Seago and colleagues recommend specific changes in the policies of institutions that employ LPNs, including allowing LPNs to "perform all of the nursing tasks permitted to them under existing scope-of-practice regulations" and providing better compensation to those who complete additional training and certification programs. They also suggest that, because minorities are better represented among LPNs than among RNs, it may be easier to recruit minorities into practical-nursing careers. Although the authors may be concerned about provision of nursing care to patients in light of the current and projected nursing shortage, some of the implications of their findings are alarming.

I'm concerned that the authors, in trying to show that LPNs can help address the nursing shortage, may be overestimating the degree to which LPNs can do the work of RNs. We have to ensure that we have the right type of nursing personnel to meet the nursing care needs of the patient population, including vulnerable minority communities during a time of persistent racial and ethnic health disparities.

I'm also concerned about the perception that minorities could be easier to recruit into the ranks of LPNs as the minority population grows. Such a perception may become a kind of self-fulfilling prophecy, in which educators steer minority nursing students into LPN education, thereby exacerbating inequalities that already exist in nursing. (It should also be noted that although the authors speak in terms of "minorities," it is African Americans, rather than Asian Americans or Hispanic Americans, who are overrepresented in the LPN ranks.)

LPNs have been contributing members of the health care delivery system for decades. However, the roles that they should play in that system have been debated for nearly as long. Some community health centers and ambulatory care clinics have been using LPNs to interview patients and elicit their chief complaints before they're seen by the nurse practitioner or physician. Is this an assessment and triage function that should be the responsibility of an RN? The facilities have argued that the LPNs are just getting information and passing it along to the appropriate practitioner.

The suggestion that much of the work done by RNs could be performed by LPNs if their scope of practice were broadened undervalues the role of the RN. The authors refer to the recent study by Needleman and colleagues that found better patient outcomes with increased licensed nursing hours, including LPN hours. 1 But Needleman and colleagues also concluded that keeping the total number of nursing hours constant and increasing the proportion provided by RNs is the most cost-effective approach to improving patient outcomes from nursing care, noting that "greater use of RNs in preference to LPNs appears to pay for itself." Without additional education, the substitution is unlikely to produce the same improved outcomes for patients.

The use of LPNs outside of their scope of practice could be perceived as exploitation of a group of workers who are at a lower rung of the health care delivery system. Do we really want to encourage the recruitment of more minority workers into a practical-nursing track, then ask them to do the work of an RN but receive less in wages-all of which may have the ultimate consequence of costing the health care system more because of poorer patient outcomes?

Consider the experience of an African American student currently enrolled in our nursing program. She has taken a long journey to achieve her RN status and is now obtaining a baccalaureate. Though she had already completed some college work, she was advised by a guidance counselor to go to an LPN program because it would take only nine months to complete. She felt that she had the ability and skills to complete an RN program, but she was told that she could do just as well by becoming an LPN. She followed this advice. In her work setting she was constantly discouraged from furthering her RN education. When she realized that if she stayed in that work situation and position she would never achieve her goal of becoming an RN, she left and went to an associate's degree program.

As Seago and colleagues note, there is a higher representation of minorities, particularly African Americans, in the practical-nurse pool than in the RN group. Why are minorities overrepresented in this group? We need hard data on this question, but I and other ethnic minority nurses have heard too many stories about minority students being tracked into these programs by misinformed counselors in their elementary and secondary schools. Health disparities continue to ravage minority communities. The care required by underserved and vulnerable populations is complex and necessitates the use of professional nurses who have a broad knowledge base and understand these communities and their needs. The role of the LPN should be supportive to the role of the RN, not a replacement for it; but many facilities already use LPNs in place of RNs. The expansion of LPN programs swells the licensed nursing ranks with the least educated practitioners, who have limited opportunities to pursue RN education. It is a disservice to those interested in nursing and to minority populations to suggest that, because minorities are increasing in the population, they should be steered into practical nursing careers instead of registered nursing careers.

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