RPNs/LPNs working in long term care (LTC) love their profession, despite the many challenges and hardships they encounter, and there certainly has been a myriad of challenges during the COVID-19 pandemic. Their profound concern for the well-being of the residents is driven by their deeply held values and a desire to provide the highest quality of care possible. This translates into a passion for, and commitment to, the residents who live in the Home.
Registered Practical Nurses/Licensed Practical Nurses (RPNs/LPNs) represent the largest category of nurses working in LTC (approximately 70%) and the majority of these RPNs/LPNs work directly on the care units. As their education and scope of practice has continued to expand and be recognized, the role of the RPN/LPN has grown and evolved in LTC. RPNs/LPNs are responsible for increasingly complex activities, including leading teams, supervising Personal Support Workers (PSWs)*, critical decision-making, dealing with families, and collaborating with others.
Examples of Roles of the RPN/LPN Nurse Leader in LTC
• monitor and supervise care provided by PSWs
• collaborate with the interdisciplinary care team
• communicate with staff, residents, families, as well as other members of the care team
• problem-solving and decision-making
• respect, value, and empower others
• build trusting team relationships
• manage conflict
• mentor and coach others
• offer emotional support to others
• conduct resident assessments (formal and ongoing)
• identify resident risk indicators
• complete documentation
• work with resident and family to develop care plans – set goals, interventions, time frames
• administer medications and treatments
• transcribe medical orders
• maintain unit medication management process
• ensure resident and staff safety
The job position of the RPN/LPN working on the care units may be referred to as “clinical leader,” “team leader,” “nurse supervisor,” or “charge nurse” etc., and these titles are familiar to most people who work in LTC. These titles are often used interchangeably, resulting in ambiguity in the responsibilities and accountabilities encompassing this role. This vagueness causes confusion for staff, residents, families, and even for the RPN/LPN Nurse Leader his/herself. In this article, the term “RPN/LPN Nurse Leader” refers to both the leadership aspect of this role, as well as the clinical, knowledge-based skills and competencies essential to achieving quality resident care.
The Impact of Effective RPN/LPN Nurse Leadership
The RPN/LPN Nurse Leader is in a unique position of being able to influence not only the quality of care being provided to the residents, but also positively impacting PSW job satisfaction. Research reports that effective nurse leadership directly impacts resident outcomes and staff satisfaction (McGilton et al., 2016a). When RPN/LPN Nurse Leaders stand strong and uphold their personal and Home’s values, they garner respect from everyone, but in particular from the front-line staff. PSWs quickly recognize they share many of the same values of their RPN/LPN Nurse Leader, and as a result, they are inspired to follow their leader. The result is a work environment where staff are truly committed to providing quality resident care. As RPN/LPN Nurse Leaders effectively lead and support the direct care staff, they are not only impacting quality of care, but they are also respecting, valuing, encouraging, and empowering the care team. As the saying goes, “happy staff means happy residents.” PSWs who are “happy” experience more joy at work, provide better care, and are less likely to leave their jobs. This has even more relevance as a high turn-over of PSWs can result in poor resident outcomes such as increased infections, pressure ulcers, increased falls, and resident behavioural issues. RPNs/LPNs who inspire their staff contribute immensely to positive resident outcomes and less PSW turnover. This fosters their personal sense of achievement and “of making a difference” – in other words, they achieve a sense of self-actualization.
Challenges Facing the RPN/LPN Nurse Leader in LTC
Up until 2020 and the COVID pandemic, much of this article would be focused on leadership development or clinical strategies, in an effort to enhance the role and practice of the RPN/LPN Nurse Leader. But the pandemic has now placed such a heavy burden on all staff working in LTC, that this challenge has taken priority. For the RPN/LPN Nurse Leader the stress and added workload has been demoralizing. Many RPNs /LPNs are now considering leaving LTC, with some even leaving nursing altogether. Others who stay are feeling frustrated, exhausted, and under-valued, although even with all the added pressures they have endured, they carry on. This raises real concern for RPNs’/LPNs’ personal health and well-being. Strategies to help address this can be found in a previous article, Nurse Well-Being and Implications for Long Term Care.
In the context of this article, given the discussion about the positive impact RPN/LPN Nurse Leaders have on quality resident care and PSW job satisfaction, this is of critical concern. Some of the challenges faced by RPN/LPN Nurse Leaders include:
- Given the ongoing challenges that COVID has created, the RPN/LPN Nurse Leader may become so absorbed in meeting new and ever-changing requirements, they may unintentionally lose focus on their staff needs. They may not recognize the PSWs’ frustrations and fears, seek their input less often, or not listen and really “hear” their staffs’ concerns.
- Staff shortages have required the RPN/LPN Nurse Leader to step in and help other nurse leaders, especially new nurses, or agency staff, who are not familiar with the residents and/or policies. This may include assisting when there is a change in a resident’s health status or completing work left by the previous shift. RPNs/LPNs are also filling gaps when they are short PSWs, spending more time helping with direct resident care. This increased workload affects the RPNs/LPNs ability to connect with, and support, the care staff, often leaving them frustrated in their abilities to do their job well.
- There may be a lack of support from senior nurse managers, given they are being pulled away to deal with other COVID related demands. This limits their availability to connect with the RPN/LPN Nurse Leaders on the units, and to hear their issues and concerns.
- Role clarity and scope of practice for RNs and RPNs/LPNs has not been well understood and still is open to misinterpretation. Nurses have had difficulty differentiating between the scope of practice of the RN and RPN/LPN leading to tension, confusion, and ambiguity as to their roles, responsibilities, and functions. It is not uncommon in LTC to hear that the RN and RPN/LPN role is the same. Although there is significant overlap and many of the tasks and functions are similar, this does not always take into consideration the complexity of knowledge, judgement, and critical thinking required of nurses to support clinical decision making. This has become even more of an issue during the pandemic. Due to the shortage of RNs working in long term care, it is more challenging for the RPN/LPN to find an RN to collaborate and consult when necessary. RPNs/LPNs may inadvertently step outside of their scope of practice and assume additional responsibilities in an effort to meet the needs of the resident.
- There has been limited availability, or requests for, professional development. When feeling overwhelmed and exhausted this is very understandable. However, further learning and education empowers the RPN/LPN and can increase their confidence and work performance. The RPN/LPN is more likely to be motivated and loyal to their organization that invests in them and supports their development. One example of this in Ontario is the RPN-RN bridging program, with reimbursement of tuition fees and other financial support. Participants must agree to work in long term care post-education for a designated time – a fantastic opportunity, as well as recruitment and retention strategy.
- Fair compensation has also been a challenge. In Ontario when the MOHLTC announced a $3.00 hour wage increase for PSWs, the RPNs supported this initiative, as they understood more than anyone the challenges PSWs have faced in the past prior to COVID, and now continue to confront during the pandemic. However, no additional financial support has been offered to the RPN Nurse Leaders, or others, in long term care. This has fostered a tense work environment at times, as RPN do not feel recognized for the contribution they have made, and continue to make, to ensuring quality care. The $3.00 an hour raise was a PSW recruitment and retention strategy, and yes, we need more PSWs in LTC. However, RPNs/LPNs feel they have been treated with a lack of respect and dignity, and it has given them one more reason to re-consider their future in LTC, especially given the growing workload, stress, and responsibilities they are facing.
- COVID-19 has highlighted the significant shortcomings in our health system, and in particular LTC. Nurses have been calling for reform in LTC for many years due to the struggles they have encountered in the optimum delivery of person-centered care and quality of life for residents. Increased funding is a high priority; for more LTC care staff, more full-time positions, and adequate staffing levels, are essential. As governments move ahead with plans to significantly improve long term care, RPNs/LPNs working in the sector need their voices heard, as they are experts.
Realizing the Opportunities
The list of challenges facing RPNs/LPNs working in LTC are substantial, but there is reason for optimism. Never before has there been so much attention focused on LTC … by the government, media, families, other groups, and associations. Governments are committed to making significant improvements to ensure the safety and quality of life for residents and to improve the work environment for staff.
While the disproportionate number of resident deaths, and countless hours of overtime to the point of exhaustion, has taken a profound emotional and physical toll, there is hope.
Staff, residents, and families are accepting the new realities, and making adjustments. Public sentiment has shifted in support of change in long term care. These changes signal a new era, a period of hope and renewal – a just reward for all who have served their residents so courageously through the pandemic.
RPNs/LPNs need to seize this opportunity! This is the time to renew your passion for LTC. Dig down deep and find your inner strength, courage, and commitment to the residents. Consider this …
Hearing patients reflect on their families, their grandchildren, their lives—and often being with them in their final moments—offers a professional and personal significance that keeps many long-term care nurses right where they are.Wolters Kluwer Health May 05, 2015
*PSW – personal support worker, may also be referred to as a personal care attendant/aide