Defining the scope of practice of enrolled nurses in medication administration in Australia: A review of the legislation

Article Outline

• Summary
• Introduction
• Literature review methodology
• Findings
  • Scope of practice
  • Scope of practice in medication administration
  • Queensland
  • New South Wales
  • Victoria
  • Western Australia
  • Tasmania
  • South Australia
  • Australian Capital Territory
  • Northern Territory
• Discussion
• Conclusion
• References
• Copyright

Summary 

Changing workforce patterns and changes in models of care delivery have renewed interest in the role of the enrolled nurse in Australia. A number of major reviews have confirmed the enrolled nurse as an integral member of the Australian health workforce and identified that the role of enrolled nurses is expanding in many practice settings. Medication administration is increasingly being delegated to enrolled nurses raising issues related to role, scope of practice, educational preparation, competence and delegation and supervision of nursing activities. Published reports and studies have identified a range of issues related to scope of practice nurses in Australia that have prompted the development of decision-making frameworks and a range of policies and guidelines to better define practice parameters. A review of the literature and documents available from various Australian nursing regulatory bodies related to medication administration by enrolled nurses was undertaken to determine the scope of practice of enrolled nurses in medication administration in Australia. The review confirmed that there is considerable variation in practice between jurisdictions, individual health care settings and on a daily basis in clinical practice. Despite the availability of a number of policy and practice guidelines, there is limited evidence on how they are used in clinical practice and the impact of variable policies on registered and enrolled nursing practice.

Keywords: Enrolled nurse, Scope of practice, Regulation, Delegation, Supervision

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Introduction 

Internationally, there have been significant changes in models of care delivery with the United Kingdom and New Zealand phasing out enrolled nurse training and no longer registering nurses in the classification (Dixon, 2001, Webb, 2000). Changing workforce demographics and increasing pressure to provide quality health care have meant that current models of health care delivery are no longer meeting service needs. The current environment of rapid medical and technological advances, an increasing focus on primary health care, illness prevention and community-based care, increasing expectations of consumers and financial constraints has forced health care managers to rethink and review how health care is provided and delivered (Gibson & Heartfield, 2003; Heath, 2002; Lawson & Collison, 2004; Milson-Hawke & Higgins, 2003; Queensland Nursing Council, 1995).

New Zealand initially phased out the second-level (enrolled nurse) classification, but has reintroduced the classification following a review of the scope of practice (Dixon, 2001). The United Kingdom now considers all nurses to be registered nurses with no distinction between enrolled nurses and registered nurses. Enrolled nurses are registered on a second level of the register and are expected to work under the Code of Professional Conduct of the Nursing and Midwifery Council (Nursing & Midwifery Council, 2006; United Kingdom Central Council for Nursing Midwifery and Health Visiting, 2000). Many enrolled nurses undertook conversion programs to move to the first level of the register, but some enrolled nurses have, for various reasons, not converted to the higher register and are still practising as enrolled nurses in the United Kingdom (Webb, 2000).

In Australia, there has been no change to the classification of Enrolled Nurse. Apart from Victoria, all Australian States and Territories maintain separate registered nurse and enrolled nurse registers. In Victoria, all nurses are recorded on the same register with Division 2 the equivalent to Enrolled Nurse in other states. In this paper, the term “Enrolled Nurse” refers to Division 2 Nurse and Enrolled Nurse classifications. Enrolled nurses are prepared in the Vocational and Technical Education sector. Up until 2007 each state has had separate state accredited programs. The new Health Training Package (HLT07), endorsed in February 2007, provides the first national framework for the pre-registration preparation of enrolled nurses in Australia. The eight Australian nursing regulatory bodies register enrolled nurses for practice and, under mutual recognition, enable enrolled nurses to register to practise anywhere in Australia and New Zealand once initial registration has been gained on completion of entry qualification (Mutual Recognition Act (Cth) 1992; Trans-Tasman Mutual Recognition Act (Cth) 1997).

Recently, there has been renewed interest in the role of the enrolled nurse in Australia. Increasing numbers of enrolled nurses in the workforce and the changing roles of enrolled nurses has raised questions about the role and scope of the enrolled nurse in clinical practice. In the last few years, there have been a number of significant reports (Heath, 2002) and studies related to the role and scope of practice of enrolled nurses (Department of Health Western Australia, 2005, Gibson and Heartfield, 2003; Koutoukidis, 2005, nursesboardsouthaustralia, 2006a, Queensland Nursing Council, 1998). These reports and studies have confirmed the enrolled nurse as an integral member of the Australian health workforce and identified that enrolled nurses are expanding, extending or advancing their scope of practice in many practice settings. To assist nurses clarify and determine scope of practice, Australian state or territory nursing regulatory bodies and professional nursing organizations have developed decision-making frameworks, professional competency standards and practice guidelines to set parameters around enrolled nursing practice in their jurisdiction and to assist registered and enrolled nurses determine and differentiate the scope and practice of the registered and enrolled nurse.

Invariably, any discussion of enrolled nurse scope of practice gravitates to the role of the enrolled nurse in medication administration (Gibson & Heartfield, 2005; Heath, 2002, Milson-Hawke and Higgins, 2003) and secondly to issues related to broader constructs of scope of practice, role, educational preparation, competence, delegation of care and supervision. Some states or territories formally recognize advanced or extended practice through an endorsement process; while others leave it to individual health care facilities to establish the parameters of practice.

This paper provides a review of the policies and guidelines that the various Australian nursing regulatory bodies have developed to define and guide the scope of practice of enrolled nurses in medication administration in Australia.

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Literature review methodology 

Google Scholar was used for an initial broad search of the literature. A refined search used the nursing and health databases CINHAL, Pubmed, Meditext, Health and Medical Direct, Science Direct, Journals@ovid and ERIC followed the initial search. The search was limited to articles in English and year of publication from 1999 to 2006. Advanced keyword searches using combinations of the terms the enrolled nurs*, div* two nurs*, scope of practice, medication administration, delegation and supervision yielded less than 50 articles with CINHAL, Pubmed and Google Scholar the most useful sources. Reference lists of articles, reports and practice guidelines were also scanned for additional references. The literature search confirmed reports that there is limited literature related to the enrolled nurse or enrolled nursing practice in Australia (Australian Nursing Federation, 2005; Milson-Hawke & Higgins, 2003).

All Australian state or territory nursing regulatory bodies websites were searched for documents relating to scope of practice, enrolled nurse medication administration, decision-making frameworks and delegation or supervision. Some state nursing bodies had a range of documents, while others had only one or two. A search of the websites of professional organizations including the International Council of Nurses, Australian Nursing and Midwifery Council, Royal College of Nursing Australia, Australian Nursing Federation and the Community Services and Health Industry Skills Council was also undertaken. Articles, reports and documents that related to the role and scope of practice of enrolled nurses in medication administration in Australia were selected for inclusion.

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Findings 

Scope of practice 

Defining the scope of practice for nurses is a nursing responsibility (International Council of Nurses, 2004). National nursing bodies have a key role in defining the scope of practice of nurses that are consistent with the definition expressed by the International Council of Nurses (ICN) and the legislative and regulatory frameworks and health needs of the relevant jurisdiction. Individual nursing roles are defined by “educational preparation, experience, skills and knowledge in context of practice” and are not restricted to “specific tasks, functions or responsibilities” (International Council of Nurses, 2004). In Australia, the Australian Nursing and Midwifery Council (ANMC) has developed national competency standards for registered and enrolled nurses (Australian Nursing & Midwifery Council, 2002; Australian Nursing & Midwifery Council, 2005) that reflect the ICN position statement and are frequently referred to in definitions of scope of practice for nurses practising in the Australian context.

Over the last decade, there has been, and is continuing to be, a considerable amount of work done to determine and define the roles and scopes of practice of the various levels of nurses in Australia (Australian Nursing & Midwifery Council, 2002; Australian Nursing & Midwifery Council, 2007a). These reports and studies have identified a number of issues related to enrolled nurse practice in Australia including

Not surprisingly there is confusion, blurring and ambiguity around the different nursing roles and definitions of scope of practice and a perceived similarity of role between registered and enrolled nurses (Gibson & Heartfield, 2003; Gibson & Heartfield, 2005; Heartfield & Gibson, 2005; Heath, 2002, Kimberley et al., 2004; Milson-Hawke & Higgins, 2003; Milson-Hawke & Higgins, 2004; Queensland Nursing Council, 1995, Stringer, 2006). The literature reveals that enrolled nurses experience frustration and dissatisfaction, feel undervalued and consider that there is a lack of respect and recognition of their contribution to health care delivery across all health care settings (Gibson & Heartfield, 2003; Gibson & Heartfield, 2005; Hannan & Berryman, 2001; Heartfield & Gibson, 2005; Heath, 2002; Milson-Hawke & Higgins, 2003; Milson-Hawke & Higgins, 2004) and that both registered and enrolled nurses experience frustration in making clinical practice decisions (Gibson & Heartfield, 2003; Milson-Hawke & Higgins, 2004). The role and scope of practice of enrolled nurses is also perceived to fluctuate according to workforce variations in the supply of registered nurses and employment of increasing numbers of unlicensed health care workers.

Within the nursing profession there is increasing pressure from enrolled nurses to increase, expand or advance their scope of practice (Australian Nursing Federation, 2005; Gibson & Heartfield, 2003; Heath, 2002, Kimberley et al., 2004; Milson-Hawke & Higgins, 2003; Milson-Hawke & Higgins, 2004) as well as workplace pressures for enrolled nurses to expand their roles. In many cases, enrolled nurses are reportedly being asked to practise beyond their educational preparation and level of competence without appropriate post-graduate education or professional development to prepare for advanced or extended practice (Gibson & Heartfield, 2005; Hannan & Berryman, 2001; Milson-Hawke & Higgins, 2003; Milson-Hawke & Higgins, 2004). Conversely enrolled nurses also report that, in some instances, they are unable to practise at the level for which they have been educationally prepared (Australian Nursing Federation, 2005; Gibson & Heartfield, 2005; Milson-Hawke & Higgins, 2004). Variable policies and guidelines and differences in interpretation and application of policies and guidelines, create practice issues related to delegating nursing care and supervising delegated work that are a major factor in the disparity of enrolled nurse scope of practice in Australia (Gibson & Heartfield, 2003; Gibson & Heartfield, 2005; Heartfield & Gibson, 2005; Kimberley et al., 2004; Milson-Hawke & Higgins, 2003; Milson-Hawke & Higgins, 2004). Enrolled nurses are also reported at times to be placed in untenable situations where they are required to work outside their scope of practice to meet the immediate patient needs because there is no one else to do the work, to maintain a harmonious workplace or because they feel too uncomfortable or intimidated to decline the delegated work (Gibson & Heartfield, 2005; Heartfield & Gibson, 2005; Milson-Hawke & Higgins, 2004).

In an attempt to resolve the difficulties and issues that have been identified, the various nursing regulatory authorities and national nursing organizations have developed a range of strategies to assist nurses determine the scope of practice of registered, enrolled nurses and unlicensed health workers. Queensland has led the way with the development of a decision-making framework (Queensland Nursing Council, 2005c) with Western Australia and Tasmania adopting a similar approach (Department of Health Western Australia, 2005, Nursing Board of Tasmania, 2006b). South Australia (nursesboardsouthaustralia, 2006a) and Victoria have begun projects to review and develop an enrolled nurse scope of practice framework; but New South Wales and the Northern Territory have not yet initiated projects to develop frameworks (Australian Nursing & Midwifery Council, 2006). The Australian Capital Territory has previously implemented a scope of practice framework, but it is not currently available. Following the increasing national trend to implement decision-making frameworks and in line with recommendations made in the National Review of Nursing Education (Heath, 2002), the Australian and Nursing Midwifery Council has recently developed a national decision-making framework to assist determine the scope of practice of nurses and unlicensed health care workers in the health workforce (Australian Nursing & Midwifery Council, 2007a).

Scope of practice in medication administration 

There is considerable variation in the scope of practice of enrolled nurses in medication administration across Australia (Australian Nursing Federation, 2005; Gibson & Heartfield, 2005; Gibson & Heartfield, 2003. Griffiths & Forrester, 2002; Grant, 2006). The current review of enrolled nurse practice in South Australia (nursesboardsouthaustralia, 2006a) has identified that medication administration by enrolled nurses is “arguably the most contentious and least understood area of enrolled nurse practice with significant variance in legislation, regulation and practice across Australia” (p. 7). Each state or territory has legislation that regulates management of drugs and poisons and various disciplines in the health workforce. Regulations under the acts empower the nursing regulatory bodies in the various jurisdictions to establish requirements for nursing practice (Griffiths & Forrester, 2002). Underpinning the various legislative frameworks are a range of regulatory and organizational policy guidelines that define and prescribe enrolled nurse scope of practice in medication administration (ACT Nursing & Midwifery Board, 2005; Department of Health Western Australia, 2005, Health Professionals Licensing Authority, 2006, New South Wales Health, 2004, Nurses Board of Victoria, 2006, nursesboardsouthaustralia, 2002b, Nursing Board of Tasmania, 2004, Queensland Nursing Council, 2005b). Some states have established processes that enable enrolled nurses to expand their scope of practice in medication administration through an endorsement on the practising certificate or license (Department of Health Western Australia, 2005, Nurses and Midwives Board of New South Wales, n.d., Queensland Nursing Council, 2005b). However, the scope of practice of enrolled nurses in medication administration is variable between Australian states and territories and enrolled nurses moving between individual states and territories are required to make separate applications to the nursing regulatory for medication endorsement as they move from state to state or territory. While there appears to be no mutual recognition of medication endorsement between jurisdictions, education programs completed in other states may be recognized as appropriate preparation for medication endorsement by the individual state or territory boards. The NT Nursing and Midwifery Board guideline is the only regulatory document that specifically states that medication endorsement in another state is not recognized in that jurisdiction (Health Professionals Licensing Authority, 2006). Table 1 provides a summary of the various parameters of enrolled nurse scope of practice in medication administration across Australia. A summary of the medication administration scope of practice parameters for each state and territory is provided below. Table 1 summarizes the key points.

Table 1. Nursing regulatory authorities’ parameters of enrolled nurse scope of practice in medication administration in Australia

^*Policy amended 2006 to included S8 medications; ^#EN scope of practice currently under review.

Queensland 

In Queensland, enrolled nurses with a current license to practise have legislative authority to administer Schedule 2 (S2) and Schedule 3 (S3) medications (Queensland Nursing Council, 2005b). The Queensland Nursing Council (QNC) has further provision to endorse enrolled nurses to broaden their scope of practice in medication administration based on the principles outlined in a decision-making framework (Queensland Nursing Council, 2005b, Queensland Nursing Council, 2005c) and the ANMC National Competency Standards for registered and enrolled nurses (Australian Nursing & Midwifery Council, 2002; Australian Nursing & Midwifery Council, 2005). The actual scope of practice of individual enrolled nurses in Queensland is determined by the context of practice and their skill, knowledge, experience, competence and what is delegated by the registered nurse.

All enrolled nurses in Queensland have authority to administer S2 and S3 medications, including PRN medications under certain conditions but medication endorsed enrolled nurses have authority to administer some S4 (restricted) medications as identified in the drugs and poisons legislation that applies in Queensland (Queensland Nursing Council, 2005b, p. 3). In 2006, the policy was amended to include Schedule 8 medications in the scope of practice for medication endorsed enrolled nurses (Queensland Nursing Council, 2006). Medication endorsed enrolled nurses have authority to administer substances by intramuscular or subcutaneous injection and to provide care for patients receiving intravenous therapy through peripherally sited intravenous lines (excluding peripherally inserted central lines), including intravenous fluids containing medications or being administered through a burette (Queensland Nursing Council, 2005b, p. 6). Nursing care activities related to intravenous therapy include preparing intravenous lines, changing the rate of infusion (excluding cytotoxic infusions), changing bags of fluids, including those containing additives, blood and blood products and filling a burette with intravenous fluid containing medication or other substance (but excluding cytotoxic substances) providing all fluids, including blood and blood products, are checked with a registered nurse or doctor. All enrolled nurses can check medications (Queensland Nursing Council, 2005b, p. 7) but enrolled nurses who are not endorsed may have limitations in their knowledge of medications used in practice and the indications, contraindications and adverse effects that may result from their use.

New South Wales 

In New South Wales, only endorsed enrolled nurses are authorized to administer medications (New South Wales Health, 2004, Nurses and Midwives Board of New South Wales, n.d.). The Nurses and Midwives Board of New South Wales endorses enrolled nurses to administer medications under certain conditions following approval to extend the role of enrolled nursing practice by the New South Wales Health Department (New South Wales Health, 2004). Medication endorsed enrolled nurses in New South Wales are authorized to administer up to Schedule 4, but excluding Schedule 8 medications, if the enrolled nurse is recognized by the employer as having completed the requirements for endorsement and they are accredited every year by the employer, are working under the supervision of a registered nurse and there is a valid order for the medication. Individual health services are responsible for developing and having in place, policies relating to the role of the enrolled nurse in medication administration, including their role in intravenous medication (New South Wales Health, 2004). Enrolled nurses may administer nurse initiated medications if the drug is on the facility's list of approved drugs, the enrolled nurse has confirmed with the registered nurse that the medication is appropriate and that the administration is recorded appropriately (Nurses and Midwives Board of New South Wales, n.d.). Following requests from industry and professional organizations, the Nurses and Midwives Board New South Wales is currently seeking legal advice regarding the delegation of administration of medications to enrolled nurses (Nurses and Midwives Board of New South Wales, n.d.).

Victoria 

Enrolled nurses in Victoria are endorsed to administer medications by approved enteral or topical routes under the supervision of registered nurses if there is a valid order (Nurses Board of Victoria, 2006). PRN medications may be administered where there is a valid order, including nurse-initiated orders provided the task is delegated by a registered nurse. Enrolled nurses are not able to accept telephone or verbal medication orders. Health care facilities are responsible for having in place policies, procedures and protocols to support the extended role of medication endorsed enrolled nurses, including their role in checking medications. Enrolled nurses in Victoria do not currently have a role in the administration of parental medications; however Nurses Board of Victoria is currently reviewing the guidelines related to enrolled nurse medication administration (Grant, 2006).

Western Australia 

In Western Australia, the role of the enrolled nurse in medication administration is clearly outlined in the industrial agreement which governs enrolled nurses (Department of Health Western Australia, 2005). The policy is transferable across public hospitals in that state and is implemented under a decision-making framework (Nurses Board of Western Australia, 2004). Enrolled nurses can administer Schedule 2, 3 or 4, but not Schedule 8 medications. Expanded enrolled nurse practice includes intravenous administration of medications (Nurses Board of Western Australia, 2006).

Tasmania 

The Nursing Board of Tasmania endorses enrolled nurses to administer Schedule 2, 3 and 4 medications by routes other that injection where there is a valid order and they are under the indirect supervision of a registered nurse (Nursing Board of Tasmania, 2004). Administration of medications by subcutaneous and intramuscular injection must be in close proximity to a registered nurse or medical or dental practitioner. PRN and variable dose medications may be administered by enrolled nurses under indirect supervision, in consultation with a registered nurse and providing there is a clearly documented order for the medication. Enrolled nurses do not have a role in the preparation and administration of intravenous therapy, but may check Schedule 8 medications.

South Australia 

The nursing regulatory authority in South Australian (Nurses Board South Australia) does not endorse enrolled nurses for medication administration and currently does not have any clear parameters for the role and scope of practice of the enrolled nurse in medication administration in that state. However, the current review of the enrolled nurse scope of practice (nursesboardsouthaustralia, 2006a) is seeking comment from key stakeholders regarding issues to be considered to enable enrolled nurses to administer oral medications up to and including Schedule 4 in the workplace and the role and scope of practice of enrolled nurses in intramuscular, intravenous and Schedule 8 medications. The current standards for medication administration issued by the Board (nursesboardsouthaustralia, 2002b) reflect the legislative framework and the “increasing complexity and scope of nursing practice, the changes to nursing educational preparation and the accountability and autonomy of nurses in decision making for the delivery of client oriented care” (p. 2). Enrolled nurses in South Australia can seek authorization to practice without the supervision of a registered nurse within the scope of their practice, but there are no guidelines related to medication administration in these circumstances (nursesboardsouthaustralia, 2002a).

Australian Capital Territory 

The ACT (Australian Capital Territory) Nursing and Midwifery Board authorizes enrolled nurses to administer Schedule 2, 3 and 4 medications by enteral and topical routes including transdermal applications, eye and ear medications and subcutaneous and intramuscular injections (ACT Nursing & Midwifery Board, 2005). Enrolled nurses are not permitted to administer intravenous or Schedule(S) 8 medications, but may check S8 medications if they have completed an approved course. PRN medications may be administered by an enrolled nurse in collaboration and under the direct supervision of a registered nurse. Enrolled nurses may also administer vaccinations if they have completed training as identified in the current national guidelines (National Health & Medical Research Council, 2003) and comply with the national guidelines and procedures.

Northern Territory 

In the Northern Territory, the legislation provides no guidelines or direction in relation to enrolled nurses administering medications, but the relevant act is under review (Health Professionals Licensing Authority, 2006). The Nursing and Midwifery Board does not endorse enrolled nurses in medication administration, but has issued information related to enrolled nurses and medication administration. The Board places no restrictions on the role and scope of practice of enrolled nurses apart from stating that they must be competent in medication administration and work under the supervision of registered nurses and in accordance with workplace policies and guidelines. Medication endorsement elsewhere in Australia does not automatically mean that enrolled nurses can include medication administration in their scope of practice in the Northern Territory (Health Professionals Licensing Authority, 2006). Medication administration by enrolled nurses was identified as an issue for resolution in a joint Australian Nursing Federation (ANF) and Northern Territory Department of Health and Community Services Nursing Certified Agreement Taskforce established in 2004 to address a number of items outstanding from previous enterprise bargaining agreements in the Northern Territory (Nursing Certified Agreement Taskforce, 2004–2006). The findings and outcomes of the Taskforce are yet to be finalized and reported (ANF NT Branch, M. Gardiner, personal communication August 30, 2006).

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Discussion 

The various medication policies and guidelines developed by the Australian states and territories refer registered and enrolled nurses, either directly or through scope of practice decision-making frameworks, to workplace policies and guidelines for clarification of their role in medication administration. Western Australia is the only jurisdiction that demands health care facilities “adopt policies that allow enrolled nurses who are medication competent to carry out the administration of medications in Schedules 2, 3 and 4” (Department of Health Western Australia, 2005, p. 10) in accordance with directives from the Department of Health Western Australia. The respective state or territory legislation and nursing regulatory authorities place responsibility on the health care facilities in their jurisdiction to ensure workplace policies and guidelines are in place to guide and define the practice parameters of enrolled nurses and other health care workers in their facility. The way these workplace policies relate to the role and scope of practice of enrolled nurses varies from workplace to workplace, ward to ward and shift to shift (Gibson & Heartfield, 2003; Milson-Hawke & Higgins, 2004; nursesboardsouthaustralia, 2006a) and contribute to the confusion and dissatisfaction expressed by registered and enrolled nurses.

Every Australian jurisdiction clearly identifies that enrolled nurses work under the direction and supervision of registered nurses and that registered and enrolled nurses are accountable for their own practice and responsible for their own actions (Australian Nursing & Midwifery Council, 2002). The decision-making frameworks in Queensland (Queensland Nursing Council, 2005c), Western Australia (Nurses Board of Western Australia, 2004) and Tasmania (Nursing Board of Tasmania, 2006a) are designed to provide a systematic, objective process for determining if health care workers have the required education and experience in the practice setting to undertake specific nursing activities in consideration of the legislation, regulatory and organizational policy and the individual needs of the patient. The process also allows for nurses to advance or expand their scope of practice in “planned and structured way” (Queensland Nursing Council, 2005c, p. 3) and supports the professional accountability of individual nurses to make decisions in practice and remove “artificial barriers” (Nurses Board of Western Australia, 2004, p. 9) that have limited enrolled nurse practice in the past.

The final determinant of the scope of practice of enrolled nurses in medication administration and other nursing care activities in clinical practice settings is the registered nurses delegating and supervising nursing care in clinical practice settings (Kimberley et al., 2004). Although the scope of practice of enrolled nurses needs to be flexible and responsive to the needs of individual practice settings (despite the desire of some nurses to prescribe the role and functions of enrolled nursing practice) (Gibson & Heartfield, 2005) where there is a lack of clear policies and guidelines there is evidence that enrolled nurses are determining their own scope of practice and undertaking nursing care activities that they feel comfortable with and where they feel they are not “overstepping the mark” (Milson-Hawke & Higgins, 2004, p. 49). The findings of Milson-Hawke and Higgins (2004) are significant and worrying to nurses and nursing as they are contrary to state and territory legislative and regulatory guidelines and the Australian Nursing and Midwifery Competency Standards for Enrolled Nurses (Australian Nursing & Midwifery Council, 2002) that clearly state that enrolled nurses work under the direction and supervision of registered nurses.

Legislation, regulatory guidelines and policies and decision-making frameworks in the various Australian states and territories and the ANMC National Competency Standards for registered and enrolled nurses all clearly state that registered nurses have a responsibility to directly or indirectly supervise enrolled nurses. Direct supervision generally means that the registered nurse is present with the enrolled nurse while the nursing activity is undertaken and indirect supervision is generally interpreted as the registered nurse being available in the health facility to provide guidance, support and monitoring of activities (Australian Nursing & Midwifery Council, 2007a; nursesboardsouthaustralia, 2006a).

While the various Australian decision-making frameworks and policy guidelines offer principles and guidelines for delegating and supervising work, there is little research evidence or discussion about what nurses understand of their role and responsibilities in delegating and supervising work, how nurses delegate and supervise work and the skills and abilities that nurses need to effectively delegate and supervise nursing care activities (Anthony, Standing, & Hertz, 2001; Quallich, 2005). Gibson and Heartfield (2005), drawing on findings of a national review, found that there is considerable variation around how work is delegated and level of supervision in clinical practice.

Anthony et al. (2001) investigated how American nurses (registered licensed practical nurses and vocational nurses) rate their abilities in relation to delegation and supervision of unlicensed health care workers undertaking direct nursing care activities and whether educational preparation, experience, context of practice, job responsibilities and geographical location have any influence on their ability to delegate and supervise nursing care. Nurses considered that they were comfortable and well prepared to delegate work and had confidence in delegating work despite an identified lack of educational preparation for the role (Anthony et al., 2001). Nursing experience and functional role were significant in determining how often nurses delegated work, their level of control over delegation and how comfortable they were in delegating work.

While decision-making frameworks have been found to provide nurses with a useful tool to determine scope of practice (Australian Nursing & Midwifery Council, 2007a; Davies & Fox-Young, 2002) and support the expansion of enrolled nursing practice, the variations between the policies and guidelines of the various Australian jurisdictions and health care facilities as well as the interpretation and application by individual nurses contribute to the general dissatisfaction and confusion around the role of the enrolled nurse in Australia. The role and scope of practice of the enrolled nurse in medication administration continues to be a contentious issue and highlights many of the problems facing registered and enrolled nurses in clinical practice in local and national arenas. National reviews (Heath, 2002, Lawson et al., 2005; Productivity Commission, 2005) have identified the need to develop national consistency in legislation and regulation of nursing, defining the scope of practice of nurses and the educational preparation of nurses to address some of the variability and inconsistency in nursing regulation and practice that impacts on the provision of health care in Australia. It remains to be seen whether the proposed moves to national registration (Australian Nursing and Midwifery Council, 2007b) and the new units of competency in medication administration in the new Health Training Package (HLT07) have any impact on the definition and consistency of scope of practice of enrolled nurses in medication administration.

Despite the findings of significant projects and reviews commissioned to investigate the role and scope of practice of nurses and the implementation of tools and strategies to address the identified issues (for example the recently completed Queensland Nursing Council evaluation of the decision-making framework implemented in 1998 framework, Queensland Nursing Council, 2005a), there is little published evidence of how nurses implement and use decision-making frameworks and apply the regulatory policies and guidelines in clinical practice.

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Conclusion 

There is limited evidence of how the guidelines and polices related to medication administration by enrolled nurses are understood and used in clinical practice to determine the scope of practice of individual enrolled nurses. The impact of variable regulatory and workplace policies on registered and enrolled nurses is also not well reported. The issues that arise in clinical practice related to the administration of medications by enrolled nurses frequently reflect broader practice issues that impact on patient outcomes, the quality and safety of nursing care, the educational preparation of nurses, health service provision and health workforce planning. The purpose of this paper has been to explore the regulatory guidelines that apply in Australia to define and guide the scope of practice of enrolled nurses in medication administration in Australia. Further investigation of the role and scope of practice of enrolled nurses in medication administration in Australia is needed to expand and clarify the findings identified in the literature.

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