Nancy J. Brent, MS, JD, RN
Editor’s Note: Welcome to the first blog from Nancy Brent. As a nurse attorney, Nancy brings a special perspective to the issues facing today’s nurses.
It is becoming increasingly apparent to me that many who have been long-gone from their school days before college and before their entry into the non-school world have missed an important lesson—the value of a school nurse during those school days.
There isn’t a day that goes by that I don’t read about the latest demise of the school nurse. Headlines and comments, such as “District cuts jobs, contracts for school nurses”; “No, the school nurse is not in”; “Fewer school nurses lead to greater medication errors”; “…districts report difficulty filling positions because of uncertainty of the job or cuts in salary or benefits,” flourish.
Sure, financial exigencies abound in school districts. Taxpayers want good schools and good school services and programs but are more and more upset about increased property taxes to pay for quality schools, school services, and school programs. School boards are under constant pressure to keep the costs of running schools and providing school services and programs within their respective budgets.
Despite financial constraints on school boards, most state constitutions in the United States require that every school-age child receive a free, public education. In order to meet this mandate, students must be ready to learn to the best of their ability. How can that education take place when students are enduring complicated health problems, including asthma, peanut allergies, diabetes, cerebral palsy, paralysis, drug and alcohol use disorders, and depression, as examples? Without a school nurse to provide the required health needs of these students, not only is the health and well-being of students at risk but so, too, is the education they are entitled to under state laws.
School nursing services clearly foster student learning by contributing to a student’s staying in class. One study indicated that when a school nurse saw 64% of school-age students (grades 1-12), 95% of those students returned to class as opposed to only 82% of students returning to the classroom when a non-licensed staff member saw 36% of the same student group.
Special Education students, whose numbers and medical needs have overwhelmingly grown in schools in recent years, also raise legal and ethical problems when a school nurse is not present. Federal laws, such as The Individuals With Disabilities Education Act (IDEA) and the Americans With Disabilities Act and its Amendments, mandate specific obligations schools must comply with in order to meet the educational needs of these students. For example, one mandate in the IDEA requires a registered nurse with specific credentials to be a member of the Individualized Education Plan (IEP) team and provide input into the IEP for the student with a disability.
So, what happens to students, special education and otherwise, who have no access to a school nurse? Although well intended, the student’s needs are met by non-medical and often minimally “trained” teachers, school secretaries, administrators, and teachers’ aides who do not have the professional nursing judgment and education essential to provide nursing care to students. Other school staff are substituted in the school nurse’s role in required mandates for the Special Education student.
Front-line descriptions and reported court cases of what happens when no school nurse is present abound. Your nurse colleagues share scenarios of medication administration handled by placing all student medications in a “big bowl” by the school secretary and students on those medications simply coming into the school office and picking their medication from the bowl. Another shared a story of school staff allowing a diabetic student to sleep in the former nurse’s office during the school day due to his high blood sugar level with no contact with the parents, or anyone else, about his condition.
Field reports also give accounts that when a qualified school nurse is absent from the IEP team, disabled students are not receiving a required, comprehensive medical review and written IEP plan based on their educational, nursing, and medical needs.
The delegation of care by the school nurse to non-medical school personnel inconsistent with state nurse practice acts and other applicable laws when the school nurse simply cannot meet the needs of the school-age students for whom he or she is responsible also occurs with regularity due to the lack of school nurses. This situation can result in liability for the school district and the school nurse.
For example, a school nurse who was told by the school principal to delegate the performance of a clean intermittent catheterization required by a student with spina bifida to a health aide became the focus of a court case and the Oregon Board of Nursing (BON). Although the parents taught the health aide the procedure, the school nurse did not provide the health aide with written instructions and only provided “periodic and monthly supervision” of the catheterizations. When the health aide filed a case asking the Oregon court to prevent the school from requiring her to perform this nursing responsibility, as she was not a licensed nurse, the court asked the Oregon BON for its opinion about this procedure being done by the health aide after being trained.
The Oregon BON held that the school nurse did not follow the nursing process in delegating this care to the health aide and that the school nurse must always do an assessment of a patient (student) in order to determine a patient’s need. It further warned that only a nurse, not a parent or a school principal, can lawfully assess a patient’s health condition and delegate and teach nursing care tasks. The school nurse was also disciplined by the BON.
School nursing services are essential services to the well-being of any school-age student. Are you aware of what is going on in your child’s school or in your community’s schools? Have you met the school nurse, if your child’s school has one? As a nurse yourself, have you looked into how the care your child needs while in school is being met?
It is essential that you become informed about what is happening, not only to ensure safe and quality nursing care to your child but also to support your school nurse colleagues as they attempt to provide school nursing services and to formulate needed changes.
If you are aware of the current, negative situation in your community’s or child’s school, have you actively helped your school nurse colleagues by joining in their efforts to change the current situation in a positive way?
Think back to when a school nurse provided you with the care you needed, or assessed your illness and called your parents to come and get you from school when you were really sick. Think about the injury to your friend at a school event and the school nurse’s intervention that saved him or her. Think about the necessity and importance of quality nursing services provided by qualified nurses to all patient populations, including school-age students.
Think about it. Identify solutions. Act on them. Advocate for school nursing to legislators and to the community alongside your school nurse colleagues. Utilize the legal system as a taxpayer to prevent the gutting of school nursing services, as a group of taxpayers successfully did in Illinois. Challenge administrative rule changes that regulate your state school code as they pertain to the devastation of school nursing.
And don’t forget to include in your solutions reeducating those who have failed to learn the importance of school nursing during their school days. School-age students are counting on you. So is the very existence of school nursing.
Nancy J. Brent received her Juris Doctor Degree from Loyola University Chicago School of Law. Ms. Brent concentrates her solo law practice in education, consultation, and the defense of healthcare providers (mainly nurses) before the Illinois Department of Financial and Professional Regulation. She has published and lectured extensively in the area of law and nursing practice. The information in this article is for educational purposes only and does not constitute legal advice.
With Disabilities Act of 1990. Public Law 101-336 (1990).
With Disabilities Amendments Act of 2008. Public Law 110-325 (2008).
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Nurse.com. http://news.nurse.com/apps/pbcs.dll/article?AID=2011109260036. Accessed June 25, 2012.
With Disabilities Education Act, 20 U.S.C. Sections 1400 et seq, as amended and
incorporated into the Education of All Handicapped Children Act (EHA) 1975 P.L.
94-142 and subsequent amendments with Regulations at 43 C.F.R. Sections
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School District No. 3, et al, Washington County Court, Case Number 87-1142C
Association of School Nurses. Caseload assignments, 1-3. http://www.nasn.org/PolicyAdvocacy/PositionPapersandReports/NASNPositionStatementsFullView/tabid/462/ArticleId/7/Caseload-Assignments-Revised-2010. Accessed June 25, 2012.
School Nurse Digest, April 17, 2012, April 24, 2012,
and May 8, 2012. (School Nurse Digest is
a free online newsletter provided by School Health Alert. Subscription is
available at email@example.com).