According to NASN (2013), approximately 26.6% of children have special health care needs including 86% taking medications, 52% requiring specialty care, 33% requiring vision care, 25% requiring mental health care, and 11% requiring some type of medical equipment. These data reinforce the need for prior notification to the school nurse by school staff and assessments by the school nurse prior to any field trip. A systems approach is needed to ensure that the rights of students are protected and that students receive the same level of care on a field trip as in a classroom. If all students cannot be accommodated, the school district must have options for cancellation of or alterations to the trip.
Important Note: If all students cannot be accommodated, the school district must have options for cancellation of or alterations to the trip.
Best practice suggests that school nurses should be part of the initial approval process for any field trip. By being involved early on in the planning, the school nurse can identify potential concerns with the location, safety, transportation, qualifications of chaperones, meals and food plans, and special health care provisions. Early involvement and notification also means that the school nurse can have the needed time to make special arrangements for care, investigate state laws pertaining to nursing care out of state, and conduct training of staff and chaperones. A minimum of four weeks notification should allow for adequate planning and obtaining any necessary approvals. Many schools in this state and around the country have instituted districtwide policies that now require school nurse authorization prior to principal approval and transportation commitments. For those communities without a web-based approval system, sample approval forms are available in Appendix B.
School nurses are essential to the planning process because of their comprehensive assessments and decision-making skills regarding the health care needs of students. Key areas to consider when conducting a nursing assessment for field trips include:
- Health care needs of the students
- What are the health needs?
- Do the students require medication?
- What types of special health care procedures will need to be performed while on the trip?
- Do any of the students require health monitoring and, if so, what type of monitoring?
- Is a nurse needed to meet the health needs of the students on the trip or can the health needs of the students be met by unlicensed personnel?
- Type of trip
- Length of trip (day, overnight, several days)
- Intensity of activities
- Indoor or outdoor
- Location (e.g., close to health care facilities, in an isolated location, availability of adequate and timely emergency response)
- Time of year (i.e., any concerns based on weather, allergens, etc.)
- Is there adequate cell phone or other communication service?
- If a nurse is needed on the trip and it is not the school nurse, what preparation is needed?
- Are the staff qualified/competent to perform health care procedures or administer medication if appropriate?
- Are parents accompanying their children (note: a school district cannot require this as a means of accommodating a child with special health care needs)?
- Will meals/food be offered on the trip?
- Do any students have special dietary needs?
- What accommodations are needed?
- Nurse-Accompanied Trips:
- What coverage is needed for the school building if the school nurse attends trips?
- If it is outside the state, what are that state or country’s requirements to practice nursing (i.e., do you need a temporary license or does that state grant a “visiting nurse” status)?
- Non-nurse Accompanied Trips
- What health care procedures including medication administration and health status monitoring can be delegated to the unlicensed personnel?
- If the trip is out-of-state or out-of-country trip, what are the delegation laws/rulings that determine what health care procedures including medication administration may be delegated to an unlicensed personnel accompanying the trip? Are there limitations? Are there competency verification requirements?
- What nursing supervision is needed during day trips?
- What nursing supervision is needed on overnight trips or extended period trips?
- What alternatives are in place in the absence of nursing supervision?
If it is determined that unlicensed personnel may perform health care procedures or administer medication on field trips, school nurses have the responsibility to ensure that all staff are properly trained, can demonstrate competency in the task being delegated to them, and know what to do or who to contact in an emergency. Training of school personnel should include:
- Review of the task, the medical orders, the nursing care plan, and demonstration of the ability to safely and competently carry out the task (i.e., the health care procedure, such as blood glucose monitoring or administration of the medication).
- Review of what constitutes an urgent or emergent situation and what steps to take in an emergency.
- Review of documentation required for each task or each administration of medication.
Specific training requirements for medication administration is noted in the box below.
Medication Administration Training
For the purposes of medication administration, the training requirements by the school nurse or school medical advisor are outlined in Section 10-212a-3, Training of school personnel, as used in Sections 10-212a-1 through 10-212a-10 of the Regulations of Connecticut State Agencies and include:
- The general principles of safe administration of medication.
- The procedural aspects of the administration of medication, including the safe handling and storage of medications, and documentation.
- Specific information related to each student’s medication and each student’s medication plan including the name and generic name of the medication, indications for medication, dosage, routes, time and frequency of administration, therapeutic effects of the medication, potential side effects, overdose or missed dose of the medication, and when to implement emergency interventions.
The school nurse must also determine how and what type of supervision for the unlicensed personnel is needed during the field trip. Supervision is necessary to ensure the safety of the students and provide the unlicensed personnel with the support needed to effectively and efficiently carry out the task at hand. Supervision should include an established communication system between the school nurse and the staff providing the care during the trip; whom to contact if the school nurse is not available (e.g., the student’s physician or local emergency room); and a debriefing session upon return to school to properly review documentation and care provided.
The use of licensed practical nurses (LPNs) on field trips should be a consideration. The LPN may participate in field trips within Connecticut to provide routine/planned care to students under the direction of an RN or school nurse. In some cases, this may be a good option for students with health care needs when the school nurse is not participating in the trip and the nursing tasks or medication administration cannot be delegated to unlicensed personnel. For out-of-state or out-of-country trips, the LPN has the same obligation as the registered nurse to determine the nurse practice act and scope of practice in the state or country in which the students are visiting and request permission to practice in that respective state or country.