SUMMARY
It is the position of the National Association of School Nurses that the school nurse is the only school staff member who has the skills, knowledge base, and statutory authority to fully meet the healthcare needs of students with diabetes in the school setting.
Healthcare services must be provided in the school setting to students with diabetes to meet requirements of federal laws and ensure the safety of the student with diabetes in the school setting.
Effective and safe management of diabetes is complex and requires careful planning by a licensed professional school nurse. Individualized healthcare planning is a nursing responsibility that is regulated by State Nurse Practice Acts and cannot be delegated to unlicensed individuals (NCSBN, 2005).
The delegation of procedures/treatments may be used only in compliance with individual State Nurse Practice Acts, state regulations, and guidelines provided by professional nursing organizations.
HISTORY
Diabetes is the second most common disease in childhood, with an increasing number of children being diagnosed with both type 1 and type 2 diabetes. Approximately 1 per 400-600 children under age 20 has type 1 diabetes, with about 13,000 diagnosed annually in the United States. Additionally, approximately 8% to 45 % of all new diabetes diagnosed in youth is type 2 diabetes. The increase in type 2 cases among children has been attributed to an increase in overweight and obese children, a decrease in exercise among children, and environmental factors. It is estimated that of the children born in the year 2000, one in six girls will develop diabetes and one in eight boys will develop diabetes in their lifetime (CDC, 2005).
Along with the increase in cases of diabetes, the technology and treatment plan have also changed. The Diabetes Control and Complications Trial (1996) showed that intensive management of diabetes helps decrease the long-term complications of the disease. Advancing technology and the focus on intensive management has changed the way students manage their diabetes at school. Many more students are taking diabetes medications and monitoring their glucose levels frequently in the school setting.
Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 prohibit discrimination against handicapped people by school districts receiving federal financial assistance. They require schools to provide individuals with disabilities a Free and Appropriate Public Education (FAPE), with nondisabled students to the maximum extent as appropriate, with access to buildings, programs, and services, including participation in nonacademic and extracurricular activities (Gelfman, 2001). Parents of students with diabetes have increasingly become aware of their child’s right to a Free and Appropriate Public Education and expect schools to provide appropriate health services that safely manage care for their child in the school setting. School personnel need to provide the appropriate safe accommodations for students with diabetes so they may participate in the same academic, nonacademic, and extracurricular activities as their peers.
DESCRIPTION OF THE ISSUE
Each student with diabetes is unique in regard to his or her disease process, developmental and intellectual abilities, and levels of assistance required for disease management. Schools must ensure the students’ rights to full participation in academics and extra curricular activities. To accomplish this, a safe environment and safe care management for all students with diabetes are essential.
The goal of diabetes medical management is to maintain blood glucose levels at or near normal range. Poorly controlled diabetes can lead to long-term complications such as retinopathy, macro vascular and micro vascular cardiovascular disease, and nephropathy as well as cause immediate concerns because fluctuating blood glucose may affect academic performance.
Hypoglycemia (low blood glucose) is the immediate concern with students in school. This condition can be treated easily if it is identified early, or it can be a life-threatening event if left untreated. Despite a quick and favorable response to treatment for low blood glucose, cognitive ability can remain impaired for several hours. Untreated hypoglycemia can lead to increased confusion, unresponsiveness, and seizures. An Emergency Plan developed by the school nurse is essential for managing hypoglycemia. Hyperglycemia, high blood glucose, can also affect a student’s success in school. The student may not feel well, experiencing symptoms of nausea, fatigue, blurry vision, thirst, and frequent urination. Severe hyperglycemia with the presence of ketones can be very serious, and a student’s individualized health plan (IHP) developed by the school nurse with input from the family and health care provider must address this issue.
To achieve optimal diabetes management, the student needs access to a variety of diabetes supplies that allow her/him to perform multiple diabetes self-management tasks during the school day. Management strategies included in the IHP for a student with diabetes should be developed considering the knowledge base of the student, developmental level of the student, and individual needs of the student. The availability of professional staff also needs to be considered to oversee the implementation of the IHP. Students who lack diabetes management experience or cognitive and developmental skills must have assistance with their diabetes management during the school day. In addition, the student must have access to glucose monitoring equipment, oral or injectable medications, including insulin and glucagon, nutritional supplements such as snacks, and a fast acting source of glucose. The student must have knowledge about the equipment used in her/his diabetes management (syringes, insulin pen, insulin pump), access to a documentation system for his/her blood glucose readings, insulin dosages, and access to a bathroom. For those students who are independently managing their diabetes, a protocol should be in place to document their ability to perform the self-management tasks independently.
An Individualized Health Plan developed by the school nurse documents and communicates the student’s needs and the school’s management strategies for that student in the school setting. The school personnel who surround the student with diabetes during the school day and for extra curricular activities need to be knowledgeable about that student’s health plan. The consequences of uncontrolled blood glucose, which can be evident in classroom or school activities, can be minimized or avoided by having informed personnel available to assist the student with diabetes management.
School nurse assignments, directed by the school district, may prevent the nurse from being consistently available to the student with diabetes in the school setting. School districts are responsible for having policies in place that address the needs of students with health conditions at school. State laws and nurse practice acts will determine the extent to which school nurses can delegate nursing tasks such as insulin and glucagon administration to other school personnel in the absence of the school nurse. The decision to delegate is a nursing decision and should be done on a case-by-case basis taking into consideration student safety, proximity of the student’s classroom to the health office, and the availability of the school nurse and other appropriately trained staff. Unlicensed staff and volunteers who receive training regarding general diabetes management without regular professional supervision are not a safe and appropriate management system for children with diabetes. If the student’s condition, age, cognitive ability, or skills require it, a school nurse should be on site to appropriately manage that student.
RATIONALE
The school nurse is the qualified person to coordinate and implement the plan of care for school, which is unique to the nurse role. The 504 Plan, IHP, or IEP for the student with diabetes integrates management strategies preferred by the student, family, and health care provider.
School nurses have the professional skills needed to assess and support the child with diabetes in the school setting. School nurses are uniquely prepared to develop an IHP, Emergency Care Plan (ECP), 504 Plan, and/or provide information to the multidisciplinary team to develop an Individual Education Plan (IEP). Both high and low blood glucose levels affect the student’s ability to learn and can endanger the student’s health. Glucose levels should be as close to the desired range as possible for optimal learning and testing of academic shills. Recent research indicates that maintaining the glucose levels within a goal range can prevent, reduce, and reverse long-term complications of diabetes (DCCT, 1996). The IHP is a description of the nursing interventions and school accommodations that the student needs during the school day. The plan reflects the individual needs and competencies of the student during a particular period of time. The process used by the school nurse for developing the IHP includes:
Assessing the developmental, cognitive, and physical status of the student within his/her family structure to determine the ability of the student to independently manage diabetes care at school. The younger, less experienced and newly diagnosed student may require more assistance with diabetes management. The adolescent student with diabetes may need support in transitioning to independent self-management of diabetes.
Identifying and coordinating the medical interventions the student requires at school, based on orders from the health care provider and the nursing assessment of the student;
Determining the nursing interventions and school accommodations needed for all school activities based on the developmental cognitive, and physical status of the student;
Identifying and coordinating the interventions for school activities, which may include blood glucose monitoring, insulin administration, dietary intake, and instruction in identifying signs of and response to hypoglycemia/hyperglycemia;
Assisting the student in determining realistic and achievable personal goals for attaining self-care and independence in the management of her/his health.
Under the direction of the school nurse, management strategies may be incorporated in a seamless fashion between home and classroom to help the student with diabetes stay healthy, be academically focused, and participate in all academic and extra curricular activities. School districts need to provide nurse assignments that ensure the student with diabetes has direct access to the school nurse. The student’s management plan must conform to state and federal laws and regulations as well as the state’s nurse practice act and the related rules for delegation. If diabetes care is delegated to LPNs or UAPs, the school nurse needs to be immediately accessible to provide direction (Schwab, Hootman, & Gelfman, 2001).
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 school nurse can be instrumental in preventing and managing emergency conditions that can result from glucose fluctuations by instructing the entire school team on basic diabetes information and management. Emergency conditions are not necessarily the result of a lack of management and may require nursing interventions even in those situations in which the student is skilled in handling his/her own care. Factors such as illness, hormones, or stress may cause a student who closely follows her/his diabetes plan to experience an emergency situation. The student with diabetes requires the professional supervision of the school nurse to enhance his/her self-care skills. The school nurse is essential to fulfill the unique role of care coordination, planning and development of the care plan for management of diabetes in school to facilitate academic success. NASN recommends a full-time professional licensed school nurse to facilitate the coordination of quality care for students with diabetes among the school setting, home, and community.
References
American Diabetes Association. (2006). Position statement: Diabetes Care in the School and Day Care Setting. Diabetes Care, 29 (Suppl. 1), S49-S55.
Blum, M. (2002). Are school nurses using the recommendations of the diabetes control and complications trial in the care of students with diabetes? Journal of School Nursing, 18(3), 138-143.
Centers for Disease Control and Prevention (CDC). (2005). National diabetes fact sheet: General information and national estimates on diabetes in the United States. Atlanta, GA. U.S. Department of Health and Human Services.
Chatterton, J., Kaup, T., & Swanson, M. (2006). Diabetes Management in the School Setting. In J. Selekman (Ed.), School nursing: A comprehensive textbook. Philadelphia, PA: F.A. Davis.
Diabetes Control and Complications Trial Research Group (DCCT). (1996). Epidemiology of severe hypoglycemia in diabetes control and complications trial. Journal of American Medical Association, 90, 450-459.
Gelfman, M. (2001). Discrimination in School: 504, ADA, and Title IX. In N. Schwab & M. Gelfman. (Eds.) Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses. (pp.335-371). North Branch, MN: Sunrise River Press.
Kaup, T., and Chatterton, J. (2005). Diabetes. In C. Silkworth, M. Arnold, J. Harrigan, and D. Zaiger (Eds.), Individualized healthcare plans for the school nurse. North Branch, MN: Sunrise River Press.
Kolar, K., et al. (2002). Type 1 Diabetes in children and adolescents: What’s new? Journal of School Nursing, 18(3), 144-149.
National Association of School Nurses. (2002). Issue Brief: School health nursing services role in health care. Castle Rock, CO and Scarborough, ME: Author.
National Association of School Nurses. (2005). Issue Brief: Section 504 of the Rehabilitation Act of 1973. Castle Rock, CO and Scarborough, ME: Author.
National Association of School Nurses. (2005). Consensus Statement: Safe delivery of care for children with diabetes in schools. Castle Rock, CO and Scarborough, ME: Author.
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National Association of School Nurses. (2004). Issue Brief: Delegation of care in the school setting. Castle Rock, CO and Scarborough, ME: Author.
National Association of School Nurses (NASN) and American Nurses Association (ANA). (2005). School nursing: Scope and standards of practice. Silver Spring, MD: Author.
National Council of State Boards of Nursing. (2005). Working with others: a position paper. Retrieved on March 9, 2006, from http://www.ncsbn.org/pdfs/Working_with_others.pdf
National Diabetes Education Program (NDEP). (2003). Helping the student with diabetes succeed: A guide for school personnel. Washington, DC: U.S. Department of Health and Human Services. Retrieved December 20, 2005, from http://www.ndep.nih.gov/diabetes/pubs/catalog.htm#ndep-61b
School Nurse Organization of Minnesota Diabetes Task Force. (2003). Helping the student with diabetes succeed: A guide for school personnel: Supplementary material for implementation in Minnesota schools. St. Paul, Minnesota: Author. Retrieved April 20, 2006, from www.minnesotaschoolnurses.org/DiabSchoolSupplMNwCover.pdf
Schwab, C., Gelfman, M., & Cohn, S. (2001). Fundamentals of U.S. law. In N. Schwab & M. Gelfman, (Eds), Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses. (pp.55-79). North Branch, MN: Sunrise River Press.
Schwab, N., Hootman, J., and Gelfman, M. (2001). School nursing practice: Professional performance issues. In N.Schwab & M.Gelfman, (Eds), Legal issues in school health services: A resource for school administrators, school attorneys, and school nurses. (pp. 123-165). North Branch, MN: Sunrise River Press.
Resources
American Association of Diabetes Educators (AADE) website: http://www.aadenet.org
American Diabetes Association (ADA) website: http://www.diabetes.org
Juvenile Diabetes Research Foundation International (JDRF) website: http://www.jdrf.org
National Association of School Nurses (NASN) website: http://www.nasn.org
National Diabetes Education Program (NDEP) website: http://www.ndep.nih.gov
School Nurse Organization of Minnesota (SNOM) website: http://www.minnesotaschoolnurses.org
Blood Sugar Monitoring in the School Setting:
Adopted: June 2001
School Nurse Role in Care and Management of the Child with Diabetes:
Adopted: November 2001
Revised: June 2006