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 Nursing Practice > You Asked Us Online 

 Last modified Oct. 19, 2005 

Nurse responsibilities regarding Bill 3

The College of Nurses of Ontario (CNO) has received a number of calls about Bill 3: An Act to Protect Anaphylactic Students, 2005 (also known as Sabrina’s Law). This law states that public school boards must:

  • provide regular training for staff on dealing with allergies;
  • maintain individual files for students with an anaphylaxis allergy;
  • identify and communicate emergency procedures for those students; and
  • designate storage for emergency EpiPens.

In preparation for the enactment of Bill 3 on January 1st, 2006, school boards have asked Public Health Nurses to train principals and teachers in the use of EpiPens for treatment of anaphylactic reactions. In turn, nurses have contacted the College asking about their accountability when teaching principals and teachers how to use EpiPens.

In the June 2004 edition of The Standard, the You Asked Us section featured an article on this topic; however, clarification is needed about specific issues related to the implementation of this law. The following Q&As were developed in response to recently asked questions:

Q: How can we determine that it is appropriate to teach the learner (e.g., a principal) when we do not have adequate time for a thorough assessment of the learner?

A: When time does not permit a thorough assessment of a learner’s specific needs at the time of teaching, assess the situation as a whole before entering into the teaching relationship. It is likely that any school employee could use an EpiPen in the event of an anaphylactic reaction even without specific training. The role of the nurse is to provide information and education to reduce the risk that school staff will administer this treatment inappropriately, and improve the effectiveness of this emergency measure. Because increased safety and well-being of the clients is the goal, and there is a legal requirement mandating the education, this would be an appropriate situation in which to teach unregulated care providers (UCPs).

Q: Do I need to delegate the authority to the teachers and others to use the EpiPen?

A: Administering a substance by injection is a controlled act that members of the public cannot perform without delegation. An exception in the Regulated Health Professions Act (RHPA), however, allows any unregulated person to perform a controlled act when providing first aid or temporary assistance in an emergency. School staff, therefore, would have the authority under the emergency exception in the RHPA to use an EpiPen in an emergency situation without the need for delegation.

Q: When teaching UCPs to use EpiPens, how can we adequately determine that learners are competent?

A: Nurses who provide teaching are responsible for determining what constitutes demonstration of competence based on the characteristics of the learners, the settings and the particular activities being taught. Demonstration, and return demonstration, of the use of trainer EpiPens (i.e., ones that do not contain any active medication) by learners is one way to help nurses confirm that learners are competent. Other methods, such as testing the knowledge of the theoretical component of the education using a quiz, could also be effective. Nurses need to use their judgment in determining the most appropriate way to assess competence in a given situation.

Q: How can we ensure that learners maintain competence after the initial teaching?

A: Nurses who teach a controlled act such as the administration of a medication by injection are responsible for knowing what provisions will be made in the work setting to evaluate learners’ continuing competence, and to make recommendations for provisions if none are in place.Teaching nurses would ensure that arrangements for follow-up are made. For example, nurses could ask: will an annual refresher be needed; how will new employees be educated on the procedure; should written material be reviewed, and how often; and, who should the school contact if questions arise after the teaching?

It’s important for nurses to know how the principal or school board plan to incorporate the monitoring of the use of EpiPens as part of the teachers’ ongoing professional development. Public health nurses may act as resources or provide resources for the ongoing monitoring of competence.

Q: If principals who we teach to use the EpiPen subsequently train the teachers, are we accountable for the quality of instruction provided by the principals?

A: Nurses are accountable for their decision to teach the procedure, for the quality of the teaching provided and for appropriately determining the competence of the learners at that point in time. Nurses should also indicate whether or not it is appropriate to teach others how to use the equipment and document that communication. If the nurse knows that the principal is teaching other staff members, the nurse would share some accountability with the principal for the quality of the teaching. If, however, the nurse is not informed of the principal’s plans to teach others, then the nurse would not be accountable.

Q: How do we document the teaching that we provide when teaching such large groups of learners?

A: As with most public health educational programs, a written, standardized teaching plan can be used as an important part of your documentation. This plan should include the purpose, objectives and expected outcomes to ensure that learners gain the appropriate knowledge, skill and judgment to administer the EpiPen safely and competently. If you teach according to the plan, then it would be adequate to have the teaching plan and a record of attendance, including the names of participants and the location of the session, as documentation. Your documentation should also include an evaluation of the teaching offered and a specific area for documentation of any advice, care or services provided to individuals within the group that deviated from the standardized teaching plan.

Q: Can we use an EpiPen on one child that belongs to another child?

A: Ultimately, patient safety is a nurse’s main concern. If the only available EpiPen is not the one of the child who has gone into anaphylaxis, then the decision to use someone else’s EpiPen would be in the best interest of the child in anaphylaxis. Nurses have to consider the circumstances of the particular situation, such as whether the entire group or class was exposed to an allergen, and whether using another child’s EpiPen would put that child at risk. It would be prudent to have additional EpiPens that may be used by a student as back-up in an emergency.

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