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A response to MOH discussion document:
May 2001
This response is collated from:
* Responses to the interactive feedback set up on the College of Nurses
website
* Responses from the circulation to all Regional Co-ordinators of the
College
* Review by members of the Academic Committee and Board of the College.
In Summary
1. We support the introduction of competencies, regulation and training
for a Second Level Health Worker to assume aspects of patient care traditionally
undertaken by nurses, but only in non acute settings. In acute settings
this person is more usefully employed to contribute to the context in
which nursing occurs.
2. We do not support the use of the term "enrolled nurse" or
"nurse" in line with this health worker nor the implication
that the Second Level Health Worker is a nurse. It is misleading to use
the same title for a person who has a three year degree and full accountability
for practice and a person who has a brief procedural training and is supervised
in their tasks.
3. We are concerned that the use of the term Nurse in this discussion
paper will distort the responses to this paper and perpetuate the confusion
in the sector that this issue is about support or otherwise for existing
enrolled nurses rather than a plan for a future workforce.
General comment
Many responding to this document have simply stated that they wish to
see no reactivation of the enrolled nurse position and scope. They cite
the considerable evidence that has been utilised to demonstrate that this
is not an appropriate response to workforce concerns within nursing.
We prefer therefore to first raise questions beyond those requested by
the document.
1. Where will they work?
The document states clearly and accurately that the imagined role is not
suitable for employment in an acute setting. The mental health sector
has stated unequivocally that they see no position or place for a second
level nurse.
Midwives are very clear that one is either a midwife or one is not, but
there is no room for second level people in midwifery related settings.
The profession is clear that with the imminent development and extension
of nursing in primary health care roles there is no place for a partially
prepared professional in the community.
The document is clear and appropriate in stating that a second level nurse
would be supervised by registered nurses.
Where, we then ask, will this group be employed? It is unlikely that the
aged care sector will employ second level nurses, AND enough registered
nurses to provide appropriate supervision. The College is concerned that
funding will be invested in preparing a semi-trained nurse for whom no
real role or employment exists.
2. What will they be called?
We are aware that a decision on the title of the second level worker has
not been finalised. The terms nurse and second level health worker are
not synonymous and presenting a discussion document where they are represented
as synonymous simply demonstrates the problems which will persist if this
issue is not appropriately resolved. For instance in the submission process
to this document, reviewers cannot be sure the responses given refer to
an EN or to both levels of workers.
Some members of the profession have argued that patients fare best when
cared for by a person who is aligned with nursing, trained by nursing
and supervised by nursing to ensure reliable standards, oversight and
levels of accountability. We suggest that a name that denotes that the
role is assistive to nursing may satisfy these needs whilst avoiding the
confusion and inaccuracy of calling the person nurse.
College responses to stated questions
These questions are answered from the perspective that this is a second
level worker who is conceptually different from the second level nurse.
1. DO YOU AGREE THAT TRAINING PROGRAMMES FOR THE SECOND LEVEL NURSES SHOULD
BE DELIVERED AT LEVEL 4 - 5 ON THE NZQA FRAMEWORK?
The training and preparation of a second level worker should be to the
level of level 4 on the NZQA framework. Level 5 equates to the first year
of a Bachelor programme and is too advanced, in fact totally inappropriate,
for the level of training for a health care worker.
Requiring delivery at a NZQA level will mean this training can only be
delivered by a NZQA accredited provider. This will incur an additional
cost to DHBs.
We believe that the regulatory authority for these health workers needs
also to approve the training programme i.e. Nursing Council.
We further argue that this training should be nationally standardised
but may best embrace differential modules relevant to the employment site.
In the event of an unfortunate decision that this worker will be designated
nurse, we DO NOT support the use of unit standards for the training programme.
2. SHOULD THE SECOND LEVEL NURSE'S SCOPE OF PRACTICE INCLUDE 'APPLYING
THE PRINCIPLES OF HEALING PROCESSES'?
The second level workers should work under the delegated authority and
direct supervision of a RN/RM, or other health professional.
Their training should NOT include principles of healing processes. It
requires a sound knowledge base to competently undertake assessments safely
especially with the complex patients in acute clinical areas or consumers
in the community i.e. the aged with multiple co-morbidities.
We believe that all initiated assessment, diagnosis, planning and delivery
of nursing care must remain under the authority of the RN/RM/Health Professional
who is accountable for health outputs and outcomes he/she may delegate
some tasks to the second level worker. The competencies of the second
level worker should emphasise this delegated role not name the tasks.
The principles of supervision and delegation are now clearly outlined
in the relevant Nursing Council document. It is the responsibility of
the health professional to ensure that anyone to whom they delegate tasks
has the knowledge and ability to undertake the task.
3. SHOULD THE SECOND LEVEL NURSE'S SCOPE OF PRACTICE INCLUDE 'THE HANDLING
OF MEDICATIONS'?
No. If the patient is well and stable enough for a health worker to administer
medicines then they are able to self medicate. If this is not the case
then they will require more qualified supervision to oversee the process
and their response.
Administration of medications is the responsibility of the registered
nurse/midwife who may delegate aspects of this role as per the supervision
and delegation processes as above.
4. PLEASE COMMENT ON THE COMPETENCIES FOR SECOND LEVEL NURSES OUTLINED
IN THIS DOCUMENT. DO YOU AGREE WITH THESE COMPETENCIES? SHOULD ANYTHING
BE ADDED OR REMOVED?
The competencies do not clarify the boundaries to the scope of practice
of a second level worker. The knowledge specified in competency 1 is too
extensive. A second level worker should deliver care and undertake tasks
according to set procedural guidelines, polices or specifications. They
will not have a knowledge base as described in competency one and three.
Competency 5 in particular is a competency for the RN/RM and is not appropriate
for any second level worker.
5. DO THE COMPETENCIES REFLECT THE NEW ENVIRONMENTS THE SECOND LEVEL NURSE
WILL BE WORKING IN? ARE THERE ANY OTHER THINGS THAT NEED TO BE CONSIDERED?
There is little consideration of the future roles needed in the health
services. To reflect future needs the competencies need to be kept simple,
focus on the role these people will undertake and the fact that they should
work under the delegation and supervision of a health professional who
will frequently but not always be a registered nurse.
The tasks they will undertake will vary from place to place, in different
contexts and change with time. This is an additional reason why designating
this person as a nurse is totally inappropriate.
6. PLEASE COMMENT ON THE PROPOSAL THAT THE SECOND LEVEL NURSE UNDERGO
GENERIC TRAINING FOLLOWED BY CONTEXT SPECIFIC TRAINING. DO YOU AGREE WITH
THIS PROPOSAL?
We envisage that there will be a generic training that will be supplemented
by context specific training occurring concurrently. This is completed
through an apprentice type training where classroom and practice experience
occurs together. There will be ongoing skill development as the person
gains experience and expertise in the specific area.
The worst nightmare present in the long standing debate about second level
nursing is the NZNO proposal that a second level nurse will specialise
and be integrated on to the clinical career pathway for registered nurses.
If implemented this will ensure many more years of tension, role confusion
and conflict, not to mention inappropriate deployment of inadequately
trained personnel.
7. ARE THERE ANY OTHER ISSUES THAT SHOULD BE ADDRESSED IN THIS DOCUMENT?
The document lists an assumption (5) that this programme should be a training
pathway that prepares these people to progress into further training e.g.
nursing. This training does not give the academic preparation to assist
a person to enter a degree programme.
However working as a second level worker may support an application into
nursing by showing an ability to work in an health care setting with vulnerable
people. This cannot and should not be considered a pre-nursing course
this requires a process to support the development of the academic skills
required to undertake a nursing degree.
We do NOT support the use of RPL for second level workers into the Bachelor
of Nursing degree. The BN degree is already too short and too intense.
It is notable that physiotherapists, occupational therapists and social
workers undertake a four year degree. It is completely unacceptable to
further reduce the period spent in a three year degree programme for registered
nurses.
The length of this programme is important. Currently there is a wide array
of programmes of varying lengths of time. As stated previously this needs
to be an apprentice type programme in the work environment that requires
skill/task focused teaching processes directed to a specific job description.
This should be a short programme individualised to the specific needs.
Ideally this should be completed in 3 to 6 months.
Conclusion
It is the view of the College that the resumption of training for a second
level nurse represents an ill-advised retrograde step that will expend
precious resources for no health gain. This is completely unacceptable
in the current climate where need is so high and resources so constrained.
We believe that the Ministry of Health and the Minister of Health should
respond thoughtfully to the evidence rather than react to the political
lobbying of some members of the New Zealand Nurses' Organisation.
Dr Jenny Carryer
Professor of Nursing
Executive Director CNA(NZ)
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