Understanding RN and LPN Patterns of Practice in Nursing Homes Kirsten N. Corazzini, PhD; Ruth A. Anderson, PhD, RN, FAAN; Christine Mueller, PhD, RN, FAAN; Selina HuntMcKinney, PhD, RN; Lisa Day, PhD, RN, CNRN; and Kristie Porter, MPH Understanding how nurse regulators can ensure optimal registered nurse–licensed practical/vocational nurse (RN–LPN) collaborations for patient safety and care quality is critically important. To aid this understanding, researchers conducted a comparative, multiple-case study on RN and LPN practice in the areas of assessment, care planning, supervision, and delegation in two states, Minnesota and North Carolina. The researchers identified three factors that differentiated nursing practice patterns in nursing homes: the quality of the connections between RNs and LPNs, the degree of interchangeability between RNs and LPNs, and RN-to-LPN staffing ratios. Findings indicate several levers for improving RN–LPN collaborations and the capacity to provide higher quality care.
idespread quality-of-care problems in nursing homes persist (Mor et al., 2011), and achieving the ideal number and composition of nurses remains a significant challenge (Zhang, Unruh, Liu, & Wan, 2006). Currently, licensed practical or vocational nurses (LPNs) provide 70% of all licensed nursing hours per resident day in nursing homes, and the percentage has been steadily increasing over the last decade (American Health Care Association, 2011). Strong evidence indicates that higher registered nurse (RN)-to-LPN ratios are related to better care quality (Akinci & Krolikowski, 2005; Horn, 2008; Horn, Buerhaus, Bergstrom, & Smout, 2005; Weech-Maldonado, Meret-Hanke, Neff, & Mor, 2004). The findings on LPN-to-RN ratios are not as clear (Castle, 2008). Some studies indicate that higher LPN-to-RN ratios are linked to poorer quality of care (Zhang et al., 2006); others find they are linked to better quality (Castle, 2008); and still others find no relationship (Decker, 2006). Arling, Lewis, Kane, Mueller, and Flood (2007) concluded that certain factors, such as how nursing care is organized, may be stronger determinants of quality. Scope-of-Practice Confusion
Research indicates that LPNs do not always stay within their scope of practice in nursing homes (Mueller, Anderson, McConnell, & Corazzini, 2012), in part because LPNs and RNs are confused about the differences between their scopes of practice (Reinhard, Young, Kane, & Quinn, 2003). Even though a nurse practice act (NPA) may clearly distinguish between specific dimensions of nursing practice for RNs and LPNs, nurses may have difficulty identifying specific behaviors for RNs and LPNs (Spector, 2005; White et al., 2008). For example, an NPA can state that only RNs conduct comprehensive assessments and LPNs contribute 14
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to assessment through focused assessments. In practice, however, RNs and LPNs may struggle with where a focused assessment ends and comprehensive assessment begins. This confusion is not limited to RNs and LPNs. Agency policies and procedures as well as hiring and promotion decisions also may muddle the differences between RN and LPN scopes of practice (Seago, Spetz, Chapman, Dyer, & Grumbach, 2004). LPNs describe inadequate RN presence on nursing units and low RN-to-LPN staffing ratios as barriers to staying within their scope of practice. LPNs say they find themselves in roles that require RN-level licensure and preparation because of a lack of RN supervision (Mueller et al., 2012). The purpose of this study is to describe behaviors used by RNs and LPNs affecting core components of their scopes of practice. The study focuses on four domains of practice—assessment, care planning, delegation, and supervision. These domains constitute the core components of the nursing process and practice (American Nurses Association, 2010) and often have unclear boundaries between RNs and LPNs in long-term care (Corazzini et al., 2010; Mueller et al., 2012; Reinhard et al., 2003). Thus, understanding how nurse regulators can ensure optimal RN– LPN collaborations for patient safety and care quality is critically and increasingly important (Frenk & Chen, 2010; Institute of Medicine [IOM], 2011; International Council of Nurses, 2010).
Method Researchers conducted a comparative, multiple-case study (Yin, 2009) to describe how RNs and LPNs practice assessment, care planning, supervision, and delegation in two states, Minnesota (MN) and North Carolina (NC).
Ten NC and MN nursing homes licensed by Medicare or Medicaid were selected, using simple random sampling in each of nine NC and six MN Area Health Education Center regions to capture geographic diversity within the states. In each nursing home, researchers sampled the RN Director of Nursing (DON) and at least two other licensed nurses. RNs and LPNs from eight nursing homes in NC and two nursing homes in MN participated in the study (Table 1).
Procedures Trained interviewers conducted semistructured telephone interviews lasting from 30 to 60 minutes with each participating nurse. Interviewers asked nurses to describe their contributions and approaches to assessment, care planning, supervision, and delegation (Table 2). Probes elicited explanations of strategies used to accomplish these key aspects of practice. Interviews were transcribed verbatim from digital audio recordings, verified for accuracy, and analyzed in Atlas.ti (Friese, 2011).
Analysis Using a template organizing analysis approach (Symon & Cassell, 2012), the research team coded the first few interviews with codes developed from the literature and study aims. The team coded instances of the four practice domains and developed additional codes to capture aspects of practice within each domain. The team discussed coding and modified codes as appropriate before coding the next set of interviews in an iterative process. Coding discrepancies were reconciled by the full coding team. Next, the revised code list was used to code all of the interviews to describe the four practice domains and the nurses’ descriptions of strategies, explanations, and outcomes of strategies used in their practice. After each interview was coded by two research team members, coded transcripts were combined and reconciled to assemble a master set of coded interviews. All coded interviews for one case were collated and read as a set by a research team member, who developed a case summary describing practices regarding supervision, delegation, care planning, and assessment in that facility. Summaries were circulated to team members and read. Each case was discussed to identify confirming or disconfirming evidence of emerging patterns for the case. Then, three members of the research team conducted more verification of all case summaries. Key findings in case summaries were used as a new set of codes that described attributes of the case. These codes were then used to recode the original interview transcripts to verify that these attributes were identifiable in the case. The three members constructed matrices with these verification codes by interview and reviewed them to identify any further confirming and disconfirming evidence, revising the case summaries accordingly. Volume 4/Issue 1 April 2013
Sample by Nursing Home Case (N = 10 Nursing Homes) Interviewees Case
Results Three factors—the quality of connections between RNs and LPNs, the degree of interchangeability between RNs and LPNs, and the RN-to-LPN staffing ratios—differentiated the cases regarding how assessment, care planning, delegation, and supervision are performed. Quality of connections is the degree to which formal and informal connections were used in assessing, care planning, supervising, and delegating. Formal connections included scheduled, documented activities between RNs and LPNs, such as stand-up meetings or quality improvement committee work. Informal connections included unscheduled activities, such as chance encounters on the unit. Regarding assessment and care planning, an LPN noted, “I just try to communicate with [the RNs]…so they can make sure [information on acute changes] get to the right people. [The RNs]…do the care plans, and they’ll come around and…ask us questions.” She described how she initiates connections by communicating with the RNs and how the RNs connect with LPNs by asking questions of the LPNs. Degree of interchangeability is the degree to which LPNs are considered equivalent to RNs in assessing, care planning, delegating, and supervising. One DON indicated that in her facility, RNs and LPNs are indistinguishable: “There are some duties [for which] an RN has to be immediately available…but pretty much [RNs and LPNs] are tit for tat in what they do…. We don’t have any…nursing skills here that…an LPN or an RN cannot do.” Although the DON acknowledged some differences, she viewed LPNs and RNs as essentially equivalent or “tit for tat.” In her facility, LPNs are almost completely interchangeable with RNs. An LPN described how interchangeability shaped RN practice, not just LPN practice: “If you’re an RN…, mostly you’re a supervisor; …[if] an RN is on the floor passing medications, they…just do what an LPN does on the floor.” www.journalofnursingregulation.com
Sample Interview Questions and Probes Practice Domain
How would you describe your approach to guiding or supervising other nursing staff?
What strategies do you use for guiding or supervising nursing staff? How did you develop these strategies? How do you know when these strategies are working or not working?
Assessment and care planning
Who delegates nursing care tasks in your facility? If you delegate nursing tasks, what is your approach to delegating care?
How did you develop this approach?
How would you describe your role in assessment and care planning in your facility?
Including the strategies that we talked about before, are there specific things that you do to guide or supervise how nursing staff are contributing to the assessment and care planning process? If yes, would you describe them?
What do you expect to happen when you use this approach?
Do you find that there are differences in what RNs and LPNs do in your facility? If so, what are those differences? How do they relate to your role in assessment and care planning in your facility? If not, why do think this is so?
Staffing ratio reflects the degree to which the nursing home has an adequate number of RNs for RN-level clinical expertise and management of LPN contributions to assessing, care planning, delegating, and supervising. One DON explained, “Because we have problems getting RNs…we do have LPNs functioning in roles that RNs should be filling.” As another LPN explained, “It usually flows down from the DON to not many RNs [to] LPNs and then from the LPN to the [certified nurse assistant] CNA to ‘let’s get the job done.’” This LPN described inadequate numbers of RNs to support how LPNs contribute to practice, which ultimately means interchangeability between RNs and LPNs in an effort to “get the job done.” Interrelatedness between staffing ratios and interchangeability was found in other cases as well, suggesting that inadequate staffing ratios may be sufficient for interchangeability to occur. Assessment and Care Planning
In cases characterized by more connections, less interchangeability, and higher RN-to-LPN ratios, RN-level assessment and care planning were valued and considered distinct from LPN contributions, and RN expertise was closely linked to LPN contributions. An LPN clarified, “Assessments are...done by the RNs….It’s really defined between what the LPNs are doing and what the RNs are doing….If we have falls or anything, we have to make sure we have an RN for those additional assessments.” This LPN describes both the differences between RN and LPN contributions to assessment and the way connections are used to ensure RN involvement. By contrast, in cases characterized by fewer connections, more interchangeability, and lower RN-to-LPN ratios, LPN 16
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contributions were largely unlinked to RN-level expertise. An LPN explained, “The LPN gets the admission package….This is what you need to do….It’s up to you to get the package done; this means your pain assessment, the actual assessment, everything….It’s not passed on; you have to get that done.” Another LPN admits, “We do the initial assessment, fill out the papers, and they go to the Minimum Data Set nurse, and she makes up the care plan from the information we give….She may not even see the patient.” Delegation and Supervision
In cases with more connections, less interchangeability, and higher RN-to-LPN ratios, researchers found nurses delegating by considering scope of practice differences, rather than simply following the chain of command (Corazzini et al., 2010). Regarding supervision, researchers found direct RN supervision integrated with all levels of the staff that inform assessment and care planning. An LPN described just how embedded direct RN supervision is in her nursing home: “You try to just be vigilant….If I’m not able to track what may be a factor, then I’m going to bring in my RN [to] do an assessment, and then [the RN] usually will carry it from here….Everything that we do here is basically going through the RNs…. Delegation in settings with fewer connections, more interchangeability, and lower RN-to-LPN ratios followed the chain of command, regardless of licensure status. As one DON described, “The [LPN] unit coordinators do the day-to-day delegation of the tasks to the…LPNs and RNs on the floor…, [and they]… do the day-to-day delegation to the CNAs.” These settings were
characterized by little direct RN supervision. The LPNs provided primary oversight of licensed and unlicensed staff. Ends of the Spectrum
Each of the 10 cases in the study was described in terms of the degree to which overall practice patterns fell along the spectrum ranging from many RN–LPN connections, little RN–LPN interchangeability, and a high RN-to-LPN staffing ratio to few connections, much interchangeability, and a low RN-to-LPN staffing ratio. The following two cases exemplify these ends of the spectrum (Figure 1). The practice pattern in the Case 1 nursing home clearly differentiates between RN and LPN contributions to assessment, care planning, supervision, and delegation. The DON described how she increased the proportion of RNs in the facility to enhance practice in these areas. Assessment and care planning is a dynamic process with multiple system redundancies for effective communication between RNs and LPNs. The facility uses customized CareTracker™ software to support an interactive, real-time care planning and assessment, and nurses informally communicate changes and information to ensure accurate and real-time care planning and assessment that integrates RN-level expertise. As one LPN described, “If there’s something that needs immediate assessment, we usually make sure the RN is on the unit, then we do those things together….Our RNs are very, very involved, and we know there are things that we just don’t do.” RN-level supervision occurs throughout the home and is viewed as a way to inform assessment and care planning. Delegation is linked to scope of practice, as described by another LPN, “We… stay within our practice…, and we delegate the appropriate assignments to our CNAs, and then anything that we’re unable to handle, we…make sure that we place in the proper hands.” The practice pattern in the Case 2 nursing home is characterized by assessment and care planning with few RN–LPN connections and a low RN-to-LPN ratio. Assessment is primarily an administrative process that has little impact on direct care. An LPN described the workflow: “We collect the data and give it to them [the RNs], and they put it together.” This LPN could not explain how this process looped back to inform care. Further, when RNs are not available, LPNs believe they have to complete assessments. Another LPN explained, “In all nursing homes, LPNs are doing your entire assessments…implementation, evaluation, all that.” Thus, interchangeability occurs in assessment and care planning. Further, this nursing home has no clear plan for supervision and delegation, and RNs and LPNs are confused about how LPNs should supervise. The DON is frustrated about supervision and delegation practices and said that the nurse aides “run the show.”
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Spectrum of Practice Patterns Many Connections Little Interchangeability High RN-to-LPN Ratio
Case 1 ⦁⦁ Non-profit ⦁⦁ Urban, NC ⦁⦁ <130 beds ⦁⦁ DON, 2 RNs, 3 LPNs ⦁⦁ 5-star CMS rating
Few Connections Much Interchangeability Low RN-to-LPN Ratio
Case 2 For-profit, chain ⦁⦁ Rural, NC ⦁⦁ >130 beds ⦁⦁ DON, 1 RN, 2 LPNs ⦁⦁ 2-star CMS rating ⦁⦁
Discussion Three key factors differentiate practice and result in a wide range of approaches to RN–LPN collaboration in nursing practice. The study found that by not articulating the differences between RN and LPN licensure levels, ensuring adequate RN staffing levels, and identifying ways to enhance connections between RNs and LPNs, nursing homes risk establishing nursing practice patterns that thwart effective implementation of nursing care. The findings also demonstrate that failing to differentiate RNs from LPNs and optimize RN–LPN collaboration results in more than having LPNs practice beyond their scope, as previous research indicates (Mueller et al., 2012). Practice environments that consider RNs and LPNs interchangeable also devalue the professional nursing expertise of the RN, as occurred with the RNs who were expected to limit their practice to the scope of the LPN when functioning in the job title of floor or unit nurse. In essence, RNs are not practicing to the full extent of their scope of practice in these situations. Therefore, developing effective RN–LPN collaborations is critical to developing health care systems that facilitate nurses performing to the full extent of their scope of practice (IOM, 2011). Thus, merely understanding a nursing home’s staffing level is insufficient and likely explains the mixed research findings regarding staffing and outcomes (Castle, 2008). Focusing instead on how care is organized (Arling et al., 2007) may significantly improve the capacity to establish regulations that support the development of practice models for improved quality of care. Although the study’s methodological approach yielded vital empirical knowledge of RN and LPN practice in nursing homes, the method did not allow the researchers to measure the prevalence of these patterns or to relate the three factors to quality-of-care outcomes in representative ways. Future research should estimate the prevalence of particular nursing practice patterns along these factors. Further, research should measure the relationships between these patterns and quality-of-care
outcomes, identifying potential thresholds necessary to achieve quality and safety benchmarks. The study findings indicate multiple, potential levers for change in RN and LPN practice to improve the capacity of a nursing home for quality of care. The interrelated nature of the factors suggests that multiple stakeholders, including owners and prelicensure nurse educators, need knowledge and strategies to support optimal nursing practice models in nursing homes.
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Kirsten N. Corazzini, PhD, is Associate Professor, Duke University School of Nursing and Senior Fellow, Duke Center for the Study of Aging and Human Development. Ruth A. Anderson, PhD, RN, FAAN, is the Virginia Stone Professor of Nursing at Duke University School of Nursing and Senior Fellow, Duke Center for the Study of Aging and Human Development. Christine Mueller, PhD, RN, FAAN, is Professor and Associate Dean for Academic Programs, and holds the Long Term Care Professorship, School of Nursing, University of Minnesota. Selina Hunt-McKinney, PhD, RN, is Consulting Associate, Duke University School of Nursing. Lisa Day, PhD, RN, CNRN, is Assistant Professor, Duke University School of Nursing. Kristie Porter, MPH, is Research Project Director, Duke University School of Nursing.