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~J The state enrolled nursein the communityAnthony J. CarrAt long last the 'Report of the Work-ing Party on the Education andTraining in District Nursing for theState Enrolled Nurse' has been pub-lished.

The report is written in two parts.Part 1 conforms to the terms ofreference, which were: 'To devise animproved syllabus or curriculunf forthe district training of the enrollednurse without prejudice to the im-plementation of the Briggs Report onNursing.' Our detailed reasoningleading to the course of study we haveproposed is contained in Part 1 ofthe report. Part 2 deals with thosematters such as grading of the stateenrolled nurse, change of designationof qualifications, mandatory trainingand ratios ofdistrict nurses to districtenrolled nurses.

Difficult reportIt has been a difficult report to

write because the present role andfunction of the state enrolled nurse indistrict nursing is in most casesvague. I personally believe that therole of the state enrolled nurse inhospital is equally ill defined.

The first task of the working party,after receiving written evidence from127 organisations and individuals(which still consisted of over $0 pageswhen condensed), was to define boththe role and function of the stateenrolled nurse. We identified thestate enrolled nurse as a full contri-buting member of the primary healthcare team with the district nurse(SRN/RGN) taking overall respon-sibility for all patients. It was in thenursing team within the primaryhealth care team that the workingparty saw the full role and function ofthe SEN being fulfilled. Our definitionis therefore: 'The state enrolled nurseis a member of the district nursingteam. She is accountable to the dis-trict nurse (SRNfRGN) for carryingout part or all of the nursing careprogramme for individual patientsand their families, recording her find-

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ings and reporting back to the districtnurse (SRN/RGN).'

We go on to explain that statementby saying: 'Therefore, her professionalrole (the part she plays in relation toothers) is working with and to thedistrict nurse (SRN/RGN). Her func-tion (the work she does) is carryingout either the whole individualpatient care programme, or parts ofit, as assessed and planned by thedistrict nurse (SRNIRGN) afterappropriate consultation. We haveassumed that on the occasions whenthe district nurse (SRN/RGN) isabsent from duty for any reasonanother district nurse (SRNiRGN)will undertake the supervision of thestate enrolled nurse.'I do hope that all state enrolled

nurses will understand fully what ismeant by these statements. It isimportant to understand that it is notstatus that is being mentioned in thissection, it is looking critically at basicpupil nurse training and seeing whatparticular part the qualified stateenrolled nurse with additional train-ing has to play in caring for patientsin the community.

Aim and content of new courseThe state enrolled nurse's .contri-

bution is very important and theemphasis on the basic nursing skillsaspect show that the working party'sview the state enrolled nurse is quali-fied by training and good post-basicexperience to undertake many of theaspects of the nursing process in thecommunity under the overall guid-ance ofthe district nurse (SRN/RGN).

It would be a great pity if somestate enrolled nurses saw our defi-nition as taking away duties andresponsibilities which rightly belongto them. Where state enrolled nursesalready do the work of registerednurses, this is the fault of the nursemanagement and not that of the stateenrolled nurse. Also, the pressure ofstaff organisations for a senior gradeon an ad hoc basis has not helped this

situation, but I hope that what isproposed in Part 2 of our report willsolve this problem permanently.

The aim of the course is two-fold.The first is to see that the stateenrolled nurse is 'competent to under-take delegated nursing duties withinthe community under the directionof a district nurse (SRN/RGN)'.Secondly, to be 'held personallyaccountable for the nursing standardsof such delegated duties'. I believethese aims will allow the state en-rolled nurse to expand her role sig-nificantly in the clinical area as aprofessional nurse and in consequenceshould lead to a satisfying job ofwork.

We identified eleven key tasks thatthe state enrolled nurse shouldundertake and from them proposedfour objectives. These were:

'1. To assist in meeting the nursingneeds of patients and theirfamilies in the community.

2. To impart appropriate skillsand knowledge by formal andinformal methods as an integralpart of the nursing care plan.

3. To be skilled in communicationsin order to establish and main-tain good relationships with thepatient and his family, and tomaintain effective verbal andwritten communications as acontributing member of theprimary health care team.

4. To be skilled in the manage-ment of patient care within thecareiprogramme and in 1;0-

operating with appropriateservices.'

We have laid great emphasis on theuse of the nursing process. It is thedistrict nurse (SRN/RGN) that fullyidentifies and assesses the needs ofthe patient, arranges a plan of care,either supervises or gives care andevaluates the care given. Only whenthis type of system is in operation candifferent' levels of care be identifiedand the skills of the state enrollednurse be matched with the pro-gramme of care. It is not fair to the

Journal of Community Nursing

Entry requirements and length ofcourse

The entry requirements do notrequest either '0' levels or CSE gradesbut a careful assessment of abilityshould be made. We have recom-mended two years post qualificationgeneral nursing experience. Thereasons are that her task is basicallypractical, and she will often work r-------------------.,...--------------alone, supervised at a distance. The THERE~S A STRONG ARGU·· M··ENTwritten, verbal and numeracy skills

also need to be tested. I:lORR~COMM EN 01NG COOlSThe proposed length of the course is r~ ~' . .16 weeks, exclusive of annual leave. ,.. :

80A shorter time than this will not inour opinion be sufficient for the

. student to absorb the content of thecourse satisfactorily. No set theory topractice ratios are laid down but,because the course is a demandingone, we have proposed that the stateenrolled nurse is a full-time studentfor the whole of the training pro-gramme. A two-hour examinationpaper will be taken at the end of thecourse and each student will prepareeither a care study or project. Bothcourse work and practical work willbe assessed.

state enrolled nurse, even when shehas taken this new course, to allocatework without a previous evaluation ofthe patient by the district nurse(SRN/RGN).

In the appendices we have givenboth an outline and detailed cur-riculum. The outline curriculumidentifies ten skills. These are:

1. Collection of information2. Recognition of fundamental

'"11 nursing needs3. Organising own work within

agreed care plan4. Giving nursing care5. Monitoring patient care6. Interpersonal relationships r7. Communication8. Reporting and recording9. Health teaching

10. Use of social provisionsMatching knowledge and attitudesare also described.

Other proposalsIn part 2 of our report we propose

that the qualification held by regis-tered. nurses, presently designatedNDN Certificate (NDN Cert.), remainunchanges. All enrolled nurses hold'ing, at present, district nursing quali-fications, or future ones, shall beentitled to the 'National DistrictEnrolled Nurse Certificate' (NDENCert.).We propose that the registered

June 1980

nurse holds the title 'district nurse' .and the enrolled nurse 'district en-rolled nurse'. To our mind thisseparates more clearly the work ofthe two types of nurse. This doesnot alter local arrangements wherebyregistered nurses are called sister orcharge nurse.

The grading of the 'district enrollednurse' is important. Although theNurses and Midwives Whitley Councilmust decide this matter we believethat the training should be mandatoryand that all state enrolled nurseswhile taking the course should receivethe salary of a state enrolled nurse.Upon qualification as a 'district en-rolled nurse' we propose that a highersalary should be given to recognisethe higher level of work they performwith supervision carried out at adistance. In the light of this recom-mendation I repeat here that I dohope all district enrolled nurses willfully understand that the workingparty held their work at a very highlevel. So when we talk of the districtenrolled nurse as being 'under super-vision' we are talking of''function' andnot 'status'. Function is the work thatshould be done, status is reflected insalary and title. We have given thestate enrolled nurse a new title and

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proposed a higher salary to go withthat new title.

Overall responsibilityWith the district nurse (SRN/RGN)

having the overall responsibility ofpatients we have proposed that onlytwo other staff be attached to .her,that is, district enrolled nurses and/ornursing auxiliaries. More than thatnumber will not allow a proper work-ing relationship to be established.

The report is now published and itis up to the profession to make ajudgement for itself. I am fortunate inhaving been appointed to the chair-manship of both working parties(SRN and SEN). in district nursingand I hope that what has beenproposed is both acceptable and effec-tive so that in the late 1980's it can beclearly demonstrated that patientsare nursed more effectively and thatboth district nurses and districtenrolled nurses are totally fulfilled in .their own individual work.

Anthony J. Carr, SRN, NDN Cert,QN, FHA, FRSH, MBIM, is AreaNursing Officer in NewcastleAHA·(T). He was chairman of the workingparty on the education and training indistrict nursing for the state enrollednurse.

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