The following federal laws (Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act, and the Individuals with Disabilities Education Act) are important considerations in the planning and implementation of school-sponsored trips. These laws provide the safeguards to protect students with disabilities and ensure these students have the same access to school-sponsored trips as their peers. Because of these laws, the ethical obligation to students, and the increasing number of students with special health needs in schools, it is critical that school nurses understand these pertinent laws and assist in developing policies and procedures to assure safe and quality care both in school and on school-sponsored trips. The following information regarding these laws is adopted from the Connecticut State Department of Education’s Clinical Procedure Guidelines for Connecticut School Nurses (2013). More detailed information regarding these laws and resources is available in Part A: Legal Issues—Educational of the Clinical Procedure Guidelines.
Section 504 of the Rehabilitation Act of 1973 (Section 504)
Section 504 covers qualified students with disabilities who attend schools receiving federal financial assistance. To be protected under Section 504, a student must be determined to: (1) have a physical or mental impairment that substantially limits one or more major life activities; or (2) have a record of such an impairment; or (3) be regarded as having such an impairment. Section 504, together with the Individuals with Disabilities Education Act, requires that school districts provide a free appropriate public education (FAPE) to qualified students in their jurisdictions who have a physical or mental impairment that substantially limits one or more major life activities.
Major life activities, as defined in the Section 504 regulations at 34 CFR 104.3(j)(2)(ii), include functions such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working. This list is not exhaustive. Other functions can be major life activities for purposes of Section 504. In the Americans with Disabilities Act Amendments Act (ADAAA), Congress provided additional examples of general activities that are major life activities, including eating, sleeping, standing, lifting, bending, reading, concentrating, thinking, and communicating. Congress also provided a nonexhaustive list of examples of "major bodily functions" that are major life activities, such as the functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. The Section 504 regulatory provision’s list of examples of major life activities is not exclusive, and an activity or function not specifically listed in the Section 504 regulatory provision can nonetheless be a major life activity (CSDE, 2013).
Individuals with Disabilities Education Act (IDEA)
Special education is provided to students with an identified disability who need specially designed instruction to meet their unique needs and to enable students to access the general curriculum of the school district. Students who are eligible for special education services are entitled by federal law to receive a free appropriate public education (FAPE) at no cost to the family. FAPE differs from student to student because each has unique needs. Students who receive special education services also receive “related services.” Related services means “transportation and such developmental, corrective, and other supportive services as are required to assist a child with a disability to benefit from special education, and includes speech-language pathology and audiology services, interpreting services, psychological services, physical and occupational therapy, recreation, including therapeutic recreation, early identification and assessment of disabilities in children, counseling services, including rehabilitation counseling, orientation and mobility services, and medical services for diagnostic or evaluation purposes. Related services also include school health services and school nurse services, social work services in schools, and parent counseling and training” (34 CFR § 300.34[a])(CSDE, 2013).
As noted in the brief overview provided above and the corresponding resources from the CSDE’s Clinical Procedure Guidelines,all students have the right to participate in all educational opportunities whether they are provided on site or on a school-sponsored trip.
Medication Administration by School Personnel
Connecticut General Statutes (C.G.S.) and the Regulations set forth the laws and regulations for Connecticut Schools regarding administration of medications to students during school hours for both in-school and out-of-school activities. This statute, C.G.S. §10-212a, and the Regulations, §10-212a-1 through §10-212a-10, clearly articulate the responsibilities of school nurses administering medications in schools; who can give medications in the absence of the school nurse; what medications may be administered by qualified personnel for schools; the training and supervision to be provided by the school nurse; the documentation of administration and proper storage required; and the provisions for self-administration of medications by students when allowed and appropriate. These statutes and regulations pertain to practices acceptable within Connecticut only. The administration of medication by the school nurse or school personnel on a field trip outside of the state or country is determined by that state/country and will be discussed further in the delegation section below.
Qualified Personnel for Schools
Section 10-212a-1. Definitions
As used in Sections 10-212a-1 through 10-212a-10 of the Regulations of Connecticut State Agencies:
“’Qualified personnel’ for schools means (a) a full-time employee who meets the local or regional board of education requirements as a principal, teacher, occupational therapist or physical therapist and has been trained in the administration of medication in accordance with Section 10-212a-3 of these regulations; (b) a coach and licensed athletic trainer who has been trained in the administration of medication pursuant to Section 10-212a-8 of these regulations; or(c) a paraprofessional who has been trained in the administration of medication pursuant to Section 10-212a- 9 of these regulations. For school readiness programs and before- and after-school programs, directors or director’s designee, lead teachers and school administrators who have been trained in the administration of medication may administer medications pursuant to Section 10-212a-10 of these regulations.”
It is important to note that the Connecticut Board of Examiners for Nurses (CBEN) has deemed medication administration as solely nursing activity, meaning that only a nurse may administer medications, unless specific statutory exemptions exist (1995). For administration of medications by unlicensed personnel in Connecticut schools, C.G.S. 10-212a and accompanying Regulations:
- provide legal authority for the administration of medication by unlicensed personnel; and
- protect both the school nurse and the school personnel when administering medications to students in the absence of a school nurse from liability for ordinary negligence, although not from liability for acts or omissions constituting gross, willful or wanton negligence.
Therefore, when a field trip is within the State of Connecticut, these statutes and regulations apply and it is acceptable practice, if deemed safe by the school nurse, for qualified personnel for schools to administer medication to students during these trips. However, it is necessary that the local or regional board of education have adopted written policies and procedures with respect to the administration of medication by qualified personnel. Also, medication may only be administered pursuant to the written order of an authorized prescriber, with the written authorization of the student's parent or guardian, and with the written permission of the parent for the exchange of information between the prescriber and the school nurse to ensure safe administration of the medication (C.G.S. section 10-212a[b]; Regulation section 10-212a-2). These statutes and regulations do not allow for administration of medication by qualified personnel during extracurricular activities, so school nurses may assist in planning for the needs of students but may not delegate medication administration.
The C.G.S. §20-87a has established the Nurse Practice Act as the following:
The practice of nursing by a registered nurse is defined as the process of diagnosing human responses to actual or potential health problems, providing supportive and restorative care, health counseling and teaching, case finding and referral, collaborating in the implementation of the total health care regimen, and executing the medical regimen under the direction of a licensed physician, dentist or advanced practice registered nurse. A registered nurse may also execute orders issued by licensed physician assistants, podiatrists and optometrists, provided such orders do not exceed the nurse’s or the ordering practitioner’s scope of practice. (C.G.A., 1975).
This practice act provides the legal foundation for nursing care and assists the nurse in understanding his/her scope of practice in all settings. School nurses need to abide by this act and, therefore, whether accompanying students on the trip or not, are authorized to be part of the planning process for field trips in order to ensure that the medical regimen is followed and there are health care plans in place to respond to actual or potential health concerns and needs of students.
National standards suggest that delegation requires that the registered nurse (RN) “must determine which student care activities may be delegated, under what circumstances it is appropriate to delegate aspects of student care, and by whom the...care can safely be provided” (NASSNC, 2000). One key tool for school nurses to guide their decision-making is the Five Rights of Delegation(NCSBN, 2005). More details regarding delegation are available in the Clinical Guidelines for School Nurses.
In addition to the Nurse Practice Act and national standards, school nurses need to be aware of any rulings, regulations, or other legal guidance that supplement or enhance the Nurse Practice Act, and in particular any rulings about delegation of nursing activities. Guidance regarding delegation can vary from state to state; however, Connecticut has a declaratory ruling to guide practice. Delegation By Licensed Nurses To Unlicensed Assistive Personnel (CBEN, 1995) outlines the nurse’s responsibility when delegating nursing care to unlicensed personnel. This is particularly relevant to school nurses and field trips since there is not always a school nurse available during these trips. Key points in this ruling include:
- decisions to delegate can be made only by a registered nurse;
- the decisions are based on the nursing process, rather than a list of tasks;
- only implementation of care may be delegated to an unlicensed person;
- supervision of the unlicensed personnel is required; and
- no care requiring nursing judgment or assessment may be delegated to an unlicensed person.
These considerations can help inform the school nurse when planning for nursing on field trips. The full declaratory ruling regarding delegation can be found on the Connecticut Department of Public Health's Web site.
For field trips outside of Connecticut, it is necessary that the school nurses also annually determine the licensure and practice acts in the state or country where the students are visiting. As previously stated, the regulations for practice can vary from state to state and because Connecticut is not part of the Nurse Licensure Compact, the nurse is only licensed to practice in Connecticut and, if he/she is accompanying the trip, the nurse must request permission to practice in another state or determine if the state or country grants visiting privileges. If the school nurse is not going on the trip and there are nursing procedures or medications to be administered by unlicensed personnel, the school nurse must determine what aspects of care may be delegated to unlicensed personnel in that state prior to delegating any procedures including medication administration. The school nurse can obtain this information by contacting the respective state’s board of nursing to request and receive permission to practice in that state and to learn the scope of practice and delegation rules in that state. For trips outside the country, the school nurse must contact the consulate of the visiting country for guidance and permission (NASN, 2013 & Kentucky Department of Education, 2013). If the state does not offer visiting privileges, it is recommended that permission be obtained for each trip individually to ensure that the permissions are current; however, if there are several field trips to the same state over the course of the academic year, all trips may be included in one letter to the board of nursing. The Kentucky Department of Education’s Web site maintains current contact information of each state’s board of nurses. In addition, a sample letter requesting permission and scope of practice information is included in Appendix A.