Using LPNs in Acute Care Delivery

By Rose O. Sherman, EdD, RN, NEA-BC, FAAN

It seems that everyone is jumping on the bandwagon of adding LPNs to their care delivery systems. Should I be doing this now? It is a question that a number of CNOs have posed to me as they look to redesign their care delivery systems in an era of severe staffing shortages.

My answer is nuanced.  I have a long leadership history of working with LPNs during the 25 years I spent with the Department of Veterans Affairs. Many of the LPNs I worked with began their careers in the military as 91 Charlies or practical nurse specialists.  Throughout most of my career in the VA, we practiced team nursing, and the LPN was an integral part of that team.  Their scope of practice was governed by their state of licensure and the LPN clinical ladder that the VA had in place. Many of these LPNs were not only excellent clinicians but had strong critical thinking skills, which RNs depended on as a second set of eyes and ears.

Fast forward to where we are today in healthcare. LPNs have primarily worked in long-term care or rehabilitation settings during the past two decades. They usually have an expanded scope of practice per state nurse practice acts in these settings. In long-term care, they can directly supervise patients’ care. This is not true in acute care settings where they must always be working under the direct supervision of an RN.  Today’s patients are much higher acuity than during my time practicing in the VA. It is much more difficult today to give the LPN an assignment that is truly within their scope of practice in acute care (which does not include responsibility for patient assessment in most states).

The challenge of very high acuity patients is not the only caveat to implementing the LPN role.  In most acute care settings today, the turnover rate of RNs is very high, and there is a constant churn of new graduates who usually stay less than two years. Teamwork has been significantly disrupted.  Today’s RNs are developing their own clinical skill set. Most have little or no experience with supervision and delegation. They may not fully understand that when an LPN is assigned to work with them as a partner, the patients assigned to the LPN are considered the RN’s responsibility. Communication is critical – a skill set that we are now learning is challenging for Generation Z nurses. I reviewed disciplinary actions for the Florida State Board of Nursing for many years. A failure to follow up on care delegated was high on the list of problems that led to disciplinary actions.

My last concern concerns the LPN workforce itself. In most states such as mine (Florida), LPNs are also in very short supply.  LPNs are the backbone of the long-term care industry. Nurse leaders in long-term care are now sounding the alarm.  If acute care systems do a full-court press to recruit LPNs, long-term care settings will have to close beds and possibly shut down completely.  It is already happening in many areas, even without LPN recruitment into acute care.  Challenges with patient placements in nursing homes, rehabilitation facilities, hospice, and assisted living adds to patient volume woes in acute care settings across the country.

My recommendation to any nurse leaders considering adding LPNs to their teams is to carefully think through the potential benefits and the challenges.  There needs to be intentionality and planning along with conversations with partners in other settings in your community. It may be a great choice, but maybe not. As with many other decisions we make in leadership, the unintended consequences of choices also need to be considered.