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The
preceding chapters reported on the work
of LPNs, their demographic characteristics,
the process of education for LPNs, and
their demand and supply. While the
data presented in these chapters provide
substantial information about the LPN
workforce, it does not answer some key
questions. How do LPNs and their
employers view their role in the workforce?
How do they interact with RNs? Are
LPNs interested in pursuing additional
education? To answer these questions,
we turn to qualitative research methods,
including focus groups and key informant
interviews. This chapter reports
on qualitative work conducted in four
States to better understand these issues
related to the LPN workforce.
Methods
The
qualitative approaches used in this study
included key informant interviews and
focus groups. Key informant interviews
were conducted with officials from State
nursing boards, nurse administrators in
acute care hospitals and long-term care
settings, and directors of LPN educational
programs in community colleges and adult
schools. Focus groups were conducted
separately with practicing LPNs and RNs
to learn the perspectives of staff nurses.
We
selected four States in which to conduct
qualitative research: Iowa, California,
Massachusetts, and Louisiana. These
States were selected to provide geographic
variation and a range of restrictiveness
of scopes of practice. California
and Iowa have relatively restrictive scopes
of practice, with scores of 4. Massachusetts
and Louisiana’s scopes of practice
are among the most liberal in the U.S.,
with scores of one. In California,
Louisiana, and Iowa, we visited both a
large city and a smaller city in order
to determine whether population density
was associated with differences in the
utilization of LPNs. In California,
these cities were Los Angeles (population
3,694,820) and Bakersfield (population
247,057); in Iowa we visited Des Moines
(population 198,682) and Cedar Rapids
(population 120,758); in Louisiana we
visited New Orleans (population 484,674)
and Baton Rouge (population 227,818).
In Massachusetts, we conducted our interviews
and focus groups in Framingham, a city
halfway between the large city of Boston
and the smaller metropolitan area of Worcester.
Key informant interviewees and focus group
participants were selected from these
seven sites.
Key Informant Interviews
Potential
hospital key informant interviewees were
identified using data from the American
Hospital Association (AHA) Annual Survey
of Hospitals (American Hospital Association,
1999). With these data, we examined
the number of beds at each hospital and
the share of licensed nurses who were
LPNs. We attempted to schedule key
informant interviews with people from
hospitals with at least 100 beds and with
at least 10 percent of their licensed
nursing staff was comprised of LPNs.
In some cases we visited hospitals that
were slightly smaller or had somewhat
fewer LPNs in their nursing staff.
To
identify potential interviewees in long-term
care facilities in the target States,
we utilized the Medicare Web site, Nursing
Home Compare, which includes data
on all Medicare certified nursing homes
in the country (U.S. Department of Health
and Human Services, 2004). We targeted
nursing homes with more than 75 beds in
order to assure a staffing mix that would
include both RNs and LPNs.
A
research assistant contacted potential
interviewees and read a telephone script
that explained the purpose of the study,
the purpose of the interview, and procedures
for voluntary consent and confidentiality.
Once interviewees agreed to participate,
a follow-up letter and email were sent
including the interview details, a written
information sheet, and a copy of the consent
form to be signed at the time of the interview.
In
total, there were 24 key informant interviews
conducted in the four States. Most
of these were in-person interviews, scheduled
to coincide with the focus groups in each
State. When schedules did not permit
in-person interviews, telephone interviews
were held subsequent to the focus groups.
There was no overlapping participation
between the focus groups and key informant
interviewees although several of the focus
group participants were employees at facilities
where the Director of Nursing was interviewed
as a key informant.
The Employer Perspective
LPN practice in hospitals
In
general, LPNs tend to be a small component
of the total nurse staffing in hospitals,
regardless of the State and scope of practice.
LPNs generally are employed in medical-surgical
units, rehabilitation units, hospital-based
skilled nursing facilities, and outpatient
clinic settings. However, the RN
shortage seems to be increasing LPN employment
in hospitals. In more than one State,
nursing directors of hospitals Stated
that LPN employment was increasing in
all types of patient units. Some
respondents Stated that they were considering
increased LPN staffing or replacing some
nursing assistant staff with LPNs.
Factors Favoring LPNs
in Hospitals
Nursing
directors in hospitals Stated that several
factors made it attractive to hire LPNs.
The major attraction of LPNs is that they
cost less than RNs and can be used for
nursing functions within their scope of
practice. LPNs are attractive because
they have more skills and training than
nurse aides and are licensed to perform
functions that nurse aides are not allowed
to do, such as administer medications.
In some locations, LPN wages are not much
higher than those of nurse aides. Wages
for RNs and LPNs varied widely across
the four States we studied, but the difference
between RN and LPN salaries averaged $5
per hour. Hospitals were particularly
interested in hiring LPNs who are enrolled
in RN programs and working their way through
school. The students are attractive
because they have a high level of skills
and knowledge and can also be recruited
for a future position as an RN.
Another factor making LPNs more attractive
in some States is that they are more plentiful
than RNs and can perform many of the same
functions. Regardless of the State
or scope of practice, experienced long-tenured
LPN employees were highly valued in the
acute care units where they work.
They were trusted by the RNs, highly skilled
as a result of their education and experience,
which was valued by the nurse managers
and directors.
Factors Unfavorable
for Hiring LPNs in Hospitals
Factors
that made LPNs unattractive to hire primarily
centered around their limited, or perceived
limited, scope of practice. Because
there are many nursing functions such
as advanced IV therapy, patient assessment,
and administration of blood that LPNs
are not able to perform, they must be
teamed with an RN who then shares the
patient assignment. Some RNs consider
this more burdensome than helpful.
Even States with the most liberal scopes
of practice have limitations in LPN scope
of practice that reduce LPN utility in
acute care settings. Other factors
that limit the attractiveness of LPNs
were limited training in critical thinking
and the lack of clinical experience in
specialized hospital units.
LPN and RN Working
Relationships
In
general, most nursing directors felt that
RNs and LPNs worked well together in their
hospitals. On the inpatient units,
RNs are in charge (make the assignments
and supervise all staff). LPNs usually
have an independent assignment and may
care for complex patients, but the RN
on the team performs RN-required procedures
for those patients. On hospital-based
skilled nursing units, LPNs often have
the role of charge nurse with a supervising
RN overseeing the LPN. In the outpatient
setting, LPNs may work alongside RNs in
performing a variety of outpatient services
including patient screening and education.
In one interview site, a large integrated
health system practice, LPNs function
as health educators in the outpatient
setting.
Substitution
All
hospital nurse administrators interviewed
Stated that LPNs could not substitute
for RNs in any situation that required
an RN skill level. LPNs can, and
often do, substitute for nurse aides as
well as other allied health staff such
as EKG technologists if they are trained
in that skill.
Adequacy of LPN Education
Most
interviewees felt that LPN education was
adequate. Nursing directors usually
preferred particular LPN education programs
in their region and tended to recruit
primarily from the preferred schools.
These hiring preferences provide feedback
to the schools on the strength of the
curriculum and teaching. Hospital
nursing directors generally thought that
the longer LPN programs (18 months or
more) were better. Several interviewees
mentioned that they do not support the
challenge exam in which certain categories
of LPN candidates, generally those with
a military background, are allowed to
take the LPN licensing exam without completing
a training program.
Appropriateness of
Scope of Practice
Most
nursing administrators in hospitals agreed
that the scope of LPN practice was appropriate
even though it varied widely between the
restrictive and liberal States.
Some Stated that the challenge facing
hospitals and the RNs who manage the patient
care units is to assure that LPNs are
allowed to perform up to the maximum of
their legal scope of practice, yet not
exceed that scope. Problems occur
when there is a lack of knowledge of the
LPN scope of practice, or when RNs are
unwilling to let LPNs maximize their practice.
LPN practice in long-term
care facilities
Long-term
care facilities are a major employer of
LPNs across the country and in the four
States where we conducted interviews.
LPNs are hired in LTC facilities for virtually
all nursing functions except those that
require an RN under Medicare requirements.
LPN functions include supervision of nurse
aides, administration of medications,
IV care, and other skilled care within
the LPN scope of practice in that State.
Factors Favoring LPNs
in Long-term Care Facilities
LPNs
are attractive to long-term care facilities
for several reasons. The primary
reason is that LPNs are less costly than
RNs for nursing functions that can be
performed by either LPNs or RNs, such
as basic bedside care, administration
of oral medications, supervision of nurse
aides, and interaction with patients and
their families. In addition, LPNs
as compared to RNs are more available
for hire, often have more experience in
geriatric settings, and have a more positive
attitude about working in long-term care
facilities.
Factors Unfavorable
for Hiring LPNs in Long-term Care Facilities
LPNs
may be unattractive to hire in long-term
care facilities for reasons similar to
those cited for acute care settings.
Patients entering skilled nursing facilities
can be acutely ill, requiring complex
treatments, IV therapy, and wound care,
some of which is outside the LPN scope
of practice. Thus, an RN may be
preferred over an LPN to fill a vacant
position because of the broader scope
of practice for RNs. In addition,
skilled nursing homes must hire RNs to
meet Medicare requirements for RN staffing,
at least 8 hours per day, and to complete
the Medicare Minimum Data Set (MDS).
The MDS is the Medicare mandated report
on patient level and facility level data
that is required for all Medicare and
Medicaid certified nursing home residents.
Other interviewees mentioned that RNs
are better able to perform patient assessments.
While LPNs are more likely to note that
a patient’s condition has changed,
RNs are in a better position to assess
and diagnose the problem.
An
unexpected, but understandable, negative
factor cited by employers was that LPNs
who were studying to become RNs often
do not stay in LPN roles long enough to
obtain significant experience in nursing.
In areas where many LPNs follow career
ladders to RN licensure, LPNs tend to
spend fewer years in LPN practice and
the number of highly experienced LPNs
in the community is diminished.
LPN and RN Working
Relationships
All
interviewees Stated that RNs and LPNs
work well together in long-term care facilities,
sometimes performing the same functions
or with the RN performing RN-required
functions only. Some long-term care
facilities hire a greater proportion of
RNs and others hire only the minimally
required number of RNs. LPNs often
act as charge nurses in long-term care
facilities, while RNs function as the
Director of Nursing.
Substitutability
There
were mixed responses to questions about
the substitutability of LPNs for other
staff in long-term care facilities.
A few said that LPNs substituted for RNs
but most said that LPNs only substituted
for aides. In fact, when facilities
have a high rate of turnover of nurse
aide staff, LPNs are more likely to substitute
for nurse aides. Some of this substitution
is intentional and pre-scheduled in order
to give the LPNs an opportunity to get
to know the patients better and to better
understand, or recall, the role of nursing
aides.
Adequacy of LPN Education
Most
of the long-term care interviewees believed
that LPN education in their State was
adequate. Most agreed that not all
programs are equal and that the longer
courses are better than “fast track”
courses. There was consensus that
the curriculum could be stronger in two
areas important to long-term care facilities:
supervisory skills and geriatric care.
Iowa addresses this concern by requiring
a continuing education supervisory course
that is mandatory for all LPNs within
6 months of employment in a long-term
care facility. The Iowa State Board
of Nursing developed the course and it
is offered at community colleges throughout
the State. Facilities in California
offer in-service programs to strengthen
LPN supervisory skills. Some interviewees
recommended curriculum additions including
psychosocial content focused on interacting
with patient families, preventive care,
and assessment.
Scope of Practice
Most
interviewees agreed that the LPN scope
of practice is adequate for their State.
Some commented that requiring an RN to
sign off on LPN patient assessments is
an unnecessary practice since frequently
the RN is merely providing the signature
rather than oversight of practice.
Others stated that LPNs are not able to
practice to the full scope of practice
because RNs would not or were not allowed
to delegate certain functions. For
example, in Louisiana, LPNs are not allowed
to perform certain functions under their
scope of practice because the RN scope
of practice forbids RNs from delegating
those functions.
The Educational Program
Perspective
We
interviewed directors and faculty of several
types of LPN educational programs in the
four focus States, including private adult
schools, community college degree programs,
and community college non-degree programs.
Some of the programs are ladder programs
in which students receive credits toward
an RN program and can matriculate into
an RN program after completing the LPN
program and passing the LPN licensure
exam. Other programs were built
in as part of RN programs. For example,
some of the community college programs
in Iowa are ladder programs in which students,
seeking RN or LPN training, enter a single
nursing program. After the first
year of study, students are prepared for
and encouraged to take the LPN exam.
Some students stop at this level and pursue
a career and employment as an LPN.
Students seeking an RN license, and who
meet the minimum grade point average,
continue in the program for another year
to earn an associate degree in nursing.
In one of these programs about 85 percent
to 90 percent of students eventually pursue
their RN license.
Another
nuance found in some of the LPN programs
was the requirement of certified nursing
assistant (CNA) training as a prerequisite
for entry into the LPN program.
The purpose was to assure that students
master basic skills of the CNA so the
LPN curriculum can proceed at a faster
pace.
Enrollment Trends
In
most of the programs, enrollment has increased
over the past 2 years. Most of the
programs had no difficulty filling available
slots and some have a waiting list of
a year or more. Several program
interviewees believed that the enrollment
increase was greater in recent years due
to the national nursing shortage and the
downturn in the economy, which made competing
occupations less attractive. Several
interviewees noted an increase in the
diversity of student enrollment over the
past few years with greater enrollment
of males and ethnic minorities.
Adequacy of Preparation
prior to LPN Program
Interviewees
generally thought that many students were
not adequately prepared for the LPN program.
They felt that students are less well
prepared than in the past and believed
poorer high school education, less rigorous
admission criteria, and an increasing
number of new immigrant applicants contributed
to the lack of preparation. They
also Stated that the skills most lacking
were in math, reading, and writing.
To address these deficiencies, many of
the programs instituted prerequisite math
courses or a math entrance exam as an
admission requirement. Others offered
English as a second language and math
tutoring to help students through the
program. These interventions help
students who would otherwise likely fail
to complete the program. However,
remedial programs and tutoring are costly
and the tuition fees are not adequate
to cover these expenses.
Program Completion
Rates
Completion
rates for the LPN programs ranged from
55 percent to over 95 percent. Some
programs tried to assure completion by
allowing students multiple opportunities
to retake courses until they passed.
Other programs increased their completion
rates by being more selective in the admission
process. In States with open access
admission, such as California, programs
wee not allowed to be selective in admissions
even if there are more applicants than
student slots.
Pass Rates on State
Board Exam
Data
on passing the LPN State board exams were
not available from all the programs interviewed.
The programs that provided information
reported that their pass rates ranged
between 64 and 95 percent. One program
director reported that the program’s
low first-time pass rate had resulted
in pressure from the State licensing board
to improve. The director Stated
that the program offered free tutoring
for students to prepare for repeating
the exam if they failed it the first time.
The director felt that the State board
should consider second and third-time
pass rates when reviewing programs.
Because we selected only a few programs
in each State to interview, overall State
board pass rates give a better indication
of performance in that State.
Academic and Social
Support Services
The
educational programs offered a variety
of academic support services including
tuition assistance, loans, educational
tutoring, and peer counseling as well
payment for books and supplies for students
who need assistance in getting through
the LPN program. Interviewees Stated
that a variety of services and support
are needed to assist some students through
the program. LPN programs located
at the community colleges took full advantage
of campus learning centers, academic advising,
practice labs, tutoring services, and
financial assistance. Some programs
also took advantage of county workforce
programs to offer students transportation
and childcare services in order to help
them complete the program.
Barriers to Completion
Respondents
indicated that barriers to completing
LPN programs were those targeted by the
support services. Financial needs
and lack of educational preparation were
cited as the primary barriers to students
completing LPN programs. Programs
directors Stated that most LPN students
found it necessary to work part or full
time while in school. Many students
are older than other college students
and have families to support; many are
single parents. Although most programs
had the ability to offer some type of
financial aid or loans, the amounts were
rarely enough to cover a student’s
total financial needs. The other
major barriers to completing the program
were student lifestyle issues. Some
students have difficulty focusing on school
and the need to study, some have attendance
problems, and others have unexpected family
issues and health problems that impede
their ability to focus on school.
Most program directors Stated that these
students are usually identified and leave
the program early, although often not
early enough for the slot to be filled
by another student from the waiting list.
Curriculum and Employment
Opportunities
Not
surprisingly, most LPN program directors
felt that the curriculum at the institution
was adequate preparation for the students’
future work. The program directors
based this perception on the positive
feedback they get from employers directly
or from employers recruiting and hiring
the program graduates. Program directors
Stated that the students had no difficulty
getting jobs, although most Stated that
hospital jobs were less available and
jobs in long-term care facilities were
abundant. This employment landscape
for LPNs may be changing as a result of
the RN shortage, and may be altered with
staffing legislation such as that recently
implemented in California.
One
of the LPN programs is a bit unique in
that it also prepares LPNs with skills
in phlebotomy, EKG, coding, and medical
office computer skills. Some of
the graduates take non-traditional LPN
jobs in clinical laboratories or medical
offices. It was not clear how this
extra course work fit into the curriculum
or whether it was an add-on that could
be selected by students.
Pursuing RN Education
According
to the program directors, many LPN students
want to pursue RN education, although
the number of students who eventually
complete RN education varied among the
programs. The ladder program schools,
such as those in Iowa, have a much higher
rate of students who finish RN education
because the program structure is one program
with two possible exit points. Other
programs that are well articulated with
RN programs also have higher proportions
of LPN graduates pursuing an RN license.
In these programs, the length of the RN
program is one to two semesters shorter
when LPN program credits are accepted.
The vocational and/or certificate LPN
programs create a greater challenge and
time commitment for LPNs who wish to pursue
an RN license. In most cases, graduates
of vocational LPNs programs must start
at the beginning of an RN program, including
taking the RN program prerequisites.
Scope of Practice
The
program directors generally thought that
the LPN scope of practice in their State
was appropriate. They felt that
they produce a much-needed bedside caregiver
who is well prepared for his or her role
and scope of practice. One interviewee
noted that the RN board wields a great
deal of power over the LPN scope of practice.
She does not anticipate any changes in
LPN scope of practice due to the RN board’s
power to impede any movement toward expanding
LPN practice. Another noted that
if the LPN scope of practice does change,
s/he will be ready to alter the LPN program
curriculum, but that it would likely mean
expanding the length of the program.
A few program directors noted that they
thought the intravenous administration
of some medications and nutritional solutions
should be permitted under the LPN scope
of practice. One director argued
that medications that are available over-the-counter
should be permitted for IV administration
by LPNs.
Boards of Nursing
Perspective
In
all four States, we interviewed officials
at the State board overseeing LPNs.
In Iowa and Massachusetts, a single board
oversees RNs and LPNs. In Louisiana
and California there are separate boards
for RNs and LPNs. The predominant model
in the United States is for the boards
to be combined.
Board Composition
Whether
or not the LPN and RN board is combined
may have implications for the scope of
practice for LPNs in that State.
It is possible that LPNs have relatively
less power when a combined board represents
them, and thus their scope of practice
may be limited. However, when boards
are separated they may not consult with
each other regarding the scope of practice.
We do not have adequate data to assess
whether it is beneficial for patient care
and nursing practice in general and for
LPN practice in particular to have separate
or combined boards of nursing.
The
directors of the State boards of nursing
interviewed were RNs with varied backgrounds
in nursing care, administration, nursing
education, and State government.
Most had served for a considerable time
in their board position and were knowledgeable
about trends and issues in nursing for
their State.
Board Responsibility
for LPN Practice
The
chief responsibility of the State boards
of nursing is consumer protection and
assuring compliance with regulations governing
the practice of nursing in that State.
All the board directors felt strongly
that the regulatory role was their major
responsibility. Most quoted directly
from State statutes regarding authority
and responsibility of the board of nursing
as a consumer protection agency.
Those responsibilities include oversight
of the licensing and license renewal process,
collecting and summarizing data on licensees,
investigation of complaints, administering
the disciplinary process, and determining
scope of practice based upon the laws
and regulations in the State. Other
board functions include setting policy,
presiding over board meetings, reviewing
nursing education programs in the State,
and conducting research on nurses in the
State. Boards track trends in NCLEX
pass rates and demographic data of nurses.
All four States have State health care
workforce task forces or committees to
study the nursing shortage and health
workforce issues in the State. State
board staff members were usually participants
in those efforts.
LPN Data
The
nursing board directors provided detailed
data on the number of LPNs in the State
the number of educational programs, graduates,
exam pass rates, and other demographic
data. Some of the boards have this
information readily available on their
Web sites, while others gave us copies
of written reports and summary data.
Financial resources and staff capacity
limit the ability of each State to gather
data on LPNs and analyze trends.
Nevertheless, there was a great deal of
detailed data available for each of the
four focus States.
LPN Scope of Practice
Changes
In
the four focus States, the LPN scope practice
has had only minor or no changes over
the past 5 years. In Louisiana,
the scope has not changed since 1948 although
the board director noted that the utilization
of LPNs in clinical settings has changed.
The scope of practice Statements in Louisiana
and Massachusetts are very broad, leaving
it open to interpretation. Iowa
has a specific Statement of the scope
of practice, and there have been minor
changes. For example, a change in
the scope of practice was required to
allow limited performance of intravenous
therapy by LPNs and to include the requirement
of the supervisory course for LPNs working
in long-term care facilities. Iowa
is considering expanding the scope of
LPN practice in managing end-stage renal
disease and hemodialysis. Recently
in California, there have been changes
in the interpretation of the scope of
practice to allow LPNs to perform hemodialysis
and to administer IV medications during
the dialysis procedure.
Substitution
All
nursing board directors Stated very specifically
that LPNs could not substitute for RNs
in their State. Each saw the role
of LPNs as very different from RNs and
did not think that the roles overlapped.
Interviewees stated that LPNs supplement
RN care and perform routine care but the
educational preparation of LPNs and RNs
is very different and should remain so.
Enrollment
Board
directors generally agreed that enrollment
in LPN programs had increased over the
past 2 years in each of the States we
visited. One interviewee said that,
over the long-term, LPN enrollment has
been tied to the general economy and the
availability of alternate careers.
Over the past several years, nursing has
been considered a secure career, and the
increased awareness of registered nursing
has created more interest in LPN programs
as well. The RN shortage seemed
to contribute to an increase in LPN enrollment
in some States. During the nursing
surplus of the 1990s, there was a decrease
in LPN enrollment, presumably due to a
diminished number of jobs available for
LPNs. During that time, the State
Board of Licensed Practical Nursing in
Louisiana recommended a moratorium on
new LPN programs. However, with
the advent of another nursing shortage,
Louisiana has seen a 12 percent increase
in enrollment in LPN programs over the
past year.
LPN Shortages
All
the State board directors are concerned
about a shortage of RNs in the State.
There were mixed responses about whether
there were an adequate number of LPNs.
In Louisiana, board staff felt that there
was an adequate supply of LPNs but that
they were not all working in health care.
Because of overwork due to the nursing
shortage and higher salaries available
in other occupations, some LPNs have stopped
working in health care. LPNs work
for local registries or traveling nurse
agencies and some are practicing out of
State. Even Iowa, which has one
of the highest RN to population ratios
in the Nation, loses nursing staff to
neighboring States that pay higher salaries.
In Iowa, nurses living near the border
are able to work as traveling nurses in
a neighboring State while still living
at home. In California, more LPNs
are needed to work in long-term care and
home health settings. Massachusetts
interviewees felt that the shortage in
their State was not as severe as other
States.
Board Suggestions
There
were various responses to the question
of how States are addressing RN and LPN
supply issues. Most respondents
focused on the need for increased funding
for nursing at both the Federal and State
level. Funding is needed to build
programs, hire faculty, increase the number
of clinical sites, and provide tuition
assistance for students. Iowa passed
legislation 2 years ago to increase the
education of the nursing workforce but
funding was not made available.
California has devoted over $34 million
via the Nursing Workforce Investment Act
to fund nurse workforce development.
In Louisiana, the State has few funds
to allocate for addressing the nursing
shortage.
Perspectives from
Working RNs and LPNs Focus Groups
Methods
Eleven
focus groups were conducted, 7 with LPNs
and 4 with RNs. A professional focus
group organization recruited RNs and LPNs
via telephone from lists provided by public
and private sources. All of the
groups were held between May 21 and June
9, 2003, in the following locations:
- Iowa:
Des Moines: 1 group each of RNs and
LPNs; Cedar Rapids: 1 group of
LPNs
- Louisiana: New
Orleans: 1 group each of RNs and
LPNs in New Orleans; Baton Rouge: 1
group of LPNs in Baton Rouge
- California:
Los Angeles: 1 group each of RNs and
LPNs in Los Angeles; Bakersfield: 1
group of LPNs in Bakersfield
-
Massachusetts: Framingham: 1 group each
of RNs and LPNs in Framingham
Jennifer
Arthur, Principal of Arthur Associates,
moderated the focus groups using discussion
guides (Appendix F). Each focus
group lasted one and one-half hours and
participants were paid incentives ranging
from $75–85 for LPNs and from $100–125
for RNs. The different amounts were
determined based on customary incentives
for this type of activity for each geographic
area. The groups were held in focus
group facilities or hotel conference rooms.
Prior to each focus group, participants
were asked to complete a two-page written
survey (Appendix F).
Description of Participants
A
total of 67 LPNs and 43 RNs participated
in the 11 focus groups. The average age
of LPNs and RNs in the focus groups was
46.1 and 45.2 years of age, respectively.
LPNs had slightly more children under
18 living at home than did RNs (2.1 versus
1.8). The LPNs were somewhat less likely
than RNs to be married (47 percent versus
62 percent), and more likely to be divorced
(33 percent versus 21 percent).
A higher percentage of RNs (75 percent)
were Caucasian than LPNs (59 percent),
while LPNs (13 percent) are more likely
than RNs (5 percent) to be Asian.
According
to written survey responses, 44 percent
of LPNs attended community or junior colleges,
versus 23 percent of RNs. Adult
school education was obtained by 32 percent
of LPNs and 2 percent of RNs. Similar
percentages of LPNs and RNs attended a
4-year college (17 percent and 16 percent,
respectively). Among the RNs, 33
percent earned an ADN, 23 percent a diploma,
and 21 percent had a BSN. Over one-fourth
(29 percent) of the RNs obtained an LPN
license before they pursued their RN license.
LPNs in the groups had been licensed an
average of 15.8 years, while RNs had been
licensed an average of 17.1 years.
Key Findings From
Focus Groups
Despite
the differences in licensure and employer,
both RNs and LPNs Stated that direct patient
care is the main responsibility of both
RNs and LPNs. The acute care setting
was desired by most RNs and LPNs if pay
was equal. LPNs, however, predominate
in long-term care settings in a more hands-on,
technical capacity. RNs are more
prevalent in acute care, where they are
more likely to supervise and perform highly
skilled tasks. Though some LPNs
who work in the acute care setting expressed
resentment regarding their lower pay and
perceived lower status, most LPNs and
RNs in the focus groups reported that
relationships between the two groups are
generally positive.
Although
some of the focus group LPNs were not
interested in obtaining an RN license,
one or more individuals in each LPN group
are either currently studying for their
RN license, or are very interested in
doing so. The LPNs in the focus
group cited few barriers to earning their
LPN license, saying they found it fairly
easy. However, there are significant
barriers for LPNs to obtain RN education
and licensure. The major obstacles
to LPNs obtaining an RN license appear
to be:
- The
need to take prerequisite courses such
as math and science
-
The difficulty of finding time off from
work to take courses
-
The expense of financing additional
education
The
majority of focus group participants were
generally familiar with the State’s
scope of practice for LPNs. There
were differences between what the regulations
actually explicated and what members believed
that LPNs were permitted to do.
Those areas of discrepancy generally centered
on patient assessment, IV therapy, and
administration of blood products.
Some LPNs reported that they are not permitted
to perform all of the activities outlined
in the scope of practice, while others
felt that they have responsibilities that
go beyond the State’s regulations.
Several LPNs who had knowingly practiced
outside their scope of practice by performing
tasks in the RN scope of practice expressed
discomfort. Reasons for the discomfort
included concern about legal liability
issues and the fact that they are paid
less than RNs and should not be expected
to perform “RN tasks”.
Focus
group participants were generally satisfied
with their choice of nursing as a career
and certain aspects of their current jobs.
In the written survey of the participants,
over half the LPNs (56 percent) and three-fourths
(74 percent) of RNs said that they strongly
agree they are satisfied with nursing
as a career (Appendix F1).
Summary
of Workforce Perspectives
The
key informant interviews yielded information
from working RNs and LPNs about scope
of practice issues, relationships between
the two groups of nurses, and how each
group perceived the practice of practical
nursing, its limitations and opportunities.
Both RNs and LPNs were generally aware
of the legal scope of practice for LPNs
in their State, yet there was wide variation
in interpretation and implementation.
There was uncertainty in some groups about
the difference between institutional policy
and State law. Both RNs and LPNs
often assumed that the “law”
was what was practiced in their institution.
Some individuals expressed surprise at
the actual language of the State Practice
Act and indicated that the scope was broader
than their institutional policy allowed.
In
the focus groups, we learned about perceptions
of scope of practice, educational barriers,
and the relationships between RNs and
LPNs. Although most of the LPNs
stated a desire or intention to return
to school to get the RN license, few were
actually enrolled in RN programs.
Barriers such as time, a need to keep
working, challenges in getting into courses,
and family issues were among those that
kept LPNs from pursuing further education.
Relationships between LPNs and RNs in
the workplace were reported to be cordial.
There was some resentment by LPNs of the
higher wages paid to RNs for what is seen
by the LPNs as similar work. RNs,
on the other hand, expressed some discontent
over the need to supervise LPNs because
it often added to their workload.
References
American
Hospital Association. (1999). The AHA
Annual Survey Database Fiscal Year 1997
Documentation. Chicago, IL: Health Forum.
U.S. Department of Health and Human Services.
(2004). Nursing Home Compare, 2004, from
www.medicare.gov/NHCompare/home.asp
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