The Journal of School Nursing2025, Vol. 41(3) 398–403© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405241263953journals.sagepub.com/home/jsn
AbstractFederal law requires school health leaders to ensure meaningful access to language resources to promote optimal health and education outcomes. This paper aims to inform all stakeholders, including decision-makers, about the importance of developing language access plans and policies. Multiple sources and legal guidelines provide a comprehensive overview of the issue. Including an examination of current practices and challenges that school nurses encounter, specifically regarding language resources, guidance is offered to elucidate meaningful language access policies that ensure equitable access to school health services. Supporting meaningful language access includes providing school nurses with qualified interpretation and translation services to care for those who do not speak, read, or write in English or have limitations with the English language. Additionally, local and state agencies may implement language access services requirements and enforce compliance with a language access plan to meet federal funding requirements.
Keywordslegal/ethical issues, limited English proficiency, school nurse, school health services, language access
School nurses are essential to educational success and population health. Recognizing the strong association between academic achievement and health status, the National Association of School Nurses underscores the value of promoting student health and well-being (McCabe et al., 2024). For school nurses to be influential in practice, they must be able to communicate with students and their families who depend on them to support students’ health and wellbeing (National Association of School Nurses, 2020). Communication barriers, however, may exist in the school setting if students or their guardians do not speak or understand the same language as the school nurse. Given the prevalence of U.S. households where English is not the primary language, encompassing one out of every five students, communication barriers present a pervasive challenge experienced in U.S. K-12 schools (National Center for Education Statistics, 2021).
The limited literature in this area highlights the increasing need for school nurses to have access to language resources, including interpreter services (Bennett & Watts, 2022; Matza et al., 2015; Whitman et al., 2010). State and local agencies’ failure to provide these services harms students and may violate federal civil rights laws (Balingit, 2023). School staff report that they rely on “get-by” strategies to overcome language barriers, such as calling on untrained school staff and students for interpretation, even though neither should be used as interpreters unless there is an emergency (Bennett & Watts, 2022; Roberts et al., 2023). Guardians may resort to imperfect interpretation solutions, including bringing a bilingual acquaintance to school meetings to meet their family’s language needs (Lauer & Alvarez, 2021). A lack of training in interpretation and healthcare terminology by these acquaintances may lead to misunderstandings and unsolicited advice and contribute to unsafe, lower-quality care, all while violating privacy laws (Paradise et al., 2019; Tam et al., 2020). Online translation applications, such as Google Translate©, are not consistently accurate nor compliant with privacy laws, placing organizations that use such services at legal risk (Squires, 2018).
Based on these concerns, the purpose of this review is to provide guidance to key stakeholders to better understand current laws and policies needed to ensure language access through interpretive and translation services for families with Limited English Proficiency (LEP) in U.S. K-12 schools. The gap in knowledge surrounding school language and translation services may be especially pronounced when school nurses have had prior experience in a hospital setting where language services are readily available. Knowledge concerning laws and policies requiring interpretive and translation services is particularly salient, with schools experiencing an increased demand for language resources when communicating with immigrant families (Closson, 2023).
In school health services, effective communication is crucial, and persons with LEP may have varied and limited ability to communicate in English (Ortega et al., 2022; U.S. Department of Justice, 2002). Importantly, Title IV of the Civil Rights Act of 1964 has been interpreted to prohibit the denial of equal access to federal programs and activities to students and families with LEP, creating a civil right to an interpreter in educational, healthcare, and legal settings (U.S. Department of Health and Human Services, 2000). Language barriers can cause misunderstandings and frustration, lead to errors in care delivery, increase the risk of persons experiencing harm during a healthcare encounter (Gerchow et al., 2020), reduce quality and safety, and increase healthcare costs (Betancourt & Tan-McGrory, 2014). Therefore, translation and interpretation services are critical in school health offices to overcome language barriers and provide adequate healthcare services to families and students with limited English proficiency (LEP) (Squires, 2018).
Prior research exploring nurses’ experiences with LEP families in the U.S. identified the need for cultural education and policies to support nursing practice (Gerchow et al., 2020). To address this need, organizations must provide culturally and linguistically appropriate services to support nurses by developing commensurate policies and guidelines, and nursing leadership within organizations must strive to take responsibility for the training required to ensure that nurses are culturally informed (Chae & Park, 2019). Barriers to implementing culturally and linguistically appropriate services include a lack of organizational infrastructure and costs for interpretive services (Wilson, 2013).
Much more remains to be done to ensure that the language one speaks does not diminish the quality of health care one receives. As our nation continues to become more culturally and linguistically diverse, we owe it to…all our LEP patients to ensure that communication is not an impediment to health (Chen et al., 2007, p. 367).
Schools are required by law to accommodate physical, emotional, and behavioral health conditions so that students may participate fully in class activities (U.S. Department of Education, Office of Civil Rights [DOE OCR], 2023a). This requirement places school nurses front and center in addressing students’ health problems, necessitating effective communication under the Civil Rights Act of 1964 and the Equal Educational Opportunities Act of 1974 (Civil Rights Act, 1964; Equal Educational Opportunities Act, 1974), which entitles all children enrolled in public schools to equal educational opportunity without regard to national origin, color, sex, or race. Furthermore, local or state education agencies that receive financial assistance from the federal government may not discriminate against individuals based on their country of origin (U.S. Department of Justice, Civil Rights Division [DOJ CRD], 2021). These laws aim to ensure that individuals with LEP have the equivalent access to educational programs, including school health services, as those who do not identify as LEP (U.S. Department of Justice, 2002).
The U.S. Department of Health and Human Services cited deficiencies in delivering equitable healthcare access and in a recent report emphasized that meaningful language access is a top priority (U.S. Department of Health and Human Services, 2024). Failing to offer language access services to students and families with LEP is discriminatory because it denies equal access to federally funded programs and school activities. The U.S. Supreme Court has ruled that failure to provide instruction in a student’s native language denies him or her a meaningful opportunity to participate in public education in violation of Title VI (Lau v. Nichols, 1974). Also, because language is often seen as a proxy for national origin, courts have held that language inequity is a form of discrimination based on national origin (Olagues v. Russoniello, 1986).
According to guidance released by the U.S. Department of Education (DOE) and the U.S. Department of Justice (DOJ) (U.S. Department of Justice, Civil Rights Division, U.S. Department of Education, Office for Civil Rights, 2015), school administrators, educators, nurses, and staff must meet specific requirements when communicating with LEP families. Specifically:
Schools may not rely on students or untrained staff to interpret
Schools must provide language assistance upon request from a guardian, and
Schools must offer free, appropriate, and competent communication that does not involve asking staff members who speak the target language to interpret (U.S. Department of Justice, Civil Rights Division, U.S. Department of Education, Office for Civil Rights, 2015).
As healthcare professionals, school nurses are also subject to additional mandates outlined in the Patient Protection and Affordable Care Act, including using interpreters proficient in healthcare terminology and phrasing in both spoken English and the target language (U.S. Department of Health & Human Services [DHHS], 2021). Therefore, school nurses may not use a bilingual minor child or accompanying adult without appropriate healthcare training to communicate health information to LEP families (DHHS, 2021; Paradise et al., 2019). These ad hoc interpreters may not maintain objectivity or confidentiality, and their interpretative quality may be questionable. If an unqualified interpreter is used, words might be emphasized differently than intended, opinions may be interjected after the care provider communication, and not all communications may be relayed as needed, potentially generating a false picture of the student’s health history and needs and leading to inadequate treatment and outcomes (Squires, 2018).
The DOE OCR (2023b) enforces Federal civil rights laws barring discrimination in programs or activities receiving federal funding. In 2022, the DOE OCR experienced a record volume of alleged civil rights violations, totaling 18,804 complaints, with 17% associated with discrimination based on race, color, or national origin. There were complaints regarding English learners’ services, parental communication regarding LEP families, testing regarding LEP students, and special education for English language learners (DOE OCR, 2022). To safeguard equal access to education nationwide by actively enforcing civil rights and to help manage the timely processing of complaints, DOE OCR now offers mediation as an option for the complainant at the time of filing. This alternative aims to provide an expedited resolution process for which OCR has jurisdiction over a complaint and where both parties are willing to participate in mediation (DOE OCR, 2022). Table 1 lists examples of settlement agreements between the DOE OCR (2022) and local and state education agencies.
The Civil Rights Division of the U.S. Department of Justice (DOJ CRD) shares responsibility for enforcing federal civil rights laws, including those regarding LEP. The DOJ CRD has the authority to conduct investigations or file lawsuits against entities it deems to have violated these laws. After an investigation, if there is evidence of a civil rights violation, the DOJ CRD may enter into a settlement agreement with state and local agencies. The agreements outline the steps the entity must take to remediate and comply with federal law (U.S. Department of Justice, Civil Rights Division, 2021, 2023, 2024). Notably, neglecting to offer school-based language access services to families who do not speak English is a direct violation of federal civil rights law and can have profound legal implications. Underscoring the seriousness of the issue, each agreed-upon settlement involves providing language access by using interpretation and translation resources and establishing a language access plan.
Schools have a responsibility to ensure effective communication and language services are provided to individuals with LEP by implementing language access plans and developing policies. For school nurses, Bennett et al. (2023) serve as a practical guide that provides education, guidelines and resources, including a toolkit, for guiding school nursing practice when working with LEP families. Understanding the legal duty of schools to provide interpretive and translation services to students and families with LEP will equip school nurses to advocate with their school administrators and school districts for improved LEP plans and policies.
Language access plans and policies in the educational setting include language resources, both interpretation and translation, for communication with English Language Learner students and LEP families. Typically, the plan includes policies and procedures for identifying and serving LEP individuals, such as language screening and interpretation services, translation of essential documents, and bilingual interpreter training. Interpreter services can be made available through in-person, telephone, or video methods. Interpreter services should be readily available, given the urgent nature of the healthcare environment, to comply with relevant laws and ensure on-demand responses while using qualified interpreters (Squires, 2018). Because school nurses are healthcare providers and communicate health information to students and families, qualified medical interpreters must be used (Squires, 2018). Such interpreters must be trained in the target language, culture, healthcare, and terminology.
Furthermore, all agencies accepting federal financial aid directly or indirectly must offer meaningful language access. This obligation means language assistance should provide correct, well-timed, and helpful interactions at no charge to the person with LEP needing interpretation or translation services. Meaningful access requires that language services should not be significantly hindered or delayed and that services supported by this federal financial assistance should not be of lower quality than those provided to individuals proficient in English.
Organizations, including school health services teams, can assess demand for language services access by collecting the following data: (1) the number of LEP individuals served by the school (including number of languages they speak), (2) the regularity of interactions with LEP individuals within the health care service; and (3) satisfaction with interpreter services or modalities of persons with LEP. It will also be important to examine the financial resources needed to deliver language access to LEP individuals and develop a plan to scale them up over time. Meeting these criteria will help schools and districts comply with the DOE OCR and the DOJ CRD, as they are the same criteria used to evaluate a language access plan in achieving meaningful access. All factors are considered equally important when considering language access, and none should be considered independently (DOJ CRD, 2011; U.S. Department of Justice, Federal Coordination and Compliance Section, 2011). A well-designed language access plan, therefore, needs to improve the quality of services for LEP individuals and help organizations comply with legal requirements.
School nurses are crucial for identifying and addressing health barriers affecting learning. These nurses are skilled in understanding the unique health needs of students and families and can then advocate and acquire appropriate support. Overcoming language barriers in schools is crucial for promoting equity in the U.S. educational setting and complying with federal civil rights laws. To achieve balance, local and state education agencies should develop and implement language access policies that provide effective communication and language services to students and their families with LEP. A vital compliance step is prioritizing making qualified interpretative and translational services available for school nurses and others involved with a student’s health to provide comprehensive care in the school health office. By implementing a comprehensive language access policy, schools can improve the quality of health services provided to LEP individuals, comply with legal requirements, and ensure equitable access to education for all students.
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.
Ellen McCabe https://orcid.org/0000-0003-2901-1670
Sheryl Bennett https://orcid.org/0000-0003-1444-5564
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Ellen M. McCabe, PhD, RN, PNP-BC, FNASN, Hunter College, Hunter-Bellevue School of Nursing, The City University of New York, New York, NY, USA.
Sheryl Bennett, MSN, RN, NCSN, Orvis School of Nursing, University of Nevada, Reno, NV, USA.
Kerri McGowan Lowrey, JD, MPH, Legal Resource Center for Public Health Policy, University of Maryland Francis King Carey School of Law, Baltimore, MD, USA.
Allison Squires, PhD, RN, FAAN, Rory Meyers College of Nursing, New York University, New York, NY, USA.
1 Hunter College, Hunter-Bellevue School of Nursing, The City University of New York, New York, NY, USA
2 Orvis School of Nursing, University of Nevada, Reno, NV, USA
3 Legal Resource Center for Public Health Policy, University of Maryland Francis King Carey School of Law, Baltimore, MD, USA
4 Rory Meyers College of Nursing, New York University, New York, NY, USA
Corresponding Author:Ellen M. McCabe, Hunter College, Hunter-Bellevue School of Nursing, The City University of New York, 425 West 25th Street, New York, NY 10010, USA.Email: em3766@hunter.cuny.edu
