A Critical Commentary on Intraprofessional  Collaboration between Enrolled and Registered  Nurses in the Care of Clinically Deteriorating Ward Patients: A Qualitative Study

Krishna Prasad Sharma

International Journal of Nursing and Health Care Research

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A Critical Commentary on Intraprofessional Collaboration between Enrolled and Registered Nurses in the Care of Clinically Deteriorating Ward Patients: A Qualitative Study

by Krishna Prasad Sharma^*

Nursing, Brunel University London, UK

^*Corresponding author: Krishna Prasad Sharma, Nursing, Brunel University London, UK, BA, B.ED & MA , Tribhuwan University, Nepal

Received Date: 13 July 2025

Accepted Date: 21 July, 2025

Published Date: 24 July, 2025

Citation: Sharma KP (2025) A Critical Commentary on Intraprofessional Collaboration between Enrolled and Registered Nurses in the Care of Clinically Deteriorating Ward Patients: A Qualitative Study. Int J Nurs Health Care Res 8:1652. DOI: https://doi. org/10.29011/2688-9501.101652

Abstract

Evidence-based practice (EBP) is essential in nursing, ensuring clinical decisions are grounded in the best available evidence while supporting professional accountability and ethical care. Chua et al. [1] investigated the collaboration between Registered Nurses (RNs) and Enrolled Nurses (ENs) in acute care, focusing on communication and recognition of clinical deterioration. Using Caldwell et al.’s [2] framework, this critique evaluates the study’s research design, methodological rigour, and alignment with EBP principles. The study addresses a critical patient safety issue: communication failures and power imbalances between RNs and ENs that hinder timely responses to deterioration. While a qualitative descriptive design is appropriate for exploring lived experiences, several methodological weaknesses undermine the study’s credibility. The literature review lacks a systematic search strategy and critical appraisal, limiting its foundational strength. The sampling strategy, though claiming purposive intent, relied on convenience methods, introducing bias and restricting diversity. Semi-structured interviews provided depth but lacked triangulation. Key methodological omissions include inadequate participant demographic detail, the absence of researcher reflexivity, and failure to use Braun and Clarke’s thematic analysis framework. The claim of thematic saturation appears underdeveloped and insufficiently justified. Ethical considerations were inconsistently addressed. While informed consent and pseudonymisation were observed, issues such as participant distress support, data protection, and withdrawal rights were not fully documented. The findings highlighted practical barriers to collaboration, such as exclusion from handovers and hierarchical dynamics. However, the discussion underemphasised broader systemic and cultural factors. Recommendations for handover inclusion and training are valid but predictable. In conclusion, while Chua et al. [1] offer useful insights into RN-EN collaboration, limitations in methodological transparency, reflexivity, and ethical detail reduce the study’s contribution to EBP. Future research should adopt more rigorous qualitative designs, integrate reflexive practices, and critically engage with thematic analysis to enhance relevance, transferability, and clinical impact.

Keywords: Evidence-Based Practice; Nursing; RN-EN Collaboration; Clinical Deterioration; Qualitative Research; Communication; Methodological Rigour; Patient Safety

Introduction

Evidence-based practice (EBP) ensures clinical decisions use the best available evidence, supporting professional accountability and ethical responsibilities. The strength of evidence depends on research design, with rigorous methodologies considered the ‘gold standard’ for providing high quality, relevant evidence [3,4]. In nursing, applying evidence is vital for delivering safe, high quality, person-centered care [5]. Despite the recognized benefits of EBP, nurses face barriers such as restrictive implementation models and contextual challenges that hinder its consistent application [6]. Caldwell et al.’s [2] framework will guide this critique by evaluating philosophical stance, research design, context, sampling, data collection, credibility, and transferability of findings, aiding novice researchers in understanding qualitative and quantitative methods. Chua et al. [1] conducted a qualitative study examining collaboration between Registered Nurses (RNs) and Enrolled Nurses (ENs) in general wards, focusing on recognizing and responding to clinical deterioration. The authors- are affiliated with reputable institutions such as the Alice Lee Centre for Nursing Studies and La Trobe University, reinforcing the study’s academic credibility.

The study addresses a critical issue: ineffective communication and poor teamwork between registered nurses (RNs) and enrolled nurses (ENs) delay responses to clinical deterioration and compromise patient safety. This aligns with the Nursing and Midwifery Council code, which stresses recognizing human factors and system failures that lead to harm [7]. The research question arose from observations in a Singapore general ward, focusing on collaboration challenges between RNs and ENs [8]. Exploring their collaborative experiences responds to the rising number of ENs.

In acute care and increasing patient acuity, supporting the NMC’s emphasis on evidence-based emergency practice [9]. The study highlights a knowledge gap around communication failures, tensions from differing care expectations, and the vital role of structured communication in improving teamwork and patient outcomes [10]. Recognizing the need for evidence-based improvements, systematic reviews are essential for synthesizing findings to inform best practices [11]. The literature review does not fully align with the established standards expected of a systematic review, which requires a rigorous methodology to support evidence-based interventions and practices [12].

While relevant studies are referenced, they lack a clear and systematic search strategy, omitting critical information such as the databases searched, inclusion and exclusion criteria, and the timeframe covered [13]. This omission creates ambiguity around how studies were selected and reduces replicability. The absence of formal critical appraisal tools, such as those recommended by the Critical Appraisal Skills Programme, further weakens the ability to assess the quality and trustworthiness of the included studies [14]. Given the pivotal role of methodological rigour in qualitative research outcomes, this omission represents a significant flaw that compromises the trustworthiness of the review’s findings [15]. Hong et al. [16] identified key inter-professional nursing challenges that center on communication, teamwork, and collaboration. Their findings are supported by multiple studies e.g., [17-21]. However, the review’s reliance on literature only up to 2018 despite its 2022 publication date renders it outdated and incomplete. Moreover, it draws from a narrow pool of researchers-such as Chua WL, Liaw SY, and McKenna L-which limits its breadth and critical depth.

The analysis is predominantly superficial and descriptive, with minimal methodological critique, which undermines the overall rigour and credibility of the presented evidence [22]. Although several publications have been released about the nursing associate role since its introduction in the UK, these resources have not been effectively utilised in the literature review for this research [23]. The study employed a qualitative descriptive (QD) methodology, suitable for capturing rich, detailed insights into participants’ experiences [24]. However, while QD’s flexibility is a strength, the rationale for selecting this approach over other qualitative methods was not clearly linked to the research objectives, though alignment between paradigm and research questions is essential [25].

Semi-structured interviews effectively explored participants’ perspectives in depth [26], but relying solely on interviewswithout supplementary data such as observational notes or diarieslimited methodological triangulation and potentially weakened the findings’ robustness [27]. The study claimed purposive sampling with maximum variation to include ENs and RNs with six months of experience [28]. Nevertheless, recruitment was reliant on nurse managers and posters, akin to convenience sampling, which introduces potential bias and limits the study’s qualitative richness and participant diversity. [29-31]. Nevertheless, insufficient detail on participant demographics, such as clinical areas or years of experience, raises concerns about researcher bias and limits transferability [32]. Ethical practices, such as obtaining written consent and implementing pseudonymisation, were appropriately followed; however, the lack of clear documentation regarding participants’ right to withdraw and the absence of psychological support represent significant ethical oversights [33].

While data transcription and verification were rigorous [34,35], the study failed to detail data protection protocols, raising questions about GDPR compliance [36]. The lack of researcher reflexivity further undermines bias reduction and credibility, highlighting the need for stronger reflexive practices to enhance trustworthiness [37] Data collection relied exclusively on audiorecorded interviews, despite rigorous transcription and verification [34,35], limited data richness. Interviews in private hospital rooms encouraged open discussion of sensitive experiences [38], yet the choice of semi-structured interviews over alternatives like focus groups or diaries lacked clear justification, raising concerns about methodological fit [39].

Excluding supplementary data sources reduced triangulation and depth [27]. Insufficient detail on sampling, analysis, and reflexivity weakened transparency and credibility [40]. Ethical rigour suffered due to unclear data storage and protection practices [36,41]. Researcher reflexivity was absent, compromising bias reduction and trustworthiness [37]. Thematic saturation typically occurs after 9 to 17 interviews [42], but the larger sample size may indicate inefficient resource use without added depth [43]. The study overlooked cultural and ethnic diversity, limiting applicability [44]. Lastly, the gender imbalance-only 2 of 23 participants male-reflects Singapore’s nursing workforce, where male representation rose from 8.2% in 2008 to 11.6% in 2020 [45], yet raises concerns about bias and limits generalisability which is also a key aspect of qualitative research [46]. The data analysis employed a rigorous qualitative approach; however, the study’s reliance on thematic saturation remains problematic, as the methodology fails to address ongoing epistemological debates about its conceptual validity [47].

The researchers’ assertion of achieved saturation appears theoretically naive, particularly given their neglect of Braun and Clarke’s [48] established analytic framework. While the inductive approach appropriately centred participant voices [49], critical methodological weaknesses emerge in insufficient documentation of bias mitigation strategies and ambiguous protocols for resolving coding discrepancies. These flaws could have been mitigated through consensus coding or external validation [50]. The study’s strengths - including multiple coders and iterative theme development-are undermined by inconsistent field note integration [51] and inadequate reflexivity. Though transferability measures were attempted [52], the absence of rigorous coding conventions and systematic reflexivity ultimately limits the study’s scholarly contribution. Future research would benefit from adopting more transparent qualitative protocols and engaging more critically with saturation’s theoretical complexities.

Through critiquing the findings, the study presented raw data, including figures, percentages, and participant quotes directly in the text and tables, avoiding supplementary files. presents the demographic and background characteristics of the participants, while provides a detailed account of the emergent themes and subthemes identified in the analysis. The absence of visual data representations such as graphs, bar charts, or scattergrams was noted. To further enhance rigor, findings should ideally be linked to measurable outcomes like patient deterioration rates. Virtual reality (VR) and early training approaches mentioned are innovative but lack robust evaluation and implementation strategies, which limits their practical effectiveness [53,54]. The Discussion section effectively highlights major barriers to EN-RN collaboration- exclusion from handovers, power imbalances, and lack of mutual support-which are linked to reduced recognition of patient deterioration [55]. The inclusion of concepts such as “knowing the patient” adds clinical and professional relevance [56]. However, the repeated emphasis on handovers becomes redundant over time.

The absence of subheadings reduces clarity, especially for nonspecialists. Recommendations like EN involvement in handovers and curriculum changes are practical but predictable [57]. Broader systemic barriers are overlooked [58], and portraying RNs as dominant without exploring EN agency or collaborative models feels one-sided [59].The study demonstrates transparency by acknowledging limitations in generalizability and context, yet several critical flaws diminish its rigour. Insufficient thematic saturation weakens qualitative depth, while the absence of postinterview debriefing and a psychological harm management plan raises ethical concerns regarding participant welfare. Although structured handovers are noted as beneficial, their impact is undermined by lacking operational tools. For example, Singapore General Hospital’s RIMMS approach improves nurse communication but is limited by minimal patient involvement [60]. Additionally, the underused “Big Five” teamwork model represents a missed opportunity to enhance findings [61]. Ethical issues such as informed consent, participant distress management, and data security are inadequately addressed [62]. The lack of researcher reflexivity threatens interpretive objectivity [63], and the singlesite design further restricts transferability and applicability.

The research conclusion section effectively synthesises the study’s key findings related to EN and RN interprofessional practice and its significance in recognising clinical deterioration. It presents valuable practical recommendations for nursing education and workplace training. However, the section would benefit from more explicit connections between the findings and the original research questions, a critical discussion of the study’s limitations, and consideration of broader policy implications. While the proposed future research directions are relevant, their academic rigour would be enhanced by greater methodological specificity. Additionally, the overall impact of the conclusion would be improved by a more compelling closing statement to complement its otherwise logical structure and professional tone.

At the end, Chua et al. [64] explore RN-EN collaboration in acute care. The study attempts to align with evidence-based practice, though its success in doing so is somewhat uneven yet insightful. Its academic credibility is strengthened through affiliations with reputable institutions and the appropriate use of a qualitative descriptive methodology to explore participant experiences [65-68]. However, the study falls short of demonstrating the methodological rigour expected in high-quality qualitative research. A critical shortcoming lies in the literature review, which lacks a systematic search strategy, rigorous appraisal tools, and breadth in author representation, weakening the foundational evidence base. Although semi-structured interviews are justified for, exploring lived experiences, the absence of triangulation and insufficient participant demographic details limit the depth and transferability of findings.

The sampling strategy, leaning towards convenience over purposive principles, introduces potential bias and reduces the study’s qualitative richness. Importantly, Braun and Clarke’s [48] well-regarded thematic analysis framework are overlooked, and the claim of thematic saturation appears theoretically underdeveloped. Researcher reflexivity is notably absent, undermining credibility and objectivity. Ethical safeguards were inconsistently addressed, with inadequate attention to participant distress and data protection-significant ethical oversights. The research paper’s conclusion attempts to unify findings and propose practical recommendations, but it lacks critical depth and explicit linkage to research aims [69]. As Braun and Clarke emphasize, thematic analysis demands reflexivity and transparency both insufficiently demonstrated here [70]. Future studies should adopt a more methodologically robust design and engage more critically with reflexive and epistemological frameworks to truly embody the principles of EBP.

“The article has been doble -blind peer reviewed”

References

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