Testing the Waters

An LPN is seeking support for an initiative that would allow practical nurses to 'challenge' RN licensure exams

By Joe Darrah

It's not hard to find LPNs who are unhappy with the politics of their profession. ADVANCE's online forum alone provides plenty of comments from practical nurses who say they feel disrespected, unappreciated and, essentially, undervalued by RNs and administrators.

Many also argue that job restrictions and scope of practice prevent them from working to their full potential.

These discussions are becoming more common as more facility administrators are requiring practical nurses to go back to school to earn their RN degrees or face termination or reassignment.

If only the solution were that easy.

Many LPNs who claim they'd like to earn their RN also claim to have difficulty finding the time and/or money to go back to the classroom.

Then there's the hurdle of being accepted into a nursing school, they say, especially with the faculty shortage placing strict limits on the number of students who make the cut.

Instead, many veteran LPNs are wondering why their respective boards of nursing don't give them the opportunity to challenge the RN boards, much like schools allow them to challenge certain courses.

A few months ago, Lisa Morell, LPN, stopped talking about this possibility and decided to take action. Today, she's trying to effect change through an online petition she hopes will eventually lead to nursing legislation that would allow LPNs to "test out."

Specifically, she's proposing that any LPN in her home state of Connecticut with at least 10 years of hands-on nursing experience be permitted to attain RN licensure through state nursing boards by sitting for examination.

"I don't really know what I'm getting myself into, but I'm too involved now to not move forward," admitted Morell, who's worked as an LPN the past 30 years. "Even if I don't get anywhere with this, if I can at least make some noise by just speaking my mind as a taxpayer and as a nurse who feels underutilized, I'll be satisfied."

Starting Small, Dreaming Big

Morell's diligence toward this effort is starting to make others in the profession take notice. While, as she expected, some nurses openly disagree with her plan, she also has her supporters. And, surprisingly enough, the pro and con sides of this debate do not fall evenly between LPN and RN lines.

As of May 30, Morell had accumulated more than 150 signatures in favor of her "e-petition" (http://www.petitiononline.com/lps2t/petition.html) since launching it the weekend of April 18. Any U.S. resident is eligible to sign the document (including those in the general public), though Morell is currently focusing her efforts in Connecticut.

"Every state's laws are different," she said. "And as much as I'd like to, I can't do what I'm doing for every state, it'd just be too much work. When I feel like I've received enough support, I plan to approach my congressman in Connecticut to take action."

A handful of signatures had come from Connecticut (including LPNs and RNs) but does this petition have legs in Morell's home state? While she couldn't speak for the entire board of nursing, Heidi Darling, LPN, a representative of the Connecticut BON, told ADVANCE she's strongly considering adding her name to the list.

"With the nursing shortage what it is today, this sounds like a great idea," said Darling, a 20-year nurse from Manchester, who's currently on staff in a dialysis center. "I think it's feasible, but I also think she's in for a fight."

That's at least one premise that Darling and Regina Thomson, LPN, president of the Connecticut LPN Association and Patricia Bouffard, RN, chairperson of the state nursing board, agree on.

The latter two believe it's a fight Morell can't win.

"The regulations are clear that an LPN program prepares you to be an LPN and the RN programs prepare you to be an RN," said Bouffard. "According to the regulations, the two don't mingle at all. While some skills may overlap from LPN to RN, the education preparation is different. I can't comment on the chance this has of becoming law, but I don't agree with it."

Thomson echoed these thoughts.

"[Morell's] trying to compare apples and oranges," she said. "I know other LPNs who think their license is similar to an RN's, but it's not. It's like saying being an RN for 10 years makes you a doctor. It doesn't. Her chances are slim to none."

Despite these viewpoints, as a board rep in the Constitution State, Darling said she'll exercise her right and responsibility to discuss this with board officials.

"I will bring this up; it should be brought to the board's attention that this is something people in our state our talking about," she added.

Time Has Come?

Morell isn't the first to offer such a proposition. The discussion of "grandfathering" experienced LPNs to the RN level has been discussed before, Darling said.

"Years ago, they told us in LPN school that we'd be eventually phased out and grandfathered into RN programs."

It's also been proposed in other states and, considering today's significant RN shortage combined with the dearth of available faculty to educate the necessary number of registered nurses to fill those demands, Morell said the time has come for her proposal to to be seriously considered. However, most nursing officials interviewed by ADVANCE who live outside of Connecticut disagree.

"It's not realistic to think that a nursing board would support this," said Maryann Alexander, chief officer of nursing regulation for the National Council of State Boards of Nursing (NCSBN). "The mission of a board of nursing is to protect the public, and boards strongly believe that nursing education is integral to public protection. I do not foresee any change [occurring] in the way boards think about this. This would not be safe practice."

Though not a board member, Barbara Newman, MS, RN, director of nursing practice for the Maryland Board of Nursing, supported Alexander's sentiments.

"I don't think our board would entertain this idea," she said. "The decision-making model that LPNs are taught to follow is substantially different from what the RNs do. And, in this state, the legal scope of practice and the education of the LPN form the basis for the decision-making model the LPN uses to make nursing decisions."

Judy Hale, LPN, a representative of the Pennsylvania Board of Nursing, said she wouldn't sign the petition or support such legislation if it were proposed in her state.

"As an LPN, I don't know how a practical nurse could function as an RN without going back to school," she said.

Doing 'RN Work'

But Morell argues that despite their limited scope, she and other practical nurses are being asked to perform RN duties on the floor in light of the ongoing nursing shortage.

"LPNs have long been expected to do everything that an RN does by the bedside," she said. "It's just that we don't get credit for doing what we do because of our scope of practice.

"For instance, most LPNs are technically not allowed to assess patients without an RN present, but we're constantly assessing," Morell said. "How could I not be assessing as a nurse when I'm on the floor? If someone is warm to the touch, I know they could have a fever. It's all semantics. That's why I'd also like to see the LPN scope of practice change. All states' scope should include assessment, delegation and critical thinking."

(Morell is also encouraging LPNs to participate in an online survey regarding scope of practice at http://www.freeonlinesurveys.com/rendersurvey.asp?sid=mf3tlykimxryisu422606).

In Alexander's opinion, LPNs who claim to be doing the work of an RN are probably misguided.

"It may be that they lack an understanding of the role and scope of practice of an RN and, if they truly are performing activities that should be done by an RN, they are practicing outside their scope and violating the state's nurse practice act," she said. "Studies demonstrate that many individuals 'don't know what they don't know,' and RNs do more than perform tasks. Their scope of practice entails critical thinking and high-level decision-making that has to be supported by physical assessment skills and knowledge of physiology, as well as nursing science.

"This is not to underestimate what LPNs do," Alexander continued. "They play an important role in healthcare, but it is distinct from the RN, and their education prepares them for practice at a different level."

But not all RNs agree with Alexander's premise. Count Robin Arnicar, RN, director of nursing (DON) at Frederick Villa Nursing Center, Catonsville, MD, in that number.

A former LPN who earned her ADN in 1997, Arnicar said she's gained most of her nursing knowledge working on the floor, rather than what she learned in nursing school.

"I fully support Lisa," said Arnicar, a member of the National Association Directors of Nursing Administration/Long Term Care. "I would say that 90 percent of what I've learned to do as an RN I learned while working as an LPN. I don't know that 10 years is a magic number for having enough experience [to challenge the RN exam], but then again, not everyone who goes to RN school passes the test, either."

Other Options

Academicians in practical and registered nursing speaking with ADVANCE, however, challenge the idea that experience is enough.

"Becoming a professional in anything is more than just passing a test, and it's more than just working in a particular area for 10 years," said Rocky Hanock, MBA, BSN, RN, a PN instructor with the State of Connecticut Vocational-Technical Education Department in Middletown and Eli Whitney State Technical School in Hamden. "I don't know how LPNs can think they can get the theoretical and professional development an RN receives without getting a professional degree. LPNs may get plenty of life and clinical experience, as everyone does if they spend a significant amount of time in a profession or occupation, but a degree is required for professional development and for broader and diverse perspectives on the healthcare industry."

Patty Knecht, MSN, RN, president of the Pennsylvania Association of Practical Nursing Administrators, agrees. However, she does believe in the value of practical nurse education.

"I don't believe this initiative is educationally sound, nor is it positive for the profession as a whole," said Knecht, who's also director of the PN program at the Center for Arts and Technology, Coatesville, PA. "Seamless, cost-conscious, educational career ladders should be the goal. The depth and breadth of educational differences is an issue here, as are different job roles."

The difficulty LPNs face in earning credit and being accepted into RN schools is one of the reasons Morell said she has decided to pursue this path.

"Even with articulation programs, it's very lengthy and expensive, it's still almost like starting from scratch," she said. "Schools want you to pay to take an effective-speaking class, yet facilities hire foreign nurses who can barely speak English. I'm not bashing higher education. But with the economy the way it is today, you're paying a lot of money to go back to school just to do a job you're already doing. Plus, people work full time and have kids," Morrell continued."

Morell would like to see educators who disagree with her premise help set standards and criteria for testing such skills as assessment, critical thinking and delegation to be considered in addition to hands-on experience prior to LPNs being allowed to sit for boards.

In terms of education, Thomson would rather see nursing instructors and officials preach career-ladders to LPNs. "I don't think the shortcut is the best way to your RN," she said. "The LPNs who I know who want to become an RN are going back to school for it."

Passing The Exam

Hale said she isn't sure LPNs should be made to believe they could pass the RN exam.

"Knowing what I know as a nurse, I know you have to have the appropriate knowledge to pass that test," she said. "I don't think I'd pass the test, I don't think Morell would pass the test, I don't think any LPN would."

Newman said this logic would also likely impact her state's board.

"You wouldn't want to set people up for disappointment," she said. "To grant an opportunity you'd want to promote success, not failure."

Morell and Darling prefer to think differently than Newman.

"This is all still a work in progress," Morell said. "We should be able to take the test as many times as an RN student would be permitted. I don't think that's something people think about anyway. And I may ultimately lose this battle, but at least I can go to bed at night knowing I tried to do something about it. If people already agree with me, nobody can tell me I'm wrong."

"I'd be interested to see if I could pass the test," Darling added. "I think at some point some of us get too old to go back to school, or at least too set in our ways as nurses. I think there'd have to be strict criteria for taking the test though, not just 10 years of experience."

Reeling In More Believers

Morell has heard the arguments against her "testing-out" initiative, but she still hasn't been persuaded to abandon the cause.

"Everyone has the right to disagree or add their perspectives, and I'm expecting more opposition as I move forward because people who set the agendas have already set the agendas," Morell explained. "But I also expect support to grow as well because those RNs who work with LPNs and respect us know we're competent and know that they need us."

One such individual is Maureen McCarthy, BS, RN, who signed the petition the weekend it went online.

"I don't agree with many of the restrictions that are placed on LPNs," said McCarthy, owner and operator of Celtic Consulting LLC, Goshen, CT. "For instance, in some states LPNs can't work as MDS coordinators. That's ridiculous, and facilities shouldn't have to use all their existing RN resources when they could turn to their LPNs."

Though she signed the petition, McCarthy believes there should be limitations to it.

"I do agree that LPNs should be able to challenge the boards, but I think they should be limited to attaining the ADN and should be forced to practice in the setting they're experienced in," she said. "So, I don't think you should be able to work 10 years as an LPN in long-term care and then challenge the boards to work as an RN in the OR. And the BSN degree is more geared toward management and scientific research, which isn't the same as experience working at the bedside."

Similarly, Darling proposes that those LPNs who would test out receive a level of pay commensurate with ADN nurses.

"That way, this initiative would clearly be about the nursing, not about the money," she said.

But Arnicar isn't sold on these theories. Passing the test is passing the test, she says.

"Many LPNs have the skills and abilities to do what RNs do," she said. "In fact, 90 percent of my administrators are LPNs. I honestly consider my two best clinical nurses to be LPNs. I only staff RN in administration where required by law."

What Would Happen To The LPN?

This "challenge" discussion begs the question, Alexander says, of what would become of the LPN role if states followed this trend. Would LPNs simply disappear or would they lose their duties to experienced unlicensed staff?

"I wonder if these same LPNs who want to challenge the RN licensure exam would be comfortable with nursing assistants with 10 years' experience being allowed to challenge the LPN exam, and taking their jobs," she mused. "But boards of nursing would not support that because it'd be as equally an unsafe a situation as LPNs challenging RN boards, and I'm sure LPNs wouldn't support this either."

As far as Morell is concerned, this is already an issue, sort of.

"There are many facilities who promote the use of unlicensed personnel instead of the LPN," she said. "In Connecticut, we now have paid feeding assistants — people who feed residents who have no swallowing difficulties. By using these unlicensed personnel, facilities can get things done cheaper. It's just not fair. The RNs could argue the same thing against LPNs, but if our scope of practice was more involved, we wouldn't have to be looked at in that light."

Joe Darrah is associate editor at ADVANCE.