Special Report: Improving Staffing Quality

Expanding use of LPNs boosts staffing flexibility

Hospice exceeds requirements, aims for top quality

The Hospice of Lancaster County in Lancaster, PA, never hired home health aides and homemakers because when the not-for-profit hospice was founded 25 years ago, hospice managers chose to go a step beyond the minimum requirements. "We think outside the box," says Janet Carroll, MSN, RN, CHPN, vice president of clinical services for the hospice.

Replacing home health aides with LPNs provides the hospice organization with flexibility, as well as providing opportunity for quality improvement, Carroll says. "For example, if an aide was going into the home and the patient was incontinent, and the aide changed the bed, now the patient would need a Foley catheter, which would require another visit by a licensed person," Carroll says. "By the time that person got there, the patient would be incontinent again, and the bed would need to be changed again, and that would be more disruptive for the patient and family than if the LPN was there from the start to make that assessment and intervention."

Likewise, the hospice hires social workers with MSWs, instead of settling for the minimum requirement of BSW, Carroll says. "I think it’s important for our industry to be continually stretching itself," she adds.

While it may cost extra for a hospice to go beyond the minimum requirements, the overall financial bottom line probably will benefit, Carroll notes. For example, in the situation in which an LPN is able to provide a nursing service that an aide cannot provide, the agency is saving money by not having two disciplines making a visit to the home, with the double cost in mileage and salary, Carroll says. "There’s also an issue with training and supervision, and when you have licensed staff, you start a little ahead of the game," she notes.

Also, there is the cost of staff turnover to consider. "Our experience has been that LPNs have a high degree of job satisfaction because there’s an independence in their practice that they might not have in another setting," Carroll says. "And we do expect them to do more; they provide LPN and homemaker services."

For instance, LPNs will provide some complex wound care, as well as blood draws, and they may give hospice management feedback on symptom management, Carroll says. "The LPN works closely with the RN and the coordinated plan of care," she says. "We look to the LPN’s input and experience to complement what the RN care manager is doing."

One of the reasons why job satisfaction is high among LPNs at the hospice is that these employees are given more autonomy and bedside work, Carroll notes. The LPN staff typically have moved to hospice care after working in other health care settings where they were given greater desk responsibilities that took them away from hands-on patient care, she says. "Basically, we look for people who want to get back to hands-on care and want to spend time with patients," Carroll says. "They let go of the role of being the charge nurse, which is often their role in a nursing home." At the same time, the hospice LPN works with a strong interdisciplinary team that shares responsibility for patient care.

When hiring new LPN staff, Carroll often hears this refrain: "We’ve heard your nurses get to spend time with their patients; that’s why I became an LPN instead of an RN, because I want to spend time with patients." One of the challenges in using LPNs instead of aides is that there’s a potential for role-blurring, Carroll notes. "There isn’t anything that an LPN does that an RN can’t do," she says. "Then there’s a component that only an RN can do."

Since LPN staff may vary in skills, hospice managers work on maximizing each employee’s gift and skills, Carroll says. "Sometimes it’s hard for RNs to give up tasks, so it’s important to build relationships and trust, so the right hand feels good about what the left hand is doing," she explains.

Team leaders may work with RNs to encourage this trust. For instance, a team leader might say to an RN, "The LPN is going there today, and perhaps the LPN could ask this question or assess this point and get back to you, vs. making two visits to the patient if that’s unwarranted," Carroll says.

Training LPNs for hospice care is similar to RN training, but with the omission of case management and physician orders, Carroll says. The hospice provides education in pain and symptoms, spiritual care, grief and loss, reimbursement, overall benefits, and raising the level of the agency’s practice to provide greater flexibility in responding to patients’ needs, she says.