Special Education – Working collaboratively with parents of students with Developmental disabilities Parents of students with developmental disabilities hold a special place in my heart. They are their child’s primary caregiver from twenty-four hours a day, seven days a week…often for the rest of their lives. There is no break; there is no vacation….and often they do not get to experience the milestones of developmental independence that parents of typically developing children enjoy. This means missing out on the joy of traditional experiences such as junior high, high school, proms, teenage crushes, graduation; and then going off to college, followed by marriage and grandchildren.
It is the fortunate parent of a child with developmental disabilities that can leave their child overnight or for a weekend with a relative or friend. A vacation? I don’t think so. In all of the years of working with children with developmental disabilities, I don’t remember one parent ever complaining about that to me. That is pretty remarkable.
However, my subject is working with parents of students with developmental disabilities. So why bring up the preceding? Because it prepares the school nurse for meeting these parents where they are. They have a tough, 24/7 job as a caregiver and only want the best for their children. They want to know we care about their child as much as they do; that we want their child to succeed to the best of their ability. So here are my best tips for collaborating successfully with parents of students with developmental disabilities.
Listen to them; hear their concerns. Let them express what they want for their child from the nursing staff – and if you can do what they ask, then please do. If you can’t meet their needs because it’s not practical or legal, then explain why. Be willing to let them vent a little; however, you are not a verbal punching bag and you don’t have to take abuse. If they are yelling at you, then tell them you will be happy to speak to them at a later time and end the call. Don’t tolerate verbal abuse of your staff, either.
When you call and it’s not an emergency, say so. If you say the School Nurse is calling, they immediately think the worst, so put their mind at ease at the beginning of the conversation. They will not hear a word you say until they know their child is okay.
Be clear and direct with what you need from them from a medical standpoint. Know the Ed Code and stand on that for your nursing practice. Be flexible within the parameters of your job and license – not everything is black and white.
If you can do something to make their lives a little easier, do so. Maybe it’s typing orders for them to take to the doctor. Or faxing orders to the doctor for them to save time. We don’t implement orders without a parent signature, but once we have that we fax orders all the time. And typing orders ensures we get complete orders for our needs at school – a win-win!
Call once in a while just to check in and see how they are doing. If their student is out ill for more than a few days, check on them. Parents love to know you care about their child.
If you or your staff makes a mistake, say you are sorry. Often, that is all it takes to resolve issues. If you or staff makes a medication error, call immediately to let them know. Explain how you will take steps to ensure it won’t happen again. Humans make mistakes – parents just want to know we care enough to look at our processes and change what doesn’t work.
Be kind. Courtesy and kindness often go a long way, even during difficult discussions.
Diabetic management at School: More than Insulin
Most school nurses have worked with a teenager that is a noncompliant diabetic. These children are often angry because they aren’t just like everyone else and in control of their own lives. The can feel as if their parents or the diabetes is in control of their life (Kelo M, 2011).
School nurses attempt to teach complex daily management skills so they can be independent. Some of the skills they teach are how to count carbs, calculate how much insulin to give, what to do when you forget your needles, bend a needle or many other small emergencies and even how to handle that the cafeteria lunch when it is not what’s on the menu. The invisible part of that complex management skills are psychological issues (Silverstein et al., 2005 ) that are more important as the child ages (Kelo M, 2011). Nurses have been trained to treat the whole child and the family and are an important part of any educational team (Silverstein et al., 2005 ).
Here is one small story that illustrates this issue.She would take the cupcake and put it in her lunch box to take home. It was the end of the year and my 3rd grader was sad because her class had won first place and was to have popsicles. She was sad because she couldn’t take the Popsicle home before it would melt.I wanted her to feel like the other children if only for one day. I wanted her to feel that diabetes is not an insurmountable obstacle but just a small hiccup in the road. I went in search of the carb count, found out when they would be given out and then she and I sat down and did all the calculations gave the insulin then I wrote the teacher a note to let her know that my student could have a popsicle. I followed her to make sure that the teacher didn’t have any questions. There was surprise in her voice that she could have one and before I turned to leave. I saw her run to sit by her best friend swing her legs in unison and laugh as she ate her coveted treat.While I was working on the popsicles issue, the secretary was doing her job working on early dismissal of a large number of students, calling teachers and looking for lost children.
School nursing involves more than just calculating how much insulin to give and jabbing the student. We teach what how to manage diabetes, how to handle an emergency and that you are in control of your diabetes it is not in control of you. These days make nursing all worth it and I know that you all have similar experiences and these are what keep us going.
Kelo M, M. M. a. E. E. J. (2011). Self-care of school-age children with diabetes: An integrative review. Journal of advanced nursing, 67(10), 2096-2108. doi: 10.1111/j.1365-2648.2011.05682.x
Silverstein, J., Klingensmith, G., Copeland, K., Plotnick, L., Kaufman, F., Laffel, L., . . . Clark, N. (2005 ). Care of Children and Adolescents With Type 1 Diabetes: A statement of the American Diabetes Association. Diabetes Care, 28(1), 186-212
Collaboration, Creation and Leadership by Sherri Vitali, MS, RN, Coordinator IV, San Joaquin County Office of Education
One of the most rewarding experiences I’ve had as a school nurse was my recent collaboration with fellow nurses on SB 1266, the new law requiring schools to stock epinephrine auto-injectors for the treatment of anaphylaxis.
I readily volunteered to be a committee member when Cathy Owens sent an email inviting CSNO members to provide input on the CDE epinephrine training standards. It isn’t often that opportunities to be involved in policy change arise, and as a coordinator I felt it was my duty as well as an opportunity to further develop my leadership skills. I like to write, analyze and edit, so I thought this would be perfect for me. The committee convened in November beginning with reading through the current CDE epinephrine training standards, consulting with various agencies and revising language to align with SB 1266 guidelines. We produced the fruits of our labor by mid- December: revised CDE training standards, a training power point, a resource binder complete with information on laws, training standards, competency check lists, an anaphylaxis protocol and algorithm, and directions for the acquisition of epinephrine. The binder was uploaded to zip- drives and made available as a resource for purchase from CSNO by December 19th, 2014. Whew!
I was asked to write about how so much was accomplished in such a short time. Certainly, the ability to communicate electronically played a large part. Many emails and documents were sent back and forth for review, which saved a great deal of time. Great leadership was another factor in completing the project. Cathy Owens’ leadership provided direction that kept members on track. Cathy was open to suggestions and quick to make edits that allowed the work to move forward. The leadership of my director, Dr. Sheri Coburn, was invaluable to my work on the project. Sheri gave me creative license and supported the initiative I took to develop materials. Her suggestions, guidance and collaboration were phenomenal and greatly contributed to my professional growth.
Through my involvement with this project I was able to:
· Learn the requirements of SB 1266
· Become more familiar with sections of the Ed Code
· Improve computer skills, (shortcut keys, PowerPoint) word processing and editing.
· Get to know colleagues throughout the state
· Further develop Leadership skills
· Be involved in the creative process
In closing, I would encourage school nurses to reach outside your comfort zones and become involved in special projects, policy development, or any other activities that contribute to your professional growth. The rewards are great; at least they were for me.
The Go To "Green Book" Manual
I am a Special Education School Nurse. Many of our students require specialized physical healthcare procedures or medications to be able to attend school on a daily basis. Anything we do for students in school require a physician’s order, except for sunscreen. Often, when the students are referred to our program, the administrator has not thought to invite the School Nurse to the IEP meeting. So we have to contact the parents to start the process of gathering all of the information needed to request physician’s orders and develop a care plan.
Often a student has multiple medical needs, which can make the process overwhelming and seem insurmountable. What one needs are a plan, and a system to gather the needed information so that every time a new student with medical needs is referred to your program, you can follow the same routine. My go-to: The GREEN BOOK (otherwise known as Guidelines for Specialized Physical Healthcare Services in School Settings, 2nd edition)! Everything you need (almost!) to plan care for students, including questionnaires to use with parents, and the documents you will need to fully develop the plan of care.
The wonderful thing about the GREEN BOOK is that there are quite a number of standardized care plans and accompanying customizable medical orders for the most common healthcare procedures, as well as training forms and notification posters to hang on classroom walls. Even if you aren’t sure of exactly what you will need, the GREEN BOOK’s resources for legal issues and administrative issues will help guide you as you develop a plan of care individualized for each student you serve. Because let’s face it – not every student is the same and not all sets of orders fit each situation you will encounter. The original revised GREEN BOOK was released in 2012; an update featuring Seizure Management was released in 2013.
Personally, I use one form or another out of the GREEN BOOK every day in my School Nurse practice. I can’t imagine practicing School Nursing without it! The GREEN BOOK, contained on a disk drive, is available from the CNSO Store on our website. It is a valuable resource for the School Nurse, with the standardization necessary to deliver safe, consistent, legal nursing care to your students. Give it a look!
Pediatric Stroke
What is a stroke? A stroke occurs when the blood supply to any part of the brain is interrupted resulting in tissue injury and loss of brain function. If blood flow is interrupted for longer than a few seconds, brain cells can die, causing permanent damage. The level or severity of impariment resulting from the stroke depends on the location and extent of injury to brain tissues. Perinatal stroke occurs before, during or within the first moth after birth. A stroke that occurs before birth may also be call a prenatal stroke. Childhood Strokes occurs between one month and 18 years of age. Incidence of pediatric stroke Perinatal stroke occurs in approximately one in 4,000 full-term births. Childhood stroke occurs in approximately 6 in 100,0000 children. What causes Pediatric Stroke Doctors find the cause of pediatric stroke in about 2/3 of the cases. Risk factors include heart disorders, clotting disorders, premature birth, prolong or difficulty delivery and infection. In about 1/3 of all pediatric stroke cases no cause is identified. The most common risk factors for childhood stroke are Sickle Cell Disease and heart disease, but can also include infections, birth defects, dehydration and head trauma. Each child may experience symptoms of stroke differently, depending on the area of their brain that has been affected. The most common symptom is a weakness along one side of the body. This may be difficult to recognize in children who may be too young to verbalize how they feel. A child's face may droop to one side and his/her speech may be affected. Other common symptoms may include: -Blurred or double visions or unequal pupils. -Brief loss of consciousness -Drooling -Seizures -Sudden onset of diffculty speaking, such as slurred or garbled speech -Sudden onset of partial or complete blindness -Sudden, severe headache Children exhibiting any of the above symptoms should be evaluated in a stroke certified medical center. (Information compliments of UCSF Benioff Children's Hospital.
Board Membership has It's Benefits!!!!!
It was
one year ago that I was approached by a colleague at the CSNO State Conference
with the proposal of joining the Northern Section CSNO board. I was caught off
guard by the proposal and initially thinking it would be fun, so I agreed on
the spot to do it. A few minutes later I thought to myself, “what did I just
agree to do?”. Although I was haunted by doubt for a while, after attending a
couple of board meetings, I knew I made the right decision.
With
the Northern Section hosting the state conference this year, I am not only
learning my role as the Public Relations Chair, but actively working on the
conference committee as well. Having attended the CSNO Conference for many
years, it has been fascinating to see how it all comes together. I am getting
so much more out of my involvement than I am giving. I have met many new
colleagues, heard about their devotion to the children in their district, and
witnessed their commitment to the school nurse organization; the board members
have been a true inspiration!
Currently,
the board is working hard to make the 64th annual CSNO State
Conference a success, and working amongst this great group of colleagues makes
it fun and easy. Having attended both a board meeting and conference meeting
this past Saturday, I shared, listened, and was inspired by how each person’s part
contributes to the whole. On my drive home I felt motivated and renewed in my
role as a school nurse and board member. I am still working to understand my
role as the PR Chair, but have relaxed knowing I have a whole team of support.
I
encourage each of you to become active in CSNO. My first year on the board has
proven to be a rewarding experience. Don’t forget to register to attend this
year’s state conference--it is going to be spectacular! As chair of the
Hospitality Suite, I hope you stop by and mingle with your colleagues from
across the state. I look forward to seeing you in March!
Karen Anderson,
BSN, RN
Public Relations Chair, CSNO Northern Section
Local Control Funding Formula (LCFF) and School Nurse Implications
By Sheri Coburn, Ed.D., M.S., R.N., Director, Comprehensive Health, San Joaquin County Office of Education, Northern Section Past President, CSNO Conferenc Co-Chair, ACSA Region 7 President
It is an unprecedented time in California Schools. In June of 2013, the Legislature approved Gov. Jerry Brown's Local Control Funding Formula (LCFF), which has ignited educational fiscal reform. LCFF represents a historic shift in how California funds public schools. Rather than legislators deciding how school district funds should be spent, LCFF shifts the focus on local decision-making, equity, accountability and transparency. Essentially, it lays the foundation for local education agencies to improve student outcomes and close the achievement gap, by identifying how school district funds will be spent. School districts must develop an eight-year implementation plan, with 2013-14 as the transition year.
The paradigm shift to reallocate local control of school funding places an emphasis on enlisting parental involvement and community engagement to serve as the trajectory in placing educational organizations on the right path to ensure all students have equal opportunities in school and in life.
What does this mean for school nurses? It means that local decisions for school nurse funding will come from community and parent input as well as key district decision makers. Now is really the time for school nurses to capitalize on the relationships they have built to advocate for more school nurses with in the districts. If we are not at the table this year while plans are being developed, we could possible miss the chance for initial or additional funding for school nurses over the next eight years. Find out when LCFF talks and input will be held. Link up with those who are developing the LCFF plan. It is usually the Federal and State Categorical person that has been charged with this responsibility. Ask questions and assert your role in supporting the district in this arena of supporting student outcomes.
When meeting with district administrators, focus on these key talking points:
· Share the impact you have on student attendance. District funding centers on seat time of students. As a school nurse you can help case manage chronically ill/truant students by working with local health care providers in mitigating students being at school. Rather than sending students home, school nurses can “assess” students to see if they are truly ill. Additionally, school nurses can make home visits to check up on students and work with parents to help support school attendance. Further share the role you have had in helping asthmatics, diabetics and other students with health issues to ensure they show up each day.
· Remind district officials about the recent decision from Supreme Court ruling, which prohibits unlicensed personnel from administering Controlled II substances i.e. Ritalin and many other ADHD medications. In its decision the California Supreme Court stated, “This does not mean, however, that only licensed health care professionals may administer prescription medications in public schools. It means, rather, only that the Board‟s regulations do not authorize unlicensed school personnel to administer such medications in violation of other applicable laws or regulations. To illustrate, only licensed health care providers may administer controlled substances. (See Health & Saf. Code, § 11154, subd. (a).) Also, the Legislature has mandated specific training before unlicensed school personnel may administer three specially regulated emergency medications to students. (See §§ 49414 [epinephrine auto-injectors for anaphylaxis], 49414.5 [glucagon for severe hypoglycemia] and 49414.7 [antiseizure medication for epilepsy].) A school employee without the licensure or training required by statute for such medications would not be “allowed by law” (tit. 5, § 604, subd. (a)) to administer them and, thus, not permitted to do so solely by force of the Board‟s regulations. Compliance with those other laws would also be necessary. It is not acceptable for classified staff to administer Ritalin and Adderall.
· Advocate that the expansion of Medi-Cal means that more students within your districts will qualify for Medi-Cal services, including special education students. With increased numbers of students on Medi-Cal means increased LEA Medi-Cal Billing Reimbursement for districts. If you have additional school nurses, they can bring increased reimbursement to the district for those “newly identified” Medi-Cal students.
· Medi-Cal Administrative Activities (MAA) has been scaled back and identifies specific individuals that can participate in the Universal Claiming Pool for MAA. School nurses are one of those job titles that have a specific role in MAA. The more school nurses you have participating in MAA, the more unrestricted federal MAA reimbursement you can generate to the school.
· Also, please remember the VSP certificates and resources you bring for students.
· What are others that you can think of? Do you have school nurses working with community partners to write grants? Perhaps you have helped in securing local business support for health related supplies? Or you have even brought business partners in supporting school health policies, which in turn has increased school district revenue. Your role in your district and school must be conveyed to local decision makers especially the LCFF planners. Who are they?
It will be critical for you to advocate not only for your school nurse position but also increasing the number of school nurses during this LCFF development time to enhance the revenue for districts. If districts view you as a critical piece in closing the achievement gap and helping increase student outcomes and revenue, they will be sure to support your role as a school nurse. We must step up to the plate during this LCFF shift and let our voices be heard.
The Call came in at 3:45 p.m.
By Sue Horn, B.S.N., R.N., CSNO Northern Section Adolescent Chair
The call came at 3:45pm. The school day had ended and a student walked into the school office. She said she thought she ate a cookie with nuts in it and that she had a nut allergy. The nurse walked through the door to find the student sitting in the nurse’s office complaining of difficulty breathing and her throat closing up. There was no documentation of a nut allergy and no epi-pen for this student. The nurse grabbed an epi-pen in the cabinet belonging to another student and injected the student while instructing the staff to call 9-1-1. This is not the first incident of epi-pen “borrowing”. In this instance, the nurse decided that the liability was worth saving the student’s life. The student was hospitalized for one night and an epi-pen and protocol were developed immediately for this child. The parent called and said “thank-you for saving my child’s life”.
Nurses in Yolo County knew that this dilemma existed where parents don’t always inform the student of an anaphylactic allergy or don’t bring the epi-pens to school because of the expense. To solve this problem, we got together as a group and managed to work through the process of obtaining free epi-pens for all our schools in Woodland, Davis and West Sacramento. Here are the steps to our process and the hand-outs that our nurses are using to train our staff.
Step 1: We met with our direct supervisors to discuss the idea of having standing epi-pens at our school sites for unidentified anaphylactic reactions and anaphylactic situations without epi-pens. Our supervisor then took the information to our school insurance agency.
Step 2: We met with our health officer and proposed the idea of standing epi-pens at our schools. We shared the CDE standards for Administration of Epinephrine Auto-Injectors and had a discussion about next steps.
Step 3: Time passed and we all got busy doing what we do best, nursing. Then the Davis nurse received an e-mail about receiving Free Epi pens. This was too good to be true, but alas, it was true. The link is www.EpiPen4Schools.com<http://www.epipen4school.com. This site provided standing orders and ordering form for epi-pens.
Step 4: We got together as a group to discuss developing training for staff who would be involved in administering the epi-pens if we were not present. A power point presentation was developed along with a standard protocol for students with undiagnosed anaphylactic reactions. The training was based on the standards developed by the CDE.
Step 5: The training was shared with the health officer and the health officer signed orders for the epi-pen ordering and administration.
Step 6: The nurses calculated how many epi-pens were needed in their districts. Elementary schools received 2 epi-pen juniors and 2 regular epi-pens and middle and high school received 2 regular epi-pens.
Step 7: Develop a timeline
Step 8: Each district decided how to do their trainings for their staff, which is voluntary. They must be CPR trained. (Refer to Administration of Epinephrine Auto-Injectors training standards and California Education Code)
Step 9: Determine funding for Epi-pens for future years. We are looking at Medi-cal and MAA funds.
Step 10: Train response teams annually to deal with an anaphylactic situations.
Home Hospital vs. Home Based Program by Sharon Sinclair, BSN, PHN, RN Northern Section CSNO Special Education Specialty Practice Chair
As school nurses we often get pulled into situations to assist a district or an individualized education program (IEP) team to determine whether a student requires a home hospital program or home-based program. This can become very difficult when a student has an IEP and health issues. In our county, we were having a particularly difficult time with local physicians writing prescriptions stating that the special education student was to be placed on home hospital or a home-based program. Parents are often under the
impression that all they need is a note from the doctor stating their child
required either a home based or home hospital program. I did some research and
wrote a letter to our local physicians outlining the differences and I am
constantly educating parents and staff about the differences. My SELPA
director and I signed the letter. It has not solved the problem completely, however I do feel that it has improved the situation. It is important that you understand the differences and guide your districts with the most appropriate plan to meet the needs of the student.
The following definitions are taken from the California Department of Education website (http://www.cde.ca.gov/sp/eo/hh/hhprogramsummary.asp). The purpose of home hospital instruction is to provide instruction to a student with a temporary disability in the student’s home or in a hospital or other residential health facility, excluding state hospitals (this applies to all students whether or not they have an IEP). A temporary disability is defined as a physical, mental or emotional disability incurred while a student is enrolled in regular day classes or an alternative education program, and after which the student can reasonably be expected to return to regular day classes or the alternative education program without special intervention. A temporary disability does not include a disability for which a student is identified as individual with exceptional needs pursuant to California Education Code (EC) Section 56026. The primary outcome of home and hospital instruction is to maintain a student at the student’s former level of while recovering from the temporary disability so as not to jeopardize the student’s future performance upon returning to a regular day class.
The law does not limit length of time for home hospital instruction however it does state that it is for the purpose of a “temporary disability”. The team shall have an assessment that includes a medical report from the physician stating the diagnosis as well as verifying the severity of the condition that prevents the student from attending a less restrictive placement along with a projected calendar date for the pupil’s return to school (California Code of Regulations – Title 5 30315.4). The key phrase is “to maintain a student’s former level of performance” therefore the student is not expected to make educational progress the purpose of home hospital is only to maintain skills.
If a student has a chronic illness and has missed more than five consecutive days as a result of their acute health problem the IEP team shall meet to determine the appropriate educational services. When a student with an IEP requires a Home Based Program it is done so at the recommendation of the (IEP) team. Input from the child’s primary physician is always welcome and recommendations are considered and reviewed but ultimately it is the team’s decision. The IEP team needs to document its rational for placement in any program other than the pupil’s school and classroom. The documentation shall indicate why the pupil’s handicap prevents his or her needs from being met in a less restrictive environment.
