School nurses face many challenges while striving to provide excellent care for their students. According to a position statement from the National Association of School Nurses (NASN), school nurses in many areas of the United States serve large student populations and are responsible for multiple schools. Beyond addressing urgent student needs such as playground injuries or influenza, school nurses also care for students with disabilities and those with chronic medical and psychological conditions, including asthma, diabetes, epilepsy, and behavioral disorders. These conditions may require health-related services, such as administering medications or tube feedings, and managing medical devices, such as ventilators.
No matter what the challenges, however, school nurses are responsible for delivering quality care. Failure to do so could lead to legal action or loss of license. To reduce the risk of liability, school nurses must understand the areas of risk and take steps to mitigate them.
Liability risks
Several situations can lead to legal or licensure actions against a school nurse, starting with the failure to properly manage a student’s health condition. For instance, failing to work with teachers, students, and staff to protect a student with an immunocompromised status can lead to liability if the student contracts an infection.
Inappropriate management of communicable diseases is another potential area of liability, underscoring the importance of proper infection prevention techniques. With declining vaccination rates in the United States, school nurses need to be vigilant in taking action to prevent the rapid spread of diseases such as measles.
Other potential sources of liability include failing to recognize signs that a student requires urgent care, such as those experiencing asthma exacerbations or diabetic hypo- or hyperglycemia. School nurses may also be held liable for not managing emergencies, such as anaphylaxis, appropriately or for failing to take the appropraite actions when a student sustains a concussion or other injury. Inadequate planning for students' healthcare needs during school trips can also lead to harm.
Finally, inadequate staffing can hinder care and increase the risk of litigation. For example, when nurses are required to travel to multiple schools, each with unique needs, it becomes challenging to provide proper care. Short staffing may also lead to inappropriate delegation, as nurses struggle to meet students’ care needs.
Reducing risk
School nurses can take several steps to reduce their liability risk.
Know relevant federal and state regulations and legislation, such as nurse practice acts and laws. The state’s nurse practice act specifies what nurses can and cannot do. In addition, nurse practice acts, or additional legislation, often have guidance specific to school nurses and their duties. For example, many states address the delegation of administering specific medications by non-medical personnel. For instance, according to a 2024 survey from The Network for Public Health Law, Florida permits a “trained school personnel member” to administer short-acting bronchodilators. Laws also may specify staffing requirements for school nurses. In addition, school nurses must be familiar with the legislation and regulations governing the licensed practical nurses (LPNs)/license vocational nurses (LVNs) they work with. For instance, typically only an RN, not an LPN/LVN, can conduct student assessments.
Follow scope and standards of practice. The two key references are: NASN’s School Nursing: Scope and Standards of Practice, 4th ed., and the American Nurses Association’s Scope and Standards of Practice, 4th ed. Another helpful resource is NASN’s code of ethics.
Adhere to best practices and clinical guidelines. In cases of litigation, a key question is whether the defendant provided the standard of care. Following best practices and clinical guidelines reflects the delivery of standard of care. NASN offers several evidence-based clinical practice guidelines, including “Students with Allergies and Risk for Anaphylaxis.” These can be accessed at https://learn.nasn.org/courses?courses%5BrefinementList%5D%5Bcategories.name%5D%5B0%5D=Clinical%20Practice%20Guidelines#.
Develop protocols, policies, and procedures. These should be evidence-based and communicated to key personnel. Sample topics include medication administration, school-sponsored trips, concussion protocols, and emergency response (e.g., when a student needs to be transported to the hospital). Collaboration among school nurses, teachers, and administrators is needed to successfully develop these documents. In addition, standing medication orders should be reviewed and updated annually.
Conduct thorough assessments. Conducting a thorough physical assessment is essential for delivering quality care and protecting against liability. However, a school nurse may face a variety of issues that can make completing an assessment difficult (e.g., staffing concerns, setting, type of injury, and student’s ability to cooperate). Having sufficient time to evaluate the physical needs of a student can allow a nurse the opportunity to assess conditions that may escalate into more serious problems. Despite the challenges that can arise, a school nurse is responsible for delivering quality care.
Maintain confidentiality. The Family Educational Rights and Privacy Act (FERPA) is a federal law that gives parents the right to access their children’s education records, to seek to have the records amended, and to control the disclosure of personally identifiable information from those records.
In general, FERPA prohibits a school from disclosing a student’s personally identifiable information to a third party unless the student’s parent has given consent. However, there are several exceptions, including “school officials” (for example, teachers) who have a “legitimate educational interest” in the information.
When information needs to be disclosed, the school nurse should only share what is necessary for the student’s best interest, so that confidentiality is protected.
Delegate appropriately. Only delegate tasks permitted under standards of care, legislation, and law. Based on these factors, the school nurse may delegate to an LPN/LVN or unlicensed personnel, such as a health assistant or school staff. When delegating to both licensed and unlicensed personnel, ensure that the person has the necessary training and competency.
Special care must be taken when delegating medication administration, starting with the school nurse’s evaluation of a studentis capacity for self-administration. If the student is not capable, the alternatives are to have another person (the nurse or an appropriate delegatee) either supervise the student taking the medicine or administer the medication to the student. Again, if the nurse delegates administration, training and competency assessment are essential.
In all cases, delegatees should be appropriately supervised. This may involve periodic observation of the delegatee performing the assigned procedure.
Provide education. Teachers and other staff can support the school nurse’s efforts to deliver optimal care. For example, they can be taught to recognize signs of anaphylaxis and to detect hypoglycemia in students with diabetes. Staff should have a protocol to follow in these types of situations, including whom to notify.
Communicate. Effective communication is essential for both students and parents or caregivers. This includes providing education about the student’s condition and explaining potential situations in which action may be needed. Collaboratively developed plans can support communication (sidebar), which is essential for promoting the strong link that school nurses serve between parents, the school, and a student’s healthcare provider.
Document. Key conversations should be documented in the student’s health record. Other needed areas of documentation include student assessments, school trip plans, individual student health plans, emergency care plans, medication administration, employee training, competency evaluations of delegates, development and review of student support plans, and referrals to other care providers. General consents should be kept on file and updated periodically.
Keeping students safe and healthy
Students have the right to expect excellent care for health problems that arise at school and to receive support for chronic health issues. School nurses can use the strategies outlined in this article to provide optimal care and support, promoting student health and safety while reducing liability risks.
Cynthia Saver, MS, RN, of CLS Development, is a medical writer in Columbia, Md.
Sidebar
Supporting students
Several plans are used to support students’ health. Rawe and Miotto and colleagues highlight some of the most common.
Individualized education program (IEP). IEPs came out of the federal Individuals with Disabilities Education Act. Parents, students, and school personnel collaboratively develop the IEP, which outlines the support and services the school will provide to meet the needs of a student with a disability; health components such as medication administration may be included. The plan must be reviewed at least annually, and the student must be reevaluated at least every three years to see if an IEP is still needed.
504 plan. A 504 plan fulfills Section 504 of the federal Rehabilitation Act of 1973, which protects against discrimination. Although sometimes less detailed than an IEP, these plans should also be developed collaboratively. Miotto and colleagues note that the plan may include specifics related to an individual student’s access to medication during school and school-sponsored events. Frequency of plan review varies by state, but times often mirror IEP: review annually, reevaluation every 3 years.
Individualized health plan. This is a plan of care developed by the school nurse to document the nursing process. It should be updated at least annually.
Emergency care plan. School nurses develop this plan to help unlicensed assistive personnel recognize potential emergent conditions and know what to do in these situations. It should be updated at least annually.
Sources: Miotto MB, Balchan B, Combe L. Safe administration of medication in school: Policy statement. Pediatrics. 2024;153:6:e2024066839; Rawe J. The difference between IEPs and 504 plans. Understood. 2024. https://www.understood.org/en/articles/the-difference-between-ieps-and-504-plans
References
American Nurses Association. Nursing: Scope and standards of practice, 4th ed. 2021.
Council on School Health. Role of the school nurses in providing school health services. Pediatrics. 2016;137(6):e20160852 (reaffirmed 2023).
Miotto MB, Balchan B, Combe L. Safe administration of medication in school: Policy statement. Pediatrics. 2024;153:6:e2024066839.
National Association of School Nurses (NASN) Position Statement: School nurse workload—essential staffing for safe and equitable student care. J School Nurs. 2025;41(5):642-645.
National Association of School Nurses Position Statement: School-sponsored trips—equitably addressing student health needs. J School Nurs. 2024;40(5):584-585.
National Association of School Nurses. Code of Ethics. 2024.
National Association of School Nurses. School nursing: Scope and standards of practice, 4th ed. 2022.
Rawe J. The difference between IEPs and 504 plans. Understood. 2024. https://www.understood.org/en/articles/the-difference-between-ieps-and-504-plans
Shannon R. School nurse delegation: Do’s and don’ts of the d-word. National Association of School Nurses. 2020. https://schoolnursenet.nasn.org/blogs/robin-shannon-ncsn-rn-dnp1/2020/08/03/school-nurse-delegation-dos-and-donts-of-the-d-wor
The Network for Public Law. School nursing scope of practice and ratio laws: 50-state survey. 2024. https://www.networkforphl.org/wp-content/uploads/2025/01/School-Nursing-Scope-Of-Practice-And-Ratio-Laws-1.pdf
U.S. Department of Education. What is FERPA? n.d. https://studentprivacy.ed.gov/faq/what-ferpa
U.S. Department of Education. A parent guide to the educational rights and privacy act (FERPA). 2021. https://studentprivacy.ed.gov/resources/parent-guide-family-educational-rights-and-privacy-act-ferpa
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