The Journal of School Nursing
2021, Vol. 37(2) 99-108
© The Author(s) 2019
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DOI: 10.1177/1059840519849098
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Michelle Lineberry, EdD1 , Melody Noland, PhD2, and John F. Wilson, PhD3
Many children have diagnosed diabetes that must be safely managed at school. New laws have created the potential for school systems to rely more heavily on unlicensed assistive personnel (UAP) than on nurses to deliver health services, including administration of insulin injections. Using the theory of planned behavior as a framework, aims were to (1) determine the nature and extent to which health services related to diabetes were being delegated to UAP in Kentucky schools, (2) describe the attitudes of Kentucky school nurses regarding the delegation of diabetes health services to UAP, and (3) examine the relationship of selected variables to school nurses’ intentions to delegate diabetes health services. Survey results revealed that school nurses in Kentucky intended to delegate some diabetes-related tasks despite their lack of support for delegation of those tasks.
diabetes, school nurse knowledge/perceptions/self-efficacy, quantitative research, delegation/UAP
The role of school nurses in America today was described in the document “21st Century School Nursing Practice” as being made up of five principles: (1) care coordination, (2) leadership, (3) quality improvement, and (4) community and public health (National Association of School Nurses [NASN], 2016a). These four principles are surrounded by “Standards of Practice” which is the fifth principle. Under the principle of care coordination, nurses provide many services, including direct care, chronic disease management, and student care plans. Diabetes is a serious, chronic condition that requires management at home and at school and school nurses are often charged with managing this condition at school.
The National Diabetes Statistics Report 2014 (Centers for Disease Control and Prevention, 2014) stated that approximately 208,000—or 0.25%—of people younger than 20 years of age had diagnosed diabetes (type 1 or type 2). A study by Dabelea and colleagues (2014) reported that the prevalence of both type 1 and type 2 diabetes among children and adolescents in the United States increased significantly between 2001 and 2009. Specifically, during that 8-year period, the prevalence of type 1 diabetes increased by 21.1% and the prevalence of type 2 diabetes increased by 30.5% (adjusted rates; Dabelea et al., 2014). Imperatore and colleagues (2012) projected that the burden of type 1 diabetes in children and adolescents will nearly triple by 2050, while the number of youth with type 2 diabetes will have a 4-fold increase. Since most children under the age of 20 years attend school, school systems must implement processes and procedures to safely manage diabetes among students.
While the health service needs of students have increased, so have various state and federal mandates such as health screenings, immunization reporting, and the Individuals with Disabilities Education Act (Resha, 2010). At the same time, there is a shortage of qualified nursing staff in schools, budgetary constraints that limit schools’ ability to hire and retain qualified staff, and staffing patterns that assign nurses to multiple schools, leaving some schools without a nurse for periods of time (Resha, 2010). Given these competing factors, many states have passed laws and regulations that allow health services to be delivered to students by teachers and other school staff rather than by a registered nurse. This process is called delegation, and the teachers and staff delivering the health services are called unlicensed assistive personnel (UAP).
The American Nurses Association (ANA) defines nursing delegation as the transfer of responsibility of performing a nursing activity to another person while retaining accountability for the outcome (NASN, 2014). Throughout the United States, health services are delegated to staff serving a variety of different primary roles in the school including clerical staff/secretaries, teachers, classroom paraprofessionals, principals, playground attendants, and bus monitors or drivers, among others (NASN, 2016b). An appropriate UAP is not determined by the staff’s job title or primary role in the school, but on that person’s availability to the student, understanding of the child’s condition, competency to perform the delegated task, and ability to identify potentially life-threatening situations which necessitate immediate attention by a licensed health professional (Resha, 2010). Students also frequently self-administer medications, with the type of medication and students’ grade level influencing nurses’ level of comfort with and extent of supervision of self-administration (Ficca & Welk, 2006; Kelly, McCarthy, & Mordhorst, 2003; McCarthy, Kelly, & Reed, 2000). However, delegation can cause conflicts. Wilt and Foley (2011) explained that because some state laws empower a school administrator to delegate tasks, there can be a conflict between a nurse attempting to follow professional standards of care and the administrator’s directive. This situation may put the school nurse and his or her license in a precarious position.
Mueller and Vogelsmeier (2013) explained that in making the decision to delegate, nurses must evaluate the potential for harm, complexity of care, and unpredictability of the outcome. Delegation of diabetes health services is controversial because, while some of the tasks related to the treatment of diabetes are routine (e.g., blood glucose monitoring), other diabetes health services could have potential for harm and could be complex (e.g., carbohydrate counting, administration of insulin). The National Diabetes Education Program (NDEP, 2010) described the management of diabetes as a balancing act between diet (which typically makes glucose levels increase) and exercise, insulin, and diabetes medications (which cause glucose levels to decrease). Corrective actions depend on the student’s glucose level and follow the medical orders designed by the student’s medical practitioner. For example, mild hypoglycemia can be managed with glucose tablets or gel, fruit juice, regular soda, or honey. Severe hypoglycemia, on the other hand, constitutes a medical emergency and necessitates treatment with a glucagon injection.
Delegation of diabetes health services varies widely. Some states such as Arkansas do not allow delegation of glucagon because any child with severe hypoglycemia is unstable, thereby necessitating assessment and nursing judgment that cannot be delegated (Jones, n.d.; National Council of State Boards of Nursing, 2016). States like Colorado consider training and delegating glucagon and insulin administration to UAP necessary in order to appropriately meet the needs of students with diabetes (Colorado State Board of Nursing, 2015). Kentucky legislators have recently adopted Colorado’s stance by amending Kentucky Revised Statute (KRS) 158.838 (Kentucky Legislative Research Commission, 2014) to require at least one employee on duty at all times at each school to administer insulin injections to students with diabetes. This legislation necessitated an extension of the services that could be delegated to UAP to include administration of insulin injections.
Lineberry, Whitney, and Noland (2018) found that few Kentucky school nurses had experienced changes in their jobs as a result of the amendment to KRS 158.838. Several said that, although the law had changed to allow school nurses to delegate the delivery of more diabetes-related health services to UAP, they had no plans to change their practices. In other words, they planned to have a nurse on duty at all times at each school to administer insulin injections to students with diabetes, so that they did not have to delegate that task to UAP. Some nurse participants had positive opinions of the new regulation because it mandated more training for UAP, which the nurses felt could serve to increase student safety. Despite some positive regard toward KRS 158.838, participants believed that having a school nurse in every school to provide care for students while on school property (as opposed to field trips, for which delegation is necessary) was the safest and most ideal strategy for the delivery of school health services. Focus group data revealed that a rich, timely, and undocumented issue in Kentucky school nursing was the delegation of diabetesrelated health services to UAP in schools. Focus group participants reported vastly different practices and support across schools for the delegation of five specific tasks: carbohydrate counting, blood glucose monitoring, insulin administration, insulin dose verification, and glucagon administration (Lineberry, Whitney, & Noland, 2018).
Because of the current demands made on school nursing that are increasing the need for delegation, and because of the specific concerns and practices about delegating tasks related to diabetes, the current study was undertaken. The current study investigated Kentucky school nurses’ practices and attitudes related to the delegation of five specific tasks related to diabetes, and, in light of the recent amendment of KRS 158.838, their intentions to delegate them in the future. While there is a paucity of published research in this area, the theory of planned behavior (TPB) has previously been used to study the intentions of school nurses (Chabot, Godin, & Gagnon, 2010; Stretch et al., 2009) and therefore was selected as the theoretical framework for this research. The following discussion briefly describes the TPB.
According to the TPB (Ajzen, 1991), three independent constructs determine intention: attitude toward the behavior, subjective norm, and perceived behavioral control. Attitude toward the behavior refers to the extent of a person’s positive or negative appraisal of the behavior. In this study, this was operationalized as attitude toward delegation of five diabetes-related tasks. Subjective norm refers to “the perceived social pressure to perform or not perform the behavior” (p. 188). In this study, subjective norm refers to perceived social pressure to delegate these diabetes-related tasks. The third construct, perceived behavioral control, is a person’s perceived ease or difficulty of performing the behavior of interest. Nurses’ perceived ease or difficulty of delegating was of interest. Finally, the fourth construct, intention, is an indication of how hard people are willing to try to perform the behavior. In this case, the behavior of interest was delegation of the five diabetes-related tasks. According to Ajzen, the stronger the intention to engage in a behavior, the more likely should be its performance. The culmination of attitude toward the behavior, subjective norm, and perceived behavioral control predicts behavioral intention, while behavioral intention along with perceived behavioral control predicts engaging in the behavior. The current study incorporated a fourth construct—demographics—into Ajzen’s model as a predictor of the three TPB constructs of attitude, subjective norm, and perceived behavioral control.
Since diabetes is a common and growing chronic condition among children and adolescents, it is imperative that school systems implement policies and procedures to safely manage diabetes in students. Given the recent amendment to KRS 158.838 in Kentucky that requires at least one employee on duty at all times at each school to administer insulin injections to students with diabetes, there is the potential for school systems to rely more heavily on UAP (upon delegation by nurses) than on nurses to deliver health services to students with diabetes. One qualitative study (Lineberry et al., 2018) indicated that Kentucky school nurses’ delegation practices and support for delegation varied widely. There are many serious issues surrounding delegation of diabetes-related tasks including problems that could arise from nurses’ unwillingness to delegate certain diabetes-related tasks or problems that could arise when delegation does occur. Because there is very little guidance in the research literature regarding this topic, the current study was undertaken.
The purposes of this study were to (1) determine the nature and extent to which health services related to diabetes were being delegated to UAP in Kentucky schools, (2) describe the attitudes of Kentucky school nurses regarding the delegation of diabetes health services to UAP, and (3) examine the relationship of selected variables to school nurses’ intentions to delegate diabetes health services, using the TPB. The research questions associated with the survey research were:
The University of Kentucky Institutional Review Board approved this study in the fall of 2015. Published and unpublished research was utilized to develop a web-based survey for data collection. This was a nonexperimental, descriptive correlational study.
As previously described, the TPB was chosen as the model to frame this research due to its prior use in studies on the intentions of school nurses. A fourth construct, demographics, was added to the model as a predictor of attitudes, subjective norms, and perceived behavioral control.
Evidence compiled from a systematic review of the literature on the role and impact of school nurses (Lineberry & Ickes, 2015) and unpublished survey data collected by a Kentucky school nurse (E. Stone, personal communication, December 17, 2013) were used to draft survey items related to school nurses’ demographics, attitudes regarding delegation, and past delegation behaviors. Survey data by the Rutgers Center for State Health Policy (Farnham et al., 2011) evaluating delegation to certified home health aides guided the development of survey items addressing perceived behavioral control. Survey items related to subjective norm (α = .88) and intention (α = .91) were informed by the work of Chabot, Godin, and Gagnon (2010) who studied determinants of elementary school nurses’ intentions to adopt a new health promotion role. An early draft of the survey was reviewed by 25 Kentucky school nurses during three focus groups throughout the state. Information gleaned from the focus groups improved wording and expanded answer choices for several survey items. The reader is referred to Lineberry et al. (2018) for more detail about the focus groups.
The final Kentucky School Nurses Survey consisted of 41 multiple-choice, Likert, and open-ended items (Table 1 displays a Survey Item Map) that focused on the delegation of school health services for students with diabetes. Items related to practices (behaviors) and resources for delegation were rated on a 3-point scale (yes, no, and unsure). Items such as support (attitude) for delegation and policies, confidence (perceived behavioral control), perception of other support (subjective norm), and intention to delegate in the future were rated on a 5-point Likert-type scale. This survey is relevant for intended use because it was constructed by referring to items on a previous survey of nurses (E. Stone, personal communication, December 17, 2013) and because school nurses provided feedback on an earlier version of the survey through focus groups (Lineberry et al., 2018). In addition, before administering the survey, it was reviewed by four university faculty members with specialties in health promotion, public health, and biostatistics to ensure face validity.
The web-based survey was administered and data collected through Qualtrics (www.qualtrics.com). A link to the Kentucky School Nurses Survey was distributed via the Kentucky School Nurses listserv (KYNURSE), a listserv provided and administered by the University of Kentucky College of Education used primarily by school nurses but open to anyone with vested interest. The survey link was embedded in an e-mail describing the purpose of the study and containing all institutional review board–required information pertaining to anonymity, privacy, voluntary participation, and the investigator’s contact information. The cover letter gave instructions that only school nurses were eligible for the study. In addition, the first item on the survey asked “Are you a school nurse in Kentucky?” (yes/no). If no, Qualtrics skipped the respondent directly to the end of the survey. This “skip logic” was intended to increase the validity of results by encouraging responses from Kentucky school nurses only. Reminder e-mails were distributed via KYNURSE 1 week beyond the initial e-mail and 1 day prior to the survey closing. At the end of the survey, participants were invited to click a link that opened a separate Qualtrics survey (not tied to their responses) to enter their e-mail address for a chance to win one of the five US$50 Visa gift cards. The Kentucky School Nurses Survey and gift card eligibility survey were open for 3 weeks. Of the 566 subscribers, 111 (19.6%) responded. Given that not all subscribers were school nurses and, thus, ineligible to participate, the actual response rate for nurses was likely higher than 19.6%.
Data were exported to SPSS (Version 23.0) for analysis. Categorical data were described with frequencies and percentages. Responses to items measuring attitudes, perceived behavioral control, subjective norm, and intentions to delegate were each recoded into three categories prior to analysis in order to facilitate adequate distribution of the data: 0 = strongly oppose/oppose, strongly disagree/disagree, definitely will not/probably will not; 1 = neither support nor oppose, neither agree nor disagree, unsure; and 2 = strongly support/support, strongly agree/agree, definitely will/probably will. Attitude and intention variables were not scaled, but rather the recoded score for each item was used as its own variable for analysis. Perceived Behavioral Control and Subjective Norm Scale scores were calculated by adding the recoded values for each of the items mapped to those constructs. Therefore, the perceived behavioral control total score—which included 6 Likert-type items, the responses to which were recoded into 0, 1, or 2—had a possible range of 0–12. Likewise, the subjective norm total score—which included 5 Likert-type items, the responses to which were recoded into 0, 1, or 2—had a possible range of 0–10. McNemar’s x2 tests were used to determine whether nurses’ attitudes and intentions were different for the delegation of each diabetes-related task. Similarly, McNemar’s x2 tests were used to determine whether nurses’ attitudes were different across tasks, and whether nurses’ intentions were different across tasks. Pearson’s product moment correlations were employed to determine individual relationships among attitudes, perceived behavioral control, subjective norm, and intention to delegate each diabetes-related task. Open-ended responses were not analyzed but used to better understand the quantitative findings.
Demographic data describing the 111 survey respondents are illustrated in Table 2. The majority of nurses in the sample had at least 3 years’ experience as a school nurse, were licensed as a registered nurse, cared for between 1 and 10 students with diabetes, worked in an elementary school, worked in two or more schools, and had experienced a reduction in school nursing (either number of paid hours decreased or number of school nurses decreased) in the past year. There were 65 of the 120 Kentucky counties represented by the respondents. Reliability of the perceived behavioral control and subjective norm index scores was calculated using Cronbach’s a procedures, and both scales were found to have acceptable internal consistency (perceived behavioral control, α = .72; subjective norm, α = .81).
Research question one asked if school nurses’ demographic characteristics were associated with attitudes, perceived behavioral control, and subjective norms about delegation. An inverse relationship was identified between years of experience as a school nurse and attitude regarding the delegation of insulin administration (p = .017), indicating that the more experience school nurses had, the less favorable their attitudes were toward delegation of this task. Those with higher levels of education had greater intentions to delegate carbohydrate counting (p < .05) and insulin dose verification (p < .05). In addition, a relationship was found between working in more than one school and intention to delegate carbohydrate counting (p < .05). No other associations with demographic characteristics were found to be statistically significant.
Research question two asked if school nurses’ attitudes, perceived behavioral control, and subjective norm were associated with intention to delegate. Before determining the relationship between each of these variables with intention, it is important to investigate the association of these variables with each other. Table 3 illustrates bivariate relationships between attitudes, perceived behavioral control, and subjective norm. Perceived behavioral control was related to subjective norm (p < .01) as well as attitudes regarding the delegation of insulin dose verification (p < .01) and blood glucose monitoring (p < .01). In addition to its relationship with perceived behavioral control, subjective norm was related to attitudes regarding the delegation of insulin dose verification (p < .05), blood glucose monitoring (p < .01), and glucagon administration (p < .05). Table 4 illustrates associations between attitudes regarding the delegation of specific diabetes-related tasks, perceived behavioral control, and subjective norm with intentions to delegate those tasks. As shown in the table, attitudes are associated with intentions to delegate each of the five diabetes-related tasks. In addition, subjective norm is associated with intention to delegate insulin administration (p <.05).
Table 5 displays respondents’ attitudes regarding the delegation of each of the five diabetes-related tasks to UAP, as well as their intentions to delegate those tasks in the future. The percentages of school nurses who intended to delegate carbohydrate counting, insulin dose verification, and insulin administration were statistically significantly higher than the percentages of school nurses who supported the delegation of those tasks. Comparisons of respondents’ attitudes regarding delegation of tasks revealed significantly less support (p < .01) for insulin administration than for carbohydrate counting, insulin dose verification, blood glucose monitoring, and glucagon administration. Support for blood glucose monitoring and support for glucagon administration were significantly higher (p < .01) than support for carbohydrate counting and insulin dose verification. The difference between support for blood glucose monitoring and support for glucagon administration was also statistically significant (p <.05), with respondents having more support for glucagon administration. Comparisons of respondents’ intentions to delegate diabetes-related tasks indicated that nurses had stronger (p < .01) intentions to delegate glucagon administration and blood glucose monitoring than carbohydrate counting, insulin dose verification, and insulin administration.
Research question three asked “Do Kentucky School Nurses delegate some tasks more than others?” When asked which diabetes-related tasks they had delegated in the past, 40.5% responded that they had delegated insulin dose verification, 73% blood glucose monitoring, 79.3% glucagon administration, 42.3% carbohydrate counting, and 29.7% insulin administration. McNemar x2 tests revealed that more Kentucky school nurses in this sample had delegated carbohydrate counting and insulin dose verification than insulin administration (p < .01); and more had delegated blood glucose monitoring and glucagon administration than carbohydrate counting, insulin dose verification, and insulin administration (p < .01).
Analysis related to the first research question revealed that the more years of experience that school nurses had, the less supportive they were of delegating insulin administration to UAP. The research literature gave no information to explain this result, but the researchers speculate that school nurses’ years of experience led them to have deeper concerns over the possible risks of what “could” happen, situations for which a UAP has not been trained. Results also indicated that school nurses with more education had higher intentions to delegate carbohydrate counting and insulin dose verification to UAP. Future studies should examine what aspects of education in particular contribute to intentions to delegate. Furthermore, results indicated that the more schools that nurses covered, the greater their intentions to delegate carbohydrate counting to UAP. It seems intuitive that, since nurses cannot physically be in more than one school at any one time, they would have greater intentions to delegate services to UAP whether they were responsible for more than one school. However, it is interesting that the correlations between number of schools covered and intentions to delegate to UAP were not also statistically significant for the tasks (e.g., insulin administration and glucagon administration) for which each school must have at least one employee on duty at all times to deliver care. Further investigation is needed to explain this finding.
The second research question investigated the association between school nurses’ attitudes, perceived behavioral control, subjective norm, and intentions to delegate diabetesrelated tasks to UAP. Analyses revealed that school nurses’ attitudes regarding the delegation of each of the five diabetes-related tasks were associated with their intentions to delegate those specific tasks to UAP. However, nurses’ perceived behavioral control was not associated with their intentions to delegate any of the diabetes-related tasks. Subjective norm was associated with school nurses’ intention to delegate insulin administration, which indicates that nurses who perceived that their peers or stakeholders (e.g., principals, teachers, parents, nursing association) wish for them to delegate insulin administration to UAP have greater intentions to delegate that task in the future.
Investigation of the third research question revealed that delegation of diabetes-related tasks seems to fall into three tiers, with most nurses having delegated blood glucose monitoring (73%) and glucagon administration (79.3%), a moderate amount having delegated carbohydrate counting (42.3%) and insulin dose verification (40.5%), and few (29.7%) having delegated insulin administration. These three tiers seem to align with the amount of skilled judgment and assessment involved with those tasks, as well as with the severity of their associated risks. For instance, blood glucose monitoring and glucagon administration have been delegated by the majority of respondents. Out of the five tasks studied, these involve the least amount of judgment. If a UAP is tasked to monitor a student’s blood glucose level, his or her delegated instructions are likely to assist the student in pricking the skin with a lancet, placing a drop of blood on a test strip, and inserting the test strip into a blood glucose meter that shows the student’s blood glucose level on a digital display (NDEP, 2010). The UAP then notes the blood glucose level in the chart. This is a critical task in managing diabetes but is purely technical and does not require judgment on the part of the UAP. Similarly, if a UAP is tasked to administer glucagon injections in case of severe hypoglycemia, his or her instructions are to inject a predosed amount of glucagon from a kit. There is no measurement of dosage required and, although glucagon may cause nausea or vomiting when a student regains consciousness, it cannot harm a student (NDEP, 2010). On the other hand, if the UAP is delegated the task of carbohydrate counting, he or she must insure that the nutritional content and portions of food that the child consumes are precise to obtain accurate calculations (National Institute of Diabetes, and Digestive and Kidney Diseases, 2014). Since the amount of insulin to be administered is based on carbohydrate counts, inaccurate calculations could easily result in too much or too little insulin being administered, which could in turn result in hypo- or hyperglycemia for the student. Similar risks exist for insulin dose verification and for insulin administration. Therefore, it makes intuitive sense why more school nurses have delegated blood glucose monitoring and glucagon administration than carbohydrate counting, insulin dose verification, and insulin administration. Furthermore, this notion is supported by these survey responses:
Carbohydrate counting can be taught but many times schools run out of what is on the menu so it takes a lot of time to really figure out the number of carbs the student is going to consume and what can be substituted. Also, some students do not eat all the carbs they choose and then someone needs to figure out what needs to be done regarding the dose of Insulin (which is ordered to be given BEFORE the student eats). Physical activity must also be figured, that (affects) the amount of insulin given/taken.
I have no problem delegating an emergency medication with a plan to follow to UAP. My hesitancy begins when there (are) nursing judgment calls that have to be made before the medication is given and whether that medication may cause irreparable damage if not given appropriately (e.g., insulin).
As evidenced by the statistical significance of the relationships detailed in Table 4, attitude related to each of the five diabetes-related tasks was associated with intention to delegate each task in the future. It seems natural that a medical professional’s attitude—the extent of her positive or negative appraisal—about a patient care activity would be associated with her intention to engage in that behavior. Subjective norm, however, was associated with intention to delegate insulin administration but none of the other four diabetes-related tasks. Although none of the items contributing to the subjective norm scale specifically mentioned policy, it could be that the recent amendment to KRS 158.838 (Kentucky Legislative Research Commission, 2014) affected participants’ assessments of others’ expectations and support for the delegation of insulin administration. Certainly, the passage of legislation that all but mandates the delegation of this task in schools that enroll students with diabetes but do not employ a full-time nurse gives the perception of support. Perceived behavioral control was not associated with intention to delegate any of the tasks, but this could have been a factor of the wording of the survey items. It is possible that the perceived behavioral control items assessed nurses’ self-efficacy related to the skills necessary to delegate tasks to UAP rather than their perceived control over the situation. That is, perhaps the nurses in this study believed that they have the requisite skills to delegate health services to UAP, but there are other issues out of their control (e.g., funding to have a nurse in every school at all times) that affect their true perceived behavioral control over delegation that were not assessed in the survey instrument. While the survey instrument did not measure contributing factors outside of nurses’ control, several participants’ open-ended comments support this notion. For instance, one nurse wrote:
I am very confident in my skills to teach and supervise UAP but I feel that it is unsafe. We should not be expecting non-medical personnel to make nursing decisions. If we don’t have a full time nurse in every school I will definitely be training UAP to perform all of ... these tasks because that is my only option.
One interesting finding was that nurses’ intentions to delegate carbohydrate counting, insulin dose verification, and insulin administration to UAP in the future were statistically significantly higher than nurses’ support for (attitude related to) delegation of those tasks (see Table 5). In other words, many school nurses who did not support or strongly support the delegation of those tasks reported that they do intend to delegate them. School nurses may intend to delegate insulin administration in the future simply because they feel forced to due to new legislation, demanding workloads, and dispersed student populations. Budget cuts to education have led to a reduction in resources for school districts and individual schools, causing a reduction in the employment of school nurses. The nurses who are still employed must cover additional schools and care for more students in fewer hours and with little to no administrative support. Since KRS 158.838 mandates that there must always be a school employee on-site during the school day to administer insulin injections to students with diabetes, nurses who are assigned to more than one school must delegate that task to UAP for the times that they are off-site. However, it is troubling that school nurses feel pressured to delegate tasks to UAP despite their nonsupport because of a lack of resources, while they (as opposed to the UAP, school, or district) maintain liability or accountability for the outcome (201 KAR 20:400; American Nursing Association, 2012; Kentucky Legislative Research Commission, 1999).
One limitation of this study was that the method of distribution did not sample all school nurses in the state. Some may have received the survey e-mail but did not have the opportunity to complete the survey during the window of time when it was available. In addition, the return rate was effectively 25%, which was lower than desired but not surprising for surveys given to health professionals (Ryuhei et al., 2018). These limitations reduce the generalizability of the results of this study to the population of Kentucky school nurses. Although the reliability of the subjective norm and perceived behavioral control scales were acceptable, these indices may not have fully represented the TPB constructs. In addition, factors outside of school nurses’ control such as infrastructure, resources, and legislation were not explored. There were a variety of response biases that are present in most surveys that could have affected the responses of the participants.
This study has many implications for future research, practice, and policy. As districts in Kentucky choose how to best comply with KRS 158.838, additional studies should be undertaken to determine resulting changes in the delivery of school health services in Kentucky. Likewise, other states facing similar legislative changes should research school health services in their own states. There are a variety of state laws governing diabetes-related tasks, such as delegation of glucagon (Wilt & Foley, 2011), that must be considered. Because Kentucky school nurses are employed by a number of agencies including Departments of Education, Health Departments, and even community hospitals, there was no all-inclusive list of school nurses to utilize in participant recruitment. Other states may employ school nurses in a more centralized manner, thereby offering researchers a comprehensive mechanism of participant recruitment. Regarding perceived behavioral control items, future surveys should utilize items that assess situational control (e.g., policy, workload) over delegation rather than, or in addition to, efficacy of individual skills required for delegation of nursing tasks. Future studies should also further investigate the discrepancies between attitude and intentions; that is, why are nurses planning to delegate tasks to UAP if they do not support the delegation of those tasks?
The finding in this study that nurses’ intentions to delegate were higher than their support for delegation may indicate that school nurses and schools should take advantage of the increased education that is available for UAPs. Perhaps more comprehensive training for UAPs will help nurses be more comfortable in supporting the use of UAPs.
As discussed in the section above, the reason that school nurses intend to delegate some diabetes-related tasks despite their lack of support for UAP administering those services is likely insufficient resources. Comments from the survey provide anecdotal evidence that school nurses are passionate about their jobs and the students they serve. They should never feel forced to compromise student safety or put their licensure in jeopardy due to policies that are unsupported by funding.
All authors contributed to conceptualization of the manuscript, data analysis, and preparing the first drafts; critically revising the manuscripts; approving the final versions; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Michelle Lineberry, EdD https://orcid.org/0000-0001-6934-0693
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Michelle Lineberry, EdD, is the assistant dean for students and academic success in the College of Medicine, University of Kentucky, Lexington, KY.
Melody Noland, PhD, is the George and Betty Blanda endowed professor in Education and Professor of Health Education, Department of Kinesiology and Health Promotion, College of Education, University of Kentucky, Lexington, KY.
John F. Wilson, PhD, is a professor in the Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, KY.
1 College of Medicine, University of Kentucky, Lexington, KY, USA
2 Department of Kinesiology and Health Promotion, College of Education, University of Kentucky, Lexington, KY, USA
3 Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, KY, USA
Corresponding Author:Michelle Lineberry, EdD, College of Medicine, University of Kentucky, MN 115, 800 Rose St., Lexington, KY 40536, USA.Email: michelle.lineberry@uky.edu
