ANA, groups continue to fight for control of practice, patient safety
The California Supreme Court soon will weigh arguments about why everyone — including schoolchildren — deserves safe care, and why it is crucial that nurses everywhere have authority over their own profession.
Represented by the American Nurses Association (ANA) Office of General Counsel, ANA, the American Nurses Association\California (ANA\C), and the California School Nurses Organization (CSNO) continue to fend off appeals of a 2009 trial court decision, which found that the California Department of Education’s effort to sidestep the state’s Nursing Practice Act and allow unlicensed assistants to give insulin to children in schools was unlawful.
ANA and the other groups have the backing of more than 50 nurses’, teachers’, and other organizations from around the country who filed amicus briefs that support ANA’s stance.
Two courts have already ruled in favor of ANA’s position, but the American Diabetes Association asked the California Supreme Court this summer to review the case. The U.S. Department of Justice and medical groups filed amicus briefs supporting the diabetes association’s position, as well. These groups claim that trained laypersons can safely administer insulin, and that the “nursing shortage” will prevent children from receiving care or attending school, which would violate federal disability law.
“On the surface, this case is about the delivery of insulin to California schoolchildren who are too young or developmentally unable to self-administer,” said ANA Chief Programs Officer Amy Garcia, MSN, RN, CAE, an expert in school nursing issues. “Nurses want every child to have the quality care they need to attend school. We do not believe cost or convenience is a reason to lower a standard of care, particularly regarding the care of vulnerable patients like the young or disabled.
“ANA believes that the California Department of Education can, and should, prioritize the health and safety of children and respect the nurse practice laws that provide safety for all members of society.”
ANA, ANA\C, and CSNO also have launched efforts to educate parents, school authorities, and other nurses about this patient safety issue, and ensure that California schools continue to follow both federal and state law while the legal case is pending.
Speaking up for children
Clare Nicholson has a 6-year-old daughter who attends a California public school and has Type 1 diabetes.
Nicholson knows full well the complexity of diabetes management, from the physical symptoms of low blood sugar to the timing of insulin shots and snacks to the calculating of calories and carbohydrates. She also knows the state law: only licensed health care providers, such as school nurses, RNs, and LVNs, and lay persons who are legally authorized to do so, such as a parent or a designated family friend, may administer insulin to students with diabetes.
So for five weeks, Nicholson vigorously campaigned to have a nurse available on site — while also coming to the school every day to test her daughter’s blood glucose levels and administer insulin.
She ultimately was successful in not only gaining an LVN to administer insulin to her child, but also to another child who needed assistance. She now is trying to drum up support from other parents for more school nurses and, in turn, safe care throughout California. (The school nurse in Nicholson’s district had to cover numerous schools.)
“Some school districts will just tell parents that no one can do it [administer insulin],” Nicholson said. “So some parents are forced to allow their children to run high blood sugars because there is no one to provide care. Or they have to be at the school themselves to provide this care, which is not always possible. Self-management is not an option.
“We need good care programs in place and constant care for our young Type 1s. Volunteers are not educated or understand the lethality of insulin. Allowing unlicensed people to administer insulin ignores the severity of diabetes and undermines the management of this chronic disease.
“Parents do not know or understand their legal rights to licensed care. It is complicated and many feel overwhelmed. If more parents joined together and used their rights, we could get our much-needed nurses back in our schools providing the care our children desperately need.”
Insulin, in general, has a high potential for errors, and mistakes in its administration can kill, said ANA\C Executive Director Tricia Hunter, MN, RN.
“The schools have really done a disservice to parents,” Hunter said. “They tell them they don’t have a legal right to a licensed professional to administer insulin, and all the things they’ve already had to cut because of their budget issues, like the football program. They end up victimizing the kids who have a right to health care.”
Unlicensed personnel are also caught in the middle.
Beyond the patient safety issue, ANA and the other nursing groups also believe that both state and federal disability laws bolster their position.
In its Supreme Court brief, which was filed by ANA’s Senior Counsel, Maureen Cones, ANA explains that under federal and state law, disabled students’ right to receive free, appropriate public education — including the right to receive medications from licensed health care professionals as required by California’s Nursing Practice Act — “cannot be constricted by monetary limitations.”
Schools cannot justify using unlicensed personnel instead of nurses to administer insulin and other medications because they have tight budgets, according to Cones.
School nurses matter
School nurse and CSNO President Katy Waugh, MS, RN, said there are 18 children with diabetes in her district, which has about 18,000 students in 25 schools.
“Most middle and high school students administer on their own,” Waugh said. For others, whose health issues also may be further complicated, nurses administer insulin.”
Waugh knows that school nurses’ involvement in schoolchildren’s diabetes management has made a concrete difference in their health and perhaps has saved lives. For example, a school nurse she knows discovered one child was getting improper dosages, because her mother was unable to do basic math calculations. Waugh, herself, found that another child was not getting his insulin injections, because his father didn’t want to “hurt” his son.
“We have personal relationships with children’s families,” she said. “Hospitals and ERs may deal with these children for a certain period of time, and even a pediatrician may see them only periodically. [In our district], we see them once a week or more, and that leads to a continuity of care.”
Looking beyond diabetes management, school nurses matter — to the health of students with chronic conditions and to all children’s overall health.
For example, school nurses, in conjunction with parents and other key school professionals, develop an individualized health plan for every child with a chronic condition, such as asthma or epilepsy. Plans can be fairly basic to extremely detailed, depending on the child’s condition.
School nurses also perform vision screenings on all children throughout the district, ensure students are up-to-date on required immunizations, and assess and address acute care needs, among other functions.
Calling it an equity issue, Waugh noted that in some instances, the school nurse might be the only source of health care a child receives.
“Because of our education and skills, we are very cognizant of the disease process,” Waugh said. “We observe, assess, and detect nuances that someone who is not in our profession, like teachers, cannot.”
Said Hunter, “A school nurse is just as important as a school counselor or a principal.”
Implications reach far beyond California, schools
The school setting these days is a complex place. Besides children who need insulin and other medications, there are children with every kind of illness or disability. Some of the students require tube feedings, are on ventilators, or need complex care, Garcia noted.
“These [procedures] require a nurse, and it’s what nursing is about,” Garcia said. “Anyone can fill up a syringe and give an injection. That’s a task. As nurses, we assess, create a care plan, perform interventions, use our judgment and evaluate care.”
Yet across the health care landscape, there appears to be a chipping away at the medications that nurses administer. For example, ANA\C and CSNO were unable to stop a measure that now allows non-nurses to give Diastat in California schools. In Rhode Island schools, non-nurses now can give glucagon, said Donna Policastro, RNP, executive director of the Rhode Island State Nurses Association.
In some states, there also has been a stripping away of nurses’ function to administer medications in other settings, such as long-term care, assisted living, and other community-based settings.
What some parties find particularly troubling in the Department of Justice’s court filing is its claim that federal disability law trumps state licensing law.
Kathy Patrick, MA, BSN, RN, NCSN, was involved in the Colorado Association of School Nurses’ decision to sign on to the amicus brief supporting ANA, ANA\C, and CSNO. Of prime concern was the idea that another agency, such as the California education department, could just ignore the state practice act and negate the authority of the board of nursing, which is created to safeguard the public.
Allowing that to happen in California “opens the door” to the same thing happening in other states, Patrick said.
Policastro added that nurses must understand the implications of what’s happening in California, be united in their call for patient safety, and be ready to address issues that might affect practice in their states — whether in schools or other settings.
In addition to patient safety, this is an issue of who regulates nursing practice, Garcia said.
“If a nurse’s employer can choose to ignore a state nurse practice act because of convenience or cost, we are all in trouble,” she said. “Nurse practice acts exist to protect the public. And nursing stands to lose our status as a profession.”
Cones hopes that the California Supreme Court will hear oral arguments in December and that the case will be decided before the next school year.
— Susan Trossman is the senior reporter for The American Nurse.
