An exploration of similarities and differences in registered and enrolled nurse pre-registration education and role expectations on graduation

Two levels of nurse are employed in Australia to deliver patient care. Registered Nurses (RNs) have been regulated in the state of Victoria since 1923. Enrolled nurses (ENs) were introduced into the nursing workforce in the 1960s in response to economic pressures and shortages of RNs. The last ten years has seen significant changes to the scope of practice (SOP) of both ENs and RNs. Changes to the SOP of ENs, to enable them to utilise a larger skill set and undertake enhanced roles, have led to modifications in their educational preparation, with preregistration education increasing from certificate to diploma level. The increasing number of skills and diversity of roles of ENs have led to overlapping of roles between ENs and RNs, resulting in role confusion and ambiguity between the two levels of nurse. However, little research has been undertaken to understand differences in educational preparation and resulting graduate role expectations of the two levels of nurse. In this thesis by partial publication, findings are reported from a multi-phase mixed methods research project which aimed to investigate differences and similarities in educational preparation and resulting role expectations of RNs and ENs in Victoria, Australia. The research utilised four separate phases to explore different perspectives: Phase 1: comparison of RN and EN curricula content, educational philosophies, curriculum design, and educational teaching and learning approaches; Phase 2: nursing course coordinator expectations of RN and EN student education and role outcomes; Phase 3: EN and RN nursing students’ expectations of their graduate roles; and Phase 4: senior nurse expectations of graduate RN and EN roles on commencement to clinical practice. Analyses of data were undertaken using various techniques including thematic, content, descriptive and statistical analyses. Similarities were found between certificate, diploma and degree level nursing courses in terms of educational topics, basic patient care skills, and student role expectations. Although similarities existed, differences in entry criteria, educational focus, teaching and learning approaches, some clinical skills and role expectations on graduation have led to considerable variation in student outcomes between graduates of the three course levels. The three nursing programs were found to prepare graduates for different roles and career expectations. The greater depth of knowledge and critical thinking ability of degree-prepared RN graduates was seen to enable them to care for patients of a higher complexity. Considerable variation between workplaces exists in practice expectations of ENs. Although no specific role was identified only for the graduate EN, the role of caring for complex, acute or deteriorating patients was specific for RNs. Graduates from both EN and RN programs expected to undertake skills in clinical practice which senior RNs felt were outside their abilities. Confusion and ambiguity in role expectations of ENs remains an issue for nurses in Victoria. Previous to this study, no research had focused on understanding differences in educational preparation of the different levels of nurse registered to practice in Australia. This research has addressed this gap, identifying considerable differences in educational preparation and role expectations between EN and RN graduate nurses. This research helps to inform educators, clinicians and students regarding differences and similarities in the educational preparation of ENs and RNs and how they are prepared for different levels of practice. This may influence how skill mix is determined in clinical practice, particularly in acute areas, and how allocation of patient care is undertaken to ensure optimal patient care and safety. It is concluded that RNs must be available in all clinical areas in high enough numbers to enable supervision of ENs and ensure deterioration of patient conditions is detected and managed.