By Mathew J. Keller, RN JD
MNA Regulatory and Policy Nursing Specialist
Those of us who collaborate with LPNs on a daily basis have come to respect their knowledge and experience in caring for patients. We know that LPNs are an important part of the patient care team. In fact, many MNA RNs started out as LPNs. That vital experience has proven to them that while both roles are valuable, they’re not interchangeable. Any facility that’s thinking of weathering any kind of storm by just staffing more LPNs will be inviting trouble and risk.
There are several differences in LPN vs. RN scope of practice that legally prohibit LPNs from performing the work of RNs. For example, MN Statute §148.171 Subds. 14 & 15 specify that RNs perform comprehensive assessments establishing a patient’s baseline status, whereas LPNs perform focused assessments. If an LPN’s focused assessment finds that an aspect of a patient’s health has changed from the baseline established by an RNs comprehensive assessment, the LPN must report the status change to an RN for his or her assessment and intervention. Notably, MN Stat. §148.171 Subd.14(1) further specifies that LPNs conducting focused assessments are responsible for “reporting changes and responses to interventions in an ongoing manner to a registered nurse…”
The Minnesota Nurse Practice Act also indicates that only RNs may develop nursing care plans, implement patient teaching plans, supervise the practice of nursing, and delegate nursing tasks. LPNs may not legally perform these tasks.
Other regulatory guidelines also delineate the scope of LPN versus RN practice. For example, the Center for Medicare Services (CMS) specifies that, as a condition to receiving Medicare reimbursement, adequate numbers of RNs must be available on each unit for every patient to receive RN bedside care. As CMS’ interpretive guidelines put it:
“There must be a RN physically present on the premises and on duty at all times. Every inpatient unit/department/location within the hospital-wide nursing service must have adequate numbers of RNs physically present at each location to ensure the immediate availability of a RN for the bedside care of any patient. A RN would not be considered immediately available if the RN were working on more than one unit, building, floor in a building, or provider (distinct part SNF, RHC, excluded unit, etc.) at the same time… A RN must supervise the nursing care for each patient. A RN must evaluate the care for each patient upon admission and when appropriate on an ongoing basis in accordance with accepted standards of nursing practice and hospital policy.”
Patients should care about how much of their nursing care is delivered by RNs as well. Perhaps the most exhaustive study on the predictive relationships between RN vs. LPN care in hospitals found that “higher percentages of RNs in the skill mix predicted a lower number of adverse events and shorter lengths of stay, controlling for patient age and complications” (Frith et al., 2012). Lastly, and perhaps most importantly to hospital administrators, the impact of a higher proportion of RNs to other nursing personnel in hospitals is so effective in improving patient outcomes that Needleman (2012) discovered that the “greater use of RNs in preference to LPNs appears to pay for itself.” Needleman’s findings were further validated by Marstolf (2014), who also found richer RN-to-LPN mixes to be cost saving.
Lastly, professional nursing organizations specify nursing tasks which may or may not be appropriately conducted by LPNs. For example, The American Association of Critical Nurses’ (AACN) Delegation Handbook (2004) specifies that LPNs should not conduct initial or ongoing assessments, receive independent patient assignments, insert or utilize PICC lines, draw blood, administer IV medications or access IV ports, administer blood, provide patient education, accept verbal orders, or determine nursing diagnoses.
We respect LPNs as an integral component of the patient care team, and nobody wants to be put into a position where they’re asked to complete tasks that are out of his or her scope of practice. It’s not good for the nurse, and it’s not good for the patient. As licensed caregivers, we must respect the training that entitles us to our respective license and the roles that we play.
Certified medical assistants are just as good if not better trained we do the same job and for the clinic setting do way more then the rn in a clinic setting cma’s deserve more credit then what they get
When I worked an RN/LPN team nursing approached to patient assignments in the 80’s, it worked out very well with each role doing their specific jobs. Much better than primary care nursing and it built teamwork.
LPNs cannot replace RNs. Back in the ’90s, I worked on a medical/surgical unit as an RN and was assigned six patients. We had LPNs assigned six patients also. Administration did not realize the LPNs should be assigned to an RN. With the help of the MNA, that was changed. Later, all LPNs were eliminated from the unit. With the high acuity of the hospitalized patients, it was extremely challenging to determine which nursing tasks could be delegated. Most of the activities I perform, require the expertise of the professional nurse. In my nursing education, I received additional education, additional skill sets, and more clinical experiences than an LPN and with that came a lot of responsibility. I perform nursing activities that are not within the scope of professional nursing judgment to delegate such as physical, psychological, and social assessments which require professional nursing judgment, intervention, referral, or follow-up; formulation of the plan of nursing care and evaluation of the patient’s response to the care rendered; and I have the responsibility for designing patient teaching and performing health counseling. In Minnesota, only an RN can delegate because delegation is a process and not a list of tasks, The critical issue to delegation is what professional nurses should do. The MN NPA defines my scope and it is different than the scope of an LPN. Research supports what Mat has said so well.