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Supreme Court Decision on Insulin Injection Shapes the State’s Use of School Nurses

The California Supreme Court’s unanimous decision last week that public schools have a right to allow unlicensed — but trained — school personnel to administer prescription medication to children was fueled partly by necessity.

There’s a dearth of school-based nurses in California to administer insulin to children. As diabetes and obesity among children have risen, the number of school nurses in California has decreased.

That’s where the discussion turns into a chicken-or-egg debate. Nursing advocates say the problem isn’t a lack of nurses but a lack of state funding for nursing positions. They say the shortage was created by the state’s layoffs and non-replacement of school nursing jobs over the past two decades.

The ruling by the state’s seven-judge Supreme Court does not necessarily shut the door on the issue. Advocates are considering an appeal to federal court.

Risks, Benefits for Children

“This is a big victory for the schools and for school children,” said Dwight Holing, chair-elect of the national board of directors for the American Diabetes Association. “It’s all about them.”

Holing said the numbers don’t lie.

“There are only 2,800 school nurses in the entire state for about six million children,” he said. California schools have about 14,000 diabetic children, according to state estimates cited by the court. “The reality is, there aren’t enough [school nurses] throughout the state, and some school districts don’t have one at all.”

The ADA used to be on the other side of this debate, going so far as to file a lawsuit against the state, claiming there weren’t enough nurses to handle the diabetes epidemic in schools. That suit was settled in 2007, and diabetes advocates joined the state’s side in the more-recent lawsuit brought by the American Nurses Association. Nurses argued that only licensed health care workers could administer medicine according to a state law barring unauthorized practice of nursing.

“Look, no one’s thrilled that there’s a shortage of school nurses,” Holing said. “Their work is critical for children with diabetes. But diabetes is a 24/7 disease, and this [ruling] allows kids to get the insulin when they need it.”

Nursing advocates say there could be real harm done to California’s children by well-meaning volunteers who help kids with insulin injections.

“Insulin in the hospital setting requires two registered nurses to administer,” said Linda Davis-Aldritt, president of the National Association of School Nurses. “It can cause illness and even lead to death. It is not a medication without risk.”

That’s in contrast to other prescription drugs that non-certified volunteers can administer, such as epinephrine, which is much less injurious when given improperly, Davis-Aldritt said.

“Dropping the blood sugar can be dangerous,” she said. “And right now, we’re looking at no standard of training to administer [insulin] medication. There is little supervision, and little accountability.”

Clare Nicholson, parent of a diabetic daughter in Aptos near Santa Cruz, said the decision to allow non-nurses to administer insulin means schools will start laying off or not replacing school nurses now. She said school personnel are reluctant to volunteer to help because of the potency of insulin.

“I’m mortified.” Nicholson said. “I’m going to lose my nurse. Insulin is a lethal drug, so school staff do not come forward to help in schools.”

Tom Torlakson, California’s Superintendent of Schools and lead appellant in the state Supreme Court case, said school nurses aren’t going anywhere.

“One of the best things we can do to help keep our students safe and healthy in school is to have a school nurse present,” Torlakson said, “and this need is one reason among many that I have always pushed — and will continue to push — for full funding for our education system.”

That funding presents a hard reality, Torlakson said, that needs a real-world solution.

“The fact remains that not every student has access to a school nurse and, for some of them, that has been a very real obstacle to attending school and learning with their peers,” he said. “I hope this decision removes that obstacle.”

Future of School Nurses a Concern

Nursing advocates say the “full funding” sought by Torlakson may never come, and establishing rules that replace nursing duties is a step toward eliminating those nurses altogether.

“There is a lack of funded [school nurse] positions in the school districts,” Davis-Aldritt said. “This has been going on since Prop. 13 [in 1978], mostly through attrition in the districts. Then in the 1990s, when we had the recession, that’s when huge numbers of school nurses were laid off. Since then, it’s been up and down, laying them off, rehiring them, laying them off again.”

According to Holing of the ADA, it doesn’t matter so much how the state got in this position as much as it matters how the state deals with these children now.

“This ruling now means that students with diabetes won’t be without their insulin even if the nurse isn’t there,” Holing said. “Trained school personnel can administer life-saving insulin. It provides schools with a backup plan.”

Staff volunteers need to undergo training and work in concert with physicians’ orders, Holing said. He also pointed out that parents must give their consent to allow the injections.

“We already have non-certified people who give injections,” Holing said, including parents and the children themselves. “And some kids need help administering insulin,” he said.

“What’s important here is that this in no way lessens the role of school nurses,” Holing said. “It only means now that schools will have a backup plan.”

ADA officials said it’s unlikely legislation would be passed in California to establish standards of training, since the ADA has a set of standards that could be implemented.

Davis-Aldritt disagreed, saying that legislation has been needed to set other standards of care and because insulin is much more problematic than other medications it will need state intervention.

One of the big concerns not addressed in the Supreme Court decision, she said, is where responsibility would lie if something does go wrong and children are harmed by the new process. That’s a big question still, she said.

“Insulin has a high rate of error, even in the clinical or hospital setting, and there’s great indication that there are parents or grandparents who have made errors,” Davis-Aldritt said.

“If an error is made, the risk is very high. There are significant consequences,” she said. “So that’s a question that needs to be resolved, and something that I don’t think the ruling addressed. Where does the responsibility fall?”

Besides determining liability, guidelines for training still must be established. ADA officials could not say how long that process might take. Nursing advocates do not have a timeline for a possible appeal of the ruling.

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