Schools with diabetic students – that would be nearly every public school in California – received a mandate from the state Supreme Court on Monday to provide students with the insulin shots they are entitled to under the Americans with Disabilities Act, regardless of whether a nurse is on campus.
While school nurses argued that insulin legally must be administered only by licensed health care providers, the court disagreed and found that California law permits “trained, unlicensed personnel” to administer prescription medication under a doctor’s orders, including insulin, the drug used in treating diabetes.
During nine years of related litigation, the case highlighted the pressures on schools to provide health care for students in a time of dwindling budgets for school nurses, as well as the stress on families who want to ensure care for their children as the incidence of childhood diabetes rises, with 1 in 400 children diagnosed with diabetes nationwide, according to the American Diabetes Association.
What began as a 2005 federal class action suit by elementary school students in Northern California to receive the insulin shots they needed during school hours ended up as a fight between the American Nurses Association and the state Department of Education about who could provide the shots. California has one school nurse for every 2,200 students, the court noted in its decision. And while 5 percent of California schools have a full-time nurse, 69 percent have a part-time nurse and 26 percent have no nurse at all.
“Finally the confusion has been eliminated – the California Supreme Court has unanimously interpreted the governing state statute to allow non-medical personnel to carry out a physician’s orders,” said Larisa Cummings, an attorney with the Berkeley-based nonprofit Disability Rights Education and Defense Fund, which filed the original lawsuit.
The plaintiffs in the 2005 lawsuit included four elementary school students with diabetes who were battling the San Ramon Valley Unified School District and the Fremont Unified School District to receive insulin shots and blood-sugar readings. Maile Costello was about to enter kindergarten at Greenbrook Elementary in Danville with a diagnosis of Type 1 diabetes when her mother, Laurie Costello, approached the school to talk about her daughter’s care. She wanted the school to do a mid-morning reading of Maile’s blood sugar levels and push the button on her insulin pump if needed.
“I wasn’t asking them to give her a shot,” said Costello. “I’m asking them to push a button and look at a number and say yes or no. They said, we can’t do it because if we commit to it, we have to be there every day and there’s no physical way we can do it. We’ve got one nurse for six elementary schools.” The school suggested that Costello sit outside the kindergarten classroom so she could monitor her daughter’s blood sugar levels. Costello and her family joined the lawsuit.
Ultimately, the San Ramon Valley Unified School District assigned a paraprofessional teacher’s aide, who was working at the school, to stop in at 10:30 a.m. to help Maile monitor her blood sugar levels and go with her on field trips, if necessary, Costello said. “The district was fantastic,” she said. The aide worked with Maile through fifth grade.
Adequate training to be defined
With the new ruling, schools that don’t have enough school nurses must decide how to provide the care that some diabetic students need. “The operative word in this Supreme Court ruling is a ‘trained’ person,” said Lynda Burlison, immediate past-president of the southern section of the California School Nurses Organization. “We are going to spend the next six months coming up with what trained means, if schools don’t hire a nurse.”
The dispute about who is allowed to administer medication to students is decades old in California, the court noted in its decision, and various legislative and legal decisions have been interpreted in diverse ways by school districts. The result is a hodgepodge approach, with some schools allowing unlicensed teachers, aides or volunteers designated by parents to administer insulin shots, while other schools have forbidden the practice.
“It varies across the state,” acknowledged Maureen Cones, associate general counsel for the American Nurses Association. She said a major concern now is whether California students will receive appropriate diabetes management as more schools turn to unlicensed personnel to provide care. “I hope that I am wrong and that there is no negative impact on the health of students in California public schools,” she said.
A key issue will be training in diabetes management and insulin shot administration for unlicensed personnel, she noted. “Because nurses in California cannot delegate the administration of medication to an unlicensed person, nurses have been reluctant to train,” she said.