New Demands on Nursing Services
Students with special health care needs are placing new demands for services on school districts across the nation. Local school boards are being asked to provide health care staff to perform a level of nursing service not seen before in the school setting.
There are 4 reasons for these new demands on school administrators:
1. The trend toward outpatient and homebound treatment rather than treatment in an acute care setting;
2. Advances in medical technology which allow monitoring and health maintenance services outside the confines of acute care institutions;
3. The federal mandate for mainstreaming of special education students with complex health needs;
4. Parent's expectations regarding their child's right to care in the school setting.
These developments raise issues of educational placement, student safety, and school and professional liability that need to be addressed.
(This section used with permission of The National Association of State School Nurse Consultants, Inc. ©1990)
In making decisions
..about the educational placement of students with health care needs, and
..about who is to provide the nursing .service to students with health care needs
1) the primary concern must be for the health and safety of the student.
2) The secondary concern is for the legal responsibility of all involved parties (e.g., the school board, school administrators, school staff and, in particular, the School Nurse).
School administrators are legally responsible for the safety of all students - and this responsibility includes the responsibility for providing the required health services by a qualified staff.Using non-qualified staff could risk potential harm to students. In addition, administrators must realize non-licensed school staff are liable if they practice nursing or medicine without a license.
The School Nurse's Responsibility for Quality Care
The School Nurse's ultimate responsibility is to the student for the quality of nursing care rendered. If the School Nurse's decisions on care, and who can safely perform it, are in error, the student suffers. In addition, the School Nurse can be personally liable and possibly in violation of the Nurse Practice Act, which might precipitate disciplinary action against his/her license to practice.
The School Administrator's Responsibility
School district administrators have the responsibility to determine educational placement of the student. Administrators are not responsible for deciding whether or not the required nursing service must be provided by a licensed health care provider. The registered (school) nurse is required to make that decision based on the Nurse Practice Act. If another licensed health care practitioner delegates nursing care to a non- licensed individual while the nurse is responsible for the supervision, then the nurse must make delegation determinations before assuming responsibility for the activity.
Questions About Delegating Care
There are 2 critical questions involved in delegating and supervising nursing care:
1. Is this nursing task under the State's definition of nursing?
Nursing and medical activities are defined by state statute and interpreted by state boards of nursing and state boards of medicine and/or state attorneys general and courts. Based on this definition, the nurse needs to decide whether or not the procedure is one that must be performed by a registered nurse.
* (In Nebraska, nursing and medicine are regulated by the Nebraska Health and Human Services .)
2. Can the procedure be rendered by non-licensed school staff under the supervision of a registered nurse?
Nursing activities not specifically addressed in statute or legal interpretations can be performed by a non-licensed individual:
-- if the activity does not require the exercising of nursing judgment and
-- if delegated and supervised by a registered nurse.
Determination Required in Each Case
By answering the above two questions, the delegating and supervising registered nurse makes the following determinations for each student with health care needs and each nursing activity required on a case-by-case basis:
1. The nurse validates the necessary physician orders (including emergency orders) parent/guardian authorization, and any other legal documentation necessary for implementing the nursing care.
2. The nurse conducts an initial nursing assessment.
3. Consistent with the Nursing Practice Act and related regulations of each state's board of nursing, and with his/her assessment of the student, the nurse determines who can be delegated the task - licensed (registered nurse or licensed practical vocational nurse), unlicensed health care provider or other staff person.
4. The nurse determines the amount of in-service training required for the individual performing the nursing service consistent with the Board of Nursing regulations governing the practice by unlicensed personnel. * Nebraska has no such rules/regulations at this time.
5. The nurse evaluates the competence of the individual to safely perform the task prior to delegation.
6. The nurse provides a written care plan to be followed by the unlicensed staff person.
7. The nurse determines the amount and type of registered nurse supervision necessary.
8. The nurse determines the frequency and type of routine student health reassessment and reevaluation necessary for ongoing safety and efficacy.
9. The nurse provides in the care plan for instances when a change in student condition, performance of procedure or change in other circumstance warrants registered nurse intervention and/or reassessment.
10. The nurse determines and requires the amount and type of documentation to be done by unlicensed staff, consistent with the State's Nurse Practice Act and rules promulgated by each State Board of Nursing.
11. The nurse documents activities appropriate to the nursing actions listed above.
If the School Is Not the Best Setting for Care
If the delegating and/or supervising nurse determines that a requested procedure may cause harm or cannot safely and efficaciously be performed in the school setting, the nurse should take the following steps:
1. Write a memo to his/her immediate supervisor explaining the situation in specific detail, including:
a. The reason the procedure should not be performed in school, and a rationale to support this; or
b. Recommendations for safe performance of the procedure in the school
2. Maintain a copy of the memo for the School Nurse's personal file.
3. Forward copy(ies) of the memo to one or all of the following as indicated:
-- The State Board of Nursing
-- the District Superintendent, and
-- the state School Nursing Consultant/Coordinator
4. Repeat notification that the requested procedure should not be performed in school until resolution of the issue;