Mandated Continuing Education Requirements for Health Care Professional State Licensure: The Texas Model

ABSTRACT

It is well acknowledged that persons who have experienced human trafficking and persons at risk for victimization often present for health care services. It is also extensively documented in scientific literature that awareness of trafficking among clinical providers remains relatively low. Well-intentioned but poorly executed trainings spread misinformation, aid propulsion of stigma and bias, and often neglect to provide individualized and practically actionable messages for specific clinical audiences. Widespread adoption of standards to ensure evidence-based, patient-centered, trauma-informed, and culturally responsive care is lacking. The state of Texas recently passed legislation requiring direct health care providers to complete one hour of continuing education on human trafficking to qualify for licensure renewal. Advocates guided the implementation of this law based on lessons of previously enacted legislation in other states. Texas can serve as a regulatory policy model for adhering to evidence-based standards in human trafficking educational state or federal mandates.

KEYWORDS:

• Human trafficking
• continuing education
• health care providers
• regulatory requirements
• legislation

State-Mandated Continuing Education for Health Care Professionals

State-mandated continuing education for professional health care licensure renewal has long been a controversial topic in the United States. Advocates urge using mandates to enhance patient outcomes by providing supplemental education on new and emerging trends and technologies, thereby promoting elevation of and adherence to professional standards of practice. Opponents protest associated personal and organizational costs of such requirements and the tendency of legislatures to adopt “pet” projects or causes of constituents without an accurate evidence base.

Inconsistencies in State-Mandated Human Trafficking Education

The current landscape of mandated human trafficking education is problematic for several reasons. First, states with newly adopted laws or regulations on human trafficking training face the significant challenge of training very large numbers of professionals within a relatively short period of time. For example, there are more than 400,000 nurses and physicians practicing in Texas. At a conservative estimate of $10 per continuing education credit, opportunity is ripe for entrepreneurs to provide quickly written and poorly informed education in exchange for a rapid and easily discovered lucrative financial return. A quick internet search will reveal many paid options from for-profit companies and national anti-trafficking experts anecdotally report remunerative offers for endorsement of quickly constructed courses.

Second, the adoption by states of universal standards in required training modules is lacking, leaving a wide degree of variability in content. Failure to adopt content and design standards contributes to stigma, bias, and misinformation. For example, when well-known trainings use sensationalized imagery, such as chains, health professionals may neglect to identify patients who are controlled psychologically or financially by their trafficker. Trainings that exclusively focus on sex trafficking of Caucasian American female youth, while largely ignoring labor trafficking, and victimization of other races, genders, and age groups further bias professionals (Albright & D’Adamo, 2017). Those health professionals first learning about trafficking through non-representative portrayals may be biased from detecting exploitation among patients who fall outside the demographics presented. Well-intentioned but poorly informed grassroots advocacy groups often disseminate community-based education that is not evidence-based, trauma-informed, or culturally responsive. Training on trafficking that is limited to a narrow audience within a singular discipline leads to a disjointed health care response within and across institutions. Many trainings delivered to health care audiences are delivered by law-enforcement professionals without relevant translation to clinical care, framed with a justice-based mindset rather than a patient-centered mindset. This diverts adequate attention from the holistic psychosocial and health needs of persons who have been trafficked and those at risk. Furthermore, some training curricula use terms that are derogatory and inappropriate (e.g., child “prostitute”) or outdated (e.g., “child pornography” rather than child sexual abuse materials”) (Albright & D’Adamo, 2017). Often, training curricula are not survivor-informed, meaning survivors of human trafficking are not consulted in the development or implementation process despite acknowledgment of this by experts as best practice. Some states with training mandates do not have guidance, or if prescribed guidance exists, it is not transparently available online. No states except Texas specify criteria for design of the course among their standards. Some states, such as Iowa, Massachusetts, and Pennsylvania, only mandate trafficking training as part of child abuse training, de facto excluding trafficking of adults. Florida’s content specificity is limited to broad categories of labor and sex trafficking, how to identify individuals who may be victims of human trafficking, how to report cases of human trafficking, abut lacks further granularity in content (Jones Day, 2021).

Third, inclusion of professions in mandated training requirements is variable, with no clear national standard. As human-trafficking response has emerged from a largely criminal justice narrative, health care has lagged in translational response to a health care paradigm. A patchwork of requirements currently exists among states, with legislative and regulatory bodies enacting a wide variety of laws and regulations requiring different professions to complete varying content areas of education regarding human trafficking, with variable levels of oversight (Atkinson et al., 2016; Jones Day, 2021). State laws and regulations also differ in the professions targeted to complete training. Some states require workers within industries such as cosmetology, hospitality, and truck driving to complete education while health care professionals are excluded entirely. The Human Trafficking and Health Care Providers: Legal Requirements for Reporting and Education publication, also known as the Jones Day report (2021), provides a report of the differences in legislative and regulatory requirements by state. Florida has mandates that apply to physicians, dentists, nurses, and physical therapists. Connecticut’s mandate is limited to hospital emergency room staff and urgent care facility staff who have contact with patients. Iowa’s mandate covers a broad array of clinicians, including dental hygienists; however, when it comes to physicians, only those who provide primary care to children are included. In Louisiana, the mandate extends only to licensed abortion providers. New Jersey’s mandate applies to employees of every licensed health care facility. In some states, health care professionals are lumped in with other mandated trainee groups, such as law enforcement personnel, judges of the Superior Court, prosecutors, public defenders and other attorneys who represent criminal defendants, and it is unclear if the same content is delivered to all. Overall, in this environment, health care provider awareness of trafficking remains low (Barron et al., 2017; Cole et al., 2018; Donahue et al., 2019; Fraley et al., 2018; Katsanis et al., 2019; Lutz, 2018; Recknor & Chisolm-Straker, 2018; Sinha et al., 2018) although it is well acknowledged that persons who have experienced human trafficking and persons at risk for victimization often present for health care services (Lederer & Wetzel, 2014). Acknowledging these health care presentations, the Office of Trafficking in Persons, an Office of the Administration for Children and Families under the USDHHS, released Core Competencies for Anti-Trafficking Response in Health care Systems in January of 2021. These seven competencies outline necessary skillsets for individual clinicians, health care organizations, and academic institutions inclusive of medicine, nursing, mental behavioral health and social work to respond to trafficking. This document is intended to continue to influence and set standards for human trafficking response, with practical, measurable applications for health care providers undergoing mandated training to implement evidence-based clinical responses for individual clinicians, as well as academic institutions and health care systems (U.S. Department of Health and Human Services [USDHHS], 2021b).

Finally, oversight strategies for course content and development also vary among states. In Connecticut, the Commissioner of Children and Families, in consultation with the Commissioner of Emergency Services and Public Protection, created the content (Jones Day, 2021). In Florida, depending on the type of clinician, a professional group board or department may oversee which trainings are approved. In Iowa and Michigan, the state’s department of health oversees training. In Louisiana, while Louisiana’s Human Trafficking Prevention Commission promotes and provides trainings, there is no clear oversight body for quality control. In Massachusetts, there is no clear oversight body for quality control of training. In New Jersey, oversight falls to Department of Health, in consultation with the state’s Commission on Human Trafficking. In New York state, the commissioner may identify organizations or providers for consideration by subject facilities to provide training under this section. The commissioner may, in consultation with the Office of Temporary and Disability Assistance and the Office of Children and Family Services, make regulations under this section (Jones Day, 2021).

The Texas Model for State-Mandated Continuing Education

In the 2019 regular session of the Texas legislature, a Democratic representative from El Paso authored House Bill (HB) 2059 to require direct health care providers in the state of Texas to take mandatory continuing education on human trafficking. It should be noted that Emergency Medical Service personnel were not included in the mandate. He partnered with a national nursing professional organization engaged in anti-trafficking advocacy, the National Association of Pediatric Nurse Practitioners (NAPNAP) as expert consultants who contributed to crafting the bill language. The three existing state chapters in NAPNAP, in conjunction with the national chair of NAPNAP’s Alliance for Children in Trafficking, advised on bill language and requirements (NAPNAP, 2021). Lessons learned from previous state requirements were heavily considered. A Republican senator from the Houston area was secured as a co-sponsor, engaging bi-partisan cooperation. Care was given to craft the bill language to require any courses meeting the bill’s specifications to first be approved by the Texas Health and Human Services Commission (HHS, 2021a) commissioner and at least one of the listed courses had to be offered free of charge. HB 2059 was signed into law by Governor Greg Abbott to take effect on 1 September 2019 and for licensees to be compliant for renewals starting on 1 September 2020.

During this planning year prior to implementation, Texas HHS convened a stakeholder group and established a working group to establish standards and processes. With nursing and other health care input, it was recommended and decided upon to use Health, Education, Advocacy, Linkage (HEAL) Trafficking’s assessment tool for continuing education provider trainings. This tool is the product of a collaboration between HEAL Trafficking and the Laboratory to Combat Human Trafficking (LCHT). It provides a systematic method of assessing the degree to which a curriculum is comprehensive, trauma-informed, rights-based, and culturally responsive (Miller et al., 2020). The tool was featured in the 2020 U.S. State Department’s Trafficking in Persons report and is being used in eight countries in addition to the state of Texas as a standard-setting metric in human trafficking curriculum development (HEAL Trafficking, 2021; United States Department of State [USDS], 2020). Each entity wishing to provide education must go through a rigorous approval process with evaluation of the course adopted from the HEAL standards. Its assessment categories include design and content elements. A training that excludes sensational imagery and consults with trafficking survivors are two of the standards for design. There are over thirty content-based element standards, including that the training provides samples of appropriate language to assist with identification, that the training differentiates between human trafficking and consensual commercial sex, and that the training discusses the importance of the use of professional interpreters (HHS, 2021b). A three-layer formal evaluation process includes assessment for quality of content, editorial review, and legal review. Each review takes approximately six weeks. After approval, the course is listed as approved on the Texas HHS website for providers to access. The approval granted is designated for two years, at which time the course must be reviewed and renewed. Approved courses are then listed on the Texas HHS website for easy retrieval by relevant users. The trainings are available as written courses, online synchronous environments, online asynchronous videos, or interactive courses, or in-person seminars or workshops (HHS, 2021a).

The first course to be approved in Texas was the Stop, Observe, Ask, Respond (SOAR) to Health and Wellness course delivered by the National Human Trafficking Technical Training and Assistance Center (NHTTAC), directed by the United States Office on Trafficking in Persons, an office of the Administration for Children and Families at the United States Department of Health and Human Services (USDHHS). This training is free and accredited for continuing education by most health care providers (USDHHS, 2021a). In the first week following Texas HHS approval of this course, more than 10,000 new users registered to take the training. Courses mandated by HB 2059 in Texas are not required to be accredited for continuing education but do require approval by Texas HHS. Some course providers also accredit their course for various health professions.

Bill language in HB 2059 requires that at least one training approved and offered by HHS (2021a) must be free of charge, ensuring equitable access and limiting commercial bias. State and federal standards for accessibility are required. There is no cost to submit a training for approval, and the cost of review is borne by Texas HHS budget. Participating entities will need to invest resources in course creation and resubmission for approval every two years. In the first year following launch, more than 50 education activities have been approved. Approximately twenty of these are offered free of charge and the others range from $5 to $50 (HHS, 2021a). As part of the systematic, comprehensive design of the initiative, Texas HHS will explore opportunities for process improvement and options for collecting outcome data. While there is currently no evaluation of data, adherence to a prescribed set of standards (HEAL) begins to set a measurable bar for outcomes, which will be critical moving forward.

Considerations for Other States

While an increasing number of states are mandating human trafficking education for health care professionals, more than 30 states and the District of Columbia still have no requirement or regulation of anti-trafficking education. Although some standards exist in other states, Texas by far has the most objective and complete standards and process for approval. For those states contemplating new regulations, several key concepts should be considered to ensure that mandated training is evidence-based, patient-centered, trauma-informed, and culturally responsive. Recommendations for states implementing anti-trafficking continuing education include:

• Inclusion of all health professions

• Design and content should meet the HEAL assessment tool criteria

• Quality control for content development and oversight for education delivery should ensure rigorous adherence to quality standards before course approval

• Free access for required participants to at least one course that meets the prescribed requirements

Conclusion

Although state mandated continuing education continues to be controversial, there is agreement on significant need to equip health care providers for effective response to persons victimized by trafficking who present in health care settings. Clinicians desire clinically relevant information that enables them to provide trauma-informed and culturally responsive patient care (Powell et al., 2017). The Texas Model facilitates thoughtful design of evidence-based human trafficking education that helps prevent the spread of misinformation, empowers recognition of at-risk patients, and assists providers in offering appropriate care and services. By adhering to strictly enforced standards and careful processes, Texas seeks to ensure that high-quality, evidence-based, trauma-informed, culturally responsive training is provided in response to the requirements of HB 2059. Further research is needed to evaluate clinical outcomes related to mandated continuing education.

Author Contributions

The authors confirm contributions to the manuscript including conception, manuscript preparation and editing. All authors reviewed and approved the final version of the manuscript.

Ethics Statement

This manuscript has not been submitted to any other journal and has not been previously published. All authors contributed to the design, drafting, revising, and editing of the manuscript and all authors approved the final submission.

Acknowledgments

The authors would like to acknowledge Brandi Soules, Program Specialist at the Texas Human Trafficking Resource Center; Specialty and Family Services; Health, Developmental & Independence Services at the Texas Department of Health & Human Services. Her efforts in planning and oversight of the administration of HB 2059 were instrumental to its success.

Data Availability Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

[redacted].