Okay, first I know the technical difference between an RN and an LPN.
I just moved my parents to a new personal care/assisted living community near me that came well recommended. (I have since learned a LOT about how things work at senior living places which would have been helpful a month or two ago).
Quick background: Dad has type 1 diabetes and a mild brain injury so he cannot manage his insulin on his own anymore. Long story but I had him temporarily in a skilled nursing home because it was the only place he could live in a crisis situation - I had lived with him for a week but had to go back to work.
While there he had 2 low blood sugar episodes, including one ER trip when he passed out. Both times he was being treated by LPNs and the facility later told me that their LPNs don’t have the training/experience to manage brittle diabetics. Fine - I was more upset about the procedures and not the individual staff members who were helping dad. (i.e.Why did the charge nurse (RN) not have better protocol in place?)
So when I was considering this new community I did ask to meet with the director of nursing because I wanted to hear how they serve diabetics and their protocol for checking sugar and dispensing insulin etc etc. In an email with the marketing person I said I was very surprised that their Nursing Director was an LPN and not an RN. She did pass on my comment to the nurse and in our meeting the Nursing Director was pleasant about it but a little defensive, explaining that she had working in personal care for 20+ years and people often looked down on the LPN degree etc etc. I had originally mentioned it because of my experience in the prior facility who did not want LPNs making management decisions on dad plus I was curious to know if they had RNs on staff.
(Now I see the place in operation and there are RNs for every shift managing things, but I did not know this at the time)
So . . .(TL;DR) did I make a really bad faux pas with the nursing director? I know it was pretty forward to question the degrees after her name, but I had been through 2 really scary events with my dad and I needed to know their exact procedures and experience with Type 1 diabetics for my peace of mind.
IMHO, it wouldn’t hurt to explain to the nursing director why you’re concerned. After that, if she’s still defensive, it’s on her. You didn’t mean to offend and she didn’t need to assume the worst.
I ran into something similar when a family member needed skilled care at home. In our area, only RNs can do anything to PICC lines. I found that out after we got home and learned that the hospital’s discharge staff had failed to explain how we could provide adequate care. Several home care providers got huffy with me when I requested an RN, before I could explain why.
I hope this episode does not cause any concern about the quality of care your father will receive. Good luck!
If her title is nursing director/Director of nursing, what reqs does such a title have in your state? Two minutes on google indicates a degree as a basic requirement with some discretion for nurses with associate’s (which I would take to still be RN, not LPN). Does her position direct RNs in nursing care, or is it purely administrative?
I cannot imagine she would take offence as she would well know that experience is imperative, but also would be well aware that a lack of credentials is a career limiter. I suspect most customers just don’t enquire about this stuff. That is far from being forward. It cannot possibly be the first or last time this has come up.
I think I would have waited until she, the director of nursing explained their protocol before asking about a degree rather than asking about a degree before even hearing the protocol. I doubt it will influence her direction to her staff about your family members care.
Since you had such scary/poor experiences with your dad’s prior care, I’d mention that and tell them with their protocol in place and functioning well you’re hopeful he will get the appropriate care he deserves and needs.
It is reasonable to be concerned about care of loved ones, especially when they can’t advocate for themselves and we’ve had scare prior experiences elsewhere.
It’s been my experience that medical professionals are pretty used to their patients/clients having had bad prior experiences. I’d just explain to her and I’m sure she’d understand.
She knows how hard and frightening it can be to look after a loved one in frail health. Just bring up your concerns.
To clarify, my original comment was to the marketing person, where I said I was surprised that the Dir of Nursing was an LPN and I was wondering if they did in fact have any RNs on staff. (I was naive in thinking that because the “top dog” was an LPN then perhaps there were no staff with a more advanced degree)
This director is new in the job, the prior Dir of Nursing was an MSN and got promoted up the corporate chain.
So in the meeting the Director of Nursing did say, “I understand you had questions about me being an LPN and not an RN” which gave me a chance to explain that in his prior community the administration had told me that their LPNs could not make decisions for diabetes (only carry out instructions) and so I was confused about how/whether she could treat him.
I imagine her job is more paperwork and administrative than clinical but I thought the title meant that all nursing care falls under her watch. Which it does. But I have since met the charge nurses who work directly with dad and supervise the LPNs who do vitals, administer meds etc and I am very satisfied with their experience and care.
Secretly I am curious as to how the charge RNs feel about working for an LPN. I am also questioning the decision the community made to hire an LPN for this job when I am sure there were a lot of qualified candidates of all backgrounds. Without sounding gossipy, she did not give the same air of professionalism as all the other admins I met did. She did not dress professionally nor was she as polished as everyone else I met - head of food services, business manager, charge RNs etc. So that also could be influencing me. Those observations of course have nothing to do with her educational background!
I have a meeting in a week with the Dir of Nursing to review the first 2 weeks and I am wondering if I should apologize again or just let it go. She has been very nice to me in all our interactions and I have no qualms about the care.
The main thing is the care. It is not unreasonable to ask about credentials for a new place that you are entrusting your vulnerable loved one. I would NOT apologize again but give honest feedback as to how you and your dad feel his treatment meant has been–great, awful or how it could be even better tho it was good, etc.
In my state, LPN scope of practice is definitely limited in comparison with RNs (who may have associates degrees or Bachelor’s degrees-the licensing exam is the same for both), and the Board of Nursing is very specific about what LPNs can and cannot do. For one thing, no LPN in my state may supervise the nursing practice of any RN, so an LPN being the Director of Nursing would probably not pass the smell test. The LPN would probably have a different title.
Most nursing homes/SNFs/LTCs are staffed primarily with LPNs but have several RNs who are either on site or available by phone.
The LPN Director of Nursing discussed in the OP would no doubt have have faced these kinds of questions before and should not be taking it personally or be offended by it. RNs have more extensive scopes of practice because they have more formal education, just as advanced practice nurses have wider scopes than RNs because of their more extensive formal education. It’s not an issue of anyone being “better,” but simply having different credentials commensurate with their training.
If the OP’s father’s diabetic treatment needs tweaking or more attention, that is what should happen. OP is her father’s advocate, and asking about this is entirely appropriate. Low blood sugar can be quite dangerous. Regular protocols may not be effective for him, so his doctor may need to change the orders for how the nurses should address his needs. It does start with the doctor’s order. LPNs should be able to follow a written protocol. The issue may be less about LPN scope and more about staffing issues.
Slightly off topic: Have you looked into the new insulin pump/CGM hybrid from Medtronic? The two devices work in concert automatically to guard against the kind of lows you describe. Might be helpful to your dad.
@13thFloor my dad used to be on the pump until he suffered a brain injury that affects his facility with numbers and his short term memory.
So the doc took him off the pump to avoid the possibility of him giving himself the wrong dose etc. I wonder if some pumps have a “lock out” feature?
The issue that sent him to the ER was a nurse who gave him his morning insulin while he was still in his room and did not know that he should eat momentarily. So she either left him make his way to the dining room or did not escort him. By the time he got to the dining room his sugar was 30 and he had a seizure.
I do agree with @Nrdsb4 that this is more a protocol issue. I informed the staff that dad should never have insulin without a meal in front of him. The new place has opted to deliver the dose after his meal, just to be sure.
The bottom line is the care your father receives. If you are happy with how the place is run and your father gets goo professional care degree titles for management don’t matter.
The long time experience that LPN director has could make her good as an administrator while the RN’s are doing the needed good care. As far as being well dressed- the hospital managerial RN’s where I was an anesthesiologist (meaning MD) dressed a lot better than I ever did when I was in street clothes! As long as this person has the management skills and those doing patient care have the knowledge and skills I wouldn’t worry. She sounds like an exception for her degree level and if she were to start over would have the RN degree instead.
You were not out of line in the slightest. I’m a bit surprised an LPN is the head person, and I’m sure you aren’t the only one to wonder. I was in the ER once and a PA and a Nurse Practitioner were in with me - I asked the difference and got quite the education, which I now don’t remember. I actually do want professionals to act, look and behave like professionals - makes me wonder what else they’re sloppy about if they can’t bother to look or talk appropriately.
Reread the thread title. Who cares about any “faux pas”, it wasn’t one anyhow. Not a social situation. As a physician I also would have been asking the questions. She should be able to handle them gracefully and understand questioning credentials since she is the exception rather than the rule in her position.
Your father is lucky you care and take the time to ensure his care is optimized.
Thanks for your comments! I am preparing the claim forms for my folks’ LTC insurance and the personal care facility has to complete a 3 page form on the patient’s condition etc. It needs to be signed by the head medical person and the form clearly states it can only be signed by an MD, DO, CRNP, or RN.
I know they have a doctor who comes in one day a week but I thought it interesting that the Director of Nursing would not be able to sign the form documenting the care of a resident.
My friend who is the director of nursing at a rehab hospital has a RN and I believe a master’s degree as well as many certifications. There is nothing at all wrong with questioning the credentials of someone who will be providing medical care or supervision for you or a loved one. Such due diligence is entirely appropriate. I check out the credentials of folks who are providing my care and that of my loved ones all the time.
It is on her for not getting better credentialed in her ‘20+’ years of experience. Frankly, I would question the judgment of an organization that put an LPN in charge of their entire Nursing organization. (Full disclosure, my mother was an RN and has a BSN). Anyone involved in that business would understand that the RN requires considerable more knowledge and effort to complete. Could you imagine a hospital putting a General Practitioner as Head of Surgery? How about a Paralegal as the head of a law firm?
What about a CEO with only a BS and maybe an MBA running a biotech company full of PhDs and MDs? Happens all the time. Folks who are organized, have a vision, and trust their technical staff with decision-making make good leaders.
If the CEO of the company happened to be an LPN, fine. I would expect they would not even mention the LPN credential as the BBA or MBA would be more relevant to the actual job of managing. You are right in that at some point most of these become administration rather than job-specific knowledge, but that is not what is being explained. This is a barely qualified nurse being placed in charge of nursing with apparently no other credentials other than 20+ years of being a subordinate nurse. She is either ignorant or lazy. Most companies would assist with tuition, so it is not the cost. The LPN-RN programs are 1-2 years (your mileage may vary). So she either was unwilling to get the additional training or was unable to pass the coursework.
There is a third possibility - maybe she was and is exceptional at what is required from an administrator in that position, so there was no need to go through all that extra schooling.
Happens all the time. Folks who are organized, have a vision, and trust their technical staff with decision-making make good leaders.