2. Fundamental Principles

Clinical guidelines for Connecticut school nurses (clinical guidelines) addresses students’ specialized health care needs, potential settings, school environments and staffing patterns. The school nurse, administrator, teacher, and other school staff must collaborate with the student and family to find the best solution to meeting the health service needs of the student. In many situations, the required care may, be best provided by the school nurse or, under the supervision of a school nurse, another member of the school health team (such as, RN, LPN, or trained and certified health aide), or by another health professional when the care is within that professional’s scope of practice. However, when safe care does not require direct nursing intervention, allowing other members of the school team to participate in the provision of care, when appropriate, can promote student independence; enhance opportunities for students with special health care needs to attend school in the least restrictive environment; and maximize efficient use of resources.

Student’s health impairment can significantly influence the student’s ability to perform and derive benefit from his or her educational program. Due to the dynamic nature of a student’s health status, special health care needs may be present:

• daily;
• only once or twice a week;
• periodically;
• seasonally;
• on an emergency basis; or
• for a single protracted episode.

Additionally, such special needs may change in type or severity at any time, either abruptly, as in a crisis, or more gradually, as with maturation or chronic disease progression.

The following fundamental clinical principles must be universally applied to all procedures in the Clinical Guidelines: delegation, documentation, and control.

For a student with special health care needs of any age to access and derive benefit from an appropriate program, whether in special or regular education, preschool or adult transition, it is essential for school personnel to collaborate and coordinate services with families, health care professionals and other community service providers. Children with special health care needs must attend school in an environment that is safe, that promotes maintenance of an optimal health status, and that fosters the achievement of normal developmental tasks, personal satisfaction, optimism, and independence. School personnel must not only understand and address the special health care needs of individual students, but must also understand the priorities of their families and support the individual student and family to achieve their goals. Therefore, if school programs and support services are to meet the varied needs of students with special health care needs, they must be:

• child focused;
• family centered;
• developmentally appropriate;
• continuous and flexible;
• coordinated with health services, other community services and family;
• provided in a safe and least restrictive environment;
• high quality;
• evidenced-based; and
• documented.

The following guidance further expands upon the definition of these fundamental clinical principles in meeting the needs of students with special health care considerations.

Delegation

“Delegation of nursing tasks to unlicensed assistive personnel (UAPs) in school settings continues to be a necessary, yet challenging practice. Although the practice of delegation to UAPs in schools, as in other healthcare settings, is necessary due to limited resources and increasing healthcare needs, it remains essential to provide students with healthcare that is safe and high in quality. Therefore, school nurses must understand delegation decisions and processes and develop the skills necessary to train and supervise UAPs” (Resha, 2010).

Delegation is defined as the transfer of responsibility of performing a nursing task to unlicensed assistive personnel while retaining the accountability of doing the task. “The need for delegation of nursing tasks in the school setting is greater today than ever before due to the following factors identified by NASN (2006a), NASSNC (2000), and Spriggle (2009):

• unfunded mandates, such as health screenings and immunization reporting, that pull the school nurse away from direct care;
• shortage of qualified nursing staff in schools, i.e., lack of nurses who meet the state requirement to work as a school nurse;
• budgetary constraints that limit the schools’ ability to hire and retain qualified staff;
• staffing patterns that assign one nurse to multiple school buildings thereby leaving buildings without nurses at various times; and
• federal and state requirements, such as the Individuals with Disabilities Education Act (IDEA) of 1975, Section 504 of the Rehabilitation Act of 1973, and the Americans with Disabilities Act of 1990, requiring that school health services for complex student health needs, such as providing care to ventilator-dependent children, be provided so that students can access their education” (Resha, 2010).

“This growing need to provide skilled nursing care increases the need to properly utilize trained UAPs, while continuing to provide safe and high quality healthcare in the school environment... In order to provide safe healthcare in the school setting, school nurses need to understand the legal parameters, e.g. their state Nurse Practice Acts, rules, and regulations; along with clinical parameters, such as the standards of practice and professional health-related position statements developed by professional organizations, including, among others, the American Nurses Association, the National Association of School Nurses, and the American Academy of Pediatrics, for delegating nursing tasks and responsibilities to UAPs. In addition, the individual nurse’s critical thinking skills are of utmost importance in providing safe care” (Resha, 2010).

The National Council of State Boards of Nursing (NCSBN) has identified “Five Rights of Delegation” that provide a resource for the licensed registered nurse to facilitate decisions about delegation. These include the right task, right circumstances, right person, right direction/communication and the right supervision.

The Connecticut Board of Examiners for Nursing (CBEN) issued a declaratory ruling on April 5, 1995, on “Delegation by Licensed Nurses to Unlicensed Assistive Personnel” (see appendix A). The declaratory ruling defines in detail the responsibilities of registered professional nurses regarding the delegation of nursing functions to unlicensed assistive personnel (UAP) in Connecticut, including tasks which “meet [a] client’s basic human needs and activities of daily living.” The declaratory ruling provides guidelines and sets standards for school nurses (and the agencies that employ them) in making decisions regarding delegation and supervision of nursing services, and appropriate training of unlicensed assistive personnel in Connecticut. In addition, the CBEN considers these delegation standards when adjudicating a specific case.

The following premises on which Clinical Guidelines are based are reaffirmed in the declaratory ruling, as excerpted from sections III.A.2. and III.A.3 of the CBEN 1995 declaratory ruling on “Delegation by Licensed Nurses to Unlicensed Assistive Personnel”:

In Connecticut, assessment, planning, evaluation, and nursing judgment cannot be delegated.

1. The registered nurse shall be responsible for determining what aspects of the medical and nursing regimen the registered nurse may delegate to the licensed practical nurse and unlicensed personnel, consistent with this ruling, regardless of the setting in which this occurs.
2. The performance of non-nurse delegated and non-nurse supervised nursing activities by unlicensed persons constitutes practicing nursing without a license and is not in the interest of the health, safety, and welfare of the public.
3. The registered nurse retains responsibility for the total nursing process and for its outcomes in all situations where delegation has occurred (CBEN 1995).

According to the CBEN, any task (except the insertion of a Foley catheter and tube feeding) may be delegated as long as it does not require nursing judgment. “The nurse, when making decisions about delegation, shall consider:

• client safety and the potential for client harm;
• the stability and acuity of the client’s condition;
• the nature and complexity of the task and the type of technology employed in providing nursing care with consideration given to the knowledge and skill required to effectively use the technology;
• relevant infection control and safety issues;
• the requisite competency of the person to whom the task is being delegated;
• the ability of the nurse to provide supervision and evaluation of the specific task being delegated;
• the adequacy of resources available to the nurse to support, direct, supervise and evaluate the delegated activity; and
• the proximity and availability of the nurse responsible for delegation or assistance” (CBEN, 1995, 7).

It is counterproductive and potentially unsafe to require an unwilling or reluctant staff member to provide the specialized care.

In each individual situation, the decision to delegate a specific activity for a specific student must be made by the health professional whose scope of practice includes relevant assessment of the student and performance of the procedure. In nursing, the delegating school nurse determines on an individual basis:

• the level (intensity and acuity) of care required by the student;
• whether certain aspects of care or health care activities can be delegated;
• the type of personnel to whom the care can be delegated (licensed, unlicensed, certified, noncertified); and
• what training and supervision are required (see appendix A regarding nursing delegation and appendix B regarding LPN scope of practice).

The building administrator, in collaboration or consultation with the nursing supervisor, determines which personnel in the identified category are available to perform the procedure. This may require the administrator to review job descriptions (see chapter 5), school policy and procedures, relevant bargaining agreements, personnel schedules, other responsibilities of the staff members in question, and personnel data regarding prior standardized training and certification, such as home health aide or nursing assistant preparation.

Delegation consists of: assessing and planning; communication; surveillance and supervision; and evaluation and feedback.

After ensuring that sufficient and appropriate training has been completed, the school nurse must document the training (including date or the training and training content), assesses the competence of the assigned unlicensed assistive personnel, and determine whether to proceed with delegation of the task to the specific staff members designated by the building administrator.

The school nurse remains responsible and legally accountable for any delegated tasks and must provide regular, ongoing supervision to individuals carrying out the activities. Additionally, the school nurse may determine at any time that the health care activity can no longer be delegated based on a change either in the health status of the student or in the staff member’s performance of the care.

Documentation

Documentation for health care procedures must be done in accordance with the district’s documentation policy or procedures and professional standards. The recommended procedures presented in this manual require written authorization by a prescribing health care provider and approval by a parent or guardian. In some cases, the procedure may be ordered using a procedure or treatment authorization form, such as for tube feeding or suctioning. For procedures such as blood glucose monitoring, the prescriber may have a signed plan of care from a pediatric endocrinology clinic for a student with diabetes. Other procedures may be part of a medication authorization that does not require an additional authorization, such as using a spacer with a metered dose inhaler (MDI).

Districts may choose a variety of methods, including narrative charting of procedures, to document clinical or medical procedures. Some examples include using a procedure or treatment record for daily tube feedings; a diabetes flow sheet for blood glucose monitoring; or the Individual Student Medication Record for a spacer used with an MDI. Documentation methods must be consistently used and may be done manually or electronically, depending on the documentation system a school district uses.

Regardless of the documentation system and options that a school district utilizes, the fundamental principles of nursing documentation must always apply. Documentation of health care in the school setting is required to meet legal mandates in creating a record that:

• accurately reflects professional nursing practice;
• provides a means to communicate with other health care professionals and families;
• provides a vehicle for quality assurance; and
• provides support in case of legal allegations.

Infection Control / Standard Precautions

Infection Control

Infection control, including hand washing and the use of nonsterile gloves, and other personal protective equipment as necessary, must be used when providing nursing care identified in these Clinical Guidelines. When the school nurse delegates a procedure, the nurse is responsible for ensuring that the training provided includes infection control, and the staff members receiving the delegation of each procedure demonstrate competency. All school personnel must follow standard precautions guidelines, including those specific to bloodborne pathogens.

School districts are required to:

• establish a written exposure control plan, as required by Occupational Safety and Health Administration (OSHA);
• establish adequate hand-washing facilities or alternatives;
• require staff to routinely observe standard precautions to prevent exposure to disease-causing organisms; and
• provide necessary equipment/supplies to implement the exposure control plan and budget for the replacement of supplies.

Exposure Control Plans

In December 1991, the OSHA published the Occupational Exposure to Bloodborne Pathogens Standard (29 CFR 1910.1030). This standard requires public school employers who have employees with occupational exposure to establish an exposure control plan that describes what work practices will be used to protect employees. It is important to note that all written programs must be site specific. The schools exposure control plan:

• should be developed by the chief administrative officer, with the advice of the school nurse or school health services program manager and the school medical adviser;
• use the guidelines from the Centers for Disease Control and Prevention (CDC), state and local health departments;
• must be a written policy; and
• should be reviewed annually.

School Exposure Control Plan Requirements

1. Delineate safe work practices that protect employees from exposure to bloodborne pathogens, including standard precautions (see Standard Precautions that follows), and the use of protective equipment such as gloves, face shields, and OSHA-approved sharps.
2. Outline how staff should handle blood-contaminated materials, including determining what engineering modifications and changes in practices are necessary (such as facilities and procedures for hand washing, use of needle-less devices, and disposal of hazardous waste within school buildings and facilities).
3. Determine which employees could reasonably be expected to have exposure to bloodborne pathogens or other materials potentially contaminated with blood as a result of performing job duties. This may include the school nurse, custodians, special education teachers, and bus drivers.
4. Provide training and education for all school staff, including custodians, transportation, and food services staff, on the prevention of exposure to bloodborne pathogens, standard precautions, availability of hepatitis B vaccine for staff in predetermined job positions and post-exposure procedures. This training needs to take place for new employees within 10 days of their employment and annually for all school staff.
5. Provide hepatitis B vaccine for occupationally exposed employees at no cost to the employee. Note: Some schools provide and administer this vaccine; others pay for the vaccine and have the local health department or other agency administer it.
6. Determine a post-exposure procedure to follow. The procedure should include a reporting procedure and must include immediate post-exposure medical evaluation and follow-up.
7. Determine how maintenance of records, including medical records, staff training records, sharps injury logs, and vaccine administration, will occur in accordance with guidelines for confidentiality of health records. (U.S. Department of Labor. OSHA.)

Standard Precautions

Standard precautions are recommended practice for protection against transmission of bloodborne pathogens and other infectious diseases in the workplace. This is the practice of treating all human body substances (such as blood, urine, and feces) in any form (except sweat, which is not considered to be potentially infectious) as if it is infected with a bloodborne or other pathogen and avoiding all direct contact with this material. The guidelines pertain to all body fluids (regardless of visible blood), non-intact skin, and mucous membranes (CDC, 2005).

According to the Centers for Disease Control and Prevention, “schools inherently foster the transmission of infections from person to person because they are a group setting in which people are in close contact and share supplies and equipment. However, schools also can be instrumental in keeping their communities healthy by:

• encouraging sick students and staff to stay home and seek medical attention for severe illness;
• facilitating hand hygiene by supplying soap and paper towels and teaching good hand-hygiene practices;
• being vigilant about cleaning and disinfecting classroom materials and surfaces;
• providing messages in daily announcements about preventing infectious disease;
• adopting healthy practices such as safe handling of food and use of standard precautions when handling body fluids and excretions; and
• encouraging students and staff to get annual influenza vaccinations” (CDC, 2011).

References

American Nurses Association (ANA) and the National Council of State Boards of Nursing (NCSBN). Joint Statement on Delegation. Retrieved on November 23, 2011.

Caldart-Olson, L., McComb, M., Mazyck, D., Wolfe, L., Byrd, S. Field Trip Precautions. NASN. School Nurse, Mar 2005; vol. 20: pp. 7.

Centers for Disease Control and Prevention (CDC), Division of Healthcare Quality Promotion. (2007). Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

Centers for Disease Control and Prevention (CDC), Division of Healthcare Quality Promotion. (1998). Guidelines for Infection Control in Healthcare Personnel.

Centers for Disease Control and Prevention (CDC). (November 2011). Infectious Diseases at School. Retrieved on March 15, 2012.

Centers for Disease Control and Prevention (CDC). (April 2005). Standard Precautions.

Clinical Guidelines for School Nurses Sixth Edition. (Revised 2007). School Health Alert.

Collins, N., Murphy, P., Winters, L., Van Cleve, C., Minchella, L. National Association of School Nurses. Newsletter, Mar 2008; vol. 23: pp. 24-25.

Connecticut Board of Examiners for Nursing. Declaratory Ruling on Delegation by Licensed Nurses to Unlicensed Assistive Personnel. Retrieved on November 23, 2011.

Connecticut Board of Examiners for Nursing. Declaratory Ruling on LPN Scope of Practice. Retrieved on November 23, 2011.

Costante, C. School Health Nursing: Framework for the Future Part II. The Journal of School Nursing, Apr 2001; vol. 17: pp. 64-72.

Davis-Alldritt, L. If I Delegate, Am I at Risk? School Nurse, Sep 2009; vol. 24: pp. 180-183.

Erickson, C., Splett, P., Mullett, S., Stoltzfus, H., and Bielski, M. The Healthy Learner Model for Student Chronic Condition Management--Part I. The Journal of School Nursing, Dec 2006; vol. 22: pp. 310-318.

Gordon, S., Barry, C., and Charlotte D. Delegation Guided by School Nursing Values: Comprehensive Knowledge, Trust, and Empowerment. The Journal of School Nursing, Oct 2009; vol. 25: pp. 352-360.

Gursky, Beverly S., Ryser, Barbara J. A Training Program for Unlicensed Assistive Personnel. The Journal of School Nursing, Apr 2007; vol. 23: pp. 92-97.

Harrigan, Judith F. What would you do? School Nurse, May 2002; vol. 17: pp. 20.

National Association of School Nurses. Delegation and the School Nurse. School Nurse, Jan 2008; vol. 23: pp. 15.

National Association of School Nurses. What Would You DO? School Nurse, May 2001; vol. 16: pp. 22.

National Council of State Boards of Nursing. (2005). Working with Others: A Position Paper. Retrieved on November 23, 2011.

O’Dell, C., O’Hara, K., Kiel, S., McCullough, K. Emergency Management of Seizures in the School Setting. The Journal of School Nursing, June 2007; vol. 23: pp. 158-165.

Resha, C. “Delegation in the School Setting: Is it a Safe Practice?” OJIN: The Online Journal of Issues in Nursing, May 2010; vol. 5, No. 2, Manuscript 5.

Shelton, T.L. and Stepanek, J.S. (1994). Family-Centered Care for Children Needing Specialized Health and Developmental Services.

Solum, Linda L., Schaffer, Marjorie A. Ethical Problems Experienced by School Nurses. The Journal of School Nursing, Dec 2003; vol. 19: pp. 330-337.

Spriggle, M. Developing a Policy for Delegation of Nursing Care in the School Setting. The Journal of School Nursing, Apr 2009; vol. 25: pp. 98-107.

United States Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH). Bloodborne Infectious Diseases HIV/AIDS, Hepatitis B Virus, and Hepatitis C Virus.

United Stated Department of Labor. OSHA. Occupational Safety and Health Standards. Retrieved January 23, 2012.

United States Department of Labor. OSHA. Universal Precautions. Retrieved on April 19, 2011.