A California ruling that would allow non-licensed adults to administer insulin in schools cheapens and devalues not only the practice of nursing, but also the clout of its own licensing authorities.
My daughter has a spinal cord defect and because of that, the law says the school district must provide her with physical therapy. But what if she got to school at the beginning of September and I found out that rather than getting PT from a licensed physical therapist, she'd receive it from the school secretary instead?
It's a ridiculous scenario, and one that wouldn't ever happen, right? But in California, there's something similar afoot, something that threatens to devalue nursing and that the American Nursing Association is fighting hard to prevent.
Here's the issue: The California Department of Education wants to allow unlicensed personnel to give insulin [PDF] to children in schools. Two lower courts have already ruled that this violates the state's Nursing Practice Act, which says that administering medication is a nursing function that cannot be performed by unlicensed individuals.
The American Diabetes Association, however, and others have appealed to the California Supreme Court, arguing that the law puts students' safety at risk because not all schools have nurses. Oral arguments began on May 29.
Maureen Cones, associate general counsel for the ANA, tells me that the implications of this case could extend way beyond what happens in California schools.
"With budgets being what they are, schools and school districts are quick to eliminate nursing positions," she says. For that reason, this case is being watched by many states experiencing the same issues. "If the ADA prevails and the decision is overturned, it will give license to any state to allow unlicensed personnel to administer insulin."
Moreover, the ANA believes that overturning the previous rulings would set a dangerous precedent: Cones says it will be the first time anywhere that a healthcare licensing law would be preempted in favor of a federal disability law.
"That would have very far reaching implications nationally," Cones says.
The ANA says its position doesn't mean that federal disability laws don't apply; they're simply saying that the two laws need to work together. In fact, the ANA says that the courts' rulings "do not prevent students with diabetes in California's public schools from receiving the health services to which they are entitled. California law permits several categories of individuals to administer insulin in the school setting, including parental designees." Moreover, nursing positions in schools shouldn't be on the chopping block because of budget constraints.
The ADA says this on its website:
[F]amilies of children with diabetes and diabetes health care experts not only disagree with the idea that you need a health care license to administer insulin, but know that this position puts students with diabetes at risk. There is only one school nurse for every 2,200 students in California and a budget crisis with school personnel being laid off across the state. And even if there was a full-time school nurse in every school, the nurse wouldn't be available for all extra-curricular activities and field trips.
The ADA position says that "because there's not a nurse in every school, effectively the licensing laws should be ignored," Cones says. "What's next? If a nurse doesn't have to provide medication in accordance of state law are gym teachers going to be providing physical therapy?"
That "what's next?" statement gets to the heart of the real issue that should be worrying to nurses everywhere: Ruling that anyone can administer insulin cheapens and devalues not only the practice of nursing, but also the clout of its own licensing authorities.
"The hallmark of any true profession is the ability to regulate itself. If the ADA prevails, the board of nursing will no longer be able to decide who is qualified to administer any medication," Cones says. "It erodes the profession of nursing."
Nurses are naturally protective of their turf and are trying to preserve school nursing jobs. Some people might see irony here because this fight is being waged at the same time that nursing unions and advocates are lobbying to extend scope-of-practice laws in many states. Nurses with advance practice licenses rail against physician groups who want to keep them from practicing without physician supervision.
However, in my opinion, this isn't it's an accurate parallel. Secretaries and teachers and janitors aren't healthcare professionals like doctors and nurses so it's like comparing apples and oranges. I know how to do my daughter's PT stretches and I'm sure lots of people could be taught how, too, but I still expect a licensed physical therapist to provide her PT her in school. She's entitled to that under law.
Read the ANA's position [PDF] and ADA's position [PDF], and tell us what you think in the comments below.
Alexandra Wilson Pecci is an editor for HealthLeaders.
