Current Issues in School Nursing - 2013 Cindy Galemore MSEd, BSN, RN, NCSN Director of Health Services Olathe District Schools, Olathe, KS Editor NASN School Nurse Professional Standards Chair for Kansas School Nurses Organization

Objective Identify three or more current issues in school nursing and discuss effective strategies for management

Missouri – Diabetes Education House Bill 675/Senate Bill 211 – Management of Diabetes in Elementary and Secondary Schools Optional training for non-licensed staff (not mandatory) Training tools are under development by the Dept. of Elementary and Secondary Education(Due date by statute is Jan. 15, 2014) Developed in consultation with DHHS, ADA, AADE, School Nurses Association, Diabetes Control Program, and MO state board of nursing.

Missouri – Diabetes Education Training Content Recognition and treatment of hypo & hyperglycemia Understanding physician instructions for medication drug dosage, frequency, and manner of administration Performance and documentation of blood glucose monitoring and ketone checks Administration and documentation of glucagon and insulin Understanding basic insulin pump functions Recognizing diabetic emergencies Understanding schedules and food intake for meals and snacks, effect of physical activity upon blood glucose levels, and actions for schedule disruptions

Missouri – Diabetes Education Training Requirements Minimum of three employees at each school attended by a student with diabetes Participation in training is voluntary by employees Trained personnel are protected from liability School employees shall not be subject to any penalty or disciplinary action for refusing to serve Coordinated by a school nurse Take place prior to the star of each school year or within 30 days following the enrollment or diagnosis of a student with diabetes.

Missouri – Diabetes Education Miscellaneous stipulations Coordination, delegation, and supervision of care shall be performed by a school nurse or other qualified health care professional. All school personnel may be trained in the recognition of hypo/hyperglycemia and actions to take in response to emergency situations. The school nurse or at least one trained diabetes care personnel may be on site and available to during regular school hours, all school sponsored activities including before and after school programs, field trips, extended off-site excursions, extracurricular activities, and on buses if bus driver has not completed the training

Missouri – Diabetes Education Conclusion No physician, nurse, school employee, charter school or school district shall be liable for civil damages . . . Speaks to students with diabetes being allowed to self-care if authorized in medical management plan, to possess all necessary supplies, and to be provided a private area if needed for care. Pros and cons of this legislation

Out-of-State Field Trips Not a new issue, but becoming more complicated Number of children attending school with special healthcare needs & complex medication conditions continue to increase (26.6%) (Van Cleave, Gortmaker, & Perrin, 2010) Federal laws protect all students’ rights to participate in Field trips (Section 504 of the Rehabilitation Act 1973, Title II of the American Disabilities Act of 1990, IDEIA reauthorization in 2004) Delegation laws vary greatly by state Enter into this confusion compact states

Out-of-State Field Trips School nurses are responsible for knowing the scope of practice First thing to determine is if the destination state allows nurses from another state to practice “temporarily” in their state Second thing to determine is if the destination state allows nurses from another state to delegate in their state If yes, what can be delegated. This might be different than your own state.

Out-of-State Field Trips Now the Third Ingredient - Nursing Licensure Compact States (NLC) Allows nurses from NLC states to practice in another NLSC state without a second license Similar to a driver’s license Currently 24 NLC states Applies to RNs and LPNs Does not apply to unlicensed personnel or APRNs

Nursing Licensure Compact States

Advocacy from NASN NASN’s conversations with the National Council of State Boards of Nursing (NCSBN) concluded that school nurses need to contact each board of nursing prior to a field trip to ask permission to practice nursing temporarily in that state. It is hoped that by increasing the number of school nurses contacting boards of nursing across the nation, states WILL ask the NCSBN to work on national recommendations allowing the regulations of the state of origin to cover the student on field trips and to allow all licensed nurses to practice in other states for the purpose of school field trips and activities that cross state lines.

Nursing Licensure Compact States Kentucky has conducted extensive research in this area and compiled helpful information and charts specific to each state at the following link: http://education.ky.gov/districts/SHS/Pages /Field-Trips-and-Medication- Administration.aspx More helpful for Missouri than Kansas, since Missouri is a compact state Use the chart cautiously with an understanding of limitations (become outdated quickly)

Out of state field trips concluding guidance Inform your administrator of the need for advance notice of all out-of-state field trips (at least 2 months notice). Brainstorm avenues to remove the need for nursing care and/or delegation on field trips (e.g. students self-carry asthma and severe allergy medication if capable, parent of student attends field trip – possibly even incentivizing by offering to pay the parent, annual per-planning discussion of field trip plans for students with severe health needs discouraging teachers from field trips that cross the state lines wherever possible, training staff that will be attending field trip in basic CPR and First Aid – for example, the First Aid courses now include information on assisting someone who self-carries an inhaler or auto- injector epinephrine). Contact the Board of Nursing for state’s that will be receiving students where nursing care is needed. Determine from information received how the health needs will be managed (e.g. school nurse will attend, delegation is allowed, parent will accompany and provide care, and/or agency nurse in visiting state will be hired to care for the student).

Kansas – Kancare Effective January 1sts, 2013 Medicaid and HealthWave became KanCare Three managed care organizations (MCOs) Amerigroup of Kansas, Inc Sunflower State Health Plan UnitedHealthcare of the Midwest (Brown, Kim. 2013. Presentation at Kansas School Nurse Conference, July 17, Director, Managed Care, KS Dept. for Aging and Disability Services)

Kansas – Kancare Goals Reforms how care is delivered Improve care coordination Reduce cost growth in the program Improve quality of care overall Reforms how care is delivered Eligibility is the same Services are the same. Providers may be paid more, but cannot be paid less Moves the focus to promoting health rather than treating illness

Kansas – Kancare - Enrollment This year’s enrollment ended April 4th New consumers have 90 days to choose plan If the covered individual did not choose a plan, it was assigned according to an algorithm. Around end of November, enrollees will be contacted and informed of the open enrollment period for the new year which goes from January 1 to April 4th (consumer makes phone call) otherwise they will stay with the same MCO. Participants must also show continued eligibility annually. http://www.kancare.ks.gov/index.htm

Kancare – Value-Added Services Highlights For all plans: Rewards/incentive programs for health behaviors like completing wellness/KBH exams Health pregnancy programs Free cell phones for high-risk members For Amerigroup: Free hypo-allergenic bedding for members with asthma and allergies For Sunflower and United: Free memberships to Boys and Girls club, 4-H, Brownies, and other community programs

Other Pearls from National and State Conference DSM-5 Terminology Changes Roman numeral replaced with a number Intellectual Disability (forbids use of Mental Retardation) Attention-Deficit Hyperactivity Disorder (do not use ADD) Autism Spectrum Disorder (use to include Asperger’s, childhood disintegrative disorder, Rett’s disorder, pervasive developmental disorder not otherwise specified, and autism. Asperger’s disorder no longer exists) Communication Disorders – now called speech sound disorder and stuttering is now called Childhood-onset Fluency Disorder

Other Pearls from National and State Conference Do not send home Head Lice letters when a case of head lice is found. Causes unnecessary treatment, hysteria, risk of privacy breech, etc. Much better to do periodic parent generalized teaching. Health Information Exchange Being developed in all states Kansas network is called the KHIN – Kansas Health Information Network School nurses can become users – requires annual fee ($50.00) and other things like a security officer who will perform a privacy audit every month

Other Pearls from National and State Conference New NASN Allergy and Epinephrine resources available – too numerous to mention all. Go to http://www.nasn.org/ToolsResources/FoodAllergyandAnaphylaxis

NASN Trained Epinephrine Resource Nurses Amy Wehr, BSN, RN, NCSN wehramy@rockwood.k12.mo.us Barbara Brommelhorst, BSN, RN barbarabrommelhorst@wentzville.k12.mo.us Deborah Haar Scales, BSN, RN scales@stjustinmartyr.org Cindy Galemore, MSEd, BSN, RN, NCSN galemorec@olatheschools.org

If I Knew Then What I know Now! By Gerri Harvey – school nurse Available at http://snp.homestead.com/contents.html

I would worry less about being the only health professional in the school and take more delight in being the resident expert.

I would spend less time trying to get my staff to understand my role and more time trying to understand how my role supports theirs.

I would remind myself every day that those things that are most important must never be at the mercy of those that are the least important.

I would smile more and complain less. I would make sure I looked, really looked, at every child who came into my office.

I would be less dragged down by those staff who are full of negativity and pessimism about children, families, administration, education and each other and more buoyed by those who are optimistic and positive year after year because they see and focus on the goodness, the successes, and the opportunities to be change agents among those very same others.

I would begin each day with a simple thought: perfection is not the goal, and the person who is the busiest or most stressed is not necessarily the most effective.

I would understand this: there will never be enough time to do it all, but that is OK. The important thing is to spend my time well, keep my focus on how I, as a nurse, can make a difference, one child at a time. Because that is what adds up over the years, and perhaps in the end, the only thing that really matters.

If I Knew Then What I Know Now!!!