According to the latest workforce census, there were around 17,000 Enrolled nurses (ENs) working across Australia’s aged care sector in 2020.¹

Enrolled nurses are fundamental members of aged care teams and their work contributes valuably to the care of many older people around Australia.² Many ENs are highly experienced health professionals and provide important leadership and clinical expertise working in collaboration with and under the guidance of registered nurses (RNs) and multidisciplinary teams.

Despite their vital contribution to health and aged care teams, the role of ENs in Australia’s aged care system is poorly defined and fails to recognise the unique contribution to care and the vast experience that ENs offer. Recent reforms, including introducing mandatory direct care minute targets for nursing homes distinguishes between care that is provided by RNs and care from ‘other staff’ and outlines mandatory RN care minute requirements. This legislation, however, neglects to distinguish the care provided by ENs versus care from other staff such as personal care workers (PCWs).³ A consequence of this has been that some aged care providers appear to have made ENs redundant or reclassified them into other, often lower, positions.⁴

To explore and better understand this and other issues facing ENs in Australian aged care, the ANMF released a national survey (22 June-25 August 2023) for staff working in aged care. Key objectives of the survey were to gather the perspectives of particularly ENs regarding the impacts of recent Federal Government reforms including mandated direct care time and RN 24/7 on ENs, their roles, and their work.

Some key findings were:

• 91% of participants reported that an EN worked at their service/facility.
• 35% of participants had been told by a colleague or their employer that there was no funding allocated for ENs as part of the RN 24/7 and care minute funding requirements.
• One-third had been told by their employer that there would be a reduction in EN shifts as a result of this.
• Since October 2022, 35% of participants reported that there was a noticeable reduction in EN shifts.
• Over one-third of participants report that their employer has tried to reclassify EN positions, mostly as lower positions, such as PCWs.
• Participants reported that a reduction in EN shifts would impact their workplace in the following ways: more work for RNs, decreased resident/client safety due to the loss of ENs, and staff working extra hours or extra shifts. Only 6 participants responded that the loss of ENs would have no impact.
• 89% of participants believed that the Federal Government should specify ENs in the care minute funding allocation. Only 5% of participants were not supportive.

The findings suggest that the lack of specification of ENs in aged care funding legislation has led to some providers discounting the unique role of ENs and failing to recognise their contribution to aged care and their ability to offer clinical care beyond what PCWs are trained for. This issue had previously occurred in Tasmania and South Australia in 2022 when the new direct care minute targets were introduced, with a provider making ENs redundant and substituting them with PCWs to save on costs.⁵ This has led to other providers suggesting that as EN care minutes are not specifically included in aged care funding arrangements, ENs are an unnecessary expense. Reducing the number of ENs in aged care, however, is likely to be detrimental to care and safety for the residents as well as an increased burden on other staff.

Results from the ANMF survey reveals that the main duties of an EN greatly vary across direct care, clinical care, and care coordination, and therefore, the loss of ENs is extremely detrimental on the safety of residents and has a significant impact on other aged care staff. Participant responses highlight the diversity of EN roles and the value that their experience can bring.

“… [W]e are the ones on the floor, supervising staff, monitoring the workflow, talking to the families and GPs, administering meds, treating wounds, ordering stock, emailing the GPs, arranging appointments, acting as advocates for staff and residents. We do it all.”­ (EN, SA)

The results highlight the importance of ENs and indicates that providers who would reduce or replace ENs to saving costs could be negatively impacting the quality and safety of care provided to residents and clients. Enrolled nurses are highly trained, regulated health professionals and many ENs possess extensive experience working in health and aged care. The work and roles of ENs are important to the operation of many nursing homes and community care providers, as they perform valuable duties related to healthcare such as health monitoring and assessment, wound care and first aid, assisting RNs in the delivery of medication, and assisting PCWs in hygiene care. Further, while many people might work as EN for the duration of their careers, for some, working as an EN can be an important and helpful ‘step’ towards higher education to become an RN.

Unfortunately, partly due to a lack of empirical evidence that focuses on the contribution of ENs in aged care,^2,6,7 some providers are taking advantage of uncertainty to make ENs redundant, reduce shifts, or reclassify their roles to save money. More research focussing on ENs is needed and broader awareness of the importance of ENs should be raised. Erosion of Australia’s EN workforce is particularly concerning considering ongoing workforce shortages and challenges in attracting and retaining experienced and qualified staff, particularly in regional and remote areas. The results of this survey should serve as a basis for building evidence base to supports the roles of ENs in aged care, highlight their important and valuable contribution, to safeguard EN positions from undue shift reductions, reclassifications, or redundancies.

The ANMF will continue to lobby and work with governments and aged care providers to ensure that ENs remain a valued and critical part of the future aged care workforce. One pathway proposed by a motion put forward at the 2023 Biennial National Conference (which, as with all motions, is yet to be officially endorsed by the ANMF’s Federal Executive) would be though advancing a rationale to specifically mandate EN direct care minutes. As noted by Annie Butler, the misinformation that ENs are not currently funded via the Australian National Aged Care Classification (AN-ACC) funding model must be dispelled as ANMF will actively advocate and lobby for legislative amendments to more clearly and specifically stipulate EN care time, roles, and contributions to high quality care delivery.

The National Aged Care Survey 2023 – Enrolled Nurses in Aged Care Report can be found here.

References

1. Australian Government Department of Health and Aged Care. 2020 Aged Care Workforce Census Report. Commonwealth Government of Australia. Online. 2021. Available at: https://www.health.gov.au/sites/default/files/documents/2021/10/2020-aged-care-workforce-census.pdf

2. Peters MD. Recognising and supporting the role of enrolled nurses in Australian nursing homes. Medical Journal of Australia 2023; 218(6): 284-.

3. Australian Government Department of Health and Aged Care. Care minutes. Online. 2023. Available at: https://www.health.gov.au/our-work/care-minutes-registered-nurses-aged-care/care-minutes#:~:text=ENs%20provide%20nursing%20care%20as,tasks%20as%20delegated%20by%20nurses.

4. Fedele R. Enrolled Nurse minutes a key pillar of funding for aged care reforms. Australian Nursing and Midwifery Journal. ANMJ. 2023. Available at: https://anmj.org.au/enrolled-nurse-minutes-a-key-pillar-of-funding-for-aged-care-reforms/#:~:text=Last%20October%2C%20the%20Government%20introduced,provided%20by%20a%20registered%20nurse.

5. Australian Nursing and Midwifery Federation. Media Release: Enrolled Nurses Cut from Understaffed Nursing Homes. Austrlian Nursing and Midwifery Federation. Online 2022. Available: https://www.anmf.org.au/media-campaigns/media-releases/enrolled-nurses-cut-from-understaffed-nursing-homes

6. Eley R, Hegney D, Buikstra E, Fallon T, Plank A, Parker V. Aged care nursing in Queensland – the nurses’ view. Journal of Clinical Nursing 2007; 16(5): 860-72.

7. Endacott R, O’Connor M, Williams A, et al. Roles and functions of enrolled nurses in Australia: Perspectives of enrolled nurses and registered nurses. Journal of Clinical Nursing 2018; 27(5-6): e913-e20.

8. Butler A. Editorial. Australian Nursing and Midwifery Journal 2023; 28(2): 1.

Authors:

Jarrod Clarke and Adjunct Associate Professor Dr Micah DJ Peters are based in the Australian Nursing and Midwifery Federation’s (ANMF) National Policy Research Unit (Federal Office) at the Rosemary Bryant AO Research Centre, Clinical and Health Sciences, University of South Australia. Micah also holds adjunct appointments at the University of Adelaide with Health Evidence Synthesis, Recommendations and Impact (HESRI) in the School of Public Health and the School of Nursing, Health and Medical Sciences.