The current climate in healthcare is enormously challenging. The COVID-19 pandemic, a preexisting nursing shortage, and increased staffing turnover have been crippling for healthcare systems. For a multitude of reasons, many RNs have chosen to leave their nursing positions or the profession of nursing altogether, leading to great intellectual and experiential loss at the bedside and severe staffing shortages.1
Staffing losses can be extremely disruptive to healthcare services, resulting in reduced staffing levels, increased use of temporary staff, greater use of overtime, and diminished quality of patient care. Frequent changes in teams can negatively affect team dynamics, compromising communication and cohesiveness, and can increase the workload of current staff as they're charged with training new team members and filling gaps in staffing.2 High RN-to-patient ratios have been linked to adverse patient outcomes, decreased RN job satisfaction, higher nurse burnout, and lower retention.3-8
Innovative solutions are needed to support staff and ensure comprehensive patient care. Every healthcare team should examine their roles and responsibilities to determine if there are tasks that could be done by another individual.9 MacKinnon suggests that certain RN-required tasks could be delegated to assistive personnel, freeing the RN to focus on higher levels of care, care coordination, and team direction and providing increased staff presence at the bedside.10 Moreover, it could help mitigate higher turnover rates related to high patient-to-RN ratios, decreased satisfaction, and increased burnout, and save hospitals money spent recruiting and orienting new nurses.2,6-8,10,11 Development of a care team or team-based approach in healthcare settings is an option for supporting hardworking RNs challenged by an increasingly complex healthcare system.5,7
A care team or team-based care is the provision of care by two or more healthcare professionals working collaboratively, and each at their maximum scope of practice, to provide care to patients.4-7 This approach can improve patient outcomes, create more efficient care and support, and improve the morale of overburdened healthcare professionals.6,12
The LPN initiative
The year 2020 was incredibly challenging for the healthcare industry. In August 2020—when acute care hospitals were navigating a global pandemic, healthcare professionals and allied staff were fatigued, and a nationwide nursing shortage was growing—the executive nurse leader in the authors' healthcare system recognized the potential challenges of the imminent future, including long-term pandemic care issues, recruitment and retention of sufficient RN staff, and staff wellness. As a result, the executive nurse leader asked site CNOs to explore the development of a staffing approach that would optimize and support current staff through a diversified staffing model. Knowing that many RN responsibilities could be completed by an assistive care provider and that a team-based approach can reduce adverse events and increase patient satisfaction, leaders considered the addition of the LPNs in a supportive role to RNs.7
LPNs in acute care
In recent years, the LPN role has been used primarily in long-term, subacute, and community settings rather than the acute care setting. In this state, licensed LPNs may perform a variety of duties (such as obtaining vital signs, bedside care, screening, and medication administration) within a specific scope of practice. LPNs can make observations and provide care but can't complete patient assessments.13 Using LPNs to function within their scope of practice allows the RN to focus on high-acuity situations, complex care needs, and demanding disposition issues.14 Compensation for LPNs is less than that of an RN and using LPNs in conjunction with RNs can create a collaborative care team model that maximizes both roles, ultimately stabilizing staffing and optimizing patient care.2,14 Given today's healthcare climate, nurse leaders should consider implementing the RN/LPN care team model in the acute care setting as a potential staffing and patient-care solution.6,15 (See Figure 1.)
LPN pilot: First stop—medical-surgical
Within the healthcare system, one site CNO volunteered to pilot the LPN role and a care team model on a medical-surgical unit. Staffing mixes, patient volumes, and unit needs were examined. Most medical-surgical units used RN staffing combined with clinical techs who provided bedside care and activities of daily living support but no advanced nursing care. Nurse leaders considered the potential skills an LPN could bring to a medical-surgical unit that were beyond those of a clinical tech, including medication administration, wound care, phlebotomy, and I.V. initiation. The objective was to create a robust care team that would support, rather than replace, RN positions and promote patient care. New medical-surgical LPN positions were then created from within the existing budget, based on preexisting LPN job descriptions. LPNs with experience in long-term and subacute care were hired as members of the care team. The LPNs completed a hospital- and unit-based orientation that included I.V. and phlebotomy training and a review of the LPN scope of practice followed by a competency-based clinical orientation. Nurse leaders also incorporated LPNs into some sections of the nursing orientation for specific learning opportunities. Nurse leaders, including nurse managers and clinical nurse educators, educated current medical-surgical RNs on the role and scope of practice of the LPN and appropriate delegation practices.
Initially, RNs were reluctant to include LPNs in the care team model, uncertain of the new dynamic and delegation of tasks. Nurse leaders continued to coach the newly formed inpatient team, and reiterate messaging about the LPNs' role, teamwork, and the art of delegation. This led to a clarity of roles and responsibilities and effectively functioning teams. Shift reports were completed together, assignments were reviewed with the care team, and tasks were delegated.
LPNs quickly took on responsibilities and different care team strategies were trialed on the medical-surgical units. In one configuration, LPNs assumed medication administration and patient-care interventions within their scope of practice but beyond the scope of practice of a clinical tech (for example, wound care and I.V. initiation) for two to three patients in each RN's patient assignment. This reduced the RNs workload, giving them more time to focus on high-level patient management issues and improved patient care.
Staff appreciated the LPNs' contributions to the team, clinical and technical skills, team-based approach, new energy, and positivity. RNs found their assignments to be more manageable and the team approach more comprehensive. The LPNs were excited about being an integral part of the acute care team and anticipated a future of increased learning and development.
Second stop: LPNs in the ED
As the LPN initiative in the medical-surgical setting became increasingly successful, nursing administrators proposed replicating the program in the ED. The ED hasn't traditionally used the LPN role, more commonly employing patient clinical technicians (PCTs). However, EDs have experienced unusually high RN turnover rates, leading to considerable staffing issues and high use of agency RNs. According to the 2021 NSI National Health Care Retention & RN Staffing Report, EDs in this state had a turnover rate of 20% in 2020 (up from 18.5% in 2019), and approximately 24% of nurses were in their first year of practice.16 Due to a national RN shortage and the demands of the ED nursing specialty, filling vacant ED RN positions was challenging. Additionally, the high rates of retirement and nurses leaving the specialty created a knowledge and practice deficit, as new ED RNs filled the shoes of seasoned, experienced ED RNs. To support novice ED RNs, as well as experienced ED RNs who were tired and challenged, EDs were interested in diversifying and expanding their care teams to include LPNs.
Education plan development
The LPN initiative team examined the medical-surgical LPN pilot and its outcomes. The team considered implementation strategies, educational materials, and modifications to the initiative. Other considerations for adopting the care team model in the ED setting included methodically introducing RNs to the LPN role and scope of practice, delegation, and communication.5,17
A job description specifically for LPNs in the ED was approved and hospital policies were examined and updated to reflect this role. The team prepared an LPN onboarding package, including education plans and materials (orientation guides, competency checklists, skills verification, and unit-specific orientation materials). It was distributed to every hospital in the system to ensure consistency in practice in all hospital EDs and to reduce the burden on the hospital education teams. Each hospital's Professional Development, Innovation & Research Department/Nursing Education and ED clinical nurse educators incorporated the LPN educational package into their orientation programs.
Interprofessional collaboration and logistics
Corporate Nursing Informatics examined the LPN role and documentation parameters in the various electronic health records (EHRs) and built documentation profiles. The goal was to limit access to skills and tasks that weren't within the LPN scope using rules engines, security profiles, and clinical decision support mechanisms. Because this healthcare system was transitioning to a new, systemwide EHR, this information was also incorporated into the future state build.
Discussions were held with corporate pharmacy. Medication administration parameters and restrictions were examined, in addition to automated dispensing cabinet access and documentation. The pharmacy department disseminated information about the LPN role to all the pharmacy leadership to ensure awareness of this new role.
Human Resources worked closely with nurse leaders to find suitable candidates. LPNs were hired for full- and part-time, day and night, 12-hour shift positions, depending on the needs of the hospital and the unit. Some EDs chose to hire LPNs in an 11 a.m. to 11 p.m. shift to correspond to peak patient volumes. Like RNs, LPNs also worked weekend shifts. LPNs were assigned to shifts as an RN-extender, rather than as a replacement, which served to augment the care team and didn't affect the RN-to-patient ratio.
As LPNs hadn't been in the acute care setting for many years, most candidates were from subacute or long-term-care facilities. There was an excellent response to the postings from LPNs interested in acute care. The positions drew LPNs who were currently enrolled in transition-to-RN education programs or were working in the hospital as PCTs, despite their LPN license. Optimistically, these staff members will stay on as RNs when their education is complete.
The right team member in the right place
ED leaders and the clinical nurse educators were extremely committed to the introduction of the LPN role in the ED setting. Before the LPN's arrival, the ED RN and Clinical Team was prepared through huddles and discussion on the LPN's role and scope of practice. Moore and colleagues strongly encourage the availability of position descriptions for all categories of nurses in hospitals, to ensure a clear understanding of each other's roles and scopes of practice.19 The Clinical Nurse Educators and the ED nursing leaders selected the RN preceptors and discussed the orientation requirements. Successful RN preceptors were those who understood and appreciated the care team model, effective delegation, and the role of the LPN.
After successful completion of a competency-based orientation, LPNs were assigned to their respective clinical areas. In the inpatient environment, the LPN rounded out the care team, providing support to the RNs and improving patient safety and timely patient care. In the ED, the LPNs were assigned to work with an RN partner in various areas of the ED, depending on department configuration, patient flow, and staffing. The ideal role for the LPN in each ED was less clear, as all EDs are unique, requiring a trial-and-error period and clear communication.
Several EDs incorporated LPNs into the main area of the ED, assisting their RN partners with I.V. initiation, phlebotomy, wound care, medication administration within their scope of practice, and long-term ostomy and tracheostomy care. Two hospitals used the midshift LPNs effectively in large, low-acuity, fast-track areas for technical tasks such as phlebotomy, ECG, or specimen collection while the RN completed the triage, assessments, and first medications. In the fast-track areas (low-acuity area Emergency Severity Index 4 and 5), a care team model was created consisting of RNs, LPNs, clinical techs, and providers. After introducing LPNs, the patient volumes increased but patient discharge times remained consistent, demonstrating an efficient fast-track system and an effective use of the new model of care. As the fast tracks closed in the late evening, the LPNs would help close the assignment before moving on to a nursing pod in the main ED, providing supportive, highly skilled bedside care for the remainder of the shift. Another ED had less success in the main ED but had great results when using an RN/LPN/PCT care team in a low-acuity overflow area. Varied success was found when placing LPNs in a Provider in Triage scenario; it worked very well in one ED and not as well in another. Each ED worked diligently to determine where the LPN role was most successful and maximally used.
Many lessons have been learned in the development of the LPN role and care teams. (See Figure 2.)
Education and orientation. During the original medical-surgical LPN pilot, RNs initially struggled to understand the LPN role, scope of practice, and delegation. With coaching and communication, the inpatient care team approach improved. The experiences of the medical-surgical pilot informed the introduction of LPNs to the ED setting, and the role and scope of practice of the LPN were carefully and thoughtfully reviewed with ED staff prior to the introduction of the role. This resulted in a smoother and positive LPN transition to the ED.
The creation of LPN orientation materials for the system reduced the workload on the clinical nurse educators at the various sites and created continuity in the educational approach and practice for the system. Continued support of nurse leaders, from emergency nursing specialists and nursing education, was instrumental in ensuring sustainability and success. The orientation period proved sufficient for the LPNs to transition their practice successfully to the medical-surgical and ED settings and provided the EDs with time to find the most suitable practice areas for the LPNs to work.
Delegation. RNs found the act of delegation to LPNs challenging. Because team nursing has been largely absent in acute care for many years, newer RNs haven't experienced the care team approach. Seasoned RNs suggested that staff would benefit from more education on care teams and delegation. With coaching and communication from nurse leaders, the RNs learned more about care teams, the LPN role, and LPN's scope of practice, and delegation improved. Furthermore, LPNs had a clear understanding of their scope of practice because it was reviewed in their orientation program, so they were empowered to communicate with the RNs when they were asked to complete tasks outside of their scope. In the hospitals, the care team approach evolved, and staff learned and continue to learn how to work together effectively.
Role confusion. In one ED, the physicians and midlevel providers struggled to understand the LPN scope of practice, which caused some confusion. Providers expressed frustration that LPNs had restrictions in practice (for example, medication administration limitations), and they struggled to remember which team member could take on what tasks or skills. This issue was solved through increased communication with the provider team and education on the LPN role. Furthermore, pairing an LPN with a RN created a more productive team approach with the provider and more efficient patient-care workflows.
Unintended positive outcomes
Introducing LPNs to the medical-surgical and ED areas has resulted in several unintended positive consequences. Many LPNs were surprised that the acute care settings would consider employing them and were excited and eager to work in a fast-paced, dynamic environment that held increased opportunities for education, growth, and advancement. Several expressed that they enjoyed the variation and excitement of the ED, as their previous positions had been routine-oriented. They welcomed the opportunity to learn about new patient presentations and illnesses, and several RNs appreciated the LPNs' desire to learn more about the intricacies of the patient's presentation and treatment. The staff found this new burst of positive energy infectious and invigorating. The LPNs brought welcomed, strong bedside skills and were good “team players,” as they had come from environments where team-based care is well established. The RNs have found the LPN role supportive, productive, and more than “another set of hands.” Their comprehensive bedside skills have proven valuable for novice RNs, and there have been many moments where LPNs taught newer RNs bedside care techniques and the nuances of teamwork.
At the bedside, the LPNs have been communicative with patients and families and have provided the much needed bedside presence and support that's essential in comprehensive, safe patient care. Because the RN role wasn't replaced, the teams felt more robust and collaborative. In both medical-surgical and in the ED, RN staff have expressed a great appreciation for their LPN colleagues and the care they provide. The potential for increased patient safety, improved patient outcomes, and increased patient satisfaction is evident. Lastly, many of the LPNs hired are currently in LPN-to-RN/BSN programs or have expressed an interest in advancing their education. As hospitals prepare for an uncertain future, with staffing shortages and shifts related to the COVID-19 pandemic, investing in LPNs could prove to be a recruiting advantage.
There's potential to continue to develop and maximize the role of the LPN through additional education and role development, remaining mindful of the LPN's scope of practice. Although elements of teamwork have always been incorporated into health professional education, generally individual skills, knowledge, and roles have been emphasized.18 Further development of the care team model in hospitals, with increased education on communication, collaboration, and delegation, would be beneficial. Additionally, interprofessional collaborative education would prepare and potentially improve a collaborative approach to patient care.19 There are opportunities to further specialize the LPN role in the ED setting, with increased education in resuscitation and trauma team care. Expanding to other areas, such as maternal-child health, could also be explored.
Because LPN attrition rates have been low since the inception of the program, further investment in the LPN program would be worthwhile. A few LPNs left the acute care setting to pursue full-time RN studies or because they preferred the subacute and long-term settings. However, most are content in their new work settings, and some are looking to progress academically, taking advantage of the tuition reimbursement programs. As a recruiting strategy, it's beneficial to support these LPNs during their studies to become RNs. Partnering with LPN education programs and providing clinical rotations could facilitate more hiring opportunities for LPNs in the future.
Maximizing current resources
The role of the LPN has been successfully integrated into this hospital system, in both the medical-surgical and ED settings. LPNs now work on many of the medical-surgical floors and in 11 of the 12 EDs as valued members of the care teams. Today's healthcare climate demands that we examine every aspect of our healthcare team to maximize the care team approach and resources and provide comprehensive patient care. With ongoing innovative thinking, a collaborative approach to problem-solving, and an appreciation of the strengths of different healthcare team members, care teams can continue to grow and develop successfully to optimize patient care.
1. Lopez V, Anderson J, West S, Cleary M. Does the Covid-19 pandemic further impact nursing shortages. Issues Ment Health Nurs
2. Bae S-H, Kelly M, Brewer CS, Spencer A. Analysis of nurse staffing and patient outcomes using comprehensive nurse staffing characteristics in acute care nursing units. J Nurs Care Qual
3. Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA
4. Bleich MR, Zimmermann D, Hancock B. Unprecedented leadership: how nurses responded to the COVID-19 pandemic. Nurse Lead
5. Lomax SW, White D. Interprofessional collaborative care skills for the frontline nurse. Nurs Clin North Am
6. Smith CD, Balatbat C, Corbridge S, et al. Implementing optimal team-based care to reduce clinician burnout. NAM Perspectives
. 2018. Discussion Paper, National Academy of Medicine, Washington, DC. doi:10.31478/201809c.
7. Will KK, Johnson ML, Lamb G. Team-based care and patient satisfaction in the hospital setting: a systematic review. J Patient Cent Res Rev
8. Shin S, Park J-H, Bae S-H. Nurse staffing and nurse outcomes: a systematic review and meta-analysis. Nurs Outlook
9. Singer SJ, Kerrissey MJ. Leading health care teams beyond Covid-19: marking the moment and shifting from recuperation to regeneration. NEJM Catal Innov Care Deliv
. 2021. https://catalyst.nejm.org/doi/full/10.1056/CAT.21.0169
. Accessed March 1, 2022.
10. MacKinnon K, Butcher DL, Bruce A. Working to full scope: the reorganization of nursing work in two Canadian community hospitals. Glob Qual Nurs Res
. [e-pub Jan. 29, 2018]
11. Aiken LH, Sloane D, Griffiths P, et al. Nursing skill mix in European hospitals: cross-sectional study of the association with mortality, patient ratings, and quality of care. BMJ Qual Saf
12. Dickerson J, Latina A. Team nursing: a collaborative approach improves patient care. Nursing
13. NJ Board of Nursing Statutes. LPN job description. 2020. www.njleg.state.nj.us
. Accessed March 1, 2022.
14. Walker A, Olson R, Tytler S. Collaborative nursing practice: RNs and LPNs working together. Can Nurse
15. Weaver SH, de Cordova PB, Leger A, Cadmus E. Licensed practical nurse workforce in New Jersey as described by LPNs and employers. J Nurs Regul
16. NSI Nursing Solutions. 2022 NSI National Health Care Retention & RN Staffing Report. 2022. www.nsinursingsolutions.com/Documents/Library/NSI_National_Health_Care_Retention_Report.pdf
. Accessed March 1, 2022.
18. Zajac S, Woods A, Tannenbaum S, Salas E, Holladay CL. Overcoming challenges to teamwork in healthcare: a team effectiveness framework and evidence-based guidance. Front Commun
19. Moore J, Prentice D, Crawford J, Lankshear S, Limoges J, Rhodes K. Collaboration among registered nurses and practical nurses in acute care hospitals: a scoping review. Nurs Forum