IMMIGRATION and deportation have come to the forefront over the last several years in the US and across the globe. Migrants face obstacles to receiving healthcare such as lack of access to services, discrimination and anti-immigrant sentiment, lack of English proficiency, cultural barriers, legal status, economic difficulties, and social isolation.1-3 Further, changes to immigration policies in the US since early 2017 have increased the number of unauthorized immigrants prioritized for deportation.4 This may lead to detrimental societal effects as well as chronic physical, mental, and public health implications for migrants, their families, the health workforce, and the broader public.5,6
This article provides an overview of an independent study conducted by the first author, an RN-to-BSN student, on potential ethical issues associated with detention and deportation of undocumented immigrants from the US to Portugal.
Despite perceptions to the contrary, there is an inverse relationship between immigration and crime rates in the US.7,8 Of the 3.7 million people deported from the US between 2003 and 2013, most were not criminals. The largest number of criminal removals involved immigration-related convictions.9 Further, it has been noted that hostility toward immigrants and refugees is rising worldwide, which may negatively impact the health and well-being of immigrants, their families, and broader local and global communities. Fear of detention also causes ongoing stress and may generate long-term mental health issues, especially in children.1,10
Undocumented immigrants in the US may also face barriers from financial limitations, to discrimination and fear of deportation in accessing healthcare.3 In interviews conducted for this study, the author was told of the anger, frustration, and lack of trust felt by deportees when they first arrive; deportees refusing to take their medications; and paperwork missing important information about their medication and biophysical profile.
Probing the problem
The US and Portugal have a long diplomatic migration history. In 2007, in response to the Illegal Immigration Reform and Immigrant Responsibility Act of 1996, the US and Portugal agreed to facilitate a protocol to provide Social Security benefits, Portuguese language instruction, housing, and healthcare to support reintegration for deportees.1,11
The author's work was conducted as part of an international student exchange. In preparation for this bidirectional exchange, the author was one of eight students enrolled in a semester-long Portuguese language class, in which she read extensively about immigration and deportation trends between Portugal and the US. Throughout the semester, the author studied national and international codes of ethics for nurses, human rights literature, relevant US federal documents, and trends in immigration and customs enforcement. The author also interviewed key informants in both countries to better understand the implications of detention and deportation among undocumented immigrants.
During a week in Portugal, the author made visits to two government-sponsored community healthcare agencies dedicated to promoting the health, assimilation, and integration of formerly undocumented immigrants who had been deported from the US. Scheduled interviews were held with two nurses, a social worker, and a psychologist.
The author also interviewed three men who had been deported from the US to Portugal. They asked to not be quoted but shared commonalities when describing the deportation process as being confusing and complex, with far-reaching legal and financial implications for themselves and families left behind. They also noted a decline in their physical and mental health coupled with feelings of frustration, depression, anger, and stigmatization following deportation.
The interview included a discussion about long-term detainment in the US as an alternative to deportation. The men said they would have preferred to be detained in a US facility rather than deported to Portugal, where they might never see their children again.
Back in the US, the second part of the exchange involved interviews with key informants from an immigration agency, a detention and correctional facility, and a local mental health center that worked in close contact with agencies in Portugal and immigrant families in the US.
This project included one particular highlight: the author acting as a change agent regarding a policy at a US detention facility in which men were not aware that in Portugal, their medications would have a different name, color, and shape from what was prescribed in the US. After learning about this policy through discussions with nurses in Portugal, the author passed this information to administrators at the US detention facility, who soon implemented a teaching and learning module to help alleviate deportees' concerns and increase their medication adherence postdeportation.
The author identified far-reaching consequences resulting from detention and deportation with ethical, social, humanitarian, legal, financial, health, and political implications. These include a feeling of injustice in being deported after living and working in the US for many years, lack of familial and other support systems, lack of legal representation, inability to engage in work due to being stigmatized, and lack of healthcare resources in their country of birth.
Informants who spoke with the author expressed an overarching concern regarding their ability to provide appropriate resources to detainees, deportees, and their families because their needs were complex and multifactorial. From diverse perspectives, all sides described the challenges deportees faced regarding their health, stigmatization, and reintegration, providing a holistic view of the issue.
If they desire, deportees returning to Portugal from the US can enter a process to obtain housing, healthcare, and financial support provided by the Portuguese government. In spite of this, a lack of continuity of healthcare during and after this transition may further impact their health and quality of life.
Nurses can have a significant impact on the care of immigrant populations, both nationally and internationally. However, nurses must first examine their own views and values related to immigrant populations and related social determinants of health. Nurses are obligated to contemplate a path forward with political activism in local, state, and national policy forums. Health policy competencies for nursing students and nurses are crucial.
The author found no formal protocols to guide nurses in caring for immigrants across clinical settings in the literature. As a vulnerable group, immigrants need protection from hostile healthcare environments that include incivility and discrimination against immigrant groups that threaten the quality and/or safety of their care.12 Nurses are well suited to create civil and healthy workplaces.12 In-services with nurses and other healthcare providers from acute and community agencies to advocate for quality care in a safe environment may be helpful. Nurses' aptitude to refer patients to community health resources and social support agencies is imperative. During provision of care, nurses should discuss the health concerns of immigrant patients and their families, paying special attention to women and children.13
Cultivate cultural competence and humility
Nurses and other healthcare professionals must enter the relationship in a culturally humble manner. Cultural humility is considered a dynamic and lifelong process that focuses on self-reflection and personal critique.14 This concept is used in domestic and global work to encourage healthcare providers to be humble and avoid forcing unwanted changes on vulnerable groups. Take this approach during patient visits by recognizing that patients may be fearful and distrust healthcare providers. Pay close attention to barriers to access, language and interpretation needs, insurance status, and medical history. Nurses must follow the International Council of Nurses and American Nurses Association Codes of Ethics for Nurses in their encounters with this vulnerable group, establish trust, and ensure that culturally competent care is delivered compassionately and at the appropriate health literacy level.
Nurses as patient advocates
This study revealed the global need for nurses and nursing organizations to partner with national and international agencies in the identification, care, and treatment of those in detention and at risk for deportation. It is imperative that nurses collaborate with community stakeholders to identify health and healthcare disparities of people facing deportation and those left behind, discuss solutions, and act on their social responsibility by advocating for change.
Formal protocols to guide nurses in caring for immigrant families and populations of all ages are needed for all healthcare settings and in nursing curricula. Research into the phenomenon of the ethics of deportation and role of the nurse is needed. This author remains determined to educate medical and other community members about this important global nursing issue, especially when caring for this vulnerable population in the community and place of employment.
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