In response to Dr Welton's provocative column, I would like to suggest that a different issue be the focus of our national dialogue. "What is the appropriate scope of practice for the licensed practical nurse (LPN) and which practice settings, if any, are safe for this level of practitioner?" Based on the results of these spirited conversations, changes in educational curricula, including clinical training, should follow.

Hospital environments are dynamic. Patients are more acutely ill, nurses are being asked to assume greater spans of control with increasing responsibility, and workforce demographics are shifting. Dr Welton is correct that the impending exodus of our aging nursing workforce into phases of retirement will have a negative impact on the health of our citizens if an adequate supply of nurses is not replenished. It is time to address the appropriate competencies and education for each level of nursing provider based on a new national model of nursing care encompassing education and skills, roles, and outcomes across the continuum. As nursing leads the way in interdisciplinary models of care teams to improve our nation's health, will we ignore other providers in our profession who can contribute to the team in some aspect including not advocating for a role for the LPN?

The success of a new model of healthcare delivery will necessitate changes to educational requirements, scope of practice, and competencies for all levels of providers. "What level of nursing professionals is best suited to practice in which care setting to meet the economic and physical needs of our populations?" The decision to eliminate LPNs from all areas of hospital practice has not reached concurrence at a national level. The Institute of Medicine report supports allowing practitioners to practice to the extent of their licensure.1 Is this widely supported recommendation applicable only to nurses with APRN and BSN degrees? Currently, 252,130 LPNs work in either long-term care (LTC) or adult elder care.2 If a family member or friend was in an LTC setting, wouldn't we want his/her LPN care provider to be able to recognize changes in condition, understand the medications including actions and adverse effects, and act and communicate appropriate levels of information to the RN and MD team members? Will valuable RN resources be further stretched to replace LPNs in practice settings where they have been integrated into care teams? If LPNs are not exposed to the dynamic and complex environment of an acute care hospital as part of their training, will they possess critical thinking skills, at an appropriate level for their scope, when needed?

I advocate that nursing, as a profession, use the momentum of the Regional Action Coalition meetings (an initiative of the Robert Wood Johnson Foundation/American Association of Retired Persons Future of Nursing: Campaign for Action) to address scope of practice and appropriate roles for all nurses in addition to discussions about transition to higher levels of education. Implementation and transition plans for education, training, and competency should then follow. I am convinced that the number of training opportunities for LPNs in acute care hospitals will decrease but suggest that nursing lead this transition as a united profession in a thoughtful, deliberate manner to ensure continuity of care and workforce supply in the transition. Some LTC settings would function with fewer providers if forced to replace LPNs with RNs. Thus far, only selected hospitals have been able to transition solely to an all RN staffing model, often because of workforce supply or economic constraints. Strained national resources are presenting an opportunity for the profession of nursing to use our talents and skills to meet the nation's vast and underestimated need for healthcare. I predict that, for the next decade, the new model of care in some practice settings will incorporate educated and skilled LPNs and that high-quality clinical education will be essential.

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