By David Nash, Esq., Director of Legal Education and National Outreach, FEA
At a time when the health challenges facing students continue to rise, school districts are increasingly struggling to ensure they have proper nursing coverage both in school and, when necessary, during school field trips and at school-related functions. Two recent broadcast memos (one on March 26, 2025 and the other on December 13, 2023) from the New Jersey Department of Education underscore the importance of this issue, the legal obligations that must be addressed, and potential options available to school districts. In this article we review key aspects of those memos, the underlying legal obligations, the common challenges that school districts face, and key considerations for identifying and addressing those challenges.
Nursing Coverage Requirements in School
Let’s begin with a review of nursing coverage requirements under New Jersey law. Pursuant to N.J.S.A. 18A:40-1 and 3.3 a school district must have a certified school nurse (CSN) for each school building or complex. A certified school nurse is a person who holds a current license as a registered professional nurse (RN) from the State Board of Nursing and an educational services certificate from the New Jersey State Board of Examiners, with the school nurse endorsement OR with the school nurse/non-instructional endorsement pursuant to N.J.A.C. 6A:9B-12.3 and 12.4.
It is permissible to supplement the services provided by the certified school nurse with non-certified nurses, provided that the non-certified nurse is assigned to the same school building or school complex as, and is supervised by, the certified school nurse. A “noncertified nurse” means a person who holds a current license as a professional nurse from the State Board of Nursing and is employed by a district board of education or nonpublic school, and who is not certified as a school nurse by the Department of Education. This may include both RNs and licensed practical nurses (LPNs). It is important to note that as per the New Jersey Board of Nursing, supervision does not necessarily require direct continuing presence of the CSN. It may instead be “intermittent observation, direction, and occasional physical presence” of the CSN. Note that the administration of medication, under proper supervision, does fall within the Board of Nursing’s permissible scope of practice for LPNs.
In the event that a certified school nurse is not available to cover a school building or school complex, a school district may employ a Substitute School Nurse. Pursuant to N.J.A.C. 6A:9B-7.5(a), the Board of Examiners may issue a substitute school nurse/non-instructional credential to the holder of a valid New Jersey registered professional nurse license (RN). A substitute school nurse/non-instructional may serve a total of 60 instructional days in the same position in one school district during the school year. Substitute school nurses are authorized to administer medication.
Additional requirements for nursing services may arise as a result of a student’s IEP or 504 plan. A school is required to provide, at no cost to the parent, related services that are necessary for the child to access a Free Appropriate Public Education (FAPE). Such related services would include health-related services that the student needs in order to access a public education that may be provided by a school nurse. When a child’s IEP or 504 plan requires a school nurse to provide services, the child’s school must provide for coverage during nurse absences. If a school district contracts with a third party to provide its students with nursing services, this does not change the school’s obligations under IDEA and Section 504 to properly implement each student’s IEP and 504 plan, including nursing services, and a failure to provide for a substitute nurse could constitute a denial of FAPE. Requiring the child’s parent to come to the school and provide the services would also constitute a denial of FAPE. If a child has to stay home because there is no nurse to perform nursing services as outlined in the IEP or 504 plan, the child has been denied FAPE.
Administration of Medication
As reiterated in the NJDOE’s December 13, 2023 memo, in most cases, the school physician and the school nurse are the only employees authorized to administer medication to students or provide other medical care. However, there are a number of exceptions where students may be authorized to self-administer medication, and/or designated and trained school employees may be authorized to administer medication and provide other emergency care. Those exceptions include the following:
- N.J.S.A. 18A:40-12.3 permits the self-administration of medication by a pupil for asthma or other potentially life-threatening illnesses, a life-threatening allergic reaction, or adrenal insufficiency.
- N.J.S.A. 18A:40-12.6c requires the school nurse to recruit and train volunteer designees to administer epinephrine via an auto injector when the nurse is not present.
- N.J.S.A. 18A:40-12.14 requires the school nurse to designate the administration of glucagon to a student with diabetes who is experiencing severe hypoglycemia when a school nurse is not physically present at the scene.
- N.J.S.A. 18A:40-12.15 allows for students with diabetes to self–manage their care and administer medication related to their diabetes.
- N.J.S.A. 18A:40-12.24 directs the school nurse and trained school personnel to administer opioid antidotes in the event that someone is believed to be experiencing an opioid overdose.
- N.J.S.A. 18A:40-12.30 requires the school nurse to designate the administration of hydrocortisone sodium succinate to employees who volunteer when the nurse is not available.
- N.J.S.A. 18A:40-41a through c, otherwise known as Janet’s Law, requires that school districts have at least 5 individuals in each high school who hold current certifications in CPR and the use of an AED, and that AEDs be within reasonable proximity of school athletic fields.
Nothing in the above exceptions permits a student to carry and self-administer over-the-counter or other medications that are not specifically authorized by statute. In addition, nothing in the above exceptions permits school personnel other than the school nurse or school physician to administer over-the-counter medications, or other medications that are not specifically authorized by statute (e.g. epinephrine, glucagon, hydrocortisone sodium succinate, opioid antidotes).
Nursing Coverage Requirements on Field Trips
The question of whether or not a school nurse is needed for a school field trip depends on whether or not there are students on the trip who require the services of a school nurse as part of an IEP, 504 plan or Individualized Health Care plan or Individualized Emergency Health Care Plan. As noted in the NJDOE’s March 26 memo, when an individual student requires health services during a field trip or school-sponsored event, failure to provide those services may constitute a violation of the student’s rights under Section 504 of the Rehabilitation Act. As discussed above, with narrow exceptions, school employees other than the school nurse or school physician are not authorized to administer medication to students.
Consider the following scenario taken from the U.S. Department of Education’s Parent and Educator Resource Guide to Section 504 which makes clear that a student’s participation in a field trip cannot be conditioned on the parent’s ability to attend:
Scenario – Unjustified Different Treatment
Ricardo has a peanut allergy. His fourth-grade class is going on a field trip to the local aquarium and Ricardo’s father is told that he must chaperone Ricardo on the trip because the teachers will be very busy and cannot ensure that Ricardo will be protected from exposure to peanuts or peanut products while on the trip, especially during the lunch break. Ricardo’s father cannot go on the field trip because he has to go to work. As a result the teachers tell Ricardo he cannot attend the field trip. Ricardo’s father complains to the principal, noting that no other parent is required to attend the field trip. Should the school have required Ricardo’s father to attend the field trip?
Answer to Scenario:
No. In this case, none of the parents of students without disabilities were told that they must attend the field trip; therefore, the school may not require Ricardo’s father’s attendance simply because Ricardo has a disability. Under Section 504, the school is responsible for making it possible for Ricardo to participate in this learning opportunity like his peers, without parental assistance.
The issues around field trips may become more complicated if the trip is outside New Jersey. New Jersey is part of the Nurse Licensure Compact (NLC), which provides a means for nurses licensed in one state to become authorized to engage in nursing services in another state. Most, but not all, states are part of the NLC. It is important to stress that even for states like New Jersey that are part of the NLC the individual nurse must apply for a multistate license through the New Jersey Board of Nursing. For travel to (or through) states that are not part of the NLC, school districts should contact the Board of Nursing in the applicable State to ensure compliance with that State’s requirements for the duration of the field trip. Where necessary, the school district should make alternative arrangements for student health services in advance of the trip, which may include contracting with a nursing service in the respective state to ensure that the nurse is properly licensed.
For an out-of-country field trip, the school should contact that country’s consulate to ensure the nurse may provide nursing services to their students in the visiting country. Note that while other countries may have different rules related to health services and student conduct, the applicable rules for New Jersey students cannot be lessened. For example, if a foreign country has a lower drinking age or rules allowing minors to access certain controlled dangerous substances, that would not allow New Jersey students to consume alcohol or use CDS on the trip. The United States Department of State may be of assistance in reaching a consulate in order to determine the specific requirements in a particular country. Additional information can be located at: https://travel.state.gov/content/travel/en/international-travel.html and at https://www.usembassy.gov.
Nursing Coverage Options
The NJDOE’s March 26 memo outlines a variety of options that school districts may consider to ensure proper nursing coverage. These include:
- Develop a robust substitute nursing pool, including active recruitment, competitive pay rates, flexible scheduling, and orientation programs that provide access to and training on local electronic health records.
- Hire per diem, float, or part-time nursing staff to provide additional coverage.
- Contract with a nursing agency to secure appropriately certified substitute school nurses as needed.
- Notify parents when the school nurse is absent, and coverage is unavailable. Notifications should include district policies on medical emergencies and how individual student health needs will be addressed.
- Remind parents of their option to visit the school to administer routine medications.
- Establish agreements with neighboring school districts to share nursing coverage when substitutes are unavailable. Partner with a local educational services commission or special services school district to access additional nursing resources.
In addition to the options laid out in the March 26 memo, P.L. 2021, c. 296 permits a certified school nurse who is retired from the TPAF to return to employment as a certified school nurse without reenrollment in the TPAF. Reemployment must be on a contractual basis for a term of not more than one year; however, the board of education may renew the contract for one additional year. Note that a number of specific requirements must be met in order to permit this option and school districts should review the applicable requirements with the board attorney and the New Jersey Division of Pensions.
Key Considerations Moving Forward
Ensuring that proper nursing services are provided is a complex and growing challenge for school districts. School districts are expected to know and comply with a wide range of requirements, including the requirement to have a CSN in each school building or complex, to ensure that all medications are administered by authorized persons according to New Jersey law, that students are not denied access to school or school sponsored field trips due to the student’s need for nursing services, and that proper planning takes place to address out-of-state and out-of-country requirements when necessary.
It is critical that school districts demonstrate due diligence in taking all reasonable steps to ensure that proper nursing services are provided for students. As part of demonstrating due diligence, it would be prudent for school districts to be able to demonstrate that they have explored all of the other options laid out in the NJDOE’s March 26 memo (including working with a nursing agency and exploring agreements with neighboring districts) before resorting to parent notification that nursing coverage is unavailable. Even when that last resort must be exercised, the district should demonstrate a thoughtful process to have some level of coverage available to address ongoing medical needs and emergency situations that may arise.