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Texas Nursing Jurisprudence and Ethics

Introduction - Texas Nursing Jurisprudence and Ethics

The purpose of this course is to review nursing ethics and jurisprudence specifically as these relate to Texas state nursing practice and law (1). Each state nursing board works to promote the safety and welfare of clients in their state by ensuring nurses are competent to practice nursing safely.

As outlined by the Texas Board of Nursing continuing education requirements, Nursing Jurisprudence and Nursing Ethics Board Rule 216.3, all nurses, including APRNs, must complete the required two contact hours of CNE relating to nursing jurisprudence and ethics before the end of every third two-year licensing period. This requirement applies to licensing periods that began on or after January 1, 2014. All new nurses must also pass the Nursing Jurisprudence Exam (NJE) (2,3). 

Requirements also outline that education includes information related to the Texas Nursing Practice Act, the Board's rules, including Standards of Nursing Practice, the Board's position statements, principles of nursing ethics, and professional boundaries. Nurses are named in negligence and malpractice lawsuits that may claim unethical behavior/conduct, practice outside the scope of licensure, or lack of nursing supervision. Nurses must understand their state nurse practice act, scope of practice of nurse licensure, standards of practice, ethics, and professional boundaries to avoid litigation (2). 

The Texas Nursing Practice Act – Overview 

Registered Nurse Scope of Practice 

The Texas Nursing Practice Act (NPA) defines the legal scope of practice for professional registered nurses (RNs) (4). "Professional nursing" means performing an act that requires substantial specialized judgment and skill, the proper performance of which is based on knowledge and application of the principles of biological, physical, and social science as acquired by a completed course in an approved school of professional nursing. The term does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. Professional nursing involves: (4) 

• the observation, assessment, intervention, evaluation, rehabilitation, care, and Counsel, or health teachings of a person who is ill, injured, infirm, or experiencing a change in normal health processes. 
• The maintenance of health or prevention of illness. 
• A physician, podiatrist, or dentist orders medication administration or treatment. 
• The supervision or teaching of nursing. 
• The administration, supervision, and evaluation of nursing practices, policies, and procedures. 
• The requesting, receiving, signing for, and distributing prescription drug samples to patients at practices where an advanced practice registered nurse is authorized to sign prescription drug orders as provided by Subchapter B, Chapter 157. 
• The performance of an act delegated by a physician under Section 157.0512, 157.054, 157.058, or 157.059. 
• The development of the nursing care plan. 

The RN accepts responsibility for practicing within the legal scope of practice, is prepared to work in all healthcare settings, and may engage in independent nursing practice without supervision by another healthcare provider. The RN, focusing on patient safety, must function within the legal scope of practice and by the federal, state, and local laws, rules and regulations, and policies, procedures, and guidelines of the employing health care institution or practice setting. The RN provides safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs (5). 

Texas Nursing Jurisprudence and Ethics - Board Rules 

Texas Board of Nursing, Chapter 217, Rule §217.11, Standards of Nursing Practice (6) 

The Texas Board of Nursing regulates nursing practice within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted (6). 

• Standards Applicable to All Nurses. All vocational nurses, registered nurses, and registered nurses with advanced practice authorization shall: 
  • Know and conform to the Texas Nursing Practice Act, the Board's rules and regulations, and all federal, state, or local laws, rules, or regulations affecting the nurse's current area of nursing practice. 
  • Implement measures to promote a safe environment for clients and others. 
  • Know the rationale for and the effects of medications and treatments and shall correctly administer the same.

•  Accurately and completely report and document: 
  • The client's status, including signs and symptoms, is as follows: 
  • Nursing care rendered. 
  • Physician, dentist, or podiatrist orders. 
  • Administration of medications and treatments. 
  • client response(s). 
  • contacts with other healthcare team members concerning significant events regarding the client's status. 

• Respect the client's right to privacy by protecting confidential information unless required or allowed by law to disclose the information. 
• Promote and participate in education and counseling to a client(s) and, where applicable, the family/significant other(s) based on health needs. 
• Obtain instruction and supervision as necessary when implementing nursing procedures or practices. 
• Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations. 
• Notify the appropriate supervisor when leaving a nursing assignment. 
• Know, recognize, and maintain professional boundaries of the nurse-client relationship. 
• Comply with mandatory reporting requirements of Texas Occupations Code Chapter 301 (Nursing Practice Act), Subchapter I, which includes reporting a nurse: 
  • Who violates the Nursing Practice Act or a board rule and contributed to the death or severe injury of a patient. 
  • Whose conduct causes a person to suspect that the nurse's practice is impaired by chemical dependency or drug or alcohol abuse? 
  • Whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries. 
  • Whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior. 
  • Except for minor incidents (Texas Occupations Code §§301.401(2), 301.419, 22 TAC §217.16), peer review (Texas Occupations Code §§301.403, 303.007, 22 TAC §217.19), or peer assistance if no practice violation (Texas Occupations Code §301.410) as stated in the Nursing Practice Act and Board rules (22 TAC Chapter 217). 

• Provide, without discrimination, nursing services regardless of the age, disability, economic status, gender, national origin, race, religion, health problems, or sexual orientation of the client served. 
• Institute appropriate nursing interventions that might be required to stabilize a client's condition and prevent complications. 
• Clarify any order or treatment regimen the nurse has reason to believe is inaccurate, non-efficacious, or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse decides not to administer the medication or treatment. 
• Implement measures to prevent exposure to infectious pathogens and communicable conditions. 
• Collaborate with the client, members of the health care team, and, when appropriate, the client's significant other(s) in the interest of the client's health care. 
• Consult with, utilize, and make referrals to appropriate community agencies and health care resources to provide continuity of care. 
• Be responsible for one's continuing competence in nursing practice and individual professional growth. 
• Make assignments to others that consider client safety and are commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made. 
• Accept only those nursing assignments that consider client safety and are commensurate with the nurse's educational preparation, experience, knowledge, and physical and emotional ability. 
• Supervise nursing care provided by others for whom the nurse is professionally responsible. 
• Ensure the verification of current Texas licensure or other Compact State licensure privileges and credentials of personnel for whom the nurse is administratively responsible when acting in the role of nurse administrator. 

• Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: 
  • Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: 
    • Collecting data and performing focused nursing assessments. 
    • Participating in the planning of nursing care needs for clients. 
    • Participating in developing and modifying the comprehensive nursing care plan for assigned clients. 
    • Implementing appropriate aspects of care within the LVN's scope of practice. 
    • Assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs. 

• • Shall assign specific tasks, activities, and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. 
  • May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. 

• Standards Specific to Registered Nurses. The registered nurse shall assist in the determination of healthcare needs of clients and shall: 
  • Utilize a systematic approach to provide individualized, goal-directed nursing care by: 
  • Performing comprehensive nursing assessments regarding the health status of the client. 
  • Making nursing diagnoses serves as the basis for the care strategy. 
  • Developing a plan of care based on the assessment and nursing diagnosis. 
  • Implementing nursing care. 
  • Evaluating the client's responses to nursing interventions. 

• • Delegate tasks to unlicensed personnel in compliance with Chapter 224 of this title, relating to clients with acute conditions or in acute environments, and Chapter 225, relating to independent living environments for clients with stable and predictable situations. 

• Standards Specific to Registered Nurses with Advanced Practice Authorization. Standards for a specific role and specialty of advanced practice nurses supersede standards for registered nurses where conflict between the standards, if any, exists. In addition to paragraphs (1) and (3) of this subsection, a registered nurse who holds authorization to practice as an advanced practice nurse (APN) shall: 
  • Practice in an advanced nursing practice role and specialty by the authorization granted under Board Rule Chapter 221 of this title (relating to practicing in an APN role; 22 TAC Chapter 221) and standards set out in that chapter. 
  • Prescribe medications in accordance with the prescriptive authority granted under Board Rule Chapter 222 of this title (relating to APNs prescribing; 22 TAC Chapter 222) and standards set out in that chapter and compliance with state and federal laws and regulations relating to the prescription of dangerous drugs and controlled substances. (4) 

The Board's Position Statements 

15.28 The Registered Nurse Scope of Practice (See also the LVN Scope of Practice) (7) 

The Board of Nursing recommends that all nurses utilize the Scope of Practice Decision-Making Model (DMM) when deciding if an employer's assignment is safe and legally within the nurse's scope of practice (8). 

The Texas Board of Nursing (BON or Board) is authorized by the Texas Legislature to regulate the nursing profession to ensure that every licensee is competent to practice safely. The Texas Nursing Practice Act (NPA) defines the legal scope of practice for professional registered nurses (RN) (4, 9).  

The RN takes responsibility and accepts accountability for practicing within the legal scope of practice, is prepared to work in all healthcare settings, and may engage in independent nursing practice without supervision by another healthcare provider. With a focus on patient safety, the RN must function within the legal scope of practice and in accordance with federal, state, and local laws, rules, and regulations. In addition, the RN must comply with policies, procedures, and guidelines of the employing health care institution or practice setting. The RN provides safe, compassionate, and comprehensive nursing care to patients and their families with complex healthcare needs (9). 

This position statement aims to provide direction and recommendations for nurses and their employers regarding the safe and legal scope of practice for RNs and to promote an understanding of the differences in the RN programs of study and between the RN and LVN levels of licensure. The LVN scope of practice is interpreted in Position Statement (9). 

Every nursing education program in Texas must ensure that their graduates exhibit competencies outlined in the Board's Differentiated Essential Competencies of Graduates of Texas Nursing Programs Evidenced by Knowledge, Clinical Judgements, and Behaviors. These competencies are included in the program of study so that every graduate has the knowledge, clinical judgment, and behaviors necessary for RN entry into safe, competent, and compassionate nursing care. The DECs serve as a guideline for employers to assist RNs in transitioning from the educational environment into nursing practice. As RNs enter the workplace, the DECs are the foundation for developing the RN scope of practice (9). 

Completion of ongoing, informal continuing nursing education offerings and on-the-job training in an RN's area of practice serves to develop, maintain, and expand competency. Because the RN scope of practice is based upon the educational preparation in the RN program of study, there are limits to expanding the scope. The Board believes that successfully transitioning from one level of nursing practice to another requires the nurse to complete a formal education program. (10) 

The RN Scope of Practice 

The professional RN advocates for the patient and the patient's family and promotes safety by practicing within the NPA and the BON Rules and Regulations. The RN provides nursing services that require substantial specialized judgment and skill. The planning and delivery of professional nursing care are based on knowledge and application of biological, physical, and social science principles as acquired by a completed course of study in an approved school of professional nursing. Unless licensed as an advanced practice registered nurse, the RN's scope of practice does not include acts of medical diagnosis or the prescription of therapeutic or corrective measures. RNs utilize the nursing process to establish the plan of care in which nursing services are delivered to patients. The level and impact of the nursing process differ between the RN and LVN, as well as the levels of RN education (9). 

Assessment 

The comprehensive assessment is the first step and lays the foundation for the nursing process. The thorough evaluation is the initial and ongoing, extensive data collection, analysis, and interpretation. Nursing judgment is based on the assessment findings. The RN uses clinical reasoning and knowledge, evidence-based outcomes, and research as the basis for decision-making and comprehensive care (9). 

 Based upon the comprehensive assessment, the RN determines the physical and mental health status, needs, and preferences of culturally, ethnically, and socially diverse patients and their families using evidence-based health data and knowledge synthesis. Surveillance is an essential step in the comprehensive assessment process. The RN must anticipate and recognize changes in patient conditions and determine when reassessments are needed (9). 

Patient Diagnosis/Problem Identification/Planning 

The second step in the nursing process is nursing diagnosis and problem identification. The role of the RN is to synthesize comprehensive assessment data to identify problems, formulate goals/outcomes, and develop plans of care for patients, families, populations, and communities using information from evidence-based practice and published research in collaboration with these groups and the interdisciplinary health care team (9). 

The third step in the nursing process is planning. The RN synthesizes the data collected during the comprehensive assessment to identify problems, make nursing diagnoses, and formulate goals, teaching plans, and outcomes. A nursing plan of care for patients is developed by the RN, who is responsible for coordinating nursing care for patients. Teaching plans address health promotion, maintenance, restoration, and risk factors prevention. The RN utilizes evidence-based practice, published research, and information from patients and the interdisciplinary healthcare team during the planning process (9).  

Implementation 

Implementing the plan of care is the fourth step in the nursing process. The RN may begin, deliver, assign, or delegate specific interventions within the care plan for patients within legal, ethical, and regulatory parameters and consider health restoration, disease prevention, wellness, and promotion of healthy lifestyles (9).  

The RN's duty to patient safety when making assignments to other nurses or delegating tasks to unlicensed staff is to consider the education, training, skill, competence, and physical and emotional abilities of those to whom the assignments or delegation is made. The RN is responsible for reasonable and prudent decisions regarding assignments and delegation. The RN's scope of practice may include the supervision of LVNs or other RNs. Supervision of LVN staff is defined as the process of directing, guiding, and influencing the outcome of an individual's performance and activity. The RN may have to directly observe and evaluate the nursing care provided depending on the LVN's skills and competence, patient conditions, and level of urgency in emergent situations (9).  

The RN may determine when to delegate tasks to unlicensed personnel and maintain accountability for how they perform the tasks. The RN is responsible for supervising the unlicensed personnel when tasks are delegated. The proximity of supervision depends upon patient conditions and the skill level of the unlicensed personnel. In addition, teaching and counseling are interwoven throughout the implementation phase of the nursing process. (10,11) 

Evaluation and Reassessment 

A critical and final step in the nursing process is evaluation. The RN evaluates and reports patient outcomes and responses to therapeutic interventions compared to benchmarks from evidence-based practice and research findings and plans any follow-up care and referrals to appropriate resources that may be needed. The evaluation phase is one of the times when the RN reassesses patient conditions and determines if interventions were effective and if any modifications to the care plan are necessary (9). 

Essential Skills Used in the Nursing Process 

Communication 

Communication is an essential and fundamental component used during the nursing process. The RN must communicate verbally, in writing, or electronically with healthcare team members, patients, and their families in all aspects of the nursing care provided to patients. The patient record or nursing care plan must appropriately document these communications. Because RNs plan, coordinate, initiate, and implement a multidisciplinary team's approach to patient care, collaboration is crucial to communication. When patient conditions or situations exceed the RN's level of competency, the RN must be prepared to seek out other RNs with greater competency or other health care providers with differing knowledge and skillsets and actively cooperate to ensure patient safety (9).  

Clinical Reasoning 

Clinical reasoning is another integral component of the nursing process. RNs use critical thinking skills to problem-solve and make decisions in response to patients, their families, and the healthcare environment. RNs are accountable and responsible for the quality of nursing care provided and must exercise prudent and professional nursing judgment to ensure the standards of nursing practice are always met (9). 

Employment Setting 

When an employer hires an RN to perform a job, the RN must ensure that it is safe and legal. Caution must be exercised to stay within the legal parameters of nursing practice when an employer may not understand the limits of the RN's scope of practice and makes an assignment that is not safe. Before engaging in an activity or assignment, the RN must determine whether he or she has the education, training, skill, competency, and physical and emotional ability to carry out the activity or assignment safely. The RN must always provide patients with safe, compassionate, and comprehensive nursing care (9).  

Summary of RN Scope of Practice 

The RN, with a focus on patient safety, must function within the legal scope of practice and by the federal, state, and local laws, rules and regulations, and policies, procedures, and guidelines of the employing health care institution or practice setting. The RN functions under his or her license and assumes accountability and responsibility for the quality of care provided to patients and their families according to the standards of nursing practice. The RN demonstrates responsibility for continued competence in nursing practice and develops insight through reflection, self-analysis, self-care, and lifelong learning (9).  

The table below offers a brief synopsis of how the scope of practice for nurses differs based on educational preparation and level of licensure. These are minimum competencies but also set limits on what the LVN or RN can do at his or her given level of licensure, regardless of experience (9). 

Synopsis of Differences in Scope of Practice for Licensed Vocational, Associate, Diploma and Baccalaureate Degree Nurses (10) 

Synopsis of Differences in Scope of Practice for Licensed Vocational, Associate, Diploma and Baccalaureate Degree Nurses (4) 

Nursing board Position Statements are not laws, but they provide direction for nurses on issues of concern to the Board relevant to public protection. These Position Statements are reviewed annually for relevance and accuracy to current practice, the Nurse Practice Act, and Board of Nursing rules. Examples of Position Statements include the following: (9) 

• Nurses Carrying out Orders from Physician Assistants 
• Role of the Licensed Vocational Nurse in the Pronouncement of Death 
• LVNs Engaging in IV Therapy, Venipuncture, or PICC Lines 
• Educational Mobility 
• Nurses with Responsibility for Initiating Physician Standing Orders 
• Board Rules Associated with Alleged Patient "Abandonment" 
• The Role of LVNs & RNs in the Management and Administration of Medications via Epidural or Intrathecal Catheter Routes 
• The Role of the Nurse in Moderate Sedation 
• Performance of Laser Therapy by RNs or LVNs 
• Continuing Education: Limitations for Expanding Scope of Practice 
• Delegated Medical Acts 
• Use of American Psychiatric Association Diagnoses by LVN, RNs, or APRNs 
• Role of LVNs & RNs As School Nurses 
• Duty of a Nurse in any Practice Setting 
• Board's Jurisdiction Over a Nurse's Practice in Any Role and Use of the Nursing Title 
• Development of Nursing Education Programs 
• Texas Board of Nursing/Board of Pharmacy Joint Position Statement on Medication Errors 
• Nurses Carrying Out Orders from Advanced Practice Registered Nurses (APRN) 
• Nurses Carrying Out Orders from Pharmacists for Drug Therapy Management 
• Registered Nurses in the Management of an Unwitnessed Arrest in a Resident in a Long-Term Care Facility (9) 

Principles of Texas Nursing Jurisprudence and Ethics 

Professional Boundaries 

15.29 Professional Boundaries including use of social media by nurses (11) 

The purpose of this Position Statement is to guide nurses regarding expectations related to professional boundaries, including social media, and to provide nurses with guidance to prevent boundary violations (5). 

In keeping with its mission to protect public health, safety, and welfare, the Texas Board of Nursing (BON or Board) holds nurses accountable for knowing, recognizing, and maintaining professional boundaries of the nurse-patient/client relationship. The term professional boundaries is defined as the appropriate limits that the nurse should establish in the nurse/client relationship due to the nurse's power and the patient's vulnerability. Professional boundaries refer to the provision of nursing services within the limits of the nurse/client relationship, which promote the client's dignity, independence, and best interests and refrain from inappropriate involvement in the client's relationships and the obtainment of the nurse's gain at the client's expense (5). 

The National Council of State Boards of Nursing (NCSBN) defines professional boundaries as the spaces between the nurse's power and the patient's vulnerability. The nurse's power comes from the nurse's professional position and access to sensitive personal information. The difference in personal information the nurse knows about the patient versus the personal information the patient knows about the nurse creates an imbalance in the nurse-patient relationship. Nurses should respect the power imbalance and ensure a patient-centered relationship (5). 

Common to the definition of professional boundaries from the Texas Board of Nursing and the NCSBN is that a nurse abstains from personal gain at the client's expense and refrains from inappropriate involvement with the patient or the patient's family (5). 

Duty of a Nurse in Maintenance of Professional Boundaries 

There is a power differential between the nurse and the patient. The patient depends on the nurse's knowledge and relies on the nurse to advocate for the patient and ensure actions are taken in the patient's best interest. The nurse must protect the patient, establishing and maintaining professional boundaries in the nurse-patient/client relationship. Under or over-involvement can harm the patient and may interfere with the nurse-patient relationship. Visualizing the two ends of the spectrum may assist the nurse in knowing, recognizing, and maintaining the professional boundaries of nurse-patient relationships (5). 

Patients each have their own unique needs and abilities. The boundary line for any one patient may change over time and may not be the same as the boundary line for another patient. It is up to the nurse to assess and recognize the patient's needs, adjusting the nursing care accordingly. Every nurse is responsible for knowing, identifying, and maintaining the professional boundaries of the nurse-client relationship (5). 

Boundary Violations 

A violation of professional boundaries is one element of the definition of "conduct subject to reporting [Tex. Occ.Ide Sec. 301.401(1)(C)]. A professional boundary violation is also considered unprofessional conduct [22 TAC §217.12 (6)(D)]. Some of the specific categories of professional boundary violations include but are not limited to, physical, sexual, emotional, or financial boundary violations (5). 

Use of Social Media and the Protection of Health Information 

Social media and other electronic communication are expanding exponentially as the number of social media outlets, platforms, and applications available continues to increase. Nurses play a significant role in identifying, interpreting, and transmitting knowledge and information within healthcare. As technological advances expand connectivity and communication, rapid knowledge exchange and dissemination can pose risks to patients and nurses. While the Board recognizes that using social media can be a valuable tool in healthcare, there are potentially severe consequences if misused. A nurse's use of social media may cause the nurse to unintentionally blur the lines between the nurse's professional and personal life (5). 

Online postings may harm patients if protected health information is disclosed. In addition, social media postings may reflect negatively on individual nurses, the nursing profession, the public's trust in the nursing profession, or the employer and may jeopardize careers. In an NCSBN survey, many responding boards reported receiving complaints about nurses misusing social media sites. The survey results indicated that boards fired by employers have disciplined nurses and are criminally charged for the inappropriate or unprofessional use of social media (5). 

To ensure the mission to protect and promote the welfare of the people of Texas, the Texas Board of Nursing supports the guidelines and principles of social media use by the NCSBN and the American Nurses Association. By the NCSBN guidelines and Board rules, it is the Board's position that (5): 

Nurses have an ethical and legal obligation to maintain patient privacy and confidentiality. When using social media, nurses do not identify patients by name or post or publish information that may lead to patient identification. Limiting access to postings through privacy settings is not sufficient to ensure privacy. Nurses must promptly report any identified breach of confidentiality or privacy (5). 

Nurses maintain professional boundaries in the use of electronic media. The nurse must establish, communicate, and enforce professional boundaries with patients online. Nurses do not refer to patients disparagingly, even if the patient is not identified, or transmit information that may be reasonably anticipated to violate patient rights to confidentiality or privacy or otherwise degrade or embarrass the patient (5). 

Nurses must provide nursing services without discrimination and not make threatening, harassing, profane, obscene, sexually explicit, racially derogatory, homophobic, or other offensive comments (5). 

Nurses must be aware of and comply with all laws and rules, including employer policies regarding using electronic devices, including employer-owned computers, cameras, and personal devices. In addition, nurses must ensure appropriate and therapeutic use of all patient-related electronic media, including patient-related images, photos, or videos, by applicable laws, rules, and institutional policies and procedures (5). 

The use of social media can be of tremendous benefit to nurses and patients alike, for example, the dissemination of public safety announcements. However, nurses must know the potential consequences of disclosing patient-related information via social media. Nurses must always maintain professional standards, boundaries, and compliance with local, state, and federal laws. All nurses must protect their patients' privacy and confidentiality, which extends to all environments, including social media (5). 

The following are ways to avoid problems when using social media: 

• Never post any healthcare-related images, client information, or even general client information 
• Only use your organization's name or a client or family member's name to post content about or speak for your employer if your organization authorizes you to follow their specific policy and procedures. 
• Never post comments about a client, even if the client is not named. 
• Never post photos or videos of your healthcare organization or clients  
• Never post any comments about your employer or other team members 
• Never use obscenity, profanity, racial slurs, sexually inappropriate comments, homophobic comments, threats, harassing/abusive language, or any other offensive comments. Never post any image that contains the above content. 

Prevention of Boundary Violations 

The ability of a client to rely on employees as concerned and caring individuals who remain objective in their guidance is one of the tents of a safe, therapeutic relationship. The relationship may no longer be objectively therapeutic when staff interacts with patients personally. Accepting gifts, financial transactions, and romantic entanglement could lead to various negative consequences for an organization, employee, or client. Many organizations enforce a non-fraternization policy between employees and current or former clients. While there are exceptions, the expectation is that employees are not to establish a personal relationship with a current or former client. Organizations do recognize that there are times when peers, friends, family, or neighbors of employees seek treatment. In these circumstances, the relationship must remain the nature it was before admission if in the client's best interest, and the treatment plan should address the relationship to best meet the client's therapeutic needs. Employees should also notify a supervisor when an individual with whom he or she has a relationship is admitted for treatment (5). 

Texas Nurses are required to comply with mandatory reporting requirements of Texas Occupations Code Chapter 301 NPA Subchapter I, which include reporting a nurse (11): 

• Who violates the NPA or a board rule and contributed to the death or severe injury of a patient.  
• Whose conduct causes a person to suspect that the nurse's practice is impaired by chemical dependency or drug or alcohol abuse?  
• Whose actions constitute abuse, exploitation, fraud, or a violation of professional boundaries.  
• Whose actions indicate that the nurse lacks knowledge, skill, judgment, or conscientiousness to such an extent that the nurse's continued practice of nursing could reasonably be expected to pose a risk of harm to a patient or another person, regardless of whether the conduct consists of a single incident or a pattern of behavior.  

The exception is for minor incidents, peer review, or peer assistance if there is no practice violation as stated in the Nursing Practice Act and Board rules (6, 11).  

Organizations also take many precautions to ensure appropriate employee-client relationships, including (13):   

• Criminal background checks of employees 
• Employee, student, and volunteer education regarding therapeutic boundaries and issues and consequences of any violations 
• Mandatory, supportive, and confidential reporting of any violation 

Employee supervision also includes the identification of early signals that an employee may be crossing therapeutic boundaries and the institution of appropriate interventions. Employees educate clients regarding the importance of maintaining a therapeutic relationship and proper boundaries. Organizations work to ensure adequate supervision of staff and appropriate supervision of clients, such as increased observation or same-gender staff working with a client when appropriate (13). 

There must be mandatory reporting by any employee who becomes aware of a boundary violation. The employee should report this immediately to their supervisor, who will evaluate the nature and severity of the claim and initiate an investigation of the situation. In conjunction with Human Resources and Risk Management, the immediate supervisor will determine whether an accused employee should be put on immediate leave pending investigation results and whether mandatory reporting of the allegations to outside agencies is required. Legal Counsel may also be consulted when necessary. An employer may not suspend or terminate employment or otherwise discipline, retaliate, or discriminate against a person who reports, in good faith, or advises a nurse of the nurse's rights and obligations (5, 9, 11, 12).

Unprofessional Conduct - Rule §217.12 

The following unprofessional conduct rules are intended to protect clients and the public from incompetent, unethical, or illegal conduct of licensees. The purpose of these rules is to identify behaviors in the practice of nursing that are likely to deceive, defraud, or injure clients or the public. Actual injury to a client need not be established. These behaviors include but are not limited to: (all from 5) 

1.Unsafe practice – actions or conduct including, but not limited to: 

- Carelessly failing, repeatedly failing, or exhibiting an inability to perform vocational, registered, or advanced practice nursing in conformity with the standards of a minimum acceptable level of nursing practice set out in §217.11 of this chapter. 

- Failing to conform to generally accepted nursing standards in applicable practice settings. 

- Improper management of client records. 

- Delegating or assigning nursing functions or a prescribed health function when the delegation or assignment could reasonably be expected to result in unsafe or ineffective client care. 

- Accepting the assignment of nursing functions or a prescribed health function when the acceptance of the assignment could be reasonably expected to result in unsafe or ineffective client care. 

- Failing to supervise the performance of tasks by any individual working pursuant to the nurse's delegation or assignment. 

- Failure of a clinical nursing instructor to adequately supervise or to assure adequate supervision of student experiences. 

2. Failure of a chief administrative nurse to follow standards and guidelines required by federal or state law or regulation or by facility policy in providing oversight of the nursing organization and nursing services for which the nurse is administratively responsible. 

3. Failure to practice within a modified scope of practice or with the required accommodations, as specified by the Board in granting an encumbered license or any stipulated agreement with the Board. 

4. Conduct that may endanger a client's life, health, or safety. 

5. Inability to Practice Safely – a demonstration of actual or potential inability to practice nursing with reasonable skill and safety to clients by reason of illness, use of alcohol, drugs, chemicals, or any other mood-altering substances, or as a result of any mental or physical condition. 

6. Misconduct – actions or conduct that include, but are not limited to: 

- Falsifying reports, client documentation, agency records, or other documents. 

- Failing to cooperate with a lawful investigation conducted by the Board. 

- Causing or permitting physical, emotional, or verbal abuse or injury or neglect to the client or the public, or failing to report same to the employer, appropriate legal authority and/or licensing Board. 

- Violating professional boundaries of the nurse/client relationship including but not limited to physical, sexual, emotional, or financial exploitation of the client or the client's significant other(s). 

- Engaging in sexual conduct with a client, touching a client in a sexual manner, requesting, or offering sexual favors, or language or behavior suggestive of the same. 

- Threatening or violent behavior in the workplace. 

- Misappropriating, in connection with the practice of nursing, anything of value or benefit, including but not limited to, any property, real or personal of the client, employer, or any other person or entity, or failing to take precautions to prevent such misappropriation. 

- Providing information, which was false, deceptive, or misleading in connection with the practice of nursing. 

- Failing to answer specific questions or providing false or misleading answers in a licensure or employment matter that could reasonably affect the decision to license, employ, certify, or otherwise utilize a nurse. 

- Offering, giving, soliciting, or receiving, or agreeing to receive, directly or indirectly, any fee or other consideration to or from a third party for the referral of a client in connection with the performance of professional services. 

7. Failure to pay child support payments as required by the Texas Family Code §232.001, et seq. 

8. Drug diversion – diversion or attempts to divert drugs or controlled substances. 

9. Dismissal from a board-approved peer assistance program for noncompliance and referral by that program to the Board. 

10. Other drug-related actions or conduct that include, but are not limited to: 

- Use of any controlled substance or any drug, prescribed or unprescribed, or device or alcoholic beverages while on duty or on call and to the extent that such use may impair the nurse's ability to safely conduct to the public the practice authorized by the nurse's license. 

- Falsification of or making incorrect, inconsistent, or unintelligible entries in any agency, client, or other record pertaining to drugs or controlled substances. 

- Failing to follow the policy and procedure in place for the wastage of medications at the facility where the nurse was employed or working at the time of the incident(s). 

- A positive drug screen for which there is no lawful prescription. 

- Obtaining or attempting to obtain or deliver medication(s) through means of misrepresentation, fraud, forgery, deception and/or subterfuge. 

11. Unlawful practice – actions or conduct that include, but are not limited to: 

- Knowingly aiding, assisting, advising, or allowing an unlicensed person to engage in the unlawful practice of vocational, registered, or advanced practice nursing. 

- Violating an order of the Board, or carelessly or repetitively violating a state or federal law relating to the practice of vocational, registered, or advanced practice nursing, or violating a state or federal narcotics or controlled substance law. 

- Aiding, assisting, advising, or allowing a nurse under Board Order to violate the conditions set forth in the Order. 

- Failing to report violations of the Nursing Practice Act and/or the Board's rules and regulations. 

12. Leaving a nursing assignment, including a supervisory assignment, without notifying the appropriate personnel. 

There is a Texas State Board of Nursing Disciplinary Matrix that nurses can review to see the process followed when a review of a nurse's conduct is necessary. The Board will consider public safety, the seriousness of the violation, and any aggravating or mitigating factors. Other factors considered include the presence of multiple violations, prior violations, and costs which could result in a more severe disciplinary action. (13) 

Provisions of the Code of Ethics for Nurses 

Provision 1 

The nurse practices with compassion and respect for the inherent dignity, worth, and unique attributes of every person. (1) 

Provision 2 

The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population. (1) 

Provision 3 

The nurse promotes, advocates for, and protects the rights, health, and safety of the patient. (1) 

Provision 4 

The nurse has authority, accountability, and responsibility for nursing practice, makes decisions, and takes action consistent with the obligation to provide optimal patient care. (1) 

Provision 5 

The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. (1)  

Provision 6 

The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care. (1)  

Provision 7 

The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. (1)  

Provision 8 

The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. (1)  

Provision 9 

The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. (1) 

Case Study 

Rachel is a 13-year-old adolescent female client admitted to an inpatient behavioral health unit for bipolar disorder, alcohol and marijuana abuse, and borderline personality disorder. The client has a history of sexual promiscuity, lying, and has alleged abuse and rape by history. Rachel approaches the Charge RN at bedtime, saying that an employee and she "have been having sex" many times over the course of two weeks and that she realizes now that "she should have told someone". The alleged employee is currently on duty.

As Charge RN, using what you learned about Texas Nursing Jurisprudence and Ethics, how would you respond, and what are your next steps?

Conclusion - Texas Nursing Jurisprudence and Ethics

When a nurse is named in a negligence or malpractice lawsuit, it can create stress for the client, the employee, and the employer. A nurse maintaining professional, ethical, and jurisprudent conduct will help to ensure standards of practice are consistently followed. Maintaining appropriate boundaries with clients at all times helps maintain a therapeutic employee-client relationship.

It is important that nurses understand their state nurse practice act, the scope of practice of nurse licensure, standards of practice, ethics, and professional boundaries in order to maintain professionalism, meet performance standards, and avoid a breach of duty, injury, and litigation. 

Resources 

Educational Requirements:
Texas Board of Nursing (2010), Differentiated Essential Competencies (DECs) of graduates of Texas Nursing Programs. (12) 

Texas Occupations Code, Chapter 301 (12) 

Nursing Practice Act (NPA) Section 301.002, Definitions (12) 

Rule 217.11 - Standards of Nursing Practice (12) 

Scope of Practice Position Statements: (12) 

• Position Statement 15.28 The Registered Nurse Scope of Practice Web version for viewing 
• Position Statement 15.14 - Duty of a Nurse Web version for viewing 
• Position Statement 15.14 - Duty of a Nurse - HHSC/DADS/BON poster 

For the complete list of position statements, click here. (12) 

Texas Nursing Forensics

Introduction 

In the United States, sexual assault was historically considered a judicial problem; however, it is now considered a major public health concern because of the health and psychological effects on individuals. The problem most notably emerged in the public eye in the 1960s with the women's liberation movement. In recent times the #METOO movement has increased awareness of the problem, and many organizations have surfaced to assist the assaulted. This course will focus on the problem in rural areas in the state of Texas and how nurses working in these facilities can best assist patients who have been sexually assaulted. 

Statistical Evidence 

National Statistics 

According to the Rape Abuse and Incest National Network (RAINN) (1), every 68 seconds someone is sexually assaulted in the United States, and every nine minutes, that victim is a child (1). Only 25 out of every 1,000 perpetrators will end up in prison (1).in less than every 80 seconds, a person is sexually assaulted. In 2015 the Texas Statewide Sexual Assault Prevalence Study found that 33.2% of adult Texans or 413,000 individuals reported having been sexually assaulted at some point during their lives (2).  

Each year in the United States (1):  

• 80,600 inmates are sexually assaulted or raped 
• 60,000 children were victims of “substantiated or indicated” sexual abuse 
• 433,648 people 12 and older were sexually assaulted or raped 
• 18,900 military personnel experienced unwanted sexual contact 
• 1 out of every 6 women have been the victim of attempted or completed rape in her lifetime (14.8% completed, 2.8% attempted) 
• 1 in 3 men have experienced an attempted or completed rape in their lifetime 
• More women and children are sexually assaulted than men, and that girls under 18 years of age are at the highest risk. According to RAINN (1), men and boys, especially college-aged, are also at risk with transgender students at the highest risk of this group. 

Most common locations where sexual assault occurs in the U.S. (1): 

• 55% at or near the victim’s home 
• 15% in an open public space 
• 12% at or near a relative’s home 
• 10% in an enclosed but public area (i.e. parking garage or lot) 
• 8% on school property 

Activities the victims were doing when they were assaulted (1): 

• 48% were sleeping or performing another activity at home 
• 29% were traveling to and from work or school, or traveling to shop or run errands 
• 12% were working 
• 7% were attending school 
• 5% were doing an unknown or other activity 

Sexual Assault on Children (1): 

• 1 in 9 girls and 1 in 20 boys under the age of 18 experience sexual abuse or assault 
• 2 out of 3 victims of sexual assault or rape (under the age of 18) are age 12 – 17 
• Victims of sexual assault or rape under the age of 18 are about 4 times more likely to develop symptoms of drug abuse and PTSD as adults, and about 3 times more likely to experience a major depressive episode as adults 

Texas Statistics 

The latest statistics on sexual assault in the state of Texas were from 2018 and is as follows (2): 

• Total number of reported sexual assault incidents was 19,816, a 9.4% increase from the prior year 
• Of victim-to-offender relationships, 11% were romantic, 14% parental/child, 19% other family, and 55% other. 
• Victims were 88% were female and 12% male 
• Victims who were aged 10 – 14 were the group with highest number of cases 
• Of all victims, 82% were white, 17% black, and 1% American Indian/Alaskan Native, Asian, or Native Hawaiian/Pacific Islander 

Location of sexual assault incidents in Texas in 2018 (2): 

• 16,015 in residents/homes 
• 2,041 in unknown or other areas 
• 657 in a hotel/motel 
• 718 in school/college 
• 710 in a highway/road/alley 
• 506 in a parking lot/garage 
• 268 in fields/woods 
• 185 in commercial/office buildings 
• 176 in drug stores, doctor’s offices, or hospitals 

The Basics: Sexual Assault 

What is Sexual Assault? 

Sexual assault, also termed sexual violence, is described as “any type of unwanted sexual contact, including words and actions of a sexual nature against a person’s will and without their consent; a person may use force, threats, manipulation, or coercion to commit sexual violence” (3). Sexual assault is often defined separate from rape. Rape consists of penetration, whether vaginally, anally, or orally. Sexual assault is any type of unwanted sexual content and is not limited to rape.  Sexual abuse, as described by the American Psychological Association (APA) "is unwanted sexual activity, with perpetrators using force, making threats or taking advantage of victims not able to give consent" (3). Assault can be the product of domestic abuse, gang violence, date rape, and incest. Assault can be inflicted on any age or gender and often occurs by someone who is related to or knows the victim.  

What is SANE? 

In many parts of the United States, Sexual Assault Nurse Examiners (SANE), nurses who are expertly trained in performing forensic examinations and collection of evidence, are utilized (5). SANEs are nurses who specialize in forensic nursing. In forensic nursing, the health and legal system intersect (10). SANE programs began as early as the 1970s. At that time, nurses noticed that victims of sexual assault were not provided high quality care like other patients were in the emergency department. Nurses also noticed that the victims were very concerned about STDs and pregnancy and needed special treatment.  Over the next 20 years, the forensic specialty grew, and the First SANE programs were started in Tennesse, Minnesota, and Texas. Today, Texas registered nurses working in the emergency departments must learn the SANE process to perform the forensics exams and evidence collection by completing a 2-hour educational program.  

Nursing's Role 

Sexual assault is an extremely traumatic experience. Those affected can have a wide range of issues, emotionally, spiritually, physically, and psychologically. Nurses working in the emergency department are often first responders. Compassion, empathy, and privacy are a hallmark of excellent practice when caring for patients who have been sexually assaulted.  

Many patients will experience shock and disbelief. "Why me? Will I be okay?" or "It's no big deal, I'm fine" (6). There may be "fear of responses from friends, family, the public, and criminal justice providers" (7). Victims of rape may also have concerns about pregnancy, STIs, and HIV/AIDS. These patients may feel their world has turned upside down. They may be scorned, told it was deserved, and fear their names could be made public (7).  

In order to provide excellent care, all gender identities must be taken into consideration, as well as age and sexual orientation. No bias or judgment should be displayed to the patient. Customs, beliefs, religious, and spiritual needs should also be considered during the visit 

Team Collaboration 

Working with all personnel in the emergency department is essential. From paramedics, law enforcement officers, family, or anyone accompanying the patient to physicians, social workers, and forensic medical examiners, each professional has a specific skill set and role in the patient's care. Teamwork among these groups of individuals will provide the best possible outcomes for the patient. Team members involved in a victim’s care may include (8): 

• “Community-based advocates 
• Law enforcement officers 
• SANEs, physicians or nurses trained in sexual assault medical forensic evidence collection 
• Law enforcement victim service advocates 
• District Attorney’s Office personnel, legal victim advocates and attorneys” 

Interview 

The interviewing nurse should actively listen, believe what the patient discloses, validate the patient’s feelings, maintain confidentiality, and honor the patient’s decisions on what to do about the assault. When caring for patients who have sexually assaulted, treating the whole person rather than the "problem" alone is vital. Repeating information back to the patient can help to elicit more precise information. Repeating information can also help to validate what the patient is saying, creating an atmosphere of trust. Consider that patients may not want to talk about the assault, as reliving it could bring out unwanted emotions. 

If the patient arrives alone, the nurse should inquire if the patient wants a companion or an advocate to be present. An advocate could be a family member, friend, member of the clergy, or social worker. The patient can choose if they want someone present. Care must be taken to ensure the patient feels comfortable, as the presence of someone emotionally involved (or even the assaulter themselves) may deter the patient from being open and honest. An interpreter should also be arranged if needed, with the patient's consent.  

If the patient has not alerted the local police, the nurse should inquire if they wish to report the assault and if so, the police should then be called. If available, a sexual assault response team (SART) should be immediately contacted. It is of the utmost importance to remember that the patient always makes the primary decision of what to do surrounding the case. Also, the patient must give consent first before any decisions are made. Admitting the patient to a private room in a quiet area of the emergency department lessens interruptions from outside sources.  

Assessment 

After obtaining consent to perform the assessment, the patient should be advised of every step before each part of the exam. The patient should be informed they have total control of what is happening. It is important for the nurse to help the patient understand they always have the right to refuse any and all steps in the examination.  

When performing the initial assessment and gathering information, documentation must include a very detailed and complete history, including any physical trauma to the patient’s body. The history should include any bruises, lacerations, or other visual injuries and how and when they occurred. The nurse should perform the interview slowly, giving the patient time to process and answer each question. The patient may or may not want to identify the person who assaulted them and should not be coerced into doing so. 

A complete medical, surgical, and gynecologic history, in the case of a female patient, and any new symptoms occurring after the assault should be asked. Drug allergies, medications, and any alcohol or illegal drugs used at the time of the event are also documented. A compassionate and empathic tone should always be used to allow the patient to feel safe. The patient should not feel any judgment from any emergency department personnel. Patients should be given the opportunity and encouraged to grieve and react during this time. They should feel comfortable enough to ask and answer questions throughout the interview.  

According to Texas law, nurses must obtain written consent from the patient. During the complete physical exam, the nurse will be charged with ensuring physical evidence of the assault from clothing or body fluids is not disturbed. Also, during this time, suicidality and emotional support should be assessed. Providing expert treatment for patients who have been sexually assaulted is of utmost importance. When available, a SANE nurse will perform the forensic examination. This examination is vital to collect and preserve physical evidence from the patient while also assessing life and limb injuries. If a SANE nurse is unavailable, as may be the case in Texas's rural areas, a "medical forensic examiner" will perform the examination. 

Documentation 

When documenting the case, the nurse should use open-ended questions to elicit the patient's best and clearest responses. Documentation must be complete and exact, including every stage of the assault with times, dates, and descriptions, with consideration for the patient's emotional state and ability to recall. Using motivational interviewing can be helpful as well. Documenting in the patient’s own words is best practice. Nurses should try their best to document all of the following about the case (8): 

• “All those present during the patient’s history and examination 
• Time, date, and location of assault(s) 
• Contact and/or penetrative acts by suspect(s) 
• Was the suspect injured in any way, if known? 
• Use of lubricant, including saliva 
• Patient’s actions between the sexual assault and arrival at the facility (brushing teeth, using mouthwash, smoking, vaping, changing clothes, vomiting, swimming, showering, or bathing) 
• Was a condom used? 
• Did ejaculation occur? Where?  
• Any weapon use or physical force, or threat of weapon use or physical force? 
• Description of condition of clothing (and was clothing torn or stained prior to assault?)”  

In the case of a minor, a parent will give consent, and if no parent is available or is the assaulter, the child will be turned over to the appropriate child and family services in the state. If the assaulted patient has dementia or is an elder with cognitive issues and is therefore unable to consent, adult protective services should be contacted (8). There are also rules governing military sexual offenses. Remember when documenting these cases, whether using handwritten or electronic medical records, any and all information is subject to HIPAA.  

Texas Forensic Law 

The Texas government code 420.031 (9) describes the protocol that must be taken to develop and protect evidence collection in a sexual assault case. Since a major part of Texas is rural, the code was enacted to protect and care for patients and the collected evidence in areas where a SANE nurse is not available. In these cases, a medical forensic examiner may perform the exam and evidence collection.  

A medical forensic examiner is described as any practitioner Medical Doctor, Registered Nurse, Nurse Practitioner, or Physician's Assistant who has undergone a minimum of 2 hours of training in forensic evidence collection. The law outlines requirements in the collection and preservation of evidence. In 2019, the code was amended to require written informed consent from the patient or guardian for release of the evidence and must be gained prior to the history and physical. Obtaining consent also carries important psychological implications after a sexual assault since the patient's right to consent was violated by the assaulter. Sexual assault examination teams should always be involved as early as possible.  

Texas Forensic Law: Statute of Limitations 

The statute of limitations for sexual assault cases can be defined as a deadline in which a person can report a sexual assault. The statute of limitations vary per state and the length of time for reporting can depend on whether the case is criminal or civil. Criminal cases are committed against the state and prosecuted by the state; civil cases occur between individuals/groups and are prosecuted by a civil court (i.e. family court or personal injury cases) (12). In Texas, the statute of limitations varies by age and whether the case is criminal or civil. The following are general statute of limitations regarding sexual assault in Texas (13)(14). The legal age of sexual consent in Texas is 17. 

For adults, the statute of limitation is 10 years from the victim’s 18th birthday. As of 2019, victims of sexual assault can file a personal injury claim for injuries arising from childhood sexual abuse up to 30 years from the incident. 

There is no statute of limitations if: 

• During the investigation of the offense, biological matter (evidence) is collected, and the matter has not yet been subjected to forensic DNA testing 
• Forensic DNA testing results show that the matter does not match the victim or any other person whose identity is readily ascertained 
• Probable cause exists to believe that the defendant has committed the same or a similar sex offense against five more victims  
• Continuous sexual abuse of young child or disabled individual occurs 
• Indecency with a child occurs 

Texas Forensic Law: Evidence 

Sexual assault evidence can be found in several areas, including the crime scene, the patient's body, skin, hair, nails and clothing, and other items belonging to the patient (11). There is a specific kit used to collect this evidence. As described by RAINN, the kit is best known as a RAPE or Sexual Assault Evidence Kit (SAEK) and is inclusive of the items listed below (11): 

• Bags and paper sheets to put on the floor and collect clothing or other evidence that may fall off the patient while undressing, 
• A comb to collect evidence from hair 
• Forms for documentation  
• Envelopes and containers for the evidence 
• Instructions on use of the kit 
• Sampling materials and swabs 

Types of evidence collected are usually skin samples, scrapings from fingernails, and oral, genital, and anal swabbing internal and external. Directions on how to collect this evidence are included in the kit. The forensic examiner can also use special types of photography to document internal injurie. (11). Personal cameras should never be used. Remember, it is the law that the patient consents to each part of the exam. 

As described by RAINN, prior to the forensic exam, it is best if the patient has not changed clothes, combed their hair, brushed their teeth, tried to clean the area, showered, or bathed, or used a restroom. If needing to use the restroom, a urine sample should be collected, educating the patient not to cleanse the perianal area. If they have already showered or bathed and have not arrived at the emergency room yet, emergency personnel need to educate the patient to keep the clothes they were wearing and any other belongings they had with them at the time of the assault in a paper bag in order to preserve the evidence (11).  If the patient comes to the emergency department up to 7 days after being sexually assaulted, the exam can still be performed. After the 7 days, it is at the forensic examiner's discretion whether the exam should be performed. Collecting and protecting forensic evidence is a legal, moral, and professional responsibility (12). 

Any medical witness who testifies in court is held in the highest regard and as experts in sexual assault cases (5). Courts will closely scrutinize the chain of custody, and if broken, it can cause a conflict in the case and question of validity. Cases may be heard in criminal, civil, juvenile, military courts, or grand juries. If a forensics examiner is called to be a "fact" witness, no opinions on the case will be heard. Only the procedures that were performed on the patient will be admitted, and if the testifier is not the professional who performed the examination, they may be questioned regarding SANE protocols.  

If called upon to be an expert witness, the SANE nurse not only has knowledge of protocols but can educate and give opinions to the court. In either case, the necessity for excellent knowledge of SANE protocols is important. Nurses must be comfortable testifying in court as it is a rigorous and stress-provoking experience. Working with your organization's lawyers and prosecutors, as well as reviewing the case extensively, will prepare the nurse to testify in a case (5). 

Texas Law: Chain of Custody 

In order to protect the patient and evidence for the courts, a chain of custody of the evidence must be followed precisely. Failure to comply does not mean the evidence is not admissible in the courts; however, the more complete the evidence, the better chance of conviction of the assaulter. Texas A&M's nursing program offers a chain of evidence handbook outlining each step in the collection of evidence. The information below highlights the collection process from that handbook (8). 

Collection of Evidence and Packing 

• “Collect evidence so that it will be admissible as evidence in legal proceedings later. Therefore, chain of custody must be maintained and documented throughout the entire patient assessment and evidence collection processes.
• Chain of custody documents the dates and times of everyone who handles every piece of evidence, from the time it is collected through to legal proceedings."  
• Evidence should be labeled with patient’s name, date of birth, unique identifier number, examiner’s initials, date, and time. 
• If adult patient chooses non-reporting method, the external SAEK is labeled only with the unique identifier number (often the medical record number or the Track-Kit barcode). The Track-Kit identifier can be utilized. 
• Consider also labeling additional evidence not included in the kit (i.e., clothing collected when patient is reporting to law enforcement) with Track-Kit labels without the barcode. 
• Evidence inside the SAEK is labeled according to standard facility procedure. Follow facility protocols on non-reporting evidence collection. 
• Consider providing a card with the unique identifier for the patient if the Track-Kit identifier is not utilized.” 

Chain of Custody Documentation 

Documentation must include:  

• Receipt of evidence 
• Storage of the evidence  
• Transfer of the evidence 
• Date and time of each transfer 
• The printed name and signature of each person in possession of or transferring the evidence  
• Signatures of all persons transferring or receiving the evidence 

Swab and Evidence Collection 

Explain the reason and process for collection prior to collecting from each site. Nurses can use this time to take digital photos (depending on facility protocol). There should be two swabs used from each site." (8). 

Evidence must be kept in sight of the person collecting it at all times. After collected, the evidence must be dried and contained in the SAEK kit and sealed per kit instructions until it can be handed over to the appropriate law enforcement official and opened only by crime lab personnel. Each emergency department should have a locked storage space to provide temporary custody of collected evidence until it can be transferred to the appropriate persons or lab. If a patient is transferred to another facility, the chain of custody again must be documented according to the law. 

The law in Texas allows an adult to choose whether to report the assault to law enforcement. If the person chooses not to report, evidence will still be collected and preserved for up to 5 years post-assault. In the case of child sexual assault, elder abuse (over 65), or disabled persons, all medical personnel must report the case to law enforcement as mandatory reporters. Texas caregivers are also required to give patients an information sheet describing where to find appropriate services for the sexually assaulted. This document can be found on the Texas consumer protection website or here: Information for Survivors of Sexual Assault (texas.gov) 

Physical and Emotional Effects 

After a sexual assault, patients can experience anxiety and depression, post-traumatic stress disorder (PTSD) and turn to alcohol and/or substance abuse. There may be feelings of fear, denial, guilt, shame, loss of self, loss of control, and anger (8). They may feel like their world has been turned upside down, life has stopped, or they cannot move forward. They may feel ashamed and wonder if, in some way, they were responsible. They may not feel safe in their own space and may lack trust.  

In domestic cases, the patient may be concerned about their attacker. They may worry that their attacker will be prosecuted and sent away. Daily life can be disrupted to the point of self-isolation and loss of the patient's job, family, and social life. A patient may become disabled to the point of homelessness and poverty. Many may feel the attack is transparent and that others can tell they have been assaulted just by looking at them. Flashbacks can occur at any time, and they may experience nightmares of being chased or attacked. They may also have constant thoughts of the abuse, causing insomnia and intense anxiety.  

Support for Victims 

Patients who have been sexually assaulted may contemplate and attempt suicide (8). These issues can extend into long periods of time, with unknown triggers bringing flashbacks or repeated negative feelings. Patients should be informed that their feelings are normal, and each person heals in different ways and in different timeframes. Ongoing support and therapy can assist the patient in recovery as well as self-help and group programs. There are many online, telephone, and in-person programs for victims as well as organizations to assist with ongoing issues. For example, the Rape, Abuse & Incest National Network (RAINN) program can be helpful in advocating for patients and guiding them on their journey to recovery. The National Sexual Violence Resource Center is also a helpful resource. 

Many psychologists and therapists work explicitly with victims of sexual assault. The attorney general of the state of Texas website has information and resources for all crime victims. Having a trained sexual assault counselor at the emergency visit time can be of great assistance with the initial contact and subsequent referrals to professionals. Compassionate, empathic, and supportive care by emergency nurses at the initial contact can positively impact the patient's road to a safe and healthy recovery.  

Physical injuries must also be considered using clinical assessment, radiology, MRIs, and CT scans when necessary. Laboratory collection for STDs (sexually transmitted diseases), pregnancy in females, possible HIV, and other illness exposures are also a consideration during the physical exam and history taking. Follow-up care for these injuries with subsequent laboratory tests and appointments made with appropriate specialists should be made.  

Follow up 

Ideally, the nurse could schedule a telephone call with the patient in 2-3 days to assess how they are doing and for continued support and referrals. At that time, the patient may have more questions or concerns that the nurse can help with and provide for follow-up care and resources. A list of educational programs and therapists who specialize in sexual assault and support groups should be supplied to the patient at the time of the visit and subsequent phone calls. There is no handbook on how to recover from trauma; it is an individual journey that is experienced solely by each person. However, there are many resources to assist a patient who has been sexually assaulted at the time of the event and long after.  

Conclusion 

Sexual assault has become a major health problem in the United States. The state of Texas has implemented a code of laws to identify, protect, and collect evidence from patients who have experienced this crisis. The utilization of SANE nurses is common in major metropolitan area hospitals, but many rural areas in that state are not equipped with the program. To properly care for these patients and collect and protect evidence appropriately, Texas has mandated education for emergency department nurses not served by SANE personnel.  

It is imperative that emergency department nurses become educated on the use of SAEK kits for evidence collection and chain of custody protocols. The utilization of the SANE method allows for standardized care that is safe, and protective of the patient and their rights. 

Texas Human Trafficking

Introduction   

Often likened to modern-day slavery, human trafficking is a heinous global crime that is getting more and more attention in recent times. Healthcare practitioners should be up to date on the topic as much as possible, considering they are very frequently a point of contact for individuals being trafficked.

It is imperative to recognize the signs of trafficking, as well as resources available to those involved. Furthermore, it is crucial that the practitioner develops trust with the victims he or she encounters, providing patient-centered, trauma-informed care.

• Identification: Potential indicators of trafficking; barriers to survivor disclosure; strategies for building trust with victims; challenges and opportunities faced by practitioners; appropriate language and documentation. 
• Health Impact: Acute and chronic physical health problems experienced by trafficking victims; quality of life and independence issues; mental health concerns.
• Response and Follow-up: The practitioner’s role in intervention; mandated reporter obligations; resources on state and federal levels; the importance of survivor-centered, multidisciplinary organizational protocols

Human Trafficking 

A 2018 report confirms that between 50-88% of human trafficking survivors accessed healthcare services, yet only six percent of healthcare workers report treating a survivor during their career (27).  

While human trafficking remains an often-hidden crime, there are still many signs that everyone should be able to recognize. There are myriad resources available for victims of trafficking, including the National Human Trafficking Hotline Number (888-373-7888) and its text line, BeFree (233733). These options are available to call or text 24 hours a day, 7 days a week, 365 days a year. Other local and statewide resources are available and will be discussed throughout this course.  

Case Study: Mahad 

Just after midnight, a 23-year-old man named Mahad presents to the ED where you work. The triage notes state that he has been coming in for generalized fatigue, muscle aches, and nausea for the past three days. He is accompanied by an older man who states he is Mahad’s uncle and has translated for Mahad thus far.  

Upon exam, Mahad appears significantly malnourished with a firm, distended abdomen. He is noted to have jaundiced sclera, dark circles under his eyes, and several wounds of varying age on his bilateral lower extremities. The uncle states that Mahad works in a metal stamping plant and occasionally gets injured on the job.  

Mahad is reluctant to talk to you and does not make eye contact. He defers to his uncle to do the talking and translation, flinching whenever the uncle moves. Both Mahad and the uncle seem wary of the law enforcement officer walking on the floor. You feel this encounter is concerning for human trafficking, so excuse yourself to go talk with some of your colleagues about this situation.

What Is Human Trafficking?  

Human trafficking is a crime and a human rights abuse. It includes at least one of the three components of force, fraud, or coercion to obtain labor and/or a commercial sex act (3,4). It can also be defined as “the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, solicitation, patronage or coercion for the purposes of subjection to involuntary servitude, peonage, debt bondage, or slavery.” (2).  

This can happen to anyone at any time; a person of any race, age, gender, religion, or nationality can be a victim of trafficking (3). Healthcare practitioners should be aware that boys, men, and people over the age of 18, and those of any racial or socioeconomic group may be victims.  

Human trafficking is an enormously egregious yet profitable industry, comprising some $150-$600 billion of the global economy each year and affecting roughly 25-50 million people worldwide (11, 17). In Texas alone, this crime has already affected some 313,000 people (17). The majority of trafficking happens in the form of forced private sector labor, despite sexual exploitation being what initially comes to mind for many people (11).  

Unfortunately, the general public and even people being trafficked are not always aware of what is happening, for a myriad of reasons. This may be due in part to a lack of recognition of what exactly is involved in human trafficking.  

In the year 2000, the United States Congress passed the Trafficking Victims Protection Act of 2000, also known as TVPA (1). This legislation helps to define human trafficking and protect those involved.  

What Is Not Considered Trafficking 

Despite many media portrayals, human trafficking is not synonymous with smuggling or sex work.  

• Smuggling involves illegally crossing state or international borders (5). Human trafficking deals solely with the exploitation of people; human smuggling is a crime against a country and involves transportation, whereas human trafficking is a crime against a person (6, 7).  
• Consensual commercial sex (i.e., sex work) is not trafficking, provided that the person is over the age of 18. Anyone under the age of 18 who provides commercial sex, regardless of circumstances, is considered to be trafficked (3). This is because a minor, in the United States, is legally unable to provide consent for commercial sex (4, 6, 7). 

Types of Human Trafficking  

While many people think of human trafficking only involving sex exploitation, it can also include labor trafficking, child soldiering, and more (6).  

• Forced Labor – occurs when force, fraud, or coercion are used to exploit the services or labor of another person (6, 9, 19), and often involve physical or verbal violence, forced overtime, limited freedom of movement or communication, and lack of freedom to resign (8). Forced labor can include the following industries or elements: 
  • Domestic Servitude involves work in a private residence, where victims’ food, housing, and transportation are often controlled by their exploiter. 
  • Forced Child Labor still occurs in the United States, despite labor laws, and in this situation, children are forced or compelled to work. 
  • Agriculture  
  • Construction/Landscaping 
  • Illicit Activities 
  • Health and Beauty 
  • Traveling Sales Crews 
  • Retail/Small Businesses 
  • Restaurant/Food Service, Hospitality
• Sex Trafficking requires the components of acts, means, and purpose to establish a sex trafficking crime for those age 18 and over (anyone under the age of 18 who engages in commercial sex, regardless of circumstances, is a victim of child sex trafficking) (6).  
• Child soldiering is a type of human trafficking that involves unlawfully recruiting children – through force, fraud, or coercion- to act as combatants or other workers for government armed forces, paramilitary organizations, or rebel groups (10, 18). Children can also be used in sexual slavery, where they are forced or coerced to “marry” or be raped by commanders or combatants (6, 18). 

All types of human trafficking include actions, means, and purpose (7).  

• Actions are met when a trafficker does any of the following: 

• • Recruits by targeting a vulnerable person and/or using grooming behaviors 
  • Harbors by isolating, confining, and monitoring 
  • Transports by arranging travel for or moving the victim 
  • Provides something to the victim (like food or housing) 
  • Patronize the person by giving them financial support 
  • Obtains by forcibly taking or exchanging something for the ability to control the victim 
  • In cases of sex trafficking, the trafficker may also solicit or receive something of value in exchange for sexual acts by the victim 
  • They may solicit forced labor or other acts of servitude from a person in exchange for something of value. 

• Means include force, fraud, or coercion used by the trafficker. Examples of these include threats to others, debt manipulation, psychological harm, or threats of serious physical harm.  
• Purpose is the commercial sex act itself, or forced labor, and can occur in many places: in private homes, online, in hotels, brothels, massage parlors, and more.

The Trafficking Victims Protection Act of 2000 (TVPA) 

Although human trafficking has been around for centuries, no real legislation had existed in the United States or internationally to address it. There were also no good working definitions of human trafficking, as it often shares overlapping characteristics with sexual assault, smuggling, and the commercial sex trade. Since the inception of the United States, not until this century has there been any significant progress on making laws related to human trafficking. 

In November of 2000, the Palermo Protocol was adopted by the United Nations in order to prevent, suppress, and prosecute human trafficking on a global level (24). This was the year that United States followed suit by passing the TVPA (23). This legislation has also had reauthorization acts that updated measures and refined the language in 2003, 2005, 2008, 2013, 2017, and 2018 (25).  

The TVPA has three goals, also called the three Ps: to protect victims, prosecute offenders, and prevent future human trafficking occurrences (23, 25).  

Protection of victims includes efforts such as issuing a T-visa to victims of trafficking if they meet eligibility requirements and cooperate in the investigation and prosecution of traffickers. The T-visa grants non-immigrant status and allows victims to remain legally in the United States for up to four years.  

After three years or the closing of the related criminal case, they can apply for permanent residency (22). Furthermore, those who were previously ineligible for government assistance may be able to obtain it under the TVPA (25).  

Prosecution of perpetrators involves creating a series of new federal crimes that now define human trafficking and make it prosecutable in every state (25).  

Prevention of human trafficking includes both foreign and domestic efforts to increase awareness and establish laws related to this crime (25).  

The TVPA, established and amended as 22 USC §7102, recognizes that human trafficking includes three specific means, not all of which need be used, defining them as follows (1,2, 7):  

• Coercion: “Threats of serious harm to or physical restraint against any person,” a plan that would lead someone to believe that not performing a certain act would lead to serious harm, as well as “abuse or threatened abuse of the legal process”  
• Force: Can include physical harm or restraint, sexual assault, and beatings. During the early stages, the trafficker might monitor and confine victims to control them and break down resistance. 
• Fraud: False promises in regard to wages, working conditions, employment, a better life, marriage, or love. The victim may experience unexpected changes in the nature of a relationship or working conditions.  

Case Study: Mahad 

Upon consulting with the attending physician at your ED, you both agree Mahad is a potential victim of human trafficking. Since you are both new to the facility, you work with others on your team to locate appropriate resources to address Mahad’s situation. One of the nurses tells you that you should use the official translation service available in the ED and ask Mahad’s uncle to step outside of the room.  

 
When you come back to see Mahad, you bring the translation device with you and ask Mahad’s uncle to step out, which he does after a few quick phrases to Mahad. Another nurse escorts Mahad’s uncle to the waiting room, and you prepare to interview and assess Mahad more fully.

Who Is Trafficked?  

Anyone can be trafficked at any time, provided the right circumstances. While many people tend to think of girls and young women as the main trafficked persons, many boys and men are also trafficked (4, 6).  

For sex trafficking in the United States, victims are more likely to be Black (40%) or white (26%) versus other races; those being trafficked for labor are more likely to be Latino (63%) or Asian (17%) (22).  

Many victims of trafficking have certain vulnerabilities and situations that make them more likely to be trafficked (4, 12). These include, but are not limited to:  

• Experiencing poverty or economic hardship
• Being victims of violence
• Having physical or cognitive disabilities
• Presence of childhood abuse, neglect, or trauma
• Working as migrant laborers
• Being of a racial or ethnic minority
• Identifying as lesbian, gay, bisexual, transgender, and questioning (LGBTQ) individuals
• Being children in foster care and/or juvenile justice systems
• Having run away as a youth or not having adequate housing
• Experiencing housing insecurity or being homeless as adults
• Having a history of substance abuse
• Surviving a natural disaster, political instability, or armed conflict

Who Are the Traffickers?  

Just as anyone can be trafficked, anyone can be a trafficker as well; there is no universal trafficking profile. Many times, the traffickers themselves are close to or are family of those whom they traffic in (13, 14). These can include parents, intimate partners, gang members or networks, restaurant and other business owners, government representatives, corporate executives, and many more (15).  

Some traffickers experience the same types of financial or social oppression as their victims, while others use positions of power and privilege as a means of control (15.) Many traffickers target people whose needs are not being met, like young adults who seem to lack confidence, or whose emotional, financial, or material needs aren’t being met (13).  

Regardless of who the traffickers are, they are illegally participating in the exploitation of others for personal gain.  

What Are Some Common Trafficking Methods or Techniques?  

While there is a constellation of ways by which a trafficker may entrap, coerce, or defraud their victim, there are some common characteristics (14, 16). Approximately two-thirds of traffickers are men, though women are often prosecuted at a far higher rate (18).  

Many times, traffickers offer jobs or opportunities that seem too good to be true, such as a modeling contract or promise of high salary for a factory position. They may give promises of love and a place to live or shower the victim with expensive gifts. Sometimes, particularly in the case of debt bondage, the trafficker forces the victim’s children or other family members to help pay off debts (18).  

For labor trafficking, traffickers may force their victims to: 

• Live at the business, sometimes in crowded conditions with others. 
• Sign a contract in a language they cannot read. 
• Work long shifts or unusual hours, often in isolation. 
• Engage in debt bondage, where the trafficked person owes a large debt that is never paid off and continually increases. 
• Give up control of their identification documents and finances. 
• Produce goods or services that are priced below general market rates. 

For sex trafficking, traffickers may employ the following tactics: 

• Brand the people they traffic with tattoos.  
• Prohibit the victim from coming or going as they please, especially if they live in a “massage” business. 
• Hold identification documents so that the victim cannot access them.  
• Prohibit any outside communication with others that is not monitored.  
• Control their finances. 

 In addition to the methods above, there are other potential red flags that someone might be a victim of trafficking. These include, but are not limited to, the individual (34):  

• Making little, if any money, or only being paid in tips. 
• Trying to pass themself off as older, particularly if involved in commercial sex acts.
• Exhibiting a flat effect and/or avoiding eye contact.
• Acting unusually anxious, restless, fearful, tense, submissive, or nervous; particularly when there is any mention of law enforcement.
• Appearing malnourished.
• Showing signs of physical abuse, torture, restraint, and/or confinement.
• Exhibiting prolonged, untreated illness or disease and/or unexplained injuries.
• Being unable to produce any form of identification, money, or other personal possessions.
• Not being allowed to speak for themselves when in the presence of someone else who escorted them in.
• Demonstrating a lack of knowledge of the city / geographic location they are in.
• Exhibiting a sense of loss of time.
• Having several inconsistencies in their story.
• Being brought in by police for medical clearance; they may have been part of an illegal activity.

(19) 

Why Don’t We Have Better Data?  

Getting accurate data on human trafficking is an imprecise science. Due in part to the stigma associated with trafficking, as well as victims themselves are not aware of their situation. When these factors are coupled with the many types of trafficking that exist, it is difficult to get precise figures on the matter (17).  

Victims may be coached on what to say by their traffickers, or these cases may be reported under the heading of child abuse or neglect instead of being identified also as a case of human trafficking (26). Healthcare providers may lack a trauma-informed approach, leading them to miss the signs of trafficking or for the victim to lack enough trust to confide in the provider (26). As discussed above, only in the past few decades has a definition of human trafficking even been formalized, so many laypeople and healthcare practitioners may be unaware that they have even encountered a victim of trafficking.  

Human trafficking is also often a hidden crime, hard to identify, and embedded in everything from housekeeping to nail salons to agriculture. While men make up as much as 20% of trafficking victims in the United States, they are often criminalized or deported at a much higher rate than females, making their numbers virtually impossible to track (20).  

Finally, since human trafficking takes place on a global level, it is difficult to aggregate data from each country, particularly when there is no good way to reliably report known cases.  

The Health Impact of Human Trafficking  

Human trafficking can cause or exacerbate myriad physical and mental health problems among its victims and survivors. Healthcare providers should be fully versed in all the ways these can present when victims are seen in clinical settings. In a 2017 study, nearly 88% of sex trafficking victims sought treatment in the United States healthcare system but were often left unidentified or not offered adequate resources by the clinical treatment team (21).  

Acute Injuries  

When those being trafficked seek healthcare, they may present to any of the following or more: dental offices, emergency departments, walk-in clinics, OB/GYN offices, mental health care facilities, substance use disorder treatment centers, and primary care providers. Upon presentation, certain acute injuries may be present. These include, but are not limited to (20, 22):  

• Amputation  
• Anxiety and/or depression 
• Back or neck pain 
• Burns 
• Contusions  
• Dental complaints 
• Fractures 
• Headaches
• Head and neck trauma
• Infectious diseases from worksite, including parasites, hepatitis, and tuberculosis
• Musculoskeletal pain or trauma
• Pelvic pain and/or pelvic inflammatory disease
• Respiratory problems from occupational hazards
• Sexually transmitted infections
• Skin conditions: scabies, lice, suspicious tattoos
• Substance abuse
• Suicidal ideation
• Unplanned pregnancy or abortion complications  

Almost 60% of human trafficking survivors report physical injuries, with up to 95% of those enduring physical and/or sexual violence (20). There is a degree of overlap between domestic violence signs and those found in human trafficking; healthcare providers should note wounds or injuries of varying ages, injuries around the head or genital areas, burns or contusions, and any wound that appears self-inflicted (20).  

Other acute injuries to be aware of are dehydration and/or malnutrition, visual complaints, somatization, injuries, or illness due to exposure to unsafe water or hazardous chemicals, poor dental care, and impacted tampons in vagina (19).  

Chronic Injuries  

Due to the nature of trafficking occurring primarily within the labor and sex markets, there are some chronic injuries the healthcare provider might anticipate. Some of these include (20, 22):  

• Addiction disorders 
• Back pain 
• Cancer 
• Chronic generalized or localized pain
• Headaches
• Hearing loss from working conditions
• Hepatitis
• Human Immunodeficiency Virus (HIV)
• Pelvic inflammatory disease 

Many chronic conditions may stem from repetitive work, such as those involved in factories or through repeated sexual trauma. These can also include reproductive and mental health issues as well.  

Mental Health Issues  

Since force, fraud, and/or coercion are necessary parts of human trafficking, a plethora of mental health problems can be experienced by its victims. While many survivors report having a preexisting mental health condition before being trafficked, these conditions can also be created or exacerbated by the condition of trafficking (20, 21, 22).  

Human traffickers often use methods like sleep or food deprivation to increase compliance of their victims (20). They may also employ tactics such as forced social isolation, close monitoring of behavior, control over identification documents and finances, abuse, and neglect (20).  

Mental health issues often experienced by victims and survivors include, but are not limited to:  

• Anxiety disorder 
• Autonomic arousal 
• Cognitive or developmental delays, learning disabilities in the younger population
• Depression
• Dissociation, which can lead to memory loss or impairment
• Insomnia, sleep disturbances, nightmares
• Obsessive-compulsive disorder (OCD)
• Post-traumatic stress disorder (PTSD)
• Self-harm or mutilation
• Suicidal ideation
• Trauma bonding (i.e., Stockholm Syndrome)  

 Also, due to its horrific impact on body and mind, human trafficking can cause other mental health problems, such as: anger, irritability, hopelessness, isolating behavior, fear of being alone, denial, exhaustion, aggression, recurrent or intrusive memories of abuse, guilt/ shame/ self-blame, increased crying, numbness, distrust or fear of strangers, difficulty concentrating, and more (22).  

Furthermore, many victims may be retraumatized if faced with other instances of violence or having to face their trafficker(s) again, perhaps in a courtroom setting (22).  

Healthcare providers should be aware of the impact their own demeanor can have on people who are trafficked; if particularly curt or rushed with a patient, that can cause the victim even further traumatization and more reluctance to disclose their situation.

Other Health Impacts  

While human trafficking undoubtedly causes or exacerbates countless physical and mental health conditions, it has other overlapping impacts as well.

Substance Abuse  

Substance abuse is a very common comorbidity within the human trafficking realm, and for many reasons. Some victims already had a history of substance abuse, others use(d) it as a coping mechanism for their situation, and others yet were forced or coerced to use substances of abuse (22). Since traffickers understand that those who are addicted are more easily manipulated and controlled, this remains a popular tactic used (22). A victim of human trafficking who is abusing a substance may also be afraid to seek out help from law enforcement, as they might fear prosecution (20).

Reproductive and Sexual Health Concerns  

While mentioned above in both acute and chronic conditions, sexual health concerns can leave a lasting impact on a trafficked person’s life. Since those being trafficked for sex often encounter a large number of sexual partners, STIs and unwanted pregnancies occur at high rates (20, 21, 22). Some victims have absorbent items like sponges placed in their vaginal vaults during menstruation so that they may still “work;” this can lead to chronic pelvic infections and vaginal pain (20). Repeated pregnancies and abortions can also take their toll on a victim’s body, leading to chronic pain, infections, and fertility problems (20, 22). Finally, since up to 80% of sex trafficking victims in the US are female, healthcare practitioners who provide women’s services should be aware of how to identify, treat, and provide resources to victims (20).

Quality of Life, Autonomy, and Independence  

During the time a person is trafficked, much of their life is often not under their control. They frequently have their whereabouts monitored, social interactions limited, and do not have a great deal of physical or mental autonomy and independence. As discussed above, many victims of human trafficking experience physical and psychological abuse, leading to innumerable problems. Psychological issues and substance abuse often go hand-in-hand, severely limiting the victim’s quality of life (22). The repeated trauma, potential for trauma bonding, and lack of basic needs being met can severely interfere with long-term healing and establishment of independence for survivors.  

Case Study: Mahad 

Now that you know Mahad is willing to meet with you away from his uncle, you, and another nurse plan how to best approach the situation. Since neither of you has much experience with people who have potentially been trafficked, you decide on some basic care parameters for this encounter.

Trauma-Informed Care 

Providers involved in the care of any vulnerable population should be cognizant of trauma-informed care. This paradigm acknowledges that traumatic experiences can pervade all aspects of an individual’s life and behavior, including their self-perception and their relationships with others (44).  

Trauma-informed care prioritizes the emotional, psychological, and physical safety for everyone involved, including staff members. Further, this type of care emphasizes the goals of treating, educating, and empowering the patient, not for the disclosure of victimization (37).  

The Substance Abuse and Mental Health Services Administration (SAMHSA) defines individual trauma as a circumstance or event that results in mental, physical, and/or life-threatening harm (31). Furthermore, SAMHSA goes on to describe the “three Es” of trauma (32):  

• Event: A circumstance or set of events that occurred to an individual, which may include natural disasters, violence, warfare, and so on 
• Experience: How the person experiences the event defines it as traumatic to them or not; for it to be traumatic, it needs to be physically or psychologically harmful.  
• Effects: These can be acute or chronic, and adversely impact the person’s physical, social, emotional, mental, and/or spiritual well-being.  

 As victims of human trafficking are very often traumatized, it is essential that the practitioner provide care specifically geared toward this population. SAMHSA has developed some goals of such care, called the trauma-informed approach, that is ideal for interactions with survivors of human trafficking (32).

The main goals of trauma-informed care are:  

• Safety: Patients and the staff around them feel safe, physically, and psychologically 
• Trustworthiness and Transparency: The goal of building trust is developed through making decisions in a transparent manner 
• Peer Support: Others with a similar experience are involved in care, and are used by the treating organization as an integral part of the services provided 
• Collaboration: Whenever possible, shared decision-making is utilized among patient, clinician, and other staff 
• Empowerment: Strengths of both patient and provider are recognized and built upon, fostering the ability to heal from trauma in a resilient way 
• Humility and Responsiveness: Any biases and stereotypes are recognized and addressed, as is historical trauma  

What can practitioners do? SAMHSA offers “four Rs” to using the trauma-informed approach (32):  

• Realizing the prevalence and immense impact of trauma 
• Recognizing the clinical and signs and symptoms of trauma in patients and other staff members 
• Responding to the situation by utilizing the appropriate resources in the institution and within the wider community 
• Resisting re-traumatization of the people being served by not making the situation worse with language or action 

Patient-Centered Approach 

When providing high-quality care to potential victims of human trafficking, it is essential to use a trauma-informed, patient-centered approach. This means providing for the person’s safety, well-being, and dignity first and foremost.  

The following are some elements of this type of care (33):  

• Safety: Ensure that the patient is alone, having escorted other guests to a waiting area while any screenings or assessments are being conducted. The person should feel comfortable with the provider and any other staff members or professional interpreters present. If possible, give the patient the option of where to sit in the room, perhaps with the door in sight. 
• Physical needs: Since victims of human trafficking are often sleep- or food-deprived, it is reasonable to offer them food or water if appropriate. This may not be feasible for those who need a SANE evaluation, but for others, it may make it easier for them to respond. Offer bathroom breaks and check to see if the patient is as physically comfortable as possible. Soft lighting may also help, if available.  
• Use non-threatening, open body language: Try not to cross arms across the chest and sit or squat near the patient. Establish eye contact frequently, and respect personal space. Do not touch the patient unless necessary for the exam, and always inform them beforehand.  
• Engage the patient: Use calm, slow, nonjudgmental speech. Try to keep facial expressions neutral and avoid generalizing about the person’s experience. Make sure to give adequate time for listening.  
• Resist probing too many details: Since the goal is to ensure the patient’s safety and adequate care, only obtain information necessary for their care at this time. Avoid criticizing the trafficker, since this can cause the trafficked person to become distressed or defensive.  
• Use respectful, empathetic language: Say things such as: 

• “This seems difficult for you to talk about. Please, take your time and let me know if you need anything, including a break. I will try to make this as brief and comfortable as possible for you.” 
• “Please answer the following questions as ‘yes,’ ‘no,’ or ‘I don’t know.’ You do not have to answer a question if it makes you too uncomfortable.”  
• “I want you to feel safe here. Please let me know if I can do anything else to help.” 

• Be prepared to help coach the patient through a trauma reaction. Talking about such difficult experiences can re-traumatize the patient, potentially resulting in a trauma reaction. In this case, the person may experience a flashback or anxiety/panic attack. These techniques can help:  

• 4-7-8 breathing: Have the person put their tongue on the roof of their mouth, behind their teeth. They should then exhale through their mouth loudly, close their mouth, and inhale through their nose for 4 counts. Have them hold their breath for 7 seconds. Finally, have them exhale again through their mouth with the tongue still on the roof of their mouth. This 4-7-8 cycle can help immensely and can be done in the future.  
• 5-4-3-2-1 technique: Have the person think of 5 things they can see in the room, 4 things they can feel, 3 they can hear, 2 they can smell, and 1 they can touch. This can help ground the person in the present moment, instead of getting lost in traumatic memories.  

Identification and Assessment  

While a healthcare provider may suspect a patient is potentially being trafficked, certain considerations need to be made when assessing this population. A person being trafficked may be present for care at any time, in any situation. They may want to be seen for an injury related to their trafficking, or for something else, like mental health services, dental care, evaluation of pre-existing conditions, addiction treatment, or a general check-up (19).  

In a 2014 study, nearly 88% of human trafficking victims sought healthcare while in their situation, 68% of which were emergency services (19). Perhaps more concerningly, more than half of the survivors surveyed in another study stated that they were not asked any questions about trafficking or abuse during their healthcare visit (27).  

Challenges and Opportunities When Interfacing with Trafficked Persons  

While there are many reasons human trafficking goes undertreated and underreported, the practitioner must keep in mind that disclosure is not necessarily the ultimate goal when encountering these victims.  

First and foremost, the person’s safety is paramount, then their medical care, and finally, if appropriate and with available resources, disclosure of the potential crimes.  

Though not exhaustive, the following are some challenges healthcare professionals may face when they encounter potential victims of human trafficking, and ways they may be addressed: 

1. Guilt or shame: Victims may often feel guilty for what has happened to them or feel ashamed of their situation. The practitioner should do their best to provide calm, non-judgmental care. This can be conveyed through open body language, cultural awareness, eye contact as appropriate, and a non-rushed manner of talking and assessing.  

What to say:  

“I’m here for you to listen to what you have to say. It is not my job to judge you”.  

“This situation is not your fault.”  

What NOT to say:  

“How come you let yourself get into this situation?”  

“Does your mother know what you do for a living?” 

1. Lack of trust: Due to the nature of the crime, traffickers have likely conditioned their victims to distrust healthcare providers, law enforcement professionals, and others. Though more time consuming, building as much trust as possible is in the best interest of human trafficking victims.  

Ways to establish oneself as trustworthy are to first establish a private setting to interview and assess the patient. Follow through on promises, give the person time to speak, exude a calm demeanor, and reiterate to the person that they are in a safe place.  

What to say:  

“I care about your safety and your health.”  

“I will help you to the best of my ability.”  

What NOT to say:  

“What do you think I can do for you today?”  

“We’ll send you home soon and make a follow-up appointment”  

1. Language barrier: English may not be a language the victim speaks well or at all. Be wary of anyone accompanying the patient who wishes to act as sole interpreter. It is absolutely critical to use a formal interpreter provided by the practitioner’s facility.  

As much as possible, ensure that the interpreter has no relation to the potential victim or their situation, and has training in translating in situations such as these.  

What to say:  

“We will get you a professional interpreter.”  

“Please let me know if you don’t feel comfortable talking about this.”  

What NOT to do:  

Do NOT use the person who accompanied the patient as the interpreter.  

Do NOT use your phone’s translation app or other informal web-based program.  

1. Psychological disturbances: Whether from prior history, acute trauma, substance abuse, or a combination of these factors, many people who are trafficked may not be able to fully discuss their situation upon initial assessment. It may take time for the victim to be more coherent, particularly if the disturbances are drug-induced.  

What to say:  

“I’m here for you if you would like to talk.” 

“I can wait until you feel a little better.”  

What NOT to say:  

“Why did you use drugs if you knew you were going to come in here?” 

“Focus and talk to me.” 

Case Study: Mahad 

After getting Mahad in the room alone, you secure the services of your facility’s formal interpretation service. Through the interpreter, you ask Mahad if his cell phone is off. After a minute, he reluctantly turns it off. Next, you ask Mahad if he would like a male interviewer instead, or a male chaperone, since some cultures prefer to speak with the same gender for these types of encounters. Mahad declines, and you are able to begin your formal history and physical.  

Throughout the process, you discover that Mahad came to this country from Somalia on a student visa three years ago, and his visa is now expired. The man accompanying him is not his uncle, but rather one of the people he works for at the metal stamping plant. The man, who just goes by the letter J, found Mahad when his student visa was expiring, and promised him a lucrative factory job and a place to stay. After a month of working without a paycheck, Mahad asked J where his money was. J told Mahad that he owed him the cost of the room at the factory, as well as a referral bonus for getting him the job in the first place. That was now six months ago, and Mahad has yet to see any money.  

When Mahad tried to leave the factory to return home to Somalia, he found the factory perimeter locked and a guard who prevented him from leaving. J confronted Mahad and told him if he left, he would face arrest and deportation. At that time, J took Mahad back to his room and severely beat him. Mahad states that he has been working for 14 to 16 hours a day with hardly any breaks. At night, he and the other workers drink whiskey until they fall asleep, since J provides one meal a day and allows the workers to bond over drinking alcohol the company provides. Mahad states there are seven other men living with him in cramped quarters, all of them from Somalia. The other men tell Mahad that they have been there for years and have been threatened with death or deportation if they leave the factory grounds.  

Mahad states that this is his third visit to the emergency department. He had come before due to a concussion sustained from a work-related injury, as well as alcohol poisoning before that. He said no one had ever asked him much about his situation, assuming he was a lazy alcoholic.  

Upon examination, Mahad is cooperative but with a flat affect. He states things matter-of-factly, without much emotion. His skin assessment reveals bruises on all extremities, his back, and his abdomen. His sclera appears jaundiced, and he endorses right upper quadrant pain accompanied by intermittent nausea. He states he has had no appetite for the past few days and was only allowed to come to the emergency department because of his inability to work. J stated that he was to get seen, get put on medications to help, then get back to work immediately.  

Barriers to Disclosure  

As stated before, the healthcare provider’s main goal with a potential victim of human trafficking should be to maintain safety and focus on their well-being. There may be myriad, insurmountable reasons a person may not want to disclose their situation. These include, but are not limited to (22):  

• Fear of arrest: Due to the illegal nature of human trafficking and some of the illicit industries it encompasses, the victim may worry about being arrested and incarcerated.  
• Fear of retaliation: Traffickers may have threatened the victim’s family or friends if disclosure occurs.  
• Fear of deportation: If the victim is not a US citizen, they may worry that they will be sent back to their country of origin, where the situation may be even worse for them.  
• Fear of stigmatization: It may be humiliating or embarrassing for a person to disclose all that has happened, exacerbated by the extra layer of social stigma.  
• Lack of trust of the healthcare workers: Even if the trafficker has not predisposed their victim to mistrust of the healthcare system, the particular individuals the victim encounters may not develop sufficient trust for the victim to feel comfortable disclosing their situation.  

Provider Challenges to Identification and Response  

In addition to the barriers related to a victim’s self-disclosure of their trafficking, there are more challenges to identifying potential human trafficking victims. Generally, these fall into two categories: provider-related and individual-related (29). To prevent individual-related barriers, the practitioner should be aware of them and be prepared to resolve them.

Provider-Related Barriers 

While there is increasing awareness of healthcare providers to identify and treat human trafficking victims, some roadblocks still remain. Common reasons providers may not be able to properly recognize or assist victims may include:  

• Lack of understanding of human trafficking and related laws 
• Bias of how a person who has been trafficked may present 
• Feeling the case may be too complex for their level of practice 
• Uncertainty of available resources or referral options 
• Not having adequate training on trauma-informed care; may exhibit victim-blaming and/or culture stereotyping 
• Misidentifies the case, often as abuse or neglect without further context 
• Lack of access to neutral and appropriate translators 
• Feeling that it is not their role to get too involved in the case 
• Frustration with questioning patient: may feel their story is rehearsed, or that the patient is hostile or uncooperative 
• Concern over fears of violating HIPAA (Health Insurance Portability and Accountability Act)  

Individual-Related Barriers 

Since human trafficking is a complex matter with no cookie-cutter case, the victims themselves may also have difficulty identifying themselves as such. Other possible obstacles of people who have been trafficked include:  

• Language barriers and/or limited literacy that hinder communication 
• Lack of identification 
• Legal worries: not understanding their rights in this case, or feeling complicit in an illegal activity  
• Concern that the traffickers will cause harm to the patient or their loved ones 
• Fear of deportation, arrest, being sent back to an abusive place, or going into foster care 
• Presence of trauma bonding (also called Stockholm Syndrome) with the trafficker and/or other victims 
• Feelings of shame, fear, guilt, hopelessness, and helplessness 
• Lack of trust toward the provider and/or other authority figures 

How to Combat Barriers to Identification  

First and foremost, it is crucial to establish trust with the potential victim of trafficking. The healthcare provider must have the person’s well-being and safety as their primary goals. Trust can be developed by slowly talking to the patient, keeping body language open and non-judgmental, and giving plenty of time to speak. Personal space and eye contact are to be dictated by the patient’s perceived comfort, as well as their culture.  

The provider should reiterate to the person that the clinical environment is always a safe one, and that their information will be kept as confidential as possible, within the limits of the law. If possible, it may be helpful to enlist the help of others in the facility: a social worker, sexual assault nurse examiner (SANE) nurse if required, legal counsel, patient advocate, and others. If the patient fears retaliation on their family members or other loved ones, they should know they can get help in this matter and can return to the healthcare facility any time as needed.  

Providers need to be aware of their own implicit biases. Human trafficking victims are a diverse population; there is no single gender or racial or ethnic makeup that comprises this group of people. Men, especially those working in manual labor jobs and the hospitality industry, can also be trafficked, regardless of age, race, or religion. Furthermore, the provider should be aware that in cases of sexual assault or abuse, a further investigation needs to be done to determine if the situation involves trafficking. Simply treating a sexually transmitted disease and discharging the patient after being seen by a SANE nurse is not sufficient care if trafficking is suspected.  

The Importance of a Professional, Unbiased Interpreter 

In the United States, it is estimated that over 350 languages are spoken (30). It is thus likely that in any given shift, a healthcare provider will need at least some degree of translation services for their patients. When working with potential human trafficking victims, it is of the utmost importance that an unrelated, unbiased, professional translator be used. This interpreter should have familiarity with medical language and be free from judgment when translating for the patient. Some things to keep in mind when using an interpreter service for potential victims are (30):  

• If possible, talk to the interpreter alone before talking with the patient to briefly explain the situation. The interpreter should be calm and free of prejudice, ideally having had experience with this type of situation before. Both the provider and interpreter should use a trauma-informed, patent-centered approach.  
• Ensure the patient’s comfort with the particular interpreter; the patient may wish to specify a certain gender, race, or dialect to best meet their needs.  
• An in-person translator is always preferrable, though not always feasible.  

Maintaining a Safe Environment for Staff and Patients  

Without proper safety measures, an encounter with a person who is potentially being trafficked, especially if they are present with their trafficker, can become dangerous very quickly. Providers should remember that human traffickers are criminals and may be armed or violent (35).  

The healthcare practitioner must take steps to ensure that everyone remains safe, including other staff members and patients. When meeting with a potential victim of human trafficking, here are some ways to best maintain a safe environment (35, 37):  

• Privacy: Have a plan to get the patient alone to conduct the interview and assessment. This may be difficult to enforce, so it is critical to have a protocol in place to ensure private conversations with those suspected of being trafficked. There should be a plan to physically separate the patient from their escort and may require the services of security personnel. Some strategies may include: 

• • Assess the power dynamics between the patient and accompanying person(s), and if the patient seems to be comfortable talking about their situation 
  • Decide who is to do the separating  
  • Give reasons such as the patient needs to go for a diagnostic test in another area; cite clinic or hospital policy to interview the patient alone; ask the accompanying party to step out to help complete paperwork or a phone call for scheduling an appointment 
  • Always maintain safety in the environment, noting that involving law enforcement at this point might not always be in the best interest of the patient, particularly terms of future safety 

• Safety Screening: Ask questions pertaining to the person’s physical safety at the time of the interview. This might include asking:  

• • Do you feel safe talking here?  
  • Is there anything that would make you feel safer here as we talk?
  • Can you bring information or phone numbers back with you?
  • Is it safe to contact you another day? If so, which phone number is best? How should I introduce myself when I call? How can we get back in touch if we get disconnected?  

• Conclusion of Visit: If the patient is discharged, how can it be done safely? If the patient is admitted for further care, what will be done with the person escorting them? Does law enforcement need to be involved? If so, how will that be handled? There should be a protocol in place to address these and other immediate safety concerns.  

The Healthcare Provider’s Role  

If the healthcare practitioner suspects a patient is being trafficked, these are the steps that should be taken (47):  

1. Provide safety and privacy for the person.  
2. Assess and treat the medical conditions.  
3. Follow mandatory state reporting laws, as described in the Mandated Reporting section below. 
4. Follow institutional policies for law enforcement involvement if patient is in immediate, life-threatening danger. As much as possible, work with the patient to determine whether or not to involve law enforcement. 
5. Offer the patient resources for reporting and additional services, as described below.  
6. During discharge planning, address safety concerns and future plans. 
7. Ensure proper documentation of assessment and treatment, as described below.  

Survivor-Centered, Multidisciplinary Referrals 

For a situation as sensitive as human trafficking, it is crucial to provide survivor-centered, multidisciplinary referrals to all victims. The referrals should be both within the healthcare organization where the survivors are seen, as well as with community partners. Having survivor engagement enables organizations to better serve this population, as well as create better programs and opportunities within the healthcare system and the larger community.  

Since each survivor is unique, he or she will require a specific mix of resources. These can include any and all of the following: public health professionals, survivor networks, healthcare, legal aid, law enforcement, social services, and behavioral health. Depending on the person’s situation, emergency resources might be needed for housing, food, medical and mental healthcare, substance abuse treatment, legal assistance, and overall safety (48). Ongoing needs may also include transportation to service appointments, therapeutic counseling, and emotional support.  

Appropriate Documentation  

As with all other aspects of nursing, documentation is key. In cases of human trafficking, however, this proves challenging for several reasons. First and foremost, the healthcare practitioner’s role with the patient is to diagnose and treat, while providing for safety. There may be legal ramifications for any information included in the medical record, and legal counsel should be available in cases such as these (37).  

Some aspects to consider include (37): 

• Limit the amount of initial questioning if a SANE nurse evaluation will be done; the SANE nurse will collect evidence with patient consent, and keeping the rehashing of the situation to a minimum will reduce the likelihood of retraumatizing the patient even further.  
• If the case goes to trial, some information entered into the medical chart can harm the victim (e.g., if the patient was involved in illicit activity, they may be prosecuted for this). It is best for the practitioner to clarify with law enforcement and prosecutors how the information may be used and released.  
• In cases of sexual assault or injury, using direct quotations from the patient can be helpful, but might be detrimental if any of the details of the story change later on.  
• Any photographs taken during the medical assessment may be shared with a defense attorney and potentially the traffickers themselves; this can retraumatize the victim, particularly if these photographs are displayed during their trial.  
• Developing an institutional system for flagging potential victims of human trafficking is beneficial; documentation of resources provided (e.g., “Gave patient number for National HT Hotline” or “Referred patient to community agency…”) can both protect the patient and show the clinician’s suspicion of the situation.

Mandated Reporting  

The healthcare provider is in a unique position when it comes to human trafficking cases. While the primary goals are to provide patient safety and give high-quality medical care, there are also legal obligations in certain cases.  

If a minor, elderly person, or person with a mental or physical disability is suspected of being a victim of human trafficking, they are classified as being abused under Texas law, and thus fall under the mandated reporting category for healthcare professionals (41).  

In Texas, mandated reporting obligations pertain to suspected abuse, neglect, or exploitation of the following populations (38):  

• Children under the age of 18 
• Elderly persons aged 65 or older
• People with disabilities

Suspected abuse or neglect of children must be reported within 48 hours. For suspected abuse or neglect of those 65 or older or adults with disabilities, a report must be made to the Department of Family and Protective Services (DFPS) and/or law enforcement immediately. This task may not be delegated to anyone else; the provider who suspects the abuse is responsible for making the report (40, 41).  

The following information for must be included in cases involving the elderly or people with disabilities: The name, age, and address of the suspected victim; the name and address of the caretaker or person involved; the nature and extent of the abuse, neglect, or exploitation; the basis of the reporter’s knowledge; any other relevant information. Failure to report suspected cases can result in a Class A misdemeanor. Further, as long as the report was made in good faith, the reporting party is immune from civil or criminal liability in Texas (38).  

All suspicions described above should be reported to the Texas Department of Family and Protective Services (DFPS) at 1-800-252-5400, particularly if they are urgent and need to be investigated within 24 hours (40).  

As always, in a life-threatening situation outside of a hospital or correction facility, it’s best to call 9-1-1. For matters that can wait more than 48 hours, an online report may be made to DFPS here: https://www.txabusehotline.org/Login/Default.aspx .  

As of September 1, 2023, all reports of children suspected of being abused, neglected, or exploited can no longer be made anonymously to DFPS. Reporters must give their first and last name and a phone number where they may be reached. Though not anonymous, this information is kept confidential by law. If the reporter wishes to make an anonymous report, they may do so with local and state law enforcement agencies instead (40).  

A healthcare provider is not to report the abuse of adults younger than 65 and with no disability without the trafficked person’s consent. Still, the provider can submit a report to the National Human Trafficking Hotline (888-373-7888), without the trafficked person’s identifying information (46). It should be reiterated to the patient that they are welcome to return to the facility any time, that they are safe there, and that they can decide to report at any time.  

Implications of Law Enforcement  

As discussed in this course, victims of human trafficking may be understandably fearful or apprehensive of law enforcement. Depending on the concurrent crimes involved during the period of trafficking, the survivor may face legal repercussions. Luckily, law enforcement officials can provide some resources to healthcare providers, including (42):  

• Local victim service providers 
• A network of resources available through a human trafficking task force, where available 
• Assistance with applying for immigration relief  

It is best for the provider to limit disclosures to law enforcement related to the individual if the potential victim of trafficking wishes to speak to law enforcement, or if the provider suspects imminent danger to the staff and/or individual (42).  

Contacting Community, Local, and/or State Resources  

Fortunately, there are a wide variety of resources available for people who are trafficked and the clinicians who take care of them.  

The National Human Trafficking Hotline, or NHTH (888-373-7888), is available 24/7, toll-free.  

The NHTH is also available by texting BeFree, or 233733.  

This hotline helps maintain a federal database of anti-trafficking agencies and resources and is a response to protecting trafficked persons. The NHTH also has an online directory of anti-trafficking services and groups: https://humantraffickinghotline.org/en/find-local-services.  

In Texas, there is a wide array of online resources that can aid practitioners and potential victims of human trafficking or other forms of abuse:  

• Texas Association against Sexual Assault (TAASA): https://taasa.org/
• The TAASA Service Directory: http://taasa.org/wp-content/uploads/2018/10/TAASA_Service-Directory-102318.pdf
• Texas Department of Family and Protective Services (DFPS) and/or local law enforcement: Reporting Abuse, Neglect, or Exploitation: https://www.dfps.texas.gov/Contact_Us/report_abuse.asp
• Texas Health and Human Services (HHS) Provider Guidebook: Services for Victims of Human Trafficking in Texas: https://www.hhs.texas.gov/sites/default/files/documents/services/safety/human-trafficking/provider-guidebook-services-victims-human-trafficking-texas.pdf
• Office of the Texas Governor’s Child Sex Trafficking Team: https://gov.texas.gov/organization/cjd/childsextrafficking 

(3) 

Organizational Protocols 

With such a multifaceted issue as human trafficking, it is essential that every healthcare organization have clear policies, guidelines, and protocols for responding to this situation. While awareness of the issue is on the rise, many facilities are lacking adequate resources and training to combat human trafficking. 

The benefits of organizational protocols include some of the following (37): 

• Optimizing patients’ interaction with healthcare staff 
• Improving staff’s ability to recognize and appropriately treat patients at risk for trafficking  
• Maximizing staff and patient safety 
• Assuring adequate support for trafficked patients who are not ready or able to disclose their situation or accept assistance  

To develop a functional and helpful protocol within a healthcare setting, these are some of the first steps (37): 

1. Identify community multidisciplinary responders 
2. Engage non-medical community entities  
3. Utilize medical stakeholders within the community 
4. Understand local and national indicators of health and human trafficking  
5. Create and convene an interdisciplinary protocol committee 
6. Develop a multidisciplinary treatment and referral plan

(49)

Building a Trusted Local Network of Resources  

Since each community has its own unique population, various resources may be needed to appropriately address the needs of the individuals involved. It would behoove the practitioner and their institution to establish or build upon a list of resources available for human trafficking. In addition to the list above, there may be other services available in each community. Establishing a good working relationship with local social workers, lawyers, and law enforcement officers is crucial for any healthcare establishment.  

Conclusion

Human trafficking is a heinous crime that affects individuals from every walk of life. In the United States, most of those who are trafficked will seek some form of healthcare during the time they are trafficked. It is up to healthcare professionals to collaborate with relevant community resources to provide safe, adequate, compassionate care to this vulnerable population.  

It is essential that healthcare providers be aware of the people and organizations available to help their patients, and to have an institutional protocol in place to appropriately address the issue of human trafficking.  

By providing patient-centered, trauma-informed care, the healthcare professional will be able to best assist survivors of human trafficking. This means adopting a nonjudgmental approach to all patients, and to realize why disclosure is not necessarily a goal of each encounter. Local law enforcement and social services may be needed, and accurate documentation is crucial in all these cases.  

Finally, the practitioner should be aware of mandated reporting laws, as well as how to best provide adequate safety and confidentiality for their patients. It is with all these concepts in mind that the healthcare field may help more fully address the challenges inherent in human trafficking.  

Nurse Advocacy: Elder Abuse

Introduction

The term “advocate” refers to an individual that supports and promotes the interests of another person (1). As nurse advocates, we protect our patients against incompetency while safeguarding their wellbeing (2). As a nurse advocate in a suspected elder abuse situation, we are obligated, by law, to identify, report, and protect individuals experiencing elder abuse. As trusted members of the healthcare team, we are often the first interaction with a patient (and their family). Therefore, we are in a pivotal position to assess a situation for suspected abuse and neglect, while assuring patient safety, appropriate treatment, and improved outcomes.

Statistically, it is believed that approximately one in 10 Americans over the age of 60 years has experienced some type of elder abuse (3). As our aging population continues to grow, the likelihood of increased rates of elder abuse is a national concern. Nurse professionals often interact with the aging community and must be educated on the many aspects of caring for a person in a suspected abuse situation.

Statistics 

The aging population is facing many challenges related to finances, health and well-being, and safe secure housing options. In 2023, Senior List, a site dedicated to researching senior related products and services, reported some alarming statistics regarding the occurrence of elder abuse on a worldwide scale.

From financial fraud to nonfatal assaults and exploitation, it is estimated that “one in 10 older adults will experience some form of elder abuse, and many endure multiple types of abuse simultaneously” (4). The World Health Organization estimates that “320 million seniors will suffer from some form of elder abuse by the year 2050” (4).

According to a 2019 report by the Office of Inspector General, “1 in 5 emergency room visits among nursing home residents was attributed to abuse or neglect” (5). As the world population of elder persons continues to grow, the occurrence of elder abuse may also continue to grow, due to mental and physical decline, challenges with limited incomes, growing healthcare costs, and lack of appropriate age-related resources and support systems.

Types of Elder Abuse 

According to the World Health Organization, there are many types of elder abuse. In 2022, it was estimated that approximately one out of every six adults over the age of 60 had been subjected to some form of abuse in the prior calendar year (6). While rates are higher in institutions such as nursing homes and related long term care facilities, many forms of elder abuse occur in the home setting (6). The following list highlights various types of elder abuse. Any intentional act (or lack of appropriate action) that results in harm or distress to an older person is considered abuse.  

Psychological Abuse
Psychological abuse is any action (or even the threat of action) that causes fear of violence or humiliation, a feeling of hopelessness, or isolation. This abuse may manifest itself as threats, verbal abuse, and intimidation tactics. 

Physical Abuse 

Physical abuse is any action that causes physical harm or injury to an elder person. This abuse may present itself as unexplained cuts, bruises, and broken bones. 

Financial Abuse / Financial Exploitation 

Financial abuse/exploitation is any action taken against an elder person’s money, belongings, or financial related documents. Financial exploitation can include unauthorized removal of money from bank accounts, fraudulent transfer of funds, unauthorized use of one’s savings and property, and internet scamming. 

Sexual Abuse 

Sexual abuse is any kind of sexual contact that occurs without the person’s consent. This abuse may present as unexplained sexually transmitted infections, torn or bloodied undergarments, difficulty walking, bruising on genitalia or inner thighs, and possible internal injuries. 

Neglect 

Neglect is a unique form of elder abuse, in that the abuse occurs from the lack of doing something (omitting care) versus the actual infliction of injury. Forms of neglect may include withholding medications and necessary medical treatment, withholding basic food and fluid requirements, and not seeking appropriate medical care for the elderly person when indicated. Victims of neglect may often present with dehydration, in under medicated (subtherapeutic) states, and often lacking basic hygiene care (dirty, soiled diapers or undergarments, disheveled appearance, malnourished). 

Other Abuse Signs/Symptoms 

Other signs and symptoms that may indicate elder abuse can include unintentional weight loss, a noted withdrawal from family and friends, unusual financial transactions, and a lack of basic medical needs such as routine medications and assistive devices (glasses, hearing aids, dentures). Further explanation is needed in these situations, as (the perception of) abuse and neglect may actually be the result of extenuating circumstances unrelated to actual abuse.

Risk Factors and Protective Factors 

There are certain individual characteristics that put an elder person at risk for abuse. Persons with poor physical and mental health often do not have the ability to seek appropriate care within their community. Additionally, those who suffer from forms of cognitive impairment or physical disability may inadvertently place themselves in vulnerable situations.

Finally, those with low income and lack of a support system, especially those living alone, are at higher risk of becoming victims. Protective factors place an elder person at a lower risk for abuse. These include good health, financial stability, appropriate physical activity/physical ability, and a strong social support system. The important thing to remember is that elder abuse can occur across all cultures, races/ethnicities, and socioeconomic levels. There are no single identifiers that confirm or exclude an elder person from possible abuse. 

Conversely, alleged perpetrators of elder abuse may suffer from issues that increase the risk of abuse to an elder person. Untreated medical and mental health issues such as mental illness, illegal substance abuse, and financial instability may all heighten the risk of abuse. Alleged abusers may be male or female, and in “almost  60% of elder abuse and neglect incidents,” the perpetrator is a family member” (7). “Two thirds of perpetrators are adult children or spouses,” who thus have had the opportunity to be well versed in knowing the victims physical and/or mental vulnerabilities (7).  

Additionally, alleged perpetrators of elder abuse often have no other means of support, aside from the victim’s social security checks, personal savings, and housing (8). Many have a prior criminal record, suffer from mental illness or disabilities themselves, and frequently have a history of drug and alcohol abuse (8).

Prevention 

The prevention of elder abuse is multifaceted. There is no single answer/action that prevents abuse in this vulnerable population. However, there are guidelines in place to maximize an elder person’s safety and well-being. The overall goal of elder abuse prevention is to lower the risk factors associated with heightening the occurrence of abuse. As nurses, we are in a pivotal position to advocate for the elder patient, as well as identify potential resources to benefit both patient and family (9).  

The “accusation” of suspected abuse will most likely be ill-received. Caregivers, family members and others close to the elder person may feel threatened, defensive, and angry when a healthcare professional discusses their concerns over what appears to be suspected elder abuse.

The suspected victim may also feel humiliated, embarrassed, and fearful of law enforcement involvement. The suspected victim has most likely been abused by someone who has violated their trust and taken advantage of them. Therefore, it is possible that many victims of abuse are fearful of further retaliation, especially if the alleged perpetrator is an immediate family member. 

When possible, the members of the healthcare team should interview caregivers and all suspected abusers separately from the alleged victim. Sometimes, subtle discrepancies between the suspected abuser and the victim interview may give unique insights worthy of further investigation.  

Consider the following scenario. An elderly patient arrives via ambulance, from her private home, and appears malnourished, incontinent, and confused. As you document your findings, a team member voices concerns over suspected abuse. You are told the patient lives with an immediate family member. Initial calls are made to alert authorities of a possible elder abuse situation. The family member arrives, and states they are the patient’s primary caregiver. 

1. The primary caregiver is the 19-year-old granddaughter. What are your initial concerns over what appears to be neglect? 
2. The primary caregiver is the 78-year-old husband, appearing frail, walking with a cane, obviously undernourished. Do your concerns change?  
3. The primary caregiver is a 45-year-old son, unemployed, avoiding eye contact, appearing disheveled. Any additional concerns? 

The nurse advocate must remain objective, nonjudgmental, and empathetic while investigating the situation. What initially appears as intentional abuse and neglect may also be due to the fact that many caregivers are also overwhelmed by the complexity of the situation, whether it be lack of knowledge, financial insecurity or mental/physical disabilities themselves.

The goal of nurse advocacy in these challenging situations is to fully assess not only the health and well-being of the elder, but that of the caregiver. All related documentation on a suspected abuse case must remain objective, reflecting only actual statements made by the patient and accompanying caregiver/ family member, as well as physical examination findings.  

For guidance on medical record documentation when elder abuse is suspected, visit Documenting in the Medical Record by Stanford Medicine. ***Always check with your current worksite for site specific protocols/guidelines regarding approved documentation standards. 

The current elder population is growing rapidly. By 2030, one in six people in the world will be aged 60 years or over. At this time the share of the population aged 60 years and over will increase from one billion in 2020 to 1.4 billion.

Common age-related health conditions occur often leading to complex medical issues at a time when finances, family/community support, safe housing options, and available resources may be in limited supply (10). Over time, the once healthy vibrant elder person can become frail, malnourished, depressed and isolated. This is the pivotal point in which many nurses first cross paths with the elder person.  

A multidisciplinary team approach may be needed to address the various physical, mental and emotional needs of a vulnerable elder, dependent on the current health status, physical needs, and financial means. Team goals should include efforts to return the elder person to an environment best suited to support healthy eating, physical activity, a safe and affordable living environment, accessible transportation, and a supportive community.

Depending on the health status of the individual, the goal can vary the spectrum, from independent living to nursing home placement. Again, these efforts are best addressed by a multidisciplinary team approach.  

In the acute phase, when elder abuse is suspected (or confirmed), the safety of the victim is the highest priority. As nurses, we are mandated to report all suspected abuse, including that of vulnerable adults. Your specific workplace should have written protocols regarding the reporting of suspected abuse, as well as guidelines of documentation of the suspected abuse.

Failure to do so may result in a variety of penalties, including but not limited to fines as well as criminal charges (ranging from misdemeanor to felony charges). It is imperative that you, as a licensed professional, become familiar with your state’s mandatory reporting laws (11).  

Reporting 

As stated previously, a nurse’s workplace should have written protocols in place to report suspected elder abuse. The majority of states also have written guidelines in place for reporting suspected abuse. The United States Department of Health and Human Services also offers guidelines for all persons in the reporting of such abuse.

If the person is in immediate or life-threatening danger, the local authorities should be notified through 9-1-1. In the event that abuse is suspected, but there is no immediate threat to life or limb, the recommendation is to notify the local adult protective services (APS) or police department (12).

End of Life Considerations

According to the position statement on end of life care from the American Nurses’ Association, nurses “are often ideally positioned to contribute to conversations about end of life care and decisions, including maintaining a focus on patients’ preferences, and to establish mechanisms to respect the patient’s autonomy” (13). Similarly, a statement entitled “The Right to Self Determination” from the Code of Ethics for Nurses with Interpretive Statements also emphasizes the nurse’s role in end of life planning and care: 

“The importance of carefully considered decisions regarding resuscitation status, withholding and with-drawing life-sustaining therapies, forgoing nutrition and hydration, palliative care, and advance directives is widely recognized. Nurses assist patients as necessary with these decisions. Nurses should promote advance care planning conversations and must be knowledgeable about the benefits and limits of various advance directive documents. The nurse should provide interventions to relieve pain and other symptoms in the dying process consistent with palliative care standards and may not act with the sole intent of ending a patient’s life” (13). 

What these statements say is that nurses have ethical roles and responsibilities that are fundamental to nursing practice. Nurses should ensure that both patients and family members understand the options and treatments that have been presented to them, and should ensure that the patient’s autonomy is being respected throughout all aspects of their care. Nurses are first and foremost patient advocates, and this is especially crucial during the end of life stage. Nurse advocacy during this time can encompass anything from symptom and pain management, culturally sensitive care provision, and ethical decision making (14).

Talking to Patients and Families

Talking to a patient and their family about end of life care can be a huge challenge for nurses. In addition to managing patients’ and families’ emotions, nurses must manage their own emotions and approach the subject with professionalism as well as empathy.

Often, during the end of life planning phase, patients will go through the five stages of grief, as outlined in the book “On Death and Dying” by Elizabeth Kubler-Ross. The five stages of grief include (14):

Denial: Usually a temporary defense, patients may say that they’re fine, or that this is some mistake.
Anger: Once the patient is no longer in denial, anger is often the next stage. It may be difficult to care for the patient during this stage, as they may misplace their angry feelings on their caregivers.
Bargaining: At this stage, the patient seeks ways to postpone death – often in the form of promising to reform a lifestyle in exchange for more life.
Depression: This stage may involve the refusal of treatments or visitors, and the disconnection from people, love, and affection.
Acceptance: The final stage, which is not reached by all patients. In this stage, the patient has come to terms with their mortality and has accepted that death will happen.

It is important for the nurse to understand these five stages, as most patients will be experiencing one or more of the stages during the end of life process.

Here are some helpful techniques for nurses to use when talking to patients about hospice or end of life planning, according to the American Academy of Family Physicians (15):

Make sure you have time.

While this may seem impossible while on a shift when you have other patients, it’s imperative that a nurse allow enough time to have this difficult conversation. This is not a conversation that can be rushed – rushing through the conversation may make a nurse miss important details that the patient has shared.

Turn off your phone.

Minimizing distractions during these difficult conversations will ensure that the nurse can get ample information from this patient and family interaction.

Listen to the patient.

Above all, listen to what the patient is saying. Begin the conversation by asking what the patient and their doctor have already discussed. Be sure that the plan of care has been reviewed with the doctor prior to this conversation, then have the patient repeat their plan of care as they understand it. If there are major differences in the plan of care and what the patient says, this may warrant further conversation with the health care team to clarify and identify knowledge gaps.

Learn what the patient’s goals are.

Active listening is crucial during the conversation phase of end of life care planning. Once the nurse has determined that the patient understands the options that have been presented, it is vital to ask them what their goals are for palliative and comfort care. Understanding a patient’s goals can help identify what resources will be best suited for their individual needs.

Conversations surrounding end of life care should happen as soon as possible. Do not wait until the patient is no longer able to participate in the discussion. Encourage the presence of family members, but be sure to respect the patient’s wishes regarding who is involved in the planning process. Other members of the healthcare team that should be included in the planning process include social workers, patient navigators (if applicable in that setting), and any primary and specialist physicians involved in the patient’s care.

Additional Resources 

The Elder Abuse Guide for Law Enforcement (EAGLE) 

 Use this website to review state-specific elder justice laws.  

https://eagle.usc.edu/state-specific-laws/  

National Adult Protective Services Association 

Use this website to find specific contact information for your state location 

https://www.napsa-now.org/help-in-your-area  

ElderCare Locator/ United States Administration on Aging  

Use this website to connect with services for older adults and families. 

https://eldercare.acl.gov/Public/Index.aspx  

World Elder Abuse Awareness Day 

June 15th has been declared World Elder Abuse Awareness Day (WEAAD). For more information, visit https://eldermistreatment.usc.edu/weaad-home/. The website offers multi-language downloads on elder abuse facts, as well as social media guides, awareness campaigns, elder justice groups, and associated tool kits.  

Conclusion

As the elder population continues to grow, so does the risk of elder abuse. As nurse professionals, we must continue to advocate for the safety and well-being of our aging population. We must continue to stay informed and educated on identifying abuse throughout the age spectrum.

Lastly, we must be knowledgeable of our own available resources to best assist the elder population and their basic needs, including food and shelter, access to healthcare, and transportation, as well as community wide support services.

Texas Tick-Borne Diseases

Introduction   

Ticks are more than just a bothersome pest; they are carriers of debilitating diseases. Tickborne diseases are unfortunately increasing in incidence. Clinicians should expect tickborne disease in patients presenting with flu-like symptoms during the spring and summer months. This is especially true in regions with rich biodiversity like Texas.  

We will review the most common types of ticks and the diseases they carry. These diseases, while potentially severe, are treatable, especially when caught early. The course will review symptoms, stages, and the epidemiology of tick-borne diseases.  

It is meaningful to explore the diagnostic tests and treatment protocols for tick-borne illnesses, including the use of antibiotics and supportive care measures. Prompt diagnosis and treatment can prevent complications and death.  

We will closely examine the pharmacokinetics of each medication used to treat the diseases, including the uses, mechanism of action, side effects, and contraindications. Counseling patients on preventative measures for protective clothing and tick repellents during outdoor activities can help minimize the risk of infection.  

Introduction to Ticks 

Ticks found in Texas encompass a variety of species, each with their unique characteristics and disease implications. Ticks are most active in the warmer months of spring and summer. The most common ticks in Texas are the Lone Star tick, American dog tick, Black-legged tick, and the Brown dog tick. These species vary in appearance, habitat preferences, and the diseases they can transmit.  

Lone Star Tick  

Lone Start Tick (Amblyomma Americanum): A distinct white dot or "lone star" on the female's back helps this tick to be identified easily. It is found throughout Texas, especially in wooded, bushy areas. Lone star ticks are known for transmitting diseases such as Ehrlichiosis and Southern Tick-Associated Rash Illness (STARI). In addition to their competence for pathogen transmission, Amblyomma Americanum (A. Americanum) has recently been associated with delayed red meat allergy (7). 

American Dog Tick 

American Dog Tick (Dermacentor variabilis): This tick prefers grassy areas with little to no tree cover. It primarily targets dogs but will bite humans and can transmit Rocky Mountain spotted fever and Tularemia. 

Black-legged Tick 

Black-legged Tick (Ixodes scapularis): This tick is also called the deer tick. It is prevalent in the eastern and northern parts of Texas. This tick is known for transmitting Lyme disease, Anaplasmosis, and Babesiosis to humans. The black-legged tick prefers wooded and brushy habitats. 

Brown Dog Tick 

Brown Dog Tick (Rhipicephalus sanguineus): Unlike other ticks, the brown dog tick is more adapted to dryer environments and can live and reproduce indoors. 

  Image 1. Common Ticks in Texas (3) 

Tick-Borne Diseases in Texas 

Ticks are vectors for a wide array of bacterial, protozoan, and viral pathogens causing such diseases as Lyme borreliosis, spotted fever rickettsioses, anaplasmosis, tularemia, ehrlichiosis, babesiosis, and the recently emerging viruses: Heartland (HRTV), Powassan (POWV) and Bourbon (BRBV).  

These vectors are found in many geographic areas of Texas and unfortunately have a steady increase in presence. Cases of tick-borne diseases have more than doubled in the last decade in the United States and territories, and account for 77% of all vector-borne disease reports (7).  

Lyme Disease  

Lyme disease (LD) is caused by the bacterium Borrelia burgdorferi and rarely, Borrelia mayonii. It is transmitted to humans through the bite of infected black-legged ticks. Lyme disease is the most frequently diagnosed tick-borne illness in the United States, however, it oddly has a low incidence in the state of Texas.  

The incubation period is 3–30 days (5). Research shows the probability of host infection gradually increases as tick attachment continues, reaching 70% after 72 hours of attachment and a greater than 90% probability of infection after a complete tick blood meal (13).  

Clinically, B. mayonii-infected patients show higher loads of spirochetes in the blood, and some have had focal or diffuse rash, or developed neurological symptoms. 

There is significant research that explores and combats this bacterium’s ability to avoid immune detection and response. Similar to other blood-borne pathogens, LD spirochetes have developed multiple strategies to overcome innate immunity, thereby avoiding clearance by the immune system of the host by ways such as changing their surface composition (13). This action makes it difficult for the immune system to create antibodies against it.  

Early clinical signs and symptoms (3 to 30 days after a tick bite) include (5):  

• Erythema migrans (EM)— This is a worrisome “target” or “bull’s-eye” rash. It is a red annular or homogeneous rash at the site of a tick bite. The rash typically expands slowly over several days and may feel warm to the touch (5). EM occurs in 70–80% of infected individuals (5) [See image 2]. 
• Headache 
• Fever 
• Chills 
• Malaise or fatigue, myalgia, arthralgia § Lymphadenopathy 

Lyme disease that is not treated will progress to disseminated disease for about 60% of patients with varied manifestations (5) Rheumatologic signs and symptoms are particularly delayed and can cause severe damage to the joints, heart, and nervous system (5).  

 Image 2. Class Erythemia migrans rash (5) 

Anaplasmosis and Ehrlichiosis  

Anaplasmosis, known as human granulocytic anaplasmosis (HGA), is a disease caused by the bacterium Anaplasma phagocytophilum (A. Phagocytophilum). These bacteria are spread to people by tick bites primarily from the black-legged tick (Ixodes scapularis) and the western black-legged tick (Ixodes pacificus). The first case of human anaplasmosis was described in 1990 when a patient in Wisconsin developed a severe febrile illness following a tick bite and died two weeks later (6). 

Anaplasma organisms are small, gram-negative, and intracellular. A. phagocytophilum targets neutrophils, alters their function in the host, and forms morulae within vacuoles. The majority of damage it causes is thought to be related to host inflammatory processes. Since Ixodes ticks are also carriers for Lyme disease, babesiosis, and tick-borne encephalitis, coinfection with multiple diseases can and does occur in humans. 

Ehrlichiosis, known as Human Monocytic Ehrlichiosis (HME), is similar to anaplasmosis in molecular structure but is less commonly found than anaplasmosis.  

The median age of patients with anaplasmosis and ehrlichiosis is around 50 years old (6).  

Doxycycline is the drug of choice for adults and children of all ages with anaplasmosis (5). 

Clinical signs and symptoms of anaplasmosis and ehrlichiosis are non-specific and typically include: 

• Fever 
• Headache 
• Muscle aches 
• Fatigue 

Spotted Fever Group Rickettsioses  

Spotted fever group rickettsioses (spotted fevers) are a group of diseases caused by similarly structured bacteria. Rocky Mountain Spotted Fever is within this group of diseases and is considered the most serious and most commonly reported spotted fever group rickettsiosis in the United States (5). These bacteria are spread to people through the bite of infected mites and ticks. The ticks responsible are typically the American dog ticks (Dermacentor variabilis), Rocky Mountain wood tick (Dermacentor andersoni), and the brown dog ticks (Rhipicephalus sanguineus) (5). 

Spotted fevers have a wide range of signs and symptoms, including (5): 

• Eschar - dark scab at the site of the tick bite 
• Fever 
• Headache 
• Rash 

Doxycycline is the treatment of choice for all spotted fever infections (5). 

Tick-borne Relapsing Fever 

Tick-borne relapsing fever (TBRF) is an infection caused by certain species of Borrelia bacteria. Relapsing fever Borrelia infections are categorized into three main groups based on the vector that transmits the bacteria: soft ticks, hard ticks, and body lice. These diseases differ in their epidemiology and severity.  

TBRF is uniquely caused by soft ticks, instead of hard ticks (like the other diseases). Soft ticks are generally found in animal burrows, dens, caves, or human dwellings such as huts, cabins, or sheds. The disease is often linked to someone recently sleeping in a rustic cabin in the mountains. Soft ticks have a wrinkled body appearance and do not latch as long as hard ticks (5). 

The main symptoms of TBRF are: 

• High fever (e.g., 103° F) 
• Headache 
• Muscle and joint aches.  

The fever comes in a unique pattern of lasting roughly 2-7 days, followed by 4-14 days without fever, followed by another 3 days of fever. Without antibiotic treatment, this process can repeat several times. 

Babesiosis 

Babesiosis is an emerging tick-borne disease caused by parasites of the genus Babesia (9). This disease has increasing incidence worldwide and a risk of human-to-human transmission through blood transfusion.  

The majority of those infected by babesiosis remain asymptomatic or present with mild flu-like symptoms (9). However, in susceptible populations, such as the elderly or immunocompromised individuals, symptoms can include severe anemia, acute respiratory distress, organ failure, and death (9). 

Tularemia 

Tularemia is caused by infection with the bacteria Francisella tularensis. Transmission routes include tick bite, deer fly bite, inhalation, ingestion, and skin contact with infected animals (4). Signs and symptoms of tularemia can vary widely depending on the route of exposure and subtype of F. tularensis. Tularemia can become serious or fatal without adequate treatment.  

Possible signs and symptoms include (4): 

• Fever, chills 
• Headache 
• Malaise, fatigue 
• Anorexia 
• Myalgia 
• Chest discomfort 
• Non-productive cough 
• Sore throat 
• Vomiting, diarrhea 
• Abdominal pain 
• Localized or regional lymphadenopathy 
• Cutaneous ulcer at the site of bite/infection  
• Photophobia 
• Vision impairment/loss 
• Conjunctivitis 

General laboratory findings: 

• Hyponatremia 
• Leukocytosis 
• Thrombocytopenia 
• Elevated hepatic transaminases 
• Elevated creatine kinase 
• Elevated erythrocyte sedimentation rate 
• Myoglobinuria 
• Sterile pyuria 

Viral Pathogens: Heartland (HRTV), Powassan (POWV) and Bourbon (BRBV) 

Arboviral disease is a broad term used to describe infections caused by a group of viruses spread by the bite of infected arthropods (insects) such as mosquitoes and ticks (15). These include Heartland (HRTV), Powassan (POWV) and Bourbon (BRBV). Other diseases spread by the bite of an infected tick are bacterial infections and babesiosis (a parasitic infection), which are not arboviruses. It is important to note that if a highly suspected infected individual (positive for symptoms and tick bite) does not have improvement of symptoms following an antibiotic regimen, a viral pathogen from a tick may be the culprit.

Removal of Ticks 

Imagine you are evaluating a patient who has not removed a tick attached to their skin. It is imperative that you quickly, yet appropriately, remove it manually (unless your facility has another method). There are other commercially available tick-removal devices, but there are currently no substantial studies that have evaluated their usefulness. 

The Centers for Disease Control and Prevention (CDC) provides the following steps as a guide on how to manually remove a tick: 

1. Apply gloves and clean the area well. 
2. Use blunt forceps (tweezers). Do not use sharp forceps.  
3. Grasp the tick as close to the skin’s surface as possible, and pull upward with steady, even pressure.  
   1. Do not squeeze or puncture the tick’s body. 
   2. Do not twist or jerk the tick (this can cause the mouth-parts to break off and remain in the skin) 
   3. If you notice the mouth-parts remain on the skin after removal, grasp and pull with tweezers.  
4. After removing the tick, thoroughly clean the bite with an antiseptic solution.

Medications Used to Treat Tick-Borne Diseases 

The treatment of tick-borne diseases often involves antibiotics, with the choice of medication depending on the specific disease diagnosed. It would be helpful to consult an infectious disease specialist about individual patient treatment plans as the specific duration of treatment can vary based on each disease, the severity of symptoms, and individual patient traits.  

Here's a brief overview of treatments for some of the most common tick-borne diseases: 

Lyme Disease 

The first-line treatment for Lyme disease is typically oral antibiotics, with doxycycline, amoxicillin, and cefuroxime axetil being the most commonly prescribed. In cases of more severe Lyme disease, intravenous antibiotics, such as ceftriaxone, may be used. Depending on a person’s age, medical history, underlying health conditions, pregnancy status, or allergies, these regimens may need to be adjusted. The table below outlines treatment regimens for the erythema migrans rash, which is the most common manifestation of early Lyme disease. 

Table 1. Treatment Regimen for Erythema Migrans Rash (5) 

Rocky Mountain Spotted Fever (RMSF) 

Doxycycline is the treatment of choice for RMSF for both adults and children. Early treatment is critical to prevent severe disease complications. 

Ehrlichiosis and Anaplasmosis 

Doxycycline is also the preferred treatment for both ehrlichiosis and anaplasmosis, regardless of the patient's age. 

Southern Tick-Associated Rash Illness (STARI) 

Although the cause of STARI is not well understood, doxycycline may be used to treat the rash and possible infection, similar to the treatment for Lyme disease. 

Babesiosis 

This disease is typically treated with a combination of atovaquone and azithromycin. In more severe cases, clindamycin and quinine may be used instead. 

Tularemia 

Treatment can include several different antibiotics, such as gentamicin, streptomycin, doxycycline, or ciprofloxacin (4). The table below outlines treatment regimens for Tularemia.  

Table 2. Treatment Regimen for Tularemia (4) 

Antibiotics that Inhibit Protein Synthesis 

When treatment is initiated for patients with tick-borne diseases, the prescriber needs to understand the pharmacokinetics of antibiotics that inhibit protein synthesis and biochemistry. Examples of these antibiotics include tetracyclines, chloramphenicol, macrolides, lincosamides, streptogramins, oxazolidinones, mupirocins, and peptide deformylase inhibitors (1). Knowledge of the mechanisms of action of antibiotics in interfering with the life cycle of these bacteria is critical in evaluating patient outcomes. 

Protein synthesis is an essential process in all cells, including bacterial cells. The ribosome performs protein synthesis by translating the genetic information encoded in messenger RNAs (mRNAs) into proteins. The bacterial ribosome is composed of three RNA chains (16S, 23S, and 5S) and more than 50 proteins assembled into two individual subunits. These include the small 30S and large 50S subunits, which join together to form the 70S ribosome. To proceed efficiently and translate the information, many protein factors need to interact sequentially with the ribosome.  

Keep this process in mind as we discuss antibiotic drugs in effectively treating tick-borne diseases. 

Doxycycline 

Pharmacologic Category 

Antibiotic, Tetracycline Derivative 

Uses: Labeled Indications 

• Acne 
• Actinomycosis 
• Acute intestinal amebiasis 
• Clostridium: Treatment of infections caused by Clostridium spp. when penicillin is contraindicated. 
• Ehrlichiosis and Anaplasmosis 
• Gram-negative infections: Treatment of infections caused by Escherichia coli, Enterobacter aerogenes, Shigella spp., Acinetobacter spp., Klebsiella spp. (respiratory and urinary infections), and Bacteroides spp.; Neisseria meningitidis (when penicillin is contraindicated). 
• Gram-positive infections: Treatment of infections caused by Streptococcus spp., when susceptible. 
• Listeriosis 
• Malaria prophylaxis 
• Mycoplasma pneumoniae: Treatment of infections caused by Mycoplasma pneumoniae. 
• Ophthalmic infections 
• Periodontitis  
• Relapsing fever: Treatment of relapsing fever caused by Borrelia recurrentis. 
• Respiratory tract infections 
• Rickettsial infections: Treatment of Rocky Mountain spotted fever, rickettsialpox, and tick fevers caused by Rickettsiae. 
• Sexually transmitted infections  
• Infections caused by Staphylococcus aureus (doxycycline is not the drug of choice in the treatment of any type of staphylococcal infection). 

Mechanism of Action 

All tetracyclines have the same mechanism of action to block the protein synthesis of bacteria.  

Tetracyclines inhibit protein synthesis by binding to the 30S subunit of the ribosome (1). Essentially, the drug inhibits the binding of amino-acyl tRNA to the A-site of the ribosome. The 7S ribosomal protein is part of the binding site. Tigecycline also binds at the A-site of the 30S subunit of the ribosome and inhibits bacterial protein synthesis.  

Tetracyclines can bind equally well to both prokaryotic (70S) and eukaryotic (80S) ribosomes. Eukaryotic cells are not affected by the antibiotic because they do not accumulate tetracycline in the cell. This makes tetracyclines selective against bacteria. Tetracyclines may also cause alterations in the cytoplasmic membrane (1). 

Pharmacodynamics 

Absorption: (Oral) Almost completely absorbed from the gastrointestinal tract (GI) tract; average peak plasma concentration may be reduced by high-fat meal or milk (16). 

Distribution: Widely distributed into body tissues and fluids including synovial, pleural, prostatic, seminal fluids, and bronchial secretions. Saliva and cerebral spinal fluid (CSF) penetration is poor. 

Protein binding: >90% 

Bioavailability: Reduced at high pH; may be clinically significant in patients with gastrectomy, gastric bypass surgery, or who are otherwise deemed achlorhydric. 

Metabolism and Excretion: Not hepatic; partially inactivated in the GI tract by chelate formation. 20-40% excreted unchanged in the urine; some inactivation in the intestines and enterohepatic circulation with excretion in bile and feces. 

Half-life: 14-17 hours (longer time frame in severe renal impairment) 

 Figure 1. Pharmacodynamics of Doxycycline 

Adverse Effects 

1% to 10% has reported the following (16): 

• Cardiovascular: Hypertension (3%) 
• Central nervous system: Anxiety (2%), pain (2%) 
• Endocrine & metabolic: Increased lactate dehydrogenase (2%), increased serum glucose (1%) 
• Gastrointestinal: Diarrhea (5%), upper abdominal pain (2%), abdominal distention (1%), abdominal pain (1%), xerostomia (1%) 
• Hepatic: Increased serum aspartate aminotransferase (2%) 
• Infection: Fungal infection (2%), influenza (2%) 
• Neuromuscular & skeletal: Back pain (1%) 
• Respiratory: Nasopharyngitis (5%), sinusitis (3%), nasal congestion (2%) 

Contraindications/Precautions 

Hypersensitivity to doxycycline, other tetracyclines, or any component of the formulation. Contraindicated in infants and children younger than eight years of age, during the second or third trimester of pregnancy, and breastfeeding (16). 

Patient Education 

• Instruct the patient to finish the entire dose as directed, even if feeling better, and take missed doses as soon as possible unless it is almost time for the next dose. 
• Advise patient to avoid taking antacids, calcium, magnesium-containing medications, sodium bicarbonate, and iron supplements within 1-3 hours of oral doxycycline. 
• Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions. 
• Advise patient to report signs of superinfection (black, furry overgrowth on the tongue, vaginal itching, discharge, watery or foul-smelling stools) or intracranial hypertension (headache, blurred vision, diplopia).

Aminoglycosides 

Aminoglycosides include streptomycin, neomycin, kanamycin, amikacin, gentamicin, tobramycin, sisomicin, netilmicin, plazomicin, and others (2). Gentamicin and streptomycin are recommended in the treatment of tularemia, so we will closely examine this group.  

ALERT: US Boxed Warning for Aminoglycosides 

Toxicity (17): 

As with other aminoglycosides, gentamicin is potentially nephrotoxic. The risk is greater with impaired renal function and prolonged therapy. Neurotoxicity, manifested by ototoxicity (both vestibular and auditory) can occur in patients treated with gentamicin.  

Clinicians should closely monitor renal function and eighth cranial nerve function, especially in patients with reduced renal function at the onset of therapy. Assess urine for decreased specific gravity, increased excretion of protein, and the presence of cells or casts (17). Routinely check serum urea nitrogen (BUN), serum creatinine, or creatinine clearance (CrCl). Monitor serum concentrations of aminoglycosides to ensure adequate levels and to avoid potentially toxic levels.  

Avoid concurrent use of other potentially neurotoxic and/or nephrotoxic drugs: cisplatin, cephaloridine, kanamycin, amikacin, neomycin, polymyxin B, colistin, paromomycin, streptomycin, tobramycin, vancomycin, and viomycin (2). Avoid the concurrent use of gentamicin with potent diuretics. 

Pregnancy 

Aminoglycosides can cause fetal harm when administered to a pregnant woman. 

Gentamicin  

Pharmacologic Category 

Antibiotic, Aminoglycoside 

Uses 

Treatment of serious infections: Sepsis, meningitis, urinary tract infections, respiratory tract infections, peritonitis, bone infections, skin, and soft tissue infections, caused by susceptible strains of the following microorganisms: Pseudomonas aeruginosa, Proteus species, Escherichia coli, Klebsiella species, Enterobacter species, Serratia species, Citrobacter species (2). 

Mechanism of Action 

As with all aminoglycosides, gentamicin interferes with ribosomal peptide/protein synthesis (14). It binds to 16S rRNA (located on the smaller 30S component of the ribosome of the bacteria), stops its functionality, and halts ongoing protein synthesis (14). Aminoglycosides are not able to penetrate the hydrophobic bacterial cell membrane and are only active against aerobic bacteria because an electron transport system used during the cell’s respiratory cycle is needed to accomplish this (2). 

Pharmacodynamics/Kinetics 

Absorption: Intramuscular: Rapid and complete 

Oral: Poorly absorbed  

Distribution: Primarily into extracellular fluid (highly hydrophilic); high concentration in the renal cortex. 

Protein binding: <30% 

Half-life elimination: 

• Adults: ~2 hours 
• Neonates: <1 week: 3 to 11.5 hours; 1 week to 1 month: 3 to 6 hours 
• Infants: 4 ± 1 hour 
• Children: 2 ± 1 hour 

Time to peak, serum:  

• IM: 30 to 90 minutes 
• IV: 30 minutes after a 30-minute infusion  

Excretion: Urine  

Clearance: Directly related to renal function 

• Neonates: 0.045 ± 0.01 L/hour/kg 
• Infants: 0.1 ± 0.05 L/hour/kg 
• Children: 0.1 ± 0.03 L/hour/kg 
• Adolescents: 0.09 ± 0.03 L/hour/kg 

Adverse Effects 

Some adverse effects include (17): 

• Cardiovascular: Edema, hypertension, hypotension, phlebitis, thrombophlebitis 
• Central nervous system: Abnormal gait, ataxia, brain disease, confusion, depression, dizziness, drowsiness 
• Dermatologic: Alopecia, erythema, pruritus, skin rash, urticaria 
• Endocrine & metabolic: Hypocalcemia, hypokalemia, hypomagnesemia, hyponatremia, weight loss 
• Gastrointestinal: Anorexia, Clostridioides difficile-associated diarrhea, decreased appetite, enterocolitis, nausea, sialorrhea, stomatitis, vomiting 
• Genitourinary: Casts in urine (hyaline, granular), oliguria, proteinuria 
• Hematologic & oncologic: Agranulocytosis, anemia, thrombocytopenia 
• Hepatic: Hepatomegaly, increased liver enzymes 
• Hypersensitivity: Anaphylaxis, anaphylactoid reaction, hypersensitivity reaction 
• Local: Injection site reaction, pain at injection site 
• Neuromuscular & skeletal: Arthralgia, muscle cramps, muscle fatigue, weakness 
• Ophthalmic: Visual disturbance 
• Otic: Auditory impairment, tinnitus 
• Renal: Decreased creatinine clearance, decreased urine specific gravity, increased blood urea nitrogen, increased serum creatinine, polyuria, renal failure (high trough serum concentrations), renal tubular necrosis 
• Respiratory: Dyspnea, laryngeal edema, pulmonary fibrosis, respiratory depression 
• Miscellaneous: Fever 

Streptomycin 

Pharmacologic Category 

Antibiotic, Aminoglycoside 

Uses 

Primarily used for treating aerobic gram-negative bacterial infections, such as tularemia, brucellosis, tuberculosis (in combination with isoniazid, pyrazinamide, and rifampin), and certain cases of endocarditis when combined with beta-lactam antibiotics (14).  

Mechanism of Action 

Interferes with bacterial protein synthesis by binding to 30S ribosomal subunit resulting in a defective bacterial cell membrane (2). These actions inhibit the bacteria from creating the needed ongoing protein synthesis. 

Pharmacodynamics/Kinetics 

Absorption:  

• Oral: Poorly absorbed 
• IM: Well-absorbed 

Distribution: Distributes into most body tissues and fluids except the brain; small amounts enter the CSF only with inflamed meninges. 

Protein binding: 34% 

Half-life elimination:  

• Newborns: 4 to 10 hours 
• Adults: 2 to 4.7 hours (prolonged with renal impairment) 

Time to peak: IM: Within 1 to 2 hours 

Excretion: Urine (29% to 89% as unchanged drug); a small amount (1%) excreted in bile, saliva, sweat, and tears (18) 

Adverse Reactions 

Adverse reactions include (18): 

• Cardiovascular: Hypotension 
• Central nervous system: Drug fever, facial paresthesia, headache, neurotoxicity 
• Dermatologic: Exfoliative dermatitis, skin rash, urticaria 
• Gastrointestinal: Nausea, vomiting 
• Genitourinary: Azotemia, nephrotoxicity 
• Hematologic & oncologic: Eosinophilia, hemolytic anemia, leukopenia, pancytopenia, thrombocytopenia 
• Hypersensitivity: Anaphylaxis, angioedema 
• Neuromuscular & skeletal: Arthralgia, tremor, weakness 
• Ophthalmic: Amblyopia 
• Otic: Auditory ototoxicity, vestibular ototoxicity 
• Respiratory: Dyspnea 

Compound Use of Atovaquone and Azithromycin for Babesiosis 

The current arsenal for the treatment of human babesiosis includes atovaquone, azithromycin, clindamycin, and quinine. The first-line compound typically used is atovaquone and azithromycin. Atovaquone is used to treat several human diseases, including Pneumocystis jirovecii pneumonia, toxoplasmosis, and malaria. In apicomplexan parasites such as the genus Babesia, atovaquone targets the cytochrome bc1 complex of the mitochondrial electron transport chain (9). Azithromycin is a relatively broad-spectrum antibiotic indicated for the treatment of numerous bacterial infections; it is a well-characterized protein synthesis inhibitor, which in apicomplexan parasites targets the translation machinery in the apicoplast (9). 

Tick Testing  

The Department of State Health Services (DSHS) and the University of North Texas Health Science Center (UNTHSC) Tick-Borne Disease Research Laboratory have teamed up to test ticks for disease agents in the Borrelia, Ehrlichia, and Rickettsia genera using molecular methods (11).  

Ticks should be submitted to the DSHS Zoonosis Control office for identification after which they will be forwarded to UNTHSC for testing (11). There is no charge for testing, however, this service is available only to Texas residents submitting ticks found at a location within Texas. Only ticks that were attached to a human should be submitted (11).  

For free testing of ticks found in the environment or on pets, visit the Texas Tick Project. The program is designed for tick surveillance, not disease diagnosis. If infected with a tick-borne pathogen, individuals usually develop symptoms before the test results are available.

Prevention and Control 

It is meaningful to provide teaching on prevention tips if you notice a patient is at high risk for encountering a tick outdoors. This includes patients who enjoy hobbies outdoors (such as hiking) or whose job duties involve spending a significant amount of time outdoors.  

Prevention teaching: 

• Always inspect yourself, family members, and pets from head to toe for ticks after spending time outdoors. 
• Keep grass trimmed and remove overgrowth. 
• Remove bird feeders and other food sources that attract wildlife, such as deer, that can carry ticks. 
• Discuss tick and flea prevention methods with your veterinarian if you have pets. 
• Move picnic tables, swing sets, and outdoor lawn furniture away from trees and shrubs. 

Upcoming Research 

Significant research studies are being conducted on the treatment and prevention of tick-borne diseases, however, there is a need for prevention of the spread of tick bites. One interesting study is exploring the prevalence of common tick-borne pathogens in white-tailed deer and coyotes in south Texas (19). Identifying vehicles (various wildlife) that carry these tiny ticks over long distances can help researchers treat wildlife for ticks and ultimately slow the spread. Upcoming research relies on effective collaboration between medical professionals, wildlife and ecological professionals, researchers, and policymakers. 

The current evidence on babesiosis is not comprehensive and treatment consists of combinations of atovaquone and azithromycin or clindamycin and quinine (9). These drug compounds are associated with mild or severe adverse events and a rapid emergence of drug resistance, thus highlighting the need for new treatment therapies to combat Babesia parasites.

Conclusion

Ticks aren’t just annoying—they’re also a source of serious illnesses. As tickborne diseases become more common, healthcare professionals should be alert to the possibility of these diseases in patients who have flu-like symptoms in the spring and summer, especially in areas rich in wildlife, such as Texas.  

This course provided information on prevalent ticks and the illnesses they transmit, as well as the symptoms, progression, and medications used to treat each pathogen. The pharmacokinetics, adverse effects, and uses are meaningful components of treating patients who are infected with a tick-borne disease.

Non-Opioid Chronic Pain Management

Introduction   

Chronic pain is common and debilitating condition, affecting about one in five people globally (6). Musculoskeletal conditions such as back pain are typically the most common conditions leading to chronic pain, followed by headache, orofacial pain, and visceral pain (6). Fibromyalgia and neuropathic pain are also prevalent.

About one-third of people with chronic non-cancer-related pain are prescribed opioid analgesics; however, long-term research finds that the potential harms likely outweigh the benefits.

Chronic pain can be difficult to treat, and management is often suboptimal. The most common non-opioid drug treatment is paracetamol (acetaminophen) and non-steroidal anti-inflammatory drugs, but they need to be used with caution and for short periods because of the risk of serious adverse events with long-term use (6)

We will dive into the pharmacokinetics of various non-opioid pain management options and explore this option for optimal outcomes for patients with chronic pain.

Definition 

Pain is a subjective term. The one experiencing the pain is responsible fordescribing and rating it. Pain can be associated with actual or potential tissue damage or abnormal functioning of nerves. It may be classified as acute, chronic, or cancer pain. Pain may also be categorized as adaptive or maladaptive. 

• Adaptive (Physiologic) Pain   

• • Nociceptive Pain – Examples include touching something hot or sharp.  
  • Inflammatory pain – Examples include trauma or surgery.  

• Maladaptive (Pathologic) Pain 

• • Pathophysiologic pain (e.g., postherpetic neuralgia, diabetic neuropathy, fibromyalgia, irritable bowel syndrome, chronic headaches) is often described as chronic pain.  
  • It results from damage or abnormal functioning of nerves in the central nervous system (CNS) or peripheral nervous system (PNS). Pain circuits sometimes rewire themselves anatomically and biochemically, resulting in chronic pain, hyperalgesia, or allodynia (condition in which the pain stimulus typically should not cause pain, like “touch” on sunburned skin). 

The steps in processing pain are: (10)

• Transduction – Stimulation of nociceptors. 

• • Nociceptors, located in somatic and visceral structures, are activated by mechanical, thermal, and chemical stimuli.  
  • Noxious stimuli may cause release of cytokines and chemokines that sensitize and/or activate nociceptors. 

• Conduction – Receptor activation leads to action potentials that continue along afferent fibers to the spinal cord.  

• • Stimulation of large-diameter, sparsely myelinated fibers stimulate sharp, wider spread pain.  
  • Stimulation of small-diameter, unmyelinated fibers produce aching, poorly localized pain. 

• Transmission – Synapse occurs in the spinal cord’s dorsal horn, releasing excitatory neurotransmitters. 

• • The signal to the brain’s higher cortical structures.

• Perception – Experience of pain happens when signals reach higher cortical structures. 

• • Relaxation, meditation, and distraction can lessen pain.
  • Anxiety and depression can exacerbate pain. 

• Modulation – Attributing factors can possibly include glutamate, substance P, endogenous opioids, γ-aminobutyric acid (GABA), norepinephrine, and serotonin. 

The margin between neurons a