Today is National School Nurse Day and a time when many are recognizing the 74,000 school nurses in the U.S. So, it's a perfect time to take a look at the current landscape of school nurses.
Of course, we thank those make it their professional responsibility to take care of kids in school. There are a lot of great nurses out there who do wonders for our taking care of our D-Kids and make sure they are safe in school. We appreciate all that you do!
But there also people involved in this profession who can make diabetes care in school a complicated and contentious issue. To make matters worse, many schools are slashing these nurses in the wake of budget cuts. Kids with diabetes often get caught in the crossfire, and are left dangling between an unsupportive school and rules that don't allow them to turn elsewhere to get the help they need.
That's unfortunately led to some serious bad blood and legal battles between educators and parents -- whereas they should be collaborating toward academic success AND health success in school.
The Case of Insulin Delivery in California Schools
In the past few years, all eyes have been on California, where the role of school nurses in routine D-Management has boiled over into the state's highest courts. Almost three years ago now, a state appeals court ruled that state law is written to allow only school nurses to give diabetic students insulin, and that no one else can be trained to do so because it's a nursing function and requires some skill and scientific knowledge.
You know, because it's not like anyone without a nursing degree can ever deliver insulin properly... (I'm still waiting to receive my nursing degree).
What's most fascinating about this case is that all the courts that have ruled on it think the law is wrong. They recognize that it's basically the American Nurses Association and school nurses lobby that are all about job protection here, not necessarily what's practical and beneficial to the health of CWDs in schools. But there's nothing they can do about it, because changing laws is up to legislators, not the courts. Here's one judge's take on the issue, from that 2010 ruling:
"Even though it seems to me that allowing trained school personnel other than nurses to administer insulin injections for diabetic school students when necessary would be the wiser public policy decision, I must defer to the Legislature's policy judgment and the subsequent legislative and executive decisions preventing a change in that policy -- regardless of whether they were the product of legitimate concern for the safety of diabetic public school students or the result of a labor organization protecting its turf and flexing its political muscle."
UPDATE: The state justices apparently have a sense of humor, as they decided on National School Nurse Day that they'll hear arguments in this case at 9 a.m. May 29, in San Francisco. What timing, they have!
The case boils down to whether the state law as written runs afoul of Section 504 of the American Disabilities Act... but even that isn't easy, since it could become a federal law issue that a different U.S. court has to decide.
Meanwhile, CWD parents, educators and school nurses themselves are left waiting on a final decision while continuing to navigate these often-thorny and contentious issues in their districts. Not to mention the T1D kids, who are getting very limited help in school now.
What Happens in California... Doesn't Stay in California
This particular case may currently be confined to California, but we have no doubt it's going to set the standard for how these issues are dealt with nationwide.
From the American Diabetes Association, senior manager of advocacy communications Susan McCarthy says that some non-nurse trained volunteers are providing D-Care to students currently, but that's few and far between.
"In most cases, only school nurses are permitted to provide care, leaving many students struggling to get the proper care they need to stay healthy," McCarthy says. "It's hard to say if the pending case in California has or will have impact on any other states. Each state has very specific laws, so changes to a law in one state would not necessarily prompt another to explore creating a similar law. That said, when the CA Supreme Court decision is made, we do expect the decision to receive attention from across the country and potentially from national-level media outlets."
Well, of course it will... just like with everything, states watch precedents set by others on controversial issues and often take guidance when crafting their own policies and strategies. The ADA couldn't give us a breakdown of either the frequency or amount of calls it receives relating to school nurses, which is unfortunate, but we know they are getting calls.
Likewise, we asked the National Association of School Nurses for a response on how this issue is being handled nationally, but only got a canned statement from the group's head of Diabetes and Nursing Education:
"Managing diabetes at school is most effective when there is a partnership among students, parents, school nurse, health care providers, teachers, counselors, coaches, transportation, food service employees, and administrators. The school nurse provides the health expertise and coordination needed to ensure cooperation from all partners in assisting the student toward self-management of diabetes. The National Association of School Nurses continues to provide resources for school nurses on the topic of diabetes management in schools. Resources are available at http://www.nasn.org/ToolsResources/DiabetesinChildren."
We pushed for more, but got nothing... Disappointing! Clearly they've never spent time with a diabetic kid in school if they really believe in this utopian vision of some kind of coordinated team -- including the lunch ladies! -- who are going to "assist the student toward self-management of diabetes." Huh?!
For the Good of the Kids, Right...?
What blows my mind is that California's school nurses, and by extension many across the country, aren't willing to acknowledge that mistakes happen and they're not always the most qualified to deal with diabetes decision-making. As this story in Texas shows, nurses shouldn't be the end-all-be-all when it comes to diabetes management.
We know that Highs and Lows don't wait for a nurse who may be at another school, or helping some other kid. It's not responsible for nurses to say they are the only ones who can navigate these tasks, when that's clearly not the case (hello, from one of the millions of non-nurses who've been administering injections successfully for decades). This position can put kids in danger, and it's not what school nurses should be about.
Or school administrators, who can create all kinds of resistance for families trying to get accommodations for their students with diabetes.
As seen in Indiana, where a high school teen with diabetes faced resistance from school administers who didn't want to allow a 504 plan (agreement on a student's care), asking for D-related accommodations like being able to test glucose in class. The local ADA chapter says the school turned it down based on "what might happen in the future" and "other kids get sick all the time," so why should that particular student with diabetes get special treatment? REALLY?
Apparently, this case involved a girl with type 1 who was a freshman in high school and instead of just protesting to administrators, she wrote an article about the issue for the school paper -- and then got censored and was told she had to alter the article before it could be published (!) The only reason that situation didn't escalate is because the family opted to drop it and not pursue the 504, the ADA chapter says. How sad is that?
And then there's this Tennessee case in which administrators filed a Child Neglect Report against parents they felt were keeping their daughter with diabetes too high at home and forcing lows at school -- even though the child had an insulin pump and CGM, and the court records show the administrators clearly didn't understand the basics of type 1 diabetes management. The school argued it felt the CWD was in danger and so the report was warranted, while the parents argued it was done in retaliation for their pressuring school officials about 504 accommodations that included checking BGs in class. A lower court sided with the school, but in early April a federal appeals court ruled in favor of the parents. That decision now applies to Kentucky, Michigan, Ohio, and Tennessee, and could set the stage for other rulings across the U.S.
Of course, the bad situations get talked about a lot more than the good examples. It's unfair to paint every school or nurse with the same brush. And there are likely many school nurses who don't agree with the politics the lobbying arms take. That's important to recognize.
Personally, I interpret the facts to say that it's political and the nursing profession's self-preservation is clearly an issue. To me, insisting that only nurses can give insulin or administer D-Care is ridiculous and goes against the nurse's universal Florence Nightingale Pledge to "devote myself to the welfare of those committed to my care."
This shouldn't be a nursing profession position or a liability issue, but an issue focused keenly on the safety and well-being of diabetic kids, ensuring that they're able to attend school the same as any other kid. The whole point behind 504 plans is not to hand out special privileges, but to ensure that kids with disabilities have access to the same kind of education that other kids get.
We're crossing our fingers that folks in the nursing world can take a lesson from the great advocates out there putting kids first, instead of their own self-interests.
Then, School Nurses Day will really be something to celebrate in the Diabetes Community.