Licensed practical nurse scope of practice and quality of nursing home care

Although higher levels of registered nurse (RN) staffing in nursing homes are related to better care quality, licensed practical nurses (LPNs) provide most licensed-nursing care; prior research is mixed regarding how this influences quality. The nature of LPN practice, and RN direction of that practice, follows in part from state nurse practice acts (NPAs).

Among the 50 states and the District of Columbia, the aims of this study were to describe regulatory differences in how LPNs contribute to nursing assessment, care planning, delegation and supervision, and RN practice in these domains and to explore how these regulatory differences relate to quality of care in nursing homes.

The study design was a sequential explanatory mixed-methods design of NPAs and Centers for Medicare and Medicaid quality measures of long-stay nursing home residents. In the qualitative strand, 51 NPAs and related administrative code were analyzed to classify guidance on RN and LPN practice; then, the coded data were transformed to quantitative indicators of specificity regarding LPN and RN scope of practice. In the quantitative strand, state NPA data were linked to facility-level Centers for Medicare and Medicaid staffing and quality measures (N = 12,698 facilities) for cross-sectional, quantitative analyses.

States varied considerably in how NPAs guided LPN and RN scope of practice. NPA differences were related to quality indicators of resident pain, catheter use, weight loss, and restraints, even when accounting for nursing home staff mix.

Care quality was better in states where the NPA clearly described LPN scope, but only when there was also greater RN availability (p < .05). Classifying scope of nursing practice regulations moves beyond traditional staffing measures to inform understanding of the effects of the RN-to-LPN staffing ratio on quality of care in nursing homes.