Case Study Overview
A growing number of US school students rely on school nurses to administer their medications. In some cases, the neglect of medication can be deadly. Yet overworked nurses find it difficult to meet the critical needs of students throughout the school day. A 2009 USA Today report drew attention to this problem. Documenting the extent of this dilemma, USA Today reports:
- Forty-five percent of US schools only have 1 full-time nurse on staff.
- US Census data confirmed that there is 1 nurse for every 971 students; federal guidelines recommend 1 nurse for every 750 students.
- In 13 states the average nurse to student ratio is 2,000 to 1.
- The workload for high school nurses has increased by 14 percent.
This is precisely the environment that delegation is intended for. In an environment that has only one nurse, it is inevitable that designated personnel will be needed to take that nurse’s place. Yet state laws complicate the ability of nurses to delegate tasks to unlicensed personnel. Further, school nurses do not have the same management capacity that they would in a formal health care organization.
Challenges and Constraints
The school setting provides many challenges for school nurses. While they do not have to handle intensive care situation, their role in insuring the safety of students is no less important. The extent to which school health care facilities are understaffed is unmatched by most other medical care facilities. Further, school nurses do not have the luxury of being supported by staff that is trained in medicine. When an UAP is designated, it is usually a staff member whom the nurse does not have direct authority over. Thus empowerment may seem to be a more respectful approach to delegation in this regard.
Legal considerations serve as an immediate constraint for nurses wishing to delegate the authority to administer medications to students. Even when it conflicts with the ability to provide care, nurses are bound by overarching rules and regulations when adopting managerial practices (National Association of School Nurses, 2010). What makes the public school setting unique is that nurses are trapped in between the layers of federal and state law. Federal law requires them – as public employees – to administer medication to students, as dictated by a provision of the Americans With Disabilities Act. Yet, the National Association of School Nurses (2010) notes that state laws often prohibit school nurses from utilizing the managerial tools necessary to ensure that this is accomplished. It would appear that the law is the only factor that prevents nurses from handing responsibilities to other school staff members.
However, before making this determination there is a second constraint that needs to be considered. Because the public school environment weakens the ability of nurses to delegate tasks, their duty to ensure the safety of their patients must be taken into consideration. In the states that allow school nurses that discretion, the careful method of delegation is replaced by the “hands-off” nature of empowerment. According to the Journal of School Health (2000), fifty percent of nurses reported that a higher number of dosage errors occurred when they appointed a UAP to administer medications to students. Further, school staff members who were next-in-line were drastically unqualified; sixty-six percent of UAPs in a school setting were school secretaries. Patient safety is another key consideration when determining how school nurses can use effective management practices to administer medical care to students.
Recommended Actions
The first constraint, legal obligations, cannot be ignored. If a state law prohibits school nurses from allowing other school personnel to administer medication, then the nurse is obligated to obey this law. While delegation would be ideal in this situation, the nurse’s hands are tied. However, nonessential tasks, such as running errands or filling supplies should be designated to a UAP so that the nurse is available to assist students at all times.
The second constraint notes that nurses also have a duty to ensure the safety of students. In a setting where UAPs have no medical training, empowerment is not an appropriate model. It is impossible for nurses to provide in-person supervision at every moment, but they can still implement the criteria for delegation set by Cherry and Jacob (2005). They must clearly state the guidelines for administering medications to the UAP. If in-person supervision is not possible, the nurse can create a checklist that must be completed each time the UAP interacts with a student for medical reasons. This provides the necessary oversight to make sure that errors are minimized.
Summary and Conclusion
The severe shortage of nurses in public school setting exacerbates the personnel problems that are spread across the profession. Meeting the criteria established by McDonnell (2007), nurses are often in a position where empowerment takes place over delegation. This subtle difference means that the UAPs in public school settings are given full autonomy in administering medications to students. Further, legal restraints often prevent nurses from adapting their profession to their surrounding environment. However, the lack of qualified medical assistance sacrifices the safety of students whenever strict oversight is neglected. For these reasons, it is important that school nurses delegate responsibilities, rather than empower their fellow staff members. This will allow them to meet the growing demands of their patients
References
Cherry, B., & Jacob, S. (2005). Contemporary nursing: Issues, trends, & management. St. Louis, MO: Elsevier Inc.
McCarthy, A.M. (2000). Medication administration practices of school nurses. Journal of School Health. 70 (9). 371- 376.
McConnell, C.R. (2007). The effective healthcare supervisor (6th ed.). Sudbury, MA: Jones and Bartlett Publishers.
National Association of School Nurses. (2010). Position paper on delegation. Retrieved from http://www.nasn.org/Default.aspx?tabid=349
Toppo, G. (2009, August 10). School nurses in short supply. USA Today. Retrieved March 17, 2011, from http://www.usatoday.com/news/health/2009-08-10-school-nurses_N.htm
