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JOURNAL OF NURSING PRACTICE APPLICATIONS & REVIEWS OF RESEARCH

Human Trafficking: Knowledge and Awareness in Nursing Practice

Jeanann Sousou Coppola, E. Renee Cantwell, Debashis Kushary, & Cynthia Ayres

Accepted for publication January 5, 2019 https://doi.org/10.13178/jnparr.2019.0901.0907

Correspondence to: Abstract

Jeanann Sousou Coppola, DNP, Background: Human trafficking (HT) is a global, national, and local public health issue
RN, CNM, CNE with many quantifying concerns, including the identification and care of these individuals.
[email protected] Perpetrators of trafficked individuals target vulnerable populations through force, violence
and victimization. Nurses in the clinical setting are in a crucial position to recognize, as-
Authors’Affiliation sess, and refer victims of HT. However, nurses may not be aware of the presence of HT
Jeanann Sousou Coppola, DNP, in their communities or of the signs and symptoms that may alert nurses of potential HT
RN, CNM, CNE victims.
Clinical Assistant Professor,
Rutgers, The State University of Objective: The purpose of this study was to gain a better understanding of nurses’ famil-
New Jersey, School of Nursing, iarity of HT, their perception of HT as a problem in their community, and their ability to
Camden recognize, assess, and refer potential HT victims for assistance.
E. Renee Cantwell, DNP, RN, Methods: A literature review and descriptive cross-sectional study using survey method-
CNE, CPHQ ology was used to help gain a better understanding of nurse’s familiarity and perception
Clinical Associate Professor and of human trafficking.
Director, Accelerated Program,
Rutgers, The State University of
Results: Findings of this study have the potential to inform the development of educa-
New Jersey, School of Nursing,
tional interventions to increase identification, assessment, and referral of HT victims who
Camden
present to the clinical setting for care.
Debashis Kushary, PhD
Conclusion: Identification and proper reporting of potential HT victims can be chal-
Associate Professor, Rutgers, The
lenging to the healthcare professional because of the perplexing and covert nature of HT.
State University of New Jersey
Healthcare professionals are at the front lines in both facilitating the identification of po-
Cynthia Ayres, PhD, RN, FNAP
tential victims and treating and referring them to the right resources. Several comments
Associate Professor, Rutgers, The
made by the respondents clearly identified the need for HT education related to insufficient
State University of New Jersey, education and understanding of this public health issue.
School of Nursing, Camden
Keywords: human trafficking, nurse, educational resources, nursing survey results
Funding
The authors did not receive a
grant from any funding agency in
the public, commercial, or not-
for-profit sectors.

Conflict of Interest
The authors declare that there is
no conflict of interest.

J Nursing Practice Applications & Reviews of Research Vol. 9 No. 1 January 2019
41
Background short window of time in the health care setting may offer
Human trafficking (HT) is a global, national, and local opportunities for early identification and timely treatment
public health issue with many quantifying concerns that of trafficked victims (Baldwin, Eisenman, Sayles, Ryan, &
include accurately identifying the victims and providing Chuang, 2011).
proper healthcare needs for these individuals. It is a crime
of modern-day slavery in which this crime has been under- Significance
estimated and underreported (Coppola & Cantwell, 2016; Human Trafficking is a global problem with national roots.
Hachey & Phillippi, 2017). The “traffickers target vulner- The United Nations Office on Drugs and Crime (UNODC)
able populations which frequently include persons living recognized HT as an issue in 2004 and brought forth The
in poverty, refugees from areas of conflict, runaways, and United Nations Convention against Transnational Orga-
homeless youth, victims of domestic violence or sexual nized Crime document that helped bring about international
assault and ethnic minorities” (Long & Dowdell, 2018, p. policies and offered legal advice to governments on pre-
376). The perpetrators often seek out these persons us- venting this world health issue (UNODC, 2004). Glob-
ing force, violence or intimidation to control their victims ally, the estimated number of victims is difficult to identify
(Scannell, MacDonald, Berger, & Boyer, 2018). as there are numerous barriers due to inconsistencies with
both national and international laws, secrecy related to the
According to the U.S. Department of State (2013), human nature of the crime and its impact on society, lack of aware-
trafficking is the recruitment, harboring, transportation, ness that trafficking is occurring in a particular geographi-
provision, or obtaining of a person for labor or services cal area, fearing personal safety if one were to be become
through the use of force, fraud, or coercion for the purpose involved in helping a victim, and failure of victims to freely
of subjection to involuntary servitude, peonage, debt bond- identify that they are being victimized (Lutz, 2018; Kon-
age, or slavery. Victims of trafficking may be performing stantopoulos et al., 2013). The UNODC’s Global Report on
jobs or activities which they were coerced or deceived into Trafficking in Persons (2004) recognizes that “legislation
and which they cannot leave (International Labor Organiza- does not always comply with the Protocol, nor does it cover
tion [ILO], 2012). Furthermore, individuals are considered all forms of trafficking and their victims, leaving far too
to be trafficking victims “regardless of whether they once many children, women and men vulnerable. “Even where
consented or even participated in a crime as a direct result legislation is enacted, implementation often falls short be-
of being trafficked” (Office to Monitor and Combat Human cause of either lack of early identification or lack of follow
Trafficking, 2014, p.1). through after identification” (UNODC, 2004, p. 1).

There are several risk factors associated with human traf- Trafficking for forced labor is prominently detected in
ficking. These include social determinants of health such North, Central and South America and “accounts for more
as poverty, lack of formal education, limited English pro- than half of all the detected HT victims; in South America
ficiency and limited support systems (Hachey & Phillippi, alone, the share is above 40 percent. It is very likely that
2017). A history of violence, trauma and abuse are also trafficking for forced labor is underreported to an unknown
highly related to risk for trafficking, and globalization is- extent in some South American countries” (UNODC, 2004,
sues of migration, refugee displacement, and victims locat- pg. 72). In the United States (U.S.), the government esti-
ed in conflict zones and civil wars also increase the risk of mated that approximately 600,000 to 800,000 people were
an individual being trafficked (Hachey & Phillippi, 2017). trafficked across global borders each year, and if trafficking
Individual HT victims suffer from numerous physical within all countries were to be included in the total world
and psychological problems (Coppola & Cantwell, 2016; figures, approximately 2 million to 4 million people were
Hachey & Phillippi, 2017). For victims held in captivity, trafficked annually (United States Government Account-
healthcare professionals are often the only people who may ability Office, 2006). Of those trafficked victims, 80% are
encounter and interact with them. More often than not, women, with 50% of these females considered to be minors
healthcare professionals who care for the victims may not (Doyydaitis, 2010; Miller, Decker, Silverman, & Raj, 2007;
recognize that the individual is being trafficked (Hachey U.S. Department of State, 2007). An estimated 50,000
& Phillippi, 2017; Long & Dowdell, 2018). Subtle cries women and children are annually trafficked into the U.S.
for help may go unnoticed if the healthcare provider is not (Barrows & Finger, 2008; Doyydaitis, 2010; Miller et al.,
aware of the signs and symptoms of HT. 2007). It is important to note that the exact number of U.S.
victims of HT is difficult to determine due to the under-
A recent study (Long & Dowdell, 2017) revealed that ground nature of trafficking networks and practice (Miller
87.8% of human trafficking survivors had been in contact et al., 2007).
with a healthcare provider in some capacity during their
victimization. Furthermore, it concluded that 68.3% had Published data do not represent the full scope of human traf-
received an evaluation in the emergency department. This ficking. These statistics are “considered reliable estimates

J Nursing Practice Applications & Reviews of Research Vol. 9 No. 1 January 2019
42 Human Trafficking: Knowledge and Awareness in Nursing Practice
based on information gathered from governmental and non- Several organizations and associations have presented posi-
governmental organizations around the world. Even though tion statements based on the nature and importance of this
different sources report different information, it is reason- issue and reinforce the position that healthcare providers
able to say that whatever the estimated numbers, they are all have an obligation to recognize and help identified victims.
too high and there are far too many victims” (Peters, 2012, American Academy of Pediatrics Policy Statement (2017)
p. 281). Significant underreporting can be related to sev- recommend that all individual healthcare professionals can
eral factors, including lack of general awareness and lack prevent trafficking, recognize victims and intervene appro-
of identifiable resources to assist victims (UNODC, 2014; priately. The statement further indicates that there should be
Polaris, 2017). global efforts to address the social determinants of health,
which are intimately connected to push and pull factors for
In a multi-city study conducted at the University of Penn- human trafficking; and advocate for training of health care
sylvania, Wolfe, Greeson, Wasch and Treglia (2018) found professionals (Greenbaum et al., 2017).
that one in five of the youth were victims of sex trafficking
and that two out of three homeless females reported being The Emergency Nurses Association and International Fo-
solicited for paid sex. Cities represented by this study were rensic Nurses Dual Position Statement on Human Traffick-
Phoenix, Washington DC, and Philadelphia. For all gen- ing Awareness posits that nurses “play a vital role in rec-
ders, 22% of those homeless youth who were approached ognizing and responding to the needs of victims…. (and
for paid sex had this happen on the first night of being home- that) capturing these lifesaving opportunities requires pro-
less. Transgender youth were particularly vulnerable, with active measures aimed at education awareness and training”
90% of transgender youth reporting being offered money (Emergency Nurses Association and International Forensic
for sex. Ninety-five percent had a history of child abuse. Nurses, 2018, p 2).
Among those who were maltreated, the highest percentage
of youth reported being sexually abused (49%), followed The Association of Women’s Health, Obstetrics and Neona-
by physical abuse (33%). In addition, 67% percent of those tal Nursing Organization (AWHONN), an organization sup-
trafficked did not graduate from high school (Wolf et al., porting nurses caring for both female and infant populations,
2018). put forth a position statement recognizing HT as a health is-
sue recommending several initiatives, including developing
Not only is it challenging to identify the number of victims a validated, brief screening tool to better identify victims of
both on a global and national level, but it is also perplexing human trafficking in the clinical setting; advancing research
that healthcare professionals may not recognize the signs or on the long term health implications for victims; and en-
know how to manage these individuals once they are identi- hancing multisector collaboration and coordination in order
fied. Lutz’ (2017) study on integrating human trafficking to support information sharing (AWHONN, 2016).
education into a standard nursing curriculum recognized
there were gaps in knowledge among healthcare provid- Literature Review
ers regarding definitions of HT, laws related to the public Studies have found that the percentage of victims in the
health issue, global and national prevalence, identification U.S. who encounter health care professionals while under
and treatment of victims, as well as community resources the control of the trafficker ranges from 28 percent (Lederer
available to help identified victims. In a study conducted by & Wetzel, 2014) to 87.8 percent (Family Violence Preven-
Egyud, Stephens, Swansan-Bierman, DiCuccio, and White- tion Fund, 2005). Traffickers may bring or allow the victims
man (2017) on educating emergency room nurses found to obtain medical care either when their illnesses or inju-
that formal education and screening is necessary to iden- ries are interfering with their ability to work or for routine
tify true victims of HT because they can resemble victims care including obtaining contraceptives or testing for sexu-
of other crimes, including prostitution, domestic violence, ally transmitted infection (STI) (Tracy & Konstantopoulos,
abuse, addiction and assault. 2012).

Coppola and Cantwell (2016) recognized how nurses work- Several studies (Beck et al., 2015; Grace et al., 2014;
ing at the frontlines in clinical settings or emergency depart- Chisolm-Straker, Richardson & Cossio, 2012; Ross et al.,
ments intersect with this hidden and underestimated public 2015) have shown that training can have a significant im-
health issue. Nurses are the first healthcare professionals pact on clinicians’ knowledge of trafficking and their ability
that victims encounter when seeking care. “Trafficked vic- to recognize and care for these victims. Beck et al. (2015)
tims typically receive healthcare only when their condition conducted a survey to evaluate knowledge gaps and train-
becomes serious” and nurses caring for these individuals ing needs of medical providers in order to demonstrate the
may not clearly recognize that there is more to their initial importance of provider training to meet the pediatric HT
call for help (Sabella, 2011, p. 32). victim’s specific needs, and to highlight barriers to the iden-
tification of and response to victims. Findings in a sample

J Nursing Practice Applications & Reviews of Research Vol. 9 No. 1 January 2019
Jeanann Sousou Coppola, E. Renee Cantwell, Debashis Kushary, & Cynthia Ayres 43
of 168 participants, indicated 48% correctly classified a mi- Purpose of the Study
nor as a HT victim, and 42% correctly distinguished an HT Nurses in the clinical setting are in a crucial position to rec-
victim from a child abuse victim. In all, 63% of respondents ognize, assess, and report victims of HT. However, nurses
said that they had never received training on how to identify may not be aware of the HT in their communities or of the
HT victims. Those with training were more likely to report signs to alert them of potential HT victims. Therefore, the
HT as a major problem locally (p ≤ .001), to have encoun- purpose of this study is to gain a better understanding of
tered a victim in their practice (p ≤ .001), and to have great- nurses’ familiarity of HT, their perception of HT as a prob-
er confidence in their ability to identify victims (p ≤ .001). lem in their community, and their ability to recognize, as-
The greatest barriers to identification of victims reported sess, and refer potential HT victims when encountered in
were a lack of training (34%) and awareness (22%) of HT. the clinical setting. Findings of this study have the potential
to inform the development of educational interventions to
Grace et al. (2014) conducted a study aimed to determine increase identification, assessment, and referral of HT vic-
whether an educational presentation increased emergency tims in the clinical setting.
department (ED) providers’ recognition of HT victims and
knowledge of resources to manage cases of HT. Knowl- Methods
edge increased by an average of 1.42 points in the interven- This descriptive, cross-sectional study using survey meth-
tion group versus 0.15 points in the comparison group (1.57 odology helped to gain a better understanding of nurses’
[1.02–2.12], p < 0.001); the proportion of participants who familiarity of HT, their perception of HT as a problem in
rated themselves as knowledgeable/ very knowledgeable their community, and their ability to recognize and assess
increased from 7.2% to 59.0% in the intervention group and potential HT victims in the clinical setting. All registered
was unchanged (15.0%) in the comparison group. Knowl- nurses licensed in the state of New Jersey were to be in-
edge of who to call if they encountered a potential victim in- cluded. No registered nurses were excluded. After obtain-
creased more in the intervention group (from 24% to 100%) ing University Institutional Review Board approval, an on-
than the delayed intervention comparison group (from 20% line survey was sent to approximately 120,000 Registered
to 35%): (61.4% [28.5%–94.4%], p = 0.005). Additionally, Nurses either working or retired in New Jersey, through a
the proportion of participants in the intervention group who listserv obtained from the State Nurses Association. The
suspected that a patient was a victim of HT doubled (from listserv included all NJ registered nurses to the date the re-
17% to 38%), whereas the comparison group remained at searchers obtained the list. Of the emails sent, 2400 emails
10% (20.9% [8.6%–33.1%], p = 0.003) were returned as undeliverable. A total of 117,600 emails
were successfully delivered. The final sample was 734 indi-
Chisolm-Straker et al. (2012) developed and piloted an edu- vidual RNs, having a response rate of 0.6%. This response
cational intervention for emergency providers on HT and rate was quite low and therefore generalizability to all New
how to identify and treat these patients. Findings indicate Jersey nurses is very limited.
that prior to the intervention, 4.8% felt some degree of con-
fidence in their ability to identify and 7.7% to treat a traf- Qualtrics, an online, secure survey program, was used to
ficked patient. After the 20-minute intervention, 53.8% felt collect the survey data. The survey was pre-tested with
some degree of confidence in their ability to identify and faculty colleagues and minor revisions were made to the
56.7% care for this patient population. questions prior to utilization. Demographic questions were
asked, such as gender, age, education, clinical practice, and
Ross et al. (2015) conducted a cross-sectional survey to educational sessions or programs related to HT attended.
estimate the proportion of National Health Service (NHS)
professionals who have come into contact with trafficked To assess familiarity of HT, nurses were asked “How famil-
people and to assess NHS professionals’ knowledge and iar are you with the term “Human Trafficking”? Response
confidence to respond to human trafficking. Thirteen per- options ranged from extremely familiar to not familiar at
cent of the participants reported previous contact with a all. Knowledge was assessed through questions related to
patient they knew or suspected of having been trafficked; those individuals they considered victims of HT and the
among maternity services professionals this was 20.4%. characteristics they presented with; demeanor, eye contact,
However, 86.8% (n = 679) reported lacking knowledge and escorts.
of what questions to ask to identify potential victims and
78.3% (n = 613) reported that they had insufficient training To assess for nursing awareness based on these character-
to assist trafficked people. Seventy-one percent (n = 556), istics, they were asked, “In your opinion, do you believe
67.5% (n = 528) and 53.4% (n = 418) of respondents lacked Human Trafficking is a problem in your community?” Re-
confidence in making appropriate referrals for men, women sponse options ranged from strongly agree to disagree.
and children, respectively, who had been trafficked.
To assess nurses’ ability to identify victims of HT and pro-
vide resources to assist them, nurses were asked, “When
J Nursing Practice Applications & Reviews of Research Vol. 9 No. 1 January 2019
44 Human Trafficking: Knowledge and Awareness in Nursing Practice
you suspect a patient is a victim of human trafficking, do of employment was in the hospital setting. The remaining
you address your suspicion with the patient?” Response op- respondents worked in office, clinic, academic and other
tions ranged from always to never. settings including but not limited to college health facilities,
correctional facilities, telehealth, long term care and acute
Additionally, nurses were asked “If the patient validated care facilities, home care, drug and alcohol rehabilitation
your suspicion, were you able to refer the patient to any facilities, and insurance companies. Close to 43% of the re-
help?” Response options were dichotomized, yes/no. spondents indicated that they had worked in healthcare five
Open-ended questions were also asked to obtain additional year or less and approximately 20% had worked more than
information around resources available to both HT victims 16 years. About 76% of the respondents were employed
and nurses. Finally, an open comments section was included full-time while 17.66% were employed part-time. Job titles
at the end of the survey to collect any other information that of the respondents included staff nurses, unit managers, di-
the nurse wished to share. rectors, nurse practitioners, research nurses, nurse educa-
tors. Additionally, 17.39% of the respondents worked in
After results were collected, unfinished responses and du- pediatrics and 82.6% worked in adult care. See Table 1 for
plicates were removed from the data set, which was then sample demographics.
analyzed for significant trends and indicators. All analyses
were performed using SAS 9.4 (TS1M2) for windows op- Knowledge and Familiarity with HT
erating system. Most respondents (n = 550, 86.62%) were familiar with
the concept of HT while about 85 respondents (13.38%)
Some of the questions included “skip logic,” an option that were slightly or not familiar at all. The respondents con-
did not appear to those for whom it did not apply (as deter- sidered that victims of HT were associated with underage
mined by how the respondent answered a previous ques- girls forced into prostitution; associated with a person who
tion), and as a result, percentages included in this article is traded for goods or services; associated HT with a factory
indicate the percentage of respondents who answered that worker working in unsafe conditions; associated HT with a
particular question. domestic helper who is forced to work more than 12 hours a
day; associated HT with a foreign worker who is smuggled
Chi-Square tests were used to establish the dependency into the country.
HUMAN TRAFFICKING: NURSING Nineteen (0.69%) respondents indicated
KNOWLEDGE
among the variables. Only the significant
results with p-value less than 0.05 are re-
Table 1. Sample Demographic Variables
ported here. A limitation worth noting is
that even though p-value is affected by Characteristic n %
sample size and the sample size for this Nursing Practice Specialty
survey for some questions were not high Neonates 2.66%
enough, some of the dependency was not Pediatrics 11.91%
Adolescents 2.82%
significant at the 5% level. A multiple lin-
Adults 63.95%
ear regression model was also built to un- Older Adults 18.65%
derstand the simultaneous impact of above- Age
mentioned variables on the frequency of 18-24 15 2.08%
addressing the issue. 25-34 83 11.53%
35-44 114 15.83%
Results 45-54 171 23.75%
Demographics 55-64 257 35.69%
65-74 78 10.83%
The respondents’ ages ranged from 18-84
75-84 2 0.28%
years of age (M = 45.54). There were 39 85 or older 0 0.00%
(5.42%) males and 681 (94.58%) female Years in Practice
respondents. Most respondents indicated 0-5 years 273 42.86%
that the most primary language spoken was 6-10 years 103 16.17%
English (99.38%) and Spanish (41.34%). 11-15 years 88 13.81%
Other languages included Russian, Viet- More than 16 years 173 27.16%
namese, Hindi, and other bilingual. Degree Earned
Diploma 30 4.68%
Associates 88 13.73%
Of the respondents, 43.21% responded hav- Bachelors 277 43.21%
ing a Bachelor’s degree and 27.93% had Masters 179 27.93%
Master’s degree education. Approximately Doctorate 23 3.59%
43.47% of the respondents’ primary place Currently in program 44 6.86%

J Nursing Practice Applications & Reviews of Research Vol. 9 No. 1 January 2019
Jeanann Sousou Coppola, E. Renee Cantwell, Debashis Kushary, & Cynthia Ayres 45
other scenarios, including “adult men and women forced cions with the patients and if so, how did the patient react.
into prostitution,” “male/female not underage,” and “any Approximately 135 respondents (76.07%) indicated that
that could have been taken or kidnapped” while only three victims who were addressed about the possibility of their
(0.11%) responded they did not know. being HT victims, did not react positively, while 41 respon-
dents (23.30%) responded extremely, very or moderately
Awareness of HT as a Problem well. Only 44 respondents (24.18 %) indicated that the pa-
When asked if they believed HT is a problem in their com- tient verbally validated their suspicions, while 138 respon-
munity, almost half of the respondents (46.07%) neither dents (75.82%) did not provide verbal validation.
agreed nor disagreed, and more than half agreed it was
(53.93%). Ability to Provide Resources
Sixty-four respondents (45.71%) offered help to HT victims
Ability to Identify HT Victims while 76 respondents (54.29%) did not offer help. When
One hundred and forty-six respondents (22.99%) indicated help was offered to the victims, 32 of the victims (32.32%)
that they possibly had provided care to an HT victim, while accepted help, 38 respondents (38.38%) were unsure if they
49 respondents (7.72%) indicated they definitely cared for a accepted it, while 29 of the victims (29.29%) did not accept
HT victim. Of that number, 38 respondents (15.77%) rec- it. Not all respondents offered a response to the above ques-
ognized the signs during the physical examination, 136 re- tion on whether the victim accepted help from the provider.
spondents (56.43%) during the health history intake, and 67 Respondents offered that a majority of cases were referred
respondents (27.80%) suspected they were an HT victim at to the social worker (75%), while police and authorities
some other point during their encounter. Examples of these (42.31%) and human trafficking hotline or resource center
include during a treatment, noting lack of eye contact dur- (16.35%) were also suggested. Other examples of refer-
ing encounter, and discussion during subsequent encounters. rals offered included battered woman’s shelter, advocacy
The suspicions stemmed from noticing a “weird relationship groups, safe house, and Sexual Assault Nurse Examiner
between parent and guardian” if a child was suspected of (SANE) nurse (19.23%).
being a victim; observing strange characteristics while the
victims were “waiting in the waiting room”; while others Available HT Nursing Education
found that “the client volunteered the information.” Three hundred and ninety-one respondents (63.06%) indi-
cated that they have not attended nor participated in any
One hundred and seventy-five respondents (27.56%) of- program or session dedicated to HT education. Two hun-
fered they definitely never cared for a patient who they dred twenty-nine respondents (36.93%) stated (36.93%)
either suspected or was a victim of HT; and 265 respon- stated that they had attended HT education as follows:
dents (41.73%) did not know whether or not they cared for forty-nine (7.90%) respondents attended a training work-
a victim of human trafficking. Of the nurses who indicated shop, 42 (6.77%) attended a conference or symposium, 86
suspicion, 152 respondents (45.11%) verbally validated (13.87%) attended a webinar or web-based presentation,
their suspicion with the patient, 110 respondents (32.64%) and 52 (8.39%) attended other symposiums. There were no
sometimes did; while 75 respondents (22.26%) never did. follow up questions on the survey to identify who offered
the training or in what capacity it was presented.
The patient’s overall demeanor, presence of an escort, lack
of eye contact, unexplained bruises or discomforts, were all More than half of the respondents (58.77%) identified
factors that led the nurses to suspect HT. All characteristics how HT education was not provided by the nurses’ places
were part of the survey choices that allowed for free text by of employment, while only 196 respondents (33.39%) did
the respondents. Most responded that the patient’s overall not know if any HT education was available where they
demeanor was noted to be withdrawn, quiet, fearful, guard- worked. Only 46 respondents (7.84%) stated that there
ed, and anxious. The types of eye contact the nurse noted definitely was HT education at their place of employment.
were poor, avoided, minimal, or lacked eye contact. The When asked if their place of employment offered social ser-
suspected HT victim’s responses to questions were vague, vices or outreach programs for identified victims of HT, 348
short worded, evasive, minimal, and poor. Responses also respondents (59.39%) did not know..
included that the nurses’ suspicion was heightened when an
escort was present and refused to leave the patient alone When asked about barriers in their place of employment
with the nurse. Responses noted that the presence of bruis- that prevented outreach or social services to victims of HT,
ing and/or contusions were sometimes or always noted on 40 respondents (22.99%) indicated there were barriers, al-
multiple areas of the patient’s body. Respondents noted that though 56 respondents (32.18%) were not aware of any bar-
patient visits to the facility were sometimes to frequent. riers. Respondents who stated there were barriers indicated
lack of federal agency support, lack of funding, lack of HT
The nurses were also asked if they addressed their suspi- knowledge, and lack of training.

J Nursing Practice Applications & Reviews of Research Vol. 9 No. 1 January 2019
46 Human Trafficking: Knowledge and Awareness in Nursing Practice
The survey also asked nurses about whether there was inter- tics of the victims (yes/no)” (p < 0.0001), (3) “Number of
est in attending a HT program that would include HT ma- programs/sessions attended about Human Trafficking” (p <
terials and information about mechanisms for assisting vic- 0.0001) and “Whether place of employment provides ser-
tims. Greater than three quarters of respondents (86.42%) vices or training” (yes/no) (p < 0.0015). All the variables
offered they would attend educational sessions, while the are standardized to compare the individual effects in terms
remaining indicated they were either not interested or indif- of percentages. Model checking and outlier detection were
ferent. performed. In terms of percentages, “Awareness of the
Characteristics” has the highest impact (52.6%) which is
Correlations followed by “Attending Programs” (23.3%), “Training pro-
Chi-Square test shows that health care professionals with gram at work place” (12.3%) and the least impact on all
stronger beliefs or perceptions that Human Trafficking is variables was “Belief that Human Trafficking is a problem
a problem in the community are more likely to address the in their community” (11.2%).
problem with a patient when they suspect the patient is a HT
victim (p = 0.0064). About 54% of the people who “Strong- Discussion
ly Agree/Agree” that Human Trafficking is a problem in Identification and proper reporting of HT can be challeng-
the community almost always address the issue with their ing to the healthcare professional because of its perplexing
victims, while only about 42% always address the problem and covert nature. In any healthcare setting, the healthcare
and 37% sometimes address the problem in the other groups professionals are the first in helping to facilitate treatment/
who do not strongly beleive that HT is a problem in the referral after identifying them as victims. Several com-
community. ments made by the respondents clearly identified the need
for HT education for New Jersey RNs, as several respon-
While checking the impact of attendance at a HT program dents noted a lack of proper training and understanding of
on addressing the issue, Chi-Square test demonstrates a this serious public health issue. However, since this was
strong relationship. Among health care professionals who a limitation of the study it is difficult to generalize on a
attended at least one HT program or conference, about national level, but the impact of this public health issue is
56% addressed the issue almost all the time whereas only greatly recognized.
35% did so among the people who did not attend any (p =
0.0049). One respondent offered “It appears that the victim is treated
as a commodity by the handlers and the arrival in a health-
Awareness about the characteristics of the victims also in- care environment may occur frequently as a result of this
fluences RNs to address the problem more frequently than relationship. There may be other human conditions, such
those who are not aware. About 59% of the RNs who in- as abusive relationships, which can mimic the symptoms of
dicated they were aware of at least one characteristic ad- Human Trafficking so the education offerings could consid-
dressed HT with their patients, while only 29% of the rest er these other human conditions and assessments, interven-
took the similar action (p < 0.0001). tions, and evaluations for these as well.” One respondent
offered they feel that “(t)here currently is no information
Services or training at the work place motivate people sig- available. (When they) worked for immigration detention,
nificantly to address the issue. Though there are few places “we heard these stories all day long, but outside in the real
where such training and services are available, it shows world” we hear nothing.
that about 68% of those who address it almost all the time
worked in an environment that offered training and ser- Nurses also need to keep in mind that some victims may
vices to victims, while only 41% among others do so (p = not trust the sources of referral. Language or social bar-
0.0345). Further tests also show people with services/train- riers can lead to feelings of isolation and victims may not
ings can help the victims effectively than others. About either speak or understand English, and may therefore de-
67% of those who have had HT training helped the victims pend on the trafficker for interpretation. “Any information
while only 42% of the others could the same (p = 0.0396). that victims receive is totally controlled, which keeps them
unaware of any resources or services designed to help” (Pe-
Multiple Regression ters, 2013, p. 283).
To understand the simultaneous effect of all the variables
on the frequency of addressing the issue of HT in the clini- The survey results overwhelmingly indicate that RN re-
cal setting, a multiple linear regression model was used. spondents lack HT information and want to learn. As dis-
The dependent variable in the model was the frequency of cussed above, several organizations and associations have
addressing the issue and the independent variables are, (1) presented position statements based on the nature and im-
“How strongly they believe that HT was a problem in their portance of this issue and reinforce the position that health-
community ” (p = 0.0097), (2) “Aware of the Characteris- care providers have an obligation to recognize and help

J Nursing Practice Applications & Reviews of Research Vol. 9 No. 1 January 2019
Jeanann Sousou Coppola, E. Renee Cantwell, Debashis Kushary, & Cynthia Ayres 47
identified victims. However, it is not clear how frequently Conclusions
or consistently education and training are offered, or in Registered Nurses in the clinical setting are in a crucial po-
what capacity it is offered. sition to recognize, assess, and refer victims of HT. How-
ever, nurses may not be aware of the HT in their communi-
There are at least 36.93% of the respondents who have at- ties or of the signs which could alert them that their patient
tended HT training in one form or another. However, based may be a victim of HT. If victims can be identified, then
on the survey response, it is not standard onboarding pro- they may be referred to the appropriate support services.
cess to include HT as part of orientation. Currently, there is This survey indicated that RNs may lack information relat-
no HT education available specifically directed toward the ed to identifying, assessing and referring HT victims. Face
RN population. For example, in the state of New Jersey, “all to face education for RNs, which includes demonstration
healthcare workers and volunteers in New Jersey who have and return demonstration of assessment techniques, may
contact with patients – regardless if the contact is clinical or improve patient outcomes for the population of HT victims.
non-clinical – must complete training in recognizing and in- The results of this survey only help to open to door to more
tervening in cases of human trafficking” (New Jersey Hos- research on human trafficking and implementation of more
pital Association, 2018). These materials are geared toward training for healthcare professionals.
all healthcare workers, including RNs, and volunteers. The
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