School nurse does not want to float

[beachynurse, ASN, BSN]

I have been a school nurse for 40 years with the last 21 in a high school. There have been times when a nurse was absent with no substitute available, and I had been asked to run over to that school in order to cath a student, or start and end a tube feeding. Our job function is to ensure the well being, safety, and health of the students. What would happen to that student if no one agreed to go to that other school to cath them? Even though the nurse was absent, the treatments still have to be done, so I don't mind running over to a nearby school to help out. I may need the same help at my school one day, and would hate for another nurse to refuse to help my students.

[Nurse Beth, MSN]

There is a great school nurse forum here on allnurses, I hope you'll reach out to your colleagues here for helpful insight.

Not being a school nurse, my questions for you are:

• What is the general consensus of school nurses in your area? Are school nurses generally agreeable to covering another school, or is this a hill most would die on?
• You refused to float due to two significant health concerns at your assigned school. Does that mean you would be open to floating if there weren't substantial health concerns?
• Do you feel there are ethical concerns around refusing to float?
• Are you unionized?
• How are sick days and vacations managed?

Here are a couple of key resources that include position statements and guidelines regarding school nursing roles and staffing:

National Association of School Nurses (NASN)

If you are a NASN member, you can access their peer-reviewed journal for articles on safe staffing and school nurse access. If you are not a member, joining your professional organization provides valuable resources and enhances your credibility.

NASN has a position statement on School Nurse Workload: Staffing for Safe Care, but it is not prescriptive as to floating. That said, NASN guidelines recommend the following ratios:

• 1:750 — For schools where students generally have good health and few complex health needs.
• 1:225 — For schools with students who need daily or frequent professional school nursing services, such as those with chronic health conditions.
• 1:125 — For schools with students with more complex health care needs, including multiple medical conditions requiring individualized care or interventions.
• 1:1 — In situations where a student has complex, ongoing medical needs, such as a severe disability or medical condition, a dedicated nurse may be required.

American School Health Association (ASHA)

ASHA provides essential resources regarding school health policies and practices. Although it does not have specific position statements on floating, it addresses school nurse practice standards.

New York State Department of Health 

The New York State Department of Health's School Health Services (NYS School Health Services) position on school nurse staffing is that school boards ensure appropriate and adequate licensed nursing personnel to meet student health needs. While this focuses more on guidelines than position statements, it can provide local regulations that back up your position.

These documents can provide additional support for your argument, especially around the need for school nurse staffing, the safety of students, and the limitations of floating when special health needs are involved.

Alternate Solution

You are not likely to find black-and-white, enforceable regulations covering schools other than your assigned school. Guidelines and position statements often tend to be just that—high-level guidance.

Actually, this is an exciting opportunity to address a problem. You could be part of the solution.

Consider proposing a solution that shows your flexibility while maintaining your professional responsibilities and commitment to your students.

Here are a few suggestions that could balance the need for staffing flexibility with the obligation to provide proper care for students:

Designated Floater Role

• Proposal. Suggest creating a designated floater nurse role within the district. This nurse is tasked explicitly with covering absences across multiple schools, but it would be a separate position from yours.
• Benefits. This ensures that the nurse with specialized knowledge of the school remains in place to provide care for students with ongoing health needs (e.g., diabetes) while addressing the staffing gaps at other schools.
• Solution. If the budget is a concern, you could propose sharing this floating role between schools part-time or rotating, so the burden is spread out.

Set Priorities for Care

• Proposal. When you're required to float on short notice, propose a clear protocol for prioritizing care based on students' immediate health needs. This would involve assessing which schools have higher-risk students (e.g., those with chronic conditions like diabetes, asthma, or severe allergies) and ensuring you remain at your assigned school if these students' health requires continuous monitoring.
• Solution. Have a nurse coordinator or supervisor decide where you should float based on a real-time assessment of health risks. This way, you won't be placed in a situation where you have to choose between your responsibilities at your assigned school and covering another school with unknown health issues.

Rotating Nurse Coverage Between Schools

• Proposal. Propose a pre-arranged rotating schedule where nurses alternate their floating duties on a predictable basis (e.g., one week per month) rather than being asked to float on short notice.
• Benefits. This provides you with adequate time to plan and prepare for the responsibilities at your assigned school, and it ensures that other schools are staffed without creating sudden disruptions.

Clear Floating Protocol and Limitations

• Proposal. Ask for a clear floating policy to be implemented within the district. This could include:
• There are limits on floating frequency. For example, you can only float once per month or only when there are no students with critical care needs at your primary school.
• Specific parameters for when you float. Floating only for short periods (e.g., one day or half-day shifts) and only when adequate nursing support is available in your assigned school to handle urgent care situations.
• Benefits. A clear, standardized policy can prevent confusion and ensure consistency across schools. It helps avoid situations where you're forced to float without proper planning or consideration for your existing responsibilities.

Delegation of Routine Tasks

• Proposal. In exchange for agreeing to float, suggest delegating routine or less complex health tasks to another staff member (within NY's regulations) when you're out of the school.
• Benefits: This ensures your students' ongoing health needs are met while you're floating to another location.

Advanced Notice for Floating

• Proposal. Ask for at least 48-72 hours' notice when you're required to cover another school, if possible. This gives you enough time to rearrange schedules and ensure that your primary school's needs are met.
• Benefits. With advance notice, you can plan ahead and possibly work with other staff to ensure the students' needs in your assigned school are covered. This would also give you a better opportunity to make informed decisions about whether to float.

Compensation for Floating

• Proposal. Request additional compensation (e.g., extra pay or additional time off) for the additional work and responsibilities you're being asked to take on.
• Benefits: Compensation acknowledges the extra strain and work involved in floating and helps maintain job satisfaction and morale.

Document Health Risks & Safety Concerns

• Proposal. If you agree to float, emphasize that patient safety is your highest priority. Propose a formal document outlining the health risks associated with students' ongoing health needs and the steps that will be taken to minimize risks when you're not on-site.
• Benefits. This formalized approach ensures that your concerns are clearly documented and potential safety issues are proactively addressed. It shows you're committed to maintaining high standards of care even when floating.

Presenting the Proposal

When presenting these solutions to your supervisor or the board, frame them regarding student safety, quality of care, reduced risk, and practical staffing solutions. Emphasize that while you're willing to be flexible, the unique health needs of the students in your assigned school require continuity of care, and that these proposed solutions allow you to continue to provide the best possible care while ensuring that other schools are adequately staffed.

You could say something like:

"I am committed to ensuring all our students receive the best care possible. However, as we all know, some students have very specific and ongoing health needs, such as diabetes and other chronic conditions, that require consistent, skilled nursing intervention. My experience and training make me the best fit to provide that care at my assigned school. I understand the need for coverage at other schools, and I am open to discussing potential solutions that ensure all students are cared for while maintaining the high-quality care for those with critical health conditions. I've outlined several options that could help us achieve this balance and look forward to working together to find the best solution."

This approach is constructive, solution-oriented, and demonstrates your commitment to your students and your role.

Best wishes,

Nurse Beth

 

[Jim Slayton]

Thanks for the information- If I didn't have a student with multiple needs throughout the day (Pre K) for diabetes and fairly new to a pump, and a student with a fractured femur of one week, I would have floated to the other school. I am assigned to my school and felt that their needs were my responsibility. If I left to cover another school who would adjust the insulin dose for the student at my school? For beachynujrse response.

 

[NutmeggeRN, BSN]

NASN has a position statement on School Nurse Workload: Staffing for Safe Care, but it is not prescriptive as to floating. That said, NASN guidelines recommend the following ratios:

1:750 — For schools where students generally have good health and few complex health needs.

1:225 — For schools with students who need daily or frequent professional school nursing services, such as those with chronic health conditions.

1:125 — For schools with students with more complex health care needs, including multiple medical conditions requiring individualized care or interventions.

1:1 — In situations where a student has complex, ongoing medical needs, such as a severe disability or medical condition, a dedicated nurse may be required.

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The updated school nurse staffing position statement is coming to the BOD this month for approval. Keep an eye on the NASN website for the current version.

[Duranie]

Another consideration— does the diabetic student have a 504 plan or IEP? What does their plan state in regards to having nursing care available during the day? Is there any sort of care plan or action plan on file wherein the student's physician has outlined steps to be taken for various scenarios? I'd be surprised if there weren't a written plan in place... otherwise, where are you getting the dosage adjustment parameters that the Dr has approved?

Any of the above documents constitute a contract between the school (including you, if nursing care is stipulated, or if there's a specific care plan) and the student's guardian/parent acting on their behalf/in their best interest.  If having you float to another campus would interfere with your ability to fulfill your responsibilities under any existing care plan, then the answer would necessarily be that you cannot float, because to do so would put both you and the school in a bad place if there was an issue while you were away from your campus.

As an aside— consider drawing up a care plan for any temporarily disabled, injured, or ill students. That will potentially cover you as to your need to stay put at your assigned school, depending of course on what their Dr. actually outlines.  Remember that how you write your parts of the care plan, can influence what the physician "orders". Your suggestions or proposals may be what the Dr uses as the outline to write his plan. 
 

Good Luck.