Julianne Badenoch

25 May 2015

Dear members,

Each year APNA selects a conference theme that is meant to inspire. This year has been no exception. The Hon Ms Sussan Ley, Minister for Health and Ageing, opened APNA’s Brave to Bold conference held on the Gold Coast last week to share in the excitement and celebration of primary health care nursing. Brave to Bold brought together wonderful, enthusiastic nurses from all over the country, to meet, learn, teach, share, network, and inspire creative and innovative nursing practice. I can also tell that more than a few of you had a little fun too. The APNA members of the Conference Advisory Committee and the staff team are all to be congratulated on what I feel was our best conference ever. Our highly regarded and much loved Commonwealth Chief Nurse, Dr Rosemary Bryant, shared with us her brave to bold story, in what will probably be one of her last big appearances before she retires in a few months.

We had a sensational line-up of truly inspiring national and international speakers who really are brave and bold, encouraging nurses to lead the way in many areas of primary health care and career development. Thank you to our international guests Dr Sheila Tlou, Dr Mary Moller, Professor Sue Cross, Deb Davies and Brian Dolan, and to our very own Professor Megan-Jane Johnstone, who gave some of the most enlightening, inspiring and invigorating presentations that I have the pleasure of attending. For those of you unable to attend the conference I urge you to look at the bios on our conference web page and view their great nursing work. We were spoilt for choice for the abstract papers and workshops presented at Brave to Bold. Thank you to all our wonderful presenters.

Thank you to the APNA staff who pulled this together, helped members navigate the conference and whose tireless effort helped to make the Brave to Bold conference special and to keep some of us sane. A big welcome to Alexis Hunt in her new role as CEO and her first APNA conference. Most of all thank you to our members who also made this special – you are the reason for APNA moving from brave to bold!

Next year’s APNA conference will be in… envelope please… Melbourne! See you there.