School Nursing: An Essential Service

▪ 28A.210 RCW; An act relating to clarifying the authority of a nurse working in a school setting.  An RN or an ARNP working a school setting is authorized and responsible for the nursing care of students to the extent that the care is within the practice of nursing. […] Such practice includes the administration of medication pursuant to a medication or treatment order and the decision to summon emergency medical assistance.

 ▪  RCW 28A.210.260 Public and Private Schools—Administration of medication - Conditions.  The Board of Directors shall designate a professional person licensed pursuant to chapter 18.71 RCW or chapter RCW 18.79 as it applies to registered nurses and advanced registered nurse practitioners, to delegate to, train, and supervise the designated school district personnel in proper medication procedures.

▪  RCW 28A.210.280 Catheterization of public and private school students.  School districts must provide for Clean Intermittent Catheterization of students […] if the catheterization is provided for in substantial compliance with: (a) Rules adopted by the state nursing care quality assurance commission on the instructions of a registered nurse issued under such rules […].

▪ RCW 28A.210.320 Children with life-threatening health conditions -- Medication or treatment orders -- Rules.  (5) As used in this section, "medication or treatment order" means the authority a registered nurse obtains under RCW 18.79.260 (2).

▪ RCW 28A.210.370 Students with asthma [and anaphylaxis]

(1) The superintendent of public instruction and the secretary of the department of health shall develop a uniform policy for all school districts providing for the in-service training for school staff on symptoms, treatment, and monitoring of students with asthma and on the additional observations that may be needed in different situations that may arise during the school day and during school-sponsored events. The policy shall include the standards and skills that must be in place for in-service training of school staff.

b) The student has demonstrated to the health care practitioner, or the practitioner's designee, and a professional registered nurse at the school, the skill level necessary to use the medication and any device that is necessary to administer the medication as prescribed.

▪ RCW 28A.210.380 Anaphylaxis-Policy guidelines-Procedure-Reports.

(1) The office of the superintendent of public instruction, in consultation with the department of health, shall develop anaphylactic policy guidelines for schools to prevent anaphylaxis and deal with medical emergencies resulting from it. The policy guidelines shall be developed with input from pediatricians, school nurses, and other health care providers, parents of children with life-threatening allergies, school administrators, teachers, and food service directors. The policy guidelines shall include, but need not be limited to:
a) A procedure for each school to follow to develop a treatment plan including the responsibilities for [of] school nurses and other appropriate school personnel responsible for responding to a student who may be experiencing anaphylaxis;

▪ RCW 28A.210.383 Epinephrine Auto-injectors (Epi-pens) — School supply—Use.

(1) School districts and nonpublic schools may maintain at a school in a designated location a supply of epinephrine auto-injectors based on the number of students enrolled in the school. (3)(a) When a student does not have an epinephrine auto-injector or prescription for an epinephrine auto-injector on file, the school nurse may utilize the school district or school supply of epinephrine auto-injectors to respond to an anaphylactic reaction under a standing protocol according to RCW 28A.210.380.

▪ RCW 28A.210.330 Students with diabetes -- Individual health plans -- Designation of professional to consult and coordinate with parents and health care provider -- Training and supervision of school district personnel.

(1)(b) The board of directors, in the course of developing the policies in (a) of this subsection, shall seek advice from one or more licensed physicians or nurses or diabetes educators who are nationally certified.

(3) The board of directors shall designate a professional person licensed under chapter 18.71, 18.57, or 18.79 RCW as it applies to registered nurses and advanced registered nurse practitioners, to consult and coordinate with the student's parents and health care provider, and train and supervise the appropriate school district personnel in proper procedures for care for students with diabetes to ensure a safe, therapeutic learning environment. Training may also be provided by a diabetes educator who is nationally certified.

▪ RCW 28A.210.350 Students with diabetes -- Compliance with individual health plan -- Immunity.  A school district, school district employee, agent, or parent-designated adult who, acting in good faith and in substantial compliance with the student's individual health plan and the instructions of the student's licensed health care professional, provides assistance or services under RCW 28A.210.330 shall not be liable in any criminal action or for civil damages in his or her individual or marital or governmental or corporate or other capacities as a result of the services provided under RCW 28A.210.330 to students with diabetes.
WAC 181-87-070 Unauthorized professional practice.  Any act performed without good cause that materially contributes to one of the following unauthorized professional practices is an act of unprofessional practice.
(1) The intentional employment of a person to serve as an employee in a position for which certification is required by rules of the state board of education when such person does not possess, at the time of commencement of such responsibility, a valid certificate to hold the position for which such person is employed.
(2) The assignment or delegation in a school setting of any responsibility within the scope of the authorized practice of nursing, physical therapy, or occupational therapy to a person not licensed to practice such profession unless such assignment or delegation is otherwise authorized by law, including the rules of the appropriate licensing board.
(6) Provided, That for the purpose of this section, good cause includes, but is not limited to, exigent circumstances where immediate action is necessary to protect the health, safety, or general welfare of a student, colleague, or other affected person.

▪ RCW 18.79.030 Licenses Required—Titles.  (1) It is unlawful for a person to practice or to offer to practice as a registered nurse in this state unless that person has been licensed in this state.

▪ RCW 18.79.040 “Registered nursing practice” defined—Exceptions. (1) “registered nursing practice” means the performance of acts requiring substantial specialized knowledge, judgment, and skill based on the principals of the biological, physiological, behavioral, and sociological sciences in either: […]. (b) The performance of such additional acts requiring education and training that are recognized by the medical and nursing professions as proper and recognized by the commission to be performed by registered nurses licensed under this chapter and are authorized by the commission through its rules; (c) the administration, supervision, delegation, and evaluation of nursing practice.

▪ WAC 246-840-700 Standards of nursing conduct or practice.  The purpose of defining standards of nursing practice through WAC 246-840-700 and 246-840-710 is to identify responsibilities of the nurse in health care settings and as provided in the Nurse Practice Act, chapter 19.79 RCW.  Violation of these standards may be grounds for disciplinary action pursuant to chapter 18.130 RCW.  Each individual, upon entering the practice of nursing, assumes a measure of responsibility and public trust and the corresponding obligation to adhere to the standards of nursing practice.  The nurse shall be responsible and accountable for the quality of nursing care given to clients.  This responsibility cannot be avoided by accepting orders or directions of another person.  The standards of nursing conduct or practice include, but are not limited, to the following:

For registered nurses: (2) Delegation and supervision: the registered nurse shall be accountable for the safety of clients receiving nursing service by: (a) Delegating selected nursing functions to others in accordance with their education, credentials, and demonstrated competence. (b) Supervising others to whom she/he has delegated nursing functions. (g) The registered nurse shall report unsafe nursing acts and practices, and illegal acts as defined in WAC 246-840-730.

▪ RCW 18.79.120 Application of Uniform Disciplinary Act. The Uniform Disciplinary Act, chapter 18.130 RCW, governs unlicensed practice, the issuance and denial of licenses, and the discipline of licensees under this chapter.

▪ RCW 18.130.190 Practice without license -- Investigation of complaints -- Cease and desist orders -- Injunctions -- Penalties.   

o    (5) Neither the issuance of a cease and desist order nor payment of a civil fine shall relieve the person so practicing or operating a business without a license from criminal prosecution therefore, but the remedy of a cease and desist order or civil fine shall be in addition to any criminal liability. The cease and desist order is conclusive proof of unlicensed practice and may be enforced under RCW 7.21.060. This method of enforcement of the cease and desist order or civil fine may be used in addition to, or as an alternative to, any provisions for enforcement of agency orders set out in chapter 34.05 RCW.     

o    (6) The attorney general, a county prosecuting attorney, the secretary, a board, or any person may in accordance with the laws of this state governing injunctions, maintain an action in the name of this state to enjoin any person practicing a profession or business for which a license is required by the chapters specified in RCW 18.130.040 without a license from engaging in such practice or operating such business until the required license is secured. However, the injunction shall not relieve the person so practicing or operating a business without a license from criminal prosecution therefore, but the remedy by injunction shall be in addition to any criminal liability.     

o    (7) Unlicensed practice of a profession or […], unless otherwise exempted by law, constitutes a gross misdemeanor for a single violation. Each subsequent violation, whether alleged in the same or in subsequent prosecutions, is a class C felony. All fees, fines, forfeitures, and penalties collected or assessed by a court because of a violation of this section shall be remitted to the health professions account.

▪ RCW 18.79.260 Registered nurse -- Activities allowed -- Delegation of tasks. 

(2) A registered nurse may, at or under the general direction of a licensed physician and surgeon, dentist, osteopathic physician and surgeon, naturopathic physician, podiatric physician and surgeon, physician assistant, osteopathic physician assistant, or advanced registered nurse practitioner acting within the scope of his or her license, administer medications, treatments, tests, and inoculations, whether or not the severing or penetrating of tissues is involved and whether or not a degree of independent judgment and skill is required. Such direction must be for acts which are within the scope of registered nursing practice.

▪ OSPI Bulletin NO. 31-98 EDUCATION SUPPORT  (April 24, 1998)  The Administration of Oral Medication in Schools:

Page 7 IV.  Emergency Medications: […] training and supervision by a registered nurse or physician of non-nurse school staff in the administration of epinephrine to prevent anaphylactic shock in students with known hypersensitivity to bee stings, food, latex, etc.
Page 8 V. Training of School Staff in the Administration of Medications: The medication statute requires that staff who have been designated by district policy to give medications, are to be trained and supervised by a professional person licensed pursuant to chapter […] 18.79 RCW as it applies to registered nurses and advanced registered nurse practitioners (ARNP).
Page 9 In order for the district to receive immunity from liability based upon substantial compliance with the statute, non-nurse school staff must be trained and supervised by a registered nurse or MD.

 

▪ OSPI Bulletin NO. 61-02  LEARNING AND TEACHING SUPPORT (September 18, 2002) Children with Life Threatening Conditions – Diabetic Students:

Page 3 II. General Provisions […] a life threatening condition is defined as “a health condition that will put a child in danger of death during the school day if a medication or treatment order and a nursing plan are not in place.”
Page 5 Nursing Plan […] Nursing practice statutes that pertain to components of developing nursing plans and the implementation process are: RCW 18.79.040, RCW 18.79.260, WAC 246-840-010 (10) and (11) and WACs 246-840700 and 710.

▪OSPI Memorandum 064-12M Secondary Education and Student Support House Bill 2247 – Amending RCW 28A.210.260 and RCW 28A.210.270. Public and Private schools — Administration of oral medication by — Conditions & Immunity from Liability – Discontinuance procedure

HB 2247 expands the types of medication that a registered nurse or advance registered nurse practitioner may delegate to a public or private school employee to administer. It

    amends RCW 28A.210.260 to include topical medication, eye drops, and ear drops.

OSPI Memorandum 013-14M Secondary Education and Student Support (March, 2014)

RCW 28A.210.383 (ESB 5104) – K-12 schools-Epinephrine Auto injectors

ESB 5104 allows schools to maintain a supply of epinephrine auto injectors to treat

     anaphylaxis.

▪ OSPI Memorandum M037-14M Secondary Education and Student Support (July, 2014)

Nasal Spray Administration

SHB 1541 expands the types of medication that a registered nurse or advance

      registered nurse practitioner may delegate to a public or private school employee to

      administer. It amends RCW 28A.210.260 to include nasal spray.

▪ OSPI Memorandum 044-14M Secondary Education and Student Support (August, 2014) Key Provisions of Senate bill 6128: School Employees – Medication Administration and Nursing Services

Outlines key provisions of Senate Bill 6128 related to the delivery of medications and

      services by unlicensed school employees. (2) […] (a) rules adopted by the state nursing    care quality assurance commission and the instructions of a registered nurse of  

      advanced registered nurse practitioner […]. (3) […] registered nurses and               advanced registered nurse practitioners to consult and coordinate with the student’s parents and health care provider, and train and supervise school district personnel.

Registered nurses in school settings function under a special provision which allows them to delegate and supervise the administration of oral medications to unlicensed school personnel.  The Commission assumes that the registered nurse uses the nursing process to assess the care needed, verify orders, individualize standard guidelines based on student’s needs, and that certain tasks will not be delegated when the registered nurse determines that care is too complex.

▪Standing Orders and Verbal Orders (September, 2014)

•Registered Nurse Delegation in School Settings (July, 2019)

•RN Coordinating Seizure Management (2005)

•Field Trips and Medication Administration (April, 1980)

•Job Titles/License Titles: Can a registered nurse work as a licensed practical nurse or a Nursing Assistant?

Registered Nurse and Licensed Practical Nurse
Scope of Practice       

 

Other Resources:

Staff Model for the Delivery of School Health Services Washington State Nursing Care Quality Assurance Commission and Washington State Office of Superintendent of Public Instruction.
April, 2000.
N. Schwab and M. Gelfman (2001). Legal Issues in School Health Services: A Resource for School Administrators, School Attorneys and School Nurses. Sunrise River Press: North Branch, MN.