Representative responses
Representative responses for each free-text survey item were selected by study authors to demonstrate how responses were codified into themes and to exhibit the range of both specific and generalized experiences with ILE in the healthcare setting. They are reported here as stated by respondents (i.e., with grammatical and other mistakes included) along with a brief explanation of how they were coded by theme and subtheme.
“Why did you think that immigration law enforcement was respectful to the detained patient?“
Response 1: “I think it’s hard to quantify this: because I had several ICE agents that were absolutely cordial, respectful of the women and children in their custody, and respectful of us. Conversely I had several who were absolutely awful to have to deal with, talked smack about “those people” in front of patients, and assumed I - as a white male - have similar views. I think there tend to be agents who grew up around here, or are from similar border communities, and then there are people who get shipped here from parts of the country where they don’t speak spanish, or have our border community identity”.
Response 1 captures three concurrent themes that were reflected in many of the comments the authors analyzed. These themes are neutral (“respectful”), positive (“absolutely cordial”), and negative (“absolutely awful;” “talked smack”) sentiments regarding ILE’s respectfulness with patients. As with many other free-text comments, the respondent answered in general terms about their experience with ILE and not about specific instances. Additionally, rather than highlighting the structural and legal impact of agents in the hospital setting, this respondent chose instead to focus on the summative experience of all their interpersonal interactions with agents. In addition to expressing general sentiments that run the gamut, this respondent also brings up elements of relatability and understanding, deemed necessary to a positive experience with ILE. According to the respondent, those agents that “speak spanish” and “have our border community identity” might be more respectful to patients and healthcare personnel.
Response 2: “They helped with interpretation as needed, didn’t try to force is to discharge patient. Wanted to ensure medical clearance for discharge”.
Response 2 captures three concurrent themes as well - neutral, positive, and underinformed. The last of these is especially poignant. Underinformed responses are those that do not recognize the clearly established rights of patients in this setting. This quote captured a specific practice that is oppositional to standard ethical expectations (often enforced by hospital policies and/or local/federal law) that indicates the respondent is underinformed. As interpreters are specifically licensed and employed to translate in a healthcare setting, the use of family members, friends, or ILE agents as interpreters is often considered ethically inappropriate. As such, the fact that this respondent included “they helped with interpretation as needed” indicates that ILE agents were inappropriately used as interpreters and calls into question the training that this provider has had regarding interpretation services and the ethics behind it. Such underinformed comments were common across many respondents.
Response 3: “They were courteous to the patient and allowed for them to receive the appropriate care that they were brought to the emergency department. Often times, they would bring up concerns that were not the intended reason for transfer to the hospital. Last night, I had a patient that was sent for medication refill but the BP agent voiced a concern that the patient had not urinated for greater than 24hours and went over 36hours without food or water”.
Response 3 captures a specific event that has both neutral and positive themes. While codifying various responses, those that mentioned courtesy or professionalism were commonly coded as neutral (as these are expected neutral practices within the ILE profession and their interactions with healthcare providers). As such, when the respondent proffers that the agents were “courteous to the patient,” they reflect neutrally on their behavior toward patients. Additionally, this quote highlights both a generalized positive statement about the fact that ILE agents mentioned concerns about patients and a specific example of this statement in which an ILE agent showed extra concern beyond what was expected of them in their professional duties to ensure that a patient was adequately fed and hydrated.
“Why did you think that immigration law enforcement was disrespectful to the detained patient?“
Response 4: “While in the Emergency Room we were ruling out a heart attack on a detained patient while two border patrol were in the room. They saw my classmate and I were medical students and they started lecturing us on how the patient was ‘playing us’ and the he was making it all up to get out of the detention center. Then they proceeded to say we should not forget to check for parasites by saying; ‘if you’re dealing with central americans you always got to check for parasites, sometimes with the Mexicans too.’ I felt compelled to speak up but wanted to focus on my patient and did not want my patient to have repercussions if I were to confront the Border Patrol officer’s lack of empathy/respect for my patient.”
Response 4 represents both negative and hierarchical/power related themes. The negative sentiments of the response come from a specific interaction with ILE agents in which they used language that could be considered harmful, especially regarding stereotypes of Central American and Mexican migrants and regarding migrants’ alleged abuse of the system. The response also highlights a specific power dynamic between ILE and medical students. The respondent outlines how the medical student felt powerless to confront the ILE agent about their negative statements out of fear for negatively affecting their patient’s care.
Response 5: “CBP have some agents that have been acclimated to an institutional culture of crassness and dehumanization. One BP agent, who spoke no Spanish, said things like “75% of them don’t make their trial”, and “How could you put your kid in that much danger?” Without realizing that I volunteer my time with migrants at a local Shelter and actively despise CBPs presence in a children’s hospital. [Study site] needs a common sense policy to handle their presence. It’s contrary to a place of healing for children in need.”
Response 5 highlights negative and hospital policy related themes. The negative theme is found in the generalized sentiment regarding CBP’s “culture of crassness and dehumanization.” The respondent also explicitly responds that the hospital study site needs “a common sense policy” regarding immigration law enforcement. Lack of clarity in the policies at the study site (and in general local and federal policies) was stated in multiple quotes.
“Why did you think that immigration law enforcement was respectful to you [the provider]?“
Response 6: “I’m a doctor in a white coat.”
Response 6 exhibits an inverse power dynamic than that stated in Response 4. By highlighting their position as a physician in a white coat, the respondent seems to show that they deserve respect due to the hierarchical nature of their position in the hospital setting.
Response 7: “The majority of officers have not impeded my ability to deliver care. They have been cordial. I have never asked one of them to leave a room because I never did anything that required them to leave, so I am judging respect based off of good interactions.”
Response 7 ascribes to neutral, negative, and underinformed themes. In the neutral light, the description of the officers as “cordial” and “respect[ful]” represents expectations of ILE’s professional duty to be courteous with the individuals they interact with. The negative theme was so assigned because of omission. That is to say that this author specifically mentions that “the majority have not impeded my ability to deliver care.” Indicating this majority, also indicates that there were a minority of ILE agents that did impede care, which fits into the negative overarching theme. Finally, the underinformed theme was found in the respondent’s assertion that they did not have to ask the agents to leave the room. As there are specific scenarios in which HIPAA would require a private interaction with a patient, this assertion demonstrates that the respondent was underinformed in protecting their patients’ right to privacy.
“Why did you think that immigration law enforcement was respectful to hospital personnel?“
Response 8: “I feel like it’s hit or miss. Some are very nice and respectful while others can be belligerent more so to nursing staff etc.”
Response 8 captured both neutral and negative sentiments in a generalized manner. The description of ILE as “nice and respectful” neutrally states their ability to act professionally in the hospital setting. However, the “miss” and “belligerent” behavior indicate that ILE’s interaction with other hospital staff can have negativity attached.
“In the space below, please provide additional experience you have with immigration law enforcement at BUMC:“
Response 9: “Our LAW ENFORCEMENT officials that I have interacted with in the [Emergency Department (ED)] have been nice to work with and respectful. They have never given me push back when I asked them to leave for a sensitive exam or when I was asking sensitive questions. These immigrants are in their custody because they broke laws. Because of this, our law enforcement officials are obligated to keep them detained and ensure they do not escape. In my opinion they could be much more strict (shackles, restrictions, etc) but they do not. I have never had one of them be disrespectful to a patient. I have never had them be abusive or demeaning. They follow orders and regulations just like any other law enforcement agency who deals with individuals who break laws. I appreciate that they do a good job of enforcing the law at our borders.”
This quote was codified as possessing unrelated, underinformed, neutral, and policy themes. The unrelated theme was codified due to the last sentence of the comment, which discussed appreciation for the work that ILE agents did at the border, a statement that was unrelated to the purpose of the survey which was addressing the interactions of ILE, patients, and staff in the medical setting. The underinformed theme was highlighted as the respondent discussed the need for more strict regulations on patients that misalign with standard protections for patients under any law enforcement authority and against patient privacy and autonomy in certain situations. The neutral theme was again selected as agents were “not disrespectful, “never…abusive or demeaning” and as “[t]hey follow orders and regulations,” indicating that ILE officers were neutrally conducting their roles in the hospital setting. The policy theme was chosen for this comment as it discusses changes that could be made to allow the officers to be “more strict.”
Response 10: “They rush patients in the shower and threaten to come in if they don’t hurry. They have watched a mother breastfeed her daughter (patient). They have made jokes about the patient when immigration news was on the television. border patrol agents kept asking for updated medical information on patients and when they would be discharged.”
This quote was codified as possessing negative and hierarchy/power themes. The negative theme comes from three specific negative actions that the respondent witnessed – the first having to do with rushing a patient in a medically appropriate and necessary action related to personal hygiene; the second had to do with inappropriately disrespecting a patient’s privacy and dignity while she breastfed, and the third had to do with targeted comments against immigrants. The comment was also codified as one which discusses hierarchy and power as the respondent seems to point out how ILE agents constantly use their role and power against patients and in ways that rush providers.
Response 11: “Medical students, providers, and staff need training on the fact that HIPPA still applies to detained patients!!!!!!!!!!!!! I after I was finishing up doing seeing my patient in the morning, the border patrol agent in the room asked me how many more days would the patient need to be here. I had told the patient he had some labs that were downtrending but still way to elevated to be discharge, so the border patrol agent must have spoken some Spanish because he then ask me what labs are still elevated that are keeping the patient here. I responded some kidney labs. He said which ones. I then said that I didn’t not believe that I could share patient information with him. He replied that according to his understand, HIPPA did not apply to him and that I could tell him patient information. I respectfully responded that that was contrary to my understand and I would need to check with my attending to clarify. The only reason I felt confident to give that response if because I had just attended a talk that same week put on by the [study site] residents/attendings) on what our rights are as providers with respect to patients in Border Patrol/ICE/etc custody!!!!! EDUCATE ALL WITH INTERACTION WITH PATIENTS PLEASE !!! Also people should be encouraged to ask the officers to step outside of the room during patient interactions.”
This quote was codified as possessing negative and policy themes. The negative part of the comment points out a specific action that an ILE agent took to attempt to coerce a trainee into discussing protected health information pertaining to a patient. The second highlights the need for education and training as the respondent multiple times with emphatic language and exclamation marks, proclaims that providers at the study site need more clear training on the policies and the rights that they have in protecting migrant patient information.
Response 12: “Having immigration law enforcement around is often an impediment to quality care. They should not be allowed in the operating room and should be held to HIPAA regulations as are all of us.”
This quote was codified as possessing negative and policy themes. The respondent first gives a general statement that highlights a potential negative effect of ILE presence on patient care while the second part of the comment requests a change in policy that might better protect patient privacy in the operating room (as well as in other areas of the hospital).