Using a SANE interdisciplinary approach to care of sexual assault victims

Sexual Assault in an Adolescent Female: A Pediatric Simulation Case for Emergency Medicine Providers

INTRODUCTION

Many emergency medicine (EM) physicians have limited training in the care of sexual assault patients. Simulation is an effective means to increase the confidence and knowledge of physicians in such high-stakes, low-frequency clinical scenarios as sexual assault. We sought to develop and implement a sexual assault simulation with a structured debriefing for EM residents and to determine its impact on resident learners' attitudes and knowledge skills in the care of patients with sexual assault.

METHODS

The simulation blended psychomotor skills (e.g., collecting forensic evidence), cognitive skills (e.g., ordering laboratory studies and medications), and communication skills (e.g., obtaining relevant patient history, responding to psychosocial concerns raised by team members and simulator). Our emergency department checklist was available as a cognitive aid for each step of the evidence collection process. A content expert answered questions in real time during the simulation and provided structured debriefing following the simulation. Trainees completed an anonymous survey within a week after the intervention and a follow-up survey within 8 months.

RESULTS

Nineteen EM trainees participated. Presimulation, 39% reported never having received training in the medical care of a patient with sexual assault. The proportion of trainees agreeing or strongly agreeing with the statement "I am comfortable and confident managing a case of sexual assault" increased from 21% to 74% following the simulation (p < .05).

DISCUSSION

This intervention was associated with EM trainees' increased confidence with and knowledge of medical and forensic evaluations for an adolescent with sexual assault.

Characterizing Drug-Facilitated Sexual Assault Subtypes and Treatment Engagement of Victims at a Hospital-Based Rape Treatment Center

Variation among existing studies in labeling, defining, identifying, and subtyping cases of suspected drug-facilitated sexual assault (DFSA) poses challenges to integrating research findings for public health purposes. This descriptive study addressed methodological issues of nomenclature and DFSA operational definitions to improve case identification and was designed to distinguish assault subtypes. We studied a 2-year ethnically diverse cohort of 390 patients who presented acutely to an urban rape treatment center (RTC). We abstracted data from RTC medical and mental health records via chart review. Assault incidence rates; engagement into medical, forensic, and mental health services; injury sustained; and weapon use were calculated separately for assault subtypes and compared. DFSA accounted for over half of the total sexual assault (SA) cases. Involuntary DFSA (in which an incapacitating substance was administered to victims without their knowledge or against their will) increased from 25% to 33% of cases over the 2-year period. DFSA victims presented sooner, and more often attended medical follow-up and psychotherapy than non-DFSA victims. Incidence rates indicated increasing risk for young males. These findings indicate that DFSA continues to be a growing and complex phenomenon and suggest that DFSA victims have greater service needs. The field would benefit from innovations to address symptomatology arising from this novel type of trauma and the unique risks and needs of male victims, as well as underscoring the ongoing need for DFSA-specific prevention efforts for both victims and perpetrators.

A Strategy for Increasing Postrape Medical Care and Forensic Examination

Despite the physical and emotional damage of sexual assault, most raped women do not receive postassault medical care. This article describes a social marketing strategy to sell sexual assault nurse examiner (SANE) services available on a college campus directly to matriculated students (potential victims and allies). Significant results found in postcampaign surveys were that the majority of students saw posters and generally retained the information in them, students exposed to more sources of information had more accurate knowledge of services, and students' recommendations concerning SANE usage reflected their exposure to information and their perception of assault risk. The article concludes with policy recommendations.

Low-fidelity hybrid sexual assault simulation training's effect on the comfort and competency of resident physicians

BACKGROUND

Alternative training methods are needed for resident physicians to ensure that care is not compromised should they practice in settings without well-established Sexual Assault Nurse Examiner (SANE) programs.

OBJECTIVE

The purpose of this study is to determine the effectiveness of a simulation-based sexual assault response course for resident physicians at an institution without an on-site SANE program.

METHODS

Educational intervention study of 12 emergency medicine residents using a low-fidelity hybrid simulation model. The study was comprised of eight male and four female physicians at a military medical center in San Diego, CA. Assessment occurred using three separate metrics. The first was a written knowledge test. The second was a simulated interview and evidentiary examination. These metrics were given 1 month before and 3 months after an 8-h training course. The final metric was Likert-scale questionnaires surveying pre- and post-course feelings of competency and comfort.

RESULTS

The emergency medicine residents showed a 13% improvement (95% confidence interval [CI] 7-20%) in written examination scores pre and post intervention. Post-course interview and examinations reflected a 44% improvement (95% CI 24-64%) in critical action completion. Pre-course comfort and competency questionnaires were a median of 2 (interquartile range [IQR] 1-3) on a Likert Scale. Post-course survey responses were a median of 4 (IQR 2-5).

CONCLUSIONS

Low-fidelity hybrid simulation is a useful tool to train inexperienced physicians to perform evidentiary examinations and interviews without sacrificing the privacy and direct care of sexual assault victims.

Pediatric sexual assault nurse examiner care: trace forensic evidence, ano-genital injury, and judicial outcomes

INTRODUCTION

Although pediatric sexual assault nurse examiners (P-SANEs) have been providing care for over two decades there remain major gaps in the literature describing the quality of P-SANE care and legal outcomes associated with their cases. The purpose of this study was to compare quality indicators of care in a pediatric emergency department (PED) before and after the implementation of a P-SANE program described in terms of trace forensic evidence yield, identification of perpetrator DNA, and judicial outcomes in pediatric acute sexual assault.

METHOD

A retrospective review of medical and legal records of all patients presenting to the PED at Nationwide Children's Hospital with concerns of acute sexual abuse/assault requiring forensic evidence collection from 1/1/04 to 12/31/07 was conducted.

FINDINGS

Detection and documentation of ano-genital injury, evaluation and documentation of pregnancy status, and testing for N. gonorrhea and C. trachomatis was significantly improved since implementation of the P-SANE Program compared to the historical control.

DISCUSSION

The addition of a P-SANE to the emergency department (ED) provider team improved the quality of care to child/adolescent victims of acute sexual abuse/assault.

Sexual assault nurse examiners' perceptions of their relationship with doctors, rape victim advocates, police, and prosecutors

In response to the negative and inefficient treatment of rape victims by emergency room personnel, the first Sexual Assault Nurse Examiner (SANE) programs began in the late 1970s. While SANEs, doctors, rape victim advocates, police officers and prosecutors work together to ensure the most comprehensive and sensitive care of rape victims, they all have very different roles and objectives. This research explores SANEs' perceptions of their relationships with other professionals who treat or interact with rape victims. Data from interviews with 39 Sexual Assault Nurse Examiners from four East Coast states indicate positive relationships are marked by open communication, respect shown towards SANEs as well as rape victims, and a sense of appreciation among SANEs. On the contrary, negative relationships result when SANEs believe police treat victims poorly, when advocates overstep boundaries and question SANEs about evidence collection or the exam, and when prosecutors fail to properly prepare them to testify during a trial.

Alternate light sources in sexual assault examinations: an evidence-based practice project

The ability of sexual assault nurse examiners to correctly identify and collect DNA evidence improves patient outcomes and prosecution rates. The purpose of this paper is to present findings from a collaborative evidence-based practice (EBP) project between forensic nurses and baccalaureate nursing students. The goal of the project was to determine best practice using an alternate light source (ALS) to identify trace DNA evidence in sexual assault forensic examinations. Using the Johns Hopkins Nursing Evidence-based Practice model, the team searched several databases to summarize the limited amount of evidence available regarding this topic. Recommendations from the EBP project include: elimination of the Wood's lamp in sexual assault examinations; use of an ALS that provides appropriate wavelengths to detect DNA; education of forensic nurses about the advantages and limitations of an ALS; and additional research related to use of an ALS. By participating in similar collaborative efforts, practicing forensic nurses have the opportunity to collaborate with local colleges and universities to make complex projects more manageable while fulfilling the International Association of Forensic Nurses vision for ethical practice.

Assessment of trauma nurse knowledge related to forensic practice

Assessment of forensic practice specific to the trauma setting was the purpose of this pilot study. Thirty-eight trauma nurses from a level II trauma center completed a questionnaire related to their knowledge of forensic practice. Although 58% of nurses had some education related to forensics, emergency department nurses were significantly more knowledgeable about existence of protocols than were intensive care unit nurses. Most respondents indicated a willingness to incorporate forensic principles into practice. Forensic education and standardization of protocols would enhance clinical practice in the trauma setting.

Implementation and Evaluation of a Training Program for the Management of Sexual Assault in the Emergency Department

STUDY OBJECTIVE

Sexual assault nurse examiner (SANE) programs have improved the quality of care for sexual assault victims. An adverse effect of these programs is reduced resident clinical exposure to victims of sexual assault. The objectives of this project are to determine the baseline level of resident competence in knowledge and management of sexual assault and to demonstrate the effectiveness of training in developing resident competence.

METHODS

The study included 27 emergency medicine residents at an urban academic center with an active SANE program. The design included pretest, intervention, and retest at 6 months. The intervention included 8 hours of lecture, role play, and skills laboratories. Objectives were based on SANE standards. The 4 assessments were a written knowledge test, evidence collection on mannequin, standardized patient interviews, and a written emergency department note. Data were compared with paired t tests.

RESULTS

Twenty-three (85%) residents completed the study. Preintervention, residents scored 56% on the written knowledge test, 63% on evidence collection, 71% on standardized patient interviews, and 66% on the written note. Residents showed significant postintervention improvements in written knowledge (improvement 24%; 95% confidence interval [CI] 20% to 27%) and evidence collection (improvement 18%; 95% CI 12% to 24%). Performance on standardized patient-based communication skills did not change after the intervention. Resident posttest scores were similar to those of SANE providers.

CONCLUSION

Emergency medicine residents training in an urban center with an active SANE program had limited knowledge and skills in the treatment of victims of sexual assault. Our multimodal educational intervention increased residents' knowledge and evidence collection skills to levels equivalent to that of experienced providers in a SANE program.

Why SANEs matter: models of care for sexual violence victims in the emergency department

This study examines models of SANE service in the ED and quality of care. Nurse managers of all 82 EDs in Virginia were surveyed (RR 76%). Five models emerged: 1) No SANE services (27.4%); 2) Victims transferred off-site for services (14.5%); 3) Partial coverage of services by ED SANEs (16.1%); 4) SANEs called in from off-site (6.5%); and 5) Full-coverage of services by ED SANEs (35.5%). Models 4 and 5 consistently provided a higher quality of care.

Health care-based interventions for women who have experienced sexual violence: a review of the literature

Thirty publications that evaluated health care-based interventions for women who experienced sexual violence were reviewed. The findings highlight that clinicians often need training in the provision sexual assault care, and that not all emergency departments have sexual assault care protocols. Studies examining effectiveness found that Sexual Assault Nurse Examiner programs are very helpful, that health care-based sexual assault treatment settings attract more women than do forensic-based settings, that sexual assault survivors often prefer a combination of medication and counseling treatment, and that preexam administration of a video explaining the collection of forensic evidence may reduce women's stress during the procedure. Studies on postexposure HIV prophylaxis found that many women did not complete the treatment regimen, often because of side effects. Emergency contraception to prevent postrape pregnancy is not consistently offered to women. Only one study reported on abortion as part of the range of sexual assault services.

The effectiveness of sexual assault nurse examiner (SANE) programs: a review of psychological, medical, legal, and community outcomes

In sexual assault nurse examiner (SANE) programs, specially trained forensic nurses provide 24-hour-a-day, first-response medical care and crisis intervention to rape survivors in either hospitals or clinic settings. This article reviews the empirical literature regarding the effectiveness of SANE programs in five domains:(a) promoting the psychological recovery of survivors, (b) providing comprehensive and consistent post-rape medical care (e.g., emergency contraception, sexually transmitted disease [STD] prophylaxis), (c) documenting the forensic evidence of the crime completely and accurately, (d) improving the prosecution of sexual assault cases by providing better forensics and expert testimony, and (e) creating community change by bringing multiple service providers together to provide comprehensive care to rape survivors. Preliminary evidence suggests that SANE programs are effective in all domains, but such conclusions are tentative because most published studies have not included adequate methodological controls to rigorously test the effectiveness of SANE programs. Implications for practice and future research are discussed.