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Letter to the Editor

Nurses Need Not Be Guilty Bystanders: Caring for Vulnerable Immigrant Populations

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Elizabeth Moran Fitzgerald, EdD, M.S., MEd, RN, CNS-BC
Judith G. Myers, PhD, RN
Paul Clark, PhD, MA, RN


Nurses face many dilemmas when providing healthcare to immigrants, a vulnerable population. Racist, rancorous dialogue can create a hostile care environment that may place patients at risk for substandard care. This article presents a two part case study about a Hispanic patient to illustrate both examples of inappropriate dialogue (Part I) and potential nursing actions (Part 2). The authors review myths versus facts about Hispanic immigrants and introduce activist Thomas Merton’s concept of the guilty bystander, the nursing professional code of ethics, and Professor Joseph Badaracco’s concepts of quiet leadership as practical tools and approaches that nurses can use to advocate for safe, quality, ethical care of immigrant populations.

Citation: Fitzgerald, E.M., Myers, J.G., Clark, P., (December 1, 2016) "Nurses Need Not Be Guilty Bystanders: Caring for Vulnerable Immigrant Populations" OJIN: The Online Journal of Issues in Nursing Vol. 22, No. 1.

DOI: 10.3912/OJIN.Vol22No01PPT43

Key Words: Ethics, vulnerable/immigrant populations, quiet leadership, guilty bystander, incivility, Code of Ethics for Nurses with Interpretive Statements, rancorous discourse, American Nurses Association, tenacity, immigration myths, nursing education, bullying, hostile workplaces, hostile work environments, personal responsibility, racism, Thomas Merton, Joseph Badaracco.

Historically, incivility toward immigrant groups increases during economic downturns when access and the provision of public services is perceived as a costly drain on scarce resources. Immigrants have been part of the fabric of the United States (U.S.) since its inception, and despite this reality, certain immigrant groups continue to be viewed negatively by members of the dominant culture throughout the United States. Historically, incivility toward immigrant groups increases during economic downturns when access and the provision of public services is perceived as a costly drain on scarce resources. This negative view can be extended into the realm of healthcare, creating situations in which nurses become involved in the contentious discourses and ethical challenges surrounding the provision of healthcare to vulnerable immigrant populations. Johnstone and Kanitsaki (2010) posit that racism as an ethical issue has been overlooked in discourse on healthcare ethics and suggest that if it is not addressed by healthcare providers, preventable harmful consequences can occur.

In 1998, the American Nurses Association (ANA) issued a position statement on Discrimination and Racism in Health Care. This quote from the summary of the ANA position statement underscores the importance of redressing this important issue:

Discrimination and racism continue to be a part of the fabric and tradition of American society and have adversely affected minority populations, the health care system in general, and the profession of nursing. Discrimination may be based on differences due to age, ability, gender, race, ethnicity, religion, sexual orientation, or any other characteristic by which people differ. The American Nurses Association (ANA) is committed to working toward the eradication of discrimination and racism in the profession of nursing, in the education of nurses, in the practice of nursing, as well as in the organizations in which nurses work. The ANA is further committed to working toward egalitarianism and promotion of justice in access and delivery of health care to all people (ANA, 1998, p.1).

Civil and healthy workplaces are created by the ordinary, everyday actions of individual nurses. Civil and healthy workplaces are created by the ordinary, everyday actions of individual nurses. Therefore, it is crucial that nurses in all settings and levels of practice be guided by and held accountable to a professional code of ethics, and that they have the skills needed to serve as effective advocates for all patients, families, and populations. The voice of the individual nurse is one of the strongest tools of advocacy. Yet, when caught in the middle of rancorous, racist discourses related to the provision of healthcare to immigrants, some nurses chose to remain silent, perhaps perceiving themselves to be innocent bystanders.

...some nurses chose to remain silent, perhaps perceiving themselves to be innocent bystanders. This article employs activist and philosopher Thomas Merton’s (1966) concept of guilty bystanding to challenge the notion that those who are silent witnesses to conversations and other actions that perpetuate racism and discrimination are innocent. Additionally, the concepts of Quiet Leadership outlined by Harvard Business School’s Joseph Badaracco (Badaracco, 2002) are offered as useful strategies to deal with complex, multilayered issues, arrive at win-win solutions and provide the best quality of care for patients, families, and populations. Nurses can use these skills in any setting to buffer and protect immigrant populations, families, and each other from the negative effects of prejudice and racism in the workplace. A case study from an actual healthcare encounter is used to illustrate these concepts, with specific emphasis on guilty bystanding and the key elements of Quiet Leadership.

Immigrants as a Vulnerable Population

Vulnerable populations are defined as “those at greater risk for poor health status and health care access” (Shi & Stevens, 2005, p. 148) and who have a greater than average risk of developing health problems (Aday, 2001). Merriam-Webster (2010) defines vulnerable as being susceptible to attack and subject to criticism. Vulnerability often exists among certain populations because of marginalized sociocultural status which is correlated with limited access to economic resources (de Chesnay, 2008).

While there are a wide variety of populations and subcultures in the United States which qualify as “vulnerable,” this article considers a specific example that reflects the authors’ witness of encounters between Hispanic patients and healthcare providers in a mid-western state over a period of six years. According to the Pew Research Center Hispanic Trends (Stepler & Brown, 2016), there were 55.3 million Hispanic persons in the United States in 2014, comprising 17.3% of the total U.S. population. In 1980, 14.8 million Hispanic persons lived in the United States and comprised 6.5% of the total U.S. population. The latest projections by the U. S. Census Bureau indicate that the nation’s Hispanic population is projected to grow to 119 million by 2060 (U.S. Census Bureau, 2014). The Pew Research Center notes that the primary factor for the growth of the Hispanic population in the United States between 1980 and 2000 was immigration. However, since 2000, the main source of Hispanic population growth has changed from immigration to native births. The statistical trends in the present decade project a repeat of this pattern, with 3.9 million Hispanic births in the Unites States between 2010 and 2014, compared with 1.4 million newly arrived Hispanic immigrants (Stepler & Brown, 2016).

According to the U. S. Department of Health and Human Services Office of Minority Health (2016), Hispanic persons have the highest uninsured rates of any racial or ethnic group in the United States. The report, Profile: Hispanic/Latino Americans, noted that in 2012, 29% of the Hispanic population was not covered by health insurance, whereas 10.4% of the non-Hispanic White population was uninsured. The Centers for Disease Control and Prevention Health Disparities and Inequality Report (2013) revealed that the prevalence of Hispanics with adult diabetes is higher and Hispanics also had the highest rate of work related fatal injuries (4.4 per 100,000 workers). Among persons age 18 years and older with hypertension, rates of controlled blood pressure were lower among Mexican-Americans and persons who were uninsured. Compared with Whites, tuberculosis rates in 2010 were seven times higher among Hispanics.

Healthcare provider (HCP) bias toward vulnerable populations occurs. In a systematic review of 15 studies, 14 out of 15 studies indicated HCP bias toward people of "color" (Hall et al., 2015). Many of these studies noted HCP have an anti-black bias; however, four of the 15 studies noted a bias against Hispanic/Latino/Latina individuals, compared with white individuals, with two of these four studies noting HCPs have a moderate to strong implicit bias toward this population (Hall, et al., 2015). HCPs include physicians, dentists, and nurses, among others. However, this solid evidence points to the existence of bias toward this population, adding to the vulnerability of Hispanic populations.

Culturally, the United States is changing, and consequently what it means to be an American is shifting rapidly. Abramsky (2010) discusses both the use of hyperbolic rhetoric used by many people in the United States as well as socioeconomic and political factors, including the recession in 2008, as contributors to a growing atmosphere of anger and fear toward both documented and undocumented immigrants. Expressions of bitterness and frustration have become commonplace. Culturally, the United States is changing, and consequently what it means to be an American is shifting rapidly (Abramsky, 2010). “Culture wars” (Abramsky, 2010, p. B7) as well as the increased backlash against immigration are reactions to these changes. Nurses, who witness racist dialogue, may find themselves wedged between the desire to act ethically as advocates for their patients and the fear that doing so might result in ostracism by some members of their peer group. This type of dilemma is exemplified in the following case study. Identifying information, such as names and countries of origin, have been changed to protect confidentiality.

Case Study, Part 1: Ms. Martinez.

Ms. Ximena Martinez is a Guatemalan national who is pregnant and has been admitted to the Mother Baby Unit in a local hospital to deliver her child. She is accompanied by several members of her extended family who do not speak English. During shift report, a nurse complains of being sick and tired of “illegal aliens” coming to the United States and “dropping their babies” so their children can become U.S. citizens. To her co-workers this nurse states, “If these people are living in the United States they need to learn to speak English.” Another co-worker nods in agreement and attributes rising unemployment to “. . . illegals taking jobs that Americans need.” Two other nurses and the nursing student assigned to Ms. Martinez remain silent during this dialogue. Later, the student learns that Ms. Martinez is a U.S. citizen, has a graduate degree, and is employed by a large corporation. Regardless of the patient’s race, gender, socioeconomic status, nationality, or educational level, these comments made by the two RNs were unethical at least, and demonstrate a gross lack of professionalism and racism at worst. The student goes to the clinical instructor for guidance.

Myths versus Facts About Hispanic Immigrants

A popular misconception is that pregnant, non-U.S. citizens enter the country illegally so that their newborns can have citizenship. A popular misconception is that pregnant, non-U.S. citizens enter the country illegally so that their newborns can have citizenship. Experts who study the demographics of Hispanic immigration, such as Princeton University demographer Douglas Massey, note that it is rare for immigrants to migrate to the United States only to have babies and obtain citizenship (Christie & Weber, 2010). According to the Immigration Policy Center of the American Immigration Council, research shows that unauthorized immigrants do not come to the United States simply for healthcare benefits or any other public services for which they are not eligible (California Immigrant Policy Center, 2006). More often, immigrants come to the United States for economic reasons and to find work, and then remain in the United States in search of a better life for their families (Associated Press, 2010; California Immigrant Policy Center, 2006). Armed with these facts, how could the two nurses and the student respond to this instance of incivility? Philosopher Thomas Merton holds that silence is not an option and that remaining silent only contributes to the injustice that occurs in the case of Ms. Martinez and others.

Guilty Bystanding

...remaining silent in the face of an injustice does not preserve innocence. Instead, silence indirectly perpetuates and contributes to the injustice, leading one to be a “guilty bystander.When nurses witness derogatory, stereotypical comments directed toward patients, families, and/or or co-workers, some for a variety of reasons may remain silent. Are nurses who remain silent when witnesses to derogatory, stereotypical comments directed toward patients, families, and/or or co-workers, inadvertently supporting and participating in incivility and abuse? Philosopher and activist Thomas Merton (1915-1968), a Roman Catholic priest, peace activist, and Trappist Monk who resided in the monastery of Our Lady of Gethsemane near Bardstown, KY provided guidance about the power of language and the dangers of remaining silent (Padgett, 2009). Merton asserted that remaining silent in the face of an injustice does not preserve innocence. Instead, silence indirectly perpetuates and contributes to the injustice, leading one to be a “guilty bystander” (Merton, 1966).

Many who witness these unjust acts fear that voicing an objection may jeopardize their standing in a group... or lead to an uncomfortable confrontation. In Letter to an Innocent Bystander, Merton (1966) explained that there are individuals who seek power solely for themselves and unjustly deprive others of the same opportunities. Many who witness these unjust acts fear that voicing an objection may jeopardize their standing in a group, such as a work or social group, or lead to an uncomfortable confrontation. As a result of these fears, those who witness unjust acts choose not to respond and not to witness against these unjust acts. Merton (1966) cautioned against remaining silent in the face of any injustice, noting that remaining silent does not maintain one’s innocence nor does it relieve one of the responsibilities of acting (Padgett, 2009). On the contrary, by not responding one becomes a guilty bystander, inadvertently participating in the acts of injustice. As Merton (1966, p. 55) noted, “A witness to a crime, who just stands by and makes a mental note of the fact that he is an innocent bystander, tends by that very fact to become an accomplice.”

...guilty bystanders in work settings are involved in a system that helps build and contribute to ethical collapses. In addition, guilty bystanders contribute to the cause of those perpetuating unjust acts. Individuals, who seek power at the expense of others, use bystander silence as an affirmation of their behavior, providing them motivation to continue their unjust acts. While perpetuators of injustice do bear responsibility for their actions, if these actions are left unchecked, even small abuses of power can grow and worsen. Padgett (2009) applied Merton’s ideas to the workplace and noted that guilty bystanders in work settings are involved in a system that helps build and contribute to ethical collapses. By remaining silent, these individuals inadvertently help to create an environment that perpetuates injustice, ethical lapses, and abuses of power.

Based on Merton’s philosophy, when professional nurses witness an act of incivility perpetrated by one healthcare provider against another person (e.g. a patient, staff member), these nurses have an obligation and a duty to work toward creating justice. Nurses do not have sole responsibility to correct the situation; however, by registering disagreement with the perpetrator’s incivility and then by removing themselves from the rancorous conversation, nurses do not silently become a part of the acrimonious, unjust dialogue. On the contrary, they use their voices to act ethically; to resist participation in harassing, intimidating, uncivil comments; to contribute to righting the situation; and thus avoid guilty bystander status (ANA, 2015).

Professional Code of Ethics

Because ordinary actions of individual nurses shape the environments in which healthcare is provided, it is crucial that nurses are guided by a dynamic professional code of ethics in all settings and levels of practice. The American Nurses Association provides The Code of Ethics for Nurses with Interpretive Statements (ANA, 2015). Provision 1 of the code promotes professional practice with compassion and respect for the inherent dignity, worth, and uniqueness of every individual. Provision 1.2 of the code states, “Nurses establish relationships of trust and provide nursing services according to need, setting aside any bias or prejudice” (ANA, 2015, p. 1) This ethical code is unrestricted by consideration of the social or economic status, personal attributes, or the nature of health problems of patients.

The code of ethics urges nurses to advocate for and protect the health and safety of his or her patients, noting that every nurse’s primary commitment is to their patients, which includes the individual, family, group, community, or population (ANA, 2015). Standard 1.5, relationships with colleagues and others, states, “Nurses value the distinctive confrontation of individuals and groups as they seek to assure safe, quality patient outcomes in all settings. Additionally, they collaborate to meet the shared goal of providing compassionate, transparent, and effective health services” (ANA, 2015, p. 4) The code of ethics is the nursing profession’s “non-negotiable” standard and is an expression of the profession’s commitment to society.

In the case example, the nurses who remained silent while listening to harsh remarks made by colleagues about Ms. Martinez were, by definition, guilty bystanders and as such were complicit in the failure to uphold nursing’s professional code of ethics. Holding a professional license implies a right and duty to uphold ethical norms which respect the dignity, worth, and unique aspects of every person (ANA, 2015). According to Padgett (2009), “Acting professionally especially on the basis of adherence to a specific code of ethics can lead to conflicts with one’s own personal values and commitments” (p.38).

As professionals, nurses must provide the right patient care regardless of conflicting political views. Nurses may hold strong political views about a particular social issue, which is not necessarily an ethical concern unless the nurse acts on a particular viewpoint in a manner that jeopardizes the quality of care patients receive. As professionals, nurses must provide the right patient care regardless of conflicting political views. The nurses in the scenario involving Ms. Martinez needed to hold one another accountable for adherence to the ANA code of ethics which clearly prohibits any show of disrespect toward a patient or any group of people under their care (ANA, 2015).

The ANA House of Delegates in 2010 upheld its 1958 position that healthcare is a basic human right and that all persons who reside in the United States should have access to healthcare. This stance is also unrestricted by consideration of the immigrant’s residency status, and thus includes both documented and undocumented immigrants (ANA, 2010). The ANA policy is in alignment with the International Council of Nurses' position statement regarding health services for migrants, refugees, and displaced persons (International Council of Nurses, 2006).

...layers of management and decision-makers within most organizations make it difficult to know who is responsible for holding any person occupying a particular role to a professional code of ethics. According to Padgett (2009) the layers of management and decision-makers within most organizations make it difficult to know who is responsible for holding any person occupying a particular role to a professional code of ethics. When a situation involving an ethical dilemma is brought to light, typically those immediately involved, usually at the level of management, are tasked with arriving at a solution. However, Merton’s concept of guilty bystanding challenges this approach and shifts responsibility to all who witness or observe actions that break nursing’s professional code of ethics (Padgett, 2009). Nevertheless, how can nurses, who perceive that their response to an unethical situation may bring about negative repercussions, be challenged to move beyond guilty bystander status?

Quiet Leadership as a Resource

Harvard Professor Joseph Badaracco (2002) in his book, Leading Quietly: An Unorthodox Guide to Doing the Right Thing, shared guiding principles that can assist nurses to navigate the turbulent waters when providing care to vulnerable patients. “Before beginning the difficult effort to change the world, even in a small way, men and women must assess how much they care” (Badaracco, 2002, p. 41). The critical question, indicated Badaracco, is not about right and wrong; moral concern is necessary but not sufficient. In fact, the only sufficient course is to take the problem seriously and personally enough so as to care enough to act and stop an injustice, be persistent and tenacious to find a solution, and push forward until solutions are implemented (Badaracco, 2002).

Successful quiet leaders do not merely think they should act; they take the problem personally enough so that they do act. Successful quiet leaders do not merely think they should act; they take the problem personally enough so that they do act. Yet, successful quiet leaders also focus on what is attainable without causing self-harm. Quiet leaders concentrate their efforts on the small yet important sphere of influence in which they can act in accordance with professional and personal values, advocating for others without bringing direct harm to their careers (Badaracco, 2002). How do they do this?

Drilling Down

Quiet leaders drill down into complex problems. Quiet leaders drill down into complex problems (Badaracco, 2002). Drilling down involves: 1) not letting a problem’s complexity obscure one’s primary responsibility; 2) focusing on the problem and thinking it through; 3) never attempting to find a solution alone; and 4) sending problems too complex for one person to solve to the next level (Badaracco, 2002).

Table 1. Quiet Leaders: Drill Down and Tenacity (Badaracco, 2002)

Drill Down

Prevent complexity from obscuring responsibility

Focus on problem and think it through

Never seek solutions alone

Work complex problems “up” to the next level


Patient, careful, incremental problem solving approach

Personal, moral, and emotional urgency to act, rooted in caring and respect for all involved

Solution derived from urgency to act

When problems surface with many layers of complexity, nurses may be tempted to avoid seeking a solution to the problem. However, avoidance potentially prevents nurses from fully carrying out their primary patient care responsibility. According to the ANA Code of Ethics for Nurses with Interpretive Statements (2015), provision 6.3, nurses should address concerns through the proper channels regarding healthcare working conditions, keeping safe patient care as their motivation to find solutions.

Quiet leaders grapple with various levels of complexity, avoiding black and white, either-or ways of thinking. A second aspect of drilling down involves focusing on the problem and thinking it through. Quiet leaders grapple with various levels of complexity, avoiding black and white, either-or ways of thinking. The struggle with complexity, in turn, yields more opportunities for maneuvering and reframing problems. Seeing problems in a new light over days, weeks, or even months can reveal multiple solutions which can be implemented to solve problems. Thinking about a problem, journaling, and even sleeping between thinking/journaling sessions will allow solutions to become evident.

Drilling down involves a third process of seeking a wide variety of input from experts (such as transcultural nurses) with different perspectives; this feedback will add to the body of information to help solve the problem (Badaracco, 2002). Oftentimes, once contributions from others are gathered, a return to the thinking/journaling stage allows new details to become part of the solution process.

Finally, when drilling down, nurses should not be afraid to work the problem up the management chain when it is more complex than one person alone can solve (Badaracco, 2002). Human resource personnel, management and directors, and other workplace leaders may have to drive the process of finding a solution to a highly complex problem, and bring about an organizational cultural change.

In the case of Ms. Martinez, quiet nurse leaders who address the uncivil behavior must first focus on and be motivated by their ethical responsibility to provide her with nursing care. Yet this decision is, at least on the surface, fraught with peril. Perhaps the nurses who made the uncivil remarks are in leadership and could make working conditions more difficult for those who oppose their views. Nursing students or clinical instructors who take a stand may anger those who made the remarks, putting in jeopardy that school’s clinical positions with this facility. However, to avoid being guilty bystanders and to continue the process of drilling down, nurses must be motivated by their responsibility to provide Ms. Martinez the safest, highest quality nursing care possible.

...listeners must decide whether or not to address remarks immediately. The next step is to think it through. The prejudicial remarks made about Ms. Martinez can happen quickly, and listeners must decide whether or not to address remarks immediately. However, the more complex problem is addressing the behavior driving the comments. Working through these issues is painful and will require quiet nurse leaders to reflect on potential options, risks of addressing the individuals, how to address the remarks, and the risk to Ms. Martinez by remaining silent. Grappling with these complex questions through reflection, journaling, or even talking through the issues with a confidant will provide insight into the solution process. It may take some days or weeks before a final solution emerges.

Drilling down continues as the nurse seeks a wide variety of expert input, including human resources personnel, chaplains, a trusted leader, or an expert in the field of diversity training. These sources may provide a variety of input about professional and legal responsibilities, methods to address behavior, and resources to address the situation. Developing ways to address people who make uncivil, prejudicial remarks through fact and without judging the individuals will prevent putting one’s social status or a school’s clinical status at risk. Experts and others with varying perspectives will provide clarity and direction.

Finally, drilling down will occasionally make the nurse aware that more resources are required to solve a problem than one person can provide. When the behavior of the nurses who made those remarks is addressed and the rancorous comments continue, then nursing care for patients like Ms. Martinez is further compromised. This problem now needs to be moved up to the next level. Nurses who hear prejudicial remarks are not responsible for changing the minds and hearts of those who are prejudiced toward any class of people. However, just as nurses have an ethical obligation to make others (e.g., human resources, management) aware of a chemically impaired nurse to prevent patient harm, so too must nurses also seek other resources to deal with intractable, uncivil, prejudicial behavior that will bring about patient harm if unaddressed (ANA, 2015).


The virtue of tenacity, one of the six tenets of Quiet Leadership (Badaracco, 2002), allows the quiet nurse leader to make small, yet useful, practical efforts that can result in organizational change. Badaracco’s principle of tenacity is a virtue that all nurses, who want to live by their values and seek solutions for challenging serious problems, can embrace. Furthermore, noted Badaracco, they can do so without risking their careers or reputations! Tenacious quiet leaders do not lose their voices. Instead, they learn to use their voices in a different way, by working day in and day out to eventually find solutions to challenges within their organizations.

When using the virtue of tenacity, the nurse’s actions are patient, careful and incremental. When using the virtue of tenacity, the nurse’s actions are patient, careful and incremental. Sometimes knowing when to act or which course of action to take is based on ones’ instincts or intuition. Is it better to wait to move forward or to take immediate action? According to Kinsey (2010), it is important for nurses to learn to “count their political capital, and spend carefully” (p. 2), and it may be better to “buy time before jumping into action” (p. 2). This is especially important when dealing with uncertain or sensitive situations fraught with personality conflicts and mixed or underlying motives. Tenacious nurses refuse to ignore the problem, and when necessary, they search for ways to bend rules without breaking them. They use critical thinking skills to find solutions to problems that others may view as insolvable and work diligently toward solutions that will ultimately strengthen the unit and the organization (Kinsey, 2010).

Saying “ouch.” When dealing with the uncivil comments of the two vocal nurses toward Ms. Martinez, the tenacious quiet nurse leader could embrace Merton’s philosophy and avoid being guilty bystanders simply by stating “ouch,” or “That comment is offensive to me” (Aguilar, 2006). These simple, yet powerful statements are not judgmental and address the injustice by registering disapproval of the comments; in addition, this approach maintains the social capital of the quiet nurse leader on the unit. The quiet nurse leaders who are on an equal peer footing with those making the prejudicial comments may at another time privately address the prejudicial behavior of these nurses directly by explaining their discomfort and what those comments meant to them personally.

Using M.E.E.T. Another approach is the “M.E.E.T. protocol,” a mnemonic which stands for Make time to discuss (“Do you have a minute?”); Explore differences by explaining why comments are offensive to the listener and exploring the perspective of the person making the comments (“I felt frustration or confusion about your comment regarding Ms. Martinez. The way I look at it is. . . What’s your perspective?”); Encourage respect by finding common ground without giving ground (“This is important to both of us because. . .”); Take responsibility which admits to multiple perspectives and encourages those who made the comments to realize there are multiple perspectives (“Can you see some of the reality that patient faces daily? Can we agree that there is more than one way of seeing her care?”) (Selsius™ Corporate & Career Training, 2016). However they choose to deal with this issue, quiet nurse leaders demonstrate tenacity by breaking their silence and taking a professional stand against acts of prejudice and bigotry. The quiet nurse leaders’ essential nursing roles of commitment to compassion and advocacy drive them to break their silence.

Uneven tables. Being at uneven tables, according to Kritek (2002) is learning to negotiate conflicts in situations where some parties may be at a disadvantage that others do not acknowledge. Making the tables even involves selecting from a range of possible options as the best response to the situation, while recognizing the imbalances that individuals may be creating when they overemphasize dominance and power. Kritek (2002) asserts that a series of decision points must be addressed before taking action: “Why am I going to this table? What do I hope to achieve? “What I am willing to do to achieve this?” (p.157). Negotiators must pay attention to the symbols of dominance that may be influencing the negotiation, such as money, social status, and credentials, and consider how much importance these symbols are given to those involved in the negotiation. Kritek admonishes us to consider these questions as well: “What risks do I take? What price will I pay?” (p.158) to determine if one should proceed in the negotiation.

Effective change can come from the bottom up or the top down as a shared responsibility. Effective change can come from the bottom up or the top down as a shared responsibility (Kinsey, 2010). Quiet Leadership is an approach that nurses at all levels of an organization can adopt. Tenacious quiet leaders solve problems through respectful resistance and every-day efforts to build and maintain work environments that support rather than undermine quality patient care. Quiet leaders are prepared, cautious, courageous, and they pay attention to detail. They use their critical thinking skills to focus on analyzing and solving problems instead of being reactive. They avoid blaming, shaming, and complaining.

Case Study, Part 2: Ms. Martinez

In the role of ‘Quiet Leader,’ one of the nurses who witnessed the debasing comments invited the clinical instructor and the other witnessing nurse to join her in a space outside of the patient care area and away from others to discuss the situation. The nurses expressed sadness and disgust with what was said, and the clinical instructor described her frustration and concern about the impact on nursing students. “How will this impact their understanding of nursing and professionalism?” the clinical instructor asked.

In this meeting, facilitated by the quiet nurse leader, they all agreed that their primary responsibility is to ensure that Ms. Martinez and her family receive safe, high quality nursing care. They then discussed the potential negative consequences of acting: the staff nurses expressed concern that reporting the incident will jeopardize their social and collegial relations on the unit. They also wondered about possible retaliation: might their choices for vacation weeks and holidays be denied if they challenge the more senior nurse about her comments? The clinical instructor worried that the school of nursing may be denied access for future student placement. In the end, they all agreed that these fears and potential threats must not prevent them from acting.

Employing the model of Quiet Leadership, they decided to consult with experts. One of the staff nurses contacted the anonymous ethical compliance line available through the hospital to discuss options. Another took a trusted assistant manager aside, explained what happened, and asked for guidance about how to address the issue. The clinical instructor elicited advice from the course coordinator and a colleague with expertise in transcultural nursing.

Given the sensitive nature of the discussion, the assistant manager consulted with a healthcare system-level nursing educator who is an expert in uncivil workplace behavior. This expert met with the two nurses and the clinical instructor to review the situation, and build a scenario with this specific case in mind (changing names and details to protect the staff members involved; as well as Ms. Martinez). The case was presented by this expert at the next staff meeting which was attended by the nursing students and clinical instructor.

Nurses and other staff of this unit expressed surprise that nurses would behave in such a way, and a group discussion ensued around care of vulnerable patients, including immigrants. The staff agreed that there is a need for further training in care of immigrant and marginalized patient populations. Training was planned to occur during staff meetings and at separate, continuing education credit sessions. As a follow up conversation with the students, the clinical instructor explained the principles of Quiet Leadership and how she worked with staff and university faculty to address the situation. She allowed each student an opportunity to discuss their thoughts and feelings about the situation and the principals of Quiet Leadership.


Immigration and healthcare reform are highly politically charged issues; however, provision 8.2 of the ANA Code of Ethics for Nurses with Interpretive Statements (2015) notes that health promotion to support the common good is a universal right. The 2016 elections for president and other federal and state offices have sparked a new wave of debate. Many states are grappling with tight budgets and are making difficult choices regarding what they can afford or implement in terms of health promotion to vulnerable, immigrant populations. If nurses encounter rancorous, racist dialogue in the workplace, they can use the principles of Quiet Leadership and avoid becoming guilty bystanders. They can drill down by familiarizing themselves with the issues and be tenacious in interactions with peers, administrators, and policy makers. These principles provide the nurse with a measured response that allows the unjust behavior to be addressed and also maintains the nurse’s social capital.

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. 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. When nurses begin to redress these issues, it will create tension in the field that may be uncomfortable or even painful (Johnstone & Kanitsaki, 2010). However, it is important not to be a guilty bystander and side step the issue. Such tension may provoke conscientious healthcare providers to examine their own or coworkers engagement in racialized practice and take action to have crucial conversations (Cipriano, 2013).

Former President John F. Kennedy said, “There are risks and costs to a program of action. But they are far less than the long-range risks and costs of comfortable inaction” (United Press International, 1961, p A3). Nurses have the tools of Quiet Leadership to assist them in stepping out of the role of the guilty bystander, and into the role of a strong advocate, committed to compassionate, quality care for all patients, families and populations.

Acknowledgment: The authors would like to thank Mr. Mark C. Meade, Assistant Director of The Thomas Merton Center at Bellarmine University, Louisville, KY for his highly valued assistance in understanding the philosophy of Thomas Merton.


Elizabeth Moran Fitzgerald, EdD, MEd, M.S., RN, CNS-BC

Elizabeth Fitzgerald has an EdD in Counseling and Student Personnel and a MEd from the University of Louisville, a M.S. in Nursing from the Ohio State University, and a BSN from the University of Kentucky. She is an Associate Professor of Clinical Nursing at The Ohio State University and a Clinical Nurse Specialist in Child and Adolescent Psychiatric/Mental Health Nursing. She has over 35 years of experience working with vulnerable populations in the community, nation, and global settings. She has presented at national and international conferences and is published in peer-reviewed journals.

Judith G. Myers, PhD, RN

Judy Myers holds a PhD in Sociology with a concentration in social inequality and an MSN in psychiatric nursing. Her teaching interests include mental and public health, complimentary therapies and holistic nursing, nursing research and senior capstone clinical experience. Most recently her research focused on the clinical and biochemical effects of massage and HRV on insomnia and fatigue during radiation treatment for breast cancer. She has published works on domestic violence, women's health in Appalachia and conducted a socio-historical analysis of the birth control movement in Kentucky, 1933-1943. She has presented at regional, national and international meetings.

Paul Clark, PhD, MA, RN

Dr. Clark holds a PhD in nursing (2010) as well as Masters degrees in nursing (2006) and theology (1997). Current positions include Assistant Professor at the University of Louisville School of Nursing, and System Educator in the Norton Healthcare System in Louisville, KY. Dr. Clark’s research focus centers on Health Services Research, improving the safety and quality of in-patient care. He partners with bedside & stretcherside nurses in projects such as developing a critical incident debriefing process with pediatric nurses and improving perinatal loss care.


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© 2016 OJIN: The Online Journal of Issues in Nursing
Article published December 1, 2016

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