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The role of the Licensed Practical Nurse (LPN) in an acute care setting has been a point of debate for many years. Increasing LPN job responsibility has not been widely reported. In this article, the authors describe the process used to advance the LPN role. Emphasized here is the educators' contribution to the process from inception to implementation.
Traditional roles of healthcare workers are evolving as costs and resources are scrutinized. Multitasking is used to increase staff flexibility and productivity as a means of addressing financial concerns. The challenge to the nurse educator is to provide quality education and clinical experiences for healthcare workers as their roles are expanded. The practical application of this challenge was raised at our institution, a 700-bed tertiary care hospital.
Through bimonthly meetings of unit managers and the Vice President of Surgical Nursing, themes of staff frustration had surfaced. Twenty-six nursing units were staffed with Registered Nurses (RNs) and Nursing Assistants (NAs). Two 44-bed nursing units had an RN/LPN/NA staffing mix that presented issues unique to these units. Both the orthopedic/urology and trauma/ surgical units were typically staffed with a 50% RN and 50% Licensed Practical Nurse (LPN) ratio. Some LPNs, aware of the scope of their practice act, had been questioning current hospital practice. They believed that their role was limited and expressed the desire to take on added responsibilities. RNs were expressing frustration with their workload and had similar concerns about the LPN role restriction. Unit managers and administrators wished to respond to the concerns affecting the 44 RNs and 32 LPNs.
Managers examined various options both including and excluding the LPN role. The leaders were persuaded to retain the LPN role for two reasons: 1) LPNs were a group of long-term, valued, and dedicated employees, and 2) the RN/LPN/NA mix was a cost-effective model.
The Vice President of Surgical Nursing formed a work group to initiate discussion on this topic (see Table 1). The group quickly agreed on two major points: 1) A change in LPN practice should be further investigated, and 2) it was essential that LPNs join the group. The decision was made not to include staff RNs because the unit-based Clinical Nurse Specialists (CNSs) function as educators and clinical experts as well as take a weekly patient assignment. It was believed that this was appropriate RN representation. Primary objectives of the group were identified as follows:
* Expanding the role of the LPN within the Practice Act parameters,
* improving RN satisfaction,
* improving LPN satisfaction,
* improving overall efficiency of the LPN units, and
* implementing cost-neutral changes.
The initial tasks of the group were identified: 1) research the literature; 2) identify an LPN from each nursing unit to join the group; 3) consult Risk Management and Human resource department; and 4) compare the Pennsylvania LPN Practice Act and the institution's LPN job description. The four initial tasks were assigned to various group members to be addressed outside the formal meeting. Information was then to be brought back to the group for discussion.
The two centralized educators, clinical development specialists, researched the nursing and related literature from the past five years. The literature was found to be lacking in information that specifically addressed expansion of the LPN role. However, nonlicensed assistive personnel have, in recent history, been the focus of multitasking. The literature indicated that when upgrading job skills the importance of formal education, clinical application, and RN leadership were identified as key components (Hathaway & Longabucco, 1996; Shaffer, Phillips, Donlevy, & Patrick, 1998). These key components seemed applicable to this project.
The group reconvened to hear the results of the literature review and discuss concepts of the desired level of LPN practice. Joining the group at this time were LPN representatives from the two nursing units. The LPNs described their current practice patterns and their own ideas for role change. Examples of more advanced LPN practices elsewhere in the state were discussed. It became evident to the group that LPN practice at the institution had been restricted and there existed a potential to expand the role.
Variations in the level of practice were identified. For example, some LPNs had relatively advanced assessment skills while several had limited assessment abilities and left this practice component to the RNs with whom they worked. The LPNs also believed that some RNs purposefully limited LPN duties while others gave them a fairly broad range of independence.
Discussion took place to identify specific tasks and skills that were performed only by RNs in the institution but which had the potential to be performed by LPNs as well. The group was able to immediately exclude IV push medication, blood transfusion and autotransfusion, Total Parenteral Nutrition, and epidural care from the list because of Pennsylvania licensure restriction allowing only RNs to perform these skills. The decision was made to maintain verbal and telephone orders as an RN-only skill. The hospital is an acute care setting and RNs are readily available and present to take orders. In addition, hospital policy is that verbal orders be given only in emergency situations. The remaining skills were divided into related skill groups as follows:
* Group 1: Central lines; PICC lines.
* Group 2: Admissions; Discharges; Transfer forms; Care plans.
* Group 3: Order transcription; Daily chart checks for missed orders; Review new orders.
* Group 4: Receive intershift and interdepartmental reports.
Subgroups were formed to address/review each of the four skill groups. Each subgroup was given the following questions to answer:
1. What is current practice?
2. What are the Practice Act restrictions?
3. What are recommendations for expanding/enhancing the LPN role on this item?
4. Will the recommendations result in the need for additional education for RNs and LPNs?
Many skills were recommended and quickly accepted for advancement by the group with little discussion. Several skills were more controversial and led to a more indepth evaluation. In particular, issues of high risk and variable frequency generated further discussion. For example, the institution uses multiple brands of central venous access devices. Ninety percent of the central and PICC lines were of the same brand. The remaining devices were used less frequently. The decision was made to limit LPN practice expansion to the most commonly used devices because it was believed that LPNs should work with catheters that they would see in use with patients on a daily basis. This would serve to maintain competence. LPNs in the group agreed with this conclusion and added that they believed limiting the number to be learned would help to increase the LPNs' confidence in manipulating the devices.
Although not identified on the initial list, LPNs on one unit had requested that nasogastric tube insertion and removal be added to the skills list. The group concluded that the skill would be advanced on the requesting unit only. This decision was based on high frequency of these procedures on this unit.
Because two of the primary objectives of the group involved improving satisfaction, it was decided that before implementing any changes a presatisfaction survey should be developed. The director of nursing research was consulted to help develop a tool (see Table 2). The tool was developed and content validity was established through a panel of nursing experts. This was the first time the tool was used; therefore, no reliability data were available. The survey tool was distributed to both RN and LPN staff 1 month before the educational plan was implemented. The staff were asked to return the anonymous survey to the CNS in a 2-week time period. Demographic information was collected and job satisfaction then measured.
As hypothesized by the group, job satisfaction of LPNs and RNs on the two different units varied. Although moderately satisfied, there was room for satisfaction to be increased.
The two remaining tasks, before curriculum design, were to consult a risk management specialist (regarding any legal issues) and a human resource specialist (regarding the LPN job description and the potential for inability to perform advanced skills). One of the risk management specialists was invited to a group meeting. After presenting the Pennsylvania LPN Practice Act and explaining the educational plan, the risk manager agreed that there were no problems with proceeding. The risk management specialist was advised by the group that all policies and procedures would be revised to reflect LPN involvement. Also invited to this meeting was a human resource specialist. The job description was reviewed and found to be adequate to cover the LPN role expansion. The human resource specialist decided that any performance issues would be dealt with on a one-to-one basis.
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