Digital Repository Doctoral Projects Fall 2022 Improving Clinician Identification of Human Trafficking in an Emergency Department Devon L. Brower Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Brower, D. L. (2022) Improving clinician identification of human trafficking in an emergency department. Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. HUMAN TRAFFICKING EDUCATION STANDARDIZATION 1 Improving Clinician Identification of Human Trafficking in an Emergency Department Setting by Devon L. Brower A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah Oct. 3, 2022 _______________________________ ______________________________ Student Name, Credentials (Electronic Signature) Date _______________________________ _____________________________ DNP Project Faculty (Electronic Signature) Date _______________________________ ______________________________ Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE Date Graduate Programs Director Devon L. Brower, BSN, RN Oct. 3, 2022 2 Table of Contents Abstract ........................................................................................................................................... 4 Improving Clinician Identification of Human Trafficking in an Emergency Department Setting . 5 Background and Problem Statement ........................................................................................... 6 Diversity of Population and Project Site ..................................................................................... 6 Significance for Practice Reflective of Role-Specific Leadership ............................................. 7 Literature Review and Framework ................................................................................................. 8 Search Methods ........................................................................................................................... 8 Human Trafficking Victims ........................................................................................................ 9 The Need for Educational Modules .......................................................................................... 11 The Module ............................................................................................................................... 13 Framework ................................................................................................................................ 16 Discussion ................................................................................................................................. 16 Implications for Practice ........................................................................................................... 17 Project Plan ................................................................................................................................... 17 Project Design ........................................................................................................................... 17 Needs Assessment/Gap Analysis of Project Site and Population ............................................. 18 Cost Analysis and Sustainability of Project .............................................................................. 20 Project Outcomes ...................................................................................................................... 21 Consent Procedures and Ethical Considerations....................................................................... 21 Instrument(s) to Measure Intervention Effectiveness ............................................................... 21 Project Implementation ................................................................................................................. 22 Project Intervention ................................................................................................................... 23 Utilizing Deliverables ............................................................................................................... 23 Project Timeline ........................................................................................................................ 25 Project Evaluation ......................................................................................................................... 25 Data Maintenance and Security ................................................................................................ 26 Data Collection and Analysis.................................................................................................... 26 Findings..................................................................................................................................... 28 Discussion ..................................................................................................................................... 29 Translation of Evidence into Practice ....................................................................................... 30 3 Implications for Practice and Future Scholarship ..................................................................... 31 Sustainability............................................................................................................................. 31 Dissemination ........................................................................................................................... 32 Conclusion ................................................................................................................................ 32 References ..................................................................................................................................... 34 4 Abstract Purpose: A need exists for increased human trafficking education among emergency department staff to raise clinician awareness of human trafficking and their ability to treat and provide appropriate community resources to this vulnerable population. This DNP project aimed to improve human trafficking education among clinicians at Intermountain Medical Center’s Emergency Department (ED) by implementing an educational module to increase clinician knowledge of human trafficking laws, definitions, prevalence, victim identification, treatment, and community resources. Methodology: Department clinicians completed pre- and post-intervention surveys to assess sociodemographic information and confidence in knowledge about human trafficking. These surveys contained Likert-style scale responses, and quantitative data were collected during the module intervention and evaluation. Results: Data analysis showed increased clinician confidence at the 4-week mark regarding knowledge of human trafficking laws, definitions, prevalence, victim identification and treatment, and referral of community and social resources. Data analysis from the second post-survey at the 8-week mark showed a slight decrease in clinician confidence in the ability to treat victims and a slight decrease in knowledge of the community and social resources. Implications for practice: Outcomes show that human trafficking education did increase but saw a slight decrease in confidence in victim identification and community resources at the 8-week mark. Further investigation will need to be done to ensure long-term content retention. The educational module can be adapted and updated to fit current needs. Project findings support the continued use of the education module at Intermountain Medical Center’s ED. Keywords: human trafficking, educational module, emergency department, clinicians 5 Improving Clinician Identification of Human Trafficking in an Emergency Department Setting The human trafficking (HT) industry draws in $150 billion worldwide, with approximately 40.3 million trafficked victims yearly (Polaris Project, 2019). Of these 40.3 million, 917 trafficking victims were identified in a health services access point last year. HT is a type of modern-day slavery that includes the recruitment, transportation, provision, and soliciting of a person for sex or work (CDC, 2021a). This vulnerable population often seeks medical assistance in emergency departments (EDs), primary care offices, urgent care clinics, and dentist offices (Lamb-Susca & Clements, 2018). In addition, they seek medical care for commonly seen complaints such as broken bones, trauma, dental pain, and sexually transmitted infections. Healthcare providers and clinicians are exceptionally equipped to treat patients with these presenting complaints, but they are not adequately trained to identify human trafficking victims (Grace et al., 2014). According to Lederer and Wetzel (2014), 87.8% of HT victims stated they accessed healthcare services during their captivity. Of this, 68.3% sought medical care in an ED setting. However, despite these staggering numbers and accurate clinical assessment and diagnostic skills, it is difficult to pinpoint the exact numbers of human trafficking victims seen in a healthcare setting (Lamb-Susca & Clements, 2018). This difficulty is partly due to the lack of standardized HT education and screening tools for identifying this vulnerable population. For example, a rescued HT victim stated, "During the time I was on the streets, I went to hospitals, urgent care clinics, women's health clinics, and private doctors. No one ever asked me anything anytime I ever went to a clinic" (National Human Trafficking Resource Center, 2016). 6 Registered nurses and providers are responsible for assessing and treating victims such as this human trafficking victim. An increase in education will help these clinicians potentially rescue these patients from life-threatening situations. The primary purpose of this project is to recommend, implement, and evaluate an evidence-based practice change that improves the identification and resource referral of human trafficking victims in an ED setting. Healthcare leaders can laterally implement this change in other specialties that see HT victims, such as dentist offices, gynecologists, and primary care clinics (Lamb-Susca & Clements, 2018). Background and Problem Statement An opportunity for this quality improvement project was identified when emergency department nurse educators identified a need for increased HT education. Intermountain Medical Center's ED currently sees hundreds of patients a day, with these patients coming from a wide range of locations and demographics. When a triage nurse and provider initially see a patient, it is an opportune time for these clinicians to screen for and identify situations such as human trafficking. However, there is no established human trafficking educational module for triage clinicians and providers (L. Taylor, emergency room nurse educator, personal communication, May 18, 2021). The Polaris Project (2019) identified over 200 human trafficking cases in Utah in 2019, and many of these victims utilized EDs for health care. A lack of ED triage human trafficking educational modules can result in these victims not being identified and receiving the resources they need to escape a potentially life-threatening situation. Diversity of Population and Project Site This DNP evidence-based project will occur in the ED of Intermountain Medical Center, located in Murray, Utah. J. Avery, emergency room nurse manager (personal communication, Apr. 18, 2021), stated this is a 64-bed level 1 trauma ED with approximately fifty medical 7 doctors and fifteen advanced practice providers (APPs). It will target healthcare personnel in direct contact with patients, such as registered nurses, medical doctors, and advanced practice providers. These clinicians care for diverse populations of different cultures, religions, ethnicities, and local sub-populations, such as homeless patients. In addition, nurse educators at this ED promote education of vulnerable populations such as domestic violence, and this quality improvement project will provide further supplemental education on vulnerable people. Significance for Practice Reflective of Role-Specific Leadership With over 917 trafficking cases identified in a healthcare access point last year, increasing clinician identification and resource referral of HT victims should be a priority for healthcare organizations and clinics (Polaris Project, 2019). As a nurse leader working in this department, it will be beneficial to implement a quality improvement project to increase clinician identification of this vulnerable population. Additionally, emphasis is placed on the education of vulnerable people, such as domestic violence, and extensive educational modules have been implemented due to this need. HT victims are a vulnerable population deserving of equal resource allocation and education. Nurse Practitioners (NPs) play a vital role in assessing and treating these patients in this department. According to the Emergency Nurses Association (2019), NPs are ethically obligated to follow professional standards to provide exceptional care to diverse and vulnerable populations. This project will aid these NP leaders and their clinician team in delivering ethical care for HT victims. A literature review provides adequate evidence to support the need for this quality improvement project. 8 Literature Review and Framework This literature review explores evidence-based practice standards around developing and implementing a standardized educational module to increase clinician awareness of human trafficking and resource referral following the identification of HT victims. Themes emerged from the literature review to help guide this module development: (a) 88% of human trafficking victims saw a healthcare provider during captivity (Greenbaum et al., 2018), and 63% of these victims were seen at an ED at some point (Lederer & Wetzel, 2014); (b) educational programs have been shown to increase clinician awareness and resource referral of HT victims (Grace et al., 2014); and (c) clinicians and healthcare staff know HT exists in their departments, but these clinicians noted there was no official HT education for identifying and providing resource referral to these patients (Long & Dowdell, 2017). The framework used to guide this project is the Health Promotion Model created by Nola Pender. Search Methods Search terms for this project include human trafficking, human trafficking victims, emergency departments, human trafficking statistics, human trafficking healthcare, human trafficking educational programs, human trafficking screening tools, human trafficking identification, human trafficking resource referral, and educational module standard practice guidelines. Databases used were Google Scholar, EBSCO, UpToDate, and PubMed. The Stewart Library was utilized through the Weber State University library system. Database search excluded articles over 11 years old and articles that do not align with the most advanced evidence-based practice regarding vulnerable populations. 9 Human Trafficking Victims According to the CDC (2021a), HT is defined as modern-day slavery of men, women, and children, including the recruitment, transportation, provision, and soliciting of a consensual person for sex or work. There were an estimated 22,326 victims and survivors of sex and labor trafficking in the United States, with only 11,500 of these situations being identified. In addition, only 917 of these situations were identified in a health services access point (Polaris Project, 2019). It is difficult to accurately estimate the prevalence of HT victims, mainly due to victims' hesitancy to self-report. This hesitancy may lead to an even more significant number of trafficking victims being exploited and unable to receive the psychological, financial, and medical care they need (National Human Trafficking Hotline, 2019a). These victims can be coerced into any situation of forced labor, such as manufacturing and growing products for no pay and sexual exploitation. HT also includes domestic servitude, where victims are forced to work in domestic homes as nannies or maids with little to no income (Department of Homeland Security, 2021). HT shares similar consequences and health problems as other vulnerable populations, such as intimate partner violence and gang violence victims. These vulnerable populations are seen extensively in EDs and other clinics, where clinicians have experience identifying and assessing these vulnerable populations (Patel et al., 2010). Victims of these vulnerable populations include women and girls of all races, genders, and ethnicities, and they do not need to be transported across country lines to be considered trafficked (CDC, 2021a). Identifying these victims is difficult, but indicators include living with an employer in a poor living environment. Other indicators include cramped living environments, physical or emotional abuse signs, and accompanying “friends” that withhold identification information (US Department of State, 2021). In addition, political instability, civil 10 unrest, and natural disasters increase the risk of a human becoming an HT victim. Finally, women are more likely to suffer from HT situations due to gender inequalities and societal norms; they are expected to be submissive and work for little to no money (Government of British Columbia, 2014). Traffickers often offer their prey false promises and threaten their families with death or similar trafficking situations if they do not remain quiet. In addition, drug addictions in the trafficked victim are standard to keep them from returning to their trafficker for more drugs (Government of British Columbia, 2014). Consequences If HT is not identified by the proper authorities or healthcare access points, these vulnerable patients could be subjected to many health ailments. These ailments may be because they cannot contact outside resources or visit medical services without first gaining captor approval (Dovydaitis, 2010). Physical health problems often stem from lack of food, sleep, clean water, clean living spaces, increased stress, physical harm, and travel hazards. HT victim health complaints often go unattended until their disease process is very advanced, including tooth loss, limb loss, septic infections, bone infections, and advanced sexually transmitted infections. According to Ottisova et al. (2018), trafficked children were more at risk for developing complex posttraumatic stress disorders; this disorder hampers the child from forming interpersonal relationships, creating concepts of self, and regulating disassociation and affect. Suppose an HT victim manages to overcome these health ailments and eventually gain freedom from their captor. However, they may still face significant consequences of secondary victimization and stigmatization from their families and communities (Shelley, 2010). Communities with a higher incidence of immigrants and victims of racial minorities may have 11 increased hostility and discrimination towards ethnic minorities. This higher incidence may lead to increased stigmatization of ethnic minority victims. Another consequence is potential harm to HT victim's family; traffickers may harm or kill their captured victim's family or enslave more than one family member into human trafficking. Finally, HT has severe demographic consequences; the HT industry removes childbearing women from communities and strains population and family dynamics (Dovydaitis, 2010). The Need for Educational Modules According to studies by Greenbaum et al. (2018) and Lederer and Wetzel (2014), 88% of trafficked victims see a healthcare provider, and 64% of these victims were seen in an ED or clinic setting at one point during their captivity. Therefore, EDs, urgent care, dentist offices, primary physician offices, and the obstetrical-gynecological clinic would be opportune healthcare access points for these victims to seek urgent and non-emergent care (Lamb-Susca & Clements, 2018). Since these healthcare access points are great ways for HT victims to seek care, an effective practice change would involve a standardized educational module for clinicians to identify and resource referrals of HT victims and other vulnerable populations. According to Tiller and Reynolds (2020), ED providers and nurses in EDs are in a unique position to assess these patients, as they are more likely to interact with HT victims than the general population. Grace et al. (2014) conducted an experimental, randomized control trial study that examined 258 participants in 20 different northern California emergency departments to determine whether an educational tool increased emergency department clinicians' knowledge, recognition, and referral of human trafficking victims. The results found that ED clinicians reported a more significant understanding of human trafficking after using the education tool. Of importance, participants noted a substantial increase in knowledge of appropriate resources to 12 call after identifying human trafficking victims after completing the educational tool. This study is essential as it highlights the need for educating clinicians on proper referrals and resources once they have identified human trafficking victims. Despite being positioned to assess and help these vulnerable HT patients, clinicians lack standardized databases for victim presentations (Patel et al., 2010). Language barriers complicated HT identification, which indicates the need to integrate resources regarding language interpretation in an educational module. Victims' fear of authority may complicate identification and treatment, so proper interview techniques and red flags must be included in HT educational modules. According to an ethnographical, qualitative descriptive study by Long and Dowdell (2017), nurse perceptions may affect HT identification. This study asked ten experienced nurses in a large level 1 trauma center their perceptions of human trafficking; these nurses knew HT was a problem in their area but had no official screening education or official human trafficking educational module for guidance. This study also found that nurses thought victims were primarily young, female, sad, and grieving. This study brings importance to addressing misconceptions about human trafficking victims and incorporating these biases and assumptions into an educational module. A non-experimental, cross-sectional retrospective cohort survey study was done by Ross et al. (2015) on 892 health care professionals. Most of these clinicians believe they will or already have contact with human trafficking victims but stated they had not had enough training to identify and provide resources for trafficked victims. Significant findings for the Ross et al. (2015) study included clinician knowledge that human trafficking was high, but providers showed difficulty identifying victims. They also lack knowledge of asking about human 13 trafficking and contacting authorities. Contact was most increased in maternity, emergency medicine, mental health, and pediatric settings (Ross et al., 2015) The Module There is no official screening tool for ED and clinical healthcare staff to quickly identify HT victims (Lamb-Susca & Clements, 2018). There is one screening tool called the Polaris Project Medical Assessment Tool. However, this study has not been adequately analyzed enough to verify its reliability or validity to become the national standard (Bespalova et al., 2014). Creating a screening tool for HT victims is virtually impossible, which requires a shift in focus to clinical education in educational modules. These modules can be designed in various ways. One recommended form is a printed module dispersed throughout the department during the staff's quarterly skills. This module will be essential to include common misconceptions of human trafficking, such as victims being primarily young, female, and from a foreign country. In addition, HT victims are often viewed as sad and grieving, whereas prostitution victims are considered challenging. Long and Dowdell (2017) address misconceptions and highlight essential assumptions to be assessed in an educational module. This module should also educate clinicians on accurate assessment and recognition of common signs of malnutrition, psychological conditions, broken bones, sexually transmitted infections, urinary tract infections, and more (Dovydaitis, 2010). In addition, clinicians need to be aware of HT red flags, such as patients being accompanied by controlling visitors or patients lacking official documentation or documentation supplied by the controlling individual. Patients who do not know their location should also raise red flags for human trafficking situations (Shwarz et al., 2016). 14 Berishaj et al. (2019) conducted a quantitative, quasi-experimental study with a convenience sample of 93 nurses looking at the effect of an educational intervention on nurses' self-reported knowledge and beliefs regarding human trafficking. A 19-item survey was given to the participating nurses, and a pre-and post-test research element was included in the study design. This survey assessed whether the nurses knew the difference between sex and labor trafficking, whether they understood the difference between prostitution and sex trafficking, and how to recognize victims. A pretest was done before an educational module. Then a post-test was used to assess module effectiveness. The study showed that an educational tool is an effective way of increasing clinical awareness of HT. A module created by the National Human Trafficking Resource Center (NHTRC) outlines three objectives for caring for HT victims: (a) defining human trafficking and recognizing how they may seek care, (b) learning how to identify these victims, and (c) how to assist practitioners who may have identified a potential trafficking victim. The NHTRC states that trafficking victims can be seen in many places, such as an emergency department, gynecological visits, prenatal care visits, primary physician checkups, mental health checkups, and addiction service clinics. This module details how physicians can detect these patients and identify specific complaints; musculoskeletal injuries, malnutrition, lack of preventative care, poor dental hygiene, untreated infections, vision issues, chemical or unsafe water exposures, or somatization (NHTRC, 2016). An educational module should also include indicators such as controlling relationships, signs of sexual or physical abuse, controlling finances or identification, and inappropriate clothes for the weather. An educational module should focus first on the primary assessment and health 15 of the patient, then concentrate on resource referral if the clinician feels it is warranted. Services such as the NHTRC Hotline (1-8880-3737-888) should be included (NHTRC, 2016). Barriers Despite the growing support and need for an educational module for human trafficking victim identification, there are a few barriers to overcoming these modules. Even with a well-organized module, human trafficking victims may still be hesitant to self-identify due to the shame or guilt (NHTRC, 2016). Fear of retaliation by the trafficker may be a significant reason why HT victims do not self-identify. In addition, fear of arrest or deportation back to their home country may hinder victims from seeking legal help, especially if they face other human rights issues in their home country. A lack of transportation, or not knowing where they are in a geographical location, also hinders their escape and ability to create an escape route (Lamb -Susca & Clements, 2018). Additionally, a lack of understanding of the US healthcare system prevents these victims from seeking care (NHTRC, 2016). Resources and Referrals Multiple resources are available to human trafficking victims and those that suspect a human trafficking situation. The National Human Trafficking Hotline is a 24/7, confidential, multilingual hotline that can be reached by phone (1-888-373-7888), text, email, or online chat (US Department of Health & Human Services, 2019). The National Human Trafficking Hotline staff is trained to listen to all forms of trafficking survivors, help with safety planning in crises, follow up on reports of suspected trafficking cases, and offer survivors judgment-free support and options to re-integrate into society (National Human Trafficking Hotline, 2019b). The National Human Trafficking Resource Center (2016) has made a referral directory of anti-trafficking organizations that offer emergency, long-term, or short-term transitional help. In 16 addition, it provides resources and opportunities in the anti-trafficking field. These services include emergency shelters, legal services (civil and criminal), mental health services, supportive counseling, addiction services, case management, child care, job training, family reunification, healthcare, and many others. In addition, these resources are critical to include in an educational module to increase clinician awareness and resource referral of human trafficking victims (The National Human Trafficking Resource Center, 2016. Framework This DNP quality improvement project focuses on the Health Promotion Model created by Nola Pender. This model emphasizes three areas: individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes (Nursing Theory, 2020). This model states that each person has unique personal experiences and characteristics that affect subsequent change. This DNP project focuses on increasing awareness of human trafficking characteristics and experiences. The learner (the clinician) intends to take these unique, learned personal experiences and apply them to their practice to potentially identify and provide resource referrals to human trafficking victims. As clinicians become more aware of the easily missed opportunities to identify HT victims, they will be more alert in their assessment and ability to identify such situations (Nursing Theory, 2020). Discussion Evidence shows that standardization of human trafficking education modules can improve clinician awareness of human trafficking victims and resource referral (Berishaj et al., 2019). Implementing a standardized educational module starting with printed quarterly skills educational modules can help increase nurse and medical technician awareness and identify human trafficking victims. Following the successful implementation of these quarterly skills, an 17 online academic module system could be adapted and distributed across the healthcare organization's emergency departments. Barriers to this implementation may include staff unwillingness to accurately fill out pre-and post-test data and the reluctance to identify human trafficking victims. Implications for Practice Educational modules have demonstrated an increase in clinician awareness of human trafficking victims. However, there are no such educational modules in the emergency department of Intermountain Medical Center, nor are there similar modules in the entire hospital's academic Learning System. Therefore, developing and implementing an educational module will improve patient care, increase clinician education, and improve patient outcomes. In addition, creating a human trafficking academic module may set the standard for developing further vulnerable population education modules within the hospital system. Project Plan This project includes creating and implementing a human trafficking educational module dispersed to a level one trauma emergency department with over 250 staff members to increase awareness and educate about this vulnerable population. In addition, the plan includes educating nurses, mid-level providers, and doctors on human trafficking identification, treatment, laws, and resource referrals. Project Design This quality improvement project aims to standardize human trafficking education in an emergency department. ED providers and nurses are trained to identify and address broad aspects of vulnerable population needs; this module addresses a lack of specific vulnerable population education on human trafficking victims. Following evidence-based practice research and 18 protocols will reduce clinician practice variability and allow for better identification, treatment, and resource referral of human trafficking victims. Needs Assessment/Gap Analysis of Project Site and Population The need for this quality improvement project is apparent after creating a gap analysis of Utah’s glaring human trafficking problem. For 2019, there was an estimated 22,326 victims and survivors of sex and labor trafficking in the United States, with 11,500 trafficking situations identified by law enforcement. Still, only 917 of these situations were placed in a health services access point (Polaris Project, 2019). In Utah, there have been a total of 1,225 contacts made from sex and labor trafficking victims since 2007, with 207 of these contacts being from 2019 alone (National Human Trafficking Hotline, 2019). Emergency departments are frequently utilized by sex and labor trafficking victims and perpetrators. Emergency triage nurses have the tools and assessment skills to identify and provide resources for these victims. According to Berishaj et al. (2019), an educational tool on human trafficking increased nurses’ understanding of human trafficking situations and the appropriate ways of responding to these situations. A. Berrigan, emergency room Advanced Nurse Practitioner (personal communication, Feb. 6, 2021), stated that there is a need in the emergency department for more training and a standardized tool to increase nurse and provider awareness of human trafficking situations, specifically in new hire triage classes. This project focuses on indirect patient care of a mesosystem. This project's direct population is ED clinicians and providers who have direct contact with patients and routinely triage potential human trafficking victims. These clinicians care for diverse populations of different cultures, religions, ethnicities, and local sub-populations, such as homeless patients. In addition, nurse educators at this ED promote education of vulnerable populations such as 19 domestic violence, and this QI project will provide further supplemental education on vulnerable people. Participants of this project include the department educational committee and department nurse education managers, who will be responsible for dispersing the module and educating the floor staff on its contents. Stakeholders include the department managers, who will receive project evaluation and impact data. Creation of the module, its deliverables, and analyzing and dispersing of project data will be conducted by the student. This module will address various social determinants of health and diversity considerations for human trafficking victims. According to the CDC (2021b), social determinants of health are conditions where people and patients live, learn, and work that affect their health and quality of life. Many social determinants of health influence health disparity among human trafficking survivors, including socioeconomic isolation (NHTRC, 2016). These survivors are often placed in situations with no financial compensation or ability to access healthcare and are often solely reliant on their captors for all their needs. Other factors, such as guilt, stigma, fear of judgment, and fear of retribution by the traffickers, are social determinants of health. In addition, fear of law enforcement authorities can prevent these survivors from gaining the courage to seek freedom, justice, and the care they need. These factors apply to survivors currently in trafficked situations and to survivors who have escaped their trafficking situation and integrated into regular society (NHTRC, 2016). This module will address these social determinants of health by including education on how socioeconomic isolation, lack of healthcare access, and guilt and fear affect human trafficking and how ED clinicians can use this knowledge to identify better and treat this demographic of patients. 20 Cost Analysis and Sustainability of Project Budgetary requirements for this project have been discussed with the project team and are approved for nursing education and printing. The department's administrative budget covers printing costs, and the education budget covers out-of-standard hours. Costs include the following: • First-year expenditures: quarterly module $700, QR code (quick-response matrix barcode used to contain data on a website) database $150. 3-year total expenditures: quarterly module $2,100, QR code database $150 (See Appendix A). • Hourly out-of-standard staff education compensation depends on individual staff’s experience, hours worked, and seniority. Out-of-standard education committee hours also rely on individual staff's hourly rates (See Appendix A). • Depending on staff education improvements, the project's completion can spearhead creating an Intermountain Healthcare ED-wide human trafficking educational module. Costs for this endeavor are purely hypothetical (refer to Appendix A). Previously developed educational modules such as this effectively increase clinician knowledge of vulnerable populations in the short term. Still, they need a sustainability plan after initial project implementation, evaluation, and dissemination. As this program moves forward, it aims to use evidence of educational improvement from the initial module to spearhead an organization-wide MyLearning module for all 15 Intermountain hospitals and EDs, encompassing approximately 1000 employees. The initially printed learning module will be rotated yearly, and the QR code accessed database will be available indefinitely. 21 Project Outcomes The project outcomes will be evaluated by measurement of the following module learning objectives: • All clinician staff will show an increase in ability to identify human trafficking definitions, laws, prevalence, victim identification, treatment of victims, and resource referrals by the two-week post-module closure date of Mar. 1. • All clinician staff will show long-term retention of their ability to identify human trafficking definitions, laws, prevalence, victim identification, treatment of victims, and resource referrals by the six-week post-module closure date of Mar. 29. Consent Procedures and Ethical Considerations The Institutional Review Board (IRB) at Weber State University confirmed that this project meets the requirements for quality improvement and does not need formal IRB approval. Likewise, the IRB at Intermountain Healthcare also ensures that this project meets the requirements of a quality improvement project and does not need further review or formal approval. Information will not be collected from the end of the module quiz, as it is a standardized quarterly educational requirement meant to assess staff completion of the module. Survey data gathered through Survey Monkey will be anonymous, and demographic data will not include any identifying information. Data will be recorded on a password-protected computer, and the survey data will be reported as an aggregate to reflect the number of clinicians submitting each survey. Instrument(s) to Measure Intervention Effectiveness According to Lutz (2018), limited research on human trafficking means there are no validated surveys to assess clinician education and awareness of human trafficking victims. 22 Therefore, the chosen instrument for this DNP-FNP project will be a pre/post survey consisting of six Likert-style questions on a 4-point scale. These six questions will evaluate clinicians on six outcomes of learning: (1) definitions, (2) laws, (3) prevalence, (4) victim identification, (5) treatment of victims, and (6) referral of community resources. Each question will have four responses that range from 1 (really not confident) to 4 (really confident). In addition, the pretest will include demographic questions such as age, gender, ethnicity, years of nursing experience, and previous experience with human trafficking education. This pre/post survey will be modeled after the instrument utilized in the Lutz (2018) study. This study’s instrument was chosen because it was adapted with permission from the University of British Columbia researchers and followed all the Harvard University Program on Survey Research guidelines. In addition, Elsevier and Copyright Clearance Center granted permission and a license to use these survey questions, responses, and Likert survey format. This Likert-style survey was distributed via Survey Monkey to employee emails. See Appendix B for pre-and post-surveys. Due to limited research in this field, no validated surveys were identified to use in the Lutz (2018) study. This lack of official validity in this chosen survey may distort data analysis during project analysis. Project Implementation This project was implemented and adopted successfully during the 2022 first quarter education of the emergency department at Intermountain Medical Center. Hospital and system-wide adoption of this educational module is the long-term sustainability goal of this project but remains hypothetical at this point. The education provided in this module aims to form department and hospital-wide policies and protocols that will direct clinicians to proper resources when interacting with suspected human trafficking victims. This implementation used a top-23 down approach from the department's Nursing Manager and Nursing Educator, yet the hospital will still have to approve and buy into the module. Project Intervention Interventions used for this project’s implementation included a multidisciplinary and collaborative approach to leadership communication that facilitated the adoption of the educational module. The early intervention involved collaborating with the department educational committee and social work department on the module's proper promotion and staff education. In addition, committee members were met two weeks before module roll-out to familiarize themselves with the content and post-module quiz answers. Utilizing Deliverables The pre-survey was emailed to clinician staff two weeks before the module roll-out (see Appendix B). Multiple on-site hours were spent during shift-change huddles and on the floor, promoting the completion of the pre-survey. The educational module went live at the beginning of the 2022 educational first quarter and was included in every clinician’s skill packet. This deliverable was in a printed format, which included a post-module quiz. Every staff nurse in the department was required to read the module and complete the quiz, per educational department standards. The module, quiz, and resources were emailed to every department provider, as these providers were not required to complete the same skills packet as the department nurses. A printed and laminated handout with the Intermountain logo and QR code (see Appendix C) was dispersed to all high-visibility areas in the department to be seen and scanned by all staff members. This QR code handout was discussed in detail and promoted on every page of the educational module. This handout will remain hanging in select high-visibility areas of the 24 department to ensure continued and sustained access to all, including human trafficking resources, policies, and decision-making flowsheets. In Field Time The student did field time to ensure proper utilization and comprehension of the pre-survey, printed module, post-module quiz, and QR code database. Module promotion was done in the field at shift-change huddles and on the floor. Questions about educational content and how to utilize resources were answered in the field. Various social work department members also promoted and responded to questions about module content and available resources. The social work department was given a printed version of the module and additional resources, decision-making flowsheets, and handouts to promote the project's sustainability. Clinicians offered encouraging feedback and positive reception of the module and its contents. According to educational department requirements, every nurse was confirmed to have completed the module and the associated post-module quiz. In-field time was also used to promote the academic module to department providers, including medical doctors (MDs) and advanced practice registered nurses (APRNs). Ensuring Outcome Goals and Sustainability The department’s first-quarter education concluded in the middle of February, with all clinicians confirmed to have finished the project module. A post-module survey will be dispersed to all clinicians one month after module completion to assess retained knowledge of correct identification, definitions, treatment, and resource referral of human trafficking victims. This project's overarching goal or outcome is the following: ED clinician shows knowledge gain in all six module objectives regarding human trafficking. A hypothetical long-term goal of this project 25 is to spearhead a hospital and system-wide module. Still, this theoretical long-term goal will be initiated after the DNP project completion. After project completion, a top-down approach will be utilized to send the hospital educational department and information technology department an email outlining steps to initiate this educational module system-wide. Project Timeline The project timeline covers the initial research, literature review, and development and implementation of an ED clinician educational module on human trafficking victims. This timeline includes the project’s education, planning, implementation, and evaluation phases. The timeline proceeded through the initially planned interventions to meet the implementation deadline. It was a project management tool to keep the project team updated on deadlines and outcomes. Project implementation concluded in mid-February, with project evaluation completed in March. See Appendix D for the project timeline and management tool. Project Evaluation An educational module at Intermountain Medical Center in Murray, Utah, was offered to all ED clinicians. The module was included in the 2022 first-quarter mandatory education for all ED nurses and was an optional email sent to all department physicians and mid-level practitioners. In total, 250 clinicians were given the educational module. Forty-nine clinicians completed the pretest survey, 45 completed the first post-test survey, and 41 completed the second post-test survey. Survey items reflected a 4-point Likert scale to evaluate a perceived degree of knowledge of human trafficking. The six-item survey addressed knowledge of human trafficking laws, definitions, prevalence, victim identification, victim treatment, and available community and social resources. 26 Data Maintenance and Security Project data was secured on a password-protected computer. Survey Monkey data was also secured on a password-protected website with two-step verification. First, all survey data was anonymous, and demographic data did not include any identifying information. Survey data was reported as an aggregate. Data Collection and Analysis The pre-survey Survey Monkey link was distributed via email two weeks before the educational module roll-out. The first post-survey link was distributed one month after module completion. The second post-survey link was distributed four weeks later. Survey results were organized and analyzed by Survey Monkey’s analysis software. The beginning of the pre-survey showed participant demographics (see Table 1). The clinician's knowledge of current laws regarding human trafficking was assessed. In addition, they were asked to evaluate their ability to define human trafficking, as well as their ability to recognize the prevalence of human trafficking in their area. Clinicians were also asked about their confidence in their ability to identify victims, treat these victims, and provide appropriate community and social resources (see Table 2). 27 Table 1 Sociodemographic characteristics of participants n % Age 20-29 14 28.57 30-39 25 51.02 40-49 7 14.29 50-59 3 6.12 Gender Female 42 85.71 Male 7 14.29 Years of experience 1-5 21 42.86 5.1-10 17 34.69 10.1-15 5 10.2 15.1-20 2 4.08 20.1-25 4 8.16 Previous HT education Yes 25 51.02 No 24 48.98 Previous education on treating HT victims Yes 17 34.69 No 32 65.31 Note. N = 49. HT refers to human trafficking. Table 2 Results of pre-and post-survey questions Really confident % Confident % Not very confident % Really not confident % HT law knowledge 0.00 (13.33) (17.07) 10.20 (73.33) (51.22) 67.35 (13.33) (29.27) 22.45 (0.00) (2.44) HT definition knowledge 4.08 (28.89) (47.50) 42.86 (68.89) (35.00) 46.94 (2.22) (17.50) 6.12 (0.00) (0.00) HT prevalence knowledge 2.04 (20.00) (43.90) 28.57 (60.00) (34.15) 61.22 (20.00) (19.51) 8.16 (0.00) (2.44) Victim identification ability 0.00 (2.22) (2.44) 12.24 (66.67) (60.98) 81.63 (31.11) (36.59) 6.21 (0.00) (0.00) 28 Victim treatment ability 0.00 (24.44) (26.83) 25.00 (68.89) (48.78) 64.58 (6.67) (24.39) 10.42 (0.00) (0.00) Knowledge of HT community and social resources 0.00 (53.33) (48.78) 8.16 (24.44) (14.63) 65.31 (22.22) (36.59) 26.53 (0.00) (0.00) Note. N = 49 for pre-survey. N = 45 for first post-survey. N = 41 for second post-survey. HT refers to human trafficking. The first and second post-survey results are in parentheses, respectively. To see complete surveys, see Appendix I. Findings The surveys showed that Intermountain Medical Center’s Emergency Room clinicians benefited from an educational module on human trafficking one month after the initial module roll-out. The academic module improved clinician confidence in the knowledge of human trafficking laws and human trafficking prevalence, as well as an understanding of human trafficking definitions. The module also increased clinicians’ confidence in identifying, treating, and providing appropriate community and social resources to human trafficking victims. However, the second post-survey showed that clinician confidence decreased slightly at the 8- week post-module marker, especially in clinician ability to treat human trafficking victims and clinician knowledge of the community and social resources. This decrease in confidence needs to be addressed more in-depth to identify ways to maintain clinician confidence in these areas. Strengths This project's strength was the large group of clinicians sent the educational module and their varied characteristics. The diverse clinician backgrounds allowed examination of the beliefs and knowledge of clinicians with varying years of work experience, ages, genders, previous human trafficking education, and previous exposure to human trafficking victims. The educational module was a convenient, organized way to disperse large amounts of human 29 trafficking education in a streamlined fashion to a large clinician group. The module effectively increased clinician confidence in human trafficking laws, prevalence, definitions, identification, treatment, and community resource referral. Weaknesses Two weaknesses were identified in the project implementation and evaluation. First, department physicians and mid-level providers were not required to complete the nurse quarterly educational skills packet that contained the academic module. These providers were instead emailed the module and asked to complete it. The department nurses were required to complete the educational module. The difference in requirements could have reduced the number of participants who completed the module. A more substantial number of participants would provide more data for evaluation of the intervention and make the necessary changes to improve the module content. The other weakness was that the pre-and post-surveys were emailed to participants before and after module completion; this made it hard to gather a substantial number of survey responses compared to the number of participants who completed the module. Discussion This project aimed to standardize human trafficking education for an emergency department of approximately 250 clinicians, with future plans to expand the project’s reach to all Intermountain emergency and Instacare sites. This standardization was done by creating a human trafficking education module following evidence-based standards and research. This research was then integrated into the module via a quarterly educational packet for all floor nurses and emailed to all department providers. The PDCA quality improvement module kept this project on track. Other project components included practical translation, sustainability, nursing education implications, and future scholarship. Project completion showed moderate improvement in 30 clinician confidence of human trafficking education, and this sustainable quality improvement project can be easily translated into practice and disseminated throughout the organization. Translation of Evidence into Practice Intermountain Healthcare does not have standardized human trafficking education modules or protocols. Current evidence indicates that human trafficking education modules have improved clinician identification and resource referral of this vulnerable population (Berishaj et al., 2019). This project further corroborates the evidence of previous studies that education on specific aspects of human trafficking education increases clinician identification, at least during the first 8-weeks of module implementation. The successful implementation of this project can be translated to other facilities in a similar format, as the educational module was a standardized Microsoft format that is universally recognized and easily interpreted. The outcomes of this project were in line with the project timeline, despite being carried out during a global pandemic with extensive nursing burnout and staff turnover. New knowledge gained from this project includes awareness of the lack of human trafficking education and the lack of resources available for this population. However, perhaps the resource databank was the most impactful knowledge gained from this project, apparent during extensive on-site hours and surveys. These hours showed that the staff appreciated the resource bank. Many stated that they will refer to it regularly and may utilize it more than the knowledge gained from the educational module. The department went through many manager changes, technological difficulties, and electronic health record downtimes that made it apparent that departments need to not rely on computer-based education as the primary source of education for vulnerable populations. Utilizing the current QR data bank flyers and posters throughout the department will help 31 supplement staff resource education and resource availability, even if technical difficulties exist. Having a stored source of these resources with the social work department will guarantee that patients receive these resources, even if they have limited computer availability. Implications for Practice and Future Scholarship The project findings demonstrate that standardization of human trafficking education modules can improve this vulnerable population’s short-term clinician identification and resource referral. Knowledge declined after module roll-out by the eight-week mark, which implies that continued use of these modules is critical for increased clinician education. Even if the knowledge gained by these modules is not held long-term, it raises awareness in clinicians that human trafficking is prevalent in their community. Therefore, they need to be proactive in researching local resources and organizations that can assist them if they encounter possible trafficking victims. Quarterly utilization of these educational modules would hypothetically negate clinician decline of this information; therefore, the use of educational modules at least four times a year would help increase long-term retention of information. Suggestions for future scholarship include providing educational resources and human trafficking information to various regional, state, and national locations where trafficking may not be so apparent. Sustainability The costs of this project’s planning and implementation were minimal. Therefore, the sustainability of this project is very realistic. As this project continues to move forward, it aims to use evidence of educational improvement from the initial module to spearhead an organization-wide MyLearning module for all 15 Intermountain hospitals and EDs, encompassing approximately 1000 employees. The initially printed learning module will be rotated yearly, and the QR code accessed database will be available indefinitely for all facilities. 32 In addition, the social work department will have access to the resource databank and can offer patients printed resources if need be. Continued monitoring during the module roll-out and provision for education oversight will be provided while making updates as needed. Dissemination This project and its outcomes were shared with the project, educational, and a managerial team of Intermountain Medical Center’s emergency department. In addition, this project’s plan, implementation, evaluation, and data were disseminated during a department charge nurse meeting via PowerPoint presentation. Future plans include presenting this project’s findings and data next quarter during an education committee meeting. There is also a consideration for presenting this project to the corporate Intermountain educational division to stress the importance and implications of increasing clinician human trafficking education and creating policies related to victim treatment. Conclusion Increased human trafficking education led to a short-term increase in emergency department staff recognition of definitions, laws, prevalence, victim identification, treatment of victims, and referral of community resources of this patient population. By implementing this project via a quarterly printed educational module, one emergency department showed an 8-week increase in staff confidence in the module’s six outcomes. Since the implementation, evidence exists that continued use of the educational module will benefit long-term retention of module education. A long-term retention need was evident after seeing a slight decrease in staff confidence after the 8-week mark. Long-term use of this module and resource databank will promote knowledge retention and sustainability of this project and improve care for a vulnerable population. After continued use of this educational module, it can be adapted to provide 33 education on other vulnerable persons such as the homeless, domestic abuse victims, and those with severe mental illness. 34 References Bespalova, N., Morgan, J., & Coverdale, J. (2014). A pathway to freedom: An evaluation of screening tools for the identification of trafficking victims. Academic Psychiatry, 40, 124-128. https://doi.org/10.1007/s40596-014-0245-1 Berishaj, K., Buch, C., & Glembocki, M. (2019). The impact of an educational intervention on the knowledge and beliefs of registered nurses regarding human trafficking. The Journal of Continuing Education in Nursing, 50(6), 269-274. https://doi.org/10.3928/00220124-20190516-07 Centers for Disease Control and Prevention [CDC]. (2021a). Sex trafficking. https://www.cdc.gov/violenceprevention/sexualviolence/trafficking.html Centers for Disease Control and Prevention [CDC]. (2021b). 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M., Dewey, M., Zimmerman, C., & Oram, S. (2015). Human trafficking and health: A cross-sectional survey of NHS professionals' contact with victims of human trafficking. BMJ Open, 5. Article e008682. doi:10.1136/bmjopen-2015- 008682 Shelley, L. I. (2010). Human trafficking: A global perspective. Cambridge University Press. 37 Schwarz, C., Unruh, E., Cronin, K., Evans-Simpson, S., Britton, H., & Ramaswamy, M. (2016). Human trafficking identification and service provision in the medical and social service sectors. Health and Human Rights, 18(1), 181–192. Tiller, J., & Reynolds, S. (2020). Human trafficking in the emergency department: Improving our response to a vulnerable population. The Western Journal of Emergency Medicine, 21(3), 549–554. https://doi.org/10.5811/westjem.2020.1.41690 US Department of State. (2021). Identify and assist a trafficking victim. https://www.state.gov/identify-and-assist-a-trafficking-victim/ US Department of Health & Human Services. (2019). National Human Trafficking Hotline. https://www.acf.hhs.gov/otip/victim-assistance/national-human-trafficking-hotline 38 Appendix A Human Trafficking Identification and Resource Referral Module Activity: Rotating Quarterly Module Year 1 Year 2 Year 3 Total Staff $500 $500 $500 $1,500 Supplies $200 $200 $200 $600 Total Cost $700 $700 $700 $2,100 Human Trafficking Identification and Resource Referral Module Activity: QR code accessed resource database Year 1 Year 2 Year 3 Total Staff $0 $0 $0 $0 Supplies $150 $0 $0 $150 Total Cost $150 $0 $0 $150 Human Trafficking Identification and Resource Referral Module Activity: Hypothetical MyLearning Module Year 1 Year 2 Year 3 Total Staff $10,000 $8,000 $8,000 $26,000 Supplies $0 $0 $0 $0 Total Cost $10,000 $8,000 $8,000 $26,000 39 Appendix B 1. What is your age group? 20-29 30-39 40-49 50-59 2. What is your gender? Female Male Not Specified 3. Years of experience 1-5 5.1-10 10.15 15.1-20 20.1-25 Not specified 4. Have you had previous human trafficking education? Yes No 5. Have you had previous education on treating human trafficking victims? Yes No Pre- and Post-Test Survey 40 1. How confident are you in your knowledge of laws regarding human trafficking? Really confident (4) Confident (3) Not very confident (2) Really not sure (1) 2. How confident are you in defining human trafficking? Really confident (4) Confident (3) Not very confident (2) Really not sure (1) 3. How confident are you in your knowledge of the prevalence of human trafficking? Really confident (4) Confident (3) Not very confident (2) Really not confident (1) 4. How confident are you in your ability to identify victims of human trafficking? Really confident (4) Confident (3) Not very confident (2) Really not confident (1) 5. How confident are you in your ability to correctly treat a victim of human trafficking? Really confident (4) Confident (3) 41 Not very confident (2) Really not confident (1) 6. How confident are you in your knowledge of community and social service resources for victims of human trafficking? Really confident (4) Confident (3) Not very confident (2) Really not confident (1) 42 Appendix C Want more resources? Scan this QR code to access a DropBox database of human trafficking resources, available anytime, anywhere. This database can be used to supplement the human trafficking educational module from the Spring 2022 skill’s packet. You can find: o Polaris Project assessment guidelines o Established, validated screening tools and protocols o Survivor accounts and TED talks o Nonprofit links and resources Emergency Department Human Trafficking Education DropBox database of resources… 43 Appendix D Project Timeline an d Gantt Chart Task Start Date Days to Complete Complete IHC CITI Modules 7/5/21 7 Submit IHC IRB Request 7/5/21 7 Complete Section II: Literature Review/Framework 7/5/21 7 Present Project Proposal 8/31/21 14 Obtain IRB Approval 8/31/21 21 Create Pre- and Post-Test 8/31/21 14 Create Education Module 8/31/21 30 Complete Section III: Project Plan 2/7/22 14 Complete Section iV: Project Implementation 2/282022 14 Send Out Pre-test 1/1/22 7 Implement Education Module 1/15/22 30 Send Out Post-test 3/15/22 7 Complete Project Implementation 2/15/22 7 Begin Project Evaluation 3/20/22 7 Complete Section V: Project Evaluation 8/30/22 14 Complete Section VI: Discussion of DNP Paper 8/30/22 21 Complete Project Evaluation 8/30/22 30 Complete Project Dissemination 8/30/22 30 7/5/218/24/210/13/212/2/211/21/223/12/225/1/226/20/228/9/229/28/22 Complete IHC CITI Modules Submit IHC IRB Request Complete Section II: Literature Review/Framework Present Project Proposal Obtain IRB Approval Create Pre- and Post- Test Create Education Module Complete Section III: Project Plan Complete Section iV: Project Implementation Send Out Pre-test Implement Education Module Send Out Post-test Complete Project Implementation Begin Project Evaluation Complete Section V: Project Evaluation Complete Section VI: Discussion of DNP Paper Complete Project Evaluation Complete Project DisseminationStart Date Days to Complete