It is the position of the National Association of School Nurses (NASN) that school districts develop written medication administration policies and procedures that focus on safe and efficient medication administration at school by a registered professional school nurse (hereinafter referred to as school nurse). Policies should include prescription and non-prescription medications, and address alternative, emergency, research medication, controlled substances, and medication doses that exceed manufacturer's guidelines. These policies shall be consistent with federal and state laws, nursing practice standards and established safe practices in accordance with evidence based information. The Individuals with Disabilities Education Act, and Section 504, mandate schools receiving federal funding to provide “required related service”, including medication administration (O’Dell, O’Hara, Kiel, & McCullough, 2007).
Medication administration to students is one of the most common health-related activities performed in school. Historically, administering medication within the school setting has been a school nurse responsibility. As more chronically ill, medically stable children enter the school system each year, awareness of the factors that can promote and support their academic success increases, including the need for medications that enhance the student’s overall health or stabilize their chronic condition.
DESCRIPTION OF ISSUE
There has been a dramatic increase in the range of medications used in schools, making the medication administration process in school more complex, not less (McCarthy, Kelly, Johnson, Roman, & Zimmerman, 2006). Medication non-adherence at school has been linked to a variety of poor educational, social/emotional and physical outcomes. In addition, non-adherence to medication treatment regimes can lead to an array of educational, behavioral, and academic consequences for a child with chronic health conditions (Clay, Farris, McCarthy, Kelly, & Howard, 2008).
Policies regarding administration or carrying of any medication or product should be applied consistently with all students. The school nurse should assess each request for administration or student self-administration of any medication based on school district medication policies.
The school nurse can administer medication safely and effectively while adhering to the following set of guidelines that include:
Adherence to school district specific medication handling and administration procedures/policies, national school nurse standards of practice, state nurse practice acts and state laws governing these practices.
The administration of a specific medication is in accordance with existing State Board of Nursing rules and regulations, school district policies, school nursing protocols or standing orders.
District policies must address how over-the-counter (OTC) medications are received, stored, and labeled.
Procedures must be established and periodically reviewed for receiving, storing, administering, clarifying prescriptive orders, determining the prescribed dosage is within the safe dose range for the child’s age and weight and accounting for all medications held or administered in the school setting.
District policies must require parental consent for exchange of information between the school nurse and prescriber for clarification of administration and report of response to medication and adverse effects.
Student confidentiality is maintained in all written and verbal communications, in accordance with FERPA regulations.
Specific issues and procedures are addressed on a district-by-district basis including medication errors, missed doses, transportation concerns and monitoring unlicensed assistive personnel (UAP) administration.
Medication administration policies and procedures should also address the following:
In some states, medication administration can be delegated to licensed practical nurses and UAP. Delegation by nurses is defined by the American Nurses Association (ANA) as “transferring the responsibility of performing a nursing activity to another person while retaining accountability for the outcome” (ANA/NCSBN, 2006; National Association of State School Nurse Consultants [NASSNC], 2010). Nurses remain accountable to:
• State laws, rules, and regulations;
• Employer/agency regulations, and
• Standards of professional school nursing practice, including those pertaining to delegation.
The decision to delegate is a serious responsibility that the school nurse determines on a case-by-case basis based on the needs and condition of the student, stability and acuity of the student’s condition, potential for harm, complexity of the task, and predictability of the outcome (ANA, 2005). Prior to medication administration, a student assessment is completed by the school nurse. This assessment will guide the school nurse in determining if the task can be delegated and what level of training and supervision is required for safe delegation for this specific student and assignment (Gursky & Ryser, 2007). In most circumstances, a UAP is an ancillary health office staff member (health assistant/aide) who is trained in basic first aid, selected medical procedures as indicated by the needs of the school and the students served, in addition to the district health office clerical and confidentiality procedures (AAP, 2009). An audit completed by Canham, et al. (2007), highlights the importance of training in medication administration by stating that training is not a once-a-year event, but a process that is needed to ensure and sustain the safe and accurate administration of medication.
The National Center for Complementary and Alternative Medicine (NCCAM) defines Complimentary and Alternative Medicine (CAM) as “group of diverse medical and health care systems, practices, and products that are not generally considered part of conventional medicine.” (NCCAM, 2011). Medication administration policies should reflect local and state policies related to the administration of alternative medications and treatments.
Pharmaceutical controlled substances are drugs that have a legitimate medical purpose, coupled with a potential for abuse and psychological and physical dependence. They include opiates, stimulants, depressants, hallucinogens, and anabolic steroids. The safe and effective use of controlled substances by students at school has increased dramatically because of their accepted use in treatment of illness and disability enabling many sick and disabled children to attend school.
Immediate access to emergency medication is a high priority and is crucial to the effectiveness of these life-saving interventions (AAP, 2009). The administration of emergency medications, like all medications, is regulated by state laws and guidelines as well as local school district policies and protocols. Students with medical orders for life-saving medications should have a nursing assessment, and an Emergency Care Plan, developed by the school nurse.
Medication prescriptions for children that do not fall within the established United States Food and Drug Administration (FDA) guidelines for pediatric use and/or dosing may fall into two categories: off-label medication and experimental medications. Off label medications are those FDA approved medications prescribed for non-approved indications in children. Pediatric experimental or investigational drugs are those medications currently involved in clinical trials. These medications are undergoing formal study to determine the efficacy and safety of pediatric dosing, but they do not have FDA approval.
Medication administration policies should address the specific requirements for administering research medication in school, including providing the school nurse with information regarding the protocol or a study summary from the research organization, signed parental permission, reporting requirements, and any follow-up nursing actions to be taken.
School nurses are in a position to influence the development and use of school medication policies. They are a valuable resource and should be utilized in the development of school district policies/procedures and consult on the creation of legislative policies relating to medication administration in the school setting (Canham et al., 2007).
The school nurse is often the sole healthcare provider in the school setting, providing an expertise in health related care for students. A school nurse is the professional that has the knowledge and skills required for delivery of medication, the clinical knowledge and understanding of the student’s health and the responsibility to protect the health and safety of students (AAP, 2009).
American Academy of Pediatrics. (2009). Policy statement guidance for the administration of medication in school. Pediatrics 124, 1244-1251.
American Nurses Association / National Council of State Boards of Nursing (ANA/NCSBN). (2006). Joint statement on delegation. Retrieved from https://www.ncsbn.org/Joint_statement.pdf
American Nurses Association (ANA). (2005). Principles of delegation. Silver Springs, MD: Author.
Canham, D.L., Bauer, L., Concepcion, M., Luong, J., Peters, J., & Wilde, C. (2007). An audit of medication administration: A glimpse into school health offices. Journal of School Nursing, 23, 21-27. doi: 10.1177/10598405070230010401
Clay, D., Farris, K., McCarthy, A.M., Kelly, M.W., Howard, R. (2008). Family perceptions of medication administration at school: errors, risk factors and consequences. Journal of School Nursing, 24, 95-102. doi: 10.1177/10598405080240020801
Gursky, B. S., & Ryser, B. J., (2007). A training program for unlicensed assistive personnel. Journal of School Nursing, 23, 92-97. doi: 10.1177/10598405070230020601
McCarthy, A.M., Kelly, M., Johnson, S., Roman, J., & Zimmerman, M.B. (2006). Changes in medications administered in schools. Journal of School Nursing, 22, 102-107. doi: 10.1177/105984050602200207
National Association of State School Nurse Consultants (NASSNC). (2010). Position statement: Delegation of school health services. Retrieved from: http://www.nassnc.org/files/pdf/NASSNCDelegationPostApril,2011.pdf
National Center for Complementary and Alternative Medicine. (2011, March). What is complementary and alternative medicine? Retrieved from http://nccam.nih.gov/health/whatiscam/
Odell, C., O’Hara, K., Kiel, S., & McCullough, K. (2007). Emergency management of seizures in the school setting. Journal of School Nursing, 23, 158-165. doi: 10.1177/10598405070230030601
Wilt, L. & Foley, M. (2011). Delegation of glucagon in the school setting: A comparison of state legislation. Journal of School Nursing. Pub ahead of print. doi: 10.1177/1059840511398240
Acknowledgment of Authors:
Susan Zacharski, MEd, BSN, RN
Carole A. Kain, PhD, ARNP, PNP-BC
Robin Fleming, PhD, RN, CNS
Deborah Pontius, MSN, RN, NCSN
Revised: September 1997
Revised: June 2003
Revised: June 2011
Amended: January 2012
This document combines and replaces the following Position Statements:
Alternative Medication in the School Setting (Adopted: June 2001; Revised: June 2006)
Controlled Substances in the School Setting (Adopted: November 2001)
Rectal Medication for Seizures, The Role of the School Nurse Caring for Students Requiring (Adopted: November 2003)
Research Medications in the School Setting (Adopted; June 2001)
Resources for supporting information:
NASN’s Position Statement on Delegation, 2010 and AAP Clinical Guidelines for Medication Administration, 2009
Non Patient Specific Epinephrine, 2011