- BON Position Statement 15.13, Role of LVNs and RNs as School Nurses, recommends that the school nurse be a RN, but does not absolutely preclude a LVN with appropriate experience and supervision from fulfilling this role. The Texas Diabetes Council training guide for UDCAs, however, defines a school nurse in accordance with 19 Texas Administrative Code (TAC) (Texas Education Agency), 153.1021 (a) (17), as:
(17) School nurse--An educator employed to provide full-time nursing and health care services and who meets all the requirements to practice as a registered nurse (RN) pursuant to the Nursing Practice Act and the rules and regulations relating to professional nurse education, licensure, and practice, and who has been issued a license to practice professional nursing in Texas.Can a LVN be a school nurse? Can a LVN train UDCAs or serve in other roles (consultative relationship, administratively responsible)?
Answer: As you have already noted, the BON does not preclude LVNs from being employed in school settings; however, the BON has no jurisdiction over employment practices or facility policies. If you primarily utilize one or more LVNs in a specific school or school district, BON Staff recommends you contact the Texas Diabetes Council/Program at www.dshs.state.tx.us/diabetes/ or 512-458-7111.
- Who is responsible for determining which school employees will be trained as UDCAs?
Answer: Neither the training of Unlicensed Diabetes Care Assistants in Texas public schools or the implementation of HB 984 is within the BON's jurisdiction. According to the language in HB984, the school principal determines which school personnel are appropriate to be trained to assist students with diabetes if/when a nurse is not available. In schools that do not have a registered nurse, the principal assures that training is provided by a health care professional with expertise in diabetes care. Questions regarding training of UDCAs should be directed to the Texas Diabetes Council/Program.
- As the school nurse assigned to one school, must I be responsible for training the UDCAs in my own school? Can a healthcare provider with expertise in diabetic care be contracted to do all of the training for an individual school or a school district?
Answer: This is not within the jurisdiction of the BON to determine. The training guide developed by the Texas Diabetes Council defines who can be a healthcare provider for purposes of training UDCAs. The training guide is located on the Department of State Health Services web page at
The language in HB984 states that the school nurse will "coordinate" training. The decision of who provides the training and what the school nurse's role(s) is/are may be negotiated between the nurse and principal and may be incorporated into job descriptions/functions.
- a) As a school nurse assigned to 3 different elementary schools within one district, I rotate between the schools. The principals at my schools assign who will be trained as UDCAs. The principals also assume administrative responsibility for these staff whether they are functioning within their job descriptions or in the "extra" role of UDCA. Working with the principals at all 3 schools, I have coordinated training of all UDCAs through another RN with expertise in all aspects of the care of children with diabetes.
Given my situation (as described), what is my role with the UDCAs from a BON standpoint?
Answer: Based on your description above, you have a "consultative" relationship with the UDCAs at each of your schools.b) Since I will have only a consultative relationship with the UDCAs at each campus, I am concerned about how to provide adequate communication and information to the UDCAs at each school related to the diabetic care needs of each child.
Congruent with the Diabetes Management and Treatment Plan (DMTP) and the Individualized Health Plan (IHP) for each child with diabetes, I have developed information sheets with emergency contact numbers, reportable conditions, and how to intervene in a number of possible emergency situations that could occur with each child. I know that HB984 and school policy mandate that this information be given to any school employee transporting a child or supervising a child during an off-campus activity. My question is--Can I provide this same information to the UDCAs for students at their respective schools? Is this a violation of HIPAA or FERPA to share this information with the UDCAs?
Answer: While you are not responsible for training or assessing ongoing competency of each UDCA in the situation you describe (above), you are responsible to assure the safety of each student attending school at your assigned campuses. Though HB984 designates certain staff who must receive written information for each child, your duty as a nurse falls within the BON's jurisdiction, and in particular Rule 217.11, Standards of Nursing Practice.
Nothing in HB984 or in the BON's NPA or rules precludes a school nurse from sharing this written information with UDCAs. BON staff would, in fact, encourage this type of communication and discussion with the UDCAs as being in the best interest of each child [§217.11(1)(B) and (1)(P)].
Under the training guidelines established by the Texas Diabetes Council and the School Health Division of the Texas Department of State Health Services, basic information about the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and Family Educational Rights and Privacy Acts (FERPA) is included along with other federal laws [Americans With Disabilities Act (ADA), Individuals with Disabilities Education Act (IDEA), and Section 504 of the Rehabilitation Act] in the initial UDCA training. However, you may want to check school policy and procedures regarding compliance with HIPAA and FERPA and other local, state, or federal laws applicable to UDCA duties. Additional information may be available from the Texas Diabetes Council at www.dshs.state.tx.us/diabetes/.
- I understand that HB984 (Section 168.008) mandates schools to permit and encourage students' abilities to engage in self-care. However, we have had issues on our campus in the past where used supplies, such as insulin syringes or blood-stained gauze, were not disposed of properly, exposing other children to potentially hazardous bodily fluids/blood that could carry HIV or Hepatitis. One of our school employees felt that HB984 mandated that a child always be permitted to engage in the self-management of diabetes anywhere on the campus, regardless of the health threat posed on other students if a given student isn't capable of disposing of used supplies and cleaning the testing area in a responsible manner.
Must we allow a student who is not capable, either by age, maturity or both, of appropriately maintaining supplies and equipment (not losing his/her glucometer, leaving used supplies where others could be exposed to blood, used sharps, etc) to self-manage?
Answer: The Standards of Nursing Practice (Rule 217.11) require all nurses to prevent exposure of clients (students) to infectious pathogens and communicable conditions. The language in HB984 (Section 168.008) prefaces the mandate to permit/encourage self-management with the phrase "in accordance with the student's individualized health plan...".
Based on maturity, intellectual understanding, or other factors, if a student with diabetes is unable to safely accomplish self-management, then the nurse should assure that this issue is addressed in discussions with the principal, parents, physician and teacher(s) in revising the IHP as necessary to protect both the child with diabetes as well as other children in the school setting. The IHP may require multiple revisions as the child's ability to engage in responsible self-management increases. You may also wish to consult the School Health Program at the Department of State Health Services.
- Does the LVN have to report signs and symptoms or changes in the student's health status to the school nurse (RN)?
Answer: First, LVNs are licensed nurses, so do not confuse RN "delegation" to an unlicensed person with a RN who may be supervising assignments being carried out by LVNs. LVNs and RNs are responsible for the assignments that they make or accept, and for complying with the NPA and Rules as outlined in Rule 217.11, Standards of Nursing Practice.
There is nothing to preclude a LVN from carrying out appropriate nursing measures to assess and treat a children with diabetes within the LVN's scope of practice. The RN should be at least telephonically available for consultation as the LVN's supervisor.
See Rule 217.11 and the Board’s Guideline on LVN Scope of Practice at Rule 217.11 - Standards of Nursing Practice and http://www.bon.state.tx.us/practice/lvn-guide.html for additional information.
- Can the LVN develop the Individualized Health Plan (IHP)?
Answer: No. This would be in violation of HB984, Health and Safety Code §168.003 that defines the IHP as a "coordinated plan of care" developed by the principal and the school nurse (RN) in collaboration with the student’s parent/guardian and the student’s physician, if possible. Developing or initiating a student’s IHP would also be beyond the LVN’s scope of practice as defined by the BON in Rule 217.11(2)(A).
- What if the principal refuses to act on a school nurse’s report that the UDCA is unable or unwilling to carry out applicable duties?
Answer: The BON has no jurisdiction over employment issues; however, the nurse should consider reporting up the chain of command, or if necessary, reporting to the Texas Education Agency (TEA), http://www.tea.state.tx.us/. The nurse always has a duty to provide a safe environment for the client, which may include advocating for the client through other channels to prevent harm. (Position Statement 15.14, Duty of Nurse in Any Practice Setting http://www.bon.state.tx.us/practice/position.html#15.14. Failure to do so may result in the reporting of the nurse to the BON with a subsequent investigation and possible sanctions on the nurse’s license for failing to intervene in the client’s best interest. The BON staff would encourage nurses to utilize the chain of command within their employment setting. If unable to reach a resolution, then ultimately the nurse may have to choose between changing employment settings or risking action on his/her nursing license.
- Is it within the RN’s scope of practice to train the UDCA?
Answer: Though all RNs receive both knowledge and skills training in care of clients with diabetes across the life span, this does not necessarily mean that every RN is capable of effectively training a UDCA. What is within the scope of practice for one RN may not be within the scope of practice for another. See articles on the BON web page under "Scope of Practice" for specific guidance on how each RN can determine what is within his/her individual scope of practice http://www.bon.state.tx.us/practice/gen-practice.html.
- If I only train the UDCA, am I responsible if they make a mistake?
Answer: No; "Training" is not "delegation."
- How do I know my role(s) in relation to UDCAs?
Answer: Read through the bullet points in the "Quick Cards." If you are still not certain, try collaborating with other school nurses through relationships or through professional nursing organizations such as the Texas School Nurse Organization at http://www.texasschoolnurses.org/.
- How often should the nurse that trained the UDCAs do a re-check on their knowledge and skills?
Answer: This is a school policy question; the BON has no jurisdiction over the UDCAs or school policies.
- Can a nurse train UDCAs, teachers and other school personnel in the administration of glucagon?
Answer: While the BON has no jurisdiction over school district policies, nurses do have the obligation to promote a safe environment for students and staff [Rule 217.11(1) (B)] and to institute appropriate nursing interventions to stabilize a client's condition and prevent complications [Rule 217.11 (1) (M)]. Glucagon is prescribed to thousands of students with diabetes. Both students and their parents or guardians are instructed by providers and pharmacists on administration of glucagon should a hypoglycemic reaction occur.
Rule 224.6 [delegation criteria] would permit a RN to train and delegate the administration of glucagon to unlicensed personnel in the school setting. Though the rule precludes the nurse from delegating tasks that require professional nursing judgment, it does permit the unlicensed person to "take any action that a reasonable, prudent non-health care professional would take in an emergency situation." Thus, UDCAs, teachers and other school personnel could take reasonable and prudent action in an emergency situation after appropriate instructions from the school nurse.
The BON wishes to thank Anita Wheeler, BSN, RN, Texas School Health Network Administrator and School Nurse Consultant at the Texas Department of State Health Services, and Susan Young, MSN, RN, Nurse Consultant for the Diabetes Program at the Texas Department of State Health Services, for their assistance in the development of this document.