School Nurses Fight to Block Unlicensed Injections

A California ruling that would allow non-licensed adults to administer insulin in schools cheapens and devalues not only the practice of nursing, but also the clout of its own licensing authorities.

29 comments on "School Nurses Fight to Block Unlicensed Injections"
Suzette Scheuermann PHD RN (5/17/2014 at 9:52 PM)

Now that our KY board of nursing has permitted delegation of insulin to unlicensed school staff, they are now considering the undersight of mental health aides and medication administration. This will impact our home health and public health nurses. Nurses get ready to be replaced, Kentucky no longer has a nursing shortage!
Suzette Scheuermann PHD RN (8/23/2013 at 2:59 PM)

I think it is short and sweet to say, ...the school system can delegate any task they wish to do so on their unsuspecting school staff and personnel. Please don't make the nurse liable for this delegation. Make the delegation result from the parent or the prescriber of the insulin. This will have the same impact that medication aides have had in long term care with no licenses, one RN maybe and a bunch of administrators. The real impact will be that no nurses will choose this environment for practice so all care for these children will be at the discretion of the school anyway.
Pat Dunn, PhD, RN (6/18/2013 at 2:45 PM)

Administering insulin is not simply a matter of performing an injection. What must be considered is the importance of giving the right dose and type of insulin to the right child as well as monitoring for potential side effects at specific times. UAPs cannot be educated to safely administer insulin as they have no background in anatomy, physiology, pharmacology, or health assessment. In today's litigious environment if a bad outcome is associated with a medication error or failure to identify an associated problem, many deem this negligence. This results in lawsuits, loss of money, and bad will between workers. Can a School District afford millions of dollars to settle a case because hypoglycemia caused brain damage or loss of life? Nurses are educated not just in the procedure of giving insulin correctly but in managing complications that may develop. UAPs are incompetent to give insulin!
Rob Stewart RN (6/17/2013 at 4:51 PM)

How did the California Nurses Association and the California Medical Association allow this to happen?
Mike RN (6/17/2013 at 7:31 AM)

This is such a non-issue for nursing. This is a complete waste of our nursing resources fighting this fight. Let's spend time and money on the education of nurses. Saying its okay being the least educated of the medical professions on average is really what devalues nursing.
Belinda Childs APRN, CDE, BC-ADM (6/15/2013 at 10:29 AM)

As an ADA professional member and an ANA member for over 35 years, I agree with those who have noted if nurses have done their job this is not a risk. MANY states allow delegation including Kansas and have not seen lawsuits or issues. I work with an endocrinologist and do over 350 school plans a year and work closely with the school nurses in our state. We need to teach children about self care, empowerment, living life. The issue changed when we went from two shots a day to four shots a day and pumps. Now almost every child takes injecions during the day. 15 years ago they did not. This does not devalue nursing, it values our role as teachers.
Dr. Suzette Scheuermann PHD MSN RN (6/14/2013 at 10:01 PM)

It has been said that having a trained unlicensed personnel give insulin to a student could be done safely. There is no insurance to this statement nor is there research in the literature that shows that this is a safe practice. What is noted in the research is that nurses in the school system can significantly lower the absenteeism and responses to co-morbidities that children in the 21st century now have in the public school system. This would save money since this is the ONLY reason a school system would consider such a plan. In Kentucky, this issue is now being legislated publicly with the Department of Education pushing to have existing school nurses to be responsible for delegation of this act to an ULP. While some do not think that this activity impinges on nursing practice, it does. It makes the nurse responsible for the actions of an unlicensed personnel under their supervision. That is a liability for the NURSE not the school. I say if the school wants to sign the liability policy for the injuries that WILL ultimately occur, then it is their conscience. The nurse should not be left hanging and responsible. But NO NURSE should support this step backwards for nursing and huge falling down for SAFE CLIENT CARE. I fear we will lose all school nurses because why would one risk not only their license but their livelihood, possessions etc. PS. Self administration or family administration has nothing to do with nursing practice.
Kay T. Roberts (6/14/2013 at 7:58 PM)

I fear I hear my colleagues give the same argument that physicians pose against allowing nurse practitioners to practice at their full scope of practice. Recently I heard a school nurse testify at a legislative hearing against allowing school personnel use EpiPens for allergic reactions. I teach this content in CPR classes and was a bit taken back by this argument. If we cannot provide enough school nurses to give the care, I think we should spend our energy helping schools to give necessary treatments safely and effectively and be less protective of "nursing territory." Keep an eye on helping others achieve good health, even if we give up a bit of "territory." I think this makes nursing stronger,not compromised.
Mc (6/14/2013 at 7:16 PM)

I find this opinion absurd. I am a NP,CDE and part of my practice is to help empower people towards self management of their diabetes. Dorothea Orem and other nurse theorists have been proponents of self care. We teach family members, neighbors and teachers to inject insulin. The ADA has a Safe at Schools program for just this issue. In fact I find ANAs position discriminatory to people with diabetes. They are putting people at risk by withholding insulin until a nurse can be available to give the insulin. If parents, grandparents and siblings can be taught to administer insulin, teachers or other school staff can as well. My nursing education emphasized the importance of self empowerment. Children with diabetesiften give their own injections. Those of us who work with people with diabetes everyday know of the challenges and strongly disagree with the ANA position. Giving an insulin injection is not rocket science. But withholding insulin can be a life or death situation.
Barbara Dunn (6/14/2013 at 6:30 PM)

A couple of thoughts the current dialogue. School children can (and should) be taught to manage their own diabetes once they are capable of higher order thinking. A labile 40 pound first grader who runs BS of 450 and 45 in the same school day doesn't yet have the requisite judgment. Parents can leave work and come administer. It takes many of our parents more than an hour to drive from work. Many parents in our school system have no transportation at all and no phone availability at home or work. Many aren't English speakers. Even when the stars are aligned, many of our parents simply can't be located during the school day. Delegation is an important nursing measure when it's appropriate. School secretaries, GOD bless them, no matter how well instructed, aren't ready for insulin administration when there is no licensed professional for miles around. When parents can't be found, have no transportation, no phone contact, it's a game-changer for both the school and the school-aged child with diabetes.
Barbara Dunn (6/14/2013 at 5:44 PM)

The Georgia Legislature fixed this quagmire in Georgia during the 2011 (I think) General Assembly. It mandated that, in the absence of an RN (maybe an LPN?), each school must have someone available to use the glucometer and administer insulin if indicated. Perhaps five years ago, only about 50% of Georgia's schools had a school nurse. I'm not sure what those schools did. In Savannah, our school board recently voted to phase out RNs in lieu of LPNs. It's my opinion that LPNs are not prepared to manage children with diabetes. What more can I say!
ks (6/14/2013 at 5:27 PM)

We teach unlicensed personnel to give insulin and count carbs all the time. These unlicensed personnel are called parents (or grandparents or other primary-care givers). As a nurse practitioner, I am constantly faced with the panic call from physicians that I am unable to provide some type of care because I lack the knowledge or skill or education to preform such-and-such a task. Patients will be injured worse. Only a doctor can provide quality, safe healthcare. As nurses, just as with physicians, we do not hold the market on knowledge or skill or ability. When pharmacists were granted the right to give injections, nursing associations where crying that there would be untold numbers of casualties due to these people doing what has traditionally been seen as a "nursing" function. Pharmacists could be taught the skill of giving an injection but could never be able to acquire the knowledge behind the skill. Well guess what. People are not suffering adverse events. And more people are becoming vaccinated against disease. The same thing will occur when teachers, school secretaries and the "lunch lady" are educated on helping primary-aged school children inject insulin. Children will not be dying in the halls from inappropriately given insulin. Nurses have to stop worrying about their turf. No one will be able to replace us. What we do is unique. However, we don't have a lock on everything nursing.
Catherine R. (6/14/2013 at 4:48 PM)

In our hospital, not one nurse but two licensed nurses must verify insulin before it's administered. Even a small miscalculation can be detrimental to the endocrine system, cause rapid hypoglycemia, and many other ailments. Will these unlicensed personnel also be trained to observe for such side effects? There was a local daycare who administered too much Tylenol to a teething baby (an over the counter medication that average lay people administer daily to their own families) and the baby died. I am a nurse and obviously wish to protect our rights and laws but as a Mother, I would have a huge problem with someone who was unqualified administering insulin to my child. Would they remember to do it at the right time? Would they make sure they received a snack within 15 minutes of a rapid acting insulin? Do they know the differences in insulin and the appropriate time for it's peak? Would they remember to use an alcohol swab to clean the site? Do they wash their hands? Too many unknowns in the scenario.
Louise Zielinski, MSN, ELC, RN (6/14/2013 at 4:02 PM)

Most anyone can be taught to administer an insulin injection, at what may be the correct or incorrect dose, syringe and needle, it is the consequence of the insulin injection that an unlicensed layperson is not trained to rapidly recognize and respond to. In addition, who will take responsibility for the outcome? We nurses have worked very hard, as we all know, to get through nursing school to be eligible to take state board examinations to protect the patient population against incompetent, unsafe care. Nurses are expected to know and refrain from performing interventions that are out of their legal scope of practice, and rightly so. Many facilities require a two nurse double check on an insulin injection prior to administration to a patient, nurses are aware an insulin error can easily be life threatening. Would you want an unlicensed professional to administer insulin to your child? Would you want that same unlicensed professional to rewire your home without being a certified electrician and not require an inspector to approve it? Allowing layman to administer insulin, forcing them to take this responsibility is both unfair to the layman expected to perform the task and the unsuspecting "student."
Katherine, Texas (6/14/2013 at 3:01 PM)

I was a substitute school nurse in Texas for almost 2 years. My pay was $8.00. This issue should focus on the real issue. Taxpayers are not willing to raise state & local taxes to allow the school districts to pay teachers and nurses. They feel they are between "a rock and a hard place." I loved working for the kids, hated school district administration and principals. They all got raises and bonuses but the employees in the district did not. Until taxpayers are willing to support the schools, the pay alone will be enough for the districts to justify cutting all nurses because they need to pay teachers. I'm not saying this is right but it's wrong not to address the real problem.
Rhonda Conlin (6/14/2013 at 1:41 PM)

I am wondering about the teacher or lunch lady or whomever is going to ge giving insulin. I would not be comfortable with this kind of responsibility as a lay person. The parents should also have a say in this, and I would not as a parent want someone who is untrained giving my child any kind of injection.
Kathy H. (6/14/2013 at 1:39 PM)

While it is true that almost anyone can learn the "mechanical" task of administering an injection, the bank of knowledge required to fully care for the underlying medical reason necessitating the injection is an entirely different manner. If a child is entitled by federal law to receive services at school from a "licensed" healthcare provider, why are some parents so willing to settle for less? Would these same parents allow unit secretaries to care for their child in the hospital? If not, then why are they allowing school districts to be exempt from the law rather than demanding school district compliance to the law? Only the clinical setting is different. The crux of the matter is that if outside self-interest groups are allowed to define and regulate the profession of nursing (rather than nursing's own licensing board) then the practice of nursing is indeed cheapened and eroded. And if such a precedent allowed to occur in the school setting, then what setting will be next? What profession will be next?
Heather Scott, RN, JD (6/14/2013 at 1:19 PM)

It is very dangerous and irresponsible to advocate that unlicensed individuals administer any injection. Aside from the fact that an improperly performed injection can cause harm, the medication that is administered via injection can have consequences. Insulin is not benign, nor is any other medication. The patient must be monitored. Unfortunately, the lay public, including school budget administrators, do not see the art of nursing when the licensed professional performs an activity and artfully measures the patient's response. Nurses assess for therapeutic responses to meds and adverse events. The real crime is that the public allows the policy makers to remove crucial positions from the budget. Nurses provide value. Removal of school nurses negatively impacts the health and safety of our children at school. It is a sad commentary on our communities when it is believed that school superintendants are more valuable than the nurses, if the quality of education our children receive is any indication of the value provided.
Michael Harrison (6/14/2013 at 12:27 PM)

I have problems enough with allowing pharmacist to give vaccinations in our state. The reasons, I will not go into here, except to say that the roles should be maintained. When non-licenced personnel make a honest mistake and kill a kid everyone will be "up in arms" A century ago licensing was begun for the sake of the public not Nursing. Our generation is so short sighted. Each time we deregulate banking we get a banking crisis and there are people already talking about that again. The only disagreement I have with the opinion is to say,"Don't worry about nursing being devalued, it already is." As long as nurses are an "expense." the money will be trying to further the devaluation of Nursing.
LV (6/14/2013 at 11:01 AM)

For insulin only I do not see the harm in it as the patients are non-licensed and give themselves insulin shots. My nephew is giving anticoagulant shots to my niece during her pregnancy. I just do not see either one infringing on my nursing profession.
Bonnie Altman,BSN,RN (6/14/2013 at 9:23 AM)

How right that statement is: "Ruling that anyone can administer insulin cheapens and devalues not only the practice of nursing, but also the clout of its own licensing authorities... "It erodes the profession of nursing." "The hallmark of any true profession is the ability to regulate itself. The devaluing of the nurse seems to be on the rise! And as suggested above, why not teach unlicensed teachers to teach...that would also cost a lot less. Why not teach unlicensed caregivers to be physicians...that would cost a Lot less. A quick little watered down course in physics and chemistry could go a long way...yes? Why not teach unlicensed mechanics how to pilot commercial planes... really cost effective. Nurses, unite! Say "No." Take control of your PROFESSION before it is no longer a profession. Are we professionals or are we pack mules? Take whatever is handed to us ,weigh us down until our positions are undervalued and we lose all respect. Help!
Maria (6/14/2013 at 8:35 AM)

Interesting that an organization such as the ADA that has so many members that are nurses would propose to essentially devalue the service and expertise of nurses. What's next [INVALID] unlicensed personnel giving injections and managing insulin in hospitals? This sets a very dangerous precedent.
Karen Kelly (6/13/2013 at 4:38 PM)

We are still fighting this issue in Illinois. When the ADA began to wage this battle in several key states, they failed to connect with the National School Nurses Association or the American Nurses Association. As the mother of a person with autism, I would have sued if my son received speech therapy from the cafeteria lady!
Colleen Conklin (6/12/2013 at 2:19 PM)

Nurses who administer medications are not only trained on how to administer the correct dose at the right time & dose, but also to understand the condition for which the medication is prescribed,situations in which to hold the med & call the physician for revaluation, an understanding of the medication's side effects, precaution & contraindications. allowing unlicensed persons (other than the individual student's parents (designee) who know that child's medical issues) puts the child at risk for medication complications & errors in administration. parents rely on the school's due diligence in protecting their children. legalizing non medically licensed staff to administer me ds in school gives. parents the incorect belief that this practice is safe & protects the child. Colleen Conklin, MS,RN
Kristy (6/12/2013 at 12:37 PM)

This make absolutely no sense! Why when budgets get tight do they try and eliminate positions that are needed the most? Why would a school nurse be on the chopping block? Also I agree, this is degrading for those of us who have studied the profession. Nursing is incredibly complicated. Why would they agree to allow someone who knows nothing about the mechanics of the disease process or how the human body responds to medications, and injections be permitted to give insulin shots? I just feel that if this law is passed it would be a big mistake and potentially dangerous to patients.
Mary K (6/11/2013 at 3:50 PM)

I don't think this devalues nursing at all. In fact, if handled appropriately, it has the ability to empower individuals to manage their own care and to role-model those behaviors necessary to ensure quality of life. Everyday life doesn't mean a nurse is following us around, ready to do those tasks that are considered "nursing." Administering insulin can be done by the patient, the parent, or a parent designee (as stated in the article). The thing that makes this a nursing skill is the TEACHING that goes into it. If a nurse has done his or her job well, then the patient or adminsterer of the medication will be able to appropriately and accurately deliver the medication safely and in a timely fashion. Please, don't make nursing all about injections when it's so much more.
mythbuster (6/11/2013 at 3:28 PM)

Hypocrisy: Nurses are fighting to prevent non-nurses from doing a task that even children can be easily trained to do, while simultaneously lobbying for expansion of scope of practice laws. In essence, nurses are saying "no one but we licensed few can [perform this task]," the same way that many physicians are saying "no one but we licensed few can... [perform this task]." Hubris: Each group is being unreasonably exclusionary in its attempt to protect eroding turf under the pretense of ensuring patient safety.
P. Deinert (6/11/2013 at 2:58 PM)

This would be the gateway to many lawsuits. One mistake by an unlicensed office worker that kills a kid (i.e. wrong dosage) could be a formula for disaster. My sister in law, a CA school nurse for many years is quite conceerned in how this would effect her school system. Cut out other school programs, but keep school nurses. These kids are entitled to professional care.
Cynthia McDaniel MSN RN (6/11/2013 at 2:18 PM)

Nurses in Oregon have been delegating the task of administering an insulin injection by non-nurses to individuals whose medical condition is stable and predictable since 1989 with positive outcomes. Nursing delegation in Oregon has not de-valued the practice of nursing - instead it has reinforced the value of a nurse's judgement and ability to teach. The nurse remains involved in the care and oversight of the individual, and of the delegated task to the non-nurse. Nursing is much bigger than an task, and the only aspect being delegated is the task, not nursing judgement. A good process will require ongoing assessment, monitoring, and supervision. Everyone wins with this ruling - the individual requiring care, the nurse, and the system. This practice makes good care and economic sense.


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