Can the Use of Lpns Alleviate the Nursing Shortage? Yes, the Authors Say, but the Issues—Involving Recruitment, Education, and Scope of Practice—Are Complex

By Jean Ann Seago, PhD, RN, Joanne Spetz, PhD, Susan Chapman, PhD, RN, and Wendy Dyer, MS

Can the Use of LPNs Alleviate the Nursing Shortage? Yes, the authors say, but the issues—involving recruitment, education, and scope of practice—are complex.

OVERVIEW: LPNs may be able to help fill some of the gaps caused by the nursing shortage, but little research has been conducted on the demographic characteristics of LPNs, their education and scope of practice, and the demand for their services, all of which vary from state to state. In 2002 and 2003, the authors conducted a comprehensive national study, Supply, Demand, and Use of Licensed Practical Nurses, and have summarized that study’s findings in this article. They found that RNs and LPNs are similar in age and tend to have similar numbers of children, but that racial and ethnic minorities, particularly African Americans, and those who are single, widowed, divorced, or separated are better represented among LPNs. Expanding LPN educational programs might draw more people into nursing. Some LPNs would like to become RNs, so expanding LPN- to-RN “ladder” programs could also be beneficial. LPNs can’t replace RNs entirely, but they could perform much of the work now performed by RNs. While long-term care facilities already depend heavily on LPNs, hospitals could benefit from employing more LPNs. The authors make several specific policy recommendations to improve the education and employment of LPNs.

ince World War II, each successive nursing Association for Practical Nurse Education and Service, shortage in the United States has prompted go to www.napnes.org/about/about.htm.) This article, health care leaders to evaluate the ways in based on the findings of a comprehensive national which adequate nursing care can be pro- study, Supply, Demand, and Use of Licensed Practical vided in hospitals and other settings. One Nurses (authored by the four of us plus Kevin Squestion repeatedly asked is How can LPNs be bet- Grumbach, MD, and found online at ftp://ftp.hrsa. ter used? The current shortage is no exception, and gov/bhpr/nationalcenter/lpn.pdf), asks whether the nurse executives and hospital administrators have use of LPNs can solve or help to solve the nursing been asking how much nursing care can be per- shortage.1 formed by LPNs. Although LPNs organized into LPNs—known as LVNs in Texas and California— professional groups as early as 1941, there is little in numbered 596,355 in 2000, according to U.S. Census the literature on the scope of LPNs’ practice, the Bureau estimates.2 The same year, the National demand for them in health care, and how they can Council of State Boards of Nursing reported that be used efficiently. (For more on the National there were as many as 902,154 active LPN and LVN licenses in the United States and its territories.3 Jean Ann Seago and Joanne Spetz are associate professors and Susan Usually LPNs obtain a license after 12 to 18 months Chapman is an assistant professor at the School of Nursing, University of postsecondary education. In contrast, RNs com- of California, San Francisco. Wendy Dyer is a senior market research analyst at the Kaiser Foundation Health Plan, Inc., in Oakland, CA. plete two to four years of education before licensure. Contact author: Jean Ann Seago, [email protected]. It’s difficult to categorize the work of LPNs in the Research discussed in this article was supported by Contract 1U79 HP00032 and Cooperative Agreement 1U79 HP00004, Bureau of United States because practice acts and scopes of Health Professions, Health Resources and Services Administration, U.S. practice vary substantially by state. LPNs usually Department of Health and Human Services. The authors of this article have no significant ties, financial or otherwise, to any company that work under the supervision of an RN or physician, might have an interest in the publication of this educational activity. and their responsibilities typically include basic

40 AJN M July 2006 M Vol. 106, No. 7 http://www.nursingcenter.com 3.5 HOURS Continuing Education

hygienic and nursing care, measure- ment of vital signs, and administration of prescribed nonintravenous medications. In some states, LPNs can administer IV fluids that do not con- tain medication and withdraw blood. A recent study indicates that outcomes in patients with urinary tract infections, pneumonia, shock, and cardiac arrest are positively associated with increases in RN hours.4 The substitution of LPNs for RNs is depend- ent on employers’ belief that LPNs’

skills are suited to their practice envi- h s u ronments, as well as on the adoption o R

n of sufficiently permissive scope-of- e r a K practice regulations. f o

We framed our study by asking y s e t r

whether LPNs might be used to u o c

address a nursing shortage in several s h p

ways, including the following: a r g o • If the population from which LPNs t o h p

are drawn is different from that of l l RNs, recruiting LPNs might bring A more people into nursing than the Novlette Clark recruitment of RNs alone would. Bronx, New York • If, in response to changes in wages, working Age: 39 conditions, and other characteristics, LPNs make different kinds of employment decisions e have the touch! LPNs have the time than RNs do, LPNs might be attracted to work when RNs are dissuaded from employment. to slow down and talk, just being • If education programs for LPNs could expand ‘W more rapidly than those for RNs because of dif- there. That’s what’s needed, the touch.’ ferences in costs or accreditation regulations, LPNs might be able to enter the labor market In May, AJN’s clinical editor, Karen Roush, interviewed and photographed more quickly. LPNs also could subsequently pur- several students in the LPN program at Putnam–Northern Westchester sue RN education. Board of Cooperative Educational Services in Yorktown Heights, New York. • If the scope of practice for LPNs is sufficiently She talked with them during a clinical rotation at Northern Westchester broad, they might be able to perform many of Hospital, in nearby Mount Kisco, about their professional aspirations and the same tasks RNs perform. why they chose to be LPNs rather than RNs. Roush’s photographs and Each of these possibilities will be reviewed, fol- excerpts from her interviews are interspersed throughout this article. lowed by assessment of the potential role of LPNs Above, Novlette Clark, a single mother of four children, assists new in the current nursing shortage. mother Mary Anne Russo and one-day-old Jaclyn Alexis Russo. Clark wanted to move up from her job as a certified nursing assistant, where METHODS earning enough meant working double shifts, leaving little time or energy The national study, sponsored by the Bureau of for her family. “Time and money were really the issues for me,” she says of Health Professions, U.S. Health Resources and her decision. She started taking courses toward a degree but found the Services Administration, was a comprehensive demands overwhelming. The 10-month, full-time LPN program was the best look at LPN demographic and employment char- route for her to attain her goals: a career she loves, a better income, and acteristics, scope of practice, and education in the time for her children. She plans on resuming her RN studies in January. [email protected] AJN M July 2006 M Vol. 106, No. 7 41 California, Iowa, Louisiana, and Massachusetts. Michelle Grant Those interviewed included practicing LPNs and Bronx, New York RNs, nurse educators, hospital administrators, and Age: 27 representatives from the boards of nursing. Details about these research methods came to realize that are provided in the report. ‘Ithe LPN deals a lot with FINDINGS Are RNs and LPNs drawn clinical and patient care, from the same pool? There while the RN does a lot of are some dissimilarities in the groups of people who choose paperwork and care plans.’ to become either LPNs or RNs. The different educa- When her mother was dying of cancer, tional requirements associated Michelle Grant helped the nurses care for with RN and LPN licensure her and was deeply influenced by their skill may be a primary reason for and dedication. She researched the roles of this; LPN education takes less RNs and LPNs before enrolling in the LPN time and is less expensive than program at Putnam–Northern Westchester RN education. Board of Cooperative Educational Services If RNs and LPNs are in New York. Believing that it would give drawn from different pools her more direct patient contact, she of potential nurses, recruiting decided to try the LPN program first. Her LPNs might bring more peo- student clinical experiences have illumi- ple into the nursing profes- nated the different roles and increased her sion than recruiting RNs respect for RNs. “In comparison with the alone. To determine whether LPN, the RN has a lot of duties to fulfill,” this possibility is true, we she says. “They have to do a little of every- examined data from the thing: the paperwork, the patient care, 2005 Current Population 2 making sure everything is correct. It’s a Survey. Comparisons of the great responsibility!” She plans on continu- characteristics of LPNs and ing her education to become an RN. RNs demonstrated that the “Nurses are in great demand and I’m willing to learn as much LPN workforce had much in common with the RN about nursing as possible,” she says, adding, “but I’m still excited workforce but also differed in potentially signifi- that I get to be an LPN and see what each is about.” cant ways (see Table 1, page 43). Age and sex. In 2003 the average age of both LPNs and RNs was 43 years; while men represented a small percentage of both workforces, the percent- United States and its territories and was conducted age of RNs who were male (8.1%) was nearly twice in 2002 and 2003. Data from the U.S. Census the percentage of LPNs who were male (4.4%). Bureau, the Bureau of Labor Statistics, the Race and ethnicity. Racial and ethnic minority American Hospital Association, the National groups were better represented in the LPN work- Council of State Boards of Nursing, and the Centers force, almost entirely due to the fact that 20% of the for Medicare and Medicaid Services were analyzed. LPN workforce were African American, compared Scope-of-practice information was obtained from with only 10% of the RN workforce. The percent- each state’s board of practical nursing and charac- age of LPNs who were white was 69%, while the terized in terms of its level of restrictiveness and its percentage of RNs who were was 77%. Well under specificity about various tasks in order to elucidate 10% of LPNs and RNs were either Asian or how practice regulations vary and how they affect Hispanic. Efforts to expand the LPN workforce the demand for LPNs. Interviews and focus groups might be particularly successful as the U.S. minority were conducted with nursing leaders in four states: population grows.

42 AJN M July 2006 M Vol. 106, No. 7 http://www.nursingcenter.com Marital status. Although nearly two-thirds of both LPNs and RNs had children, a higher percent- Table 1. Demographic Characteristics of LPNs and RNs age of LPNs were widowed, divorced, or separated. LPN education might be attractive to this group, Characteristic LPNs RNs because of the relatively short and inexpensive course of study required for licensure. Age (mean, in years) 43.12 43.28 Are employment decisions of LPNs and RNs Male 4.4% 8.1% different? If LPNs and RNs respond differently to wage levels, working conditions, and other factors, White 69.1% 77.3% LPNs might be attracted to jobs when RNs are not. African American 20.3% 10.1% Few data are available on the employment decisions of LPNs. The Current Population Survey Hispanic 5.4% 3.8% asked about respondents’ occupations; some peo- Native American 0.6% 0.5% ple who reported “LPN” as their occupation indi- cated that they weren’t working. However, there Asian 3.9% 7.5% isn’t any completely reliable way to determine how U.S. born 89.7% 86.5% many people who hold an LPN license are not cur- rently working as nurses or are working in another Married 54.6% 68.8% field. Thus, we can study the nursing workforce only to the extent that LPNs and RNs work. Widowed/divorced/separated 29.7% 7.9% There were similar employment trends among Never married 15.8% 13.3% RNs and LPNs—more nurses in each job category were employed in 2003 than in 1984. Have children 0–5 years old 16.2% 18.8% However, as seen in Table 2, at right, the work Have children 6–12 years old 24.0% 24.7% settings of LPNs and RNs differed markedly. While more than 60% of RNs worked in hospitals, only Have children 13–17 years old 23.3% 22.4%

37% of LPNs did; while 33% of LPNs worked in U.S. Census Bureau. Current Population Survey, outgoing rotations 1979–2005. Santa nursing homes, assisted living facilities, and other Monica, CA: Unicon Research; 2005. personal care settings, only 8% of RNs did. Some studies have found that the RN labor supply is relatively unresponsive to wage increases in the short term.5 We used multivariate regression Table 2. Employment Patterns of LPNs and RNs analyses to examine the characteristics that affected Characteristic LPNs RNs the number of hours LPNs and RNs worked per week, and found that wage increases are associated Employed 30 or more hours per week 76% 75.6% with more hours of work for LPNs, but not for RNs.6 Thus, wage growth caused by shortages that Hours worked per week (mean) 37.63 37.3 result in an increase in the number of hours worked may lead to changes in the mix of nurses available, Private-sector employee 90.5% 86.1% if LPNs are easier to recruit. Government-sector employee 8.5% 12.7% Is LPN education easier to expand? If education programs for LPNs can be started or expanded Self-employed 0.7% 1.2% more rapidly than can programs for RNs because Hospital employee 37.1% 62.5% of differences in costs or accreditation regulations, more LPNs will be able to enter the labor market Nursing and personal care facility employee 32.8% 7.5% more quickly. Also, LPNs can pursue RN education subsequently, and “career ladder” programs that Employee of physicians’ offices and clinics 9.9% 6.5% advance LPNs into RN programs may prove useful Health services not elsewhere classified 4.1% 3.8% in addressing RN shortages. Since the 1990s, the number of LPN programs Other settings 16.1% 19.7% has remained relatively stable, but there has been a U.S. Census Bureau. Current Population Survey, outgoing rotations 1979–2005. Santa decline in the number of graduates. Curricular Monica, CA: Unicon Research; 2005. [email protected] AJN M July 2006 M Vol. 106, No. 7 43 requirements in LPN education programs vary by willing to devote additional resources to expanding state and territory. Most states specify the content RN programs. and number of hours of training, and some states’ Most of the LPNs in our focus groups expressed specifications are more detailed than those of oth- a desire or an intention to return to school to get ers. Most programs require training in basic nurs- the RN license, but few were enrolled in RN pro- ing skills, such as taking vital signs and collecting grams. Insufficient time, the need for an ongoing other patient data, providing care and comfort, and salary, too few open slots in courses, and family administering medication. Most states require addi- obligations were among the reasons that LPNs tional education for those LPNs who plan to prac- cited for not pursuing further education. In some tice in areas that require skills not usually taught in regions, LPNs in long-term care facilities had a basic LPN course of study, such as IV infusion and salaries equal or almost equal to those of hospital IV medication administration. RNs. These LPNs tended to be less interested in Our interviews with nurse educators and state pursuing an RN license. In regions where there was boards of nursing did not indicate that it was a substantial gap between RN and LPN salaries, always easier to start an LPN program than an LPNs were more interested in becoming RNs. RN program. LPN programs can be completed Is the scope of LPNs’ practice broad enough? more quickly, usually in 12 to 18 months, which Whether LPNs can fill the RN gap depends, at least results in lower overall costs per LPN graduate. in part, on the legal scope of LPNs’ practice, which But many college presidents and nursing school varies from state to state and is regulated by state deans, recognizing that the shortage of RNs is nursing boards and state nursing practice acts. more severe than that of Typically, nurses’ scope of prac- LPNs, have been more tice and educational requirements are specified in state legislation. Most boards then allow for expanded practice— usually in administering IV Dolores Duffy infusions and IV medications, Croton-on-Hudson, New York performing hemodialysis, and Age: 43 supervising other staff—with additional education. In most ou see an LPN working cases the practice acts declare very hard for much less that the LPN must work under ‘Y the supervision of an RN, a pay. It just makes sense to go on.’ physician, or in some states, a pharmacist, podiatrist, or Dolores Duffy is no stranger to stressful jobs. other health care professional. Despite 20 years as a New York City detec- States explicate the work of tive, she was surprised by the demands of LPNs in a variety of ways. nursing school. “I knew I had my work cut Some, such as Louisiana, out for me,” she says, “but I didn’t know my Montana, Maine, and Nevada, whole life had to change.” She cites her age have detailed lists of tasks that and her status as a single mother of three LPNs can and cannot perform. children (ages nine to 15) as the deciding Other states, such as Georgia, factors in choosing the LPN track over the RN track. “I had vari- Alaska, Kentucky, and Oklahoma, have “decision ous opinions, from ‘Try the LPN first’ to ‘You have to go for the trees” to be used as guides for deciding which tasks RN,’ but basically I made my own decision,” she says. She’ll can be performed by LPNs. Some states, such as continue her nursing studies—whether in an associate’s-degree Colorado and Nebraska, use the structure of the or bachelor’s-degree program depends on how many college nursing care plan (goals, assessment, planning, inter- credits will transfer from courses she took years ago. She sees vention, and evaluation) to detail the work that can LPNs as having the advantage of being able to provide more be performed by RNs, LPNs, and certified nursing personal care to patients but at a disadvantage when it comes assistants. South Carolina has developed charts that to wages. delineate allowable tasks according to system of the

44 AJN M July 2006 M Vol. 106, No. 7 http://www.nursingcenter.com body, job category, and experience level within job cate- gories. Neither Michigan nor Texas has defined the scope of James Keane LPN or LVN practice or passed Yorktown, New York a practice act defining it. Age: 49 In order to better understand the scopes of practice of LPNs, we obtained documen- thought the LPN was a tation from virtually every board that regulates the prac- ‘Ilittle lower on the nurs- tice of LPNs and LVNs. Our hypothesis was that there is ing food chain. But you’re variation in the restrictiveness right in there. It’s life and of the scopes of practice for LPNs, and that this restrictive- death.’ ness influences the role and flexibility of LPNs in work When James Keane started talking about settings. Our data indicate a career in nursing, after 22 years in law that there are similarities— enforcement, his wife said, “Jim, what are such as allowing basic nursing you, crazy?” But the nurses he knew, tasks such as hygiene to be including a sister and a sister-in-law, performed—in the LPN nurse encouraged him. He’d recently retired practice acts across states, but from an administrative position at Rikers variation in how the states Island, a prison complex on the East River regulate the details of the work of LPNs. in New York City. “I enjoyed my years in corrections,” he says. Interviews with leaders of state boards of nurs- “Some guys were waiting for that day to run out the door. But I just ing, LPN educational programs, hospitals, and want to deal with people again and have some fun with it.” For nursing homes allowed us to compare the actual him that means not ending up in a supervisory or administrative practice of LPNs with the written regulations. State role, a move he sees as inevitable for an RN. “I think the LPN has nursing board leaders were aware of the differences more hands-on contact with patients,” he says. In the hospital set- in scope-of-practice regulations across states and ting he feels himself a part of a team with RNs, but in the nursing didn’t find these differences troublesome. They also home he feels “distant” from them. He may one day return to recognized that employers establish their own inter- school. “It will make me a better nurse,” he says. “But for the title nal practice guidelines, which may be more restric- of RN? It really doesn’t make a big difference to me.” tive than the scope of practice allowed by law. Some hospital and education leaders considered their states’ scope of practice to be too restrictive. Nursing home leaders agreed that LPNs are essential to the provision of care in their facilities; the mentation. Participants’ perceptions of the scope of scope of practice of LPNs is well suited to the needs their own practice occasionally differed from state of their patients, who tend to be less acutely ill and regulations. This discrepancy was usually related more stable. Hospital leaders varied in their will- to their employers not allowing LPNs to practice to ingness to employ LPNs. Most recognized that the full extent of their legal scope of practice. experienced, capable LPNs could be an asset to a To examine the effect of scope-of-practice regu- nursing care team but found that the scope of prac- lations on the demand for LPNs, we conducted tice of LPNs was too limited to allow for significant multivariate regression analyses for LPN employ- employment of LPNs in acute-care settings. ment using national data.6 Restrictive scope-of- The focus groups revealed that both RNs and practice laws had a significant negative effect on LPNs were fairly knowledgeable about the legal hospital demand for LPNs. The restrictiveness of scope of practice of LPNs in their state, yet there the scope of practice also, not surprisingly, had a was wide variation in its interpretation and imple- negative effect, although a weaker one, on demand [email protected] AJN M July 2006 M Vol. 106, No. 7 45 Two Perspectives

An Evaluation of Seago and Colleagues’ Study Calls for More Research

PNs are an established but minimally studied part of oppose certification for particular tasks such as pharmaco- Lthe nursing workforce. Seago and colleagues help to logic training. Such training may further encourage fill that gap with their excellent study. employers to substitute LPNs for RNs, which may not be in Several factors have overshadowed any serious efforts the patients’ interest. Studies that examine outcomes in a to articulate nursing education—that is, to develop efficient variety of settings with differing scopes of practice are and effective educational ladders, including LPN-to-RN needed to establish the optimal scope of practice for LPNs. education. (These factors include alarm over the well- The authors’ last recommendation—that more effective publicized RN shortages of the last few years; the contro- laddering from lower to higher skilled jobs would benefit versy over the education and role of RNs who have earned both employers and nurses and decrease the total cost of associate’s and bachelor’s degrees; and an increasing educating nurses—is an old argument. We are not aware emphasis on new levels and models of education, such as of studies that show that such ladders decrease the total the clinical nurse leader.1) While such education issues con- cost of education. In fact, they may contribute to duplica- tribute to some of the disarray in nursing practice, the focus tion of course work and an increase in the number of of Seago and colleagues is on how LPNs can be used years required to become an RN. Also, LPNs’ ability to more effectively as part of the nursing workforce. complete an RN curriculum successfully shouldn’t be The authors recommend that before the scope of prac- assumed. The view that the proper educational path to tice of LPNs is altered, states should assess whether easing nursing is a BSN degree makes it difficult to efficiently scope-of-practice restrictions, which vary extensively across articulate the existing nursing education system. Also, states, will affect the quality of care. We agree. Profess- because longitudinal career-development studies of ional nursing has been focused on establishing the inde- nursing are lacking, it’s unclear whether prior nursing pendent contributions of RNs to the quality of patient experience as an aide or LPN contributes positively or care.2, 3 We hope that such an assessment of LPNs’ scope negatively to RN retention and participation. of practice will be free of the polarization sometimes Finally, the research and data needed to make distinc- found in the debate about the roles of associate’s- tions in the quality of care provided by variously composed degree–prepared and baccalaureate-prepared RNs and teams of RNs, LPNs, and nursing aides are, so far, unavail- will focus instead on what the most appropriate educa- able. Such research is essential to evaluating the quality of tional path and scope of practice are to best provide effec- care provided by various mixes of nurses, as well as to tive practice teams in various settings. establishing the total quantity of personnel needed in multi- The authors recommend that employers “examine how the ple health care settings.—Carol S. Brewer, PhD, RN, asso- work of LPNs can be distributed safely and reasonably, so ciate professor, School of Nursing, State University of New that RNs aren’t overwhelmed and LPNs can perform all of York at Buffalo, and Christine Tassone Kovner, PhD, RN, the nursing tasks permitted to them under existing scope-of- FAAN, professor, College of Nursing, New York University, practice regulations.” As more research shows that the level New York City of RN staffing makes a difference in patient care outcomes,4 we need to study whether use of LPNs can improve patient REFERENCES care, and whether reducing the role of nursing aides would 1. American Association of Colleges of Nursing. Fact sheet: the clinical nurse leader. 2005 Jun. www.aacn.nche.edu/CNL/pdf/ heighten such an effect. Until there is more research, we are CNLFactSheet.pdf. concerned that the substitution of LPNs for RNs could have a 2. Kovner C, et al. Nurse staffing and postsurgical adverse events: an negative impact on the quality of care, although such substi- analysis of administrative data from a sample of U.S. hospitals, tution has the potential to decrease costs. 1990–1996. Health Serv Res 2002;37(3):611-29. 3. Needleman J, et al. Nurse staffing in hospitals: is there a business Further, Seago and colleagues recommend providing case for quality? Health Aff (Millwood) 2006;25(1):204-11. financial incentives to LPNs who undertake additional train- 4. Horn SD, et al. RN staffing time and outcomes of long-stay nursing. The authors don’t provide evidence in their study that ing home residents: pressure ulcers and other adverse outcomes are less likely as RNs spend more time on direct patient care. Am J this would be effective. LPNs evidently are more responsive Nurs 2005;105(11):58-70. 5 to wage increases than are RNs, but the jury is still out. It’s 5. Brewer CS, et al. Factors influencing female registered nurses’ work not clear what this additional training would be. We behavior. Health Serv Res. [Epub 2006 Mar 23].

46 AJN M July 2006 M Vol. 106, No. 7 http://www.nursingcenter.com Concerns Remain About LPNs’ Scope of Practice and Recruiting Minorities to Become LPNs

eago and colleagues recommend specific changes in the tional education, the substitution is unlikely to produce the Spolicies of institutions that employ LPNs, including allowing same improved outcomes for patients. LPNs to “perform all of the nursing tasks permitted to them The use of LPNs outside of their scope of practice could be under existing scope-of-practice regulations” and providing bet- perceived as exploitation of a group of workers who are at a ter compensation to those who complete additional training lower rung of the health care delivery system. Do we really and certification programs. They also suggest that, because want to encourage the recruitment of more minority workers minorities are better represented among LPNs than among into a practical-nursing track, then ask them to do the work of RNs, it may be easier to recruit minorities into practical-nursing an RN but receive less in wages—all of which may have the careers. Although the authors may be concerned about provi- ultimate consequence of costing the health care system more sion of nursing care to patients in light of the current and pro- because of poorer patient outcomes? jected nursing shortage, some of the implications of their Consider the experience of an African American student cur- findings are alarming. rently enrolled in our nursing program. She has taken a long I’m concerned that the authors, in trying to show that LPNs journey to achieve her RN status and is now obtaining a bac- can help address the nursing shortage, may be over- calaureate. Though she had already completed some college estimating the degree to which LPNs can do the work of RNs. work, she was advised by a guidance counselor to go to an We have to ensure that we have the right type of nursing per- LPN program because it would take only nine months to com- sonnel to meet the nursing care needs of the patient popula- plete. She felt that she had the ability and skills to complete an tion, including vulnerable minority communities during a time RN program, but she was told that she could do just as well by of persistent racial and ethnic health disparities. becoming an LPN. She followed this advice. In her work setting I’m also concerned about the perception that minorities she was constantly discouraged from furthering her RN educa- could be easier to recruit into the ranks of LPNs as the minority tion. When she realized that if she stayed in that work situation population grows. Such a perception may become a kind of and position she would never achieve her goal of becoming self-fulfilling prophecy, in which educators steer minority nurs- an RN, she left and went to an associate’s degree program. ing students into LPN education, thereby exacerbating inequal- As Seago and colleagues note, there is a higher represen- ities that already exist in nursing. (It should also be noted that tation of minorities, particularly African Americans, in the although the authors speak in terms of “minorities,” it is practical-nurse pool than in the RN group. Why are minorities African Americans, rather than Asian Americans or Hispanic overrepresented in this group? We need hard data on this Americans, who are overrepresented in the LPN ranks.) question, but I and other ethnic minority nurses have heard too LPNs have been contributing members of the health care many stories about minority students being tracked into these delivery system for decades. However, the roles that they programs by misinformed counselors in their elementary and should play in that system have been debated for nearly as secondary schools. Health disparities continue to ravage long. Some community health centers and ambulatory care minority communities. The care required by underserved and clinics have been using LPNs to interview patients and elicit vulnerable populations is complex and necessitates the use of their chief complaints before they’re seen by the nurse practi- professional nurses who have a broad knowledge base and tioner or physician. Is this an assessment and triage function understand these communities and their needs. The role of the that should be the responsibility of an RN? The facilities have LPN should be supportive to the role of the RN, not a replace- argued that the LPNs are just getting information and pass- ment for it; but many facilities already use LPNs in place of ing it along to the appropriate practitioner. RNs. The expansion of LPN programs swells the licensed nurs- The suggestion that much of the work done by RNs could ing ranks with the least educated practitioners, who have lim- be performed by LPNs if their scope of practice were broad- ited opportunities to pursue RN education. It is a disservice to ened undervalues the role of the RN. The authors refer to the those interested in nursing and to minority populations to sug- recent study by Needleman and colleagues that found better gest that, because minorities are increasing in the population, patient outcomes with increased licensed nursing hours, they should be steered into practical nursing careers instead of including LPN hours.1 But Needleman and colleagues also registered nursing careers.—Catherine Alicia Georges, EdD, concluded that keeping the total number of nursing hours RN, FAAN, associate professor and chairperson, Department constant and increasing the proportion provided by RNs is of Nursing, Lehman College, Bronx, NY the most cost-effective approach to improving patient out- REFERENCE comes from nursing care, noting that “greater use of RNs in 1. Needleman J, et al. Nurse staffing in hospitals: is there a business case preference to LPNs appears to pay for itself.” Without addi- for quality? Health Aff (Millwood) 2006;25(1):204-11.

[email protected] AJN M July 2006 M Vol. 106, No. 7 47 sion. In general, it isn’t easier to open or expand an LPN program than to open or expand an RN pro- Anshu Dhar gram. Because many LPNs are interested in pursu- Peekskill, New York ing RN licenses, nursing educators should increase Age: 31 opportunities for them to do so. LPN-to-RN programs can help LPNs advance into RN jobs, and omeone will come in and teach you a their success may in turn improve the overall diver- skill, but you don’t know why you do it. sity of the nursing workforce. Flexible programs ‘S can be implemented to provide RN education to You don’t have that background or education working LPNs in part-time, evening, and weekend schedules. Additionally, a growing number of to support what you’re doing.’ employers offer scholarships.7 Expansion of current LPN education programs or creation of new ones is Ask Anshu Dhar why she pursued an LPN rather than an RN not likely to solve the RN shortage completely, but license, and her immediate response is, “Stigma!” She is from targeted LPN-to-RN programs can help fill the gap. northern India, where nursing has long been regarded as “a Although all nursing leaders and focus group messy and low-grade job,” although that perception is beginning members stated that LPNs could not replace RNs, to change with the increase in technology in nursing care. “I was most acknowledged that much of the work that RNs very scared of the reaction of my family, perform could be performed especially my husband’s family, who are still by LPNs, even though their in India,” she says. “I said to them, ‘Let me scope of practice is more lim- start with LPN first and see,’ because you ited. There are, of course, dif- need that acceptance from your family.” ferences in the training and Her family is now “thrilled” about her skills of the two different nursing career, and with their support she groups, just as there are differ- plans on entering a master’s program for ences among individuals in second-degree students (she holds a bache- each occupation. Long-term lor’s degree in psychology), with a goal of care institutions could not becoming an NP. She regards the LPN role function without LPNs, and as “more challenging” than that of the RN it’s likely that LPNs could be when it comes to direct care, but she sees used more fully in hospitals. RNs as providing a “directional path” for However, even if direct substi- LPNs. “They pave the way with their expertise tution were possible, there’s and education,” she says. little hope that the current number of LPNs would be able to augment the RN workforce sufficiently to fill in long-term care facilities the need. More LPNs and (weaker, perhaps, because RNs are needed. long-term care facilities Based on our findings, we rarely require the tasks, recommend the following: such as IV “push” medication delivery or blood • Before making changes to LPNs’ scope of prac- administration, that LPNs are prevented from per- tice, states should assess whether the evidence forming in the more restrictive states). indicates that easing practice restrictions would negatively affect patient care. CONCLUSIONS AND POLICY RECOMMENDATIONS • Employers should examine how the work of Based on our findings of demographics, education, LPNs can be distributed safely and reasonably, so scope of practice, and demand for LPNs and RNs, that RNs aren’t overwhelmed and LPNs can per- we believe LPNs can help address the current nurs- form all of the nursing tasks permitted to them ing shortage in a limited way. New LPNs are drawn under existing scope-of-practice regulations. from a different demographic pool than RNs are; • Employers should provide additional compensa- therefore, expanding LPN education can bring a tion to LPNs who complete additional training broader group of people into the nursing profes- and obtain certification beyond that required for

48 AJN M July 2006 M Vol. 106, No. 7 http://www.nursingcenter.com basic LPN licensure; this would provide educational incentives to LPNs. 3 5 HOURS • Nurse educators should facilitate the matricula- . Continuing Education tion of LPNs in RN educational programs. More efficient “laddering” of workers from lower-skill EARN CE CREDIT ONLINE: TEST CODE AJN1306 to higher-skill health care jobs would benefit Go to www.nursingcenter.com/CE/ajn and receive a certificate within minutes. both workers and employers and, ultimately, GENERAL PURPOSE: To summarize for registered profes- would decrease the total cost of educating sional nurses the findings of the authors’ comprehen- nurses. sive national study, Supply, Demand, and Use of At present, the LPN workforce is not being used Licensed Practical Nurses. to its fullest capacity. Employers, state boards of LEARNING OBJECTIVES: After reading this article and nursing, and educators should strive to ensure that taking the test on the next page, you will be able to all types of licensed nurses are part of the effort to • discuss the background information and demo- M graphics relevant to the authors’ study of LPNs and alleviate the nursing shortage. the nursing shortage. • summarize the key findings of the authors’ study. REFERENCES • outline the authors’ conclusions and recommenda- 1. Seago JA, et al. Supply, demand, and use of licensed practi- tions related to their study. cal nurses. San Francisco: University of California; Nov TEST INSTRUCTIONS 2004. ftp://ftp.hrsa.gov/bhpr/nationalcenter/lpn.pdf. To take the test online, go to our secure Web site at 2. U.S. Census Bureau. Current Population Survey, outgoing rotations 1979–2005. Santa Monica, CA: Unicon Research; www.nursingcenter.com/CE/ajn. 2005. To use the form provided in this issue, 3. Crawford L, et al. 2000 licensure and examination statistics. • record your answers in the test answer section of Chicago: National Council of State Boards of Nursing Inc; the CE enrollment form between pages 63 and 64. 2001. http://www.ncsbn.org/pdfs/2000lic_exam_statistics_ Each question has only one correct answer. You report_on-line.pdf. may make copies of the form. 4. Needleman J, et al. Nurse staffing in hospitals: is there a • complete the registration information and course evalu- business case for quality? Health Aff (Millwood) 2006;25 (1):204-11. ation. Mail the completed enrollment form and registration fee of $24.95 to Lippincott Williams and Wilkins 5. Spetz J, Given R. The future of the nurse shortage: will wage increases close the gap? Health Aff (Millwood) CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723, 2003;22(6):199-206. by July 31, 2008. You will receive your certificate in 6. Coffman JM, et al. Minimum nurse-to-patient ratios in four to six weeks. For faster service, include a fax acute care hospitals in California. Health Aff (Millwood) number and we will fax your certificate within two 2002;21(5):53-64. business days of receiving your enrollment form. You 7. Spetz J, et al. Hospital demand for licensed practical nurses. will receive your CE certificate of earned contact hours West J Nurs Res [In press]. and an answer key to review your results. There is no minimum passing grade. DISCOUNTS and CUSTOMER SERVICE • Send two or more tests in any nursing journal published by Lippincott Williams and Wilkins (LWW) together, and deduct $0.95 from the price of each test. • We also offer CE accounts for hospitals and other health care facilities online at www.nursingcenter. com. Call (800) 787-8985 for details. PROVIDER ACCREDITATION LWW, the publisher of AJN, will award 3.5 contact hours for this continuing nursing education activity. LWW is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 3.5 contact hours. LWW is also an approved provider by the American Association of Critical-Care Nurses (AACN 00012278, CERP Category O), Alabama #ABNP0114, Florida #FBN2454, and Iowa #75. LWW home study activities are classified for Texas nursing continuing education requirements as Type 1. Your certificate is valid in all states.

[email protected] AJN M July 2006 M Vol. 106, No. 7 49