Appendix F

F1.  Findings From Focus Groups

Patient care is the major role for both RNs and LPNs

Despite the differences in their licensure and employer, LPNs and RNs Stated that direct patient care is their main responsibility. While LPN and RN licenses specify different scopes of practice, and LPNs predominate in the long-term care setting with RNs more prevalent in acute care facilities, the focus group respondents cited similar overall duties in their current jobs.  Specifically, direct patient care is the most often-mentioned responsibility with most of the participating LPNs and RNs claiming this duty.  In descending order of importance, both groups also Stated responsibility for: patient education, supervision of other nurses, education of other staff members, and supervision of non-nursing staff.

When LPNs and RNs work side-by-side in a particular facility or department, the actual patient-care duties performed by each differ, with LPNs serving in a more hands-on, technical capacity and RNs more likely to supervise and to perform specific highly skilled tasks.  However, when RNs greatly outnumber the LPNs in a particular setting, their duties may be fairly similar, except for those activities the LPN is not licensed to perform.  When LPNs greatly outnumber the RNs in a setting, usually in long-term care, the LPNs report to an RN, but may take on broader responsibilities.

Relationships between RNs and LPNs are positive

The relationships between the LPNs and RNs in the focus groups and the other nursing staff members with whom they work are generally positive. LPNs Stated that the RNs with whom they interact are, for the most part, supportive and respectful, while the RNs Stated that they appreciate the contributions of the LPNs and rely on them to get the job done.  In the acute care setting, some LPNs resent their lower pay and perceived lower status, although not all hospital LPNs felt this way.  The few specific instances of friction cited by focus group respondents were believed to be isolated examples of personality clashes or the occasional frustrated or overworked individual.

There are significant barriers for LPNs in obtaining RN education and licensure

If it were easier for LPNs to get their RN license, more LPNs would be interested in doing so.  Although some of the focus groups’ LPNs are not interested in obtaining an RN license, many would like to obtain the more advanced license.  In each of the LPN focus groups, at least one individual was currently enrolled in an RN program, and several others Stated an intention to enroll in the future.  Still others in each group claimed to have been interested in an RN license in the past, but to have shelved their aspirations for a variety of reasons.  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

Some LPNs who Stated that they are not interested in obtaining a RN license said that they would be paid less as a newly licensed RN than as an experienced LPN.  Some LPNs said that they perceive RNs to have more non-patient-care responsibilities, such as paperwork, and that they personally did not want to leave bedside nursing.

The following ideas were proposed by the group to help LPNs address barriers in gaining RN licensure were suggested by focus group participants:

• Have RN programs that give substantial credit for the expertise and knowledge of an experienced LPN
• Offer employer-sponsored programs that provide financial assistance and scheduling flexibility to LPNs interested in pursuing the RN license
• Offer LPNs who meet certain criteria an opportunity to challenge the RN boards without further course work
• Offer more LPN–RN ladder programs such as those offered at most Iowa Community Colleges

Most participants agree with the LPN scope of practice in their State

The four States visited varied in LPN scope of practice.  The majority of focus group participants were generally familiar with their State’s scope of practice for LPNs.  In each group, several individuals were able to articulate the LPN scope of practice and could specify how it differed from the RN scope of practice.  Even many respondents who did not feel comfortable articulating the guidelines appeared knowledgeable about what RNs and LPNs are and are not permitted to do in the workplace.  In each focus group, a few individuals seemed unsure about what the regulations specify.

While focus group members generally understood the LPN scope of practice in each of the four States, there are a few differences between what the regulations State and what members believed that LPNs are permitted to do.  Those areas of discrepancy mostly centered on patient assessment, IV therapy, and treatment with blood products. 

Most focus group participants were in agreement with their State’s scope of practice, although a few respondents, particularly LPNs, felt that the scope is too restrictive.  Those who support the current scope of practice believe that it appropriately captures the level of training and skills possessed by LPNs.  Those who felt that the scope of practice is too limiting expressed the following perspectives:

• Some LPNs mentioned that they are not permitted to perform all the activities outlined in the scope of practice.  LPNs Stated that they are guided more by employer-specific policies and procedures stating their specific job tasks and responsibilities than by everyday knowledge of the State’s scope of practice.  Employers have the prerogative to establish internal practice guidelines that are more limited than the legal scope of practice.   
• In reality LPNs often perform many RN tasks, with the RN signing off on their completion.
• Many LPNs with experience have greater technical abilities than junior RNs
• LPNs are more practiced at the technical, hands-on aspects of nursing while RNs spend more time doing administrative work.
• Another limiting factor in LPN scope of practice is that of what RNs are allowed to delegate to other health professionals, including LPNs.  For example, in the State of Louisiana, the RN scope of practice limits the tasks that an RN may delegate to an LPN, thereby de facto reducing the LPN scope of practice.

Some LPNs felt that they have responsibilities that go beyond the State’s regulations. 

According to the focus group participants, when the LPNs functioned outside the scope of practice, it was usually for one of the following reasons:

• In some units/department (e.g., ER, ICU, cardiac catheterization lab), the pace is so hectic that everyone must pitch in and do what is required, regardless of regulatory boundaries.
• If an RN has confidence in a particular LPN’s knowledge and skills, that LPN may be permitted to bend the rules.
• In long-term care facilities and on night and weekend shifts, there may be few or no RNs available, so LPNs must perform tasks outside of the scope of practice.
• In emergency situations LPNs may perform tasks outside their scope of practice.
• A relatively junior RN may have a lower skill level than a more senior LPN, who therefore is asked to perform a task in his/her stead.

Several LPNs who had knowingly practiced outside their scope of practice expressed discomfort with this both because of legal liability and because they are paid less than RNs and should therefore not be expected to take on RN tasks.

Many LPNs are interested in earning an RN license

In each LPN group, one or more individuals are either currently studying for their RN license, or are very interested in doing so.  Still others considered getting an RN license at some time in the past, but were unable to complete the process.  Among the reasons LPNs cited for wishing to become an RN are:

• Higher pay
• Greater respect from patients, physicians, other staff members
• Ability to supervise other and less hands-on work
• Already do everything RNs do, but not paid as much
• RNs work at a slower pace with more paperwork to do
• Greater opportunities for advancement
• To gain more knowledge and skills 
• Priority in scheduling work-shifts (acute care)

Several LPNs also Stated that they were not interested in becoming RNs.  Among the reasons they wished to remain an LPN were:

• Because of seniority, earn more than most RNs
• Not a risk-taker
• Not sure I have what it takes to get the RN license
• LPNs today have more opportunities than they did in the past
• Can’t afford to quit work to pursue the RN license
• Would have to take the various prerequisite courses (math, science, history)
• LPNs have less responsibility and lower legal liability
• RNs don’t do as much direct patient care

Barriers to LPN education and licensure are fewer than for RN licensure

The LPNs in the focus groups cited few barriers to earning their LPN license, saying they found it fairly easy.  The obstacles mentioned by individual respondents included difficulty in the following areas:

• Finding information about LPN programs in the area
• Fulfilling prerequisites
• Attending the program as a single mother or when raising a family
• Lack of employer tuition reimbursement
• Obtaining paid time off from work to attend school
• Competing with other students for prerequisite courses

Once initial barriers such as finding a program and completing prerequisites were completed, most of the LPNs Stated that they had few barriers to completing LPN educational programs.  The major barrier cited was the need to work and attend school as well as juggle family responsibilities.

Most RNs and LPNs were satisfied with their career and job

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 of LPNs (56 percent) and three-fourths (74 percent) of RNs say that they Strongly Agree that they are satisfied with nursing as a career, while over half of LPNs (56 percent) and two-thirds (67 percent) of RNs Strongly Agree that they are not considering leaving the field.  Three-fourths of LPNs (73 percent) and half of RNs (50 percent) strongly agree that they like working with a mix of different types of nurses.  However nearly half of each group believed that their supervisors value their opinions.  The most negative scores were given to salary level.  Just 2 percent of LPNs and 12 percent of RNs strongly agree that their pay is satisfactory for their work.

Most RNs and LPNs preferred to work in acute care settings if pay was equal

The written survey results showed that LPNs are more than twice as likely as RNs to work in the long-term care setting, while RNs are more than twice as likely as LPNs to work in acute care hospitals.  Part of this is due to the fact that in the 1990s, many acute care hospitals reduced or eliminated LPN positions in an attempt to increase the percentage of RNs in their work forces.  In addition, the typically lower skill set of the LPN is adequate to meet the needs of the less acutely ill long-term care patient population.

Nurses who work in the acute care setting Stated that they preferred that setting for several reasons:

• Acute care is a more exciting, fast-paced and challenging 
• Use more skills and uses a wider variety of skills
• Greater variety of patient cases 
• Pay is generally higher
• Employee benefits are better
• Opportunities for travel and per diem positions

The participants who preferred the long-term care setting cited the following reasons for their views:

• Longer lengths of stay allow staff to get to know the patient and family
• Work hours often shorter and usually more regular
• Mandated overtime rarely exists in long-term care.
• LPNs pay is usually higher in long-term care than in acute care hospitals.
• Pace of work is generally slower

F2.  Key Informant Interview Questions

Interview Questions for employers

Questions to be asked in the employer interviews include, but are not limited to:

• To what extent do you employ LPNs in your facility?
• What factors make LPNs attractive to you?
• What factors make LPNs unattractive to you?
• How do LPNs work with other personnel in your facility?
• To what extent do you substitute LPNs for other personnel in your facility?
• Do you believe LPN education is adequate?
• What changes to LPN education would you recommend?
• Do you believe the scope of practice of LPNs in your State is appropriate?
• What changes to the scope of practice would you recommend?

Interview Questions for educators

Questions to be asked in the educator interviews include, but are not limited to:

• What factors help students complete their LPN education?
• What factors are barriers to the completion of LPN education?
• What positions do your LPNs obtain after completion of your program?
• Do you believe LPN educational requirements are adequate in your State?
• What changes to LPN educational requirements would you recommend?
• Do many of your students want to pursue RN education after completing LPN education?
• How difficult is it to pursue RN education after LPN education?
• Do you believe the scope of practice of LPNs in your State is appropriate?
• What changes to the scope of practice would you recommend?

Interview Questions for Boards of LPN/LPN

Questions to be asked in the Boards of LPN/LPN interviews include, but are not limited to:

• What is the philosophy behind the scope of practice of LPNs in your State?
• Do you believe the scope of practice regulations for LPNs in your State are effective?
• What changes to the scope of practice are under consideration?
• How do you accredit LPN educational programs in your State?
• Is adequate LPN education available in your State?
• How difficult is it to pursue RN education after LPN education?
• Where do LPNs work when they complete their education in your State?
• Does there appear to be a shortage of LPNs?

F3.  Focus Group Questions

Focus Group Questions for RNs

Questions to be asked in the RN focus groups include, but are not limited to:

• How do LPNs work with other personnel in your facility?
• Do you supervise LPNs?
• What difficulties do you experience working with LPNs?
• To what extent do LPNs substitute for other personnel in your facility?
• Do you believe LPN education is adequate?
• What changes to LPN education would you recommend?
• Do you believe the scope of practice of LPNs in your State is appropriate?
• What changes to the scope of practice would you recommend?

Focus Group Questions for LPN/LPNs

Questions to be asked in the practicing LPN focus groups include, but are not limited to:

• How do LPNs work with other personnel in your State?
• To what extent do LPNs substitute for other personnel in your State?
• What factors are barriers to the completion of LPN education?
• Do you believe LPN education is adequate?
• What changes to LPN education would you recommend?
• How difficult is it to pursue RN education after LPN education?
• Do you believe the scope of practice of LPNs in your State is appropriate?
• What changes to the scope of practice would you recommend?