4.3 Spotlight Application
Open Resources for Nursing (Open RN)
This section will apply the tools from the “Community Assessment” chapter to providing care for victims of human trafficking as an example of a nurse generalist caring for a member of a vulnerable population. See Figure 17.12[1] regarding human trafficking initiatives.
After hearing about a sexual trafficking arrest at a local hotel in the news, a nurse who works in the emergency department reads more information on the National Human Trafficking Hotline. Because the community is located near a major national interstate, the nurse realizes there are likely many unidentified victims of human trafficking passing through the community. The nurse develops a goal to improve the identification and support of individuals experiencing human trafficking in the community.
The nurse begins a community health needs assessment by reading statistics on the National Human Trafficking Hotline, as well as additional information in the Adult Human Trafficking Screening Tool and Guide PDF by the U.S. Department of Health and Human Services’ Administration for Children and Families. Based on this research, the nurse keeps the following tips in mind when conducting an assessment with a potential victim of trafficking[2],[3]
- Lack of self-identification. Many victims do not self-identify as human trafficking victims due to lack of knowledge about the crime, as well as power and control dynamics involved in trafficking situations.
- Being conscious of verbal and nonverbal messages. When speaking with a potential victim of trafficking, the nurse plans on adopting open, nonthreatening body positioning; maintaining a calm tone of voice; displaying a warm, natural facial expression; using active listening skills; and mirroring the language the potential victim uses. For example, if the potential victim refers to her controller as her boyfriend, referring to that person as a “pimp” or a “sex trafficker” can negatively impact a therapeutic nurse-client relationship.
- Being aware of power dynamics. If a third party accompanies or interprets for the potential victim, the nurse plans on trying to speak to the potential victim alone or in a secure area with an official interpreter.
- Being aware of canned stories. Scripted stores are common, and the true story may not emerge until trust has been built with the potential victim.
- Meeting the person’s physical needs by offering a snack or beverage. Most individuals experiencing human trafficking have been deprived of basic necessities, such as food, fluids, sleep, and urgent medical needs. Hunger is a very common problem for individuals who have been trafficked; a person who is hungry will have difficulty focusing and may be irritable.
- Never allow confidential data to leave the office. Ensure secure mechanisms to maintain privacy of client data (e.g., use effective passwords and/or locked file cabinets).
- Being empathetic. The decision to disclose trafficking can be mentally challenging, emotionally draining, and potentially physically unsafe for the victim. If the victim does not feel prepared to disclose during the immediate clinical visit, disclosure may occur at a future visit.[4]
Assessment
The nurse is aware of the warning signs an individual who is a victim of human trafficking or sexual violence may exhibit[5]:
- Shares a scripted or inconsistent history
- Is unwilling or hesitant to answer questions about an injury or illness
- Is accompanied by an individual who does not let the patient speak for themselves, refuses to let the patient have privacy, or who interprets for them
- Shares information about controlling or dominating relationships
- Demonstrates fearful or nervous behavior or avoids eye contact
- Is resistant to accept assistance or demonstrates hostile behavior
- Is unable to provide their address
- Is not aware of their location, the current date, or time
- Is not in possession of their identification documents
- Is not in control of his or her own money
- Is not being paid or wages are withheld
Sex trafficking victims may exhibit the following[6]:
- Patient is under the age of 18 and is involved in the commercial sex industry
- Has tattoos or other forms of branding, such as tattoos that say “Daddy,” “Property of…,” “For sale,” etc.
- Reports an unusually high number of sexual partners
- Does not have appropriate clothing for the weather or venue
- Uses language common in the commercial sex industry
- Experiences multiple sexually transmitted infections, pregnancies, miscarriages, or terminations
If concerning assessment findings are noted, the nurse plans on using a screening tool found in the Adult Human Trafficking Screening Tool and Guide PDF. Before beginning any conversation with the client, the nurse plans to assess for potential safety risks that may result from asking the client sensitive questions and to ensure privacy. The nurse also plans on being transparent about the limits of confidentiality regarding mandated reporting.[7]
Diagnosis
Several nursing diagnoses may apply to individuals experiencing human trafficking or sexual violence. Examples of diagnoses include the following[8]:
- Post-Trauma Syndrome related to insufficient social support
- Powerlessness related to insufficient sense of control
- Chronic Low Self-Esteem related to inadequate belonging
- Risk for Impaired Emancipated Decision-Making as manifested by insufficient privacy to openly discuss health care options
Outcome Identification
The overall goal of the nurse is to identify and support victims of human trafficking or sexual violence. Individual SMART goals can be established for clients based on their circumstances. Some examples of SMART outcomes are as follows:
- The client will remain safe from injury and death.
- The client will verbalize local resources and support before the end of the visit.
- The client will acknowledge the traumatic experience and begin to work through the trauma by verbalizing feelings of fear, anger, anxiety, or helplessness during the visit.
Planning Interventions
The nurse prepares to respond quickly based on the client’s circumstances by doing the following:
- Knowing how to contact law enforcement if the client or staff are in immediate danger.
- Being prepared to complete mandatory reporting requirements for minors and other circumstances according to state law.
- Creating a list of local services and resources to provide to human trafficking victims.
The nurse plans on sharing these resources regarding human trafficking with local community representatives associated with urgent care centers, clinics, primary care providers, and emergency departments.
Implementation
The nurse implements interventions with individuals seeking care based on assessment findings. Individualized interventions may include these steps:
- Contact law enforcement if the client or staff are in immediate danger.
- Create a safety plan by identifying the current level of risk and safety concerns. Outline concrete options for responding when the individual’s safety is threatened.
- Refer the victim to local services and resources, such as food, shelter, and legal services.
- Share referral options. For assistance with finding referrals or other resources, contact the National Human Trafficking Hotline at 1–888–373–7888.
- Be prepared to respond to a potential trauma reaction. Encourage relaxation breathing and grounding techniques for immediate de-escalation. (Review crisis intervention in the “Stress, Coping, and Crisis Intervention” chapter and grounding techniques in the “Anxiety Disorders” chapter.)
- Perform mandatory reporting for minors and other circumstances according to state law. Read more about mandatory reporting in the box below.
- Report the case confidentially to appropriate authorities trained on human trafficking.
- Document assessment findings and referrals. Maintain client privacy and ensure the documentation is secure electronically or on paper.
Mandatory Reporting
Mandatory reporting is required for minors. Read more about mandatory reporting in the “Legal and Ethical Considerations in Mental Health Care” chapter. If reporting human trafficking of adults is not a component of your state’s mandatory reporting statutes, certain circumstances may be considered reportable. Some of these “reportable” circumstances may include domestic violence, injuries caused in violation of criminal law, or injuries caused by a deadly weapon (e.g., firearm, knife, or machete). Some professionals hesitate to report potential victims of trafficking due to fears of violating the rules of the Health Insurance Portability and Accountability Act (HIPAA). HIPAA was written to protect patient confidentiality but was not designed to prevent the reporting of trauma and crimes. If you’re unsure about whether HIPAA permits the reporting of patient information in a specific situation, human trafficking can still be reported without divulging individually identifiable patient health information. For example, you could report the gender, age of patient, and type of trafficking.[9]
Evaluation
The nurse plans on evaluating the success of achieving the overall goal to improve the identification and support of individuals experiencing human trafficking in the community in a variety of ways:
- Reviewing statistics reported by local law enforcement agencies regarding human trafficking cases.
- Reviewing statistics reported by the National Human Trafficking Hotline.
- Informally interviewing local community representatives associated with urgent care centers, clinics, primary care providers, and emergency departments regarding human trafficking cases.
- ”OAG-2020-Sex-Trafficking-Poster-English” by Office of Attorney General for the District of Columbia is in the Public Domain. ↵
- National Human Trafficking Resource Center. (2011). Human trafficking assessment for domestic violence & sexual assault programs. https://humantraffickinghotline.org/sites/default/files/Assessment%20-%20Domestic%20Violence-Sexual%20Assault%20Programs.pdf ↵
- Macias-Konstantopoulos, W., & Owens, J. (2018). Adult human trafficking screening tool and guide. Administration for Children & Families and National Human Trafficking. https://www.acf.hhs.gov/sites/default/files/documents/otip/adult_human_trafficking_screening_tool_and_guide.pdf ↵
- Tracy, E. E., & Macias-Konstantopoulos, W. (2021). Human trafficking: Identification and evaluation in the health care setting. UpToDate. Retrieved March 16, 2022, from www.update.com ↵
- Tracy, E. E., & Macias-Konstantopoulos, W. (2021). Human trafficking: Identification and evaluation in the health care setting. UpToDate. Retrieved March 16, 2022, from www.update.com ↵
- Tracy, E. E., & Macias-Konstantopoulos, W. (2021). Human trafficking: Identification and evaluation in the health care setting. UpToDate. Retrieved March 16, 2022, from www.update.com ↵
- Tracy, E. E., & Macias-Konstantopoulos, W. (2021). Human trafficking: Identification and evaluation in the health care setting. UpToDate. Retrieved March 16, 2022, from www.update.com ↵
- Ackley, B., Ladwig, G., Makic, M. B., Martinez-Kratz, M., & Zanotti, M. (2020). Nursing diagnosis handbook: An evidence-based guide to planning care (12th ed.). Elsevier. ↵
- Macias-Konstantopoulos, W., & Owens, J. (2018). Adult human trafficking screening tool and guide. Administration for Children & Families and National Human Trafficking. https://www.acf.hhs.gov/sites/default/files/documents/otip/adult_human_trafficking_screening_tool_and_guide.pdf ↵