There is a long tradition of nurses acting as advocates for vulnerable people within healthcare settings...immigrants have long faced barriers at every level of healthcare...Social justice, or the belief that economic and social inequality affects health and should be addressed, is a concept at the core of nursing. There is a long tradition of nurses acting as advocates for vulnerable people within healthcare settings (Egenes, 2009). The American Nurses Association (ANA) and the International Council of Nurses’ (ICN) codes of ethics mandate that all nurses work to advocate for social justice (ANA, 2015; ICN, 2012). Thus, nurses are expected to use these ethical principles in practical application in their professional roles.

Immigrants are considered one of the most vulnerable populations in the United States (U.S). (Derose, Bahney, & Lurie, 2009) This article will discuss immigrant vulnerability in the healthcare system and offer a framework to increase understanding about why these vulnerabilities exist. We will address ways that nurses can advocate on immigrants’ behalf individually; within a hospital system or community; and at the federal level.

Argument for Advocacy

Tomajan stated that advocacy “is to work on behalf of self and/or others to raise awareness of a concern and to promote solutions” (2012, para. 5). The nursing profession has been guided by a principle of ethics and advocacy. This is well summarized by the ANA “Code of Ethics for Nurses with Interpretive Statements”, a dynamic document asserting that nursing is “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities and populations” (2015, pg. 10). Such a mandate requires nurses to actively advocate for patients and populations, no matter their education level, clinical setting, or political view.

Immigrants as Vulnerable Populations

According to the U.S. Census Bureau (2019), about 40 million people, or 13% of the total population are immigrants. Immigrants are more likely to live in poverty (19% overall to 15% immigrant) and lack health insurance (87% to 66%) than native born Americans. In addition to these basic inequalities, immigrants have long faced barriers at every level of healthcare, including discrimination, financial, and policy barriers (Fortier & Bishop, 2004). These barriers are even greater for undocumented immigrants (Hacker et al., 2015).

Inquiry into the ethnic basis of healthcare disparities in the United States can be traced to the Institute of Medicine report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” (2003). This study brought national attention to prevailing disparities that ethnic minorities experienced in the American healthcare system. Derose, Bahney, and Lurie (2009) completed a systematic review of population based studies of immigrants and healthcare. Their review included 67 quantitative studies that assessed the effect of immigration on healthcare outcomes. The study found that immigrants and those with Limited English Proficiency (LEP) have poorer access to quality primary care and health insurance than native born citizens.

Understanding the Immigration System

In the aftermath of World War II, the refugee convention was adopted to protect people from persecution. The first immigration laws passed soon after the Revolutionary War, with the Naturalization Act of 1790 (National Archives, 2019), which limited eligibility for citizenship to free white propertied males. In 1866, the Fourteenth Amendment guaranteed citizenship to former slaves (National Constitution Center, 2006), but in 1882, Congress passed the Chinese Exclusion Act to ban immigration from China. (African American Policy Forum, 2019). In 1924, country quotas were created to limit immigration from countries other than Northern and Western Europe. In the aftermath of World War II, the refugee convention was adopted to protect people from persecution. In 1986, laws enabled legalization for Latin American and other immigrants who had been in the U.S. since before 1982. In 1996, there was a tightening of laws to restrict immigration and increase the number of people who could be deportable. This was the last major reform of immigration laws, leaving millions of immigrants in the U.S. without a path to attain lawful status.

In 2003, as a response to September 11th, the provision of immigration services was restructured under the Department of Homeland Security, with a focus on preventing terrorism (Cohn, 2015). The Department of Justice oversees the Immigration Courts and the Board of Immigration Appeals, which have a backlog of nearly one million cases.

There are many types of immigrant status.There are many types of immigrant status. Non-citizens can be lawful permanent residents (i.e., green card holders); hold temporary legal status (e.g., as tourists, students, temporary workers); or may be considered undocumented (immigrants who overstay a visa or enter the country without permission). People granted Deferred Action for Childhood Arrivals are neither in lawful status nor fully undocumented, having been given a two-year protection from deportation. Generally, U.S. citizenship can be acquired at birth or applied for by those who reside in the country as lawful permanent residents, but is not an option for most undocumented people living here.

The majority of permanent immigration to the United States is family- and employment-based, requiring a petition by a particular relative or employer. Other narrower avenues for immigration include the diversity lottery, refugees, and asylees. Refugees and asylum seekers both have to prove that they have been persecuted or have a well-founded fear of being persecuted on account of their race, religion, nationality, membership in a particular social group, or political opinion (Blizzard & Batalova, 2019). Refugees are screened and processed abroad, while asylum seekers first reach the US and then make their claim. The United States is obligated to accept both of these populations under international law (International Rescue Committee, 2018).

There is widespread confusion about the ability of immigrants to access public benefits.There is widespread confusion about the ability of immigrants to access public benefits. (Skomra, 2019) While the laws are in flux as to the immigration consequences a person might later face for having used services such as emergency care, the legal right to use those services is not in question.

The U.S. immigration system is complex, but a basic understanding can be useful when working with immigrant populations. Providing healthcare services to undocumented immigrants is not against the law, and healthcare providers are not required to report or collect immigration information about their patients. (National Immigration Law Center, 2017).

Providing healthcare services to undocumented immigrants is not against the law...Table 1 provides additional facts about current immigrants.

Table 1. Facts about Current Immigrants

(Anti-Defamation League, 2019)

Individual Advocacy

Individual advocacy is demonstrated when nurses know and implement the highest quality of care possible to immigrant patients. For example, one essential practice is the use of a professional, medical interpreter who fluently speaks the immigrant’s primary language. Providers should not rely on family members, untrained, or informal interpreters. The use of qualified medical interpreters has a profound effect on positive clinical outcomes and patient’s satisfaction (Karliner et al., 2007).

The use of qualified medical interpreters has a profound effect on positive clinical outcomes and patient’s satisfaction In addition to using interpreters, nurses need to self-evaluate their understanding of racial and cultural biases. While cultural competency has been the dominant framework for reducing healthcare disparities, there is neither consistency, nor evidence that this is sufficient or results in improved patient outcomes (Renzaho et al., 2013; Sequist et al., 2010; Tervalon & Murray-Garcia, 2009; Truong, Paradies, & Priest, 2014). Further development of the concept of cultural competency needs to include research that addresses both cultural humility and anti-racist frameworks. Tervalon & Murray-Garcia noted in 1998 that, "cultural humility is a lifelong process of self-reflection and self-critique whereby the individual not only learns about another’s culture, but one starts with an examination of her/his own beliefs and cultural identities, as a commitment and active engagement … on an ongoing basis with patients, communities, colleagues, and with themselves" (Tervalon & Murray-Garcia, 1998, pg 1).

A nursing concept analysis of cultural humility expands to say “implies one being aware of power imbalances and being humble in every interaction with every individual and requires time, education, reflection, and effort, it should be employed daily with all individuals in the basic interest of kindness, civility, and respect” (Fitzgerald, Myers, & Clark, 2016, n.p.).

There is no single approach that an individual nurse uses to develop cultural humility.There is no single approach that an individual nurse uses to develop cultural humility. This process can be especially difficult for white nurses working with non-white populations, because “In nursing as a whole whiteness is an unacknowledged source of structural advantage and the identification that being a caring profession inadvertently creates and maintains identity of color blindness” (Schroeder & DiAngelo, 2010, pg 246).

Nurses should engage in critical self-reflection of personal biases, develop an understanding of their own cultural perspective and the basis for structural health inequalities. Nurses need to learn the skills to ask the right questions and understand the needs of individual patients. This can be as simple as asking patients about their cultural and personal beliefs, their identity and understanding of their own health. (Mcgee-Avila, 2018).

This can be as simple as asking patients about their cultural and personal beliefs...Another way to advocate for immigrants may be uncomfortable for many and involves speaking up when witnessing prejudiced or racist actions or language. Fitzgerald, Meyers, and Clark (2016) outlined this ethical imperative in addition to practical tools that help nurses stand up against discrimination. “Dealing with the problem of incivility toward vulnerable populations in the healthcare setting starts with taking a stand against disrespectful conduct by voicing opposition to all forms of incivility.” Be well informed on facts surrounding immigration and become comfortable with identifying and addressing prejudice. Table 2 contains examples of free online resources to educate yourself about biases, cultural humility and intercultural health.

Table 2. Free Online Resources About Culture

 
Clinic and Systems Level

...it is important to address inequalities at the community and systems levels

In addition to the individual level, it is important to address inequalities at the community and systems levels. In your community, become familiar with local organizations and other institutions that work with immigrant populations. They can provide other opportunities for advocacy, and may provide useful services to your patients.

For example, at the healthcare organization level, work to understand existing policies and structures in place to address systematic inequalities and racism. One tool to help address these systematic inequalities is the Cultural and Linguistic Standards created by the United States Department of Health and Human Services Office of Minority Health (DHHS, 2019). These standards outline what every system should provide for their minority patients, including:

• A quality, easy to use interpreter system that is readily available to all staff. Work towards training all staff being trained in the use of this system
• Assess how your system partners with the local immigrant community
• Perform outreach to community organizations
• Encourage your organization to create immigrant focus groups or targeted marketing
• Work to add the CLAS standards into your strategic plan
• Help create policies in your organization to ensure safety of immigrants in your hospital system

Other helpful practices that healthcare professionals can implement in their clinics are available at National Immigration Law Center (2017).

State and Federal Levels

There are many opportunities at the state and federal levels of government that nurses can take to improve conditions of immigrants. Become familiar with immigration organizations that can provide assistance for patients. For example, nurses may encounter girls and women who have suffered from female genital mutilation; immigrant victims of domestic violence; and immigrant survivors of other traumas. Several regional and national immigration organizations, such as the Northwest Immigrant Rights Project and the American Immigration Lawyers Association, may be able to refer a patient to a qualified immigration attorney (Northwest Immigrant Rights Project, 2020; American Immigration Lawyers Association, 2019). Legal representation can make the difference in whether a person obtains lawful immigration status (Eagly & Shafer, 2016).

Legal representation can make the difference in whether a person obtains lawful immigration status Finally, watch for volunteer or advocacy opportunities. The current refugee crisis at the U.S. border with Mexico has led to multiple deaths of children in detention from fevers and other illnesses. (Acevedo, 2019) Volunteer opportunities for medical professionals are available in a variety of time increments, from a Saturday to as little as an hour. (Give an Hour, 2020; Refugee Health Alliance, 2019) Participate in coalition building, such as through the National Network for Immigrant and Refugee Rights. Finally, contact your elected officials to relate your experience and express your opinions on healthcare policies that affect immigrants.

Summary

Nurses have a professional and ethical responsibility to advocate for social justice (ANA, 2015). Immigrants are one of the most vulnerable populations in the US and they interact with nurses at all levels of the healthcare system. Small, collective actions of nurses to become more educated and skilled in cultural competence have the potential to make a tremendous impact to bridge disparities and improve the well-being of immigrants throughout the country.

Authors

Mary Ellen Biggerstaff, DNP, MSN, RN, FNP
Email: maryellen.biggerstaff@frontier.edu

Mary Ellen Biggerstaff is a family nurse practitioner working at Summit Pacific Medical Center and a faculty at Frontier Nursing University. She has published and presented nationally on providing quality healthcare for immigrants and on rural healthcare issues. She completed the Duke Johnson & Johnson Nursing Leadership Fellowship. She is currently an MPH Student at the University of California at Berkeley and is a member of the ARNPs United Board of Washington. She graduated from Mount Holyoke College with a bachelor’s degree in International Relations and with an MSN and DNP from Frontier Nursing University.

Taiyyeba Safri Skomra, JD
Email: Taiyyeba@sggimmigration.com

Taiyyeba Safri Skomra is certified as a specialist in Immigration and Nationality Law by the State Bar of California Board of Legal Specialization. She is a Partner at Stone Grzegorek & Gonzalez LLP. Ms. Skomra was the lead attorney in the case of Calderon-Rodriguez v. Sessions, 878 F.3d 1179 (9^th Cir. 2018), involving an immigrant detainee who was denied a proper evaluation of his mental competence. Ms. Skomra graduated magna cum laude from Mount Holyoke College with a bachelor’s degree in International Relations, and earned her juris doctor degree from the University of Washington School of Law. She is admitted to practice by the State Bars of Washington, Illinois, and California; she is also admitted to practice before the U.S. District Court for the Northern District of Illinois, and the U.S. Court of Appeals for the Seventh and Ninth Circuits.