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https://www.infirmiere-canadienne.com/blogs/ic-contenu/2022/06/20/medicaments-par-intraveineuse-optimiser-le-champ-d

Patients & nurses benefit from education program developed by employer

By Sky Ashmore & Brenda Banglayan
June 20, 2022

Why optimize LPNs’ scope of practice?

The scope of practice for administering intravenous (IV) medications varies for licensed practical nurses* (LPNs) across Canada. In some provinces and territories, this practice is out of scope. Where this practice is within scope, education for administering IV medications is provided either in practical nursing programs or as additional education following employment. In 2016, the British Columbia College of Nurses and Midwives (BCCNM) expanded the scope of practice of LPNs to include IV medication administration (with limits and conditions), requiring that they complete additional education before performing this new practice.

LPNs “provide health care services for the promotion, maintenance and restoration of health, with a focus on clients with stable or predictable states of health” (BCCNM, 2021, p. 4). Without the additional education, LPNs in B.C. rely on registered nurses (RNs) to administer IV medications, which can lead to delays in patient care and tension between RNs and LPNs.

A team in the Fraser Health Authority’s professional practice department, which provides consultation and educational support to optimize scope and promote best practice, developed the LPN IV medication administration education program. Implementation for an estimated 1,200 acute care LPNs started in December 2019 with a projected 20-month timeline. With the onset of the COVID-19 pandemic, the timeline was shortened to 10 months in anticipation of an influx of patients and strain on nursing resources.

*Graduates of practical nursing programs in some provinces and territories are called registered practical nurses.

About the LPN IV medication administration education program

The Fraser Health education program supports LPNs to become skilled in administering IV medications through self-directed learning, hands-on simulation practice, and mentorship in the clinical area. The program requires LPNs to complete the following three steps:

Step 1: completion of prerequisites (4 hours)

• Self-directed learning
  • Online education modules
  • Self-learning module
  • Online theory exam

Step 2: completion of learning lab (7.5 hours)

• In-person classroom session
  • Review of theory
  • Review of case studies from self-learning module
  • Simulation-based hands-on learning

Step 3: competency building and verification (during scheduled work time)

• Mentorship guided by 4 skills checklists
  • Each checklist to be completed at least 3 times
  • Verification for each of the 4 skills recorded online

To optimize success and warrant the costs and time commitment for this project, we provided criteria for hospitals to determine which of their clinical areas would participate. The criteria included having RNs proficient in IV medication administration to mentor LPNs and sufficient opportunities for LPNs to achieve and maintain competencies (within the limits and conditions of their scope of practice). In most hospitals, clinical areas that met the criteria included emergency, medicine, surgery and hospital-based outpatient services. LPNs working in the clinical areas that participated account for approximately 90 per cent of LPNs in our health authority’s hospitals.

Clinical nurse educators (CNEs) in Fraser Health’s professional practice department developed the education program with the support of experts in areas such as practical nursing, medication safety, vascular access, online learning, information tracking, and evaluation. We created learning materials, communication templates, tracking tools, and evaluation strategies.

We led the implementation at all 13 acute care hospitals in Fraser Health in partnership with hospital leadership (such as directors, managers, and educators) and coordinated and facilitated 118 hospital-based learning labs. Hospital CNEs supported LPNs and RNs at the unit level and collaborated with us to reinforce key messages, celebrate successes, and mitigate challenges.

Overall, nurses were eager for the scope expansion. LPNs were excited to expand their knowledge and administer IV medications, although many were nervous about learning new skills and taking on the added responsibility. Many RNs welcomed the opportunity for LPNs to broaden the scope of care they could provide for their patients. However, some were concerned about the initial increased workload of mentoring the LPNs.

Initially, hospital leadership was responsible for deciding when to implement the education based on budget and other priorities. However, with the onset of the COVID-19 pandemic, Fraser Health prioritized this education across the health authority and approved funding to implement it in all acute care clinical areas that met the criteria for participation. Costs associated with implementation included LPN education time (11.5 hours), facilitator time and supplies.

Expanding LPN scope improves patient and provider experience

We asked LPNs, RNs, CNEs, patient care coordinators and managers from participating units to complete a survey evaluating the impact of the scope expansion. Most responses indicated a positive impact on the continuity of patient care, workflow and job satisfaction for LPNs and RNs.

Impact survey results

• 86% reported a positive impact on continuity of patient care
• 88% reported an improved workflow in the clinical area
• 85% reported a positive impact on job satisfaction

Comments included the following

• “This is a wonderful game changer. The patients benefit from this greatly!” (LPN)
• “It certainly is an empowering thing to be able to care for your patient in this way.” (LPN)
• “It has freed up some time for RNs to spend with sicker patients and improves time management. It has created a stronger bond between LPNs and RNs in my opinion.” (RN)
• “This has improved my relationship with the LPNs because they do not feel ‘bad’ asking for my help so frequently.” (RN)
• “LPNs are very happy that they don’t have to wait for an RN to give IV medications to their patients. The LPNs can administer IV medications in a timely manner.” (CNE)
• “With the increasing acuity, it has been an enormous benefit to have LPNs that can administer IV medications. It has taken some of the pressure off the RNs so they can concentrate on their own patients.” (patient care coordinator)
• “The whole nursing team has welcomed this change. The physicians are thrilled, and the LPNs have expressed an appreciation for being able to further apply their nursing skills.” (manager)

Challenges become opportunities

Initially, some hospital CNEs were concerned about the amount of work needed — including co-delivering learning labs with CNEs from Fraser Health’s professional practice department — to support the scope expansion. However, as Fraser Health dedicated additional resources for this education, we were able to hire temporary CNEs and relieve hospital CNEs from teaching the classes.

COVID-19 physical distancing restrictions limited the number of people allowed in a classroom, which increased the total number of classes needed. However, the smaller class size improved facilitator to learner ratios, allowing more time for facilitators to focus on individual learning needs.

We encourage health authorities to provide additional education for their LPNs to optimize scope and improve the patient experience.

We hosted learning labs at the hospitals for the convenience of learners. Some LPNs reported feeling uneasy that classes were close to COVID-19 outbreaks, testing locations and inpatient units. These concerns added to LPNs’ anxiety about having to complete formal, complex and time-sensitive education as a new expectation of their job. Although we were unable to change some of the unfavourable circumstances, being more specific when communicating precautions and allowing time to discuss their concerns improved the LPNs’ experience.

LPNs require mentorship to achieve the competencies for administering IV medications. Some hospitals relied on RNs to mentor during their scheduled shift, which was challenging because LPNs often felt rushed and it took RNs away from their own patient assignment. Other hospitals created temporary positions for RNs to mentor LPNs. These RNs did not have a patient assignment, giving them more time to focus on the LPNs’ learning needs and reinforce best practices for all nurses. This additional resource significantly improved the experience for learners and mentors.

Ongoing optimization

Fraser Health’s professional practice department continues to provide IV medication administration education for LPNs. By the end of the hospital-based implementation, approximately 85 per cent of LPNs working in clinical areas that met the criteria had participated in the education. Ongoing education meets the needs of LPNs who were unable to take part during hospital-based implementation and LPNs who are new to acute care.

We revise the curriculum as needed based on feedback, harmful events, updates to scope of practice, and changes to protocols. Now that hospital-based implementation is complete, the professional practice department and the hospitals share responsibility for funding the ongoing education.

We are eager for practical nursing (PN) programs in B.C. to incorporate IV medication administration into their curriculum. IV medication administration is a complex skill with a potentially high risk of harm to patients. Ideally, PN students should learn these competencies as they build their foundational knowledge of medication administration. To illustrate, two LPNs who completed our program said the following:

• “The course was too much to learn in one day. It would help me retain the information if it were taught gradually.” (LPN)
• “The main issue I find is lack of time. We are working short often during this pandemic, and therefore time to practise this skill and gain competency and confidence is lacking.” (LPN)

In provinces and territories where administering IV medications is within scope but not within the PN curriculum, we encourage health authorities to provide additional education for their LPNs to optimize scope and improve the patient experience. This will also prepare LPNs to mentor PN students in IV medication administration, anticipating the education becoming part of the PN curriculum. To optimize learning, we highly recommend that hospitals have dedicated mentors to support LPNs with competency building while implementing this scope expansion.

Summary

Fraser Health prioritized scope optimization and allocated funds for the LPN IV medication administration education program for acute care clinical areas across the health authority over an expedited timeline in response to the COVID-19 pandemic. The successful collaboration of multiple individuals and groups enabled educators with Fraser Health’s professional practice department to support 1,362 LPNs through this education as of June 2022. This initiative demonstrated that investing in nurses benefits patients, the nursing team and the health-care system.

Reference

British Columbia College of Nurses and Midwives. (2021, September). Scope of practice: Standards, limits, conditions. Retrieved from https://www.bccnm.ca/Documents/standards_practice/lpn/LPN_ScopeOfPractice.pdf

Sky Ashmore and Brenda Banglayan are clinical nurse educators in the Fraser Health professional practice department. Fraser Health is one of five regional health authorities in B.C., delivering hospital- and community-based health services to over 1.9 million people within the traditional territories of the Coast Salish and Nlaka’pamux Nations.