At a recent meeting among several companies, the topic of licensed practical nurses (LPNs) in the intensive care unit (ICU) came up. For most of the attendees, the question was “who uses LPNs in their ICU?” The answer was that our hospital has been utilizing LPNs in our ICUs for years! During this conversation I also learned that more hospitals across the country are considering adding LPNs/LVNs to help with staffing shortages.
To start a conversation about LPNs and LVNs (licensed vocational nurses) in the ICU, it’s necessary to know that these two titles are essentially the same. The terms depend on the state you work in. For me, that’s New York, so our nursing staff includes LPNs, and their nursing scope of practice is guided by the New York State Practice Act. Our hospital values our LPNs for their nursing abilities. We accept their scope of practice limitations, but also want them to practice to their fullest potential (or based upon the practice act), and we incorporate them as essential members of our staffing plan.
LPN Scope of Practice
To ensure our LPNs practice within their scope of practice, we developed several policies that define the LPN’s nursing practice as well as their working relationship with RNs. For LPNs in New York, we follow “Education Law Article 139, Nursing,” which delineates the abilities and limitations of the LPN. Each of our LPNs works under the direction of the co-assigned RN. This means that all LPN documentation is co-signed by an RN, and the LPN works with the RN to provide appropriate interventions.
A large difference in scope of practice is RN assessment versus LPN data collection. LPNs are not allowed to perform assessments, because assessment data is interpreted by an RN to identify patient concerns/needs that require nursing interventions. LPNs must collect data (observations, measurements, test results, etc.) and collaborate with the RN for necessary nursing interventions.
Following are some items our LPNs can perform as well as tasks they cannot perform (since this is a partial list, please refer to your state’s guidance on LPN scope of practice):
Within the LPN Scope of Practice
- Gather data
- Identify normal vs. abnormal and report findings
- Perform peripheral IV insertion/removal and blood draws
- Flush peripheral intravenous catheters
- 2nd nurse co-sign insulin SQ and drips
- 2nd nurse co-sign for heparin drips
- 2nd nurse co-sign blood products
- Reinforce patient education/teaching
- Suctions (in-line endotracheal and tracheal)
- Trach care
- Blood glucose monitoring
- Enteral feeding
- Foley insertion
- Non-titrated medication drips
- Arterial line setup
- CRRT setup
- Compressions, bag-valve-mask respirations, runner during a code
- Postmortem care
NOT Within the LPN Scope of Practice
- Perform assessments and reassessments
- Independently alter or develop a plan of care
- Care for central access devices (venous and arterial) (flushing, zeroing, dressing changes, etc.)
- Administer IV push medications
- Administer blood products
- Insert feeding tube or NG tube
- Initiate patient education
- Flush nephrostomy tubes or thoracic pigtails
- Titrate medication drips
- Monitor abdominal pressure
LPN ICU Orientation
Our LPNs attend an orientation similar to the one for our ICU RNs. They attend our new-hire Nursing Practice Orientation, which introduces them to the hospital and to the nursing department, followed by a critical care service orientation. The critical care service orientation for a new grad RN lasts six months and includes an ICU RN residency program with six class days, completion of “Essentials of Critical Care Orientation” and a transition to practice class after completing orientation.
For an LPN, the orientation is three to six months depending on their previous experience. New LPN graduates or those coming from long-term care areas often require a longer orientation than LPNs with previous medical/surgical or ICU experience. These LPN classes are different from the ICU RN residency classes in that they are designed for LPNs. Their scope of practice is different from an RN’s. The LPNs are required to complete a dysrhythmia class that is appropriate for the LPN role and maintain their American Heart Association Basic Life Support certification.
Preceptors for LPNs include both RNs and LPNs (if there are LPNs available on the unit). Preceptors complete biweekly evaluations with the orientees, ensuring the LPNs are meeting the necessary orientation standards. During orientation, our LPNs, the same as our RNs, participate in various shadow opportunities, including:
- Respiratory therapy
- Physical therapy
- IV and phlebotomy
Working Relationship in the ICU
Registered nurses and LPNs work together to care for patients on the unit. If an LPN takes an assignment, they are always partnered with an RN. They listen to report together, and both are present during the first shift assessment, which is completed by the RN. After this first assessment, the LPN performs data collection and observations in place of the RN reassessment. All LPN documentation is co-signed by the RN during and before the shift ends. Throughout the shift, the LPN updates and collaborates with the RN on any patient changes and necessary nursing interventions. If the LPN does not have an assignment but is “helping hands,” they do not have a co-assigned partnership but work with individual nurses to complete necessary and appropriate interventions.
Examples of ICU LPN assignments (our typical ICU nurse to patient ratio is 1:2):
- The ICU RN has two patients (patient A and patient B), but patient A needs 1:1 care. The LPN is assigned to care for patient B under the direction of the RN, and the RN cares for patient A.
- In this situation, the LPN may also be assigned to another RN, completing the LPN’s two-patient assignment.
- While this is an option, our LPNs prefer to remain with one RN as it promotes a more cohesive team and shift.
- The LPN may also have a split assignment: caring for one patient and also serving as an LPN float.
- The ICU RN charge nurse needs to take an assignment, so the LPN is assigned to care for both patients under the direction of the charge RN.
- In this situation, the LPN is caring for both patients with the charge RN, but this arrangement also allows the charge nurse to focus on the needs of the unit.
- LPN float or “helping hands” means the LPN does not have a patient assignment but is available to help all the other nursing staff on the unit.
- In this situation, the LPN may administer medications, turn and reposition, help with mobility, answer call lights or perform any other activities within their scope of practice.
- The LPN may assist with multiple patients in this role, so it is the responsibility of the patient’s primary RN to co-sign the LPN for any documentation completed on their patient.
LPN Career Advancement
We have developed an LPN career advancement system that mirrors the one for RNs. There are three levels in the LPN system:
- Proficient LPN (first level, contributes to the unit, accountable for direct patient care, assists staff with providing care)
- Expert LPN (second level, at least two years of clinical experience; in addition to the abilities of the proficient LPN, they work as part of the team, anticipate their patient’s needs, assist staff with providing care for complex patients)
- Mentor LPN (third level, at least five years of clinical experience; in addition to the abilities of an expert LPN, they incorporate evidence-based practice into their patient care, and contribute to and support staff performance and growth)
As members of our Professional Nursing Council (the hospital’s shared governance council), LPNs and RNs are expected to embody our Nursing Professional Practice Model. This model includes professional development, interdisciplinary collaboration, patient advocacy, quality improvement practices and positively impacting patient and nurse satisfaction.
ICU LPNs at our organization:
- Participate in councils, teams and committees and as champions of different initiatives
- Participate in staff development as preceptors and mentors
- Achieve national certification (vascular access certification, IV therapy and pharmacology certification are the most common certifications for our ICU LPNs)
Recruitment and Retention
Many of the LPNs working at our organization continue their education to become RNs. Some decide to stay in their home unit and continue their professional development as RNs. Others have found their passion in other populations, working as RNs in our facility. Whether they stay on the unit or change units, they often remain in our hospital system. LPNs are a valuable resource and contribute to our pool of potential RNs.
Summary
Adding LPNs to the ICU is a true collaboration between both nursing roles. It requires that all nursing staff find value in each other, accepting that both LPNs and RNs attended nursing school, passed their credentialing exams and completed their training on the unit. If there is a respectful appreciation for each other, regardless of their degree, then the partnership will likely work well. LPNs and RNs are individuals who entered the nursing profession at different levels but with the same goal - to care for patients and families. As nurses, it is up to us to welcome and embrace everyone who makes the decision to join this amazing profession.
Are you ready to integrate LPNs/LVNs into your ICU? Please tell us about what works at your facility.
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