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INTRODUCTION
The Individuals with Disabilities Education Act (IDEA) grants to eligible children with disabilities the legal right to receive a free appropriate public education in the least restrictive setting. Access to education for many children is only achieved through the provision of necessary health services (e.g., administration of intravenous medications, catheterization, tracheostomy care, and gastrostomy tube feedings). The safety implications attached to these services for children support the leadership role of the school nurse in advocating for the health and educational needs of students. The National Association of School Nurses (NASN) believes that such children have the right to receive the specialized health services required to assure their inclusion and safety in the school environment, and that further, these special health services should be provided or supervised by a Registered Professional Nurse (serving as and referred to hereinafter as school nurse).
BACKGROUND
The Education for All Handicapped Children Act (EHA) was passed as law in 1975. It established national standards for the free appropriate public education of children with disability-related learning problems in the least restrictive environment. In 1990, the EHA was renamed the Individuals with Disabilities Education Act and since that time has been referred to as IDEA. Congress made amendments to IDEA in 1997 directing educational interventions for children 3 through 21 years of age who have qualifying disabilities that impede their ability to learn. Eligible students are entitled to support services at school. These are known as "related" services. The federal regulations provide definitions for the eligibility criteria and specific related services. The definitions should be considered "educational definitions". In health care, these conditions and services may be defined differently (Schwab, Gelfman, & Cohn, 2001b, p. 387).
The 1997 IDEA amendments included a definition of IEP team members that did not include specification about the participation of a school nurse. The Congressional Record did however, in the preface to IDEA 1997, record that there are situations that merit a licensed registered nurse being on the IEP team (Committee on Labor and Human Resources, U.S. Senate, 1997, in Schwab, Gelfman, & Cohn, 2001.) However, in many jurisdictions, it remains that school nurses are not included in the multidisciplinary team that develops and implements a student’s IEP or IFSP. In these areas, specialized health services either are not included or are improperly and dangerously, performed by individuals who lack requisite training and supervision.
In 1999, United States Supreme Court ruling in Cedar Rapids Community School District v. Garret F. (hereinafter known as "Garret F.") held that IDEA requires school districts to provide school nursing services when such supportive services are necessary in order for students to access and benefit from their educational program.
Garret F. held that IDEA requires a school district to be financially responsible for the provision of nursing services that students require in order to access and benefit from their educational program. The Court based its ruling on IDEA’s definition of "related services" and on the United States Supreme Court decision Irving Independent School District v. Tatro (hereinafter known as "Tatro") (1984). Garret F. involved a student who required continuous nursing services in school, including urinary bladder catheterization, tracheostomy tube suctioning, nutrition and fluids on a regular schedule, positioning, monitoring of ventilator settings, artificial ventilations by ambu bag when the ventilator malfunctioned, assessment of respiratory status for respiratory distress or autonomic hyperreflexia, blood pressure monitoring, and bowel disimpaction.
NASN played an active role in Garret F. and signed on to amicus curiae (Friend of the Court) brief. This brief argued that the Supreme Court should affirm the lower Court’s decisions related to the responsibility of school districts to provide the types of nursing services required by Garret F.
In 2004, IDEA 1997 was reformed again and renamed by Congress as the Individuals with Disabilities Education Improvement Act, which continues to require school districts to educate children in the least restrictive environment with emphasis on participation in the general education curriculum and a strong preference for regular classroom placement. Inclusion in the regular education setting must consider the preference used in determining the educational placement of children with any disability. Appropriate educational placement in an inclusive setting helps to break down the attitudinal and physical barriers that prevent individuals with disabilities from participating fully in society and affords an opportunity for all students to benefit from interaction and active participation with peers of chronological age, and to learn age-appropriate behavior.
Children with health conditions may become eligible for special education services if the child’s disability has an impact on his or her educational performance. The school multidisciplinary team determines eligibility and necessary services, with the school nurse serving as a crucial member of the team. Because children with chronic and special health care needs have unique health considerations, individualized nursing assessment, planning, and intervention are critical to identifying appropriate placement and service decisions. The team determines the health services necessary to enable children with disabilities to attend school and to participate fully and safely in educational activities and programs. The team develops an appropriate educational program, known as an Individualized Education Program (IEP) for children 5–21 years or an Individualized Family Service Plan (IFSP) for eligible children ages 3-5 years.
RATIONALE
Managing the health and safety needs of children with profound health conditions is difficult. The interaction with the educational system is often complex because many people are involved in the process and multifaceted regulations must be addressed. State licensing laws for health care professionals identify and define professionals slightly differently from state to state.
State educational certification regulations or other mandates regarding qualifications of school nurses may also add to differences in interpretation of "qualified school nurse or other qualified person" (Schwab, Gelfman, & Cohn, 2001b, p. 393). State Nurse Practice Acts (NPA) continue to need to be reviewed to ascertain what is allowed in a particular state.
No federal law or regulation dictates who must perform certain health care procedures (Rapport & Lasseter, 1998). States’ Nurse Practice Acts and other laws set forth these requirements. Delegation of nursing care to unlicensed assistive personnel may be appropriate in situations when proper assessment, training, and continued supervision can occur. Sometimes school nurses are asked to provide or delegate services that may not be delegated under that state’s Nurse Practice Act. The parent or school personnel may never assume responsibility for delegating procedures requiring skilled nursing care. These actions would be considered practicing nursing or medicine without a license and could be subject to disciplinary action (Hootman & Hula, 2001).
The school nurse is professionally prepared in both issues of health and the educational process and can serve as a natural interpreter to the student, family, and health and education systems relative to students’ special health needs during the school day. While estimates of the actual number of children eligible for "related services" are varied, trends in health, chronic disease, and disability for children support the need for related services. These trends include (1) increases in the number of children in schools with life-threatening allergies, (2) increases in the incidence, prevalence, and severity of asthma, (3) management of HIV as a chronic disease, (4) long-term survival of students with complex medical problems due to advances in medical technology, (5) continued increases in the number of children who are medically-fragile and technology dependent in regular classrooms, and (6) increased parental knowledge about the rights of children to education and "related services" in the least restricted environment.
The impact of Garret F. on school districts and on school nursing is significant. It is important for school districts to be aware of the increasing number of students enrolling in schools with complex medical and nursing needs. The school nurse plays a vital role in developing this awareness by explaining the implications of Garret F., IDEA 1997, and IDEA 2004 on administrative decisions about policy, staffing, collaborative decision-making, and clinical nursing practice in the schools. This landmark decision solidifies and reaffirms the central role that school nurses play in the delivery of related school health services under the IDEA and the obligation of school districts to pay for such services.
Regardless of the actual number of students with disabilities who may require the supportive services of a nurse, school districts need to be cognizant of necessary and reasonable services and ever mindful of the inclusion and safety requirements for these students. These may include any level of service on a continuum, from direct or indirect nursing services one hour per week, a nurse on- site in the building at all times, or one-on-one nursing care throughout an entire school day. Regardless of the level of the service required, nursing services must be provided as determined in the student’s IEP. It is critical therefore, for school nurses to be part of IEP teams for students whose health conditions have an actual or potential impact on their learning and for school districts to ensure that school nurses are integral members of their schools’ early identification and special education teams.
Each student with a complex medical condition or a need for modification of the school environment due to a health condition should have an Individualized Health Care Plan that reflects the health needs of the student and directs how those health needs are to be managed during the school day. The school nurse should be responsible for the writing of the IHP in collaboration with the student, family, and health care providers (NASN, 1998).
ROLE OF THE SCHOOL NURSE
The school nurse plays a vital role in applying IDEA and Garret F. and in explaining its implications on administrative decisions about policy, staffing, collaborative decision-making, and clinical nursing practice in the schools. The cost of providing intensive nursing services can no longer be used as a basis for excluding students. School nurses and school nurse administrators must assist school districts in determining and identifying necessary and reasonable levels of care and are in a position to identify potential sources of payment for nursing services, such as Medicaid funds.
Because health insurance companies often have lifetime limits on coverage, some states now require school districts to disclose to families the potential impact of using their own insurance to pay for in-school services. The implication is that when parents use their own insurance benefits to cover school-based nursing services, they may be limiting their child’s future available insurance coverage. School nurses can guide districts in understanding their obligation to pay for in-school nursing services when the school nurse has determined the appropriate level of care needed and included it in the student’s IEP. This same guidance can be given when discussing these issues with families.
The school nurse is a team member who participates in the identification and evaluation of students who may be eligible for services under IDEA. Through shared responsibility with other team members, the school nurse assists in the planning and implementation of Individual Education Plans or Individual Family Service Plans, as needed. The school nurse ensures the safe delivery of necessary health services to eligible children with disabilities through participation on the multidisciplinary educational team and direct care with the student. As a member of this multidisciplinary education team, the school nurse assists in identifying children who may need special educational or health-related services. These include the following actions:
assesses the identified child’s functional and physical health status, in collaboration with the child, parent(s)/guardian(s), and health care providers;
develops individualized health and emergency care plans;
assists the team in developing an Individual Educational Plan (IEP) that provides for the required health needs of the child, which enables the student to participate in his/her educational program;
assists the parent(s) and child to identify and utilize community resources;
assists the parent(s) and teachers to identify and remove health-related barriers to learning;
provides in-service training for teachers and staff regarding the individual health needs of the child;
provides and/or supervises unlicensed assistive personnel to provide specialized health care services in the school setting;
evaluates the effectiveness of the health-related components of the IEP with the child, parent(s), and other team members, and makes revisions to the plan as needed;
participates in the identification and evaluation of students who may be eligible for services under IDEA, and through shared responsibility with other team members, assists in the planning and implementation of Individual Education Plans or Individual Family Service Plans as needed;
develops student goals and objectives and nursing protocols to meet student-specific health needs during a school day, monitors student progress, and initiates an IEP reassessment when indicated; and
serves as the team liaison to the medical community.
REFERENCES
Cedar Rapids Community School District v. Garret F, 119 S.Ct. 992, 29 IDELR 966 (U.S. 1999). To view the full decision, go to: http://supct.law.cornell.edu/supct/html/96-1793.ZS.html.
Gaffrey, E. A., & Miller, W. R. (2001). Contracting with managed care organizations. In N. C. Schwab & M. H. B. Gelfman (Eds.). Legal issues in school health services: A resource for school administrators, school attorneys and school nurses. Pp. 453-471. North Branch, MN: Sunrise River Press.
Gelfman, M. H. B., & Schwab, N. (2000). School health services after Cedar Rapids Independent School District v. Garret F. Journal of School Nursing, 16(4) 54-59.
Heller, K. W., & Tumlin, J. (2004). Using Expanded Individualized Health Care Plans To Assist Teachers of Students with Complex Health Care Needs. Journal of School Nursing. 20(3) 150-160.
Hootman, J. & Hula, B. (2001). Partnering with the school nurse. Small Talk. 1(3), 1-4.
Individuals with Disabilities Education Act (IDEA). (1975). 20 U.S.C. §§ 1400 et seq., as amended and incorporating the Education of All Handicapped Children Act (EHA), 1975, P.L. 94-142, and subsequent amendments; Regulations at 34 C.F.R. §§ 300-303 [Special education and related services for students, pre-school children, and infants and toddlers].
Irving Independent School District v. Tatro, 468 U.S. 883, EHLR 555:511 (1984).
National Association of School Nurses. (2000, November). National Association of School Nurses membership survey results. Scarborough, ME: Author.
National Association of School Nurses. (2001). Issue brief: Impact of Cedar Rapids Community School District vs. Garret F. on School Nursing Services. Scarborough, ME: Author.
National Association of School Nurses. (2003). Position statement: Individualized Health Care Plans. Scarborough, ME: Author.
National Association of School Nurses. (2004). Position statement: Caseload assignments. Scarborough, ME: author.
National Information Center for Children and Youth with Disabilities. (1997). The IDEA amendments of 1997. NICHCY News Digest, 26, 11-39.
Public Law 105-17. (1997). Reauthorization of the Individuals with Disabilities Education Act.
Public Law 108- 446. (2004). Reauthorization of the Individuals with Disabilities Education Act.
Rapport, M.J., & Lasseter, D. J. (1998). Physical disabilities: Education related services. 16, 77-94.
Schwab, N., Gelfman, M., & Cohn, S. (2001). IDEA: Current Issues in Dispute. In N. C. Schwab & M. H. B. Gelfman (Eds.), Legal issues in school health services: A resource for school administrators, school attorneys and school nurses (pp. 399-418). North Branch, MN: Sunrise River Press.
Schwab, N., Gelfman, M., & Cohn, S. (2001). Special Education Law. In N. C. Schwab & M. H. B. Gelfman (Eds.), Legal issues in school health services: A resource for school administrators, school attorneys and school nurses (pp. 373-399). North Branch, MN: Sunrise River Press.
U.S. Department of Education. (1999) National Education Association Policy Statement on appropriate inclusion. Retrieved from http://www.nea.org/publiced/idea/ideaplcy.html.
U.S. Department of Education, Office of Special Education and Rehabilitative Services. (1999). Annual report to Congress on the implementation of the Individuals with Disabilities Education Act. 1988-1998. Retrieved from http://www.nces.ed.gov/pubs99
U.S. Department of Education, Office of Special Education and Rehabilitative Services (1999). Annual report to Congress on the implementation of the Individuals with Disabilities Education Act, 1988-1998. Retrieved from http://www.nces.ed.gov/pubs99.
Walsh, M. (1999). Educators say ruling could drain budgets. Education Week, 18(26): 1 & 12. 2001.
Impact of Cedar Rapids Community School District vs. Garret F. on School Nursing Services
Adopted: 2001
Inclusion
Adopted: 1995; Revised: 2001
School Nurses and the Individuals with Disabilities Act (IDEA)
Adopted: 1996; Revised: 2002; Revised: July 2006 |