LPNs are an established but minimally studied part of the 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 efficient and effective educational ladders, including LPN-to-RN education. (These factors include alarm over the well-publicized RN shortages of the last few years; the controversy over the education and role of RNs who have earned associate's and bachelor's degrees; and an increasing emphasis on new levels and models of education, such as the clinical nurse leader. 1) While such education issues contribute to some of the disarray in nursing practice, the focus of Seago and colleagues is on how LPNs can be used more effectively as part of the nursing workforce.

The authors recommend that before the scope of practice of LPNs is altered, states should assess whether easing scope-of-practice restrictions, which vary extensively across states, will affect the quality of care. We agree. Professional nursing has been focused on establishing the independent contributions of RNs to the quality of patient care. 2, 3 We hope that such an assessment of LPNs' scope of practice will be free of the polarization sometimes found in the debate about the roles of associate'sdegree-prepared and baccalaureate-prepared RNs and will focus instead on what the most appropriate educational path and scope of practice are to best provide effective practice teams in various settings.

The authors recommend that employers "examine how the work of LPNs can be distributed safely and reasonably, so that RNs aren't overwhelmed and LPNs can perform all of the nursing tasks permitted to them under existing scope-of-practice regulations." As more research shows that the level of RN staffing makes a difference in patient care outcomes, 4 we need to study whether use of LPNs can improve patient care, and whether reducing the role of nursing aides would heighten such an effect. Until there is more research, we are concerned that the substitution of LPNs for RNs could have a negative impact on the quality of care, although such substitution has the potential to decrease costs.

Further, Seago and colleagues recommend providing financial incentives to LPNs who undertake additional training. The authors don't provide evidence in their study that this would be effective. LPNs evidently are more responsive to wage increases than are RNs, 5 but the jury is still out. It's not clear what this additional training would be. We oppose certification for particular tasks such as pharmacologic training. Such training may further encourage employers to substitute LPNs for RNs, which may not be in the patients' interest. Studies that examine outcomes in a variety of settings with differing scopes of practice are needed to establish the optimal scope of practice for LPNs.

The authors' last recommendation-that more effective laddering from lower to higher skilled jobs would benefit both employers and nurses and decrease the total cost of educating nurses-is an old argument. We are not aware of studies that show that such ladders decrease the total cost of education. In fact, they may contribute to duplication of course work and an increase in the number of years required to become an RN. Also, LPNs' ability to complete an RN curriculum successfully shouldn't be assumed. The view that the proper educational path to nursing is a BSN degree makes it difficult to efficiently articulate the existing nursing education system. Also, because longitudinal career-development studies of nursing are lacking, it's unclear whether prior nursing experience as an aide or LPN contributes positively or negatively to RN retention and participation.

Finally, the research and data needed to make distinctions in the quality of care provided by variously composed teams of RNs, LPNs, and nursing aides are, so far, unavailable. Such research is essential to evaluating the quality of care provided by various mixes of nurses, as well as to establishing the total quantity of personnel needed in multiple health care settings.

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