A Call for Nurse Leader Action: Ethical Nursing Care of Latinx Unauthorized Immigrant Children and Families.

Latinx unauthorized immigrant children and children of unauthorized immigrant parents are at risk for care disparities and negative health outcomes. Unauthorized immigration from South and Central America to the United States has elevated to crisis level, exposing many children to poor health conditions, human rights violations, and risk of death. Unauthorized status greatly influences care access and delivery in the hospital setting. Restricted nursing care creates ethical dilemmas. Nurse leaders are in key positions to influence and advocate care. This article explores issues surrounding nursing care using the Theory of Bureaucratic Caring and identifies opportunities for nurse leader action. 2020 by Elsevier Inc. All rights reserved.

Ethical issues, barriers to care, and negative health outcomes surround care of unauthorized immigrant Latinx children and families.

The Theory of Bureaucratic Caring provides a framework for nurse leaders to examine ethical and bureaucratic issues in the hospital setting.

Nurse leaders must act now and bring about real change in the ethical care of unauthorized immigrant Latinx children and families.

Imagine you are a parent of 5 children, ranging in age from toddler to teen. You immigrated to the United States from Mexico on a work visa, but it has expired. You have lived in the United States for over 10 years, making a home for you and your family. Your children have been healthy. However, you worry about access to care for your 2 eldest children of Mexican origin. recognizing that limitations to care are primarily based on their country of birth. Your citizenship status, as well as 2 of your children’s, is a divisive barrier to care that elicits feelings of angst when considering the difficult decisions that may arise. Diagnosis of a condition requiring intensive treatment may result in transfer of care from a US medical facility to your children’s country of origin.

Current Us Immigration Trends

Migration from one country to another for safety, employment, and personal opportunity has occurred for years. Since 1990, the United States has consistently received the most immigrants. Although the number of unauthorized immigrants declined in 2017, Pew Research Center reported that persons born in Mexico still account for the largest percentage (47%) of all unauthorized immigrants. Approximately 5 million children in the United States, under age 18, live with at least 1 unauthorized parent. Large numbers of children arriving from Central America have been detained at the United States–Mexico border, overwhelming normal governmental processes and resources, and have reached crisis status in Texas and California. Approximately 56,000 unaccompanied minors have been detained since October 1, 2018. Additionally, news reports are replete with stories of children who crossed the United States–Mexican border with parents, were separated, and then placed in detention centers, exposing the children to poor health conditions, human rights violations, and risk of death. , The COVID-19 pandemic poses additional cause for concern.

Throughout the United States, nurses encounter challenges in caring for the children and their families. Ethical issues, barriers to care, and negative health outcomes surround the health of unauthorized immigrant Latinx children and their families, and have persisted for over 20 years. , 8, 9, 10 Nurses in the hospital setting may experience moral distress due to disparities in care or care restricted by law. Nurses’ decisions and actions are likely influenced and limited by organizational policies and procedures. The care they desire to promote may directly conflict with policies, regulations, or laws. Although moral norms, nursing practice position statements, and ethical codes guide care and decision-making, none fully delineate the appropriate course of nursing action. The Theory of Bureaucratic Caring provides a novel framework for examining issues surrounding care of Latinx unauthorized children and children of unauthorized parents and identifying action areas. This paper discusses issues using a spiritual–ethical and bureaucratic lens and encourages nurse leaders to evaluate and take action within their organization, community, state, and nation.

Theory of Bureaucratic Caring

The Theory of Bureaucratic Caring combines the thesis of nurse caring and antithesis of bureaucratic caring. Nurses may value caring for children and families, regardless of their citizenship status and cost, whereas administrators may be concerned for the economic well-being of the organization. Nurses view caring as a spiritual–ethical factor based on choice, creativity, love, community, justice, fairness, and doing what is right. Conversely, administrators may view caring as a bureaucratic commodity with an associated cost. Physical, social–cultural, legal, technological, educational, and political bureaucratic factors influence care within the organization. Bureaucratic factors interconnect with the spiritual–ethical factor at the center of the caring relationship.

Interconnection of Legal and Spiritual–Ethical Factors

Health Care–Related Laws

US laws regarding immigration, access to care, and care delivery are complex, confusing, and vary across states. Laws often complement ethical standards; however, laws addressing unauthorized immigrant health care coverage elicit conflict, confine nurses’ care, restrict parents’ choices, and deny the child’s fundamental right to health care. The legal system discriminates who qualifies for health care coverage, thereby limiting access and rights to health. Unauthorized immigrant children live in limbo without a pathway to attain health care coverage or citizenship status. Table 1 provides a listing and brief explanation of relevant laws and regulations affecting care.

Table 1

US Laws and Regulations Discriminating Care of Unauthorized Children and Families

Year	Law	Description
1986	Emergency Medical Treatment & Labor Act (EMTALA)39	• Ensures emergency care (assessment and treatment) regardless of ability to pay.
2009	Children’s Health Insurance Program Reauthorization Act (CHIPRA §214)40	• Denies coverage of children who are undocumented or granted Deferred Action for Childhood Arrivals (DACA) (Dreamers). • Offers states an option to access Medicaid or Children’s Health Insurance Program (CHIP) funds for immigrant children lawfully residing in the United States during the 5-year waiting period for Medicaid/CHIP coverage. As of May 2018, 34 states cover care.
2010	Patient Protection and Affordable Care Act (ACA)41	• Denies coverage of children who are undocumented. Allows undocumented parents to apply for coverage for a dependent child. • Does not require parent to disclose immigration status for application for the child. • Does not allow use of immigration status to be used by US Immigration and Customs Enforcement for immigration enforcement.

A health care visit may place an unauthorized immigrant child or parent at risk for seizure. The US Immigration and Customs Enforcement (ICE) and Customs and Border Protection (CBP) agencies generally avoid action in health care settings because of designation as a sensitive location; however, action is allowed in public places if permission is granted by designated personnel. , The child and family have protection in areas of the hospital designated as private, such as a patient’s room. Although nurses are not mandated to report unauthorized persons seeking care, issues such as cost-prohibitive, limited access to care and the risk for apprehension in the hospital setting prompt ethical concerns for nurses.

Ethical Codes and Position Statements

Position statements and ethical codes can inform and guide nursing practice regarding care of unauthorized immigrant children. A foundational work related to ethics is the Universal Declaration of Human Rights. The Declaration set expectations for upholding human rights, such as dignity, health, and wellness, and advocates for the care of women and children. The United Nations specifically defined the rights of the child in 1989 with the Convention on the Rights of the Child. Supporting human rights in the context of nursing, the International Council of Nurses (ICN) released a position statement in 1983 recognizing the negative physical and psychosocial effects and barriers faced by migrant persons, especially children who are most vulnerable. The ICN continues to call nurse leaders to recognize and resolve discrimination and disparities, change policy, and affect care at the point of delivery across systems. When bureaucratic factors conflict with ethical care, nurses have a responsibility to advocate for the patient’s human rights. , The Code of Ethics for Nurses and nursing position statements, such as Health of Migrants, Refugees, and Displaced Persons, Pediatric Bill of Rights, and Child Welfare, provide additional guidance for ethical decision-making and action by recognizing key ethical principles: dignity of a person, right of the child to health care, nurses’ duty to care, and the importance of family.

Dignity of the human person

The dignity of human life originates from the belief that humans are created in the image of God. The value and dignity of one’s life is equal to that of another. Dignity is characterized by freedom of choice, consciousness, promotion, and development. A climate of incivility exists in which Latinx immigrant children and families are dehumanized, demonized, mistreated, and devalued. Youth and parents’ experiences , and child protection strategies indicate fear of seizure and deportation limits choice, invades consciousness, and impedes promotion and development.

Right to health care

States have an obligation to provide resources to support a person’s growth, including access to food, housing, and basic health care. , The child and parents’ inability to obtain citizenship and legal residence infringes upon the right to health care.

Nurses’ duty to care

Nurses have a legal and moral duty to provide care for all children regardless of citizenship status, ability to pay, etc. The nurse’s responsibility is to the patient, above all others, and is demonstrated through protection and promotion of the patient’s rights, health, and safety. In the case of unauthorized children seeking care, the reality is nurses’ duty to care is largely controlled by health care organizations and laws.

Importance of the family

The importance of the family garners meaning from a spiritual ethos. In Christian tradition, the child’s family is the center of love and acceptance and the foundation of society. A family’s responsibility is to nurture the child to fullest potential. At any moment, unauthorized children and family are at risk for disruption of the family unit. Fear of potential or actual separation can have a long-lasting emotional impact on the child.

Physical Concerns

Unauthorized status has deleterious effects on the child’s mind and body. Interviews with 54 immigrant parents revealed their children feared parent and self deportation, and demonstrated hypervigilance, sadness, crying, and depression due to anti-immigration policies. Children with unauthorized status reported feelings of inequality, restriction, and loss of dreams and hope. Additional related feelings include isolation, alienation, and liminality.

Political Influences

Although nurses and physicians advocate for policies supporting the health and care of unauthorized children and families, , , delivery of hospital care once the patient is stable is greatly influenced by the child’s access to coverage. In the absence of citizenship and insurance, administration deems medical repatriation a solution. In this case, the administration holds power, the dollar speaks, and nursing care becomes a controlled and limited commodity.

Cost Of Care

Reports on the cost of care delivered to unauthorized persons are limited but indicate a significant economic impact. In 2010, the Texas Health and Human Services Commission reported expenditures of $96 million on services and benefits. Texas public hospital districts delivered $717 million in uncompensated care, approximately $100 million more than 2 years prior. The report illustrates the states’ financial burden but does not delineate the cost of caring for children with unauthorized status in public or pediatric hospitals. In 2018, almost half (45%) of unauthorized immigrants were uninsured. Financial instability created by unaffordable medical care costs decreases the families’ likelihood of demonstrating self-sufficiency: a legal necessity for inadmissibility on public charge grounds requirements.

Latinx Culture

Social–cultural factors of personalismo and respeto are important for establishing trust in the context of communication. , Parents value friendliness and respect offered by nurses, which opens communication and information exchange. An important core value is family or familism. Children are highly cherished. Touch, togetherness, and closeness extended to biological family members as well as padrinos, or godparents, characterize relationships within this culture. These values and the tendency of the culture to focus on the moment may have particular meaning in gaining the patient and family’s trust in the ever-present fear of deportation.

A Call to Nursing Action

Ethical duty to care compels nurse leaders to notice challenges and health effects experienced by unauthorized children and families. Opportunities exist within the workplace, community, state, and nation to advocate for children and families with unauthorized status. Areas of action include self, education, practice, and research.

Self-Assessment and Education

Nurse leaders should analyze personal beliefs, values, and knowledge and assess for biases, prejudices, or misconceptions. Analyzing ethical questions, dilemmas, and distress associated with patient encounters and influencing factors within the organization are important actions. Other endeavors to increase awareness and knowledge include participation in cultural competence training and national and international nursing associations concerned with immigrant care. ,

Practice and Research

In addition to translation of knowledge to practice in face-to-face ethical care of children and families,23, 24, 25 nurse leaders can become involved in organizational nursing shared governance structures, policy and procedure councils, and national and international nursing associations that advocate for human rights and access, coverage, and equity of care for all children. Research is needed that explores spiritual–ethical and bureaucratic factors of caring in the hospital and exposes the sufferings, barriers, challenges, and health outcomes experienced by Latinx children and families with unauthorized status.

Conclusion

Analysis of caring for unauthorized children in the hospital setting with the conceptual framework of the Theory of Bureaucratic Caring reveals complex, multifactorial issues with spiritual-ethical and bureaucratic implications for nurse leaders. Nurse leaders must ensure ethical decision-making and action-taking that supports nursing care and the health and well-being of unauthorized children and their family. The words of Annette Kennedy, President of ICN, are a reminder of the important role of nurse leaders in solving care issues:

Together as nurses, we hold the power to influence, to drive change and to call for action. Only nurses hold the unique understanding . . . about a patient’s history, diagnosis, health care needs, personal worries and the concerns of a patient’s family and friends. As nurses we need to recognize this is informational power, which is unique to nurses and we have a duty to our patients to use this power in every conversation about health care.

Nurse leaders in the hospital setting must seize opportunities to sit at the table with administrators, problem solve creatively, and influence decisions benefiting care of unauthorized children. Nurse leaders are in ideal positions to direct policies, procedures, and treatment programs that enable the child to remain in the United States for care and support the integrity of the family. Establishment of trusted nurse–parent relationships can create communication channels for informing parents of the child’s right to care, dispelling myths, and fostering health. Nurse leaders must advocate for the nonnegotiable, basic human right of health care for all children and exercise duty to care when laws and organizational policies threaten or fail to support children’s health and well-being.

Challenges encountered in caring for Latinx children and families with unauthorized status have remained without resolution. Current social incivility, care disparities and inequities, and child and family health risks confirm the gravity of the situation. Now is the time for nurse leaders to evaluate spiritual–ethical and bureaucratic factors within their organizations, recognize their unique power, and take action to bring about change in the ethical nursing care of Latinx unauthorized immigrant children and their families.