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Background and Significance
Licensed practical nurses (LPNs), called
Licensed Vocational Nurses (LPNs) in Texas
and California (Seago & Ash, 2002)
, have been working with physicians and
registered nurses in many settings for
years. Some women who cared for others
but had no formal education frequently
called themselves “practical nurses”
(White & Duncan, 2001) . However
there were early schools of practical
nursing including the Ballard School in
New York City founded in 1892, the Thompson
Practical Nursing School in Vermont in
1907, and the Household Nursing School
in Boston in 1918 (White & Duncan,
2001) . These schools followed the opening
of three of the first schools of “trained”
nursing in the United States. These “trained”
nursing schools were Bellevue Hospital
in New York City, Massachusetts General
Hospital in Boston, and New Haven Hospital
in Connecticut, and they opened around
1873. LPNs organized into professional
groups as early as 1941 with the creation
of the National Association for Practical
Nurse Education & Service, Inc. (NAPNES)
and the National Federation of Licensed
Practical Nurses in 1949 (NFLPN) (National
Association for Practical Nurses Education
& Service, 2004) .
In a conversation in March of 2004 with
Helen Larsen, the Executive Director for
the National Association for Practical
Nurse Education and Service, Larsen spoke
about the State-by--State evolution of
giving waivers to and licensing practical
nurses.
In 1946 NAPNES recommended that States
become active in seeking licensure for
"Practical Nurses" and State-by-State
it happened. The "Practicals"
were licensed through waivers and different
States had different ways. Some required
a letter of recommendation from a physician,
a supervisor, etc., and the nurse had
to have worked as a practical nurse for
at least 5 years immediately prior to
application. But State-by-State, they
were waivered into nursing. Their licenses
had a "W" on it and for many
of them it was a stigma until they actually
took the licensure exam.
It is difficult to categorize the work
of LPNs in the U.S. because there is substantial
variation in the practice acts and scopes
of practice in the various States. Although
the National Nursing Council recommended
mandatory licensure for LPNs in 1948,
not all States acted on the recommendation
(Brown, 1948) . For example, Ohio did
not require mandatory licensure until
1965 (Licensed Practical nurse Association
of Ohio, 2002) . Some States had a “grandfather
clause” to allow licensure of persons
who were practicing as practical nurses
at the time the licenses were mandated.
This is commonly done when new regulations
are implemented.
During cycles of nurse shortage in the
U.S., there typically is a renewed interest
in the licensed practical nurse as a potential
worker to augment the nurse workforce
and as a potential substitute for registered
nurses. In response to a nursing shortage,
California Senate Bill 1625 was introduced
in 1951, leading to approval of California’s
first LPN education program at Chaffey
College. The notion of LPNs supplementing
or substituting for RNs has been discussed
in nursing literature during most of the
shortage cycles (Bray, 1979; Kenney, 2001)
In general, the scope of practice of LPNs
is more limited than that of RNs. In
some settings LPNs can serve as substitutes
for registered nurses (RNs), but in other
settings the scope of practice of LPNs
is more restricted. These restrictions
may be because of State regulations, Federal
regulations, or institutional policy.
LPNs can perform many of the functions
that RNs perform but at times are not
allowed to practice to the full legal
limit of practice acts.
One of the broadest descriptions of LPN
scope of practice comes from the U.S.
Department of Labor Occupational Outlook
Handbook: “Licensed practical nurses…
care for the sick, injured, convalescent,
and disabled under the direction of physicians
and registered nurses" (US Department
of Labor, 2002) . State regulations tend
to be more specific about the role of
LPNs; for example, the California Board
of Vocational Nursing and Psychiatric
Technicians (BVNPT) States that the duties
“include, but are not limited to,
provision of basic hygienic and nursing
care; measurement of vital signs; basic
client assessment; documentation; performance
of prescribed medical treatments; administration
of prescribed medications; and, performance
of non-medicated intravenous therapy and
blood withdrawal (requires separate Board
certification.)” (California Board
of Licensed Vocational Nursing and Psychiatric
Technicians, 2004)
In 1998, LPNs accounted for 39 percent
of licensed nurses in hospitals and 46
percent of licensed nurses in long-term
care settings (Bureau of Labor Statistics,
2000) . Through the 1990s growth in demand
for licensed nurses was fairly consistent
(Buerhaus, 1996;Spetz, 1996) with that
demand being lower in areas heavily penetrated
by health maintenance organizations. Additionally,
during the 1990s employment of LPNs shifted
away from the acute care setting toward
long term care (Buerhaus, 1996). This
shift was likely related to cost cutting
measures in hospitals. The movement of
LPNs out of hospitals created a gap in
the acute care experience of LPNs, requiring
substantial re-training and orientation
of vocational/practical nurses who are
brought back into the acute care setting
(Barber, Bland, Langdon, & Michael,
2000) .
Reported annual turnover rates for LPNs
in nursing homes range from 32 percent
to 61 percent and demand for LPNs is growing
each year (Decker, Dollard, & Kraditor,
2001) . Poor wages, mandatory overtime,
and physically demanding work are thought
to contribute to higher turnover rates
(Decker et al., 2001) . A number of bills
have been introduced in State legislatures
and Congress that seek to improve the
work environment for LPNs and RNs. Eliminating
mandatory overtime, providing more resources
for nurse training, increasing payment
rates, offering whistleblower protection,
and developing needlestick prevention
programs are among issues being considered
through legislation (AFT Healthcare, 2002;
Bellandi, 2001; Galloro, 2001) . Some
States and the Federal government are
considering minimum licensed nurse-to-patient
ratio regulations for acute-care hospitals,
although California is the only State
to have instituted such requirements.
The only national staffing requirements
for long term care settings are minimal
standards set by the Centers for Medicare
and Medicaid Services (CMS) (formerly
Health Care Financing Agency (HCFA)) (Center
for Medicare and Medicaid Services, 2002)
.
A number of studies have demonstrated
that increased nursing hours are related
to better patient outcomes (Aiken, 2000;American
Nurses Association, 2000;Needleman, 2002)
and organizations have called for increasing
nursing hours in hospitals and long-term
care settings (Spetz, 1998;AFSCME, 2002).
There also is some evidence to indicate
that improved patient outcomes may be
related to higher education levels of
RNs (Aiken, 2003). The literature generally
focuses on the importance of RN staffing
in improving quality of care, and the
evidence is difficult to apply to the
LPN workforce. The education and training
of LPNs vary widely across States. LPNs
can apply to take a licensing examination
after completing a 1 or 2 year program
at a community college, an adult educational
program, or private vocational school.
RNs typically are viewed as workers who
have a great deal of skill flexibility,
while LPNs have a more limited degree
of flexibility. During periods of nursing
shortage, there is interest in creating
a more efficient educational path for
LPNs to become RNs. Many schools and colleges
across the U.S. provide career mobility
mechanisms to allow LPNs to make this
transition (Eastern Tennessee State University,
2002) . However, these programs are specific
to States, geographic regions, or even
schools, and popularity of programs waxes
and wanes depending on the nursing labor
market and economic climate. A number
of barriers, including access to courses,
funding, and variation in requirements,
prevent LPNs from progressing efficiently
through the career ladder and little systematic
study has been done to identify and reduce
those barriers.
Although LPNs organized into professional
groups in the early 1940s, there is little
literature about the practice, work, demand
or efficient utilization of the licensed
practical nurse. Additionally, there is
little guidance as to how to most effectively
make use of this practitioners' skills
to enhance patient care and augment the
nurse workforce. In the 1990s, there
were published works that explored the
creative use of LPNs in critical care,
as advice nurses, and in intravenous therapy
teams, (Buccini,1994; Ingersoll,1995;
Eriksen,1992; Roth,1993); interest in
trying new care delivery models using
LPNs in acute care hospitals has been
renewed in the 2000s (Kenney, 2001) .
However, little systematic study has occurred
that explore these staffing strategies.
It is important to measure the effects
of these roles and how they work with
the scope of practice of the LPN. This
study will fill some of the gaps in our
understanding of the LPN workforce in
the United States.
Purpose and Organization
of This Report
The objective of this study is to inform
nurse educators, employers, the health
professions community, the public, and
policy makers about the demand, supply,
utilization, and scope of practice of
LPNs in the 50 United States, the 4 U.S.
territories, the District of Columbia,
and the Commonwealth of the Northern Marianas
Islands. Particular attention is paid
to educational issues, career mobility,
geographic distribution, and the ability
of LPNs to substitute for registered nurses.
Since most boards refer to this provider
as a licensed practical nurse, we will
use the title LPN and not LVN. The terms
“licensed nurse” and “nurse”
are used to refer to the combined group
of RNs and LPNs
This research will seek to answer these
questions:
- What is it that LPNs do and in what
settings are they employed? (Chapters
2 & 3)
- What is the demographic profile of
the LPN workforce? (Chapter 2)
- What are national and State educational
trends in applications, enrollments,
and graduates? (Chapter 4)
- What are the supply, demand, and
adequacy of the LPN workforce? (Chapter
5)
- To what degree can LPNs substitute
for RNs? (Chapter 3)
- Is there any evidence of increasing
demand for LPNs as a result of the RN
shortage? (Chapter 6)
- What are the issues precluding greater
utilization of LPNs as a way of mitigating
the current RN shortage? (Chapter 3)
- What are employer, educator, and
practicing LPN perspectives on the current
State of the LPN workforce and its ability
to substitute for registered nurses?
(Chapter 6)
This report is organized into seven chapters,
each addressing specific research questions.
Each chapter includes an overview of the
questions addressed, the significance
of the questions, the design and methods
used, specific findings, and a discussion
of the meaning of the findings. Chapter
2 provides a general description of the
LPN workforce. Using secondary data,
we describe the demographic and employment
characteristics of the LPN workforce.
Chapter 3 provides a discussion and analysis
of data on LPN scope of practice and recent
legislation related to the work of LPNs.
Data on the scope of practice of LPNs
were collected from all 50 States. Information
was gathered from officials in State licensing
boards and government Internet sites.
Recent legislation regarding the practice
of LPNs was identified with assistance
from the National Conference of State
Legislatures and other sources. The legislative
activity is evaluated to assess how the
use of LPNs has changed or might change
in the near future.
Chapter 4 provides a description and
analysis of LPN education using both primary
data collection and secondary data analysis.
Chapter 5 examines the supply and demand
of LPNs. The supply of RNs is known to
vary with personal characteristics and
economic conditions (Link, 1985;Buerhaus,
1994;Brewer, 1994). We estimate a multivariate
regression equation to identify the relative
importance of factors that affect the
supply of LPNs. How does the labor force
participation of LPNs change as LPNs age?
How responsive is the LPN workforce to
changes in wages or economic conditions?
Has the underlying supply of LPNs changed
over time? Then, we estimate multivariate
regression equations for the demand for
LPNs by hospitals and nursing homes, using
national data. These models enable us
to determine the relative importance of
quantity of care provided by facilities,
wages of all personnel, scope of practice
regulations, Medicare and Medicaid reimbursement
rates, managed care penetration, and other
factors on the demand for licensed vocational
nurses. The analysis takes into account
the fact that demand for LPNs may affect
the wages of LPNs and other personnel,
and that scope of practice may be affected
by demand for LPNs using instrumental
variables techniques (Newhouse & McClellan,
1998) .
Chapter 6 considers the perspectives
of employers, educators, and practicing
LPNs regarding the practice and education
of LPNs. We selected 4 States in which
to conduct in-depth qualitative research,
including focus groups and interviews
with LPN employers, educators, and Boards.
From this research, we gain more depth
in our understanding of how LPNs practice
in the United States, and what the future
may hold for these professionals. Finally,
Chapter 7 summarizes our findings, conclusions,
and recommendations.
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