Ana Elizabeth Cowan, J.D., LL.M candidate
It is no secret U.S. hospitals are currently experiencing nurse shortages. Despite rigorous recruiting efforts, over 126,000 registered nurse ("RN") positions are waiting to be filled across the country. See AHA News, 7/30/2001, Vol. 37 Issue 38, p.6. To make matters worse, the future is not expected to bring improvement. By 2010, projections indicate a shortage of one million nurses. See AHA News, 7/9/2001, Vol. 37 Issue 27, p.6. This shortage of qualified workers invariably takes its toll on patient healthcare, forcing healthcare entities to face the dilemma of how to maintain quality care while balancing the realities of supply and demand.
Hospitals have reacted to the shortage of nurses by offering more overtime, reducing inpatient beds, and postponing elective surgeries. None of these measures benefits hospitals or patients in the long run because nurses are overworked and the publicís ability to access healthcare is limited. As a result, hospitals are increasingly attempting to hire a wider array of individuals to perform tasks once performed by RNs. The hiring of these less qualified individuals offers an effective means of addressing economic realities. However, in order to maintain quality care, it is imperative to ensure that the tasks assigned to these less qualified individuals are appropriate. Just as uniform standards govern the boundaries of care by RNs or physicians, there must be a clear understanding among healthcare entities as to what duties these newly hired individuals can perform. Unfortunately, because these standards do not exist, hospitals and healthcare workers are exposed to civil and criminal penalties.
The determination of whether an individual should perform a particular task depends on two factors. The overriding concern should be whether the individual actually possesses the knowledge and expertise necessary to safely perform the task. The next determination is the amount of supervision required over that individual. The level of supervision correlates directly with the complexity of the task assigned. Take a hypothetical job description from a Texas hospital seeking an individual to perform the following duties: (1) administer injections; (2) provide patient education; (3) monitor vital signs; and (4) coordinate blood transfusions. Assuming RNs are not available, the hospital is faced with the question of whether a less qualified or unlicensed individual can perform these listed duties.
It is only natural for a healthcare entity to prefer a credentialed individual to perform the above mentioned tasks over an unlicensed individual. As a result, a hospital will often seek a licensed vocational nurse (hereinafter, "LVN") when RNs are not available. However, in hiring LVNs, hospitals are faced with a unique problem. The Texas Legislature has failed to provide any kind of true standard or "practice act" as to what kind of tasks are appropriate for an LVN. Consequently, specific nursing interventions and clinical skills relative to LVNs are not delineated. The Board of Vocational Nurse Examiners has provided "statements" outlining the proper roles of LVNs. Regrettably, these statements are sparse and only address a few procedures. The only true guidance offered is that "care responsibilities of vocational nurses should be within the parameters of their educational preparation and their demonstrated abilities" See http://www.bvne.state.tx.us/scope_of_practice.htm. The effect is that hospital administrators are left to speculate as to what is appropriate--resulting in haphazard standards.
In one instance, a healthcare entity may apply stringent criteria, while in other situations a hospital will be more lax, ultimately endangering patients. These types of determinations are inappropriate. There is a definite need to set forth the boundaries and duties of LVNs, especially during a time when hospitals are hiring an assortment of individuals to execute tasks once performed by RNs.
An appropriate stepping stone to providing clearer LVN standards is the Texas Nursing Practice Act (NPA). The NPA does an excellent job of determining what tasks are appropriate for RNs. Great care is taken in formulating the boundaries of professional nursing and the various duties of RNs. With respect to the hypothetical job description, there is no question that RNs may perform all nursing duties. For example, as part of an RN's duties, he or she must accurately and completely report and document: (1) the administration of medications and treatments; (2) a clientís signs, symptoms, and responses; and (3) promote and participate in client education. See Rules and Regulations Relating to Professional Nurse Education, Licensure and Practice Section 217.11 (February 2001).
In comparison, healthcare entities are left to rely on non-comprehensive statements to determine whether LVNs may carry out the exact same duties. Of course, it is easier to determine the tasks appropriate for an LVN when considering simpler tasks, but the sticky issue of assessing the appropriateness of more complicated procedures is unsystematic. According to published statements, LVNs may not perform venipuncture, administration of intravenous fluids, intravenous medications, and intravenous push medications until completion of a validation course. This short list omits a multitude of procedures that hospitals would like LVNs to perform. At the very least, a code should be established in which LVNs have notice of the various duties they may perform and whether they have the authority to delegate activities to unlicensed individuals.
I mention a need for comprehensive rules concerning delegation because when nurses are unavailable, the need arises for unlicensed individuals to undertake duties previously performed by RNs. It makes sense to capitalize on existing RNs or LVNs by utilizing their knowledge and expertise to supervise less qualified individuals. This allows nurses to delegate simple procedures in order to concentrate on more complicated cases.
In terms of the hypothetical job description, the question has been answered in terms of what RNs may delegate to an unlicensed individual. For example, RNs may delegate: (1) the collection, reporting, and documenting of vital signs; and (2) the reinforcement of patient health education (but the unlicensed individual cannot be directly responsible). The one stringent prohibition is that the unlicensed individual is precluded from administering injections. See Rules and Regulations Relating to Professional Nurse Education, Licensure and Practice Section 218.7 (February 2001).
The NPA provides guidance as to the scope of LVN delegations. For example, if RNs cannot delegate the administration of injections, it is safe to assume that LVNs cannot make the same delegation. The more difficult situation arises when RNs have the power to delegate. The two forms of delegation must be differentiated. Although the unlicensed individual may have the same expertise in both situations, LVNs do not possess the same knowledge as RNs. As a result, the levels of supervision available are not equivalent. Hence, proposed standards for the scope of practice of LVNs should also consider appropriate delegation powers.
In light of todayís RN shortages, the hiring of new individuals and the delegation of duties are cost effective measures that may be properly administered to the benefit of both patients and health care entities. However, health care entities should not be left to play a guessing game as to what duties are appropriate.