Dr. Sandie Morgan is joined by Lisa Murdock as the two discuss the critical response of medical institutions to human trafficking.
Lisa Murdock, MSN, RN, CNE Pediatric Acute Care Nurse & Co-Chair Healthcare subcommittee of the Orange County Human Trafficking Task Force. Over the past 23 years, Lisa has worked in pediatric acute care hospitals nationwide and in Puerto Rico. Lisa began her journey in anti-trafficking efforts in 2014 after meeting a survivor in the community. That meeting inspired her to expand her work to include exploitation and human trafficking in healthcare education and to implement comprehensive, multidisciplinary, evidence-based protocols for inpatient pediatric hospitals. Lisa believes that healthcare providers, specifically nurses, are uniquely positioned at the frontlines of patient care to identify, advocate, and improve healthcare outcomes for at-risk individuals or those already being trafficked. She is the co-founder of ReVEST Medical Experts which provides healthcare providers and institutions with the necessary tools to improve their knowledge, recognition, response and prevention of violence, exploitation, and risky behaviors amongst their patients and families.
- It is important to inform health care workers with an updated and accurate education regarding human trafficking to move away from the sensationalized imaging and education they might be receiving from the media.
- Using a screening tool that is comprehensive, including not just commercial sex trafficking, but also labor trafficking and aids in sensitively asking high risk questions, is important in both aftercare and prevention.
- It is essential for an organization to have a policy surrounding exploitation and human trafficking, as well as a response protocol in place, to ensure that people know who to call and how to respond.
- Upon discharge, it is critical a healthcare provider be aware of resources and referrals to provide the survivor with the tools they need to stay safe.
- Ensure Justice
- Human Trafficking Task Force Health Care Subcommittee
- Orange County Human Trafficking Task Force
- #278 – Identifying and Interacting with Minor Victims of Human Trafficking, with Dr. Jodi Quas
- #259 – Which Screening Tool Should I Use, with Dr. Corey Rood
- Ending Human Trafficking Handbook
- Orangewood Project Choice
Sandra Morgan 0:00
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You’re listening to the Ending Human Trafficking podcast. This is episode #313: Four Pillars of Medical Institution Response to Human Trafficking. My name is Sandie Morgan, and this is the show where we empower you to study the issues, be a voice, and make a difference in ending human trafficking. Our guest today is Lisa Murdock, MSN, RN, CNA. Look at all of those letters after her name. She is a pediatric acute care nurse, and here in Orange County, she is co-chair of our Human Trafficking Task Force Health Care Subcommittee. Over the past 23 years, Lisa has worked in pediatric acute care hospitals nationwide, and in Puerto Rico. Lisa began her journey in anti-trafficking efforts in 2014, after meeting a survivor in the community. That meeting inspired her to expand her work to include exploitation and human trafficking in health care education. Lisa believes that health care providers, specifically nurses, are uniquely positioned at the frontline of patient care to identify, advocate, and improve healthcare outcomes for at risk individuals or those already being trafficked. Lisa, welcome to the podcast.
Lisa Murdock 3:31
Thank you so much for having me, Sandie, I really appreciate it, especially as a fellow nurse and a mentor. I appreciate being here.
Sandra Morgan 3:39
I’m so glad to have you here. The focus I want to drill down on today is something that you have been so diligent to create here. As you are working in an acute care facility, as you are working in our anti-trafficking community and serving on our Orange County Human Trafficking Task Force, you’ve built a model, and collaborated with others on a model of four pillars for medical institution response to human trafficking. This is so helpful because so many times nurses particularly learn more about human trafficking, and try to get something started in their E.R. in their admission somewhere, and it becomes bogged down in lots of bureaucracy, and how do you take the next step? So today, Lisa is going to give us some solid foundations for how we proceed. So let’s start by taking a look at why you chose these four pillars.
Lisa Murdock 5:01
Absolutely, and I can give you a little bit of background too, as to why I got started in finding he action steps in working with acute care, and also survivors. We know that survivors are intersecting with health care providers and not getting recognized, not being linked to the resources needed, not having prevention, and our response for people at risk. So that really stimulated me into thinking, okay, how can we make this better? And then also, as I started talking with healthcare providers, specifically nurses, I think what people don’t realize, especially in large healthcare institutions, nurses are the largest part of the workforce, and nurses saying, “I knew there was something off, I knew I was missing something, but I didn’t know the right questions to ask or the right steps to take.” So that really inspired me to create something that would be both survivor facing and also assist providers in having the tools to do their job.
Sandra Morgan 6:08
I like that. And for me, when I was the taskforce administrator, I went to hospitals. I tried to get them to adopt algorithms and all kinds of things, but I was not part of the internal workings, and I think you brought that specific perspective to this. So how did you decide what elements had to be part of this foundational model?
Lisa Murdock 6:38
Well, I started with a response algorithm back in 2018, and it was really created based on other algorithms that I worked with, for other diagnoses. So we have an algorithm for asthma, for example, or appendectomies. It’s very common in healthcare for people to be familiar with response algorithms for certain diagnoses. So I basically took that format, and applied that to exploitation and human trafficking. But from there, I’ve done the Evidence Based Scholar Program and extensive literature review and synthesis, and realized that there were huge gaps in multiple facets of anti-trafficking work and response in healthcare. So first and foremost, education and training. So what is currently out there for education and training? A lot of times, and health care workers are susceptible to this as well, is the sensationalized imaging and education that they’re receiving from the media. So as I spoke with health care providers, they were still looking for kidnapping and other situations that aren’t really reflective of the scope of exploitation and human trafficking. So that was the first pillar, we definitely need updated, accurate education, on what is human trafficking and exploitation, where it intersects with health care, what it’s going to look like in different facilities and with different diagnoses, and also have the training not only on human trafficking and exploitation, but on trauma informed care. I look at trauma informed care. Many health care providers may have knowledge of what it is and how it affects the neurobiology of the brain, but I look at trauma informed care as a skill. So do you know how to implement it? Do you know how to ask the sensitive questions, provide a safe place, build rapport? So that is basically how I came up with that first pillar is looking at the literature, the gaps, and also from survivor study and perspectives on their experience within healthcare.
Sandra Morgan 8:58
Wow. Okay, so pillar one, education. What’s pillar two?
Lisa Murdock 9:04
Screening, so really asking the sensitive questions. Many people with lived experience for both, there’s multiple barriers to disclosure, both from the provider’s side and the survivor’s side. So from the provider side, maybe they’re not asking the sensitive questions, maybe they are not aware that most people entering health care are either fearful, feel ashamed, have been groomed to not say anything or evade the questions, so they may not readily disclose. So you really have to build the rapport and be able to ask those sensitive questions without judgment, and really creating the environment that would increase that disclosure. Using a screening tool that’s comprehensive, not limited to just sex trafficking, but that includes labor trafficking, that includes the high risk questions, so we can capture those at risk as well, before they’re exploited or being trafficked and end up in situations, or vulnerabilities that are beyond their control. So I think that’s another very important step that we need to take because it doesn’t just stop at education, we really need to go forward in order to make a difference.
Sandra Morgan 10:24
This idea of screening requires a little more rigor than just being trauma informed, and sensitive, and building rapport. Dr. Jodi Quas was on the podcast last year, with her research that showed that while youth and children with child abuse, child sexual abuse, will disclose in a certain kind of pattern, those who are being sexually exploited, commercially sex trafficked is the term we often use, are not disclosing. I know for myself that I have been in situations with victims, where I, in my mind, I’m asking the questions, and then I’m deciding, “Oh, okay, so she’s not a victim, oh, he’s not a victim,” so I skip to the next group of questions. So it’s not a necessarily great algorithm, because I’m making that choice. In a rigorous screening tool, you have to go through every checkbox and that helps overrule your own biases, and I think that’s an important piece. What would be a screening tool you would recommend?
Lisa Murdock 11:58
You know, I work closely with Dr. Corey Rood, and we both work in pediatrics. So he’s a child abuse pediatrician, and has done extensive work, both clinically, but then also in research and in the use of screening tools, even in other states, like Ohio and Utah, and we developed our own screening tool for youth under 18, just to fill some of those gaps, because there’s many screening tools that might focus on sex trafficking, or might focus on the adult population. I think that’s really important to capture both sex trafficking, labor trafficking, and also high risk behaviors. I think what, for me, is most important for institutions, is to make sure you’re using a screening tool that is for your population, the population that you’re working with. There are some conversations around not creating something that appears to be a checklist, to have more of a natural conversation, which, in part I agree with, but when you’re working with large healthcare institutions, and healthcare providers are working with multiple populations and diagnoses in a very fast pace setting, not everybody is going to have expert level of human trafficking, exploitation, trauma informed care, and screening tools. So it’s really having a screening tool that’s written in a trauma informed way, that is applicable to your settings. So a very long screening might not be applicable, like an emergency room setting where things are very fast paced, you need a more efficient tool. The other thing I will say about screening, before you even get into choosing a validated screening tool for your population, we’ve created a checklist, both myself and Dr. Rood, to make sure that you have steps in place that it is safe, and you have these steps in place before you start screening. Are your staff educated? Once you start screening and you’re increasing your identification of people in these situations, do you have response and referrals in place? Which kind of go to our next pillar, but you really need all the pillars together, and you have to make sure you have the environment that’s going to be conducive to that safe response that’s based on evidence based practice.
Sandra Morgan 14:31
So when I’m listening to you, I’m thinking about that conversation about checklists and being more organic, and you know, pilots who have flown hundreds of flights use a checklist every time. So even if it isn’t a really overt process, it is still a very valuable process, and as we do move to the next pillar, I do want to remind listeners that Dr. Corey Rood did a whole episode about the screening tools, so I’ll put a link to that in the show notes. What’s the third pillar Lisa?
Lisa Murdock 15:17
I would say policy and protocol. Making sure your organization has a policy surrounding exploitation and human trafficking with a response protocol in place, so when you are identifying people with lived experience, or those vulnerable to trafficking, people know who to call, and how to respond.
Sandra Morgan 15:39
Lisa Murdock 15:40
This would really include that response algorithm that we’ve been talking about, but also a comprehensive policy that defines: What is human trafficking? What is exploitation, including youth under the age of 18, who are exchanging sex for something of value or a place to stay? That’s one that kind of falls between the cracks for some health care providers and pediatrics, and that is something I’ve seen in recent practice, where people are not aware that that still falls under that umbrella of exploitation. So really having a policy, and what that does is it extends beyond any one person’s employment or position in the organization. It’s something sustainable, it’s something that people in healthcare and multiple institutions, once you have a policy in place that’s defining what it is and how to respond, that will carry on beyond any one person’s employment.
Sandra Morgan 16:42
And this is the thing that I love about policy and you hear me say this often, it’s even in the Ending Human Trafficking Handbook that my friends and I wrote, that policies create process and develop patterns of ethical best practices. If you have policies in place, then someone who says, “Oh, I don’t think I need to do that this time because she looks like she’s got a good family support system around her,” policies help us overcome our own biases, and help us resist taking shortcuts.
Lisa Murdock 17:24
Absolutely. In healthcare, policies exist for many processes within institutions, I was surprised from my own experience at where human trafficking and exploitation was in policies. In one instance, it was mentioned in the Victims of Violence Policy, and it basically stated exploitation is a form of human trafficking. It didn’t define it, it didn’t say what that meant, what the federal definitions were, and it didn’t say how to respond or who to call. In pediatrics, anybody under 18, even if it’s just suspected that somebody is being exploited, that you need to call CPS and law enforcement, similarly with other abuse situations, but it wasn’t defined as such. So when somebody is pulling a policy, if it’s not complete and comprehensive as to what exactly is it and what to do about it, then it’s going to fall by the wayside. That’s why I feel policy is really important, and if you would have asked me 23 years ago that I started out in nursing, and I still work clinically at the bedside, that I would be advocating and writing policy…
Sandra Morgan 18:42
Oh my goodness me too!
Lisa Murdock 18:43
I’d be like, “Wait, I’m a clinical nurse, I’m a bedside nurse.” So if I can do this, anybody can do this, you just need to have the passion and the work ethic to really want to make a difference. That goes beyond hearing about human trafficking, and everybody has that kind of visceral reaction, like, “This is horrible. This is happening in our community, in Orange County.” I want to take it a few steps further and say, “We can absolutely do something about this. We have the evidence, there is multiple articles on all of these pillars, and what needs to happen to create this comprehensive response. Let’s do it. Let’s put these things in place.”
Sandra Morgan 19:24
Tell us the fourth pillar.
Lisa Murdock 19:26
Resources and referrals. Really important that we’re educating our staff, they’re trained on trauma informed care and actually how to implement it. We have a policy, a response protocol, we’re screening, we’re increasing identification. Okay, then what happens upon discharge? Do we have safety planning that needs to be survivor driven? Working with survivors on what is safe upon discharge, whether that’s a phone number, warm handoff to another agency, it really needs to be comprehensive, and it needs to be clear to healthcare providers, so they know who to call upon discharge. A lot of times, it’s discharge time and you’ll get your paperwork based on your diagnoses or whatever follow up you need to do, but do they have a safe place to stay, do they have resources? A youth survivor that I was talking with said, “Even if I had resources just for one night, would have been helpful.” Another youth had said, “Yeah, I was getting called noncompliant because I didn’t go to my appointments. But if you expect me to take the bus in my neighborhood where my trafficker was, or friends or my trafficker, I don’t feel safe taking the bus.” So you know, really asking questions about transportation, was I able to get there? And another interesting thing that I found in my work the last four years, is that not all health care institutions have the knowledge of what we have available in Orange County for resources. So whether it’s Project Choice, or Lighthouse, or other agencies, Way Makers for victims assistance. Many institutions weren’t aware, or how to coordinate those resources and conversations to create more of a comprehensive resource and referral follow up upon discharge.
Sandra Morgan 21:26
Those resources and referrals, for me personally, are one of the most critical steps in helping a survivor take the initiative themselves, for this not to be in the context of a rescue, but of a restoration. They’re part of the process, because it’s hard work. It’s not just moving from inside one building to outside. Many times in a healthcare situation, personally and I’m sure you’ve experienced this, you have to let them go, knowing that they’re not completely safe. So how do you give them all the possible tools and resources you can to help them reach a better outcome? I am so glad that’s part of this four pillar section. When I look at this, and if it’s okay with you, Lisa, I’m going to put this graphic in the show notes for this podcast, because overlapping all four of these pillars of education, screening, policy and protocol, and resources and referrals, is data collection and distribution. What does that mean? I have to have like a university professor here all the time?
Lisa Murdock 23:00
No, I think, I mean, it would be great, right? We’d have a biostatistician and researchers that were available for all units on all projects. But no, when it comes to data collection, it’s just really important that we are looking at each of these pillars, like let’s take education, for example, and just gathering data on that. Was it effective? Is it comprehensive? Is it equipping the provider with the tools they need to recognize and respond? And so what I have experienced with some surveys, so let’s just take education, for example, some surveys will say, “Do you feel that this education, this training, this webinar, has increased your knowledge, and your ability to recognize human trafficking or to know what it looks like? And of course, people are going to say yes, because after your webinar, you absolutely feel well equipped, because you definitely have a higher level of knowledge than you had before taking it. But it’s interesting, if you look at different studies, even ones done here locally in Southern California, if you give a provider or first responder a scenario, and then ask if they’re able to detect it, that doesn’t always happen. So it’s really being able to assess, using different scenarios, was it really effective? Are they really able to detect what exploitation, human trafficking, or high risk behaviors are after the training? So when it comes to data collection, it’s really taking that data on each of the pillars and see, is it comprehensive? Is it effective? Does it need to be modified and improved? Hospitals use PDCA cycles for many things. Plan, Do, Study, Act, you know, we’re very accustomed to looking at our response, and our evidence, and our practice, and then coming back to what can we do better. So it’s just taking the same cycles that hospitals already use to evaluate policy procedure, and just applying this to anti-human trafficking work.
Sandra Morgan 25:18
We’ve got four pillars, education and training, screening and implementation, policy and protocol, referrals and resources, and we’re collecting data on this. That’s like building a home, a house, and I think that there has to be a pretty comprehensive plan for starting this foundation, this model in your hospital, in your clinic. How are you going to do that? I was really impressed when you were asked that question, you created a flowchart for creating an organizational response. And for some of us, who we start off and we’re motivated, but then we don’t know what the next step is, I think this seven step process would be really helpful. Can you just run us through it very quickly?
Lisa Murdock 26:19
Yeah. So are you referring to kind steps to create an organizational response?
Sandra Morgan 26:24
Lisa Murdock 26:25
So this really starts with identifying a human trafficking champion, in your facility or institution where you work. This is really important, because if you don’t have somebody that keeps pushing momentum forward, in my experience, especially when the pandemic hit, if I didn’t keep caring and pushing forward talking to larger stakeholders, it would be really easy to kind of have that program fall through the cracks. So it’s really making sure that you have somebody to champion that within your organization. The next step would be to form a multidisciplinary team to address the needs of your institution when it comes to human trafficking and protocol implementation. That’s important. That includes all key stakeholders. So all departments, not just the emergency room, but maybe inpatient. If you work in a clinic, including physician social work, nursing, security, administration, making sure that you have that kind of multidisciplinary team to address all the needs.
Sandra Morgan 27:32
Lisa Murdock 27:33
The next step would be providing education in trauma informed care to all staff. Sometimes it needs to roll out in sections, so maybe start with clinical staff. I’m a firm believer that it really should be all staff that work within your institution. There have been situations where clinical staff have not picked up on a youth that is in this exploitive situation. Even environmental services heard a phone call while they were cleaning in the room and picking up the trash, heard the youth on the phone and reported it to staff. So that’s why I think it’s really important that everyone’s aware of the signs, risk identifiers, and have basic understanding of human trafficking and trauma informed care.
Sandra Morgan 28:23
And then we get to move to the next step
Lisa Murdock 28:27
Implementing a validated human trafficking screening tool for your patient population. The next step would be creating that patient response algorithm specific to your facility. So a flowchart basically, so people know what to do at each step of the way, with the list of the numbers so they’re not fumbling, looking for numbers while they’re in this situation. Having everything ready.
Sandra Morgan 28:27
Lisa Murdock 28:55
The next one would be ensuring that you have the referral and resources available for patients upon discharge, and then collecting the data. So knowing how many patients maybe you identified, that was a big one. When I started this program at an institution that I was working with, a biostatistician had asked me, “Well, how many have we seen in the past?,” and it will look like zero, because nobody’s actually recording it with the ICD 10 codes for the diagnoses. It’s really hard when people are doing retrospective chart reviews to really pull how many patients you’ve seen because nobody’s actually documenting it. Collecting data is really important, not only based on how many patients you’re seeing, but also is your education, up to date and effective, is your response, policy and protocol, is that effective? Do you have all the information you need? Have there been situations where there was a phone number or referral and resource on that algorithm that didn’t exist, and people can add to that to make it more more robust? Is your policy comprehensive? Does that need to be modified? Really collecting that data on all those pillars and then sharing that information with other institutions. Whether it’s at a national conference, whether it’s within your own county, maybe by being a member of your local coalition or Taskforce, but really making sure that information is available, because that is what’s helpful to other people. You know, when people talk about liability, like what if we see somebody that might be being trafficked and they get discharged, is that a liability? And I’m like, “No, the liability is if you’re not recognizing people.” People continue to get victimized, traumatized, and tortured, and we’re not giving them the tools they need to enter recovery.
Sandra Morgan 30:48
That leads to my favorite, because it’s almost like back to the beginning, now’s your opportunity to improve and modify, and this iterative process, every time we do it, we get better. We share that information and our community response is better as well. Lisa, there’s so much here. I am thinking through some of the areas where we need to drill down and I have to have you come back and do another podcast. So listeners, if you are in the healthcare field, and you have questions, I think we need to have a health care provider q&a. If I get enough questions, I’ll pull that together. In the meantime, as we wrap up this episode, Lisa, I am so grateful for your leadership, but especially for your ability to do the detailed and sometimes boring work. You nailed it. When you said as a bedside nurse, you’re like, I don’t want to do policy, and now it’s like you see the tremendous value. I think we all have to create space, as a movement in the health care, anti-human trafficking, create space for our various abilities and directions, because we need everybody in that section you talked about at the beginning of the seven steps. Interdisciplinary and multidisciplinary teams. I remember when I was a night charge nurse in pediatrics and we didn’t even have the language of “human trafficking,” but we did deal with sexual assault of children, and it was a respiratory therapist. That was the one who came and said, “I saw this, what should I do about that?” Everybody needs to be on the team. I love that in your response, protocol as well. Last statement, you’ve got one statement to close out. What do you want, especially nurses to do next?
Lisa Murdock 33:21
Well, first, I just want to thank all the survivors that are colleagues, friends, people with lived experience, who actually inspired me to go down this path and improving health care for all people, especially those most vulnerable. And to all the health care providers out there, it’s really working together to make sure they have the tools to do a better job, to improve practice, and to make sure that they don’t leave work, feeling like “I missed something. I feel like I missed something, I wish I could do something better.”
Sandra Morgan 33:57
Wow, and that is in the heart of every nurse. I have worked with nurses across the California area, nationally and internationally, male, female, everybody has this sense of care that extends beyond just, “I’m going to take your temperature, I’m going to get you well enough to discharge you. I want to see you thrive.” And that’s one of the things I love about being a nurse, and I think it’s why Lisa, you and I have stayed friends now for a decade, and I’m grateful for you. Thank you for being on the podcast today.
Lisa Murdock 34:45
Thank you so much for having me, Sandie.
Sandra Morgan 34:48
I will see you all again in two weeks. In the meantime, go to the show notes to find the links we’ve talked about here today, and if you haven’t been to the website, go over to endinghumantrafficking.org, where you can find a library of past episodes, of resources, and get more connected with our community.