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Elizabeth Lo the Universi

Elizabeth B. Villanova, P

For correspo the Universi E-mail: eliza

J Emerg Nu 0099-1767

Copyright © All rights re https://doi.o

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NURSES' PERCEPTIONS OF VICTIMS OF HUMAN TRAFFICKING IN AN URBAN EMERGENCY DEPARTMENT: A QUALITATIVE STUDY

Authors: Elizabeth Long, BSN, RN, CEN, Elizabeth B. Dowdell, PhD, RN, FAAN, Philadelphia, PA and Villanova, PA

Contribution to Emergency Nursing Practice

• Emergency nurses are in a key position to identify and care for victims of human trafficking but do not have enough education regarding how to identify these victims and which resources to use for them.

• Differing perceptions of emergency nurses regarding victims of violence, prostitution, and human trafficking can potentially affect the care delivered to these patients.

Abstract

Introduction: Human trafficking is estimated to surpass the drug trade as the leading illegal industry in the world. According to a recent study, over 87.8% of trafficking survivors came into contact with a healthcare professional while they were enslaved and were not identified as a victim of human trafficking. The aims of this study are to understand the perceptions of emergency nurses about human trafficking, victims of violence, and prostitution.

Methods: A qualitative, descriptive study using a semi-structured interview approach was done with ten registered nurses in a

ng, Member, PA-ENA Chapter, is Clinical Nurse III, Hospital of ty of Pennsylvania, Philadelphia, PA.

Dowdell is Professor, Villanova University College of Nursing, A.

ndence, write: Elizabeth Long, BSN, RN, CEN, Hospital of ty of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104; [email protected].

rs ■.

2017 Emergency Nurses Association. Published by Elsevier Inc. served. rg/10.1016/j.jen.2017.11.004

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large, urban Emergency Department in the northeastern U.S. Interviews were recorded and transcribed; thematic analysis was performed.

Results: Six themes emerged from the interviews including, “human trafficking exists in the patient population” yet no nurse has screened or treated a victim; human trafficking victims are perceived to be “young, female, and foreign born”; all of the emergency nurses reported having worked with or screened a victim of violence; victims of violence were viewed as patients who present as “sad and grieving”; prostitutes are seen as “hard and tough”; and emergency nurses did not have education on human trafficking victims’ needs or resources.

Discussion: Emergency nurses should be more aware about victims of human trafficking. The media portrayal of human trafficking victims had influenced the nurses’ perceptions of this population. Victims of violence are perceived to be very different from prostitutes, but there is a desire for education about violence as well as information about specific resources open to victims.

Key words: human trafficking; Emergency Department; victims of violence; prostitution

H uman trafficking, also known as modern-day slavery, is one of the largest illegal industries globally, generating more than 150 billion US

dollars each year.1 Because of its increasingprevalence, victims of human trafficking have become a growing public health concern in the United States.1 It is estimated that there are

more than 21 million adults and children enslaved worldwide, more than at any time in history.2,3 The Emergency Nurses Association (ENA) position statement, released in February 2015, emphasized the vital role of emergency nurses in educating other professionals, the public, and policy makers about human trafficking.4 Emergency nurses are key persons to identify victims and direct resources to assist them.

Two categories of human trafficking are forced labor and sex trafficking.5 Victims of forced labor trafficking can be found in domestic servitude in places such as restaurants, carnivals, and migrant farms. Sex trafficking is present in online escort services, residential or disguised brothels, and prostitu- tion.6 Globally, more than 4.5 million people have been forced into sex trafficking, often lured into romantic relationships with traffickers and then forced into prostitution.7

The literature suggests that traffickers target vulnerable populations, which frequently include persons living in poverty, refugees from war or conflict, runaways and

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FIGURE 1

Interview questions.

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homeless youth, victims of domestic violence or sexual assault, and ethnic minorities. Often, traffickers seek vulnerable persons from certain ethnic or cultural back- grounds, imprisoning and exploiting their victims through the use of force, psychological coercion, and violence. Traffickers deceive victims with false promises of chances for prosperous lives and job opportunities or secure, loving relationships.6 These criminals do not necessarily present to health care providers as domestic violence abusers might. Rather, they are often charismatic and manipulative, feigning concern as romantic partners, family members, or community leaders.6,8 These key assessments are frequently overlooked in the early identification of human trafficking perpetrators and their victims.

In 2015, the National Human Trafficking Resource Center (NHTRC) received more than 21,947 phone calls, 1,275 emails, and 1,535 online tip reports about human trafficking in the United States.9 The 2015 NHTRC annual report found that 74.6% of cases were related to sex trafficking, and 13.0% of cases were related to labor trafficking.9 In sex trafficking cases, more than 91.4% of victims were women, and 34.7% were US citizens or legal permanent US residents.9 Of all the calls to the NHTRC in 2015, only 1.9% of callers were medical professionals.9 These

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statistics speak to the increasing prevalence of this injustice and the need for nurses to play a vital role in identifying victims. Having an awareness of human trafficking will help nurses acquire the vital skills needed for in-depth screening.10

Victims are challenging to identify. They are men, women, or children and American citizens or foreign nationals.9,10

They are not likely to self-identify, and therefore it is important for the emergency nurse to pay attention to nonverbal body language when screening for abuse or human trafficking. Victims of violence and victims of human trafficking present in similar ways; however, victims of human trafficking are more likely to be isolated, abuse drugs and have infectious diseases, malnutrition, and complications from poor medical care.9,10

Research has focused heavily on the physical and psychological effects of human trafficking. Victims of human trafficking can suffer from physical, sexual, and psychological health problems such as sexually transmitted infections, genital mutilation, urinary difficulties, pregnancy resulting from rape or prostitution, broken bones, burns, concussions, dental problems, and infections in addition to post-traumatic stress disorder, anxiety, and depression.5,6,11–13

Because of the growing incidence of human trafficking and the related health concerns, institutions and health care

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TABLE 1 Demographic data

Registered Nurses

Age (years) Gender Certifications Ethnicity Number of Years Working in the ED

Previous Specialties

1 34 Male TNCC Caucasian 4 None 2 25 Male TNCC Asian 3 Research 3 26 Female TNCC Caucasian 4 Occupational Health 4 41 Male TNCC Caucasian 8 None 5 35 Female TNCC, SANE, CEN Caucasian 4.5 Critical Care 6 57 Female TNCC, CEN Caucasian 38 None 7 38 Female TNCC, CEN Caucasian 16 None 8 40 Female TNCC Caucasian 10 Cath Lab 9 35 Male TNCC, CEN Caucasian 7 None 10 29 Female TNCC African American 6 Telemetry

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providers are now being asked to develop policies and screening protocols. Emergency departments have been identified as ports of entry for many victims of human trafficking into the health care delivery system because of progressive interpersonal violence policies, experienced staff, and specially trained nurses such as forensic nurse examiners (FNEs) or sexual assault nurse examiners (SANEs) who have expanded roles within the emergency department. However, there is a gap in the literature documenting how RNs—specifically, emergency nurses—perceive this topic and how the policies, or lack thereof, in their hospitals affect their perceptions of screening policies for victims of human trafficking. The purpose of this qualitative study is to examine the perceptions of emergency nurses about human trafficking, prostitution, and victims of interpersonal violence so that they can better identify and screen for these victims.

Methods

A descriptive qualitative design was chosen for this study. Data were collected using semistructured interviews exploring emergency department nurses’ experiences with human trafficking, prostitutes, and victims of interpersonal violence (IPV) to better understand the emergency nurse perspective. Before the selection of participants, institu- tional review board (IRB) approval was obtained from the university at the academic medical center and from the researchers’ university. Both IRBs determined that oral consent was adequate for participation in the study. Subjects were provided with a written description of the study, risks and benefits of participating, and information stating that participation in the study was voluntary. Oral

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consent was obtained following the reading of the information sheet at the time of the interviews and assurance that their interviews would remain confidential.

Sample and Setting

A purposive sample of emergency nurses were recruited for this study. Nurses were recruited through flyers and at shift change meetings over the span of 3 months. Criteria to participate in the study included being a registered nurse with a Bachelor of Science in Nursing (BSN) degree who had worked for at least 2 years in the emergency department. All emergency nurses worked in the same emergency department, which was part of a large, academic, urban emergency department; it is also the region’s level I trauma center, in the northeastern US. This emergency department was chosen because of its location in a city identified with a large human trafficking population, its progressive IPV policy, and the number of experienced emergency nurses, which included a SANE on each shift.

Data Collection

Semistructured interviews were selected as the means of data collection in anticipation of capturing information specific to experiences with human trafficking. All interviews were audio-recorded and transcribed verbatim. Each interview consisted of 12 open-ended questions (Figure 1) that asked the emergency nurses about their experiences in caring for victims of human trafficking,

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prostitution, and violence. Sociodemographic data were also collected identifying participants’ gender, ethnicity, age, years of experience in the emergency department, nursing specialty areas in which they worked previously, and their level of education. Data saturation was reached after 10 emergency nurses were interviewed.

Content analysis was used to analyze the data. The interviews were transcribed verbatim by the first author and read and confirmed by the second author to ensure a comprehensive examination of the data and credibility during the process of analysis. Field notes were taken concurrently by the first author to document nonverbal communication. The interviews were recorded, transcribed, and thematic analysis was performed. Data collected from the interviews were analyzed systematically, which is recommended for qualitative data.14,15 Transcripts were read and reread by both authors to ensure a rigorous examination, and field notes were used as supplementary data in the analysis process. Data were coded manually, guided by the research questions, and potential themes and subthemes were identified.14,15 Each transcript and all field notes were read individually and then together to identify themes. Trustworthiness was addressed by both authors in discussions about data credibility and confirm- ability to identify any bias that might have influenced the analysis process.

Results

The final sample consisted of 4 male and 6 female emergency nurses with nursing experience ranging from 3 to 38 years. The sample included 4 nurses who were certified emergency nurses (CENs) and 1 who was a SANE (Table 1).

Through the data analysis process, 6 core themes were identified. This paper reports on each theme by using quotes from the emergency nurses to illustrate the findings. Pseudonyms are used to protect participant confidentiality.

THEME 1: HUMAN TRAFFICKING EXISTS IN THE PATIENT POPULATION, BUT NO SCREENING IS PERFORMED

Each emergency nurse was asked, “In your practice here in this emergency department, have you screened and or worked with a victim of human trafficking?” None of the nurses interviewed had ever screened, identified, or knowingly treated a victim of human trafficking. There was a repetitive level of uncertainty regarding victims of human trafficking, screening, or identification and their presence in the patient population of the emergency

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department. Screening for human trafficking is based on ED experience, and all the nurses stated “never” having worked with a victim of human trafficking either domestic or sex trading. There was awareness by the emergency nurses that human trafficking occurs in their patient population, but there was a lack of having screened and knowingly having treated a victim.

• Ashley, when asked if she had screened or treated a victim of human trafficking, stated, “I have never come across one that I have definitely known about.”

In answering the question, the emergency nurses described their perception of how a victim of human trafficking would be similar to a victim of IPV. The nurses frequently linked human trafficking presentation in the emergency department as being similar to patients who experience IPV. These responses illustrate how emergency nurses are aware that human trafficking victims would present similarly to victims of IPV but also shows that there is uncertainty directly related to a lack of experience with these types of patients. Because victims of human trafficking do not self-identify and can present in a variety of ways, it can be very challenging for the emergency nurse to screen for them.

THEME 2: HUMAN TRAFFICKING VICTIMS ARE “YOUNG, FEMALE, AND FOREIGN BORN”

All of the emergency nurses in this study held the belief that victims of human trafficking must come from different countries (foreign born) and are young women or girls.

• Ashley said, “…we generally think of them (victims of human trafficking) as young, or children, but I know in different areas (of the city) we still see women from Russia, women from China…I think that when we see them we feel we will see them with an overbearing man, because that is the normal presentation of abuse…it’s what I see on TV.” • Henry stated, “I imagine they (victims of human trafficking) would look very traumatized…be scared.”

These quotes highlight the misconception of victims of human trafficking being similar to that presented in mainstream media. Ashley’s quote, in which she stated that the patient would present with an overbearing man, is more often true with victims of IPV. Victims of human trafficking can present with charismatic, well-mannered “boyfriends” or “family friends.” No study participants mentioned this presentation of a suspected trafficker, and this speaks to a lack of education on the topic. Also, victims of human trafficking are similar to victims of IPV, as they

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are usually not forthcoming with information about their situations.16

• Carol shared: “I think that it would be a person who is easily preyed upon…probably a minority in ethnicity: for example, maybe a foreign person who comes in and isn’t a citizen of the US and who came in via various means, like promised something and was never given it. And also a younger person: for example, a young woman, who was maybe sold by her family to these terrible people and just people who don’t have resources who are used by people of stronger means.” • Henry also reported that he wasn’t sure if men or boys would present to the emergency department as victims of human trafficking “because it’s not really portrayed in the media.”

These statements speak to how the media can add to the impression of victims of human trafficking being exclusively young, foreign women in the sex trade. Furthermore, these responses show how emergency nurses’ perceptions of human trafficking victims are largely influenced by the media and reports of human trafficking in our society.

THEME 3: IDENTIFYING VICTIMS OF VIOLENCE

All the emergency nurses in this study reported that they consistently screened and worked with victims of IPV. This positive finding demonstrates how these emergency nurses are routinely screening all patients for IPV and emerged as a strong theme related to their current bedside practice. When compared with their uncertainty related to human trafficking screening, the study participants were all comfortable and certain of their skills in screening for IPV. The innovative ED policy, combined with multiple in-service education modules, may be considered to be factors that have increased levels of understanding and acquisition of skills. These study participants are playing a significant role in identifying this vulnerable population that often does not self-identify.16

• Ashley reported, “Oh sure, we always screen for victims of violence here in the emergency department.” • Dave said, “Yes, I’ve seen a whole range of things…I see people who are first time and multiple times being assaulted…it is not pretty”

The quotes by these emergency nurses reflect their awareness of the problem as well as adherence to federal law. Nurses play a critical role in identifying these patients and providing them with the tools they need to leave an abusive situation. It is encouraging to see that all patients are being

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screened for IPV. The interactions that nurses have with the victims of violence can truly make an impact.

THEME 4: VICTIMS OF VIOLENCE VIEWED AS “SAD AND GRIEVING”

The participants in this study frequently described victims of IPV as expressing a “sad and grieving” or “defensive” presentation. They reported that victims of IPV reacted differently from prostitutes because they believed that victims of IPV are often in states of shock.

• Clara shared that victims of IPV are “usually very upset at the time they present; it’s an emotionally charged incident, and they behave like that in the emergency department.” • Lucy shared: “The patients themselves come across as withdrawn with a flat affect…some of them come across as being aggressive, feeling defensive.”

In these comments, study participants identified characteristics of the psychological impact that the violence has had on these victims. There is a sense that these patients require special consideration when providing care. Partic- ipants in these interviews perceived these victims to present in various ways that were similar to the stages of grief. Some patients appeared defensive, whereas others seemed with- drawn and “delicate.”

• Mary reported, “Patients who have experienced violence are pretty anxious when they come into the emergency department, and they are delicate.”

These comments also reflect the perspective that victims of IPV present as fragile. There is a sense of uncertainty about what type of emotion these victims will share, but, regardless, the nurse must have consideration when dealing with these patients. Overwhelmingly, study participants expressed their sympathy and compassion when caring for these victims. They recognized that they are in a key position to identify and care for them.

THEME 5: PROSTITUTES ARE SEEN AS “HARD AND TOUGH”

Because of the close relationship between sex trafficking and prostitution, the participants in this study were asked about their experiences in caring for women or men who were prostitutes. There was no indication from any of the participants that many prostitutes are also victims of human trafficking or are being traded for sex. Study participants reported that prostitutes appear in the emergency depart- ment as “hard and tough, because they have chosen their life style.” The description of prostitutes’ presentations served as a stark contrast to how they perceive victims of IPV.

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FIGURE 2

Questions to report a victim of human trafficking: National Human Trafficking Resource Center 2 (NHTRC).9

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• Henry stated, “They are a little rough around the edges. It’s hard to figure out if they willingly want to do this (prostitution).” • Dave said, “Those women (prostitutes) are more aggressive than regular victims of violence…They are not timid; they don’t have as many downplayed eyes, they’re like ‘this is what I do, this is who I am, and this is what I need.’” The impact of being labeled “hard” or “tough” emerged

as a key difference between how study participants viewed victims of IPV and prostitution. Participants echoed this sentiment that prostitutes are often not viewed as victims because they perceived that prostitutes “have chosen this life style.” None of the participants in this study expressed a belief that prostitutes were forced into a life of prostitution or that there was a link between sex trafficking and prostitution. These viewpoints about choice of lifestyle, whether correct or not, might influence the care provided to these patients.

THEME 6: NO HUMAN TRAFFICKING EDUCATION FOR EMERGENCY NURSES

All the nurses who participated in the study reported receiving education on caring for victims of IPV and the available resources while in nursing school or during continuing education courses. All the study participants reported not having received any formal education on human trafficking, and many used their education on how to identify and care for victims of IPV when asked how they would identify a victim of human trafficking.

• Dave reported that he thought that resources for human trafficking victims would include “social work, and we can call the police at any point, but mostly social work.” • Carol shared: “I would have no idea what to do, but I would call social work first and see if they know, and I’m sure the city has resources (for victims of human trafficking), but not any that I know of.”

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Most study participants expressed that they would contact social work, which is standard procedure in this emergency department when a nurse needs a referral for safe housing, group housing, or cab vouchers. However, as one participant pointed out, social work is not available at night, when many of these victims might present to the emergency department.

• Ashley stated, “There is a big discrepancy between day and night shift because there is no social work at night…and we get a lot of patients who are victims of violence at night.”

The study participants did mention that the city probably had shelters but did not know of ones that were specifically designated for victims of human trafficking. These comments about consulting with social work are, in part, based on a belief that the social worker might know more about how to help a trafficked victim. Although there was a gap in education regarding victims of human trafficking, all participants reported interest in having education on how to care for victims of violence and provide resources for them. The SANE specifically expressed how in her nurse practitioner program she had not received education on this topic and, therefore, had the same level of education as the staff nurses in this study. This desire for education demonstrates that emergency nurses are interested in learning as well as implementing best practices at the bedside to help this population.

Discussion

The findings of this study emphasize that emergency nurses are in a key position to identify as well as provide care to victims of human trafficking and violence. Because nurses are often the first health care providers to see patients in emergency departments, it is important that they are given the tools to better identify and care for these victims.

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The passage of the Affordable Care Act (ACA) in 2010 mandates that health care providers screen for victims of violence including all women ages 14 to 46 for IPV.17,18

This mandate, and increased awareness among health care providers, has allowed nurses to screen for and identify these victims routinely.19 The screening for victims of IPV was part of the care delivered by these emergency nurses, which supports their report of all having cared for victims of IPV. Most study participants reported that their victims of domestic violence have been women, and that is reflective of national statistics, which state that, in IPV cases, 76% of victims were women compared with 24% of men.18 The perception of victims of IPV as “sad or angry” is a stark contrast with the participants’ perceptions of prostitutes as “tough and hard.” Study participants viewed prostitutes as unapologetic and hardened about their situation. They also viewed the prostitutes not as victims, but as women who “made a choice.” This perception speaks to the media’s portrayal of prostitutes and pimp culture. Pimps are glorified in pop culture today, especially in online games and music.20,21 Because of this, the public has an inaccurate perception of pimps, and that can affect the way emergency nurses screen and identify victims of human trafficking.

Another interesting finding is that although the study participants did not knowingly care for any victims of human trafficking, they all believed that it occurred in their patient population. This speaks to the awareness of emergency nurses that human trafficking occurs but also points to further education needed for nurses to identify and care for these victims. A recent study noted that 87.8% of trafficking survivors came into contact with health care professionals while they were enslaved and were not identified as victims of human trafficking.22,23Furthermore, 63.3% of those survivors reported being seen in emergency departments.22,23 Emergency nurses are in a prime position to identify these victims, just as they identify and routinely screen for victims of violence.

Although most human trafficking victims do not self-identify, it is vital for nurses to ask questions. If patients say they do not feel safe, there are additional questions that health care providers can ask to identify whether these patients are victims of human trafficking (Figure 2).9

Furthermore, study participants perceived human trafficking victims as young, female, and foreign-born, although 43.8% of all victims of sex trafficking in the United States are American citizens, compared with 12.9% of foreign national victims.24 Also, although women are overwhelmingly victims of sex trafficking, 50.9% of men trafficked are victims of labor trafficking in the United States.25

The study participants’ perceptions of these victims reflect the media’s portrayal of human trafficking victims coming from other countries and being forced into the sex

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trade. Also, the controlling, overbearing man is what nurses are taught to look for with victims of violence, but the literature suggests that this is often not the typical presentation of human traffickers.6 Human traffickers are experts at manipulating people and often present as charismatic, concerned boyfriends, community leaders, or family members.24

Study participants reported having had in-service programs, online courses, and courses in nursing school about victims of violence. They reported providing many resources for victims of IPV that are offered in the emergency department, such as women’s shelters, the Special Victims Unit, and even lipsticks with a crisis hotline number inside. However, the SANE participant in this study reported that although they do offer these resources, they are often difficult to use. The SANE participant reported having difficulty calling shelters across the city to find a spot for victims of violence because the shelters were filled. This speaks to the prevalence of violence against women in this urban setting and across the country, where 1 in 3 women and 1 in 4 men experience some form of IPV in their lifetimes.19

The participants in this study expressed that they had never had any education or in-service programs on victims of human trafficking in professional practice or education. This gap in education affects patient care, particularly on night shifts when social workers are not available in this particular emergency department. The nurses, especially charge nurses and clinical resource coordinators, are left with the task of coordinating resources for these patients. Without a strong foundation in knowledge of these resources, the health care team is not providing optimal care for this unique patient population. Victims of human trafficking have different psychological and physical needs from victims of violence, so these specific shelters are important resources that should be made available to victims of human trafficking.5,6,11–13 A positive finding from this study is that most study participants did have education or in-service programs on how to care for victims of violence in the emergency department. The participants in this study were adamant on the importance of screening for victims of violence. Overall, study participants expressed a desire to become more aware of the specific needs and resources for victims of human trafficking.

Limitations

There were some limitations in this study, which included the small sample of nurses interviewed, the range of ages and nursing experience, specific emergency department, and

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gender. Furthermore, having 4 male and 6 female participants could have affected how victims of violence and prostitutes are perceived through a gender-specific lens. Also having only 1 SANE participate in the study affected the results because the other participants did not have the same depth and breadth of educational content to care for victims of sexual assault and violence. Finally, another limitation to the study was that the emergency department did not have a policy on human trafficking regarding screening or caring for victims. This did not allow the researchers to determine how hospital policy affected nursing practice in the emergency department.

Implications for Emergency Nurses

This research suggests that although violence is a significant part of a nursing assessment, there is a group of victims who are being excluded. The context of today’s busy emergency department often encourages nurses to conduct generalized screening for violence with minimal to no education provided to develop the skills necessary to identify patients who are victims of human trafficking. It is important for emergency nurses to be empowered with the tools and assessment skills to identify as well as provide care to these vulnerable patients. Within the health care system, emergency nurses are at the forefront of patient care and are often some of the first people with whom patients interact in the emergency department. Emergency nurses are in key positions to use current research and guidelines to advocate for a federal mandate to screen for these patients. Also, emergency nurses can use their education on the topic to develop hospital-wide policies on screening and encourage their colleagues in other specialties to be aware and screen for this high-risk patient population.

Conclusions

Emergency nurses are in key positions to identify and provide care to victims of human trafficking, violence, and prostitution. This study shows how each of these patient populations is perceived differently by emergency nurses. Finally, this study speaks to the fact that emergency nurses want to become more aware and have additional education on resources specific to victims of human trafficking.

Acknowledgments

This work was supported by a summer grant from the Davis Family Undergraduate Student Research Fund, Villanova University College of Nursing. The authors would like to thank the emergency department nurses who participated as

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well as the nurse manager. The authors would also like to thank the Davis Family and Dean M. Louise Fitzpatrick from the College of Nursing.

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