enrolled nurse conversion: a review of the literature

Journal of Nursing Management, 2000, 8, 115–120

Enrolled nurse conversion: a review of the literature

B. WEBB rgn, msc, bsc (hons), dms

Professional Development Manager, Postgraduate Education Centre, Princess Marina Hospital, Northampton, UK

Correspondence webb b. (2000) Journal of Nursing Management 8, 115–120B. Webb Enrolled nurse conversion: a review of the literatureNorthampton HealthcarePostgraduate Centre Aim The aim of this literature review was to examine the policies and professionalPrincess Marina Hospital literature from the last 50 years about the introduction, the role and subsequent plight ofNorthampton the enrolled nurse (also known as second level nurses), and the need to convert to the firstNN5 6JH

level of the UKCC nursing register.Background Nurse shortages within the NHS have been cyclical since its inception in1948. The policy decision to cease the training of enrolled nurses within the frame ofmodernizing the education and training of the nursing workforce had two distinctimplications for enrolled nurses. Firstly, they could choose to stay as enrolled nurses orconvert to first level nursing. Nevertheless, enrolled nurses have cited the lack of fundedconversion course places, and managerial support for non-conversion.Methods A critical review of the national policies and professional literature concernedwith the evaluation of enrolled nurses’ contribution to the NHS.Findings It was argued that national policy needs to be supported on the ground, wherebyenrolled nurses are proactively supported to come forward for conversion and/ormeaningful roles are created and sustained where enrolled nurses continue to make avaluable contribution to the NHS agenda. Finally, the paper challenges all NHSorganizations to consider the profile and value of enrolled nurses and become proactive intheir recruitment and retention of this nursing group.

Accepted for publication: 6 September 1999

Introduction available. It will be argued that the policy documentProject 2000: A New Preparation for Practice [United

The literature review will show that the ‘problem’ of Kingdom Central Council for Nursing, Midwifery andenrolled nurses is not new but has occupied policy makers, Health Visiting, (UKCC) 1986], which specifically rec-professional bodies and health service managers for over ommended an end to the training of enrolled nurses,half a century, and it appears that at times of economic confused matters further by failing to develop a plan ofrecession and/or cost containment in the British National how and when this policy might be implemented on theHealth Service (NHS), such as now, that the problem ground. The result was that health service managers andcomes to the fore. The ‘problem’ is shown to be one of educationalists were left with the responsibility of con-nursing shortage and recruitment more generally, rather verting enrolled nurses to the first level of the UKCCthan being specific to enrolled nurses. However, it is register without being given suBcient resources nor theenrolled nurses who have borne many of the attempts to authority because the conversion of enrolled nurses was

not made compulsory by the UKCC.deal with nursing shortages within the financial resources

115© 2000 Blackwell Science Ltd

B. Webb

The introduction and training of the enrolled third year state registered nurse trainees and fully qualifiedstate registered nurse. This appeared to be an attempt tonursereassure critics such as the Scottish Departmental

The publication of the Nurses’ Act (1919) provided forCommittee on Nursing (Chairman, Alness) (1938), who

one level of state registered nurse, consequently manydid not support the concept nor adoption of the assistant

hospitals became nurse training schools and most hospi-nurse, that safeguards were in place to protect the public.

tals employed trained or trainee nurses. The hospitalsDespite the controversy, the enrolled nurse had secured

caring for the chronically ill employed trained nurses andits place in the nursing profession and appeared to resolve,

untrained auxiliary workers. The 1930s was the decade albeit in the short term, the problem of nurse recruitment.of the Great Depression and state registered nurses becamean expensive commodity (Brown 1994). This initiated the

The status of the enrolled nursedebate on the role and need for an assistant nurse. Therewas opposition for the introduction of a separate roll for The low status of enrolled nurses appeared prior to andassistant nurses. The Lancet Commission on Nursing more explicitly on the introduction of the statutory roll.(1932) and the Report of the Scottish Departmental The inclusion of ‘assistant’ in the job title formally placedCommittee on Nursing (Chairman, Alness) (1938) claimed the enrolled nurse in a subordinate position to statethat the introduction of an assistant nurse would under- registered nurse colleagues. A second example of the lowmine the status of the state registered nurse and risk status was that enrolled nurses had to be qualified forinappropriate delegation of tasks that an assistant nurse more than 4 years before their remuneration was higherwas not trained to carry out, therefore posing a danger than the untrained auxiliary worker (Dan Mason Nursingto the public. Research Committee 1962). The enrolled nurse continued

The Second World War prompted the need to explore to have ‘assistant’ in the job title until the Nurses’the ongoing problem of low pay and shortages within the (Amendment) Act (1961), when it was oBcially removednursing profession. A national committee was established in an attempt to raise the status of the enrolled nurse andto examine this issue and took the opportunity to consider make it a more attractive career pathway. However,the option of a separate roll of assistant nurses (Webster Brown (1994) reported that in 1962 the entry requirements1988). Subsequently, the Interim Report of the Inter- for nurse training were declared as two O-levels forDepartmental Committee on Nursing Service (Chairman, enrolled nurse training and five O-levels for state regis-Athlone) (1939) recommended that a second level of nurse tered nurse training. These lesser qualifications werecould be trained and given a recognized status and placed believed to be all that was required to prepare for theon a roll under the control of the General Nursing role of an enrolled nurse who was subservient to the stateCouncil. The passing of the Nurses’ Act (1943) introduced registered nurse.the statutory title ‘assistant nurse’ (subsequently the state Nevertheless, Brown (1994) stated that over time,enrolled assistant nurse (Royal College of Nursing 1956). enrolled nurses in the workplace were delegated more

The Report of the Working Party on the Recruitment and more duties and responsibilities. This trend wasand Training of Nurses (1947) asserted that without doubt highlighted in one of the findings of The Report of thethe introduction of the assistant nurse had prevented the Committee on Nursing (Chairman, ASA Briggs 1972, p.1).breakdown of nursing services, especially in hospitals that The committee was set up ‘to review the role of the nursecared for the chronically sick. The new role had widened and the midwife in the hospital and the community andthe entry gate to nursing and individuals who were unable, the education and training for that role, so that best usedue to their limited educational qualifications, to enter is made of available manpower to meet present needs andstate registered nurse training would be able to access the needs of an integrated health service’. The committeeenrolled nurse training. Additionally, the enrolled nurse commissioned a number of research surveys from othertraining itself was of a shorter duration than the state professional bodies and undertook their own surveys toregistered nurse programme and the quicker availability seek views from all grades of nurses about aspects ofof qualified nurses for employment was one way of their work, training and nurse recruitment. Samplingtackling the problem of nurse shortages and diBculties of techniques were used to ensure a representative samplerecruitment to the profession. drawn from the national population of nurses were

The report by the Committee on the Position of the targeted for the study. Postal questionnaires and personalEnrolled Assistant Nurse Within the National Health interviews were the primary methods adopted. The levelService (1954) strongly advised that the enrolled nurse of responses to the surveys was high and ranged between

79 and 87%. Webster (1996) remarked that this reportrole was one of assistance and subordinate to second and

116 © 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 115–120

Enrolled nurse conversion

was a very credible and scholarly piece of work. The nurses would have the opportunity to convert to the firstlevel of the register if they wished. Alternatively theycommittee found that the work assigned to the enrolled

nurse was often very similar to that of a state registered could choose not to convert and their registration wouldremain valid. The publication of this policy resurrectednurse. The committee believed that this had, inevitably

led to confusion about the division of labour in nursing and strengthened the controversy about enrolled nursesbecause the UKCC (1986) wanted a single level of nurseand disharmony within the nursing workforce.

Hockey (1972) surveyed the views of a representative yet failed to insist on the conversion of all enrolled nurses.In addition the training of new enrolled nurses did notsample of all grades of nurses general practitioners and

medical oBcers in 50% of the United Kingdom’s local finish until 1992. This was six years after the launch of‘Project 2000’ (UKCC 1986). This reflected a major contra-authorities (community) about the employment and use

of enrolled nurses. Work schedules, postal questionnaires dictory approach to policy development and implemen-tation about the cessation of enrolled nurse training.and personal interviews were used to acquire the data.

Hockey (1972) found that enrolled nurses had responsi- The publication by the UKCC of The Scope ofProfessional Practice (1992), confounded the tension andbility delegated to them, dependent on whether or not a

state registered nurse was available, rather than the skills lack of clarity about enrolled nurse conversion becausethe policy encouraged enrolled nurses to develop andof the individual. This practice was reported again in a

later survey by Davies and Rosser (1986), when enrolled expand their practice without the need to convert.Moreover this policy was launched at a time when careernurses reported unhappiness about the lack of develop-

ment opportunities and the variability of their status that opportunities for enrolled nurses were declining becauseposts previously filled by them were now being taken bychanged on a daily basis. Although one finding of the

earlier survey of the Dan Mason Nursing Research first level nurses or health care support workers who areunqualified helpers who work under the direct supervisionCommittee (1962) stated that the majority of enrolled

nurses surveyed were content in their job role, Hockey of qualified health care professionals (Brown 1994). Apossible cause for this finding, is the misunderstanding of(1972) found that 83% of enrolled nurses declared that

should their daughters take up nursing it should be to NHS managers that The Scope of Professional Practice(UKCC 1992) only applies to first level nurses becausetrain as a State registered nurse not an enrolled nurse.

This may suggest that although the division of labour enrolled nurses are unable to advance their skills becauseof the constraints of their qualification. This misunder-between the two levels of nursing was blurred, there was

a view that it was more progressive for individuals to standing may emerge from the interpretation of Rule18(2) of the Nurses, Midwives and Health Visitorsbecome a state registered nurse rather than an enrolled

nurse. Statutory Instruments (UKCC 1983) that describes thecompetency of the enrolled nurse at initial qualificationThe findings of these important surveys were very

similar. That is, although in the workplace the level of as one of ‘assistance’ to the first level nurse. Someemployers assume that this is the scope of their contri-responsibilities were similar to first level nurses, enrolled

nurses retained a lower status in the nursing profession. bution to health care (Cole 1995). However, beyond initialregistration, like the first level nurse, they can progressArguably this situation forms one basis of the argument

to return to a single level of registered nurse to deliver and work at a higher level. The Audit Commission (1991)strongly recommended that practices and policies thatpatient care.restrict the role of enrolled nurses, based on these misun-derstandings, should be reviewed urgently because the

Revision of the education and training of nursesvaluable contribution of enrolled nurses has been over-looked and may be contributing to the current shortageThe UKCC established a project in 1984 known as ‘Project

2000’ to ‘determine the education and training required of nurses.Mixed messages from the UKCC, the primary policy-for the professional practice of nursing, midwifery and

health visiting in relation to the projected health care making body for the nursing profession created confusionand uncertainty for both enrolled nurses and employersneeds in the 1990s and beyond and to make recommen-

dations’. The project recommended that the training of alike. The UKCC failed to provide a coherent messageand policy direction to guide these groups to take theenrolled nurses would cease (UKCC 1986). A new division

of labour was proposed, a single level of registered nurse appropriate steps to secure a robust nursing workforcefor the future delivery of patient care.that would embrace the work of the present two levels,

a support worker and an advanced or specialist nurse Conversion of enrolled nurses to the first level of theUKCC register may address some of the nursing shortages(UKCC 1987). The UKCC (1986) stated that all enrolled

117© 2000 Blackwell Science Ltd, Journal of Nursing Management, 8, 115–120

B. Webb

because NHS managers will recruit converted enrolled Supporting enrolled nursesnurses to the nursing workforce. In addition conversion

Support for the plight of enrolled nurses came from theto the first level of the register is likely to provide the

Nursing Times which launched a major campaign on‘key to the door’ for enrolled nurses to professional their behalf by producing a charter. The main points weredevelopment and career opportunities currently not made to call for a formal end to enrolled nurse training byavailable to them. However, 110 529 enrolled nurses have 1992, an end to the abuse of the UKCC’s Rule 18 andnot converted and remain on the UKCC nursing register, misuse of enrolled nurses, more conversion courses andof these 36 000 still plan to convert (Institute of protection and development for those enrolled nurses whoEmployment Studies 1997). The next section will explore choose not to convert. The Nursing Times challenged allthis issue further. health authorities to sign the charter. Cole (1989) evalu-

ated the impact of the campaign and declared that over100 (two thirds) of all health authorities had signedthemselves to it. However, this raised the question ofaccountability as no-one was placed or put in a positionReasons for non-conversionto call health authorities to account if they did not act in

A number of writers have addressed the issue of non- the spirit of that charter. Themes of concern for enrolledconversion and have highlighted the lack of conversion nurses have continued in the professional literature andcourse places nationally. In 1988, Cottingham estimated formulates the anecdotal evidence that has developedthat out of 100 000 enrolled nurses, 50 000 wanted to based on writers’ experiences and relationships withconvert, however, places were limited to 1000 per year. enrolled nurses and conversion (SwaBeld 1991; BrownThe enrolled nurse qualification was suBcient to gain a 1992; Buchan 1992; Cooper 1993).place on the conversion course, nevertheless demand The determination to support the enrolled nurse becameoutstripped availability and colleges responded by very apparent in the literature during the last decade, yetdeveloping enhanced criteria for entry onto a conversion the ability to influence the policy development or resourcescourse rather than increasing the number of course places. for policy implementation had remained limited.

Laurent (1989) observed that the demand from enrollednurses for conversion courses was increasing as the UKCCworked its way towards the goal of a single level of Current situationnursing. However, Chudley (1988) highlighted that the

An important policy document is Enrolled Nurses: Acontinuing national shortage of nurses resulted in NHSStudy for the UKCC (Institute of Employment Studies

managers’ reluctance and possible inability to release(IES) 1997, p. 10), commissioned by the UKCC to ‘under-

enrolled nurses for conversion because services to patientstake a survey which would explore issues of concern to

would be reduced. UKCC (1987) addressed the diBcultiesenrolled nurses and inform council policy’. The survey of

that enrolled nurses face in its newsletter Register andnurses and employers of nurses based on postal question-

detailed the actions that would be taken to enable the naires, has re-iterated many of the previous survey findingsquicker access for conversion for those enrolled nurses and the anecdotal evidence published in the professionalwho so-wanted. The actions included a wider entry gate journals. The study found that there are 110 529 enrolledto conversion courses and the introduction of flexible and nurses on the UKCC nursing register of which 42 788open-learning methods, therefore reducing the pressure to work in the NHS. Of these, 81% are on the lowest clinicalbe released full-time from the workplace. grades of ‘C’ or ‘D’. This confirms the earlier evidence

The UKCC (1986) declared that all enrolled nurses who that enrolled nurses do not enjoy the same career oppor-wanted to would have the opportunity to convert, yet tunities as first level nurses. The study also found aenrolled nurses encountered a number of barriers when migration of enrolled nurses from NHS employment totrying to achieve this. For instance the lack of suBcient the private sector, this at a time of nursing recruitmentcourse places and inability to meet demand and the and retention diBculties. The study reported that 36 000reluctance of managers to release them to attend because enrolled nurses still planned to convert, claiming that lackthey could not aCord to release them from the workplace. of funding, managerial support or lack of places asAt the same time the training of new enrolled nurses was reasons for not being able to fulfil their ambitions.continuing and this demonstrates the contradictory and The study by the IES (1997) has had a major impactconflicting messages that enrolled nurses and employers on the Government and has resulted in the availability of

funds to encourage conversion of enrolled nurses and thereceived from the UKCC.


Enrolled nurse conversion

return of enrolled nurses into the NHS workforce. For period. However, a national survey cannot always reflectthe situation in a local context and NHS organizationsexample, NHS trusts have been urged by the Government

to develop ways of recruiting enrolled nurses and establish need to understand the profile and needs of the localenrolled nurse workforce to inform local workforce,systems to enhance their professional development and

route to conversion to begin to tackle the recruitment education and training plans.The literature has found that enrolled nurses do notproblems (NHS Executive 1998a; NHS Executive 1998b).

Financial resources via education consortia will support professionally develop at the same rate as their first levelnursing colleagues due to perceived discriminatory behav-this drive and is the first serious attempt to meet the

needs of enrolled nurses who want to convert and continue iours of managers. This is a significant risk to theorganization in light of the clinical governance agendatheir contribution to the delivery of high quality patient

care. recently imposed on the NHS in the policy document TheNew NHS Modern Dependable (Department of Health1997), which stresses the need to ensure the continuous

Conclusionprofessional development of the NHS workforce.Therefore NHS organizations have a responsibility to doFor the last 50 years the shortage of nurses has been a

continuous problem nationally. The enrolled nurse was two things, pro-actively support enrolled nurses to convertto the first level of the UKCC register and continue theirintroduced in the 1940s to address this shortfall. However,

from the outset the literature has demonstrated confusion professional development in the same way as their firstlevel colleagues. Secondly, NHS organizations need toand controversy within the NHS about the role of the

enrolled nurse and this has continued to the present day. create meaningful roles whereby enrolled nurses retaintheir second level status but have equal access to develop-The publication of Project 2000 (UKCC 1986) declared

an end to the enrolled nurse training programme and ment and career opportunities that currently appear toescape them. These actions need to be underpinned bypromised that all enrolled nurses could, if they wished,

convert to the first level of the nursing register. robust UKCC policy that clearly articulates the pro-fessional nursing structure. By addressing the needs ofThe limited number of course places and inability of

employers to release enrolled nurses for conversion has enrolled nurses in an ethical and progressive way, enrollednurses will be encouraged to remain in the NHS workforcecreated diBculties for this policy to be implemented.

Further disharmony has resulted by the misinterpretation and continue their valuable contribution to health caredelivery.of employers to restrict the practice of enrolled nurses

because of the misunderstanding of the UKCC policiesScope of Professional Practice (1992) and Rule 18(2)

References(1983).These issues continue against the current absence of a Audit Commission (1991). The Virtue of Patients: Making Best Use

professional nursing structure that is clearly understood of Ward Nursing Resources. HMSO, London.and communicated formally by the UKCC. That is Brown G.D. (1994) Enrolled nurses: where do they go from here?

Journal of Nursing Management, 2, 213–216.employers and nurses remain confused about the futureBrown R. (1992) Discontent among enrolled nurses. British Journalroles of specialist nurses, health care assistants and the

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enrolled nurse conversion: a review of the literature

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