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Discussion

Difficulties Defining Scope of Practice

So.... In nursing school at the University of Wisconsin-Eau Claire, where i graduated with my BSN last December- I was taught that patient education was one of the things that was specifically within the scope of practice of RNs, and only RNs, because it required evaluation- and that while we can delegate all kinds of things to LPNS and CNAs... we cannot delegate tasks that require evaluation.

So... now I work in Iowa at a nursing home, and it's staffed by some RNs and some LPNs... and I kind of feel like the whole delineation of practice between the RNs and LPNS is thrown out the window. For one thing, while LPNS are required to practice Under the supervision of a Registered Nurse according to the Nurse Practice Act of Iowa... the LPNs at my facility have their own patient loads, and don't really answer to a registered nurse at all, unless you're counting the DON, who might or might not be present. Yes, RNs are in the facility, at least on the day shift... but they don't have any legitimate authority over the LPNS at all.

Further, the LPNs regularly engage in activities that require evaluation of outcomes of patient care- which I was pretty sure was NOT something that was in their job description.

I'm a bit confused I guess, about what the hell they are and are not supposed to do... and a bit concerned about the fact that they're acting without really being under direct supervision of an RN... and in my mind, I now have a question of, "If I'm an RN on the floor while an LPN is working and screws up- whose supervision are they under? Mine? Is it on my head, or someone else's?" If I'm the only RN on the floor- am I responsible for the care being provided to all 120 patients in the facility even though I am not directly supervising the care of more than 15 of them?

I read the nurse practice act, but it was kind of un-helpful and did not really include much for specifics other than pertaining to IV therapy.

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    Great thread! I'm finishing up school right now and realizing that there are tons of legal issues & conundrums we didn't discuss in school. I think LTC is a magnet for a lot of those issues. I just read another thread about nursing homes "hospital dumping" - sending unwanted residents (unwanted due to behaviors or finances) to the ER and refusing to take them back (without giving the legally required 30-day notice to the pt/family). I think nurses often have to be the advocates on these issues since we're on the front lines and are often held accountable. One thing I'm noticing about nurse practice acts is that they do still leave ambiguities & gray areas. Probably the only way to know how they are enforced is to review BON cases and malpractice case law.

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    LPNs assess until the cows come home. It's just called "data gathering." You can bet when my experienced LPNs "gathered the data" that indicated a change in condition I jumped as high as they told me to.

    What education is happening in LTC beyond, "No, don't spit that out. It's your heart medicine"?

    Being supervised by RNs never meant that they need us breathing down their necks.

    LPNs are not little automations incapable of anything beyond technical tasks. They are highly skilled, intelligent nurses who can't legally care plan, hang blood, hang the first bag of abx, push IV meds or, in NYS in LTC, do much with anything other than a peripheral line.

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    I agree with you about LPNs often having excellent skills. As an about-to-be-new-grad RN, I have no doubt that an LPN with several years experience is probably more knowledgable and has better skills than I'll have as a new grad RN.

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    Scope of Practice will depend on what state you live in. I suggest if you are not sure contact your BON for clarification.

    This is an old link but it's a starts:

    http://nursing.advanceweb.com/article/lpns-and-iv-administration.aspx

    As far as assesments, yup we do 'em, patient education, yup that too. In one of your statements:

    Further, the LPNs regularly engage in activities that require evaluation of outcomes of patient care- which I was pretty sure was NOT something that was in their job description.

    How do you KNOW it's not in their job description?????????? Have you read their job description, what are the policies of your facility?

    LPN/LVN's are licensed nurses and work under our own license, I think your school did you a real diservice in educating you as to what LPN/LVN's actually do.

    I'd also ASK some of the LPN's at your facility, we are all very aware of our scope of practice, and most would be more than willing to educate you as to what they can and cannot do.

    In my current state of GA there are very few restrictions here and depends usually on facility policies, yet in another state where I'm licensed (Ohio) there are more restrictions.

    This is one of the reasons I'd like us to do away with state BON's and go to a national licensure like ASCP for MT's, MLT's and phlebotomists.

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    I don't know that the OP's intention was to say that LPN's aren't capable of all these things. I understand the frustration in not understanding the legalities of it all. I have had the same frustration. I am still in school but it's never really all that clear to me. I have LPN friends and have tons of respect for them and they are wonderfully people and wonderful nurses that I can go to and ask questions. I have found many times where we get into discussions about scope of practice and it doesn't seem all that cut and dry to me. Some work in LTC and even they have admitted that the scope of care is sometimes bent in those situations. I think maybe the OP's frustration in not understanding came through as frustration with LPN's. I didn't read it that way but seeing some of the replies makes me think others did.

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    I'm an RPN in Ontario and we hang blood. It's just new since 2010, but times are changing!

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    • Experts
    so.... in nursing school at the university of wisconsin-eau claire, where i graduated with my bsn last december- i was taught that patient education was one of the things that was specifically within the scope of practice of rns, and only rns, because it required evaluation- and that while we can delegate all kinds of things to lpns and cnas... we cannot delegate tasks that require evaluation.

    so... now i work in iowa at a nursing home, and it's staffed by some rns and some lpns... and i kind of feel like the whole delineation of practice between the rns and lpns is thrown out the window. for one thing, while lpns are required to practice under the supervision of a registered nurse according to the nurse practice act of iowa... the lpns at my facility have their own patient loads, and don't really answer to a registered nurse at all, unless you're counting the don, who might or might not be present. yes, rns are in the facility, at least on the day shift... but they don't have any legitimate authority over the lpns at all.

    further, the lpns regularly engage in activities that require evaluation of outcomes of patient care- which i was pretty sure was not something that was in their job description.

    i'm a bit confused i guess, about what the hell they are and are not supposed to do... and a bit concerned about the fact that they're acting without really being under direct supervision of an rn... and in my mind, i now have a question of, "if i'm an rn on the floor while an lpn is working and screws up- whose supervision are they under? mine? is it on my head, or someone else's?" if i'm the only rn on the floor- am i responsible for the care being provided to all 120 patients in the facility even though i am not directly supervising the care of more than 15 of them?

    i read the nurse practice act, but it was kind of un-helpful and did not really include much for specifics other than pertaining to iv therapy.

    can a lpn perform a patient assessment?

    a. in the state of iowa, a lpn may not perform an initial assessment. once the initial assessment has been completed by a rn or a physician, the lpn may then perform further assessments with collaboration and supervision of the rn or physician.

    the rn or physician is responsible for verifying the lpn's assessment findings. the mechanism by which verification and supervision is carried out may be determined by institutional policy.

    q. can a lpn triage?

    a. triage is considered to be part of the assessment phase of the nursing process and considered to be the initial assessment in determining the care of the patient. therefore, a lpn may not triage without the direct supervision of a rn or a physician and the rn would be responsible for verifying the assessment findings with the patient.

    you may access the iowa

    administration code 655, chapter 6, and section 6.3 to view the minimum standards of practice for the licensed practical nurse concerning the nursing process.

    http://www.iowa.gov/nursing/faq/practice.html#l1

    . what are the requirements for the supervision of the lpn?

    a. a lpn may not practice independently. a lpn must be supervised by a rn or physician.

    the healthcare setting defines if the rn or physician must be present in proximate area, refer to

    iac 655, chapter 6, section 6.3(5) and 6.3(6).

    the facility defines the degree of supervision through institutional policy.

    you are very smart to investigate the individual state's nurse practice act as they do vary state to state. but essentially yes.....you are the rn, they are under your and the don's license.

    :D

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