The results of this national survey built on the results of three previous national surveys (Campbell et al., 2005; Ciancone et al., 2000; Ledray, 1997a, 1997b) by examining: (1) the intersection of SANE and law enforcement policies; (2) SANEs' perceptions of working relationships with community organizations; (3) the perceived benefit of SANE programs for survivors; and, (4) barriers and potential solutions to barriers in addition to various programmatic issues. Results will be discussed for each of these four topics.
First, although there was relative consistency among programs for the primary forensic documentation tools, 20% of programs reported never using a colposcope a tool which has been cited as a very important documentation tool because it increases injury detection (Bowyer & Dalton, 1997; Lenahan, Ernst, & Johnson, 1998; Slaughter & Brown, 1992). Several programs mentioned they did not use a colposcope because they could not afford one or the one they had was not in working condition. Also, the majority of programs (53%) reported their outside time parameter for collection of DNA evidence was 72 hours, however a small percentage of programs reported they would still try to collect DNA evidence up to 120 hours (15.5%) or even longer (3%) under certain circumstances, such as if the survivor had been held captive.
Research suggests that the shorter the time between the assault and the forensic exam, the better the forensic evidence will be (Sugar, Fine, & Eckert, 2004), and the better the documentation of injury, which increases the likelihood that charges will be brought against the assailant (McGregor et al., 1999; 2002). However, most programs reported that even if the survivor presented past their outside time parameter they may try to collect DNA evidence depending on the case (the victim was held captive for days, or the victim was in an institutional setting where consensual sex should not occur), or they would provide an exam to document injury. These responses have been noted as important aspects of the SANE program (Department of Justice, 2004; Ledray, 2001).
An especially interesting result was that only 38.5% of programs reported there was a formal system in place to let SANE programs know about case outcomes (arrest, prosecution, and conviction of offenders). Even of those programs that reported a system was in place, less than half were aware of the number of arrests made in the prior year. Those programs that indicated they did not have a formal system in place to provide feedback about case outcomes reported a number of barriers to accessing the information such as limited time or personnel to establish and maintain the system and limited communication with criminal justice system personnel. In fact, 35% of programs reported cases were never discussed in a multidisciplinary format.
Knowledge of case outcomes might provide a unique opportunity for learning, especially when prosecutors, investigators, and SANEs come together in reviewing cases from multiple perspectives in order to identify strengths and weaknesses in each participant's contribution to the case. Understanding how to overcome these barriers within funding constraints will be important as well. Even though increases in the number of cases where arrests are made, charges are filed, and prosecution proceeds, are viewed as important objectives of SANE services, and therefore, as critical outcomes to evaluating SANE programs (Campbell et al., 2005; Ledray, 2001; Littel, 2001), this aspect of SANE programs has not been widely examined. More research is needed to examine whether this type of feedback would be helpful or not to SANEs, and whether this information might be important in securing future program funding.
Another controversial aspect of SANE programs is whether or not survivors must report to law enforcement at the time they present to the emergency department in order to receive a forensic exam. The rationale for conducting a forensic exam when the survivor is unsure about reporting to law enforcement is to allow for the possibility that the survivor might reconsider her initial decision, thus collecting the evidence post-assault would allow for the possibility that evidence and documentation would be available for legal proceedings. Just over half of the programs indicated that their program requires survivors to report the assault to law enforcement for a SANE to conduct the forensic exam, mainly to comply with requirements for reimbursement. In cases where the survivor does not choose to report to law enforcement at the time of presenting to the SANE, survivors are provided a medical exam and care through regular ED procedures.
The national protocol for SANE programs suggests that programs should try to include survivors who do want to report to law enforcement as well as survivors who do not at the time they present to the emergency department (Department of Justice, 2004). However, there were a number of issues mentioned that have to be worked out if SANE programs are to allow survivors to receive forensic exams without reporting the assault to law enforcement, including how, where, and for how long evidence is stored.
SANE coordinators discussed a number of obstacles that prohibited the collection of evidence without a police report, such as funding constraints (in some localities and states, the SANE program is only reimbursed for the exam if the survivor makes a statement to the police), or other community contextual factors. More information about how these barriers could be overcome would be helpful to programs.
The majority of SANE coordinators indicated that the criminal justice system benefits from their services because of the quality of evidence collection, their expertise in testifying, and better communication with the justice system, all of which are better than they would be without the work of SANEs. These are all factors that have been identified in other documents (Ledray, 2001; Littel, 2001). Even so, this study's results indicated that the working relationship with law enforcement and prosecutors could be improved, with only about half of the programs indicating they had an excellent working relationship with these agencies.
Other agencies were identified as having a less than excellent working relationship with the SANE program including hospital administrators and staff, and crime labs. Relationships and communication with crime labs is important because receiving feedback regarding contents and quality of evidence collection is important for SANEs' learning and quality assurance for exams. Further, it may be very important to establish good working relationships with community agencies providing indigent care. In many communities, these agencies may not be aware of the benefits of referring individuals for forensic evaluation or how to refer survivors to SANE programs. Also, good community collaborations (Planned Parenthood, health department, and rape crisis) may contribute to improved follow-up care for survivors when SANEs are unable to provide particular services. In fact, the rape crisis services are important to the SANE program for crisis intervention and possibly follow-up care, yet about 20% of programs indicated that their relationship was less than excellent. Greater attention to building successful collaborative relationships with various community stakeholders is warranted.
Multiple benefits of SANE programs for survivors have been noted throughout the literature as well as from our survey respondents including client-centered care, quality of evidence collection, and the referrals and resources that are offered to survivors. In fact, the current study results showed the majority of programs offered a variety of services or referrals to services for survivors. STD and HIV testing were reported least often by programs as something they offered. The decision to routinely conduct STD and HIV testing has been eschewed by many programs and the national protocol for sexual assault medical forensic exams out of concern that positive findings among sexually active individuals would have no forensic value because the results of those tests may not be valid that close to the assault, and because any positive findings could be used against the survivor by defense attorneys, and it is expensive (Department of Justice, 2004). The provision of HIV prophylaxis is recommended only for clients at high risk for exposure (Department of Justice, 2004), and SANEs should discuss the uncertainties and known limitations and benefits of taking HIV prophylaxis to high-risk clients.
The low rate of follow-up care by the SANE is likely due to lack of funds and staff. However, follow-up care may be especially critical for survivors of sexual assault and may improve forensic evidence collection (Department of Justice, 2004). Of course referrals and follow-up care by other agencies may be an important part of the SART protocol, but may or may not offer the same kind of services and forensic follow-up a SANE would offer.
Finally, participants in the current study listed a number of problems they experienced in developing or maintaining the SANE program. The most frequently mentioned problems included staffing, funding, and conflicts or lack of communication with the community and various agencies. Participants also mentioned a variety of solutions they had implemented or were planning on implementing to address these problems. Some of these solutions were very creative such as holding independent fundraisers and changing the interview process to better match recruited nurses to the needs of the program. However, the problems that were most frequently mentioned are likely to be ongoing problems especially within the social, political, and economic environment of cuts in funding for social service programs. While acknowledging that certain communication and networking modes are helpful (such as the SANE-SART and IAFN Web sites, and national conferences), SANE program coordinators mentioned that increased access and sharing of information and increased access to training and continuing education would be very helpful in overcoming barriers or problems.
Several limitations to this study need to be mentioned. First, limiting the survey to SANE program coordinators may present a biased picture of the SANE program. In order to obtain the most objective information it would be useful to talk to a variety of program stakeholders. Also, talking to a nurse who is not the coordinator may provide a different picture of the program. Further, given limited resources for the study a random sample of programs were surveyed rather than all programs. It would be informative to include all or most of the programs in order to better represent geographic and community context differences in program characteristics; however, conducting such a study would raise the same problem encountered in any study of SANE programs, which is creating an all-inclusive list of active programs.
Even with its limitations, for two reasons this study provides some important in-depth information about SANE programs. First, this study had a high response rate of over 200 randomly selected SANE programs. Second, this study examined aspects of the SANE program that have not been widely addressed in the research literature. Results point to the importance of community support and collaborative working relationships with community agencies to resolve problems in localities with unique constraints and resources.
Networking and exchanging information among SANE programs can uncover common problems and potential solutions to be shared and modified. Thus, the results suggest that surveys can be useful in providing information to SANE programs. This methodology may be useful in other ways for SANEs as well. For example, an important area for future research may be to survey potential nurse trainees, non- or never-practicing SANEs, and formerly-practicing as well as currently- practicing SANEs to identify barriers and problems to address retention and scheduling issues.
Broadening the scope of research with SANEs may strengthen SANE programs, increase information to secure funding, and help new programs just getting started.
J Foren Nurs. 2007;3(1):24-34. © 2007 International Association of Forensic Nurses
Cite this: Sexual Assault Nurse Examiner Program Characteristics, Barriers, and Lessons Learned - Medscape - Apr 01, 2007.