Immigration enforcement as structural exposure: Provider moral distress in U.S. health and social care-An integrative...

Immigration enforcement shapes access to and quality of U.S. health and social services, positioning frontline providers as mediators between care and immigration control. Although a growing body of empirical work documents provider experiences of ethical conflict and moral distress in immigration policy-affected settings, this literature has not been synthesized in relation to the policy, legal, and institutional ecology of U.S. immigration enforcement. Following Whittemore and Knafl (2005) and PRISMA 2020, we conducted a comprehensive database search for U.S.-based studies on provider experiences in settings serving immigrant populations or under immigration enforcement; 25 studies (20 qualitative or qualitative-adjacent, 5 quantitative cross-sectional or mixed-methods; 2012-2025) were included. Thematic synthesis used deductive coding anchored to structural vulnerability and ethics of care frameworks, extended inductively to capture provider perceived policy-to-practice mechanisms. Three interlocking themes explain how policy becomes practice and why distress follows: the moral landscape, in which providers report encountering preventable suffering and dual-loyalty tensions that accumulate as moral residue; policy as intervention, wherein enforcement-linked rules reconfigure triage and documentation, shifting providers into gatekeeping roles and narrowing clinical discretion; and institutional mediation, whereby organizations variably buffer provider exposure through sanctuary protocols, legal consultation, and protected debriefing, and where those buffers are absent, ad hoc workarounds substitute. Immigration enforcement operates as structural exposure producing patterned moral distress; durable change requires decoupling enforcement from care settings, status-neutral access, and institutional levers including information-protection policies, legal consultation pathways, and protected debriefing.