The Journal of School Nursing2024, Vol. 40(6) 703–723© The Author(s) 2024Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/10598405241245955journals.sagepub.com/home/jsn
Abstract
Child trafficking poses a momentous public health threat to students in public schools. Although school nurses are exceptionally positioned to identify and respond to trafficking, most lack training and resources in this critical area. This project aimed to evaluate the impact of a multifaceted intervention on school nurse preparedness and practices related to child trafficking in an Oklahoma public school district. The project involved Unbound Now’s nationally accredited training program for school nurses, implementation of the Fuentes et al.’s Toolkit for Building a Human Trafficking School Safety Protocol (HTSSP) funded by the U.S. Department of Health and Human Services, and facilitation of a roundtable discussion to initiate community collaboration. The results of the pretraining Fraley and Aronowitz School Nurses’ Awareness and Perceptions Survey (SNAPS) illuminated variations in school nurses’ knowledge and awareness of child trafficking, demonstrating the need for continued training. Post-training evaluations exhibited highly positive feedback, suggesting its effectiveness in meeting the training’s objectives. Following the community stakeholder roundtable, the lead school nurse employed the HTSSP toolkit and directed efforts in successfully constructing and implementing a district-wide policy of procedures to respond to suspected cases of human trafficking. However, the project’s limitations include a small sample and a single-school district focus. Despite these limitations, this project delivers valuable insights into the challenges and opportunities for enhancing school nurse preparedness in addressing trafficking. This project serves as a foundation for future initiatives to improve students’ safety and wellbeing in public schools.
Keywordsschool nursing, human trafficking, school nurses, Child trafficking
Child trafficking is a pervasive public health threat directly impacting the health, safety, and wellbeing of students throughout America (Doiron & Peck, 2022). While federal law defines human trafficking as the exploitation of a person through force, fraud, or coercion, the performance of any commercial sex acts by persons under age 18 is abuse regardless of the presence or absence of these factors (National Center on Safe Supportive Learning Environments [NCSSLE], 2021). The International Labor Organization (ILO), Walk Free, and International Organization for Migration (2022) report specifies updated global estimates indicating that approximately 28,000,000 individuals are trafficked globally, of which 3,300,000 (12%) are children. With approximately 3,300,000 children being trafficked annually worldwide, human trafficking within the pediatric population is an emergent ubiquitous public health threat impacting the safety and welfare of students in the school setting(ILO et al., 2022; Peck et al., 2021; Reid et al., 2019) Within the United States, the National Human Trafficking Hotline (2021) report identified more than 2,214 youths experiencing trafficking in 2021 alone, many of whom are students in the American school system still attending school (Fraley & Aronowitz, 2019; Fraley et al., 2020; NCSSLE, 2021).
While schools should be a safe, supportive environment that nurtures growth and development, child exploitation significantly jeopardizes overall safety. Children experiencing trafficking endure many multifaceted traumas and suffer acute and chronic physical and psychological consequences (NCSSLE, 2021; Fraley et al., 2018; Jaeckl & Loughton, 2020). Even amidst the grip of traffickers, trafficked youth persist in pursuing essential medical care for acute and chronic physical and mental health needs, often turning to resources like school health clinics (NCSSLE, 2021; Jaeckl & Loughton, 2020). Nevertheless, the ongoing challenge persists, as numerous trafficking cases go unnoticed by healthcare professional due to the intricate nature of recognizing and effectively responding to them, exacerbated by the complexities of response and recognition at the school level (NCSSLE, 2021; Jaeckl & Loughton, 2020). This lack of early recognition and collaborative response can lead to detrimental delays in nursing advocacy efforts to prevent traumatization and to break the cycle of victimization early in the process.
This project aims to evaluate the impact of implementing human trafficking training for school nurses and ancillary personnel, leveraging the Public Health Intervention Wheel (PHIW) to build sustainable community engagement, and operationalizing a customizable federally issued toolkit on school nurse preparedness and practices surrounding identification and response to children victimized by human trafficking within the public school setting. This article will explore the overarching holistic health impacts imposed by child trafficking, detail implications for school nurses, and demonstrate the adoption of a district-wide response plan project.
Human trafficking is a global health crisis that violates human rights and is a multibillion-dollar industry (United Nations Office on Drugs and Crime [UNODC], 2020; U.S. Department of State, 2020). Alarmingly, despite school nurses’ auspicious position to intervene, mitigate risk, and advocate for children with vulnerability to human trafficking in the school setting, school nurses are consistently underrepresented in human trafficking training, prevention, education, and collaborative efforts (Doiron & Peck, 2022). Moreover, few protocols, toolkits, or resources exist in practice to guide school nursing education and response efforts to human trafficking (Doiron & Peck, 2022). Many school nurses doubt their knowledge of reporting mandates and how to expedite care for at-risk students or those experiencing commercial sexual exploitation due to inadequate resources and education (Doiron & Peck, 2022; Fraley et al., 2018). Personal communication with the lead nurse for the public school district in Oklahoma confirmed that no toolkit or protocol currently exists to guide school nursing personnel when children are at risk for or victimized by child trafficking. This information validates findings reported in the literature, illuminating the lack of research and resources surrounding antitrafficking response protocols in the school setting. Further, this highlights the need to implement a sustainable training program to support school nurses in recognizing and responding to human trafficking, thus promoting safety and wellbeing of children across the care continuum. This article evaluates the impact of an intervention that is based on the Fuentes et al.’s (2022) Toolkit for Building a Human Trafficking School Safety Protocol (HTSSP) (funded by the U.S. Department of Health and Human Services) on school nurse preparedness and practices related to child trafficking in an Oklahoma public school district.
Underrepresentation. The threat of child trafficking and sexual exploitation is pervasive in public schools (Doiron & Peck, 2022). While many studies assert school nurses’ advantageous, valuable, and distinct position in identifying youth at risk for or victims of human trafficking, these studies also illuminate the lack of inclusion of school nursing in collaborative antitrafficking efforts (Dorion & Peck, 2022; Fraley et al., 2018; Jaeckl & Laughon, 2020). Subsequently, although a few government, academic, and professional organizations have created guidelines for schools to respond to child trafficking, they lack a coordinated, community-based, collaborative effort between school nurses and other personnel (Doiron & Peck, 2022). With the recognized effectiveness of school nurse-led interventions for obesity, tobacco cessation, and violence prevention, school nurses have an unprecedented opportunity to identify and prevent child trafficking (Fraley & Aronowitz, 2017). However, school nurses remain underrepresented in trafficking prevention and response efforts (Doiron & Peck, 2022). This apparent underrepresentation within the literature highlights a critical gap in stakeholder involvement in antitrafficking efforts.
Lack of Knowledge and Confidence for Recognition and Response. As part of a select group of healthcare providers who frequently interact with at-risk students, school nurses are well-positioned to identify and respond to those vulnerable to exploitation. However, many school nurses report limited knowledge of human trafficking, uncertainty about their role in working with at-risk individuals, and a lack of formal training (Fraley et al., 2018). These barriers often prevent school nurses from recognizing key risk factors of trafficking and mislabeling those at the most significant risk (Fraley et al., 2018). School nurses also regularly miss opportunities to identify potential indicators of human trafficking, including violent behaviors, poor attendance, hypersexuality, early sexual development, food insecurity or hunger, disordered sleep, and genitourinary infections (Fraley et al., 2018). Additionally, when school nurses have an opportunity to intervene, many lack confidence and knowledge in reporting mandates and expediting care for those at risk for or involved in trafficking (Fraley et al., 2018; Doiron & Peck, 2022). These findings illuminate a detrimental gap in the education and training of school nurses on child trafficking and show how a lack of clear guidelines for response negatively impacts nurse confidence when intervening.
Awareness, Training, and Education. Although there is limited high-quality level of evidence literature surrounding antitrafficking interventions for school nursing staff, previous child sexual exploitation training predicts individual awareness, attitude, and role perception among school nurses (Fraley et al., 2018). When expanding research criteria to include other specialties, targeted educational interventions for healthcare professionals were effective in changing negative attitudes toward those at risk of human trafficking, raising awareness of risk factors and prevalence, and increasing overall confidence in identification (Doiron & Peck, 2022; Fraley et al., 2020; Greiner-Weinstein & Bacidore, 2023). As education and awareness increase, providers’ perceptions shift from viewing affected individuals as victims rather than complicit partakers (Fraley et al., 2020). Effective identification, assessment, and response to human trafficking also require that clinicians are well-informed and equipped with comprehensive education and the necessary tools and protocols to guide a multifaceted, evidence-based approach when providing care for individuals affected by exploitative behavior (Greiner-Weinstein & Bacidore, 2023).
Human trafficking education for health professionals holds several potential pitfalls and should be approached with great care. Overall awareness among nursing professionals remains very low, and most have not had antitrafficking education (Doiron & Peck, 2022; Fraley & Aronowitz, 2019; Peck & Meadows-Oliver, 2019). Well-meaning but ill-informed organizations can deliver education that is not trauma-informed, causing unintentional harm by provoking moral distress, triggering retraumatization, and perpetuating stigma and bias about human trafficking among health professionals (Peck et al., 2021). Currently, of the 20 states that require human trafficking education, Texas is the only state that enforces minimum evidence-based national standards (Miller et al., 2016; Peck et al., 2021; Texas Health & Human Services Commission, n.d.). In addition, with demand for antitrafficking education soaring, the opportunity exists for for-profit continuing education entities to capitalize with rapidly constructed, poorly vetted education (Peck et al., 2021). It is essential that human trafficking education for health professionals be evidence-based, trauma-informed, patient-centered, and perhaps most importantly, survivor-informed (Peck, 2021; Peck et al., 2021). Education as a singular intervention is insufficient for long-term retention, sustained practice change, and structural adaptations (Bergren, 2023; Frieden, 2010). However, because of the political narratives and social salaciousness of human trafficking, the importance of providing the highest-quality education as a starting point cannot be overemphasized.
Response Protocols and Toolkits. While education is imperative, it is unethical to increase awareness of child trafficking in the school setting without equipping individuals with the tools and resources needed to respond.
An effective response requires a clearly outlined course of action supported by collaborative efforts with child protective services, school professionals, social services, law enforcement, and community-based resources (Doiron & Peck, 2022). Although no specific literature on human trafficking response programs for school nurses currently exists, using guidelines and protocols in other healthcare settings positively impacts providers’ confidence and ability to identify and respond to trafficked individuals (Donahue et al., 2019; Greiner-Weinstein & Bacidore, 2023). More specifically, when employed within the emergency setting, targeted education and the creation of a protocol or treatment algorithm effectively improve providers’ awareness, understanding, identification, and response to trafficking (Donahue et al., 2019; Egyud et al., 2017; Greiner-Weinstein & Bacidore, 2023; Stoklosa et al., 2017). Providing nurses with a combination of human trafficking education and evidence-based response protocols can significantly improve patient care, safety, identification, and management when caring for those potentially affected by human trafficking (Greiner-Weinstein & Bacidore, 2023).
This project, employing a mixed methods design, sought to implement a sustainable training program and use the HTSSP to support school nursing in recognizing and responding to human trafficking, thus promoting safety and wellbeing of children across the care continuum. TheHTSSPisaprescriptive, practical guide with four aims: (1) identify students at risk for trafficking, (2) ensure adherence to mandatory reporting laws, (3) ensure staff and student safety, and (4) connect impacted students to relevant service providers and programs (Fuentes et al., 2022). The school district’s vision accentuates creating a safe and mutually respectful environment to ensure the highest level of student achievement, which aligns with the project’s overarching aim of promoting the safety and wellbeing of children.
This project contained four critical interventions to achieve the project’s aims:
(1) Increase awareness through intensive training on trafficking to school nurses, who are more likely to notice red flags through their profession and position (NCSSLE, 2021);
(2) Provide a customizable toolkit and local resource guide for school nurses’ response to suspected or confirmed cases of trafficking in accordance with state laws (Fuentes et al., 2022);
(3) Utilize the PHIW to build community engagement and collaboration by facilitating a roundtable discussion (Doiron & Peck, 2022; Moore et al., 2017; NCSSLE, 2021); and
(4) Assist the school district in applying the toolkit to create a district-wide human trafficking protocol (NCSSLE, 2021).
The success of the project’s interventions was measured by evaluating established objectives:
(1) Measure knowledge, beliefs, and attitudes about child trafficking from 100% of participants using Fraley and Aronowitz’s (2021) School Nurses’ Awareness and Perceptions Survey (SNAPS) for Youth At-Risk of Trafficking (see Figure 1).
(2) Measure the effectiveness of the implemented training for 100% of participants using Unbound Now’s postcontinuing education training evaluation.
(3) Appoint an individual within the school district to apply the HTSSP toolkit to make a school districtspecific protocol and reevaluate the training and protocol annually to promote sustainability.
The partnering public school district is a prominent educational institution in Oklahoma’s central urban area, serving over 10,000 students across 12 locations. This district is recognized as a leading school district in Oklahoma, serving a diverse student population.
Purposeful sampling was utilized to select participants. All nursing staff currently employed by the partnering school district were invited to participate. To be eligible, nursing participants must have had current employment with the school district and a current licensed practical nurses (LPN) or registered nurses (RN) license. Participants were automatically excluded if they did not meet these criteria. A total of 10 school nurses met this criterion. An exempt designation was granted from the affiliated University’s Institutional Review Board.
Using the Plan-Do-Study-Act methodology ensures efficiency and the ongoing implementation of quality improvement efforts in the school setting (Institute for Healthcare Improvement [IHI], 2023) (See Figure 2).
Theoretical Model
The Health Belief Model (HBM), a social-psychological framework that explains and predicts health behaviors by concentrating on individual beliefs and attitudes, was chosen for theory application (Kirscht et al., 1966; Maiman & Becker, 1974; Rosenstock, 1974). The HBM closely aligns with the project given the multimodal approach, use of Fraley & Aronowitz’s (2021) survey to evaluate school nurses’ awareness and perceptions of youth at risk for trafficking, and the objective to develop a sustainable antitrafficking protocol in a school setting (Maiman & Becker, 1974). Application of the six constructs of the HBM is crucial in ensuring an effective approach with favorable results (Maiman & Becker, 1974; Rosenstock et al., 1988; see Table 1). Applying and considering all six constructs to address underlying beliefs among school nurses created an effective and sustainable approach to preventing and responding to human trafficking in the school setting.
The nursing staff’s knowledge, beliefs, and attitudes toward child trafficking were evaluated using the SNAPS survey. With the SNAPS survey’s established reliability and validity through exploratory and correlation factor analysis, and a Cronbach’s α of 0.94, this survey was identified as suitable (Fraley & Aronowitz, 2021). The nursing staff were trained using Unbound
Now’s nationally accredited continuing education training platform and the HTSSP toolkit. Unbound Now’straining program is specifically designed for school nurses and is accredited by The National Association of Pediatric Nurse Practitioners (NAPNAP), a highly respected continuing education provider for pediatric health professionals. In addition, Unbound Now was instrumental in setting education standards for healthcare professionals after the passage of House Bill 2059 in Texas, requiring school nurses and other healthcare professionals to take mandated training (Peck et al., 2021). Their training has been provided to thousands of school nurses and was selected for this project as an established, respected, and reliable educational program. Two hours of education is insufficient to change beliefs and attitudes effectively, but it can raise awareness and serve as a catalyst for behavior change, as illustrated in the application of the HBM (Bergren, 2023; Frieden, 2010). Therefore, postintervention analysis with SNAPS was not conducted but may be revisited in the sustainable protocol. Unbound Now’s postevaluation tool was used to measure the effectiveness of education implementation as it meets rigorous standards of NAPNAP and HEAL Trafficking (Miller et al, 2016).
Lastly, the Minnesota Department of Health’s (2019) PHIW was leveraged to build community engagement, mobilize key stakeholders in collaborating to create a district-specific protocol, and ensure the sustainability of interventions (Dorion & Peck, 2022). The PHIW is a widely used framework to assist health professionals in planning, implementing, and evaluating interventions across different levels of practice that encompass three levels of practice (community, systems, and individual/family) and 17 public health interventions (Minnesota Department of Health, 2019; Schaffer et al., 2016). A recent integrative review exploring the role of nursing in the school setting to address the exploitation and abuse of children through child trafficking included the practical application of the PHIW to antitrafficking interventions (Doiron & Peck, 2022).
Critical support included the Executive Director and Director of Educational Programs at Unbound Now, the Executive Director of Student Services, and the lead nurse at the partnering school district. The project followed a strict timeline, with Unbound Now’s training commencing only after collecting all ten participants’ SNAPS survey responses (see Figure 3). Unbound Now’s 2h“Human Trafficking: Raising Awareness to Identify Victims in the Clinical Setting” training for healthcare professionals was presented and followed by an open-floor question and answer session. Copies of the HTSSP toolkit with a corresponding local resource guide were distributed, and the major components of each of the four chapters within the toolkit were reviewed. Batley et al.’s (2021) Core Competencies for Anti-Trafficking Response in Healthcare and Behavioral Health Systems, sponsored by the National Human Training and Technical Assistance Center, was then also provided to guide school nurses’ response protocol to suspected or confirmed cases of trafficking. This guide provides a self-assessment tool for individual clinicians and systems-based care, applicable in the school setting, for systems-based care (Batley et al., 2021).
The roundtable discussion occurred immediately following the school nurse training. Attendance at the roundtable was taken. The roundtable discussion was opened by providing a brief on Oklahoma-based human trafficking statistics. Next, the harrowing account of a local survivor of human trafficking who had attended school in the district, along with her parents’ perspectives on the issue, was shared with careful consideration of evidence-based survivor inclusion and best practices (Lockyer, 2022). The survivor, now aged 18 years, bravely recounted her experience of being trafficked from age 11 until she turned 14, marking the first time she had spoken publicly about her experience. A review of the provided HTSSP toolkit, a local resource guide, and Batley et al.’s (2021) Core Competencies for Anti-Trafficking Response in Healthcare and Behavioral Health Systems followed the local speakers. Lastly, the roundtable concluded with each participant discussing how they could collaborate with the school district in combating human trafficking within the public school system.
Following the training and roundtable session, the project directors acted as consulting content experts to assist the school district and the community’s stakeholders in utilizing the customizable toolkit presented to create a personalized protocol specifically for their school district. The lead nurse at the school district accepted responsibility for leading efforts in creating a district-specific protocol and annual re-evaluation to ensure program sustainability. The school nurses were given the links to Unbound Now’s on-demand human trafficking training and information for NAPNAP’s ACT Advocates Program, a train-the-trainer program for nurse advocates who want to be equipped to effectively engage their community in antitrafficking efforts (NAPNAP Partners for Vulnerable Youth, n.d.).
SNAPS Survey data was transferred to Microsoft Excel, de-identified, assigned an identification number, and imported to SPSS statistical software. Sample mean, range, standard deviation, and sampling error were assessed for each SNAPS survey question aside from the demographic questions to remain consistent with Fraley et al.’s (2018) approach. Descriptive statistics were used to examine demographic data and school setting characteristics, including frequency distributions, means, standard deviations, and skewness (Fraley et al., 2018). Given the small sample size (n = 10), correlation studies are inappropriate and not statistically significant enough to have a p-value of ≤ 0.05.
Unbound Now’s posteducation evaluations matched the number of training participants, and each evaluation question was assessed for sample mean, standard deviation, and skewness with a correlating Likert scale beyond the demographic data obtained. The community roundtable discussion recorded an itemized list of attendees and their affiliations. For the totality of the project, members of National Association of School Nurses and NAPNAP were invited to review the protocol via email and obtained feedback from a human trafficking survivor consultation via Zoom. All input was considered and resulted in necessary changes and improvements.
Desired outcomes for implementing the school districtspecific protocol encompass garnering support from the district administration and community stakeholders and whether the district successfully develops and adopts a district-specific human trafficking protocol by employing the HTSSP. The school district has been equipped with Batley et al.’s (2021) assessment tool for the annual evaluation of their protocol. Nevertheless, the entire process serves as an interim outcome, including the adoption, integration, and evaluation of the HTSSP toolkit, and the subsequent establishment of a district-specific protocol. The protocol’s implementation is envisioned as a protracted, continuous, and sustained endeavor to catalyze sustained structural transformative change within the district. This comprehensive process demands long-term evaluation methods to gauge its efficacy over time.
Table 2 reflects a descriptive analysis of the SNAPS survey taken by all ten school nurses before participating in the training event. The specified descriptive statistics offer valuable discernment into diverse aspects related to school nursing and issues encompassing Commercial Sexual Exploitation of Children (CSEC) and trafficking. Among the prominent findings, school nurses in the sample have an average mean of 8.55 years of experience and an average mean age of 45.40 years. These figures deliver a glimpse into the professional backgrounds of the respondents and indicate a comparatively experienced group of school nurses.
Respective statements were presented in the SNAPS survey to gauge school nurse views, and it is noteworthy that they largely agree on the importance of understanding and addressing CSEC. For instance, the mean score of 3.50 out of 5 for the statement “It is important to know of CSEC in my role as a school nurse” indicates unanimity among respondents about the significance of this issue in their profession. Additionally, the school nurses indicate awareness that sex trafficking is a major problem (mean score = 3.5), a problem in their state (mean score = 4.2), and a major US problem (mean score = 4.4). This suggests school nurses understand the importance of addressing trafficking and may be motivated to take action.
However, there is some variability in responses, as seen in the standard deviations and ranges for various statements in the student risk perception-related questions. Notably, the responses related to student risk perceptions, such as child sexual abuse, juvenile justice system involvement, emotional risk, dating relationships, poverty, and challenges of caring for runaways, showed mixed opinions among the nurses, with low mean scores. This data suggests a knowledge gap among this sample of school nurses, particularly regarding familiarity with the term throwaway and awareness of student CSEC victim characteristics, which were among the survey questions with the lowest mean Likert scores. Despite high mean scores for awareness and surrounding state and national level awareness of CSEC, low mean scores covering awareness of risk factors indicate the need for continued evidence-based education and training.
The survey also addressed the school nurses’ perceived ability to address CSEC and related issues in their roles. While most participants agreed it is important to know about CSEC in their role, there were varying levels of confidence in their ability to identify and help students involved in CSEC. This discrepancy in confidence could highlight the need for additional training and resources to support school nurses in addressing this critical issue effectively.
Table 3 reflects the descriptive analysis of the Unbound Now training. The evaluation results of Unbound Now’s nationally accredited continuing education training are overwhelmingly positive. Participants found that the training’s learning outcomes and educational objectives were completely met (mean = 3.9), and 100% of participants expressed a strong commitment to using the information gained in their future practice. Many participants intend to change their professional practices, such as posting awareness materials and being more mindful when interacting with students. The positive responses also extended to the speaker’s presentation, which was described as interesting (mean =3.9) and knowledgeable (mean = 4.0), and the visual aids were deemed useful (mean = 3.9). The training environment was conducive to learning (mean = 3.9), and participants would highly recommend the program to their colleagues (mean = 4.0). Despite these positive outcomes, there were some potential barriers identified. Notably, staffing issues and time constraints were recognized as challenges to applying new strategies and knowledge gained from training. Additionally, there was a concern about possible pushback from administrators lacking knowledge and the high need for additional and repeated human trafficking training in the area.
In summary, the evaluation results indicate that Unbound Now’s nationally accredited continuing education training successfully achieved its objectives. To enhance and improve the training for future participants, addressing identified barriers such as time constraints and the need for additional training opportunities may be beneficial. It is also important to acknowledge that while evidence-based, trauma-informed, patient-centered, survivor-informed education is an essential cornerstone of any antitrafficking intervention, it is insufficient to generate and sustain systems-based change (Bergren, 2023; Frieden, 2010).
A total of 26 individuals were in attendance for the entirety of our roundtable discussion. Specifically, 10 school nurses, six district mental health specialists, the Parent Teacher Association and executive director of the school district foundation, the director of student assistance program, six leaders of local nongovernment organizations who support survivors of human trafficking, 1 lead child welfare specialist, and the director of school safety and security were present for the roundtable. The roundtable and the project’s education and toolkit interventions successfully exemplify the impactful application of the PHIW to ensure sustainable, transformative change (see Table 4).
Following the roundtable discussion, the lead school nurse successfully employed evidence-based human trafficking training for all school administrators and counselors in the district. Following this training, she also successfully collaborated with district administrators to operationalize the HTSSP toolkit in creating and implementing a district-wide policy of procedures for suspected human trafficking cases with an associated data tracking plan for evaluation. Since implementing the district-wide policy of procedures for suspected cases of human trafficking, this district has already identified several students who screened at risk. Ongoing efforts are underway to develop a reliable augmented formal data collection system within the protocol, aimed at accurately quantifying students who have screened at risk, identified, and referred to appropriate services.
There is a paucity of published research and evidence-based or quality-improvement project results in nursing literature. The mere fact that the US Federal Government saw it fit to issue a toolkit speaks to the seriousness of this issue. However, there is much work to do in developing shared nomenclature, determining reliable databases, applying principles of epidemiology, and other measures of scientific rigor. A 2020 integrative review by Jaeckl and Laughon considering CSEC in the context of school nursing outlined a myriad of specific risk factors including race, education levels, environmental predictors, parental substance use, familial sex trading, poverty, systems involvement (e.g., juvenile justice and foster care), childhood maltreatment, mental health diagnoses, and substance use disorders. Another element that deserves further consideration is the health disparity and disproportionate exploitation of Indigenous Americans, of which Oklahoma has the third largest population in the United States (U.S. Department of Health & Human Services, 2023). There is a need for attention paid to murdered and missing indigenous persons, including children in school and their families and support systems. Although analysis of risk factors is emerging as the most robust literature base of scientific evidence in health-related journals, there are still significant gaps in evidence-based nursing intervention, and important consideration needs to be given to an upstream approach to the prevention of harm rather than a downstream responsive approach after harm has occurred.
The data from the SNAPS survey illuminates the complexity of the school nurse’s role in identifying and addressing the multifaceted, holistic health impacts of human trafficking in the public school system. The inconsistent levels of awareness and confidence among school nurses in our survey results emphasize the need for continued targeted educational programs and resources to endow school nurses with the knowledge and resources to identify and assist students at risk effectively. Additionally, the high recognition of the significance of child exploitation and human trafficking as major problems denotes that school nurses are integral allies in fighting against human trafficking, making them strategic stakeholders in protecting vulnerable youth.
The positive feedback regarding the speaker’s presentation, visual aids, and training environment suggests that the Unbound Now training program was well-received. The findings emphasize the importance of tailored training programs to equip school nurses with the knowledge and tools to combat child trafficking in schools effectively. The roundtable and employment of the PHIW ensured support for a system-based sustainable change. Identified barriers, such as time constraints and the need for additional training opportunities, should also be considered to enhance further and improve future participants’ training. Despite the examined limitations, this project delivers valuable insights into the challenges and opportunities for enriching school nurse preparedness in addressing and identifying child trafficking.
Despite the examined limitations, standardized nursing response to trafficking occurring among children in school settings is in its infancy. The federally issued HTSSP is an essential step in the right direction. Prior to its release, a comprehensive internet search found only 10 resources for schools, including seven from federal or state government entities, one from an academic medical center, and two from nonprofit organizations. Alarmingly, only two of those 10 addressed the school nurse’s role, and none included the school nurse as essential or leading in any response (Doiron & Peck, 2022). Serving as a cornerstone, this initiative paves the way for future endeavors aimed at advancing student safety and wellbeing in public schools throughout the United States.
Our project, aimed at enhancing school nurses’ awareness and response to human trafficking, provides valuable insights into the challenges and opportunities in this critical area of the public school system. While the post-training evaluation results are favorably positive, the project has key limitations that should be acknowledged. First and foremost, education alone is insufficient to generate effective outcomes through systems change. Following that, two primary limitations of the project lie in the sample size of school nurses who participated and the convenience sample we chose. Although it provides a glimpse into the demographics and views of the respondents, the sample size is comparatively small, comprising only 10 participants. The sample is also only representative of one school district, although it is not insignificant that these 10 nurses collectively serve thousands of children. This sample size limits the translation of the findings and might not fully embody the diversity of school nurses. A more extensive and diverse sample would provide a more comprehensive understanding of school nurses’ baseline knowledge, attitudes, and perceptions regarding child exploitation and trafficking, which would be critical for program expansion.
Furthermore, the SNAPS survey responses highlight variability in the school nurses’ perceptions and awareness levels related to child exploitation and trafficking. This variability indicates the need for tailored training and support. Conducting qualitative interviews or focus groups with a subset of the participants could yield more profound insights into their specific needs and barriers, potentially further refining the training program. This is not a simple problem to fix but instead requires interprofessional collaboration over a sustained period to address the complexities of the HTSSP toolkit implementation systematically. Continued development of standardized outcome measures at the federal level also needs to be continued to assess effectiveness, sustainability, and prevention of unintended harm.
In conclusion, this project has shed light on the expansive issue of human trafficking, particularly concentrating on its impact within the public school setting and the role of school nurses. The interventions, which included an intensive training program, community engagement using the PHIW, and the implementation of a customizable toolkit, demonstrated significant aptitude in endowing school nurses with the knowledge and resources needed to address and identify human trafficking. By equipping school nurses with the necessary knowledge, tools, and support, we can take momentous strides toward constructing a safer and more protective environment for students in public schools. However, continuous efforts, collaboration, and further research are required to refine and enhance these initiatives to ensure the safety and wellbeing of all students. Future efforts should consider expanding the sample size and involving more diverse settings to gain a more all-inclusive understanding of the challenges and needs of school nurses in creating and implementing frameworks for the prevention and early recognition of child trafficking.
The authors extend their gratitude to the school district staff for their support in bringing this project to fruition. Special thanks to Unbound Now for providing their training and to Dr. Fraley for granting permission to use the SNAPs survey. We also appreciate the community stakeholders who participated in our roundtable. Lastly, we acknowledge the bravery of the survivor and her family, who bravely volunteered to share their story with us.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The authors received no financial support for the research, authorship, and/or publication of this article.
Katherine Hettenhaus https://orcid.org/0009-0007-2780-6978
Kelcey King https://orcid.org/0009-0005-4833-0572
Kelley Rigby https://orcid.org/0009-0006-5709-8880
Batley, C., Chon, K., Garrett, A., Greenbaum, J., Blank, S., Hopper, E., & Stoklosa, H. (2021). Core competencies for human trafficking response in health care and behavioral health systems (pp. 1– 46). National Human Trafficking. Training and Technical Assistance Center, Office on Trafficking in Persons, Administration for Children and Families, US Department of Health and Human Services.
Beck, M. E., Lineer, M. M., Melzer-Lange, M., Simpson, P., Nugent, M., & Rabbitt, A. (2015). Medical providers’ understanding of sex trafficking and their experience with at-risk patients. Pediatrics, 135(4), e895–e902. https://doi.org/10.1542/peds.2014-2814
Bergren, M. D. (2023). Education is not enough. The Journal of School Nursing, 39(2), 103–104. https://doi.org/10.1177/10598405231158450
Doiron, M. L., & Peck, J. L. (2022). The role of nursing in the school setting to lead efforts to impact child trafficking: An integrative review. The Journal of School Nursing, 38(1), 5–20. https://doi.org/10.1177/1059840520987533
Donahue, S., Schwien, M., & LaVallee, D. (2019). Educating emergency department staff on the identification and treatment of human trafficking victims. Journal of Emergency Nursing, 45(1), 16–23. https://doi.org/10.1016/j.jen.2018.03.021
Egyud, A., Stephens, K., Swanson-Bierman, B., DiCuccio, M., & Whiteman, K. (2017). Implementation of human trafficking education and treatment algorithm in the emergency department. Journal of Emergency Nursing, 43(6), 526–531. https://doi.org/10.1016/j.jen.2017.01.008
Fraley, H., & Aronowitz, T. (2021). Psychometric evaluation of the School Nurses’ Awareness and Perceptions Survey (SNAPS) for youth at risk of trafficking. Journal of Nursing Measurement, 29(3), 462–475. 10.1891/JNM-D-20-00018
Fraley, H., Aronowitz, T., & Jones, E. (2018). School nurses’ awareness and attitudes toward commercial sexual exploitation of children. Advances in Nursing Science, 41(2), 118–136. https://doi.org/10.1097/ANS.0000000000000197
Fraley, H. E., & Aronowitz, T. (2017). The peace and power conceptual model: An assessment guide for school nurses regarding commercial sexual exploitation of children. Nursing Science Quarterly, 30(4), 317–323. https://doi.org/10.1177/0894318417724456
Fraley, H. E., & Aronowitz, T. (2019). Obtaining exposure and depth of field: School nurses “seeing” youth vulnerability to trafficking. Journal of Interpersonal Violence, 36(15-16), 7547– 7573. https://doi.org/10.1177/0886260519836779
Fraley, H. E., Aronowitz, T., & Stoklosa, H. M. (2020). Systematic review of human trafficking educational interventions for health care providers. Western Journal of Nursing Research, 42(2), 131–142. https://doi.org/10.1177/0193945919837366
Frieden, Thomas R. (2010). A framework for public health action: The health impact pyramid. American Journal of Public Health, 100(4), 590–595. https://doi.org/10.2105/AJPH.2009.185652
Fuentes, C., International Organization for Adolescents, Littrell, J., & Shimer, J. (2022). Toolkit for Building a Human Trafficking School Safety Protocol. U.S. Department of Health and Human Services, Administration for Children and Families, Office on Trafficking in Persons.
Gordon, M., Fang, S., Coverdale, J., & Nguyen, P. (2018). Failure to identify a human trafficking victim. American Journal of Psychiatry, 175(5), 408–409. https://doi.org/10.1176/appi.ajp.2018.18010007
Greiner-Weinstein, G., & Bacidore, V. (2023). Implementing a human trafficking educational module and protocol in the emergency department. Journal of Emergency Nursing, 49(4), 534– 538. 10.1016/j.jen.2023.01.006
Institute for Healthcare Improvement. (2023). How to improve. https://www.ihi.org/resources/Pages/HowtoImprove/default.aspx
International Labour Organization, International Organization for Migration, and Walk Free Foundation. “Global Estimates of Modern Slavery: Forced Labour and Forced Marriage.” Report, September, 2022. https://www.ilo.org/wcmsp5/groups/public/—ed_norm/–ipec/documents/publication/wcms_854733.pdf
Jaeckl, S. E., & Laughon, K. (2020). Sex trafficking of minors in the United States: A perspective for nurses. Online Journal of Issues in Nursing, 25(3), 1–10. https://doi.org/10.3912/OJIN.Vol25No03Man05
Kaltiso, S. A. O., Greenbaum, V. J., Agarwal, M., McCracken, C., Zmitrovich, A., Harper, E., & Simon, H. K. (2018). Evaluation of a screening tool for child sex trafficking among patients with high-risk chief complaints in a pediatric emergency department. Academic Emergency Medicine, 25(11), 1193–1203. https://doi.org/10.1111/acem.13497
Kirscht, J. P., Haefner, D. P., Kegeles, S. S., & Rosenstock, I. M. (1966). A national study of health beliefs. Journal of Health and Human Behavior, 7(4), 248–254. https://doi.org/10.2307/2948771
Lockyer, S. (2022). Beyond inclusion: Survivor-leader voice in antihuman trafficking organizations. Journal of Human Trafficking, 8(2), 135–156. https://doi.org/10.1080/23322705.2020.1756122
Maiman, L. A., & Becker, M. H. (1974). The health belief model: Origins and correlates in psychological theory. Health Education Monographs, 2, 336–353. https://doi.org/10.1177/109019817400200404
Miller, C. L., Duke, G., & Northam, S. (2016a). Child sextrafficking recognition, intervention, and referral: An educational framework for the development of healthcare-provider education programs. Journal of Human Trafficking, 2(3), 177–200. https://doi.org/10.1080/23322705.2015.1133990
Miller, C., Greenbaum, J., Napolitano, K., Rajaram, S., Cox, J., Bachrach, L., Baldwin, S., & Stoklosa, H. (2016b). Assessment tool for health care provider human trafficking training. HEAL Trafficking: Health, Education, Advocacy, Linkage. https://healtrafficking.org/2018/12/assessment-tool-for-health-careprovider-human-trafficking-training/
Minnesota Department of Health (2019). Public health interventions: Applications for public health nursing practice (2, pp. 1–249). Minnesota Department of Health.
Moore, J. L., Kaplan, D. M., & Barron, C. E. (2017). Sex trafficking of minors. Pediatric Clinics, 64(2), 413–421. 10.1016/j.pcl.2016.11.013
NAPNAP Partners for Vulnerable Youth. (n.d.). ACT advocates program. ACT Advocates Program | NAPNAP Partners. https://www.napnappartners.org/act-advocatesprogram
National Center on Safe Supportive Learning Environments (NCSSLE). (2021). Human traffickinginAmerica’s schools: What schools can do to prevent, respond, and help students to recover from human trafficking, (2, pp. 1–19). U.S. Department of Education, Office of Safe and Supportive Schools. https://safesupportivelearning.ed.gov/human-trafficking-americas-schools.
National Human Trafficking Hotline. https://humantraffickinghotline.org/en/resources/2021-national-report
National Human Trafficking Hotline. (2023a). Oklahoma. National Human Trafficking Hotline. https://humantraffickinghotline.org/en/statistics/oklahoma
National Human Trafficking Hotline (2023b). 2021 National report.
National Human Trafficking Resource Center. (2016). Recognizing and responding to human trafficking in a healthcare context. National Human Trafficking Hotline. https://humantraffickinghotline.org/sites/default/files/Recognizing%20and%20Responding%20to%20Human%20Trafficking%20in%20a%20Healthcare%20Context_pdf.pdf
Peck, J. (2021). A train-the-trainer programme to deliver high quality education for healthcare providers. Anti-trafficking Review, 17, 140–147. https://doi.org/10.14197/atr.201221179
Peck, Jessica L, & Meadows-Oliver, Mikki (2019). Human trafficking of children: Nurse practitioner knowledge, beliefs, and experience supporting the development of a practice guideline: Part one. Journal of Pediatric Health Care, 33(5), 603–611. https://doi.org/10.1016/j.pedhc.2019.05.006
Peck, J. L. (2020). Human trafficking of children: Nurse practitioner knowledge, beliefs, and experience supporting the development of a practice guideline: Part two. Journal of Pediatric Health Care, 34(2), 177–190. https://doi.org/10.1016/j.pedhc.2019.11.005
Peck, J. L., Greenbaum, J., & Stoklosa, H. (2021a). Mandated continuing education requirements for health care professional state licensure: The Texas model. Journal of Human Trafficking, 10(1), 168–173. https://doi.org/10.1080/23322705.2021.1981708
Peck, J. L., Meadows-Oliver, M., Hays, S. M., & Maaks, D. G. (2021b). White paper: Recognizing child trafficking as a critical emerging health threat. Journal of Pediatric Health Care, 35(3), 260–269. https://doi.org/10.1016/j.pedhc.2020.01.005
Polaris. (2015, May 1). Sex trafficking in the U.S.: A closer look at U.S. citizen victims. Polaris. https://polarisproject.org/resources/sex-trafficking-in-the-u-s-a-closerlook-at-u-s-citizen-victims/
Raghavan, C. (2015). Trauma-coerced bonding and victims of sex trafficking: Where do we go from here? International Journal of Emergency Mental Health and Human Resilience, 17(2). 583–587. https://doi.org/10.4172/1522-4821.1000223.
Reid, Joan A, Baglivio, Michael T., Piquero, Alex R, Greenwald, Mark A., & Epps, Nathan (2019). No youth left behind to human trafficking: Exploring profiles of risk. American Journal of Orthopsychiatry, 89(6), 704–715. https://doi.org/10.1037/ort0000362
Rosenstock, I. M. (1974). The health belief model and preventive health behavior. Health Education Monographs, 2(4), 354–386. https://doi.org/10.1177/109019817400200405
Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the health belief model. Health Education Quarterly, 15(2), 175–183. https://doi.org/10.1177/109019818801500203
Schaffer, M. A., Anderson, L. J., & Rising, S. (2016). Public health interventions for school nursing practice. The Journal of School Nursing, 32(3), 195–208. https://doi.org/10.1177/1059840515605361
Stoklosa, H., Showalter, E., Melnick, A., & Rothman, E. F. (2017). Health care providers’ experience with a protocol for the identification, treatment, and referral of human-trafficking victims. Journal of Human Trafficking, 3(3), 182–192. https://doi.org/10.1080/23322705.2016.1194668
Texas Health & Human Services Commission. (n.d.). Health care practitioner human trafficking training. Texas Health and Human Services. https://www.hhs.texas.gov/services/safety/texas-humantrafficking-resource-center/health-care-practitioner-humantrafficking-training
United Nations Office on Drugs and Crime (UNODC). (2020). Global report on trafficking in persons. United Nations, New York. https://www.unodc.org/unodc/data-and-analysis/glotip.html
U.S. Department of Health & Human Services. (2023, November 7). Keeping us whole: Preventing missing and murdered Indigenous People - podcast series. The Administration for Children and Families. https://www.acf.hhs.gov/ana/podcast/keeping-us-whole-preventing-missing-and-murdered-indigenouspeople-podcast-series
U.S. Department of State (2020). Trafficking in persons report, 20th ed. https://www.state.gov/wpcontent/uploads/2020/06/2020-TIP-Report-Complete-062420-FINAL.pdf
U.S. National Human Trafficking Hotline Statistics. Polaris. (2022). https://polarisproject.org/resources/us-national-human-trafficking-hotlinestatistics
Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, FAAN, is a professor at the Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA.
Katherine Hettenhaus, DNP, CPNP-PC graduated from the Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA.
Kelcey King, DNP-CPNP-PC, graduated from the Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA.
Kelley Rigby, BSN, RN, is a doctoral scholar at Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA.
1 Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA
Corresponding Author:Katherine Hettenhaus, DNP, CPNP-PC Louise Herrington School of Nursing, Baylor University, 333 N. Washington, Dallas, TX 77546, USA.Email: Katherine_hettenhau1@baylor.edu
