Nurses take on Calif. schools over insulin shots

A 5-year-old court battle in California pits nurses who say they're the only ones medically trained to administer insulin to public school students against diabetes advocacy groups who say it's necessary to let other school personnel give the shots to increase access to care.

The California Supreme court has 90 days to rule on the matter. The case, which dates to 2007, could reach a conclusion as the court heard arguments Wednesday on whether or not school nurses should be the only personnel allowed to inject elementary-school students with insulin to treat them for diabetes. State law currently gives only school nurses that task.

The American Diabetes Association and others argue that the injections don't require medical qualifications. They say if the school has a note from a physician on file and has parental permission, school personnel other than nurses should be allowed to inject students with the drug. Some states do allow unlicensed school staff members to administer insulin, but only if they are properly trained. The diabetes association says it's a supply problem, as 95% of California's 10,000 public schools don't have full-time nurses. For the diabetes association, it's an access-to-care issue; loosening the requirements on who could inject students with insulin, they argue, means that more students could be treated, as school nurses aren't always available.

The American Nurses Association says about 35% of California elementary and secondary school districts have school nurses. As the nurses' leading professional organization, the ANA worries what would happen if a diabetic student's needs escalated to an emergency without a nurses' care. They argue that diabetic students should have access to the best possible care available, and that means being treated by a school nurse. There are about 14,000 diabetic students who need insulin shots enrolled in California public schools.

“This is really about protecting the students and ensuring a high level of care,” said Maureen Cones, lead counsel for the ANA.

Two lower courts have ruled in favor of the ANA. The case sprouts from a class-action settlement from five years ago when the California Department of Education agreed to broaden requirements and allow nonlicensed personnel to administer the injections. The ANA and other nurses groups balked and sued, leading up to the current legal showdown. The state Supreme Court heard about an hour of oral arguments Wednesday and has 90 days to make a ruling.

The nurses worry that the California case could set a precedent nationally and affect who regulates the scope of practices issues, and that state nursing boards will lose authority. The ANA argues that nurses have the training to avoid medical errors and the experience to understand complications. In a rare show of solidarity among rival nursing groups, the ANA is leading the charge to ensure that only school nurses are allowed to administer the drug, and have partnered with other nursing groups, including their rivals, the California Nurses Association. The CNA is a union, and the largest affiliate of the National Nurses United, the largest nurses union in the country. They've contributed to a declining membership with the ANA, which considers itself more of a teaching organization and has distanced themselves from labor issues. For their part, their opposition doesn't seem focused on any labor ties.

“The administration of insulin does not require substantial scientific knowledge or technical skill,” said Dennis Maio, lead counsel for the American Diabetes Association. “It's readily safe to administer by laypeople.”

Maio said he believes the nurses' groups and the diabetes associations both have the students' best interests in mind but have different ways of addressing the problem: “Sometimes you have people with exactly the same motivation coming at issues at different ways.”

The Obama administration filed an amicus brief urging the court to allow nonlicensed personnel to administer the shots.

Critics say the nurse unions just want to increase employment for nurses and are disregarding access issues. But the nurses reject that charge.

“It's a child safety issue,” said Linda Davis-Alldritt, president of the National Association of School Nurses.

There are other states that allow nonlicensed personnel to inject insulin, but because state laws with scope of practice vary so wildly, it's difficult in coming up with a list, Davis-Alldritt said. For example, in March, Virginia lawmakers passed a bill that exempted those trained to administer insulin from liability.

The nurses' groups note that other states require training for unlicensed people to administer insulin shots but that the case in California lacks such a requirement. That's something that will be needed if the court allows nonlicensed personnel to give the insulin shots, Maio said.

Follow Ashok Selvam on Twitter: @MH_aselvam



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