All we can say is whew! This week the California Supreme Court ruled that the law in that state doesn't mean that only school nurses are qualified to give insulin shots to students with diabetes. In a critical victory for the D-Community, the court says "trained, unlicensed school personnel" can also take on the task of administering insulin as long as both a doctor and parents give their OK.
We're incredibly relieved to hear that common sense prevailed here in a reading of a law that, as the court says, "expressly and practically" permits something that clearly doesn't require nursing skills. The fact that it took more than seven years in court to get to this point is somewhat amazing, and seems awfully wasteful. But the long road to the right conclusion feels a little sweeter (pun intended) to the diabetes community right now.
In this highly-watched case, the court issued a 26-page ruling that will likely have ripple effects across the country, as many states and schools grapple with the issue of providing diabetes care within classrooms if and when a trained nurse is not available. California's justices heard arguments from attorneys on May 29, and the relatively quick decision here is crucial in that it comes just before the school year starts and many families are meeting with administrators now to talk over their so-called 504 plans for D-management in school.
In a pretty crushing defeat for the powerful American Nurses Association (ANA) and the California Nurses Association, the seven-member court issued a unanimous ruling that actually overturned two previous rulings on this issue. The nurses groups had argued that unlicensed personnel could handle monitoring a diabetic student's blood sugars and even determine how much insulin is needed, but couldn't deliver the shot. What?! As if parents, caregivers, and students themselves haven't been administering shots to kids with diabetes for decades now... As if... this would somehow threaten the nursing profession.
Now thankfully, the California court has made it clear that state law provides a medical-order exemption that allows non-nurses to carry out a doctor's medical order.
"California law expressly permits trained, unlicensed school personnel to administer prescription medications such as insulin in accordance with the written statements of a student's treating physician and parents," Justice Kathryn Mickle Werdegar wrote for the court, citing state law and education regulations. "Through these provisions, state law in effect leaves to each student's physician, with parental consent, the question whether insulin may safely and appropriately be administered by unlicensed school personnel, and reflects the practical reality that most insulin administered outside of hospitals and other clinical settings is in fact administered by laypersons.* The Nurses' arguments to the contrary lack merit."
*Italic emphasis above is mine.
Since these school personnel aren't holding themselves out to be specifically-trained medical professionals or nurses, the court determined that they aren't "assuming to practice nursing" as the national organization had argued.
This is a huge win for the current 14,000 school-age D-families in California, which has the worst nurse-to-student ratios in the country with 1 school nurse for every 2,200 public school students. Yikes! Some have allowed unlicensed personnel to give insulin shots, while others haven't and some school nurses have refused to train non-nurses on insulin injections out of fear of being disciplined by the professional nursing board. That means: if a school doesn't have a nurse on hand, a parent would have to make arrangements to travel to the school specifically to give a shot of insulin for a meal bolus or higher blood sugar correction.
In its ruling, the court pointed to a state law provision that requires specific training for only three controlled substances -- one of those being glucagon to treat severe hypoglycemia. So non-nurses are allowed to administer glucagon, but whoever does so must be trained on the use of that substance in advance. Seems reasonable, and that part of the law could be used as guidance on how schools and lawmakers decide what kind of training might be put in place when it comes to administering insulin.
In Search of Common Sense
In reading coverage of the new ruling, this quote from a California D-Mom caught my eye in the LA Times:
"As a working parent, I either left my job to help my child or employed a nanny who could provide that service when my child was too young to administer his own doses," Linda Mecoy said. "Once my son was able to administer his own injections, he was permitted to do so. So the school allowed an 8-year-old to do what it wouldn't allow an adult health aide to do."
And then there's this, from the president of the California Nurses Association:
"'I think it's a great disservice to our children and I think we'll live to regret this decision,' said Deborah Burger, president of the California Nurses' Association. The ruling, she added, strips the value of skilled nursing from the school setting."
Again, I added the emphasis, because... Well, WTF?!
It seems a bit crazy that the nurses' apparent argument is that "lay people" would be qualified to test blood sugar levels, decide on a dosing amounts, and even draw up the insulin in a syringe -- yet somehow they aren't qualified to poke the patient with the needle. Common sense says making the dosing decisions is the part that's potentially dangerous (because it can lead to dangerously lead low blood sugars).
We've written before that this whole case doesn't appear to be about "the protection and safety of students" at all, but rather the politics of nurses trying to protect their own jobs. The state justices thankfully recognized that, and hopefully this ruling means the legal battle is over.
But it may not be...
Nurses Fight Back
The ANA indicates it may not be giving up the battle; the organization issued a statement saying it's "extremely disappointed" in this ruling and that it believes the court has set a "dangerous precedent" that endangers students with diabetes everywhere.
"This decision also sets a disturbing precedent for California and the nation. In essence, the reversal of the lower court decisions permits a state agency other than the Board of Nursing to control the scope of nursing practice. Moreover, the California Supreme Court has essentially decided that state health care licensing laws meant to protect patients can be ignored to the detriment of vulnerable populations."
Now, the group is "assessing its options" and deciding whether it might appeal the California ruling to the Supreme Court of the United States. It's unknown of course whether SCOTUS would accept this as one of the just 1% of cases it reviews each year. The ANA has 90 days to file an appeal there.
The California Supreme Court referred the case back to the original lower state court to wrap up the details on exactly how schools might implement the new law.
As expected on the other side, the ADA celebrated the court's ruling as one that protects safety and health, and does NOT diminish the importance of school nurses. The D-association is urging schools to take whatever steps may be needed to train school staff, and the ADA is offering to help in that training as much as needed.
"The Happy Dance"
For D-Parents watching the case and issue, the online community in California and beyond was lit up with excitement and praise for the justices' decision. Many pointed out their own concerns with local school staff, and say they plan to reference this court order when talking with administrators about their kids' D-care in schools.
"We are doing the happy dance here in California," said D-Mom Lisa Shenson, who's been watching this case for years since her type 1 daughter was attending a state public school that didn't have an on-site nurse. Now an adult, Lisa's daughter was diagnosed at age 6. With no school nurse on hand, Lisa had to be constantly available to rush to school while her daughter was young. Many families experience the same resulting burdens, including job loss and financial hardship, as a result of schools' inability to assist with their children's shots.
On the day of the ruling, Lisa told us she'd spent much of her day talking with families excited to hear about the court ruling. Many are heading into their 504 plan meetings this week, and had already been told that no school nurses are available and no one else would be allowed to administer insulin -- along with other issues such as counting carbs not being allowed during morning snacks and no checking blood sugars in class. Yikes!
Now, those parents can be prepared to leverage this ruling to talk with school officials about what's best for their kids with diabetes.
"For those of us who've been long-attached to this issue, and been the loud squeaky wheels on this, we see this as a significant win to protect children with diabetes," Lisa said. "This can open the door for forging partnerships with school nurses to do what they're supposed to: advocate for what's in the best interest of these kids. This decision can be a foundation to build those relationships."
We sure hope so.