Indiana Bulletin - February 2018

THE BULLETIN
Volume 44 • Number 2
February, March, April 2018
Brought to you by the Indiana Nurses Foundation (INF) and the Indiana State Nurses Association (ISNA) whose
dues paying members make it possible to advocate for nurses and nursing at the state and federal level.
Quarterly publication direct mailed to approximately 115,000 RNs licensed in Indiana.
MESSAGE from the PRESIDENT
Unity in Nursing: Being Part of the Team
Jennifer L. Embree, DNP, RN, NE-BC, CCNS
As I drive a distance
to work, I have time for
reflection several times a
week. I need personal time
to continue to grow and to
be able to think back on life
events, and on what I learn
from those occurrences. I am
blessed with gifts in the form
of people, time, and support.
I am grateful for supporters
and for the opportunities that
redirect me daily. I also know that I am never alone.
I am thankful to be a part of the larger “team” of
nurses.
When I first graduated from nursing school, I
worked in a small intensive care unit. I felt that I had
to “handle my patients” alone, to prove my worth.
At that point in my career, I did not know it was all
about the “team,” the “oneness, harmony, agreement,
or balance, known as unity.” I felt that asking for help
was a sign of weakness in me as a nurse. I learned a
useful lesson. It took me several years of being hard
on myself and others, to readily ask for assistance.
Together, we accomplish more.
With every new role I assumed as a nurse, I had
new learning. Lessons continued to shape how I
processed information and communicated with others.
I had to learn how to temper my words, actions,
and how I approached others. Learning appropriate
interaction is being part of a team that makes us
all part of the same bench strength. With lessons, I
meet new and diverse people. If I do not know about
them or their differences, I ask what they need from
me, and how I can best communicate with them. I
am personally grateful to the people who support me
so that I can do the work of nursing. Nursing work is
all about the person who needs our care, support, or
guidance.
I recently reconnected with friends from my first
nursing degree. I had not seen my friends since we
graduated from college many years ago. As we have
spent time together over the last two years, it is as
if we were never apart from each other. As nurses,
counselors, and therapists, we were all still part of
that early team. We have committed to staying in
touch. We each draw upon the strengths of each other.
We continue to laugh, cry, and feel as deeply. The
friendship and love that began on that hard road of our
first college experience continue.
After I started my master’s degree in nursing as a
clinical nurse specialist, my cohort was guided by Dr.
Nancy Dayhoff that “you all need to be part of your
professional organization!” When I first joined ISNA,
I did not know many members or nurses throughout
the state. I knew that I lacked knowledge about the
political process and the importance of protecting our
communities and our nurses. I attended critical care
conferences, and other continuing education, and was
a member of the critical care organization, but not the
association in Indiana that protects my license, nurses,
and my community-ISNA.
While in my master’s degree in nursing program,
there was an opening on the ISNA board for a member
at large. I read through the requirements and felt
Message from the President continued on page 3
INSIDE
Certification Corner
Page 2
CEO Note
Page 3
Policy Primer
Page 4
The Healthy Hot Spot
Page 8
Indiana Nurses Foundation
Research Grant
Pages 10-11
Independent Study: Understanding Human
Trafficking in the Nursing Sector
Page 13
current resident or
Non-Profit Org.
U.S. Postage Paid
Princeton, MN
Permit No. 14
See
pages
10-11

2
The Bulletin February, March, April 2018
CERTIFICATION CORNER
Sue Johnson
I want to share with you
Charisse Prall’s Oncology
Certification Story. Charisse’s
journey to certification is
unique and I think you will be
inspired by it as I am.
“Let me begin telling my
certification story with the
answer to why I became a
nurse. I first chose nursing
because my daughter was
diagnosed with type 1
diabetes when she was 8
years old. At the time, I was a stay at home mom
following a career in business and computer science
(software engineering). After caring for this child, I
said to myself, “I can be a nurse, I can do that job.”
And my mother had graduated from nursing school
7 years earlier, so I felt that following her example,
it was doable to go back to school and pursue a
different career.
So, I began my shiny new nursing career at
a local hospital in the inpatient oncology unit. I
chose that job over another because I completed
my internship on that unit and I felt that I already
had a connection with the staff and patient
population. When I started as a new RN, the
expectation was to achieve Oncology Nursing
Certification within 2 years of hire. That seemed
like such a daunting task at first, but with the
mentoring of the management and the very
knowledgeable unit educator who is now retiring
after many years of service, I, along with other
RNs, was able to prepare for and pass the Oncology
Nursing Certification examination and become OCN
Certified. OCN certification is important due to
the continued Oncology Certification status of the
Inpatient Oncology unit at the hospital. Individual
certification may be important for personal and
career satisfaction, but, in my experience, nobody
succeeds in nursing by themselves and nursing
certification may also be important to the overall
team that you work with in order to be a highly
recognized and skilled provider of nursing care and
service.
Being an OCN certified nurse requires recertification
every 4 years, and that process helped
to guide me to my next career goal, earning a
masters in nursing as a family nurse practitioner
in May 2017. After graduation and board
certification, I continued to build on my oncology
nursing career and extend my OCN certification
as a nurse practitioner at a Medical Oncology
and Hematology practice. I started my new nurse
practitioner career at this practice in August and
I am privileged to work with an awesome team of
very experienced physicians, nurse practitioners,
physician assistants, RNs, and medical staff in the
oldest, experienced, and most successful oncology
practice in this area of Indiana.
The impact that I can make in the field of
nursing is that age is just a number. I believe
that my success as an adult learner can inspire
others to continue to pursue further education
in the nursing profession. If I have learned
anything over the past 10 years, it is that change
is inevitable. Changes are occurring almost
daily in the healthcare profession and it takes a
commitment to education in order to keep up with
the changes, no matter what your age. The field
of nursing has embraced the concept of change
and I feel fortunate to be part of the momentum
that is growing which recognizes and validates
the contributions that nurses make every day
in patient’s lives as healthcare providers. To be
recognized as a patient’s primary health care
provider is an awesome responsibility and honor,
and one that advanced practice registered nurses
can now be part of.”
Thanks, Charisse, for sharing your certification
story with us!
Now, it’s YOUR turn! Certification is an
opportunity to demonstrate your nursing expertise.
You can follow Charisse’s example and you’ll be
glad you did!
Do you want to share your certification story with
your colleagues? It may encourage them to join
you! Please contact me at SueJohn126@comcast.
net to share your experiences!
THE BULLETIN
An official publication of the Indiana Nurses Foundation and
the Indiana State Nurses Association, 2915 North High School
Road, Indianapolis, IN 46224-2969. Tel: 317/299-4575. Fax:
317/297-3525. E-mail: info@indiananurses.org. Web site:
www.indiananurses.org
Materials may not be reproduced without written permission from
the Editor. Views stated may not necessarily represent those of the
Indiana Nurses Foundation or the Indiana State Nurses Association.
ISNA Staff
Gingy Harshey-Meade, MSN, RN, CAE, NEA-BC, CEO
Blayne Miley, JD, Director of Policy and Advocacy
Marla Holbrook, BS, Office Manager
ISNA Board of Directors
Officers: Diana Sullivan, President; Angie Heckman, Vice-
President; Barbara Kelly, Secretary; and Ella Harmeyer, Treasurer.
Directors: Lorie Brown, Emily Edwards, Denise Monahan, and Amy
Pettit.
Recent Graduate Director: Audrey Hopper
ISNA Mission Statement
ISNA works through its members to promote and influence
quality nursing and health care.
ISNA accomplishes its mission through unity, advocacy,
professionalism, and leadership.
ISNA is a multi-purpose professional association serving
registered nurses since 1903.
ISNA is a constituent member of the American Nurses
Association.
Address Change
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Nursing. Send your address changes to the Indiana Board of Nursing
at Professional Licensing Agency, 402 W. Washington Street, Rm
W072, Indianapolis, IN 46204 or call 317-234-2043.
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mail to The Bulletin, 2915 North High School Road, Indianapolis,
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www.indiananurses.org
Published by:
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Publishing Agency, Inc.

February, March, April 2018 The Bulletin 3
Message from the President continued from page 1
confident that I could meet the board member
criteria. I filled out the application and asked to be
appointed. A board member from southern Indiana
was needed, and I was selected to be part of another
team-the ISNA board. I had much to learn, and since
I am a great listener, I continued to grow in nursing
policy knowledge. And I am forever grateful to Ernie
Klein and Gingy Harshey-Meade for having the
foresight to recommend Blayne Miley as our director
of policy and advocacy. Because, as much as I love
learning, I could never keep up the pace needed for
traversing the political systems and Blayne is our
consistent ear and voice for policy and advocacy
in Indiana.
As I rejoined the ISNA board again in September
as your elected president, I felt the support of the
current team members that have mentored me
in the past and new members with relationships
to forge or enhance. Continuing to join us are past
president Diana Sullivan and Barb Kelly, Treasurer,
our Executive Director Gingy Harshey-Meade, our
Director of Advocacy and Policy Blayne Miley, and
our Office Manager, Marla Holbrook. Joining our
CEO NOTE
team are former students Drs. Emily Sego, Vice-
President, and Leah Scalf, Secretary. The new
graduate board member at large, Lauren Wright and
I worked together on a nursing leadership institute
grant and currently work within the same health
care system. Angela Marmat, another tremendous
new board member, joins us from southern Indiana.
Returning board members are Denise Monahan, Amy
Pettit, and Audrey Hopper. I look forward to the work
of the ISNA Team! Supporting each other is key to
helping Indiana nurses and community members.
As I began a full-time faculty role, I had more life
lessons and another language to grasp-academese!
New teams, new supportive team members, and
different guidelines. Just as I began thinking
that I had learned the academic language, I was
invited back into a health care role as part of my
academic world. Although vetted in the needs of
the underserved; I had a new much larger health
care system environment to traverse. With the
support of multiple teams, I felt that I landed in an
excellent role.
The teams in a health care system are more
extensive than in rural health care. The nursing work
in a system is more complicated. I continue to ask
team members for explanations and help. Asking
for support from other healthcare professionals
has become more comfortable. Being invited to
work hard, to make a difference, and to be part of
different strong teams is a blessing. I continue to be
amazed at the gifts and the strength of nurses and
the healthcare team members. With their talents,
they make the work look easy. As nurses, we know
hard work.
Experiencing a particularly difficult time, I asked
one nurse leader how she worked so very hard every
day. She responded with: “I just keep putting one
foot in front of the other (Denny, 2017).” Another
great nurse leader says she learned from a sage
woman that it is always about that one four letter
word that makes all of the difference in the world.
I hesitantly asked what that word was. She said
“Hope. Never give up hope. When life is very hard,
it will get better (Lough, 2017). Learning from
team members that support each other makes the
work fulfilling.
No nurse is left behind, and no team member
is left behind. ISNA is your nursing association.
Advocating on behalf of Indiana Nurses since
1903, ISNA is your organization. Join us in
making a difference in nursing and the lives of our
community members.
Relive the great moments in your life. Reflect back
on your gifts. Keep your ego in check and identify
where you can best serve. Indiana lives, and Indiana
nurses are depending on you!
In December, the new
Board of Directors for
the Indiana State Nurses
Association (ISNA) met for
the first time. A good portion
of the time was spent on
orientation. What is the role
of an Association board?
What are the duties of an
Association board? These
are the questions that were
discussed. The board members
learned and or reviewed their duties and responsibilities.
The focus of the association is defined by the
Mission. The Mission is to provide direction to and
a voice for the nursing profession in the healthcare
environment and the community. The four core pillars
of ISNA that rest on the mission are Unity, Advocacy,
Professionalism and Leadership.
Each quarter we pick a core pillar as the focus
of the newsletter. As you read the Bulletin keep this
is mind. The Indiana State Nurses Association is
here to protect the profession and the public. ISNA
depends on dues money to accomplish its mission.
The only way ISNA gets dues money is by nurses
becoming members. So – here comes the ask. Join as
a member of ISNA and help protect nursing and help
protect the public. Go to www.Indinannurses.org and
hit the join button.
BRAND NEW STATE-OF-THE-ART FACILITY
We have openings for Registered Nurses.
A new, 350,000 sq. ft. state of the art facility,
conveniently located with easy access just off
Interstate 74, about 25 miles SE of Indianapolis, is
home to nearly all of our physicians. Patients have
their doctors appointment, lab work, and imaging
all completed in one location.
All healthcare needs on one campus.
The new MHP Medical Center is home to
30 Primary Care providers and 27 Specialist
Physicians.
40 private inpatient rooms.
Each room has been designed to provide the
patient with new treatment technologies and to
promote shorter patient stays - which equals a cost
savings to the patient. Also included in the new
MHP Medical Center are 38 outpatient rooms in
our newly designed Ambulatory Care Center.
For more information on open
positions or to apply,
visit our website
www.mymhp.org

4
The Bulletin February, March, April 2018
POLICY PRIMER
Blayne Miley, JD
ISNA Director of Policy & Advocacy
Hello nurses, welcome
back to Indiana General
Assembly season! As you
read this, the session is
already into its second
trimester, and there is
a flurry of legislative
activity that impacts you.
ISNA represents you at
the Statehouse, and I
encourage all of you to be
involved in the discussions
that shape your world
by contacting your state legislators! If you are
interested in learning about policy issues, our
upcoming Policy Conference is a great opportunity.
2018 ISNA Policy Conference – February 14th
We have a great lineup of speakers for this year’s
Policy Conference in downtown Indianapolis:
• Indiana State Health Commissioner Dr. Kristina
Box
• Indiana Family and Social Services
Administration Secretary Dr. Jennifer Walthall
• Rylin Rodgers with Family Voices of Indiana
• Rebecca Fotsch, Associate Director at the
National Council of State Boards of Nursing
These fantastic speakers will be discussing
health policy current events and taking your
questions! We also plan to have state legislators
stop by to speak to the crowd. Registration is still
open, so click the banner at www.indiananurses.org
to reserve your seat!
2018 Indiana General Assembly Session Legislation
By my count 117 bills were introduced that
potentially impact nurses. ISNA members receive
weekly updates from me through the ISNAbler, our
e-newsletter, on all of them. Here are some bills of
note with where things stand as of late January.
Nurse-Specific Bills
SB 28 – Nurse Faculty Loan Repayment Program
I am thrilled to report a bill was introduced
to create a state program to help nurse faculty
with student loans as a means of recruitment
and retention! This proposal was endorsed by
the Interim Study Committee on Public Health,
Behavioral Health, and Human Services in the fall,
and as I type this we are less than 48 hours from
a scheduled hearing before the Senate Health and
Provider Services Committee.
SB 410 & HB 1302 – APRN Practice
Last year’s HB 1474 had three elements: (1)
change APN to APRN, (2) require certification or its
equivalent for prescriptive authority, and (3) retire
the collaborative practice agreement. Two bills on
the subject of APRN practice have been introduced
this year. Both are a bit different than last year’s
bill, and are works in progress as legislators attempt
to find a compromise that both the nursing and
medical communities will accept.
HB 1317: Nurse Licensure Compact & More
As part of a bill that touches on multiple health
care topics, HB 1317 would have Indiana join the
NCSBN’s nurse licensure compact. This issue will
be the subject of Rebecca Fotsch’s presentation
at the ISNA Policy Conference. The last time this
issue arose, there was vocal objection from the
Indiana Attorney General. ISNA currently is neutral
on the issue of the compact. Any ISNA member can
request a modification of the ISNA Policy Platform
by submitting a resolution for our annual convention
in September.
HB 1119: Allow APNs to Validate POST Forms
This legislation would remove a piece of
physician-exclusive language from the Indiana Code.
Currently only a physician can validate this type
of advanced directive, however this bill would add
advanced practice nurses and physician assistants.
It also formalizes a health care consent hierarchy.
Cancer
SB 23 & HB 1380: Tobacco Cessation
The three tobacco cessation measures that failed
to pass last year are back again this year. Public
health advocates once again are asking the General
Assembly to (1) repeal employment protections for
tobacco users, (2) increase the tax on cigarette
packs, and (3) increase the minimum age to buy
tobacco from 18 to 21.
SB 209: Minors Cannot Use Tanning Salons
Prohibits anyone under 18 from using a tanning
bed at a tanning facility. Current law allows 16
and 17 year-olds to do so with parent/guardian
permission. The bill contains an exception for
medical phototherapy treatment. ISNA worked with
the proponents of the bill to ensure this exception
is inclusive of advanced practice nurses with
prescriptive authority, and is supportive of the bill.
SB 210 & HB 1143: Make Prior Authorization More
Provider-Friendly
Requires insurers to post their requirements
for prior authorization and accept electronic
submissions. The insurer must respond to PA
requests within 48 hours for urgent care situations
and within 5 days for non-urgent care situations.
If a request is denied, the insurer shall state the
reason why and specify any additional information
required. Any appeals of a PA denial must be
reviewed by a panel that includes an individual with
the same specialty as the provider who proposed
or delivered the health care service. This bill is
especially relevant for oncology patients.
Opioid Epidemic
SB 106: Add Fentanyl as a Schedule I Controlled
Substance
This is in response to the rash of overdose deaths
related to fentanyl.
SB 107: Anyone with a Controlled Substance
Registration Must Register with INSPECT
Starts with applications and renewals on July 1,
2018 and thereafter.
SB 139: Coroners Must Investigate Overdose
Deaths
If the coroner suspect’s a person’s death is the
result of an overdose of a controlled substance, they
shall run an INSPECT report, collect and test bodily
fluid for controlled substances. The results of these
steps shall be shared with the state department of
health.
SB 219: INSPECT Gets Overdose Intervention Drug
Data and a Watchdog Group
First responders would be required to
send information to INSPECT regarding any
administrations of overdose intervention drugs.
This means practitioners would be able to lookup in
INSPECT whether a patient had been administered
an overdose intervention drug by a first responder.
The bill also creates an INSPECT peer review
subcommittee to review INSPECT prescribing data
looking for prescribing outliers. The subcommittee
would ask outliers for an explanation and if the
practitioner does not respond or does not provide
a satisfactory explanation, the subcommittee can
refer them to the attorney general for investigation.
The members of the subcommittee are specified,
with one being an advanced practice nurse.
SB 221: Practitioners Must Check INSPECT Before
Prescribing an Opioid or Benzodiazepine
This is a gradual rollout starting with
practitioners who have INSPECT integrated into
their EHR systems in 2018. Then in 2019, adding
emergency departments and pain management
clinics, in 2020 for all hospital patients, and
in 2021, for everyone. Includes a waiver if the
prescriber’s workplace does not have internet
access.
SB 225: Opioid CE Required for Controlled
Substance Prescribers
Requires any practitioner with a controlled
substance registration to complete 2 hours of
continuing education on opioid prescribing and
opioid abuse every two years. If a practitioner
already has a CE requirement, like advanced
practice nurses with prescriptive authority, the
2 hours counts for both requirements, it is not in
addition to the other requirement. ISNA supports
this proposal.
SB 293: Overdose Intervention Drug Administration
is Probable Cause for Cops to Get a Blood Test
If a person overdoses and is saved by naloxone,
then law enforcement can get a warrant for a blood
test for controlled substances. If it is positive,
then the person can be prosecuted for abusing
a controlled substance. Anyone charged with
this offense can enroll in any available diversion
program.
SB 335: Prescriptions Must Be Electronic & CE
Required for Opioid Prescribers
As of July 1, 2019, all prescriptions for controlled
substances must be electronic. As of July 1,
2018, all prescribers must complete 3 additional
hours of continuing education every 2 years on
the prescribing of opioid medication in order to
continue issuing prescriptions for opioid medication.
Unlike SB 225, this would add to the total CE
requirement.
SB 339: Schedule II Drugs Must be Dispensed in a
Lockable Vial
Requires pharmacies to sell/dispense schedule II
controlled substances in a lockable vial and bill the
manufacturer for the cost of the vial. Prohibits the
pharmacy from billing the patient for the cost of the
vial.
SB 398: Regulate Office Based Opioid Treatment
Programs
Requires the Division of Mental Health and
Addiction to oversee office based opioid treatment
programs. Sets forth requirements for patients,
and only allows a physician to waive those
requirements. Requires a physician to conduct
the initial assessment and determine dosing and
administration of medication, as well as other
treatment procedures. Regulates how these
programs conduct treatment.
HB 1131: Prescribers Must Discuss Opiate Risks
Before issuing an initial prescription for an
opiate, a practitioner is required to discuss the risks
of addiction, overdose, concurrent substance use,
and the responsibility to safeguard medications.
This discussion must be noted in the patient’s
medical record. This requirement does not apply to
hospice patients.
Cannabidiol
SB 52: Zero THC Hemp Extract
Allows for the manufacture, distribution, and safe
of zero THC hemp extract, which the bill excludes
from the definition of controlled substances.
SB 214: Legalize CBD Oil
Replaces the convoluted affirmative defense for
certain patients passed last year with across the
board legalization. CBD oil is defined as a product
containing not more than 0.3% THC, at least 5%
cannabidiol by weight, and no other controlled
substances.
SB 280: Exclude Cannabidiol from the Definition of
Marijuana
Makes a substance with a THC concentration
of 0.3% or lower fall outside the definition of
marijuana. These products would be classified the
same as industrial hemp and fiber.
SB 294: Regulate the Sale and Possession of CBD
Oil
Requires registration cards for the CBD registry
created last year to include a unique identification
number and scannable code. Sellers of CBD oil
must record the identification number of all the
people they sell to.

February, March, April 2018 The Bulletin 5
POLICY PRIMER
SB 307: Legalize Medical Marijuana
Creates a state agency to oversee medical
marijuana for patients with a physician
recommendation.
SB 310: Exclude Low-THC Substances from
Definition of Marijuana
Excludes substances containing less than 0.5%
THC from the definition of marijuana.
HB 1224: Interim Study Committee on Cannabidiol
Asks for an interim study committee to examine
the benefits of cannabidiol for patients with
chronic conditions.
HB 1273: Physicians and Only Physicians Can
Treat a Patient Utilizing CBD Oil
Allows for the sale, dispensing, and
administration of CBD oil by a physician to treat
patients. It eliminates the limitation passed last
year that only applied to epilepsy, allowing for
broader application, and the creation of a patient
registry. Does not allow nurses to be involved at all
with possession or administration.
School Health
SB 24: Allow Sunscreen in Schools
Requires schools to allow students to possess
sunscreen in school without a doctor’s note and
without having to store it in a specific location. The
sunscreen must be non-aerosol and FDA approved.
School personnel may, but are not required, to
assist with application, and have civil immunity.
ISNA has been in discussion with the Indiana
Association of School Nurses to ensure this bill
does not negatively impact school nurses, and
both are supportive of the legislation.
SB 65: Require Parental Consent for Sex
Education in Schools
School corporations must make sex ed
instructional materials available for inspection
by parents and receive parental consent before
providing sex ed instruction to students.
Maternal & Newborn Care
HB 1017: Screen Newborns for Spinal Muscular
Atrophy
Adds spinal muscular atrophy and severe
combined immunodeficiency (SCID) to the list of
required screenings for newborns.
SB 142 & HB 1192: Maternal Mortality &
Morbidity Review Committee
Requires the Department of Health to create a
committee to review deaths from any cause related
to or aggravated by pregnancy or management
of pregnancy, and develop recommendations.
Members are appointed by the state health
commissioner, and must include individuals
representing certain service areas, including nurse
midwifery and public health nursing. Health care
providers have an obligation to report maternal
mortalities to the committee and to provide health
care records.
HB 1287: Newborn Blood Testing
Specifies that the blood specimen must be
collected not earlier than 24 hours after birth,
except for preterm infants and infants who receive
a total exchange blood transfusion. If the newborn
is discharged in less than 24 hours after birth,
then the sample must be collected immediately
(amended from 3 hours) before discharge.
SB 193: Study Committee on Pregnant Women on
Healthy Indiana Plan
Asks for an interim study committee to examine
the impact of having pregnant women stay on the
Healthy Indiana Plan instead of moving to the
Hoosier Healthwise Medicaid Program.
Professional Licensing Agency
SB 223: Healthcare Provider License Renewal
Surveys Get Bigger
Healthcare provider license renewal surveys
would be required to collect the following
information: (1) each location where the
practitioner worked, (2) practitioner’s scope of
practice, (3) total number of hours the practitioner
worked during the previous two years, (4) number
of practitioner’s patients who were enrolled in
Medicaid, and (5) percentage of the practitioner’s
patients who were enrolled in Medicaid.
HB 1299: Additional Review of PLA Rulemaking
Requires review of proposed occupational
rulemaking to ensure the proposed rules comply
with federal antitrust law and are the least
restrictive and least costly alternative.
What You Can Do
Whew, that is a lot of proposals that could
impact your profession. I am here as a resource for
anyone who wants to be involved in health policy. I
can help you reach out to your legislators, connect
with other stakeholders, and optimize the timing
of your advocacy. I also welcome any input on
any policy issue, just drop me a line at bmiley@
indiananurses.org.

6
The Bulletin February, March, April 2018
ISNA WELCOMES our NEW and REINSTATED MEMBERS
Naomi Adamski
Jonathan Amburgey
Janice Armstrong
Susie Arthur
Kristen Bagot
Melissa Bagshaw
Jessica Ball
Cherish Batts
Janna Boone
Laura Borsa
Tamera Brinkman
Katherine Brodersen
Sonia Bryan
Kelly Buck
Alicia Bueche
Teresa Butcher
Dana Butler
Diane Carr-Lynn
L Kathleen Cerbin
Shannon Clark
Tasha Cohee
Julie Collings
Jeanetta Conway
Vickie Copeland
Patricia Cousin
Lara Cowan-Vesper
Cristina Davis
Lori Deck
Allissa Dever
Amber Dillon
Micah Driscoll
Annette Drook
Taryn Eastland
Julia Elliott-Felton
Jean Fabini
Megan Finch
Christy Flynn
Elizabeth Fouch
Pamela Fountain
Orland, IN
Lexington, IN
Westfield, IN
Gary, IN
North Webster, IN
Henryville, IN
Clarksville, IN
Thorntown, IN
Marion, IN
Bourbon, IN
Danville, IN
South Bend, IN
Seymour, IN
Carmel, IN
South Bend, IN
Cutler, IN
Bedford, IN
Griffith, IN
South Bend, IN
Carmel, IN
Sharpsville, IN
Floyds Knobs, IN
Fishers, IN
Madison, IN
Indianapolis, IN
Carmel, IN
Indianapolis, IN
Newport, IN
Fort Wayne, IN
Mount Vernon, IN
Valparaiso, IN
Carmel, IN
Gary, IN
Bloomington, IN
Fort Wayne, IN
Terre Haute, IN
Scottsburg, IN
Arcadia, IN
Fort Wayne, IN
Carla Fouse
Michelle Fox
Michelle Mary Freiberger
Amanda Galik
Denise Gard
Lynceta Givens
Nicole Graves
Paige Groves
Joy Halsted
Stephanie Hamilton
Zachary Hermann
Melissa Hillier
Carlee Hindbaugh
Karen Hooker
Julee Hudson
Teri Huffman
Kimberly Huffmn
Jamie Jackson
Heather Jacobs
Sarita Jenkins
Jennifer Jimenez
Pam Johnson
Rhonda Johnson
Lisa Jordan
Michele Kadenko-Monirian
Rimple Kaur
Elizabeth Kendall
Marie Kennedy
Harleyjo Kennedy
Erin King
Erin Kirby
Kisha Knight
Anuroopa Kommareddy
Stella Korrie
Paula Kramer
Jennifer Kruse
Anne-Mette Lachmann
Shannon Lacy
Jennifer Likens
Terry Little
Tiffany Loza
Kimberly Maggart
Penny Marlatt
Molly Martin
Stacy Maurer
Christina McAfee
Michele McConnell
Wendy Meeks
Brittany Meyer
Joanne Mickley
Morgan Miller
Dawn Miller
Cayaurima Miller
Michelle Millikan-Wilkin
Winchester, IN
Indianapolis, IN
Clarksville, IN
Merrillville, IN
Munster, IN
Gary, IN
Elkhart, IN
Greenville, IN
Crown Point, IN
Hobart, IN
Evansville, IN
Kokomo, IN
Columbia City, IN
Culver, IN
Indianapolis, IN
Granger, IN
Plainfield, IN
Flora, IN
Fort Wayne, IN
Schererville, IN
Fishers, IN
Hartford City, IN
Indianapolis, IN
Fishers, IN
Fort Wayne, IN
Indianapolis, IN
Zionsville, IN
South Bend, IN
Versailles, IN
Terre Haute, IN
Pittsboro, IN
Merrillville, IN
Crown Point, IN
Indianapolis, IN
Evansville, IN
Churubusco, IN
Hammond, IN
Indianapolis, IN
West Terre Haute, IN
Yorktown, IN
LA Porte, IN
Syracuse, IN
Rushville, IN
Fishers, IN
Indianapolis, IN
New Albany, IN
Fort Wayne, IN
Monroeville, IN
Sunman, IN
Huntington, IN
New Albany, IN
Kokomo, IN
Indianapolis, IN
Fishers, IN
Mitchell Molenda
Mary Morrow
Katrina Motley
Matt Motycka
Heather Mullin
Debbie Nail
Rose Napier
Naquetta Newsome
Jacqueline Newton
Daniel Noel
Judy Northern
Lori Orzechowski
Dawn Otis
Sharryl Overdorf
Kellie Parker
Jaime Parkes
Susan Peck
Lindsay Pena
Dorn Penry
Tereasa Petrow
Leslie Phillips
Melissa Pipes-Collins
Deborah Plummer
Scott Prather
Roxie Puckett
Josiah Reish
Patricia Riley
Dale Robbins
Cindy Robbins
Heather Roberts
Deanna Sheeks
Catherine Shultz
Karla Sigo
Pamela Simmons
Jeanne Sims
Michelle Singleton
Kristina Sloderbeck
Laura Sparks
Nekia Stanley
Karen Stephany
James Stowers
Michelle Strahl
Jason Straw
Corrie Suess
Deborah Tavares
Jon Templeman
Heidi Tharbs
Danielle Trout
Jacqueline Turner
Jaime Vinson
Dawn Walcott
Jenna Walthour
Marsha Weamer
Morgan Welsh
South Bend, IN
Hammond, IN
Indianapolis, IN
Evansville, IN
Kirklin, IN
Nineveh, IN
Indianapolis, IN
Surprise, AZ
Newburgh, IN
Columbus, IN
Indianapolis, IN
Aurora, IN
Fort Wayne, IN
Brookston, IN
Granger, IN
Vincennes, IN
Leo, IN
Fishers, IN
Fishers, IN
New Palestine, IN
Frankfort, IN
Brazil, IN
Danville, IN
Indianapolis, IN
Muncie, IN
Fort Wayne, IN
Hobart, IN
Warsaw, IN
Munster, IN
Lebanon, IN
Corydon, IN
Carmel, IN
Lafayette, IN
Indianapolis, IN
Lawrenceburg, IN
Elkhart, IN
Westfield, IN
Clarksville, IN
Noblesville, IN
Michigan City, IN
Evansville, IN
Amo, IN
Westfield, IN
Zionsville, IN
Franklin, IN
Edinburgh, IN
Indianapolis, IN
Terre Haute, IN
Hobart, IN
Fort Wayne, IN
Rising Sun, IN
Fort Wayne, IN
Granger, IN
Greenwood, IN
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February, March, April 2018 The Bulletin 7
GET YOUR
PROFESSIONAL
TOOLKIT
ü LICENSE –
BOARD OF NURSING
ü MEMBERSHIP –
INDIANA STATE NURSES
ASSOCIATION (ISNA)
ISNA IS CARING
FOR YOU WHILE
YOU PRACTICE
www.indiananurses.org
Our programs focus on:
• extensive clinical experience
• proven student outcomes on licensure/certifications
• nationally recognized faculty
We are currently offering the following degrees:
• Bachelor of Science in Nursing • Post MSN Certificate
• RN Completion (RN-BSN) • Doctor of Nursing Practice
• Master of Science in Nursing
USI nursing promotes:
• highly sought workplace skills
• online education
Knowledge for Life
• flexible course delivery
• valuable clinical experiences
For more information about these programs,
please visit our website at http://USI.edu/health
2018 Policy Conference
Wednesday
February 14
9 am to 2 pm
Lunch Included
For More Information and Registration
www.IndianaNurses.org
WE WILL HAVE THESE SPEAKERS
PLUS LEGISLATORS WILL STOP BY
Dr. Kristina Box,
Indiana State Health
Commissioner
Dr. Jennifer Walthall,
Indiana FSSA Secretary
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E-mail: simplewreath@gmail.com
Custom orders and monograms available!

8
The Bulletin February, March, April 2018
The Healthy Hot Spot
Brittany Gilson, BSN, RN
Kara Tierney, BSN, RN
Now that it’s February, your New Year’s
resolution has probably come and gone,
whether it was losing a few pounds,
starting a new diet, or training for that
5k you’ve been wanting to run. But
don’t let the loss of time hinder your
progress; NOW is always a perfect
time for a fresh start. January first is
merely the beginning of a new year to
start working on a new you. However,
a new you is not always what some
people need. There’s always room
for improvement no matter who you
are, but what’s most important is being
comfortable in your own skin. So, embrace
new goals and accept room for change; don’t
just try to restart as someone new. Get rid of
the excuses, make lifestyle changes, and commit to
resolutions.
An important aspect to keep in mind while sticking
to your goals is your reason behind changing or
improving. You must not lose sight of why you want to
become a better you. It’s hard to continue on a tough
journey without purpose. For example, I’ve always
wanted to run a full IRONMAN. However, I’ve always
made excuses as to why I couldn’t train for one: it’s
too hard, I can’t do it, I don’t have enough time, blah
blah blah. This year I finally threw away my excuses
and said, “Yes I can!” I told my friend if she signed
up, I would sign up too; and here we are.
Maybe starting with a buddy is helpful for you.
Begin together and when one of you loses that
inspiration (which will inevitably happen. Trust
me it happens to me), your buddy can help
remind you why you started in the first
place and vice versa. So, first find your
purpose, commit to your goal, and
challenge yourself to complete it! Now
that we have all decided to begin our
journeys together, let’s pick a goal.
Listed below are a range of fun events
to sign up for in the spring/summer of
2018. These are just suggestions, so
don’t be afraid to find something else
you love! Remember, your body can do
anything; you just have to convince your
mind that you can!
“The key is not the will to win…
everybody has that. It is the will to prepare to
win that is important.” – Bobby Knight
RUNNING
• Shamrock 5k beer run 3/17/18 – Indianapolis, IN
• Easter Egg 5k 3/31/2018 – Indianapolis, IN
• Wakarusa Maple syrup festival 5k – Wakarusa, IN
• Mini marathon 5/5/2018 – Indianapolis, IN
TRIATHLON
• Eagle Creek Sprint triathlon 6/9/18 –
Indianapolis, IN
PADDLE and RUN
• Eagle Creek Paddle and Run 7/21/18 –
Indianapolis, IN
OBSTACLE COURSE RACES
• Spartan Race 7/7/18 – Lawrenceburg, IN
• Tough Mudder 8/25 & 26/18 – Chicago, IL
YOGA
• Monumental Yoga (tentative summer date) –
Indianapolis, IN
FAVORITE
• Place to work out? Cycle Bar
• Outdoor sport? Snow Skiing
• Animal? My dog Rusty
• Summer event? Country concerts
• Baseball team? Houston Astros
What area of nursing are you in and why did
you choose it?
I am on a cardiac medical critical care unit. I
chose this specialty because I am intrigued by the
complexities of the heart. I learn something new every
day and I’m always kept on my toes.
Why do you like working on your unit?
I love the teamwork and camaraderie that my
coworkers provide. They’re great teachers and together
we provide great care to our patients.
What keeps you motivated to stay fit?
I like outdoor activities so to keep up with what I
love, I have to stay in shape!
RNs & LPNs
- FT, PT, PRN
Opportunities available at all three
locations. Stop in or apply online today!
jobs.hcr-manorcare.com
Indy South
(317) 881-9164
Summer Trace
(317) 848-2448
Prestwick
(317) 745-2522

February, March, April 2018 The Bulletin 9
Nurse Unity:
A Powerful Work of Art
Audrey Hopper BSN, RN, CPN
Unity is oneness or harmony, but I like to think
of nurse unity as a tapestry of many related nursing
parts in a complex system working towards one
congruent result – like a powerful work of art. To
create a beautiful thriving community and world, we
need engaged nurses from diverse specialties and
backgrounds to come together and explore common
purposes and give voice and power to change. My
mom, a nurse, always told me that very few people
in the world really understand what it means and
how difficult it is to be a nurse. What we do is
messy, intimate, heart breaking, and exhilarating.
That is why I feel recharged after spending time with
my nurse friends and why I find such joy and purpose in joining my fellow
nurses at ISNA. Do you find uniting with other nurses powerful? In what ways
are you connecting and creating your nursing tribe?
This need for unity in the profession of nursing is why ISNAs value
pillar of unity is so important. ISNA is the place where nurses can bring
passion and knowledge from their nursing silo and join other passionate
nurses to increase our power and our purpose. ISNA is engaged in the
(1) promotion of the professional/educational development and welfare of
nurses, and (2) improving health standards and the availability of health
care services for all people. For example, ISNA promotes legislation that
includes language needed to protect and promote standards of nursing
practice, supports nursing research, and promotes relationships within the
nursing community and with the public. Without unity we are limited in
our agency (power) to influence change on a larger, long term scale for
patients, families, nurses, and our community. ISNA is lucky to have
engaged members who are living nurse unity by creating a powerful work
of art in their own communities. If you are thinking of joining us, you will
not regret the decision because the support and community you will gain
is inspiring – just do it! How are you engaged in your community? Are you
feeling connected to your passion and purpose?

10
The Bulletin February, March, April 2018
RESEARCH GRANT CRITERIA
Each Year the Indiana Nurses Foundation (INF) awards up to two (2) $2,500
Research Grants.
The purpose of the research grants program is to support sound research
projects conducted by Registered Nurses in Indiana.
Eligibility:
• Any registered nurse who practices in the state of Indiana.
• Members of ISNA are given preference.
• Projects may be quantitative or qualitative.
• Project must have a sponsoring institution identified in which to send the
grant money, if awarded.
• Applications that are not prepared according to the guidelines will not be
reviewed and will not be returned.
Deadline:
• The deadline for submitting applications is February 28th this year. Award
recipients will be notified in March of each year.
• Research Grants will be awarded at the INF luncheon typically held in March
or April; the date, time and place will be posted in the Indiana Nurses Bulletin
and on www.IndianaNurses.org and or call 317-299-4575 for information.
Grant Proposal Guidelines:
• A cover page is to include the title of the study and the investigator’s name,
credentials, address, phone number.
• The completed research proposal and relevant accompanying documents
should be sent to:
Grant Selection Chair
Indiana Nurses Foundation
2915 North High School Rd.
Indianapolis, In 46224
The proposal must include the following along with the cover sheet as noted
above.
1. Title Page (required form included).
2. Abstract: in 250 words, single spaced, or less.
3. Total Projected Budget
4. INF Budget – should not exceed the maximum of $2,500
5. Biographical Sketches – For the principal investigator; and if applicable, coinvestigators,
consultants, and academic advisors. (A curriculum vitae is not
acceptable)
6. Narrative: Maximum 6 double-spaced typewritten pages (excluding
references).
7. Appendices:
A. Copy of all instructions to be utilized.
B. Advisor’s evaluation and documentation of committee approval.
C. Copy of (1) IRB approval and (2) Human Subjects Review (if applicable):
IRB approval may be submitted as late as the last day of the month
preceding the awards luncheon (usually March 31st). The award will be
pending receipt of IRB approval.
D. Documentation of Consultation if applicable
E. Documentation of Support and Access (if part of the investigation)
for where the research will be conducted at locations other than the
sponsoring institution.
If a proposal is reviewed but not approved for funding; or if it is reviewed but no
funds are available, the proposal will not be returned to the author. The Foundation
and the Research Grants Review Committee, that reviews each proposal, will
provide no research critique.
If no proposals are submitted that are deemed to be of sufficient merit to be
awarded a research grant, INF reserves the right to hold the funds over for the next
grant deadline. Proposals may be resubmitted.
There is no mandatory requirement to award grant funds every year. If there
are no proposals deemed to be of sufficient merit, funds may be held over to the
following year. Proposals not funded may be resubmitted in subsequent funding
cycles.
Information obtained about a proposed study during the review process by the
reviewer(s) will be kept strictly confidential.
Proposals will undergo a blind review by the Research Grant Committee of
the Foundation. If a potential conflict of interest exists between a reviewer and
applicant, the reviewer will withdraw from the proposal review process.
All publications and presentations emanating from research projects funded by
INF must contain the following: “This project was supported in part by a research
grant from the Indiana Nurses Foundation, the Foundation of the Indiana State
Nurses Association.”
Expectations
The recipient of the research grant must submit a report to INF describing
the progress of the study and/or final results at the end of the calendar year. In
addition, the recipient is required to share the progress of the project and/or final
results with ISNA members using one of a variety of means: blog post, abstract or
article for the Indiana Nurses Bulletin, poster presentation or some other agreed
upon means.
At the end of one year all unused grant funds must be returned to the INF.
The Foundation of the Indiana State Nurses Association
2915 N. High School Road • Indianapolis, IN 46224
Phone: 317-299-4575 • Fax: 317-297-3525
www.Indiananurses.org
*updated 10/6/2016

February, March, April 2018 The Bulletin 11
RESEARCH GRANT CRITERIA

12
The Bulletin February, March, April 2018

February, March, April 2018 The Bulletin 13
INDEPENDENT STUDY
Understanding Human Trafficking in the Nursing Sector
This independent study was developed by:
Christina Conrad, LSW, Anti-Human Trafficking
Case Manager, The Salvation Army, Columbus,
Ohio. Revisions and updates were made by Ruth
Downing, MSN, RN, CNP-SANE-A, Founder and
President, Forensic Healthcare Consulting.
OUTCOME: The nurse will be able explore the
issue of human trafficking and identify, as well as
communicate, with potential victims of trafficking.
This independent study has been developed for
nurses to explore the issue of human trafficking
and the nurse’s role. 1.25 contact hours will
be awarded for successful completion of this
independent study.
The Ohio Nurses Association is accredited as
a provider of continuing nursing education by
the American Nurses Credentialing Center’s
Commission on Accreditation (OBN-001-91).
Expires: 9/2018. Copyright © 2011, 2014, 2015
Ohio Nurses Association
DIRECTIONS
1. Please read carefully the enclosed article
“Understanding Human Trafficking in the
Nursing Sector.”
2. Complete the post-test, evaluation form and
the registration form.
3. When you have completed everything of
the information, return the following to the
Indiana State Nurses Association at 2915 N.
High School Road, Indianapolis, IN 46224.
A. The post-test; completed registration
form; check and evaluation form.
The post-test will be reviewed. If a score of
70 percent or better is achieved, a certificate
will be sent to you. If a score of 70 percent is
not achieved, a letter of notification of the final
score and a second post-test will be sent to you.
We recommend that this independent study be
reviewed prior to taking the second post-test. If
a score of 70 percent is achieved on the second
post-test, a certificate will be issued.
If you have any questions, please feel free to
call Marla Holbrook at mholbrook@indiananurses.
org or the Indiana State Nurses Association at
317-299-4575.
The authors and planning committee members
have declared no conflict of interest.
Disclaimer: Information in this study is intended
for educational purposes only. It is not intended to
provide legal and/or medical advice.
and keys, and walks out without so much as a word
spoken or a glance your way.
At this point it is two minutes after midnight. The
pimp enters, you’re still naked but these days you
don’t even bother to cover yourself anymore. He tells
you “That guy paid me what he owed but said you
didn’t do good enough. You better re-learn how to put
on that happy face for the next one or else I’ll give
you something to be sad about!” Knowing another
beating would result if you ignore his instructions
you smile at him. It’s less than halfhearted; smiling
now means nothing more than facial tension. “That
will have to do,” he says, “now go clean your filthy
body whore. The next guy is going to be here in 20
minutes.”
This sounds like a nightmare concocted from
one of those tragic stories you’ve heard maybe
once or twice, but never really allowed yourself to
believe could be real, or happen to anyone you love.
Unfortunately, this is not a terrifying dream. This is a
depiction based off of survivor testimonies about just
one night in the life of a sex trafficking victim.
The Crime of Human Trafficking
Sex trafficking accounts for the largest portion
of victims and profits in the ever-present tragedy
of human trafficking. Human trafficking is more
commonly referred to as Modern Day Slavery because
it exists when men, women, and children are forced
into physically laborious situations to profit another
individual. The U.S Department of Health and Human
Services reports that globally human trafficking is the
second largest form of organized crime and fastest
growing (The U.S. Department, 2011).
This criminal enterprise is tied with arms dealing
(illegal weapon sales) and second only to the dealing
of illegal drugs worldwide (The U.S. Department,
2011). The Trafficking in Persons Report of 2010
tells us that the major forms of trafficking in persons
include: Forced Labor, Bonded Labor (including
Debt Bondage Among Migrant Laborers), Involuntary
Domestic Servitude, Forced Child Labor, Child
Soldiers, Forced Prostitution (Sex Trafficking), and
The Commercial Sexual Exploitation of Children
(including Child Sex Tourism) (U.S. Department of,
2010). These categories are all roughly placed into
two different groups; that of Sex Trafficking and
Labor Trafficking. The estimated global annual profits
made from the exploitation of all trafficked persons or
forced labor is $150 billion based on U.S. currency
(The International Labour Organization 2014).
Breaking Down the Definition
Generating a solid understanding of the definition
of human trafficking is important as this crime
involves many forms of abuse and related offenses.
Deciphering the parties involved (the perpetrators,
victims, and sometimes customers) and their role in
the crime of human trafficking presents a challenge.
Traffickers use unique ways of recruiting, trapping,
and exploiting their victims so the crime can easily
go un-recognized or misinterpreted as another. The
Victims of Trafficking and Violence Protection Act of
2000 (TVPA) clearly states the definition of human
trafficking as a recognized illegal activity (Department
of Health, 2003).
The term ‘‘severe forms of trafficking in persons’’
includes the following:
Sex Trafficking: A commercial sex act is induced
by force, fraud, or coercion, or in which the person
induced to perform such act has not attained
18 years of age (U.S. House of Representatives,
2008).
In the United States there are aspects of the
commercial sex industry that are legalized like
strip clubs, forms of pornography, and areas of
prostitution. This can make separating the individuals
who are legally involved in the sex industry from those
who are trafficked difficult. Each trafficking situation
involves a unique individual and corresponding story.
When contemplating if a patient you are treating is
a victim of trafficking, utilize the TVPA’s definition
by looking at the five areas of focus: Force, Fraud,
Coercion, Definition of “commercial sex act,”
and Age.
1.) Force: Any physical restraint or causing serious
harm (U.S. House of Representatives, 2008).
An example would be a woman physically
overpowered, tied down to a bed, or locked in
a hotel and raped by a trafficker or customer
(more commonly referred to as a “John”).
Independent Study continued on page 14
Tenure-Track Faculty
Indiana University School of Nursing, Bloomington (IUBSoN) seeks
four tenure-track faculty. Required qualifications: earned doctorate in
nursing or related field and MSN with teaching experience.
Academic rank and salary depends on scholarly, teaching, and
service achievements.
Apply online at https://indiana.peopleadmin.com/postings/5052.
For additional information, contact Dr. Amy Wonder, Search Committee
Chair at awonder@iu.edu, (812) 855-1734, or William Weiss, Human
Resources Coordinator, at wweiss@iu.edu (317) 274-3796. EOE
INDIANA UNIVERSITY BLOOMINGTON
STUDY
The red number two just clicked to a three on
the digital clock that sits crooked on the end of
the cabinet across the room. It’s now 11:53 pm.
The time is difficult to read because this guy didn’t
even bother to turn off the lights when he came in
to see you; the numbers are faint. The rank smell of
the sheets is infiltrating your senses as your face is
being thrust into the bed. A headache ensues as you
taste the dry smell of cigarette smoke that permeates
the fabric from years of people ignoring the “no
smoking” sign. Click. The clock changes again, one
of the lights is dim but you can tell it is a four. This
comes with relief because you know there are only six
minutes left before you can go take the shower you
were promised. The hot water will feel good because
this man makes you feel even dirtier than the others
you had to see that night. He is in his late 50’s
and overweight, much like your grandpa Pap who
used to rock you to sleep when you were scared of
thunderstorms. His waxy skin engulfing your body
makes you feel more trapped than the pimp outside
the door, waiting to take his money for the service
you’re providing. When his awful grunting stops
resounding in your ear you can tell the old man just
ejaculated and the deed is done. You can finally take
a breath as the pressure of his massive body on top
of yours is lifted. He sits on the edge of the bed for a
minute before getting dressed. He collects his watch
ONLINE convenience,
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The University of Southern Indiana College of Nursing and Health
Professions is accredited as a provider of continuing nursing
education by the American Nurses Credentialing Center’s
Commission on Accreditation. USI was recognized as
accredited with distinction through November 30, 2018.

14
The Bulletin February, March, April 2018
Independent Study continued from page 13
2.) Fraud: According to the TVPA, fraud refers to a false promise made
to the victim by a trafficker to lure or entrap the victim as a means of
control (U.S. House of Representatives, 2008). Examples of fraud
include false promises for specific employment, promises of a certain
amount of money that is never paid, being told he or she would receive
legitimate immigration documents that are never obtained (U.S. House of
Representatives, 2008).
3.) Coercion: Threats of serious harm to or physical restraint against any
person; any scheme, plan, or pattern intended to cause a person to believe
that failure to perform an act would result in serious harm to or physical
restraint against any person; the abuse or threatened abuse of the legal
system (U.S. House of Representatives, 2008).
4.) “Commercial Sex Act:” Any sex act (prostitution, stripping, and
pornography) on account of which anything of value is given to or received
by any person (U.S. House of Representatives, 2008). Your role as a nurse
is to decipher if there was anything of value exchanged for a sex act. Was
there money, drugs, or valuables traded because of a sexual encounter?
5.) Age: The TVPA directly states that if a minor is caught in a commercial
sex act, then they are automatically considered to be a victim of Human
Trafficking. This is because in no other circumstance can that individual
consent to a sexual encounter.
Labor Trafficking: The recruitment, harboring, transportation, provision, or
obtaining of a person for labor or services, through the use of force, fraud, or
coercion for the purpose of subjection to involuntary servitude, peonage, debt
bondage, or slavery (U.S. House of Representatives, 2008).
This is the most recognizable form of Modern Day Slavery as it can be more
easily compared to the slavery of past times. It is essentially the same as people
who are made to work physically or at a specific trade without pay or freedom
of movement. These victims have been found and rescued from agricultural
areas, factories, restaurants, hotels, and family homes. There are various ways
labor traffickers entrap their victims and utilize them for their personal profit but
debt bondage is most commonly used. This is when a trafficker establishes an
inflated fee (based on transportation and living costs) that the victim must pay
back before they obtain freedom. A trafficker may insist that a young man pay
him $1,200 US dollars as reimbursement for the cost of the van ride, meals, and
apartment stay when crossing a border. The trafficker will then not pay the young
man for his migrant work, claiming he is taking his cut of the debt incurred.
This essay will address occurrences of Labor Trafficking and its reproductions
but not in extensive detail. The primary focus of this essay will be to provide
education about sex trafficking as it is the type most common in our society.
More importantly, the victims of this type of trafficking are knowingly and
unknowingly being treated in our nation’s medical centers on a daily basis. The
health care provider plays a key role in their rescue and rehabilitation using
the specific skills s/he possesses and the opportunities available through their
facilities.
The Prevalence of Human Trafficking in the United States
The Statue of Liberty, the American Flag, and the Constitution of the United
States represent the freedom and justice for all citizens on our soil. Men and
women have fought and died to honor and protect these principles for which our
nation exists.
Understanding our society’s value of freedom makes it easier to see how the
issue of human trafficking is largely hidden. ‘Slavery’ is often considered to be
a term of the past. Most people cannot fathom that there are currently people
in our country who have no element of choice or freedom in their lives. Human
trafficking is modern day slavery. Times and technology have changed the way
people are exploited and controlled. For example, women were once sold legally
at town auctions to work on plantations. Today, women are sold to the highest
bidder over the internet. The methods of sale and control have advanced but not
the underlying issue - that the woman is being sold against her will and used for
another person’s profit.
The rate at which slavery exists in our country is astounding. Due to the
inconspicuous nature of this crime, the numbers are difficult to track. Regardless
of the challenge, research has provided some figures concerning prevalence of
human trafficking. The most conservative estimate given by the International
Labor Organization, found that there are at least 12.3 million people in forced
labor worldwide (Belser, 2005). Although the accepted estimate is thought to
be more realistic, there are currently 27 million people living in slavery (Bales,
2007). The Trafficking in Persons Report (TIP) shows that between 600,000 and
800,000 individuals are trafficked across international borders every year (U.S.
Department of, 2010). Annually 18,000 to 20,000 persons are trafficked into the
U.S. (U.S. Department of State, 2003). Those numbers of course do not include
our own U.S. citizens who are also controlled and exploited. We know from the
Center for Missing and Exploited Children that there are at least 100,000 US
children caught up in commercial sexual exploitation (CSE), with the belief that
there are upwards to 300,000 minors victimized (Allen, 2010).
The only way to prioritize this subject when screening patients is to recognize
that, behind every one of these numbers, is a person. These are not just
statistics, these are lives. These men, women, and children have been brutalized
to the highest degree, yet they can still think, feel, love others, and build lives.
Take for example Samantha, a client of The Salvation Army of Central Ohio’s
Anti Human Trafficking Program. Samantha is a kindhearted spirit who has
overcome tremendous trauma in her life with a remarkable ability to care for
others. Samantha was trafficked in Florida when she turned 18 after deciding
to experience life in a new state. Invited into an apartment by a man claiming
to show her the city, Samantha became a victim of forced prostitution that very
night after receiving her first assault and beating. This would become routine in
the 11 months that would follow.
During one of Samantha’s pimp’s violent rages he threw her out of a three story
window. These injuries brought her to the area hospital where she finally found
sanctuary. This was the first time in almost a year Samantha was able to feel
safe. This hospital stay became her opportunity to become free. With the help
of the nursing staff, she was treated and reconnected with her family. Today, 36
years have passed since this horrifying ordeal and Samantha embodies what it
means to be a survivor. Samantha feels blessed to be able to be a full time wife
and mother of five children. She embraces the needy with philanthropic work and
personally when friends are in distress. Samantha raises awareness about the
reality of domestic minor sex trafficking in efforts to save other girls from this
terrible fate.
Human Trafficking in the Health Care Setting
Health care facilities can be a place of refuge and restoration for victims of
trafficking. The traffickers know there is opportunity for their crimes to be
exposed in these settings. Thus trafficking victims are typically brought into
hospitals and clinics only when injuries and ailments are life threatening or
debilitating enough to affect the victim’s ability to make money. One European
study showed that 28% of Human Trafficking victims came into contact with
the health care system at least one time during their captivity (Family Violence
Prevention, 2005). Regrettably not one of these encounters resulted in the
trafficking victim being rescued. This is most likely attributed to a lack of training
necessary to understand this crime and its victims. A recent study shows the
need for health care providers to be educated in our country. The study surveyed
emergency room staff where 23% of those surveyed were nurses, learned
that although 29% thought it was a problem in their emergency department
population, only 13% felt confident or very confident that they could identify a
trafficking victim, and less than 3% had ever had any training on recognizing
trafficking victims (Chisholm-Strike, & Richardson, 2007).
These studies represent crucial missed opportunities to save people from
immense suffering. Luckily this problem has an easy solution. Simply educating
yourself and your health care facility’s staff on the issue of Human Trafficking
will help with victim identification and rescue. As a health care provider (HCP)
you have a golden opportunity to reach out to victims. The health care system
is one of only four fields where workers are likely to encounter a victim of
trafficking while they are still in captivity (The others are clergy, law enforcement,
and school systems) (Crane, & Moreno, 2011). That is why the duration of this
essay will discuss the signs and symptoms trafficking victims typically present
when accessing treatment. You will gain an understanding of the victim’s situation
which affects their mindset. Knowing this will directly affect your ability to move
forward in treating the victim and aiding in their rescue.
The Mindset of the Victim
Anytime a person experiences trauma, their attitude is severely altered which
is then linked to behavior change. Trauma can be broken into two areas, physical
and psychological. Medically speaking trauma is “a serious injury or shock
to the body” (The American Heritage Dictonary, 2000). Psychologically it is
“an event outside your control in which you experienced or witnessed a severe
physical threat” (Najavits, 2002). The vast majority of human trafficking victims
experience both forms. One study that interviewed 207 survivors of trafficking
showed the following: 76% had experienced physical violence, 90% experienced
sexual violence, and 71% experienced both during the time they were trafficked
(Barrows, DO, MA (Bioethics), & Finger, MD, MPH, 2008). That is why being
conscious of the victim’s trauma and sensitive in your questioning and response is
extremely important.
Adult Victims
Adult victims of human trafficking are typically overlooked. This is because
outsiders (friends, social service providers, family, and HCPs) assume that since
they are adults they are able to freely make good decisions for themselves.
When outsiders do not take a second look to see what is guiding the adult’s
decisions, they tend to make negative assumptions which leads to stigma. For
example, many times a patient may come into a hospital who is a known sex
worker. Nursing staff may assume “that’s a filthy lifestyle and she has a bad
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February, March, April 2018 The Bulletin 15
attitude, she’s getting herself into trouble and
abusing the system.” When the patient picks up
on the judgmental undertone of the nurse, they
will completely shut down due to shame and
anger – shame because the life consists of daily
sexual assault and anger because the nurse lacks
understanding of the patient’s circumstance. Did
the nurse stop to think about how someone would
end up in this profession? If the nurse would take
that time, he or she would find that most likely the
“lifestyle” was introduced to the patient as a child.
The U.S. Department of Justice Child Exploitation
and Obscenity Section conducted a nationwide study
which found that as many as 70% of women involved
in prostitution are introduced to the commercial sex
trade in early adolescence (11-14 years of age) or
early childhood (U.S. Department of Justice).
The most conservative estimates suggest between
75% - 90% of adult female prostitutes are under
the complete control of a pimp (sex trafficker)
(Farley, Baral, Kiremire, & Sezgin, 1998). By federal
definition, this makes them victims of sex trafficking
because pimps/sex traffickers use both physical
and psychological torture to control “their” women
(Williamson, 2008). Pimps/sex traffickers will rape,
beat, verbally abuse, and threaten the lives of people
whom the women love. Such tactics consistently
lead to complete obedience and a breakdown of
personal agency and autonomy (Williamson, 2008),
thus making it easier for the pimps to profit off of
the women they control. The pimp is the one who will
receive all or most of the allocated money (or thing
of value: drugs, food, etc) for the sexual service the
woman provided, or rather ‘endured.’
The routine beatings and rapes do not leave these
women unscarred. The victims may appear to adapt
to their situations but it is only a defense mechanism
used to evade further pain. Victims learn ways to
negotiate favor amidst the violent environment where
pain and fear are imposed upon them whenever they
break a rule or attempt escape (Crane, & Moreno,
2011). Restricted movement, isolation, and battery
distort the woman’s reality. Victims survive by making
cognitive changes which allow them to believe their
situation is better than it really is compared to other
life experiences they witness or imagine. Most will
reach a point of complete mental defeat as they give
up hope for a better life (Crane, & Moreno, 2011).
Post-Traumatic Stress Disorder (PTSD) is an
anxiety disorder that results after one sees or
experiences a traumatic event. The symptoms that
result include acute anxiety, depression, insomnia,
persistent flashbacks of the event, physical hyperalertness
and self-loathing that is long-lasting and
resistant to change (Bisson, & Andrew). One research
study interviewed prostituted women from nine
different countries. They found the level of PTSD
in these women to be at 68%, which is the same
range as that of combat veterans (Farley, 2003). The
damaging effects of trauma infiltrate almost every
aspect of trafficking survivors’ lives. Trauma causes
women to become consumed by PTSD symptoms and
the abusers teach women to distrust the world and
feel worthless.
Since women in the sex industry are surrounded
by people who control them, sexually exploit them, or
judge them, they rarely have a concept of a healthy
human relationship. My experience in working
directly with adult survivors of sex trafficking and
prostitution has shown me that the confusion about
healthy relationships lead to the greatest challenges
in recovery. Humans are relational creatures and sex
is the ultimate act of intimacy. Though we can argue
the varying affects, it is evident that sex dramatically
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shapes ones attitude toward relationships. For women
trapped in the sex industry this can be the heart of
the dysfunction. These women are made to enter
into complete intimacy with strangers, sometimes
up to 7 days a week. The actions of “John’s” and the
indoctrination of traffickers construct the identity of
a woman as purely sexual. If you are engaged in the
sex industry, almost 100% of your time is consumed
by sex. You are having sex, surrounded by it, or
recovering from it.
Therefore, no time passes before you begin to
believe the lie that your only source of value is in your
sexuality. This lie breaks down a woman completely
because there is no greater way to dehumanize an
individual than objectifying them to nothing more
than flesh. Tania, a survivor from Eastern Europe,
says “They {traffickers and clients} didn’t see us as
human beings, but just as whores, just as flesh that
they could use. That’s all” (“Interview tania,” 2006).
Once sexual violence brings a woman to this point,
the real psychological collapse begins. Survivors of
sex trafficking are left with major emotional burdens
that include severe depression, immense feelings
of shame and grief, overwhelming anxiety, selfdestructive
behaviors (self-mutilation/suicide) as well
as disassociated ego states that result in mind/body
separation (U.S. Department of, 2009).
Minor Victims
When children are violently stripped of their
innocence through painful labor and sexual
aggression, they are left with an equal burden
of psychological damage. The crime of human
trafficking involves kidnapping, restraint,
brainwashing, ongoing sexual molestation,
depravation of physical needs (proper sleep, medical
care, nutrition), and over use of the body from a
developmental standpoint. The core symptoms that
result from these forms of trauma result in thought
patterns which include: Shame, Powerlessness,
Betrayal, and Ambivalence. These core concepts
were identified by Megan Crawford, a licensed Social
Worker who counsels minor victims of sex trafficking
in Columbus Ohio, in combination with theories from
Dr. Dan B. Allender.
Shame: Girls who are trafficked feel shame. The
shame exists despite the fact that it is produced
by situations which are not their fault and more
importantly out of their control. The girls are made
to believe that they enjoy the sexual activity and are
willing participants - threatening her wellbeing if she
doesn’t cooperate, but vocalizing that she is obtaining
pleasure from the act as a “good” adult woman
should. This coercion works well at the developmental
stage of childhood and adolescence. Many times
actual sexual arousal happens despite the fear.
This mixed with the natural desire for love and
intimacy creates conflict. The girls hate and mistrust
their hunger for male relationships as all previous
relationships have been damaging.
In reality, the shame and pain felt results from
failed trust. However, children are not able to process
this truth so in attempts to protect them from further
pain, girls begin to blame themselves and develop
self-loathing behaviors. Girls often listen to the lies
and decide that they are the source of their own
misery. This is easier than attempting to understand
the magnitude of the abuse they are suffering at the
hands of those who are supposed to care for them
properly.
Powerlessness: Minor victims feel powerless which
results in despair and becoming emotionally dead to
the surrounding world. This happens because there is
a major “loss of self” (Allender, 2008). Girls feel like
strangers in their own skin as they’re disconnected
from their bodies as a result of trauma. When you
are a victim of trafficking, you are owned by someone
else. As a young victim, you become bonded to that
abuser and your identity is what they create. You
don’t have your own likes or dislikes. What type
of things you like; the places you go, what clothing
you wear are all decided by the pimp. Stunting
this growth process is very damaging because
adolescence is the crucial stage of development when
identity is formed.
Therefore, you typically become molded for
life with the individuality generated by the one
exploiting you (Crawford, 2011). It becomes hard to
Independent Study continued on page 16
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16
The Bulletin February, March, April 2018
Independent Study continued from page 15
differentiate the lies from the truths. More often
then not, the negative coercion will overpower
the truth and girls develop hardened hearts, self
hatred, aggressive attitudes, distrust of others,
and identity confusion. Girls may wholeheartedly
adopt the belief that they are “stupid or naïve,”
“worthless or stained,” “completely used
and discarded,” and undeserving of kindness
(Crawford, 2011). That is until someone can
come in and guide them to view themselves with
compassion.
Betrayal: Girls feel the major effects of betrayal
because they are betrayed by people who promise
to protect them. The costs of this are destructive
and the following are produced:
Hypervigilance - When a person is constantly
tense and “on guard.” A person experiencing this
symptom of PTSD will be motivated to maintain
an increased awareness of their surrounding
environment with the goal to never be surprised
(Tull, 2009).
Suspiciousness - A haunting feeling of mistrust
that motivates a person to engage with someone
and then pull away in fear of harm (in relation to
PTSD) (Lanham, & Charette).
Distortion & Denial - The victim/survivor will live
in a haze and lack objectivity (Allender, 2008).
Loss of a Hope for Strength & Justice - gives
up hope for protection, goodness, independence
(Crawford, 2011).
Loss of the Hope for Intimacy - Comes to
believe that intimacy with another person is either
dangerous or unreal (Allender, 2008).
The betrayal can also be used as another
mechanism of control by the traffickers.
One negative encounter with a social service
professional, or lie about them, can set future
precedent. For example, hospital staff or law
enforcement may treat them as a delinquent teen
rather than a victim, reinforcing the idea that there
is no one who understands or cares about their
pain.
Traffickers will use any opportunity to highlight
a truth or a lie that will make the victims feel as
if they are betrayed by the system (meaning social
services, hospitals, law enforcement) so they
become hopeless and more dependent on the
trafficker (Crawford, 2011).
Ambivalence: Girls feel ambivalent towards
their individual situations. This means they feel
two contradictory emotions at the same moment.
When minors are trafficked, “Traumatic Bonds”
may form; positive feelings/loyalties to the abuser
(trafficker) (Allender, 2008). Dr. Allender is quoted
as saying “central to understanding ambivalence
is the fact that the very thing that was despised
also brought some degree of pleasure.” It makes
sense that a girl who was starved for love and
attention her whole life received those to some
degree from her trafficker. In the back of a girl’s
mind she knows that the very person who is
abusing her has the power to save and protect her
from worse harm. This Traumatic Bond becomes a
form of “love language” that they use to relate to
other people. Due to this effect, after a child victim
attains freedom they may sometimes return to the
trafficker/pimp because their sense of self is so
engrained in that individual (Crawford, 2011).
Secondary effects of trafficked girls drastically
affect their behaviors and future health. Many
surface in unusual ways like: sexual promiscuity,
addiction, complete or loss of sex drive. Regardless
of where they lie on the spectrum, all minor victims
of trafficking have a broken, distorted view of
sex because everything in their lives was at one
point prematurely sexualized (Allender, 2008).
Sexual addiction can become a way of normalizing
the unwanted actions that were done to them
previously.
Other compulsive disorders exist because
of the survivor’s desire to regain a control that
was previously taken. Many girls will struggle
with substance abuse, eating disorders,
perfectionism, Obsessive Compulsive Disorders,
and self-mutilation in the aftermath of their trauma
(Allender, 2008). It can also mean taking power of
one’s out of control emotions.
International Victims
International victims of trafficking face many
barriers that prevent them from becoming free.
Foreigners trafficked into the U.S. are not only
traumatized but are completely out of the comfort
of their home culture. These victims do not
understand the people, language, or cultural norms
of the United States. Traffickers feed false realities
(to those they control) about professionals (law
enforcement, social services, and health providers)
so those they control will distrust those systems
and not seek help (Crane, & Moreno, 2011). A
15-year-old Nigerian girl trafficked as a domestic
servant was told by her family that doctors in
American hospitals would give her medicine that
would paralyze her. Therefore, when the girl was
identified in an East Side Columbus Hospital she
fought nurses and refused medication.
Traffickers will also cultivate distrust of
authorities by playing on the victim’s fear of arrest
and deportation. The victims are made to believe
that they are the criminals as they are engaging
in unlawful activity in a country in which they do
not legally reside. Documentation is often taken
or destroyed to further ingrain this belief (Crane,
& Moreno, 2011). In order to rescue international
victims, it is essential to enlist the trust of
translators to bridge the communication barriers
and dispel the myths that victims are convinced
are true.
The Role of the Nurse
As a nurse you are given an opportunity that few
other professionals have to free victims of human
trafficking. Health care providers are among only
four professions where you are likely to encounter
a victim while they are still in captivity (the
others being clergy, law enforcement, and school
teachers) (Barrows, DO, MA (Bioethics), & Finger,
MD, MPH, 2008). In a study of survivors from
San Francisco, Los Angeles, and Atlanta areas,
researchers found that although 28% came into
contact with health care providers during their
captivity, the providers didn’t realize their patients
were being trafficked (Family Violence Prevention
Fund, 2005).
Upon entering a patient’s room, begin an
initial assessment of the patient’s medical issues
and demeanor. Both government agencies and
Nongovernment Organization (NGO’s) have
developed a list of clues that a victim of trafficking
may exhibit. Assess for the following (U.S.
Department of, 2008) (Hughes, 2003):
• The patient is accompanied by another person
who seems controlling.
• The accompanying person insists on giving
health information.
• The patient acts unusually fearful or
submissive.
• The patient does not speak English.
• The patient speaks some English, but
someone else is speaking for him or her.
• The patient has recently been brought to this
country from Eastern Europe, Asia, Latin
America, Canada, Africa, or India.
• The patient lacks a passport, immigration, or
identification documentation.
• The person doesn’t seem to know where she
or he is.
• The person has no spending money.
• The person appears to be under the control
and supervision of someone who never leaves
the person alone.
• There are signs of malnutrition, dehydration,
drug use or addiction, poor general health, or
poor personal hygiene.
• There are signs of physical abuse or neglect,
such as scars, bruises, burns, unusual
bald patches, tattoos that raise suspicion
(for example, “Property of—” or gang-like
symbols), or untreated medical problems.
• The person appears depressed, frightened,
anxious, or otherwise distressed.
• The person’s story about what she or he is
doing in this country or on the job doesn’t
make sense.
• The person lives with an employer or at
the place of business and can’t give you an
address.
If you answer “yes” to any of the questions
above, you should investigate further as there
could be trafficking involved. None of these
solely indicate if there is trafficking but raise the
possibility. Further questioning may lead to the
discovery of another form of abuse the patient is
enduring. It is vital that we begin to put human
trafficking on our radar as we automatically screen
for domestic violence or sexual abuse in hospitals.
Presenting medical issues can also be
indicators of a trafficking situation. Victims of
this crime typically receive health care only
when their conditions become life threatening or
dramatically affect their ability to work (Barrows,
DO, MA (Bioethics), & Finger, MD, MPH, 2008).
Preventative care is almost nonexistent for preexisting
conditions (Cole). This is because entering
a health care setting presents a high amount of
risk to the trafficker about exposing their crimes
(Barrows, DO, MA (Bioethics), & Finger, MD,
MPH, 2008) (Isaac, Solak, & Giardino, 2011)
(Zimmerman C, Yun K, Watts C, 2003):

February, March, April 2018 The Bulletin 17
• Bodily injuries from extreme physical
stress (cigarette burns, fractures, bruises,
contusions)
• Hepatitis (as well as other bloodborne
diseases)
• Reproductive and genitourinary issues
• Multiple Sexually Transmitted Disease
infections (Including HIV/AIDS)
• Tuberculosis
• Malnourishment
• Poor dental hygiene
• Older broken bones that did not heal properly
• Traumatic Brain Injuries
• Pregnancy and abortion-related complications
(for women and pubertal female children)
• Chronic back, visual, or respiratory problems
from working in dangerous manual labor
conditions
• Drug and alcohol dependency
• Abnormal menstrual cycles (unusual
discharge, chronic vaginal and cervical
infection, pelvic inflammatory disease) leading
to pain during intercourse and an unpleasant
odor from infections
A study published in 2014 included 107
survivors of domestic sex trafficking, ages 14-
60, from 12 cities across the U.S. including Ohio.
These survivors shared their health concerns. The
majority (88%) of these survivors stated they had
contact with the healthcare system while being
trafficked.
Common forms of violence/abuse included:
forced sex (82%); punched (74%); beaten (69%);
kicked (68%); forced unprotected sex (68%);
threatened with a weapon (66%); strangled (54%);
abused by a person of authority (51%).
Common health problems included: Any physical
health problem (99%); neurological (92%); general
health (86%); injuries (69%); cardiovascular/
respiratory (69%); gastrointestinal (62%); dental
(54%).
Psychological health problems included:
depression (89%); flashbacks (68%); shame/guilt
(82%); PTSD (55%); attempted suicide (42%).
Best Practices for Communicating with Victims
The key to utilizing this power is to identify the
victim on your own. You cannot expect the victim
to self-identify. It is extremely rare that a victim of
trafficking will vocalize their needs because they
do not realize they are victims. Additionally, victims
live in fear of being discovered as the threats
regarding exposure are immense. For example,
before entering a hospital a victim may be told by
her trafficker, “If anyone in there finds out what
you’re doing, I am going to make sure your friend
doesn’t eat for a week.” This is why asking the right
questions in the proper ways are so imperative.
The first step in overcoming these obstacles is
to build trust and rapport with the potential victim.
Ideally you will have the time it takes to generate
this trust through ongoing personal encounters,
but most likely this will need to be done at a
rapid pace. Upon beginning to treat a victim, give
them respect and some degree of control through
choice. If they are a victim of trafficking, they have
no power or ability to choose what happens to
them on a daily basis. Therefore, any element of
choice you can give them will allow the victim to
see you as a nurse who they can trust. Having the
victim make a decision about what type of drink
they would like, when they prefer to take medicine
(if that is an option), if they would like the curtains
open or closed, or when they want the specialists
to come by will help make them feel powerful. At
no point can you take for granted what the victim
may be deprived of and how that has devastated
their self-worth.
Good interviewing and questioning begins with
the understanding that asking direct questions
will most likely not lead you to connect with the
potential victim or gain the truth of their story.
Victims are often “coached” by traffickers on
how to answer these direct questions and have
stories prepared to deter any suspicions of abuse.
A victim of trafficking will not connect with the
term “human trafficking” due to unfamiliarity with
the term; being unaware that it is a crime, and
disbelief that their unique circumstance could fall
under the specifications of a crime because of selfblaming.
Asking questions surrounding the issues you
suspect will give you the answers to your initial
concerns. If you ask directly “are you involved with
prostitution?” the patient will feel embarrassed,
exposed, and immediately shut down. A survivor
of trafficking involved in The Salvation Army of
Central Ohio’s Anti Human Trafficking Program,
I’ll call Ann, describes one of her short encounters
with the heath care field. She encourages nursing
staff to be sensitive with questioning. Ann was
forced into street prostitution at age 17; she had a
violent pimp who deprived her of all human rights.
Ann became extremely ill and was finally escorted
to a medical clinic. The doctor informed her that
she had tumors covering her fallopian tubes. Ann
remembered the doctor being kind and how much
that helped her see the hospital as “a way out.”
However, this dream was temporarily cut short
once the physician asked “Ann, are you taking hard
drugs? Are you walking the streets?” Ann admitted
that the direct questioning made her “clam up”
because there was implied judgment that she was
doing bad things and that she had gotten herself
into that situation. Years after this opportunity for
freedom was missed, Ann said she still wishes the
doctor would have taken the same time to simply
ask “Are you alone? Are you afraid?” Ann said that
she realized his abilities were limited as he was a
doctor, safely on to the next patient, but also saw
him as an opportunity. Ann said all it would have
taken was for the doctor to say “Is there anything
that I can do to help other than perform surgery?”
to give her the confidence to say she was trapped,
as the woman waiting in the lobby was sent by the
trafficker to watch her every move.
This real life example demonstrates the need for
nurses to be sensitive to what is unknown about
the patients they come in contact with regularly.
A more sensitive approach for interviewing would
be asking a series of related questions in which
a discussion can grow; “What do you do to make
money?,” “How many sexual partners have you had
in the past 30 days?,” “Is there someone who is
making you do something you don’t wish to do?,”
“What are the obstacles that are preventing you
from getting off of the streets?” The answers to
these can help paint the picture of the patient’s
life without making them feel judged or threatened.
Generating an environment where the patients
feel comfortable talking with you is also necessary
if you want to receive the truth. Isolating the
victim from anyone who accompanies them is the
first step. This must be done in a non-suspicious
manner because even the most unlikely person
can be a trafficker or someone who is loyal to the
trafficker. Informing all who came with the patient
that it is the facility’s protocol that the patients
only interact with staff during the first exam has
been noted to be simple and successful.
The second step is enlisting the skills of a
translator or social service professional (like a
hospital social worker) if necessary. Typically, too
many new people can be overwhelming, but if the
patient does not speak English or is a minor, the
additional social supports may be necessary to
foster good communication. It is at this point that
you must stress confidentiality and safety. Inform
patients of their rights of confidentiality according
to your facility’s guidelines. In general potential
victims will want to know that the information
they say will not leak to the trafficker under any
circumstances. This is not to override honesty.
Almost all victims would rather hear a hard
answer than a lie because they have been fed
false truths so much. A disappointing but genuine
answer will speak volumes to you as a nurse as
it allows them to trust your words. For example,
let the patient know that if you assess there is
potential that the victim could be further harmed,
they will need to tell authorities to protect them
from further abuse.
Once you move into the information gathering
stage of assessment, after the immediate medical
needs are met, carefully craft your questions.
You can utilize the list of questions below.
These were generated to help guide you to some
understanding of your patient’s situation without
directly confronting the issues they fear will
become exposed.
Independent Study continued on page 18

18
The Bulletin February, March, April 2018
Independent Study continued from page 17
o What type of work do you do and can you
leave that situation if you want?
o Are you paid for your work? If so, how much
do you keep for yourself?
o When you are not working, can you come and
go as you please?
o Have you been threatened with harm if you try
to quit?
o Has anyone threatened your family?
o What are your working or living conditions
like?
o Where do you sleep and eat?
o Do you have to ask permission to eat, sleep or
go to the bathroom?
o How did you come to this facility? City? State?
o Is there anyone who has your identification?
Simultaneous with questioning is counter
messaging the negative thoughts of the victims.
Victims of trafficking feel trapped and scared as
their lives are constantly threatened. Even though
as a nurse you’re offering help, they will see your
questioning as something that will lead them into
trouble. While you are asking these questions,
keep in mind that you need to speak past the
brainwashing. As noted, victims are fed lies about
hospitals and will initially believe the lies over what
you say for the majority of your encounter.
Messages to convey while communicating with
potential victims (Barrows, DO, MA (Bioethics), &
Finger, MD, MPH, 2008):
• We are here to help you; you deserve to be
free of abuse
• We will not judge you for anything you say or
any situation you have been in before
• Our first priority is your safety
• We are not in the business of deportation
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• We will give you the medical care that you
need
• We want to make sure what happened to you
doesn’t happen to anyone else
• No one deserves to be suffering abuse at the
hands of another
• You are entitled to assistance; we can help you
get assistance
• If you are a victim of trafficking, you can
receive help to rebuild your life safely in this
country
If a patient keeps denying all accusations
or becomes disengaged, but you still feel like
something is not right, keep pursuing. Your
instincts as a nurse are key. If you’re uneasy about
a person’s attitude, then it is worth the time to
investigate further. As a nurse your role is not to
discern the whole truth about the patient’s life or
trafficking situation, but to assess the need for
medical intervention and follow up care.
Safety Concerns
Security is an important issue when identifying
a patient who may be a victim of trafficking. There
may be an immediate or potential safety concern
for the patient as well as the staff. Best practice
is to review the potential safety concerns now,
to avoid the confusion that could ensue when
encountering a potential trafficking patient. These
safety concerns should then be discussed with
your safety officer and supervisors, and have a
plan of action in place.
If there is an immediate concern, dial 911
immediately and provide a safe place for the
patient. If there is not an immediate concern for
the safety of the patient or staff, you may call the
national hotline or your local human trafficking
hotline for further advice on the best response to
the situation at hand. When you call the national
hotline, you may be referred to your local coalition,
with local resources and advice on how best to
address this patient’s immediate needs.
Follow up care
So what happens if your instincts are correct
and your patient is a victim of human trafficking?
There is much that needs to happen to rescue
and restore the victim. There are many people,
like therapists and social workers, who will play a
part. The needs of trafficking victims upon rescue
are great. Immediate assistance includes medical
care, housing, food, clothing, and safety. Mental
health follows with trauma counseling and therapy.
Income assistance and legal status present
challenges as well (Barrows, DO, MA (Bioethics),
& Finger, MD, MPH, 2008). In order to not be
overwhelmed, focus on what you can offer as a
skilled nurse. You have three main tasks:
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1.) Treating the medical needs (ideally with
follow up care)
2.) Identifying the victim and fostering their
rescue through questioning and assessing
3.) Making the proper referrals (social services,
law enforcement, safe family member, etc.)
Your skill base as a medical professional is to
treat and ideally heal the presenting medical
issues upon arrival. Concurrently, by taking the
time to understand the patient’s emotional needs
and life circumstances, you can instill in them
the desire for freedom. Just as important as
giving them hope for a better life, you are able to
foster that hope with your status as a health care
professional. As a nurse you are a valued and
trusted member of society who has the power to
contact others that can help the victim attain
safety. When you begin to make the referrals you
see necessary, make sure they are all discussed
with the patient. Patients will feel great anxiety
if they are unaware of their surroundings or next
steps forward. You must come mutually to the
decision to call outside supports. If you find it
necessary regardless of their consent (for example
a minor where you are mandated to call children
services), you must explain in detail why you came
to that decision, who you are informing, when they
will arrive, and your best idea of what will happen
when more people hear their story.
If you have any doubts about your assessment
of a patient, you can confidentially call the
National Human Trafficking Hotline for guidance
at 1-888-373-7888. This operates 24 hours a
day seven days a week. This can also be a way
to help the victim if your best attempts to rescue
them fall short due to circumstances outside
your control.
Giving the phone number to someone you
may believe to be trafficked on an inconspicuous
note card can give the victim the opportunity
to seek help when the time is right. Do not be
disheartened because more often than not, this
may be all you can do to help someone. However,
it is not to be underestimated. Just by offering
a trafficked victim respect, the knowledge that
there are people out there who want to help and
the power to help themselves (having them hold
onto a hotline of which the trafficker is unaware) is
invaluable.
As a nurse the number one thing you can offer
these victims is Hope. You may be the only person
who ever tells them that they have worth and the
possibility of a better life. The attention you show
as a nurse to the victim’s needs, both physically
and emotionally will not go unnoticed. They will
hold onto the security you offer with your affection
and trust that the facility you work in can offer
them freedom. When nurses utilize the skills listed
throughout this paper and understand the mindset
of a trafficking victim, they can ultimately give
more than nursing care, they can offer hope.
Registration Form
Name:______________________________________
(Please print clearly)
Address:____________________________________
(Street)
___________________________________________
(City/State/Zip)
Daytime phone number:_______________________
Please email my certificate to:
Email address:_______________________________
Fee:_______ ($20)
ISNA OFFICE USE ONLY
Date Received:___________
Check No._______________
Amount:___________
MAKE CHECK PAYABLE TO THE
INDIANA STATE NURSES ASSOCIATION (ISNA).
Enclose this form with the post-test, your check, and the
evaluation and send to:
Indiana State Nurses Association
2915 N. High School Road | Indianapolis, IN 46224

February, March, April 2018 The Bulletin 19
Understanding Human Trafficking in the Nursing Sector
Post-Test and Evaluation Form
DIRECTIONS: Please complete the post-test and evaluation form. There is only one answer per question.
The evaluation questions must be completed and returned with the post-test to receive a certificate.
Name:_______________________________________________________________________________ Date:____________________________ Final Score:________________
1. Human trafficking is ranked ___
on the global scale of organized
crime?
a. First
b. Second
c. Third
d. Eight
2. Based on federal reports how many
victims of trafficking are being
brought into the U.S. annually?
a. 14,500 – 17,500
b. 21,000 – 24,000
c. 100,000 – 300,000
d. 18,000 – 20,000
3. When are victims of human
trafficking typically going to come
in contact with health care?
a. When the ailments/injuries first
surface so that they can be
addressed before the victim’s
ability to profit the trafficker
diminishes
b. When there is a health clinic
that offers free services in a
convenient location
c. When the injuries/ailments
become life threatening or
have interfered with the
victim’s ability to make money
for the trafficker
d. When health care professionals
conduct outreach to the
patients in their facilities and
communities
4. When a nurse cares for a patient
who may be a victim of trafficking
(sex or labor), they should be most
cautious and sensitive to what?
a. The victim’s physical and
psychological trauma
b. The victim’s physical injuries
c. The victim’s medical history
d. The victim’s understanding of
cultural norms
5. Post-Traumatic Stress Disorder
(PTSD) is extremely common
amongst trafficking victims; it is a
______ disorder, which symptoms
include ______, _______,
_______.
a. Anxiety Disorder; violent
outbursts, insomnia, obsessive
compulsive traits
b. Adjustment Disorder;
persistent flashbacks,
resistance to change,
aggression
c. Anxiety Disorder; depression,
persistent flashbacks, hyperalertness
d. Obsessive Compulsive
Disorder; sleep loss,
compulsive hand washing, selfloathing
6. What are the core symptoms that
result from trafficking related
trauma in youth, identified by
Megan Crawford (LSW) and Dr.
Dan B. Allender?
a. Shame, Powerlessness,
Betrayal, and Ambivalence
b. Powerlessness, Anger,
Confusion, and Grief
c. Grief, Shame, Anger, and Role
Confusion
d. Ambivalence, Distrust, Self-
Hate, and Powerlessness
7. What is one major result of a girl
feeling powerless?
a. Content
b. Loss of Self
c. Distrust
d. Hostility
8. What is one reason “Trauma
Bonds” often form between a
trafficking victim and the abuser?
a. A girl realizes that the very
person who is abusing her has
the power to save and protect
her from worse harm
b. The victim is naive and doesn’t
know any other way to act
c. The abuser who the girl
despised also brought her
some degree of pleasure or
happiness
d. A & C
9. Why do some minor victims of
trafficking become or appear to be
sexually promiscuous?
a. It becomes a way to normalize
the previously, unwanted
actions
b. They develop a genuine
fondness of sexual activity
c. The girls have more
opportunities to meet men
d. More people realize they can
take advantage of the girls
10. What barriers exist for international
victims of trafficking to come
forward to nursing staff about their
abuse?
a. They do not speak English or
their skills are limited
b. They do not understand the
cultural norms
c. They are fed lies about
medical professionals by
traffickers and distrust the
nurses
d. All of the above
11. Health care providers are among
only four professions where you
are likely to encounter a victim of
human trafficking while they are
still in captivity.
a. True
b. False
12. Which of the following is NOT an
indicator that a patient may be a
victim of human trafficking?
a. The patient’s story about
what she or he is doing in this
country or on the job doesn’t
make sense
b. The person accompanying the
patient insists on giving health
information
c. The patient forgets his/her
medical history
d. The patient lacks a passport,
immigration, or personal
identification
13. Why is preventative health care
almost nonexistent for victims of
trafficking?
a. The victim or trafficker cannot
afford the care
b. It builds strength and
endurance for the victim to
keep working
c. Few low income health clinics
exist in areas where trafficking
is present
d. Traffickers don’t allow their
victims to access treatment
because entering a health care
setting presents a high amount
of risk to the trafficker about
exposing their crimes
14. Which of the following presenting
medical issues are not red flag
indicators that a patient may be a
victim of trafficking?
a. Traumatic Brain Injuries
b. Severe fainting spells
c. Multiple Sexually Transmitted
Disease infections
d. Older broken bones that did
not heal properly
15. What must first happen before you
can properly communicate with a
patient who is a potential victim of
trafficking?
a. The victim must receive food
and drink
b. The nurse must inform another
staff member of their concerns
c. The victim must have time
to relax and sleep off their
stressors
d. The nurse must treat the
impending medical concerns
and work to build rapport and
trust with the potential victim
16. In the story about Ann (the survivor
of trafficking), what did she say
would have helped make her
feel comfortable enough to tell
the doctor about the abuse she
was enduring at the time of her
captivity?
a. A hug and an approving look
from the doctor
b. Indirect questioning about the
activities she was made to
perform and genuine concern
for her wellbeing
c. The promise that the doctor
could single handedly help her
become free
d. A bribe that would have been
favorable to Ann
17. When gathering medically relevant
information from a patient you
assume may be a victim of
trafficking, rather than asking a
patient “are you being trafficked by
someone?” you could ask:
a. “Is someone raping you for
profit?”
b. “Tell me details about the
sexual experiences you’ve been
having”
c. “I think you may be a victim of
trafficking; would you agree?”
d. “Are you being made to do
something you don’t want to
do?”
18. Why is it important to interview
trafficking victims alone?
a. It limits the amount of staff
filling out paperwork
b. The greater the number of
people involved the more
complicated the assessment
can become
c. For the client’s safety because
even the most unsuspecting
person can be a trafficker or at
least loyal to the trafficker
d. It is quieter and creates a
more therapeutic environment
for the patient to self-disclose
19. Which of the following is an
important message to convey to
a potential trafficking victim who
seems fearful?
a. “We are here to help you, you
deserve to be free of fear and
abuse”
b. “This may be your fault and
you will have to confront that
at some point”
c. “If you don’t come forward
with the truth other people will
get hurt”
d. “I sense you’re scared and
that’s common after your body
has been brutalized”
20. What are the three main tasks
you have as a nurse to help assist
in rescuing victims of human
trafficking in a health care setting?
a. Counseling the victim, meeting
their medical needs, getting
them in touch with family
b. Treating the victim’s medical
needs, identifying the
patient as a victim through
assessment, making the proper
referrals to needed service
professionals
c. Making the proper referrals,
notifying law enforcement,
acting sympathetic to the
victim’s situation and needs
d. Getting the victim in touch with
family, meeting their medical
needs, acting as a counselor
21. You should never make a major
decision for a victim of trafficking
or take a step forward without
proper explanation.
a. True
b. False
EVALUATION
1. Was the outcome met?
OUTCOME: The nurse will be able
to explore the issue of human
trafficking and identify, as well
as communicate with, potential
victims of trafficking.
_____ Yes _____ No
2. What one strategy will you be able
to use in your work setting?
3. Was this independent study an
effective method of learning?
_____ Yes _____ No
If no, please comment:
4. How long did it take you to
complete the study, the post-test,
and the evaluation form?
5. What other topics would you like to
see addressed in an independent
study?