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Teachers, Nurses, and Medical Care in California Schools

June 2, 2011

In California, we have a school staffing problem.  By many measures, we are the worst in the nation when it comes to putting enough people in place to do the jobs we expect of our schools and districts.  With school nurses, the ratios are far too low to meet needs, but the potential consequences for some students are more immediate and more dire.

The federal government has inserted itself into a state legal battle over a law that would press non-nurse staff members into job duties currently delegated to school nurses.  Here’s the opening of an article from The San Francisco Chronicle (“Obama administration steps into insulin shot fight” – May 30, 2011).

 The Obama administration has stepped into a California case involving 14,000 diabetic schoolchildren, urging the state’s top court to let school employees give insulin shots if no nurses are available.

Two lower courts have ruled that California law allows only licensed doctors and nurses to administer medication, including insulin, except in emergencies. But U.S. Justice Department lawyers say that given the state’s shortage of nurses, that would effectively deny care to thousands of children and violate their rights under federal disability laws.

My first reaction to this article was that it’s a sad state of affairs when we might change a health and safety law in order to compromise the quality of medical care for children, rather than pay for the appropriate level of care called for under the law.  Then again, I see the other side: given that the school nursing shortage is here, now, we need to look at ways to keep them healthy and safe at school.  I do understand that rules and laws vary, and that the California interpretation of what’s appropriate or safe might differ from the standards elsewhere.  I decided to put the question to some friends in other places and other professions, and they allowed me to present their views here.

A middle school English teacher in Northern California: “my first reaction is that this falls into that category of what teachers need to stand together and refuse to do — what exactly is our profession again?”

A self-employed friend in New Orleans: “Diabetes is becoming increasingly common, if not epidemic, among children. If a parent or child, even a “friend”, all non-professionals, can safely administer a shot of insulin, why can’t a non-nurse school employee? I think teachers should be allowed to refuse, but what about those who are ok with it? Is a teacher no longer allowed to do CPR or the heimlich on a kid?”

I chimed in: “I see your point, and personally, I’d be comfortable giving an insulin shot. However, I worry about a few aspects of it. First, the exceptional incident, where a trained eye is important in addressing an emergent problem. Second, it adds to a workload that, for many school personnel, already has too many non-teaching tasks. Third, it will mask the real problem of not having enough nurses, making so that we seem to be getting along okay without them, but they’re not there when we have more serious problems like seizures, shock, intoxication/overdose, etc.”

An elementary school teacher in California wrote: “Our neighbor has a three-year-old with Type 1. It’s such a terrible disease, and incredibly serious. Our neighborhood elementary school principal asked to be a “magnet” for kids with Type 1 so they could have a nurse. If there isn’t a nurse when this little girl goes to school my neighbor said she would go over 2x’s a day to administer insulin. My husband and I were “trained” in what to do in case of emergency – and it was a big undertaking. NOT something I would want to be responsible for at school. Sure, an older kid who understands how to manage his/her health might be okay without a nurse, but what about a kindergartner who innocently sneaks food from a friend? Bottom line, we need nurses.”

A teacher at a private school on the East coast replied: “I think, first, schools need nurses. Absolutely. But second, I once had an advisee (a 6th grader) who trained me, and his other teachers, to give him insulin. One could argue kids with diabetes are safest if a variety of adults can care for them if needed.”

And I replied: “That’s a good point. There’s a difference between being trained to handle a problem, and being expected to manage daily meds.”

My friend in New Orleans returned with this: “Well, then it sounds like a school should not even be allowed to be open if there is not a full time nurse/doctor on the campus. If you don’t have one at your school, it should be closed immediately.”

To which I replied: ” I’d almost agree with you (re: closure). That was kind of my question at the outset – are we settling for the inappropriate option because we don’t feel like paying for the appropriate option? On a less critical level, it’s similar to what I faced when I was a non-union production assistant in radio and television. I had the necessary skills to lay video cables on a TV production, and the skills to write newscopy at the radio station, but work rules were pretty strict in preventing me from doing those union jobs in order to protect those hired for those purposes. You can argue that unions inflate the costs of doing business, but I don’t feel like ABC or CBS ever got a raw deal in those situations. I do think my willingness to do those jobs for $6.50 an hour at age 21 would undermine the opportunity for other skilled people to earn a decent living. (For what it’s worth, I did get some experience laying cables a few times due to a limited allowance in union rules, but I think for everyone’s safety, it was best that I was supervised by an experienced and unionized employee).”

The California elementary school teacher added: “I had a parent give me some further insight.  She said that up until a few years ago a parent of a Type 1 could become the “diabetes person” at a school. The nurses union didn’t like this because it took away from their job, however many parent organizations liked this solution since nurses aren’t at schools full-time. The state, by disallowing non-nurses to give insulin and simultaneously failing to provide nurses to administer insulin, is in clear violation of the Americans with Disabilities Act. So, there are parents who are happy with the Obama administration for getting involved. I shouldn’t have assumed that by non-nurse they automatically meant classroom teacher.”

My friend in New Orleans again: “A rock and a hard place. I support unions, but I do not support all union behavior — i.e. not allowing parents/others to administer insulin shots just to protect their own jobs! Our priorities are pretty messed up when we think it’s not important to spend money on school nurses, teachers, or health care in general for that matter, but we get very emotional about how millionaire football players are getting screwed by the billionaire owners! Yet we think that teachers and government workers don’t ‘deserve’ to earn $50K!”

The Northern California middle school English teacher returned to the dialogue: “I’ll just say again that as a teacher, I do not want that kind of responsibility. I have plenty to do with too many students and too many academic expectations. We are teachers, not medical personnel. And David is right — if we make it look like we don’t need nurses, we will no longer have nurses at schools at all.”

A Southern California teacher joined in: “Keep in mind that it is illegal for a teacher to give a cough drop or an aspirin. Teachers will be held personally responsible for well-intentioned medical practicing, just as good Samaritans are now liable for any injury caused to people in car accidents, etc., that they help.”

A California pediatrician added: “I agree. Even experienced parents of a diabetic child sometimes panic and make mistakes. I had a patient whose dad found him passed out, and he assumed ‘Hey, he’s diabetic, he must need insulin.’ Wrong. His sugar was too low, not too high. Dad gave a dose of insulin that could have caused seizures, even death. Non-nurses should not face that legal liability or emotional stress!”

A California science teacher with emergency medical training had the last word: “Children are very different than adults when it comes to diabetes. Because of their small size, they are much more susceptible to very fast changes in blood sugar. I am trained as an EMT and back in collage was on an ambulance crew and I know for sure I don’t want to be responsible for dealing with diabetic emergencies at school. Giving insulin is not comparable to an epi-pen. The argument that the union is trying to save jobs is a false one. When they fire all the janitors and you’re expected to clean your room, the union will protest, even though janitors are not union members. The union thinks this is a stupid idea because a) students may die if this gets screwed up. b) teachers should be allowed to do their jobs, not everyone else’s. c) we need nurses on campus for a variety of reasons, this just masks the problem. d) not a good idea to give parents something else they can sue us over.
By the way, not only do they want us to give insulin, but also diastat, an anti-seizure medication administered rectally.
And sure, make it optional so we can say no. That just means the probationary teachers will be the ones ‘volunteering’.”

What are your thoughts?  Is it acceptable to add medical-related duties to non-medical personnel in schools?  The trade-offs seem pretty clear, but which concerns trump the others?  What priorities should guide policy-makers and judges, districts and teachers?


7 Comments leave one →
  1. Tiffany permalink
    June 2, 2011 4:16 pm

    This is such a great post, and a fantastic way to look at this topic. Everyone seems to think everyone else is out for self-interests only, it’s good to hear varying viewpoints come together on this issue. It’s a tough one, but you presented it well. I’m going to share.

  2. Tom permalink
    June 2, 2011 5:03 pm

    I wouldn’t mind doing the blood test for a type A, but not the insulin. I agree with the pediatrician.

  3. June 2, 2011 5:24 pm

    There’s more to administering insulin that just giving the shot. You have to figure out how much to give based on the students levels before and after eating and on their activity level. You also need to no what to do if they get too high or low during the day. It isn’t just giving a shot.

  4. June 2, 2011 8:09 pm

    If the child is on a stable dose and well controlled on that dose, and can draw up the correct amount by him/herself, but just needs someone to give the med, there sould be no problem. The person should be trained to give injections. It should not be the role of the classroom teacher, however. They have too much to do already. If there is a perceived emergency, the child should be brought to the nearest ER ASAP. No one should give meds to a child in an emergency, except nurses or MDs in an emergency room.

    To correct one misconception, the California Good Samaritan law specifically exempts from liability anyone trying to help in an emergency situation, like an auto accident with injuries.

  5. June 3, 2011 1:00 pm

    I’m going to agree with the pediatrician too. We are already blamed for things out of our control. We don’t need to be blamed for the accidental deaths of wrongly injected children.

    It’s one of the dumbest ideas I have ever heard, actually.

    And David’s point about masking the problem of not enough nurses (I never had one at the 3 schools I worked at in 13 years in CA) is almost as a good a reason NOT to do it as the doctor’s.

  6. June 3, 2011 1:36 pm

    Great post, David. I appreciate your highlighting something (school nurses) that the public doesn’t immediately think about when considering cuts to education.

    My opinion: there should be a registered nurse in every school.

  7. June 4, 2011 2:49 pm

    This is one of those difficult ethical questions. The nurses are already gone from California elementary schools and have been for a decade (at least locally). Given the shortage of nurses in California, the schools are unlikely to be able to get them back.

    Most of the time, the nurses at an elementary school have very little to do that calls for their training. The reason for having nurses was to handle the rare exception, and to do routine comforting that any reasonably sympathetic adult could do.

    There are some children whose medical needs require more than just comforting by a sympathetic adult. So we, as a society, have to decide how to handle this need. Do we station nurses everywhere such children may be? Do we put nurses where there is a sufficient concentration of such children to justify the expense (including the opportunity cost of not having those nurses available in other places, such as emergency rooms)? Do we cluster the children with medical needs so that there is sufficient concentration to justify the cost of services? Do we require some children to go without needed services? Do we allow/require inadequately trained people to provide medical help? Do we try to recruit and train huge numbers of new nurses?

    None of these questions have easy answers. Questions about allocating scarce resources (in this case, trained nurses) rarely do.

    My off-the-cuff opinion (which might change on further discussion or reflection) is that nurses are too scarce a resource in California to dedicate one for every 400 students, so we can’t reasonably expect to have a nurse at every school. I think that clustering the students with medical needs at a single school in a district (for districts with multiple schools) could be a good compromise—one that neither compromises children’s health nor requires more nurses than can be provided.

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