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Each of the 50 States, the District of
Columbia, the U.S. territories (Guam,
U.S. Virgin Islands, American Samoa, and
Puerto Rico), and the Commonwealth of
the Northern Mariana Islands, have Boards
and legislation regulating the practice
of registered and practical nursing, as
well as advanced practice nurses and other
workers [1].
These documents display both similarities
and differences in legislation, language,
and scope of practice. In order to provide
an overview of the scope of practice of
the practical nurse in the U.S., this
chapter summarizes major similarities
and differences in the practice of LPNs
and provides a methodology for categorizing
the practice acts. Additionally, based
on scope of practice data, we discuss
issues that limit the utilization of LPNs
in various States and settings.
With the exception of four States, the
56 boards have a single governing board
that oversees the practice of both RNs
and LPNs. California, Georgia, Louisiana,
and West Virginia have separate boards
for RN and LPN practice. Texas changed
to one board on February 1, 2004. The
National Council of State Boards of Nursing
(NSBCN) (National Council of State Boards
of Nursing, 2004) is a not-for-profit
organization whose membership is comprised
of the boards of nursing of the
50 States, the District of Columbia, four
United States territories--American Samoa,
Guam, Puerto Rico, the Virgin Islands--and
the Commonwealth of the Northern Mariana
Islands. The purpose of NCSBN is to serve
as an organization through which boards
of nursing cooperate and work together
on matters of common interest and concern
affecting the public health, safety and
welfare, including the development of
licensing examinations in nursing. NCSBN's
activities include developing the National
Council Licensure Examination for Registered
Nurses (NCLEX-RNŽ) and the National Council
Licensure Examination for Practical Nurses
(NCLEX-PNŽ), performing policy analysis
and promoting uniformity in relationship
to the regulation of nursing practice,
disseminating data related to the licensure
of nurses, conducting research pertinent
to NCSBN's purpose, and serving as a forum
for information exchange for members.
NSBCN has developed a model nurse practice
act that can be used by the members to
guide legislation.
Typically the boards have basic practice
acts and documents related to scope of
practice, including the education and
training that is required for the practice
of practical nursing, and what work LPN
basic education allows. Most boards then
allow for expanded practice with additional
education. The most common areas for
expanded practice relate to intravenous
infusions, intravenous medications, hemodialysis,
and supervision of other staff. In order
to engage in expanded practice, the practical
nurse must obtain further training and/or
certification. Generally, the practice
acts declare that the practical nurse
must work under the supervision of a registered
nurse, a physician, and, in some States,
pharmacists, podiatrists, or others.
The typical paths to licensure are examination,
endorsement, and temporary licensing.
For example, California allows application
for the licensing examination in five
ways: 1) after completion of an approved
in-State program, 2) after completion
of an approved out-of-State program, 3)
with equivalent experience (such as having
worked as a nurse aide and taking a pharmacy
course), 4) with experience as a military
corpsman, and 5) after the first year
of an RN program. In an interview that
took place in February 2003, Suellen Clayworth
of the California Department of Consumer
Affairs, Board of Vocational Nursing and
Psychiatric Technicians, Stated that “there
was a period of time that California did
not use the standardized examination and
nurses who were licensed during that time
may not get endorsement to other States.”
Until 1974, California used the National
League for Nursing examination. From
May 1974 through March 1986 California
used a State constructed licensure examination.
People licensed during this time may not
be able to get endorsed to other States.
According to Ms. Clayworth, the State
began using the NCSBN licensure examination
in October of 1986. Because of examination
standardization, most States now approve
endorsement of currently licensed practical
nurses from other States.
States have elected to explicate the
work of practical nurses in a variety
of ways. Some, such as Louisiana, Montana,
Maine, and Nevada, have detailed lists
of tasks that practical nurses can and
cannot do. Other States, such as Georgia,
Alaska, Kentucky, and Oklahoma, have decision
trees that are to be used to decide on
appropriate tasks that can be done. Connecticut
has an extensive algorithm for decision-making
that can be used regarding issues of practice.
Washington has a decision tree that is
used for making decisions and specifically
States that there is no “laundry
list” of approved and prohibited
tasks. Some States such as Colorado and
Nebraska use the sections of the nursing
care plan to detail work that can be done
by different nursing personnel (RNs, LPNs,
and aides). South Carolina has developed
extensive skills charts that are organized
by body system, job categories, and experience
level within job categories. Neither
Michigan nor Texas has a scope of practice
or practice act for practical nurses.
There are several points of contention
that exist in the scopes of practice of
registered nurses and practical nurses.
These issues typically surround the words
“assessment”, “delegation”,
“supervision or charge nurse”
and, more recently, “decision-making”
and “critical thinking”.
Since the American Nurses Association
defined registered professional nursing
as the diagnosis and treatment of human
responses to actual or potential health
problems, assessment has been a key to
the boundary of practice between the registered
nurse and other nurses and nurse assistants.
Practical nurses and nurse assistants
are permitted to “collect data”
rather than assess patients; however,
the boundary between data collection and
assessment is difficult to define.
Delegation has traditionally been thought
of as a management function reserved for
the registered nurse. However, practical
nurses delegate functions to other providers
in many settings, and some practice acts
acknowledge that fact. The positions
of supervisor and charge nurse are similar,
in that those roles traditionally involve
management. In long-term care settings
practical nurses function in those roles
routinely. In 1994, the U.S. Supreme
Court upheld a decision by the Sixth Circuit
Court of Appeals that said in that case,
the licensed nurses involved were supervisors,
and therefore no longer covered by collective
bargaining agreements (Supreme Court of
the United States, 1994) . The concepts
of decision-making and critical thinking
are now included in some scopes of practice,
usually in order to define the practice
boundary between the practical and registered
nurse. However, as with the term “assessment”,
it is difficult to argue that practical
nurses do not engage in decision-making
and critical thinking activities.
As in many fields, the professions of
RN and LPN seek to protect and expand
their jobs and opportunities. The scope
of practice regulations delineate the
roles of these licensed nurses and thus
RN and LPN organizations lobby for scopes
of practice that protect jobs. Additionally,
in States with powerful RN unions, union
contracts and proposed legislation have
been explicit about what is and is not
the practice of the RN, as compared to
the LPN. For example, there has been
a controversy in California over whether
or not LPNs may administer intravenous
medications to patients as part of hemodialysis
and blood bank procedures. (Editor, 2003)
The California Nurses Association (CNA),
which represents RNs, bitterly opposed
a change in regulations permitting these
activities, while Service Employees International
Union (SEIU), which represents LPNs and
other hospital workers, supported it.
On January 29, 2003, the California Office
of Administrative Law approved the new
regulation. (Editor, 2003)
When there are shortages of registered
nurses, licensed practical nurses often
are suggested as substitutes for RNs,
or as members of multidisciplinary care
provision teams. The ways in which patient
care can be allocated across employees
depends on the legal scopes of practice
of LPNs. In order to better understand
the scopes of practice of LPNs, we obtained
documentation from virtually every board
that regulates the practice of practical
and vocational nurses. Our underlying
hypothesis was that there is variation
in the “restrictiveness” of
the scopes of practice for LPNs, and that
this restrictiveness influences the role
and flexibility of LPNs in work settings.
The data show substantial variation in
the restrictiveness of scopes of practice,
but there also are complexities that require
additional explication. As we reviewed
the practice acts and scopes of practice
information, we determined that there
was also variation in the specificity
of scopes of practice. Some practice
acts and supporting documents are highly
specific and others are very vague in
describing the roles LPNs can play and
the tasks they can complete. Thus, we
found that practice acts were variable
both in the way the States restricted
or enlarged the roles of LPNs and in the
specific or nonspecific language they
used to detail the roles. We determined
that in order to discuss the practice
acts and related documentation reasonably,
we would categorize the States based on
both restrictiveness and specificity of
the scopes of practice. To determine
our ratings, we relied upon supporting
documentation, key informant interviews,
focus group data, Web based information,
and telephone interviews (Appendix C).
We defined the term restrictiveness as
limiting the level of autonomy, flexibility,
or independence in the practice of LPNs.
The term specificity was defined as explicating
or not the defined parameters of practice
of LPNs. We created categorical scales
for each of the terms and evaluated each
State’s scope of practice documents
(Appendix C). The scales included the
following instructions and relative values.
Restrictiveness
As a relative value, on a scale of 1-4,
with 1 being the least restrictive and
4 being the most restrictive, categorize
each State’s LPN scope of practice.
“Restrictive” is defined as
not allowing a level of autonomy, flexibility,
or independence in the practice of LPNs
4- Most Restrictive – allows
limited practice under the direct supervision
or delegation from an RN or physician,
usually allows some IV infusion administration
with additional training, but no administration
of IV medications.
3- Fairly Restrictive –
allows limited scope of practice with
some direct supervision. IV medication
administration of premixed solutions is
allowed, as well as other functions that
may include IV insertion and maintenance.
2- Somewhat Restrictive –
IV medication administration of premixed
solutions allowed, as well as the functions
allowed under #3. An additional 2-3 functions
are allowed, but not the advanced functions
such as those listed in #1
1- Least Restrictive – allows
the broadest scope of practice that may
be delegated but not directly supervised.
Allows broad range of practice including
IV therapy, and in addition several additional
advanced functions such as administration
of cancer agents, hyperalimentation, arterial
blood draws, or patient assessment.
Specificity
As a relative value, on a scale of 1-4,
with 1 being the least specific and 4
being the most specific, categorize each
State’s LPN scope of practice. Specificity
is defined as explicating defined parameters
of practice of LPNs.
4-Most specific – Documents
are clear and there are detailed regulations
with consistent telephone information.
Regulations list specific permitted and
prohibited activities.
3-Fairly specific – Documents
have specific information about permitted
activities, but the information is not
detailed or complete. Information obtained
by telephone also is not complete and
allows some room for interpretation.
2-Somewhat specific –Little
information is provided with the regulatory
documents about specifically permitted
and prohibited activities. The telephone
information is answered with little detail.
1-Least specific – There
is little information in regulatory documents,
and no or limited telephone information.
Methodology for Assigning
Categories
The three principal investigators for
the study, two registered nurses and one
economist, met to categorize the practice
acts of the boards. We individually reviewed
documentation for every board and each
reviewer made a determination of specificity
and restrictiveness based on individual
experience and expert judgment. We read
all available documentation, including
Web based information, telephone interviews,
focus group data, and key informant information,
but did not discuss our decisions with
each other. We individually categorized
both restrictiveness and specificity for
every board and completed the scale forms.
A research assistant entered the results
of the initial determinations into a database.
After the data were entered, one of the
reviewers evaluated the results of the
three scores. If all three reviewers agreed
on a score, the score was accepted. If
two reviewers agreed and the third score
did not differ by more than 1 point, the
majority score was accepted. If there
was no agreement among the three reviewers,
or if there was a difference of more than
1 point in any of the three scores, the
file was pulled for further review. In
the initial review, we had insufficient
data to review the three territories and
the commonwealth. For the restrictiveness
scale, there were 40 scores that met the
criteria for agreement and 12 that were
reviewed a second time by all reviewers.
For the specificity scale, there were
32 scores that met the criteria for agreement
and 20 that were reviewed a second time
by all reviewers. During the second review,
the reviewers discussed the issues until
agreement was reached.
Results
 [D]
As noted in Figure 3.1, most of the States
are in the first or second categories
of restrictiveness. There are 13 boards
in the two most restrictive categories.
 [D]
As noted in Figure 3.2, most States are
in the first or second category of specificity,
meaning that most States do not have very
specific scopes of practice for LPNs.
Eighteen States are in the more specific
categories.
Based on the focus group data from four
States (Louisiana, Massachusetts, California,
Iowa), we have indications that individual
employers restrict practice of practical
nurses even more than regulations require.
A number of the focus group members remarked
that they were surprised when the facilitator
read the actual scope of practice documents.
Their responses varied from, “I
am not going to mention this to my employer
because I will have to do more for the
same pay” to “I am going to
go back and ask my employer why the practice
is restricted more than the legislation
allows.”
Conclusion
Our data indicate there are similarities
in the practice acts across States but
variation in how the States express the
details of the work of practical nurses.
The data also indicate that most States
are flexible in the practice requirements
and not overly specific in the tasks that
are enumerated. However, there are a number
of States with restrictive practice or
very specific detailing of tasks that
can and cannot be done by practical nurses.
These data are used in Chapter 5 to examine
whether the restrictiveness and specificity
of the scope of practice affect demand
for LPNs. The descriptive data presented
above suggest that it may be possible
to identify States that could reasonably
increase their utilization of practical
nurses by reducing the restrictiveness
of their practice.
References
Editor. (2003). Vein of controversy:
The dispute over LPN scope of practice
goes to court. Nurses World Magazine,
October 12-16.
National Council of State Boards of Nursing.
(2004). Home page, from http://www.ncsbn.org/about/index.asp
Supreme Court of the United States. (1994).
NATIONAL LABOR RELATIONS BOARD, PETITIONER
v. HEALTH CARE & RETIREMENT CORPORATION
OF AMERICA on writ of certiorari to the
united States court of appeals for the
sixth circuit; No. 92-1964; May 23, 1994,
from http://supct.law.cornell.edu/supct/html/92-1964.ZO.html
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