Executive
Summary
Although licensed practical nurses (LPNs)
organized into professional groups as
early as 1941, there is little in the
literature about the practice, work, demand
for, or efficient utilization of the licensed
practical nurse. There also is little
guidance about how to make effective use
of these 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, publications explored
the creative use of LPNs in critical care,
as advice nurses, and in intravenous therapy
teams (Buccini, 1994;Ingersoll, 1995;
Intravenous Nurses Society, 1997 ;Eriksen,
1992;Roth, 1993). However, little systematic
study has occurred to explore these roles.
This study examines the demand, supply,
utilization, and scope of practice of
LPNs in the United States. Particular
attention is paid to educational issues,
career mobility, geographic distribution,
and the ability of LPNs to substitute
for registered nurses. The research team
analyzed data from the Bureau of the Census,
American Hospital Association, National
Council of State Boards of Nursing, and
Centers for Medicare and Medicaid Services
to learn about LPN characteristics, education,
and employment. Scope of practice information
was obtained and characterized to learn
how practice regulations vary nationally
and how they affect the demand for LPNs.
Key informant interviews and focus groups
were conducted in four States: California,
Iowa, Louisiana, and Massachusetts. The
findings of the study are provided in
this report.
Data from the Bureau of Labor Statistics’s
Current Population Survey to describe
the demographic characteristics of LPNs,
was compared to registered nurses (RNs)
from 1984 to 2001. The data indicate
the following similarities and differences
between LPNs and RNs.
Similarities:
- Both workforces are aging, with LPNs
being slightly older than RNs on average;
- Males represent a small percent of
both workforces, but are slowly increasing;
- The western region of the U.S. has
the lowest numbers of LPNs and RNs relative
to the population;
- On average, RNs and LPNs work between
36 and 38 hours per week;
- The shares of RNs and LPNs working
in offices and clinics of physicians
doubled between 1984 and 2001; and
- The hourly pay rate of RNs and LPNs
increased 19 percent between 1984 and
2001.
Differences:
- The RN workforce is larger than the
LPN workforce, but the actual size of
the LPN workforce is unclear because
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 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.
State boards of nursing regulate the
practice of LPNs. Most States have a
single board that oversees RNs and LPNs.
Some States have separate boards for RNs
and LPNs. The boards are responsible
for developing scope of practice regulations
and issuing licenses. They also have
disciplinary responsibility and can revoke
licenses. There are similarities in the
nursing practice acts across States, but
variation in how the States express the
details of the work of practical nurses.
Most States have relatively flexible practice
requirements and not very specific about
the tasks that are permitted. However,
some States have very restrictive practice
regulations and/or specific detailing
of tasks that can and cannot be done by
practical nurses. These data are used
in Chapter 5 to examine whether the restrictiveness
and specificity of the scope of practice
affect demand for LPNs. These data suggest
that it may be possible to identify States
that could reasonably increase their utilization
of practical nurses, particularly in hospitals,
by reducing the restrictiveness of their
practice.
Since the 1990s, the number of LPN education
programs has remained relatively stable
but there has been a decline in the number
of enrolled students and graduates. Despite
the drop in graduates, the total number
of active licenses increased slightly
through the 1990s. This suggests that
LPNs are remaining in the workforce at
higher rates than in previous years.
The number of first time US-educated graduates
who are taking the LPN licensing examination
has dropped, but the percentage of those
passing the examination has remained relatively
constant.
LPN educational requirements vary among
the States and territories. Most States
specify the content and number of hours
of training, and some are more detailed
than others. Most curricula teach similar
basic nursing skills, such as measuring
vital signs, patient data collection,
patient care and comfort measures, and
oral medication administration. Most
States have additional training requirements
for more advanced skills, such as phlebotomy,
IV infusion, and IV medication administration.
Even though requirements vary across States,
States generally license LPNs that have
been licensed in other States without
further requirement.
Key informant interviews with leaders
of State boards of nursing, LPN education
programs, hospitals, and nursing homes
allowed us to compare the actual practice
of LPNs with the written regulations.
State nursing board leaders are aware
of the differences in scope of practice
regulations across States, and do not
find these differences troublesome. They
also recognize that employers establish
their own internal practice guidelines,
which may be more restrictive than the
legal scope of practice. Some hospital
and education leaders think their States’
scopes of practice are too restrictive.
Nursing home leaders agreed that LPNs
are essential to the provision of care
in their facilities; the scope of practice
of LPNs is perfectly suited to the needs
of their patients. Hospital leaders varied
in their willingness to employ LPNs.
Most recognized that experienced, intelligent
LPNs could be an asset to a nursing care
team, but found that the scope of practice
of LPNs was too limited to allow for significant
employment of LPNs in acute care settings.
Participants in the focus groups discussed
their perceptions of their scope of practice,
which occasionally differed from State
regulations. Most of the LPNs Stated
an intention to return to school to become
RNs, but few were enrolled in RN programs.
Barriers such as time, the need to keep
working, challenges in getting into courses,
and family issues were among those that
kept LPNs from pursuing further education.
Most LPNs and RNs felt they have good
working relationships with each other.
Some LPNs expressed resentment about the
higher wages paid to RNs for what is seen
by the LPNs as similar work. Other LPNs
said they did not envy RNs, because RNs
have a greater amount of paperwork to
complete and thus have less time to be
with patients. Some RNs expressed discontent
about the need to supervise LPNs because
supervision adds to their workload.
Based on findings in this report, we
make the following recommendations:
- 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.
Intravenous Nurses Society. (1997).
The role of the licensed practical nurse
and the licensed vocational nurse in the
clinical practice of intravenous nursing.
J Intraven Nurs, 20(2), 75-76.
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.
November 1, 2004
Prepared for the Department of Health
and Human Services, Health Resources and
Services Administration, Bureau of Health
Professions, Office of Workforce Evaluation
and Quality Assurance by the Center for
Health Workforce Distribution Studies,
University of California, San Francisco
under Grant # 1-U79-HP-00032-01
Prepared by: Jean Ann Seago, PhD, RN;
Joanne Spetz, PhD; Susan Chapman, PhD,
RN; Wendy Dyer, MS; Kevin Grumbach, MD;
Center for California Health Workforce
Studies, University of California, San
Francisco
|