When people experience sexual assault,
they may sustain more than just physical injuries; trauma also affects short-
and long-term mental health. The medical treatment needed may require a
provider to examine parts of the body that were recently violated, which can
cause more distress. When reporting an assault, survivors often lack the
information they need about how to proceed.
Sexual assault nurse examiners
(SANEs) are trained to help survivors across this spectrum of patient care.
From providing evidence-based treatment to performing assessments to collect
forensic evidence that can be used in a criminal trial, these nurses play a
critical role in supporting survivors at the beginning of their recovery
What Is the Role of a Sexual Assault Nurse Examiner?
When a sexual assault survivor comes to a SANE-certified hospital or community health center, a sexual assault nurse examiner is the first point of care, according to Kim Day, forensic nursing director for the International Association of Forensic Nurses (IAFN). SANEs ask the patient if they would like a forensic exam, which can be completed even if the patient decides to not report their assault to law enforcement.
“Just going through the process with
someone and providing holistic patient-centered care for that patient during a
traumatic time in their life can really impact the way they leave the
hospital,” Day said.
Forensic exams are meant to document
trauma from the assault and collect evidence that could be used in a criminal
trial. This includes taking a medical history; documenting scratches, bruises,
abrasions, and other injuries on a body map diagram; taking photos of injuries;
collecting DNA swabs to be processed; and observing the patient’s behavior. In
cases where toxicology information is relevant, SANEs will also perform those
tests on a patient.
In addition to performing a forensic
exam, the main duty of a SANE is to provide holistic nursing care for the
patient. Survivors of assault may need access to testing for pregnancy, as well
as prophylactic antibiotics to prevent the contraction of diseases. Depending
on the patient’s needs, SANEs also provide referrals to see other specialists,
such as a licensed professional counselor, who can help them in their recovery
The SANE in Court: It’s Not Like “Law and Order”
Beyond working in the clinical
setting, SANEs are qualified to testify in court if a patient’s case goes to
trial. The specialized training SANEs receive prepares them to effectively
answer questions regarding evidence discovered during a forensic exam. However,
while SANEs can play a critical role in the trial process, the legal aspect of
the job is not the main focus, Day said.
“If the nurse goes into this work
thinking that they’re going to get the bad guy and put him behind bars, they
will fail at this… because that is not what we do,” she said. “The work we do
is nursing. We take care of the patients.”
This is a key factor to consider when choosing to become a SANE. Nearly 80 percent of sexual assaults are not reported to law enforcement, according to a Justice Department analysis of violent crime in 2016 (PDF, 669 KB). While performing a forensic exam and being prepared to provide evidence in court is a requirement of the job, the emotional and medical needs of a patient come first.
SANEs are trained to work within a multidisciplinary team, also known as a Sexual Assault Response Team (SART), which includes survivor advocates, members of law enforcement, and mental health providers. Together, these professionals coordinate the response to survivors of sexual assault.
What Is a Sexual Assault Response Team?
SANEs and other trained health care
providers: When an individual decides they
would like to have a sexual assault forensic exam (SAFE), health care providers
like Nurse Practitioners (NPs) or SANEs address the initial physical and
psychological needs the patient might have as a result of their assault.
Survivor advocates: Individuals who need access to information and emotional
support can work with an advocate to navigate their path to recovery. A
survivor may reach out to an advocate via a crisis center, or one may be
brought in to support someone who has decided to seek treatment at a hospital
or report their assault to the police.
Law enforcement: In cases where an individual decides to report their
assault, police officers and detectives are responsible for taking statements,
coordinating with the hospital to receive the results of the forensic exam, and
investigating the alleged assault.
Prosecutors: In cases where the survivor has chosen to report their
assault and enough evidence is present, prosecutors are tasked with making the
decision on whether to bring the case to court.
Therapists and counselors: In the aftermath of an assault, whether a case goes to trial
or not, survivors need additional support to continue their recovery process.
Mental health professionals trained in working with sexual assault survivors
may provide care at any step in the recovery process, from coping with the
immediate aftermath of an attack to navigating long-lasting trauma.
Why Is Access to SANE Care Important?
According to the Centers For Disease Control and Prevention (CDC), one in three women and one in four men have experienced sexual violence involving physical contact during their lifetimes. The effects of experiencing an assault can be both physical and psychological, necessitating specialized care that embodies the concept of cura personalis, or care for the entire person. This holistic attention to the entire individual is the expertise of clinicians like nurses.
SANE education programs are designed
to train nurses to address survivors’ specific needs. After completion of this
training, SANEs become uniquely qualified to treat this vulnerable patient
group. This means that they can provide trauma-informed care to minimize the
harm of invasive exams that may trigger a patient. In doing so, they can also
equip their patients with forensic evidence that can be used if they decide to
report their assault.
Not all hospitals have SANE
programs. IAFN’s database of registered SANE
programs indicates that there are currently 962 in the
United States. As a result, patients are sometimes required to travel long
distances to access SANE care, according to a 2016 report on the availability of forensic examiners (PDF,
191 KB). This means that the facilities with SANE
expertise must be ready to do what they can to help every patient who walks in
Trauma-Informed Care and Practicing Consent
One of the key challenges of
completing a sexual assault forensic exam (SAFE) is examining a patient’s
physical injuries without retraumatizing them. To help survivors feel
comfortable, SANEs ask for consent during each step of the way while providing
information on why they are doing each test.
“Consent is not just a piece of
paper with a signature on it,” Day said. “It’s a process throughout the exam.”
In practice, the process of asking for consent may resemble the following:
- The SANE
will inform the patient what body part they will examine and ask permission to
“I’m going to examine your neck now
to see if there are any injuries. Do I have your permission to do so?”
- If the
patient grants this permission and the SANE notices something that may require
a sample collection, the nurse will again ask for permission to collect a
specimen and explain why collecting that evidence is appropriate.
“I notice a scratch that wasn’t
mentioned when I documented your health history. There may be DNA or other
materials near this wound, so I would like to swab it. Is that OK with you?”
In any instance where the patient
does not want a test performed, the SANE is directed to honor the patient’s
request. This integration of consent throughout the exam is meant to give the
patient a sense of control, a feeling that may have been lost during their
What Are the Requirements to Become a SANE?
Because SANEs work with a patient population that requires specialized care, nurses are required to meet certain expectations in order to take on this role. While some nurses go through training at the local level or through smaller programs, IAFN offers the most recognized certification for SANEs. Nurses can become certified as a SANE-A to care for adults and adolescents or a SANE-P to work in pediatrics. Some nurses elect to pursue both certifications so they can provide care to patients across all age groups.
Steps to SANE Certification
- Education: To become a certified SANE, a nurse must have the minimum of a registered nursing (RN) license.
- Experience: Prior to starting the certification process, a nurse must have at least two years of clinical experience working as an RN or at a higher level, such as an NP.
- Training: As part of the certification process, nurses are expected to complete 300 hours of SANE clinical skills training.
- Testing: The final requirement to become a certified SANE is to pass a certification examination. IAFN holds exams two times a year.
Information for Further Reading
Citation for this content:
[email protected], the online MSN program from the School of
Nursing & Health Studies
The anti-vaccination (“anti-vaxx”) movement is a global phenomenon that has received a great deal of press, but how much do we really know about it? How do educated adults come to turn against medicines that have been saving literally millions of lives since the early days of smallpox inoculations?
One partial explanation is offered by health policy reporter Stuart Lyman. In a February column for STAT, he writes, “The [pharmaceutical] industry has been engaging in bad behavior for several decades, and these self-inflicted wounds have turned much of the public against it…” After reciting a horrifying litany of pharma-company scandals the public has witnessed, he concludes, “All of this has contributed to the prominent anti-pharma themes voiced by the anti-vaxx crowd.”
Anti-Vaxx is No Longer In Its Infancy
But “the anti-vaxx crowd” shows no signs of giving up their crusade anytime soon. From their original focus on parents of autistic children, they have proceeded to target orthodox Jewish communities and recently bereaved parents. Perhaps the most influential US group behind anti-vaccine campaigns is ICAN (Informed Consent Action Network). According to the Washington Post, ICAN, founded by former daytime television producer Del Bigtree, is largely funded by New York city philanthropists Bernard and Lisa Seltz, who have contributed $3 million since joining in 2012.
Lisa Seltz now serves as ICAN president, and continues to fund the organization’s message that the government and “Big Pharma” are colluding in a massive coverup regarding the hidden dangers of vaccines. Robert F. Kennedy, Jr, a nephew of the late president, runs Children’s Health Defense, his own anti-vaxx organization, and another flush-with-cash group, The National Vaccine Information Center, is run by Barbara Loe Fisher (who claims her son’s learning disabilities were the result of a 1980 DPT shot that was followed by “convulsion, collapse and brain inflammation within hours”).
Some Quick Tips from NSO’s Georgia Reiner
Considering that these wealthy and powerful organizations are finding fertile ground in today’s conspiracy-minded culture, DailyNurse interviewed Georgia Reiner, a risk specialist for Nurses Service Organization (NSO), to request a few tips for nurses who find themselves confronted by this strange controversy.
DailyNurse: What are the
actual dangers posed by the anti-vaxx movement?
GR: It is important to state up front that the vast majority of people do vaccinate. However, the anti-vaccination movement has gained a lot of attention and helped foment outbreaks of largely preventable diseases that can be deadly. The anti-vaxx movement spreads misinformation and conspiracy theories online on social media, and by word-of-mouth in tight-knit, culturally isolated communities.
Anti-vaxx propagandists have helped to create pockets of unvaccinated people, which have contributed to public health issues like the measles outbreak seen recently in Orthodox Jewish communities in New York and New Jersey. These outbreaks of highly contagious diseases such as measles put vulnerable people, including newborn babies and people who have weakened immune systems, at great risk.
Outbreaks also distract
and divert resources from other important public health issues, and cost state
and local governments millions of dollars to contain. However, nurses are in an
ideal position to counter this messaging.
DN: What are nurses doing
to counter the anti-vaccination movement?
GR: Nurses are a trusted
source of credible information and can have tremendous influence over the
decision to vaccinate. This is true even for parents who are vaccine-hesitant.
Working on healthcare’s front lines, nurses can help inform families about
vaccinations and the role they play in keeping their children healthy and
stopping the spread of disease. Nurses can also learn about questions parents
may ask about vaccines, and how to effectively address common concerns.
DN: How can nurses cope
with anti-vaxx parents?
GR: First, nurses should
assume that parents will vaccinate. Research has shown that when healthcare
providers use presumptive language, significantly more parents accept vaccines
for their child. Then, if parents are still hesitant or express concerns,
nurses should work with the treating practitioner to convey the importance of
Nurses should listen to
parents’ concerns, work to understand why they are questioning the science, and
respond respectfully. Provide parents with information about vaccines and
vaccine-preventable diseases, both verbally and in writing. Document parents’ questions
If parents still decline to vaccinate, the parents should sign a Refusal to Vaccinate form. Parents should sign a new form each time a vaccine is refused so there is a record in the child’s medical file. To minimize potential legal exposure, nurses should document all discussions, actions taken, and educational material provided.
For further information, visit the American Academy of Pediatrics site document “Countering Vaccine Hesitancy.”
Department issues guideline on tapering and discontinuation
Clinicians seeking to wean patients
off opioid painkillers should do so slowly and only with shared decision-making
involving the patient, according to a new guideline released
Thursday by the Department of Health and
Human Services (HHS).
The lone exception is when patients
face a life-threatening crisis if opioids are continued, the document stated.
HHS also lists situations in which
clinicians should consider tapering dosages or discontinuing opioids
altogether, starting with “Pain improves” and ending with “The
patient has been treated with opioids for a prolonged period (e.g., years), and
current benefit-harm balance is unclear.”
In between are common-sense
scenarios including patient request, overdose, evidence of misuse, and use of
other medications that shouldn’t be combined with opioids.
Sudden Tapering is Risky
But the guideline’s main thrust is
to discourage clinicians from simply stopping prescriptions abruptly.
“Risks of rapid tapering or sudden discontinuation of opioids in physically dependent patients include acute withdrawal symptoms, exacerbation of pain, serious psychological distress, and thoughts of suicide,” the document emphasizes in a colored box. It also notes, perhaps unnecessarily, that “patients may seek other sources of opioids, potentially including illicit opioids, as a way to treat their pain or withdrawal symptoms” if suddenly deprived without their agreement.
Among the steps clinicians should
take before changing doses were making a commitment “to working with your
patient to improve function and decrease pain.” This could include
alternative medications as well as nonpharmacological treatments, the document
indicates, adding, “Integrating behavioral and nonopioid pain therapies
before and during a taper can help manage pain and strengthen the therapeutic
“Obtain Patient Buy-In”
The guideline also advocates a
thorough discussion with patients that includes soliciting their perceptions of
the risks and benefits of continuing on opioids.
Notably, it also states that
“tapering does not need to occur immediately. Take time to obtain patient
Included in the guideline is a
multi-step flow chart to walk clinicians through the decision-making process,
from the initial assessment of benefits and risks of patients’ current regimens
to a recommended quarterly re-evaluation of patients’ progress. And, also in a
colored box, is the definition of opioid use
disorder as given in the DSM-5 diagnostic
“Care must be a patient-centered experience. We need to treat people with compassion, and emphasize personalized care tailored to the specific circumstances and unique needs of each patient,” said Adm. Brett P. Giroir, MD, assistant HHS secretary for health, in a statement announcing the guideline. “This Guide provides more resources for clinicians to best help patients achieve the dual goals of effective pain management and reduction in the risk for addiction.”
Originally published in MedPage Today
Federal, private funders bet food-as-pharmacy programs will deliver healthcare cost savings
When low-income patients with high blood pressure fill their “produce prescriptions” at certain New York City pharmacies, they walk away with $30 in vouchers to spend on fresh fruits and vegetables at the city’s farmer’s markets.
The city’s “Pharmacy to Farm
Prescriptions Program” has reached more than 1,000 hypertensive SNAP
recipients since it launched in 2017, and has grown from 3 to 16 participating
pharmacies. It is set to report outcomes data next year.
The program is supported in part by
a grant from the U.S. Department of Agriculture (USDA), which is poised to make
an even bigger impact on the food-as-pharmacy programs that have been growing
in popularity. The 2018 Farm Bill established a national Produce Prescription Program
that sets aside millions in grants each year.
With diet-related illnesses like
heart disease and obesity costing hundreds of billions of dollars each year in
the U.S., other funders are also expecting a healthy return-on-investment (ROI)
in these programs, which means more initiatives like New York City’s may find
the means to thrive.
Not Just for SNAP Recipients
USDA has been supporting projects to increase healthy food consumption among SNAP recipients since 2014, under the Gus Schumacher Nutrition Incentive Program (GusNIP, formerly the Food Insecurity Nutrition Initiative). The bill now guarantees GusNIP can administer $25 million in produce prescription grants—not just for SNAP-based programs—for the fiscal year beginning in 2018, jumping to $45 million for the 2019 fiscal year and rising to its cap of $56 million in 2023. The first grants will be awarded in October.
Food Hub in Charlottesville, Virginia, currently receives funding
from local businesses and philanthropies, but has applied for a federal grant.
Its Fresh Farmacy program
provides low-income patients who have chronic disease with produce from local
farmers. Participants pick up their “shares” every other week during
the growing season.
“We have seen first-hand the
impact of incorporating healthy food to manage weight, maintain healthy blood
glucose levels, and reduce the risk of diabetes complications,” said
Patricia Polgar-Bailey, a nurse practitioner at the Charlottesville Free
Clinic, which participates in Fresh Farmacy.
Non-Profit and Private Sectors Pitch In
Federal dollars aren’t the only way to keep food-as-pharmacy programs afloat. Wholesome Wave, a non-profit that was co-founded by Gus Schumacher, has been supporting produce prescription projects since 2010.
Wholesome Wave gets money from
philanthropies and corporate partners – including Target, Chobani, and Humana,
to name a few – to foster such programs.
“There are non-profits and
private-sector supporters trying to prove the model in the interest of getting
insurers and the healthcare industry to really step up,” said Julie
Peters, director of programs at Wholesome Wave.
An example of the organization’s
support: it’s putting money into a produce prescriptions pilot for diabetes at
Community Health and Wellness Partners (CHWP) in Logan County, Ohio, which is
also supported by state and federal dollars.
Healthy Food = Healthier Lives
Once a month, participants attend nutrition classes taught by staff dietitians, and subsequently receive vouchers for up to $120, depending on family size, to purchase produce at local grocery stores or farmer’s markets.
Among those who have completed three
months of classes, HbA1c has already declined 0.6 percentage points on average,
said Jason Martinez, a clinical pharmacist at CHWP who has analyzed preliminary
data from the program.
Will these improvements translate to
reduced healthcare costs? That has been the case at Geisinger Health System’s Fresh Food Farmacy initiative. The program
focuses on patients with type 2 diabetes who experience food insecurity. In
addition to 15 hours of disease and nutrition counseling, participants get
enough healthy food for 5 days of the family’s weekly meals.
Over 18 months, participants’ HbA1c
levels fell 2.1 points on average, compared with declines of 0.5-1.2 points for
those taking two or three medications only. Along with improvements in weight,
cholesterol, and hypertension, that has translated to an 80% drop in healthcare spending for 37 of about
200 participants who were insured by Geisinger, according to early data.
“We know the cost of the program, all-in, for the food and the clinical care is around $2,500, so it’s reasonable to assume that there’s an ROI that we would experience with that,” said Allison Hess, vice president of health and wellness at Geisinger. She’s hopeful that ROI will convince insurance companies “to potentially fund this as part of a benefit package.”
Similarly—albeit hypothetically—a recent simulation study of
Medicare and Medicaid recipients predicted that providing a 30% subsidy on
fruits and vegetables would prevent nearly 2 million cardiovascular events and
save almost $40 billion in annual healthcare costs.
This story was originally posted on MedPage Today.
It was no great leap for Austin Regional Clinic to embrace the
concept of population health, an approach that aims to improve the health of groups
of people, particularly those with more medically complex conditions. Our
medical group was founded on those principles back in 1980, when no one ever
heard of the term. Over time, we became very good at population health and now we
are often asked to present our “best practices.”
What’s the secret to
our success? The
long answer often includes a description of our IT investments. No doubt the
advent of electronic medical records has made us better — instead of reacting
to illness, we are beginning to use the data to predict illness, allowing us to
shift resources to the sickest patients.
But it is the human
element — the way each provider engages with the patient — that takes us from
simply identifying the high-risk to making a difference in their lives. The
technique we’ve honed is motivational interviewing.
Listen Versus Fix
The “front line” of
our population health program is our nurse navigation team. Ten years ago, it
consisted of four trained nurse navigators who primarily guided our Medical
Home patients — individuals living with chronic conditions who rely on frequent
care from various specialists. Today, this team has grown to 25 and now
includes in-hospital nurse navigation as well as a Home Health Navigator.
While the roles within
our team have expanded, our approach to patient interaction has not. Instead of
telling our patients, we ask questions. We hire listeners, not fixers.
To a psychologist, motivational interviewing is a fundamental technique. It is less well known in most doctor and nurse cultures. Providers are taught to fix. Yet, we’ve found, that without first understanding the patients’ goals and then uncovering the obstacles that stand in the way of their goals, our sickest patients don’t feel compelled to change.
How does it work? Instead of telling
patients to change, we guide them to express their own commitment out loud,
which has been shown to improve patients’ ability to actually make a change.
‘Fishing with My
When I asked one of my
patients with a chronic breathing disorder about his goal, he replied, “I’d
like to be able to fish with my grandson.” Later, at his appointment and
others, I asked questions about what might be getting in the way of his goal.
“I can’t breathe outside” or “I can’t leave the house without my breathing
device.” We discussed the obstacles and set forth reasonable small goals to
progress him forward. Each time he achieved a goal, he was motivated to set another.
My patient was aware
of his barriers. With motivational interviewing, he became empowered to learn
how to overcome them.
population health program is an investment in time and money, but the effort pays
off. As last year showed, Austin Regional Clinic’s success has the numbers
to back it up:
than $3 million in 2018 shared savings, bringing the total to almost $25
million in the past eight years
80% screening rate for depression and fall risk, up from 38% just two years
of diabetic patients moved to “good controlled” from “poor controlled”
of our Medicare population is up to date on their colorectal screenings, up
from 65% a few years before
Every year we set new
population health goals, raising the bar just a bit. Admittedly, improving
population health is a marathon, and we are only in the first leg of the race. Enhanced
predictive analysis using artificial intelligence and machine learning will guide
us to the patients for whom we can make the greatest impact on their health.
Our philosophy concerning our patients is unwavering — to not just consider each patient’s illness, but to see the person. To understand their values, their lives, and their support. To listen and to empower.
The most accurate
predictive analysis cannot compel a patient to change — a patient’s will
does that … and the dream to fish with a grandson.
In recognition of Suicide Awareness Month, Georgia Reiner, a risk specialist for Nurses Service Organization (NSO), shares her expertise on the subject of nurses and suicide prevention with DailyNurse.
Q: What do you consider the most
striking statistics on suicide in the nursing profession?
A: The phenomenon of nurse suicide has been largely overlooked by researchers in the US. The most prominent research in this area by Davidson and colleagues — just published this year — found that suicide incidence was significantly higher among nurses than the general population. The researchers found suicide rates of 11.97 per 100,000 person-years among female nurses and 39.8 per 100,000 among male nurses, compared to 7.58 and 28.2 per 100,000 person-years among general population women and men, respectively.
Q: Why might nurses be
particularly at-risk? Are they more prone to depression than the general
A: More research needs to be done to determine why nurses
have greater odds of dying by suicide than the general population. However,
existing research has suggested that there are some collective risk factors for
nurses, including undertreatment of depression and other mental health issues,
knowledge of and access to lethal doses of medications, and a combination of personal
and work-related stressors. The high-pressure, emotionally draining environment
that nurses work in, compassion fatigue, burnout, and job dissatisfaction can
each contribute to these risk factors.
Q: Is the phenomenon gaining
attention in the healthcare field—and if it is, what measures are being taken
to reduce the danger?
A: Yes, and work is being done by organizations like the
American Nurses Association, the American Organization of Nurse Executives, the
National Academy of Medicine, and the National Suicide Prevention Lifeline to
try to raise awareness of the issue and promote protective factors. While
systemic and organizational-level solutions in healthcare are critical to
addressing burnout, depression, and suicide among nurses and other healthcare
professionals, progress in implementing evidence-based solutions has frankly been
slow or nonexistent. Therefore, it is also important for nurses to take
Q: How can nurses bring this
problem to the attention of their own institutions?
A: Supporting nurse well-being requires sustained
attention and action at the organizational level. This first requires buy-in
and investment from leadership and managers. Nurses should work with their
managers and organizational leadership to promote a healthier, more positive
work environment that cares for nurses as whole people. This includes educating
nurse managers and staff nurses about suicide prevention, how to offer support
to someone who may be struggling, where to get help, and alleviating the stigma
around suicide and depression.
Q: What sorts of self-care practices
can nurses follow to reduce the risk of depression and suicide?
A: Nurses need to support each other and take time to have
open dialogues with their colleagues about issues affecting them personally and
professionally. Increasing connectedness, or a sense of belonging, has shown to
be a protective factor against suicide. Nurses also need to work on an
individual level to build resilience to cope with stressors in their
professional and personal lives. Practicing mindfulness, eating well,
exercising, getting enough sleep, limiting time spent on social media, and
taking regular time off from work are all important. Speaking to someone,
whether by going to a therapist or by attending a support group, can also help
nurses feel better and improve their mental health and resiliency.
Q: Are nurses more or less
likely to enter therapeutic treatment than people outside their field?
A: Nurses face many of the same barriers to mental health
care as other people: the stigma associated with mental illness and asking for
help, how difficult it can be to get the energy to reach out for help when
you’re depressed, and then the time and cost associated with accessing mental
health treatment. These barriers can be extremely difficult for some individuals
to overcome by themselves, which is why it is so important for nurses to look
out for one another.
Q: Are there resources
specifically to help nurses who might be suffering from suicidal ideation or
actively considering suicide?
A: It is important for nurses to learn about how they can
look for signs of someone who may be struggling with suicidal ideation. Starting
the conversation, providing immediate support, and helping someone who has
suicidal thoughts to connect with ongoing support can help save lives.
If you or anyone you know are considering self-harm or suicide, feeling anxious, depressed, upset, or just need to talk to someone, it is important to know that there are people who want to help. The National Suicide Prevention Lifeline is available 24/7 at: 1-800-273-8255, as well as the Crisis Text Line, available by texting “START” to 741741 at any time, for any kind of crisis.
Also of interest: A Nurse I Know Tried to Commit Suicide
At NSO, Georgia Reiner is responsible for educating
healthcare professionals on professional liability issues and risk management
strategies by creating informative risk management content, including
self-assessment tools, newsletters, webinars, and claim reports.