The Journal of School Nursing2022, Vol. 38(1) 5–20© The Author(s) 2021Article reuse guidelines:sagepub.com/journals-permissionsDOI: 10.1177/1059840520987533journals.sagepub.com/home/jsn
Registered professional and advanced practice nurses in the school setting, as a specialized practice entity, are leaders in implementation of evidence-based practice, skilled coordinators of care, advocates for students, and experts in designing systems assisting individuals and communities to reach full potential. Child trafficking (CT) is an emerging public health threat impacting safety and well-being of students present in the school setting. This literature review identified four themes in five studies: (1) training impacts nurses’ knowledge, awareness, and attitudes; (2) school nursing is underrepresented in training, education, prevention, response, and research; (3) lack of collaboration exists between school staff and school nurses; and (4) formal education and length of experience impact levels of interventions school nurses are able to provide. School nurses are opportunely situated to intervene as advocates for vulnerable children to develop a coordinated, effective response to CT risk factors, mitigating risk and fostering resiliency with systems-based change.
integrative reviews, school nurse knowledge/perceptions/self-efficacy, violence, safety/injury prevention, abuse, screening/risk identification, collaboration/multidisciplinary teams, health disparities
Child trafficking (CT) is an egregious and pervasive emerging public health threat impacting the safety and well-being of students present in the American school setting. Children are trafficked in the United States primarily for commercial labor or commercial sex (National Center on Safe Supportive Learning Environments, 2020). CT is both understudied in professional scientific literature and underreported to authoritative bodies. A recent literature review found less than 10% of more than 22,000 articles on human trafficking (HT) pertained to children, and only one third of all articles were published in health journals, suggesting consideration of CT through a criminal justice or legal paradigm, rather than a paradigm of health (Sweileh, 2018). Accurate tracking systems for incidence and prevalence are nonexistent, largely related to the lack of centralized reporting databases and challenges associated with intersecting victims in health care systems and a criminal enterprise. The United Nations Office of Drugs and Crime estimates 40,000 identified HT victims globally, 33% are children (Greenbaum & Brodrick, 2017).
Many governmental, academic, and organizational entities have published guides and resources for school officials to effectively respond to CT in educational settings, emerging as early as 2011 (Table 1). Of concern, however, is the lack of specific guidance for and coordination with school nurses. In an internet search for available resources to guide policy development in schools for CT, 10 resources were identified from varying sources including federal and state government entities , academic medical centers , and nonprofit organizations (n = 2). Eight address both labor and sex trafficking, while two only address child sex trafficking. Intended audiences varied including school officials, school administrators and staff, educators, and the general public. Only two of the 10 resources address the role of the school nurse in planning school policy and response.
Registered professional nurses in the school setting, as a specialized practice entity, are leaders in evidence-based practice implementation, skilled coordinators of care, advocates for students, and experts in designing systems to assist individuals and communities reach their full potential. School nurses are opportunely positioned to intervene as advocates for vulnerable children to enact systems change (National Association of School Nurses [NASN], 2020). The purpose of this literature review is to explore the evidence concerning the role of nursing in school-based health to lead policy development and health service delivery for children present in the school setting who are victims of or at risk for CT.
The Trafficking Victims Protection Act of 2000, reauthorized in 2017, provided the first federal definition of HT (U.S. Department of State, n.d.). Previously viewed through a criminal justice paradigm, recent efforts are gaining traction to reframe HT as a public health issue. HT victims often encounter health care professionals (HCPs), particularly nurses, who are well-positioned to provide evidence-based, trauma-informed, and culturally responsive intervention with appropriate resource connection (Scannell et al., 2018). Well-meaning but inaccurate information about the nature of CT continues to impede effective clinical response efforts. Conspiracy theories and parental fears tend to center on methods of abrupt stranger abduction when the reality is many children know their trafficker and experience grooming behaviors in their entry to trafficking. Sprang and Cole (2018) reported 31% of CT victims were exploited by a family member with sexual acts and 25% were exploited by a family member in pornography. To date, most HCPs receive little or no formal training despite demonstration of efficacy in implementing evidence-based education to equip health care providers (Barron et al., 2017; Cole et al., 2018; Donahue et al., 2019; Donnelly et al., 2019; Fraley et al., 2018; Katsanis et al., 2019; Lutz, 2018; Peck & Meadows-Oliver, 2019; Recknor & Chisolm-Straker, 2018; Sinha et al., 2018; Viergever et al., 2015). Children frequently do not self-identify victimization or may not seek assistance related to fear of consequences of criminalized behavior, legal prosecution, immigration violations, stigma, or self-blame (Rajaram & Tidball, 2018). Evidence-based training designed specifically for health care professionals is needed to skillfully identify CT risk in a trauma-informed and culturally responsive manner.
Significant risk factors for CT include family members who are incarcerated; familial or individualized history of substance use or misuse; prior history of physical, emotional, or sexual abuse (Sprang & Cole, 2018); intellectual disability (Reid, 2018); self-identification as lesbian, gay, bisexual, transgender, queer, and intersex; unidentified or unaddressed mental health problems; prior interaction with the foster care system, child protective services, or juvenile justice entities; homeless and runaway situations (sometimes referred to as “throwaway” status); undocumented, marginalized, unaccompanied, migrant, or refugee status; and familial poverty or interfamily violence (Greenbaum & Bodrick, 2017). The most compelling risk factor universally is childhood trauma (adverse childhood events), particularly sexual abuse. The longer the abuse occurred, the greater the risk. These occurrences can contribute to the development of toxic stress, resulting in neurological changes, significant damage to interpersonal skills, and flattening of affect and numbing of emotional responses (Choi, 2015).
Significantly, since the global shutdown related to the novel coronavirus pandemic, early results demonstrate dramatically increased risks for child exploitation. More than 1.5 billion children worldwide are isolated in their homes with only digital devices for companionship and connection. The National Center for Missing and Exploited Children reported a fourfold increase in reports of online exploitation and abuse, soaring from 1 million reports in April 2019 to 4 million reports in April 2020 (U.S. Department of Education, 2020). Operation COVID Chatdown Fresno arrested 190 adult contacts who sought minor victims for sexual encounters in a 2-week period from July 20 to August 2, 2020 (U.S. Immigration and Customs Enforcement, 2020). Additionally, in the economic fallout of COVID-19, millions of families are impoverished and at risk for extreme poverty, creating vulnerability to trafficking exposure. With return-to-school policies looming large in public discourse and policy decision-making arenas, it is critical for school nurses to be prepared with skills to identify CT vulnerability and effective policies and protocols to guide a trauma-informed, evidence-based response to potential incidences of CT.
This review covered a 6-year period (2015–2020) and was conducted using methods described by Whittemore and Knafl (2005) and the preferred reporting items for systematic reviews and meta-analysis guidelines (Liberati et al., 2009). An electronic database search of Cumulative Index of Nursing and Allied Health, PubMed, and the Baylor University holdings in Ovid was completed in June and July 2020 with the last search completed on July 11, 2020. The search strategy included combining keywords, subject headings, and Medical Subject Headings terms as follows: (“school nurse” OR “school nursing” OR “school health nursing” OR “school health services”) AND (“child trafficking” OR “human trafficking” OR “sex trafficking” OR “sexual exploitation” OR “child abuse, sexual” OR “labor trafficking” OR “child labor”).
The following inclusion criteria were used to screen the articles: (1) published in a peer-reviewed journal between 2015 and 2020, (2) full text, (3) written in English, and (4) addressed the nurse’s role in response to CT occurring in children within U.S. school settings. The reference lists of included articles and PubMed recommendations were also reviewed to identify whether they also met inclusion criteria. Exclusion criteria included: (1) articles focused on HT of adult victims, (2) studies addressing CT from a criminal justice lens outside the context of applicability to the school setting, (3) studies researching the context of international CT, and (4) commentary, opinion, and clinical articles not based on research. The date range, peer reviewed, and English language limits were applied through the search strategy. A flow diagram was constructed to demonstrate the search process (Figure 1).
Polit and Beck’s (2020) evidence hierarchy for therapy/intervention questions was used to identify the level of evidence for each article. The Polit–Beck hierarchy has eight levels of evidence, with Level I being the highest level and least biased evidence. First, Level I includes systematic reviews and meta-analyses of randomized controlled trials (RCTs). The second level contains individual RCTs. Nonrandomized (quasi-experimental) trials make up Level III. The fourth level consists of systematic reviews of nonexperimental and observational studies. Level V encompasses individual nonexperimental and observational studies. Systematic reviews and meta-syntheses of qualitative studies comprise Level VI. Qualitative and descriptive studies constitute Level VII. Finally, Level VIII is composed of nonresearch sources, like internal evidence and expert opinions.
The quality of evidence in the studies was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system described by Guyatt, Oxman, Kunz, et al. (2008), Guyatt, Oxman, Vist, et al. (2008), and Higgins and Thomas (2020; Table 2). The GRADE system provides a framework to evaluate the quality of evidence, rating it high, moderate, low, and very low. The initial rating is determined by a study’s methodology. Generally, systematic reviews and meta-analyses of RCTs and RCTs are rated high, observational studies are rated low, and expert opinion and case studies are rated very low. From there, studies can be downgraded due to study limitations, inconsistent results, indirectness of evidence, imprecision, and publication or reporting bias. The quality of studies may also be elevated when there is a large or very large magnitude of effect in methodologically sound studies, plausible confounding biases that cause an underestimation of the true effect, or there is a dose-response gradient.
The methodologic framework described by Whittemore and Knafl (2005) was used as the basis of this integrative review. The literature search was conducted by the first author with assistance from a medical librarian to identify appropriate search terms. After the first author manually screened article titles and abstracts and carefully reviewed all eligible full-text articles, the second author also reviewed the eligible articles. The authors fully agreed about the included and excluded articles. Themes for analysis were subjectively identified through author collaboration.
A total of 237 articles were originally identified. An electronic database search yielded 231 articles, and reference list review and PubMed recommendations resulted in another six. After screening for duplication, 222 articles required further screening for inclusion. Assessment of the titles and abstract resulted in the exclusion of 180 articles, leaving 42 for full-text review. Six peer-reviewed articles were selected according to the content of the full text and included for analysis (Figure 1).
The six articles reviewed and analyzed included one quantitative nonexperimental descriptive study (Schaffer et al., 2016), one mixed-methods study (Fraley et al., 2018), one systematic literature review (Fraley et al., 2020), one integrative literature review (Fryda & Hulme, 2015), one qualitative study (Fraley & Aronowitz, 2019), and one theoretical model application (Fraley & Aronowitz, 2017).
The theoretical study applied a conceptual model to commercial sexual exploitation of children (CSEC) within the context of school nursing (Fraley & Aronowitz, 2017). One study evaluated school nurses’ awareness, attitudes, and role perception toward CSEC using a mixed-methods design (Fraley et al., 2018). The qualitative study used Grounded Theory and interviews with school nurses and trafficking survivors to explore risk factors for CT and how school nurses can identify at-risk youths (Fraley & Aronowitz, 2019). The systematic literature review examined the HT educational interventions aimed at health care providers (HCPs; Fraley et al., 2020). One study provided school nurses with information about the state of school-based childhood sexual abuse (CSA) prevention programs through an integrative literature review (Fryda & Hulme, 2015). One quantitative nonexperimental descriptive design described how school nursing interventions are a type of public health nursing (Schaffer et al., 2016). A table of evidence (Table 3) was constructed summarizing each study’s design, level of evidence, sample population and size, interventions, outcomes, strengths, and limitations.
Four of the studies included in the review received a final rating of low-quality evidence. These studies started out as a combination of high-, moderate-, and low-quality studies. Each initial grade was adjusted according to the five quality reduction factors and three quality strengthening factors. The fifth and sixth studies, the qualitative study and theoretical application, did not qualify for GRADE analysis due to their qualitative and theoretical natures.
There are no universal criteria to evaluate the attitudes and awareness of nurses and other health care providers or the effectiveness of interventions and education regarding HT or CSA. As such, the included studies evaluated and reported data in a multitude of ways.
An analysis of the six articles yielded four related to aspects of HT or CSA and school nursing. The fifth article viewed school nursing through the lens of a public health framework. Four themes emerged: (1) HT training and formal education impact nurses’ knowledge, awareness, attitudes, and role perceptions toward trafficking; (2) nursing, especially school nursing, is underrepresented in CT training, education, prevention, response, and research; (3) a lack of collaboration between school staff and school nurses; and (4) formal education and length of experience impact the levels of interventions school nurses are able to provide.
Educational interventions aimed at increasing knowledge and awareness of HT impact nurses’ attitudes and role perceptions. Fraley and Aronowitz (2019) used Grounded Theory to explore school nurses’ perception of commercially exploited youth in the school setting. In this study, the concept of invisibility was identified to explain the phenomenon of not “seeing” exploited children or recognizing risk. Although at-risk children were found to frequent the school nurse’s office with unspoken perceptions of cries for help, the nurses often missed the opportunity for risk identification, mislabeling these presentations as conscious engagement in risky behavior. School nurses and other school leaders often did not recognize mental health signs including violent behaviors, poor attendance, and hypersexuality as potential warning signs of CT. Likewise, physical signs including early sexual development, food insecurity or hunger, disordered sleep, and genitourinary infections were often misattributed (Fraley & Aronowitz, 2019).
While it does not explicitly address school nurses, a systematic review by Fraley et al. (2020) identified targeted education interventions as an effective way to raise HCP awareness about HT prevalence and risk factors. Fraley et al. (2018) found previous CSEC training was a significant predictor of awareness, attitude, and role perception among a convenience sample of school nurses who held membership in the Massachusetts School Nurse Organization. Awareness, attitude, and role perception were significantly and positively correlated (Fraley et al., 2018). Attitude shifts in response to education and increased awareness were also evaluated by five of the seven articles reviewed by Fraley et al. (2020; Beck et al., 2015; Ferguson et al., 2009; A. M. Grace et al., 2014; McMahon-Howard & Reimers, 2013; Viergever et al., 2015). As education and awareness increased, provider perspectives tended to shift from negative to positive, meaning they viewed their patient or student as a victim rather than a complicit participant. These results confirmed by Fraley and Aronowitz’s (2017) postulation of a relationship between school nurses’ awareness of and attitude toward CSEC, recognizing awareness and attitude impact the ability to identify and care for at-risk youth.
Besides including facts about CT, such as the definition, prevalence, and risk factors, education for school nurses also needs to include information about effective clinical response within the appropriate and prescribed scope of practice, connection to relevant community resources, and timely referrals to multidisciplinary services (Peck et al., 2020). Fraley and Aronowitz (2019) identified a general lack of parental supervision, unsupervised access to social media, abuse history, and foster system involvement as risk factors for CT exposure. School nurses did not connect these elements, missing opportunity for early intervention. In the Fraley et al.’s (2018) study, school nurse participants expressed doubt in their knowledge of reporting mandates and how to expedite care for a student at risk for or suspected of involvement in CSEC. Understanding of appropriate interventions, available resources, applicable referrals, and reporting requirements may help school nurses respond confidently and competently. This in turn could produce more positive outcomes and opportunity for effective early identification and intervention.
Nursing in general, and more specifically school nursing, is underrepresented in CT training, education, prevention, response, and research. As evidenced by this literature review, there is sparse research available about school nursing and CT. Fraley and Aronowitz (2019) studied a small sample including school nurses (n = 18), nurse leaders (n = 5), and survivors , finding school nurses demonstrated unconscious bias toward at-risk youth. In addition, the school nurses lacked adequate knowledge regarding CT risk and training to initiate an evidence-based and trauma-informed assessment. Fraley et al. (2020) identified nurses as not adequately represented in the samples of most of the studies about HT educational interventions they reviewed. None of the studies in the systematic review addressed the school setting or school nursing despite the “pivotal role” school nurses play in the prevention of, identification for, and response to HT (Fraley et al., 2020, p. 139). Also, only one of the resources identified in the resource scan (Table 1) is expressly aimed at school nurses, and only one other resource mentioned the role of school nursing, a singular state resource developed specifically for schools in Ohio.
Another area where school nurses are underrepresented is planning, implementation, and evaluation of CSA prevention programs. Although school nurses and communities should not rely on school-based CSA prevention programs as a sole method of CT prevention, they can use a CSA program in conjunction with other interventions. Fryda and Hulme (2015) reviewed 31 articles, published between 1984 and 2013, about CSA prevention programs in schools. Teachers and counselors delivered the content in most courses; nurses were included in program implementation in only three of the 31 articles (Hayward & Pehrsson, 2000; Robertson & Wilson-Walker, 1985; Sloan & Porter, 1984). Despite their underutilization, school nurses can be a crucial member of multidisciplinary CSA program teams because of their knowledge of developmental stages and skills with intervention planning, implementation, assessment, communication, and relationship building. Also, as school nurses become more knowledgeable about CT, they can advocate for the inclusion of often neglected content such as grooming behaviors and safe and unsafe situations (Fryda & Hulme, 2015), which may be particularly important to CT prevention. Having important discussions about sensitive health issues is well within the skillset of a nurse, a profession that safeguards the trust of the public. This makes these pediatric nurses ideally situated and equipped to address risk factors associated with CT in the school clinical setting (Peck, 2020b).
A lack of collaboration and cohesion between school nurses and other school staff and administrators emerged as a potential barrier to identifying and caring for children both at risk for exploitation and those who have experienced trafficking. Although Fraley and Aronowitz (2019) interviewed both school nurses and school leaders, no questioning was conducted regarding collaborative efforts to identify at-risk youth in overlapping environments in which students present. Collaboration with educators and other school staff members as well as families can increase the school nurse’s knowledge of individual student risk factors including living arrangements, family relationships, peer relationships, absenteeism, learning disabilities, and changes in academic performance (Fraley et al., 2018). Identifying youths with CT risk factors improves the nurse’s ability to provide education, screening, intervention, resources, and referrals to in-need students. In addition, cooperation between school nurses and other school staff members and administrators allows for a unified and organized multidisciplinary approach to identify and protect at-risk and affected students more effectively (Fraley & Aronowitz, 2017). Collaboration can also occur with peer education and reporting of concerns. School nurses can extend this collaboration to district, community, and system levels to affect a more widespread change.
The formal educational background and the length of experience as a school nurse can impact the nurse’s response to CT. Educational experience was not reported in the demographics of 18 school nurses participating in a Grounded Theory study by Fraley and Aronowitz (2019). Fraley et al. (2018) identified a significant and positive relationship between education level and awareness of CSEC. Nurses who had at least a baccalaureate degree were more likely to be aware of CSEC when compared with associate degree–prepared nurses. Schaffer et al. (2016) found formal education level and length of experience are associated with the number and types of interventions school nurses employ. Respondents with a baccalaureate degree or higher were more likely to employ a greater number of interventions. The results were similar for nurses with at least 10 years of school nursing experience. The study also identified masters-level education or higher as being associated with more community- and systems-level interventions, like policy development and participating in collaborative work groups. These findings reinforce the importance of higher education, support the NASN position supporting a baccalaureate degree as a minimum requirement for school nurses (NASN, 2016a), and support the use of master’s- and doctoral-prepared advanced practice registered nurses in the school setting, both as primary caregivers and consultants with intentional partnerships.
This review has identifiable limitations. The search of the literature was conducted by a singular author reviewing abstracts from a multitude of articles chosen from three scientific library databases, with subsequent review by the second author. The authors screened for the target subject of school nursing from more than 200 articles on CT. Determination of identified themes was completed with subjective analysis. Generalizability is significantly limited related to sparsity of existing evidence surrounding the response of school nurses to at-risk and victimized children in the school setting. Both the quantitative study (Schaffer et al., 2016) and mixed-methods study (Fraley et al., 2018) employed convenience sampling of the school nurse population, which lends less rigor to the process and could bias the results. Fraley and Aronowitz (2017) used the application of an untested theoretical model, which needs further validation. Additionally, there was a lack of consensus surrounding identified study designs and conclusions, making it difficult to extrapolate data trends and subsequent targeted interventions.
There is insufficient research specifically addressing school nurses and the impact of evidence-based education on their awareness, attitudes, and response to CT. However, existing literature highlights that school nurses are opportunely situated to identify and respond to CT (Fraley & Aronowitz, 2017, 2019; Fraley et al., 2018, 2020; L. G. Grace et al., 2012). Many children who are at risk for or experience trafficking remain in school, and school nurses routinely interact with at-risk students (Fraley & Aronowitz, 2017; Fraley et al., 2020; L. G. Grace et al., 2012). Misconceptions subsist amid nurses and other health care providers about CT, which help promote its covert nature and lack of recognition of risk factors, including children who are trafficked and present in the school setting (Peck, 2020a).
Training, education, collaboration, and representation are essential for school nurses to effectively respond to CT. Specific effort should be taken to engage school nurses as leaders in designing and implementing education interventions for school-based teams, being sure to incorporate survivor voice (Fraley & Aronowitz, 2019). Despite the limited literature, it appears school nurses benefit from CT educational interventions. Most of the resources identified in the resource scan (Table 1) are aimed at educators or, more generally, school professionals. Also, many HCP- directed resources may not address issues specific to the school setting. As such, school nurses should use a combination of resources from both education and clinical avenues to better inform their practice. School nurses need to be invited into collaborative forums to provide professional expertise and perspective during resource development. As school nurses become more aware of CT and available resources, they can better serve their students, schools, and communities.
The NASN (2016b) identifies school nurses as leaders and advocates for evidence-based school health services directed at the physical, mental, emotional, and social health needs of students at the individual, family, community, and systems levels. CT can negatively affect the physical, mental, emotional, and social health of youths and, as such, falls within the school nurses’ purview and creates ideal opportunity for intervention.
Schaffer et al. (2016) explored application of the PHIW as a practice framework to guide nursing services to specific school populations. Although CT was not specifically addressed, the authors establish a strong foundation on which application of this model could be easily translated to address students who are at-risk for or victims of exploitation and abuse through trafficking. As national anti-trafficking scholars and advocates increasingly call for a public health approach to trafficking and as Schaffer et al. (2016) suggested, the PHIW can provide a lens through which school nurses may construct public health interventions. The PHIW outlines three intervention levels with 17 overlapping interventions grouped into five colored wedges (Figure 2). Combining levels and amplifying numbers of interventions enhance optimal health outcomes (Schaffer et al., 2016). Table 4 suggests practical application points for development of targeted interventions to apply to the PHIW.
School nurses are ideally situated to develop a coordinated, effective response to CT risk factors, mitigating risk and fostering development of protective factors that promote resiliency. More research and evidence are needed to continue to guide an evidence-based response in the school setting with careful attention to outcomes measurements.
M.L.D. and J.L.P. contributed to acquisition, analysis, or interpretation; drafted the article; critically revised the article; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. J.L.P. contributed to conception or design.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Megan L. Doiron, BSN, RN https://orcid.org/0000-0002-3707-4965
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Megan L. Doiron, BSN, RN, is a DNP student at the Baylor University Louise Herrington School of Nursing.
Jessica L. Peck, DNP, APRN, CPNP-PC, CNE, CNL, FAANP, FAAN, is a Clinical Professor at the Baylor University Louise Herrington School of Nursing.
1 Louise Herrington School of Nursing, Baylor University, Dallas, TX, USA
Corresponding Author:Megan L. Doiron, BSN, RN, DNP Student, Louise Herrington School of Nursing, Baylor University, 333 N. Washington Ave., Dallas, TX 75246, USA.Email: megan_doiron1@baylor.edu
