Interactions with emergency department persons and statistical analysis demonstrated that education was informative and productive. Statistical significance applies, but the research’s main purpose lay in evidence-based practice intervention supported by the Iowa Model’s problem-focused trigger (Moran et al., 2017). Several people described scenarios throughout their career in which HT interviewing skills and resource support knowledge would have changed patient interaction and care. Furthermore, participants noted improved knowledge regarding statistical data of trafficked person encounters in healthcare, social issues and complications for trafficked persons, and national guidelines for care.
Questions one through four showed improvements in awareness, signs and symptom recognition, interviewing, and intervention information. This was demonstrated by increased ratings for each question using the Likert scale. The median improvement involved at least one level increase and question four had a two level median increase. Discussion on human
trafficking, research support for educational information, and detailing practical improvements for patient care support were positive advances of the intervention.
Limitations
Missing Data. Twenty questionnaires were completed for both days the education intervention was offered. Those declining to participate were not counted or singled out in any way, and therefore the number cannot be determined. Additionally, one form was discarded because the post-questionnaire was not completed. While the Wilcoxon test accounts for data that is equal, the test cannot account for extensive missing information.
Professionals in Attendance. Creating HT encounter quality improvement within the emergency department was highly challenging due to comfort with the sensitive issue and responsibility constraints for providers. Persons attending the education were exclusively nursing, nursing support, and ancillary staff. Some limitations for staff included low confidence for discussions with patients as well as a disconnect between nursing responsibilities and ICD 10 coding.
A low number of emergency department providers employed and employment
responsibilities creating tight time constraints. In order to create a cohesive quality improvement in care, providers were given the material for human trafficking encounters. However, this limited the ability to comprehensively gather data and educate the entire emergency department. Additionally, lack of provider participation limits quality improvement effectiveness because providers would have the most incentive for HT specific ICD 10 coding utilization.
Post-Intervention Data Collection. The post-intervention data collection is limited due to the shortened time-frame and lack of forms completed. Although the informational seminar demonstrated improvement in understanding of human trafficking encounters, participants demonstrated difficulty with application of the knowledge. This situational discomfort is similar to other study results where healthcare personnel fail to recognize and understand how to
intervene for these vulnerable persons. Through discussions with leaders in the emergency department, key issues were highlighted. These issues included difficulty during the interviewing process, continued discomfort with intervention efforts, fear of labeling persons as trafficked, and lack of understanding regarding age and drug abuse vulnerabilities. Persons were also unlikely to understand the necessity, various applications, importance, and future use for ICD 10 code selection.
Practice Implications
This project impacted the emergency room at the hospital through increased care quality, improved patient support, and benefit for the surrounding community (Moran et al., 2017). Improved recognition and intervention included any pediatric, adolescent, or adult patient and across varying cultural and racial backgrounds. Benefits involved gaining human trafficking knowledge, understanding of red flags for trafficked persons, necessary steps for a safe
environment, and interviewing skills. Other improvements included information distribution on new national ICD 10 codes, support services within the hospital system, national support centers, resources available, and best practice methods for providing resource information to trafficked persons.
Changing staff perceptions and clarifying trafficking encounter facts aided overall practice improvements within the unit. Some of false beliefs involved perceptions of trafficked person age ranges, likelihood to ask for help, dangers faced, and abuses inflicted. Specific
improvements for the ED included enhanced nursing ownership for trafficked person encounters, new awareness for the ICD coding, and support for communication with providers and other staff about at risk individuals. Future practice improvements should involve support for health staff interviewing skill confidence and ICD 10 coding utilization.
On a larger scale, continuous education, awareness, and improved interventions impacts patient health on the community, state, and national level (Zimmerman et al., 2011). Targeted education within the emergency department modified staff perspective. This improvement allowed staff to proactively change the approach to patient care and increase understanding of that patient’s needs (Barrows & Finger, 2008). While the patient to clinician interaction impacted the micro level, the changes hospital-wide and in the surrounding community improved health
outcomes on a macro level. Education supported state and national goals to improve the quality of care by improving victim identification and addressing department quality of care measures. Research Implications
The next steps for research include ICD 10 coding comprehension and utilization and increased communication within units and clinic settings (Macias-Konstantopoulos, 2018). Considering the recent confirmation and implementation of ICD 10 coding specific to human trafficking persons, healthcare staff understanding and use should be evaluated. This project assisted with education and support for coding specifically designed to gather data and improve research as well as intervention capabilities. The changes provide comprehensive coding for minors, persons with a history of trafficking, and those currently being trafficked. The next potential research step involves evaluating if and how these codes are used.
Nursing in relation to ICD 10 code comprehension and utilization should also be
evaluated. Nurses often spend more face-to-face time with patients leading to an increased ability to recognize HT encounters. Nurses can also function as the link between HT persons and
providers as well as consults for other resources. This would be a challenging endeavor because nurses are unlikely to link coding and billing with primary nursing responsibilities and care.
The project reflects previous studies and quality improvement measures regarding health staff comprehension of HT encounters. Information from the questionnaires and personal reports confirmed a discomfort and lack of knowledge regarding encounters. However, similar to other studies, clarification of accurate HT statistics and best practice methods improved clinical knowledge and patient care techniques. Further studies can be completed on communication between ancillary staff, nursing, and providers regarding these vulnerable patients and the best plan of care.
Future analysis and research will help establish long-term expertise retention. Potential studies include increased educational interventions for free clinical care areas, community settings, nursing education areas, physician education areas, women’s health, and pediatric clinics (Barrows & Finger, 2008). An additional research project involves a study on survivors of trafficking and verifiable insights regarding interactions with healthcare personnel as well as health systems.
Although extensive information was found regarding the health impact of human trafficking on an individual, further research into post-trafficked persons’ health outcomes is indicated (Macias-Konstantopoulos, 2016). Research should involve an evaluation on links to healthcare, the biggest health challenges for the trafficked individual, and the varied health sources needed for quality of life. Strides in HT reduction and improved interventions will occur through continued data collection and research around many levels of healthcare.
Dissemination and Integration
The next steps for dissemination and integration involve continued training on ICD 10 codes for providers, a large team integration approach to quality HT interventions and care, and dissemination of final project paper results to digital commons. The new ICD 10 coding system specific to human trafficking persons was only implemented in October 2018 for fiscal year 2019 (U.S. Department of Health and Human Services, 2018). Considering the recent coding changes, lack of confidence as well as training on HT, a project focusing on understanding and use of the codes by providers is in order. Furthermore, training on this available measurement tool should be given to leaders, administrators, and coding specialist within the hospital system. This coding system has the potential to enhance HT population statistics, collect historical information for
former HT persons related to acute and chronic medical conditions, improve data analytic accuracy, and guide future health policies (Macias-Konstantopoulos, 2018).
The next step for the health organization should be a broader based approach with a team of informed persons. The larger team-based approach has been used in many hospital systems with success including one in the midwestern United States that utilized a medical legal partnership (Schwarz, Unruh, Cronin, Evans-Simpson, Britton, & Ramaswamy, 2016; Zimmerman et al., 2011). This requires commitment and input from providers, security
personnel, nursing staff at all levels, forensic nurse specialists, administrators, and support staff. Best practice for fighting human trafficking through interventions for trafficked persons
encountered in the health system involves a multi-layered team approach.
Lastly, the dissemination plan includes submitting the project paper to digital commons, submission to a health journal, potential research conferences, podium presentation, and a poster presentation. Two specific conferences include the Virgina Henderson Research Symposium and Liberty Research Week. Further dissemination comes through reflection and discussion of current anti-trafficking projects. Through conversations, continued education, and support for colleagues throughout the HT learning process, the goals of health staff involvement and improved intervention will continue. As healthcare personnel learn these essential aspects, interaction, intervention, and post-care methodology quality will improve.
Conclusion
Human trafficking impacts a range of enterprises and victims often intersect with healthcare staff. By examining the issue, researching background information, preparing and implementing a methodology for change, analyzing and evaluating that change, an evidence- based study was established (DNP Handbook, 2017). Increasing awareness, changing clinical
evaluation, cultivating interactions with patients, and improving interventions, aided health staff who directly care for human trafficking victims.
Nursing provides a vital role to recognize and intervene in trafficked person situations, link patients to resources, communicate concerns with providers, and improve emergency department protocols. Similarly, providers perform essential services relating to HT encounters including improved ICD 10 coding, patient interviewing, assist with quality outcome
improvement, and link patients to follow-up care. Human trafficking issues impact both professions as well as every emergency department specialty and supporting staff, system administrators, coding and billing, and community support services. Through current education, future research, and quality improvement projects, health system responses will improve.
REFERENCES
American Hospital Association. (2018). Hospitals against violence. Retrieved from
https://www.aha.org/hospitals-against-violence/human-trafficking/workplace-violence Ahmed, A., & Seshu, M. (2012). "We have the right not to be 'rescued'...": When anti-trafficking
programmes undermine the health and well-being of sex workers. Anti-Trafficking Review, (1), 149-165. Retrieved from http://ezproxy.liberty.edu/login?url=https://search- proquest-com.ezproxy.liberty.edu/docview/1500821056?accountid=12085
American Medical Women’s Association. (2017). Physicians against the trafficking of humans (PATH) toolkit. Retrieved from https://www.amwa-doc.org/our-work/initiatives/human- trafficking/
Barrows, J. & Finger, R. (2008). Human trafficking and the healthcare professional. Southern Medical Journal, 101(5), 521-524 doi:10.1097/SMJ.0b013e31816c017d
Baldwin, S., Barrows, J., & Stoklosa, H. (2017). Protocol toolkit for developing a response to victims of human trafficking in health care settings. HEAL Trafficking and Hope for Justice. Retrieved from HEALtrafficking.org.
Becker, H. J., & Bechtel, K. (2015). Recognizing victims of human trafficking in the pediatric emergency department. Pediatric Emergency Care, 31(2), 144-147.
Brown, C. G. (2014). The Iowa Model of evidence-based practice to promote quality care: An illustrated example in oncology nursing. Clinical Journal of Oncology Nursing, 18(2), 157-159. doi: 10.1188/14.CJON.157-159
CdeBaca, L. & Sigmon, J. N. (2014). Combating trafficking in persons: A call to action for global health professionals. Global Health, Science and Practice, 2(3), 261-267. doi:10.9745/GHSP-D-13-00142
Chaffee, T. & English, A. (2015).Sex trafficking of adolescents and young adults in the United States: Healthcare provider's role. Current Opinion in Obstetrics and Gynecology, 27(5), 339–344. doi:10.1097/GCO.0000000000000198
Chisolm-Straker, M., Baldwin, S., Gaïgbé-Togbé, B., Ndukwe, N., Johnson, P. N., & Richardson, L. D. (2016). Health care and human trafficking: We are seeing the unseen. Journal of Health Care for the Poor and Underserved, 27(3), 1220-1233. Retrieved from
http://ezproxy.liberty.edu/login?url=https://search-proquest- com.ezproxy.liberty.edu/docview/1813882412?accountid=12085
Chisolm-Straker, M., Richardson, L. D., & Cossio, T. (2012). Combating slavery in the 21st century: The role of emergency medicine. Journal of Health Care for the Poor and Underserved, 23(3), 980-7. Retrieved from
http://ezproxy.liberty.edu/login?url=https://search-proquest- com.ezproxy.liberty.edu/docview/1033503510?accountid=12085
Coppola, S. J., & Cantwell, R. (2016). Health professional role in identifying and assessing victims of human labor trafficking. The Journal for Nurse Practitioners, 12(5), 193- 200. doi:http://dx.doi.org.ezproxy.liberty.edu/10.1016/j.nurpra.2016.01.004
Department of Homeland Security [DHS]. (n.d.). Immigration assistance for non-U.S. citizen victims. Retrieved from https://www.dhs.gov/blue-campaign/immigration-assistance Diagnosing human trafficking when a patient is a victim. (2017). Patient Safety Monitor
Journal, 18(9), 1-4. Retrieved from http://ezproxy.liberty.edu/login?url=https://search- proquest-com.ezproxy.liberty.edu/docview/1928613850?accountid=12085
Ditmore, M., & Thukral, J. (2012). Accountability and the use of raids to fight trafficking. Anti – Trafficking Review, (1), 134-148. Retrieved from
http://ezproxy.liberty.edu/login?url=https://search-proquest- com.ezproxy.liberty.edu/docview/1500821094?accountid=12085
Doctor of Nursing Practice Handbook. (2017). Liberty university doctor of nursing practice student handbook. Retrieved from
file:///Users/travelgirl087/Documents/LU%20DNP%20Student%20Handbook.pdf Egyud, A., Stephens, K., Swanson-Bierman, B. Dicuccio, M, & Whiteman, K. (2017).
Implementation of human trafficking education and treatment algorithm in the emergency department. Journal of Emergency Nursing, 43(6), 526-531.
doi:10.1016/j.jen.2017.01.008
Greenbaum, V. J. (2014). Commercial sexual exploitation and sex trafficking of children in the United States. Current Problems in Pediatric and Adolescent Health Care, 44(9), 245-
269. doi:10.1016/j.cppeds.2014.07.001
Hall, H. R. & Roussel, L. A. (2014). Evidence-based practice: An integrative approach to research, administration, and practice. Burlington, MA: Jones & Bartlett Learning. Institute of Medicine; National Research Council. (2014). Confronting commercial sexual
exploitation and sex trafficking of minors in the United States: A guide for the healthcare sector. National Academy of Sciences. Retrieved from
https://www.ojjdp.gov/pubs/243838.pdf
International Labor Organization. (2014). Profits and poverty: The economics of forced labor. https://www.ilo.org/global/topics/forced-labour/publications/profits-of-forced-labour- 2014/lang--en/index.htm
Iowa Model Collaborative. (2017). Iowa model of evidence-based practice: Revisions and validation. Worldviews on Evidence Based Nursing, 14(3), 175-182.
Konstantopoulos, W. M. (2016). Human trafficking: The role of medicine in interrupting the cycle of abuse and violence. Annals of Internal Medicine, 165(8), 582-588.
doi:10.7326/M16-0094
Konstantopoulos, W. M., Ahn, R., Alpert, E. J., Cafferty, E., McGahan, A., Williams, T. P., Castor, J.P., Wolferstan, N., Purcell, G., & Burke, T.F. (2013). An international
comparative public health analysis of sex trafficking of women and girls in eight cities: Achieving a more effective health sector response. Journal of Urban Health: Bulletin of The New York Academy of Medicine, 90(6), 1194-1204. doi: 10.1007/s11524-013-9837-4 Laerd Statistics. (2018). Wilcoxon signed ranks test using SPSS statistics. Lundt Research Ltd.
Retrieved from https://statistics.laerd.com/spss-tutorials/wilcoxon-signed-rank-test-using- spss-statistics.php
Lederer, L. J. & Wetzel, C. A. (2014). The health consequences of sex trafficking and their implications for identifying victims in health care facilities. Annals of Health Law, 23(1), 61-91.
Leggett, T. (2017). Survey development: Creating intended consequences. Radiologic Technology, 88(5), 568-571
Lloyd, S. T., D'Errico, E., & Bristol, S. T. (2016). Use of the Iowa Model of research in practice as a curriculum framework for Doctor of Nursing Practice (DNP) project completion. Nursing Education Perspective:, National League for Nursing, 37(1), 51-53.
doi:10.5480/14-1364
Long, E. & Dowdell, E. B. (2018). Nurses’ perceptions of victims of human trafficking in an urban emergency department: A qualitative study. Journal of Emergency Nursing, 44 (4), 375-383. doi:10.1016/j.jen.2017.11.004
National Human Trafficking Resource Center. (2018). 2017 Hotline statistics. Retrieved from https://polarisproject.org/2017statistics
National Institute of Justice. (2018). Human trafficking. Retrieved from
https://www.nij.gov/topics/crime/human-trafficking/pages/welcome.aspx
Newswire, P. R. (2017). Journal of emergency nursing study underscores need for education and training to successfully identify and treat human trafficking victims ENA-nursing-study: Y. Emergency Nurses Association. Retrieved from
http://ezproxy.liberty.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true& db=bwh&AN=201706261047PR.NEWS.USPR.DC26339&site=ehost-live&scope=site Mateo, M., & Foreman, M. (2014). Research for advanced practice nurses: From evidence to
Moran, K., Burson, R., Conrad, D. (2017). The doctor of nursing practice scholarly project: A framework for success. (2nd ed). Burlington, MA: Jones & Bartlett Learning.
Muftić, L. R., & Finn, M. A. (2013). Health outcomes among women trafficked for sex in the United States: A closer look. Journal of Interpersonal Violence, 28(9), 1859-1885. doi:10.1177/0886260512469102
Polaris. (2017). Referral Directory. Retrieved from https://humantraffickinghotline.org/training- resources/referral-directory
Ross, C., Dimitrova, S., Howard, L.M., Dewey, M., Zimmerman, S., & Oram, S. (2015). Human trafficking and health: A cross-sectional survey of NHS professionals’ contact with victims of human trafficking. British Medical Journal, 5(8). doi:10.1136/bmjopen-2015- 008682
Richards, T. A. (2014). Health implications of human trafficking. Nursing for Women's Health, 18(2), 155-162. doi:10.1111/1751-486X.12112
Schwarz, C., Unruh, E., Cronin, K., Evans-Simpson, S., Britton, H., and Ramaswamy, M. (2016). Human trafficking identification and service provision in the medical and social service sectors. Health and Human Rights Journal, 18(1), 181-192.
Stevens, M. & Barishaj, K. (2016). The anatomy of human trafficking: Learning about the blues: A healthcare providers guide. Journal of Forensic Nursing, 12(2), 49-56.
doi:10.1097/JFN.0000000000000109
Tabak, R. G., Reis, R. S., Wilson, P., & Brownson, R. C. (2015). Dissemination of health- related research among scientists in three countries: Access to resources and current practices. BioMed Research International, 1-9. doi:10.1155/2015/179156
collection fields for health care providers. Administration for children and families, Office on Trafficking in Persons. Retrieved from https://www.acf.hhs.gov/otip/news/icd- 10
Viergever, R. F., West, H., Borland, R., & Zimmerman, C. (2015). Health care providers and human trafficking: What do they know, what do they need to know? Findings from the Middle East, the Caribbean, and Central America. Frontiers in Public Health, 3(6). doi:10.3389/fpubh.2015.00006
Warren, K. B. (2012). Troubling the victim/trafficker dichotomy in efforts to combat human trafficking: The unintended consequences of moralizing labor migration. Indiana Journal of Global Legal Studies, 19(1), 105-120. Retrieved from
http://ezproxy.liberty.edu/login?url=https://search-proquest- com.ezproxy.liberty.edu/docview/1030089368?accountid=12085
Zaccagnini, M. E., & White, K. W. (2014). The doctor of nursing practice essentials: A new model for advanced practice nursing (2nd ed.). Burlington, MA: Jones and Bartlett Learning.
Zimmerman, C., Hossain, M., & Watts, C. (2011). Human trafficking and health: A conceptual model to inform policy, intervention and research. Social Science and Medicine, 73(2), 327-335. doi:10.1016/j.socscimed.2011.05.028
Zimmerman, C. & Pocock, N. (2013). Human trafficking and mental health: “My wounds are inside; they are not visible.” Brown Journal of World Affairs, 19(2), 265-268.
APPENDICES