Brief Summary of Substitute Bill

Specifies that a registered nurse (RN) or an advanced registered nurse practitioner (ARNP) working in a school setting is authorized and responsible for the nursing care of students to the extent that the care is within the practice of nursing.
Provides that a school administrator may supervise a RN or an ARNP in aspects of employment other than the practice of nursing.
Provides that only a RN or an ARNP may supervise, direct, or evaluate a licensed nurse working in a school setting with respect to the practice of nursing.

Background:

Students attend school with a broad range of health conditions. These range from potentially life-threatening acute and chronic conditions to correctable vision problems. Before a child is allowed to attend public school, the school must receive a medication or treatment order addressing any life threatening health condition the child has that may require medical services, including nursing services, to be performed at the school.

The scope of practice and training for nursing is regulated through a tiered licensure system, with licensed practical nurses having the least amount of training and advanced registered nurse practitioners (ARNP) having the most training. The National Association of School Nurses (NASN) recommends that, at a minimum, a school nurse should be licensed as a registered nurse (RN).

In addition, the NASN recommends that a school nurse be clinically supervised and evaluated by a RN knowledgeable about the scope and standards of practice for school nursing. Many of the duties of a school nurse must be carried out by a RN or an ARNP, such as:

consulting and coordinating with students' parents and health care providers;
preparing student health care plans;
performing health assessments and health evaluations for special education students;
training and supervising the appropriate school district personnel in proper procedures to ensure a safe, therapeutic learning environment; and
health teaching.

In a first class school district (2,000 or more enrolled students), a school nurse must hold an education staff associate certificate. The knowledge and skills acquired through the certification process are over and above the knowledge and skills required for licensure as a RN.

Summary of Substitute Bill:

A RN or an ARNP working in a school setting is authorized and responsible for the nursing care of students to the extent that the care is within the practice of nursing. A school administrator may supervise a RN or an ARNP in aspects of employment other than the practice of nursing. Only a RN or an ARNP may supervise, direct, or evaluate a licensed nurse working in a school setting with respect to the practice of nursing.

This does not:

prohibit a nonnurse supervisor from supervising, directing, or evaluating a licensed nurse working in a school setting with respect to matters other than the practice of nursing;
require a RN or an ARNP to be clinically supervised in a school setting; or
prohibit a nonnurse supervisor from conferring with a licensed nurse working in a school setting with respect to the practice of nursing.

The Superintendent of Public Instruction must notify each school district of these requirements, within existing funds.

The "practice of nursing" means registered nursing practice, advanced registered nursing practice, and licensed practical nursing practice as defined in nursing care statute. Such practice includes the administration of medication pursuant to a medication or treatment order and the decision to summon emergency medical assistance. It also requires compliance with any state or federal statute or administrative rule specifically regulating licensed nurses, including any statute or rule defining or establishing standards of patient care or professional conduct or practice.

Staff Summary of Public Testimony:

(In support) This is the third time around for this bill; it has passed out of this committee twice before. Supervision by a principal, of a nurse in a school setting who teaches health, instructs on healthy behavior, is a pedagogical or educational activity that rightly should be supervised by a principal. However, school nurses also deliver medical attention to students and staff, such as administering medication, rendering first aid, and calling an aid car. In these cases, the medical decisions need to be made by the person trained to make them, which is the school nurse. This bill specifies whom the nurse should report to in each situation.

This bill clarifies that when a nurse is working under a registered nurse license issued by the Department of Health, then the nurse's license is held in check for medical decisions that the nurse makes. This bill puts into the education code that these decisions must be made by the nurse. It is already in the Nurse Practice Act that nurses are responsible for their own decisions. This issue comes up multiple times per year from nurses who claim that principals are intervening in medical issues. Some nurses have been disciplined after the fact for calling 911 when the nurse thought that a child needed more care than could be provided in a school setting. It takes months for a nurse to get his or her record cleared after this.

A nurse is accountable for what they do, regardless of the setting. A nurse's responsibility cannot be avoided by taking direction from the principal or other school administrator. This bill distinguishes between the responsibilities of a nurse as an employee and their responsibilities to provide safe nursing care for children.

(Opposed) None.

(Other) Some principals would like more school nurses, but are concerned about the bill language that uses the word "interfere." The exact definition of what it means to "interfere" is important. There may be situations where it is appropriate for a principal to question the judgement of the nurse, without it violating the language of the bill. In terms of clinical supervision, this is easy in a small district that has an Educational Service District to supervise the nurse, or in a large district that has many nurses. However, in a medium district with only one nurse, there is no one to evaluate the nurse's clinical practice.