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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:
- 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.
- Employers should work to create teams,
of RNs and LPNs to share workload appropriately
in both acute and long-term care.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
- 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.
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