Can the Use of LPNs Alleviate the Nursing Shortage?

40 AJN t July 2006 t Vol. 106, No. 7 http://www.nursingcenter.com

Can the Use of LPNs Alleviate the Nursing Shortage?Yes, the authors say, but the issues—involving recruitment, education, and scope of practice—are complex.

Jean Ann Seago and Joanne Spetz are associate professors and SusanChapman is an assistant professor at the School of Nursing, Universityof California, San Francisco. Wendy Dyer is a senior market researchanalyst at the Kaiser Foundation Health Plan, Inc., in Oakland, CA.Contact author: Jean Ann Seago, [email protected] discussed in this article was supported by Contract 1U79HP00032 and Cooperative Agreement 1U79 HP00004, Bureau ofHealth Professions, Health Resources and Services Administration, U.S.Department of Health and Human Services. The authors of this articlehave no significant ties, financial or otherwise, to any company thatmight have an interest in the publication of this educational activity.

By Jean Ann Seago, PhD, RN, Joanne Spetz, PhD,Susan Chapman, PhD, RN, and Wendy Dyer, MS

OVERVIEW: LPNs may be able to help fill some of the gaps caused by the nursing shortage, butlittle research has been conducted on the demographic characteristics of LPNs, their education andscope of practice, and the demand for their services, all of which vary from state to state. In 2002and 2003, the authors conducted a comprehensive national study, Supply, Demand, and Use ofLicensed Practical Nurses, and have summarized that study’s findings in this article. They foundthat RNs and LPNs are similar in age and tend to have similar numbers of children, but that racialand ethnic minorities, particularly African Americans, and those who are single, widowed,divorced, or separated are better represented among LPNs. Expanding LPN educational programsmight draw more people into nursing. Some LPNs would like to become RNs, so expanding LPN-to-RN “ladder” programs could also be beneficial. LPNs can’t replace RNs entirely, but theycould perform much of the work now performed by RNs. While long-term care facilities alreadydepend heavily on LPNs, hospitals could benefit from employing more LPNs. The authors makeseveral specific policy recommendations to improve the education and employment of LPNs.

Since World War II, each successive nursingshortage in the United States has promptedhealth care leaders to evaluate the ways inwhich adequate nursing care can be pro-vided in hospitals and other settings. One

question repeatedly asked is How can LPNs be bet-ter used? The current shortage is no exception, andnurse executives and hospital administrators havebeen asking how much nursing care can be per-formed by LPNs. Although LPNs organized intoprofessional groups as early as 1941, there is little inthe literature on the scope of LPNs’ practice, thedemand for them in health care, and how they canbe used efficiently. (For more on the National

Association for Practical Nurse Education and Service,go to www.napnes.org/about/about.htm.) This article,based on the findings of a comprehensive nationalstudy, Supply, Demand, and Use of Licensed PracticalNurses (authored by the four of us plus KevinGrumbach, MD, and found online at ftp://ftp.hrsa.gov/bhpr/nationalcenter/lpn.pdf), asks whether theuse of LPNs can solve or help to solve the nursingshortage.1

LPNs—known as LVNs in Texas and California—numbered 596,355 in 2000, according to U.S. CensusBureau estimates.2 The same year, the NationalCouncil of State Boards of Nursing reported thatthere were as many as 902,154 active LPN and LVNlicenses in the United States and its territories.3

Usually LPNs obtain a license after 12 to 18 monthsof postsecondary education. In contrast, RNs com-plete two to four years of education before licensure.It’s difficult to categorize the work of LPNs in theUnited States because practice acts and scopes ofpractice vary substantially by state. LPNs usuallywork under the supervision of an RN or physician,and their responsibilities typically include basic

[email protected] AJN t July 2006 t Vol. 106, No. 7 41

hygienic and nursing care, measure-ment of vital signs, and administra-tion of prescribed nonintravenousmedications. In some states, LPNs canadminister IV fluids that do not con-tain medication and withdraw blood.

A recent study indicates that out-comes in patients with urinary tractinfections, pneumonia, shock, andcardiac arrest are positively associatedwith increases in RN hours.4 The sub-stitution of LPNs for RNs is depend-ent on employers’ belief that LPNs’skills are suited to their practice envi-ronments, as well as on the adoptionof sufficiently permissive scope-of-practice regulations.

We framed our study by askingwhether LPNs might be used toaddress a nursing shortage in severalways, including the following: • If the population from which LPNs

are drawn is different from that ofRNs, recruiting LPNs might bringmore people into nursing than therecruitment of RNs alone would.

• If, in response to changes in wages, workingconditions, and other characteristics, LPNsmake different kinds of employment decisionsthan RNs do, LPNs might be attracted to workwhen RNs are dissuaded from employment.

• If education programs for LPNs could expandmore rapidly than those for RNs because of dif-ferences in costs or accreditation regulations,LPNs might be able to enter the labor marketmore quickly. LPNs also could subsequently pur-sue RN education.

• If the scope of practice for LPNs is sufficientlybroad, they might be able to perform many ofthe same tasks RNs perform.Each of these possibilities will be reviewed, fol-

lowed by assessment of the potential role of LPNsin the current nursing shortage.

METHODSThe national study, sponsored by the Bureau ofHealth Professions, U.S. Health Resources andServices Administration, was a comprehensivelook at LPN demographic and employment char-acteristics, scope of practice, and education in the

Continuing Education3.5 HOURS

Novlette ClarkBronx, New YorkAge: 39

‘We have the touch! LPNs have the timeto slow down and talk, just being

there. That’s what’s needed, the touch.’

In May, AJN’s clinical editor, Karen Roush, interviewed and photographedseveral students in the LPN program at Putnam–Northern WestchesterBoard of Cooperative Educational Services in Yorktown Heights, New York.She talked with them during a clinical rotation at Northern WestchesterHospital, in nearby Mount Kisco, about their professional aspirations andwhy they chose to be LPNs rather than RNs. Roush’s photographs andexcerpts from her interviews are interspersed throughout this article.

Above, Novlette Clark, a single mother of four children, assists newmother Mary Anne Russo and one-day-old Jaclyn Alexis Russo. Clarkwanted to move up from her job as a certified nursing assistant, whereearning enough meant working double shifts, leaving little time or energyfor her family. “Time and money were really the issues for me,” she says ofher decision. She started taking courses toward a degree but found thedemands overwhelming. The 10-month, full-time LPN program was the bestroute for her to attain her goals: a career she loves, a better income, andtime for her children. She plans on resuming her RN studies in January.

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United States and its territories and was conductedin 2002 and 2003. Data from the U.S. CensusBureau, the Bureau of Labor Statistics, theAmerican Hospital Association, the NationalCouncil of State Boards of Nursing, and the Centersfor Medicare and Medicaid Services were analyzed.Scope-of-practice information was obtained fromeach state’s board of practical nursing and charac-terized in terms of its level of restrictiveness and itsspecificity about various tasks in order to elucidatehow practice regulations vary and how they affectthe demand for LPNs. Interviews and focus groupswere conducted with nursing leaders in four states:

California, Iowa, Louisiana, and Massachusetts.Those interviewed included practicing LPNs andRNs, nurse educators, hospital administrators, andrepresentatives from the boards of nursing. Details

about these research methodsare provided in the report.

FINDINGSAre RNs and LPNs drawnfrom the same pool? Thereare some dissimilarities in thegroups of people who chooseto become either LPNs orRNs. The different educa-tional requirements associatedwith RN and LPN licensuremay be a primary reason forthis; LPN education takes lesstime and is less expensive thanRN education.

If RNs and LPNs aredrawn from different poolsof potential nurses, recruitingLPNs might bring more peo-ple into the nursing profes-sion than recruiting RNsalone. To determine whetherthis possibility is true, weexamined data from the2005 Current PopulationSurvey.2 Comparisons of thecharacteristics of LPNs andRNs demonstrated that the

LPN workforce had much in common with the RNworkforce but also differed in potentially signifi-cant ways (see Table 1, page 43).

Age and sex. In 2003 the average age of bothLPNs and RNs was 43 years; while men representeda small percentage of both workforces, the percent-age of RNs who were male (8.1%) was nearly twicethe percentage of LPNs who were male (4.4%).

Race and ethnicity. Racial and ethnic minoritygroups were better represented in the LPN work-force, almost entirely due to the fact that 20% of theLPN workforce were African American, comparedwith only 10% of the RN workforce. The percent-age of LPNs who were white was 69%, while thepercentage of RNs who were was 77%. Well under10% of LPNs and RNs were either Asian orHispanic. Efforts to expand the LPN workforcemight be particularly successful as the U.S. minoritypopulation grows.

Michelle GrantBronx, New YorkAge: 27

‘Icame to realize that the LPN deals a lot with

clinical and patient care,while the RN does a lot ofpaperwork and care plans.’

When her mother was dying of cancer,Michelle Grant helped the nurses care forher and was deeply influenced by their skilland dedication. She researched the roles ofRNs and LPNs before enrolling in the LPNprogram at Putnam–Northern WestchesterBoard of Cooperative Educational Servicesin New York. Believing that it would giveher more direct patient contact, shedecided to try the LPN program first. Herstudent clinical experiences have illumi-nated the different roles and increased herrespect for RNs. “In comparison with theLPN, the RN has a lot of duties to fulfill,”she says. “They have to do a little of every-thing: the paperwork, the patient care,making sure everything is correct. It’s agreat responsibility!” She plans on continu-ing her education to become an RN.“Nurses are in great demand and I’m willing to learn as muchabout nursing as possible,” she says, adding, “but I’m still excitedthat I get to be an LPN and see what each is about.”


Marital status. Although nearly two-thirds ofboth LPNs and RNs had children, a higher percent-age of LPNs were widowed, divorced, or separated.LPN education might be attractive to this group,because of the relatively short and inexpensivecourse of study required for licensure.

Are employment decisions of LPNs and RNsdifferent? If LPNs and RNs respond differently towage levels, working conditions, and other factors,LPNs might be attracted to jobs when RNs are not.Few data are available on the employment deci-sions of LPNs. The Current Population Surveyasked about respondents’ occupations; some peo-ple who reported “LPN” as their occupation indi-cated that they weren’t working. However, thereisn’t any completely reliable way to determine howmany people who hold an LPN license are not cur-rently working as nurses or are working in anotherfield. Thus, we can study the nursing workforceonly to the extent that LPNs and RNs work.

There were similar employment trends amongRNs and LPNs—more nurses in each job categorywere employed in 2003 than in 1984.

However, as seen in Table 2, at right, the worksettings of LPNs and RNs differed markedly. Whilemore than 60% of RNs worked in hospitals, only37% of LPNs did; while 33% of LPNs worked innursing homes, assisted living facilities, and otherpersonal care settings, only 8% of RNs did.

Some studies have found that the RN labor sup-ply is relatively unresponsive to wage increases inthe short term.5 We used multivariate regressionanalyses to examine the characteristics that affectedthe number of hours LPNs and RNs worked perweek, and found that wage increases are associatedwith more hours of work for LPNs, but not forRNs.6 Thus, wage growth caused by shortages thatresult in an increase in the number of hours workedmay lead to changes in the mix of nurses available,if LPNs are easier to recruit.

Is LPN education easier to expand? If educa-tion programs for LPNs can be started or expandedmore rapidly than can programs for RNs becauseof differences in costs or accreditation regulations,more LPNs will be able to enter the labor marketmore quickly. Also, LPNs can pursue RN educationsubsequently, and “career ladder” programs thatadvance LPNs into RN programs may prove usefulin addressing RN shortages.

Since the 1990s, the number of LPN programshas remained relatively stable, but there has been adecline in the number of graduates. Curricular

Characteristic LPNs RNs

Age (mean, in years) 43.12 43.28

Male 4.4% 8.1%

White 69.1% 77.3%

African American 20.3% 10.1%

Hispanic 5.4% 3.8%

Native American 0.6% 0.5%

Asian 3.9% 7.5%

U.S. born 89.7% 86.5%

Married 54.6% 68.8%

Widowed/divorced/separated 29.7% 7.9%

Never married 15.8% 13.3%

Have children 0–5 years old 16.2% 18.8%



Table 1. Demographic Characteristics of LPNs and RNs

U.S. Census Bureau. Current Population Survey, outgoing rotations 1979–2005. SantaMonica, CA: Unicon Research; 2005.

Characteristic LPNs RNs

Employed 30 or more hours per week 76% 75.6%

Hours worked per week (mean) 37.63 37.3

Private-sector employee 90.5% 86.1%

Government-sector employee 8.5% 12.7%

Self-employed 0.7% 1.2%

Hospital employee 37.1% 62.5%

Nursing and personal care facility employee 32.8% 7.5%

Employee of physicians’ offices and clinics 9.9% 6.5%

Health services not elsewhere classified 4.1% 3.8%

Other settings 16.1% 19.7%

Table 2. Employment Patterns of LPNs and RNs

U.S. Census Bureau. Current Population Survey, outgoing rotations 1979–2005. SantaMonica, CA: Unicon Research; 2005.

requirements in LPN education programs vary bystate and territory. Most states specify the contentand number of hours of training, and some states’specifications are more detailed than those of oth-ers. Most programs require training in basic nurs-ing skills, such as taking vital signs and collectingother patient data, providing care and comfort, andadministering medication. Most states require addi-tional education for those LPNs who plan to prac-tice in areas that require skills not usually taught ina basic LPN course of study, such as IV infusion andIV medication administration.

Our interviews with nurse educators and stateboards of nursing did not indicate that it wasalways easier to start an LPN program than anRN program. LPN programs can be completedmore quickly, usually in 12 to 18 months, whichresults in lower overall costs per LPN graduate.But many college presidents and nursing schooldeans, recognizing that the shortage of RNs ismore severe than that ofLPNs, have been more

Dolores DuffyCroton-on-Hudson, New YorkAge: 43

‘You see an LPN workingvery hard for much less

pay. It just makes sense to go on.’

Dolores Duffy is no stranger to stressful jobs.Despite 20 years as a New York City detec-tive, she was surprised by the demands ofnursing school. “I knew I had my work cut out for me,” she says, “but I didn’t know mywhole life had to change.” She cites her ageand her status as a single mother of threechildren (ages nine to 15) as the decidingfactors in choosing the LPN track over the RN track. “I had vari-ous opinions, from ‘Try the LPN first’ to ‘You have to go for theRN,’ but basically I made my own decision,” she says. She’llcontinue her nursing studies—whether in an associate’s-degreeor bachelor’s-degree program depends on how many collegecredits will transfer from courses she took years ago. She seesLPNs as having the advantage of being able to provide morepersonal care to patients but at a disadvantage when it comesto wages.


willing to devote additional resources to expandingRN programs.

Most of the LPNs in our focus groups expresseda desire or an intention to return to school to getthe RN license, but few were enrolled in RN pro-grams. Insufficient time, the need for an ongoingsalary, too few open slots in courses, and familyobligations were among the reasons that LPNscited for not pursuing further education. In someregions, LPNs in long-term care facilities hadsalaries equal or almost equal to those of hospitalRNs. These LPNs tended to be less interested inpursuing an RN license. In regions where there wasa substantial gap between RN and LPN salaries,LPNs were more interested in becoming RNs.

Is the scope of LPNs’ practice broad enough?Whether LPNs can fill the RN gap depends, at leastin part, on the legal scope of LPNs’ practice, whichvaries from state to state and is regulated by statenursing boards and state nursing practice acts.

Typically, nurses’ scope of prac-tice and educational require-ments are specified in statelegislation. Most boards thenallow for expanded practice—usually in administering IV

infusions and IV medications,performing hemodialysis, andsupervising other staff—withadditional education. In mostcases the practice acts declarethat the LPN must work underthe supervision of an RN, aphysician, or in some states, a pharmacist, podiatrist, orother health care professional.

States explicate the work ofLPNs in a variety of ways.Some, such as Louisiana,Montana, Maine, and Nevada,have detailed lists of tasks thatLPNs can and cannot perform.Other states, such as Georgia,

Alaska, Kentucky, and Oklahoma, have “decisiontrees” to be used as guides for deciding which taskscan be performed by LPNs. Some states, such asColorado and Nebraska, use the structure of thenursing care plan (goals, assessment, planning, inter-vention, and evaluation) to detail the work that canbe performed by RNs, LPNs, and certified nursingassistants. South Carolina has developed charts thatdelineate allowable tasks according to system of the


body, job category, and experi-ence level within job cate-gories. Neither Michigan norTexas has defined the scope ofLPN or LVN practice or passeda practice act defining it.

In order to better under-stand the scopes of practice ofLPNs, we obtained documen-tation from virtually everyboard that regulates the prac-tice of LPNs and LVNs. Ourhypothesis was that there isvariation in the restrictivenessof the scopes of practice forLPNs, and that this restrictive-ness influences the role andflexibility of LPNs in worksettings. Our data indicatethat there are similarities—such as allowing basic nursingtasks such as hygiene to beperformed—in the LPN nursepractice acts across states, butvariation in how the statesregulate the details of the work of LPNs.

Interviews with leaders of state boards of nurs-ing, LPN educational programs, hospitals, andnursing homes allowed us to compare the actualpractice of LPNs with the written regulations. Statenursing board leaders were aware of the differencesin scope-of-practice regulations across states anddidn’t find these differences troublesome. They alsorecognized that employers establish their own inter-nal practice guidelines, which may be more restric-tive than the scope of practice allowed by law.

Some hospital and education leaders consideredtheir states’ scope of practice to be too restrictive.Nursing home leaders agreed that LPNs are essen-tial to the provision of care in their facilities; thescope of practice of LPNs is well suited to the needsof their patients, who tend to be less acutely ill andmore stable. Hospital leaders varied in their will-ingness to employ LPNs. Most recognized thatexperienced, capable LPNs could be an asset to anursing care team but found that the scope of prac-tice of LPNs was too limited to allow for significantemployment of LPNs in acute-care settings.

The focus groups revealed that both RNs andLPNs were fairly knowledgeable about the legalscope of practice of LPNs in their state, yet therewas wide variation in its interpretation and imple-

mentation. Participants’ perceptions of the scope oftheir own practice occasionally differed from stateregulations. This discrepancy was usually related to their employers not allowing LPNs to practice tothe full extent of their legal scope of practice.

To examine the effect of scope-of-practice regu-lations on the demand for LPNs, we conductedmultivariate regression analyses for LPN employ-ment using national data.6 Restrictive scope-of-practice laws had a significant negative effect onhospital demand for LPNs. The restrictiveness ofthe scope of practice also, not surprisingly, had anegative effect, although a weaker one, on demand

James KeaneYorktown, New YorkAge: 49

‘Ithought the LPN was alittle lower on the nurs-

ing food chain. But you’reright in there. It’s life anddeath.’

When James Keane started talking abouta career in nursing, after 22 years in lawenforcement, his wife said, “Jim, what areyou, crazy?” But the nurses he knew,including a sister and a sister-in-law,encouraged him. He’d recently retiredfrom an administrative position at RikersIsland, a prison complex on the East River

in New York City. “I enjoyed my years in corrections,” he says.“Some guys were waiting for that day to run out the door. But I justwant to deal with people again and have some fun with it.” Forhim that means not ending up in a supervisory or administrativerole, a move he sees as inevitable for an RN. “I think the LPN hasmore hands-on contact with patients,” he says. In the hospital set-ting he feels himself a part of a team with RNs, but in the nursinghome he feels “distant” from them. He may one day return toschool. “It will make me a better nurse,” he says. “But for the titleof RN? It really doesn’t make a big difference to me.”


LPNs are an established but minimally studied part ofthe nursing workforce. Seago and colleagues help to

fill that gap with their excellent study. Several factors have overshadowed any serious efforts

to articulate nursing education—that is, to develop efficientand effective educational ladders, including LPN-to-RN education. (These factors include alarm over the well-publicized RN shortages of the last few years; the contro-versy over the education and role of RNs who have earnedassociate’s and bachelor’s degrees; and an increasingemphasis on new levels and models of education, such asthe clinical nurse leader.1) While such education issues con-tribute to some of the disarray in nursing practice, the focusof Seago and colleagues is on how LPNs can be usedmore effectively as part of the nursing workforce.

The authors recommend that before the scope of prac-tice of LPNs is altered, states should assess whether easingscope-of-practice restrictions, which vary extensively acrossstates, will affect the quality of care. We agree. Profess-ional nursing has been focused on establishing the inde-pendent contributions of RNs to the quality of patientcare.2, 3 We hope that such an assessment of LPNs’ scopeof practice will be free of the polarization sometimesfound in the debate about the roles of associate’s-degree–prepared and baccalaureate-prepared RNs andwill focus instead on what the most appropriate educa-tional path and scope of practice are to best provide effec-tive practice teams in various settings.

The authors recommend that employers “examine how thework of LPNs can be distributed safely and reasonably, sothat RNs aren’t overwhelmed and LPNs can perform all ofthe nursing tasks permitted to them under existing scope-of-practice regulations.” As more research shows that the levelof RN staffing makes a difference in patient care outcomes,4

we need to study whether use of LPNs can improve patientcare, and whether reducing the role of nursing aides wouldheighten such an effect. Until there is more research, we areconcerned that the substitution of LPNs for RNs could have anegative impact on the quality of care, although such substi-tution has the potential to decrease costs.

Further, Seago and colleagues recommend providingfinancial incentives to LPNs who undertake additional train-ing. The authors don’t provide evidence in their study thatthis would be effective. LPNs evidently are more responsiveto wage increases than are RNs,5 but the jury is still out. It’snot clear what this additional training would be. We

oppose certification for particular tasks such as pharmaco-logic training. Such training may further encourageemployers to substitute LPNs for RNs, which may not be inthe patients’ interest. Studies that examine outcomes in avariety of settings with differing scopes of practice areneeded to establish the optimal scope of practice for LPNs.

The authors’ last recommendation—that more effectiveladdering from lower to higher skilled jobs would benefitboth employers and nurses and decrease the total cost ofeducating nurses—is an old argument. We are not awareof studies that show that such ladders decrease the totalcost of education. In fact, they may contribute to duplica-tion of course work and an increase in the number ofyears required to become an RN. Also, LPNs’ ability tocomplete an RN curriculum successfully shouldn’t beassumed. The view that the proper educational path tonursing is a BSN degree makes it difficult to efficientlyarticulate the existing nursing education system. Also,because longitudinal career-development studies of nursing are lacking, it’s unclear whether prior nursingexperience as an aide or LPN contributes positively ornegatively to RN retention and participation.

Finally, the research and data needed to make distinc-tions in the quality of care provided by variously composedteams of RNs, LPNs, and nursing aides are, so far, unavail-able. Such research is essential to evaluating the quality ofcare provided by various mixes of nurses, as well as toestablishing the total quantity of personnel needed in multi-ple health care settings.—Carol S. Brewer, PhD, RN, asso-ciate professor, School of Nursing, State University of NewYork at Buffalo, and Christine Tassone Kovner, PhD, RN,FAAN, professor, College of Nursing, New York University,New York City

REFERENCES1. American Association of Colleges of Nursing. Fact sheet: the

clinical nurse leader. 2005 Jun. www.aacn.nche.edu/CNL/pdf/CNLFactSheet.pdf.

2. Kovner C, et al. Nurse staffing and postsurgical adverse events: ananalysis of administrative data from a sample of U.S. hospitals,1990–1996. Health Serv Res 2002;37(3):611-29.

3. Needleman J, et al. Nurse staffing in hospitals: is there a businesscase for quality? Health Aff (Millwood) 2006;25(1):204-11.

4. Horn SD, et al. RN staffing time and outcomes of long-stay nurs-ing home residents: pressure ulcers and other adverse outcomes areless likely as RNs spend more time on direct patient care. Am JNurs 2005;105(11):58-70.

5. Brewer CS, et al. Factors influencing female registered nurses’ workbehavior. Health Serv Res. [Epub 2006 Mar 23].

An Evaluation of Seago and Colleagues’ Study Calls for More Research

Two Perspectives


Concerns Remain About LPNs’ Scope of Practice and Recruiting Minorities to Become LPNs

Seago and colleagues recommend specific changes in thepolicies of institutions that employ LPNs, including allowing

LPNs to “perform all of the nursing tasks permitted to themunder existing scope-of-practice regulations” and providing bet-ter compensation to those who complete additional trainingand certification programs. They also suggest that, becauseminorities are better represented among LPNs than amongRNs, it may be easier to recruit minorities into practical-nursingcareers. Although the authors may be concerned about provi-sion of nursing care to patients in light of the current and pro-jected nursing shortage, some of the implications of theirfindings are alarming.

I’m concerned that the authors, in trying to show that LPNscan help address the nursing shortage, may be over-estimating the degree to which LPNs can do the work of RNs.We have to ensure that we have the right type of nursing per-sonnel to meet the nursing care needs of the patient popula-tion, including vulnerable minority communities during a timeof persistent racial and ethnic health disparities.

I’m also concerned about the perception that minoritiescould be easier to recruit into the ranks of LPNs as the minoritypopulation grows. Such a perception may become a kind ofself-fulfilling prophecy, in which educators steer minority nurs-ing students into LPN education, thereby exacerbating inequal-ities that already exist in nursing. (It should also be noted thatalthough the authors speak in terms of “minorities,” it isAfrican Americans, rather than Asian Americans or HispanicAmericans, who are overrepresented in the LPN ranks.)

LPNs have been contributing members of the health caredelivery system for decades. However, the roles that theyshould play in that system have been debated for nearly aslong. Some community health centers and ambulatory careclinics have been using LPNs to interview patients and elicittheir chief complaints before they’re seen by the nurse practi-tioner or physician. Is this an assessment and triage functionthat should be the responsibility of an RN? The facilities haveargued that the LPNs are just getting information and pass-ing it along to the appropriate practitioner.

The suggestion that much of the work done by RNs couldbe performed by LPNs if their scope of practice were broad-ened undervalues the role of the RN. The authors refer to therecent study by Needleman and colleagues that found betterpatient outcomes with increased licensed nursing hours,including LPN hours.1 But Needleman and colleagues alsoconcluded that keeping the total number of nursing hoursconstant and increasing the proportion provided by RNs isthe most cost-effective approach to improving patient out-comes from nursing care, noting that “greater use of RNs inpreference to LPNs appears to pay for itself.” Without addi-

tional education, the substitution is unlikely to produce thesame improved outcomes for patients.

The use of LPNs outside of their scope of practice could beperceived as exploitation of a group of workers who are at alower rung of the health care delivery system. Do we reallywant to encourage the recruitment of more minority workersinto a practical-nursing track, then ask them to do the work ofan RN but receive less in wages—all of which may have theultimate consequence of costing the health care system morebecause of poorer patient outcomes?

Consider the experience of an African American student cur-rently enrolled in our nursing program. She has taken a longjourney to achieve her RN status and is now obtaining a bac-calaureate. Though she had already completed some collegework, she was advised by a guidance counselor to go to anLPN program because it would take only nine months to com-plete. She felt that she had the ability and skills to complete anRN program, but she was told that she could do just as well bybecoming an LPN. She followed this advice. In her work settingshe was constantly discouraged from furthering her RN educa-tion. When she realized that if she stayed in that work situationand position she would never achieve her goal of becomingan RN, she left and went to an associate’s degree program.

As Seago and colleagues note, there is a higher represen-tation of minorities, particularly African Americans, in thepractical-nurse pool than in the RN group. Why are minoritiesoverrepresented in this group? We need hard data on thisquestion, but I and other ethnic minority nurses have heard toomany stories about minority students being tracked into theseprograms by misinformed counselors in their elementary andsecondary schools. Health disparities continue to ravageminority communities. The care required by underserved andvulnerable populations is complex and necessitates the use ofprofessional nurses who have a broad knowledge base andunderstand these communities and their needs. The role of theLPN should be supportive to the role of the RN, not a replace-ment for it; but many facilities already use LPNs in place ofRNs. The expansion of LPN programs swells the licensed nurs-ing ranks with the least educated practitioners, who have lim-ited opportunities to pursue RN education. It is a disservice tothose interested in nursing and to minority populations to sug-gest that, because minorities are increasing in the population,they should be steered into practical nursing careers instead ofregistered nursing careers.—Catherine Alicia Georges, EdD,RN, FAAN, associate professor and chairperson, Departmentof Nursing, Lehman College, Bronx, NYREFERENCE1. Needleman J, et al. Nurse staffing in hospitals: is there a business case

for quality? Health Aff (Millwood) 2006;25(1):204-11.


in long-term care facilities(weaker, perhaps, becauselong-term care facilitiesrarely require the tasks,such as IV “push” medication delivery or bloodadministration, that LPNs are prevented from per-forming in the more restrictive states).

CONCLUSIONS AND POLICY RECOMMENDATIONSBased on our findings of demographics, education,scope of practice, and demand for LPNs and RNs,we believe LPNs can help address the current nurs-ing shortage in a limited way. New LPNs are drawnfrom a different demographic pool than RNs are;therefore, expanding LPN education can bring abroader group of people into the nursing profes-

Anshu DharPeekskill, New YorkAge: 31

‘Someone will come in and teach you askill, but you don’t know why you do it.

You don’t have that background or educationto support what you’re doing.’

Ask Anshu Dhar why she pursued an LPN rather than an RNlicense, and her immediate response is, “Stigma!” She is fromnorthern India, where nursing has long been regarded as “amessy and low-grade job,” although that perception is beginningto change with the increase in technology in nursing care. “I wasvery scared of the reaction of my family,especially my husband’s family, who are stillin India,” she says. “I said to them, ‘Let mestart with LPN first and see,’ because youneed that acceptance from your family.” Her family is now “thrilled” about her nursing career, and with their support sheplans on entering a master’s program for second-degree students (she holds a bache-lor’s degree in psychology), with a goal ofbecoming an NP. She regards the LPN roleas “more challenging” than that of the RNwhen it comes to direct care, but she seesRNs as providing a “directional path” forLPNs. “They pave the way with their expertiseand education,” she says.

sion. In general, it isn’t easier to open or expand anLPN program than to open or expand an RN pro-gram. Because many LPNs are interested in pursu-ing RN licenses, nursing educators should increaseopportunities for them to do so. LPN-to-RN pro-grams can help LPNs advance into RN jobs, andtheir success may in turn improve the overall diver-sity of the nursing workforce. Flexible programscan be implemented to provide RN education toworking LPNs in part-time, evening, and weekendschedules. Additionally, a growing number ofemployers offer scholarships.7 Expansion of currentLPN education programs or creation of new ones isnot likely to solve the RN shortage completely, buttargeted LPN-to-RN programs can help fill the gap.

Although all nursing leaders and focus groupmembers stated that LPNs could not replace RNs,most acknowledged that much of the work that RNs

perform could be performedby LPNs, even though theirscope of practice is more lim-ited. There are, of course, dif-ferences in the training andskills of the two differentgroups, just as there are differ-ences among individuals ineach occupation. Long-termcare institutions could notfunction without LPNs, andit’s likely that LPNs could beused more fully in hospitals.However, even if direct substi-tution were possible, there’slittle hope that the currentnumber of LPNs would beable to augment the RNworkforce sufficiently to fillthe need. More LPNs andRNs are needed.

Based on our findings, werecommend the following:

• Before making changes to LPNs’ scope of prac-tice, states should assess whether the evidenceindicates that easing practice restrictions wouldnegatively affect patient care.

• Employers should examine how the work ofLPNs can be distributed safely and reasonably, sothat RNs aren’t overwhelmed and LPNs can per-form all of the nursing tasks permitted to themunder existing scope-of-practice regulations.

• Employers should provide additional compensa-tion to LPNs who complete additional trainingand obtain certification beyond that required for


basic LPN licensure; this would provide educa-tional incentives to LPNs.

• Nurse educators should facilitate the matricula-tion of LPNs in RN educational programs. Moreefficient “laddering” of workers from lower-skillto higher-skill health care jobs would benefitboth workers and employers and, ultimately,would decrease the total cost of educatingnurses. At present, the LPN workforce is not being used

to its fullest capacity. Employers, state boards ofnursing, and educators should strive to ensure thatall types of licensed nurses are part of the effort toalleviate the nursing shortage. t

REFERENCES1. Seago JA, et al. Supply, demand, and use of licensed practi-

cal nurses. San Francisco: University of California; Nov2004. ftp://ftp.hrsa.gov/bhpr/nationalcenter/lpn.pdf.

2. U.S. Census Bureau. Current Population Survey, outgoingrotations 1979–2005. Santa Monica, CA: Unicon Research;2005.

3. Crawford L, et al. 2000 licensure and examination statistics.Chicago: National Council of State Boards of Nursing Inc;2001. http://www.ncsbn.org/pdfs/2000lic_exam_statistics_report_on-line.pdf.

4. Needleman J, et al. Nurse staffing in hospitals: is there abusiness case for quality? Health Aff (Millwood) 2006;25(1):204-11.

5. Spetz J, Given R. The future of the nurse shortage: willwage increases close the gap? Health Aff (Millwood)2003;22(6):199-206.

6. Coffman JM, et al. Minimum nurse-to-patient ratios inacute care hospitals in California. Health Aff (Millwood)2002;21(5):53-64.

7. Spetz J, et al. Hospital demand for licensed practical nurses.West J Nurs Res [In press].

GENERAL PURPOSE: To summarize for registered profes-sional nurses the findings of the authors’ comprehen-sive national study, Supply, Demand, and Use ofLicensed Practical Nurses.LEARNING OBJECTIVES: After reading this article andtaking the test on the next page, you will be able to• discuss the background information and demo-

graphics relevant to the authors’ study of LPNs andthe nursing shortage.

• summarize the key findings of the authors’ study.• outline the authors’ conclusions and recommenda-

tions related to their study.

TEST INSTRUCTIONSTo take the test online, go to our secure Web site atwww.nursingcenter.com/CE/ajn.To use the form provided in this issue, • record your answers in the test answer section of

the CE enrollment form between pages 63 and 64.Each question has only one correct answer. Youmay make copies of the form.

• complete the registration information and course evalu-ation. Mail the completed enrollment form and registra-tion fee of $24.95 to Lippincott Williams and WilkinsCE Group, 2710 Yorktowne Blvd., Brick, NJ 08723,by July 31, 2008. You will receive your certificate infour to six weeks. For faster service, include a faxnumber and we will fax your certificate within twobusiness days of receiving your enrollment form. Youwill receive your CE certificate of earned contact hoursand an answer key to review your results. There is nominimum passing grade.

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PROVIDER ACCREDITATIONLWW, the publisher of AJN, will award 3.5 contacthours for this continuing nursing education activity.LWW is accredited as a provider of continuing nursingeducation by the American Nurses CredentialingCenter’s Commission on Accreditation. This activity isalso provider approved by the California Board ofRegistered Nursing, Provider Number CEP 11749 for 3.5 contact hours. LWW is also an approved provider by the American Association of Critical-Care Nurses(AACN 00012278, CERP Category O), Alabama#ABNP0114, Florida #FBN2454, and Iowa #75.LWW home study activities are classified for Texas nurs-ing continuing education requirements as Type 1. Yourcertificate is valid in all states.

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Can the Use of LPNs Alleviate the Nursing Shortage?

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