Abstract
Delegation of nursing procedures and medication in school is fraught with legal and ethical concerns for the school nurse. Because nurses may be responsible for coordinating care for several school buildings, delegation of nursing care and medication administration has occurred out of necessity. Nurse Practice Acts in some states, but not all, allow for delegation of medication to unlicensed assistive personnel. This article explores Glucagon® delegation laws in the United States and presents an argument against such delegation in states where Nurse Practice Acts do not allow for delegation of medication to unlicensed assistive personnel.
Introduction
The role of the school nurse has evolved into one that presents many challenges in meeting the health care needs of large populations of students, many with complex and acute medical disease processes. The incidence of chronic conditions such as asthma, diabetes, severe allergies, and seizure disorders in children are on the rise (Bloom, Dey, & Freeman, 2006). Advances in health care and technology have allowed many children with medical needs to attend school, and federal laws ensure the rights of children with disabilities to be educated with their peers in the least restrictive environment (Family Education Rights and Privacy Act, 20 U.S.C.A. 1232g, regulations at 34 C.F.R.).
Diabetes is one of the most common chronic diseases in children and adolescents. Approximately 151,000 people below the age of 20 years have diabetes, and each year more than 13,000 young people will be diagnosed with type 1 diabetes (Centers for Disease Control and Prevention, 2010). Students with diabetes require frequent assessments by the school nurse during the school day, particularly if newly diagnosed or young in age. They require complex nursing assessments, hypoglycemia management, blood glucose, and urine ketone testing, as well as the administration of insulin and possibly Glucagon®, a hormone normally secreted by the pancreas, assists the liver to convert stored glycogen into glucose. Administering a Glucagon® injection when a student has severe hypoglycemia can be a potentially lifesaving treatment (National Library of Medicine, 2008). In order to meet the needs of these students and provide for emergency care, delegation of nursing care such as blood and urine testing and emergency medication administration in the school setting is a necessity in many school districts, particularly in rural settings where one nurse may be responsible for several school buildings, and in districts with large student populations.
With that in mind, the school nurse is likely to be the only health care provider in the educational setting responsible for coordinating care for all students in a given school, district, or region. According to the National Association of School Nurses ([NASN], 2009), more than 50% of public schools in the United States do not have a full-time registered nurse on-site. The NASN and Healthy People 2010 (U.S. Department of Health and Human Services, 2000) advocate for a ratio of 1 school nurse for every 750 well students in each school in the United States. This ratio does not take into account students with chronic and complex health care needs such as diabetes, asthma, life-threatening allergies, multiple disabilities, or other chronic conditions. There exists a wide disparity of school nurse-to-student ratios across the United States. For example, Vermont’s school nurse-to-student ratio ranks first in the nation, averaging 1 school nurse for every 311 students (1:311), and Michigan ranks last with approximately 1 school nurse for every 4,836 students (1:4,836; NASN, 2010). “There exists a wide disparity of school nurse-to-student ratios across the United States.”
Budgetary constraints are often cited as the primary reason for the lack of school nurses available to meet the needs of student populations. Services that are not mandated by law are often eliminated (McCarthy, Kelly, & Reed, 2000; Telljohan, Price, Dake, & Durgin, 2004; Tetuan & Akagi, 2004). School nurses are then placed in the tenuous position of delegating care to unlicensed assistive personnel (UAP) in order to meet the needs of the student population.
The National Council of State Boards of Nursing ([NCSBN], 1997b) defines UAP as “any unlicensed individual, regardless of title, to whom nursing tasks are delegated” (p. 3). Delegation is defined as “transferring to a competent individual the authority to perform a selected nursing task in a selected situation” (p. 1). Although certain tasks may be delegated, the nurse remains accountable for the care (NCSBN, 2005). School nurses must be aware of applicable laws, regulations, and scope and standards of care in the state in which he or she practices, as states vary in their nursing delegation laws (American Nurses Association [ANA] and NASN, 2005). When state laws and/or guidelines conflict, it is often difficult to know which law or guideline supercedes the other unless an advisory opinion has been issued. When educational law empowers a school administrator to delegate or assign tasks, policies may be created that are in direct conflict with State Nurse Practice Acts, placing the school nurse in the position of making very difficult decisions. School nurses may be placed in a position where they may not be able to directly supervise an individual who has been delegated to perform nursing procedures and forced to choose between following standards of nursing practice or an administrator’s directive (NASN, 2006). This puts the school nurse and his or her nursing license in a precarious position.
It is the position of NASN (2006) that the school nurse is the only school staff member who has the skills, knowledge base, and statutory authority to fully meet the health care needs of students with diabetes in the school setting. The delegation of procedures and treatments may be used only in compliance with individual State Nurse Practice Acts, state regulations, and guidelines provided by professional nursing organizations. State Laws and Nurse Practice Acts determine the extent to which school nurses can delegate nursing tasks such as administration of insulin and Glucagon® to other school personnel in the absence of the school nurse. If the student’s condition, age, cognitive ability, or skills require it, a school nurse should be on-site to appropriately manage that student. If diabetes care is delegated to unlicensed personnel, the school nurse needs to be immediately accessible to provide direction (NASN, 2006). “The delegation of procedures and treatments may be used only in compliance with individual State Nurse Practice Acts, state regulations, and guidelines provided by professional nursing organizations.”
New Jersey is the most recent state to enact public law N.J.S.A. 18A: 40-12.11-21 (New Jersey Department of Education, 2009), requiring a school nurse to delegate administration of injectable Glucagon® to an unlicensed employee. This law is in direct conflict with the New Jersey State Nurse Practice Act. The New Jersey Board of Nursing allows for delegation of selected nursing tasks but not for the delegation of medication administration (New Jersey Board of Nursing, 2004). This raises the question of how other states address Glucagon® delegation to unlicensed personnel, if at all. The purpose of this review is to explore Glucagon® delegation laws in the United States and present an argument against such delegation in states where Nurse Practice Acts do not allow for delegation of medication to UAP.
Literature Review
There has been a great deal of research on medication administration and delegation practices of school nurses in the Unites States. Several common themes emerged from the literature review: legal concerns, comfort levels of the delegating nurses and unlicensed personnel, and medication errors. Ficca and Welk (2006) surveyed 314 Certified School Nurses (CSNs) in Pennsylvania schools to determine policies and practices in use in that state. Medication delegation violates the Pennsylvania Nurse Practice Act (NPA), yet 70% of the surveyed CSNs admitted they do not administer every student medication. Additionally, when asked the question of whether the Pennsylvania NPA allowed delegation of medication, 54% responded no, 15% responded yes, and 31% responded they were not sure. The researchers found the results indicated a lack of clear understanding of how the state NPA is applied in the school setting. O’Dell and O’Hara (2007) found a much smaller percentage (6%) of school nurses (n = 419) who were not aware of state policies in relation to the administration of rectal diazepam gel for seizures. McCarthy et al. (2000), using a random sample of school nurses from the NASN membership surveyed 649 school nurses from the United States and found that of the 491 (75.6%) school nurses who delegate medication administration to unlicensed personnel, 15% stated that their state NPA does not allow delegation and 19.1% were not sure.
Many school nurses, while finding it necessary to delegate medication administration to unlicensed personnel, reported being uncomfortable with delegation of this task (Canham, Bauer, Concepcion, Luong, Peters, & Wilde, 2007; Ficca & Welk, 2006; McCarthy et al., 2000). Furthermore, many of the delegates report being uncomfortable administering medications to students (Canham et al., 2007). It is interesting to note that in the school setting the most common delegate chosen for medication administration is the school secretary (Farris, McCarthy, Kelly, Clay, & Gross, 2003; McCarthy et al., 2000; Price, Dake, Murnan, & Telljohan, 2003) in many schools being among the personnel with the fewest years of formal education (Price et al., 2003). Price et al. (2003) surveyed 246 secretaries responsible for dispensing medications in the school setting and found that they generally disliked the responsibility for several reasons including lack of training, lack of time, errors in administration, but most commonly due to concerns of liability if an error did occur.
Studies indicate that medication errors encompassing errors in dosage, including overdosage, missed doses, administration of expired medications, and inaccurate recording frequently occur in the school setting when medications are administered by unlicensed personnel (Canham et al., 2007; Ficca & Welk, 2006; McCarthy et al., 2000; Price et al., 2003). Ficca and Welk (2006) found that errors increased when one school nurse was responsible for the care of students in multiple buildings and when unlicensed personnel administering medications included multiple individuals with varying degrees of education and training (secretaries, teachers, principals, health aides, and parents). Furthermore, statistics on medication errors may be problematic to estimate. Price et al. (2003) report that only 15% of secretaries who were responsible to administer medications to students stated that a medication error was made in the past year. Since this is inconsistent with prior studies (Farris et al., 2003; McCarthy et al., 2000), they speculate that perhaps the secretaries were not cognizant that errors occurred.
Farris and colleagues (2003) studied medication administration practices from principals' perspectives related to legal responsibility in the school setting. Surveys (n = 396) received from schools in Iowa were most commonly completed by principals (75.5%, n = 299), school nurses (3.3%; n = 13), and secretaries (1.3%; n = 5). The results indicated that both school nurses and principals reported they had the ultimate legal responsibility for medication administration. This illustrates the difficulty school nurses encounter when laws and regulations compete or overlap. According to state regulations, principals believe they are ultimately responsible for anything occurring in the school and nurses understand that by state law, nurses are ultimately responsible for medication administration. Furthermore, Farris et al. (2003) raise an important question of how principals can delegate a function they have not been trained to complete or licensed to perform.
It is striking to note the number of school nurses delegating medication administration to UAP in circumstances where delegation of medication administration either blatantly violates state law or it is unclear whether the law is violated. There appears to be a dearth of research comparing state legislation on medication delegation, perhaps due to the variability of NPAs and the fluid nature of the law. A literature search was conducted using CINAHL and LexisNexis Legal databases for current state diabetes legislation, particularly as it pertains to the delegation of Glucagon®. The LexisNexis Legal database yielded results for approximately 25 states. If the results did not address medication delegation or delegation of Glucagon® specifically, individual state NPAs and boards of nursing were searched. Table 1 depicts the findings of the search in relation to medication delegation laws.
State Comparison Chart of Medication Delegation Legislation
Note: aNote that on June 8, 2010, the California Court of Appeal, Third Appellate District, upheld the decision of the trial court’s decision that allowing UAP to administer insulin violated California laws, including the California NPA (American Nurses Association, 2010).
b Note that on June 1, 2010, HB 6065, also known as the Care of Students with Diabetes Act, was sent to the governor of Illinois for signature. The bill specifically states that non-nursing personnel are not required to administer medication (Illinois General Assembly, 2010).
c Delegation is required, not optional. Endnote: References for Table 1 listed separately.
Results
State boards of nursing and individual state legislatures differ greatly in the intricate wording of statutes, rules, and regulations, creating difficulty establishing an understanding of the laws and whether they violate state NPAs. Table 1 compares these differences by state and clearly demonstrates variations. Based on these differences, it is understandable that school nurses have difficulties interpreting individual state laws and district policies regarding the delegation of medication administration (Canham et al., 2007; Farris et al., 2003; Ficca & Welk, 2006; McCarthy et al., 2000; O’Dell & O’Hara, 2007).
There is also a great deal of variation among the 50 states and the District of Columbia in what may be delegated and under what circumstances. For example, Alaska, Idaho, and South Dakota prohibit delegation of all injectable medication to UAP. Alabama, Arkansas, Massachusetts, and Vermont prohibit delegation of injectable medication with the exception of epinephrine. Colorado, Indiana, Minnesota, Nevada, New Mexico, Oklahoma, and Texas allow delegation of insulin. New Mexico allows delegation of insulin but not Glucagon®, and Minnesota specifically allows delegation of insulin and epinephrine but does not address Glucagon®. Hawaii and Maryland allow delegation if the medication dose is premeasured or calculated by the school nurse, and Kansas allows delegation if no dose calculation is needed. See Table 1 for a comprehensive list of medications that may be delegated and under what circumstances they may be delegated.
There are a total of 19 states (see Table 2 ) that address Glucagon® delegation directly; 16 states allow delegation and 3 states (Kentucky, New Jersey, and Virginia) require delegation. Glucagon® delegation is not addressed in the laws of Connecticut, Georgia, Illinois, and Minnesota. Thirteen states prohibit the delegation of Glucagon®. Of these 13 states, 4 (Alabama, Arizona, Massachusetts, and Vermont) allow delegation of epinephrine, 4 (Alaska, Idaho, South Dakota, and Washington) prohibit delegation of all injectable medication, 4 (Mississippi, Pennsylvania, South Carolina, and Wyoming) prohibit all medication delegation, and only New Mexico allows delegation of insulin but not Glucagon®. Inferred permission is present in 14 states and the District of Columbia, stating that delegation of medication in emergency situations is allowed.
Glucagon® Delegation Chart
Note: aGlucagon® delegation required, not optional.
Discussion
Legal authority for delegation of medication administration by school nurses comes from individual state NPAs, as well as educational law. Oftentimes, NPAs do not address medication delegation expressly but provide decision-making guidelines for the delegation of nursing care and tasks. For example, Subchapter 6 (nursing procedures) of the New Jersey Board of Nursing Statutes and Regulations states in 13.37-6.2b that no task may be delegated which is within the scope of nursing practice and “requires (1) substantial knowledge and skill derived from completion of a nursing education program and the specialized skill, judgment and knowledge of a registered nurse and (2) an understanding of nursing principles necessary to recognize and manage complications which may result in harm to the health and safety of the patient.” This statute also states that in all cases, the registered professional nurse shall be available for on-site supervision (New Jersey Board of Nursing, 2004). “Oftentimes, NPAs do not address medication delegation expressly but provide decision-making guidelines for the delegation of nursing care and tasks.”
It is the position of the New Jersey State School Nurses Association (Dewitt-Parker, 2009) that educational statute N.J.S.A. 18A: 40-12.11-21 violates the New Jersey Nurse Practice Act, as it requires assessment and judgment based on nursing science and assessment skills developed through nursing education and clinical experience. The NJSSNA further contends that the legislation puts students in the danger of mismanaged care by UAP. The administration of Glucagon® requires reconstitution, withdrawing, and injecting the medication, requiring a degree of education and skill. A delegate would not have enough practice to acquire these skills since few students experience severe hypoglycemia requiring Glucagon® administration in schools. The delegate would need frequent retraining and ability to safely perform these skills in an emergency situation could not be assessed (Dewitt-Parker, 2009).
Standard 14 of the School Nursing Scope and Standards of Practice (2005) addresses resource utilization, stating: The school nurse considers factors related to safety, effectiveness, cost, and impact on practice in the planning and delivery of school nursing services. The nurse assigns or delegates tasks, based on the needs and condition of the client (student), potential for harm, stability of the client’s (student’s) condition, complexity of the task, and predictability of the outcome; as defined and permitted by individual State Nurse Practice Acts; and according to the knowledge and skills of the designated caregiver (p. 36).
Arguable points against delegation of Glucagon® in New Jersey related to Standard 14 include: stability of the condition, complexity of the task, and permission from individual state nurse practice acts, as nursing assessment is a required element in this circumstance.
Several professional nursing organizations have developed position statements and principles for delegation. The Joint Statement on Delegation (ANA and NCSBN, 2005) was developed to support practicing nurses to safely and effectively delegate nursing tasks. Both organizations consider supervision to be the provision of guidance and oversight needed for delegating nursing tasks. The ANA refers to on-site supervision and the NCSBN refers to direct supervision; both requiring physical presence and immediate availability of the supervising nurse. The principles of delegation state that the “The art and science of nursing is complex and knowledge based, thus the nursing process in its entirety cannot be delegated” (NCSBN, 2005, p. 14). Therefore, while discrete components of care can be delegated, any nursing task requiring nursing assessment, judgment, or evaluation cannot be delegated (NCSBN, 2005).
The Five Rights of Delegation (NCSBN, 1997a) is an advisory that assists nurses in the decision-making process regarding delegation. The five rights are right task, right circumstances, right person, right direction/communication, and right supervision/evaluation. Under the right task, the NCSBN lists five circumstances under which activities appropriate for delegation may occur: (a) those which frequently reoccur in the daily care of a client (student) or group, (b) those which do not require the UAP to exercise nursing judgment, (c) those which do not require complex and multidimensional application of the nursing process, (d) those for which the results are predictable and the potential risk is minimal, and (e) those which utilize a standard and unchanging procedure.
The educational statute N.J.S.A. 18A: 40-12. 11-21 conflicts with the New Jersey Nurse Practice Act, where by following one directive leads to disallowance of the other. This puts school nurses in the precarious position of having to choose which law to follow, creating concerns about the protection of their licenses. Similar controversy has been ongoing for several years in California, involving the delegation of insulin to UAP. Most recently, on June 8, 2010, the California Court of Appeal, Third Appellate District, upheld the trial court’s decision that allowing UAP to administer insulin-violated California laws, including the California NPA (ANA, 2010). This precedent should influence the transcription of other state laws affecting nursing practice.
Implications for School Nursing Practice
It is clear from the literature that school nurses experience difficulty deciphering the laws under which they practice (Canham et al., 2007; Farris et al., 2003; Ficca & Welk, 2006; McCarthy et al., 2000; O’Dell & O’Hara, 2007). Table 1 shows the myriad combinations and specifications of Glucagon® delegation laws, further complicating legal issues surrounding delegation. Justifiably, school nurses are uncomfortable with medication delegation but find themselves with little or no alternative (Canham et al., 2007; Ficca & Welk, 2006; McCarthy et al., 2000). School nurses need to continue to be involved in the legislative process. As members of local, state, and national school nursing organizations, school nurses are in a position to have their voices heard. For example, by lobbying to change one word (
It is important that school districts develop policies and procedures related not only to routine medication administration in the school setting but especially related to delegating administration of emergency medications which are compliant with state laws and NPAs. Often most individuals who compose legislation and policies have no education, understanding of jurisdiction related to nursing practice, and the laws governing practice. Therefore, school nurses should serve as resources and sought as consultants during the development of policies and legislations affecting their practice. In addition, if a school nurse makes a nursing judgment that a particular delegate would not be an appropriate person to administer emergency medication that decision must be respected and upheld. “It is important that school districts develop policies and procedures related not only to routine medication administration in the school setting but especially related to delegating administration of emergency medications which are compliant with state laws and NPAs.”
Adequate and appropriate training of UAP in the school setting will assist school nurses to ensure student safety and meet the challenges of caring for students in an emergency situation. School nurses should be a member of the team to the design, implement, and evaluate training programs. Studies report training related to medication administration received by unlicensed personnel who administer medication in the school setting varied with percentages ranging from 27% to 76.9% (Ficca & Welk, 2006; McCarthy et al., 2000; Price et al., 2003). Unlicensed personnel need regular training programs and boosters to reinforce learning, especially since sentinel events are not regular occurrences in the school setting. Written policies, protocols, and emergency treatment plans along with training programs for UAP will enable school nurses to ensure the best treatment for students with diabetes in the school.
Implications for Future Research
Further research is needed in several areas regarding care of the student with diabetes in the school setting. Research on school nurses' experiences with Glucagon® delegation would add to the existing body of knowledge and help elucidate areas needing improvement. It would be important to note whether the incidence of delegation is becoming more common throughout the United States and if so policies addressing safety need to be written. A review of case studies on students who have received Glucagon® injections by UAP, examining outcomes and any associated problems or errors with administration would also be important for best practice guidelines.
Glucagon® delegation presents a challenge in that it must be reconstituted in an emergency situation. The use of cake gel for severe hypoglycemia management should be explored as an alternative to Glucagon®. The American Diabetes Association ([ADA], 2010) recommends Glucagon® or glucose gel for unconsciousness. The Nevada Diabetes Association for Children and Adults (n.d.) also recommends glucose gel if Glucagon® delegation is not authorized or there are no appropriate personnel in the school able to administer Glucagon®. Wagner, Rosenbauer, Grabert, and Holl (2007) studied hypoglycemia in 7,266 children and found in most cases of hypoglycemia when the student was unresponsive, requiring medical assistance, oral administration of glucose was a successful mode of treatment. Further epidemiological research related to oral glucose gel for the treatment of hypoglycemia is needed. The GlucaPen™ (Enject Corporation, 2009) is a new product in development, similar in style and use to the Epipen®, which is scheduled for release in 2011 (personal communication, June 24, 2010). The development of the GlucaPen™ can ease some of the technical burden of delegation, as it will not require reconstitution and should be easier to administer.
Conclusion
Due to the increasing number of children diagnosed with diabetes in the school setting, the realities associated with hypoglycemic emergencies, school nurse availability, and recommendations set forth by state laws and governing institutions related to emergency treatment and delegation of medication administration by unlicensed personnel, it is imperative that school nurses be involved in the legislative process to maintain professional standards of practice. Student safety is a priority for school nurses, and as such, keeping abreast of research and current legislation is a responsibility not to be taken lightly. School nurses should continue to advocate for diabetic students under their care and as members of local, state, and national school nursing organizations, school nurses are in a position to have their voices heard.
Relevant State Codes and Nurse Practice Acts
Alabama: Alabama Board of Nursing, Chapter 610-X-7-.02 (2009). Retrieved June 6, 2010 from http://www.abn.alabama.gov
Alaska: Alaska Administrative Code 12 AAC 44.966-.970 (2010). Retrieved July 25, 2010 from http://www.commerce.alaska.gov/occ/pub/NursingStatutes.pdf
Arizona: Arizona Revised Statutes A.R.S. § 15-344.01 (2008). Retrieved June 3, 2010 from http://www.lexisnexis.com
Arkansas: Arkansas Code A.C.A. § 6-18-1005 (a)(6)(B)(i). Retrieved June 3, 2010 from http://www.arsbn.arkansas.gov/lawsRules/Documents/schoolnurseguidelines.pdf
California: California Educational Code § 49414.5 (2009). Retrieved June 3, 2010 from http://www.lexisnexis.com. California Code of Regulations Title V, Article 4.1 (2005). Retrieved June 3, 2010 from http://www.cde.ca.gov/ls/he/hn/documents/medadvisory.pdf
Colorado: Code of Colorado Regulations, Colorado Board of Nursing, 3 CCR 716-1 (7, 8), Chapter XIII (2007). Retrieved June 3, 2010 from www.sos.state.co.us/CCR
Connecticut: Connecticut General Statutes § 10-212a (2009). Retrieved June 3, 2010 from http://www.lexisnexis.com
Delaware: Delaware Administrative Code, Title 14, Section 817.6 (2007). Retrieved June 3, 2010 from http://regulations.delaware.gov/AdminCode/title14/800/817.pdf
District of Columbia: DC Statute § 38-651.04. Retrieved June 6, 2010 from http://government.westlaw.com/linkedslice/default.asp?SP=DCC-1000
Florida: Florida Statute § 1006.062 (2008). Retrieved June 6, 2010 from http://www.flsenate.gov/Statutes/index.cfm?App_mode=Display_Statute&URL=Ch1006/titl1006.htm&StatuteYear=2009&Title=%2D%3E2009%2D%3EChapter%201006
Georgia: Georgia Board of Nursing, Chapter 410-11-.01. Retrieved June 6, 2010 from http://rules.sos.state.ga.us/docs/410/11/01.pdf. Medications in School Training Module, Children’s Healthcare of Atlanta (December, 2009). Retrieved June 8, 2010 from http://www.choa.org/Menus/Documents/ForProfessionals/MedModule.pdf
Hawaii: Hawaii Board of Nursing § 16-89-108 (2005). Retrieved June 6, 2010 from http://hawaii.gov/dcca/pvl/har/har_89-c.pdf. Hawaii Revised Statutes Annotated HRS § 302A-1164 (2005). Retrieved June 3, 2010 from http://www.lexisnexis.com
Idaho: Idaho Board of Nursing, Administrative Code IDAPA 23.01.01, Section 490 (2010). Retrieved June 10, 2010 from http://adm.idaho.gov/adminrules/rules/idapa23/0101.pdf
Illinois: Illinois Compiled Statutes Annotated 225 ILCS 65/50-75 (2007). Retrieved June 6, 2010 from http://www.blessinghealthsystem.org/upload/docs/BRCN/NursePracticeAct.pdf. 105 ILCS 5/10-22.21b. Retrieved June 7, 2010 from http://www.lexisnexis.com
Indiana: Burns Indiana Code Annotated § 20-34-5-15 (2008). Retrieved June 6, 2010 from http://www.lexisnexis.com
Iowa: Iowa Administrative Code 281 IAC 41.404 (3). Retrieved July 26, 2010 from http://www.legis.state.ia.us/ACO/IAChtml/281.htm#rule_281_41_405
Kansas: Kansas Board of Nursing, 60-15-104 (August 2009). Retrieved June 6, 2010 from http://www.ksbn.org
Kentucky: Kentucky Revised Statutes Annotated KRS § 156.502 (2002). Retrieved June 6, 2010 from http://www.lrc.ky.gov/KRS/156-00/502.PDF. KRS § 158.838 (2005). Retrieved June 6, 2010 from http://www.lexisnexis.com
Louisiana: Louisiana Administrative Code, Title 28, Part CXV, Bulletin 741- Louisiana Handbook for School Administrators (2010), § 1129. Retrieved June 6, 2010 from http://www.doa.louisiana.gov/osr/lac/28v115/28v115.doc
Maine: Maine Revised Statutes MRSA Title 20-A § 254 (5) (2005). Retrieved June 6, 2010 from http://www.mainelegislature.org/legis/statutes/20-A/title20-Asec254.html. Medication Administration Handbook for Unlicensed School Personnel, Maine Department of Education and School Health Advisory Committee (2005). Retrieved June 7, 2010 from http://www.maine.gov/education/sh/medadmininschools/handbookunlicensedstaff.pdf.pdf
Maryland: Maryland Board of Nursing COMAR 10.27.11.05. Retrieved June 20, 2010 from http://www.dsd.state.md.us/comar/comarhtml/10/10.27.11.05.htm. Delegation of Nursing Functions to Unlicensed Direct Care Providers in a School Setting, Maryland State School Health Services Guideline (January 2006). Retrieved June 20, 2010 from http://www.marylandpublicschools.org/NR/rdonlyres/6561B955-9B4A-4924-90AE-F95662804D90/8466/DelegationofNursingFunctions.pdf
Massachusetts: Code of Massachusetts Regulations 105 CMR 210.004 (1994). Retrieved June 20, 2010 from http://www.mass.gov/Eeohhs2/docs/dph/regs/105cmr210.pdf
Michigan: Michigan Compiled Laws MCL § 380.1178 (2006). Retrieved June 7, 2010 from http://www.lexisnexis.com
Minnesota: Minnesota Statutes 121A.22. Retrieved June 20, 2010 from https://www.revisor.mn.gov/statutes/?id=121A.22 . Minnesota Guidelines for Medication Administration in Schools, Appendix B-Frequently Asked Questions, Minnesota Department of Health (September 2005). Retrieved June 13, 2010 from http://www.health.state.mn.us/divs/cfh/shs/pubs/medadmin/appb.html
Mississippi: Mississippi Board of Nursing Rules and Regulations, Chapter III, Section 1.3 (2009). Retrieved June 20, 2010 from http://www.msbn.state.ms.us/pdf/rulesandregulations2009.pdf
Missouri: Missouri Board of Nursing, Chapter 335.011-.257 (2010). Retrieved June 13, 2010 from http://pr.mo.gov/boards/nursing/npa.pdf . Medication Administration in Missouri Schools, Guidelines for Training School Personnel, Missouri Department of Health and Senior Services (April 2005). Retrieved June 13, 2010 from http://www.dhss.mo.gov/SchoolHealth/MedicationManual.pdf
Montana: Administrative Rules of Montana 24.159.1616 (2006). Retrieved June 20, 2010 from http://www.mtrules.org/gateway/ruleno.asp?RN=24%2E159%2E1616. Montana Code Annotated § 20-5-412. Retrieved June 6, 2010 from http://www.lexisnexis.com
Nebraska: Nebraska Revised Statutes R.R.S. Neb § 71-6723. Retrieved June 7, 2010 from http://www.lexisnexis.com. R.R.S. Neb § 79-225 (2006). Retrieved June 3, 2010 from http://www.lexisnexis.com. Nebraska Administrative Code 172 NAC 95-006.01 (2008). Retrieved June 3, 2010 from http://www.sos.ne.gov/rules-and-regs/regsearch/Rules/Health_and_Human_Services_System/Title-172/Chapter-95.pdf
Nevada: Nevada Administrative Code NAC 632.226 (2000). Retrieved June 13, 2010 from http://www.leg.state.nv.us/nac/NAC-632.html. Nevada Board of Nursing, School Nurse Regulation and Advisory Opinion (Revised 2010). Retrieved June 13, 2010 from http://www.nursingboard.state.nv.us/pinfo/school%20nurse%20regulation%20advisory%20opinion.htm
New Hampshire: New Hampshire Administrative Code Ed 311.02 (2009). Retrieved June 13, 2010 from http://www.education.nh.gov/legislation/ed311.htm. New Hampshire Board of Nursing, Chapter 326-B:27. Retrieved June 13, 2010 from http://www.gencourt.state.nh.us/rsa/html/XXX/326-B/326-B-27.htm
New Jersey: New Jersey Board of Nursing, Chapter 37-6.2. Retrieved June 3, 2010 from http://www.state.nj.us/oag/ca/laws/nursingregs.pdf. New Jersey Statutes Annotated N.J.S.A. § 18A:40-12.14 (2010). Retrieved June 3, 2010 from http://www.lexisnexis.com
N.J.S.A. 18A:40-12.6 (2007). Retrieved June 3, 2010 from http://www.njleg.state.nj.us/2006/Bills/AL07/57_.HTM
New York: New York Education Law, Article 139. Retrieved June 13, 2010 from http://schoolhealthservices.org/uploads/NYS%20Nursing%20Education%20Law,%20Article%20139.htm. Administration of Medication in the School Setting Guidelines, State Education Department (April 2002). Retrieved June 13, 2010 from http://schoolhealthservices.org/uploads/AdminMed.pdf. Field Memo-Training of Unlicensed Individuals in the Injection of Glucagon in Emergency Situations, State Education Department (March 2004). Retrieved June 9, 2010 from http://www.emsc.nysed.gov/sss/schoolhealth/schoolhealthservices/fieldmemo-glucagon-JAK-JDP.html
New Mexico: New Mexico Administrative Code 16.12.5.10 NMAC. Retrieved June 13, 2010 from http://www.nmcpr.state.nm.us/nmac/parts/title16/16.012.0005.htm
North Carolina: North Carolina General Statutes N.C.G.S. § 115C-375.1. Retrieved June 13, 2010 from http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter_115C/GS_115C-375.1.html
North Dakota: North Dakota Century Code NDCC § 43-12.1-16. Retrieved June 6, 2010 from http://www.legis.nd.gov/cencode/t43c121.pdf. NDCC § 54-07-05(2005). Retrieved June 6, 2010 from http://www.legis.nd.gov/information/acdata/pdf/54-07-05.pdf
Ohio: Ohio Revised Code ORC 3313.713(2009). Retrieved June 9, 2010 from http://codes.ohio.gov/orc/3313.713.
Oklahoma: Oklahoma Statutes 70 Okl. St. § 1-116.2 (2009). Retrieved June 7, 2010 from http://www.lexisnexis.com. 70 Okl. St. § 1210.196.5 (2007). Retrieved June 3, 2010 from http://www.lexisnexis.com
Oregon: Oregon Administrative Rules 581-021-0037. Retrieved June 9, 2010 from http://arcweb.sos.state.or.us/rules/OARS_500/OAR_581/581_021.html. Oregon Revised Statutes § 433.825. Retrieved June 6, 2010 from http://www.lexisnexis.com
Pennsylvania: Pennsylvania Department of Education Certification and Staffing Policy Guidelines No. 101 (2004). Retrieved June 9, 2010 from http://www.education.state.pa.us/portal/server.pt/community/certification_staffing_policies_(cspgs)/8626/ancillary_staffing_information/507118.
Rhode Island: Rhode Island Department of Education R16-21-SCHO, Section 20.4 (September 2008). Retrieved June 13, 2010 from http://www.thriveri.org/documents/Rules_Regs_School_Health_2008.pdf. Rhode Island General Laws § 16-21-28.2 (2008). Retrieved June 6, 2010 from http://www.lexisnexis.com
South Carolina: South Carolina Code of Laws, Section 40-33-42. Retrieved June 15, 2010 from http://www.scstatehouse.gov/code/t40c033.htm
South Dakota: South Dakota Administrative Rules 20:48:04.01:12. Retrieved June 9, 2010 from http://legis.state.sd.us/rules/DisplayRule.aspx?Rule=20:48:04.01:12
Tennessee: Tennessee Code Annotated § 49-5-415. Retrieved June 3, 2010 from http://www.lexisnexis.com.
Texas: Texas Education Code Section 22.052(a). Retrieved June 6, 2010 from http://www.dshs.state.tx.us/schoolhealth/chap5.pdf. Texas Health & Safety Code § 168.005. Retrieved June 3, 2010 from http://www.lexisnexis.com
Utah: Utah Code Annotated § 53A-11-601(2008). Retrieved June 7, 2010 from http://www.lexisnexis.com. § 53A-11-603 (2006). Retrieved June 6, 2010 from http://www.lexisnexis.com
Vermont: Vermont Statutes 26 VSA Chapter 28 § 1572(2). Retrieved June 6, 2010 from http://www.leg.state.vt.us/statutes/fullchapter.cfm?Title=26&Chapter=028. Joint Statement of Vermont State Boards of Pharmacy and Nursing and the Department of Education. Retrieved June 13, 2010 from http://www.education.vermont.gov/new/pdfdoc/pgm_health_services/health_services_manual/09_delegation_rev.pdf
Virginia: Virginia Code Annotated § 22.1-274. Retrieved June 3, 2010 from http://www.lexisnexis.com
Washington: Revised Code of Washington RCW 18.79.260. Retrieved June 15, 2010 from http://apps.leg.wa.gov/rcw/default.aspx?cite=18.79.260. RCW 28A.210.260. Retrieved June 15, 2010 from http://apps.leg.wa.gov/rcw/default.aspx?cite=28A.210.260. Annotated Revised Code of Washington ARCW § 28A.210.330. Retrieved June 3, 2010 from http://www.lexisnexis.com
West Virginia: West Virginia Code § 16-50 and Appendix C (2009). Retrieved June 13, 2010 from http://www.wvrnboard.com/images/Scope%20and%20Delegation%20Booklet%206.09.pdf. § 18-2K-2 (2006). Retrieved June 3, 2010 from http://www.lexisnexis.com
Wisconsin: Wisconsin Statute § 118.29 (2007). Retrieved June 13, 2010 from http://www.legis.state.wi.us/statutes/stat0118.pdf
Wyoming: Wyoming Board of Nursing, Chapter 9. Retrieved June 13, 2010 from https://nursing-online.state.wy.us/Resources/CHAPTER9June2009.pdf