HELP. 1:1 District School Nurse Caring for Two Students During Lunch Breaks

[LPNinGH]

Good Afternoon~

I'd like to connect with anyone who knows of a school district policy allowing 1:1 school nurses to care for two medically fragile students to cover coworker lunches.

I've been with the same student going on three years now, first as an agency nurse and then since last year as a district-employed nurse. I was paid well enough by the agency that I didn't mind working through the 30-minute lunch break, especially since I fed my student and myself at the same time, making it a social activity. The prior school nurse was more than relieved because she didn't know how she'd manage the health room and the needs of this student. Last year, I was able to timesheet (submit time for pay) to remunerate me for working through lunch.

I've recently been informed by my supervisor that another 1:1 nurse in the SPED class and I will cover each other so we get a lunch break this year. I disagree with this wholeheartedly. Both require frequent suctioning, one via trach, one for copious oral secretions who is quadriplegic and can't so much as slightly move her head. I can't suction both at once! The latter student was to cease having a 1:1 nurse because her suctioning requirement can be delegated to a trained para. However, she started having issues at the end of last school year, suffering profound desaturation and ended up missing the remainder of the school year. She now requires oxygen to be on hand in the event of an emergency.

My concerns:

1. Liability. I am fearful something untoward is going to happen if they both need focused attention at once. I've informed my supervisor the district will have to specifically name me on their Liability Insurance if they're going to force the issue. Even then, I don't feel comfortable at all with this scenario. These are human beings! Someone's children! Plus, I worked hard for my license. I don't think the district should be asking me to do something that puts my license in jeopardy. It only takes seconds for a situation to go downhill.

3. When I voiced my refusal, the supervisor then said the main school nurse could cover lunches. How is that any better? She has two schools she manages. She's not always available for backup. Even then, our campus alone has a student body of approximately 1650 students. The health room is very busy especially at lunchtime. She is in no better position to back me up even if she was on campus. She is frequently called out of the health room to attend an urgent situation in the class or the gym, out on the field. We have circulating itinerant nurses, but most either haven't performed trach suctioning in quite some time or are relatively new nurses and never have done it. More so, they have voiced resistance at being responsible for this student in light of how busy the health room is on any given day. Trach suctioning is not a nursing task that can be delegated to unlicensed personnel.

3. I'm quite sure my student's parents would be upset to find out this was going to happen. I am their child's 1:1 nurse.

This has really put a damper on my excitement for the school year to begin. Is it likely something will happen during those 30 minutes? No one can say. Is it worth the risk? I vehemently respond that it is not. The one student was getting ready to stop 1:1 care, then she started having problems out of the blue. Things can change with these students in a heartbeat! Up until I became my student's dedicated care provider, despite O2 being physician ordered to be available in the event of an emergency, the prior school nurse didn't feel the need to get one in place. I was mortified so did something about it.

Any input would be greatly appreciated.

Thank you for reading.

[PeakRN]

45 minutes ago, LPNinGH said:

Good Afternoon~

I'd like to connect with anyone who knows of a school district policy allowing 1:1 school nurses to care for two medically fragile students to cover coworker lunches.

I've been with the same student going on three years now, first as an agency nurse and then since last year as a district-employed nurse. I was paid well enough by the agency that I didn't mind working through the 30-minute lunch break, especially since I fed my student and myself at the same time, making it a social activity. The prior school nurse was more than relieved because she didn't know how she'd manage the health room and the needs of this student. Last year, I was able to timesheet (submit time for pay) to remunerate me for working through lunch.

I've recently been informed by my supervisor that another 1:1 nurse in the SPED class and I will cover each other so we get a lunch break this year. I disagree with this wholeheartedly. Both require frequent suctioning, one via trach, one for copious oral secretions who is quadriplegic and can't so much as slightly move her head. I can't suction both at once! The latter student was to cease having a 1:1 nurse because her suctioning requirement can be delegated to a trained para. However, she started having issues at the end of last school year, suffering profound desaturation and ended up missing the remainder of the school year. She now requires oxygen to be on hand in the event of an emergency.

My concerns:

1. Liability. I am fearful something untoward is going to happen if they both need focused attention at once. I've informed my supervisor the district will have to specifically name me on their liability insurance if they're going to force the issue. Even then, I don't feel comfortable at all with this scenario. These are human beings! Someone's children! Plus, I worked hard for my license. I don't think the district should be asking me to do something that puts my license in jeopardy. It only takes seconds for a situation to go downhill.

3. When I voiced my refusal, the supervisor then said the main school nurse could cover lunches. How is that any better? She has two schools she manages. She's not always available for backup. Even then, our campus alone has a student body of approximately 1650 students. The health room is very busy especially at lunchtime. She is in no better position to back me up even if she was on campus. She is frequently called out of the health room to attend an urgent situation in the class or the gym, out on the field. We have circulating itinerant nurses, but most either haven't performed trach suctioning in quite some time or are relatively new nurses and never have done it. More so, they have voiced resistance at being responsible for this student in light of how busy the health room is on any given day. Trach suctioning is not a nursing task that can be delegated to unlicensed personnel.

3. I'm quite sure my student's parents would be upset to find out this was going to happen. I am their child's 1:1 nurse.

This has really put a damper on my excitement for the school year to begin. Is it likely something will happen during those 30 minutes? No one can say. Is it worth the risk? I vehemently respond that it is not. The one student was getting ready to stop 1:1 care, then she started having problems out of the blue. Things can change with these students in a heartbeat! Up until I became my student's dedicated care provider, despite O2 being physician ordered to be available in the event of an emergency, the prior school nurse didn't feel the need to get one in place. I was mortified so did something about it.

Any input would be greatly appreciated.

Thank you for reading.

You have a kid that is stable enough to be at home but you don't think can be paired for 30 minutes? What type of care would these kids have in the hospital, would they even be on a unit or on a floor in an assignment of four nurses?

[LPNinGH]

My student receives focused care at home 24/7 from the family who has undergone training. They refused the offer of full-time nursing in the home setting.

The hospital unit is a whole different scenario. I'm talking about medically fragile kids in a classroom and zero guarantees that licensed personnel will be available for backup. I'm one nurse with two hands.

[ruby_jane, BSN, RN]

On ‎8‎/‎21‎/‎2019 at 5:21 PM, PeakRN said:

You have a kid that is stable enough to be at home but you don't think can be paired for 30 minutes? What type of care would these kids have in the hospital, would they even be on a unit or on a floor in an assignment of four nurses?

I think the larger issues are:

1. She's paid to work 1-1 with that student. Her agency may actually have a policy that says she cannot leave that student.

2. She is unfamiliar with the care for the other student with the 1:1 and may need orientation. I went into the classroom with the 1:1 nurse to find that she had pulled meds from the bottles at home that AM (perfectly fine for her practice, not arguing that, but NO WAY was I gonna give any clear medication in a syringe at any time). School is an extension of the home environment. This happens All. The. Time.

3. This is actually irregular. With both companies my school contracts with, the nurses have "a working lunch" in the classroom with the students, or they eat when the student is eating.

So...here's thought. It's not perfect but there's probably a window of time when all procedures are done (with maybe the exception of a continuous feed) and it would- in theory- be safe to leave for 30 minutes. How does the other nurse feel?

I would totally go back to your agency policy here. Best of luck.

[LPNinGH]

@ruby_jane, BSN, RN Thank you! You understand my predicament. I appreciate your feedback so much.

Were I still an agency nurse, I would have immediately contacted my agency supervisor regarding caring for two medically fragile students of this nature. I was paid so well by the agency that I didn't mind working lunches. Plus, there was no second 1:1 nurse my first year with this kiddo and the school nurse at that time had reservations about covering lunches for the reasons voiced in my original post. However, the district hired me Summer 2018 to continue working with the same student last school year, which I did, and plan to do for this coming school year.

At no time has it ever been a stipulation of the job to "double-up" with another medically fragile child to cover lunches. It was only after I had become a district employee and submitted timesheets to get paid for working lunches that things became sticky. The current union contract supports being paid for working through lunches where no coverage is available. My situation falls into that category, so I followed this process. I still haven't been paid, though have been "assured" by my supervisor a couple of times recently that payment should be received with my August paycheck.

It's a long, convoluted story. I've been working on contract revisions for our union over the summer and begin negotiations next Tuesday. You can bet I'm addressing this issue, as well as a host of others. Last year, the district wasn't going to pay me for my time riding the bus to and from school with my student. My supervisor was able to get this straightened out and approved at the beginning of the school year. However, when she attempted to get lunch coverage approval at the same time, she never got a response. As mentioned, it was only after I submitted time sheets that she repeatedly said the other nurse and I would double-up to cover lunches. I've repeatedly stated my concerns, in writing and conversation, with my supervisor. When I told her it may be a possibility as long as the district named me personally on their Liability Insurance with specific language referring to this situation, she said she would take this to the higher-ups; of course, a response hasn't been forthcoming.

I'm so disappointed that my nurse supervisor isn't advocating for the students, but is willing to forego safety to save district funds for 30 minutes of lunch-time pay. Paying us for working lunches wouldn't force either nurse into overtime, but brings us up to an 8-hour day. They've allowed this for the last two years for two different 1:1 paras, who have cared for the same student in our class. It's my opinion that the precedent has been set.

The other nurse hasn't voiced anything and doesn't respond to contacting her even for other issues. That is another story that I won't go into here.

At any rate, thank you so much for your understanding. My primary concern is the safety of these kids and my ability to properly intervene should they both require attention for suctioning. My kiddo alone can require repeated suctioning over a 10-minute period, depending on the day and mucus production. The other kiddo is so impaired she doesn't have the ability to attempt to clear her throat or turn her head to provide even seconds of relief so she can take a breath. As I've mentioned before, nothing may happen, but it only takes one event for everyone to be tossed into a state of regret, remorse, and most likely an expensive lawsuit.

I'm also concerned about my license. I love my job. I have a connection with my student and her family. I've been unsuccessful in trying to find any kind of documented evidence-based practice for this kind of situation. NASN doesn't address it, at least that I can find, nor does my local school nurse association. I've looked at area bargaining agreements, without any luck. I've searched at length the department of health. My next step is contacting the state BON, which is on the docket today. If you have any ideas as to where I might find this or any kind of documentation, I'd be so grateful to hear them.

I think it's an unconscionable, let alone unacceptable, budget-saving measure that crosses the line of what is safe and in the best interest of these kids.

Again, thank you so much for your kind and thoughtful response.

[SaltineQueen]

How do the parents feel about the situation?

[litbitblack, ASN, RN]

File safe harbor in the mean time if you do end up covering the 2 children for 30 minutes. Then in the unlikely event something does happen you are covered.

[NRSKarenRN, BSN, RN]

Safe harbor is a TEXAS BON regulation only.

Check your contract + union regarding being hired for 1:1 nursing care of medically fragile child, now being asked to cover 2 children.

Quote

Both require frequent suctioning, one via trach, one for copious oral secretions who is quadriplegic and can't so much as slightly move her head. I can't suction both at once! The latter student was to cease having a 1:1 nurse because her suctioning requirement can be delegated to a trained para. However, she started having issues at the end of last school year, suffering profound desaturation and ended up missing the remainder of the school year. She now requires oxygen to be on hand in the event of an emergency.

I'm unaware of any specific school nursing regs --- awaiting our School Nurse peeps input. I would decline in writing that you feel it unsafe to be responsible for 2 children needing suctioning --since that supposedly could be delegated to a trained para, the para should be the one covering other child's lunch, IMHO.

[LPNinGH]

Our contract (in place before I hired on as a district employee) is not worth the paper it's written on. This was an employee association, not a bona fide union, and it almost dissolved three years ago because members wouldn't step up to the plate and participate. A handful of members volunteered to assume officer positions but essentially had no training or knowledge of what's expected in those roles. It was quite a sad state of affairs.

I finally made contact with someone actually in the association (no response to several emails to HR, my supervisor, and other classified nurses didn't know who the officers were). It was only when I attended the nurses' Xmas party in December that I finally came into contact with the association secretary. Right away I started getting notices for meetings and attended one in January 2019. I became treasurer in April 2019 when the former treasurer left the district. I've never encountered anything like this before. Members want to complain but don't want to step up to support these needs, which is all volunteer-based.

Because our contract expires August 31st and with the severe need for an entire revamp of the current contract and better member support, I joined the organizing committee. We affiliated with a union already established in this school district. It was a huge undertaking in and of itself, which I won't go into here. We finally became unionized in June 2019. Sorry, off I go again...

With the focus finally being on a new contract, I volunteered for the negotiations committee and the negotiations team (the members actually going to the table). We start bargaining for the new contract this Tuesday. The lunch coverage issue I originally posted about on this forum didn't come up until June after I submitted timesheets to be paid for working through lunches after finding out a 1:1 para in the adjacent functional core class was getting paid for working through lunches.

The other student cared for by a 1:1 nurse can't have care delegated to a para, because the student started having problems and ended up missing the last few weeks of school last Spring. The student was ultimately cleared to return to school this Fall, as long as intermittent supplemental O2 is readily available on campus.

Thankfully, I have a union rep who hopefully will be able to help me navigate what surprisingly seems to be uncharted waters.

I appreciate all the feedback! If anyone finds or comes across a situation similar to this with a final resolution, I'd be thrilled to hear about.

Thanks, everyone!

[LPNinGH]

@SaltineQueen I know the reaction the parents of my student will have, particularly mom, and it won't be pretty. It's a conversation I will be having with mom later today. As far as I'm concerned, we will continue as we have. I'll submit timesheets for working lunches and see how it goes. If my supervisor brings it up again, I'll again ask that the district provide riders to their Liability Insurance that specifically names myself and the other 1:1 nurse. That seemed to be more than my supervisor was willing to do, as I've gotten no response to the first request for such coverage.

I wish we had Safe Harbor in my state, but we don't.

Thank you for responding!