Exploration of the role of the enrolled nurse within a team nursing model: Perspectives of enrolled nurses and registered nurses

Date of Award


Degree Name

Doctor of Philosophy (College of Nursing)

First Supervisor

Professor Leanne Monteross

Second Supervisor

Professor Selma Alliex


Background: The role of the nurse and the way in which nursing care is delivered has undergone significant change in recent years. Enrolled nursing, in particular, epitomises the extent of these changes. The scope within which enrolled nurses (ENs) may now practice grows ever wider, reaching into the skill domains once reserved for registered nurses (RNs). Medication administration is one such example. These changes, while addressing issues of nursing shortages and workforce flexibility, have also resulted in increasing role confusion between RNs and ENs, creating issues around appropriate delegation and adequate supervision.

Aim:The study aim was fourfold. First to understand the impact of changes to the EN scope of practice by investigating the extent of the EN’s role in medication administration, as well as patient admission and assessment, within a contemporary team nursing model of care. Second, to explore and understand the current model of team nursing within the study hospital whose staffing mix was 70% RN / 30% EN in acute medical and surgical areas. Third, to explore the impact of broadening of the EN scope of practice by investigating the extent of the EN’s role in the specific activities such as medication administration and patient assessment. Last, to explore the strategies and resources RNs use to underpin their decision making around delegation of tasks and the level of supervision ENs require, in the team nursing model of care.

Methods: An explanatory sequential mixed two-phase method design was used. One hundred and ninety-six RNs and ENs participated in the Phase 1 work sampling (quantitative). RNs and ENs working on acute medical and surgical wards with a nursing skill mix of 70% RN/30% EN and who utilised the team nursing model of care were eligible results were used to inform the semi-structured interview guide for Phase 2 where nurses who consented to participate in Phase 1 were invited to participate in Abstract iv either a small focus group discussion or interview (Phase 2). Nurse managers were also invited to participate, as were members of the Nursing Executive team.

Results: Phase 1: Eight medical and surgical wards met the inclusion criteria. A total of 9376 activities were documented during 225 hours of observation across 30 shifts. Of the 9376 documented activities, 2709 (28.9%) were classified as direct care, 5304 (56.6%) indirect care, 486 (5.2%) unit-related and 877 (9.4%) as personal activities. The proportion of time involved in all activities were remarkably similar between RNs and ENs. Enrolled nurses spent a higher proportion of their time performing direct care activities of ‘Admission and Assessment’ than RNs (12.8% vs 11.2%) and ‘Medications and IV administration’ (6.8% vs 6.2%). Phase 2: Twenty-four nurses were involved; seven ENs, six RNs, two Clinical Nurses (CNs), five Nurse Managers (NMs) and four members of the Nursing Executive team. Four predominant themes emerged: ‘everyone else is making their own definitions’, ‘share and support’, ‘challenges’ and ‘success of failure: what matters?’. Team nursing was interpreted and implemented differently across wards. Enrolled nurses often worked in a patient allocation model of care with relative autonomy. Enrolled nurses were viewed as equivalent to RNs, such was the degree of blurring between the two roles. Evidence of poor delegation practices resulted in occasions when ENs found themselves working outside of their scope of practice. The requirement for supervision of the EN was poorly understood by both RNs and ENs. Leadership, communication and backup behaviours were identified as crucial to the success of team nursing.

Conclusion: The scope within which ENs practice grows ever wider, reaching into the domains once reserved for the skills of registered nurses. Medication administration is a prime example. The finding that ENs in this study spent a greater proportion of their workday involved in medication administration than did RNs, reflects a large-scale change to the EN scope of practice. This broadening of EN scope of practice, while addressing Abstract v issues of nursing shortages and workforce flexibility, has also resulted in increasing role confusion between RNs and ENs, to the point where nurses of all classifications are unable to discern any substantial difference between the two roles. Leadership, communication, delegation and supervision practices all suffer with a lack of role clarity, ultimately adversely impacting on effective teamwork and the success of the team nursing model of care. Clarifying the scope of practice differences between RNs and ENs is vital in ensuring the safe and efficient delivery of patient care.

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