Preceptor and learner perspectives on LPN-BN transition to practice: A pilot study

The 2017 Environmental Scan

The role of the non-medical surgical assistant in Australia: legitimacy, effectiveness, and equity

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Registered nurses (RNs) work closely with nurse practitioners (NPs) in all facets of patient care and often have a direct influence on the patient's perception of the professional who is directing the care, and a patient's perceptions may affect clinical outcomes. However, few studies have been conducted to measure RN acceptance of the NP. The authors surveyed RNs in southern Illinois to assess their attitudes concerning the level of care provided by NPs. Southern Illinois was chosen because of the limited number of NPs in the area and because of concerns that limited exposure might negatively influence RN attitudes about the NP role. A 26-item research questionnaire, previously used with school nurses, was modified to reflect RNs in general. Seven items related to demographic information, and 19 items created a five-response Likert-formatted scale (r = .93). The questionnaire was mailed to 500 randomly selected RNs from the 11 southernmost counties of Illinois. The results showed support of the NP role. RNs believed that NPs were knowledgeable, competent health care providers. RNs were also comfortable working with NPs and often consulted them for advice and information. They saw the role of the NP as a positive addition to the health care team. One identified concern was that scores indicated RNs felt that they received limited respect from NPs. Although the scores were high in this category, some RNs had concerns that NPs might not respect or understand the difficulty of the RN role in providing patient care. NPs need to recognize their collegial and professional ties to RNs and should take time to provide positive feedback to RNs as they collaborate to provide health care. Such behavior would only solidify the health team approach.

BackgroundMedication reconciliation is a safety practice to identify medication order discrepancies when patients’ transitions between settings. In nursing homes, registered nurses (RNs) and licensed practical nurses (LPNs), each group with different education preparation and scope of practice responsibilities, perform medication reconciliation. However, little is known about how they differ in practice when making sense of medication orders to detect discrepancies. Therefore, the purpose of this study was to describe differences in RN and LPN sensemaking when detecting discrepancies.MethodWe used a qualitative methodology in a study of 13 RNs and 13 LPNs working in 12 Midwestern United States nursing homes. We used both conventional content analysis and directed content analysis methods to analyze semi-structured interviews. Four resident transfer vignettes embedded with medication order discrepancies guided the interviews. Participants were asked to describe their roles with medication reconciliation and their rationale for identifying medication order discrepancies within the vignettes as well as to share their experiences of performing medication reconciliation. The analysis approach was guided by Weick’s Sensemaking theory.ResultsRNs provided explicit stories of identifying medication order discrepancies as well as examples of clinical reasoning to assure medication order appropriateness whereas LPNs described comparing medication lists. RNs and LPNs both acknowledged competing demands, but when performing medication reconciliation, RNs were more concerned about accuracy and safety, whereas LPNs were more concerned about time.ConclusionsNursing home nurses, particularly RNs, are in an important position to identify discrepancies that could cause resident harm. Both RNs and LPNs are valuable assets to nursing home care and keeping residents safe, yet RNs offer a unique contribution to complex processes such as medication reconciliation. Nursing home leaders must acknowledge the differences in RN and LPN contributions and make certain nurses in the most qualified role are assigned to ensure residents remain safe.

The availability of nursing resources is one of the most critical issues facing health care organizations in the country. The study investigated the potential factors that relate to the desire of registered nurses (RNs) and licensed practical nurses (LPNs) to continue practicing in rural hospitals of North Dakota. All RNs and LPNs who worked in North Dakota hospitals with fewer than 100 beds (490 hospitals) were mailed survey questionnaires. Approximately eight weeks later, responses were received from 291 respondents for an overall return rate of 59 percent. Correlational analyses were used to examine the subjects' responses. A moderate relationship was found among the work-related variables. Overall job satisfaction and performance constraints were the only variables to make significant contributions to the prediction of turnover intention for both RNs and LPNs. Overall job satisfaction accounted for the largest percentage of the variance (R2 = 0.42 and R2 = 0.44) for RNs and LPNs, respectively. Satisfaction with promotion was the only work-related variable to make a significant contribution to the prediction of turnover intention for RNs (R2 = 0.23). Performance constraints, role ambiguity, and shift worked were the only work-related variables contributing to the prediction of turnover for LPNs. These results are discussed in terms of their implications for the management of RNs and LPNs in rural hospitals. Clinical ladders for promotions, the identification of potential performance constraints, and supervisory training are suggested as target areas in which rural hospitals might focus attention for managing turnover in RNs and LPNs.

Although this book’s title suggests a comprehensive overview of the U.S. nursing workforce, this book has a more narrow focus on the nation’s supply of and demand for registered nurses (RNs). In part, the decision to eliminate consideration of licensed practical nurses (LPNs) and nurse aides (NAs) is based on the availability of data over a sustained period of time to enable accurate and meaningful interpretation. RNs are viewed by the authors as having “a much larger impact on the productivity of the nursing workforce” than LPNs or NAs; they “earn higher wages, and exert a much greater effect on healthcare spending, quality of care, and patient safety.” Readers of this book will not conclude that there is a national “crisis” in regard to the RN workforce. However, the authors describe in great detail a number of harbingers of considerable concern that if ignored could lead to serious compromises in our ability to provide needed health care services, especially in hospitals and skilled nursing facilities. This book is essentially an analysis of basic patterns of “supply” of and “demand” for RNs and the services they provide in the context of the U.S. health care system. The authors offer an analytical approach that is likely to be useful both for classroom applications in health care policy and labor economics and for policymakers and nursing professional advocates. Basically, the authors have updated previous estimates of anticipated shortages of RNs, suggesting that shortages between 2015 and 2020 will be in the range of 285,000 RNs—a figure somewhat lower than initially calculated a few years ago but still nearly three times the size of current shortages. More importantly, they show that the current shortages (measured by the number of vacant RN positions) have persisted since the late 1990s and represent the “longest lasting shortage in over 50 years.” In some respects, at least for RNs in the current labor market, all aspects of this analysis are unlikely to be seen as “bad news.” The authors anticipate that the shortages will result in upward pressure on RNs’ wages, followed by movement toward new educational opportunities for entry into the nursing field and an increase in the popularity of nursing as a career (on the supply side). Such changes will be followed by increased emphasis on alternative types of providers of what have been considered “nursing” tasks by health care organizations (the demand side). Many of these future scenarios are hard to conceptualize and measure precisely, but the general scope of potential change on both sides of the workforce B o o k R e v i e w s

This study explores the effect of licensed practical nurse (LPN) reductions on registered nurse (RN) staffing. RN staffing is usually evaluated by assessing RN/patient and RN/nursing staff ratios. Using these measures, researchers generally have not found deterioration in RN staffing. Despite differences in roles, RNs and LPNs frequently share a substantial amount of patient load. Given reductions in LPNs, adequate RN staffing can be assessed more completely by looking at the changes in the staffing of licensed nurses (RNs and LPNs combined). This study measures the percent change in RN, LPN, and licensed nurse staffing from 1991 to 2000 in 185 to 215 Pennsylvania hospitals. Paired sample t tests measure the significance of change from year to year and for the period overall. A 29% reduction in LPNs during the years 1991 to 2000 affected RN staffing through an increase in licensed nurses' patient load and a slight decrease in skill mix. When adjusted for acuity, both RN and licensed nurse patient load increased significantly. These results help explain the perception that hospitals are understaffed. Future research and managerial decision-making should consider the adequacy of licensed nurse staffing, and its impact on cost, performance, and quality.

Despite evidence that hospital use of licensed practical nurses (LPNs) declined in the 1990s, the current registered nurse (RN) shortage has prompted interest in LPNs as substitutes for RNs. Hospitals, being the dominant employer of RNs, have an economic incentive to use less expensive LPNs as substitutes. Beside wages, there are several forces underlying hospital demand for LPNs. In this article, the authors model and estimate hospital demand for LPNs as a function of nurse wages and hospital, market, and patient characteristics using a longitudinal data set of short-term general hospitals in the United States. The authors find evidence that higher RN wages increase hospital demand for LPNs, both in levels and relative to RNs, suggesting that hospitals at least partially substitute RNs with LPNs.

An untapped resource in the nursing workforce: Licensed practical nurses who transition to become registered nurses

Acknowledging the tension between the current availability of nurses and the need to create opportunities for student nurses, the SCO Health Service in Ottawa developed a nursing Summer Student Internship Program. This paper describes the development, implementation and evaluation of this program. A mixed-methods approach was used in this cross-sectional descriptive study. Nineteen student nurses completed a self-administered questionnaire, and seven staff nurses participated in a semi-structured interview. The findings suggest that the program was a mutually rewarding experience for students Creating a Bridge between Academic and Clinical Realities for Student Nurses: Evaluation of a Summer Student Internship Program Kathleen Holdway, RN, MScN Research Assistant, Elisabeth Bruyere Research Institute Ottawa, ON Sylvie Corbeil, RN, MScN Interim Chief Nursing Officer, SCO Health Service Ottawa, ON Christine J. McPherson, RN, PhD Research Scientist, Elisabeth Bruyere Research Institute Assistant Professor, University of Ottawa, ON Sylvie Oremush, RN, BScN Director of Nursing and Scheduling Resources, SCO Health Service Ottawa, ON Mary Ann Murray, RN, MScN, CON(C), GNC(C) Advance Practice Resource Nurse, SCO Health Service Ottawa, ON ON-LINE EXCLUSIVE 1 Nursing Leadership On-line Exclusive • April 2005 2 and staff nurses. Students reported that the program facilitated their integration into nursing practice, increased their confidence in clinical proficiency and improved their organizational skills. The program provided a vehicle for student nurses to optimize and strengthen their learning. Most students expressed an interest in future employment as a summer intern. Nurses’ responses were also positive and favoured continuing the program. Nurses appreciated the opportunity to mentor students within a unique program and considered the students’ contribution to patient care valuable. Future research should examine the utility of such a program in terms of attracting, recruiting and retaining novice and experienced nurses. In 2002, a nursing Summer Student Internship (SSI) program was piloted with five students at the SCO Health Service in Ottawa, Ontario. The SSI program was expanded in 2003, based on a high level of participant and organizational satisfaction. Twenty-four students participated. The primary goal of this program was to help address organizational summer staffing requirements in a new and innovative way. At the time of SSI program inception, the registered practical nurse (RPN) vacancy rate was about 10%. There was also an anticipated additional 10% RPN requirement to meet summer relief needs. Furthermore, there was no graduating RPN class for 2003 based on changes in program length of the RPN course curriculum. The secondary goals were to create an environment for students to acquire new knowledge, to socialize students to nursing practice and to foster professional growth. This paper describes the development, implementation and evaluation of the SSI program. Literature Review A limited number of articles have focused specifically on student nurses’ summer employment in nursing (Desrosiers 2000; Grinstead 1995; McAlpine and Cargill 1992; Tritak et al. 1997). These summer employment programs are often referred to as externship programs. An externship program is actually like an internship program but is external to the nursing program of study (Desrosiers 2000). In a pre-test and post-test study of six student nurses who had participated in a summer hospital employment program, McAlpine and Cargill (1992) examined students’ attitudes towards the profession, role identification and degree of knowledge of the hospital organization. Results indicated that students had more positive attitudes towards their profession, greater knowledge of the hospital organization and felt more “like nurses “ at the end of their summer employment. Students’ task performance was also observed and timed. Results suggested that as the number of skills performed by students per day increased, the quality of performance decreased. When interviewed, the students acknowledged that their performance was not as it should be. They reported “there is not time to take all those steps “ and “everyone does it. “ When students were observed, it was often noted that they appeared to be modelling behaviours of nurses on the unit. Other findings indicated that the students felt that they received greater support and reinforcement of their identities as “nurses” from individuals with little connection to the professional system (e.g., families, cleaners) compared to those with more connection (e.g., nurses, doctors). Lastly, although students “felt more like nurses” at the end of the summer program, the majority agreed that they wouldn’t really feel like a nurse until they passed their licensing exams. Tritak and colleagues (1997) examined nursing autonomy and dimensions of professional activity among 41 student nurse externs. Pre-test and post-test results revealed no significant differences in autonomy or dimensions of professional activity. At post-test (i.e., one year later), the results revealed significantly greater professional autonomy. Students also reported greater self-confidence and ease at answering examinations; better time management and insight into staff nurse duties; skills and knowledge development; and the opportunity to earn and learn simultaneously. Finally, the academic averages of the externs were compared with a representative group of students who did not participate in an externship program. Results found that externs obtained significantly higher mean grade-point averages, compared to the sample of non-externs. While the literature on summer student programs is limited, there was suggestion that a SSI approach would benefit students. Therefore, a decision was made to develop and implement the SSI program. Development of the SSI Program A new job category for student nurses was created through partnership and negotiation with key stakeholders. Newly defined role expectations included (1) performing care traditionally undertaken by unregulated personal care attendants (PCAs), (2) performing selected nursing skills and (3) working in close collaborative practice with a registered nurse (RN) or a registered practical nurse (RPN). Student nurses were recruited from nursing programs at two colleges and one university. An advanced practice nurse (APN) with expertise in nursing education and preceptorship reviewed the course curriculum of each school to formulate a draft list of selected skills that would be applicable to all care settings within the organization. Prior to student recruitment, the draft skills list was reviewed and refined by nurse leaders until consensus was reached. Students eligible to participate in the SSI program had successfully completed the second year of a RN program and were available for full-time work (i.e., 37.5 hours per week; 7.5 hours per shift) on either a day–evening or a day–night rotation. Prior to being interviewed by the Director of Nurse Scheduling, students’ applications were screened for eligibility by the Human Resources Department. Implementation of the SSI Program Following initial approval of the program by the Chief Nursing Officer (CNO), the Director of Nurse Scheduling in collaboration with Human Resources and the Creating a Bridge between Academic and Clinical Realities for Student Nurse 3

Patient Care Staffing Levels and Facility Characteristics in US Hemodialysis Facilities

Recognizing the emotional labour underlying interprofessional collaborations (IPCs) could be considered a crucial step towards building a cohesive nursing team. Although IPCs between registered nurses (RNs) and licensed practical nurses (LPNs) have been linked to quality nursing care, little is known about the emotions experienced by LPNs during their interactions with RNs or those factors that influence IPCs. A questionnaire administered to 309 LPNs found that (1) the professional identity of LPNs has evolved into a that of a unique social group; (2) LPNs define IPC as an interpersonal process of exploring similar or dissimilar assessments of a patient's status with RNs and, together, establishing a course of nursing actions; (3) the primary organizational factor facilitating IPCs is inclusive nursing leadership; (4) the interpersonal factor promoting IPCs is the level of trust RNs extend to LPNs; and (5) an LPN's emotional labour (i.e., internal emotional regulation) is most tangible during uncollaborative interactions with RNs.

BackgroundThere is a Registered Nurse (RN) shortage across the United States that is predicted to intensify in the upcoming years. RNs are an integral part of Emergency Departments (EDs) and perform many vital tasks, including IV placement, blood draws, medication administration, acute assessments, and patient hand-offs. Thus, RN staffing is a crucial part of ED operations, and ED initiatives should account for RN workforce shortages. Given the increase in ED visits and crowding, throughput initiatives that can expedite patient care are integral to the functioning of an ED. Team Triage is a throughput initiative that has been shown to improve ED time to provider, length of stay, and left without being seen rates. In our institution, we created a Team Triage model where advanced practice providers (APPs) perform a patient’s initial evaluation in triage and place orders for labs, intravenous (IV) catheters, and imaging. Given the RN staffing shortage, we incorporated Licensed Practical Nurses (LPNs) in Team Triage to place IV catheters and draw blood work for laboratory tests. The objective of this investigation was to describe a Team Triage model that incorporated LPNs and to report the patient safety and productivity of this model.MethodsThis was a single-site retrospective study at a large, academic, tertiary care center with over 100,000 annual visits. Adult patients who self-presented to the ED and went through Team Triage (11 am-11 pm) between Jan 1, 2020, and Jan 31, 2020, were included in this study. LPNs staffed the Team Triage, along with APPs. LPNs placed IV catheters and drew blood specimens for the Team Triage patients. The primary outcomes studied were the proportion of specimens mislabeled by LPNs, the proportion of patients receiving IV catheters, the proportion of patients receiving blood work, blood tubes drawn per hour, and IVs inserted per hour in Team Triage.ResultsDuring the study period, 1355 patients went through Team Triage. Of these patients, 1075 (79%) were ordered for blood work, and 1017 (75%) were ordered for an IV catheter. All Team Triage blood work and IV catheter placements were completed by LPNs, who staffed 372 hours of Team Triage. A total of 2558 blood tubes were collected by LPNs. The LPNs cared for 2.9 patients per hour, collected 6.9 blood tubes per hour, inserted 2.7 IV catheters per hour, and collected 2.4 blood tubes per patient. The LPNs had a 0% specimen mislabeling rate.ConclusionDue to the significant RN workforce shortage impacting Emergency Medicine coupled with increased ED crowding, there is a significant need to evaluate the integration of LPNs into Team Triage to place IV catheters and perform blood draws. This study shows that incorporating LPNs in Team Triage is a productive and safe way to address nursing shortages in Emergency Medicine.

In Canada, all nurses are required to engage in evidence-based practice (EBP) as an entry-to-practice competency; however, there is little research that examines Licensed Practical Nurses' (LPNs') information seeking behaviors or preferred sources of knowledge to conduct EBP. Due to the differences in education and roles of LPNs and Registered Nurses (RNs), it is both necessary and important to gain an understanding of how LPNs utilize evidence in their unique nursing practice. The purpose of this study was to investigate how LPNs source knowledge for their nursing practice. A descriptive, cross-sectional survey of LPNs from Alberta, Canada asked participants to rank sources of knowledge that inform their practice. Responses were correlated with age and years of practice. Analysis of variance was used to determine if there were significant mean differences between average scores and place of employment. LPN participants used similar sources of knowledge as RNs. The top source of knowledge for both RNs and LPNs was the information they learn about each individual client and the least utilized sources of knowledge were articles published in nursing, medical, and research journals, tradition, and popular media. This finding is consistent with previous studies on RNs that found nurses do not often access current research evidence to inform their practice. Since relatively few LPNs access nursing and research journals, it is important to tailor EBP education information to the workplace context. Future avenues of research might explore the potential of using in-services and webinars to disseminate information and skills training on EBP to the LPNs, as this was a popular source of practice knowledge.