Why are LPNs allowed to supervise RNs in Long-Term Care?

RNnLTC · Oct 11, 2012

I don't deny that there are some very good LPN's. My best friend happens to be an LPN and if she were unit manager I wouldn't complain because she knows a lot and she has people and communication skills...that makes all the difference in the world when someone is in a supervisor position. However, education and scope of practice does matter. If it didn't matter, all nursing programs would be a year in length at full time. Me personally--with only an ADN RN--I had to take 2 years of prerequisite work and 2 years of nursing classes, which accompanied co-requisite classes. So, there is a difference...and no disrespect, but less educated individuals shouldn't be put in supervisory positions, when they are not qualified to supervise skills which exceed their scope of practice.

BrandonLPN, LPN · Oct 11, 2012

I've never seen a unit manager (RN or LPN) that actually "lead" the floor nurses in a clinical sense. Each charge nurse is responsible for his hall. But a LPN unit manager *can* write a RN up for a med error, improper documentation or for not following company protocol. Remember, these are all FACILITY policies and quite separate from nurse practice acts.

RNnLTC · Oct 11, 2012

That's different than questioning your nursing judgement and interventions. This nurse tries to "lead" the floor in a clinical sense and most of the time doesn't even understand what's going on. A family member will come to the nurses station and ask to speak to the nurse of their family member and she will say, "I'm the charge nurse. You can talk to me." Really? In order to be charge nurse you have to make clinical decisions and If I'm working with the patient all the time, then the information they seek will better come from me unless I am super busy and she is doing me a favor...which is never the case.

TheCommuter, BSN, RN · Oct 11, 2012

Most state nursing practice acts allow LPNs to supervise RNs in an administrative capacity. This means that, in a LTC setting, the LPN unit manager or LPN/ADON can discipline the RN floor nurse for administrative issues such as attendance, narcotic discrepancies, insubordination, unprofessional conduct, patient abuse, and a wide range of issues.

LPN nurse managers, however, are not allowed to supervise RNs in a clinical capacity. However, they can act under the direction of the DON or DNS, which is almost always an RN.

If you think about it, anyone can supervise any employee administratively. Most LTC facilities have administrators who have no healthcare backgrounds whatsoever, yet they are allowed to manage nurses in an administrative capacity. They are not, however, permitted to supervise nurses in an administrative capacity.

Administrative versus clinical supervision is the key.

BlueDevil,DNP, DNP, RN · Oct 11, 2012

Do you feel that patient safety is being threatened by having a LPN in charge? Is that why you feel you must act in some way?

"It just annoys me that the Scope of Practice for RN and LPN in Michigan clearly states that an LPN cannot clinically supervise an RN, yet this is actually happening at my facility! What can I do about this?"

If not, then it is merely ego. And that is rather unprofessional, and frankly, unbecoming. Contemplate this for a while and then just breathe, and let it go. It isn't important.

jadelpn, LPN, EMT-B · Oct 11, 2012

LPN's education in some states are more clinically based, we take SOME (not ALL, SOME) of the same nursing classes as RN's, and have many hours of clinical rotations, we don't, however, take general education classes for an ADN. Scopes vary widely, and are by state and facility. We have our own licenses to protect, so we all need to be mindful we are practicing within our scope.

LTC is not acute care. The outcomes are within a certain "norm", patients are not acutely ill, but one does need to recognize when a resident becomes acutely ill. LPN's can supervise RN's, however, can not direct the clinical care an RN provides using an RN's nursing judgement. In other words, if you are not giving a BP med because a resident's BP is 90/50, you need to obtain an order, however, an LPN can not say "hey give it anyways" that type of thing.

We all work under the order of MD's or NP's (or PA's should your facility use them). How you use your nursing judgement for your patient is key. If you have an acute change in a resident that requires you to educate a family on a decline, then it would be an ethical thing to advise the person in charge (RN, LPN or Administrator on call that has a degree in health care administration) that this is happening. It doesn't mean that then they can all put in their 2 or 3 cents on why you should/should not do this, however, everyone needs to be on the same page for best patient outcome, and family informed of what's happening. Nanny, Nanny, boo-boo I know something you don't know has no place in any facility.

BrandonLPN, LPN · Oct 11, 2012

Where I've worked "unit manager" and "charge nurse" are two different jobs with different responsibilities. The unit manager makes assingments, does audits, staff evaluations, makes sure all the flow sheets and charting is kosher, stuff like that. The "charge nurse" is the floor nurse for that shift. He's the one passing meds, doing treatments, calling in the INR results, stuff like that. I thought tis is how most LTC facilities run....

RNnLTC · Oct 16, 2012

In regards to the replies here (and thank you all for expressing your opinions), I want to clarify that my post is not egotistical.

"Do you feel that patient safety is being threatened by having a LPN in charge?"

When said nurse is interfering with interventions, the education of families/caregivers or requiring that she have a "say-so" in the way treatment, care planning, and interventions are being carried out, it eventually compromises patient safety and quality of care. This would be the concern regardless of title. However, this happens to be a nurse that did not receive the in-depth training that an RN has, and thus should not be 1) going out of her scope of practice, obviously, by attempting to clinically supervise 2) Addressing herself as charge nurse to families, when she clearly cannot override the clinical decisions made by RN's. (2 nurses, x 3 shifts on this unit, 4 are RN's) I assure you it is not a matter of ego on my part. It is a matter of doing what is best for the patient and families. It appears she is letting her position get to her head and losing sight of her focus...administrative duties. Here is just an example of "her". INR comes back at 2.6. Patient's coumadin was increased from 2.5 mg to 3mg one week ago, because the INR was at 1.8 foreverrrrr. I don't feel I need to call the doctor. I can put it on his board for when he does rounds. She thinks the doctor needs to be called. ? Patient has a hx of Colon CA and esophageal stricture. No recent hx of abx use, no hx of C-Diff, no recent close contact with the patient in the facility that was suspected of having active C.Diff (C&S was pending). Patient get's put on contact isolation--per unit manager--because pt had one episode of large loose stool that smelled bad...please note loose stool, not watery stool. Me: we should monitor for loose stool for 24 hrs before initiating contact isolation. The pt is asymptomatic. Her: No, I want her on contact isolation and you need to call the doctor. Summary: The pt was placed on contact isolation x3 days, in which she didn't tolerate too well with her dementia. The patient was chemically sedated on a couple occasions in order to maintain contact isolation. This issue was being brought to the attention of the physician and thus contact isolation was D/C; pt was no longer having loose stool. Stool samples were completed x3 over a 2 week period, because the pt only had 2 episodes of diarrhea in 2 weeks. The pt would have been started on Flagyl, unnecessarily, if I didn't plea to the doctor to let us at least get one positive stool sample before starting Flagyl. These are true scenarios. Pt. with hx of stroke, anxiety, dementia, attention seeking behaviors, and subdural hematoma roams the unit in W/C . Pt decides to get close to the nurses station and sit. Pt. starts behaviors (asking for help, seeking attention, not causing harm, not getting aggressive or combative). Unit manager: "Will you please give her something! I am tired of hearing it!" Should I sedate pt's at her will? Another pt whom makes repetitive statements, with long hx of psychiatric drug use, is sitting in the W/C in the hallway for a change. Pt always seems to be in room (hmmm). Pt asks for something to drink. I bring pt close to me and administer thickened liquids, as are ordered. Unit Manager: "Why is she out here? She get's obnoxious when she is out here." Unit manager then pushes the pt. into room.

Any GOOD-PRUDENT nurse, wouldn't want to tolerate the behavior of this unit manager!

RNnLTC · Oct 16, 2012

Let me add..I am not saying ALL LPN's are like this one,but it does give a bad rep.

jadelpn, LPN, EMT-B · Oct 16, 2012

The inappropriate comments about the patients is definetely something that should be addressed. Inappropriate on a number of levels, and would have to be addressed regardless of which of the staff are making them. LPN's are members of the care team (even ones who are not in charge) so adding to or speaking with you about some ideas of plan of treatment is not off base. But as my previous sentence, perhaps the attitude needs adjusting as opposed to anything else.

The INR situation--this is a lot of "depends"--what is the theraputic range? Why is the person on Coumadin? It is not unusual for a theraputic INR to be 2-3, so 2.6 would be in that range. Coumadin is not given until evening, so I could see advising the MD at round time that the patient is or is not theraputic, so what does he want to do? However, if you have to report to the MD when the labs get back for correct coumadin dosing, then that is an entirely different thing. It depends of your facility policy. (and if the theraputic range for this patient was 1-2, then the original 1.8 would have been just fine and theraputic, so I am assuming 2-3 was the goal).

Ahhhhh the wonders of C-Diff. There are many facilities that at the first sign of loose stool flagyl for all. There are policies put in place by your infection control people. That do include precautions. Until (at least in my facility) 3 negative stools.

Because an LPN in charge (or an RN in charge) has to stick by the policies in place is no reason to give a hard time about it. She doesn't make the rules, she just needs to enforce them. What if the person DID have C-diff? (and stranger things have happend) Then it would have/could have been through your place like wildfire, and then what? Oh, RNnLTC didn't think the patient needed to be on precautions, and didn't think the patient needed flagyl, so here we are????

I get that LPN's including myself are not as educated as RN's. But common sense can be universal. And we can debate theory and treatment plans until the cows come home, but that is not going to change things when you need to go to work in a practical HAZ-MAT suit due to a C-Diff outbreak......

DSkelton711 · Oct 16, 2012

I do think there are some boundaries that this nurse is pushing. I recently went to a seminar where it was brought up that some facilities are getting pinched at surveys because they have LPNs working in a role that should be held by an RN. I work with many LPNs that have a lot of experience and very good nursing skills, but my position can only be held by an RN due to assessments and care plan development (state regulation where I live). If you are unsure about what is or is not acceptable in your situation the BON can give you guidance in interpreting nurse practice.