NP Licenses and Liability

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core0

1,830 Posts

David C. - you say you could ride as a PA. Does that mean you could be hired to a paramedic position? You'd be a PA, not a paramedic, I get that. But could a company legally allow to you work the same position as a paramedic since you have comparable (and more) skills?

I know it sounds strange to ask as why would a PA want to work in a paramedic role anyway? But perhaps the hours are more flexible or you're moving to a location that doesn't utilize PAs much. Or maybe you decide in the end that you were happier working as paramedic than as a PA. When I asked in the general forum before about why RNs couldn't work in LPN roles, I got a number of incredulous responses about why anyone would even consider that.

It's the whole "overqualified" dilemma. If for whatever reason you don't have a job at your trained level, it's hard to get a job "below" your level. But usually that's because employers figure that you'll quit as soon as something better comes along, not because it's illegal for the person to work below their training.

You would not be working as a paramedic in this case. You would be working as a PA that is doing prehospital medicine. You would have the full scope of practice for a PA. Pridemark uses PAs in this role. Usually it involves going to nursing homes and doing procedures. It gets around having to credential somebody at each facility. This is typically task based such as central line insertion or dobhoff placement.

Its not that I would want to work as a Paramedic. The issue comes up when a PA wants to volunteer for a local fire department for example. If you want to provide medical services you need a license to do that. Some PAs sought to use their paramedic license which our board did not allow. It would be a similar issue if a physician that was previously a paramedic tried to work as a paramedic to escape liability issues. In this case since the physician is still held to the physician standard no matter what the role.

I think that you are describing a similar issue with the LPN. I also see a number of other problems from an operational standpoint. If a hospital is allowed to hire a RN at LPN wages I would guess the other nurses would be fairly upset. I would also guess that there would be supervision and delegation issues. Could a LPN supervise and RN even when working in a LPN role (I work in hospitals without LPNs so I really don't know how this works).

David Carpenter, PA-C

jjjoy, LPN

2,801 Posts

Why would one assume that someone is trying to "escape liability issues" by wanting to use a previously held "lower level" license? Couldn't it just be that for whatever reason they just prefer that job? They are clearly qualified and experienced, but with the "higher level" license it's now illegal for them to work in that lower role?

Is it completely impossible to imagine a paramedic going to PA school, getting licensed and then deciding that they'd rather work as a paramedic? Again perhaps because the hours are more flexible or they end up moving somewhere where PAs aren't utilized or the like.

I'm trying to wrap my mind around it because it seems somewhat like taking away someone's motorcycle license after they get a car driver's license. I can see where holding two different licensed jobs in the same field would be a problem in terms of someone being a nurse at this facility but an NP at that facility and the like. But why couldn't someone go back to a previous license? Is it mostly because it's too risky in terms of lawsuits because I guess I could understand that. Or is there some other bigger reason?

In regard to nursing licenses...

In many LTCs, LPNs are in management positions over RNs (eg director of nursing can be an LPN in many places). In LTCs, you'll sometimes see RNs and LPNs in identical roles. In such cases, perhaps there's one dedicated RN for admission assessments and the like and there aren't other RN-only tasks for the other nurses.

And in regard to RN vs LPN wages, supposedly RNs are paid more is because their role covers more responsibilities and they've got more clinical competencies, not just because they have one paper and LPNs have another. If an RN were in a LPN role they'd only be covering LPN responsibilities - eg they wouldn't hang blood or do initial assessments. So it's not like they are paying LPN wages for someone to carry out the RN role. That wouldn't be fair.

But this is something where nursing is confused and confusing even from within. In some places LPNs do almost everything RNs do. LPNs often orient and help train new grad RNs. RNs and LPNs are always arguing on these very boards over whether LPNs work under RN supervision and are delegated work, or if they have own independent practice much like RNs working with MDs. They obviously don't cover this in much in most nursing schools except perhaps to teach LPNs that they "can do everything that RNs do except x, y and z" and to teach RNs that they may be delegating to LPNs but to careful because they're "working under your license." Gad, have I gone off-topic again?!?!

Trauma Columnist

traumaRUs, MSN, APRN

88 Articles; 21,249 Posts

Specializes in Nephrology, Cardiology, ER, ICU.

A pre-hospital RN license is an actual license in the state of IL. It allows me to act up to and including the practice act of an RN provided I have the training and experience to perform these tasks. However, conversely, it holds me to the standard of an RN also.

Specializes in Women's health/primary care.

JJoy,

You may be having trouble obtaining the nursing role you desire, because even though you would be performing tasks similar to the LPN- you are still held to the standard of the RN, because that is your highest held license. Therefore the hospice facility would have to ensure that you were covered under their as a RN not an LPN. This could lead to extra expense that the organization either does not have or doesn't want to spend. My suggestion to you would be to discuss what you are and aren't comfortable with as far as the management role goes. They may be able to use you in some direct patient care, as you wish, while employing another RN in the management role. However, I would expect that they would expect you to perform RN functions related to nursing care, not just the LPN duties. If the RN license is your most current and non-expired license, that is your standard of care comparison, and scope of practice, regardless of what your job description might say. Discreptencies in these could leave room for lawsuits.

jjjoy, LPN

2,801 Posts

Okay, I get the issue and the extra cost and how facilities might rather not deal with it. In the hospice case, one RN per shift was enough for their needs and they combined it with the supervisory position... fair enough. It's an efficient use of resources. If would cost more insurance-wise to have another RN, regardless of their actual job functions, then I can see why they'd rather avoid that. It's not that they *can't* hire an RN into the basic position - they just choose not to for economic reasons.

I don't see any other reason beyond that, though. In regard to "standards of care" what would be so different between LPNs and RNs? Certainly, the scope of practice is different. But what should an RN be more competent and skilled at than an LPN that they'd be held to a "higher" standard for? In many settings the LPN can function independently and doesn't have to "check in" with in an RN throughout the day. They just need to collaborate with an RN if their patient needs a blood product hung or make sure an RN does the initial assessment when the patient is admitted to the unit. If the LPN "missed" something, aren't they just as liable as an RN? This IS a sticky issue that most RNs and LPNs aren't well-versed in. RNs are always afraid that if an LPN "working under them" makes a mistake that they will held liable, but I haven't heard of any specific examples. And I haven't heard any clear explanation of how much liability might exist for an RN who is "covering" an LPN (that is the RN has their own patient load and is assigned to cover any RN-only tasks that may come up for the LPN who has their own patient load but otherwise isn't taking care of those patients). Or how the liability might differ between an LPN/RN team versus an RN/RN team if mistakes happen. The difference in education between an RN and LPN isn't clear to most. We just hear that an RN education has more depth. You can't get too much more in depth, though, in the extra RN year that also usually includes more bredth as well (eg more exposure to speciality areas).

I've tried discussing this in the general forums but haven't found much satisfaction as there's so much tension between RN and LPNs over who's qualified to do what. So I apologize for this going so far off from NPs. It sounds like the NPs who return to the floor as RNs avoid this by practicing in a different area of specialty than their NP license, is that correct? Otherwise, wouldn't there be similar reluctance on the part of hospitals to hire someone with an NP license into an RN position?

Trauma Columnist

traumaRUs, MSN, APRN

88 Articles; 21,249 Posts

Specializes in Nephrology, Cardiology, ER, ICU.

I started as an LPN. When I graduated from the ADN program in 1994, I did not renew my LPN license because in IN (where I was located), you couldn't hold both an LPN and RN license.

Specializes in Women's health/primary care.

JJOY: Yes, there is reluctance to hire in a NP into the RN role in the hospital, as well as allowing a new NP to maintain his or her RN position on the floor. Although, it is occasionally done, there are issues with the liablilty. for a NP is much more expensive than coverage for a RN. Additionally, the policy would probably have to state in which capacity the RN is covered. While the NP could (and in my opinion-should) carry his or her own liability insurance, in case of a lawsuit, the plaintiff would likely go for the deeper pockets (the hospital). Then the hospital would have to justify why and how a NP (RN) was involved in whatever situation had arisen to cause the damages. If a RN does something that leads to patient harm, it is often hard for the hospital to defend, but if it is a NP working in the RN role, whose actions lead to patient harm that could have been prevented-it's a bit harder to defend just because there is a standard of care difference between the two. The NP should have advanced knowledge on physical assessment and be better able to pick up on certain findings that could lead to critical situations.

On your discussion of liability of the LPN, there are some differences. Although a LPN is licensed under their own license, if the RN delegates a task to the LPN and the task is beyond their scope, then the RN becomes liable for any damages, as well. Much of the liablity has to do with delegation of duties (including patient assignment). At the hosptial I work at (and I know each facility is different), the RN, (we usually only have one RN per shift, with the other nurses being LPNs), has to be charge nurse and make patient assignments. Additionally, we are responsible for checking and entering all orders for all patients on the unit. The LPNs aren't required to check any orders (although most do double check), look at their labs, or communicate with the physician if need be. The RN has to do all of those duties. If there is a complicated patient who is very critical (on our unit) it is sometimes better to take that patient yourself, instead of delegating the care to one of the LPNs. Reason being that you know you will be checking orders, labs, etc. and want to ensure that these things are promptly considered when giving care.

Now I will say that I am so impressed with our LPNs, as they are all caring individuals who work very hard and are wonderful at what they do. They aren't NOT doing things that they are supposed to, they are doing what is required of them by the facility. This facility specific RN/LPN difference places more liablity are the RN as the delegater and supervisor of patient care for the unit. As far as basic patient care tasks, the LPN needs the RN to do only a few things (hang blood, IV push, admission assessment). But going back to your question-- if the LPN misses something, yes he or she does hold some liability, but it is the RN who delegated the tasks and is ultimately responsible that delegated tasks are followed through, so the RN becomes liable, as well. Now differences exist from state to state and facility to facility. However, RNs should always be aware of their ultimate responsibilty for delegatated tasks (including patient assignment). If you would like further information, you could contact an individual professional company (such as NSO) or your state board of nursing and talk them about your state's differences between the RN & LPN.

jjjoy, LPN

2,801 Posts

I appreciate your taking the time to so thoroughly respond to my questions!

If it's considered that RNs are "delegating" to LPNs as opposed to just "covering" RN-only tasks, then why do so many hospitals allow what essentially amounts to assigning LPN their own patient load? We know that in many cases the RN/LPN "team" split the patient load. Sure, the RN assesses the patient load and may take the more complex patients. But one day's most complex patient might be the next day's least complex patient. It's relative and the LPN easily can end up caring for very complex patients not due to any misjudgement on the part of the RN.

It would be one thing if the LPN had 3 patients while the RN had 2 of their own patients plus the LPNs three, with the RN having ACTIVE involvement with those three patient. The big difference in pay between RNs and LPNs might make more sense then. But we know the reality is that the LPN has 6 patients and the RN has 6 patients and the LPN is doing everything but initial assessment and blood hangs. Yes, the RN has more legal accountability but doesn't have the resources to properly manage that for which they are accountable, leaving the LPNs with greater unofficial responsibility.

Back to NPs, I personally know of at least 3 nurses who got their NP license and returned to floor nursing within a few years. It's quite common because experienced RNs can often make more money on the floor, their schedule is more predictable (no on-call hours) and when they're off work, they can leave it all there and not be responsible for anything until they clock back in for their next shift. I haven't heard of NPs being discouraged by the hospitals to return to RN work. I'd guess that it's worth the added expense to the hospital to have the experienced NP-RN.

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