What if the School Nurse is Busy?

In the previous story in our four-part series on in-school diabetes care, we discussed how one family found a welcoming school environment in Portland, Maine for their son with Type 1. Unfortunately, access to diabetes care during the school day varies wildly from school district to school district, and from state to state. Less than two hours west of Portland, and across state lines, another child with Type 1 is struggling to find enough help during school hours.

Ray Duckler, a columnist at the Concord Monitor in New Hampshire, wrote a piece on November 29 about Luc Gautreaux, a seven-year-old who can’t get anyone at his school in the Winnipesaukee region to help him with his diabetes self-care – excepting the school nurse, whom Luc has to go in to see several times a day. Luc’s 10-year-old sister Mellie, who told Ray that she can “do [his diabetes care] in her sleep,” isn’t allowed to help Luc while they’re in school together.

When Duckler tried to contact officials in the school district about Luc, he learned that they not only preferred not to talk to him, but that they also believed that the school nurse or a nursing assistant with the required professional credentials should be the only individuals authorized to care for kids with diabetes.

New Hampshire is one of the states that has some grey in its black letter law on care of children with diabetes while they’re at school. By state statute, school children are permitted to possess and use epipens and asthma inhalers. Also, by a 2015 amendment to state law, a parent or guardian may authorize a school employee without a nursing license to administer glucagon injections if a school nurse is unavailable to do so. The rationale here is that allergic reactions, asthma attacks, and hypoglycemia are medical emergencies requiring rescue medication, and persons suffering such emergencies are often disabled by such attacks and therefore not able to self-administer. Insulin injections are, on the other hand, seen as maintenance, as is glucose testing.

New Hampshire’s Nursing Practices Act recognizes four tiers of professional licensure. State rules allow for the licensing of another kind of medical helper – a Medication Nursing Assistants (MNA’s), to whom nurses may delegate tasks associated with medication.

As is true in nearly every state, New Hampshire requires a written medical treatment plan, submitted by the parent or guardian in consultation with a physician, for a child who may require treatment for diabetes, or any other condition requiring daily attention, at school or at school-sponsored outside activities. Yet there is no rule that requires a private or public school to provide for insulin injections, or for administration of oral anti-diabetic medications. If the nurse isn’t available and a child can’t give the injection himself or herself, that child is out of luck.

The law, as it currently stands, gives the school nurse no authority to delegate tasks to Luc’s sister Mellie, even though Mellie is quite possibly just as knowledgeable of Luc’s needs and competent to handle them, as a licensed nursing assistant. In fact, any responsible adult employee at Luc’s school who wanted to take the initiative to take a diabetes education course couldn’t care for Luc either without a license permitting them to do so. This has been the state of things, except for the glucagon provision adopted by the New Hampshire Legislature in July of this year, since the most recent technical advisory issued by the Department of Education on the subject in February 2009.

Across the country, diabetes advocates are asking state legislatures to relax in-school testing and insulin-administering restrictions – restrictions which school nurses and administrators believe in good faith they have no choice but to abide by lest they break the law and face professional disciplinary sanctions. As mentioned earlier in this series, the American Diabetes Association submitted testimony of an endocrinologist and a certified diabetes educator to this effect in Nurses’ Association v. Administrator, and succeeded in persuading the California Supreme Court to craft an accommodation in 2013 that overrode a stringent scope of practice rule under the state’s nursing practices code. The ADA, a co-plaintiff in that case, has been at work with state legislatures through its “Safe In Schools Project” to make daily diabetes care accessible to children in schools which do not offer the full range of professional staffing. The ADA is doing this by mobilizing volunteers – physicians, students with diabetes and their parents, diabetes educators, and elected and appointed officials – to advocate for legislation to bring school diabetes care into modern practice.

There have been efforts in seven states to adopt all or variations of a model reform act, which has come to be known as the Diabetes Safe in School Law. This legislation removes barriers to self-testing and self-administration of anti-diabetic medications, and secures training in diabetes care for school employees who do not hold medical licenses, so that they may administer glucagon and insulin and assist children with testing if a school nurse isn’t available.

To learn how you can get involved, check out American Diabetes Association’s Safe at School Victories.

Read the series:
Part 1 – “How to Make Canadian Schools Diabetes-Safe”
Part 2 – “Are Schools Required to Provide Diabetes Care?”
Part 3 – “The Patchwork Problem of School Diabetes Care”

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Jim Cahill is a former staff writer for Insulin Nation and a former editor of Type 2 nation.

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