NASN Position Statement
"Medication Administration in the Schools"
It is the position of the National Association of School Nurses (NASN) that the registered professional school nurse (hereinafter referred to as school nurse) be responsible for medication administration in the school setting, leading the development of written medication administration policies and procedures that focus on safe and efficient medication administration at school. Well-written policies and procedures will enable schools to fulfill their obligations to provide health-related services to all children, including those with special healthcare needs under the Individuals with Disabilities Education Improvement Act (2004) and Section 504 of the Rehabilitation Act (1973) as amended through the Americans with Disabilities Amendment Act [ADAA] in 2008.
Policies and procedures should address (Ryan, Katsiyannis, Losinski, Reid, & Ellis, 2013; U.S. Food and Drug Administration [FDA], 2013):
- delegation (when permissible by state law), training and supervision of unlicensed assistive personnel (UAP);
- student confidentiality;
- medication orders;
- medication doses that exceed manufacturer's guidelines;
- proper labeling, storage, disposal, and transportation of medication to and from school;
- documentation of medication administration;
- rescue and emergency medications;
- off-label medications and investigational drugs;
- prescription and over-the-counter (OTC) medications;
- complementary and alternative medications; and
- psychotropic medications and controlled substances.
The administration of medication by non-nursing school staff, when allowed, should be addressed (Ryan et al., 2013). These policies and procedures shall be consistent with federal and state laws including state nurse practice acts, rules, regulations, and any other laws that may apply, as well as standards and established safe, evidence-based information (Ryan et al., 2013; Bobo, 2014).
Medication administration to students is one of the most common health‐related activities performed in school. Historically, administering medication within the school setting has been a school nurse responsibility. However, as many districts and schools struggle financially, it is not uncommon for students to receive medication from non-nursing school employees who have had no medical training. This trend has caused an alarming increase in the number of medication errors made by UAP (Institute for Safe Medication Practices [ISMP], 2012). It is especially important that evidence-based medication policies and procedures be in place in those schools where a registered nurse is not present every day.
It is estimated that up to 27% of children have chronic health conditions (Van Cleave, Gortmaker, & Perrin, 2010). As more students with chronic conditions enter school systems each year, awareness of the factors which can promote and support their academic success increases. This includes the need for medications which enhance students’ overall health or stabilize their chronic health conditions.
Medications, when administered and used appropriately, can improve student health but may be harmful if administered incorrectly. Errors in medication administration are the most common medical errors (Cloete, 2015). Examples of medication errors include administering medication to the wrong person, giving the wrong dose, or not giving a dose as scheduled. For the safety of students, it is critical that evidence-based policies and procedures exist regarding medication administration. School nurses have the health expertise needed to develop, promote, and implement policies that are evidence-based; reduce errors; and increase the proper use and storage of medications in school settings (American Academy of Pediatrics [AAP], 2016; ISMP, 2012).
To reduce errors and increase safety, written policies and procedures for schools should include documentation from a licensed provider for the medication; proper labeling of medications brought to school; training of other staff involved in medication administration; storage of medication; process for administering medication (including proper identification of student and medication); documentation of medication administration, errors, reactions or side effects of medication; and proper disposal of medications (National Coordinating Council for Medication Error Reporting and Prevention [NCCMERP], 2007; 2015; FDA, 2013; Ryan et al., 2013). The principles of leadership, care coordination, quality improvement, public health/community, and standards of practice guide the practice of school nurses, including their role in medication administration (NASN, 2016).
As the expert healthcare provider in the educational setting, the school nurse is critical to the safe and effective administration of medication to students. The school nurse should lead in the development, implementation, and evaluation of medication administration policies and procedures at the school or district level. Training and supervision of UAPs who administer medications should be done by the school nurse, and consideration of safety and school nurse workload is essential. There is a decrease in errors when a culture of safety exists that includes proper oversight and written policies in place (U.S. Department of Health and Human Services [USDHHS], 2011).
School medication policies and procedures must be in accordance with all applicable laws, including nurse practice acts (NPA). For example, delegation and training are often specifically noted in states’ NPAs. Registered nurses possess the knowledge about how to comply with NPAs and issues such as over-the-counter medications, off-label usage, and alternative medications in a safe, evidence-based manner (American Nurses Association [ANA], 2012; AAP, 2016).
Medication administration is often part of a larger plan for the care and management of acute and chronic health conditions. There must be communication and collaboration between parents, providers, and schools regarding each student’s medication that describes what is to be given, the purpose, frequency, and side effects of the medication (NCCMERP, 2007; American Academy of Pediatrics, American Public Health Association, & National Resource Center for Health and Safety in Child Care and Early Education, 2011). School nurses are the health professionals in the school who coordinate care for the student, including medication administration.
The necessity for student use of medication at school has risen over the last two decades because many students who attend school have complex and chronic medical problems (ISMP, 2012). Research has shown that there are fewer medication errors in schools when medications are provided by a school nurse and when evidence-based policies are routinely followed (ISMP, 2012). Medication policies and procedures should include provisions for evaluation of medication practices and policies, including reviews of documentation and occasional audits, to identify possible concerns and adjust practice or policy as needed (USDHHS, 2011).
School nurses understand the unique needs and environments of their populations, which should be addressed in schools’ medication policies and guidelines (NCCMERP, 2015). School nurses can identify and address issues that may affect management of acute and chronic health conditions, such as environmental factors and socio-economic challenges, including obstacles to obtaining medications and delivery of medication to the school (Blaakman, Cohen, Fagnano, & Halterman, 2014). Evidence indicates that school nurses can provide culturally appropriate, sensitive information for students and families regarding management of health issues, including proper use of medications (McNaughton, Cowell & Fogg, 2014).
The school nurse should lead the development of school district policies and procedures relating to medication administration in the school setting and, where delegation of medication is permitted, the school nurse should be responsible for the delegation, training and supervision of UAP. The school nurse is the professional with the clinical knowledge and understanding of the complex issues surrounding the safe administration of medication and the responsibility to protect the health and safety of students (AAP, 2016; ANA, 2012). As the health leader in the school setting, the school nurse promotes current evidence-based practices so students requiring medication during the school day can safely have their needs met and remain in school ready to learn (Maughan, 2016)