5. Personnel

Policies and procedures related to personnel should be reviewed and revised as needed to reflect the health needs of the school community. The type and number of regular and consultant staff members that a school district may require will depend on the student population served, and that may vary over time.

The following principles and guidelines should serve as a basis for policy and procedure development in the area of personnel planning, hiring, role delineation, and related personnel issues regarding the provision of services for students with special health care needs.

General

1. The school medical adviser and school nurse supervisor/director/coordinator should be integrally involved in the development of personnel policies and procedures as they relate to school personnel working with students with special health care needs.
2. In school districts where there is not a nursing supervisor/director/coordinator (i.e., a professional nurse with supervisory or administrative responsibilities), the most qualified school nurse (for example, the school nurse with experience regarding various student health needs and district involvement), should participate in the development of such policies and procedures.
3. Consultation with other disciplines and with outside community experts in nursing, medicine, and related health fields is beneficial and may be essential.
4. School districts should examine the health services needs of the total student population to determine safe and appropriate staffing patterns. “The National Association of School Nurses (NASN) recommends a formula-based approach with minimum ratios of nurses-to-students depending on the needs of the student populations as follows: 1:750 for students in the general population, 1:225 in the student populations requiring daily professional school nursing services or interventions, 1:125 in student populations with complex health care needs, and 1:1 may be necessary for individual students who require daily and continuous professional nursing services. Other factors that should be considered in the formula-based approach are number of students on free or reduced lunch, number of students with a medical home, and average number of emergency services per year” (NASN 2010.)
5. Job descriptions should clearly delineate roles, responsibilities and lines of authority for professional personnel and should be based on standards of practice for the profession.
6. Personnel policies and procedures should require personnel to use:
   1. appropriate infection control techniques to prevent the unwanted spread of communicable diseases (see Infection Control/Standard Precautions in chapter 2); and
   2. standard precautions, when indicated to prevent exposure to blood borne viruses, including human immunodeficiency virus (HIV) and hepatitis viruses (United States Department of Labor, OSHA Instruction CPL 2-2.44A).
7. Hepatitis B immunizations must be offered free of charge to school nurses and other at risk school personnel who in the course of their regular responsibilities, are or may be exposed to blood and or other body fluids that are considered high risk for the transmission of hepatitis B (United States Department of Labor, OSHA Instruction CPL 2-2.44A). See also Infection Control/Standard Precautions in chapter 2.
8. Before a licensed health professional assigns a task to unlicensed personnel, it is necessary to determine that the employee’s job description does not prohibit the performance of such a task.

Qualifications for Regular, Contract, and Substitute Personnel

1. School districts should hire qualified personnel based on the standards for the specific profession and specialty practice, when applicable, and the needs and ages of the students to be served.
2. School districts should ascertain that licensed health professionals whom they employ are in good standing in their professions and are currently licensed to practice in Connecticut.
3. School districts should ascertain that licensed and certified health professionals whom they employ have clinical experience relevant to providing services for children and families.
4. School nurses must have no less than the minimum (entry level) qualifications mandated for both educational preparation and relevant professional experience under Section 10-212 of the Connecticut General Statutes and Regulations. In many instances, the school district may prefer to seek professional nurses, nurse practitioners, or clinical nurse specialists who, in keeping current standards within the profession, have additional educational preparation, clinical experience, or both relevant to the profession of specialized health services to children in school settings. At the master’s degree level, nurses are prepared in subspecialty areas such as pediatrics, psychiatry, and public health. Additionally, some of these nurses have expertise with infants, toddlers, and preschoolers, while others have expertise with school-age children or adolescents.
5. While Section 10-212 of the Connecticut General Statutes requires only one qualified school nurse per district, nurses who work independently (alone) in a school health office should, at a minimum, meet the basic requirements of that statute order to function as a school nurse as defined by this statute.
6. Section 10-205 of the Connecticut General Statutes requires local or regional school boards in towns having a population of 10,000 or more to appoint at least one legally qualified practitioner of medicine as school medical adviser. Section 10-207 of the Connecticut General Statutes further lists duties of medical advisers. It is strongly advised by the Connecticut School Health Advisory Council that every town, including those with populations of less than 10,000, appoint a school medical adviser or join with other towns to fill this position (see appendix D).

   School nurses are registered nurses (RNs) (see appendix F).

7. All professional and paraprofessional staff members, as well as appropriate contract and substitute personnel who may be the first responders to a medical emergency should obtain CPR/AED certification prior to employment and maintain current CPR/AED certification throughout employment.
8. All personnel should be knowledgeable about proper procedures for infection control and standard precautions and should routinely use them, as appropriate.
9. Contract personnel, such as physical and occupational therapists, should have the same qualifications for employment as required of employees. Contract personnel should be required to demonstrate participation in continuing professional education in an area of practice relevant to services for children in the school setting.
10. Substitute personnel, such as substitute nurses (registered nurses) must have the necessary credentials, knowledge, skills, and supports available to carry out the health service responsibilities of regular personnel. While LPNs can assist a school nurse, or provide one-to-one nursing for individual students and are supervised by a school nurse, using LPNs as substitute school nurses is not appropriate. By licensure and practice standards, LPNs cannot independently conduct nursing assessments that are the basis for nursing judgment and critical to safe student care. Therefore, an LPN would not be able to meet the daily acute care needs of the students.

    Health aides cannot function as a substitute nurse. They are intended to assist the school nurse and should work under the direct (on-site) supervision of the nurse.

11. Orientation of substitute personnel to school buildings, and to individual students with specialized needs, as well as supervision of their performance, is essential for maintaining a safe environment during the absence of regular personnel.
12. Any decision to hire a health aide should be made collaboratively with the school nursing supervisor/director/coordinator or school nurse and the school medical adviser. Health aides are intended to assist the school nurse and should work under the direct (on-site) supervision of the nurse.
13. When a health aide is going to be hired, the school administrator should collaborate with the nursing supervisor or school nurse in the development of the job description and selection process.
14. If a health aide is hired to assist the school nurse in the health office, the health aide should minimally have CPR/AED certification and first aid training. The health aide is further trained by the school nurse in confidentiality and privacy requirements and other responsibilities of the position and remains under the supervision of the school nurse.

Planning for the Absence of Staff Providing Health Services

1. There should be a back-up or alternate plan that can be implemented when staff members providing health services are absent or are not available to provide care so that students can continue to attend school and receive safe care. The alternate plan may include designating another staff member, who has already been trained and is competent to care for the student, to be the substitute on a short-term basis, or it may include reassigning a nurse from another building for the day.
2. Whenever an alternate plan fails and a student must stay home due to inadequate staffing, the causes should be evaluated and steps should be taken to avoid similar circumstances in the future, including revision of the alternate plan.

Consultation, Supervision, Continuing Education and In-Service Training

1. Health professionals employed in school districts are practicing in nontraditional health care settings and need regular opportunities to update their clinical knowledge and skills. School districts should require that health professionals regularly access continuing education opportunities that are appropriate to their professional practice.
2. High-quality care for students may depend on the professional’s ability to keep current with rapidly changing scientific and technological advances in the health care field and with changes in the application of these advances to the provision of individualized health care services. As is the case with educational advances, all provision of health care should be based on evidence-based practice.
3. Participation by school health professionals in continuing education designed for classroom teachers, while advantageous in some ways, will not suffice to keep the health professional current in his or her area of professional expertise.
4. All staff members (including school nurses) providing health care services should have clinical supervision by a health professional qualified to provide such supervision; they should also have access to consultation with expert health professionals.
5. In-service education and appropriate training of personnel may be necessary prior to the entry or re-entry of a student with complex physical or mental health needs to ensure the safety of the student or other students in the school. Such advance preparation must be provided as rapidly as possible so as not to become a barrier to the student’s earliest entry or re-entry into school.
6. Non-health professional staff members, including teachers, transportation aides, school paraprofessionals and security personnel, require ongoing, professional development, and student-specific training related to health care activities and emergency assistance for which they may be responsible.
7. Non-health professional staff members, including transportation aides, paraprofessionals and security personnel, require appropriate supervision on the job.
8. Personnel who have regular or potential contact with body fluids (urine, feces, saliva, tears, nasal discharge, and vomitus without visible blood, blood, vaginal secretions, semen, cerebrospinal fluid, or other body fluids containing visible blood) should have ongoing general and specific instruction in the principles, and appropriate use and implementation of standard precautions.
9. Depending on the student population served, teachers, pupil personnel specialists, administrators, nonprofessionals, and/or transportation aides may require ongoing professional development and supervision in one of more of the following areas:
   1. CPR;
   2. first aid, including recognition of potential medical emergencies/anaphylaxis;
   3. body mechanics/lifting procedures;
   4. maintenance of confidentiality;
   5. documentation;
   6. child abuse recognition and reporting; and
   7. youth suicide prevention.
10. Medication administration is another area that may need to be incorporated into ongoing professional development and training opportunities for principals and other certified and noncertified personnel, depending on their responsibilities for administering medications and according to Connecticut General Statutes and Regulations, include:
    1. principles of medication administration;
    2. EpiPen administration; and
    3. student-specific medication training.

Delegation of Health Activities, Interdisciplinary and Transdisciplinary Team Functioning

1. The health care professional , such as the school nurse or the physical therapist, cannot be required to delegate a task to another staff member (who is either less prepared or not licensed) when the health professional determines that such delegation may put the student at risk for receiving unsafe or poor-quality care or, if in the case of nursing, the Board of Examiners for Nursing has determined that such licensed function cannot be delegated (see chapter 3, part b).

   It is unsafe and potentially illegal for individuals to assume that they have adequate theoretical and clinical knowledge or skill to provide services outside their own area of expertise without individual child assessment, delegation and personnel training, supervision, and evaluation by the appropriate licensed or certified professional. The clinical assessment responsibilities of one discipline cannot be assumed by a member of another discipline. It is unsafe, unethical and, in most instances, illegal for health and education professionals to practice in areas for which they have not received formal education, supervision, experience, or appropriate licensure or certification required by law or by professional standards. (See Delegation in chapter 2.)

2. When a health professional delegates a tasks to other personnel, that health professional is responsible for the training, assessment of competencies, ongoing supervision and related evaluation of personnel to whom the tasks are delegated (see Delegation in chapter 2).
3. Licensed health care personnel are obligated to function at a level commensurate with their license but should not be required to perform new or unfamiliar procedures until they have received adequate preparation.
4. Health care professionals may require outside consultation and education to learn a new technique or application of new technology before providing specific services to a student. In addition, special equipment, equipment training, resources, materials, and reference information may be required.
5. Other school personnel, including certified and paraprofessional staff members, must not be required to take on delegated tasks and responsibilities until:
   1. they have been adequately prepared and assessed for competency by the responsible health professional; and
   2. a plan for regular and ongoing supervision is in place (see Delegation in chapter 2).
6. In general, the classroom teacher should not be designated to provide specialized health care services to individual students when doing so would represent an unwarranted commitment of time to the potential detriment of other students in the classroom. Exceptions may be necessary in an emergency.
7. Interdisciplinary collaboration among personnel and families is essential in all phases of planning, implementation, and evaluation of services for students with special health care needs in school.
8. Effective collaboration requires regular communication and time for joint planning and problem solving by supervisors and staff members involved in the provision of health services to students in school. The staff may vary according to the needs of the student and may include teachers, administrators, school medical advisers, school nurses, primary care providers, specialists, school social workers, school psychologists, school counselors, speech-language pathologists, occupational therapists, physical therapists, paraprofessionals, transportation personnel, food services personnel, and outside consultants.
9. All members of the team, including family members, must recognize the expertise of others, learn to use one another effectively, and collaborate accordingly.
10. Transdisciplinary functioning is potentially efficient and effective when staff members are crossing professional boundaries within shared areas of knowledge and expertise. Transdisciplinary functioning does not preclude the necessity for professional assessment, delegation, and supervision in areas of responsibility covered by licensure or specific to the expertise of a particular discipline.
11. Health assessment is the unique responsibility of physicians and registered nurses and cannot be delegated to other personnel, including LPNs.
12. Teachers, other certified personnel, and noncertified staff members cannot take on the licensed responsibilities of any health professional unless the responsibility is delegated, the teacher or other staff member is supervised, and the delegating health professional continues to monitor the child’s health status.
13. Each member of the team must understand his or her unique responsibilities and expertise, as well as his/her own limitations and those of other members of the team.

References

Connecticut General Statutes. Chapter 169 School Sanitation. Retrieved on November 30, 2011

Connecticut General Statutes. Section 10-212. School nurses and nurse practitioners. Administration of medications by parents or guardians on school grounds. Criminal history records checks. Retrieved on November 30, 2011.

Connecticut State Department of Education. (1989). Connecticut Advisory School Health Council: Roles and qualifications of school health personnel.

National Association of School Nurses. (2010). Caseload Assignment: Position Statement. Retrieved on October 18, 2011.

United States Department of Labor. (2001). OSHA Instruction CPL 2-2.44A: Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens. Retrieved on November 30, 2011.