It’s midnight when 19-year-old Ann, who is visibly upset, arrives in our emergency department (ED) accompanied by police. The police report to the nurse that Ann is high on cocaine and heroin. She is homeless, and appears to be under extreme emotional distress. She was brutally raped by an unknown assailant from whom she tried to obtain more drugs. Ann admits to using drugs. She explains her current situation and clearly is seeking help.
Every 2 minutes, someone in the U.S. is sexually assaulted according to the Rape, Abuse, & Incest National Network. Only about 40% of sexual assaults are reported to the police; 38% of rapists are known to the victim.
Too often rape survivors who seek post-assault health care and medical forensic evidence collection often don’t receive basic services, wait long hours, and have evidence collected by personnel who aren’t trained and lack experience. Several years ago, patients like Ann were experiencing long waits in our ED. One problem was that a physician was needed from the start to the end of the exam so the chain of collecting forensic evidence was not broken. Only one physician was trained to do the pelvic portion of the exam along with the interview. Requiring the same physician for the needed time to perform this care was nearly impossible.
We felt having a consistent, nurse-driven program to case for sexual assault victims would decrease wait times, provide optimal quality care, and provide expert collection of forensic evidence to improve prosecution rates. Nurses, nurse practitioners, nursing managers and our physician ED director completed a comprehensive, week-long training program. The goals of the program are to provide immediate, comprehensive, and compassionate care to victims of sexual assault; to develop Sexual Assault Nurse Examiner (SANE) and Sexual Assault Response Team (SART) partnerships; and to prepare for courtroom testimony.
What does a SANE nurse do?
SANE nurses are dedicated to preserving the dignity and reducing the psychological trauma experienced by the victim.
The staff notify the SANE nurse when a patient who has been sexually assaulted is in the ED. The SANE nurse is supported by the staff and is immediately assigned to the patient. The other patients are reassigned until the assault case has been completed.
The SANE nurse obtains a preliminary history, conducts an in-depth interview, and performs a physical, including a pelvic exam, to collect appropriate evidence. The nurse maintains a verified chain of evidence and collaborates with law enforcement officials, which may include testifying in court. The role also includes victim education regarding sexually transmitted disease and pregnancy risks, and making referrals for follow up care.
Training programs to become a SANE nurse are available online and through conference attendance. Requirements include didactic forensic nursing education along with clinical hours and a passing score on a comprehensive written examination.
There are many test sites across the country that offer the national certification exam developed by the International Association of Forensic Nurses (IAFN). Certification is valid for three years and validates the status and experience of the sexual assault examiner.
Although there is no research showing a direct link between a SANE examination and a guilty plea, case reports have demonstrated that when assailants are confronted with SANE evidence, they are willing to accept a guilty plea when they had denied committing any sexual abuse before seeing the evidence.
It requires a special type of nurse to be a SANE. The general characteristics compassion, excellent interpersonal skills, detail oriented, and the ability to recognize one’s own stress and who have good personal support systems.
Our program has been in place for 5 years. Our 12 SANE nurses cover all shifts.
Victims are seen within 10 minutes of arrival to the ED. The patient is immediately assigned a patient advocate followed by law enforcement personnel. The total time from arrival to discharge is approximately three hours or less. We have interpretors available around the clock for non-English speaking patients.
At monthly meetings we discuss cases SANE nurses have provided care for. Our ED now has a program to provide clothing and hygiene articles for victims of sexual assault.
Part of a team
Each SANE program should operate as part of a SART. The team includes the SANE nurse, a forensic examiner, law enforcement representatives, rape advocate, and prosecutor. Other members of the team often include crime laboratory personnel who analyze the sexual assault evidence kit, police dispatcher, EMS personnel, and other agencies serving sexual assault survivors such as social services personnel and clergy.
These professionals collaborate to facilitate the survivor’s recovery and the investigation and prosecution of the assailant by providing information, support, and crisis intervention; gathering evidence; and facilitating the movement of the survivor through the legal system.
The development of an integrated community program through a SANE/SART model offers the potential for reducing fragmentation and duplication. It provides improved efficiency in the delivery of services.
We are working towards the SART model. Our hospital, Women & Infants Hospital, is the designated hospital for care of these patients within the state of Rhode Island. A training program under the direction of our facility is currently underway for other nurses at other area hospitals.
Staff members feel confident that the care they are providing is in line with best practices throughout the country. The impact of having SANE nurses has been extremely beneficial for the patient, the SANE nurse, and the staff. Through our efforts, patients like Ann receive compassionate, competent care.
Denise Henry is the Director of Quality Management at Women & Infants Hospital in Providence, Rhode Island and LucilleForce is the Chief Nurse Executive At Universal Health Services in Boston, Massachusetts.
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Agency for Healthcare Research and Quality. Medical Examination and Treatment for Victims of Sexual Assault. www.ahrq.gov/research/victsexual/victsex2.htm Accessed July 7, 2011.
Campbell R. The effectiveness of Sexual Assault Nurse Examiner (SANE) Programs. Trauma Violence Abuse. 2005;6(4):313-29.
Ledray L. Recovering from Rape. 2nd Ed. New York, N.Y: Henry Holt and Company; 1994.
Office on Violence Against Women. The Role of the Sexual Assault Nurse Examiner in the Prosection of Domestic Violence Cases. 2007. http://www.ndaa.org/pdf/pub_role_sexual_assault_nurse_examiner.pdf. Accessed July 13, 2011.
Rape Abuse & Incest National Network. http://www.rainn.org Accessed July 7, 2011.
Sexual Assault Nurse Examiner/Sexual Assault Repsonse Team. http://www.sane-sart.com Accessed July 7, 2011.