The Journal of School Nursing2022, Vol. 38(1) 21–34© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405211026300journals.sagepub.com/home/jsn
Schools often provide medication management to children at school, yet, most U.S. schools lack a full-time, licensed nurse. Schools rely heavily on unlicensed assistive personnel (UAP) to perform such tasks. This systematic review examined medication management among K-12 school nurses. Keyword searches in three databases were performed. We included studies that examined: (a) K-12 charter, private/parochial, or public schools, (b) UAPs and licensed nurses, (c) policies and practices for medication management, or (d) nurse delegation laws. Three concepts were synthesized: (a) level of training, (b) nurse delegation, and (c) emergency medications. One-hundred twelve articles were screened. Of these, 37.5% (42/112) were comprehensively reviewed. Eighty-one percent discussed level of training, 69% nurse delegation, and 57% emergency medications. Succinct and consistent policies within and across the United States aimed at increasing access to emergency medications in schools remain necessary.
school health, medication management, medication administration, school nurse, unlicensed assistive personnel (UAP), licensed nurse
Approximately 57 million children attend school in the United States (National Center for Education Statistics [NCES], 2019). An estimated 43% of U.S. children have at least one chronic medical condition (Bethell et al., 2011). Medication management is an important facet of school health as it allows children with chronic health conditions to fully participate in learning, play, and social interaction leading to improved academic and health outcomes (Allen et al., 2018). However, medication management is often provided to children for both acute and chronic health conditions at schools not provisioned with a full-time, licensed nurse (Little et al., 2018). As schools experience reduced funding and increased expectations for medical care, many have resorted to alternate health models that rely heavily on unlicensed assistive personnel (UAPs). The most common person to administer medication to a child is an office worker or the school secretary (Canham et al., 2007; Farris et al., 2003; Fryer & Igoe, 1996; Johnson & Hayes, 2006). The National Council of State Boards of Nursing (NCSBN) defines a UAP as “any unlicensed individual, regardless of title, to whom nursing tasks are delegated†(National Council of State Boards of Nursing [NCSBN], 2020a, 2020b).
Delegated tasks are defined as a transfer of responsibility for performing a task from the school nurse to the UAP (“Delegation of School Health Services to Unlicensed Assistive Personnel: A Position Paper of the National Association of State School Nurse Consultants,†1996). However, nurses who delegate their authority keep responsibility for all outcomes. Delegated tasks require a high level of trust and partnership between the licensed nurse and UAP (Kelly et al., 2003). Currently, the “The Five Rights of Delegation†outlines this transfer of accountability definedbythestates’ Nurse Practice Act: (a) right task, (b) right circumstances, (c) right person, (d) right directions and communication, and (e) right supervision and evaluation (“Delegation of School Health Services to Unlicensed Assistive Personnel: A Position Paper of the National Association of State School Nurse Consultants,†1996; National Council of State Boards of Nursing, 2020a, 2020b). While nurse delegation provides a mechanism for school nurses and UAPs to coordinate and manage student health care, several factors must be considered. First, nurses who delegate may still be held liable even if the UAP completes the task to their best ability. Second, UAPs who complete a delegated task to the best of their ability are not always fully protected from civil liability. Third, the school may experience a heightened level of risk for liability when delegation authority is implemented on campus. Fourth, UAPs may not want to or be required to complete tasks that are not directly written into their job description.
Multiple regulatory bodies including the State Board of Nursing, the Department of Health, and the Department of Education oversee school health in the United States. Yet, variations of delegation authority for medication administration exist across states (McCarthy et al., 2000). While the State Board of Nursing regulates the licensing requirements and identifies medication administration as either the responsibility of the licensed nurse or a task that can be delegated (Gordon & Barry, 2009), the Department of Education identifies the school principal as the ultimate decision maker and delegator of tasks (U.S. Department of Education, 2020). The Five Rights defined in Nurse Practice Acts do not provide licensed nurses with a standard protocol for effective medication administration delegation across U.S. schools and regulatory agencies and these guidelines often conflict with one another (Ficca & Welk, 2006; Gordon & Barry, 2009).
Managing an acute, life-threatening event remains a top concern for licensed nurses with delegation authority (Olympia et al., 2005). In a national survey of school nurses, 68% indicated they had managed a life-threatening emergency that required emergency medical system activation (Olympia et al., 2005). While licensed nurses and UAPs should be trained for health emergencies, guidelines that address emergency medication administration in the school setting are severely lacking. For example, an asthma exacerbation can happen at any place and time and cannot be predicted. When breathing difficulties occur at school, emergency medication (e.g., albuterol sulfate) may be necessary to quickly relieve the child’s symptoms. Often, children with access to this medication return to their learning environment and the need for an emergency medical system may be obviated (Gerald et al., 2016; Lowe et al., 2021). However, schools experience numerous challenges with emergency medication administration regardless of their ability to staff a full time, licensed nurse (Morris et al., 2011). Schools that are resourced with a licensed nurse often experience delays in medication administration because the licensed nurse may be unavailable. Supervising multiple schools and rotating schedules across multiple campuses may constrain their availability to authorize or supervise medication administration tasks. The objective of this systematic review was to answer the question, “How does the level of professional training impact medication administration policies and practices in schools?â€
A protocol adapted from the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodological review framework guided the search process (Figure 1) of literature from January 2000 to August 2020 (Moher et al., 2009). We used the essential elements of Population, Intervention, Comparator, and Outcomes to define our research question of interest and to structure our search (Table 1). Keyword searches were performed in three databases: PubMed, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Education Resources Information Center (ERIC). We conducted an advanced search in PubMed using the PubMed Advanced Search builder and Medical Subject Headings (MeSH) and key and alternative search terms using and/or Boolean Operators and all fields. CINAHL and ERIC were searched using EBSCOhost Research Databases with the advanced search option and all text (TX). Table 2 lists the search strategy used in each of the databases. We further conducted a hand search using backward reference searching. This method allowed us to examine the previous work published on our research question of interest. The primary author conducted the initial search, which was independently replicated by the senior author. Articles were included for review if they focused on the research question of interest and met all inclusion criteria (Table 3). Any differences in the search results and inclusion of reviewed abstracts between the primary author and the senior author were solved by consensus among the authorship team.
Studies that met the following criteria were included: (a) children attending K-12 charter, private/parochial, or public U.S. schools, (b) UAPs and licensed nurses (Registered Nurse [RN], Masters of Nursing Science [MSN], or Doctor of Nursing Practice [DNP]) in the school setting, (c) policies and practices for medication administration at school, or (d) examined nurse delegation laws for medication administration among UAPs. We excluded all studies that (a) discussed the roles UAPs and licensed nurses have in non-K-12 school settings, (b) did not examine medication administration practices, (c) were published pre-2000, (d) were not conducted in the United States, (e) were not peer-reviewed (i.e., non-peer reviewed, gray literature), and/or (f) not published in English. We excluded all literature published before 2000 based on modern relevance to education and health, and the impact federal policies had on school health services (Table 3).
All studies included in the review were examined using a critical appraisal rating developed by Johns Hopkins University to assess and evaluate study rigor (Dang & Dearholt, 2017). A data collection tool was created to summarize all studies that were included and excluded in our review (Supplemental Appendix Tables 6 and 7). Data entry were independently performed by the primary author and reviewed by the senior author. We summarized key findings of each study including (a) authors’ names, (b) year published, (c) title, (d) database, (e) study location, (f) study design, (g) study objective, (h) sample size, (i) methods, (j) outcome measures, and (k) results. Table 4 describes the critical appraisal rating assigned to the study by the primary and senior authors. We further assessed each study for inclusion of at least one of three key concepts: (a) level of training, (b) nurse delegation to UAP, and (c) emergency medication administration. Studies were categorized and chronologically summarized according to the concepts and themes discussed within the study (Tables 4 and 5).
Our systematic search generated 112 articles that were screened based on the title and abstract. Seventy of these were excluded because they did not address the research question. Forty-five articles discussed non-K-12 settings, 12 articles did not discuss medication administration in schools, and 12 were not published in English. The remaining 43 articles were assessed for risk of bias, inclusion, and exclusion criteria and the three concepts outlined in the protocol. One article was further excluded because it was determined to have borderline relevancy to the research question of interest. The remaining 42 articles were critically evaluated. Figure 1 shows the PRISMA flow of search outcomes. Table 4 summarizes which of the three concepts were discussed by each article and the critical appraisal rating assigned to the article and Table 5 summarizes the emerging themes identified across included studies.
Overall, 81% (34/42) of articles discussed training requirements for school personnel who administered medications to students. Three themes across studies were identified: (a) differences in training requirements for school personnel (including both UAPs and licensed nurses), (b) inconsistent guidelines for medication tasks, and (c) medication errors (Tables 4 and 5). Variations in training requirements for school staff who were responsible for medication administration and the content and frequency of training was the first theme identified. Krause-Parello and Samms (2011) surveyed school nurses from 35 states. Findings indicated that medication administration in schools was typically performed by licensed, school nurses (92.7%), but a variety of nonlicensed personnel including administrators (13.9%), others (12.5%), and teachers (10.1%) also performed this task (Krause-Parello & Samms, 2011).
Farris et al. (2003) reported findings on training requirements for school personnel in 396 Iowa schools. Survey respondents (school principals, licensed nurses, and UAPs) mentioned that trainings included medication administration for oral and topical medications, documentation procedures, and emergency protocols, but the frequency of training was highly variable. Eighteen percent of school staff completed a one-time training, 31.7% completed annual training, and 39.3% completed bi or triannual training (Farris et al., 2003). Kelly et al. (2003) reported similar findings from school nurses who belonged to the National Association of School Nurses. Twenty-five percent of 649 respondents received training shorter than 2 h on medication administration practices (Kelly et al., 2003). In Florida, Johnson and Hayes (2006) surveyed public (n = 952) and private/preschool settings (n = 432), as well as National Association of School Nurses officers and state chapters (n = 98). The authors pooled survey results and examined training requirements for UAPs. Among respondents, the most common UAPs to administer medication were secretaries (66.2%), health aides (39.7%), teachers (37.9%), and others, including parents and other students (37.7%). Training for medication administration was typically less than 2 h (Johnson & Hayes, 2006).
The second theme identified within “Level of training and licensure of school nurses and UAPs†concept was inconsistent policies for medication administration practices. A nationally representative sample of the National Association of School Nurses was surveyed regarding medication administration practices. Responses from 6,298 school nurses from all 50 states indicated that 43.5% had a state-level policy, 84.8% had a district-level policy, and 12.3% cited a schoollevel policy. Some respondents used one or more sources to develop their school’s policy. Findings highlighted the need for licensed nurses to ensure local policies are in line with state-level policies. The authors recommended a national-level policy to guide school nurses with medication tasks (Maughan et al., 2018).
The third theme identified was medication errors in schools. Medication errors can lead to safety issues or prompt legal action against the school and/or school personnel (Mazur-Mosiewicz et al., 2009). Prior survey results from school nurses have suggested that most medication errors occur among UAPs (McCarthy et al., 2000; Van Niekerk, 2011) and the most common error was missed dose (55–80% of errors) (Clay et al., 2008; Kelly et al., 2003; Maughan et al., 2018). Elik (2013) used qualitative surveys to examine the root cause of medication errors in Ohio schools. Emerging themes included disorganization of the medication cabinet or medication administration record (MAR), competing priorities during recess—a timewhen many children receive medication management, lack of documentation and not counting the remaining doses of medications in storage (Elik, 2013). Best practices such as standard work instructions that used chronological steps and the need to display these steps inside the medication cabinet were implemented. After the implementation of standard work instructions, researchers observed an 18% decrease in documentation errors in a review of 16,836 medication records (Elik, 2013).
McCarthy et al. (2000) randomly sampled and surveyed 649 school nurses. Three-hundred-fifteen (48.5%) reported a medication error had occurred during the past year. The authors examined the bivariate relationship between UAPs, licensed nurses, and the occurrence of medication errors and found that medication errors were 3.1 times more likely among UAPs (confidence interval [CI]: 2.01–4.81, p < .001), 1.3 times more likely at schools with a larger population of students (CI: 1.18–4.81, p < .001), and 1.6 times more likely from nurses with higher educational attainment (licensed nurse with a Bachelor of Science in Nursing or MSN vs. UAP) (CI: 1.10–2.22, p < .05). Confounding factors such as UAPs who had more students to care for, larger school systems that had better medication reporting systems in place, and licensed nurses who recognized and reported medication errors because of their education and experience level may have influenced these results (McCarthy et al., 2000).
Ficca and Welk (2006) discussed similar findings from 314 school nurses. Results indicated that 31% of respondents reported a medication error had occurred during the past year at their school. Of the medication errors reported, 26% were missed doses, 9% were medication administered without any documented authorization, 5% were identified as a double dose or overdose, and 4% were medications that were administered to the wrong child. The authors further examined medication errors and found that increased errors were associated with school nurses who were responsible for threeplus buildings, who managed multiple UAPs or whether field trip medications were transported in envelopes versus original containers (Ficca & Welk, 2006).
Several studies explored nurse delegation practices and the impact of overlapping or conflicting laws. The National Association of Schools Nurses, American Academy of Pediatrics and Healthy People 2010 all recommend schools have a nurse-to-student ratio of 1:750, yet, in U.S. schools this ratio is closer to 1:1,300 (Durant et al., 2011; Ficca & Welk, 2006; Healthy People, 2020; “Role of the School Nurse in Providing School Health Services,†2016; Wilt & Foley, 2011). Fewer licensed nurses result in more UAPs who are delegated medication tasks. Sixty-seven percent (29/42) of studies discussed nurse delegation to UAPs. Two themes were identified: (a) local- and state-level policies and (b) lack of medication administration protocols for school field trips or school-sanctioned events.
McCarthy et al. (2000) surveyed 491 school nurses regarding nurse delegation. Fifteen percent reported that their state’s Nurse Practice Act did not allow for delegation of medication administration and 19.1% were unsure if a delegation of medication administration was allowed (McCarthy et al., 2000). Mazur-Mosiewicz et al. (2009) conducted a case law review of medication administration in schools. The authors indicated that UAPs may include school psychologists, teachers, and other school personnel who must be appropriately trained and supervised by the licensed nurse. Often the role of the UAP was limited to dispensing medication and ensuring a student takes the medication properly. Because some state education and/or health codes specify provisions that permit licensed nurses to delegate medication administration tasks, the school district’s policy should support the licensed nurse’s decision regarding the option to delegate medication administration tasks. Nurse delegation based on professional health and safety criteria should be clearly communicated to the family, health care provider, and school team. The authors recommended well-written policies that support the nurse’s decision for schools with licensed nurses who delegate medication tasks (Mazur-Mosiewicz et al., 2009). Kelly et al. (2003) conducted two focus groups. Based on an analysis of the data, they emphasized the importance of consistent written guidance throughout a state for medication administration in schools should be consistent. When guidelines are inconsistent, nurses across the state must collaborate with other nurses, educators, and school personnel to determine best practices. School nurses described a myriad of circumstances that led to barriers with delegating their authority to a UAP and the heightened anxiety they experienced with delegating medication tasks. Several nurses voiced trepidation with unclear, inconsistent, and conflicting guidelines for medication administration practices (Kelly et al., 2003).
Wilt and Foley (2011) examined Glucagon® delegation in schools and conducted a state-by-state comparison of nurse delegation laws. The authors explained that many laws and guidelines conflicted with one another, and licensed nurses had difficulty knowing which law or guideline superseded the other. Differences attributable to complex wording found in state statutes and regulations were common and policies were often composed by nonhealth professionals with little understanding of jurisdiction related to nursing practice. With nurse delegation, the authority typically comes from individual states’ Nurse Practice Act and education law. The researchers recommended the school nurse be involved in the legislative process where they can lobby to change keywords such as “require†to “allow.†School districts should further develop policies and procedures for the delegation of emergency medication compliant with state law (Wilt & Foley, 2011). Ficca et al. further reported delegation of medication administration to UAPs was indeed a violation of the State of Pennsylvania’s Nurse Practice Act, which specified that only licensed individuals could administer medications and did not include any provisions for schools (Ficca & Welk, 2006). These discrepancies and inconsistencies prompted several policy statements from the National Association of Schools Nurses, American Academy of Pediatrics and American Nurse Association (NCSBN, 2010); “The American Academy of Pediatrics Committee on School Health POLICY STATEMENT: Guidelines for the Administration of Medication in School,†2004; “Delegation of School Health Services to Unlicensed Assistive Personnel: A Position Paper of the National Association of State School Nurse Consultants,†1996).
The second theme identified was concerns for nurse delegation of medication administration during school field trips and school-sanctioned events. Often these activities occur off-campus and with administration by a UAP. Since 2000, policies for off-campus activities have largely been lacking (Kelly et al., 2003). In Iowa, policies for medication administration during field trips were reported in 73.6% of schools (n = 396). However, 80% of principals reported having a policy as compared to 64% of school nurses. Schools with younger students were more likely to have medication administration policies for off-campus events. Individuals who administered medications during a field trip included teachers (84%), the child’s parent (24%), school nurses (23%), and health aides (14%). Results indicated that medications were typically carried using different modes of transportation (envelopes [53%], original containers [34%], locked containers [16%], and other containers [10%]), some of which increased the risk for medication errors (Farris et al., 2003). Ninety-five percent of 314 Pennsylvania school nurses reported that medications were administered on field trips, but only 44% of schools had a policy for field trips. Sixty-six percent of medications were transported in envelopes, 34% in their original container, and 11% in plastic bags. Nurses stated many concerns with UAPs on field trips because guidelines for delegating medication administration among other groups such as parents or “agents of the school†may not fully protect the licensed, school nurse (Ficca & Welk, 2006).
Across the literature, 57.1% (24/42) of articles examined emergency medication administration practices in schools. We identified two themes: (a) inconsistent guidelines for emergency medications and (b) lack of access to emergency medications and/or standing medical orders. Our first theme revealed inadequate policies for emergency medication administration in schools. Wilt and Foley (2011) focused on Glucagon®, a type of emergency medication for diabetes. Glucagon® administration is a good example of the complexities of emergency medication administration, as it requires the injection of a needle, a skill that is extensively taught in nursing school. Furthermore, some circumstances involved unstable and unconscious patients who required the prompt administration of the rescue medication. They emphasized that specific guidelines for emergency medication administration were lacking and called for policies that specified emergency medication administration and nurse delegation that are compliant with state laws and Nurse Practice Acts (Wilt & Foley, 2011). Most states’ Nurse Practice Acts specify that delegation can only occur when the individual’s condition is stable and predictable (Koch, 2015). Lineberry et al. (2018) discussed how licensed nurses in some United States can legally delegate injections of insulin to UAPs, but had concerns that delegation is not a viable solution for caring for chronically ill students with diabetes who may require comprehensive health care management. Furthermore, UAPs may refuse to be responsible for this task out of fear of liability (Lineberry et al., 2018).
Four studies discussed emergency medications for diabetes and seizure conditions in schools (Galemore, 2016; Lineberry et al., 2018; O’Dell & O’Hara, 2007; Wilt & Foley, 2011). Because these conditions require less common administration routes, many complications can arise during a health emergency. O’Dell and O’Hara (2007) stated that some seizure conditions required the emergency administration of rectal diazepam gel. Survey respondents (n = 414) who were mostly experienced, licensed nurses identified major benefits of this medication including the timely control of seizures which may allow the student to avoid an emergency department (ED) visit and return to their usual functioning. However, respondents cited several barriers: 26% indicated the provision of student privacy, 21% stated the availability of a licensed nurse, 16% cited legal and delegation issues, 16% expressed staff anxiety and fear, and 13% mentioned the training of nonnursing personnel as a barrier (O’Dell & O’Hara, 2007). For schools with children who have seizure conditions such as epilepsy, the care for a child may vary widely because of inconsistencies between the jurisdictions in legislation, professional practice guidelines, and potential liability (Galemore, 2016).
Guideline concordant care in the United States specifies that immediate access to emergency medications is crucial to reducing severe side effects, ED visits, and hospitalizations (National Heart, 2007). Emergency medications can even prevent emergency medical system activation and reduce usage over time, thus saving families the cost of escalated care and the morbidity of more invasive interventions (Galemore, 2016; Gerald et al., 2016; National Heart, 2007; Powers et al., 2007; Zadikoff et al., 2014). The second theme within “Emergency Medication Administration Practices†was lack of access to emergency medications and/or standing medical orders. Eighty-three percent (29/42) of articles discussed emergency medication administration for anaphylaxis or respiratory distress. McCarthy et al. (2000) surveyed 649 U.S. school nurses and found that parents were required to complete an MAR form before any medication was dispensed or administered. Only 33.6% of school nurses reported they had a signed standing medical order for stock epinephrine. Standing orders provide schools with an additional option during anaphylactic emergencies that allow for administration of stock medication prescribed by the school’s medical consultant, especially in the case of a missing MAR form (McCarthy et al., 2000). Because 25% of first food reactions occur while a child is at school and 84% of children with existing food allergies have an allergic reaction while at school, stock rescue medication remains an important priority (McCaughey et al., 2020; Morris et al., 2011; Powers et al., 2007). Relying on a completed MAR form from the child’s family puts the school in a precarious position. Schools are left with limited options such as administering another child’s prescribed medication, calling the parent to bring the medication to the school or summoning the emergency medical system (Zadikoff et al., 2014). Furthermore, when left with limited options, using one child’s rescue medication to save another child’s life is an altruistic and necessary action. However, this action can lead to negative or even severe consequences that put licensed nurses and UAPs in a precarious position. Papp et al. (2019) discussed the unfortunate events of a licensed nurse in Baltimore, Maryland who lost her job after administering rescue medication to a child who was experiencing life-threatening respiratory distress. This event displayed how nurses are held liable for actions that are necessary for saving a child’s life. Stock medications, standing medical orders and standardized training for licensed nurses and UAPs remain necessary to decrease such events in schools (Papp et al., 2019).
Ficca and Welk (2006) found 82% of 349 certified school nurses in Pennsylvania reported their district’s guidelines covered emergency medications and 80% had existing guidelines for administering emergency medications through a standing order. However, one-fifth of schools had no existing guidelines or standing orders, thus raising concerns for emergency medication administration in the absence of these necessary tools (Ficca & Welk, 2006). Delayed treatment for anaphylaxis at school is common, largely a result of school personnel who did not follow emergency protocols and called the student’s family first for guidance (Morris et al., 2011; Powers et al., 2007; White et al., 2016). The prevention of a fatal event is contingent on the rapid recognition of symptoms and the prompt intervention of emergency medication (epinephrine). Poor outcomes are linked to any delay and/or failure to administer epinephrine promptly (Morris et al., 2011; Powers et al., 2007). Furthermore, 20% of reactions are biphasic which requires additional monitoring from trained individuals and repeated doses of epinephrine (Morris et al., 2011).
In August 2009, Illinois Public Act 96-0349 was passed which released guidelines for managing life-threatening food allergies in Illinois schools. As a result of the frequency of first-time anaphylaxis events, Illinois specified ways to extend access to epinephrine among children. The law permitted the following provisions: (a) administration of an epinephrine autoinjector by a “school nurse†to a student with an unknown allergy having a first-time anaphylactic reaction, (b) self-administration of an epinephrine autoinjector by a student with a known allergy who has forgotten his or her autoinjector or it is otherwise unavailable, and (c) administration of an epinephrine autoinjector to a student with a known allergy. Training requirements for school personnel were further specified in the law. While this policy was one of the first to include provisions for training school personnel, there have been on-going challenges during implementation regarding barriers for who is allowed to administer the medication and who is allowed to receive the medication (Zadikoff et al., 2014). Currently, 49 United States and the District of Columbia have a stock epinephrine law (Shaker, 2020).
The most recent study to investigate emergency medication in schools was conducted by McCaughey et al. (2020). Responses from n = 6,298 school nurses were examined. Nurses identified that many students had active prescriptions for these medications: epinephrine (97.1% of 5,501 schools for which this question was answered), an albuterol inhaler (99% of 5,451 schools), or glucagon (66.3% of 5,483 schools). During emergencies that resulted in stock epinephrine being administered, 28.8% (n = 1,642) allowed the UAP to administer the epinephrine to a child with a known diagnosis, and only 23.5% (n = 1,340) to children with no known allergy. McCaughey et al. was the first study to highlight two important barriers to emergency medications: (a) locking emergency medication in a secured location and (b) the cost of stock medications. The researchers explained when stock medications are locked in a secure location it impedes access and delays administration during an emergency. Recommendations included securing stock medications so they were easily accessible to trained personnel. Finally, they discussed the average retail price for some emergency medications is cost prohibitive as compared to others (e.g., epinephrine vs. albuterol) (McCaughey et al., 2020).
Another common emergency medication discussed was emergency medications for respiratory distress. Short-acting beta-agonists or albuterol is unique from other emergency medications that treat symptoms because it has an extremely safe drug profile (National Heart, 2007). In addition, albuterol costs much less than other emergency medications for chronic but life-threatening conditions. Since 2000, asthma medications have been one of the most commonly administered medications at school (Weller et al., 2004). This includes daily controller medications and albuterol inhalers to treat the symptoms of respiratory distress. McCarthy et al.’s survey of 1,000 nurses (64.9% response rate) reported that 92.2% of students were allowed to self-administer their asthma medication but 76.4% of instances required supervision (McCarthy et al., 2000). Kelly et al. (2003) reported that 33.7% of students used albuterol inhalers without direct supervision and school nurses were very comfortable having students administer the medication by themselves (Kelly et al., 2003). Farris et al. (2003) stated that best medical practices included readily access to albuterol, but that some educators did not understand the importance of this practice and advocated for zerotolerance policies. These policies restricted students from selfcarrying albuterol which subsequently decreased their access to emergency medication (Farris et al., 2003). Decreased access to albuterol has since prompted health legislation to improve these practices. As of 2016, all 50 states have selfcarry laws that allow children who can demonstrate selfefficacy with their inhaler the ability to self-carry at school (Jones & Wheeler, 2004).
This systematic review and meta-synthesis of medication administration practices among UAPs and licensed nurses provided comprehensive insight regarding medication administration practices in U.S. schools. However, we were unable to conclusively answer the question of how the level of professional training influenced medication administration practices in schools. Our search did not identify any studies of high-quality methodological design that explored how differences in training or level of administrator experience affected medication administration.
We did identify numerous factors that impact medication administration practices in schools. Three concepts with seven themes emerged across the literature: “Level of training†which emphasized (a) training requirements, (b) inconsistent guidelines for medication tasks, and (c) medication errors; “Nurse delegation to UAPs†with a focus on (a) local- and state-specific policies and (b) lack of medication protocols for off-campus events; and “Emergency medications†which focused on (a) inconsistent guidelines for emergency medications and (b) lack of access to emergency medications. Most of these studies examined in our review used a cross-sectional survey, retrospective design, or qualitative research methods. Several studies provided statistically significant results but failed to clearly state the statistical methods used, report the statistical findings transparently, or examine the numerous confounding factors known to be present in schools.
This comprehensive review illuminated four areas for future research including (a) training requirements for school personnel, (b) school-pharmacy partnerships, (c) national-level guidelines that can be adopted by U.S. schools, and (d) standing medical orders for emergency medications.
Training Requirements. First, training requirements for medication administration in schools should be evaluated. In many states, individual school districts are responsible for developing and implementing medication administration guidelines and the training of school personnel on these guidelines is often a task that falls on the licensed, school nurse. The school nurse subsequently becomes responsible for creating a curriculum that will adequately train UAPs in medication administration practices. With increasingly complex medical conditions and medication therapies currently available, many school nurses are unable to dedicate enough learning time for all medications that UAPs may encounter. Therefore, we recommend that schools, nurses, health professionals, and policymakers work together to create well-written policies that outline the content that should be included in training and the frequency at which school personnel shall be trained. Koch (2015) compiled a comprehensive list of training topics including (a) how staff should recognize signs and symptoms, (b) how to administer medications, (c) potential side effects of the medication, (d) observation of the student’s response, (e) expected actions if side effects are observed, (f) school personnel’s required actions after administration of any medication, and (g) how to document the event and the administration of the medication that can serve as a template for a national-level policy (Koch, 2015). We call for licensed school nurses to advocate for such policies and be contributors to the content of national legislation.
School–Pharmacist Partnerships. Second, we recommend that pharmacists become more involved in the training of school personnel who administer medications to students. School–pharmacy partnerships can foster more appropriate medication administration techniques by providing school personnel with improved knowledge regarding the safety and efficacy of medications. Furthermore, pharmacists’ involvement can improve medication management by providing schools with more than one labeled bottle for each child that can be used during school field trips or schoolsanctioned events which may reduce medication errors. One specific recommendation that warrants future investigation was identified by Little et al., who called for medications to be automatically delivered from the pharmacy directly to the child’s school (Little et al., 2018).
A recent study by Butler et al. (2020) discussed the changing landscape of medication administration in schools which outlined the current best practices for schools. Written from a pharmacist’s perspective, the research team recommended improved communication between the school, family, and medical home (including the child’s pharmacist) and wellwritten guidelines for schools (Butler et al., 2020).
National-level Guidelines. Third, we call for well-written and succinct guidelines across states and/or state regulatory agencies. As UAPs become common in schools, concise medication administration guidelines are necessary. Across the literature, inconsistent local-, state-, and federal-level laws aimed at guiding schools with medication administration practices exist (Little et al., 2018; National Association of School, 2012). Therefore, most licensed nurses experience barriers because they lack immediate clarity on which policy has jurisdiction and what circumstances should be deferred to the school principal and/or vice versa. An area of large concern arose from school nurses who delegated their authority to UAPs who were chaperoning students on field trips that traveled out of state. When medication administration was delegated to a UAP and the task is completed in a different state, the nurse was then delegating their authority outside of their own delegation jurisdiction. This remains an area of major concern because states remain inconsistent with medication administration laws and the nurse’s own state’s Nurse Practice Act may differ widely from the laws where medication administration has occurred. National-level guidelines that protect schools, licensed nurses, UAPs, and children during these circumstances are necessary.
Standing Medical Orders. Finally, standing orders have been effectively implemented in U.S. schools and could assist both licensed nurses and UAPs during medical emergencies. However, standing orders may require legislative changes to ensure proper protection for the licensed nurse, UAP, and prescribers who write the standing order. Foster and Keele (2006) reported on the effectiveness of a standing order for over-the-counter medications in New Mexico schools. The researchers examined student sent-home rates and found a reduction in sent-home rates one year after the policy had been implemented (Foster & Keele, 2006). Gerald et al. (2016) also reported on a district-level standing order for albuterol sulfate. The standing order resulted in a reduction in 9-1-1 calls and emergency medical system transports for asthma after implementing the district-wide policy (Gerald et al., 2016). These findings were crucial to passing legislation in Arizona. HB 2208, “Stock Inhalers for Schools†which allowed all schools to procure, stock and administer albuterol sulfate was subsequently passed. The law included several provisions that facilitated its broad implementation of stock inhalers across Arizona. All trained personnel were indemnified from civil liability for their good faith use and any individual regardless of previously known asthma can be administered the stock inhaler by a trained person. This law was written consistent with the State of Arizona’s Nurse Practice Act but also worked outside of the Nurse Practice Act to provide additional protection to school nurses, UAPs, schools, and prescribers from civil liability (Lowe et al., 2021; State of Arizona, 2017). Arizona’s provision for children with no known asthma was important and since then additional calls for pediatricians to advocate for stock inhaler legislation have been published (Pappalardo & Gerald, 2019). Currently, 15 U.S. states and the District of Columbia have modified existing stock epinephrine laws to pass a stock inhaler statute or regulation to increase access to rescue medication for school children (Allergy & Asthma Network, 2020).
We acknowledge the countless barriers licensed school nurses, educators, and school systems experience with ensuring the health needs of all children are met and we advocate for the presence of a full-time, licensed nurse in every school. We further encourage all states to allocate funding for these purposes whether through Medicaid reimbursement or through alternative mechanisms. Creating well-written, national medication policies with provisions that also increase access to emergency medication remain necessary. These policies will protect children, schools, licensed nurses, and UAPs and improve guideline-concordant care among school children.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship and/or publication of this article.
Ashley A. Lowe, PhD, MSPH https://orcid.org/0000-0001-6252-0368
Supplemental material for this article is available online.
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Ashley A. Lowe is a post-doctoral associate at the University of Arizona Asthma & Airway Disease Research Center.
Joe K. Gerald is an associate professor & program director of the Public Health Policy & Management for the Department of Community, Environment & Policy at the University of Arizona Mel and Enid Zuckerman College of Public Health.
Conrad Clemens is a professor of Pediatrics & Public Health and the associate dean for Graduate Medical Education at the University of Arizona College of Medicine.
Cherie Gaither is the director of Health Services at Amphitheater Public Schools, Tucson, Arizona.
Lynn B. Gerald is a distinguished outreach professor and Zuckerman Family Endowed Chair at the University of Arizona Mel and Enid Zuckerman College of Public Health and the associate director of Clinical Research at the Asthma & Airway Disease Research Center
1 Asthma & Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
2 Department of Community Environment and Policy, Mel and Enid Zuckerman College of Public Health, Asthma & Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
3 Department of Pediatrics, College of Medicine, University of Arizona, Tucson, AZ, USA
4 Amphitheater Public Schools, Tucson, AZ, USA
5 Department of Health Promotion Sciences, Mel and Enid Zuckerman College of Public Health, Asthma & Airway Disease Research Center, University of Arizona, Tucson, AZ, USA
Corresponding Author:Ashley A. Lowe, PhD, MSPH, Asthma & Airway Disease Research Center, University of Arizona, 1501 N. Campbell Ave., Box 245030 Rm. 2351-B, Tucson, AZ 85724, USA.Email: aaray@arizona.edu
