Evidence-Based Diabetes Management

Limiting Students’ Diabetes Management to School Nurses Does Not Improve Parents’ Perception of Safety, Study Finds

Published Online: October 01, 2013
Mary K. Caffrey
Dealing with a child’s diabetes during the school day can be challenging for all involved, so much so that in some studies parents have described it as “the worst experience,” 1 Kimberly A. Driscoll, PhD, an assistant professor at Florida State University, told an audience at the 73rd Scientific Sessions of the American Diabetes Association (ADA) meeting in Chicago (June 21-25, 2013).

It’s little wonder, then, that states are split on who should be charged with blood glucose monitoring or handling a student’s diabetic episode during school hours. Despite longstanding recommendations and an ADA campaign calling for adults beyond the school nurse to be trained to assist with monitoring or administer insulin or glucagon,2 Driscoll’s map of states showed about half limit such tasks to school nurses, other licensed medical personnel, or the child’s parent.3

Do these restrictions make students safe? Driscoll asked that question in her study, and presented the first round of results in Chicago. Parents of 464 children with type 1 diabetes mellitus (T1DM) were surveyed at major diabetes centers in Texas, Colorado, Massachusetts, and Pennsylvania. Driscoll selected 2 states—Texas and Colorado—with laws based on ADA guidelines calling for personnel other than school nurses to be trained to administer insulin and glucagon, and 2 other states—Massachusetts and Pennsylvania—where state law limit these tasks to the school nurse.

In the study, Driscoll controlled for students’ race, their blood sugar level (A1C), and how long they had lived with T1DM. For most purposes, Texas and Colorado students were treated as one group, and Massachusetts and Pennsylvania students were treated as another group. The ADA funded the study.

Driscoll’s work expanded on a 2005 survey by Hellems and Clarke4 of Virginia parents, who were studied 6 years after that state became the first to allow non-nursing personnel to treat children with diabetes at school. (They were given immunity from liability.)

Parents were asked who took care of their child, and Driscoll noted, “One thing that was striking was the number of parents who said that no one was helping their children.” But the Hellems and Clarke study did not examine parents’ perceptions of their children’s safety, which Driscoll aimed to do.

What the Survey Found

Driscoll’s survey expanded the 2005 questionnaire. Parents were asked to recall how many incidents of low blood sugar and high blood sugar—with symptoms—their children had experienced at school within the past 3 months. The study’s authors aimed to ensure that parents had strong memories of recent incidents involving their children’s diabetes, Driscoll said.

In both groups, just above 50% of the children had between 1 and 5 low A1C events in the prior 3 months, with “low” defined as <70% mg/dL. The number of incidents of high A1C, with “high” defined as >250mg/dL, was more evenly distributed among children experiencing up to 5, from 6-10, 11-15, or >15 incidents. Of note, in both the low and high A1C results, distribution was consistent between the Texas/Colorado group and the Massachusetts/Pennsylvania group.

In both groups, parents reported that their children most frequently administered their own insulin during low A1C episodes, while the school nurse most frequently administered it when the child experienced high A1C.  According to Driscoll’s results, incorrect doses are relatively infrequent, but they do occur: Out of 464 parents taking the survey, 22 in the Texas/Colorado group reported an incorrect dose in the previous 3 months, while 8 in the Massachusetts/Pennsylvania group reported a wrong dose in that period.

In both groups, the most frequently cited person administering the wrong dose was the school nurse, followed by the child with diabetes. Thus, Driscoll said, even though there were more incidents in the states that allow non-nursing personnel to treat children, “In all our states, the parents perceived it was the school nurse, who are the experts, making the mistakes.”

Do Parents Feel Safe?

Driscoll’s questions on whether parents feel safe—and how safe they feel—distinguished this study from earlier parent surveys. On balance, most parents in all 4 states felt safe (40% Texas to 60% for Massachusetts) or very safe (2% Pennsylvania to 40% for Texas); she reported that there was no statistical difference between the states that limited treatment to the school nurse, compared with those that allowed other personnel to administer insulin or assist with blood glucose monitoring.

Also, despite some minor fluctuations, Driscoll said there was also no statistical difference between parents’ perceptions of safety during the school day and at after-school activities, such as clubs, sports, or school trips. (In response to questions, however, sports coaches ranked high among those parents hoped would receive training in diabetes care.)

Still, Driscoll reported there were significant subsets in the 4 states (8% Massachusetts to 18% for Colorado) who reported feeling that their children are unsafe. Perhaps more alarming, she said, is the small share (2% Massachusetts to 15% for Pennsylvania) who report they “don’t know” or did not answer whether their child is safe at school.

“Overall, most of the parents are very satisfied,” Driscoll said. “Parents in states that allowed trained personnel to administer insulin reported they perceive similar safety and satisfaction.

Even though there were a small percentage who were not satisfied, parents were equally satisfied with diabetes care, regardless who provides the care.”

1. Polonsky, WH. Emotional and quality-of-life aspects of diabetes management. Curr Diab Rep. 2002;2(2):153-159.

2. American Diabetes Association website. Safe at School. http://www.diabetes.org/livingwith-diabetes/parents-and-kids/diabetes-careat-school/. Accessed September 11, 2013.

3. Driscoll, KA. Parent perceptions: who can deliver diabetes care at school? Presented at: 73rd Scientific Sessions of the American Diabetes Association: June 21-25, 2013; Chicago, Illinois.

4. Hellems, MA, Clarke WL. Safe at school: a Virginia experience [published online March 10, 2007]. Diabetes Care. 2007;30(6):1396-8.