The Journal of School Nursing2024, Vol. 40(4) 446–451© The Author(s) 2022Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405221100665journals.sagepub.com/home/jsn
Abstract
The number of school-aged students with diverse linguistic and cultural backgrounds is increasing across the United States. This survey identifies strategies school nurses use for communicating to families with limited English proficiency and describes recommendations to improve language needs. The online survey was completed by K–12 school nurses and data were analyzed using descriptive statistics. Among the 52 participants, only 23% (n = 12) indicated that resources they were currently using to interpret health information always met their language needs, with the most common resource described as school personnel who can speak the language needed for interpretation. To improve communication, most (73%; n = 38) participants described preferences for in-person resources and estimated that if on-demand interpreter resources were readily available, they would use on-demand resources for approximately 3.6 hours per week. By improving linguistic and cultural competencies among students and families with limited English proficiency, school nurses can improve student health outcomes.
Keywords
communication, cultural issues, language needs, limited English proficiency, social determinant of health, school nurse, interpretation
In the United States (U.S.), there are increasing numbers of students from households with diverse linguistic and cultural backgrounds, including families with limited English proficiency (LEP) (National Center for Education Statistics [NCES], 2019). Approximately, 28% of school-aged students live in households where the primary language is something other than English and 23% have parents who are foreign born (NCES, 2019). School nurses’ ability to communicate with families about health is important to achieve positive student outcomes (Holmes et al., 2016; Maughan et al., 2018). With nationwide increases in diversity of language and culture (NCES, 2019), it is important to understand school nurses’ language needs to identify strategies for improving communication to students and families with LEP.
Family engagement in students’ academic lives impacts the health of the school community (National Association of School Nurses [NASN], 2020). For example, parental engagement has been shown to reduce negative student health behaviors including cigarette smoking and physical inactivity (Michael et al., 2015). Furthermore, improved health literacy among families can lead to students having better educational outcomes, improved quality of life that can last into adulthood, prevention of adverse health events, and uptake in prevention-based care (Chang, 2019; Kolbe, 2019; Michael et al., 2015). Family engagement in students’ academic lives involves having a culturally competent school environment, which includes school nurses (Holmes et al., 2016; Maughan & Barrows, 2013; NASN, 2020).
Effective communication necessitates navigating diverse linguistic and cultural backgrounds and is essential for fulfilling school nurses’ roles (NASN, 2020). A study found that school nurses communicate with approximately eight family members daily with each communication lasting for up to 60 min (Bergren, 2016). Despite the importance of effective communication in the school nurses’ roles (NASN, 2020), literature on school nurses’ communication to families with LEP is sparse. An early study exploring Alabama chief school nurses’ perceptions of communication to families with LEP found 33% of respondents encountered difficulty in communicating with students and 51% encountered difficulty in communicating with parents (Whitman et al., 2010). Another study explored a needs assessment of cultural competency among over 2,000 school nurses nationwide (Matza et al., 2015). Significant findings from this survey include school nurses reporting language barriers (88%), a lack of resources including access to interpreters (86%), and how work-related constraints present a barrier in providing culturally competent care (95%) (Matza et al., 2015). These studies demonstrate a need for further understanding of linguistic and cultural competency among school nurses because competency is essential for establishing trust, fostering family engagement, and coordinating students’ healthcare (Maughan & Barrows, 2013; NASN, 2020).
Guided by the NASN Framework for 21st Century School Nursing Practice™ (Framework) (NASN, 2020), the purpose of the survey was to identify strategies school nurses use to communicate to students and families with LEP and describe school nurses’ recommendations for resources to improve interpretation needs. The Framework provides a guideline for school nursing practice through principles of care coordination, leadership, quality improvement, and community health (NASN, 2020). Paramount for school nursing practice to align with the Framework is culturally competent communication that must be clear and collaborative (NASN, 2020). For this project, the Framework served as an overarching guide to understand school nurses’ roles and the influence of linguistic and cultural competencies on their roles.
We conducted a survey of Nevada K–12 school nurses in April 2020 using Qualtrics XM (Qualtrics, Provo, UT), In Nevada, there are 17 school districts serving approximately 492,000 students (NCES, 2019). Among Nevada’s school population, approximately 41% of parents and 32% of students primarily speak a non-English language at home (NCES, 2019). School nurses must have a baccalaureate degree in nursing to serve as a Nevada school nurse (Nevada Administrative Code, 2020). In 2021, there were 297 school nurses working in the Nevada educational system, which is about half the number of school nurses needed to meet best practice ratio standards (Data Insight, 2021). The University of Nevada-Reno Research Integrity office reviewed the project and gave authorization to commence.
Participants were recruited from an email invitation sent out by the chair of the Nevada State Association of School Nurses (NSASN) to the members, which included 150 members. Eligibility criteria included self-identifying as a school nurse and currently working in Nevada K–12 schools. On the first page of the survey, participants provided consent to participate.
Based on literature, as well as one author’s experience as a school nurse, we developed the survey questions. We identified common resources school nurses use for interpreting health information, which included use of different school personnel who can speak the language needed for language interpretation, students who interpret for their families, interpreter services through a certified medical interpreter, and online websites or applications that interpret typed words. To assess school nurses’ recommendations for resources to improve interpretation needs, we assessed use of in-person, third person, and tablet applications. We used a 3-point Likert scale from very little (1) to very much (3) to understand school nurses’ perception of the impact on their roles if on-demand interpretation resources were available. The survey consisted of 12 questions that included single answers, multiple answers, or Likert scale answers. There was an open-ended question at the end of the survey that stated, “Is there anything you would like to add?” Participants could skip questions that they preferred not to answer.
To assess the survey questions, we distributed a pilot to 48 school nurses who worked within a single school district, of which 15 took the pilot (response rate = 31%). Responses were reviewed and an additional question was added to the NSASN survey regarding whether resources for interpreting health information were medically certified for interpretation. Participants were asked to not participate in the survey distributed by NSASN if they completed the pilot. A total of 57 NSASN members consented to participate in the survey (response rate = 38%). No incentive was provided to participants.
We analyzed data from the pilot and NSASN survey separate and present findings from the NSASN survey. We excluded five participants from the analysis because these participants provided consent but did not answer survey questions. Descriptive statistics were generated. We summarized responses from the open-ended question into broad categories and example statements. Data were analyzed using Stata v.16.1 (StataCorp, College Station, TX).
Among the 52 participants, on average, they worked for 22.8 years (standard deviation [SD] = 12.2; range 3–50 years) as a registered nurse and 11.0 years (SD = 8.4; range 1–37 years) as a school nurse. Most (n = 49; 94%) participants’ primary language was English. A total of 10 (19%) participants described speaking a non-English language, of which five spoke Spanish and five spoke a different language. Among those who stated they spoke a non-English language, only four (40%) considered themselves medically fluent in that language. Almost all (n = 47; 90%) participants described needing to communicate to students and families in languages in which the participants were not linguistically fluent.
Table 1 portrays participants’ current strategies for interpreting health information to families with LEP and the perceived accuracy of each strategy. The most common interpreter resource used was the use of school personnel who can speak the language needed for language interpretation, specifically office staff (n = 44; 85%), clinical aides (n = 24; 46%), or classroom staff (n = 20; 38%). Using interpreter services through a certified medical interpreter was the least used strategy (n = 18; 35%) yet perceived as having the highest accuracy for interpreting health information (mean = 2.8; SD = 0.4). Using students who interpret for their families was perceived as the least accurate (mean = 1.8; SD = 0.4), yet 58% (n = 30) of participants described using this strategy. Most (n = 37; 71%) participants described their current resources for interpreting health information were not medically certified for interpretation.
Only 12 (23%) participants described the resources they were currently using to interpret health information always met their language needs. To improve interpretation needs, most (n = 38; 73%) participants described wanting an on-demand in-person resource. Approximately half of participants described wanting an on-demand third person resource provided via videoconferencing (n = 31; 60%) or telephone (n = 35; 67%). A total of 23 (44%) participants described wanting an on-demand tablet application that included services using typed words.
Table 2 portrays participants’ perception of the impact to school nursing practice if on-demand interpreter resources were available. Participants perceived if an on-demand resources were readily available, the following school nurse practices would be impacted: responding during emergencies (mean = 2.7; SD = 0.5), informing families about students’ health concerns (mean = 2.7; SD = 0.5), making health referrals and conducting health assessments (mean = 2.7; SD = 0.5), and educating families about student’s health (mean = 2.6; SD = 0.5). If on-demand interpreter resources were readily available, participants would use the resource for an average of 3.6 hours per week (SD = 4.0; range 0.3–15).
A total of 22 participants submitted responses to the open-ended question. Some participants further described the strategies they were using to communicate to students and families with LEP. For example, one participant described, “I have used printed forms in other languages, but this limits a two-way conversation.” Other comments described frustration experienced due to language barriers and desires to have readily available interpretation tools: “Having to rely on other school staff to translate is often problematic because they tend to interject their own opinions or solutions to whatever issue is being discussed;” and, “…it would be nice to have something right at my fingertips I could use.” Finally, there were few numbers of participants who described how interpretation needs depend on the demographics of the school with some school districts having growing populations of students and families with LEP.
The survey characterized Nevada school nurses’ current practices with and recommendations for communicating to students and families with LEP. Understanding school nurses’ communication and interpretation needs is important due to the increasing population of school-aged students from households with diverse linguistic and cultural backgrounds (NCES, 2019) and for aligning practice to the Framework (NASN, 2020). Results of this survey can address language gaps and needs, school nursing practice, and contribute to broader health determinants.
Previous publications on school nursing practice for communicating to students and families with LEP were published more than five years ago (Matza et al., 2015; Whitman et al., 2010). Consistent with previous research (Matza et al., 2015; Whitman et al., 2010), we found language gaps when school nurses communicate to students and families with LEP and a need for interpreter services. In Matza et al. (2015), 86% of participants described a lack of resources including access to interpreters when communicating to students and families with LEP. In our study, school nurses did not describe a lack of access to interpreters but described strategies of using non-medically certified resources. Additionally, school nurses did not perceive the accuracy of their current resources for language interpretation as high. Therefore, even though school nurses did not report the gaps in resources described in previous studies (Matza et al., 2015), they reported gaps in the availability of accurate resources.
Most school nurses described the use of school personnel or students who can speak the language needed for language interpretation. Relying on school personnel or students to interpret health information could lead to miscommunication, the person projecting their own opinions within the conversation, or could be a privacy violation under the Family Educational Rights and Privacy Act (FERPA) (Centers for Disease Control and Prevention (CDC), 2018; Squires, 2018). Additionally, being able to speak the language needed for interpretation, does not qualify the individual for medical interpretation as training is needed to be a medical-certified interpreter. Further, the Civil Rights Act of 1964 states language should not be a barrier for equitable access to federally funded programs, like public schools (Chen et al., 2007; Squires, 2018). The findings indicate that current school nurse practices of using school personnel or students to interpret health information is not compliant with FERPA and the Civil Rights Act of 1964 (CDC, 2018; Chen et al., 2007).
Consistent with previous research (Matza et al., 2015; Whitman et al., 2010), school nurses described how common school nursing practices would be strengthened if on-demand interpreters were readily available. In the study, school nurses describe that they would use an on-demand interpreter for approximately four hours per week. Therefore, if communication with families last up to an hour per conversation (Bergren, 2016), approximately four conversations weekly would include the use of an on-demand interpreter. Furthermore, if on-demand resources were readily available, school nurses perceived this would have a high impact on responding during emergencies, which is relevant for school nursing care and practice changes during our ongoing pandemic (Marrapese et al., 2021).
To improve strategies for interpreting health information to students and families with LEP, school nurses and districts could do several things. First, in the survey, most school nurses desired the use of on-demand interpreter services with options for in-person, telephone and video, and application services. Therefore, school districts may want to provide school nurses with multiple options. To meet this demand, school districts could partner with local health systems that have existing interpreter services to share resources. As student health is linked with improving student health outcomes (Chang, 2019; Holmes et al., 2016; Kolbe, 2019; Michael et al., 2015), local health services may see this partnership and sharing of interpreter resources as valuable. Additionally, in the survey, as a large percentage of school nurses described using school personnel to provide language interpretation, school districts could pay for their personnel to become medically certified, thereby not needing to increase staffing, but strengthening the existing workforce. Next, even though we found more than half of school nurses expressed that video conferencing would improve services, the survey was conducted during the early stages of the COVID-19 pandemic and mass use of video conferencing and telehealth may have since increased in acceptance among school nurses (Marrapese et al., 2021). Finally, in the study, school nurses have been practicing as a nurse for approximately 23 years; therefore, nursing continuing education units could be valuable for practicing school nurses as cultural and linguistic competency is an ongoing learning process (American Association of Colleges of Nursing [AACN], 2021; American Nurses Association [ANA], 2021). Nursing continuing education units on linguistic and cultural competency or language classes could be offered at annual conferences, online, or through national specialty associations. School districts could support school nurses who are seeking opportunities to increase linguistic and cultural competency through financial reimbursement and time allocation.
The effects of language barriers among students and families with LEP extend beyond the school community as individuals with LEP experience health inequities and disparities given their language and cultural status in the U.S. (U.S. Department of Health & Human Services: Office of Minority Health, n.d). These inequities and disparities can be ameliorated through competent communication between school nurses and individuals with LEP (Maughan & Barrows, 2013). When school communities welcome diverse linguistic and cultural backgrounds, students and families with LEP and who are marginalized in most settings within the U.S., might find a safe environment within the school, which could yield positive student health outcomes (Michael et al., 2015). By meeting school nurses’ demands for multiple options of interpreter services, both school nurses and the school community could advance health equity for students and families with LEP (U.S. Department of Health & Human Services: Office of Minority Health, n.d).
Language barriers are not a new nursing care issue; rather, several researchers exploring language barriers have identified nurses’ describing challenges due to language barriers when providing care and on their workload (Ali & Watson, 2018; Chae & Park, 2019; Gerchow et al., 2020; Valizadeh et al., 2017). Language barriers is one aspect that needs to be addressed for cultural competency and for national nursing standards of practice (ANA, 2021; Sharifi et al., 2019). Nurses need foundational education on culture competency, which includes concepts of awareness, sensitivity, humility, congruency, and linguistics (AACN, 2021). This education can begin in nursing schools and continue in work settings through continuing education units. If nurses are not practicing cultural competency, then they could be violating principles within the nursing code of ethics (ANA, 2021) and contributing to the health inequities and disparities observed among individuals with LEP.
Future research could explore school nurses’ communication strategies to students and families with LEP in other states or across the U.S, as there could be regional differences. Additionally, future researchers could explore intervention-based studies to understand the effectiveness of various interpreter strategies and whether strategies improve communication to students and families with LEP. Finally, future researchers may want to explore how linguistic and cultural competency is practiced by school nurses and how competency impacts the health of students and families with LEP.
There are several limitations to the survey. First, our response rate of 38% might indicate that we received responses from school nurses who were engaged with the topic or who had relevant practice experiences. Second, the survey could have been influenced by social desirability bias as participants were asked questions about their practice. Participants might have felt that they wanted to answer questions with what they knew was correct practice, rather than with what they were currently doing. Third, the survey was conducted during the early COVID-19 pandemic, when schools rapidly changed to remote. Finally, generalizability is limited as all data were collected from Nevada school nurses.
It is important for school nurses to have the necessary tools to provide culturally competent care to the rising number of school-aged students and families with diverse linguistic and ethnic backgrounds. Current practices, such as the use of non-medically trained individuals as language interpreters is perceived by school nurses as not delivering accurate health information and is inconsistent with best practice, existing law, and potentially is contributing to health inequities and disparities among individuals with LEP. By having multiple interpreter services that are readily available, school nurses could improve communication to students and families with LEP. By improving linguistic and cultural competencies among school nurses, school nursing practice will be strengthened with the potential for positive health outcomes among students, families, and the overall school community.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Sheryl Bennett https://orcid.org/0000-0003-1444-5564
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Sheryl Bennett was a MSN student at the University of Nevada, Reno during the project.
Theresa Watts is an Assistant Professor at the University of Nevada, Reno.
1 Orvis School of Nursing, University of Nevada-Reno, Reno, NV, United States
Corresponding Author:Theresa Watts, 1664 N., Virginia St. Reno, NV 89557, United States.Email: theresawatts@unr.edu