Skilled nursing and assisted living facilities have long relied on licensed practical/vocational nurses (LPN/LVN) as the “backbone” of care to keep nursing salary costs low and increase profits, despite multiple studies demonstrating improved care outcomes with higher levels of registered nurse presence.

To state that an LPN can do “almost all the ‘work’ of an RN with the exception of initial assessments” grossly minimizes the level of RN education and expertise required to assess and synthesize the impact of complex interconnected health conditions, effects of social determinants of health, and risks for and prevention of further disabling incidents, into mere “tasks” to be performed. 

The academic preparation of an RN is a two-year associate degree, four-year baccalaureate degree program, or a three-year nursing diploma program. In contrast, an LPN/LVN typically completes an 18-month program at a vocational school or community college. RN and LPN/LVN scope of practice can vary state by state, but generally, LPNs/LVNs are permitted by license, very limited independent nursing roles. They practice under the delegation and supervision of RNs.

It is the responsibility of the RN to assess the competency of an LPN/LVN prior to delegating nursing roles and tasks and to provide supervision of their performance. The RN is responsible for the practice of the LPN/LVN and can be held responsible for improper delegation. 

The RN is responsible not only for the comprehensive assessment of the health condition and needs of an individual but the development of a plan of care and the evaluation of the effectiveness of that plan of care. The RN may delegate portions of an assessment to a competent LPN/LVN who may contribute to the development of the care plan and support unlicensed caregivers to whom the RN has delegated aspects of the person’s care.

When RN presence in long-term care is insufficient, providers may encourage or overtly expect an LPN/LVN to engage in practice not permitted by license. LPNs/LVNs may feel pressured to comply to meet the needs of individuals in their care, fear of jeopardizing their nursing license or retaliation by management. RNs may also feel pressured to unsafely delegate care.

Yes, more RNs are needed in long-term care settings to ensure best practice care. LPN/LVN practice is enhanced with effective RN leadership and guidance. Of greatest importance, individuals receiving care will benefit from improved nursing outcomes from safe, competent and compassionate care.

To effectively attract RNs to long-term care facilities, RNs’ working conditions (such as salary, health insurance and other benefits) need to be competitive with RNs in hospitals.

Challenges are many, but providers can support “career ladder” options for CNAs and LPN/LVNs with funding and scholarships. Providers may also need to scale back profit expectations.  

But, only when RNs are recognized for their professional education and expertise rather than being defined by non-nurses as “trained’ to work” will more RNs consider careers in long-term care.

Nancy M Haugen, RN, BSN, PHN, MS, is president of Elder Voice Advocates.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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