Intended for healthcare professionals

Education And Debate

Administration of medicines in school: who is responsible?

BMJ 1998; 316 doi: https://doi.org/10.1136/bmj.316.7144.1591 (Published 23 May 1998) Cite this as: BMJ 1998;316:1591
  1. M J Bannon, consultant paediatriciana,
  2. E M Ross, professor of community paediatricsb
  1. a Paediatric Directorate, Northwick Park and St Mark's NHS Trust, Northwick Park Hospital, Harrow HA1 3UJ
  2. b King's College London, Mary Sheridan Centre, London SE11 4QW
  1. Correspondence to: Dr Bannon

    By the age of 4 years, Jamie had experienced three severe allergic reactions after exposure to peanuts. His general practitioner diagnosed peanut allergy and advised that Jamie's carers should not only be capable of recognising the early signs of anaphylaxis but should also be prepared to administer subcutaneous adrenaline if necessary. After a meeting with Jamie's schoolteacher, his mother was disturbed to be told that, while the school was sympathetic, teaching staff were unable to administer adrenaline injections as this was a medical rather than a teaching responsibility. She was also advised that the school nurse covered several schools during the working week and could not be always available to give adrenaline injections. Jamie's mother then raised a question that has been asked by many other parents: just who is responsible for the administration of medicines to children while they are at school?

    This has been a contentious issue for many years, regularly resulting in conflict between parents and teachers.1 The background to the problem is complex and is a result of diverse factors.

    Summary points

    Chronic illness is relatively common in schoolchildren and often requires treatment during school hours

    There is no legal requirement for schoolteachers to administer medicines to children at school

    School health services are non-resident and are focused on health promotional activities rather than providing acute medical care for pupils

    Both parents and prescribers of drugs for children must liaise effectively with school staff

    The use of individual healthcare plans in this context represents a constructive way forward, but these have yet to be widely implemented in practice

    Changing nature of childhood illness

    Not only is chronic illness common among schoolchildren but inadequate treatment may impair a child's academic progress and general wellbeing. 2 3 There is also evidence that the epidemiology of childhood illness is changing. Recent research suggests that, for every 1000 schoolchildren, as many as 160 may have symptoms suggestive of asthma,4 four have a diagnosis of epilepsy established by the age of 11,5 and between one and two children have insulin dependent diabetes.6 Furthermore, the prevalence of asthma and diabetes seems to be rising.

    There are, in addition, an increasing number of children who present with “new” disorders that have implications for their treatment at school. Foremost among these is peanut allergy, which represents the most common cause of food mediated fatal anaphylaxis and which may affect as many as one child in every 200.7 Difficulties also arise for children who have attention deficit hyperactivity disorder and who require the administration of methylphenidate during school hours,8 those who are known to be infected with HIV,9 and those who suffer from haemoglobinopathies, particularly sickle cell disease.10

    After the implementation of the 1981 and 1993 education acts, an increasing number of children with substantial physical and medical disorders now receive their education in mainstream schools.11 These include children with cystic fibrosis12 or malignant disease13 and those who have had surgical repair for congenital heart lesions.14 An increasing number of children who have had tracheotomies and gastrostomies performed are also taught in mainstream schools.15 Consequently, teachers in mainstream schools are likely to encounter a wide variety of childhood illness that may require treatment during school hours.

    Parental expectation

    With the publication of the patient's and children's charters, 16 17 many parents now feel empowered to demand that teachers take responsibility for treating childhood illness during school hours. Handbooks such as Contact a Family list the flourishing number of parental support groups, many of which would be willing to endorse parents in this respect.18 Some parents hold the view that teachers act in loco parentis with respect to the supervision of children while they are at school and that this role should include taking responsibility for the administration of medicines if necessary. Parents would also argue that numerous devices and techniques have been developed to enable non-professionals to deliver drugs effectively to children. These devices include asthma inhalers, rectal diazepam sachets, and preloaded apparatus such as the EpiPen, which allows the administration of adrenaline in case of suspected anaphylaxis. Parents argue that, if they can learn to use these devices safely, why cannot teachers?

    On the other hand, many teachers understandably express anxiety about accepting liability for what they perceive to be a medical rather than an educational issue and one for which they have received little or no training.1 Storage of medicines at schools is also fraught with difficulty. A recent survey has indicated that, regrettably, a minority of schools allow children to be responsible for their own asthma inhalers.19

    Figure1

    Few schools allow children responsibility for their own inhalers

    Teachers' awareness of childhood illness

    Surveys conducted by health professionals have shown that teachers have limited understanding of common chronic childhood illness including asthma,20 diabetes,21 and epilepsy22 and that they are given little if any instruction on medical issues during their training. However, they showed a positive attitude towards the integration of children with chronic disorders into mainstream education and requested further specific training about the classroom implications of such disorders. A further study showed that teachers had an imperfect understanding of the school health service in terms of its remit and administration.23

    Role of the school health service

    Most parents have some contact with the school health service and may be aware that each school should have a named nurse and doctor. Surely the school nurse would be ideally placed to administer drugs or deal with other medical issues as they arise in school? The reality, however, is that school health workers are not resident and have numerous schools on their individual caseloads. Secondly, since its inception in the early years of this century, the school health service has been preventive rather than therapeutic in its focus, with activities that have always been based on health promotion and disease reduction.24 The roles, responsibilities, and recommended set of core activities of the school nurse have been defined recently in a report by a multidisciplinary working party (see box).25 School nurses are registered general nurses, who often also have specialist qualifications in sick children's nursing or school health. A key activity for them is the definition of a health profile for each school, which outlines the health needs of pupils and which is updated regularly.26 Sadly, the number of school nurses seems to have been reduced in many districts.27

    Summary of recommended core activities for school nurses

    5 year old children (year 1)
    • Conduct structured school entrant health interview with parent

    • Measure height and weight, ensure completion of preschool examination of heart, testes, and other preschool concerns

    • Measure visual acuity

    • Measure hearing (sweep test)

    • Discussion with teacher to identify concerns

    7-8 year olds (year 3)
    • Measure visual acuity

    • Measure height and weight

    • Opportunity for general health check

    11-12 year olds (year 7)
    • Measure visual acuity

    • Measure height and weight

    • Opportunity for general health check

    14 year olds (year 10)
    • Conduct general health check

    • Send questionnaire to parents and pupils

    Supporting Pupils with Medical Needs in School

    Several voluntary support organisations have already produced excellent information about common childhood illnesses for teachers, and at least one interprofessional group has carefully considered the issue.28 However, the most important recent development has been the publication of Supporting Pupils with Medical Needs in School.29 This document represents a rare but welcome example of interdepartmental collaboration between health and education. It was produced at the request of teachers, their unions, and local educational authority staff after many months of extensive consultation and considers three main areas.

    • The complex legal framework (which includes the Health and Safety at Work Act 1974, the Medicines Act 1968, and the Education Act 1993) is interpreted. The conclusion is that there is no legal duty requiring school staff to administer drugs to children, which remains a voluntary role. The term in loco parentis is obsolete and is not relevant in this context. However, school staff who are in charge of pupils have a duty in common law to act in the same manner as a responsible parent in order to ensure that children remain safe and healthy while on school premises. In certain circumstances teachers might be expected to administer drugs or to take appropriate action in an emergency.

    • Each school is advised to draw up general policies and procedures in order to support pupils with medical needs.

    • The use of individual healthcare plans is suggested in order to ensure that school staff are sufficiently informed about a pupil's medical needs, including the administration and storage of drugs. It is recommended that such plans should be jointly agreed between a child's parents, medical carers, and teachers and should provide explicit advice about appropriate measures to be followed in an emergency. Drugs must be readily available in an emergency and must not be locked away.

    Figure2

    The school nurse: a vanishing species?

    The way forward

    Supporting Pupils with Medical Needs in School represents a positive step forward, but it is advisory rather than statutory. We recommend that further action should be taken.

    • The school health service must take a lead in this area, with the school nurse as the focal point. In particular, school health profiles could be used as an index of local need, which might be incorporated into children's services plans. Health professionals should arrange training events, which could be supported by written material for teachers on childhood illness.

    • Local educational authorities should ensure that each school has general policies with respect to the administration of medicines to children in place as a matter of urgency.

    • Teachers must continue to respond as positively as they can when they encounter a child with medical needs. They should try to increase their knowledge of childhood chronic illness and they should be supported in this respect by local educational authorities and trade unions.

    • Parents and carers must acknowledge that they hold the prime responsibility for their children's welfare and that accountability for the administration of medicines must be negotiated with rather than demanded of school staff.

    Acknowledgments

    Funding: None.

    Conflict of interest: None.

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