Minnesota Medical Association Task Force Report on Delegation to Licensed Practical Nurses (LPNs) in a Clinic or Physician Office Setting This report provides guidance to physicians and clinic managers regarding the medical functions that might appropriately be delegated to a licensed practical nurse (LPN) within a clinic or physician office setting. February, 2003 LPN ISSUES TASK FORCE Terence P. Cahill, M.D., Chair, United Clinics of Blue Earth Patricia Lindholm, M.D., Fergus Falls Medical Group Richard Gebhart, M.D., Camden Physicians Kathleen M. Sweetman, M.D., Lakeview Clinic Paul Van Gorp, M.D., CentraCare Clinic of Long Prairie Virginia Barzan, CAE., Minnesota Academy of Family Practice A special thank you to nursing representatives who attended task force meetings and provided advice and counsel: Shirley Brekken, R.N., Minnesota Board of Nursing Diane O’Connor, R.N., Minnesota Nurses Association Kathy Kapla, LPN, Minnesota Council No. 65, American Federation of State, County and Municipal Employees Carol Diemert, R.N., Minnesota Nurses Association Kathy Fodness, SEIU Local 113 Donna Quam, R.N., Fergus Falls Community College Glenda Moyers, R.N., Hennepin Technical College Mary Jo Borden, R.N., The College of St. Catherine Darlene Haglund, LPN, Cambridge Clinic Kim Mellgren, LPN, Cambridge Clinic Renee Burman, LPN, Fairview Riverside Hospital Chris Lawrenz, LPN, Sleepy Eye Clinic Patricia C. Hanson, R.N., MMA Manager Quality and Data, MMA Staff to Task Force and report author The report was approved by the physician members of the Ad Hoc LPN Issues Task Force and the MMA Board of Trustees on January 18, 2003. © 2003 Minnesota Medical Association History of the Issues statutes and rules are empowered to regulate activities related to nursing education, licensure and practice within their re- The impetus for examining LPN scope of practice issues was spective jurisdictions to meet the states’ constitutional obliga- a request from members of the Minnesota Academy of Fam- tions of protecting their citizens. The State Board of Nursing ily Physicians (MAFP) who asked the MMA to review several confers a license to a qualified registered nurse (RN) or li- issues related to LPN practice in the non-acute setting. MAFP censed practical nurse (LPN) authorizing the individual to en- members were concerned because opinions issued by the Min- gage in professional or practical nursing and certifying that nesota Board of Nursing (MBON) in its publications were in- the individual has attained the minimal degree of competency terpreted by the MAFP to mean that LPNs could no longer to ensure that public health, safety and welfare will be reason- perform the skills/tasks/activities that they had routinely been ably well protected. delegated in the physician office or clinic setting. The Minnesota Nurse Practice Act (MNPA) Several physician offices and clinics began considering an LPN (Please note, for the purposes of this report, only those por- hiring freeze and contemplated hiring and training non-nurses tions of the statutes and rules that apply to RNs and LPNs will such as medical technicians or medical aides to carry out dele- be discussed.) gated medical functions that are performed in a clinic and of- fice setting. Concerned about the impact on the quality of pa- The Minnesota Nurse Practice Act defines RN practice as the tient care, many physicians questioned the advisability of practice of professional nursing [emphasis added]. The Act hiring non-nurses. Physicians believe that LPN staff are capa- states, “the practice of professional nursing means the per- ble of providing the care needed by clinic patients and that formance for compensation or personal profit of the profes- LPNs are more qualified to provide nursing care and carry out sional interpersonal service of (1) providing a nursing assess- delegated medical orders than unlicensed assistive personnel ment of the actual or potential needs of individuals, families, such as an aide or technician. or communities; (2) providing nursing care supportive to or restorative of life by functions such as skilled ministration of Because of physicians’ concerns, in August 2000 the MMA nursing care, supervising and teaching nursing personnel, House of Delegates passed the following resolution intro- health teaching and counseling, case finding, and referral to duced by the MAFP: other health resources; and (3) evaluating these actions. The RESOLVED that the MMA draft legislation amending practice of professional nursing includes both independent MN Statute 151.37, Subd. 2 (a), the Pharmacy Act, to nursing functions and delegated medical functions that may allow for physicians to direct a licensed practical nurse be performed in collaboration with other health team mem- to administer legend drugs under practice guidelines or bers, or may be delegated by the professional nurse to other protocols, and be it further RESOLVED that the MMA nursing personnel. Independent nursing function may also be work with appropriate nursing and other organizations performed autonomously. The practice of professional nurs- to develop guidelines for the supervision of LPNs by ing requires that level of special education, knowledge, and RNs or physicians that will support the provision of skill ordinarily expected of an individual who has completed quality patient care. an approved professional nursing education program…” It is important to note that the RN is termed professional and the In response, the MMA created the Ad Hoc LPN Issues Task responsibilities are delineated much more specifically than Force to study the topics addressed in the resolution. Invited those in the LPN definition that follows. Specifically, the re- to join the task force were several Minnesota nursing organi- sponsibilities of assessment, delegation, evaluation, supervi- zations including the Minnesota Board of Nursing, the Min- sion and teaching of nursing personnel, and health teaching nesota Nurses Association, the Minnesota LPN Association, are clearly defined by the Minnesota Board of Nursing as re- Service Employees International Union, and the Minnesota sponsibilities of an RN. Practical Nurse Directors and Educators Association. The task force met for several months. During this time, the nurs- The Minnesota Nurse Practice Act defines practical nursing ing organizations also met separately to discuss and work out as the “performance for compensation or personal profit of various issues that were brought up by physician members of any of those services in observing and caring for the ill, in- the task force. jured, or infirm, in applying counsel and procedure to safe- guard life and health, in administering medication and treat- ment as prescribed by a licensed health professional, which are commonly performed by LPNs and which require special- The Minnesota Nurse Practice Act (MNPA) ized knowledge and skill such as are taught or acquired in an and the Authority of the Minnesota approved school of practical nursing, but do not require the specialized education, knowledge, and skill of a registered Board of Nursing (MBON) nurse [emphasis added].” The language that has been empha- sized is the crux of the controversy about what tasks/activities The MNPA (Minnesota Statutes section 148.171-148.285) is can be assigned and delegated to an LPN. The Minnesota the statute or law that governs nursing practice in Minnesota. Nurse Practice Act does not offer examples of the activities an Nurses are also governed by Minnesota Rules Chapter 6301- LPN is licensed to perform and those that should only be per- 6330. formed by an RN. For example, the nursing statute does not specify the specific medications and treatments that may be As agents of state government, boards of nursing through administered by an LPN. What Activities Specifically Differentiate LPN and RN LPN Education Practice? Educational preparation for an LPN is usually nine to 15 A clear delineation between RN and LPN practice is difficult months in a community college or technical college, and a high because the nursing profession as a whole has not developed school diploma or the equivalent is required prior to enroll- consensus on what makes a nursing skill, task, or activity one ment. Becoming an LPN requires completion of a formal that can only be performed by an RN versus a nursing skill, training program plus supervised clinical instruction. The task, or activity that can be delegated to an LPN. Although it curriculum includes the study of nursing, body structure and would seem logical that LPN skills, tasks, and activities delin- function, basic psychology, pharmacology, math and commu- eated in statute and rules would be comparable from state to nication skills. Graduates of an approved program take a li- state and the specifics of their scope of practice reflected in censing examination for practical nursing. Upon passing the state’s statutes, this is not the case. Some state’s statutes are NCLEX-PN examination the graduate is eligible for state li- very specific about an LPN’s scope of practice, but others, such censure by the Minnesota Board of Nursing and is allowed to as Minnesota statutes, are vague and open to interpretation. use the title of licensed practical nurse (LPN). Although there are some recent studies that validate the posi- Upon graduation from an approved program, an LPN is pre- tive outcomes of care provided by RNs (NEJM, Vol 345, pared to function as a member of the health-care team by ex- No.22. May 30, 2002), there is little, if any, research that dif- ercising sound nursing judgment based on educational prepa- ferentiates the outcomes of care provided by LPNs versus ration, knowledge, skills, understanding and experiences in RNs, particularly in the outpatient setting such as a clinic or nursing situations. The LPN participates in the planning and physician office. A detailed review of the literature on this implementation of nursing care in all settings; monitors subject reveals a notable lack of research and information changes in patients’ symptoms and conditions; and performs about the effectiveness of care provided by RNs versus care more specialized nursing functions such as administering provided by LPNs.