On April 29, 2004, the National Council of State Boards of Nursing (NCSBN) convened a focus group to discuss the findings of the 2003 Licensed Practical Nurse/Vocational Nurse (LPN/VN) practice analysis and to make recommendations to the NCBSN board of directors. To ensure the broadest possible range of experience and knowledge, participants were selected from a variety of nursing-related disciplines across the United States. Some of the areas of nursing that were represented included the boards of nursing and members of the NCSBN Examination Committee, Joint Commission's Long-term Care, National League for Nursing Accrediting Commission, Institute for the Future of Aging Services, American Organization of Nurse Executives, National Federation of Licensed Practical Nurses, and the National Association for Practical Nurse Education and Service. We had an objective facilitator from England who is not a nurse but who is experienced with leading focus groups.
The NCSBN is a not-for-profit organization whose mission is to provide leadership to advance regulatory excellence for public protection. The NCSBN is composed of all 60 boards of nursing, which include the RN boards in the 50 states, the 5 US territories, the District of Columbia, and 4 LPN/VN boards of nursing. One role of NCSBN is to prepare legally defensible and psychometrically sound examinations (NCLEX-PN(C) and NCLEX-RN(C)) to ensure that the graduate has met minimal criteria for entering LPN or RN practice.
Periodically, NCSBN's Research Services Department does an incumbent practice analysis (job analysis) for nurses who have practiced for up to 6 months that provides the basis for the NCLEX-PN(C) test plan. These analyses are conducted on a 3-year cycle, and NCSBN uses a rigorous methodology to evaluate practice. This survey used stratified sampling to retrieve a representative sample. The researchers used a 5-stage mailing and had a final response rate of 25.5% or 1001 respondents.
A panel of 11 subject matter experts, all of whom were familiar with LPN/VN practice within the first 6 months and representing all areas of the country and practice settings, was assembled to provide validation to the study. Using their education and experience of LPN/VN practice, as well as job descriptions, activity logs, and past results of practice analyses, the panel members developed a list of 163 tasks that LPNs/VNs perform.1 They then considered the types of knowledge needed to perform these tasks and identified and defined a list of 14 knowledge areas. Those areas are:
* Biologic sciences
* Communication skills
* Nutrition
* Pharmacology/calculations
* Principles of teaching/learning
* Safety/infection control
* Social sciences
* Leadership/management/collaboration
* Clinical decision making/critical thinking
* Ethical legal knowledge
* Psychomotor skills
* Nursing process
* Nursing issues and trends
From the results of the 2003 LPN/VN practice analysis, it appeared that LPNs/VNs could possibly be practicing outside their scopes of practice in some states. Whereas some states have narrow scopes of practice for their LPNs/VNs, others have broader ones. The respondents were not individually linked to their particular states so it is impossible to positively conclude whether the LPNs/VNs actually were practicing outside their scopes of practice in their states. Yet, having reviewed various LPN/VN Nurse Practice Acts, it was determined that at least 25 of the 163 tasks may be outside of the scope of practice in some jurisdictions. Here are some examples:
* Some jurisdictions do not allow the LPN/VN to practice independently. Yet, LPNs/VNs did practice independently in four areas (eg, develop plan of care, make a change in the client's plan of care, plan and provide education about safety precautions, and plan and provide education to caregivers/family on ways to manage clients with behavioral disorders).
* Likewise, some jurisdictions do not allow the LPN/VN to make decisions or independent judgments about patients. Yet, LPNs/VNs did this in 6 areas (decide level of care from telephone triage, compare data collected for health history to norms for decision making, compare data collected on psychological status and ability to cope to norms for decision making, compare data collected on a client's potential for violence to norms for decision making, lead group sessions, and compare data collected on clients' nutritional status to norms for decision making).
* Some jurisdictions specifically do not allow LPNs/VNs to perform certain higher-level procedures. Yet, many of these procedures were being performed by LPNs/VNs. Examples are:
* Administering and monitoring the infusion of blood products.
* Administering medications or total parenteral nutrition through central or peripheral intravenous lines.
* Starting or restarting intravenous lines on clients over 16 or younger than 16 years.
* Changing or reinserting gastrointestinal tubes.
* Monitoring a client recovering from conscious sedation.
* Using lasers to remove unwanted hair and performing microdermabrasion.
* Assisting with peritoneal or hemodialysis treatments.
The results of this 2003 LPN/VN practice analysis stimulated many questions. Therefore, the NCSBN board of directors convened this focus group to discuss these results. The focus group discussed 4 questions, first in small groups and then in the large group. The 4 questions were:
* What do the findings of the 2003 LPN/VN practice analysis mean, considering the scope of practice of LPNs/VNs?
* What are the implications of the 2003 LPN/VN practice analysis, related to the LPN/VN scope of practice, to NCSBN?
* What are the implications of the 2003 LPN/VN practice analysis, related to the scope of practice, for education and practice?
* What are possible strategies of attaining greater universality regarding the scope of practice of LPNs/VNs across jurisdictions?
Group discussions took place on each of the questions, and then the groups convened to make recommendations. The participants stressed the importance of listening to consumers and putting patient safety first when making any future decisions. The recommendations of the focus group were all unanimously accepted by the NCSBN board of directors.
One important recommendation that came out of this focus group was for NCSBN to write a white paper, capturing the discussion of the day. As much data should be included in this paper as possible, thus making it evidence-based. This white paper can be used as a vehicle to develop partnerships and begin dialogue about the scope of practice of LPNs/VNs with employers, associations, boards of nursing, nurse executives, and educators. These partnerships can begin to promote mobility of the LPN/VN through articulation programs, such as the ones that exist in Texas, Washington, Colorado, and Kentucky.
This white paper might stimulate dialogue to create a model LPN/VN curriculum. It was thought that a more standard LPN/VN curriculum and board of nursing regulations, across the nation, would decrease some of the variances seen and enhance healthcare. Collaboration and input from various stakeholders would be important when designing this model curriculum. Some of the groups to include would be practice, education, boards of nursing, and consumers.
Another recommendation was that NCSBN might be a central clearing house for LPN/VN data. It was recognized that there are a lot of LPN data available, but those data have not been shared with various groups. Groups that collect data on LPNs/VNs should collaborate and share their data, and NCSBN should make available all of the shared data. Some groups currently collecting data on LPNs/VNs include NCSBN (practice analyses, the Continuing Ongoing Regulatory Excellence project, employer surveys, etc), National League for Nursing Accrediting Commission, National Association for Practical Nurse Education and Service, workforce data, American Association of Community Colleges, National League for Nursing and discipline data from boards of nursing. Some boards of nursing, such as Washington and Minnesota, have statewide initiatives where they are collecting LPN/VN data. The results of all these studies, taken together, will help us to identify best practices.
Most of the recommendations address 2 areas: increasing the dialogue between practice, education, regulation, and consumers about the issue of LPN/VN scope of practice, and collecting and sharing of data about LPNs/VNs. Once this dialogue and sharing of data are accomplished, we can develop partnerships and collaborations where we will develop best practices and articulation models. The NCSBN has already started some of this work. The NCSBN's Practice, Regulation, and Education Committee will be meeting in November 2004 to discuss the white paper that will be written. Once written, this white paper will be widely disseminated.
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