Why SANEs Matter: Models of Care for Sexual Violence Victims in the Emergency Department

Stacey B. Plichta, ScD; Paul T. Clements, PhD, APRN, BC, DF-IAFN; Clare Houseman, PhD, APRN, BC


J Foren Nurs. 2007;3(1):15-23. 

In This Article


Sexual assault has both long-term and short-term health consequences (Bohn & Holz, 1996; Cloutier, Martin, & Poole, 2002; Plichta & Falik, 2001; Rentoul & Applebloom, 1997) and in the aftermath there are significant medico-legal and psychotherapeutic treatment issues including ongoing fear and threats to personal safety, disruption of personal relationships, and the trauma of the prosecutorial process (Clements, Speck, Crane, & Faulkner, 2004; Clements, Asaro, Henry, & McDonald, 2005)

The detrimental effect of sexual assault on intrapsychic development and interpersonal relationships can be mitigated by comprehensive medico-legal assessment and psycho-social intervention (Heger, 1999). The emergency department (ED) is one of the first points of entry to such care for many victims and plays a dual role of both providing health care and collecting evidence (American College of Obstetrics and Gynecologists [ACOG], 1992; Ledray, 1999). The preparedness of the ED to provide competent care and referrals to victims is critical to their physical and emotional recovery as well as to the prosecution of the perpetrator(s).

The Centers for Disease Control and Prevention (CDC) estimate that 57,000 people ages 12 and older sought care in the ED following sexual assault in 2004 (CDC WISQARS, 2005). While this is only a minority of the estimated 200,000 to 400,000 people over age 12 who are victims of attempted sexual assault or sexual assault each year (Catalano 2004; Tjaden & Thoeness, 1998), the number seeking care in the ED has been increasing annually (CDC WISQARS 2005; Magid, et al., 2004). The care of these victims is complex and requires immediate medical treatment, conducting a forensic exam in accordance with state guidelines, assisting law enforcement in obtaining evidence to prosecute perpetrators and providing contact with rape crisis centers for follow-up care (Ledray, 1999).

Studies consistently indicate that forensic nurses with subspecialty certification in sexual assault examination (Sexual Assault Nurse Examiners [SANEs]) generally provide better and timelier care (Campbell, et. al. 2005; Heger, 1999; International Association of Forensic Nurses [IAFN], 2002; Ledray & Simmelink, 1997; Selig, 2000; Stermac, Dunlap, Bainbridge, 2005; Stermac & Stirpe, 2002) and are more competent at collecting evidence that meets legal standards (Sievers, Murphy & Miller, 2003).

Few studies have examined the preparedness of the ED to assist victims of sexual violence and to collect evidence (Plichta, Vandecar-Burdin, Odor, Reams, & Zhang, in press). As noted in Ledray (2005a, p. 36), "...many SANE programs today do not have the individual experience or expertise necessary to do independent research or program evaluation, or they haven't had the direction to effectively use these resources."

Therefore, there is a paucity of information available about the extent to which EDs in the United States use SANEs or other methods to provide quality care to victims of sexual violence and to engage in evidence collection (Association for Health Research and Quality [AHRQ], 2003; Ledray, 2005a; 2005b; Plichta, 2005).

The only aspects of care in the ED that have been examined on a state or national level are access to emergency contraception (Harrison, 2005; Rosenberg, DeMunter, & Liu 2005) and adherence to post-rape STD prophylaxis (Amey & Bishai, 2002), both of which have been found to be inadequate. The few studies that have examined different aspects of care offered to sexual assault victims in specific EDs found that care is incomplete (Rovi & Shimoni, 2002), inconsistent (Johnston, 2005; Sommers, et. al, 2005), and that comprehensive staff training is necessary (Lewis, DiNitto, Nelson, Just, & Campbell-Ruggaard, 2003).

This exploratory study seeks to add to the existing knowledge by identifying currently used models of care for victims found in Virginia EDs. This study employs Donabedian's classic model of health services (1985) as a conceptual framework to explore the current models of care available. In the Donabedian model, quality is defined by the presence of the structural and process characteristics and by the existence of effective outcomes related to those structures and processes. Structural characteristics are the resources necessary to provide care and process characteristics are related to how the care is actually provided.

The substantive focus of this study is on the structural and process factors related to providing sexual violence-related health care services. The type of services that should be provided by the ED are defined by current SANE (forensic) nursing guidelines and other professional groups and experts (AMA, 1995; ACOG, 2006; CDC, 2002; Ledray, 1999). This study seeks to fill a gap in the literature by examining the extent to which the utilized model of care affects the quality of services provided in emergency departments in Virginia as defined by structural and process characteristics.


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