The LPN: A Practical Way to Alleviate the Nursing Shortage
Across the country, hospitals face a shortage of nursing staff. Many hospital executives report difficulty recruiting sufficient numbers of nurses. Over the next 15 years – as the baby boom generation ages and increasing numbers of nurses themselves near retirement – the demand for nurses is projected to significantly outstrip supply.
In the face of such a potential crisis, hospitals have failed to make use of a readily available and highly qualified workforce: licensed practical nurses (LPNs). For a variety of reasons, hospitals have cut back their LPN staff at exactly the time that bedside caregivers are in short supply. To address the nation’s nursing needs and, with the aim of guaranteeing the highest quality of cost-effective patient care, hospitals must look to re-integrating LPNs as a critical component of nursing staff.
Who Are LPNs?
There are currently over 700,000 licensed practical nurses employed in the United States, 25 percent of whom work in hospitals. Like RNs, LPNs are licensed professionals, and in non-intensive settings RNs and LPNs often fill the same role. In acute care hospitals, LPNs care for the sick, injured, convalescent and disabled under the direction of physicians and RNs. In the course of this work, they perform a remarkably wide range of duties. Typically, their responsibilities include basic bedside care (such as taking vital signs), preparing and administering injections, monitoring catheters, applying dressings, treating bedsores and giving special bed care such as alcohol rubs or massages. LPNs are charged with monitoring patients and reporting adverse reactions to medications or treatments. They collect samples for testing, perform routine laboratory tests, feed patients, and record food and fluid intake and output. They assist with bathing, dressing and personal hygiene. They treat wounds and, where state law allows, give medications and perform venipuncture. In most states, LPNs give intravenous (IV) medications, hang blood, and perform other duties of care in keeping with their training and certification.
The duties that an LPN can legally perform are governed by state statute or regulation. Each state’s “scope of practice” defines the parameters within which LPNs are legally authorized to work. All states allow LPNs to perform the basic nursing duties associated with bedside care, but beyond that point state rules vary considerably. Most stateboards of nursing allow for IV infusions, IV medications or hemodialysis if LPNs have undergone additional education and certification, although there is variation among state rules for each of these duties. In most states, LPNs don’t independently develop or make changes in the plan of care or perform telephone triage.
The Decline of LPN Employment in Hospitals
In the past 20 years, the number of LPNs working in hospitals has plummeted. Between 1984 and 2005 (the last year for which data is available), the number of LPNs employed in hospitals fell by 153,000, or 47 percent, even while the total number of LPNs in the country grew by 18 percent. This falloff primarily results from two factors: the general cuts in nursing staff that followed the adoption of managed care and capitated insurance plans in the 1990s; and a more specific shift from “team nursing” to “primary care” as the dominant model of nurse staffi ng within the hospital industry. As is discussed in this report, each of these decisions is understandable in its historic context. But taken together, they have left hospitals without access to a critical workforce.
Hospitals need qualified, experienced bedside caregivers – RNs, LPNs and aides. The combination of LPNs’ education, skills, commitment and diversity enable them to make a vital contribution to hospital care. LPNs who are utilized to their full scope of practice are highly qualified, cost-effective members of the nursing team.
Hospitals are scrambling to staff units, and RNs are struggling to provide professional care and avoid burnout in the face of severely strained patient-tonurse ratios. If hospitals redesign their work processes to make greater use of LPNs, there is a ready population to meet the immediate demand for skilled and qualified nurses: LPNs who are not currently working in the occupation for which they trained. Evidence suggests that many LPNs view hospitals as the most desirable employer due to the combination of higher pay and more exciting work than in other health care settings. If there were more positions available in hospitals, some of these LPNs might return to practice.
Bring Back Effective Teams
For both immediate and longer-term staffing needs, it is time for hospitals to reconsider LPNs and models of team nursing as a strategy to meet their nursing needs. Primary care may be the appropriate staffi ng model for certain situations, but its advantages become less meaningful if nurses don’t have enough time to spend with the patient due to staffing shortages.
Indeed, it is possible to combine elements of both models in a manner that allows hospitals to make use of LPNs while retaining many of the beneficial aspects of primary care nursing. Sonia Moseley, a registered nurse practitioner and AFSCME member in California, advocates the use of team nursing, because otherwise “[T]he RN is unable to fully practice to her entire scope of practice if time is spent doing things that others are qualified to do.” In cases where unions have bargained staffi ng ratios for RNs, they have found it necessary to guarantee that other nursing staff are not cut as a result, leaving RNs hopelessly overworked. Tom Connelly, an RN and president of AFSCME Local 2026 (Ohio Council 8), negotiated a minimum staffing agreement for RNs, but had to make sure that the LPNs and ancillary staff were not being cut to fund the RNs. nursing jobs, as well as new models of nursing that integrate RNs, LPNs and aides into effective teams.
To allow LPNs to make the fullest possible contribution to patient care, and to allow hospitals to effectively meet ongoing staffing needs, a few key principles are critical.
- Hospitals can and should increase their employment of LPNs while instituting practices that enable LPNs, RNs and other members of the nursing staff to function as an effective team.
- Hospital administrators should educate themselves and their staff about the LPN scope of practice in their state. While LPNs cannot substitute for RNs, they can be utilized to their full scope of practice, thus adding a highly qualified, cost-effective member to the nursing team.
- Hospitals need to work with other stakeholders to increase the number of accessible LPN programs in order to increase the number of new LPNs.
- Nurses scope of practice, standards of practice and curriculum for training programs need to be standardized at a national level, in accordance with the recommendations of the National Association for Practical Nurse Education and Service Inc. (NAPNES).
- Research is needed on LPNs in the acute setting, including the factors driving LPNs to leave hospital nursing jobs, as well as new models of nursing that integrate RNs, LPNs and aides into effective teams.
- Nursing staff working at the bedside should have a voice in the decisions that affect them, including appropriate staffi ng levels and mix. Such a process should include:
- Creating appropriate job descriptions for LPNs, including any specialty experience needed, and making sure that the job description is clearly communicated to all current staff to prevent role confusion.
Developing a unit-specific curriculum for training LPNs to work to the full extent of their authority.
Developing and implementing an orientation and mentoring plan for LPNs.
- While the plan is being developed and implemented, it is critical to establish effective communication structures between management, RNs and LPNs.
- RNs must be trained in leadership skills, and RN programs need to include these skills in the curriculum.
- To make the transition succeed, it is important that hospitals provide additional compensation for mentors, as well as for LPNs who upgrade skills and take on expanded duties.
These recommendations will put the hospital industry in a much stronger position to address nursing shortages and to guarantee the highest quality of patient care.