Should Hospitals Rehire LPNs/LVNs?

It's said that the pendulum swings, and healthcare is certainly no exception to that old adage! Is the pendulum swinging in favor of hiring LPNs and LVNs back to the hospital setting?

Updated:   Published

  1. Should Hospitals Rehire LPNs/LVNs?

    • 88
      Yes
    • 18
      No

  2. Do you think hiring LPNs/LVNs is the answer to the nursing shortage?

    • 48
      Yes
    • 57
      No

106 members have participated

Should Hospitals Rehire LPNs/LVNs?

One large healthcare system, Allegheny Health Network in Pittsburgh, Pennsylvania, has decided to do just that-bring LPNs back to address the staffing crisis.

Note: LVNs (licensed vocational nurses) and LPNs (licensed practical nurses) are the same, but they are called LVNs in CA and Texas. The author speaks from a California perspective and experience.

LPNs/LVNs Pushed Out

Back in the '80s and '90s, LPNs and LVNs worked alongside RNs in all areas of the hospital, including ICUs. Things began to shift in the 90s and 2000's as research showed that better patient outcomes were achieved by BSN-prepared nurses than by non-BSN-prepared nurses. Hospitals, in general, were requiring RNs to have higher education.

In the early 2000's, hospitals began to phase out LPNs and LVNs. In looking at whether hospitals should hire LPNs/LVNs back, it's important to clarify their role and scope of practice.

Difference Between LPNs/LVNs vs RNs In The Hospital

Based on training and licensure, the scope of practice for LPNs/LVNs varies from state to state, but an RN's scope of practice is broader than an LPN's or LVN's scope of practice in every state. 

For example, California's Code of Regulations Title 22 states that patients must be assessed by a Registered Nurse every shift. California hospitals attempted to stay on the right side of Title 22 by parsing language and forcing RNs to "co-sign" LVNs' assessments. When an LVN performed an assessment, it was called "collecting data.” When an RN performed the same assessment, it was called...well, an assessment.

RNs were put in the position of signing their name and license to assessments they did not perform. Unless they followed each patient and listened to breath sounds themselves, they couldn't, in all honesty, co-sign "breath sounds normal.”

RNs were also well over nurse-patient ratios. They had their own 5-6 patients and had to "cover" the LVN's 5-6 patients as well. The difference between "covering" and "being responsible for" was never that clear.

In some facilities, covering an LVN meant the RN was assigned to administer whatever IV fluids, IVP medications, or IV antibiotics the LVN was not licensed to administer. RNs also had to field all the provider calls. LVNs could take a doctor's order by phone but only for orders that fell under their scope of practice. No doctor wanted to give a partial set of orders to an LVN and then wait for an RN to get on the phone to take the rest of the orders for IV antibiotics. All of which led to workflow inefficiencies.

Despite some things they are not licensed to do, LPNs/LVNs can do a great, great deal. They can insert nasogastric tubes, foleys, and IVs. They can administer tube feedings, and hang blood and IV fluids if there is no additive, such as potassium. 

Sandy and Belinda, LVNs

Sandy was an LVN who was about to be let go by her hospital until her nurse manager creatively intervened. Sandy was offered an 8 hr position, working from 1100-1930. Reporting to work at 1100, she immediately rounded on all the RNs to get a list of treatments and procedures. Sandy performed all the pre-lunch fingersticks and administered all of the insulin coverage. She did all dressing changes. It was a telemetry floor in a hospital with a busy cath lab, and she pulled all the femoral sheaths.

Because of her bespoke hours, she helped to cover lunches and even covered the floor during shift report from 1900-1930.

Knowing that Title 22 stipulates that patient teaching and patient assessments are solely the domain of RNs, Sandy's manager made sure she did not take a patient assignment, perform assessments, do patient teaching, or create care plans. In Sandy's case, her manager carved out a job that used her to the top of her license. Many LPNs/LVNs were not so fortunate.

Belinda worked as an LVN in a medium-sized California hospital on MedSurg. She had worked there for two decades when the hospital decided to do away with LVNs. She was given the choice of going back to school immediately for her RN or staying on as a nursing assistant. Belinda was dismayed. She had no interest in going back to school at that time in her life or starting over in a skilled nursing facility. She was demoted to a nursing assistant.

Where did LPNs/LVNs go?

Many LPNs/LVNs left acute care to secure employment in sub-acute facilities, namely skilled nursing facilities. According to the U.S. Bureau of Labor, LPNs work in nursing and residential care (35%), hospitals (15%), physician's offices (12%),  home healthcare services (14%), and in the government 7%.

Maybe now the time is ripe for hospitals to hire LPNs/LVNs back.

The Old Team Nursing

Is this a revival of the old team nursing? Yes and No. 

Claire Montgomery Zangerle, CNE of Allegheny Health Network, says bringing LPNs back into hospitals is not a one size fits all proposition.

LPNs/LVNs may work well in MedSurg, for example,  but not in ICU. Some hospitals are finding that LPNs/LVNs are a good fit for the less acute (fast track) sections of ED.

Using LPNs/LVNs to the top of their licensure makes all kinds of sense if it is done right. RNs will need to be educated on how to delegate within their BRN/BON regulations.

Hopefully, hospital leadership will be able to see the tremendous resource...that's always been there.

Are hospitals beginning to hire LPNs/LVNs back? Do you think they should? Are LPNs/LVNs the answer to the nursing shortage?

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Nurse Beth

About Nurse Beth, MSN

Career Columnist / Author

Hi! Nice to meet you! I especially love helping new nurses. I am currently a nurse writer with a background in Staff Development, Telemetry and ICU.

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Specializes in OR, Nursing Professional Development.

My hospital started hiring LPNs for the med/surg floors several months ago. The pendulum does indeed swing back. When I did clinicals at this hospital (mumble mumble) years ago, they had stopped hiring LPNs on the floor but those already working were kept on and just not replaced if they left/retired. 

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Specializes in Public Health, TB.

I trained and worked as an LPN in a hospital in Idaho in the 80s. Most of the staff were LPNs and aides. The charge was an RN, and the IV/chemo nurses were RNs. An RN signed off on admit assessments and the charge made all calls to docs and took all orders. Floor patients were not as sick, many were pre-op or pre-procedure, and most were walkie-talkies. This was a mainly a medical floor, and 1 neurosurgeon always sent us her patients. 

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First job, acute care, I was hired into RN role where I had an LPN to help me with half of my 12-patient load. In case there is any question that description is not mine, it's how my role and the LPN's role was described to me; that I could assign her to "help" me with not more than 6 of "my" patients. At that time/place, LPNs could not do anything with IVs except discontinue them if directed to do so. They documented their assessments which needed to be cosigned, which for me meant that I repeated every one of them before signing. The LPN was VERY helpful and took a lot off of my plate (po meds, vitals, blood sugars, other tasks in scope, toileting, etc., etc) for half of my patients, which was huge.

I do not support the part where RNs need to cosign the assessments. Not to be unappreciative, but it would've been more help to me in the long run if they could've helped with tasks in scope on all 12 instead of the way it was done at this place with them getting involved in assessments.

I do think some of the examples in the article sound like good use of LPNs scope and numerous skills.

I would hope that newer RNs would give some pushback against the cosigning of things on this go-round--because what happens in practice is that the "extra help" becomes an excuse to make assignments way too large and RNs literally do not have enough time to verify all the things they are to co-sign on all the patients for whom they are ultimately responsible.

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Specializes in Tele, ICU, Staff Development.
JKL33 said:

 

I do not support the part where RNs need to cosign the assessments. Not to be unappreciative, but it would've been more help to me in the long run if they could've helped with tasks in scope on all 12 instead of the way it was done at this place with them getting involved in assessments.

I would hope that newer RNs would give some pushback against the cosigning of things on this go-round--because what happens in practice is that the "extra help" becomes an excuse to make assignments way too large and RNs literally do not have enough time to verify all the things they are to co-sign on all the patients for whom they are ultimately responsible.

In California, after nurse-patient ratios were legislated, hospitals could not get away with assigning RNs 10 patients and justifying it by giving them an LVN to help out.

I'm always so surprised by RNs who willingly co-sign whatever they're asked to. We had the same issue with student nurses and being asked to co-sign their assessments in Cerner. No way.

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Just thought of another issue from the other side - in my first job those LPNs had very heavy assignments; heavy workload. It had to be that way. No RN in their right mind is going to begin to think they can keep a handle on 12 patients while assigning a few of their alert & oriented self-care patients to the LPN. So every one of us assigned the 5 or 6 patients with the heaviest needs. ? I feel bad about that looking back; but we were just trying to keep our head above water.

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Specializes in Tele, ICU, Staff Development.
JKL33 said:

Just thought of another issue from the other side - in my first job those LPNs had very heavy assignments; heavy workload. It had to be that way. No RN in their right mind is going to begin to think they can keep a handle on 12 patients while assigning a few of their alert & oriented self-care patients to the LPN. So every one of us assigned the 5 or 6 patients with the heaviest needs. ? I feel bad about that looking back; but we were just trying to keep our head above water.

The real culprit was our employers.

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I work in an academic medical center and magnet hospital that puts a lot of emphasis on BSN (or higher) and certifications. Under these circumstances, I don't forsee LPNs used in the inpatient setting. Luckily, we are located in an area where we don't have the severe shortage on nurses.

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Specializes in Tele, ICU, Staff Development.
RNperdiem said:

I work in an academic medical center and magnet hospital that puts a lot of emphasis on BSN (or higher) and certifications. Under these circumstances, I don't forsee LPNs used in the inpatient setting. Luckily, we are located in an area where we don't have the severe shortage on nurses.

So interesting to hear how hospitals function in different parts of the country

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Specializes in Dialysis.
RNperdiem said:

I work in an academic medical center and magnet hospital that puts a lot of emphasis on BSN (or higher) and certifications. Under these circumstances, I don't forsee LPNs used in the inpatient setting. Luckily, we are located in an area where we don't have the severe shortage on nurses.

It's the same in my area. In fact ADNs aren't utilized without a plan, regardless of experience. We have a glut of nurses, mostly newer, that have to travel for work

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Specializes in Critical Care, Procedural, Care Coordination, LNC.

When I was a student on the east coast they were pushing for BSN nurses, so that is what I did. I ended up moving to Oregon and my first job at the LTACH (Long Term Acute Care Hospital), I worked with a good portion of LPN's. They were literally the best, they taught me so much. Sometimes it was challenging because we all had full patient loads, so the RN's would be responsible for some duties on the LPN's patients, but we were such a great team we always found a way to make it work and help each other out. I love LPN's!  Teamwork makes the dreamwork & these nurses are nurses too, we should definitely utilize them. If hospitals want them to have their Bachelors they should pay for it. This is just my personal opinion. Thanks for sharing Nurse Beth! 

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Specializes in Med-Surg.

Years ago my hospital mandated an all RN staff and several LPNs retired or quit but many were motivated to get their RN.  

Now, they have recently started hiring LPNs. My unit doesn't have any yet, but  one floated to my unit for night shift recently and as I made her assignment she told me to change it because she is only to have 4 patients.  Four med-surg patients on a night shift?  Must be nice.

Our community is having a hard time staffing hospitals with all RNs so this helps.  

When I was a new grad RN, it was the LPNs that took me under their wing and helped me out, even though technically I was senior to them.  I learned early on to respect their role as a valuable team member and their experience.

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