School Nurses Must Refuse Unsafe Work. Few States Protect Them When They Do.

School Nurse Rules is a three-part Nurse.org analysis of the laws governing school nursing in all 50 states and the District of Columbia. It grew out of Jana Price’s investigation into the firing of a Pennsylvania school nurse who refused an assignment she believed fell outside her license.

At 10:23 the night before, Moriah Benjamin texted her director of student services. She was the licensed practical nurse at Millville Area School District in Pennsylvania, and the district’s Certified School Nurse had an approved day off the next morning with no substitute found.

“I can’t do both buildings alone,” she wrote. “It’s just not safe and I cannot risk my license.”

She did not report the next day. School opened two hours late. Weeks later the school board voted to terminate her, without issuing findings on whether the assignment she declined would have been legal. Jana Price’s investigation details what happened at Millville. We looked at the rules Benjamin was reasoning from, and reviewed all 50 states and the District of Columbia to see what protects a nurse in that position.

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Benjamin’s reasoning was not improvised. Under 49 Pa. Code § 21.148, a licensed practical nurse shall “undertake a specific practice only if the licensed practical nurse has the necessary knowledge, preparation, experience and competency to properly execute the practice.”

That is word for word the standard Pennsylvania applies to registered nurses at § 21.18. Same wording, same adoption date, same amendment date. Both license levels carry the identical obligation.

The same section also requires a nurse to “act to safeguard the patient from the incompetent, abusive or illegal practice of any individual.” Not only avoid doing something unsafe yourself, but speak up when someone else’s decision puts a student at risk. Failing either duty is grounds for discipline against the nurse’s license.

There is a second layer specific to schools. Pennsylvania requires school health services to be delivered by a Certified School Nurse, and state regulation at 28 Pa. Code § 23.51 provides that a child “shall be provided with school nurse services in the school which the child attends.” A district may also employ a registered nurse or a licensed practical nurse to assist that certified nurse. In a Penn*Link message sent to every local education agency on August 30, 2022, titled Provision of Certified School Nurse Services to Pennsylvania School Students, the Pennsylvania Department of Education set out the limit on that arrangement: “Although schools are permitted to enter into an agreement with a supplemental RN or LPN to assist a certified school nurse, a supplemental nurse may not be assigned a student case load.”

In 2019 guidance, the state’s Division of School Health told districts there is no set number of hours a certified school nurse must be physically present in her assigned buildings, only that she rotate through them on a regular basis. We have not located a more recent statement of that position.

The rules spell out what she has to do. They say nothing about what happens to her when she does it.

School Nurses Handle Tube Feedings, Seizures and 1,500-Student Caseloads

It is worth being specific about the job, because “school nurse” tends to conjure ice packs and thermometers.

West Virginia’s school code lists some of what the work involves: catheterization, tracheostomy suctioning, nasogastric tube feeding, gastrostomy tube feeding. Add insulin and glucagon, seizure rescue medication, epinephrine for anaphylaxis, and daily management of asthma and chronic conditions in children who could not otherwise attend school.

Usually one nurse does this across more than one building. Pennsylvania caps a school nurse’s caseload at 1,500 students, a limit the statute records as last amended in 1965. In its 2022 School Health Update, the state health department counted 2,224 certified school nurses across 3,897 school buildings. Fewer certified nurses than buildings.

The pay does not match the responsibility. Benjamin’s position paid about $28,000 a year with no benefits. We take that up in the second part of this series.

Every jurisdiction we reviewed requires a licensed practical nurse to work under the direction or supervision of a registered nurse or another authorized provider. That much is consistent across all 51.

In 36 of them, we found nothing further. The rule names who directs. It does not say whether that person has to be in the building, how quickly they must be reachable, or what happens if they cannot be reached at all.

Pennsylvania is one of the 36, and it is typical rather than extreme. The Practical Nurse Law, 63 P.S. § 651, defines practical nursing as selected nursing acts performed “under the direction of” a licensed professional nurse, physician or dentist. That is the whole of it.

When Benjamin raised her concern, the district’s director of student services replied that her license would not be at risk, and added: “Other districts operate like this all the time.”

She was right, and that is what our review found. Districts in many states operate this way, and in most of the rules we read, nothing says whether they can or cannot. Benjamin was not being misled. The rules genuinely do not settle the question, which is why two districts can handle the same day differently and both stay within the law.

In a hospital the silence matters less. There is usually another nurse down the hall. A school health office is different. You may be the only licensed person in the building, and a child’s condition can change between one class period and the next.

The rest set some kind of standard, and no two groups set the same one. Below, every state whose rules go beyond naming who directs, grouped by the kind of requirement each one imposes.

Source: Nurse.org, School Nurse Rules, a review of nurse practice acts and board rules in all 50 states and the District of Columbia.

These are not the good states and the others are not the bad ones. They are the states that answered a question the rest left open.

We examined the nursing rules of 10 states in detail to see what happens to a nurse who declines work she believes is outside her license. Nine of the 10 place a duty on the nurse. One attaches a remedy.

The nine are not equivalent. Some of those duties sit in statute, some in a board regulation, and some only in a board position statement or advisory opinion. North Carolina’s board says of its own guidance that it “does not carry the force and effect of law.” So the obligation is close to universal, and what stands behind it is not.

That one is Texas, where state law says an employer “may not suspend, terminate, or otherwise discipline, discriminate against, or retaliate against” a nurse who refuses. The protection is conditional: the nurse has to say at the time she refuses that the reason is that the work would breach the nursing act or a board rule. Texas also runs a safe harbor process a nurse can invoke before performing the work.

There is a subtler issue in the other nine. Most of these rules turn on whether the assignment truly was beyond the nurse’s license, not on whether she reasonably believed it was.

A nurse asked to do something she is unsure about faces two risks, not one. If she does it and it turns out to have been outside her scope, her board can discipline her. If she refuses, being right protects her license, but in nine of the ten states we examined, nothing in the nursing rules protects her job. She has to decide in a hallway, in about the time it takes to answer a question. If it is ever reviewed, it will be reviewed months later, in writing, by people with the full record and as long as they need.

Texas writes it the other way, asking whether the nurse “believes in good faith” that the work would violate the nursing act. That is a different question from whether she turned out to be correct, and it decides who carries the risk of a judgment call made in a hallway.

Four states have written down some form of protection, though none of them does what Texas does. Each sets out what a nurse may or must do. None of them says what happens to her job if she does it. Virginia gives school employees the right to decline non-emergency health duties. Washington protects a nurse’s decision to call for emergency help and limits non-nurse administrators to employment matters. Rhode Island provides that school health rules cannot be read to require a nurse to act against her professional practice laws. Those three sit in school law. Maryland sits in nursing law and comes closest to a plain right of refusal, stating that a practical nurse “has the right and the responsibility to refuse to perform” work beyond her education, capabilities, competency and scope. Like the others, Maryland asks whether the work actually was beyond her, not whether she reasonably believed it was.

Nursing Rules and School Employment Rules Were Never Connected

Benjamin described the problem herself, in a text the morning she did not report.

“Even though I’m considered support staff in the district, I carry a professional nursing license, and I have a scope I need to follow.”

That is the whole of it. Nursing rules make her personally accountable for staying inside her license, and her board can discipline her for getting it wrong. School employment rules put her in a support classification and say nothing about who decides when she and an administrator disagree about where that line falls. She carries the license consequence. The district controls the assignment and the job. In the states we examined closely, nobody wrote down who decides.

This is not a story about districts acting in bad faith. Nurse practice acts and school personnel codes were written decades apart, by different agencies, for different purposes. They were never written to fit together, and most people working inside one of them have no reason to read the other.

It shows up in the advice people are given. Millville’s superintendent testified he asked a state school health consultant whether the district should close when it could not find coverage, and was told, “Oh gosh, no. Don’t do that. Just do the best you can.” Sensible advice for keeping a school open. It sits alongside written state guidance saying a supplemental LPN may not be assigned a student caseload. Neither statement is wrong. They were never reconciled, and the person standing between them is the nurse.

What fills that silence is local practice. Two nurses in the same state, under identical rules, can have entirely different days depending on whether the certified nurse picks up the phone. Price’s investigation includes interviews with Pennsylvania school nurses on both sides of that line. Goodwill and habit are real, but they are not protections, and they do not travel with a nurse when she changes districts.

One state has addressed this directly in writing. South Carolina’s Board of Nursing publishes Advisory Opinion 33, setting out what is required when a licensed practical nurse works without a registered nurse on site. It names public schools specifically.

The protocol asks for a year of clinical experience before a nurse takes such a position, with competencies assessed and documented by the supervising RN. The RN writes the plans of care for the school and any individual student’s health plan, verifies skills, reviews charts, and visits periodically. If the supervising RN cannot be reached, a back-up has to be named in advance.

And this: “An emergency plan must always be in place to access the RN by telecommunication, such as a cellular phone. There must always be telephone capability for the LPN to contact 911.”

Read that against Benjamin’s text. What she was asking for the night before is roughly what South Carolina requires in writing: a named person, reachable, before the day starts.

It is not a complicated document. A state board of nursing worked out what a practical nurse alone in a school building needs and wrote it in plain language. The question this raises is not whether that can be done. It is why so few states have done it.

Next in this series: Benjamin’s school nursing job paid about $28,000 a year with no benefits. Part two compares that to federal wage data for Pennsylvania and finds the rule, in 21 states, that decides whether a school nurse is paid as a professional at all.

Related Reading

The investigation this analysis grew out of

School Nurse Rules

More on school nursing

🤔If you have ever been the only nurse in your building, what did your district tell you about who to call and how fast they had to answer? Tell us in the comments below.

About This Analysis

School Nurse Rules is a Nurse.org review of the rules governing school nursing in all 50 states and the District of Columbia, covering who is permitted to serve as a school nurse, whether districts are required to provide nursing services at all, staffing ratios, credentials and pay.

In a small number of states, a current statute and the agency guidance describing it point in different directions. Where that happened we have said so rather than choosing between the two. The findings on what protects a nurse who refuses an assignment are based on 10 states reviewed in detail, not all 51.

A small number of states define supervision for a different relationship, such as delegating tasks to unlicensed staff or overseeing new graduates; those definitions are not counted here. The Division of School Health guidance on certified school nurse presence is drawn from the Pennsylvania Department of Health’s December 2019 School Health Update, reproduced by the Pennsylvania Association of Pupil Services Administrators. The Pennsylvania Department of Education memorandum quoted here was distributed to local education agencies by Penn*Link on August 30, 2022 and is reproduced in full by the Pennsylvania Association of Pupil Services Administrators; the underlying provisions it describes appear at 24 P.S. § 14-1410, 22 Pa. Code § 49.1 and 28 Pa. Code §§ 23.51 and 23.54.

Testimony and text messages come from Jana Price’s investigation of the Millville hearing.

Nurse.org Analysis