Just as Pinocchio longed to be a “real” boy, nurses still long for legitimization (McNamara, 2009; Wolf, 2006). The term real nurse still tends to surface repeatedly in the literature and media (Bassett, 2002; Howett & Evans, 2011; Ousey, 2007). Further, the ongoing discussion of what exactly is a “real nurse” frequently centers on describing the attributes of a “real nurse” and issuing the call to arise to this epitome (Anonymous, 2009; Sears, 2006; Spahr, 2008).

Horton, Tschudin, and Forget (2007) cite over 39 descriptors that a nurse should value and incorporate into practice. Faced with an almost impossible image to live up to, in some specialities, nurses themselves struggle at times to “claim for themselves the identity of ‘real’ nurses” (Ousey, 2007; Snooks et al., 2008, p. 637). This legitimization is even more problematic for the licensed practical nurse (LPN) who faces additional barriers and often is not viewed as a “real nurse” (Salisburg, 2010). LPN marginalization, in terms of critical race theory, could be attributed to “institutionalized racism” (Yosso, 2005, p. 72). The lack of legitimization and added “marginalization [which occurs from] within” (Ramirez-Sanchez, 2008, p. 89), and across societal and healthcare structures, makes this an ongoing and salient issue for nurses today. The purpose of this paper is to explore the impact of the label “real nurse” on post-LPN to baccalaureate nursing (BN) students.

Literature Review

The word real can be understood as a state of being where one “becomes” (Janzen, Perry, & Edwards, 2011). Janzen further describes the concept of “real” as being an “active process” that is “co-defined by all individuals who interact . . . within a given” environment, and which through sustained “effort by all participants . . . evolves and grows . . . [inter] dimensionally” (p. 2). This suggests that in a profession such as nursing, the members of that profession define what is “real,” and this definition is subject to change. Additionally, the social construction of “real” is mediated by culture, history, and the larger social structures of the society (Vygotsky, 1978).

This is partially reflected in the evolving scope of practice of the various facets and fields of nursing over the past 120 years since nursing was first proposed to be a “professional occupation” in North America (Boutillier, 1994). Boutillier suggests that from the underpinnings of the 1890s, an idealist picture of what constituted a “real nurse” emerged as “an exclusionary and hierarchal model of nursing professionalization” (p. 20). This hierarchy, which still continues well into this new millennium (Platzer, 2004), has done little to provide clarity in defining the “real nurse,” leaving even the profession asking “Will the real nurse please stand up?” (Elms & Moorehead, 1977; Fletcher, 2007; Porterfield, 1986).

Specialization has only served to compound the debate of who exactly is a “real nurse” (Happell, 2006) . In addition to the presence of nurse attendants and LPNs, other levels and fields of expertise in nursing have been introduced into the healthcare arena. These include (but are not limited to) telenurses (Snooks et al., 2008), advanced nurse practitioners (Paniagua, 2010), correctional healthcare nurses (Hardesty, Champion, & Champion, 2007) , addiction nurses (Clancy, Oyefeso, & Ggodse, 2007), mental health nurses (Happell, 2006), nurse educators (MacPhee, Wejr, Davis, Semeniuk & Scarborough, 2009), and nurse managers (Bolton, 2005).

For almost 50 years, there has been a call for registered nurse (RN) to become and epitomize what was coined by Smith (1953) as a “real nurse.” At a time when the role and scope of nursing assistants (the precursors of today’s LPNs) were being determined, it was deemed that the “problem as a profession [was] to learn how [nursing assistants] best fit into a successful nursing team” (Smith, 1953, p. 180). Smith notes that, while very much needed, these nursing assistants were not considered “real nurses” but rather helpmeets for professional RNs who were struggling to deal with an ever-increasing workload and responsibilities.

While the role and title of RN have been synonymous with being a “real nurse” for decades (Porterfield, 1986; Smith, 1953), the title and role of an LPN are still anecdotally disparaged as an acronym for “least paid nurse” (Anonymous, 2007a, para. 1), “little pretend nurse,” or “licensed partial nurse” (Porterfield, 1986, p. 65). This sentiment continues to be accepted by those within and without the nursing profession, including patients, the general public, the media, nurses themselves, and other healthcare practitioners (Anonymous, 2007b; Howett & Evans, 2011; Ousey, 2007; Porterfield, 1986; Saliday, 2004) who decry the LPN as not being a “real nurse” (Salisburg, 2010).

While studies on the socialization of RN to BN students continue to emerge, there are few studies and academic writings that explore the socialization of LPNs in post-LPN-BN bridging programs (Melrose & Gordon, 2008). Melrose and Gordon (2011) note that LPNs “face unique barriers as they transition towards a new and more complex nursing role” (p. 31). Ham (2002) describes the LPN-RN transition as “difficult” (p. 3). Duncan and DePew (2011) cite that although the preexisting identity of an LPN is strong, a new identity is formed in a resocialization process, which for many LPNs is problematic.

Shane (1983) describes a resocialization process that is fraught with role conflict. Idealism as an LPN is confronted with realism of a changing role (Duncan & DePew, 2011; Harrington & Terry, 2009). Feelings of “frustration, fear of failure, and inadequacy” can result (Sweet & Fusner, 2008, p. 204). Could it be that role conflict and the struggle with new identity formation are partially rooted in the LPN not being considered a “real nurse?”

As there is relatively little known about the socialization of LPNs in post-LPN-BN bridging programs, unanswered questions arise. How do post-LPN-BN students view themselves given the labels that are placed upon them by others? Do post-LPN-BN students come to terms with these labels, and if so how? Is there a shift in perception when LPNs enter and progress through post-LPN-BN nursing programs? The purpose of this paper is to explore the perceptions of LPNs in a post-LPN-BN bridging program related to the term real nurse.

Methods

This project is part of an overarching program of research exploring the transitions that LPNs experience when they upgrade their education to become RNs. Framed from a constructivist theoretical framework, the purpose of the study was to describe post- LPN-RN student nurses’ experiences with professional socialization as they learned a more complex nursing role.

Setting and Participants

Participants were 27 LPNs enrolled in a BN nursing program who were currently attending a practicum on an acute hospital unit.

Data Collection and Analysis

Data sources included four face-to-face digitally recorded, transcribed focus group discussions. The focus groups were conducted in different cities over a period of two university terms. QRS International’s NVivo 9 was used to organize the data collection and analysis. Transcripts from the focus group discussions were analyzed for themes. Investigator triangulation and member checking ensured trustworthiness and authenticity of the findings. Full ethical approval was granted by the university’s research ethics board. In our analysis of the data, our findings led us to a variety of different issues that LPN to RN students face, and we report on these issues elsewhere. In this article, we discuss our findings related to a theme that stood out for us as particularly impactful. Our LPN participants expressed how, for them, the term RN did not just stand for registered nurse, but also “RN stands for real nurse.”

Findings

The Label of LPN: “You’re Just an LPN”

Post-LPN-BN students, given the labels that were placed upon them by others, experienced considerable bias about being LPNs. They felt looked down upon by many of their nursing RN counterparts as if they, as LPNs, were “less than” the RNs. They felt that this was a process where they were “stomped on.” One student framed this, saying, “It’s almost like there’s no recognition for what we’ve done in our careers and that is extremely frustrating because it’s like none of that mattered …”

One student related, “Even [as] an LPN, [there are] RN’s that are going, you’re just an LPN.” Despite having many of the same skill sets as the RNs, students felt “offended” and “insulted” that their expertise as LPNs was not always recognized. Students became “defensive of the LPN role.” One student, who had been an LPN for 4 years prior to entering the post- LPN-BN program, described the frustrations . . .

You kind of get tired after a while of being like, oh yeah. I’m in school doing my RN. You’re not an RN? No. I don’t know, you don’t feel like . . . you feel like you’re doing all that stuff already and so why shouldn’t I be getting … I mean it’s not about pay, and I don’t want it to seem like it is, but at the same time, it kind of is! In the end, if we’re doing the same thing and getting paid different, and I mean it’s not necessarily just the skills, because I know that that’s the number one argument for RNs, right? Is this idea that RNs see you know, this bigger scope and you’re kind of you know, population, and critical thinking which we kind of … it can be a little offensive sometimes because it’s like so my entire last 4 years, I have never looked at a patient in context of their life, you know? Or a wound in context of health or whatever and it’s just you do that, and maybe we’ve had to learn it more on the job because all we really got was skill base in our program . . .

It was not the RNs alone who expressed that LPNs were “less than” but their patients as well. This was attributed to both the historical view of LPNs as nurses’ aides and a skewed view of what a nurse was. Many patients did not know what an LPN was . . . “And you get that question, what’s an LPN? It’s frustrating because we are nurses already but people don’t see that. And they don’t know the difference.” Another student echoed this sentiment with the patients that the student cared for.

I think people don’t actually know what the role is of an LPN. Like you say, people say, oh well, what does an LPN do that’s different from an RN. I think that’s why when you say, oh, I’m an LPN, and they kind of look at you differently because they might have this thought in your mind, or in their mind that you’re kind of like a nursing attendant or something, because that’s kind of what we’ve been historically but now our scope is just like changing so fast that yeah, I think people just don’t know . . .

At times, this bias was so pointed that patients requested that the LPN get an RN when assessments were being done. One student related, “Even when I do my assessments I have like the residents say, well, maybe you should get an RN …”

LPNs were not viewed as “real nurses” because “real nurses” were attributed by patients to being solely an RN. This was illustrated by one student who said, “I think it’s more that you hear [you’re] just an LPN . . . you’re not a real nurse. Because people think RN stands for Real Nurse.” Another student reflected upon her experiences, saying, “But I mean, I’ve actually had people, I had people say to me when I was going through the PN program, oh, well, are you in the program to be a real nurse or one of those other nurses?”

There were several additional labels for LPNs that arose from patient and staff encounters. These included “limited,” unqualified, “less common sense,” “less . . . ability,” less “capable,” “less professional,” and “unable to critically think.” These labels were both “frustrating” and “offensive,” and undermined LPNs’ self-confidence.

Coming to Terms With Labels: “I Don’t Even Say LPN, I Say Nurse”

These post-LPN-BN students come to terms with these labels in several ways. Some felt that they had to “prove themselves” to those around them because, as one student said, “[s]ometimes there’s a fallacy that an RN gives you more . . . common sense or abilities than an LPN might have.”

You know, trying to prove myself to all of the these RNs and LPNs that have worked here for so long and that’s how you know, you gain their respect as an LPN by proving yourself, you know. It’s a tough world, but it’s kind of like one of those things.

Being questioned for their ability to critically think was a common experience for almost all the students. What resulted was an internal struggle. “And so I’m still finding there’s a bit of an inner battle with that because I do believe that as LPNs we are critical thinkers. We are you know, we’re amazing nurses . . .” This often led to feeling “defensive,” and as one student expressed, “I’m sick of being undervalued.”

I have been critically thinking for 7 years. Like I do total care for my patients and monitor all their blood work and all their diagnostics and everything, it’s not like I go in and do a bed bath and say, you know. I’m done for the day! No. Like get somebody up and walk them, and you know, we do everything.

Other students came to terms with the labels that they had been given by publicly relinquishing the title of LPN. Instead of telling patients that they were LPNs, they referred to themselves as only “nurses.”

I don’t even say LPN. I say nurse. When they ask what I do. I’m a nurse. It’s just because how am I supposed to explain the distinction when I don’t feel like there is much of a distinction in my role . . .

Another student framed it this way: “I don’t say to people. I’m going to be your practical nurse today. I’m your nurse today. My name is (name) and I’m going to be your nurse today. I’m here until this time.”

Students felt that without making their LPN identities known, no one “could tell the difference” between themselves and an RN. It was only when they were asked to do something outside their scope that this difference was identified by others. One student related:

I also felt limited because I feel like LPNs sometimes get that stigmatism. You would be doing work and then somebody would ask you to do something that’s out of your scope and you say, sorry, I am an LPN. And they would go, oh, I didn’t know that you’re an LPN.

This was substantiated by another student who said:

It’s almost sometimes attributed as a negative—oh, you’re an LPN! Or oh, I didn’t know. Well, if you didn’t know, then you know, why is it. . . . It must not matter. Why is it a negative? Because you couldn’t tell before that point.

Even as students moved through their post- LPN-BN practicum, they often continued to refer to themselves only as student nurses. This was a source of conflict for them as they still “felt proud of [themselves] … for the knowledge [they] already had.” In their minds, they felt they were “already a nurse.” Being a student was a step backward for them, as in their practicum they were not allowed to do many of

the skills that they did with regularity as LPNs. The students felt pressed to leave their identities and knowledge as an LPN behind, and “think like an RN.” One student reflected:

I’m still very proud of the work I do as an LPN and I’ve found it frustrating with some of the teachers and some of the assignments, like okay, you know, because there was one in I think our second cluster of classes about . . . the whole paper was on the transition and I was just like, what do you want me to say? Well, even our independent study class, she kept hammering me, well, all that stuff you do as an LPN too, this is a baccalaureate program, you need to think like an RN. And I already feel like I do think like an RN and I found it very frustrating and almost devaluing the work that I’ve already put into the profession.

Shifts in Perception: “It’s All About Empowerment”

There was a shift in perception when LPNs entered and progressed through the post-LPN-BN nursing program. There were many impetuses that contributed to this shift. Part of this was attributed to recognizing the limitations of being an LPN and the lack of mobility. One student explained it this way: “You reach a certain point where that piece of paper only gets you so far as an LPN.” Another related, “There are not so much options to further your career if you’re an LPN whereas if you’re an RN, there’s so many opportunities out there that you can go to, to specialize.”

While some students still saw being an RN as “just a piece of paper,” which would legitimize them and their knowledge, others began to identify the many ways that being an RN would change their lives. One student described this shift as “nurse life changing.” Many students began to recognize that a “transition” was occurring within them where they began to see themselves as RNs instead of LPNs. This was articulated clearly in the words “I am an RN.”

Students began to recognize that being an RN changed their outlook. While students felt that at the beginning of their program RNs and LPNs were only differentiated by their scope of practice, this perception changed. One student reflected: “In this practicum we’ve kind of realized like an RN and an LPN have totally different jobs and the amount of like thinking and researching and whatnot is totally different. And I didn’t know that till now.” While LPNs were reluctant to relinquish their title as LPNs, they were quick to identify what being an RN would mean for them. Students expressed a newfound “sense of validity.”

For myself I think, it gives me a sense of I have the right to be here, you know what I mean? I’ve earned the right and then people aren’t going to question what I bring because I am an RN.

Another student expressed: “So you can say, I’m an RN and therefore I deserve, you know, your respect.” No longer did they have to approach RNs as a conduit to physicians and decision making, but they were able to appropriate this independently. This was freeing for them. One student related, “I think that was the biggest transition for me was actually going from helpless to feeling capable.”

The students were able to construct new labels for themselves, such as “powerful,” authoritative, “role model,” “respected,” collaborator, “generalist,” “capable,” deserving, “strong,” “influential,” “autonomous,” “independent,” and “confident.” Perhaps the most impactful label that they constructed for themselves was “empowered.”

It’s all about empowerment… As a Licensed Practical Nurse, we were never taught about things like that. We were never taught that we were powerful people. We were never taught . . . that we were strong, strong individuals. In this upgrading program, we feel empowered now as we’re growing into this role.

Discussion

The results of this study lend support to the proposition that role conflict and the struggle with new identity formation are partially rooted in the LPN not being considered a “real nurse.”

Role Conflict

“Role taking [is perceived to be] an ongoing social process [which is] situated within a social system” (Bolton, 2005, p.10). The role of LPN can be simultaneously embraced and distanced, which according to Goffman (2004a) has consequences. Goffman sees these consequences as the “penetration of ego- boundaries,” which can leave individuals “fearful [and] threatened” as they attempt to stabilize their worlds (p. 137). This supports the LPN experience of significant emotion as they move through finding their place and fitting into their new roles as RNs.

LPNs can view themselves as simultaneously engaging in what Goffman (2004b) describes as two incongruent roles. One role represents an affirmation in the belief that they are still “real nurses” and another role where they are not recognized as such. This creates a sense of role conflict (Goffman, 1959).

The sense of frustration and conflict is posited to be beneficial, if not necessary, for new identity formation (Corwin, 1961). As the post-LPN-BN students find their way of being in the world (Heidegger, 1962), the role conflict that they experience does not appear to subside. While this suggests that a resolution of conflict does not occur, further study may assist in determining if the conflict eventually resolves as their identities become more solidified in their roles as RNs.

Identity Formation

Role conception, role certainty, and role frustration “all represent tangible means through which a person establishes and validates an identity” (Corwin, 1961, p. 86). Doane (2002) emphasizes that “nurses’ identities [emerge] through layers of negotiation with self, with others, and within the context of social organization” (p. 630). As post-LPN-BN students moved through their program, the negotiation was not a linear process. Rather, the process was iterative in nature as the students came to a more solidified identity and were able to construct positive labels for themselves. These new, empowering labels superseded the stigmatizing labels that had been given to them as LPNs.

Corwin (1961) describes identity formation as a process that includes both the “real” and the “ideal.” The process of establishing and validating identity is the “ideal,” while “ambiguities, conflicting and frustrating circumstances” are the “real,” or replicate the current or ongoing situation (p. 86). “Proving to others what [the LPN] already knows” (p. 86)—that they come to the program already as “real” nurses— reflects these processes. This is consistent with Cragg’s (1991) observations where the identity as a nurse is already in place through prior socialization. Bolton’s (2005) conclusions are also supported that there exists an “enduring image … as a nurse” despite the movement toward an alternate professional role (p. 19).

The “real” represented the identity that the LPN already had, while the “ideal” was a construct to which the LPN would become. This “becoming” seems to be centered in an ongoing process where LPNs “earn [both] the title” and identity of RN, for both themselves and others (Happell, 2006, p 156). This, in turn, brings “strength, creativity and diversity” (p. 156), and could represent an ongoing developmental process in which post-LPN-BN student negotiates being in the world or the world of the nursing profession (Heidegger, 1962).

The Attribution of Labels

Conceptions of the labels “ideal nurse” and the “real nurse” appear to be socially or other-constructed, as well as self-constructed. While it is believed that students personally construct their identity as a nurse (Corwin, 1961; Stockhausen, 2005), it is posited that the labels that have been socially constructed also contribute to identity formation in LPNs. These labels can be internally adopted by LPNs, and may influence resultant behaviors, decisions, beliefs, and self-concept (Ketola, 2009). The negotiation of identity could be described as an internal struggle where conceptions and labels of the “real nurse” were pitted constantly against those of the “ideal nurse.”

Williams (1978) suggests that conceptions of “the ‘ideal nurse’ [are] incongruous with those of [the] ‘real’ nurse [which are highly tied to] self-concept,” and thus their emerging identity (p. 44). In essence, the LPN comes to a crossroad where each student must choose between the “real” and the “ideal.” Publicly relinquishing his/her title as LPN may reflect this process.

Metaphorically, an LPN—like a baby bird who struggles to emerge from its shell—may find the label of not being a “real nurse” restrictive and requiring action. The resultant struggle and action toward becoming an RN could be understood as prerequisite in developing a new “RN” identity. Just as the bird’s struggle is necessary for its survival in the larger world, perhaps the struggle that the LPN engages in prepares the LPN for the rigors of the professional world in which the LPN, now as an RN, will enter.

It is a common perception that RNs “eat their young,” which can be devastating for new RNs. The post-LPN-BN students who emerge from their educational programs do so with feelings of newfound strength, confidence, and courage. This could be attributed to the considerable bias they have experienced as LPNs. The ability to construct new labels for themselves may be protective as well as empowering.

Just as a mother bird must push their young out of the nest in order to fly, the new labels can act as a springboard for launching post-RN-BNs in their new professional careers. What may result are RNs who fully believe that they can make a difference as they begin to not only fly but also soar.

Limitations

Although the purpose of qualitative research is not generalizability, a small sample presents as a limitation of this study. Krueger and Casey (2009) outline several criticisms of focus groups. These include potential intellectualization, the communication within the group lacking emotion, the possibility of not accessing true data in terms of participants making up answers, trivial results, and the presence of dominant individuals who may influence results. These limitations were countered in part by the use of multiple focus groups, the expertise of the research assistants regarding interview techniques to promote reflection, the sharing of emotion and inviting the voices of all group members, and the restriction of group size which is felt to help decrease shallow and inconsequential comments (Krueger & Casey, 2009). Additional research is needed to more fully understand the resocialization processes of the post-LPN-BN bridging program.

Implications

In response to the plea for the “real nurse to stand up,” one questions if the “real nurse” even exists or simply reflects a composite, socially constructed mirage that has become mediated and portrayed by history, culture, and sociality. There appear to be no clear answers to this question. Perhaps it is time to redefine the label of “real nurse” and instead reflect a label of the “exemplary nurse” (Perry, 2009). This may potentially be the ideal to which both LPNs and RNs can aspire without the disparaging acronyms and labels that have existed for decades.

Just as the entire human race consists of human beings despite varied skin colors, languages, cultures, and skills, it is posited that LPNs and RNs are all collectively “real nurses.” While the scopes of nursing practice serve to differentiate LPNs and RNs, the sharing of commonalities is a prospect in bringing them together. The commonalities that the label of “real nurse” provides—that of caring for, with, and about those with whom they are entrusted—can potentially identify members of both professions as “real nurses.” This can bring RNs and LPNs together rather than cause and perpetuate the divisions that have and still do exist. As Ketola (2009) noted, “the most injurious component of nursing is not the work overload, not the acuity of patients, not the cantankerous behaviour of some physicians—it is the damaged relationships we have with each other” (p. 253). Healing the fissure that has existed for almost 50 years between LPNs and RNs can only serve to strengthen their common profession—that of nursing.

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