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Caring for undocumented immigrants

Gobeyn, Jennifer Lynn, BSN, RN, LMT

doi: 10.1097/01.NURSE.0000542469.30330.13
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Explore the clinical and ethical dilemmas nurses face when providing healthcare services to these patients and consider adopting the three-step process presented here for optimal care.

Jennifer Lynn Gobeyn is employed by Oak Orchard Health in Brockport, N.Y., where she provides nursing services to migrant farmworkers. She is also self-employed in Rochester, N.Y., where she provides home care nursing services to Medicaid patients.

The author has disclosed no financial relationships related to this article.

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NURSES WORKING IN VARIOUS healthcare settings, from acute care hospitals to community health centers, have reported an increase in the undocumented immigrant patient population. Recent statistics indicate well over 11 million undocumented immigrants are now living in the United States, an increase of almost 3 million since 2000.1-3 Healthcare professionals across all care environments need to consider the ethical questions that may arise when providing healthcare services to these patients.

Undocumented immigrants are considered a vulnerable patient population for many reasons, including language barriers, socioeconomic challenges, and documentation status.2,4,5 Many undocumented immigrants in the United States are Hispanic migrant farmworkers who may endure additional barriers that negatively impact their access to healthcare, including high mobility rates, limited access to transportation, and vulnerability to exploitation related to their occupation.2 When providing healthcare services to undocumented immigrants, nurses must remember the risk factors facing this patient population and understand that many undocumented individuals may be afraid to or unable to access healthcare services because of such vulnerabilities.

Immigrant populations, both documented and undocumented, are undeniably having an impact on healthcare systems around the world, and each nation has a unique manner of addressing the challenges that can arise due to a patient's immigration status. Some countries place healthcare professionals in an ethically problematic position by requiring them to report undocumented patients to pertinent authorities. In extreme cases, certain laws may even criminalize the provision of assistance to unauthorized immigrants.4

The current dialogue about immigration in the United States has resulted in many undocumented individuals who reside in this country fearing the potential for forcible deportation of themselves or their family members. This may lead to increased anxiety about providing the necessary information to schedule medical appointments or to receive healthcare services. The National Immigration Law Center reports that healthcare professionals should be aware of the fact that healthcare facilities in the United States have been deemed “sensitive locations,” and as such, immigration enforcement practices are limited in these settings. If law enforcement officers enter the public area of a healthcare institution, well-prepared facilities can have “know-your-rights cards” made available for patients to present to officials instead of making any possibly incriminating statements. Being aware of patient and healthcare provider rights in the United States and transmitting this information to the undocumented patient population has the potential to increase the percentage of undocumented immigrants who seek access to healthcare services.6

However, beyond any potential complications to providing patient care related to immigration enforcement, it has been noted that in some countries, allowing the existence of public policy gaps limits the healthcare services undocumented patients can feasibly receive. In the United States, for example, undocumented immigrants have a right to access emergency healthcare services, but they aren't eligible to receive Medicaid, nor are they permitted to purchase private health insurance offered by state-level insurance exchanges.1 For this reason, many undocumented immigrants in the United States are uninsured.

Myriad factors, including insurance status and a lack of legal documentation, can result in ethical dilemmas for both the healthcare system in general and individual healthcare professionals who treat this underserved population. However, by following a three-step process outlined here, healthcare professionals can systematically address and overcome many of these challenges.

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Step 1: Self-analysis

First, all healthcare professionals should perform an honest self-analysis of their personal beliefs, attitudes, and feelings toward undocumented immigrants.5 Carefully consider any preconceptions, stereotypes, or misunderstandings that could impair your ability to provide healthcare services to undocumented immigrants. It's also useful to reflect on any specific challenges you encounter repeatedly while caring for these patients. Candidly assess the treatment that undocumented immigrants currently receive in your healthcare organization.1 Sometimes, the easiest solution can be to allocate different amounts of time, energy, and resources to different patients, perhaps as a result of insurance status or patient proficiency in the use of the English language.1,5 However, it's unethical for healthcare professionals to subjectively assess societal worth as a factor in the provision of (or the withholding of) healthcare services. Legally, the Emergency Medical Treatment and Labor Act (EMTALA) requires healthcare providers in the United States to provide stabilization services to all patients in an emergency, regardless of their socioeconomic or insurance status.1,5

Having successfully accomplished this self-assessment, nurses and institutions can more easily make improvements in their care for undocumented immigrants.

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Step 2: Advocate for equitable access

Legal and financial regulations sometimes conflict with our professional code of conduct.4,5 Nurses throughout the world are bound by the International Council of Nurses' Code of Ethics for Nurses, which clearly states that “the nurse's primary professional responsibility is to people requiring nursing care,” and that “the nurse advocates for equity and social justice in resource allocation, access to health care and other social and economic services.”7 Additionally, many nurses work in countries that have ratified the International Covenant on Economic, Social and Cultural Rights, which guarantees the “Right to Health” in its 12th article.8 But nurses, who must follow facility policy and procedure as a condition of employment, are sometimes required to make the difficult choice of either acting in defense of human rights and our professional values system, or of complying with institutional or governmental regulations that limit the services certain patients, such as undocumented immigrants who do not possess health insurance, may receive.4,5

Even if undocumented immigrants have access to emergency and primary care services, what about those suffering from a long-term illness or chronic disease process that doesn't fit neatly into either one of these categories? Does that mean they shouldn't be treated? For instance, should an undocumented patient with kidney failure receive dialysis at an ED several times per week because he or she isn't eligible to receive care in an outpatient dialysis center?1

This type of ethical dilemma can lead to confusion, discouragement, and frustration as the nurse and other members of the healthcare team attempt to find a solution to provide the best possible care for undocumented patients. To help mitigate the negative impact of such ethical dilemmas, nurses must recognize and speak up when they encounter situations that demonstrate a lack of congruence between human rights obligations as well as the professional code of the nursing profession on one hand and their individual institutional policies and procedures on the other. By doing so, nurses choose to effectively advocate for equitable access to healthcare for all patients.4,5 In this way, healthcare professionals may reduce the number of situations in which a sense of dual loyalty and obligation complicates the provision of healthcare services for undocumented immigrants.

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Step 3: Cultural competence training

Nurses and healthcare organizations must recognize the importance of cultural competence training for all staff members, including administrative or other supportive personnel as well as members of the care team.2 It's not only healthcare providers, but also support staff who encounter dilemmas while caring for a culturally diverse patient population.5 A unique collection of risk factors (such as socioeconomic background, immigration status, limited English proficiency, and social stigma and marginalization) can potentially turn simple questions such as “What is your name?” or “Where do you live?” into sources of discomfort for the undocumented individual and may even create a perception of threat or danger in his or her mind. Administrative staff members who are often on the front lines of the healthcare system must learn how to respond appropriately to undocumented immigrants who may react in an unexpected or negative manner to routine questions related to identity or housing. They need to understand that an undocumented patient's hesitancy when answering such questions doesn't indicate that the patient doesn't want or doesn't deserve healthcare services.

The provision of training specific to immigrant health and human rights has the potential to positively inform the decision-making of all staff members, no matter their designated position within the facility. It's likely to increase both the cultural sensitivity and the sense of personal accountability felt by members of the healthcare team, whether direct care providers or administrative staff. Expected results also include improved outcomes for undocumented patients as well as increased cultural competence and confidence among all staff in their ability to provide equitable healthcare services to diverse patient populations.5

If nurses, and healthcare organizations as a whole, commit to thoughtful self-examination by means of regular reflection and discussion, advocate for the application of international human rights declarations and professional codes of conduct within the nursing profession, and dedicate resources to a robust and ongoing program of cultural competency training, the healthcare community will be much closer to the resolution of some persistent ethical dilemmas surrounding care for undocumented immigrants.1,2,4,5

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REFERENCES

1. Berlinger N, Raghavan R. The ethics of advocacy for undocumented patients. Hastings Cent Rep. 2013;43(1):14–17.
2. Loi CXA, McDermott RJ. Conducting program evaluation with Hispanics in rural settings: ethical issues and evaluation challenges. Am J Health Educ. 2010;41(4):252–256.
3. Passel JS, Cohn D. Unauthorized immigrant population: national and state trends, 2010. Pew Hispanic Center. 2011. http://www.pewhispanic.org/2011/02/01/unauthorized-immigrant-population-brnational-and-state-trends-2010.
4. Myhrvold T. Human rights, health and our obligations to refugees. Nurs Ethics. 2015;22(4):399–400.
5. Ruiz-Casares M, Rousseau C, Laurin-Lamothe A, et al Access to health care for undocumented migrant children and pregnant women: the paradox between values and attitudes of health care professionals. Matern Child Health J. 2013;17(2):292–298.
6. National Immigration Law Center. Health care providers and immigration enforcement: know your rights, know your patients' rights. 2017. http://www.nilc.org/issues/immigration-enforcement/healthcare-provider-and-patients-rights-imm-enf.
7. International Council of Nurses. The ICN Code of Ethics for Nurses. 2012. http://www.icn.ch/images/stories/documents/about/icncode_english.pdf.
8. United Nations Human Rights: Office of the High Commissioner. International Covenant on Economic, Social and Cultural Rights. 1976. http://www.ohchr.org/Documents/ProfessionalInterest/cescr.pdf.
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