Title: Am. Nurses Ass'n v. Torlakson

State: california

Issuer: California Supreme Court

Document:

1 
Filed 8/12/13 
 
 
 
IN THE SUPREME COURT OF CALIFORNIA 
 
 
 
AMERICAN NURSES ASSOCIATION 
) 
et al., 
) 
 
 
) 
 
Plaintiffs and Respondents, 
) 
 
 
) 
S184583 
 
v. 
) 
 
 
) 
Ct.App. 3 C061150 
TOM TORLAKSON, as Superintendent,  
) 
etc., et al., 
)  
Sacramento County 
 
)  
Super. Ct. No. 07AS04631 
 
Defendants and Appellants; 
) 
 
 
) 
 
 
) 
AMERICAN DIABETES ASSOCIATION, ) 
 
 
) 
 
Intervener and Appellant. 
) 
 
____________________________________) 
 
Public school students with diabetes who cannot self-administer insulin are 
normally entitled under federal law to have it administered to them during the 
school day.  This case presents a dispute over whom state law permits to 
administer that insulin.  The dispute arises against the background of a long-
standing shortage of school nurses and a class action in federal court alleging the 
state‟s schools have failed to ensure diabetic students actually receive legally 
required health care services.  Pursuant to an agreement settling that litigation, the 
State Department of Education (Department) in 2007 advised local education 
agencies that trained school personnel who are not licensed health care providers 
may, when no nurse is available, administer insulin pursuant to the medical orders 
 
 
2 
of students‟ treating physicians.  (State Dept. of Ed., Legal Advisory on Rights of 
Students with Diabetes in California‟s K-12 Public Schools (2007) pt. IV.C 
 [as of Aug. 12, 2013] (2007 
Legal Advisory).)  In the case now before us, the American Nurses Association 
and other trade organizations representing registered and school nurses 
(collectively Nurses) challenge the Department‟s advice as condoning the 
unauthorized practice of nursing.  The American Diabetes Association 
(Association), which is a party to the federal settlement agreement, defends the 
Department‟s advice as intervener.   
In fact, California law expressly permits trained, unlicensed school personnel 
to administer prescription medications such as insulin in accordance with the 
written statements of a student‟s treating physician and parents (Ed. Code, 
§§ 49423, 49423.6; Cal. Code Regs., tit. 5, §§ 600, 604, subd. (b)) and expressly 
exempts persons who thus carry out physicians‟ medical orders from laws 
prohibiting the unauthorized practice of nursing (Bus. & Prof. Code, § 2727, subd. 
(e)).  Through these provisions, state law in effect leaves to each student‟s 
physician, with parental consent, the question whether insulin may safely and 
appropriately be administered by unlicensed school personnel, and reflects the 
practical reality that most insulin administered outside of hospitals and other 
clinical settings is in fact administered by laypersons.  The Nurses‟ arguments to 
the contrary lack merit.   
I. BACKGROUND 
The question whether California law permits unlicensed school personnel to 
administer medications is, like all questions of law, subject to de novo review.  
(See Bruns v. E-Commerce Exchange, Inc. (2011) 51 Cal.4th 717, 724.)  We thus 
draw freely from the undisputed evidence in setting out the facts of the case before 
us.   
 
 
3 
Diabetes is a chronic, incurable disease that prevents the human body from 
properly using food to produce energy.  Insulin, a hormone produced in the 
pancreas, transports glucose (a sugar derived from food) through the bloodstream 
to the cells.  In a person with diabetes, the body either does not produce insulin, or 
enough insulin (type 1 diabetes), or cannot use insulin properly (type 2 diabetes).  
All persons with type 1 diabetes and some with type 2 must take insulin to avoid 
serious short- and long-term health problems.  (See generally U.S. Dept. of Health 
& Human Services, Helping the Student with Diabetes Succeed:  A Guide for 
School Personnel (2010) p. 1 < http://www.ndep.nih.gov/media/youth_ 
schoolguide.pdf > [as of Aug. 12, 2013] (DHHS Guide).)  State law requires that 
nurses administer all medications, including insulin, in hospitals and other licensed 
health care facilities.  (Bus. & Prof. Code, § 2725.3.)  Outside of such facilities, 
however, insulin is normally administered by laypersons according to a 
physician‟s directions, most often by the diabetic persons themselves or by friends 
or family members.   
Public school students with diabetes who cannot self-administer insulin are 
normally entitled to have it administered to them at no cost.  This is a result of 
section 504 of the Rehabilitation Act of 1973 (29 U.S.C. § 794) (Section 504), title 
II of the Americans with Disabilities Act (42 U.S.C. § 12131 et seq.), and the 
Individuals with Disabilities Education Act (20 U.S.C. § 1400 et seq.) (IDEA).  
(See 28 C.F.R. § 35.104 (2013); 34 C.F.R. § 300.8(c)(9)(i) (2013) [defining 
diabetes as a disability].)  Public schools must offer to students covered by these 
laws a free and appropriate public education that includes related aids and 
services, such as medical services, designed to meet their individual educational 
needs.  (See 20 U.S.C. § 1400(d)(1)(a), 34 C.F.R. § 104.33(a), (b)(1) (2012) .) 
Under these laws, diabetic students pay for insulin, supplies and equipment but not 
the cost of administering insulin.  (See 34 C.F.R. 104.33(c)(1) [“the provision of a 
 
 
4 
free education is the provision of educational and related services without cost to 
the handicapped person or to his or her parents or guardian”]; Cedar Rapids 
Community School Dist. v. Garret F. (1999) 526 U.S. 66, 79 [school district must 
pay for required services].)  A school‟s obligations to a particular diabetic student 
are normally set out in a “Section 504 plan” or an “individualized education 
program” (IEP).   
Approximately one in 400 school-age children nationwide has diabetes, 
including about 14,000 in California.  The goal of diabetes management for 
children is to avoid both hyperglycemia (high blood glucose) and hypoglycemia 
(low blood glucose) by tightly maintaining blood glucose levels within target 
ranges determined by their physicians, through frequent monitoring and multiple 
daily insulin injections.  (DHHS Guide, p. 15.)  Accordingly, diabetic students 
who depend on insulin injections typically need them during the schoolday, both 
at regularly scheduled times and unpredictably to correct for fluctuations in blood 
glucose.  The need for insulin can arise anytime and anywhere — in the 
classroom, on field trips or during school-sponsored activities.  To serve this and 
other student health needs, California has about 2,800 school nurses, averaging 
one for every 2,200 of the state‟s approximately 6 million public school students.  
While 5 percent of schools have a full-time school nurse, 69 percent have only a 
part-time nurse, and 26 percent have no nurse at all.  Although some schools allow 
unlicensed school personnel to administer insulin, others do not.  Some of those 
that do not appear to have taken the position, possibly in reliance on 2005 and 
2006 advisory statements by the Department (see post, at p. 21 et seq.), that the 
Nursing Practice Act (Bus. & Prof. Code, § 2700 et seq.) permits only licensed 
health care providers to administer insulin in schools.  Moreover, some nurses 
have refused to train unlicensed school personnel to administer insulin out of 
concern for possible disciplinary action by the Board of Registered Nursing.  As a 
 
 
5 
result, diabetic students have encountered difficulty in receiving insulin during the 
schoolday.   
In October 2005, the parents of four diabetic students in California public 
schools, together with the Association, filed a class action in federal court alleging 
that schools in the Fremont Unified School District and the San Ramon Valley 
Unified School District had failed to meet their obligations to diabetic students 
under federal law.  (K.C. et al. v. O’Connell (N.D.Cal., C-05-4077MMC).)  The 
defendants included the Department, the State Superintendent of Public Instruction 
(Superintendent), the members of the State Board of Education (Board), and 
officials of the two named school districts.  Plaintiffs alleged the districts‟ schools 
had refused to prepare Section 504 plans for diabetic students, refused to include 
provisions for diabetes care in students‟ IEPs, refused to permit unlicensed school 
personnel to administer insulin when no nurse was available, and improperly 
required that parents or parental designees come to school to administer insulin.  
Because of these asserted violations of federal law, plaintiffs further alleged, some 
parents were required to forego employment and some students had to adopt 
insulin regimens that entailed less frequent injections, less effective control of 
blood glucose levels, and greater risks to their health.   
In July 2007, the plaintiffs in the federal litigation entered into a settlement 
agreement with the Department, the Superintendent and the Board.  The 
agreement required the Department, among other things, to fulfill its legal 
obligations to monitor local education agencies‟ compliance with Section 504 and 
the IDEA and to resolve complaints of noncompliance.  In addition, and more 
importantly for present purposes, the Department agreed to issue the 2007 Legal 
Advisory (see ante, p. 2) summarizing the rights of diabetic students under federal 
and state law.  The Department issued that document in August 2007, and the 
federal court dismissed the action.   
 
 
6 
In the 2007 Legal Advisory, as relevant here, the Department articulates eight 
categories of persons authorized to administer insulin to students in the state‟s 
public schools.  The Department describes the first seven categories as specifically 
authorized in statutory exceptions to the Nursing Practice Act (Bus. & Prof. Code, 
§§ 2725, subd. (b)(2), 2727, subd. (d)) and in a regulation concerning the 
administration of medication adopted by the Board (Cal. Code Regs., tit. 5, § 604).  
Briefly, those seven categories include:  (1) students who are able to self-
administer, (2) nurses and physicians employed by local education agencies, 
(3) other school employees who are appropriately licensed health care providers, 
(4) licensed nurses working pursuant to contracts with schools, (5) parents and 
guardians, (6) persons designated by parents or guardians who are volunteers but 
not school employees, and (7) trained, unlicensed school employees acting in 
emergencies.  (2007 Legal Advisory, pt. IV.A.)   
The 2007 Legal Advisory also recognizes that some students cannot self-
administer insulin, that licensed health care providers are not always available 
when needed, and that federal law does not permit schools to impose the cost of 
administering insulin on parents.  On that basis, the Department concludes as 
follows:  “When federal and state laws are reconciled, it is clear that it is unlawful 
for [a local education agency] to have a general practice or policy that asserts it 
need not comply with the IDEA or Section 504 rights of a student to have insulin 
administered at school simply because a licensed professional is unavailable.  In 
such situations, federal rights take precedence over strict adherence to state law so 
that the educational and health needs of the student protected by the Section 504 
Plan or IEP are met.”  (2007 Legal Advisory, par. IV.C.)  So concluding, the 
Department adds an eighth category of authorized persons, permitting insulin to be 
administered by a “voluntary school employee who is unlicensed but who has 
been adequately trained to administer insulin pursuant to the student‟s treating 
 
 
7 
physician‟s orders as required by the Section 504 Plan or the IEP.”  (2007 Legal 
Advisory, Checklist.)  The validity of the 2007 Legal Advisory‟s “category 8” is 
the crux of the present dispute.   
Two months after the Department issued the 2007 Legal Advisory, the 
Nurses challenged that document by filing the present action in the superior court 
seeking declaratory relief and a writ of mandate.  The Association responded with 
a complaint in intervention asking the court to dismiss the Nurses‟ action.  
Ultimately the court entered judgment for the Nurses.  Accepting their argument 
that state law does not authorize unlicensed school personnel to administer insulin, 
the court declared the 2007 Legal Advisory invalid to that extent and directed the 
issuance of a writ of mandate ordering the Superintendent and the Department not 
to enforce it.  The court also declared the same portion of the 2007 Legal Advisory 
invalid as a regulation adopted in violation of the Administrative Procedure Act 
(Gov. Code, § 11340 et seq.) (APA).  Finally, the court rejected the Association‟s 
argument that state law, if interpreted as forbidding unlicensed personnel to 
administer insulin, is preempted by Section 504 and the IDEA.   
The Association appealed.  The appeal automatically stayed the superior 
court‟s decision, leaving the 2007 Legal Advisory provisionally in effect pending 
the final outcome of these proceedings.  (Code Civ. Proc., § 916, subd. (a).)  The 
Court of Appeal affirmed the judgment and writ of mandate without reaching the 
APA issue.  We granted the Association‟s petition for review.  The Superintendent 
and District, who did not petition for review, support the Association‟s position as 
amici curiae.   
II. DISCUSSION 
The main question before us is whether California law permits unlicensed 
school personnel to administer insulin.  Our affirmative answer to that question 
leaves no need to decide whether federal law would preempt a contrary rule of 
 
 
8 
state law or whether the Department violated the APA in promulgating the 2007 
Legal Advisory.   
A. California Law.   
To determine whether unlicensed school personnel may administer 
prescription medications such as insulin, we first consult the body of law that 
expressly purports to answer the question:  Education Code section 49423 and its 
implementing regulations.  (All further undesignated citations to statutes are to this 
code.)  The statute declares the basic law:  “[A]ny pupil who is required to take, 
during the regular schoolday, medication prescribed for him or her by a physician 
and surgeon . . . may be assisted by the school nurse or other designated school 
personnel . . . .”  (§ 49423, subd. (a), italics added.)  The same statute ensures that 
medications are administered only in accordance with medical orders and parental 
consent:  “In order for a pupil to be assisted by a school nurse or other designated 
school personnel pursuant to subdivision (a), the school district shall obtain both a 
written statement from the physician . . . detailing the name of the medication, 
method, amount, and time schedules by which the medication is to be taken and a 
written statement from the parent, foster parent or guardian of the pupil indicating 
the desire that the school district assist the pupil in the matters set forth in the 
statement of the physician . . . .”  (Id., subd. (b), italics added.)  Section 49423 
expressly applies “[n]otwithstanding section 49422,” which provides more 
generally that only licensed health care providers may be “permitted to supervise 
the health and physical development of pupils” (§ 49422, subd. (a)).   
In adopting section 49423, the Legislature repealed and reenacted former 
section 11753.1.  (Stats. 1968, ch. 681, § 1, p. 1378, repealed and reenacted as 
§ 49423 by Stats. 1976, ch. 1010, § 2, p. 3615.)  The Legislature‟s reason for 
authorizing school personnel to administer medications, according to the original 
statute‟s legislative history, was to avoid requiring children “to leave school 
 
 
9 
during the day for necessary medication” or compelling their parents “to pay extra 
sums for a school visit by the physician.”  (Assem. Ed. Com., Analysis of Assem. 
Bill No. 1066 (1968 Reg. Sess.) p. 1.)   
Section 49423, like its statutory predecessor, did not require implementing 
regulations and was thus self-executing.  In the ensuing decades, however, some 
schools refused to administer prescribed medication to students.  Noting this, the 
Superintendent in a 1997 letter to school superintendents reminded local school 
administrators that federal law permitted students to receive medication during the 
schoolday, and that medication could properly be administered by unlicensed 
“personnel who have been appropriately trained by a credentialed school nurse, 
public health nurse, or physician.”  (Superintendent Eastin, letter to 
superintendents of schools (Sept. 5, 1997) p.  2.)  Three years later, the same 
problem came to the attention of the Legislature.  A Senate floor analysis, 
recognizing that “federal case law requires districts to accept responsibility to 
administer necessary medications,” reported complaints that “some districts „have 
required parents to sign illegitimate blanket waivers that sign away their children‟s 
right to medical treatment at school as a condition of enrollment or attendance.  In 
these instances, parents have been forced to take time off work to go to school and 
deliver the medications.‟ ”  (Sen. Rules Com., Analysis of Sen. Bill No. 1549 
(1999-2000 Reg. Sess.) Aug. 14, 2000, p. 3.)  To provide additional clarity, the 
Legislature directed the Department to develop and recommend, and the Board to 
adopt, regulations “regarding the administration of medication in the public 
schools pursuant to section 49423.”  (§ 49423.6, subd. (a), added by Stats. 2000, 
ch. 281, § 2, p. 2477.)   
Obeying the Legislature‟s command, the Board in 2003 adopted sections 600 
to 611 of title 5 of the California Code of Regulations.  (All further references to 
title 5 are to that code.)  These regulations expressly declare that unlicensed school 
 
 
10 
personnel may administer medications.  Section 604 provides:  “(a) A school nurse 
may administer medication to a pupil or otherwise assist a pupil in the 
administration of medication as allowed by law and in keeping with applicable 
standards of professional practice.  [¶]  (b) Other designated school personnel may 
administer medication to pupils or otherwise assist pupils in the administration of 
medication as allowed by law and, if they are licensed health care professionals, in 
keeping with applicable standards of professional practice for their license.”  (Tit. 
5, § 604, subd. (b), italics added.)  Section 601 defines the “ „[o]ther designated 
school personnel‟ ” who are thus authorized to act as “includ[ing] any individual 
employed by the local education agency who:  [¶]  (1) Has consented to administer 
the medication to the pupil or otherwise assist the pupil in the administration of the 
medication; and  [¶]  (2) May legally administer the medication to the pupil or 
otherwise assist the pupil in the administration of the medication.”  (Id., § 601, 
subd. (e), italics added.)  Other sections of title 5 provide for such related matters 
as medication logs and records, the contents of the physicians‟ and parents‟ 
required written statements, and the delivery, storage and disposal of medications.  
(Id., §§ 601-609.)   
Thus, section 49423 and its implementing regulations plainly establish, as the 
Legislature, the Board and the Department intended, that unlicensed school 
personnel may administer prescription medications.  The Nurses do not contend 
the Board‟s regulations are invalid, but they do offer a variety of arguments for 
interpreting them other than according to their plain meaning.  None is persuasive.   
1. “[A]s allowed by law.”   
In permitting school personnel other than licensed health care providers to 
administer medication, sections 601 and 604 of title 5 qualify that permission with 
language deferring to other laws governing the subject.  Specifically, section 604 
provides that “[o]ther designated school personnel may administer medication to 
 
 
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pupils . . . as allowed by law.”  (Id., subd. (a), italics added.)  Similarly, section 
601 limits such “ „[o]ther designated school personnel‟ ” to those who “[m]ay 
legally administer the medication to the pupil . . . .”  (Id., subd. (e)(2), italics 
added.)  The Nurses contend the italicized language means that only those school 
personnel who are licensed health care providers, such as registered nurses, may 
administer medications, and that unlicensed personnel may assist but not actually 
administer medications.  By way of illustration, the Nurses assert that unlicensed 
school personnel “are permitted to open a bottle of cough syrup and pour the 
prescribed dose but cannot pour it down the student‟s throat,” or they may monitor 
a diabetic student‟s glucose levels and determine the correct dosage of insulin but 
may not administer the drug by giving the injection or pushing the button on an 
insulin pump.   
The Nurses have misinterpreted the regulations.  Before explaining that 
conclusion, however, and in order to clarify the scope of our holding, we note that 
one significant premise of the Nurses‟ argument is correct:  There is no reason to 
believe the Legislature intended to delegate to the Board, a state educational 
agency charged with governing the public schools (see §§ 33000, 33031), any 
authority to override statutes in which the Legislature has required specific 
licensure before a person may perform a health care function.  We assume the 
Board shares this understanding.  In section 610 of title 5, the Board explains that 
“[n]othing in this article may be interpreted as . . . affecting in any way:  [¶]  
(a) The statutes, regulations, or standards of practice governing any health care 
professional licensed by the State of California in the carrying out of activities 
authorized by the license . . . .”  Viewed in this light, the language in the Board‟s 
regulations that qualifies the authority of unlicensed school personnel to 
administer medications — “as allowed by law” (tit. 5, § 604, subd. (a); see also 
id., § 601, subd. (e)(2)) — is reasonably and appropriately interpreted as reflecting 
 
 
12 
the Board‟s deference to laws articulating policy choices that lie beyond the scope 
of its delegated authority over the state‟s public schools.   
This does not mean, however, that only licensed health care professionals 
may administer prescription medications in public schools.  It means, rather, only 
that the Board‟s regulations do not authorize unlicensed school personnel to 
administer such medications in violation of other applicable laws or regulations.  
To illustrate, only licensed health care providers may administer controlled 
substances.  (See Health & Saf. Code, § 11154, subd. (a).)  Also, the Legislature 
has mandated specific training before unlicensed school personnel may administer 
three specially regulated emergency medications to students.  (See §§ 49414 
[epinephrine auto-injectors for anaphylaxis], 49414.5 [glucagon for severe 
hypoglycemia] and 49414.7 [antiseizure medication for epilepsy].)  A school 
employee without the licensure or training required by statute for such 
medications would not be “allowed by law” (tit. 5, § 604, subd. (a)) to administer 
them and, thus, not permitted to do so solely by force of the Board‟s regulations.  
Compliance with those other laws would also be necessary.   
In contrast, no such law prohibits unlicensed persons from administering 
prescription medications generally, or insulin in particular, in carrying out the 
medical orders of licensed physicians.  The Nurses attempt to find such a rule in 
the Nursing Practice Act (Bus. & Prof. Code, § 2700 et seq.) (NPA), which 
defines the practice of nursing to include a list of patient care functions including 
“the administration of medications” (id., § 2725, subd. (b)(2)), and prohibits the 
unauthorized practice of nursing (id., § 2732).  In opposition, the Association 
contends the listed functions fall within the definition of nursing practice only 
under circumstances where they “require a substantial amount of scientific 
knowledge or technical skill.”  (id., § 2725, subd. (b) [“The practice of nursing 
within the meaning of this chapter means those functions, including basic health 
 
 
13 
care, that help people cope with difficulties in daily living that are associated with 
their actual or potential health or illness problems or the treatment thereof, and 
that require a substantial amount of scientific knowledge or technical skill, 
including all of the following:  . . .” (italics added).].)  The routine administration 
of insulin outside of hospitals and clinical settings, the Association observes, does 
not require substantial scientific knowledge or technical skill and is, in fact, 
typically accomplished by the patients themselves, including some children, or by 
friends and family members.   
We need not speak to the definition of nursing practice in order to resolve 
this case.  However broadly the NPA may define the practice of nursing, and 
whatever the NPA may correlatively prohibit as unauthorized practice, the NPA 
expressly exempts from that prohibition “[t]he performance by any person of such 
duties as required in . . . carrying out medical orders prescribed by a licensed 
physician . . . .”  (Bus. & Prof. Code, § 2727, subd. (e).)  This medical-orders 
exception, as we shall explain, is broad enough to cover unlicensed school 
personnel who act as volunteers for specific students, at their parents‟ request, to 
carry out physicians‟ medical orders in accordance with section 49423 and its 
implementing regulations.   
2. The Medical-orders Exception.   
The medical-orders exception provides in full as follows:  “This chapter [the 
NPA] does not prohibit:  [¶]  . . .  [¶] (e) The performance by any person of such 
duties as required in the physical care of a patient and/or carrying out medical 
orders prescribed by a licensed physician; provided, such person shall not in any 
way assume to practice as a professional, registered, graduate or trained nurse.”  
(Bus. & Prof. Code, § 2727, subd. (e), italics added.)  The meaning of the first 
clause and its application to this case are clear:  Unlicensed school personnel 
acting pursuant to section 49423 and its implementing regulations “perform[] . . . 
 
 
14 
duties as required . . . in carrying out medical orders . . . .”  (Bus. & Prof. Code, 
§ 2727, subd. (e).) What the italicized proviso means is less clear, especially in its 
use of the word “assume.”  On this point the legislative history is uninformative, 
reflecting only that section 2727 was added as part of the original NPA (Stats. 
1939, ch. 807, § 2, p. 2349), and that the medical-orders exception was added on 
the Assembly floor for unrecorded reasons (Assem. J. (1939) p. 515).   
The Nurses argue a person “assume[s] to practice as a . . . registered . . . 
nurse” (Bus. & Prof. Code, § 2727, subd. (e)) simply by performing any health 
care function that falls within the NPA‟s definition of nursing practice (id., § 2725, 
subd. (b)).  But this cannot be what the proviso means, as it would vitiate the 
medical-orders exception.  A person who carries out a physician‟s medical orders 
with respect to a patient does not need an exception from the laws prohibiting 
unauthorized practice unless his or her conduct would otherwise violate those 
laws.  To adopt the Nurses‟ interpretation would thus render the exemption 
entirely meaningless — a result we would hesitate to accept “unless absolutely 
necessary.”  (E.g., People v. Arias (2008) 45 Cal.4th 169, 180.)  But we need not 
accept it.  The statute‟s language, broader statutory context and interpretive history 
all point to a different meaning:  To “assume to practice as a professional, 
registered, graduate or trained nurse” (Bus. & Prof. Code, § 2727, subd. (e)), 
means to hold oneself out, explicitly or implicitly, as being a nurse in fact.     
We begin with the language.  To “assume” to do a thing has two possible 
meanings in the present context.  It might mean to “undertake” to do a thing, or 
“[t]o take [a thing] upon oneself” — in effect simply to do it.  (Oxford Eng. Dict. 
Online (2013) definition II.4.a; see Webster‟s 3d New Internat. Dict. (2002) 
p. 133, definition 2.)  Alternatively, to “assume” might mean “[t]o put forth claims 
or pretensions,” to do a thing “in appearance only, . . . to pretend, simulate, feign.”  
(Oxford Eng. Dict. Online, supra, definition III.8, 9; see Webster‟s 3d New 
 
 
15 
Internat. Dict., supra, at p. 133, definition 4.)  Building upon the former definition 
(“undertake”), the Nurses contend a person “assumes to practice as a . . . nurse” 
(Bus. & Prof. Code, § 2727, subd. (e)) by undertaking to perform — in other 
words, simply by performing — any of the patient care functions listed in the 
NPA‟s definition of nursing (id., § 2725, subd. (b)(2)).  This interpretation, as 
noted, cannot be correct as it would leave the medical-orders exception without 
meaning.   
In contrast, the medical-orders exception does have meaning if one 
“assume[s] to practice as a . . . nurse” (Bus. & Prof. Code, § 2727, subd. (e)) by 
holding oneself out, explicitly or implicitly, as being a nurse in fact.  The broader 
statutory context supports this interpretation.  The list of statuses an unlicensed 
person who carries out medical orders may not “assume” — “professional, 
registered, graduate or trained nurse” (ibid.) —indicates that one may not evade 
the rule against falsely posing as a registered nurse by substituting a vaguer term 
such as “professional,” “graduate” or “trained.”  A penal provision enacted by the 
same Legislature in the same bill as the medical-orders exception similarly 
declared it “unlawful for any person or persons not licensed as provided in this 
chapter to impersonate in any manner or pretend to be a professional nurse, or to 
use the title „registered nurse,‟ the letters „R.N.,‟ or the words „graduate nurse,‟ 
„trained nurse,‟ or any other name, word or symbol in connection with or 
following his [or her] name so as to lead another or others to believe that he [or 
she] is a professional nurse.”  (Id., former § 2796, added by Stats. 1939, ch. 807, 
§ 2, p. 2356; see Bus. & Prof. Code, § 2796 [current version, adding “nurse 
anesthetist” to the list of titles one may not falsely assume].)  The order in which 
the bill‟s provisions were drafted suggests the Assembly looked to the penal 
provision, and even borrowed some of its terms, in drafting the floor amendment 
that added the medical-orders exception.  (Compare Assem. Bill No. 620 (1939 
 
 
16 
Reg. Sess.) § 2, p. 11, as introduced Jan. 13, 1939 [adding Bus. & Prof. Code, 
§ 2796], with Assem. J. (1939) p. 515 [floor amend. of Mar. 13, 1939, adding Bus. 
& Prof. Code, § 2727, subd. (e)].)   
The broader statutory context provides additional evidence supporting our 
conclusion.  The same section of the NPA that contains the medical-orders 
exception (Bus. & Prof. Code, § 2727, subd. (e)) also creates a narrower exception 
covering “[i]ncidental care of the sick by domestic servants or by persons 
primarily employed as housekeepers as long as they do not practice nursing within 
the meaning of this chapter.”  (Id., subd. (b), italics added.)  Read in the context of 
the whole statute, the italicized language expresses the thought that domestic 
servants and housekeepers caring for sick persons may not perform nursing 
functions, without regard to how they hold themselves out.  The Nurses would 
interpret the medical-orders exception similarly, yet the same Legislature, in the 
same act and section, chose the different words — “assume to practice as a . . . 
nurse” — (ibid., italics added) to qualify the exception for unlicensed persons who 
merely carry out medical orders.  The inescapable inference is that the Legislature, 
by using different words to define the two exceptions, intended them to have 
different meanings.   
The single prior interpretation of the medical-orders exception is consistent 
with our conclusion.  The Attorney General has described that exception, and the 
NPA‟s related penal provisions, as “show[ing] a legislative intent to prohibit any 
person from holding out to the public that [he or] she is specially trained or 
registered in the nursing profession unless said person is licensed by the state of 
California in this field.”  (Registered Nurse, 32 Ops.Cal.Atty.Gen. 159, 160 
(1958), referring to Bus. & Prof. Code, §§ 2727, subd. (e) [medical-orders 
exception; unlicensed person carrying out medical orders may not assume to 
practice as a nurse], 2795 [unlawful to use any title, sign, card or device to indicate 
 
 
17 
nursing licensure], and 2796 [unlawful to use the titles “registered,” “graduate” or 
“trained nurse,” or the letters “R.N.”].)  Thus, the Attorney General concluded, an 
unlicensed person employed by a physician as a “doctor‟s nurse” was forbidden to 
use titles confusingly similar to “registered nurse,” such as “ „Registered Doctor‟s 
Nurse‟ or the abbreviation „R.D.N.‟ or any title, or wear or display any pin that 
would indicate that said person is duly licensed as a registered nurse under the 
laws of the state of California.”  (Registered Nurse, supra, at p. 159; cf. Kolnick v. 
Board of Medical Quality Assurance (1980) 101 Cal.App.3d 80, 84 [declining to 
construe the exception].)   
For all of these reasons, we conclude the medical-orders exception does 
permit a layperson to carry out a physician‟s medical orders for a patient, even 
orders that would otherwise fall within the definition of nursing practice, without 
thereby violating the rule against unauthorized practice.  To fall outside the 
exception by “assum[ing] to practice as a . . . nurse” (Bus. & Prof. Code, § 2727, 
subd. (e)), one must go further by holding oneself out, explicitly or implicitly, to 
be a nurse in fact.  This conclusion disposes of the issue, because unlicensed 
school personnel do not hold themselves out to be nurses simply by volunteering 
to act on behalf of particular students in accordance with the Education Code and 
its implementing regulations.   
We thus proceed to consider the Nurses‟ remaining objections to the 
conclusion that such personnel may administer medications.   
3. Medication-specific Statutes.   
In statutes enacted between 2001 and 2011, the Legislature imposed 
additional training and administrative requirements before unlicensed school 
personnel may administer three specific emergency medications:  epinephrine 
auto-injectors to treat anaphylaxis (§ 49414, added by Stats. 2001, ch. 458, § 2, 
p. 4023), glucagon for severe hypoglycemia (§ 49414.5, added by Stats. 2003, ch. 
 
 
18 
684, § 1, as subsequently amended), and antiseizure medication for epilepsy 
(§ 49414.7, added by Stats. 2011, ch. 560, § 2).  Each of these statutes, while 
expressing the Legislature‟s preference that registered nurses administer the 
subject medications whenever possible, expressly permits trained, unlicensed 
school personnel to do so when no nurse is available.  (See §§ 49414, subd. (f)(1), 
49414.5, subd. (a), 49414.7, subds. (a), (b).)   
The Nurses contend these statutes would not have been necessary if the 
NPA‟s medical-orders exception already, by its own force, permitted unlicensed 
school personnel to administer medications.  “[T]he Legislature,” the Nurses 
observe, “does not engage in idle acts.”  (Citing California Teachers Assn. v. 
Governing Bd. of Rialto Unified School Dist. (1997) 14 Cal.4th 627, 634.)  The 
maxim is valid, but its application is flawed.  Having generally authorized 
unlicensed school personnel to administer medications (§ 49423) and directed the 
Board to adopt implementing regulations (§ 49423.6), the Legislature nevertheless 
retained the power to impose additional restrictions on drugs deemed to justify 
special precautions.  Nothing in section 49423 or 49423.6 conditioned the 
effectiveness of those statutes on further legislation, and nothing in the later-
enacted, drug-specific statutes repeals the general authority granted in the earlier, 
more general provisions.  So understood, none of the relevant statutes represents 
an idle act.  In contrast, to accept the Nurses‟ argument would entail the 
implausible conclusion that the Legislature had intended section 49423 and its 
1968 statutory predecessor (former § 11753.1; see ante, at p. 8) to lie dormant and 
ineffective until the Legislature enacted the first drug-specific statute 33 years 
later.  (§ 49414 [concerning epinephrine auto-injectors].)  History is to the 
contrary.  As we have seen, the 1968 Legislature intended the original statute to be 
self-executing, and the 2000 Legislature, to force compliance, directed the Board 
 
 
19 
to adopt implementing regulations in short order.  (See § 49423.6 [“[o]n or before 
June 15, 2001”]; see also ante, at p. 9.)   
4. Failed Legislation.   
Despite the foregoing evidence to the contrary, amici curiae supporting the 
Nurses urge us to infer from a variety of failed bills that the Legislature believes 
further, specific legislation is necessary before unlicensed school personnel may 
administer insulin.  Because section 49423 and its implementing regulations 
plainly do authorize such personnel to administer prescription medications and 
were in fact adopted for that purpose, “to undertake the problematic exercise of 
inferring legislative intent from subsequent, failed legislation seems especially 
inappropriate . . . .”  (Martin v. Szeto (2004) 32 Cal.4th 445, 451-452.)  In any 
event, we find nothing in the failed bills‟ history that supports amici curiae‟s 
argument.   
Assembly Bill No. 481 (2001-2002 Reg. Sess.) would have required school 
administrators and other designated, unlicensed personnel to be trained to 
administer insulin and required them to administer it, in the absence of a school 
nurse, in accordance with guidelines on diabetes care to be developed by a group 
of seven state and private organizations.  The Governor vetoed the bill, explaining 
his reasons as follows:  “Existing law already provides that any pupil who is 
required to take prescription medication during the regular school day may be 
assisted by school personnel if a written statement is obtained from a physician 
and a written request is made by the pupil‟s parent/guardian.  [¶]  This bill, while 
well-intentioned, would create a costly new state reimbursable mandate estimated 
by the Department of Finance to be potentially tens of millions of dollars.  Neither 
this bill, nor the 2002 Budget Act contains an appropriation for this purpose.”  
(Governor‟s veto message to Assem. on Assem. Bill No. 481 (Sept. 26, 2002) 6 
Assem. J. (2001-2002 Reg. Sess.) pp. 8872-8873 [in relevant part].)   
 
 
20 
This history does not show the Legislature in 2002 — let alone in 1968 and 
1976 when it enacted and reenacted the operative language of section 49423 — 
believed that further, more specific legislation was required to permit unlicensed 
school personnel to administer any prescription medication.  To the contrary, the 
Legislative Counsel‟s Digest of the vetoed 2002 bill noted that “[e]xisting law 
provides that any pupil who is required to take . . . medication . . . may be assisted 
by the school nurse or other designated school personnel,” and explained that the 
bill “would specifically make those provisions applicable to a pupil with diabetes” 
under guidelines to be developed later.  (Legis. Counsel‟s Dig., Assem. Bill. No. 
481 (2001-2002 Reg. Sess.), italics added.)  The bill was, thus, analogous to other 
statutes in which the Legislature has imposed, for particular medications (e.g., 
epinephrine, glucagon and antiseizure medication), additional restrictions on 
schools‟ use of the general authority concerning medications granted in section 
49423.  The Legislature‟s unsuccessful attempt to impose comparable restrictions 
on insulin did not abrogate the existing general authority.   
Three additional failed bills did not come to a vote.  Senate Bill No. 1487 
(2007-2008 Reg. Sess.) would have amended section 49414.5, which permits 
unlicensed school personnel with special training to administer glucagon in 
emergencies, to administer insulin under similar conditions.  (Assem. Bill No. 
1487, supra, § 1.)  Another bill, Assembly Bill No. 1802 (2009-2010 Reg. Sess.), 
while expressly authorizing unlicensed personnel to administer insulin, would 
have permitted parents, rather than school administrators, to designate the school 
employees who would be allowed to administer insulin.  (Ibid., § 2.)  Finally, 
Assembly Bill No. 1430 (2009-2010 Reg. Sess.) would have provided that no one 
other than licensed health care providers would be allowed to administer any 
medications in schools, except in emergencies.  (Id., § 2.)  Because none of these 
bills came to a vote, and because the Legislature‟s cursory deliberations on them 
 
 
21 
postdated section 49423‟s enactment by decades, none provides a sound basis for 
inferring the 1968 and 1976 Legislatures‟ intents on the question whether section 
49423 permits unlicensed personnel to administer insulin.   
5. The Department’s 2005 and 2006 Advisory Statements.   
In 2005 and 2006, the Department issued advisory statements recommending 
that school personnel other than licensed health care providers not administer 
medications by injection generally (2005) or insulin in particular (2006).  (State 
Dept. of Ed., Program Advisory on Medication Administration (May 2005) p. 7 
 [as of Aug. 12, 
2013] (2005 Program Advisory); State Dept. of Ed., Medication Administration 
Assistance in California . . . Frequently Asked Questions (2006) p. 1 (2006 FAQ).)  
The Nurses contend we should defer to these recommendations as authoritative 
interpretations of section 49423 by an agency charged with its enforcement.  But 
the Department‟s advisory statements are not entitled to the same judicial 
deference as the binding, quasi-legislative regulations formally adopted by the 
Board.  (Tit. 5, §§ 600-611; see § 49423.6 [regulatory authority].)  “An agency 
interpretation of the meaning and legal effect of a statute is entitled to 
consideration and respect by the courts; however, unlike quasi-legislative 
regulations adopted by an agency to which the Legislature has confided the power 
to „make law,‟ and which, if authorized by the enabling legislation, bind this and 
other courts as firmly as statutes themselves, the binding power of an agency‟s 
interpretation of a statute or regulation is contextual:  Its power to persuade is both 
circumstantial and dependent on the presence or absence of factors that support the 
merit of the interpretation.”  (Yamaha Corp. of America v. State Bd. of 
Equalization (1998) 19 Cal.4th 1, 7.)   
Reviewing the 2005 Program Advisory and the 2006 FAQ under these 
principles, we find they lack persuasive force.  Before explaining that conclusion, 
 
 
22 
however, we note those documents do not reflect the Department‟s current 
position.  In their amicus curiae brief to this court, the Department and the 
Superintendent maintain that section 49423 and its implementing regulations (tit. 
5, §§ 600-611), in combination with the NPA‟s medical-orders exception (Bus. & 
Prof. Code, § 2727, subd. (e)), do indeed permit unlicensed school personnel to 
administer insulin.  With that clarification, we turn to the documents in question.   
In its 2005 Program Advisory, the Department confirmed that unlicensed 
personnel may administer medications generally but “recommend[ed] that . . . 
unlicensed staff member[s] . . . not administer medications that must be 
administered by injection . . . .”  (Id., at p. 7.)  The 2005 Program Advisory‟s 
recommendations are nonbinding, both because the document so states (id., at 
p. 1) and as a matter of law.  (See § 33308.5 [“Program guidelines issued by the 
[Department] shall be designed to serve as a model or example, and shall not be 
prescriptive”]; tit. 5, § 611 [“The [Department], with the approval of the [Board], 
may issue and periodically update an advisory providing non-binding guidance on 
the administration of medication . . . .  The advisory shall be a program guideline 
under . . . section 33308.5 . . . .”].)  The 2005 document offers no discussion or 
analysis of its recommendation concerning injections and cites no authority that 
might support it.  The document does cite section 49423 and sections 600, 601 and 
604 of title 5 (2005 Program Advisory, at p. 6), which, as we have seen, were 
specifically intended to permit unlicensed personnel to administer medications, 
and none of which forbids administration by injection.  The document also cites 
statutes describing the specific licensure required of physicians, nurses and other 
health care providers employed as such in the schools (§§ 44871, 44873-44878), 
and also section 49422, which provides that only licensed health care providers 
and certain other persons with relevant credentials “shall be . . . employed or 
permitted to supervise the health and physical development of pupils . . . .”  (2005 
 
 
23 
Program Advisory, at p. 6.)  As already noted, however, section 49422 cannot 
mean that only licensed health care providers may administer medications in 
schools because section 49423 expressly applies “[n]otwithstanding Section 
49422.”  (§ 49423, subd. (a).)   
Unlike the 2005 Program Advisory, which the Department issued with the 
Board approval required for such documents (see § 33308.5 and tit. 5, § 611), the 
Department apparently issued the 2006 FAQ unilaterally.  In that document, the 
Department flatly asserts that unlicensed school personnel may not administer 
insulin.  (2006 FAQ, at p. 1.)  Ignoring its own conclusion just one year earlier that 
unlicensed personnel may administer medications generally, even if not by 
injection, the Department in the 2006 FAQ wrote that “[n]o . . . California statute” 
other than sections 49414 (epinephrine auto-injectors) and 49414.5 (glucagon) 
“allows an unlicensed school employee to administer any other medication in 
California public schools, even if the unlicensed school employee is trained and 
supervised by a school nurse or other similarly licensed nurse.”  (2006 FAQ, at 
p. 1, italics added.)  In attempting to justify this conclusion, the Department 
inexplicably cited section 49423 (2006 FAQ, at p. 2, fn. 2) and omitted any 
reference to the statute‟s implementing regulations (e.g., tit. 5, § 604, subd. (b) 
[“Other designated school personnel may administer medication to pupils”]).   
In its 2006 FAQ, the Department also invoked the NPA as authority for the 
following assertion:  “California law states, with a few clearly specified legal 
exceptions, that only a licensed nurse or physician may administer medication.  In 
the school setting, these exceptions are situations where [¶] The student self-
administers the medication, [¶] A parent or parent designee, such as a relative or 
close friend, administers the medication, or [¶] There is a public disaster or 
epidemic.”  (2006 FAQ, at p. 1, fns. omitted.)  The noted exceptions reflect 
statutory exceptions to the NPA.  (Bus. & Prof. Code, § 2727, subds. (a) 
 
 
24 
[gratuitous nursing by friends or family members], (d) [nursing services in 
emergencies].)  But the document entirely overlooks the medical-orders exception, 
which expressly permits “any person [to perform] . . . such duties as required in 
. . . carrying out medical orders prescribed by a licensed physician . . . .”  (Id., 
subd. (e).)   
Viewing the 2005 Program Advisory and the 2006 FAQ in their full legal 
context, we conclude the documents‟ recommendations are not entitled to judicial 
deference to the extent they might be thought to preclude unlicensed school 
personnel from administering insulin.  The 2005 Program Advisory makes no 
serious effort to reconcile its recommendation concerning injections with the 
applicable statutes (§§ 49423, 49423.6) and binding regulations (tit. 5, §§ 601-
611), and ignores the NPA‟s medical-orders exception (Bus. & Prof. Code, 
§ 2727, subd. (e)).  The 2006 FAQ shares these faults and, in addition, both 
contradicts the 2005 Program Advisory‟s correct conclusion that unlicensed 
personnel may administer medications generally and also lacks the Board approval 
required for program guidelines.  (See § 33308.5; tit. 5, § 611.)  Under these 
circumstances, the documents‟ recommendations lack persuasive force on the 
question before us, and we thus do not defer to them.  (Yamaha Corp. of America 
v. State Bd. of Equalization, supra, 19 Cal.4th 1, 7.)  We recognize, however, that 
the 2005 Program Advisory constitutes an important source of advice for local 
education agencies on matters beyond the scope of this case, and we emphasize 
that we reject that document‟s recommendations only to the extent they contradict 
the views set out in this opinion.   
6. Conclusion.   
Finding no merit in the arguments to the contrary, we conclude California 
law does permit trained, unlicensed school personnel to administer prescription 
medications, including insulin, in accordance with written statements of individual 
 
 
25 
students‟ treating physicians, with parental consent (Ed. Code, §§ 49423, 49423.6; 
tit. 5, §§ 600-611), and that persons who act under this authority do not violate the 
NPA (see Bus. & Prof. Code, § 2727, subd. (e)).  Because schools may administer 
prescription medications only in accordance with physicians‟ written statements 
(§ 49423; tit. 5, § 600, subd. (a)), state law in effect delegates to each student‟s 
physician the decision whether insulin may safely and appropriately be 
administered by unlicensed school personnel or instead whether a particular 
student‟s medical needs can be met only by a licensed health care provider.  State 
law, however, presents no categorical obstacle to the use of unlicensed personnel 
for this purpose.   
In view of this conclusion, we need not address the Association‟s contention 
that federal law would preempt a contrary rule.   
B. The APA. 
The Nurses contend the 2007 Legal Advisory is ineffective on the theory the 
Department should have adopted it as a regulation in compliance with the APA.  
(Gov. Code, § 11340 et seq.)  The superior court agreed with the Nurses on this 
point.  The Court of Appeal, ruling for the Nurses on other grounds, did not reach 
the issue.   
We also do not reach the issue, for two reasons:  First, the Nurses forfeited 
the issue in this court by failing to file, in response to the petition for review, an 
answer raising it.  (See Cal. Rules of Court, rule 8.500(a)(2).)  While we have the 
power to address additional issues (id., rule 8.516(b)(1)), the briefs touch upon the 
APA issue only cursorily, and we have not requested additional briefing (cf. Cal. 
Rules of Court, rule 8.516 (b)(2)).   
Second, and more importantly, our holding that California law permits 
unlicensed school personnel to administer insulin authoritatively resolves the 
dispute independently of the 2007 Legal Advisory, based on the relevant 
 
 
26 
provisions of the Education Code and its implementing regulations.  We therefore 
need not determine whether the Department violated the APA in adopting the 
2007 Legal Advisory.  Our decision leaves the Department free to revise the Legal 
Advisory to reflect California law as we have interpreted it, and leaves the parties 
and the lower courts free to identify and resolve, if necessary, any issues that may 
remain concerning APA compliance.   
III. DISPOSITION 
The Court of Appeal‟s judgment is reversed and the case is remanded for 
further proceedings in accordance with the views set forth herein.   
  
 
 
 
WERDEGAR, J. 
WE CONCUR: 
 
KENNARD, Acting C. J. 
BAXTER, J. 
CHIN, J. 
CORRIGAN, J. 
LIU, J. 
McGUINESS, J. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
__________________ 
 
  
Presiding Justice of the Court of Appeal, First Appellate District, Division 
Three, assigned by the Chief Justice pursuant to article VI, section 6 of the 
California Constitution.  
 
 
 
See last page for addresses and telephone numbers for counsel who argued in Supreme Court. 
 
Name of Opinion American Nurses Association v. O‟Connell 
__________________________________________________________________________________ 
 
Unpublished Opinion 
Original Appeal 
Original Proceeding 
Review Granted XXX 185 Cal.App.4th 393 
Rehearing Granted 
 
__________________________________________________________________________________ 
 
Opinion No. S184583 
Date Filed: August 12, 2013 
__________________________________________________________________________________ 
 
Court: Superior 
County: Sacramento 
Judge: Lloyd Connelly 
 
__________________________________________________________________________________ 
 
Counsel: 
 
Remcho, Johansen & Purcell, Robin B. Johansen and Kari Krogseng for Defendants and Appellants. 
 
Reed Smith, James M. Wood, Paul D. Fogel, Dennis Peter Maio; Disability Rights Education and Defense 
Fund, Inc., Arlene Mayerson and Larisa Cummings for Intervener and Appellant. 
 
Remcho, Johansen & Purcell, Robin B. Johansen and Kari Krogseng for State Superintendent of Public 
Instruction Tom Torlakson and California Department of Education as Amici Curiae on behalf of 
Intervener and Appellant. 
 
Jason D. Russell, Allen L. Lanstra, George C. Fatheree and Allison B. Holcombe for Los Angeles Unified 
School District, Children‟s Rights Clinic, Disability Rights Advocates, Disability Rights California, 
Disability Rights Legal Center, Disability Rights Texas and The Legal Aid Society-Employment Law 
Center as Amici Curiae on behalf of Intervener and Appellant. 
 
Fagen Friedman & Fulfrost, Lenore A. Silverman, Kimberly A. Smith and Melissa L. Phung for California 
School Boards Association as Amicus Curiae on behalf of Intervener and Appellant. 
 
Claire Ramsey; Morrison & Foerster, Miriam A. Vogel, Benjamin J. Fox, Sheila L. Sadovnik and Lindsay 
M. Andrews for Child Care Law Center as Amicus Curiae on behalf of Intervener and Appellant. 
 
Cooley, Lori R. Mason, Maureen P. Alger, Brandon J. Kimura and Jon F. Cieslak for American 
Association of Diabetes Educators, the American Academy of Pediatrics Section on Endocrinology, 
California District of the American Academy of Pediatrics, The Endocrine Society and the Pediatric 
Endocrine Society as Amici Curiae on behalf of Intervener and Appellant. 
 
U.S. Department of Education, Charles P. Rose, General Counsel; Thomas E. Perez, Assistant Attorney 
General (United States), Samuel R. Bagenstos, Principal Deputy Assistant Attorney General, Gregory B. 
Friel and April J. Anderson for United States as Amicus Curiae on behalf of Intervener and Appellant. 
 
 
 
 
 
 
 
 
Page 2 – S184583 – counsel continued 
 
Counsel: 
 
Pamela Allen, Brendan White; Alice L. Bodley, Jocelyn Winston, Maureen E. Cones; Pillsbury Winthrop 
Shaw Pittman, John S. Poulos, Carrie L. Bonnington and Kevin M. Fong for Plaintiffs and Respondents. 
 
Cummins & White and Melanie L. Balestra for National Association of School Nurses, American 
Occupational Therapy Association, Inc., Arkansas School Nurses Association, Association of 
periOperative Registered Nurses, Association of School Nurses of Connecticut, California Association for 
Nurse Practitioners, California School Health Centers Association, California Teachers Association, 
Coalition of Labor Union Women, Colorado Association of School Nurses, Delaware School Nurses 
Association, Emergency Nurses Association, Florida Association of School Nurses, Georgia Association of 
School Nurses, Illinois Association of School Nurses, Illinois Nurses Association, Indiana Association of 
School Nurses, Iowa School Nurses Organization, Kentucky School Nurses Association, Maine 
Association of School Nurses, Maryland Association of School Health Nurses, Massachusetts School 
Nurse Association, Michigan Association of School Nurses, National Association of Pediatric Nurse 
Practitioners, National Association of State School Nurse Consultants, National Board for Certification of 
School Nurses, Nebraska School Nurse Association, Nevada State Association of School Nurses, New 
Hampshire School Nurse Association, New Jersey State School Nurses Association, New Mexico School 
Nurses Association, New York State Association of School Nurses, Ohio Association of School Nurses, 
Pennsylvania Association of School Nurses and Practitioners, Rhode Island Certified School Nurse 
Teachers, Rhode Island Institute for Nursing, Rhode Island State Nurses Association, School Nurse 
Organization of Arizona, School Nurse Organization of Idaho, School Nurse Organization of Minnesota, 
School Social Work Association of America, South Carolina Association of School Nurses, Tennessee 
Association of School Nurses, Utah School Nurse Association, Vermont State School Nurses Association, 
Virginia Association of School Nurses, West Virginia Association of School Nurses, Wisconsin 
Association of School Nurses and Wyoming School Nurses Association as Amici Curiae on behalf of 
Plaintiffs and Respondents. 
 
Lisa C. Demidovich for United Nurses Associations of California/Union of Health Care Professionals 
NUHHCE, AFSCME, AFL-CIO as Amicus Curiae on behalf of Plaintiffs and Respondents. 
 
Laura P. Juran; David J. Strom; Michael R. Clancy, Arnie R. Braafladt; Altshuler Berzon and Jeffrey B. 
Demain for California Teachers Association, American Federation of Teachers, California Federation of 
Teachers and California School Employees Association as Amici Curiae on behalf of Plaintiffs and 
Respondents. 
 
Cummins & White, Karen L. Taillon; Vedder Price and Thomas G. Abram for National Council of State 
Boards of Nursing, Inc., as Amicus Curiae on behalf of Plaintiffs and Respondents. 
 
 
 
 
 
 
 
 
 
 
Counsel who argued in Supreme Court (not intended for publication with opinion): 
 
Dennis Peter Maio 
Reed Smith 
101 Second Street, Suite 1800 
San Francisco, CA  94105 
(415) 543-8700 
 
Maureen E. Cones 
American Nurses Association 
8515 Georgia Avenue, Suite 400 
Silver Springs, MD  20910 
(301) 628-5123 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
                                              
 
  
Presiding Justice of the Court of Appeal, First Appellate District, Division 
Three, assigned by the Chief Justice pursuant to article VI, section 6 of the 
California Constitution.