How LPNs Are Filling Nurse Staffing Gaps for Allegheny Health Network

The staffing crisis required CNO Claire Zangerle to get 'creative.'  To her nursing teams' dismay, she brought LPNs back into the health system.

As COVID-19 continues to exacerbate the nursing shortage, Allegheny Health Network (AHN) is easing the crisis by welcoming back licensed practical nurses (LPNs) who were once shown the door by most U.S. health systems.

LPNs—alternately referred to as licensed vocational nurses (LVNs)—have been phased out over the last decade by health systems seeking higher-educated nurses who can provide a wider scope of duties.

Although 14% of LPNs remain in U.S. hospitals, many (38%) took their skills to nursing and residential care venues, according to the U.S. Bureau of Labor Statistics. Others work in physician offices (13%), home healthcare services (12%), and government (7%).

Claire Zangerle, DNP, MSN, MBA, RN, FAONL, NEA-BC, chief nurse executive for AHN, based in Pittsburgh, Pennsylvania, looked for "creative" solutions to nurse staffing and saw LPNs as a key. About three months ago, AHN began a pilot program placing LPNs on nursing teams.

HealthLeaders spoke with Zangerle about the pilot program and how it's working.

This transcript has been lightly edited for clarity and length.

HealthLeaders: Let's start off with how the pandemic has affected nurse staffing in the Allegheny Health Network. I've heard you say it's the worst shortage you've faced in 30 years as a nurse.

Claire Zangerle: Yes, that's true. The nursing shortage was concerning and challenging before the pandemic, and it's just even worse after the pandemic. Not only are we seeing nurses retire sooner, but we have a different competitive animal out there right now, and that's the [staffing] agencies because the agencies are luring our nurses away from the bedside to work for much more money than we were prepared and able to pay those nurses.

I had to look at alternatives to fill those holes, and one of those are LPNs and looking to see if I can bring them back into the hospital because there were years when we were not hiring LPNs in the hospital. I'm not the only hospital system doing that. It's almost like we forgot that they existed because we stopped hiring them in acute care. They all went to post-acute care—nursing homes, assisted living facilities—because their model is such that that's usually the highest-ranking nurse in those facilities and they're paying them big dollars.

Now I have to re-look at my LPN rates and say, okay, we still use them in the outpatient area a lot, but we have to look at their rates on the inpatient side and value them more on the inpatient side than we did prior to the pandemic and prior to not hiring them anymore.

HL: Why did hospitals and health systems phase out LPNs?

Zangerle: It was mostly around the research that if you have a BSN-prepared nurse in your facility you have better outcomes—better quality, less errors, and safety is better. People going for Magnet Recognition® had to reach that BSN stat to be able to apply for Magnet and LPNs were throwing that off.

We listened to the research and the research wasn't wrong. BSNs do improve the outcomes. But I don't believe that BSNs improve outcomes at the expense of not using LPNs, and we have had to rethink our caregivers.

An LPN as part of the team is very valuable, especially in the absence of having nursing assistants or certified medical assistants and in the absence of having enough registered nurses, but that was really it. It was like, "Well, look, we don't need you guys and you guys can go work in rehab facilities or assisted livings or whatever," but that's when the nursing shortage wasn't as bad as it is now. Not even close. Now we're circling back and most of the LPNs are saying, "Okay, now we're finally getting some love here."

There are hospitals in the United States that don't hire anyone but bachelor's-prepared nurses and I think that's a mistake. Diploma nurses and associate-degree nurses have great value in our healthcare system and most of those individuals matriculate on to a bachelor's or master's degree and us not recognizing their value is kind of silly. Same thing with LPNs.

HL: Before the pandemic, about what percentage of your nursing staff consisted of LPNs?

Zangerle: Before the pandemic, it was probably about 5% and since we started hiring them again, we are probably up to about 10% of our nursing staff being LPNs and we literally are just starting to do this with gusto.

Even my own teams kind of looked at me sideways like, "What are you talking about? We're not really buying what you're selling." As time went on, I said, "Look, this is an option that we have. We can't get the nursing assistants, we can't get as many RNs as we'd like, but we have a group of people that we could reach out to." We have LPN schools around our region, and we also have two nursing schools that we can matriculate LPNs into RNs if they want to. We have to give everybody the opportunity to do the work if they want to do the work and we have the structures in place to support that work.

HL: How are you fitting the LPNs into your system now?

Zangerle: We have chosen one or two large nursing units—30, 35, 36 beds—at each of our hospitals and we're doing pilot work with what used to be called team nursing but we're calling it blended nursing because we have an initiative with throughout our enterprise called blended health between our provider organization and our payer organization.

There is a cohort of patients that is cared for by a blended team, and that blended team is led by an RN and on that blended team is an LPN and a nursing assistant. Based on their skill sets, they divide who's doing what and they're in constant communication and as team, they're taking care of their cohort of patients.

A nurse can oversee more patients if the nurse has the support at the elbow that they need, and the LPN and the nursing assistant assigned as a team gives them that support. It's just a different care model … and you can have a really good, blended team that is going to deliver high-quality care, a great patient experience, and reduce a patient's length of stay.

HL: Do you see this as a permanent solution for Allegheny Health Network?

Zangerle: I do, because our pilot units really like it. People are going to hear about this and they're going to say, "Well, this is just another version of the old team nursing," and it is another version of the old team nursing, but it's with some contemporary additions of the scope of practice.

I don't know why we would just do it now, and not continue it. The pandemic forced us to go back to this blended team nursing model and made us a little less rigid about not using the team model anymore. We got spoiled, because we didn't need to be as creative—we had the nurses to take care of the patients—but we don't have that luxury, and we're not going to have the luxury for a long time unless something drastic changes and we have more nurses that flood into the market. We just don't have the supply to meet the demand.

All the data and predictions show us that it's not going to get better in the next decade, and we need to have alternative approaches. This is a highly viable alternative approach.

Each hospital is in various stages of execution, but from our standards, objective and subjective data tells us it's working and it's a formula that's good for us. It's not on every unit, it won't work on every unit, and we don't need it on every unit. It's usually on the busy med surg units, it's good on rehab floors, it's good in orthopedics. My next target is to look how we could do this in our emergency department.

HL: What outcomes are you seeing in the last three months with blended teams?

Zangerle: Our patients are getting discharged by 11 am, because that's the goal; the teams are bird-dogging what needs to be done to get the patient out by 11 in the morning; they're working together to figure that out, as opposed to one nurse having to track down all the things that need to be tracked down to get this patient discharged. The length of stay is reducing, which means we're being able to bring in another patient to take that patient's place.

We have a huge initiative going on with hospital length of stay right now and we're seeing that, overall, our hospitals are reducing their length of stay by anywhere from half a day to a full day across the board. And when we drill down to the units, we're seeing the biggest contributor is those units where we have a blended nursing model.