National Center for Health Workforce Analysis

Supply, Demand, and Use of Licensed Practical Nurses

November 1, 2004

Table of Contents (for on-line viewing) Entire report in Adobe/pdf

Executive Summary
Chapter 1:  Introduction
Chapter 2:  The LPN Workforce
Chapter 3:  Scope of Practice and Practice Acts
Chapter 4:  Education of LPNs
Chapter 5:  Factors Affecting the Supply and Demand for LPNs
Chapter 6:  Perspectives of the Employers, Educators, State Boards, and Nurses
Chapter 7:  Summary, Conclusions, and Recommendations        
Appendices
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
Appendix F

Chapter 6:  Perspectives of the Employers, Educators, State Boards, and Nurses

The preceding chapters reported on the work of LPNs, their demographic characteristics, the process of education for LPNs, and their demand and supply.  While the data presented in these chapters provide substantial information about the LPN workforce, it does not answer some key questions.  How do LPNs and their employers view their role in the workforce?  How do they interact with RNs?  Are LPNs interested in pursuing additional education?  To answer these questions, we turn to qualitative research methods, including focus groups and key informant interviews.  This chapter reports on qualitative work conducted in four States to better understand these issues related to the LPN workforce. 

Methods

The qualitative approaches used in this study included key informant interviews and focus groups.  Key informant interviews were conducted with officials from State nursing boards, nurse administrators in acute care hospitals and long-term care settings, and directors of LPN educational programs in community colleges and adult schools.  Focus groups were conducted separately with practicing LPNs and RNs to learn the perspectives of staff nurses.

We selected four States in which to conduct qualitative research: Iowa, California, Massachusetts, and Louisiana.  These States were selected to provide geographic variation and a range of restrictiveness of scopes of practice.  California and Iowa have relatively restrictive scopes of practice, with scores of 4.  Massachusetts and Louisiana’s scopes of practice are among the most liberal in the U.S., with scores of one.  In California, Louisiana, and Iowa, we visited both a large city and a smaller city in order to determine whether population density was associated with differences in the utilization of LPNs.  In California, these cities were Los Angeles (population 3,694,820) and Bakersfield (population 247,057); in Iowa we visited Des Moines (population 198,682) and Cedar Rapids (population 120,758); in Louisiana we visited New Orleans (population 484,674) and Baton Rouge (population 227,818). In Massachusetts, we conducted our interviews and focus groups in Framingham, a city halfway between the large city of Boston and the smaller metropolitan area of Worcester.  Key informant interviewees and focus group participants were selected from these seven sites.

Key Informant Interviews

Potential hospital key informant interviewees were identified using data from the American Hospital Association (AHA) Annual Survey of Hospitals (American Hospital Association, 1999).  With these data, we examined the number of beds at each hospital and the share of licensed nurses who were LPNs.  We attempted to schedule key informant interviews with people from hospitals with at least 100 beds and with at least 10 percent of their licensed nursing staff was comprised of LPNs.  In some cases we visited hospitals that were slightly smaller or had somewhat fewer LPNs in their nursing staff. 

To identify potential interviewees in long-term care facilities in the target States, we utilized the Medicare Web site, Nursing Home Compare, which includes data on all Medicare certified nursing homes in the country (U.S. Department of Health and Human Services, 2004). We targeted nursing homes with more than 75 beds in order to assure a staffing mix that would include both RNs and LPNs. 

A research assistant contacted potential interviewees and read a telephone script that explained the purpose of the study, the purpose of the interview, and procedures for voluntary consent and confidentiality.  Once interviewees agreed to participate, a follow-up letter and email were sent including the interview details, a written information sheet, and a copy of the consent form to be signed at the time of the interview.

In total, there were 24 key informant interviews conducted in the four States.  Most of these were in-person interviews, scheduled to coincide with the focus groups in each State.  When schedules did not permit in-person interviews, telephone interviews were held subsequent to the focus groups.  There was no overlapping participation between the focus groups and key informant interviewees although several of the focus group participants were employees at facilities where the Director of Nursing was interviewed as a key informant.

The Employer Perspective

LPN practice in hospitals

In general, LPNs tend to be a small component of the total nurse staffing in hospitals, regardless of the State and scope of practice. LPNs generally are employed in medical-surgical units, rehabilitation units, hospital-based skilled nursing facilities, and outpatient clinic settings.  However, the RN shortage seems to be increasing LPN employment in hospitals.  In more than one State, nursing directors of hospitals Stated that LPN employment was increasing in all types of patient units.  Some respondents Stated that they were considering increased LPN staffing or replacing some nursing assistant staff with LPNs. 

Factors Favoring LPNs in Hospitals

Nursing directors in hospitals Stated that several factors made it attractive to hire LPNs.  The major attraction of LPNs is that they cost less than RNs and can be used for nursing functions within their scope of practice.  LPNs are attractive because they have more skills and training than nurse aides and are licensed to perform functions that nurse aides are not allowed to do, such as administer medications.  In some locations, LPN wages are not much higher than those of nurse aides. Wages for RNs and LPNs varied widely across the four States we studied, but the difference between RN and LPN salaries averaged $5 per hour.  Hospitals were particularly interested in hiring LPNs who are enrolled in RN programs and working their way through school.  The students are attractive because they have a high level of skills and knowledge and can also be recruited for a future position as an RN.  Another factor making LPNs more attractive in some States is that they are more plentiful than RNs and can perform many of the same functions.  Regardless of the State or scope of practice, experienced long-tenured LPN employees were highly valued in the acute care units where they work.  They were trusted by the RNs, highly skilled as a result of their education and experience, which was valued by the nurse managers and directors.

Factors Unfavorable for Hiring LPNs in Hospitals

Factors that made LPNs unattractive to hire primarily centered around their limited, or perceived limited, scope of practice.  Because there are many nursing functions such as advanced IV therapy, patient assessment, and administration of blood that LPNs are not able to perform, they must be teamed with an RN who then shares the patient assignment.  Some RNs consider this more burdensome than helpful.  Even States with the most liberal scopes of practice have limitations in LPN scope of practice that reduce LPN utility in acute care settings.  Other factors that limit the attractiveness of LPNs were limited training in critical thinking and the lack of clinical experience in specialized hospital units.

LPN and RN Working Relationships

In general, most nursing directors felt that RNs and LPNs worked well together in their hospitals.  On the inpatient units, RNs are in charge (make the assignments and supervise all staff).  LPNs usually have an independent assignment and may care for complex patients, but the RN on the team performs RN-required procedures for those patients.  On hospital-based skilled nursing units, LPNs often have the role of charge nurse with a supervising RN overseeing the LPN.  In the outpatient setting, LPNs may work alongside RNs in performing a variety of outpatient services including patient screening and education.  In one interview site, a large integrated health system practice, LPNs function as health educators in the outpatient setting.

Substitution

All hospital nurse administrators interviewed Stated that LPNs could not substitute for RNs in any situation that required an RN skill level.  LPNs can, and often do, substitute for nurse aides as well as other allied health staff such as EKG technologists if they are trained in that skill.

Adequacy of LPN Education 

Most interviewees felt that LPN education was adequate.  Nursing directors usually preferred particular LPN education programs in their region and tended to recruit primarily from the preferred schools.  These hiring preferences provide feedback to the schools on the strength of the curriculum and teaching.  Hospital nursing directors generally thought that the longer LPN programs (18 months or more) were better.  Several interviewees mentioned that they do not support the challenge exam in which certain categories of LPN candidates, generally those with a military background, are allowed to take the LPN licensing exam without completing a training program. 

Appropriateness of Scope of Practice

Most nursing administrators in hospitals agreed that the scope of LPN practice was appropriate even though it varied widely between the restrictive and liberal States.  Some Stated that the challenge facing hospitals and the RNs who manage the patient care units is to assure that LPNs are allowed to perform up to the maximum of their legal scope of practice, yet not exceed that scope.  Problems occur when there is a lack of knowledge of the LPN scope of practice, or when RNs are unwilling to let LPNs maximize their practice.

LPN practice in long-term care facilities

Long-term care facilities are a major employer of LPNs across the country and in the four States where we conducted interviews.  LPNs are hired in LTC facilities for virtually all nursing functions except those that require an RN under Medicare requirements.   LPN functions include supervision of nurse aides, administration of medications, IV care, and other skilled care within the LPN scope of practice in that State. 

Factors Favoring LPNs in Long-term Care Facilities

LPNs are attractive to long-term care facilities for several reasons.  The primary reason is that LPNs are less costly than RNs for nursing functions that can be performed by either LPNs or RNs, such as basic bedside care, administration of oral medications, supervision of nurse aides, and interaction with patients and their families.  In addition, LPNs as compared to RNs are more available for hire, often have more experience in geriatric settings, and have a more positive attitude about working in long-term care facilities. 

Factors Unfavorable for Hiring LPNs in Long-term Care Facilities

LPNs may be unattractive to hire in long-term care facilities for reasons similar to those cited for acute care settings.  Patients entering skilled nursing facilities can be acutely ill, requiring complex treatments, IV therapy, and wound care, some of which is outside the LPN scope of practice.  Thus, an RN may be preferred over an LPN to fill a vacant position because of the broader scope of practice for RNs.  In addition, skilled nursing homes must hire RNs to meet Medicare requirements for RN staffing, at least 8 hours per day, and to complete the Medicare Minimum Data Set (MDS).  The MDS is the Medicare mandated report on patient level and facility level data that is required for all Medicare and Medicaid certified nursing home residents.  Other interviewees mentioned that RNs are better able to perform patient assessments.  While LPNs are more likely to note that a patient’s condition has changed, RNs are in a better position to assess and diagnose the problem.

An unexpected, but understandable, negative factor cited by employers was that LPNs who were studying to become RNs often do not stay in LPN roles long enough to obtain significant experience in nursing.  In areas where many LPNs follow career ladders to RN licensure, LPNs tend to spend fewer years in LPN practice and the number of highly experienced LPNs in the community is diminished.

LPN and RN Working Relationships

All interviewees Stated that RNs and LPNs work well together in long-term care facilities, sometimes performing the same functions or with the RN performing RN-required functions only.  Some long-term care facilities hire a greater proportion of RNs and others hire only the minimally required number of RNs.  LPNs often act as charge nurses in long-term care facilities, while RNs function as the Director of Nursing.

Substitutability

There were mixed responses to questions about the substitutability of LPNs for other staff in long-term care facilities.  A few said that LPNs substituted for RNs but most said that LPNs only substituted for aides.  In fact, when facilities have a high rate of turnover of nurse aide staff, LPNs are more likely to substitute for nurse aides.  Some of this substitution is intentional and pre-scheduled in order to give the LPNs an opportunity to get to know the patients better and to better understand, or recall, the role of nursing aides.

Adequacy of LPN Education

Most of the long-term care interviewees believed that LPN education in their State was adequate.  Most agreed that not all programs are equal and that the longer courses are better than “fast track” courses.  There was consensus that the curriculum could be stronger in two areas important to long-term care facilities: supervisory skills and geriatric care.  Iowa addresses this concern by requiring a continuing education supervisory course that is mandatory for all LPNs within 6 months of employment in a long-term care facility.  The Iowa State Board of Nursing developed the course and it is offered at community colleges throughout the State.  Facilities in California offer in-service programs to strengthen LPN supervisory skills.  Some interviewees recommended curriculum additions including psychosocial content focused on interacting with patient families, preventive care, and assessment. 

Scope of Practice

Most interviewees agreed that the LPN scope of practice is adequate for their State.  Some commented that requiring an RN to sign off on LPN patient assessments is an unnecessary practice since frequently the RN is merely providing the signature rather than oversight of practice.  Others stated that LPNs are not able to practice to the full scope of practice because RNs would not or were not allowed to delegate certain functions.  For example, in Louisiana, LPNs are not allowed to perform certain functions under their scope of practice because the RN scope of practice forbids RNs from delegating those functions.

The Educational Program Perspective

We interviewed directors and faculty of several types of LPN educational programs in the four focus States, including private adult schools, community college degree programs, and community college non-degree programs.  Some of the programs are ladder programs in which students receive credits toward an RN program and can matriculate into an RN program after completing the LPN program and passing the LPN licensure exam.  Other programs were built in as part of RN programs.  For example, some of the community college programs in Iowa are ladder programs in which students, seeking RN or LPN training, enter a single nursing program.  After the first year of study, students are prepared for and encouraged to take the LPN exam.  Some students stop at this level and pursue a career and employment as an LPN.  Students seeking an RN license, and who meet the minimum grade point average, continue in the program for another year to earn an associate degree in nursing.  In one of these programs about 85 percent to 90 percent of students eventually pursue their RN license. 

Another nuance found in some of the LPN programs was the requirement of certified nursing assistant (CNA) training as a prerequisite for entry into the LPN program.  The purpose was to assure that students master basic skills of the CNA so the LPN curriculum can proceed at a faster pace. 

Enrollment Trends

In most of the programs, enrollment has increased over the past 2 years.  Most of the programs had no difficulty filling available slots and some have a waiting list of a year or more.  Several program interviewees believed that the enrollment increase was greater in recent years due to the national nursing shortage and the downturn in the economy, which made competing occupations less attractive.  Several interviewees noted an increase in the diversity of student enrollment over the past few years with greater enrollment of males and ethnic minorities.

Adequacy of Preparation prior to LPN Program

Interviewees generally thought that many students were not adequately prepared for the LPN program.  They felt that students are less well prepared than in the past and believed poorer high school education, less rigorous admission criteria, and an increasing number of new immigrant applicants contributed to the lack of preparation.  They also Stated that the skills most lacking were in math, reading, and writing.  To address these deficiencies, many of the programs instituted prerequisite math courses or a math entrance exam as an admission requirement.  Others offered English as a second language and math tutoring to help students through the program.  These interventions help students who would otherwise likely fail to complete the program.  However, remedial programs and tutoring are costly and the tuition fees are not adequate to cover these expenses.

Program Completion Rates

Completion rates for the LPN programs ranged from 55 percent to over 95 percent.  Some programs tried to assure completion by allowing students multiple opportunities to retake courses until they passed.  Other programs increased their completion rates by being more selective in the admission process.  In States with open access admission, such as California, programs wee not allowed to be selective in admissions even if there are more applicants than student slots.      

Pass Rates on State Board Exam

Data on passing the LPN State board exams were not available from all the programs interviewed.  The programs that provided information reported that their pass rates ranged between 64 and 95 percent.  One program director reported that the program’s low first-time pass rate had resulted in pressure from the State licensing board to improve.  The director Stated that the program offered free tutoring for students to prepare for repeating the exam if they failed it the first time.  The director felt that the State board should consider second and third-time pass rates when reviewing programs.  Because we selected only a few programs in each State to interview, overall State board pass rates give a better indication of performance in that State.

Academic and Social Support Services

The educational programs offered a variety of academic support services including tuition assistance, loans, educational tutoring, and peer counseling as well payment for books and supplies for students who need assistance in getting through the LPN program.  Interviewees Stated that a variety of services and support are needed to assist some students through the program.  LPN programs located at the community colleges took full advantage of campus learning centers, academic advising, practice labs, tutoring services, and financial assistance.  Some programs also took advantage of county workforce programs to offer students transportation and childcare services in order to help them complete the program. 

Barriers to Completion

Respondents indicated that barriers to completing LPN programs were those targeted by the support services.  Financial needs and lack of educational preparation were cited as the primary barriers to students completing LPN programs.  Programs directors Stated that most LPN students found it necessary to work part or full time while in school.  Many students are older than other college students and have families to support; many are single parents.  Although most programs had the ability to offer some type of financial aid or loans, the amounts were rarely enough to cover a student’s total financial needs.  The other major barriers to completing the program were student lifestyle issues.  Some students have difficulty focusing on school and the need to study, some have attendance problems, and others have unexpected family issues and health problems that impede their ability to focus on school.  Most program directors Stated that these students are usually identified and leave the program early, although often not early enough for the slot to be filled by another student from the waiting list.

Curriculum and Employment Opportunities

Not surprisingly, most LPN program directors felt that the curriculum at the institution was adequate preparation for the students’ future work.  The program directors based this perception on the positive feedback they get from employers directly or from employers recruiting and hiring the program graduates.  Program directors Stated that the students had no difficulty getting jobs, although most Stated that hospital jobs were less available and jobs in long-term care facilities were abundant.  This employment landscape for LPNs may be changing as a result of the RN shortage, and may be altered with staffing legislation such as that recently implemented in California.

One of the LPN programs is a bit unique in that it also prepares LPNs with skills in phlebotomy, EKG, coding, and medical office computer skills.  Some of the graduates take non-traditional LPN jobs in clinical laboratories or medical offices.  It was not clear how this extra course work fit into the curriculum or whether it was an add-on that could be selected by students.

Pursuing RN Education

According to the program directors, many LPN students want to pursue RN education, although the number of students who eventually complete RN education varied among the programs.  The ladder program schools, such as those in Iowa, have a much higher rate of students who finish RN education because the program structure is one program with two possible exit points.  Other programs that are well articulated with RN programs also have higher proportions of LPN graduates pursuing an RN license.  In these programs, the length of the RN program is one to two semesters shorter when LPN program credits are accepted.  The vocational and/or certificate LPN programs create a greater challenge and time commitment for LPNs who wish to pursue an RN license.  In most cases, graduates of vocational LPNs programs must start at the beginning of an RN program, including taking the RN program prerequisites.

Scope of Practice

The program directors generally thought that the LPN scope of practice in their State was appropriate.  They felt that they produce a much-needed bedside caregiver who is well prepared for his or her role and scope of practice. One interviewee noted that the RN board wields a great deal of power over the LPN scope of practice.  She does not anticipate any changes in LPN scope of practice due to the RN board’s power to impede any movement toward expanding LPN practice.  Another noted that if the LPN scope of practice does change, s/he will be ready to alter the LPN program curriculum, but that it would likely mean expanding the length of the program.  A few program directors noted that they thought the intravenous administration of some medications and nutritional solutions should be permitted under the LPN scope of practice.  One director argued that medications that are available over-the-counter should be permitted for IV administration by LPNs.

Boards of Nursing Perspective

In all four States, we interviewed officials at the State board overseeing LPNs.  In Iowa and Massachusetts, a single board oversees RNs and LPNs.  In Louisiana and California there are separate boards for RNs and LPNs. The predominant model in the United States is for the boards to be combined.

Board Composition

Whether or not the LPN and RN board is combined may have implications for the scope of practice for LPNs in that State.  It is possible that LPNs have relatively less power when a combined board represents them, and thus their scope of practice may be limited.  However, when boards are separated they may not consult with each other regarding the scope of practice.  We do not have adequate data to assess whether it is beneficial for patient care and nursing practice in general and for LPN practice in particular to have separate or combined boards of nursing.

The directors of the State boards of nursing interviewed were RNs with varied backgrounds in nursing care, administration, nursing education, and State government.  Most had served for a considerable time in their board position and were knowledgeable about trends and issues in nursing for their State. 

Board Responsibility for LPN Practice

The chief responsibility of the State boards of nursing is consumer protection and assuring compliance with regulations governing the practice of nursing in that State.  All the board directors felt strongly that the regulatory role was their major responsibility.  Most quoted directly from State statutes regarding authority and responsibility of the board of nursing as a consumer protection agency.  Those responsibilities include oversight of the licensing and license renewal process, collecting and summarizing data on licensees, investigation of complaints, administering the disciplinary process, and determining scope of practice based upon the laws and regulations in the State.  Other board functions include setting policy, presiding over board meetings, reviewing nursing education programs in the State, and conducting research on nurses in the State.  Boards track trends in NCLEX pass rates and demographic data of nurses.  All four States have State health care workforce task forces or committees to study the nursing shortage and health workforce issues in the State.  State board staff members were usually participants in those efforts.

LPN Data

The nursing board directors provided detailed data on the number of LPNs in the State the number of educational programs, graduates, exam pass rates, and other demographic data.  Some of the boards have this information readily available on their Web sites, while others gave us copies of written reports and summary data.  Financial resources and staff capacity limit the ability of each State to gather data on LPNs and analyze trends.  Nevertheless, there was a great deal of detailed data available for each of the four focus States. 

LPN Scope of Practice Changes

In the four focus States, the LPN scope practice has had only minor or no changes over the past 5 years.  In Louisiana, the scope has not changed since 1948 although the board director noted that the utilization of LPNs in clinical settings has changed.  The scope of practice Statements in Louisiana and Massachusetts are very broad, leaving it open to interpretation.  Iowa has a specific Statement of the scope of practice, and there have been minor changes.  For example, a change in the scope of practice was required to allow limited performance of intravenous therapy by LPNs and to include the requirement of the supervisory course for LPNs working in long-term care facilities.  Iowa is considering expanding the scope of LPN practice in managing end-stage renal disease and hemodialysis.  Recently in California, there have been changes in the interpretation of the scope of practice to allow LPNs to perform hemodialysis and to administer IV medications during the dialysis procedure.

Substitution

All nursing board directors Stated very specifically that LPNs could not substitute for RNs in their State.  Each saw the role of LPNs as very different from RNs and did not think that the roles overlapped.  Interviewees stated that LPNs supplement RN care and perform routine care but the educational preparation of LPNs and RNs is very different and should remain so. 

Enrollment

Board directors generally agreed that enrollment in LPN programs had increased over the past 2 years in each of the States we visited.  One interviewee said that, over the long-term, LPN enrollment has been tied to the general economy and the availability of alternate careers.  Over the past several years, nursing has been considered a secure career, and the increased awareness of registered nursing has created more interest in LPN programs as well.  The RN shortage seemed to contribute to an increase in LPN enrollment in some States.  During the nursing surplus of the 1990s, there was a decrease in LPN enrollment, presumably due to a diminished number of jobs available for LPNs.  During that time, the State Board of Licensed Practical Nursing in Louisiana recommended a moratorium on new LPN programs.  However, with the advent of another nursing shortage, Louisiana has seen a 12 percent increase in enrollment in LPN programs over the past year.

LPN Shortages

All the State board directors are concerned about a shortage of RNs in the State.  There were mixed responses about whether there were an adequate number of LPNs.  In Louisiana, board staff felt that there was an adequate supply of LPNs but that they were not all working in health care.  Because of overwork due to the nursing shortage and higher salaries available in other occupations, some LPNs have stopped working in health care.  LPNs work for local registries or traveling nurse agencies and some are practicing out of State.  Even Iowa, which has one of the highest RN to population ratios in the Nation, loses nursing staff to neighboring States that pay higher salaries.  In Iowa, nurses living near the border are able to work as traveling nurses in a neighboring State while still living at home.  In California, more LPNs are needed to work in long-term care and home health settings.  Massachusetts interviewees felt that the shortage in their State was not as severe as other States.

Board Suggestions

There were various responses to the question of how States are addressing RN and LPN supply issues.  Most respondents focused on the need for increased funding for nursing at both the Federal and State level.  Funding is needed to build programs, hire faculty, increase the number of clinical sites, and provide tuition assistance for students.  Iowa passed legislation 2 years ago to increase the education of the nursing workforce but funding was not made available.  California has devoted over $34 million via the Nursing Workforce Investment Act to fund nurse workforce development.  In Louisiana, the State has few funds to allocate for addressing the nursing shortage.

Perspectives from Working RNs and LPNs

Focus Groups

Methods

Eleven focus groups were conducted, 7 with LPNs and 4 with RNs.  A professional focus group organization recruited RNs and LPNs via telephone from lists provided by public and private sources.  All of the groups were held between May 21 and June 9, 2003, in the following locations:

• Iowa: Des Moines: 1 group each of RNs and LPNs; Cedar Rapids:  1 group of LPNs
• Louisiana: New Orleans:  1 group each of RNs and LPNs in New Orleans; Baton Rouge: 1 group of LPNs in Baton Rouge
• California: Los Angeles: 1 group each of RNs and LPNs in Los Angeles; Bakersfield: 1 group of LPNs in Bakersfield
• Massachusetts: Framingham: 1 group each of RNs and LPNs in Framingham

Jennifer Arthur, Principal of Arthur Associates, moderated the focus groups using discussion guides (Appendix F).  Each focus group lasted one and one-half hours and participants were paid incentives ranging from $75–85 for LPNs and from $100–125 for RNs.  The different amounts were determined based on customary incentives for this type of activity for each geographic area.  The groups were held in focus group facilities or hotel conference rooms.  Prior to each focus group, participants were asked to complete a two-page written survey (Appendix F). 

Description of Participants

A total of 67 LPNs and 43 RNs participated in the 11 focus groups. The average age of LPNs and RNs in the focus groups was 46.1 and 45.2 years of age, respectively.  LPNs had slightly more children under 18 living at home than did RNs (2.1 versus 1.8). The LPNs were somewhat less likely than RNs to be married (47 percent versus 62 percent), and more likely to be divorced (33 percent versus 21 percent).  A higher percentage of RNs (75 percent) were Caucasian than LPNs (59 percent), while LPNs (13 percent) are more likely than RNs (5 percent) to be Asian.

According to written survey responses, 44 percent of LPNs attended community or junior colleges, versus 23 percent of RNs.  Adult school education was obtained by 32 percent of LPNs and 2 percent of RNs.  Similar percentages of LPNs and RNs attended a 4-year college (17 percent and 16 percent, respectively).  Among the RNs, 33 percent earned an ADN, 23 percent a diploma, and 21 percent had a BSN.  Over one-fourth (29 percent) of the RNs obtained an LPN license before they pursued their RN license.  LPNs in the groups had been licensed an average of 15.8 years, while RNs had been licensed an average of 17.1 years.

Key Findings From Focus Groups

Despite the differences in licensure and employer, both RNs and LPNs Stated that direct patient care is the main responsibility of both RNs and LPNs.  The acute care setting was desired by most RNs and LPNs if pay was equal.  LPNs, however, predominate in long-term care settings in a more hands-on, technical capacity.  RNs are more prevalent in acute care, where they are more likely to supervise and perform highly skilled tasks.  Though some LPNs who work in the acute care setting expressed resentment regarding their lower pay and perceived lower status, most LPNs and RNs in the focus groups reported that relationships between the two groups are generally positive.

Although some of the focus group LPNs were not interested in obtaining an RN license, one or more individuals in each LPN group are either currently studying for their RN license, or are very interested in doing so.  The LPNs in the focus group cited few barriers to earning their LPN license, saying they found it fairly easy.  However, there are significant barriers for LPNs to obtain RN education and licensure.  The major obstacles to LPNs obtaining an RN license appear to be:

• The need to take prerequisite courses such as math and science
• The difficulty of finding time off from work to take courses
• The expense of financing additional education

The majority of focus group participants were generally familiar with the State’s scope of practice for LPNs.  There were differences between what the regulations actually explicated and what members believed that LPNs were permitted to do.  Those areas of discrepancy generally centered on patient assessment, IV therapy, and administration of blood products.  Some LPNs reported that they are not permitted to perform all of the activities outlined in the scope of practice, while others felt that they have responsibilities that go beyond the State’s regulations.  Several LPNs who had knowingly practiced outside their scope of practice by performing tasks in the RN scope of practice expressed discomfort.  Reasons for the discomfort included concern about legal liability issues and the fact that they are paid less than RNs and should not be expected to perform “RN tasks”.

Focus group participants were generally satisfied with their choice of nursing as a career and certain aspects of their current jobs.  In the written survey of the participants, over half the LPNs (56 percent) and three-fourths (74 percent) of RNs said that they strongly agree they are satisfied with nursing as a career (Appendix F1).

Summary of Workforce Perspectives

The key informant interviews yielded information from working RNs and LPNs about scope of practice issues, relationships between the two groups of nurses, and how each group perceived the practice of practical nursing, its limitations and opportunities.  Both RNs and LPNs were generally aware of the legal scope of practice for LPNs in their State, yet there was wide variation in interpretation and implementation. There was uncertainty in some groups about the difference between institutional policy and State law.  Both RNs and LPNs often assumed that the “law” was what was practiced in their institution.   Some individuals expressed surprise at the actual language of the State Practice Act and indicated that the scope was broader than their institutional policy allowed. 

In the focus groups, we learned about perceptions of scope of practice, educational barriers, and the relationships between RNs and LPNs.  Although most of the LPNs stated a desire or intention to return to school to get the RN license, few were actually enrolled in RN programs.  Barriers such as time, a need to keep working, challenges in getting into courses, and family issues were among those that kept LPNs from pursuing further education.  Relationships between LPNs and RNs in the workplace were reported to be cordial.  There was some resentment by LPNs of the higher wages paid to RNs for what is seen by the LPNs as similar work.  RNs, on the other hand, expressed some discontent over the need to supervise LPNs because it often added to their workload.

References

American Hospital Association. (1999). The AHA Annual Survey Database Fiscal Year 1997 Documentation. Chicago, IL: Health Forum.

U.S. Department of Health and Human Services. (2004). Nursing Home Compare, 2004, from www.medicare.gov/NHCompare/home.asp

Chapter 7:  Summary, Conclusions, and Recommendations

Summary

Although LPNs organized into professional groups as early as 1941, there is little in the literature about the practice, work, demand or efficient utilization of the licensed practical nurse. Additionally, there is little guidance as to how to most effectively make use of this practitioners' skills to enhance patient care and augment the nurse workforce.  Recently there has been an increased interest in trying new care delivery models in acute care hospitals using LPNs (Kenney, 2001).  In the 1990s, there were published works that explored the creative use of LPNs in critical care, as advice nurses, and in intravenous therapy teams, (Buccini, 1994; Ingersoll, 1995; Eriksen, 1992; Roth, 1993).  However, little systematic study has occurred that explore these roles. 

Information about the LPN workforce is necessary before making predictions about how best to make use of that workforce.  We found that LPNs were similar to RNs in the following ways:

• Both workforces are aging, with LPNs being slightly older on average;
• Males represent a very small percent of both workforces, but this is slowly increasing;
• The western region of the U.S. has the lowest numbers of LPNs and RNs relative to the population;
• RNs and LPNs share similar employment trends—more were employed in 2001 than in 1984;
• On average, RNs and LPNs work about the same number of hours per week—between 36 and 38 hours;
• The share of RNs and LPNs working in the offices and clinics of physicians doubled between 1984 and 2001.  Also the share working in health services “not else where classified” increased; and
• The hourly pay rate of RNs and LPNs increased 19 percent between 1984 and 2001.

Differences found between the two workforces include the following:

• The RN workforce is larger than the LPN workforce, but the actual size of the LPN workforce is unclear since the available data are conflicting;
• Compared to RNs, more LPNs live in the South and fewer in the Northeast;
• Fewer LPNs are foreign-born, whereas an increasing percent of RNs are immigrants;
• RNs work in hospitals in greater proportions than LPNs, and the share of LPNs working in hospitals declined more than that of RNs between 1984 and 2001;
• The percent of LPNs working in nursing and personal care facilities increased between 1984 and 2001, but the percent of RNs did not; and
• By 2001, the percentage of LPNs working in the private sector was greater than the percent of RNs working in the private sector.

Our data indicate there are similarities in the LPN nurse practice acts across States but variation in how the States express the details of the work of practical nurses.  The data also indicate that most States are flexible in the practice requirements and not overly specific in the tasks that are enumerated. However, there are a number of States that have a restrictive scope of practice and/or very specific detailing of tasks that LPNs are permitted to perform.  Because of the restrictiveness/specificity in selected States, it would be possible to identify States that could reasonably increase their utilization of practical nurses by reducing the restrictiveness of their practice.

Since the 1990s, the number of LPN programs has remained relatively stable but there has been a decline in number of graduates.  Therefore, since 1994, there has been a decline in the number of students each program has enrolled and graduated.  The total number of active licenses of LPNs has increased slightly through the 1990s.  This suggests that LPNs are remaining in the workforce or keeping their licenses active.  The number of first time US educated graduates who are taking the NCLEX-PN has dropped, but the percentage of those passing the examination has remained relatively consistent.

LPN educational curricular requirements vary among the States and territories.  Most States specify the content and number of hours of training, some more detailed than others.  However, most curricula teach similar basic nursing skills training, such as vital signs, patient data collection, patient care and comfort measures, and medication administration.  Additionally, most have added requirements for more advanced skills, such as IV infusion and IV medication administration.  Even though requirements vary, endorsement of LPNs from one State to another is generally done smoothly.  Therefore, the States recognize the similarities of the training programs, even though they have differences.

The supply of LPNs is affected by characteristics common to other professions.  Male LPNs are not more likely to be employed, but they tend to work more hours and are more likely to be employed full time than are females.  LPNs reduce their participation in the labor force after a given age; the probability of employment drops after age 40 or 50 and the probability of full-time work declines after LPNs reach their early forties.  Black LPNs are more likely to work full time and tend to work more hours than white LPNs.  LPNs with children in their households work fewer hours.  As LPN wages rise, LPNs are more likely to work full-time.

LPNs generally enjoy higher earnings with experience, but their earnings level off.  They also have higher wages if they have a college degree.  LPN earnings vary by employment sector, with the highest earnings enjoyed by LPNs working in personnel supply services (such as temporary and home health agencies), hospitals, and long-term care facilities.

The demand for LPNs varies with LPN wages, wages of other nursing personnel, patient volumes, case mix of patients, and market characteristics.  In general, demand for LPNs drops as LPN wages rise, and demand for LPNs rises as wages of RNs rise.  Higher patient volumes are associated with higher demand for LPNs.  In hospitals, rising patient acuity reduces demand for LPNs, while demand increases in long-term care facilities with higher ADL dependency of patients. Revenue constraints imposed by Medicaid lead to higher LPN demand in hospitals but lower LPN demand in long-term care facilities.

Finally, the scope of practice of LPNs affects demand for them.  Restrictive scopes of practice have a significant, negative effect on hospital demand for LPNs.  The restrictiveness of the scope of practice has a negative effect on demand by long-term care facilities.  The weaker effect of scope of practice restrictions on long-term care facility demand for LPNs is not surprising.  Long-term care facilities rarely require the skills that LPNs are prevented from practicing in the restrictive States.

The key informant interviews and focus groups yielded a great deal of information from working RNs and LPNs about scope of practice issues, relationships between the two groups of nurses, and how each group perceived the practice of practical nursing, its limitations and opportunities.  Both RNs and LPNs were fairly knowledgeable about the legal scope of practice for LPNs in their State, yet there was wide variation in its interpretation and implementation.  There was also variation in understanding about the scopes of practice of the two practitioners.

Although most of the LPNs expressed a desire or an intention to return to school to get the RN license, few were actually enrolled in RN programs.  Barriers such as time, a need to have a salary, challenges in getting into courses, and family issues were among those that kept LPNs from pursuing further education.  In some locations, LPNs in long-term care facilities have salaries that are at or near hospital RN salaries.  These LPNs tend to be less interested in pursuing an RN license.  In locations with a substantial gap in salary between RNs and LPNs, there was more interest in moving from LPN to RN.  In several focus group locations, long-term care facilities paid LPNs more money than acute care hospitals.  There was also a perception that LPNs are treated with less respect in acute care hospitals and that the work is more technical and less interesting.  

Workplace relationships between LPNs and RNs in the workplace are reported to be cordial.  There is some resentment by LPNs of the higher wages paid to RNs for what is seen by the LPNs as similar work.  RNs, on the other hand, expressed some discontent over the need to supervise LPNs, since this can adds to the RN workload.  

Conclusions

LPNs are now and have historically been a necessary part of the healthcare workforce in U.S. hospitals, long-term care facilities, and other organizations that provide health care. As the technical complexity of patient care has increased, the demand for more extensive education for both LPNs and RNs has increased.  Simultaneously, the demand for more LPNs, and RNs seems to require that the educational requirements be reduced.  Nurse educators and executives have responded to these conflicting demands by adding additional training to both the basic LPN and RN education programs and generally increasing the time to complete both programs.  Additionally, both practitioners can opt to expand their scopes of practice with additional training.  It is not clear that this increase in scope of practice leads to an increase in salary for the LPN or RN. LPNs with additional training and responsibility for IV medications may see no salary increase.  So, while the increased skill is good for organizations, it is not clear that it benefits the individual in a tangible way.

The LPN workforce displays the same demographic characteristic as the RN workforce, and thus has many of the same limitations, in regards to age, gender, and family obligations.  To expect the LPN workforce to substantially augment the RN workforce is unrealistic, as it presently exists.  There are selected States that have scopes of practice that limit the utility of the LPN.  Less restrictive scopes of LPN practice would increase hospital demand for LPNs but leave long-term care demand unchanged. Further, selected organizations restrict the scope of practice of LPNs further than the State laws allow.  Reasons for these restrictions may be the belief, supported by some studies, that fewer LPN hours have been found to be related to better patient outcomes in acute care facilities.  In any case, less restrictive scopes of practice would influence demand for LPNs in acute care hospitals. 

Although all key informants and focus group members stated flatly that LPNs could not directly substitute for RNs, most acknowledged that much of the work that RNs perform could be performed by LPNs.  There are, of course, differences in the training, skill, and ability of the two different work groups, just as there are differences among individuals in both work groups.  It is very clear that long-term care institutions in the U.S. could not function without LPNs.  It is also clear that LPNs could be used more fully in hospitals.  However, even if direct substitution was possible, there is little hope that the current number of LPNs will be able to augment the RN workforce in adequate numbers to fill the need. More of both LPNs and RNs are needed.

Recommendations

Based on our findings, we recommend the following: 

1. The LPN could be used to augment the workforce during RN shortages.  However, the role of LPNs is limited by their scope of practice.  How much the LPN can be used depends on the ability of States to create a more flexible LPN scope of practice. States should assess whether there is evidence that lessening practice restrictions would negatively impact patient care before making changes to the scope of practice.  Careful study of the use of the LPN in various settings is necessary to determine positive or negative impact on patient outcomes.  Federal and State governments should support research on the effect of LPNs on quality of care.
2. Employers should work to create teams, of RNs and LPNs to share workload appropriately in both acute and long-term care.
3. Boards of Nursing must ensure that bedside RNs and LPNs, nurse managers, and hospital and long term care executives have a common and accurate understanding of the scopes of practice of RNs and LPNs. Employers should clarify for their employees the differences between State scopes of practice and individual institutional policy.  
4. State Boards of Nursing should work toward standardization of LPN training, both at the basic education preparation level and beyond. One mechanism to achieve greater uniformity might involve the identification of national standards for entry level and advanced education of LPNs.
5. Nurse educators need to facilitate articulation between LPN and RN license requirements. More efficient “laddering” of workers from lower skill to higher skill healthcare jobs benefits both workers and employees, and will ultimately decrease the total cost to educate nurses.
6. Based on data related to gender, age, marital status, and ethnicity, it appears that LPNs and RNs come from essentially the same pool or potential workers.  Therefore, the long-term RN shortage is unlikely be solved with an influx of LPNs, because increased recruitment of students into LPN programs will likely offset recruitment into RN programs.
7. Employers should examine how the work of licensed nurses could be allocated safely and reasonably, so that RNs are not overwhelmed and LPNs can practice to their full scope of practice.  Although LPNs cannot directly substitute for RNs, many tasks traditionally completed by RNs can be accomplished by LPNs, with appropriate training. 
8. Employers should consider providing additional compensation to LPNs who complete additional training and obtain certifications beyond the basic LPN license, to provide LPNs with incentives to continue their education. 
9. The Bureau of Health Professions and State Board of Nursing should strive to educate the public about the LPN profession, both to give recognition to practicing LPNs and to encourage more people to pursue a career in practical nursing.
10. The Bureau of the Health Professions, National Council of State Boards of Nursing, or individual State Boards of Nursing should create a national database to track both LPNs and RNs to have accurate data for prediction of nurse and healthcare workforce needs.

References

Buccini, R., & Ridings, L. E. (1994). Using licensed vocational nurses to provide telephone patient instructions in a health maintenance organization. Journal of Nursing Administration, 24(1), 27-33.

Eriksen, L. R., Quandt, B., Teinert, D., Look, D. S., Loosle, R., Mackey, G., et al. (1992). A registered nurse-licensed vocational nurse partnership model for critical care nursing. Journal of Nursing Administration, 22(12), 28-38.

Ingersoll, G. L. (1995). Licensed practical nurses in critical care areas: intensive care unit nurses' perceptions about the role. Heart and Lung: Journal of Critical Care, 24(1), 83-88.

Kenney, P. A. (2001). Maintaining quality care during a nursing shortage using licensed practical nurses in acute care. Journal of Nursing Care Quality, 15(4), 60-68.

Roth, D. (1993). Integrating the licensed practical nurse and the licensed vocational nurse into the specialty of intravenous nursing. Journal of Intravenous Nursing, 16(3), 156-166.

Appendices

Appendix A:
A1.  Nursing-Related Web sites

Appendix B:
B1.  Summary of Responses to IV Medication Survey Sent to all Boards of Nursing except California

Appendix C:
C1.  Restrictiveness Scale Scores Sorted by Most Restrictive
C2.  Specificity Scale Scores Sorted by Most Specific
C3.  LPN Scope of Practice
C4.  Model for Categorizing Scopes of Practice
C5.  Telephone Interview Script for LPN Boards

Appendix D:
D1.  LPN Training Data Totals for U.S.:  1976-1998
D2.  Graduates of LPN/LPN Schools by State:  1976-1997
D3.  Total Enrollment in LPN/LPN Schools by State:  1977-1998
D4.  Fall Admissions to LPN/LPN Schools by State:  1977-1998
D5.  Admissions to LPN/LPN Schools by State:  1976-1997
D6.  LPN/LPN Programs by State:  1976-1997
D7.  LPN/LPN Schools by State:  1976-1997
D8.  Total Number of Active Licenses by State:  1997-2000
D9.  Summary of Licensing Activities
D10.  Number of Graduates of Foreign Nursing Programs Licensed by State
D11.  New in State Functions by Jurisdiction:  1997-2000
D12.  Maintenance Functions by Jurisdiction:  1997-1998
D13.  Total Licenses Processed by Jurisdiction:  1997-1998
D14.  Number of Candidates Taking NCLEX-PN® Examination and Percent Passing for First-Time Candidates Educated in Member Board Jurisdictions:  1997-2000
D15.  Number of First-Time Candidates Not Educated in Member Board Jurisdictions Taking NCLEX-PN® Examination and Percent Passing:  1997-2000
D16.  Summary Statistics for First-Time, U.S.-Educated Candidates Taking NCLEX-PN® Examination:  1997-2000
D17.  National Passing Rate: Licensed Practical/Vocational Nurses:  1989-1994
D18.  Number of Candidates Taking NCLEX-PN® Examination and Percent Passing by Type of Candidate:  1994-2003

Appendix E:
E1.  Means of Variables, 1994-2001 – Supply of Licensed Practical/Vocational Nurses
E2.  Means of Variables, 1990-2000 – Hospital Demand for Licensed Practical Nurses

Appendix F:
F1.  Findings From Focus Groups
F2.  Key Informant Interview Questions
F3.  Focus Group Questions

Appendix A

A1.  Nursing-Related Web sites

Advance for LPNs
http://www.advanceforlpns.com/

Board of Vocational Nursing and Psychiatric Technicians (California)
http://www.bvnpt.ca.gov/

Bureau of Labor Statistics, U.S. Department of Labor:  Licensed Practical and Licensed Vocational Nurses
http://www.bls.gov/oco/ocos102.htm/

National Association for Practical Nurse Education and Service, Inc
http://www.napnes.org/

National Council of State Boards of Nursing
http://www.ncsbn.org/

The National Federation of Licensed Practical Nurses, Inc
http://www.nflpn.org/

Appendix B

B1.  Summary of Responses to IV Medication Survey Sent to all Boards of Nursing except California