Working below your license

NurseSpeedy, ADN, LPN, RN · Feb 2, 2018

Yes. Reporting off to the other RNs on my patients and being used as an aide because only 1 was assigned for 11p-7am shift for 32 patients in a rehabilitation center

I worked for a hospital years ago as an LPN that offered 8 or 12 hour shifts. Most of the staff on the floor did 8's and the unit did 12's. I worked 12's because I was POOL staff and figured that I could schedule myself more between three jobs and work more hours (By the way, I was young and stupid. This was the recipe for burn out and I found that out the hard way about 8 years into my career). Anyways, when I worked on the floor sometimes there would be no one to follow me at 7 pm. I would sometimes be asked if I wanted to stay till 11 and work a double and if not it was up to the charge nurse how to utilize me for the 4 hours of that shift. One would have me work as the "helper" for the remainder of my shift. I would still get the same pay (which as POOL was REALLY good) and would report off on my patients from earlier that day. I would then be an extra aide/someone who could do nursing tasks/admissions. Any issues that would arise with a patient that were requiring monitoring/intervention (or just good for the nurse to know) I would report to the primary nurse for that patient and if necessary write a quick nurses note stating the issue and who was notified. Think about it. If the charge nurse was to round on your patients, notice something that a nurse would pick up on but not an aide, they would notify the primary nurse but may not actually do the required interventions needed to care for/monitor the patient. This is kind of the same idea, in a way, but you would be helping out as aide (or in my case aide plus 'helper') instead of as someone trying to increase the survey scores. Personally, I kind of liked it. Less stress sometimes. More manual labor sometimes, but I usually got out on time those days instead of getting stuck late because a patient's condition ended up deteriorating the last 30 minutes of my shift.

The other alternative would be to have you work as a nurse and be short an aide, leaving you assigned to a group of patients and also be responsible to take on more tasks that you would normally delegate to your CNA. Remember, as a nurse you are responsible to make sure that anything you delegate to your aide gets done. If they are not able to complete what you have delegated, it ultimately falls on you for not ensuring that it was done.

So, the option would be to work short staffed as a nurse or help out as an aide for the same pay and report anything pertinent to the primary nurse if you notice it during your shift.

I don't know the limitations of the LPN role in your state, but if the LPN can do almost everything that the RN is required to do at your facility, then I don't know why the role of working as the "aide" isn't shared equally...unless it's boiling down to the fact of who is being paid more. Also, many places (at least in my state) require an RN to be on duty somewhere in the building for an LPN to perform some nursing roles with post-licensure certifications (For example, when I was an LPN I had to have an RN on duty if I was doing IV push medications for my patients. Not all states allow this, but I'm in one that the scope of practice is rather broad).

bgxyrnf, MSN, RN · Feb 7, 2018

I just find this mind blowing. I've been a nurse since 1986 and have never been asked to work as an aide. But where I work now, they have you be an LPN for the first 4 hours and an aide for 8.
Just doesn't seem legal

What kind of law do you imagine is being violated?

Employers have an enormous amount of latitude about what demands they make of their employees. The only thing that might be being violated would be a contract but, unless you're part of a collective bargaining unit, you are unlikely to have a contract. In that case, it's simply up to the employer to determine the conditions, requirements, and terms of your work... and it's up to you to determine whether you're willing to accept those terms. Dissatisfaction by either party means an end to employment. It's called being an "at-will employee."

anathema, ADN, RN · Feb 7, 2018

I worked at my SNF for 4.5 years as a CNA before I became a RN, and frequently work as a CNA (for my per diem RN wages, and usually at time and a half). I do it to pick up hours, and because I really don't mind. It can be a nice break from the responsibility of the RN (34-44 patients per RN on nights) and I still can do "nurse stuff". The RN on duty loves it, as I can pass PRN meds for my patients, do assessments, etc, if I have the time, and during the night, they can take a break without worrying about their patients. I obviously don't want to do it all the time, as you do have to "switch" between RN mode (I am the nurse) vs. CNA mode (I'll have to go ask the nurse), but it isn't "beneath me". CNA tasks are part of the RN scope of practice/job description. Acute care nurses "float" and do the CNA work at the hospital here quite often.

OpinionatedCNA, CNA · Feb 11, 2018

It depends on the specific policy of your facility is (is it in your employee contract or not essentially). I know for sure when I got hired in the nursing home/rehab I'm at now they literally told us in orientation that they would require staff to "work below their license" if need be, RN or LPN to CNA, CNA to dietary or laundry if enough people call out. I've never actually seen that happen and I've been working there for over a year now. They're paying you what you're worth to do work that's essentially a magnitude below what you're used to be doing, doesn't seem terrible imo.

Although you could argue if it isn't stated in your contact you did not agree to be employed on those terms and are unwilling to work as a CNA, it is for sure legal. You are a nurse and it is still a part of your job to keep your resident/ patients clean and provide incontinence care if needed. It is not below the level of your license- although facilities don't want to pay a bunch of nurses to do everything when they can for pay one or two nurses and bring in a bunch of CNAs at min wage to do the rest. So trust me if your facility is desperate enough to ask you to work as a CNA, it won't be for long because they don't want to keep paying you as a nurse while working as an aide, it's not in their best interest which is being as cheap as possible.

Jory, MSN, APRN, CNM · Feb 11, 2018

You can work below your license but you can't be held liable below your license. You can't take your LPN knowledge away.

Example: RN tells a medical assistant to give a blood pressure medication to Patient A. The RN is responsible for knowing the blood pressure needs to be checked prior to administration. The medical assistant, in the strictest sense of their training, does not. So if they give it to a patient that has a BP of 98/54 prior to administration, guess who is liable? The RN.

Example #2: RN tells an LPN to give blood pressure medication to patient A. Patient A has a BP of 98/54. The LPN should know that if you give blood pressure medication when it's already low it can cause them to bottom out and the low BP should be reported to the RN. If the LPN gives the med anyway, the LPN will probably be held just as liable as the RN.