Whether LPNs can fill the RN gap depends, at least in part, on the legal scope of LPNs' practice, which varies from state to state and is regulated by state nursing boards and state nursing practice acts. Typically, nurses' scope of practice and educational requirements are specified in state legislation. Most boards then allow for expanded practice-usually in administering IV infusions and IV medications, performing hemodialysis, and supervising other staff-with additional education. In most cases the practice acts declare that the LPN must work under the supervision of an RN, a physician, or in some states, a pharmacist, podiatrist, or other health care professional.

States explicate the work of LPNs in a variety of ways. Some, such as Louisiana, Montana, Maine, and Nevada, have detailed lists of tasks that LPNs can and cannot perform. Other states, such as Georgia, Alaska, Kentucky, and Oklahoma, have "decision trees" to be used as guides for deciding which tasks can be performed by LPNs. Some states, such as Colorado and Nebraska, use the structure of the nursing care plan (goals, assessment, planning, intervention, and evaluation) to detail the work that can be performed by RNs, LPNs, and certified nursing assistants. South Carolina has developed charts that delineate allowable tasks according to system of the body, job category, and experience level within job categories. Neither Michigan nor Texas has defined the scope of LPN or LVN practice or passed a practice act defining it.

In order to better understand the scopes of practice of LPNs, we obtained documentation from virtually every board that regulates the practice of LPNs and LVNs. Our 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. Our data indicate that there are similarities-such as allowing basic nursing tasks such as hygiene to be performed-in the LPN nurse practice acts across states, but variation in how the states regulate the details of the work of LPNs.

Interviews with leaders of state boards of nursing, LPN educational programs, hospitals, and nursing homes allowed us to compare the actual practice of LPNs with the written regulations. State nursing board leaders were aware of the differences in scope-of-practice regulations across states and didn't find these differences troublesome. They also recognized that employers establish their own internal practice guidelines, which may be more restrictive than the scope of practice allowed by law.

Some hospital and education leaders considered their states' scope of practice to be too restrictive. Nursing home leaders agreed that LPNs are essential to the provision of care in their facilities; the scope of practice of LPNs is well suited to the needs of their patients, who tend to be less acutely ill and more stable. Hospital leaders varied in their willingness to employ LPNs. Most recognized that experienced, capable LPNs could be an asset to a nursing care team but found that the scope of practice of LPNs was too limited to allow for significant employment of LPNs in acute-care settings.

The focus groups revealed that both RNs and LPNs were fairly knowledgeable about the legal scope of practice of LPNs in their state, yet there was wide variation in its interpretation and implementation. Participants' perceptions of the scope of their own practice occasionally differed from state regulations. This discrepancy was usually related to their employers not allowing LPNs to practice to the full extent of their legal scope of practice.

Although all nursing leaders and focus group members stated that LPNs could not replace RNs, most acknowledged that much of the work that RNs perform could be performed by LPNs, even though their scope of practice is more limited. There are, of course, differences in the training and skills of the two different groups, just as there are differences among individuals in each occupation. Long-term care institutions could not function without LPNs, and it's likely that LPNs could be used more fully in hospitals. However, even if direct substitution were possible, there's little hope that the current number of LPNs would be able to augment the RN workforce sufficiently to fill the need. More LPNs and RNs are needed.

Based on our findings, we recommend the following:

* Before making changes to LPNs' scope of practice, states should assess whether the evidence indicates that easing practice restrictions would negatively affect patient care.

* Employers should examine how the work of LPNs can be distributed safely and reasonably, so that RNs aren't overwhelmed and LPNs can perform all of the nursing tasks permitted to them under existing scope-of-practice regulations.

* Employers should provide additional compensation to LPNs who complete additional training and obtain certification beyond that required for basic LPN licensure; this would provide educational incentives to LPNs.

* Nurse educators should facilitate the matriculation of LPNs in RN educational programs. More efficient "laddering" of workers from lower-skill to higher-skill health care jobs would benefit both workers and employers and, ultimately, would decrease the total cost of educating nurses.

Novlette Clark

Bronx, New York

Age: 39

'We have the touch!! LPNs have the time to slow down and talk, just being there. That's what's needed, the touch.'

In May, AJN 's clinical editor, Karen Roush, interviewed and photographed several students in the LPN program at Putnam-Northern Westchester Board of Cooperative Educational Services in Yorktown Heights, New York. She talked with them during a clinical rotation at Northern Westchester Hospital, in nearby Mount Kisco, about their professional aspirations and why they chose to be LPNs rather than RNs. Roush's photographs and excerpts from her interviews are interspersed throughout this article.

Above, Novlette Clark, a single mother of four children, assists new mother Mary Anne Russo and one-day-old Jaclyn Alexis Russo. Clark wanted to move up from her job as a certified nursing assistant, where earning enough meant working double shifts, leaving little time or energy for her family. "Time and money were really the issues for me," she says of her decision. She started taking courses toward a degree but found the demands overwhelming. The 10-month, full-time LPN program was the best route for her to attain her goals: a career she loves, a better income, and time for her children. She plans on resuming her RN studies in January.

Michelle Grant

Bronx, New York

Age: 27

'I came to realize that the LPN deals a lot with clinical and patient care, while the RN does a lot of paperwork and care plans.'

When her mother was dying of cancer, Michelle Grant helped the nurses care for her and was deeply influenced by their skill and dedication. She researched the roles of RNs and LPNs before enrolling in the LPN program at Putnam-Northern Westchester Board of Cooperative Educational Services in New York. Believing that it would give her more direct patient contact, she decided to try the LPN program first. Her student clinical experiences have illuminated the different roles and increased her respect for RNs. "In comparison with the LPN, the RN has a lot of duties to fulfill," she says. "They have to do a little of everything: the paperwork, the patient care, making sure everything is correct. It's a great responsibility!!" She plans on continuing her education to become an RN. "Nurses are in great demand and I'm willing to learn as much about nursing as possible," she says, adding, "but I'm still excited that I get to be an LPN and see what each is about."

Dolores Duffy

Croton-on-Hudson, New Yor

Age: 43

'You see an LPN working very hard for much less pay. It just makes sense to go on.'

Dolores Duffy is no stranger to stressful jobs. Despite 20 years as a New York City detective, she was surprised by the demands of nursing school. "I knew I had my work cut out for me," she says, "but I didn't know my whole life had to change." She cites her age and her status as a single mother of three children (ages nine to 15) as the deciding factors in choosing the LPN track over the RN track. "I had various opinions, from 'Try the LPN first' to 'You have to go for the RN,' but basically I made my own decision," she says. She'll continue her nursing studies-whether in an associate's-degree or bachelor's-degree program depends on how many college credits will transfer from courses she took years ago. She sees LPNs as having the advantage of being able to provide more personal care to patients but at a disadvantage when it comes to wages.

James Keane

Yorktown, New York

Age: 49

'I thought the LPN was a little lower on the nursing food chain. But you're right in there. It's life and death.'

When James Keane started talking about a career in nursing, after 22 years in law enforcement, his wife said, "Jim, what are you, crazy?" But the nurses he knew, including a sister and a sister-in-law, encouraged him. He'd recently retired from an administrative position at Rikers Island, a prison complex on the East River in New York City. "I enjoyed my years in corrections," he says. "Some guys were waiting for that day to run out the door. But I just want to deal with people again and have some fun with it." For him that means not ending up in a supervisory or administrative role, a move he sees as inevitable for an RN. "I think the LPN has more hands-on contact with patients," he says. In the hospital setting he feels himself a part of a team with RNs, but in the nursing home he feels "distant" from them. He may one day return to school. "It will make me a better nurse," he says. "But for the title of RN? It really doesn't make a big difference to me."

Anshu Dhar

Peekskill, New York

Age: 31

'Someone will come in and teach you a skill, but you don't know why you do it.

You don't have that background or education to support what you're doing.'

Ask Anshu Dhar why she pursued an LPN rather than an RN license, and her immediate response is, "Stigma!!" She is from northern India, where nursing has long been regarded as "a messy and low-grade job," although that perception is beginning to change with the increase in technology in nursing care. "I was very scared of the reaction of my family, especially my husband's family, who are still in India," she says. "I said to them, 'Let me start with LPN first and see,' because you need that acceptance from your family." Her family is now "thrilled" about her nursing career, and with their support she plans on entering a master's program for second-degree students (she holds a bachelor's degree in psychology), with a goal of becoming an NP. She regards the LPN role as "more challenging" than that of the RN when it comes to direct care, but she sees RNs as providing a "directional path" for LPNs. "They pave the way with their expertise and education," she says.

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