This article is the second on a series on healthcare today. This installment focuses on the differences between RN (Registered Nurse) and LVN/LPN (Licensed Vocational/Practical/Professional Nurse) and what it means to you.
Much media attention has been focused on the lack of nurses, as mentioned in the first article on this series. However, much of that attention has been poorly focused. This is due in part from lazy reporting. Other influences have been political influences in the medical field.
The nurse shortage is not and does not need to be as drastic as it appears to be at this moment. Almost every statistic stated about the lack of nurses focuses on RN’s. This ignores the fact that there is another classification of nurses. The other classification is called LVN or LPN, depending on which state you refer to. While the title changes, the educational requirements remain the same due to national standards of education and testing.
For the remainder of this article, I will use LPN for simplicity.
Most of the general public has been led to believe that there is a large difference between RN and LPN and the care they provide. There is little or no truth to this.
What is the difference between the two?
The role of the LPN has historically been to provide direct care to patients in the medical setting. The role of the RN was designed to be a supervisory position. Years ago, it was normal for many LPN’s to work under the supervision of one RN.
Educationally, LPN’s go through about one year of vocational training to attain their title. RN’s must attend about 2 years of nursing school to obtain an Associate’s Degree. Not too common any more is an RN Diploma, which took about 18 months to achieve. Both RN’s and LPN’s take many of the same classes, such as Anatomy and Physiology, Medications and safety, Medical Terminology, Basic Charting Methods, Age Appropriate Care, Cultural Sensitivity, Developmental Psychology, Developing Care Plans, Nursing Diagnoses.. Each must also attend clinical experiences, in which they must provide direct care of actual patients in hospitals, nursing homes and clinics for psychiatric, medical/surgical, labor and delivery and geriatric patients. However, RN’s must attend classes which LPN’s do not. Most of these focus on theory and administrative functions. Some of these classes are on subjects such as Biological Chemistry, Role of the Charge Nurse, Community Health. They must also take classes which are focused solely on the educational requirement toward gaining a degree, such as elective classes on arts or languages. One state used to have a requirement of a mandatory history class.
In short, the actual medical educations of RN’s and LPN’s are nearly, if not completely, identical. In the clinical setting, there have been numerous references to patients being safer under the care of an RN than an LPN. Yet no studies have ever proven this. Ever. One thing that has been proven is that LPN’s typically are assigned more patients to provide direct care to than RN’s have been. Most of the time, LPN’s have been considered to be working “under the RN’s license”.
The trend in recent years has been to force LPN’s out of the hospital setting. The results have been many of the problems causing the lack of safety for patients in the hospital today.
The most obvious effect has been the lack of nurses, especially in the hospital setting. Though many LPN’s are competent, capable and experienced in acute care, most hospitals today will not hire them for that role. Leaving patients at risk.
Studies have shown that the more patients assigned to a nurse (LPN or RN does not matter), the risk of serious medical error increases drastically. On a medical/surgical unit, the advised ratio of nurses to patients is 1:5. Some studies state 1:4. However, in states which do not legislate a certain ratio, 1 nurse for 8-10 patients is not uncommon. Personally, I have been the sole nurse for as many as 18 patients on a surgical unit.
The higher the ratio of patients to nurses, the higher the risk of hospital-acquired infection rises. This is for one simple reason: The faster a nurse must move, the less likely they are to wash their hands or observe infection control methods.
With each patient assigned to a nurse, the amount of charting required increases. The more time a nurse spends with a chart, the less time that nurse can spend with the patients.
With the increased time necessary to finish education in a shortage field, the waiting lists for RN schools has grown long. Some schools or geographic areas have waiting lists as long as two years. This is after all pre-requisites are met. Some schools must turn away qualified applicants due to lack of resources to train them. Other applicants choose another career choice during that waiting time. In my own case, I was on a waiting list two years long for RN school, then chose to go to LVN school. Waiting list? About 3 months. A year later, I was licensed, while others were still waiting to begin RN school. Others simply never became nurses.
Due to RN’s being paid more than LPN’s, this has led to no small portion of the drastic increase in the cost of medical care. Other aspects to this are the higher number of lawsuits due to inadequate care related to lack of staffing. Foolish situation, when you consider a lawsuit probably costs a minimum of over $100k, while an LPN salary would probably cost about $45k or less.
So, how did this come about?
The primary force behind this situation is who runs the hospitals today. Hospitals today are, of course, businesses. They are run by boards of people educated and experienced in business. Most know nothing about medicine. As advisers, they use a chain of command. Most of the people acting as advisers regarding nursing are RN’s who have never been LPN’s. The situation is similar to that of military officers who believe they are superior to enlisted personnel.
For quite some time, several organizations of RN’s have been attempting to eliminate the entire classification of LPN and have lobbied political organizations, the American Medical Association, the American Hospital Association and more in their attempts.
Schools are a big influence on the matter. Seeing dollar signs from the idea of one person paying for two or more years of college, as opposed to one year has made them eliminate (until recently) many LPN courses.
Last and most importantly is JCAHO (Joint Commission for Accreditation of Healthcare Organizations). JCAHO is an organization which applies voluntary (but very, very expensive) certifications to medical organizations, if they meet their standards of certification. While some of their standards are intelligent and reasonable, others are questionable, at best. JCAHO certifications require that hospitals have a certain percentage of RN’s over LPN’s. This remains one of their standards, even with the knowledge that this is a significant contributor to the nursing shortage and increased risk to patients. The interesting part of this is that certification by JCAHO is not mandatory by government standards because most, if not all, states inspect healthcare facilities for safety.
I will not be too redundant in the effects of all of this. It’s really simple. You are paying more for healthcare. You have fewer nurses to monitor your condition, provide for your safety and comfort. Experienced, qualified nurses are unemployed /underemployed or are forced to spend more time and money to gain a higher degree, usually to attend classes which they could teach, while taking time and money away from their family in order to do so. At the current rate, schools cannot keep up with the increasing demand for nurses.
There is no true defense against this issue. Most of it is political. Until the situation becomes truly critical, JCAHO will maintain the same standards. Until hospitals reason out that it costs far less to employ LPN’s instead of understaffing and paying out lawsuits, they will maintain the status quo.
In short, for this to change, it will take many millions more illnesses, infections, injuries and lives.
