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Caring for the Ages
Selected Articles from
October 2004;
Vol. 5, No. 10
CHF Care
Sprinklers--No More Exceptions?
LPNs in Long-Term Care
Evidence-Based Practice in LTC: To Test or Not to Test
Heart of the Matter
Update: Stroke Research
Make Resident Transfers Safer
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LPNs in Long-Term Care

Licensed practical nurse or least prepared nurse?

by Charles A. Crecelius, MD, PhD, FACP, CMD

In this new monthly column, Caring editorial board members discuss issues they find critical to the provision of long-term care in the United States.

Long-term care has been highly dependent on the services of the licensed practical nurse (LPN, sometimes referred to as licensed vocational nurse or LVN). While many efforts to improve quality and resident outcomes incorporate multiple members of the care team, none specifically target the LPN in long-term care. The result is a professional with variable skills, depending on their innate ability, training, and experience. Too often they are well intended, but undertrained, poorly prepared nurses with immense responsibility for vulnerable frail elders.

Typically LPNs serve as primary nurses for the majority of nursing home residents, supervised by a registered nurse. Ratios of RNs to LPNs average 1:6 in most nursing homes. LPNs provide a variety of services, such as basic bedside care, wound treatment, supervising nursing aides, and collecting data. Unlike RNs, though, LPNs are not allowed to assess and evaluate resident status.

LPNs receive about one year of training after high school and are licensed by individual states. Thereafter they receive no geriatric or specific long-term care training. Instead they usually undergo an apprenticeship of sorts at a nursing home.

A few homes have developed long-term care-specific training material for LPNs, although the scope is normally limited to a clinical content area (e.g., non-managerial areas such as disease states, hands-on care, medication basics--anything besides staff management skills, communicating with families, quality assurance, and so on).

There is one proprietary national training course for LPNs in long-term care (developed by the National Association of Practical Nurses Education and Services, Inc., www.napnes.org), but it has gained little acceptance. Currently there are no regional or national providers or professional sponsored educational programs that provide the comprehensive education an LPN needs to be successful in caring for frail elders.

Inadequate Training

In long-term care, clinical education is most often geared toward the RN or the CNA, with the assumption that the LPN can glean what is needed from either end of the spectrum from whatever material is offered. There is little material aimed specifically at the LPN. CNAs must meet mandatory annual training requirements, according to federal regulations, which LPNs don't have. RNs even have a geriatric certification course for which there is no LPN equivalent.

More importantly, LPNs receive almost no training on administrative and managerial topics specific to long-term care. Quality improvement, ethical and legal issues, time management, family dynamics, and supervision of aides are rarely taught to LPNs. Yet we expect people barely out of high school to possess or somehow rapidly gain these skills when they enter long-term care. Is it any wonder the system doesn't work as well as it could?

An LPN's education limits their ability to formally assess and evaluate residents and synthesize a plan of action. They are extensively relied upon to gather important resident data, however, and to discern what is clinically relevant. They are supposed to know what and how to document, and how to ensure other health professionals get critical information. They and the nursing aides they supervise are usually in the best position to know the baseline characteristics of residents and inarguably should have the skills needed to approach complex changing residents.

While they may be unable to analyze situations in depth, they should have the consistent ability to triage and handle the multiple sources of information present in long-term care. But does the LPN--a vital "middle man"--have consistent education and expectations to be an effective link between family, aides, RNs, physicians, and administrators?

Stuck in the Middle

Too often LPNs struggle in the middle between RNs, aides, and physicians. With enough training to do more than basic care, but insufficient education to assess and synthesize, LPNs are often used as RN surrogates. They are frequently asked to gather data without an appreciation for the clinical context in which it must be placed.

Some argue the answer lies in having more RNs work in long-term care. But this is unlikely to happen in the foreseeable future, given nursing shortages and economic constraints. Rather than trying to increase RN presence in long-term care, wouldn't effort be better spent improving the abilities of a more available pool of workers?

No one can deny the value of a capable RN in long-term care. Their ability to see the whole picture and provide comprehensive care via more extensive training is unquestionable. The appropriate minimum number of RNs to provide quality care should be supported. However, this does not mean that the LPN should not be utilized effectively by tailoring the right education to include long-term care.

Published evidence suggests that RN staffing is the key to improving resident outcomes.1 This assertion should be further challenged, as the value of well-trained LPNs has not been appropriately addressed. Studies using RN-to-LPN staffing ratios currently seem to identify a self-fulfilling prophecy: that more education is a good thing. To date, no studies have examined the effects of systematically training LPNs in clinical, administrative, and managerial topics on quality outcomes. It is premature to claim that only RN and not LPN staffing can affect resident outcomes until appropriate training is equally available to both.

Most long-term care tasks require consistent performance of basic processes that should be well within the capabilities of an adequately trained LPN. Too often the LPN's training is not extended from basics usually obtained in a technical school to the geriatric management skills needed to be successful in long-term care. Given the economic constraints facing long-term care, it is crucial to use available resources judiciously. At least one European country has found that appropriate use of LPNs can have favorable impact on resource allocation.2

Part of the current dilemma of effectively utilizing LPN skills resides in management practice. Most long-term care organizations use a hierarchical approach, with administration and director of nursing employing a linear transfer of information and responsibilities to LPNs. Recent research indicates that such systems may hinder effective care.

Systems that increase interaction and communication of ideas and information among people will result in better resident outcomes.3 Inadequately trained LPNs can't accomplish these goals; they need to be confident in their skills, communication, and resident interactions. Not promoting ownership of patient care inhibits accountability.

An Ideal Education

What curriculum would make an LPN successful? Geriatric clinical skills can be improved in many ways. Learning how to gather and report critical information via basic history taking, observation, communication, and documentation skills is vital. Common geriatric syndromes, such as pressure ulcers, dementia, depression, and change in condition, can be taught from a pragmatic, what-you-need-to-know-and-relay perspective. At least some basic geriatric pharmacology is essential to help identify common adverse drug reactions.

Clinical situations common to long-term care should be reviewed systematically with LPNs. All LPNs should know about potential ethical dilemmas such as feeding tube pros and cons, appropriate procedures for obtaining advance directives and code status, and working with health-care substitute decision makers. Understanding how to work with the dying patient, use of hospice, and tenets of pain management are also necessary for appropriate resident care.

Sadly, managing aides, the role of the interdisciplinary team, behavior management techniques, and self-management are rarely taught in any consistent manner to long-term care LPNs. An understanding of the long-term care survey process and how to use results to better resident care should be part of the curriculum.

Few LPNs are formally educated about the purpose and value of the Minimum Data Set, Resident Assessment Protocols, quality indicators, and related tools. How well can this information be collected and applied if these principal care participants are not exposed to the basic tools of the trade?

Some LPNs are extraordinary individuals with exceptional talents--sometimes better than their RN counterparts. But this typically happens accidentally, not intentionally. Some homes put considerable effort into mentoring LPNs, but this, too, is inconsistent and rarely includes all of the elements noted above.

Let's Invest in LPNs

Some argue that all this is asking too much. How much can we expect from someone with only a high school education and one year of extra training? Typically you get what you provide, modified by defined expectations. Too often we set our sights too low for either. Yes, extra training is needed, will cost money, and could conceivably become the expected norm if shown to be fruitful. Expectations will be higher, but without greater accountability long-term care will never move beyond what we have now.

Frankly it appears that neither professionals nor consumers are too happy with much of long-term care's current efforts, including those of an all-too-often inadequately trained LPN.

So how does an LPN become adequately trained now? The answer is experience. With time, some LPNs learn about common geriatric syndromes, basic geriatric pharmacology, managing aides, planning goals of care, and so on. The real question: Why do we wait for time to haphazardly do what well-planned training could accomplish more consistently? Where is the training that LPNs so desperately need to perform the vital functions we expect of them? Will long-term care professional organizations step up to the plate and work together to accomplish what is overdue?

Dr. Crecelius is a member of Caring's editorial board, president of Associated Medical Consultants, and medical director for Delmar Gardens, St. Louis, Mo.

References

  1. Anderson RA, Hsieh P, Su H. Resource allocation and resident outcomes in nursing homes: comparison between the best and worst. Res Nurs Health. 1998;21:297-313.
  2. Bjorkgren MA. Measuring efficacy of long-term care units in Finland. Health Care Manag Sci. 2001;4:193-200.
  3. Anderson RA, Issel LM, McDaniel RR. Nursing homes as complex adaptive systems. Nurs Resear. 2003;52:12-21.

This article originally appeared in Caring for the Ages, October 2004; Vol. 5, No. 10, p. 6-9. Caring for the Ages is an official publication of the American Medical Directors Association, published by Elsevier. This article may not be reproduced in any form, print or electronic, without permission.

The opinions expressed by the authors are their own
and not necessarily those of AMDA or of Elsevier.

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