A reader and her husband sent me an email saying they are concerned about the care their 7-year-old daughter received at a public school. Their daughter has diabetes, and apparently the school nurse administered insulin to her three times during the daughter's hypoglycemic episodes.
The school denies these incidents occurred, but the reader states they have the logs to prove it. The reader also states other deviations from the standard of care occurred, but she did not provide details. School nurses face daily challenges in their practice, one of which is caring for insulin-dependent students. Several federal laws require diabetic students to have the care they need while in school. They include the Americans with Disabilities Act, Guidance and Training on the Americans With Disabilities Act and The Education for All Handicapped Children Act of 1975 (now known as the Individuals with Disabilities Education Improvement Act). Many states also have specific statutes relating to diabetic students and the care they receive while in school. At a minimum, the laws require that each student has an Individualized Education Plan, Individualized Health Plan, and an Emergency Care Plan developed by the school nurse in conjunction with the student, family, and orders and management guidance in the Diabetes Medical Management Plan. The reader did not share what, if any, actions they took to rectify this situation, but it can be assumed that they shared their concerns with the school administrator and with members of the student's IHP and ECP to no avail.
If the parents did not discuss this issue with the school superintendent, this would be an important step in correcting the problem, since the school may be liable if an injury or death occurs due to the nurse's conduct.
Did the nurses have the correct training?
It is quite odd that a school nurse would give insulin when hypoglycemia exists. Because this is so contrary to what any nurse, including a school nurse, would do, one has to question whether the nurse is qualified to care for diabetic students. As a result, reporting the situation to the state board of nursing for review would help to remedy the situation. After investigating what happened, if the state board determines that the school nurse in not qualified to care for diabetic students, it may require the nurse to take a course, either in an academic setting or through a professional association such as the National Association of School Nurses. The board will most likely take into consideration the American Association of Diabetes Educators' Position Statement, "Management of Children With Diabetes In The School Setting." Or the board may determine this nurse has additional practice issues besides caring for a student with diabetes. In either event, providing a truthful and complete complaint to the board of nursing is most likely in order and would hopefully result in a quick solution so the student's well-being is protected.
Although the circumstances surrounding the administration of insulin when the student was hypoglycemic were not included in the parents' question, it sounds as though another problem must be considered: The student's ECP, if one existed, was not followed by the school nurse. Or, if one did exist, it may be faulty.
Although not the focus of this situation, it is important to note that one of the roles of the school nurse is to help a diabetic student become independent in his or her care. In other words, with the consent of the family, the involvement of the primary healthcare provider and consistent with school policy, a diabetic student eventually can self-administer insulin based on self-determined blood glucose levels and becomes the manager of his or her own chronic disease. The family may want to consult with a nurse attorney or attorney who practices educational law and focuses on students whose care while in the school setting is regulated by state and federal laws. If you are a school nurse or a parent of a diabetic child in the school setting, you know how important the correct intervention of a hypoglycemic event is. There is little, if any, room for error.
Take these courses on diabetes management:
CE486: School RNs Lead Education Efforts for Students with Diabetes (1 contact hr) Diabetes is one of the most common chronic diseases in school-age children. In the United States, about 208,000 people under the age of 20 have diabetes (about 0.25% of all people in this age group). Because of this incidence and the federal laws that guarantee students with disabilities access to public education, most school nurses already have students with diabetes on campus -- or will in the future. For students with diabetes to have a successful school experience, school nurses must be well informed about the students' special needs. The school nurse is the most appropriate person to coordinate the care of students with diabetes and to train school staff on diabetes-related tasks and ways to treat any diabetes-related emergency. This module informs nurses about significant factors in planning and initiating care in the school setting for students with diabetes. Overview of diabetes in children and adolescents. National Diabetes Education Program 60105: Understanding Insulin Management (1 contact hr) Healthcare providers are increasingly involved in teaching patients to control diabetes through skillful insulin management. Through blood glucose self-monitoring and intensive insulin therapy, patients can learn to \\"think like a pancreas\\" and manage insulin therapy to match their lifestyles. This course begins with an explanation of the actions and types of insulin and describes common problems of blood glucose management with various insulin dosage regimens. It also contains criteria for assessing patients' readiness to take control of their insulin management. Two approaches of insulin management are covered: the prospective and retrospective. 60168: A Healthcare Provider's Guide to Diabetes (4 contact hrs) Diabetes is a chronic condition that is reaching epidemic numbers. Every healthcare professional needs to be aware of current diabetes practices. The key components of diabetes management include medical nutrition therapy/meal planning, blood glucose monitoring, medication when indicated, physical activity/exercise, alcohol consumption within recommended limits and stress management. The purpose of this course is to communicate current information about diabetes, including new developments and changes from previous practice standards, which will enable healthcare professionals to provide safe, optimal care, and effective patient education.
