The Journal of Continuing Education in Nursing

Original Article 

Knowledge Base of Nurses Before and After a Human Trafficking Continuing Education Course

Madelaine Lawrence, PhD, RN, CHI; Paul Bauer, BA, RN

Abstract

Background:

Recent research shows up to 88% of human trafficking victims are seen in a health care setting sometime during their coerced servitude. Nurses are in key positions to identify trafficked victims but often lack sufficient information about how to assess and report trafficked victims.

Method:

This article includes participant data from one presurvey and two postsurveys from a human trafficking continuing education course.

Results:

Data demonstrate a precourse knowledge base deficit about human trafficking. The postcourse surveys indicated that participants had increased knowledge and desire to implement the course information to identify trafficked individuals.

Conclusion:

Nurses learning about human trafficking through continuing education courses can be invaluable in identifying and helping trafficked victims. [J Contin Educ Nurs. 2020;51(7):316–321.]

Abstract

Background:

Recent research shows up to 88% of human trafficking victims are seen in a health care setting sometime during their coerced servitude. Nurses are in key positions to identify trafficked victims but often lack sufficient information about how to assess and report trafficked victims.

Method:

This article includes participant data from one presurvey and two postsurveys from a human trafficking continuing education course.

Results:

Data demonstrate a precourse knowledge base deficit about human trafficking. The postcourse surveys indicated that participants had increased knowledge and desire to implement the course information to identify trafficked individuals.

Conclusion:

Nurses learning about human trafficking through continuing education courses can be invaluable in identifying and helping trafficked victims. [J Contin Educ Nurs. 2020;51(7):316–321.]

The Trafficking Victims Protection Act of 2000 defines a human trafficking victim as a person induced to perform labor or a commercial sex act through force, fraud, or coercion. Individuals under the age of 18 engaged in commercial sex are considered victims of human trafficking regardless of how they were compelled into that trade. The Polaris Project is a nonprofit, nongovernment organization committed to combating human trafficking. The organization operates the Human Trafficking Hotline, which provides support connecting callers to places that can give them shelter, safety, legal advice, transportation, and other services as needed.

In 2017, nearly 9,000 cases of human trafficking were reported to the National Human Trafficking Hotline and the BeFree Textline. The Polaris Project reported this was a 13% increase from 2016. These figures are believed to underrepresent the actual number of trafficked victims in the United States.

Key Position of Nurses to Identify Victims

A recent study (Lederer & Wetzel, 2014) revealed that approximately 88% of trafficked victims are examined for a health-related issue in a health care facility during their servitude. Unfortunately, only a limited number of victims are identified even though health professionals have the opportunity to assess the victims in a private and safe examination environment. Informed nurses are in a key position to recognize victims of human trafficking (Hachey & Phillippi, 2017). Nurses are the largest group of health care professionals in the United States, with almost 3 million nurses employed in 2018 (U.S. Bureau of Labor Statistics, 2019). There were 985,026 actively licensed physicians in the United States in 2018 (Young et al., 2019), and the number of social worker jobs in 2018 was 707,200 (U.S. Bureau of Labor Statistics, 2020).

When trafficked victims come into emergency departments, urgent care clinics, doctors' offices, and schools, a nurse is there. Hachey and Phillippi (2017) identified advanced practice RNs, including certified nurse midwives, clinical nurse specialists, and nurse practitioners, as having opportunities to interact with trafficked victims. However, lack of education about human trafficking has been a barrier to recognizing these victims.

Grace et al. (2014) studied the increase in knowledge from a standardized educational presentation about human trafficking to physicians, nurses, and social workers. The participants were randomly assigned to an intervention group (the course; n = 141) or a delayed intervention group (n = 117). The presentation varied from 30 to 60 minutes in length. The course contained information about human trafficking, relevance of human trafficking to health care, clinical signs in potential victims, and referral options for potential victims. Following the course, participants in the intervention group had increased knowledge of human trafficking, knew who to call for potential victims, and had increased ability to identify a suspected human trafficking victim. The authors concluded a brief educational intervention increased emergency department health care providers' knowledge and self-reported recognition of human trafficking victims.

In a study by Beck et al. (2015), 63% of physicians, nurses, physician assistants, and social workers surveyed had no education and limited experience in trafficked victim identification. Nurses have a practice gap in their ability to assess victims of human trafficking, knowing who is at risk, what services are available for them, and how to report victims to appropriate agencies. Stevens and Berishaj (2016) identified the following educational needs of health care providers including nurses about human trafficking: the scope of the problem, definitions, and types and elements of human trafficking, and the roles of clinicians, particularly emergency department nurses and advanced practice nurses, in screening and identifying those at risk.

The Florida Department of Children and Families (2019) counted nearly 2,198 reports of human trafficking statewide between July 1, 2018, and June 30, 2019. The Florida Board of Nursing (2020) subsequently required all nursing professionals to complete a human trafficking course every biennium beginning January 1, 2019, due to the lack of referrals coming from health care professionals. The Michigan Board of Nursing (2018) also requires nurses to take a one-time human trafficking continuing education course.

The educational needs identified by the Florida Board of Nursing included the following:

  • Types of human trafficking.
  • Factors that place individuals at greater risk of being a victim of human trafficking.
  • Public and private social services available for rescue, food, clothing, and shelter referrals.
  • Hotlines for reporting human trafficking that are maintained by the National Human Trafficking Resource Center and the U.S. Department of Homeland Security.
  • Validated assessment tools for identifying a human trafficking victim and general indicators that a person may be a victim of human trafficking.
  • Procedures for sharing information related to human trafficking with a patient.
  • Referral options for legal and social services ( https://floridasnursing.gov/help-center/has-there-been-a-change-to-ce-requirement-rules-and-regulations/) (Florida Board of Nursing, 2020).

Health Issues of Trafficked Victims

Lederer and Wetzel (2014) studied 106 survivors of sex trafficking and reported 99% had a minimum of one physical health issue including the following: neurological (91.5%), memory and concentration issues (82%), and headaches (54%). Several researchers (Becker & Bechtel, 2015; de Chesnay et al., 2013; Gibbons & Stoklosa, 2016; Mumma et al., 2017; Shandro et al., 2016) identified the following health issues in trafficked victims: physical injuries; infections, particularly the urinary tract; head trauma; untreated chronic health conditions; diseases from unsanitary housing and dirty needles; substance abuse; sexually transmitted infections; obstetric and gynecological issues; and psychosocial distress.

Continuing Education Course on Human Trafficking

The Human Trafficking course was first offered for continuing nursing education contact hours in July 2018. The course is active and free to view on the website. The target audience for the course is all nurses who work in health care facilities, particularly those working in emergency departments, urgent care clinics, obstetric and gynecological clinics, and doctor's offices.

The learning outcomes of the course were that nurses would:

  • Demonstrate increased knowledge scores of assessments of signs and symptoms of trafficked victims on a postcourse survey.
  • Demonstrate increased knowledge scores of the incidence of human trafficking and laws in their own state on a postcourse survey.
  • Report contacting appropriate hospital supervisors when a patient was suspected of being trafficked in the 3- to 6-month postcourse survey.
  • Report using hotlines for reporting human trafficking at the National Human Trafficking Resource Center in the 3- to 6-month postcourse survey.
  • Report using appropriate referral centers for legal and social services for trafficked victims in the 3- to 6-month postcourse survey.

Criteria for Awarding Contact Hours

A pilot study completed by 10 nurses was conducted to determine the amount of time the course took to complete. The average recommendation was to offer four continuing education contact hours for the course. The nurses who completed the pilot study also were asked to comment on any links that did not work as well as any content or writing errors they observed. To be eligible for contact hours, nurses had to register on the website and provide their contact information, licensing state, and license number. To receive contact hours, nurses had to correctly answer 70% of the examination questions and complete the course evaluation section.

Teaching Approaches

Teaching methods involved the use of adult learning theories, especially those described by Knowles (1970) and Cross (1992). Learning styles, particularly visual, kinesthetic, and logical styles, also were described with a website link where participants could test their own learning styles. To keep participants actively involved during the online course and to provide some kinesthetic and logical opportunities, learners could complete instant feedback questions such as, “True or false: Women are commonly forced into positions of domestic helpers serving as maids, nannies, and kitchen helpers.” Six instant feedback questions were included throughout the course. In addition, there were eight pictures, charts, and graphics to reinforce learning in a visual presentation.

Several approaches were used to increase the relevance of the course for the nurses. The incidence of trafficking section included statistics on human trafficking in each state from highest to lowest reported to the National Human Trafficking Hotline in 2017. Another page provided a link to human trafficking laws for every state and the District of Columbia. Participants could easily read about their own state's regulations, as well as their employment state if different, making the information more relevant and interesting. A free poster was included at the end of the course that learners could print and post. The poster provided learners with additional topic engagement and also provided an opportunity to teach colleagues and patients (Table 1). Specific course content related to health care visits included the content identified by researchers and recommended by the Florida Board of Nursing.

Human Trafficking Course Contents

Table 1:

Human Trafficking Course Contents

Evaluation Methods

Evaluations of this Human Trafficking course included a five-item course content examination and an evaluation section with two questions about the quality of the course. One question that asked about the number of hours required to complete the course and one question that asked about anticipated changes in professional practice were placed at the end of the course.

Pre- and postcourse surveys were completed by 97 participants. The surveys included the following questions:

  1. How comfortable are you in your ability to recognize a victim of human trafficking in your clinical setting?

  2. How comfortable are you in knowing how to respond to a victim of human trafficking?

  3. Do you know who to notify if your patient is a victim of human trafficking?

On the precourse survey, for the question that asked how comfortable participants were in their ability to recognize a victim of human trafficking in their clinical setting, only 15% of the participants indicated they were extremely or very comfortable knowing how to assess for trafficking victims. For the question that asked how comfortable they were in knowing how to respond to a victim of human trafficking, only 11% indicated they were extremely or very comfortable knowing what to say to victims. For the question that asked if they knew who to contact to report a trafficked victim, 65% indicated they did not know who to contact.

All of the items showed improvement at the end of the course. The most striking response in the posttest was the change in the 65% of participants who did not know who to contact about a trafficked patient at the beginning of the course. Postcourse, only 21% said they did not know who to contact or were unsure after taking the course. The pretest clearly showed a knowledge gap that was addressed by the course (Table 2 and Figure 1).

Scores from Precourse, Postcourse, and Follow-Up Surveys

Table 2:

Scores from Precourse, Postcourse, and Follow-Up Surveys

Pre- and postsurvey results of human trafficking course.

Figure 1.

Pre- and postsurvey results of human trafficking course.

Participants' Comments

At the end of the course, participants were asked how they anticipated applying the knowledge from the course to their clinical settings. Responses included:

  • “I will be more aware of what to look for and know what resources are available for help.”
  • “Knowing who to contact and the helpful signs gives meaning and help to recognize trafficked victims.”
  • “I will be much more vigilant in my assessments of patients to possibly identify victims of trafficking.”
  • “I will use the questions that were suggested for health care providers to use.”

Three to 6 months after the course, participants were sent a follow-up postcourse survey via email. Table 2 lists the survey questions asked about clinical practice performance in the 3- to 6-month postsurvey. Of the 24 participants who took the course and responded to the survey, two identified and reported a trafficked victim (Table 3).

Follow-Up Survey Responses at 3 to 6 Months Postcourse

Table 3:

Follow-Up Survey Responses at 3 to 6 Months Postcourse

Discussion

There are several issues to consider when educating nurses about human trafficking. It is apparent from the exceptionally low precourse scores that information about human trafficking is not part of what is taught to nurses in their initial educational experiences. The College of Nursing and Health Innovation at the University of Arizona in Phoenix currently offers a credit course in human trafficking, possibility the first of its kind. Because human trafficking is unfortunately a growing issue in the United States, general nursing programs should consider adding or increasing the amount of information available in the curriculum. Many online providers of nursing continuing education offer a course about human trafficking. This course is free to view by nursing students and nurses.

Nurses who live in states with a low incidence of human trafficking are less likely to come in contact with these victims, but all of the states have trafficked victims. States vary widely in the amount of reported trafficking. For example, California reported 1,305 incidents in 2017 compared with five in New Hampshire. Strategies to refresh learning about human trafficking could be in place when exposure to these victims is low. A few participants stated their hospitals were adding an assessment items checklist for trafficked victims to the medical record.

Some victims are reluctant to leave the trafficker. Traffickers make false promises to recruit potential victims. They could promise a loving relationship, a lucrative job, a better place to live, U.S. citizenship, a wonderful career such as modeling or dancing, or gifts of clothing or jewelry (Macias-Konstantopoulos et al., 2015). The traffickers use different techniques to keep victims with them.

Baldwin et al. (2015) interviewed 12 adult women trafficked in Los Angeles County and found that coercive tactics reinforced the submission of trafficked individuals to their perpetrator. Perpetrators threaten victims engaged in prostitution that they will be prosecuted for prostitution if they leave. Several states have established policies and laws declining prosecution for prostitution if the individuals are victims of trafficking. Traffickers may insist their victims will not have a place to live and no food to eat.

It is not enough to be able to just identify human trafficked victims. Health care facilities should have in place human trafficking advocates or access to human trafficking advocates who can assist victims with housing, legal issues, financial assistance, counseling, medical care, and support groups when possible (Dell et al., 2019).

The research indicating the amount of trafficking that occurs and the number of victims seen may be relatively new in some health care settings. Nurses' confidence in their knowledge of victim assessments and their legal reporting requirement for trafficked patients can reduce barriers to appropriate nursing intervention. Informed nurses can be invaluable in identifying and helping trafficked victims. Education and institutional support are crucial.

References

  • Baldwin, S.B., Fehrenbacher, A.E & Eisenman, D.P. (2015). Psychological coercion in human trafficking: An application of Biderman's framework. Qualitative Health Research, 25(9), 1171–1181.
  • Beck, M.E., Lineer, M.M., Melzer-Lange, M., Simpson, P., Nugent, M. & Rabbitt, A. (2015). Medical providers' understanding of sex trafficking and their experience with at-risk patients. Pediatrics, 135(4), e895–e902.
  • Becker, H.J. & Bechtel, K. (2015). Recognizing victims of human trafficking in the pediatric emergency department. Pediatric Emergency Care, 31(2), 144–147.
  • Cross, K.P. (1992). Adults as learners: Increasing participation and facilitating learning. Jossey-Bass.
  • de Chesnay, M., Chalk-Gaynor, C., Emmons, J., Peoples, E. & Williams, C. (2013). First-person accounts of illnesses and injuries sustained while trafficked (pp. 131–150). In de Chesnay, M. (Ed.), Sex trafficking: A clinical guide for nurses. Springer.
  • Dell, N.A., Maynard, B.R., Born, K.R., Wagner, E., Atkins, B. & House, W. (2019). Helping survivors of human trafficking: A systematic review of exit and post-exit interventions. Trauma, Violence, & Abuse, 20(2), 183–196.
  • Florida Board of Nursing. (2020). Has there been a change to CE requirement rules and regulations?https://floridasnursing.gov/help-center/has-there-been-a-change-to-ce-requirement-rules-and-regulations/
  • Florida Department of Children and Families. (2019). Florida Department of Children and Families annual human trafficking report: State fiscal year 2018–2019. https://www.myflfamilies.com/service-programs/child-welfare/docs/2019LMRs/Human%20Trafficking%20Annual%20Report%202019.pdf
  • Gibbons, P. & Stoklosa, H. (2016). Identification and treatment of human trafficking victims in the emergency department: A case report. The Journal of Emergency Medicine, 50(5), 715–719.
  • Grace, A.M., Lippert, S., Collins, K., Pineda, N., Tolani, A., Walker, R., Jeong, M., Trounce, M.B., Graham-Lamberts, C., Bersamin, M., Martinez, J., Dotzler, J., Storfer-Isser, A., Chamberlain, L.J. & Horwitz, S.M. (2014). Educating health care professionals on human trafficking. Pediatric Emergency Care, 30(12), 856–861.
  • Hachey, L.M. & Phillippi, J.C. (2017). Identification and management of human trafficking victims in the emergency department. Advanced Emergency Nursing Journal, 39(1), 31–51.
  • Knowles, M. (1970). The modern practice of adult education: Andragogy versus pedagogy. Association Press.
  • Lederer, L.J & Wetzel, C.A. (2014). The health consequences of sex trafficking and their implications for identifying victims in healthcare facilities. Annals of Health Law, 23(1), 61–91.
  • Macias-Konstantopoulos, W.L., Munroe, D., Purcell, G., Tester, K., Burke, T.F. & Ahn, R. (2015). The commercial sexual exploitation and sex trafficking of minors in the Boston metropolitan area: Experiences and challenges faced by front-line providers and other stakeholders. Journal of Applied Research on Children, 6(1), Article 4.
  • Michigan Nurses Association (2018). State of Michigan CE requirements. https://www.minurses.org/education-resources/resources-for-practicing-nurses/state-of-michigan-ce-requirements/
  • Mumma, B.E., Scofield, M.E., Mendoza, L.P., Toofan, Y., Youngyunpipatkul, J. & Hernandez, B. (2017). Screening for victims of sex trafficking in the emergency department: A pilot program. Western Journal of Emergency Medicine, 18(4), 616–620.
  • Shandro, J., Chisolm-Straker, M., Duber, H.C., Findlay, S.L., Munoz, J., Schmitz, G., Stanzer, M., Stoklosa, H., Wiener, D.E. & Wingkun, N. (2016). Human trafficking: A guide to identification and approach for the emergency physician. Annals of Emergency Medicine, 68(4), 501–508.
  • Stevens, M. & Berishaj, K. (2016). The anatomy of human trafficking: Learning about the blues: A healthcare provider's guide. Journal of Forensic Nursing, 12(2), 49–56.
  • U.S. Bureau of Labor Statistics (2019). Occupational employment and wages, May 2019, 29–1141 registered nurses. Division of Occupational Employment Statistics. https://www.bls.gov/oes/current/oes291141.htm.
  • U.S. Bureau of Labor Statistics. (2020). Occupational outlook handbook, social workers. Office of Occupational Statistics and Employment Projections. https://www.bls.gov/OOH/community-and-social-service/social-workers.htm.
  • Young, A., Chaudhry, H.J., Pei, X., Arnhart, K., Dugan, M. & Steingard, S.A. (2019). FSMB census of licensed physicians in the United States, 2018. Journal of Medical Regulation, 105(2), 7–23.

Human Trafficking Course Contents

Title page

Target audience

How to take the course

Introduction

Definitions

Incidence of trafficking

The victims

Traffickers and venues

Your state laws

Trafficking laws

Health care visits

Talking with victims

What to do

Free poster

Examination and evaluation

About the author

References

Scores from Precourse, Postcourse, and Follow-Up Surveys

Learning OutcomesPrecoursePostcourse


Survey Responses (n)Comfort LevelSurvey Responses (n)Comfort Level
How comfortable are you in your ability to recognize a victim of human trafficking in your clinical setting?9715% extremely or very comfortable9565% extremely or very comfortable
How confident are you in knowing how to respond to a victim of human trafficking?9611% extremely or very comfortable9560% extremely or very comfortable
Do you know whom to notify if your patient is a victim of human trafficking?94Yes: n = 33 (35%)No: n = 61 (65%)96Yes: n = 76 (79%)No: n = 20 (21%)

Follow-Up Survey Responses at 3 to 6 Months Postcourse

QuestionYes ResponsesNo ResponsesComments
Do you have signs and symptoms in mind for an assessment of trafficked patients?19 (89%)2 (11%)Bruising; ask if they are allowed to go to the bathroom and eat when they want, if they have their own bed, and if they are allowed to answer questions; check eye contact
Did you assess any individuals to determine if they were a trafficked victim?9 (38%)14 (58%); 1 (4%) no opportunity in current role
Did you discuss a potential victim with a colleague or supervisor?8 (33%)16 (67%)
Were you able to identify and report a victim of trafficking?2 (8%)22 (92%)
Did you post the free course poster on your clinical unit?2 (8%)21 (88%); 1 (4%) not in clinical practice
Authors

Dr. Lawrence is Director of Education, and Mr. Bauer is Chief Executive Officer, RnCeus Interactive, Mt. Pleasant, South Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

The authors thank the library staff and administration at the AHEC Library affiliated with Atrium Health in Charlotte, North Carolina, for their fast and always approachable assistance with needed resources.

Address correspondence to Madelaine Lawrence, PhD, RN, CHI, Director of Education, RnCeus Interactive, 2583 Kingsfield Street, Mount Pleasant, SC 29466; email: mlawrence@rnceus.com.

Received: September 02, 2019
Accepted: December 18, 2019

10.3928/00220124-20200611-07

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