Blurred Boundaries: Should we eliminate the distinction between RNs and LPNs?

jjjoy, LPN · Jan 24, 2009

In some places, it is quite clear that LPNs are working under the direction of RNs. If the RN gets their assignment, takes report on all of them, and then splits their assignment with their designated LPN, then the relationship of RN to LPN is a bit more clear.

In other places, it isn't so clear. In some places, the reality is that the RN who is supposedly overseeing an LPN simply work side by side with the LPN, each taking care of their own assignment independent of each other. In these places, the patient assignment of RNs and LPNs looks very similar, such as six patients each. From taking report from the previous shift to giving report at the end of shift, the LPN deals with all of the patient care (assessments, medications, patient education, etc) without any clear delegating from their supposed delegator. In cases like that, it's not so clear that the RN is delegating to the LPN or is in anyway supporting the LPN outside of a few specific tasks that could be easily learned. In cases like that, I can see why some might think that there's not much difference between LPNs and RNs.

lpnflorida · Jan 24, 2009

JJJoy,

Where I work we receive our assignment at the beginning of the shift. The RNdoes not assessment my patient. If I ask them they will assess a patient that I have concerns about.

Our patients need to be assessed by an RN once every 24 hours. Meaning I follow an Rn who had my patients the shift before. I work fairly autonomously due to my years of experience and the trust I have earned from the RN/s I work with. Yet I understand the boundaries. While I take take orders from a doctors I cannot sign off orders. I understand the Scope. I purposely keep this in mind. I believe an LPN can get themselves into trouble if they truly believe there is little difference between an RN and LPN they have their Scope of Practice and we have ours.

Often my co-workers have forgotten that I am an LPN I remind them. Often they come to me for answers to something they do not know. Why? As I have years of experience. I make it point to study in depth on various diseases and policies and best practice. When an RN asks me how to do something even though it is not in the LPN scope of practice I can verbally tell them the steps they need to take and back it up with what the policy says. None the less I am an LPN make no mistake about it and proud of it. For me the boundaries are not blurred and that is because I make it a point to remember the difference.

pagandeva2000, LPN · Jan 24, 2009

It's the same way here in Florida. An LPN is given an assignment and can carry out that assignment without me having to approve their every move and supervise everything they do. Almost all of their actions can be carried out independently by virtue of the license and the assignment.
In my 17 years of being the RN supervisor of LPNs, not once has an LPN gotten in trouble with the BON for stepping outside their practice, and not once have I ever seen an RN get into any kind of trouble for what an LPN has done "under their license".

I've heard similar interpretations before of various nurse practice acts in Northern America. But we're essentially talking about inpatient bedside nursing here, aren't we? Many hospitals have given LPNs roles that almost duplicate that of RN - that is LPNs are responsible for 90% of all nursing care for their assigned patients (such as everything except for the admission assessment and hanging blood). In cases like that, the distinction between LPN and RN can easily become blurred and contentious.

You are correct when you say we carry our own assignment , none the less I am still under the direction of an RN. There is no blurrying of that fact. Yes, I do many many things for which the RN does not need to be next to my side, yet still I am under the direction of an RN. I can not work on the unit without an RN present somewhere on the unit. Nor can any other LPN that I am aware of in this country. Now SNF might be different, but I still believe that an RN is available somewhere in the building.
I do not feel there needs to be contention between us. I as an LPN accept what my role in within my Scope of Practice. I do take offense when the various powers that be try to diminish our roles and our Scope Of Practice as LPN'S.
For those LPN"S who desire returning to school is an option to become an RN.

JJJoy,
Where I work we receive our assignment at the beginning of the shift. The RNdoes not assessment my patient. If I ask them they will assess a patient that I have concerns about.
Our patients need to be assessed by an RN once every 24 hours. Meaning I follow an Rn who had my patients the shift before. I work fairly autonomously due to my years of experience and the trust I have earned from the RN/s I work with. Yet I understand the boundaries. While I take take orders from a doctors I cannot sign off orders. I understand the Scope. I purposely keep this in mind. I believe an LPN can get themselves into trouble if they truly believe there is little difference between an RN and LPN they have their Scope of Practice and we have ours.
Often my co-workers have forgotten that I am an LPN I remind them. Often they come to me for answers to something they do not know. Why? As I have years of experience. I make it point to study in depth on various diseases and policies and best practice. When an RN asks me how to do something even though it is not in the LPN scope of practice I can verbally tell them the steps they need to take and back it up with what the policy says. None the less I am an LPN make no mistake about it and proud of it. For me the boundaries are not blurred and that is because I make it a point to remember the difference.

I summarize my LPN experience as this; we each have a scope of practice, but we each have a license of our own, therefore are responsible and accountable for our own practice. It is up to each discipline to know their scopes and the LPN should know when she 'falls off' and the RN must pick up, so to speak. Many RNs I know believe that they are totally responsible for the actions of an LPN; and from what I see, they are not literally responsibile for each and every step...meaning that if the LPN does neglects to inform the RN of changes and then takes it upon herself to do things out of her scope of practice, then, the LPN is totally responsible for the negative outcome.

I don't see how an RN can delegate to an LPN, but she can assign (as long as she assigns within the LPN's scope of practice under that license as well as facility policy and procedure). (Guys, let me know if I am wrong somewhere, please). Delegation means that you give an order to someone to do something that is really your responsibility (usually to unlicensed assistive personnel), such as vital signs, glucose checks, etc. The same can be assigned to an LPN, but she is responsible for her own practice. If an RN delegates to a UAP, the UAP does it and reports abnormal results...period. But, when she assigns an LPN, that LPN does have a bit more knowledge and knows that she may (for example), has to hold medications based on vital signs, maybe give juice to a hypoglycemic patient, know the disease process, so, should be able to give a more focused report to investigate; etc..., but once the situation becomes more acute, she must involve the RN.

I cannot see how these positions can merge for the same reasons mentioned, but I can see how it becomes more confusing. Let's face it...we do have some RNs that will dump on the LPN out of laziness, or maybe due to not comprehending the role of the LPN. Sometimes, policies are so insane that they limit the LPN more than they have to. I have always said that there is enough at the table for all to partake, so, there is a role for LPNs, I believe in acute care, just not assigning them to out of their scope. An LPN in acute care can medicate, maybe do IV care, wound care, suctioning, dressings, other more mundane things to free the RNs to do the more complex care and reduce their workload. I make it no secret that I am a strong proponent of LPNs being used to our fullest capacity and not being disinfranchised. I have no interest in becoming an RN, not because I am afraid of the challenge of school, but because I strongly believe that too much unreasonable responsibility is placed on RNs and I never saw that as being fair. I know I can't handle it, so, I carefully chose not do (with no regrets). But, I also know that I am a great team player, am very observant and knowledgable. Usually, when I approach an RN or physician, they respect the fact that it is worth investigating.

RN_Canada · Jan 24, 2009

I don't see how an RN can delegate to an LPN, but she can assign (as long as she assigns within the LPN's scope of practice under that license as well as facility policy and procedure). (Guys, let me know if I am wrong somewhere, please). Delegation means that you give an order to someone to do something that is really your responsibility (usually to unlicensed assistive personnel), such as vital signs, glucose checks, etc.

You would not believe the discussion I have had with our regulatory body about this one! I do not think that a nurse can delegate nursing to a nurse. If it is nursing then it is not out of scope of a nurse.

However, there may be some differences in how delegation is defined legally in various pieces of legislation.

Where I work delegation means as you have said and that is the act is out of scope of practice for the person being delegated to AND the delegation occurs ONLY for that client. so delegation is client specific.

However the legislation in Albert for LPN's states that an LPN can practice the following aspects of nursing "when delegated" so it must be a different definition of delegation.

At any rate you sound like you are very clear about your own scope of practice and comfortable with your role.

True collaborative practice can only work when nurses understand their own roles and responsibilities and how their defined scope of nursing practice might overlap.

RochesterRN-BSN, BSN, RN · Jan 24, 2009

not sure if this is universal and a "rule" but here in NY LPNs can't take verbal orders........curious as to if that is everywhere.

flightnurse2b, LPN · Jan 24, 2009

i can take a VO as long as i have another nurse verify it over the phone and sign behind me.

SuesquatchRN, BSN, RN · Jan 24, 2009

not sure if this is universal and a "rule" but here in NY LPNs can't take verbal orders........curious as to if that is everywhere.

Really? I did all the time.

RN_Canada · Jan 25, 2009

i can take a VO as long as i have another nurse verify it over the phone and sign behind me

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So what is the point then when the other nurse has to do it over again? Would it not just be easier to hand the phone over to the RN.

LPN's can take telephone orders in my jurisdiction.

Verbal orders are simply not allowed anywhere. If the physician is there he or she should be completing a written order.

flightnurse2b, LPN · Jan 25, 2009

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So what is the point then when the other nurse has to do it over again? Would it not just be easier to hand the phone over to the RN.
LPN's can take telephone orders in my jurisdiction.
Verbal orders are simply not allowed anywhere. If the physician is there he or she should be completing a written order.

no. it's not an RN-LPN thing. it's my hospital policy. two nurses have to take a verbal order, regardless of initials.

pagandeva2000, LPN · Jan 25, 2009

My hospital does not allow us to take verbal orders. Not sure about other facilities, though.

BroadwayRN, ASN, RN · Jan 25, 2009

We could eliminate the LPN program, so that every nurse would be an RN. What do you think?

I think that will never happen. Firstly it wouldn't be fair to the RN's who earned their degree. Secondly it doesnt matter how much experience an LPN has, if you haven't taken the RN courses you cannot be considered an RN. I think RN's and LPN's are both very important professions and should be kept seperately. If an LPN wants to be an RN then she/he is free to work towards it and obtain it.

RochesterRN-BSN, BSN, RN · Jan 25, 2009

RN Canada just to clarify--I was technically referring to verbal in the context of over the phone......a true verbal order.......though I work in psych emergency and take a verbal order and go ahead and get and give the drug then either the doc will write it after the emergency or more often then not the nurse will write all of the order and the doc will just sign and date/time it. Even non emergent orders we write what we need or what the doc has said he wants the patient to have and and then the doc will sign it. I find things are quite different working on emergency....and we work pretty in a bit of a different role then on a unit. If a patient has a headache and wants something I am the one to decide which is better for the particular complaint, be sure there are no allergies or medical problems that would be contraindicated for him to get the med.....write the order and approach the doc to say..."hey Mrs. Smith needs something for a headache......could you sing this order for Ibuprofen?" and wa-la....they sign it. Our docs where I am at are pretty good.

So yeah I was originally talking verbal orders as in over the phone.....