Victoria University researcher sounds alarm on nursing skill mix

Victorian aged care facilities have reduced the number of registered nurses employed in the sector following revised legislation which has allowed enrolled nurses to administer medication. Russell Freemantle, a PhD research student at Victoria University is conducting the first-ever research into the effect of enrolled nurse medication administration on nursing skill mix, care, workload and job satisfaction.
His three-year investigation, which is near completion, shows a reduced nursing skill mix and in particular, a decline in the number of registered nurses employed as team leaders or unit managers in facilities. He said enrolled nurses with medication administration endorsement are increasingly occupying these roles. In May 2006, the Victorian government amended the Drugs, Poisons and Controlled Substances Act so that registered nurses had to manage, but not necessarily administer, medication to high care residents.
“The former Nursing Board of Victoria and Australian Pharmaceutical Advisory Council (APAC) indicated the amended legislation would be used to enable enrolled nurses to administer the medication under the supervision of a registered nurse but in practice what is happening is that enrolled nurses are managing. They are basically carrying out a similar job to what the RN would be doing,” he said.
His study supports anecdotal concerns of a negative impact on skill mix arising from the changes. In 2009 unpublished studies by Western Health and by the former Nursing Board of Victoria raised concerns by some nurses regarding changes to the management of medication administration. These informal changes in the delivery of nursing care raise alarm bells as research has shown a clear link between reduced skill mix and poorer patient outcomes, he said.“Previously, for example, a facility might have had an RN, an EN and four personal care assistants working on a shift.
Now there would be one EN and five personal care assistants and possibly the only RN you can find is the facility manager and even then, I have encountered facilities that have ENs in that role.” “The impact on nursing skill mix is an informal change that has been brought about by the amended legislation. It’s not an intended or planned consequence but is something that has just happened because the reality is aged care facilities can replace an RN with an EN on much lower wages.”
He cautions against seeing the extension of the role of the EN as a panacea for the nation’s nursing shortage. “Education and skill level have been directly linked to outcomes, so the increased use of a less educated nurse and greater use of unregistered staff would reduce the standard of care.” Freemantle said the growth in high care residents is driving the demand for nurses in residential aged care, while an increase in residents over the age of 85 raises the acuity level.But overall national figures show the number of registered nurses working in aged care is declining.
According to the Australian Institute of Health and Welfare (AIHW), between 2005 and 2007, the number of registered nurses in aged care has dropped by 22 per cent from 5997 in 2005 to 4659 in 2007. Improved career pathways and higher job satisfaction are often cited as the rationale for extending the scope of practice of the EN role but in Freemantle’s study ENs reported higher workloads and increased job-related stress.
“Workloads have shifted. I have interviewed enrolled nurses that say they still have all of the work they used to carry out but now they also have the medication administration on top of it.” On the flipside, RNs have reported a reduced role in medication administration. The study utilised a mixed methods approach including initial in-depth interviews of RNs and ENs, a quantitative on-line survey of 350 participants and focused in-depth interviews.
It represents the first evaluation of the impact of the changes over the past five years and has wider implications for nursing care, as other health areas including emergency departments and acute care wards increase the scope of the role of the EN and the healthcare assistant. Freemantle said enrolled nurse medication administration is a new and unfolding phenomenon which requires a greater level of oversight to minimise any negative effects on patient safety and outcomes.
His study, entitled Understanding the unfolding phenomenon of enrolled nurse medication administration in aged care nursing  is due for completion by the middle of this year.

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