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?
