Current Practices and Nurse Readiness to Implement Standardized Screening for Commercially and Sexually Exploited Individuals in Emergency Departments in Western Washington Hospitals

IN THE TRAFFICKING VICTIMS PROTECTION ACT of 2000 (TVPA), the United States Congress defines sex trafficking as commercial sex acts induced by force, fraud, or coercion, or in which the person forced to perform these acts is younger than 18 years (The United States Department of Justice, 2018). Victims are commonly forced to engage in commercial sex work against their will in exchange for survival needs such as shelter, food, and/or protection (Goldberg & Moore, 2018), creating a cycle of entrapment and isolation that is extremely difficult to exit. Within the United States, sex trafficking has been identified in all 50 states (Polaris, 2020a), including Washington State, where 272 sex trafficking cases were reported in 2019 (Polaris, 2020c).

Commercial sexual exploitation occurs in every community, gender, sexual orientation, race, and across all educational and economic levels, but some populations are more vulnerable and disproportionately victimized. These include youth experiencing homelessness, poverty, and marginalization, especially those in foster care systems, youth of color, and LGBTQ+ (lesbian, gay, bisexual, transgender, queer) (Polaris, 2020b). Several factors make estimation of persons experiencing sexual exploitation complex, including the hidden nature of the industry, gaps between awareness, screening and intervention practices, and victims' lack of self-identification and disclosure (Albright, Greenbaum, Edwards, & Tsai, 2020). A systematic review of barriers to health care services for child sex trafficking victims found substantial organizational barriers including an absence of validated screening tools and a dearth of standardized staff training and processes for responding to trafficking (Albright et al., 2020).

Because of the illicit nature of sex trafficking, research is lacking about the lived experiences of victims and their health-seeking behaviors, making case identification in emergency departments (EDs) and provision of appropriate support challenging. Eighty percent of trafficked persons seek health care at some point while being victimized (Chisolm-Straker et al., 2016; Egyud, Stephens, Swanson-Bierman, DiCuccio, & Whiteman, 2017; Lederer & Wetzel, 2014; Long & Dowdell, 2018) and more than 60% present to EDs, yet most are neither identified nor offered support (Chisolm-Straker et al., 2016). This is due, in part, to varied health worker education and training on sex trafficking, unclear roles and responsibilities defined across teams, and the absence of standardized protocols and validated screening tools for use in health care settings such as the ED (Greenbaum et al., 2018; Richie-Zavaleta et al., 2020). These missed opportunities for care are further complicated by patients who may not self-identify as victims, face barriers to self-identification including fears of retaliation, arrest, or reporting to social services; limited or controlled access to points of care; and feelings of shame or guilt (Albright et al., 2020).

Trafficked persons more likely suffer from profound physical and mental health consequences due to the extreme isolation and physical, psychological, and sexual trauma they endure. These include sexually transmitted infections, unwanted pregnancy, acute physical injuries, substance dependence, depression, anxiety, and suicidal ideation (Hachey & Phillippi, 2017; Lederer & Wetzel, 2014; Ottisova, Hemmings, Howard, Zimmerman, & Oram, 2016). Health care settings may be viewed by victims as safe spaces (Chisolm-Straker et al., 2016), and implementation of sexual trafficking screening in the ED may be feasible (Kaltiso et al., 2021), making nurses uniquely positioned to identify and care for these patients and the range of health concerns they experience. Emergency departments are commonly accessed by trafficking victims; thus, as ED nurses may be a victim's first health care system point of contact, it is critical that they have awareness, training, and screening tools to provide trauma-informed, patient-centered care.

Many professional health care organizations, including the American Academy of Pediatrics (AAP), the Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), the Emergency Nurses Association (ENA), and the International Association of Forensic Nurses (IAFN), have position statements on the importance of health care providers' readiness to identify trafficking victims (Sousou Coppola, Cantwell, Kushary, & Ayres, 2019), including the need for screening tools (Association of Women's Health, 2016; Breuer & Daiber, 2019; Sousou Coppola et al., 2019). Although trafficking screening tools for use in specific health care settings exist (Chang, Lee, Park, Sy, & Quach, 2015; Greenbaum et al., 2018; Hachey& Phillippi, 2017), gaps remain in practice. In a survey of 99 South Texas EDs, the majority did not specifically screen for human trafficking, and screening methods varied across sites. Barriers to screening included the lack of validated screening tools and standardized protocols, as well as a clinical education knowledge deficit among health care workers on the human trafficking experience (Dols, Beckmann-Mendez, McDow, Walker, & Moon, 2019). A cross-sectional study of 810 youth aged 11–17 years evaluated a brief screening tool in three facilities that demonstrated good sensitivity (84.44%; Greenbaum et al., 2018). Notably, the study investigators also reported the highest sex trafficking rates among ED-presenting patients, followed by child advocacy centers and teen clinics (Greenbaum et al., 2018). A pilot study of a sex trafficking screening tool found its use in ED feasible and more sensitive than physician concern (Mumma et al., 2017). In a five-ED prospective study, the Rapid Appraisal for Trafficking (RAFT) was developed and validated for use in ED patient populations (Chisolm-Straker et al., 2020). To better understand the readiness for and acceptability of a standardized trafficking screening tool in Western Washington EDs, it is important to understand the experiences and current screening practices of nursing staff. These findings may improve guidance on how to systematically identify and support sexually exploited individuals presenting for care.

METHODS

This qualitative, exploratory study was conducted in two distinct stages.

Stage 1: Literature review: A literature review was conducted to (1) identify existing screening tools for detecting commercially and sexually exploited individuals in U.S. health care settings, and (2) identify “red flags” and indicators commonly used in screening tools to detect trafficked individuals. Tools and red flags were sourced from peer-reviewed and gray literature sources, and searches were limited to English language.

Stage 2: Key informant interviews: Emergency department nurse leaders at the three participating study hospitals were contacted and subsequently identified ED registered nurses and nurse managers to participate in the study. In-depth interviews were conducted with two ED nurse managers, three assistant nurse managers who also do frontline work, and four frontline nurses (n = 9) from three large, urban, referral hospitals in Western Washington between May and June 2018. Potential interviewees needed to be between the ages of 21 and 65 years, must have been working at the hospital for more than 6 months, and be primarily assigned to the ED setting. Individuals who did not interact regularly with patients in the ED were excluded as well. In-depth interviews were conducted by a nursing professor who is also a sexual assault nurse examiner. Two study sites were part of a common hospital system; all three had similar inpatient capacity (400–500 beds). They included a public, Level 1 adult and pediatric trauma center providing care to the region's most vulnerable populations; a public, nationally ranked academic health care center; and a private, pediatric hospital. These large, urban ED sites were selected as potential facilities where trafficked persons are most likely to present at. The in-depth interviews collected (1) insight into how nurses currently identify trafficking victims; (2) opinions of the acceptability of existing piloted and/or validated screening questions in their ED settings, and (3) perceptions of the utility of standardized screening tools to identify victims and improve subsequent care. Study participants were asked the following questions:

Describe any day-to-day guidelines or protocols in place in your ED to identify commercially or sexually exploited and trafficked youth. Describe how health workers/nurses are trained. Are health workers/nurses carrying out these guidelines/protocols in the same way? Please elaborate. Please review these current questions and scales related to the identification of commercially and sexually exploited and trafficked youth in other health care settings. Do these seem “do-able” in your setting given human resource and financial constraints? Circle the questions that you feel might be relevant. Is a standardized tool to identify sexually exploited and trafficked youth needed for EDs?

In question 2, the participants were asked to review questions from six previously piloted screening tools (see Supplemental Digital Content Appendix 1, available at: https://links.lww.com/AENJ/A44) identified during the literature review and select and prioritize questions they found potentially useful in their clinical settings. Of note, all six screening tools were previously piloted in clinical settings and had accessible findings in peer reviewed or gray literature, but only one (West Coast Children's Center CSE Identification Tool [CSE-IT]) has been validated. Interviews were conducted with one nurse or nurse manager at a time for a duration of 30–60 min. Audio recordings were transcribed verbatim for analysis, and thematic coding of qualitative data was used to identify themes across facilities. Undergraduate honors nursing students joined the research team under the mentorship of nursing faculty and participated in the literature review, study design, data analysis, and coding processes. The University of Washington Human Subjects Division deemed this study exempt from the federal human subjects' regulations, including the requirement for institutional review board approval.

RESULTS Screening Tools

An initial search identified 19 screening tools. Only tools previously piloted in the United States were included. Exclusion criteria included those tools (1) not designed for health care settings, (2) designed for nonclinical professionals, such as social work, or (3) were deemed overly lengthy (≥20 items). Six tools met both inclusion and exclusion criteria and were shared to gauge study participants' views on the feasibility of their use in EDs. Selected tools ranged in length from 6 to 19 items.

“Red Flags” and Indicators

Red flags and indicators for sexual exploitation are well documented in the literature (Goldberg & Moore, 2018; Polaris, 2020b; Richie-Zavaleta et al., 2020; Stevens & Berishaj, 2016). Although not an exhaustive list, the following indicators have been consistently identified in research about sex trafficked persons (see Table 1).

Table 1. - Nurse-prioritized screening tools and “red flags” Tools and “red flags” Frequency Greenboum, Dodd, and McCracken (2018) Runaway •••• 4 History of drug and/or alcohol use ••••••• 7 History of sexually transmitted infection •••• 4 History of broken bone, traumatic loss of consciousness, or significant wound •••••• 6 Chang et al. (2015) Not living at home or living with “boyfriend” ••••• 5 Homelessness •••••• 6 Center for Youth and Wellness ACEs Screening Tool You lived with a household member who was depressed, mentally ill, or attempted suicide ••••• 5 You saw or heard household members hurt or threaten to hurt each other. ••••• 5 More than once, went without food, clothing, a place to live, or had no one to protect you. •••• 4 Been in foster care ••••• 5 Bridge Continuum of Services Screening Tool History of sexual assault or abuse; emotional or physical abuse and neglect •••• 4 Runaway pattern from home, placements, or treatment facilities (two or more times) ••••• 5 Indicators of drug or alcohol problem •••• 4 Urban Institute Human Trafficking Screening Tool, 2016 Unable to leave a place or talk to people you wanted because person you worked for threatened or controlled you. •••• 4 Asked, pressured, or forced to do something sexually did not feel comfortable doing. •••• 4 West Coast Children's Center CSE-IT Screening Tool, 2014 Relationships and personal belongings questions •••• 4 Signs of current trauma questions •••• 4 Housing and caregiving questions •••• 4 Prior abuse or trauma questions •••• 4
Roles and Responsibilities

Nurses discussed an absence of existing protocols and screening tools specific to commercially and sexually exploited persons, despite routine safety screening being performed in all EDs (see Table 2). One facility established a human trafficking task force comprising nurses, social workers, and physicians. Participants in all settings described a lack of role and task clarity in the identification and care of trafficked persons across ED health care teams. Training about this population was variable across facilities and between clinicians in the same facility. Nurses from each hospital expressed the importance of engaging social workers and forensic nurse examiners to provide coordinated care and support for this patient population. All agreed that a screening tool was needed in their EDs.

Table 2. - Interview results Existing protocol Existing tool Training for staff Existing task force Role and responsibilities Hospital no. 1 No No, but questions asked re: general safety Recent training of MDs and one RN. No current ongoing training for other nurses. Yes SW and MD as resource. Hospital no. 2 No No, but questions asked re: general safety Training in ED years ago. Training is variable from nurse to nurse, and self-directed. No SW and FNE as resources. Nurses seek SW consult if “red flag” is subjectively identified. MD has a role. Hospital no. 3 No No, but questions asked re: general safety Recent training related to sexual assault. Annual training related to abuse and maltreatment, not trafficking specifically. No SW and FNE possible resources. Legal obligation to report abuse if child.

Note. FNE = forensic nurse examiner; SW = social worker.


DISCUSSION

Six qualitative themes emerged from key informant interviews. Themes reflect a common finding across at least two of the three hospitals.

1. Clarity of ED nurse role/responsibility: Nursing staff at two hospitals described roles and responsibilities across the health care team, including physicians, social workers, and sexual assault nurse examiners. A frontline nurse at Hospital 1 described some ambiguity in care team members' roles:

I would bring it up to the resident or attending first ... we don't routinely sit in on those conversations and ask not that we're not the right person.

Two nursing staff at Hospital 2 expressed differing opinions on nursing's role in screening:

In looking at these [screening tool questions] ... these are more geared towards social work or the physician ... someone sitting down and asking these questions, rather than the bedside nurse asking, and then passing the information on, and having them reassessed by a social worker ... a lot of the time spent at the bedside as a nurse multitasking. I don't know if a lot of these questions are appropriate to ask while starting an IV ... and

... this is as much a nurse's job as it is a social work job. I absolutely believe if I already have a relationship with the patient, and I develop that rapport and they tell me something like that and I say let me go get the social worker, they're going to be out of there ... we [nurses] are trusted.

The ED nurse manager at Hospital 2 described key roles of other members of the health care team who engage with this patient population:

... our social workers here are also a valuable resource, we often involve them with these domestic concerns or sexual assaults. They are our point of contact, same with sexual assault nurse examiners (also referred to as forensic nurse examiners), we involve them and they have great insight to see if something needs to be investigated further ....

2. Time demands in ED setting restrict ability to build trust: Nurses in all facilities described the fast-paced nature of the ED environment and the importance of establishing trust with patients to facilitate screening for and assessment of potential trafficking. This fast-paced environment influences staff's ability to address underlying concerns of patients:

... when they first come in they're also anxious for whatever they're here for ... and then when we hit them up with these questions .... I always wonder are you so anxious, are you even going to talk to us ... are you even hearing us, because you're so anxious about the unknown and what's going to happen to you here? (Nurse, Hospital 1)

The same nurse mentioned how other staff can offset challenges inherent in the ED environment:

... this is where I think social work is a key, key player ... and has to be trained, because they will have the time to sit and go deeper and ask the same question three different ways.

A nurse manager (Hospital 2) described the sense of urgency felt in the initial triage process:

One of the issues with triage is triage is sort of a continuing process and everyone has got too much to do ... patients are coming in, we're quickly trying to get them triaged and back in the right place.

An assistant nurse manager (Hospital 2) who provides frontline care reflected on the tension between the fast pace and the need for greater time and privacy with patients:

I think in this hectic environment we may not have time to sit down with the patient, even for five minutes. In the ER it's not a luxury that we always have. And often times we are going into their room, addressing their situation, doing nursing interventions. I think working in this environment, that luxury is often not there.

A nurse manager (Hospital 3) provided this example, highlighting the demands of both patient volume and protocols that require staff to act quickly:

... sometimes, just as an example, we'll have eight people lined up and we have to get them back quickly ... we want to get them back there fast, no longer than four minutes, so for the safety of everyone we have to move them through quickly ....

A frontline nurse (Hospital 3) described how their goals are impacted by the fast-paced environment, which does not provide space and time for building trust with clients:

... it's going to be timing and confidentiality ... we could get five people checking in in under five minutes, we need to triage in four minutes of arrival ... and for privacy, I would not dive deep into these in triage ... my general goal is to deescalate them ... some people are really keyed up and tearful ... I haven't developed rapport, I don't know you yet.

3. Screening for safety and use of clinical judgment: Nurses in all three hospitals used protocols and processes to screen for patient safety, though not explicitly for trafficking. They described the use of informal processes based on clinical judgment and the observation of patient behavior or nonverbal cues. A frontline nurse (Hospital 1) described their current practice and signaled future plans for more formal processes:

We have specific screening questions and intake questions for sexual assault victims, but for this area [trafficking], we don't have specific guidelines, protocols, questions. We will, but at this point no ... it's based on your gut feel that something is not right.

A nurse manager (Hospital 2) described processes for identifying vulnerable patient populations:

There are ED questions we ask of all our patients around safety, aimed at identifying anyone who is at risk, including abuse, child abuse, vulnerable adults. Sex trafficking, there are not specific questions for that in and of itself ... I do think that identifying things other than typical domestic violence, like sex trafficking, is incumbent upon the individual nurse to recognize....

A nurse manager (Hospital 3) described nonverbal cues frontline staff may observe that inform their assessment of the patient:

... if they[nurses] have any concerns in that process [triage], they can also enlist the help of social workers ... it might be something someone has said or it might be their nonverbal behavior, there are many cues they might get ....

4. Clarity on patient care pathway: Nursing staff at two hospitals expressed need for a decision algorithm for potentially trafficked patients.

... we have algorithms for abuse, we have a clinical standard for bruising ... for sexual abuse but if there is concern for a child being trafficked there's nothing ... if we're concerned about safety that is an attending and fellow escalation ... with any child protective concern they consult social work. Where the breakdown occurs is social work is supposed to do their patient-family risk assessment tool, but child neglect, abuse or any kind of diagnostic decision making is not the role of the social worker, it's the role of the attending in the ED .... (Nurse, Hospital 1)

A frontline nurse (Hospital 1) described a process reliant on a health worker's clinical judgment and input from several health care team members:

I would bring it up to the resident or attending first. They go into more detail of who lives at home ... we don't routinely as nurses sit in on those conversations ... not that we're not the right person to do that ... if there was something I was really concerned about, if the vibe was right I'd just go in myself, and ask a few more questions ... I could go to social work, but it would take the right person and having the right strategies to really help that person navigate through ....

Related to the theme of patient flow, there were comments regarding when ED screening questions should be asked, as expressed by this nurse manager (Hospital 3):

... I'm having a hard time with the screening [questions] because I'm imagining this happening in triage.. that's not where we would delve into this, we'd be delving into deeper questions once we have the patient back ... in an ER triage, there's no time to get this deep because we're already asking them a bunch of questions ....

5. Missed opportunities for care: A frontline nurse (Hospital 1) spoke of the potential for screening “falling through the cracks” without adequate training for staff and clear protocols and processes:

... I could see how it could fall through the cracks if there is not training on the red flags, and a pathway to go about that and talking to people about it.

A nurse manager who provides frontline care (Hospital 2) expressed concern about a general lack of awareness of sex trafficking as a health care issue, and resultant missed opportunities:

... I do think this is an issue that is not on the radar as much as it needs to be, there are missed opportunities that people don't realize.

6. Screening tool/protocol: Nursing staff in all sites stated that a screening tool would be useful in their ED settings. A clinical nurse specialist (Hospital 1) advocated for a piloted, validated screening tool to prompt further assessment:

I think an evidence-based [tool] that gets responses ... specific enough to where an additional screening can be done ... to see who needs a more detailed screening, would be great.

A nurse manager (Hospital 2) thought that a screening tool would raise staff awareness of sex trafficking as a health concern:

Yes, I do [think a screening tool would be useful]. I don't think it would be applicable to all patients ... but having a screening tool like this in front of us that we can just identify some of the risk factors, these are some questions we can ask.

Interview respondents provided a list of recommended actions to raise awareness of and improve identification and linkage to care for patients experiencing sexual exploitation. Investigators synthesized these recommendations into three primary categories—patient-centered care, process improvement, staff education, and training (see Figure 1).

F1Figure 1.:

Recommendations. EDs = emergency departments; SW = social worker.

LIMITATIONS

These findings are representative of three urban hospital EDs in Western Washington and may not be generalizable to other settings including community EDs or critical access hospitals. This study focused on nursing's role in the screening and care of patients experiencing commercial sexual exploitation. Study participants did not include social workers, forensic nurse examiners, or physicians due to time constraints. These three roles should be included in further studies, as they have essential functions and specialized expertise in screening and caring for this patient population. Further research with a larger sample size may be beneficial and demonstrate great variability in experience.

IMPLICATIONS FOR EMERGENCY NURSES

Health care settings are one place where the lives of trafficked persons intersect with the general public (Donahue, Schwien, & LaVallee, 2019). A lack of training and the absence of clear processes and established screening tools present challenges for ED nurses to identify and care for this population. Nurses expressed interest in training, tools, and other resources to better care for this population in the ED. Specifically, a common screening and care algorithm for potentially trafficked individuals for use by the entire ED team would improve case identification. Similarly, training about risk factors, indicators, and a trauma-informed approach to care would help identify, link, and provide ongoing support for trafficked individuals (Albright et al., 2020).

CONCLUSION

These study results highlight the importance of collaboration and coordination across multidisciplinary teams in EDs, including nurses, social workers, sexual assault nurse examiners, and physicians. Forensic nurse examiners have expertise in the care of this patient population and should be effectively integrated into the frontline ED care team. Clear communication and delineation of roles, responsibilities, and patient care flow will result in more effective care coordination and linkage to services for trafficked patients. Finally, engaging students on the study team with appropriate mentorship from faculty proved to be a novel, iterative opportunity to engage in practice-based research.

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