The licensed practical nurse (LPN) is a crucial, but often overlooked piece of the nursing home workforce puzzle, according to industry leaders, with minimum staffing ratios focusing more on the certified nursing assistant (CNA) and the registered nurse (RN).
LPNs are in the building every day and know the residents, but also have the clinical expertise to help make important decisions about a resident’s changing condition, experts note. As operators seek to stabilize their workforce at this point in the pandemic, the LPN’s broad range of resident and clinical knowledge makes them the linchpin in a dwindling talent pool.
Jasmine Travers, a researcher for the landmark National Academies of Sciences, Engineering, and Medicine (NASEM) report on the nursing home industry, said report recommendations listed didn’t explicitly tackle the role of the LPN – a potential hole in better understanding the overall nursing home workforce.
Regulatory bodies aren’t explicitly focusing on the role either. The Centers for Medicare & Medicaid Services (CMS) in July started incorporating the percentage of RNs that have left annually to five-star quality ratings, while LPNs are included in the total number of nurses that have left on a yearly basis.
“What we’ve been seeing is that LPNs have been used in ways that are like a substitution for the RN,” said Travers. “They’re going beyond their scope of practice, when thinking about what RNs should be doing, and what LPNs are doing.”
The LPN should not be interchangeable with the RN, of course, but that’s been happening, she said. According to a study conducted in April 2021 and published in the Journal of Nursing Regulation, researchers found that LPNs were “pretty much interchangeable,” and that the role makes “economic ‘cents’” to employers.
It’s more cost effective to hire LPNs, Travers said, but nurses in this role are still taking on more responsibilities. The LPN on average makes $50,090 annually, according to data from the Bureau of Labor Statistics; RNs make $77,600 per year.
Researchers also concluded that LPNs themselves are uncertain about their future role, and many are looking for more hands-on experience.
Zendi Meharry, director of clinical operations for Cascadia Healthcare, said she is very serious about protecting her staff from taking on work that falls outside of their scope of practice.
The main difference between the roles is the ability to conduct patient assessments and make a diagnosis, according to Travers and Meharry. Another difference is the RN has a license and practices under his or her own license, while the LPN has to be supervised or work in collaboration with a physician, advanced practice provider or RN.
Gap solutions in education, technology
Educators and operators need to provide the training and education necessary to help LPNs meet the moment, added Travers.
“We’re going to need to focus on this part of the workforce that is there, that is available, that has responsibilities they’re technically not trained to be carrying out in the nursing home setting,” Travers said. “That’s the next area of focus when it comes to the LPN and what needs to be done more on a larger level.”
Typically, an LPN is only in school for about a year prior to getting their certification, according to multiple nursing school websites. When they get into the nursing home setting, LPNs are expected to care for residents with increasingly complex needs as the sector takes on higher acuity patients.
Laura Eaton, chief nursing officer for Cascadia Boise, said she’s seeing LPNs coming to her building with less hands-on experience, leaving employers like Cascadia to fill the gaps. Eaton served as an LPN for four years during her career, starting out as a CNA and working her way up to become a nurse practitioner.
“We’re having to retrain them … they may have some basic knowledge and terminology, but when it comes to skill sets, they don’t have it,” said Eaton. “I’ve been overseeing and managing nurses of all levels most of my career, I’ve seen these LPNs come out since the pandemic and they have very unrealistic expectations.”
Employers and educational institutions must advocate for the needs of the LPN in the same way we’re seeing CNAs advocated for, added Travers. It’s an area that “needs more attention.”
The nursing home should consider supplemental technology solutions too as the sector continues to navigate a historic workforce crisis, including a RN hub that an LPN or CNA can remote into and ask questions from the bedside.
For Travers, this possibility utilizes the RN while recognizing overall workforce scarcity. A similar tactic has been done on the acute care side of the continuum, with RNs observing telemetry units remotely, then calling staff onsite if a patient has a change in condition.
“Can we do that in the nursing home setting where we have an RN hub, where we’re able to remote them in? They could be available on demand for questions related to resident needs,” said Travers.
Specialist certifications span IT, infection prevention, leadership
LPNs in the nursing home, if they’re not pursuing their RN license, are getting certified in a number of specialities, according to Meharry and Eaton, including infection prevention and wound care, along with informatics.
Leadership certification is another big expansion of the role, Eaton said, one that she hopes will further evolve in the future, along with extended oversight of patient daily care coordination.
“We’ve got to curve the model … of course, they all function within their scope of practice, although we have to help them become elevated in their skill set by giving them these trainings so they can take on more of a leadership role,” said Eaton. “In the past, LPNs were never put into leadership roles.”
LPNs provide additional education to CNAs and peer-to-peer accountability, in making sure staff are getting up to date education on a topic so crucial as the pandemic continues and more preventative measures are put in place.
CMS now requires nursing homes to have a part-time IP on-site as part of its updated rules of participation in the Medicare and Medicaid programs. While the actual position is usually filled by an RN, Meharry said, LPNs still play an important part in making sure staff is on the same page.
“[Most of] our LPNs work in support roles to an RN that is the actual infection preventionist at the facility. In some of our bigger buildings, our vent units, it takes additional staff to do teaching, training and monitoring,” added Meharry.
Informatics specialization, as Meharry puts it, is more of an IT role with a background in clinical knowledge.
“That would be the computer systems, writing the programs that make it easy for nurses to do the documentation,” added Meharry.
Overall, Meharry believes there will be a higher nursing to patient ratio in future complete with specializations, as federal agencies push for more staff coverage and the sector continues to take on higher acuity patients. The SNF nursing team will “just become stronger” in the future, she said.
“People are just sicker, coming into the nursing home. That obviously takes additional staff to care for them; now we just need the reimbursement system to catch up with that,” said Meharry.
LPNs across the care continuum
Travers, who also serves as assistant professor at NYU Rory Meyers College of Nursing, said she’s seeing something similar on the acute care side of the continuum – hospitals aren’t using LPNs like they would have in the past.
Meharry said hospitals were, prior to the pandemic, actually looking to phase out the LPN role in favor of RNs, which is why there are so many in the nursing home setting. This would have been between 2018 and 2019, she said.
According to an occupational outlook handbook published in 2020 by the Bureau of Labor Statistics, nursing and residential care facilities employed 38% of the nation’s LPNs, while hospitals employed 14%.
“A few years ago, [hospitals] were phasing out all the LPNs; hospitals wouldn’t hire them. I think that’s done – the nursing shortage is everywhere,” said Meharry. “It’s truly changing and certainly COVID has changed that too.”
An increase in LPN hiring at the acute care setting created more competition for the role, according to Meharry and Eaton, leaving nursing homes with a deficit.
“LPNs are wanting to be in the hospital … it did open some doors for LPNs to go into different fields that they’ve never been able to before,” said Eaton.
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