Should Hospitals Rehire LPNs/LVNs?

JBMmom, MSN, NP · Jan 6

When I was in nursing school one of the floors had a couple LPNs and they were THE BEST to get paired up with for a shift. One in particular was fantastic and it was always a good night if you got paired up with her. Granted since I was a student I was not completely aware of the scope of practice differences. I know that she could not hang blood, could only give IV fluids or piggyback medications (it was hard on an ortho floor given the number if IVP pain meds), and there was some assessment component that had to be done with the RN. None of the RNs on the floor minded the set-up (but I don't know how the co-signing aspect worked), but all LPNs were transitioned out of their roles in my third semester of school. This particular LPN did not want to go back to school, so she stayed on as a tech with the same pay she made as a LPN. She's still there and is an awesome tech in sameday surgery, but I think it's a shame that they phased them out. I would have to be more educated on the logistics to make an intelligent response on how it would work in my hospital but right now I think we would take ANYTHING happily, especially if it meant experienced nurses would be joining us, because the short staffing is a nightmare.

FiremedicMike, RN, EMT-P · Jan 6

I work in a fairly busy ED in an urban area and we augment with LPNs. We have several that are phenomenal and we would drown without them.

Our setup, we have zones of 8-12 beds, within each zone there will be an RN covering 4 beds each, and some combination of an LPN, tech, and/or medic, we also generally have 1-2 float RNs backing up the entire ED. If staff permits, we'll open up 6 fast track beds covered by an LPN and an APP who just keep churning their beds along. The primary assessment for those patients is done by the triage RN and IV meds are handled by either the charge or float RN.

The good LPNs are hustling as much as the RNs. They're watching for orders and filling as much as they can (hey just did XXX in room 13, need you to go push the IV drug though), handling discharges, answering call lights, covering lunches, etc. Days when we have several boarders, it is amazing to have an LPN to cover those patients (with float RN backup as needed).

Our management and LPNs stay on top of any scope of practice changes within our state and I believe we are using them to limits of what they can be used, with new things being added on pace with expansion of scope..

I can say without a doubt that the days when we're short LPNs or when we have a crappy LPN assigned to our zone are the days we go home absolutely drained of all mental and physical energy.

I love our (good) LPNs!

Peachpit · Jan 6

Some of the best nurses I've ever worked with (or been taken care of myself as a patient) were LPN's. Hospitals are selling themselves short not hiring them.

**Nurse Beth, MSN** · Jan 6

FiremedicMike said:

I work in a fairly busy ED in an urban area and we augment with LPNs. We have several that are phenomenal and we would drown without them.

I can say without a doubt that the days when we're short LPNs or when we have a crappy LPN assigned to our zone are the days we go home absolutely drained of all mental and physical energy.

I love our (good) LPNs!

@FiremedicMike I love this! It makes so much sense. Thanks for sharing!

**Nurse Beth, MSN** · Jan 6

JBMmom said:

When I was in nursing school one of the floors had a couple LPNs and they were THE BEST to get paired up with for a shift. One in particular was fantastic and it was always a good night if you got paired up with her. Granted since I was a student I was not completely aware of the scope of practice differences. I know that she could not hang blood, could only give IV fluids or piggyback medications (it was hard on an ortho floor given the number if IVP pain meds), and there was some assessment component that had to be done with the RN. None of the RNs on the floor minded the set-up (but I don't know how the co-signing aspect worked), but all LPNs were transitioned out of their roles in my third semester of school. This particular LPN did not want to go back to school, so she stayed on as a tech with the same pay she made as a LPN. She's still there and is an awesome tech in sameday surgery, but I think it's a shame that they phased them out. I would have to be more educated on the logistics to make an intelligent response on how it would work in my hospital but right now I think we would take ANYTHING happily, especially if it meant experienced nurses would be joining us, because the short staffing is a nightmare.

I think there's always a way to make it work. All RNs I know realize the value of LPNs/LVNs.

No Stars In My Eyes · Jan 6

I'm retired now, but I say YESSSSS! to go back to hiring LPN's. And, yes, it does work better with Team Nursing.

When Primary Nursing was starting, it was way different from how it is done now, as Primary Nurses had to do everything for their patients. The initial text-book about this form of nursing made the suggestion, which was roundly ignored by every facility I know of, was that a Primary Nurse, to be effective, should only have a 3-patient workload, or 4, if they weren't all difficult patients. Primary Nursing has been bastardized beyond all sense and reason, and that is one of the things that made nursing such hell, sometimes. And it isn't just the nurses that suffer for this, it is also the patients who are cared for under this impossible mess in the healthcare field.

**Lunah, MSN, RN** · Jan 6

Bring them back if they want to be there, by all means! They are an amazing and valued part of the NURSING team. I have worked with some phenomenal LPNs in various ER settings, including Army LPNs (68C) in our trauma bay in Afghanistan. Couldn't have done it without them.

**Nurse Beth, MSN** · Jan 6

Lunah said:

Bring them back if they want to be there, by all means! They are an amazing and valued part of the NURSING team. I have worked with some phenomenal LPNs in various ER settings, including Army LPNs (68C) in our trauma bay in Afghanistan. Couldn't have done it without them.

Wow! I am sure you have stories! Thank you for your service.

Mister_Masterz, RN · Jan 10

I personally think a strong argument for why hospitals should hire LPNs again is that they can provide a valuable support role to RNs in the hospital setting. LPNs are trained to perform many of the same tasks as RNs, including monitoring vital signs, administering medications, and assisting with patient care. However, they are able to do so at a lower cost and with fewer hours than an RN. This can be especially beneficial in busy hospital settings where there is often a shortage of qualified RNs and LPNs can provide much needed relief and assistance. Additionally, removing LPNs from the hospital was a bad idea to begin with because it caused additional strain on the nursing staff who had to take up the slack created by their absence. Bringing back LPNs would help alleviate this burden and allow for better patient care overall.

esrun2015 · Jan 11

Yes, I have worked with many amazing LPNs in the past. But my current hospital will probably never do this, because of the Magnet status. So instead they have hired a lot of foreign nurses, who have not taken the NCLEX, so I don't know how they can be called RNs. They take a foreign exam, but these nurses just don't seem prepared for US nursing. Some have said, the doctors pass the meds in their country and they have never done it, and it is obvious. I would much rather have US trained LPNs. And I am not racist, I just don't think they are qualified to be RNs in this country, if they can pass the NCLEX, then sure.

**Nurse Beth, MSN** · Jan 11

esrun2015 said:

Yes, I have worked with many amazing LPNs in the past. But my current hospital will probably never do this, because of the Magnet status. So instead they have hired a lot of foreign nurses, who have not taken the NCLEX, so I don't know how they can be called RNs. They take a foreign exam, but these nurses just don't seem prepared for US nursing. Some have said, the doctors pass the meds in their country and they have never done it, and it is obvious. I would much rather have US trained LPNs. And I am not racist, I just don't think they are qualified to be RNs in this country, if they can pass the NCLEX, then sure.

I oriented a nurse from Nigeria once whose background was the ED. Turns out she never started IVs bc the doctors "needed the practice". She had a tough transition in many ways, but she made it.

Gratefulbutnotstupid, ASN, LPN, RN · Jan 11

Nurse Beth said:

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?