The hierarchy issue

Those in the business will understand how a new Registered Nurse can be (legally speaking) higher in the hierarchy than an Enrolled Nurse of 20 or 30 years experience. This is an interesting phenomenon, and one that takes a while to get your head around when you first start. We are used to learning from EN's while on placement, and even as a New Grad, they are a brilliant source of information.

But EN's report to RN's. That's how it works. Time in the job doesn't matter in this instance. While we may still listen to the EN's, and ask their advice or help with something, the ultimate responsibility rests with the RN.

If an EN notices, for example, a patient's obs are in the yellow zone - they go to the RN. In other words, me. Then I get to make the decision on how to proceed. Usually this means reviewing the patient, making a note of the issue, and re-checking the anomalous reading in half an hour or so. I may initiate interventions, such as pain relief, or back to bed for a while, or withhold/give medications. Sometimes it means a phone call to the treating Doctor. Whatever the decision, it is mine to make.

This has caused me some anxiety, as most of the time, the EN will clearly know what to do (and usually do it), and reporting to the RN is just a formality. I may not necessarily know what to do. I'm still a little afraid of getting something really wrong - which I know is silly as there are plenty of experienced staff to help me. I haven't made a wrong decision yet, but it weighs heavily on my mind that a little error or omission on my part could end in disaster for somebody - and then I am up before the Tribunal.

Because the EN has reported to me (and documented this) it then falls on my head. Even if I report to the doctor and they decide not to do anything, it still falls on me, as the RN is the one there with the patient, and it is my job to give the right information for the doctor to make their decision - if I miss something important, it's my fault. If something goes wrong, I am the first line of intervention for that patient. Equally, if I choose not to inform the doctor, it rests with me. Even if I asked the EN for advice and followed it, it's my decision in the eyes of the Coroner.

There are days when I do not think I am cut out for this. It's bloody scary! So much rests on everything we do, and the only person who will protect my registration (and therefore my career) is me. Nobody else - as they will be protecting their own butt. It's a tough lesson to learn, but in health care in today's society, it's every man for himself. We may work as a team, but everyone is always protecting themselves. They have to.

My advice? Something given to me on one of my first days. Whenever you do anything, no matter how innocuous it seems, document. Don't wait for the end of the shift, you'll forget something. And when you do document, imagine the Coroner is reading it. Keep that foremost in your mind - yes, it is frightening, but it sure helps keep my mind on the job!