CA staffing ratios evoke anger 'tween RNs & LVNs

[NMAguiar]

Big news on the California nursing ratios front. As California prepares to carry out its first-in-the-nation law telling hospitals how many nurses they must have on hand for patients, a bitter dispute has broken out between rival unions over exactly who should count as a nurse.

In separate news, testifying hospitals plead for more time, citing the nursing shortage as a hinderence to nurse-patient ratios.

Both stories in entirety are here.

[tiger]

i'm not going to get into the whole rn/lvn thing, although some comments that have been made are dissapointing. i would like to comment on my own experience though if i may. i am an lpn. when i worked in tx i was charge at ltc facilities. took phone and verbal orders, and the whole bit. i have also worked at an md office where i was allowed to do ivp meds.and there you did not even get iv certified. i moved to nv in 1990. started at a hospital and was allowed to do assessments(without any cosig) including initial assessments. i was allowed to start heplocks and hang ivs via heplock or picc.i was never allowed to hang blood or do ivp here in nv. anyways, now this past year, on my floor, which is rehab now, we are not allowed to do assessments. we are given anywhere from 7 to 15 pts. while the rn has 3(depending on whether we have a cna or not). we also have a charge and unit sec. who do all the orders and calling of the doc. these pts are not critical but do need to be monitored. now, it is confusing to me. i have too many pts. to do what i used to be able to. before the staffing was even rn/lpn. yet i feel responsible for doing everything. the rns may come and spend 5 minutes doing an assessment(others just copy what was there the day before) and another 5 documenting it but other than that--i am responsible for everything else that is time consuming like blood sugars, monitoring bps, transferring, toileting/and or ic or scanning the bladder, o2sats,or monitoring for any problems the pt. has.also i am to get the pt dressed and up before breakfast.many times i have had 9 pts with no cna. can you get report starting at 6 a.m., get all your meds, pts dressed and up, not to mention showers and dressing changes by 8 a.m.? if i need an order i am to go to the charge nurse. . i'm also responsible for all meds including iv antibiotics(we very seldom have ivp orders). plus i am supposed to update care plans, do graphics, chart audits, case conference, and document any thing pertinent on the pt. it just seems f%%%%ed up to me that i cannot now give my pts. the care that i want to. i did before. anymore i feel like answering in the same manner the agency lpn did just to get out of more work so i can see my pts. YOU BETTER GO ASK THE NURSE. anyway, i'd like to finish by adding that this is on MY rehab unit.i realize it is different everywhere. and that alot of the rns will help with stuff if they know you are busy, NOT ALL. i have had rns getting my pts up and doing adls or toileting cause i'm too busy with meds or something. and i do agree that lpns probably shoild not be in critical care units due to the restrictions of their liscense. sorry if i rambled. i am frustrated with my job right now. hate to leave my benes behind though.

[-jt]

<...why shouldn lpns be taught vital things like heart lung sounds to the deepest degree>

Why not teach it anyway & make it part of the scope???>

That would do away with LPN programs & turn them all into RN programs. Well, at least the staffing ratio issue would be solved. :)

[-jt]

I didnt see anyone BLAMING the LPN for anything. The issue is the powers that be refusing to recognize that the staffing ratios they say are 1:4 will not be real if LVNs can be used to fill them. The RN will STILL have at least 1:8 - double the amount that the state is advertizing - because of the rules that govern our licenses. Nobody is blaming LPNs for that. We're blaming the big-business administrators who are looking only at the bottom $$$ rather than the reality of our jobs, nature of our professional responsibilities, our working conditions & what it means to the pt when RNs have unsafe, unmanageable pt loads.

Time and again Ive seen posted that this NOT an RN vs LPN thing.

[tiger]

why don't we just graduate lpns and then have them have to further their education in the hospital setting?

[Youda]

tiger, what a load you have at work! Sounds all too familiar, though.

To make a little more sense of what I believe rncountry is saying, is that although you are certainly capable of doing all the things you do everyday, it is the RN who is responsible for "interpreting" the results. Suppose you did the O2 sats, BS, and VS on a patient. None were really abnormal, but borderline, so you reported it to the RN. The RN would have to take all that data, look at the recent lab, run down the hall to do her OWN assessment (even though you already did one . . . because the RN would be looking for signs you were never taught to see), and then the RN would have to put it all together and decide if the Dr. needed to be called. In my hypothetical scenario, the RN concluded that although BS's were not very high (200's in the afternoon, let's say) and the O2 sat was a little low at 91%, and the last lab showed a high normal K+, and during the RNs assessment, she found a slighly sluggish reflex . . . she concluded that the patient was going into ketoacidosis and called the Dr.

I don't know any other way to say this than by a hypothetical example. LPNs are most certainly "nurses." But, do also agree that the differences in training make all the difference. Just have the technical abiilty to DO the tasks doesn't make a person the same as an RN. I don't think anyone is saying that an LPN is the same as an RN, but there is definitely a lot of "I can do everything an RN can" thinking. Well, No, an LPN can't do everything an RN can. And, it is VERY difficult to pinpoint and describe what the difference is, because it is NOT the tasks, it's the interpretation of the tasks and data.

RNs are taught an entirely different way of doing an assessment, for example. Rns don't just look for subjective data, but how to USE that subjective data to make care plans, to foresee problems, to evaluate outcomes, to prevent complications, to recognize the need for interventions, etc.

Maybe all I'm trying to say is that the differences can't be SEEN, because the difference between an RN and a LPN is what happens between the ears, not on the floor performing tasks.

And, that is the problem with this messing with the law that was passed. rncountry is quite correct. The hospitals are trying to lump EVERY nurse into the same category, under the big umbrella called "NURSE" and refusing to recognize that one nurse is not the identical twin of another.

[NurseAngie]

Originally posted by LoisJean

As California goes so goes the Nation. I suggest all LPN/LVNs hold on to their azzes, because the big blow is going to blow even harder. Cripes- the nursing shortage/crisis or whatever spin anyone wants to put on it, is just that because LPNs/LVNs ARE NOT counted as nurses in the mix of numbers. Somewhere along the line it was taken away from us--by bean counters. You RNs bring in big bucks to health care institutions--they charge for your services and pay you back in chump change. For the sake of those big bucks, someone took the autonomy and skills of the Licensed Nurse away--(never mind that it was you, the RN, who taught us and utilized us in those skills) -little by little by little until the very defination of an Licensed Nurse became muddied and murky nation wide. We were not allowed to use what we had been educated to do and were made to become the registered nurse's dependent, rather than her Assistant. And now you are complaining because you have to be responsible for us...!? Go figure. You are getting what you asked for.

I vow to all that's holy right here and now that I will not ever, never, while I am still breathing, consider myself less worthy of rightful recognition as a NURSE because I am an LPN--and don't any of you try to tell me that worthiness is not the issue. It is. If there were any recognition at all of the prime role of the LPN as a viable member of the nursing community it would not be necessary to belabor this subject. It is PRIMARILY because of this denigeration of the LPN/LVN over the past few decades that I do not any longer grace the halls of any hospital or other institution as a nurse and believe me, that is your loss not mine. I work for myself and that is what keeps me very satisfied within my nursing role. I damn well know who I am and what I am and I am damn good! And as for you, Canada--well, sorry for your experience...but you are a litigeous person--short-sighted, narrow minded people usually are.

No Peace on this one, Folks-

Lois Jean

AMEN Lois Jean.....EVERYTHING you said is right on target. It is OUR loss that you no longer grace the halls any hospital/institution! I am in awe of the strength of your character on this matter.

~Angie

[tiger]

we have a charge nurse for all the problems that come up. i go to her same as the rns do. the rns don't check labs. the charge nurse does.so do you still think the lpns should have twice the pts. or more?

[NurseAngie]

I am seeing a HUGE play on words on this board...a lot of see-sawing and lengthy posts which stray from the topic. What a shame that we all can't be entitled to our own opinions and accepted as people, if not as NURSES. Not only would I not recommend for anyone to become a LPN....I would NOT recommend that they become a NURSE. This is now my official opinion. Darn I feel good NOW!

~Angie

[-jt]

Thats right. Thats what Ive been saying. Its a big difference between having 1 Registered Nurse to every 4 pts and having 1 licensed nurse to every 4 pts.

Do LPNs think its so easy for me to have my own full assignment & also take "just 5 minutes" to hang all your pts antibx? Or that hanging that antibx is the full extent of what we have to do & are liable for with that pt? What if the LPN doesnt notice hes having an adverse reaction & doesnt call the MD? Yeah its HER responsibility & HER license. Its also mine. Because thats what the practice act & state law dictates. Would I love to have the LPN be the only one responsible for her assignment & for knowing & doing everything shes supposed to for them. But thats not the way it works. The practice act & state laws say Im stuck with the responsibility & with caring for my own full assignment of pts myself PLUS helping with hers & sharing the responsibility for them too.

THE WHOLE ISSUE IS THAT 8 PTS IS TOO MUCH TO DO ALL THIS FOR. IT PUTS THE PT AT RISK. IT PUTS MY LICENSE AT RISK. BUT IF THE HOSPITALS & SEIU GET THEIR WAY & CAN FILL VACANT RN POSITIONS WITH LVNs, IM GOING TO BE STUCK WITH THOSE RISKS FOR GOOD.

Its not about LPNs. They belong there. We're not saying get rid of them. We're saying we need ratios that allow us to manage the job the way we're supposed to - safely. If the hospitals want to fill 50% of those ratios with LVNs, then they need to change the law to ratios better than 1:4 so the RN can have a safe manageable pt load too.

>>>

This thread has made it very clear that the LPNs perception of what "covering" entails is a lot different than the RNs understanding of it. And no, thats not just in NY. In every state, the RN is accountable & responsible for the pts - even the ones assigned to the LPN.

Why do so many LPNs see only the task of the RN hanging the IV bag? Do they not see that it doesnt end there for me? She may be in there doing most of the hands on care but that pt is still on my hands too. Fine for her - she may only have the 4 pts to worry about. I may have one pt thats in pain, another that needs to have her post op wound assessed, another that is developing early signs of fluid overload during her blood transfusion - which I may miss cause Im too busy running to keep ontop of 8 pts - and another with an MAR 3 pages long which I can be brought up on state charges for neglecting & end up having to fight for my license if he complains that he didnt get his meds on time..... & you think all Im doing is "whining" because I have to take a moment of my time & just hang your antibx???

Dont I have to also take the time to know about your pt? Can he have that antibx? Whats it for? Is the order correct? Dose correct? Does he have allergies? What else is getting with it? Is he tolerating it? All of your pts can need to have antibx hung & need me to spend the same amount of time checking all of this before I hang theirs. And what else do they need me to do as far as the hadns-on tasks? To be quite honest, those tasks that some LPNs seem to keep talking about are not the RNs main concern when it comes to "covering" those pts. Its all the other stuff we have to keep straight, keeping ontop of the LPNs full assignment, following up that the pts is getting what is needed...... and ALSO managing her own full assignment at the same time. How come the LPN doesnt understand all this & only keeps talking about how its no big deal to "cover" her.

As the RN, hanging an antibx is the least of what I have to do for the pts assigned to the LPN. Thats not the LPNs fault.

I just need to have a pt ratio that will allow me to do all I have to do safely. Those 1:4 "any-nurse" ratios dont do it cause I wont have 4. Ill have 8. The issue is not that theres LPNs there. The issue is the ratio the RN ends up with in this proposal.

This thread is proving more & more that some LPNs dont realize what the RNs role & job actually is or what the implications are for us. Nobody is blaming LPNs for those implications either. Its the law that governs our license & its our profession. And being such, RNs need to have a pt load that is manageable so they can do all this safely & properly. Its not a negative reflection on the LPN.

Its not a matter of just "covering" an LPN or "signing off" her chart. To read these posts, it seems some LPNs (not all) think signing off their chart is just a simple act us of taking pen to paper that takes a second. But if I sign off that chart, it means I know full well what is going on with that pt, what was done for him, that the care was appropriate, & safe. If Im signing off on that, I better well know it to be true for a fact - not just assumed, cause I am putting my license on the line of that signature.

There is a lot more to "covering" the LPN than just the technical task that the LPN sees the RN do for her pt. Much of what we have to do cannot be seen like a task can. Much of what we have to do is not even recognized or understood by others at all -as evident right here in all these angry posts that totally miss the point of what we're saying.

The any-nurse staffing ratio is not going to reduce RNs pt loads to safer, more manageable numbers and it changes nothing about their working conditions. Why are LPNs fighting them on that?

[-jt]

Trust has absolutely nothing to do with it. You could be my best friend. I could trust you with my childrens lives. I could know you were the best damn LPN in the hospital. But that doesnt change a thing or reduce my workload.

You are responsible for your actions. I am responsible for what happens to the pts. I cannot leave anything to trust. I am obligated to KNOW what is going on, what is being done, & what is happening to/with the pts. I doesnt mean I dont trust you. I just cant assume what others are doing, or trust that all is the way it should be. I have to be sure of it, especially before I "sign off" your chart legally indicating that I am. Thats not merely my own personal preference. Thats what my license dictates.

But I cant be ontop of the 8 pts at once that this any-nurse staffing ratio will give me.

[rncountry]

Originally posted by [email protected]

Wow...when I read this, I was somewhat aghast. Does not the "N" in LPN stand for "Nurse?" Or maybe my little LPN pea-brain didn't get the letters correct.

Rebel, this is where I got pea brained from. What I was trying to illustrate was that no one said an LPN was pea brained, until this comment, which does no one any good. I think it is just not a good idea for an LPN to refer to themselves in a sarcastic manner of well, I'm just stupid I guess.

Tiger, I would not work under the conditions that you are working under. What your post illustrates for me is this. Depending on where an LPN works the job description varies greatly because there is much gray in the LPN practice acts in all states. The same thing happens in my state of Michigan. The suits, for lack of a better word, take great advantage of this, using the LPN in the most bullshit manner AND pay them less for the trouble. In my own unit about a year ago the Clinical Coordinator decided that LPNs couldn't take verbal orders, when previously they had. The rationale was that it wasn't covered in their practice act. Actually a reading of the LPN practice act for Michigan does not say that specifically. I was so irritated over this I called the BON and asked specifically whether LPNs could take verbal orders or not. I was told well, yes and well, no. I was told that because RNs are supposed to be supervising the LPN the RN should take verbal orders so they are aware of what is going on with the LPNs patients, however that is left to the discretion of the facility. It is something that each facility has to decide if right or not for them. I commented that I didn't feel this was a very good answer, but all I got back was this is the way it is. The reality is that there isn't a nursing home in the state of Michigan that could function if an LPN couldn't take verbal orders, and I can't help but wonder if an LPNs hearing suddenly goes when working in the hospital, apparently my clinical coordinator thinks it does. Personally I believe every LPN I work with is as capable of hearing physician orders as I am. It is the arbitrary way that the practice act is instituted that causes so many problems. It is things like this that make me say that LPNs are being screwed. Tiger, do you make as much money as the RN? Yet you are being expected to carry many of the same duties that in years past you would not have been doing. This is not an outgrowth of the nursing shortage, no matter what suit wants to put that spin on it. It was done deliberately as a way to get the same work done for less pay. The being responsible for so much work that previously RNs had done themselves but aren't anymore has instead pushed more RNs out of the profession as they began to fear what could potentially happen to their licenses because of these types of situations. Unfortunately when the RNs pointed out that they were responsible for things that they weren't directly doing, but were expected to know what was going on despite having higher patient loads and acuity themselves, an awful lot of LPNs felt that RNs were simply complaining that the LPN was not capable. There was no thought on the part of alot of LPNs that was not the issue RNs had. It had to do with what exactly should an LPN be doing and what an RN should be doing based on education and a true delineation of duties. Not make up the rules as the suits went along based on their bottom line dollar needs. I just do not get why an LPN would feel that this is appropriate. And I don't understand how an LPN doesn't see how this drives a wedge between two groups of nurses who need each other. Instead what I see, from my perspective, is LPNs that become defensive over whether they are bright enough to do what they are doing. It is not LPNs who have put RNs into the situations we are dealing with, and it is not RNs that have put LPNs into the situation where depending on where you work depends on what you are doing. Someone said blame the suits, oh I do. It is like watching the manipulative patient that is very skilled at dividing staff and making them work against one another, with whispers in the ear of your so much nicer than that nurse I had last night, and that nurse I had two days ago she did this and she did that but YOU never do that, your so wonderful and that nurse who is being whispered to believes it all, swallowing the whole tale and deciding that those other nurses who the patient is complaining about are the worst she has ever worked with. And all the nurses involved are clueless as to the havoc that this manipulative patient(industry) is causing on the unit. Instead of putting the focus on the manipulative patient and showing a united front and letting the patient understand that they will not divide the staff, they have focused on each other and the apparent poor abilities each have that the patient has so willingly pointed out.

Rebel, my intent is not to bash any LPN/LVN. I told you my grandmother was an LVN, and I had utmost respect for her. In her later years she became a Christian Science nurse and into her late 60's she drove her little red VW beetle from one end of the country to the other to care for patients who had the same religious beliefs as she did. Let me tell you, my grandma Crabtree was really something. What I am trying to say is that the healthcare industry wants to use "nurse" to lump LPNs and RNs together as a way to avoid the appropriate ratios, and when LPNs through their union support this, I find it distasteful.

No matter where I have worked my role has remained consistant. No stories like tiger's from me. Why? Because I have a clearly defined practice act, something LPNs do not have.

And by the way, I did read every post. It is this one I copied/pasted that set me off. From LoisJean.

As California goes so goes the Nation. I suggest all LPN/LVNs hold on to their azzes, because the big blow is going to blow even harder. Cripes- the nursing shortage/crisis or whatever spin anyone wants to put on it, is just that because LPNs/LVNs ARE NOT counted as nurses in the mix of numbers. Somewhere along the line it was taken away from us--by bean counters. You RNs bring in big bucks to health care institutions--they charge for your services and pay you back in chump change. For the sake of those big bucks, someone took the autonomy and skills of the Licensed Nurse away--(never mind that it was you, the RN, who taught us and utilized us in those skills) -little by little by little until the very defination of an Licensed Nurse became muddied and murky nation wide. We were not allowed to use what we had been educated to do and were made to become the registered nurse's dependent, rather than her Assistant. And now you are complaining because you have to be responsible for us...!? Go figure. You are getting what you asked for.

I vow to all that's holy right here and now that I will not ever, never, while I am still breathing, consider myself less worthy of rightful recognition as a NURSE because I am an LPN--and don't any of you try to tell me that worthiness is not the issue. It is. If there were any recognition at all of the prime role of the LPN as a viable member of the nursing community it would not be necessary to belabor this subject. It is PRIMARILY because of this denigeration of the LPN/LVN over the past few decades that I do not any longer grace the halls of any hospital or other institution as a nurse and believe me, that is your loss not mine. I work for myself and that is what keeps me very satisfied within my nursing role. I damn well know who I am and what I am and I am damn good! And as for you, Canada--well, sorry for your experience...but you are a litigeous person--short-sighted, narrow minded people usually are.

No Peace on this one, Folks-

Lois Jean

Not one LPN here read RN2B's post as anything but well, LPNs are not nurses. Instead of why the industry would prefer the idea that a nurse is a nurse is a nurse. The industry does not want to see the differences in education, in nurse practice acts, and does not want to make that difference clear. It hurts the LPN, as much as it hurts the RN. And yes, it hurts the patient.

[SKM-NURSIEPOOH, BSN, RN]

i think you've misunderstood or missed my point entirely. what i was saying is that rns shouldn't be forced to cover or co-sign for another license...period. when the lpn position first came into existence...this issue should've been resolved then. i believe that this is where a lot of resentment is coming from. i'm not at all saying that lpns = rns in no way...i'm just saying that since they're licensed...they should be held responsible for whatever they do.

o.k., you gave an example about not being able to write scripts & perform the same assessments as apn because you don't have the same education that that individual...that very well maybe true...but you certainly wouldn't appreciate it if you had to have them co-sign everything that you do because of it. the same could be said of non-certified rns wanting to work in areas that require certifications like: ned, ccrn, crna, acls...etc. you're all licensed rns but work under different scope of practice...correct??? would certified rns appreciate having to have to co-sign for their non-certified peers??? would those non-certified peers appreciate having to have certified rns to co-sign??? all that i'm saying is take that extra responsibility away from the rns (co-signing)...& hold the lpns responsible for their scope of practice...that's all. you've made my argument when you said:

... i am not going to be responsible for someone who is not educated to do this or licensed to do it either. it goes under the guise of the rn being able to "delegate" and "supervise" the problem is that the rn didn't get to decide if they wanted to "delegate" these things to a cna.

rns don't get the right to chance to choose whether she/he want to have a full work load & delegate & supervise the lpns either...but it's in most sbon scope of practice for the rns to supervise the lpns. i don't believe it was meant for rns to have a work load of patients, be responsible for them, in addition to all of the lpns they have to co-sign for. and i know that the charge nurse has numerous things that they have to do in a shift other than just co-sign for the lpns....i'm just frustrated that rns have allowed soooo much to be put on them is all. i don't know if because nursing is predominately female gender or what??? but since there are more males coming into this field...maybe nurses won't be taken for granted??? just a thought.

no one said that lpns are = to rns...at least that not what i've said. i've been for lpns being the entry level for the "technical nurse" but with an associate degree for example...the same as the associate rns & making the "professional nurse" entry level at a bachelor's level. this would certainly free-up the rns from having to have to monitor lpns & everyone would be responsible for their own work/ patient load. the ana has been on for years about making the bachelor's the entry level for the professional nurse. i know a lot of diploma rns & associate rns will flame me for this but there needs to be some sort of structured entry level for the technical & professional nurse...as it stands...we don't get the respect from other medical professionals now because most of their professional entry level is at least a bachelor's...some even requires a master level.

i agree that the lpns can & should be taught to "interpret" findings...i think it's pretty safe to say that they do know what adverse affects to look for as well as recognize when patient is going bad. i don't think that they would go out of their scope if they were taught a little more than just the basics of nursing. most lpns as well as novist rns often will learn much more than what they've been taught in school...after having some experience under their belts. i find it hard to believe that any nurse would just blindly perform nursing tasks without understanding the outcome of them first...i personally don't know of one nurse that does this (lpns/rns)...if they're out there...i'm sure it wouldn't just be a lpn thing...but a reckless, unsafe nurse thing.

anyhow, my point of my posts to the topic of this thread is trying to find other solutions besides just blaming hospital administrations. lpns & rns do have to work together & need each other to care for the patients properly...that's what most lpns want...but what ends-up happening here on this bbs is that they're told that they aren't really wanted or needed & shouldn't be counted as nurses (in the respect of patient/nurse ratio)...hence making lpns independent of the rns' co-signing.

again...not saying lpns = rns with the way things are now...just if they're allowed to be educated in the future as the associate level rns are educated today.

cheers - moe