Policy, Roles, and Responsibility of School Personnel

It is the legal responsibility of school boards to put health policies in place according to Minnesota Statutes § Chapter 121A.22, Subd. 4.  

Subd. 4. Administration.  

Drugs and medicine subject to this section must be administered in a manner consistent with instructions on the label. Drugs and medicine subject to this section must be administered, to the extent possible, according to school board procedures that must be developed in consultation:

(1) with a licensed school nurse, in a district that employs a school nurse;

(2) with a licensed school nurse, in a district that employs a licensed school nurse licensed under Minnesota Rules, part 8710.6100;

(3) with a public or private health or health-related organization, in a district that contracts with a public or private health or health-related organization, according to section 121A.21; or

(4) with the appropriate party, in a district that has an arrangement approved by the commissioner of education, according to section 121A.21.

School Health Services Staffing describes in detail statutory, national recommendations, and the types of nurses employed in school health services. Districts with LSNs/RNs on staff or on contract will be able to take the lead on developing school district policies and procedures which include medication program: supervision, delegation, assignment, administration, documentation, etc. Those districts with LSNs/RNs on staff or on contract will be able to call on staff to take the lead on these responsibilities.

In school districts without Licensed School Nurses/Registered Nurses (LSNs/RNs) on staff, educational administrators working with school boards are responsible to set up a system through which:

• medication administration policies are developed,
• acceptable LSN/RN/ licensed health care provider coverage for medication administration oversight via contract or other arrangements is found,
• people are assigned and trained,
• the procedures are done safely and consistently, and
• all necessary documentation is completed.

Characteristics of Sound Policies

A policy is a framework for operational decisions, which specifies a recommended course of direction consistent with the intent of the organization. Safe medication management requires sound policy for medications necessary during the school day, in emergency situations, as well as during school-sponsored on- or off campus activities.

Local district policies and procedures on medication administration should be balanced, consistent, periodically updated according to school district directives for policy review, adaptable, based on the needs and ages of the student population at-large, consider community resources, and are aligned with professional practice standards and guidelines.

Decisions made at the school district level will impact how students are ultimately served. The best policies are developed collaboratively, with the advice and assistance of the following: school board members, medical advisors, licensed health care providers, families, school staff (LSN/RN, LPN, UAPs, principal, etc.), local partners (pharmacists, public health workers, social workers, health care administrators), and other community members.  

School staff, students, and parents/legal guardians all need to be aware of, understand, comply with, and aid in successful implementation of district policy and procedures. Parents/legal guardian should be advised annually of the district’s medication policy and procedures.

The Minnesota School Board Association (MSBA) offers sample policy language for member districts and schools.

The National Association of School Nurses (NASN) had developed School Nursing Evidence-based Clinical Practice Guideline: Medication Administration in Schools as a decision-making tool to guide professional school nurses in implementing evidenced-based practices and a Toolkit for Medication Administration in Schools which provides sample policies, forms, templates, checklists and protocols.

Contents of Policy and Procedures

A policy is a framework for operational decisions, which specifies a recommended course of direction consistent with the intent of the organization. It is an understanding by members of a group that make the actions of each person more predictable. Procedures are specific steps outlining how to implement policy, a way of telling how to perform activities or tasks (e.g., who does what and when). The district medication policy should be reviewed per school board operating guidelines, but medication administration procedures should be reviewed annually, preferrable before the start of each school year and updated as needed.  This is part of quality improvement which provides for safe medication administration to students.  School procedures for medication administration should be consistent across all the district’s schools.

There are several key elements in Minnesota Statutes § Chapter 121A.22 that should be addressed in a school policy.

• “The request of a parent may be oral or in writing. An oral request must be reduced to writing within two school days, provided that the district may rely on an oral request until a written request is received.”
• “If the school is to store the drug or medication, the parent or legal guardian must inform the school if the drug or medicine is a controlled substance.”
• “For a drug or medication that is a controlled substance, the request must specify that the parent or legal guardian is required to retrieve the drug or controlled substance when requested by the school.”
• “For a drug or medication that is not a controlled substance, the request must include a provision designating the school district as an authorized entity to transport the drug or medication for the purpose of destruction if any unused drug or medication remains in the possession of school personnel.”
• “Prescription asthma or reactive airway disease medications self-administered by a pupil with an asthma inhaler, consistent with section 121A.221, if the district has received a written authorization from the pupil's parent permitting the pupil to self-administer the medication, the inhaler is properly labeled for that student, and the parent has not requested school personnel to administer the medication to the pupil. The parent must submit written authorization for the pupil to self-administer the medication each school year.”
• Epinephrine auto-injectors, with prescribing medical professional and parent authorization annually, can possess be self-administered.  Parent must provide properly labeled medication to the school.
• Prescription drugs must be in a container with a label prepared by a pharmacist.
• Each school district must adopt a procedure for the collection and transport of any unclaimed or abandoned prescription drugs or medications remaining in the possession of school personnel in accordance with Minnesota Statutes § Chapter 121A.22.  

While not addressed specifically in statute, district policies and procedures on medication administration should address the following types of medications that parents may request be administered in school. These include: prescription, stock medications (naloxone and epinephrine), FDA approved over-the-counter (OTC) medications, controlled substance, non-FDA approved OTC, non-FDA approved complementary and alternative medicines (i.e., supplements, homeopathic substances), research or off-label prescribed medications. The policy may or may exclude these types of medications determined by district in consultation with RN/LSN or licensed medical provider or consultant. Types of Medications provides additional detail related to each type of medication and possible safety considerations.

Additional topics that should be addressed include secure handling and storage of medications, original containers with labels for OTC, environmentally sound medication disposal, emergency protocols, medication errors and omissions, documentation and recording keeping, protecting student privacy during medication administration, training for those administering medications and supervision of those delegated or assigned to administer medications, and communication expectations between the school nurse, parent/guardian and licensed prescriber.

Communication

The school administration should establish procedures and tools for communication among persons in various roles (e.g., parents’/legal guardian’ and school staff members’ need for interpreters and translated materials). Communication—among staff members, with students and their families, and with the community—clarify expectations, provide education, and facilitate discussion related to student medication administration.  

Education personnel and parents/legal guardians have varying levels of understanding and ability to comply with school district health policies. Factors could include socioeconomic, physical, or psychosocial status, and cultural understanding and practices (e.g., the school might need a translator for verbal and written information related to medication administration). School administration will need to work with staff members and families to ensure understanding and compliance with policy. All communications should be tailored to the diverse populations served in the school district.

Accountability and responsibility for linking systems of student health needs and educational success is shared among nurses (LSNs/RNs/LPNs), licensed prescribers, pharmacists, the school board and administrators, unlicensed assistive personnel (UAPs), school staff, parents, and students. The contribution of persons in each of these roles is important to student success and the safe administration of medication within the framework of district policies. No employee may be coerced into compromising student safety by being required to delegate, assign, or administer medication if that person determines that it is inappropriate to do so.

Licensed Prescribers

All states, including Minnesota, have professional practice laws that govern who are authorized to prescribe medications.

Who is a licensed authorized prescribing practitioner in Minnesota?

• Physician
• Advanced practice registered nurse (APRN) with prescriptive authority (includes clinical nurse specialist practice, nurse-midwife practice, nurse practitioner practice, or registered nurse anesthetist practice)
• Physician’s assistant (PA) who has direction from a physician or written protocol.
• Dentist
• Podiatrist
• Osteopath
• Psychiatrist

Who is not a licensed authorized prescribing practitioner in Minnesota?

• Licensed school nurse (LSN)
• Registered nurse (RN)
• Licensed practical nurse (LPN)
• Medical assistant
• Nutritionist
• Psychologist
• Naturopathic provider (may order non-prescription drugs and non-invasive diagnostic therapeutic procedures (Minnesota Statute 147E.05 Scope of Practice)
• Chiropractor

The licensed prescriber can better support school staff in the administration of medication in school by aligning clinic workflows with local school policy and procedures. Clinic workflows could include establishment of communication pathways for fielding medication-related concerns from parents/guardian and school nurses, dedicated dosing (e.g., prescriptions to include a second metered dose inhaler for school or ADHA medication), and as appropriate getting parent/guardian signed consent to talk to school nurses about the condition and the medication used to manage the health condition. Licensed prescribers can contribute to safe medication administration by integrating the districts’ school medication order form into the clinic’s electronic health record and complete at the time of the visit.

The American Academy of Pediatrics (AAP) Policy Statement: Safe Administration of Medication in School  outline eleven recommendations for pediatricians and other licensed prescribers when writing prescription for medications that will be needed during the school day and school-related programing before/after the school day or off school grounds.

School Board and School Administrators

School boards and school administrators are responsible for policy and procedures leading to safe medication management for all students.  There are numerous ways in which to ensure that policy and procedures are safe, effective, and up to date.

1. Invite and include school nurses to the team to participate in reviewing the medication policy and/or procedures on a regular basis.
2. Review school health data, include the  number of students taking medications, challenges (errors and omissions),  and complexity of health conditions and required medications.
3. Allocating funding from the district budget for health- related resources (personnel, materials, up to date technology such as the electronic medical record, space, access to training and paid time for staff training, etc.)  
4. For districts not employing LSN/RN on staff, securing an agreement for school health consultation with an individual physician, an LSN/RN, local community clinic, hospital, or public health agency if needed.

School administrators are accountable for implementing  the medication administration policy/procedure with fidelity and supporting the school nurse if challenged by school staff, parents/guardians, or community members.  School administrators are responsible to provide staff time for training to ensure competency and safety in medication administration and if  required support the nurse when school staff deviated from safe practices and redirect school staff to follow the correct procedure. School administrators cannot legally fulfill the role of LSNs/RNs. Training for medication administration is beyond the role of school administrators.

Parents/Guardians

Parents/legal guardians should know the school district policy/procedure and ask questions as needed to understand to enable them to follow and support the school district policy and procedures regarding medication administration.  It is important that they advocate for safe administration of medication and communicate with the school about their children’s medication needs in schools. They are responsible for supplying the medication in an appropriated labeled container, refilling the supply as needed, transporting the medication to and from school, and signing the school medication authorization form per the school procedure.  Parents/guardians are important communicators about changes in the student’s health condition, medication schedules (home and school), changes in observed reactions to medications, and obtaining licensed prescriber authorization for medication when needed.  As a member of the team, they collaborate with the nurse in the development of an Individual Health Plan (IHP) or Emergency Care Plan (ECP) for the management of the health condition with medication administration or when the student is ready to self-administer their own medication.  If challenges develop around student refusal or non-adherence to medication administration, they can help identify ways to support the student to safely receive the medication as needed.

Students

The roles of students vary, depending on their age and developmental stage. Students at every age are learning about their health conditions and the role that medications have in managing or helping their health condition. In the early years, the emphasis might be on students as recipients of medication, but even at young ages, students can take increasing responsibility for their medications. As students develop, it is important for them to learn to make decisions regarding their medication administration and skills in self-administration and even self-carrying their emergency medication such as an epinephrine auto injector (EpiPen ™) or rescue inhaler.

The student as an active participant is responsible to be knowledgeable about their medications, take their medications correctly, and communicate any medication issues or concerns to parents/legal guardians, LSNs/RNs, LPNs, teachers, or other school staff as appropriate.

Licensed Nurses

School nurses coordinate health care for students and are the bridge between health and education systems.  They  have extensive knowledge and expertise  in delivering health and nursing care to individuals, groups, and populations.  They have been educated in pharmacology, and nursing assessment with specific knowledge related to medication administration, medication effectiveness and monitoring for medication side effects.  

School Health Services Staffing describes MN Statute 121A.21 School Health Services requirements for school nursing services, the types of nursing licensure in Minnesota and the scope of practice for each type of nursing licensure.  While there are similarities in basic nursing knowledge, the depth and breadth are different for each type of nursing licensure granted through the Minnesota Board of Nursing.  Therefore, the roles and responsibilities for medication administration will look different for the Professional Registered Nurse (RN) / Licensed School Nurse (LSN), the Licensed Practical Nurse (LPN) and the Unlicensed Assistive Personnel (UAP).

The RN/LSN has the nursing authority to determine when, how, and to whom to share the responsibility of medication administration when they can not directly provide medication administration.  The RN/LSN can assign medication administration to an LPN and provides nursing delegation to UAPs.  Whether medication is assigned or delegated the RN/LSN is responsible for monitoring and/or supervising and providing education and training for safe medication administration.  Nursing Delegation for the School Setting provides information on statutory definitions and requirements, professional standards and guidance, and requirements related to training, monitoring, and supervision.

The RN/LSN has the nursing authority to develop an Individual Health Plan (IHP) and/or Emergency Care Plan (ECP) and contributes the health care plan for students who have an Individual Education Plan (IEP) and/or 504 plan which often includes the administration of medication for both regular scheduled medications, as needed medications, and emergency medications. Nurse Care Planning in Schools provides additional detail.  

School Staff

School staff members, whether teachers, paraprofessionals, school secretaries and other health related professionals, often play a role in the safe administration of medication to students.  Teachers often are vital to helping students receive their medication “on time” or may be the first to recognize a health related problem, like breathing difficulty in a student with asthma.  Teacher support for the student’s plan is crucial so that the student has effective management of their condition to support their learning in the classroom.  RN/LSN often delegate medication administration to other school staff especially for field trips or off site events.  School staff diligence to administering the right medication, at the right time to the right student is imperative to safe medication administration. These staff members have the right to appropriate training and support and the responsibility to administer the medication as instructed by the RN/LSN.  This is the only way to provide for safe medication administration.