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California Supreme Court Weighs Nursing Case on School Insulin Injections

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By Debra Wood, RN, contributor 

June 19, 2013 - In a case that pits organizations committed to patient safety and quality of care--the American Nurses Association and the American Diabetes Association--against each other, the California Supreme Court will decide a legal fight over who is qualified to administer insulin to students while in public schools. 

“Nurses, everywhere, care about their patients, and patient safety should be at the forefront of concern, regardless of the setting where they are treating patients,” said Maureen Cones, associate general counsel, American Nurses Association (ANA), who argued the case in May for the organization. Additionally at stake is, “the ability for the nursing profession to regulate itself. When other agencies are given the authority to regulate the practice of nursing, it erodes the entire profession.”

Karen Talmadge, ADA: not enough school nurses means unlicensed personnel should be allowed to administer student insulin.
Karen Talmadge, PhD, representing the American Diabetes Association, is advocating for California to allow unlicensed school personnel to administer students’ insulin.

On the other side of the issue, Karen Talmadge, PhD, chair of the board of the American Diabetes Association (ADA), reported that not every school has a nurse and indicated in California the ratio is one school nurse per 2,200 students.

“We represent children,” Talmadge said. “If they are not allowed to have practical care at school, the [glucose] control will not be as good, and they are at risk of death and long-term complications.” 

Both sides indicate they want to do the right thing for children with diabetes and claim the other’s position puts children at risk. Additionally, both sides have lined up supporters.

The court will ultimately determine whether the California Department of Education is able to sidestep the state’s Nursing Practice Act, based on federal disability law, and allow unlicensed personnel to administer insulin to school children, or if the American Nurses Association will prevail in its quest to preserve the state board of nursing’s right to define nursing practice.

“That should be of concern to all nurses,” Cones said. 

California’s Nursing Practice Act specifically defines administration of medication as a nursing function. It requires registered nurses delegate insulin administration only to competent licensed personnel. The nurses can be subject to disciplinary action if they delegate to unlicensed people. It further states that the unlicensed person administering the drug is committing a crime, punishable by imprisonment and/or a fine of up to $1,000.

Two lower courts ruled against the department of education and said allowing unlicensed personnel to give the injections was unlawful and called for the end of that practice, but the American Diabetes Association and others have appealed to the California Supreme Court.

“Both positions (department of education and board of nursing) are diametrically opposed to one another, and that’s why the intervention of the court was required,” Cones said. 

California law permits several categories of individuals to administer insulin in the school setting, including parental designees. Talmadge said she considered it a burden to families for parents or someone they have designated to go to a school to give their child an injection. Parents, babysitters and other laypeople have learned how to administer insulin. 

Only a small number of students require assistance with administration, Cones said. She reported not having seen any evidence that the state’s school systems lack enough licensed personnel to administer the medication to those children. However, she acknowledges that budget constraints have led some districts to cut nursing positions. 

Talmadge agreed that having a nurse take care of the child while at school would be ideal, but called that a luxury not available to all children. 

“Nurses are an important profession and play a critical role in the health of children, but with diabetes, the practical reality is children need more care than most school systems will pay for in terms of nursing care,” Talmadge said. “In no way does this have anything to do with nurses. Our focus is the safety of children.”

The issue of insulin administration at school has become more pronounced, as children require multiple injections throughout the day. Research has shown that twice daily insulin does not provide optimal glucose control. 

The ANA does not dispute that children need insulin at school. The organization said in a fact sheet that it wants every child to have the quality care they need to attend school and does “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.” Additionally, it said that the prior court rulings upholding the nursing function of medication administration do not prevent students with diabetes in California’s public schools from receiving the health services to which they are entitled. 

Several other states--the ADA reports about half--allow nurses to delegate the task to lay personnel trained in how to administer the drug in schools to administer insulin, but the training may vary. Talmadge said the ADA is pursuing such authority for unlicensed personnel in other states, some legislatively.

The ANA cited a University of Iowa survey of school nurses that found medication errors are three times more likely when a drug is administered by unlicensed assistive personnel at school.

The California Supreme Court is expected to rule before August 29, 2013. If the California Department of Education’s position is allowed to take effect, unlicensed people will be able to give what classically has been considered a high-risk or high-alert medication to children unable to manage their own condition. It also would be the first time that any state health care licensing law has been preempted by federal disability law.

“If the court overturns the decision, the school secretary will become the school nurse,” Cones said. 

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