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Tim McFadden’s ability to transition from LPN to RN at Boulder (Colo.) Community Hospital is largely due to the amount of responsibility LPNs have in the cardio-telemetry unit where he works.

Timothy McFadden had little trouble stepping into his new role as an RN when he graduated in May. After working as a licensed practical nurse for 2½ years at Boulder (Colo.) Community Hospital, he was able to make the transition with almost seamless ease.

His ability to glide from role to role is largely due to the amount of responsibility LPNs have in the cardio-telemetry unit where he works. They are given as many tasks as their licensing allows: They pass medications, do phlebotomy, hang IVs, chart and—with the supervision of RNs—assist with chest tube removals and help with closing.

This do-it-all approach is the brainchild of unit director Kim Smith, RN. During her five years as director of the unit, Smith has advanced a policy of recruiting people as aides and then using the unit’s education budget to pay for their training as LPNs and later as RNs.

To facilitate that progression, McFadden said, she embraces a workplace philosophy of letting LPNs do as much as possible, so when they become RNs they can hit the ground running.

Nurses like Smith hope this comfortable employment of LPNs at Boulder might serve as a model for other facilities, especially because wider use of LPNs and licensed vocational nurses is one way of lightening the burden of RNs in the midst of a nursing shortage.

LPNs and LVNs are essentially in the same category of health care providers, with the difference in designation depending on the state where they are licensed. Their function is generally described as performing technical and manual skills under the supervision of RNs; in some states they are licensed to administer prescribed medications or start IV fluids.

Scope of practice

Yet nurse managers like Smith suggest that these tensions can be avoided if facilities make a conscious effort to address these problems.

Questions with regard to the division of roles between LPNs, LVNs and RNs appear to have increased recently. RuthAnn Terry, executive officer at California’s Board of Registered Nursing, said that during the past six months, inquiries about the scope of practice and what constitutes supervision and delegation have increased.

Acute care facilities seem to be employing more LVNs than in the past, she said, and uncertainty results because some RNs have had little experience working with them.

Ann Shuman, MS, RN, supervising nursing education consultant for the California Board of Vocational Nurses and Psychiatric Technicians, also said she has noticed an increase in scope-of-practice inquiries. “Given that role evolution, there is a lot of confusion,” she said.

Shuman attributes this to a lack of familiarity with the state’s vocational nursing practice act. She said the concepts of the act are not difficult to interpret once they are understood. The board addresses this issue with an educational approach: It strives to make these concepts clearer through information on its Web site and through on-site presentations at facilities.

In addition to role confusion, underutilization of LPNs and LVNs also can be a problem, nurses said. This can happen simply because strategies have not been developed to make the best use of their skills.

The cardio-telemetry unit at Boulder Community is a positive example of such a strategy, but McFadden said the same active outlook is not present in all the hospital’s units. In ortho-neuro, the LPN is little more than an aide who can pass medications, while in med/surg the LPNs do more but many are not yet IV-certified.

But McFadden said Smith’s approach is spreading. The new director of med/surg, Mikki Hirschfield, RN, started out working under Smith and plans to give LPNs as much responsibility as possible in her own unit.

At other times, LPNs and LVNs are underused because RNs are reluctant to trust them, nurses said. This is especially the case when RNs are unaccustomed to working with LPNs or LVNs.

Emily Sego, another LPN-turned-RN, made the change in part because she felt that at her facility, Community Hospitals Indianapolis, the role of LPNs was too limited. She said they are basically limited to passing medications and helping with bedside care, and have little voice in assessing a patient’s situation.

Getting to know you

Some facilities have programs that can help with both the trust issue and with questions about roles. Janice Maybee, RN, an emergency room nurse at Sutter General Hospital in Sacramento, Calif., said the working relationship generally is good in the ER, which has employed LVNs since about 1993. But she notes that recently a lot of travelers have been hired, and many of them have not worked with LVNs before.

To head off problems, the department has two nurse educators who specialize in educating employees and checking and maintaining records on their certifications. They also are responsible for orienting new hires, not only by making sure they are familiar with all equipment, but also by acquainting them with the help that LVNs can provide and what they are allowed to do.

On a larger scale, nurses at Kaiser Permanente West Los Angeles Medical Center take part in a shared governance committee. Areas handled by the committee, which represents both RNs and LVNs, include policy and procedure, education and research, nursing practice, and recruitment and retention. Both RNs and LVNs offer their perspectives, and any issue that emerges in these areas can be addressed with an eye toward how it affects both types of nurses.

As RNs continue to feel stressed and swamped, LPNs and LVNs are likely to remain in demand. As long as this trend continues, facilities that employ them will be faced with finding the most effective ways of using them.

“I think that’s the wave,” said McFadden, who is eager to see hospitals give LPNs a variety of responsibilities. “We need to get nurses active in all areas. We can’t just have a hierarchy of nurses aides.”

Contact Jeanne Fogler at jlfogler@neteze.com