STATE BOARD OF EDUCATION Action Item October 9, 2012 SUBJECT: Approval of New Rule 6A-6.0253, Diabetes Management PROPOSED BOARD ACTION For Approval AUTHORITY FOR STATE BOARD ACTION Section 1002.20(3)(j), Florida Statutes EXECUTIVE SUMMARY The Florida Legislature amended Section 1002.20(3), Florida Statutes, to address the management and care of students with diabetes. School districts are to have appropriate personnel, whether licensed nurses or trained school personnel, assigned to each school a student with diabetes would otherwise attend if he or she did not have diabetes. School districts are to ensure that such personnel are available to provide the necessary diabetes care throughout the school day and during school-sponsored activities. In addition, the rule shall include provisions to protect the safety of all students from misuse or abuse of diabetic supplies or equipment. Supporting Documentation Included: Proposed Rule 6A-6.0253, Diabetes Management and National Association of School Nurses Position Statement: Individualized Healthcare Plans (2008) Facilitator/Presenter: Mary Jane Tappen, Deputy Chancellor, Curriculum, Instruction, and Student Services
6A-6.0253 Diabetes Management. (1) Definitions. (a) Diabetes. Diabetes is a disease that impairs the body s ability to produce or properly use insulin, a hormone that is needed to convert food into energy. (b) Diabetes Medical Management Plan (DMMP). A DMMP is a medical authorization for diabetes treatment that includes medication orders from student s healthcare provider for routine and emergency care. (c) Emergency Care Plan (ECP). An ECP is a child-specific action plan to facilitate quick and appropriate responses for an individual emergency in the school setting. The ECP may be a component of the Individualized Healthcare Plan (IHP) that is developed in accordance with Sections 1002.20(3)(j) and 1006.062(4), F.S. The ECP shall specify when the emergency number (911) will be called and describe a plan of action when the student is unable to self-administer medication or self-manage treatment as prescribed. (d) Individualized Health Care Plan (IHP). An IHP is a written plan of care developed at the local level to outline the provision of student healthcare services intended to achieve specific student outcomes. The IHP is part of the nursing process that is detailed in the National Association of School Nurses Position Statement: Individualized Healthcare Plans (2008)( http://www.flrules.org/gateway/reference.asp?no=ref-01619), which is hereby incorporated by reference and available online at /Portals/0/positions/2008psindividualized.pdf. The IHP is developed from the DMMP by a registered nurse (RN) in collaboration with the family, student, student s health care providers, and school personnel for the management of diabetes while in school, participating in school-sponsored activities, and in transit to or from school or school-sponsored activities. The IHP is childspecific and includes a written format for nursing assessment (health status, risks, concerns, and strengths), nursing diagnoses, interventions, delegation, training, expected outcomes, and goals to meet the health care needs of a student with diabetes and to protect the safety of all students from the misuse or abuse of medication, supplies, and equipment. (e) Self-Administration. Self-Administration means that a student with diabetes is able to self-manage medication, supplies, and equipment in the manner directed by a licensed healthcare provider without additional assistance or direction. (2) In compliance with Section 1002.20(3)(j), F.S., and the local School Health Services Plan under Section 381.0056, F.S., sschool districts are to have appropriate personnel, whether licensed nurses or trained school personnel, assigned to each school a student with diabetes would otherwise attend if he or she did not have diabetes. School districts are to ensure that such personnel are available to provide the necessary diabetes care throughout the school day and during school-sponsored activities. (3) With written consent from the healthcare provider and parent, a student with diabetes shall be allowed to carry and self-administer medication, supplies, and equipment based on the student s diabetes medical management plan. (4) The Department of Education, in collaboration with the Department of Health, shall develop technical assistance regarding the care of students with diabetes, and shall identify and provide sources to school districts for training school personnel. Rulemaking Authority 1002.20(3)(j) F.S. Law Implemented 1002.20(3)(j), F.S. History New
National Association ofschool Nurses Position Statement Individualized Healthcare Plans (IHP) SUMMARY OF THE POSITION: It is the position of the National Association of School Nurses (NASN) that students whose healthcare needs affect or have the potential to affect safe and optimal school attendance and academic performance require the professional school nurse to write an Individualized Healthcare Plan (IHP), in collaboration with the student, family, educators, and healthcare care providers. It is also the position of NASN that it is the responsibility of the professional school nurse to implement and evaluate the IHP at least yearly to determine the need for revision and evidence of desired student outcomes. HISTORY: The IHP is a written document that outlines the provision of student healthcare services intended to achieve specific student outcomes. The management of school healthcare services for students with significant or chronic health problems is a vital role for school nurses (National Association of School Nurses [NASN]) & American Nurses Association [ANA], 2005). The standard for this role is based on the nursing process and must include: Assessment, Nursing Diagnosis, Outcome Identification, Planning, Implementation, and Evaluation. Documentation of these steps for individual students who have healthcare issues results in the development of Individualized Healthcare Plans (IHPs), a variation of nursing care plans. IHPs fulfill administrative and clinical purposes including management of healthcare conditions to promote learning; facilitating communication, coordination, and continuity of care among service providers; and evaluation/revision of care provided (Herrmann, 2005). DESCRIPTION OF ISSUE: Chronic mental and physical health conditions or disabilities can interfere with school participation and achievement. Many students with stable conditions, such as attention deficit-hyperactivity or mild intermittent asthma, require basic school nursing services such as health care monitoring or medication administration. Some students need specialized services and require an IHP, which may include an emergency care plan (ECP) and/or a field trip plan. The need for an IHP is based on required nursing care, not educational entitlement such as special education or Section 504 of the Rehabilitation Act of 1973. Sometimes, students need the additional protections of federal laws in order to fully participate in an educational program. PL 93-112 Section 504 of the Rehabilitation Act of 1973 (also called Section 504) identifies criteria that indicate accommodations may be required (504 plan) for an eligible student. PL 108-446 (2004), the Individuals with Disabilities Education Improvement Act (IDEIA) entitles students who are eligible for special education to receive services that are necessary to access or benefit from their educational program. Special healthcare services are outlined in the Individual Education Plan (IEP). For special education students, the IHP may be included as an attachment to the IEP. The nursing process provides the framework for the delivery and evaluation of nursing care to students (Denehy, 2004, p. 7). The Scope and Standards of Practice (NASN & ANA, 2005) outlines how each step of the
nursing process is implemented to strengthen and facilitate educational outcomes for students. These steps parallel components of a well-written IHP. Standard 1. Assessment: The data collection phase helps determine the student s current health status and any actual or potential health concerns. Standard 2. Diagnosis: The professional school nurse uses the assessment data to formulate a nursing diagnosis, including a diagnostic label, etiology, and presenting signs and symptoms. Standard 3. Outcome Identification: The professional school nurse identifies the desired results of nursing intervention and states these in measurable terms. Standard 4. Planning: Interventions are selected to achieve desired results. Standard 5. Implementation: The written IHP is put into practice and care provided is documented. Standard 6. Evaluation: The professional school nurse measures the effectiveness of nursing interventions in meeting the identified outcome. Changes are made to the plan as needed. The school nurse must determine which students require an IHP, prioritizing those students whose healthcare needs affect their daily functioning or safety. These students may have multiple healthcare needs, require lengthy procedures or treatments, require routine or emergency contact with the school nurse or unlicensed assistive personnel during the school day, or require special healthcare services as part of their IEP or Section 504 plan. Performance and documentation of the nursing process are professional school nursing functions that cannot be delegated (National Council of State Boards of Nursing, 2005). The registered professional school nurse is responsible and accountable for creating the individualized healthcare plan (IHP), for managing its activities, and for its outcomes, even when implementation of the plan requires delegation to unlicensed assistive personnel (NASNa, 2006). The IHP is developed collaboratively with information from the family, the student, the student s healthcare providers, and school staff, as appropriate (NASN & ANA, 2005). The IHP includes medical orders implemented at school. Evaluation identifies progress toward achieving student outcomes. The IHP is reviewed at least annually, updated as needed, and revised as significant changes occur in the student s health status or medical treatment. Standardized IHP s, printed or computerized, are available for common chronic pediatric health conditions. These standardized plans help promote continuity of care but individualization is essential in order to meet the unique needs of each student. In addition, NASN encourages the use of standardized language such as North American Nursing Diagnosis Association-International (NANDA), Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) in IHP development (Denehy, 2004). Standardized language facilitates communication with other nursing staff and data collection, links student health care and education outcomes, and helps nurses evaluate correlations between interventions and outcomes (NASNb, 2006). Furthermore, the use of standardized language enhances development of a common knowledge base for school nursing which is essential for evidence-based practice (Poulton and Denehy, 2005). RATIONALE: Professional school nurses are leaders in the provision of special healthcare services. Through coordination of care among the school and the home, primary and specialty medical care, and clinics, school nurses ensure continuity of care across settings and minimize the risk for miscommunication (Taras et al., 2004). School nurses are also responsible for the training, direction, and supervision of both licensed and unlicensed personnel and the delegation of select nursing tasks as directed by individual state nurse practice acts (NASN & ANA, 2005). An IHP is the written document that captures these professional activities provided to individual students (Selekman, 2006).
References/Resources Denehy, J. (2004). Using nursing languages in school nursing practice. Silver Spring, MD: National Association of School Nurses. Herrmann, D. (2005). Individualized healthcare plans. In C. Silkworth, M. Arnold, J. Harrigan, & D. Zaiger, (Eds.) Individualized healthcare plans for the school nurse. pp. 1-5. North Branch, MN: Sunrise River Press. National Association of School Nurses. (2004). Position statement: Emergency care plans for students with special health care needs. Retrieved from /Default.aspx?tabid=220. National Association of School Nurses. (2006a). Position statement: Standardized nursing languages. Available at /Default.aspx?tabid=233. National Association of School Nurses. (2006b). Position statement: School nursing management of students with chronic health conditions. Retrieved from /Default.aspx?tabid=351. National Association of School Nurses & American Nurses Association. (2005). School nursing: Scope and standards of practice. Silver Spring, MD: NursesBooks.Org. National Council of State Boards of Nursing. (2005). Working with others: A position paper. Chicago, IL. Author. Poulton, S. & Denehy, J. (2005). Integrating NANDA, NIC, and NOC into individualized healthcare plans. In C. Silkworth, M. Arnold, J. Harrigan, & D. Zaiger (Eds.) Individualized healthcare plans for the school nurse (pp. 25-36). North Branch, MN: Sunrise River Press. Rehabilitation Act of 1973, 29 U.S.C. 794 504; regulations at 34 C.F.R. pt. 104 (1973). Selekman, J. (Ed.). (2006). School nursing: A comprehensive text. Philadelphia, PA: F.A. Davis Company. Taras, H., Duncan, P., Luckenbill, D., Robinson, J., Wheeler, L., & Wooley, S. (2004). Health,mental health and safety guidelines for schools. Retrieved from, http://www.nationalguidelines.org. Adopted: June 1998 Revised: November 2003; March 2008; June 2008