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School Health Nursing Program

Report to the Minnesota Legislature: Medications Dispensed in Schools Study

January 15, 2002

Introduction

The safe and efficacious administration of medication in schools is an important issue for students, parents, school personnel and health care providers. In its policy statement Guidelines for the Administration of Medication in School, the American Academy of Pediatrics states: "Many children and adolescents are able to attend school because of the effectiveness of their medications…" "Medication may be essential for continued functioning, either as a component of an elaborate treatment plan for the student with a complex disability or as the only treatment necessary for a student to maintain or regain control of his/her chronic illness…" "For most students the use of medication will be a convenient benefit to control acute minor or major illnesses, allowing a timely return to the classroom with minimal interference to the student and others."

At the request of the 2001 Minnesota Legislature, the Minnesota Department of Health, in consultation with the Minnesota Board of Nursing, initiated a study related to the promotion of "student health and safety in relation to administering medications in schools and addressing the changing health needs of students."

Laws of Minnesota 2001, CHAPTER 9 Article 1, Section 61 [MEDICATIONS DISPENSED IN SCHOOLS STUDY] directed that:

(a) The commissioner of health, in consultation with the board of nursing, shall study the relationship between the Nurse Practice Act, Minnesota Statutes, sections 148.171 to 148.285; and 121A.22, which specifies the administration of medications in schools and the activities authorized under theses sections, including the administration of prescription and nonprescription medications and medications needed by students to manage a chronic illness. The commissioner shall also make recommendations on necessary statutory changes needed to promote student health and safety in relation to administering medications in schools and addressing the changing health needs of students.

(b) The commissioner shall convene a work group to assist in the study and recommendations. The work group shall consist of representatives of the commissioner of human services; the commissioner of children, families, and learning; the board of nursing; the board of teaching; school nurses; parents; school administrators; school board associations; the American Academy of Pediatrics; and the Minnesota Nurse's Association.

(c) The commissioner shall submit these recommendations and any recommended statutory changes to the legislature by January 15, 2002.
This report reflects the information gathered and the issues identified by the workgroup convened to provide input and develop principles related to safe medication administration in schools.

Overview of Medication Administration in Minnesota Schools

Approximately one million children attend public school (K-12) in Minnesota every day. Providing services to promote the health of its pupils from early childhood through high school is required by Minnesota Statute 121A.21. Federal education and civil rights laws assure a free and appropriate education for all students, including those with disabilities and chronic illness for whom medication is a standard component of their ongoing long-term treatment. Children are returning to school sooner after acute illness, often while still taking medication to treat their illness.

The administration of medications has become a significant and growing aspect of school health service programs. For example, 1,294 medications were administered to students in one urban school district in Minnesota in 1985. By 2000, that number had increased to 35,111. An analysis of time allocated to safely manage the administration of Ritalin to one student with ADHD showed that it consumed 1,350 minutes, or 22.5 hours, per year.

The complexity of student's health care needs and increased medication usage has placed significant demands on school health care resources. There is an increasing disparity between student needs and resources. Frequently school nurses are asked to delegate medication administration activities to unlicensed personnel or teachers who may lack formal health care training. In an informal 1999 survey of Minnesota school nurses, full-time-equivalent school nurses reported giving an average of 228.3 medications per week and part-time nurses reported giving an average of 93.5 medications per week. Full-time-equivalent school nurses reported responsibility for health services in 6.8 buildings and part-time school nurses for 2.4 buildings. Full-time-equivalent school nurses reported delegating medication administration to an average of 6.2 individuals, and part-time school nurses reported delegating the same task to an average of 4.4 individuals.

National attention has recently been directed toward building a safer health care system, especially in the area of medication administration (To Err is Human: Building a Safer Health System, Institute of Medicine, 1999). The American Nurses Association supports the implementation of medication safety practices that are based on sound science and evaluation of those practices. Minnesota is one of several states that have recognized the need to further address safe medication administration in schools.

Background Information

Historically, school districts, school nurses, parents and health care providers have looked to the Minnesota Department of Health, the Minnesota Department of Children, Families and Learning, and the Minnesota Board of Nursing to provide information, consultation and/or technical assistance regarding the administration of medication in schools. The Minnesota School Health Guide, published by the Minnesota Department of Health in conjunction with the Minnesota Department of Children, Families and Learning, contains recommendations and sample policies and procedures for the administration of medications in schools. Consultation and technical assistance regarding school health services, including medication administration, is provided by the Minnesota Department of Health's School Health Consultant.

Minnesota Statutes 148.171 through 148.285 authorize the Board of Nursing to regulate nursing practice. This Nurse Practice Act establishes the scope of practice for nurses and is applicable regardless of the setting. Thus, school nurses practice under the jurisdiction of their nurse license. The medication administration standards and practices nurses usually implement are based on a model usually applied in a health care setting where there are numerous health care personnel. In the school setting, the only health care person is often the school nurse. Delegation of medication administration to school personnel who are not trained health care personnel requires the school nurse to use professional judgment to delegate such tasks in a manner that is safe for students and within the legal scope of nursing practice.

State policy regarding the administration of medication in Minnesota schools is established in Minnesota Statutes 121A.22 and 121A.221, Administration of Drugs and Medicine. Since its enactment in 1988, this statute has been revised several times. The most recent revision (2001) dealt with the safe possession and use of asthma inhalers by students in a school setting.

In February 2000, the Attorney General's office issued an interpretation regarding the authority of school nurses to provide non-prescription medications to students upon a parent's request. This interpretation concluded "school nurses have the authority to provide over-the-counter medications to students upon a parent's request, even without a physician's order." However, the opinion also noted that the "school nurse has the ultimate authority and responsibility to reject a parent's request and to decline to administer an over-the-counter medication if the nurse believes that such medication is unnecessary, inappropriate, or could lead to patient harm." The opinion further provided that a school district "could choose to adopt a policy that requires a physician's order before a school nurse administers a non-prescription medication to a student." While this interpretation is not inconsistent with either the nurse practice act or the school medication statute, it is different from previous interpretations on which current school medication policies and procedures were based.

The increased interest in amending MS 121A.22, combined with the Attorney General's interpretation, suggests the need for a comprehensive statewide policy for the safe and efficacious administration of medication in Minnesota schools.

Legislative Study Process

The Minnesota Department of Health (MDH) and the Minnesota Board of Nursing met to design the process and timeline for the study. To provide consultation to the study and assist in the planning, analysis and evaluation of the workgroup activities, individuals from the Departments of Children, Families, & Learning and Human Services were invited to participate in an interagency state staff team.

The Commissioner of Health invited 20 key stakeholder organizations, agencies and groups to participate in the workgroup (see workgroup membership). At their first meeting, members were asked to identify the characteristics of a healthy and safe system for medication administration in schools, the challenges to assuring such a system and the elements that currently support such a system. At the second meeting, the workgroup reviewed the issues and developed ten principles that would support a healthy and safe system for medication administration in Minnesota schools.

Current Issues

The work group identified the following challenges related to safe medication administration in schools.

  • The ability to locally determine a school district's policies is the cornerstone of Minnesota's education system. Currently, there are no state medication administration standards or guidelines to inform the development of local school district policies and procedures. This causes an inconsistency between districts that readily apparent to families in our mobile society. Parents express frustration in moving from district to district, as they confront differing policies and procedures.
  • There is no single state authority responsible for the overall coordination of medication administration in the schools. The Minnesota Departments of Health, Human Services, and Children, Families, & Learning are all involved in providing technical assistance and consultation regarding school health services. School administrators, school nurses, and/or parents regularly request information and guidance regarding medication administration practices and policies from one or more of these agencies.
  • School nurses are accountable to multiple licensing boards. They are accountable to the Board of Nursing for their professional nursing licensure and public health certification and the Board of Teaching for their school nurse license. It is not commonly understood that the nurse practice act applies to any setting where nursing is practiced, including schools.
  • Parents and students expect administration of medication to be student/family centered and adaptable to student needs. Families vary in their approach and cultural beliefs related to medications. As Minnesota becomes more culturally diverse, new ideas and attitudes about health care practices including medications are emerging.
  • School personnel and parents report a disparity between student's needs and the availability of resources to help meet those needs. Schools currently use a variety of methods to fund school health services.
  • The principles of nursing delegation of medication and supervision of unlicensed and untrained personnel in the school setting are not universally understood. The health and education system utilize different definitions for the word "delegation." The authority for nursing delegation and judgment rests with the individual registered nurse.
  • There is no consistent statewide training for individuals who are not nurses or health care providers related to administration of medications to students in the school setting. A Minnesota-specific curriculum, "Assisting the Licensed School Nurse," which includes instruction on medication administration is available. The use of this or a similar curriculum needs to be encouraged.
  • Communication strategies are required to assure safe medication administration. This includes communication between students/families, school staff, and physicians about individual student needs as well as about district medication administration policy and procedures.

The breadth of these issues identified by the workgroup illustrate that ensuring "student health and safety in relation to administering medications in schools" extends beyond the relationship between the Nurse Practice Act, MS 148.171 to 148.285 and MS 121A.22 Administration of Drugs and Medicine (in schools).

Work Group Principles

Safe and efficacious administration of medications to appropriately treat illness, acute and chronic, enhances student potential to achieve educational success. The work group identified the following principles to support safe medication administration in Minnesota schools.

  • There must be school board policies regarding administration of medications in schools.
  • A mechanism must be in place for identifying and adopting appropriate statewide standards on which policies are based.
  • Local school district medication administration procedures must be based on consistent statewide standards and guidelines.
  • Procedures should be student/family centered, individualized, flexible, and culturally responsive.
  • Procedures must be developed with local health care professionals, district personnel, and district families.
  • All parties involved, including district administration, must have appropriate knowledge of delegation of medication administration and supervision of personnel to whom medication administration is delegated.
  • All personnel administering medications in school must have appropriate training.
  • Information regarding safe medication administration must be provided by the state to key constituents in a clear, consistent and timely manner.
  • Communication among student, parents, school personnel, health care providers and school districts is imperative concerning medication administration in schools.
  • State and local resources must be available to support safe medication administration in schools.

Commissioner of Health Recommendations

The mission of the Minnesota Department of Health is to protect, maintain and improve the health of all Minnesotans. Good health is a necessary foundation for students to be able to learn. Many children who have chronic and/or acute health conditions can attend school because of the effectiveness of their prescribed medications(s). Student access to medication while at school, to appropriately treat illness, acute or chronic, enhances attendance and reduces a potential barrier to educational success.

The recommendations of the Commissioner of Health are based on the workgroup issues and principles, current literature and research, and the work of the interagency state staff team. These recommendations are intended to promote student health and safety in relation to administering medications in schools and to address the changing health needs of students.

Recommendation 1:

Given that there is no single state authority responsible for the overall coordination of medication administration in the schools; that there are no state medication administration standards or guidelines; and schools use a variety of methods to provide and fund school health services, the Commissioner of Health recommends:

The Department of Health, in consultation with the Department of Children, Families and Learning shall design a state system for the safe administration of prescription and nonprescription medications in schools. The system should address (a) development and periodic review of state standards* and guidelines** for medication administration in the schools; (b) communication of such state standards and guidelines; (c) development and periodic review of model policies*** and procedures****; (d) technical assistance to school districts related to medication administration; (e) ongoing training needs for the safe administration of medications to students; (f) identification of mechanisms to assist in the resolution of conflicts; (g) ongoing evaluation of the overall effectiveness of the system in promoting student health and safety; and (h) identification of state and local school district resources needed for the effective implementation of such a system.

Recommendation 2:

Given that communication is required to assure safe medication administration in the schools; that parents and students expect administration of medication to be student/family centered and adaptable to student needs; that the principles of nursing delegation of medication and supervision of untrained personnel in the school setting are not universally understood; that the independent character of Minnesota school districts requires the development of mechanisms to achieve clarity, desirability and doability of safe student medication administration the Commissioner of Health recommends:

The Department of Health, in collaboration with the Department of Children, Families and Learning and the Board of Nursing shall convene a workgroup to provide input into the development of a state system related to medication administration in the schools. The workgroup shall include members as defined in Laws of Minnesota 2001, Chapter 9, article 1, section 61 (b).

Recommendation 3:

Given that good health is a necessary foundation for students to be able to learn and that student access to medication while at school enhances attendance and reduces a potential barrier to educational success, the Commissioner of Health recommends:

The Department of Health in collaboration with the Department of Children, Families and Learning will provide the legislature with any needed legislative changes to the implementation of a safe medication administration system in Minnesota schools.

These recommendations will move the state forward in improving conditions for safe student medication administration.

Definitions:

*Standard: A statement that defines a goal of practice. It differs from a guideline in that it carries a great incentive for universal compliance. It differs from regulation in that compliance is not always required. It usually has a based of legitimacy or validity based on scientific or epidemiological data, or, when this evidence is lacking, it represents the widely agreed upon, state of the art, high quality of practice.7

**Guideline: A statement of advice or instruction pertaining to practice. It originates in an organization with acknowledged professional standing. A guideline is developed in response to a stated request or perceived need for advice.7

***Policy: A framework for operational decision, which specifies a recommended course of direction consistent with the intent of the organization. A policy is an understanding by members of a group that make the actions of each person more predictable.8

****Procedure: Specific guidelines telling how to implement policy. A way of telling how to perform activities or tasks, e.g., who does what and when.8

References:

1. American Academy of Pediatrics, Committee on School Health. School Health: Policy and Practice. Elk Grove Village, IL: American Academy of Pediatrics; 1993:9-16.

2. Peterson, Berit. Edina Schools Health Services Annual Report, 2000-01. Edina, MN: Edina Public School; 2000-01.

3. Minnesota Department of Health. Minnesota School Nurse Informational Survey. Healthy Children Healthy Schools. Division of Family Health, Minnesota Department of Health. July 2000: 3 - 8.

4. Kohn, Linda T; Corrigan, Janet M; and Donaldson, Molla S. To Err is Human: Building a Safer Health System. Committee of Health Care in American, Institute of Medicine; 2000.

5. Foley, Mary. Testimony to the Committee on Health, Education, Labor, and Pensions. American Nurses Association; January 26, 2000.

6. Gilbert, Alan, Chief Deputy and Solicitor General. Letter to Ralph Christofferson, Superintendent, Lake of the Woods ISD #390, Re: Authority of School Nurses to Provide Non-Prescription Medications; February 14, 2000.

7. American Public Health Association & American Academy of Pediatrics. Caring for Our Children. National Health and Safety Performance Standards: Guidelines for Out-of-Home Child Care Programs. Ann Arbor, MI, 1992.

8. Minnesota Department of Health. Guidelines for Policy & Procedure Development. Minneapolis, MN: Section of Public Health Nursing, Minnesota Department of Health, December 1986.

 

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